We Want You on Board
Cover Story
Written by Mike Sharkey   
Saturday, 01 December 2007
Cover Story - We Want You on Board - American Executive - RedCoat Publishing
How hospital boards of trustees can become powerful instruments in the growing fight against medical mishaps.

When Betsy Lehman died of a chemotherapy overdose in 1994, one question was asked over and over again: how could this have happened?

Lehman, a popular and respected writer for The Boston Globe, was the least likely victim of a medical mishap. The 39-year-old had chronicled her battle with breast cancer in her personal health column, where she stressed a patient’s personal responsibility to take an active role in treatment. She’d fought cancer and won, thanks in part to her intelligent, engaged approach.

Catherine Tersigni Illustrator - We Want You on Board - American Executive - RedCoat Publishing
Illustration by Catherine Tersigni
When cancer struck again, Lehman was crushed, but prepared. She knew she would receive the best possible care at nearby Dana Farber Cancer Institute, and she knew all the right questions to ask her care providers. She even had an “in”—her husband was a research scientist at Dana Farber.

And yet, on December 3, 1994, Lehman died of complications stemming from a massive overdose of chemotherapy. Immed-iately after her death, people on all sides of the incident began asking the question: how could this have happened?

When state and federal regulators descended on Dana Farber to find out for themselves, they discovered numerous deficiencies, including protocol violations, ineffective drug error reporting, and a lack of oversight by hospital leaders on quality and safety assurance. The widely reported results shocked not only the public, but also Dana Farber’s board of trustees.

“They felt duped,” said James Conway, the man who became the new COO and executive vice president at Dana Farber shortly after Lehman’s death. “When CMS, The Joint Commission, and the Department of Public Health issued their reports, their findings weren’t a surprise to the people closest to the work, but they were an unbelievable surprise to the board of trustees. The board felt duped because the only thing they ever heard from the administration and medical staff was the good stuff. When I was hired, the board chairman held up his finger to me and said, ‘Never again. Never again allow the system to kill a patient, and never allow our board to be duped.’”

It was a message Conway took to heart, and it led to sweeping changes in the processes and culture at Dana Farber. Betsy Lehman put a face on the organization’s quality and safety data, and the board took stewardship of it. The transformation was, as Conway put it, “stunning.” On the 10-year anniversary of Lehman’s death, Dana Farber published eight years worth of quality and safety data in The Boston Globe. The Globe, in turn, named Dana Farber the safest hospital in Boston.

Today, Conway and a group of prominent governance leaders have joined forces with the Institute of Healthcare Improvement (IHI) to share Betsy Lehman and Dana Farber’s story. They’ve created an innovative program that’s helping hospital boards across the nation confront the realities of clinical practice and become key drivers of quality and safety. The message is clear: it’s time to get your board on board.

Encouraging questions
Q: How do hospital administrators know if they’ve made a successful presentation to the board?
A: The board doesn’t ask any questions.
If you answered the above question correctly, the IHI believes your hospital is the perfect candidate for its Boards on Board initiative. Take a look at your board. There’s a 99% chance it’s made up of lay people who know little to nothing about the practice of medicine. As such, the responsibility for clinical quality and safety has historically been placed squarely on the shoulders of the medical staff.

But as Bob Dylan wailed, the times, they are a-changin’. Landmark reports by the Institute of Medicine, created in part because of Betsy Lehman’s highly publicized death, have shined a spotlight on medical errors and their impact on the nation. According to the IOM’s now famous report, “To Err is Human,” an estimated 50,000 to 100,000 people die in America’s hospitals each year due to medical errors and poor quality and safety performance, destroying families and adding billions to the nation’s total healthcare bill.

Chilling statistics like those have put the emphasis in healthcare firmly on quality and safety. Consumers and state and federal agencies want to know how hospitals are performing and what they’re doing to improve. Even bond rating agencies have shifted their approach, asking hospitals for quality and safety data before they issue their scores. And the people that are increasingly being held accountable for a hospital’s quality and safety performance, whether they like it or not, are the members of the board.

“So how are boards that aren’t clinical able to make changes in clinical care?” asked Dr. James Reinertsen, healthcare leadership consultant and a key contributor to the Boards on Board initiative. “The answer is they aren’t responsible for the ideas, but they’re in a powerful position to influence will and execution. They’re the ultimate authority in the organization. If they’ve got the backbone, they can make changes happen in an organization in a very powerful way.”

The first critical step in getting your board on board, Reinertsen said, is to be honest and clear about quality and safety performance. As was the case at Dana Farber, many boards don’t know the real story—they’re being duped. They’re presented with hundreds of quality and safety metrics, but they’re not told the real story. They’re given the rate for ventilator-acquired pneumonias per 1,000 ventilator days, complete with a complex chart that points out the National Nosocomial Infections Surveillance System median. They’re directed to the line that indicates the hospital is slightly above the median and asked if there are any questions. When there aren’t any, the administrator believes he/she just made a successful presentation.

