Sunday, March 27, 2011 | 2 a.m.
Do No Harm: Hospital Care in Las Vegas, Part 5
- Sun investigation reveals flaws in hospital care; solutions offered
- How to put patients first
- Local hospitals’ willingness to change culture would be a step toward better care, transparency
- ‘You can’t kill my mother and get away with it’
- We must adopt a culture of sincere care
- How to file a complaint
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Beyond the Sun
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
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.
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.
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.