On the surface, a hospital’s mission seems pretty straightforward: provide the best health care possible. But delve beneath the surface, and the provision of care is a complex, multifaceted process that must evolve to keep pace with medical progress and the needs of patients and their families.
At Beth Israel Deaconess Medical Center, our clinicians continuously strive to make health care better, safer, more efficient, and more cost-effective by evaluating and testing the efficacy of new tools and processes as well as creating replicable models that can be taught and disseminated easily. Through its Silverman Institute for Health Care Quality and Safety, which acts as the coordinating hub for accelerating innovation in this area, BIDMC has launched medical center—wide quality and safety initiatives that have won national acclaim and numerous awards.
The articles below highlight a variety of pilot projects at BIDMC that are poised to dramatically change how we deliver health are to patients, from creatively applying new technologies to expanding the definition of care to include concepts like dignity and respect. While our clinicians have no shortage of imaginative ideas, none of these projects would ever have gotten off the ground without philanthropy, be it seed funding for a specific initiative or unrestricted funding that gives the medical center the flexibility to support original thinking. “We need to continue to be the best medical center on a national stage,” says Kenneth Sands, M.D., M.P.H., senior vice president of health care quality and safety at BIDMC, “and that involves not only being comfortable with continuously changing and continuously innovating but also requires the resources to support ideas that might be a little out of the box and allow them to grow into something that might actually produce dramatic results.”
To learn more about our innovative efforts in improving health care delivery and how you can support our work in this area, please contact the Office of Development at (617) 667-7330 or firstname.lastname@example.org. To make a gift, visit www.bidmc.org/give-now and note the name of the program.
Ready, Willing, and Able
Silence may be golden, but it can also be easily misread. Consequently, many Americans spend the final days of their lives in ways they would never choose. “None of us likes to think about getting sick, let alone the possibility that things might not get better,” says Lauge Sokol-Hessner, M.D., a BIDMC hospitalist and associate director of inpatient quality. “It’s hard to talk about serious illness so I think we tend to avoid it. But having a few conversations can make a big difference in our ability to treat people the way that they want. Without these conversations, we’re just guessing about what matters most to them.”
Sokol-Hessner is leading an inspiring effort at BIDMC, called Conversation Ready, to take the guesswork out of end-of-life preferences. The initiative is an offshoot of The Conversation Project, founded by Pulitzer Prize—winning journalist Ellen Goodman, which encourages patients and families to talk about their hopes and fears regarding end-of-life medical care. However, The Conversation Project realized that to make the most of these conversations, the party on the receiving end must be prepared to hear them—and it became clear that many health care organizations have no systems in place to adequately capture and later access the results of these discussions even if they do take place. With historical strengths in palliative care and information technology, BIDMC stepped up to become one of 10 national “pioneers” working with the Institute for Healthcare Improvement to develop and pilot new strategies to ensure that their organizations are ready to respond appropriately to these conversations and then ultimately disseminate these tools throughout the health care industry.
As team leader for Conversation Ready, Sokol-Hessner describes the process of becoming prepared in terms of the Four Rs. “We want to reach out to our patients,” he says, “and ask who is it that speaks for them if they can’t speak for themselves, communicate proactively about their medical condition, and understand what is most important to them should they get sicker. We want to record this information in the medical record in such a way that it is available to future providers so that they can reliably retrieve it and thereby do a better job of respecting our patients’ wishes whatever those wishes may be.” He stresses that this endeavor is not about limiting patients’ access to care or life-sustaining treatments; instead, it is about treating them with respect and dignity by honoring their preferences. For some patients that may mean more life-sustaining care, even if that decreases their quality of life; for others it may mean less life-sustaining care in order to maximize quality of life. “For patients with serious illness or near the end of life, it is critical that we reliably perform the Four Rs of advance care planning,” says Sokol-Hessner. “Everyone should have the opportunity to complete their life in the way that matters most to them, and we only have one chance to get it right.”
To get more information about the Conversation Ready project and end-of-life care at BIDMC, please visit www.bidmc.org/conversationready.
