BIDMC’s Transparency
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For The Record — I am a member of the Board of Trustees of Beth Israel Deaconess Medical Center (BIDMC). The Board of Trustees is NOT the same as the Board of Directors. The Board of Directors is the governing body that has fundamental oversight responsibility for the hospital. The Trustees serve as an ancillary board to the main board, and serve as members on various sub-committees of the Board. That makes me, I suppose, an “interested party.” Nonetheless, I thought it worthwhile to comment on the big story in our health care marketplace these days — which is the wrong side surgery at BIDMC.
The Boston Globe pretty much covered the incident, and BIDMC CEO Paul Levy has blogged on it several times in the past couple of days, so I won’t spend a lot of time re-hashing the facts of the case. instead, I’ll offer three — hopefully useful — observations.
1) BIDMC’s willingness to put a lot of information into the public domain immediately following the incident is noteworthy. It wasn’t so long ago that public reporting on this kind of incident would have been considered a “bad idea,” — too much information for the public at large. Ten or fifteen years ago, regulators worked on the assumption that they would get more information on poor performance from providers if there were hard and fast rules that prohibited public disclosure. BIDMC has been a market leader on transparency — but I still think the level and speed with which this information has been disclosed is a bit of a watershed event here.
2) Whenever I read one of Dr. Atul Gawande’s books or articles, I am reminded about how much is at stake — and how complex the decision-making and business processes are — whenever someone is inside a hospital. This is not a traditional business process. In most cases, if someone does everything right, the outcome is good. Inside a hospital, people can do everything right, but the outcome may still be a bad one. This doesn’t excuse BIDMC — or any other provider — that delivers a bad outcome using a bad process, and no one has made more noise about the value and utility of checklists and “forcing factors” in health care than Gawande. His argument is that the complexity and the stakes — life and death in many cases — require the use of more structured, more rigorous tools to assure “same way every time” processes inside a hospital.
3) This combination — more public disclosure and more focus on standard processes and checklists — is a good one. People who might not embrace “cookbook” approaches to process may be compelled to do so by public reporting. In addition, public reporting could create context and understanding that hasn’t existed before concerning provider performance — which despite the complexities involved — is usually quite high.
Mr. Levy and BIDMC should be commended for their openness and transparency following this incident.
Hopefully, other organizations can follow this example – not only of owning up to mistakes, but to maintaining this sort of transparency when it comes to the more sensitive, or controversial, side of health care. Incidents such as these, along with end of life care, access to care issues, and setting reasonable expectations for health outcomes will, when made public, all present far more treacherous ethical challenges than will cost transparency alone.
No discipline will ever be perfected, but – especially in health care – the ability to identify and rectify imperfections must be practiced with the highest level of integrity. The ultimate solution to rectify these specific errors is, as yet, unapparent; but Mr. Levy and his staff have demonstrated the exact kind of integrity necessary to ensure that our health care system is a true work in progress, not a broken machine.
Public embarassment, inquiry, resolves to do better: this is all good.
It is a pity that our system does not seem to be structured to deal in a similar way to problems of prevention, as in, for example, the case of Tim Russert. Untreated hypertriglyceridemia, in someone with established heart disease? I expect this situation is common enough. But isn’t is something that responsible people need to reassess?
The science, after all, seems to favor the treatment of high triglycerides. In 2006 the AHA advised one therapy (EPA + DHA, under supervision of a physician) for those with documented CHD, like Russert. More recently a scientific journal, ATVB, found that in cases of hypertriglyceridemia and low HDLs, the overweight “derive a disproportionately large reduction in cardiovascular events” from another therapy.
And yet the popular response to Russert’s untimely death is just a demand for more imaging. A disconnect, don’t you think? And not likely to promote the best use of resouces?
Susan - check out my previous post on Checklists. Dr. Atul Gawande wrote a piece in The New Yorker about checklists, in which he said, “If a new drug were as effective at saving lives as Peter Pronovost’s checklist, there would be a nationwide marketing campaign urging doctors to use it.” Too often, we think the answer is more science, when it’s oftentimes, smarter use of what we already know. Sigh.