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staff, employees and even patients of Children’s Hospital Boston
are used to hearing good news about the hospital. From research
and clinical breakthroughs, to listings among the top pediatric
institutions in the country, positive things always seem to be happening
at Children’s.
So it was with considerable sadness that the Children’s community
reacted to a Department of Public Health (DPH) review, released
late last month, of four patient cases that involved problems with
the hospital’s systems of care. In three of the cases, children
with complex medical conditions died while in the hospital’s care;
in the fourth, the site on which a radiologist was conducting an
interventional procedure was not appropriately marked, but the error
was discovered and the patient was unharmed.
While the problems did not all occur in the same department, the
details of each —as uncovered first in the hospital’s own investigation
and then in the DPH review —revealed problems relating to coordination
of care among clinical services and resident-attending communication.
The hospital’s clinical and administrative leadership responded
quickly and forcefully to the findings of the review, putting together
a far-reaching plan of correction. Implementation of that plan has
already begun. “Children’s must hold itself to a higher standard
since we care for the sickest and most vulnerable patients,” says
James Mandell, MD, president and CEO. “It is not
overstating the importance of this process to say that this is a
watershed event in the history of this hospital, and that we have
an opportunity to make changes that will ultimately improve upon
the great care we provide here every day.”
The proposed changes are extensive, and include developing better
systems of coordination and communication between the various clinical
services involved in the care of patients with complex medical problems.
For example, prior to this review, in some surgical services the
admitting surgeon retained primary oversight of a patient’s care
even while the patient was transferred to the medical/surgical intensive
care unit (MICU). Now, however, that responsibility shifts to the
MICU attending physician when the patient arrives on the ICU.
Another issue raised by the DPH review was the relationship between
attending physicians and residents and fellows. An attending—who
is fully-trained in his or her area of expertise—supervises and
works closely with trainees, who are MDs in various stages of graduate
education. Attending physicians have ultimate responsibility for
their patients. This dynamic is the backbone of the academic medicine
system; it encourages the rigorous scientific and medical questioning
necessary to solve the most complex and least common disorders,
and is what makes teaching hospitals like Children’s unique.
“This
is a watershed event in the history of this hospital, and
we have an opportunity to make changes that will ultimately
improve the care we provide here.”
—James Mandell, MD
President and CEO
Children’s Hospital Boston
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Yet in today’s world, where the level of care has become increasingly
complex, the system can only work if attendings encourage feedback
and input from trainees. Likewise, trainees must feel comfortable
seeking advice, help or outside intervention for any medical questions
that arise.
To achieve a consistent approach between departments and encourage
better communication, several actions have been taken. First, all
faculty have signed an attestation that spells out their roles and
responsibilities and provides specific examples of when their expertise
should be sought. They must also communicate these expectations
to the residents and fellows under their supervision. In addition,
regular surveys will be conducted with trainees in various departments
asking about their comfort level in requesting support.
The hospital also has created the role of Ombudsman, a person who
will be available to address individual concerns and work with leadership
around issues of communication. Associate Psychiatrist-in-Chief
David
DeMaso, MD, has accepted this role on an interim basis.
Children’s plan of correction has been accepted by the DPH and
the Center for Medicare and Medicaid Services (CMS), and reviewers
from those agencies recently were back at Children’s to examine
the hospital’s compliance with other regulatory standards. Clinical,
administrative and support staff spent four days touring reviewers
around the institution, providing documentation and answering questions.
The hospital now awaits a detailed report from the site visit. Based
on this, more changes may be required to address any issues raised.
At some point, the DPH/CMS team is expected to make a follow-up
visit to ensure the hospital’s compliance with its plan of correction.
“These surveys require a tremendous amount of time, resources and
teamwork,” says Sandra Fenwick, chief operating
officer. “It’s very impressive to see all the members of the team
perform their respective roles with responsiveness and professionalism.”
James Conway, who worked at Children’s for 27 years before becoming
the chief operating officer of Dana-Farber Cancer Institute (DFCI),
helped lead DFCI through the death of a patient from a chemotherapy
overdose in 1994. “Children’s, Dana-Farber, and probably every hospital
in the country carry the burden that their systems have sometimes
failed and led to suffering,” he says. “We distinguish ourselves
in the midst of this sorrow by our openness with patients and family
members, by our support of staff, and by our vigilance and responsibility
to prevent similar tragedies.”—MC
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