What they’re not told is how many lives were negatively impacted by the hospital’s above- the-median result. Just about every hospital in the nation has its own Betsy Lehman story, Reinertsen said, and administrators have to tell that story to the board and put a face on the quality and safety data.

“Management teams and others with the guts to tell a patient story to the board can really turn the board on to quality and safety,” he said. “A patient’s story can change a board’s life forever. Boards will start asking the questions they’ve never asked before. Questions like, ‘How could this happen at our hospital?’”

Aiming high and becoming transparent
To truly drive quality and safety improvement, Reinertsen and Conway recommend organizations discard the crutch that too many organizations have come to rely on: the median.

Being average or just above average when it comes to clinical quality and patient safety shouldn’t be good enough, Reinertsen said. “When boards see the gap between the median and the theoretical ideal, they understand what that means to patients, and the question becomes, ‘Why can’t we get to zero? Even if no one else is there, why can’t we be the first?’”

That’s the approach 475-bed Cincinnati Children’s Hospital Medical Center took when it embarked on its Pursuing Perfect Care initiative. In 2005, the IHI began working with the hospital’s board of trustees to target 18 areas for improvement, from surgical site infections to asthma care to moving patients efficiently through the system. The hospital ignores the median and sets aggressive goals for improvement, holding management and staff members accountable for attaining them. When a goal is reached, the bar is raised again.

“Where we haven’t quite met our goals, we’ll keep them in place for next year. Where we have met our goals, we’ll either up the ante or, if our met goal is unbeatable—say, zero ventilator-acquired pneumonias—our goal will be to sustain it,” said Lee Carter, chairman of the board, in an interview with IHI.

Setting aggressive goals allowed Cincinnati Children’s to deliver perfect care for children with six common conditions an industry-best 95% of the time, and according to Carter, another critical element drove rapid improvement: transparency.

Transparency is a dirty word that many healthcare organizations have come to fear during this so-called accountability movement, but Conway and Reinertsen agree it’s an essential characteristic of boards in high-achieving hospitals. “Being fearful of transparency is a mental model we’ve been taught to believe is true,” Conway said. “And it’s not. Boards believe patients will leave and the hospital will be opened up to lawsuits if they’re transparent. That’s just not true.”

“There is no data showing that those two things happen,” added Reinertsen. “In fact, what evidence there is suggests that when you go transparent, you will drive down your overall liability for these matters.”

In fact, early embracers of quality and safety transparency such as Dana Farber, Cincinnati Children’s, Beth Israel Deaconess Medical Center, and Dartmouth Hitchcock Medical Center are proving that transparency actually focuses organizations on driving improvement.

For example, back at Cincinnati Children’s, the board took an honest look at the data and discovered the hospital was harming a child every 21 days. An aggressive goal was set to reduce that rate by 80% in 18 months, and leadership got the entire organization behind the effort by being highly transparent. On every computer in the hospital, including those designated for patients and families, the hospital loaded a screen saver featuring a ticker that tracks the time between each instance of patient harm. The first time the ticker was started, it got up to 34 days before being set back to zero. A box below the ticker provided information about what happened and how the incident could be prevented in the future.

“That’s real transparency,” Reinertsen said. “The moment a child is harmed, everyone in the hospital knows about it, and everyone wants to know what happened. It’s become a driving force for everyone in the organization to dramatically reduce incidents of patient harm.”

Getting it done
IHI launched its Boards on Board initiative, which is one of six interventions in its comprehensive 5 Million Lives Campaign, in December 2006. The response, Conway and Reinertsen said, has been overwhelming.

The first conference the IHI held on the initiative sold out a month in advance, and at a Boards on Board conference in Washington State, board representatives from every hospital in the state turned out. Regular conference calls often have 500 people on the line, and more than 1,800 organizations have downloaded the IHI’s Boards on Board How-to Guide (http://www.ihi.org/IHI/Programs/Campaign/BoardsonBoard.htm).

“A perfect storm of things—regulatory pressure, legal pressure, public pressure—is energizing boards to get involved,” Conway said. “Boards are now very eager to learn how to get behind quality and safety. It’s not about learning why they should do this, it’s about learning how to do it. You don’t have to convince them or advocate, they just want to know how they can get this done.”

“It’s nothing less than a real transformation of the American healthcare system,” Reinertsen added. “I’m really excited about this. Change is happening. Just look at the results. ICU after ICU has zero central-line infections. Dozens of organizations haven’t had a ventilator-acquired pneumonia for two years now. These use to be every day events. Death rates are plummeting. I’m a data-driven guy. These are feel-good, enthusiastic programs. That’s great, but show me the numbers—and we are seeing the numbers move in the right direction.”


When patients like Betsy Lehman die of medical mishaps, the question has historically been, “How could this have happened?” As hospital boards across the nation begin leading quality and safety initiatives, the question is becoming, “What can we do to make sure this never happens again?”

 
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