Psychiatrists and other mental health clinicians typically record and share their clinical impressions and assessments with their patients as part of the evaluation and treatment process. But what if patients were actually able to access and read the notes entered into their medical records? Would it enhance the clinical experience through improved accuracy and more meaningful exchange? Or would it lead to misinterpretation and confusion? These are the questions posed by a unique pilot project at BIDMC, which allows patients to view the notes mental health professionals write up after a clinical visit on the hospital’s secure online patient portal. “We’re among the first to explore the idea of making psychiatric visit notes available to patients in the context of the larger OpenNotes project,” says Pamela Peck, Psy.D., clinical director of the Department of Psychiatry and director of the pilot, which currently includes about 500 patients, “and we’re only just beginning to understand its impact on the special collaborative relationship between doctor and patient in this environment.”
Launched in 2010 with a $1.4 million grant from the Robert Wood Johnson Foundation and additional funding from the Drane Family Fund and the Florence and Richard Koplow Charitable Foundation, OpenNotes is a unique multi-institutional initiative working to give patients access to their clinicians’ visit notes more broadly. Spearheaded by two visionary BIDMC researchers, Tom Delbanco, M.D., and Jan Walker, R.N., M.B.A., OpenNotes has attracted national attention for its success in evaluating the impact that such transparency has on the clinician—patient relationship. With their results suggesting that opening up visit notes may improve communication, enhance efficiency, and help patients become more actively engaged in their health, BIDMC Chief of Psychiatry William Greenberg, M.D., became intrigued with the idea and encouraged Peck to explore applying the concept in their department. After a few months of discussion and some start-up funding from the medical center, all the ambulatory psychiatric clinicians agreed to give it a go. “I think the fact that 100 percent of our outpatient team signed on to this project says a lot,” notes Peck. “They appreciated that they had a voice and could be part of the process in developing it. We have such a collaborative culture between our patients and clinicians, it just made sense that we would try it here.”
But applying the OpenNotes model in the mental health setting came with its own unique challenges. “Inviting patients to read what clinicians write about their feelings, thoughts, and behaviors is a bit different than sharing assessments of their hypertension or diabetes,” says Michael Kahn, M.D., a psychiatrist who has worked at BIDMC for 20 years. “We all had some reservations. What if a patient misinterpreted a note? Would they get upset about it? Would it cause anxiety or confusion?’’ While it’s still early, their experiences with the pilot suggest this type of transparency allows patients to address their mental health issues more actively by allowing for clarification and richer dialogue. It might also reduce the stigma they experience as they learn their therapist views them as a person and not a collection of symptoms. Admittedly, this process may require modifying how the notes are written, balancing medical terminology with descriptive language to humanize them. But Kahn sees this change as an opportunity. “As we become accustomed to documenting our clinical findings in ways that our patients find meaningful and useful,” he says, “we may find ourselves more closely aligned to our patients’ experience. And isn’t that just where we’d want to be?”
No Going Back
Regardless of how positive a hospital inpatient experience might be, once discharged, no one ever wants to go back without good cause. Yet one in five elderly patients ends up right back in the hospital within 30 days of leaving. Many of these readmissions are preventable, the result of a fragmented system of care that leaves patients without the support structures and follow up they need once they’re home. BIDMC has been on a mission to change this precarious—and costly—situation, and in 2012 received a $4.9 million innovations grant from the Centers for Medicare and Medicaid Innovation (CMMI) to support its Post-Acute Care Transitions (PACT) program, aimed at preventing this “revolving door syndrome” in Medicare patients. “What we’ve been learning in PACT is that there are a lot of places where there are gaps in our system of care,” says Sarah Moravick, M.B.A, interim director of process improvement at BIDMC, “and we’ve used the program to start to bridge some of those gaps with nurses and pharmacists. But I think we see a lot of opportunities to better utilize resources in new ways. We’ve really been trying to think innovatively about where that capacity might be and how we can use that capacity more actively. So the paramedics are a great example.”
The paramedics to which Moravick refers are part of a new pilot project in the PACT program, which is designed to provide extra clinical evaluation and treatment in the home so a situation doesn’t necessarily escalate to the point of rehospitalization. In the current PACT model, nurses and pharmacists serve as “care transition specialists,” initiating relationships with patients in the hospital and then calling them after discharge to monitor their health status and coordinate their often-dynamic care plans among various providers. As the program developed, however, these specialists found that when they got their patients on the phone, they often had unanticipated medical issues that warranted timely, in-person evaluation. For this fragile, elderly patient population getting to their primary care doctor or an urgent care clinic on the fly may not be so simple, which left the PACT team with the pressing question of who might get them the interim treatment they so clearly needed.
