Thursday, December 3, 2009

Quality of Care Still a Mixed Bag

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This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

Paul Levy is President and CEO of Beth Israel Deaconess Medical Center in Boston, Massachusetts. He also writes the blog Running A Hospital in which he shares his thoughts about hospitals, medicine, and health care issues.

So I know as someone who is the CEO of a hospital, quality issues are probably always at the forefront of your mind. I wanted to start by getting your impressions of what quality of care looks like today.

I think it’s still a mixed bag. I think there have been some good improvements, but I think there is a lot that remains to be done. For the most part there is still great a variation in the care that is delivered and, unless more is standardized, we’ll never make progress on using a scientific approach to adopting the types of patient care that are of the highest quality.

So when you say things need to be standardized – are there specific standards you have seen to be more successful than others?

Well we have put some into effect here. For example, installing and maintaining central lines, adopting a bundle to avoid ventilator associated pneumonia, adopting a pre-surgical protocol to help avoid wrong site surgeries or other errors of that sort in surgery. Those are examples of when the procedure is standardized for that portion of the medical care that is appropriately standardized, variation is diminished and the likelihood of preventable harm goes down.

And what roles do you see nurses having in maintaining this kind of level of quality?
Nurses are key. If the nurses are not involved in developing the protocols, helping with the training, calling out problems on the floor or in the intensive care units, then it just won’t work. Nurses well more than doctors actually have contact with the patients and have important responsibilities. The idea of doing it without the nurses is just crazy.

I know there is a lot of research out there talking about the key role that nurses can play in creating a safer environment when they are really a part of the team as you just described. What do you see as being the actual status quo in terms of the relationship between nurses and doctors? How much of a voice do you think nurses actually have?

I think it varies. In our hospital, we wouldn’t imagine trying to make quality and safety improvements without fully engaging the nursing staff in that process. When I talk with people in other hospitals, I hear that the opposite happens – that nurses are sometimes an afterthought, if any thought, and are not consulted and engaged in the process. I just don’t see how you can do it effectively with that latter model. It just doesn’t make sense.

There’s also a very low percentage of nurses involved in hospital boards.

I don’t think that matters very much. There are a very low percentage of doctors involved in hospital boards as well. I don’t think it matters very much who is on the board. The issues is not so much who is on the board. The issue is who is involved in actually designing the way care is delivered. Boards of trustees do not determine the way care is delivered. Their role is of a policy nature or setting overall targets against which the management and clinical leadership will be held accountable. You can have 10 nurses on the board or you can have no nurses on the board, but I don’t think that’s determinant of how process improvement happens in a hospital.

So it sounds like in your hospital you do take into consideration the voice of nurses when creating these measures. Do you have a specific story or example to illustrate that?

I’m not sure we have a specific one. We recently revamped our pre-surgical protocol, and that was a joint effort that the surgeons and nurses and surg techs and anesthesiologists all working together as a team. You have to have everyone who will be in the OR be part of the team. It just seems so common-sensical to me it almost seems pedantic to say it over and over again like this.

So what do you think the biggest challenge is to improving patient safety?

I think the biggest challenge is that physicians are trained to deliver medical care in a certain way, and that way does not include training in how to make process improvements in the delivery of care to make care delivery safer, more effective, and higher quality. Changing that mindset or introducing that mindset into how systemic improvements are made in an organization is something that many doctors have to learn.

How do you envision that happening, both for younger, newer doctors recently out of medical school and for those who have been practicing for years?

Ideally, you’d like to start teaching this in medical school. But, having talked to the various medical schools in Boston, there doesn’t seem to be much interest in that. So the next step is can you introduce it into the residency training, and we’re doing that in our hospitals. The residents love it. They find it fascinating and very useful to them. For those who are already attending physicians, there have to be training courses and the like just as there would be in any other aspect of their profession. Then you actually have to practice it and do it.

I saw on your blog you were recently at an event where Newt Gingrich spoke and you wrote that you thought it was interesting that he said that it’s important not to wait for government to prompt safety efforts.

Right, well it’s because the government, not because of bad intentions but just because it’s the way government always works, the priorities coming out of the government in terms of safety and quality may not be the right ones in terms of actual safety and quality, and the mechanisms they use to promote it or encourage it are not always the most motivational ways of doing that. The profession itself has to figure out how to do this.

So how do you see health reform assuming that it passes effecting quality?

It will have no impact what-so-ever. There is nothing in any of the legislation that really amounts to a hill of beans in terms of improving the quality and safety of care.

OK, that’s very straightforward. So then, beyond the improving of medical education and turning more closely toward the nursing profession, what do you see the next steps to be in terms of improving care?

I think each organization, each hospital has to figure that out for itself, depending on its local culture and how far things are along. I don’t think there’s a simple answer for that.

Do you think that there is a way to implement a similar structure for both the medical and nursing communities in other places?

I don’t think I can presume to say what would work in other places. We have an approach we are trying out here, you’ve read about it on the blog. Whether that’s right or wrong for other places, they have to figure out. But there has to be a prerequisite that the administration and medical leadership of the organization has to be committed to doing it in order to get it done. Unless this is a priority of the organization, it will not get done, whether it’s the nurses or the doctors.

So do you feel that both your hospital specifically and hospitals in general have been improving?

We know that we have improved here. The number of people harmed as the result of preventable medical errors has dropped. That’s good news. The incomplete job is to keep doing better and better at that and to eventually eliminate preventable harm, which is the goal we’ve set for ourselves. It’s good that we’ve made the changes we’ve made, but there’s still a lot left to do.

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