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July 28, 2014

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Do No Harm: Hospital Care in Las Vegas:

Admitting harm protects patients

Harvard hospital led the way on transparency in reporting cases of harm

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Leila Navidi

Paul Levy, the former CEO of Beth Israel Deaconess Medical Center in Boston, takes a walk to a frozen lake near his home in Newton, Mass., on Wednesday, March 2, 2011.

Tale of Two Hospitals

Dr. David Ring performs hand surgery at Mass General West in Waltham, Mass., Thursday, March 3, 2011. Launch slideshow »

As Nevada legislators debate this week whether to require hospitals to publicly report when they harm patients, they could learn a lot from Paul Levy’s experience in pulling back the veil of hospital secrecy.

Levy became a revolutionary figure in medicine when, as CEO of Beth Israel Deaconess — then the weak sibling among Harvard University’s teaching hospitals — he began blogging about injuries and infections suffered by his hospital’s patients. His competitors eventually followed suit and now, with Massachusetts law imposing transparency, they acknowledge openness has brought greater accountability and a more focused commitment to protecting patients.

“It’s not just fear of public embarrassment” that drives the improvements, said Dr. Ken Sands, chairman of Beth Israel Deaconess Medical Center’s health care quality department. “It’s an easy way to show something is a priority and is deserving of attention.”

This transparency effect is at the heart of the debate in Carson City, where Nevada lawmakers are considering bills requiring hospitals statewide to publicly report injuries suffered in their facilities and other quality measures.

Until last year, Nevada hospitals had kept the scale of harm to patients under wraps. Then, a two-year Las Vegas Sun investigation, based on an analysis of hospital billing records on file with the state, found 3,689 preventable infections and injuries in Las Vegas hospitals in 2008 and 2009. In 354 cases, patients died in the facilities.

Publicizing such information would allow patients to make better-informed decisions about where to seek care, said Sen. Valerie Wiener, sponsor of one of the transparency bills.

It will raise the bar for all care providers “because the light is shining on them,” she said.

Many hospital executives in Nevada and across the nation have steadfastly opposed transparency, saying they should not be blamed when patients are harmed and, moreover, the information can easily be misunderstood and lead to malpractice lawsuits and higher health care costs.

Advocates of transparency face an uphill battle. About 40 states, including Nevada, do not require hospitals to report to the public their cases of hospital-acquired injuries or infections, according to Consumers Union, a nonprofit organization.

In Massachusetts, it took an outsider like Levy — who was schooled in economics and city planning, not medicine — to grasp the power of disclosing his hospital’s failures — and be willing to risk making enemies along the way.

REDUCING THE NUMBERS

When Levy took over as head of Beth Israel in 2002, it paled in reputation alongside the other two Harvard-affiliated teaching hospitals, Massachusetts General and Brigham and Women’s Hospital.

He launched a blog, “Running a Hospital,” to chronicle his efforts to improve the facility. His unconventional online musings raised eyebrows and gained a worldwide audience because hospital CEOs are known for keeping things close to the vest.

Some in Boston’s medical community viewed Levy as full of himself and didn’t consider him part of their circle.

Then Levy proved he was an outsider. In December 2006, he published his hospital’s monthly rates of infection associated with central-line catheters, which are inserted deep into the body to rapidly administer drugs or withdraw blood.

These central line infections, which can be caused by nonsterile insertion of the catheter or not removing it soon enough, are preventable. The Centers for Disease Control and Prevention estimate 250,000 central-line infections occur annually, costing $25,000 each and claiming the lives of one in four infected patients.

Levy says he published Beth Israel’s numbers to praise and encourage his staff, which had reduced infections from about 3 per 1,000 central-line days to as low as 1 per 1,000.

But in doing so he had crossed a line, admitting publicly that his hospital was harming patients.

Then he took it a step further. Levy needled counterparts at Massachusetts General and Brigham and Women’s, writing on his blog in February 2007: “Can I ask a question? If I can post these rates for (our hospital), why can’t people from other hospitals?”

He issued the same challenge to insurance companies and Massachusetts officials. It is time to move past “a culture of blame and litigation and persuade people that transparency works,” he wrote.

By stirring the pot, he made news. “Blog tests hospital leaders’ patience; Beth-Israel CEO jabs competitors,” read a headline in The Boston Globe a week later.

Still, Beth Israel continued on its course. In fall 2007, the hospital’s governing board pledged to eliminate preventable harm to patients by January 2012.