The answer, they found, was off-duty paramedics. “We wanted to choose people who really understood the prevention aspect of our program and who were committed to keeping people safe in their homes,” says Moravick. “Many of the community paramedics we interviewed said they would go to these homes and see patients who don’t really need to come to the emergency department but that’s their only option. So they were motivated by the potential of finding another solution that keeps patients healthy and safe without transporting them.” Thus, the Paramedicine Pilot was born. Now when the care transition specialists reach patients who need extra in-person attention they can deploy an experienced paramedic in a specially equipped SmartCare van to their homes. While it’s still in the very early stages of testing, the PACT team is excited about the pilot’s prospects to improve care and prevent readmissions among these high-risk patients. But because the initial CMMI grant does not cover the pursuit of additional creative ideas like this one, without a grant from the Lowenstein Foundation and investment of both funding and staffing from Cataldo Ambulance, this project never would have gotten off the ground. “Every day I think I hear about a hundred new ideas,” says Moravick, “and the culture here is very much tasked to try and to learn. And I think the willingness of funders like the Lowenstein Foundation and Cataldo to engage with us in that testing and learning portion is really valuable in innovating and being at the forefront of these efforts.”
Wouldn’t it be nice to be able to predict the future to prepare for when things go wrong or avoid those situations altogether? In a hospital setting, this prophetic skill would be particularly advantageous, where “going wrong” can be a matter of life or death. At BIDMC, clinician—researchers are building their own kind of crystal ball for the intensive care units (ICUs) to foresee which patients will eventually develop dangerous complications like infections, blood clots, or bleeds. “The idea is to develop a computer application that constantly pulls information from the various databases in the hospital, analyzes them, and then projects in real time to everybody working in the ICU, hey, we’re tipping into an unstable situation,” says Daniel Talmor, M.D., acting chair of the Department of Anesthesia, Critical Care, and Pain Medicine. “And while ultimately we want to determine what the specific interventions might be, we think that just letting people know that the risk state is high will probably influence the outcome for the better.”
Led by Talmor and Pat Folcarelli, R.N., Ph.D., director of patient safety, the Risky States project is one of several funded through a recent $5.4 million grant from the Gordon and Betty Moore Foundation aimed at developing a host of innovations to improve health care quality and patient safety in the ICU. The innovation aspect has been critical in building a risk predictor because traditionally visualizing future outcomes was based on gut instinct and an amalgam of experience, something not simple to replicate. “If you ask experienced ICU nurses, they sort of know somewhere in their spinal cord that things are becoming dangerous, but they don’t have objective information to back that up,” says Talmor. “So we’re putting an objective measure around this—something that’s actionable with targets that can actually be used to change that risky state.”
To create these targets, the multidisciplinary team is taking an entirely new, forest-over-trees approach to analyzing risk. Instead of focusing on individual drivers for specific harms in the ICU, like the cause of a stomach bleed or a case of pneumonia, they are taking into account the total universe of complications on the unit to come up with more broad environmental indicators that something bad will happen later on, everything from the rate of admissions to the number of nurses on a shift. “So it’s looking at the safety of the factory floor instead of looking at if somebody screwed the widget in wrong to make sure that negative outcome doesn’t happen,” says Talmor. “It’s a concept borrowed from industrial engineering and systems design, and we’re working very closely with collaborators at the Massachusetts Institute of Technology, who are helping us develop these models.”
Inspirational science aside, what really intrigues Talmor is that, with additional philanthropic funding, opportunities abound to broaden the project’s scope—and ultimately make BIDMC and other medical institutions safer places. “What we like about it—well, we like everything about it—but what’s also cool about it is that we’re applying this to the ICU floor, but the same concepts could be applied to any work environment in the hospital,” he says. “So they could be applied to the operating room, the emergency room, the regular patient ward, the hospital as a whole. And that’s exciting.”