Massachusetts General Hospital President Peter L. Slavin sent this memo to his staff after receiving an inspection review that criticized many aspects of the hospital.
To: "All User MGH"
Subject: From the Desktop of Peter L. Slavin, MD
From the Desktop of . . .
Peter L. Slavin, MD
A New Year - And A New Quality and Safety Agenda for the MGH
As I look toward 2007, I know exactly what my new year's resolution for the
MGH will be:
I resolve to do whatever I can to help the MGH set a new and higher standard for quality and safety by finding ways to enhance our environment, systems and processes to ensure that our hospital is an ever-safer place for those receiving care as well as for those delivering and supporting that care.
In truth, this is much more than a resolution for 2007; it is a mandate for the years ahead.
The MGH is embarking upon an intense and multi-dimensional journey toward a new level of quality and safety. And we need to enlist the entire hospital community - without exception - to understand, embrace and accept the charge and challenges that lie before us. It will not be easy. The demands on staff at the MGH are already enormous as we strive to provide outstanding care to the thousands of people who come here seeking answers, expertise, care and hope. We are truly proud that the MGH is a world-class health care resource where highly skilled staff and specialized treatments represent the last and best chance for some. We are proud of our talented caregivers who willingly give their all and do whatever it takes to offer the best care to each patient. We are not satisfied with anything less than the best. Yet to be the best we must also offer the safest care. In this regard, we are not where we want to be. We must do better.
When we sat down with JCAHO surveyors two weeks ago for our closing discussion, we received a wake-up call of sorts. JCAHO surveyors had observed failures on our part to do some basic things. They saw staff who neglected to wash their hands or use Cal Stat before and after patient contact. They discovered certain banned abbreviations in our medical records. They found medical records with entries that had not been dated and timed. They found patient records without evidence of medication reconciliation. They saw procedures, particularly outside of the OR, being done without the universal protocol - "time out." We learned from the JCAHO surveyors that we need to be more consistent in adhering to the systems we have put into place to promote and support patient safety.
Frankly, we should, can and will do better. Our patients and their families deserve nothing less.
On the heels of the JCAHO visit, we sent out a message to staff, reminding everyone of the steps we all must take not simply to respond to the JCAHO team's comments, but to do the right thing for our patients. I want to spell out these steps again here.
- Wash your hands and/or use Cal Stat before and after every contact with patients and equipment - no exceptions;
- Put the date and time of every entry into the clinical record;
- Wear your hospital ID in a visible place at all times when at the MGH or any of its satellites;
- Conduct and document the universal protocol - "time out" - for all procedures in the OR, office, ICUs and other patient care areas;
- Do not use any unapproved - and dangerous - abbreviations in clinical documentation;
- Ensure that every patient has an appropriate and up-to-date history and physical in the chart before any interventional procedure;
- Understand that medication reconciliation is not an option, it is a requirement;
- Document pain assessment, especially after any interventions to control pain;
- Document whether patients have signed an advance directive; and
- Store all medications properly and safely. It is not enough just to offer exceptional care. We must offer exceptional care that is as safe as possible.
With that in mind, we have already taken some important steps to prepare for the work that lies ahead. We have just named Gregg Meyer, MD, as our first senior vice president for Quality and Patient Safety. A national leader in the area of quality and safety, Gregg is now heading our multi-faceted efforts to set forth a vision for what quality and safety at the MGH should be. I am confident that he will help us get to that coveted place.
We also have taken approximately 70 of our clinical and administrative leaders (including all chiefs and vice presidents) to "quality and safety school" - two educational retreats at Harvard Business School. During these retreats we analyzed and discussed cases from within and outside of the health care field to assess and determine how various approaches are being used elsewhere to foster quality and safety. Several new initiatives have already sprung out of these retreats. The first is to redraft the hospital mission statement to reflect a renewed institution-wide quality and safety-centered commitment. We also are developing a credo to spell out the values that guide the work of the MGH, and we are defining boundaries to specify behaviors and actions that will not be accepted or tolerated.
In addition, we are looking to form special groups, called "tiger teams" - a term borrowed from NASA - to focus on specific tasks that need urgent attention.
Tiger teams will be comprised of people from relevant areas who will surround a problem and dissect it from various perspectives, pursuing the best ways to address or resolve the issue at hand. In October we formed our first tiger team to focus on the unsafe situation in the Emergency Department related to overcrowding, back-ups and extended stays. We recognize that this ED problem is really a hospital-wide problem caused to a large degree by high inpatient census and the lack of sufficient inpatient beds. The ED Tiger Team is hard at work, taking a broad look at the many complex factors contributing to the situation.
As part of this process, the chiefs of each clinical service have spent at least four hours in the ED, witnessing the crowded situation firsthand and assessing ways that their clinical service might help alleviate the congestion, enhance the process and improve patient flow. It was an eye-opening and poignant experience for many chiefs, and from it have emerged some promising ideas for improvement.
Using the tiger team approach to converge upon, chase and isolate our most pressing problems and fix them effectively will be important, but we also recognize that it is not enough to simply respond to one issue after another.
Our quality agenda must go far beyond quick fixes. We need to look beyond conventional methods for improving quality and safety and focus on revolutionizing our approach if we are to move ahead to the place we aspire to be. Exactly what this place is and how we will get there remains to be seen. For the time being, we know we want to create a culture of safety at the MGH that everyone understands and embraces. We want the MGH to be a safer place this same time next year and safer still the following year. We want our hospital to be seen as a national leader in quality and safety. But most important, we want to take whatever actions we can as soon as we can to ensure that no patient is harmed, ever.
Best wishes for a happy, healthy, and safe New Year.