“Daunting, eh? You bet,” Levy blogged. “Here’s more. We will be publicizing our progress toward these goals on our external website for the world to see. In other words, we will be holding ourselves accountable to the public for our actions and deeds.”

Beth Israel’s website reports quarterly about hospital acquired infections and injuries such as advanced-stage bedsores, falls that result in injury and medication errors. From October 2009 to September, the most recent time period on the site, 128 cases of patient harm were reported.

Sands credits the public reporting as a significant factor in the hospitals progress, which includes reductions in:

• Hospital mortality of 2.5 percent, which translates to one fewer death per 40 intensive-care patients.

• Cases of ventilator-associated pneumonia, from 10 to 24 a month in early 2006 to zero in many months by mid-2006.

• Total days patients spent on ventilators from 350 to 475 a month in early 2006 to around 300 by mid-2007.

• The length of an average intensive care stay. From 2005 to 2009, the average stay was reduced by a day to about 3 1/2 days.

Levy says other hospital leaders were disdainful of his challenges, accusing him of being self-aggrandizing, hurting academic medicine and trying to gain a competitive advantage by making them look bad.

Dr. Tom Lee, network president of Partners Healthcare, a nonprofit organization that runs Brigham and Women’s and Massachusetts General, won’t comment on Levy.

Other Partners Healthcare officials, however, say Levy forced them to be transparent.

Click to enlarge photo

Dr. Tom Lee, the CEO of Partners Community HealthCare Inc., leads a meeting in the Prudential Building in Boston on Wednesday, March 2, 2011.

Dr. Tejal Gandhi, Partners’ director of patient safety, said at first there was panic over posting on the hospitals’ websites the infections and injuries suffered by patients. People worried there would be a media frenzy or a rise in malpractice lawsuits, she said.

When the information became public, in 2009, The Boston Globe published one story but there was little other reaction, she said.

The hospitals have seen no increase in malpractice lawsuits. But it has brought a new focus on reducing certain infections and injuries, including the formation of task forces and establishment of standardized safety protocols.

“It drives leadership to take action more immediately,” Gandhi said of public reporting.

LEGISLATING OPENNESS

In 2008, Massachusetts passed a law requiring hospitals to report certain infections and injuries suffered by patients to the state, which compiles a public report.

New state regulations also prohibited hospitals from charging for complications caused by the events (in states including Nevada, hospitals bill patients or their insurance for treating such injuries).

Partners Healthcare officials published their figures ahead of the state, in part to match Levy’s openness. (Levy recently stepped down as CEO of Beth Israel.)

In Nevada, the Legislature is considering similar regulations, including bills to require:

• Public reporting of each hospital’s sentinel events — unexpected cases of injury — and that hospitals allow regulators to verify their reports are accurate.

• Patient notification of each hospital’s infection rates, and posting of rates in public areas with information about how to contact regulators.

• Publication of the rate at which patients who have been discharged from a hospital are readmitted for additional treatment for the same problem.

Over the course of the Sun’s two-year investigation, most Las Vegas hospitals refused to discuss patient safety issues. The Nevada Hospital Association has since 2002 lobbied against mandated public reporting of patient harm. But since the Sun’s investigation, and with legislation pending, the association has said it will begin posting patient injury and infection data on its hospital quality website.

Experts and those who have taken similar steps say it will improve care.

Dr. Ashish Jha, an associate professor at the Harvard School of Public Health, has researched the public reporting of patient harm. He said evidence shows it changes health care providers’ behavior in ways that improve safety. In one case, where outcomes of cardiac surgeons were made public, some of the lowest performing doctors stopped practicing, Jha said. “This stuff is very powerful.”

Jim Conway, a vice president at the Institute for Healthcare Improvement, a think tank in Cambridge that helped guide Beth Israel through its do-no-harm pledge, said public reporting created what management guru Peter Senge calls creative tension, a key in getting an organization to change. Announcing a daring vision — the elimination of patient harm — combined with honestly publicizing the problems, fuels improvement, he said.

It reminds Levy of his experience on the track team in middle school.

After each meet, the coach would post runners’ event times, underlining those that were improvements over previous races and circling times if they were personal bests. Everyone wanted a circle around his time, he said.

“We did not look at them competitively with one another,” Levy said. “We looked at them competitively with ourselves.”

Publicly reporting hospital-acquired harm “isn’t me as a CEO ordering anybody around,” Levy said. “This is people holding themselves accountable to a standard of care they believe in. What stronger motivation could you ask of a doctor or nurse to improve patient care?”

At 3:30 p.m. Monday, the Nevada Senate Health and Human Services Committee will hold hearings on the proposals to mandate greater hospital transparency.

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  1. In the relentlessly for-profit hospital community in Las Vegas, injuring or infecting patients is simply regarded as a cost of doing business. The poor practices causing these injuries in hospital and office settings (e.g., the Kaplan issue) are likely to remain largely shielded and under-reported from the public, this bill notwithstanding.

  2. Like the Pinto Back Seat Job. Since kids were usually in the back seat and parents or grandparents were usually driving, you can guilt trip the drivers into thinking it was their fault or partially their fault for incinerating the kids in the back seat, rather that the poor gas tank design. "If you hadn't pulled out in front of that other car that rear ended you, your kids would be alive today." (Pinto was not the fastest accelerating vehicle.)

    So if you didn't eat all that crap food, got some exercise and visited the doctor more, you wouldn't be in the hospital for our doctor to make the mistake in the first place. "You make mistakes, don't you? Like eating that burger and fries that clogged you arteries. So our doctor made a mistake, so let's let bygones be bygones..."

    Now the doctors have a PR machine (like Kaplan) to save themselves in the media.

  3. Marshall, let me commend you and the team on your careful reporting and this outstanding series. In speaking to you over the series, I was struck by your depth of your research, your diligence, and your search to understand all sides of this story.

    In reading every piece of it, I found it challenging, disciplined, and action oriented.

    As a healthcare executive for over 35 years, dealing with suffering, harm, tragedy, and death, I've become an intense student of patient safety. I am absolutely convinced that there will be no safety without transparency. Values, and particularly the value of respect, also drive me to believe firmly that in the aftermath of a tragic event, the patient, family member, hospital staff, and community should only meet respect. Your recommendations are strong and should be carefully considered.

    Finally, I thank you for your careful review of what is going on at the Harvard hospitals. We're very proud to this journey we are on. At the same time your readers shouldn't think this leadership in patient safety, transparency, respectful practice, and learning is a remote event. A recent, widely acclaimed, publication by the Institute for Healthcare Improvement (IHI) shows efforts and evidence from around the world: http://tinyurl.com/IHIEffectiveCrisisMgm...

    Thanks again for this exceptional series.
    Jim Conway, FACHE
    Faculty, Harvard School of Public Health, Boston MA
    Senior Fellow, Institute for Healthcare Improvement, Cambridge MA
    Principal, Pascal Metrics, Washington, DC.

  4. Marshall Allen:

    Congratulations on yet another important, relevant, and very well presented healthcare article! As a surgeon who conducted his practice for almost 35 years, I wholeheartedly support the concept of transparency as it pertains to incidents in which harm is inadvertently inflicted upon patients. To not do so would imply that there is something to be concealed, and that in turn would further magnify the lack of confidence in healthcare providers that currently and (I think) understandably exists in the Las Vegas area.

    The photo (in the article) of the patient who was undergoing placement of a central venous catheter at the esteemed Massachusetts General Hospital (MGH) was an item that particularly captured my attention. The nurse who was performing the procedure appeared to have been dressed appropriately, as she was wearing a (presumably sterile) gown, mask, and gloves. The patient, on the other hand, was not wearing a mask and on the contrary was directly facing the operative field, which was not very far away. Wouldn't it have made common sense for the patient to have worn a mask as well, and to have been instructed to keep her head turned in the opposite direction, in order that her exhaled breath would have been less likely to "contaminate" the "sterile" field? It appears to me that even staff members at the esteemed MGH could benefit from additional and continuing introspection, education, and training.

  5. Thank you Mr. Allen for all that you, the LVRJ and the LV Sun have researched and published on patient safety both in Nevada and the country. Unfortunately, most people do not even realize how many medical errors occur each day until it happens to them or one of their loved ones. I am a parent caregiver of a baby who was injured here in Las Vegas. I have met many other parents from around the country and the world- who like me, become patient advocates in order to get changes made in a broken system. I can speak for many of them in thanking you from the bottom of our aching hearts. With everyone working together- we can achieve amazing results and will hopefully turn negative outcomes into positive advances! Sincerely- Johannah