March 2018
This week’s Magnet site visit has been truly invigorating, with many opportunities to reflect on what makes the Brigham so special.

For me, it’s two things: our mission – the desire to improve the lives of our patients and the health of people around the globe – and the individuals who bring it to life in countless ways every day. The seemingly small gestures, such as a cook setting aside French toast for a pediatric cancer patient each morning, as featured in the Brigham Way, make an enormous difference and are deeply appreciated by our patients and their loved ones.

On a larger scale, a number of our physicians and staff are working to raise awareness of gun violence as a public health crisis and to identify what we can do, as shared in Mission Moment. We also are part of a new citywide initiative to support individuals and communities affected by community violence, featured in Inclusion Imperative.

We are always working to improve access to care, and the establishment of the Bridge Clinic will do just that for those suffering from substance use disorder, as you’ll read in Strategy Skim.

I know the past month has not been without its share of operational challenges, including the national shortage of IV fluids and certain injectable opioids as well as the recent series of winter storms. I am deeply grateful for your work each day to ensure our patients receive the best possible care, despite the challenges.

Dedication, compassion, resilience and leadership – these qualities not only make us a Magnet-worthy institution, but they also embody the Brigham Way.  
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Strategy Skim: A Bridge to Healing and Recovery

Imagine that a patient came to the Emergency Department (ED) after experiencing a heart attack or stroke and, after receiving treatment, they were simply handed a list of phone numbers at discharge for local clinics that may not even be accepting new patients.

It’s unthinkable – and yet it illustrates how follow-up care for patients with substance use disorder, a life-threatening disease often accompanied by complex co-morbidities, has traditionally been managed by hospitals across the country.

Thanks to the thoughtful work of a multidisciplinary team, we have taken a significant step toward enhancing and expanding access to addiction treatment. The Brigham Health Bridge to Recovery – also known as the Bridge Clinic – opens its doors on the first floor of the Tower this month.

Developed in alignment with our Medicaid Accountable Care Organization (ACO) program, the clinic, an outpatient service in the Department of Psychiatry, will initially focus on patients discharged from our inpatient units or ED seeking treatment for a substance use disorder. Services include access to pharmacotherapy, individual and group counseling, case management and peer support. The team plans to soon expand these crucial services to patients in our primary care and specialty practices. The clinic will also become a hub for novel clinical trials and training opportunities in addiction medicine. 

True to its name, the Bridge Clinic serves as the “bridge” to timely, on-site treatment until access to a long-term recovery program can be secured, according to Christin Price, MD, the clinic’s program administrative director.

“The transition period from acute care to follow-up treatment is extremely fragile,” notes Joji Suzuki, MD, director of our Division of Addiction Psychiatry. “It is really hard for these patients to succeed without immediate, reliable support.”

While the opioid crisis did not create today’s challenges around timely access to addiction treatment, the scale of the epidemic exposed these deficiencies in a dramatic way. The Bridge Clinic is one of many ways we are innovating to ensure we provide each patient with the highest-quality care.
 

Focus on Financials: Planning for Today, Tomorrow and Beyond

Brigham Health continued to achieve strong financial performance in February, providing us the opportunity to plan for our future.

In January, we implemented a rolling forecast methodology, which will replace our traditional budget approach. In this ever-evolving health care landscape, we require a more dynamic way to prepare for the future and adapt to unforeseen events. By embracing continuous planning or “rolling forecasts,” we can develop valid, timely and relevant insights into risks and opportunities, while remaining nimble and focused in meeting our financial goals. These techniques will help us anticipate and mitigate changes to our forecasts.

Our continuous planning process will involve quarterly projections of our expected performance based on actual results and projected outcomes over an 18-month period. Year to date, we are ahead of budget and now, based on this new process, we are forecasting a year-end margin projection of $210 million; our original budget projected a $185 million margin. It is important to understand that the favorability experienced through February may not be as significant by year-end because of revenue shortfalls due to a variety of factors, such as volume risk and unfavorable service mix (medical volume being higher, surgical volume lower); levies associated with the recent tax reform legislation that may cost Brigham Health millions per year; and the shortage in availability of IV opioid medications, which will increase pharmaceutical costs. 

It is imperative that we continue to effectively manage our valuable assets. We must do all that we can with careful planning to meet our forecasted operating margin of $210 million, which will now be updated each quarter. By being good stewards of our available resources, we will be able to invest in our precious mission for generations to come.

February’s Key Performance Indicators
  • Brigham Health month-to-date income from operations was $9.9 million. 
  • Through the first five months of the fiscal year, income from operations was $98.1 million.
  • Year-to-date Net Patient Service Revenue has grown 8.8 percent from FY17. 
  • Inpatient discharges increased by 1.7 percent, while the Med/Surg average daily census increased 3.3 percent. 
  • Outpatient revenue has also been strong, with imaging (MRI/CT), labs and pharmaceuticals all increasing year over year.  
  • Expenses have grown 3.3 percent year over year. While we are managing our full-time equivalents (FTEs) well, overtime and temporary staff usage has increased year to date due to vacancies.
  • Supply expenses have grown by 9.4 percent as new high-cost medications have come onto the market.
 

The Brigham Way: Sweet Gesture Helps Child Cope with Cancer Treatment

If you asked 2-year-old Charlee Jacques and her mother, Erica Jensen, about the most memorable part of Charlee’s time at the Brigham, they would probably tell you it was the French toast.

For 12 consecutive days last month, Charlee and Erica traveled from their Wilmington home to the hospital for Charlee’s radiation treatments. Erica had promised Charlee a French toast breakfast after each one – the only thing that helped Charlee get through her appointments.

The first day, Erica walked to the Garden Café while Charlee was in treatment and ordered French toast with a side of bacon. The cook, Shon Way, told her that unfortunately there was no French toast left – it’s one of the café’s most popular breakfast items and sometimes sells out early. When Erica explained her daughter’s situation, Shon smiled and asked, “Will gluten-free bread be OK?” Erica said she was sold.

Shon promised Erica that he’d set aside a plate of French toast for Charlee every day and asked his colleagues to do the same on days when he was not working.

On one of the last days of Charlee’s treatments, Erica stopped by the Garden Café with a thank-you note for Shon. She said it was because of him that her daughter would smile each morning.

“Truly, it’s the little things, like holding aside a plate of French toast every day for my Charlee, that made radiation not a bad memory for her,” says Erica. “People like Shon make a difference without even knowing it. We truly were so thankful to meet Shon.”

While Shon and his colleagues serve hundreds of people each morning, he says each of his customers is special.

“I feel as though I am part of every patient’s care team, and being able to put a smile on their face and know I am doing my part to help them feel better means the world to me,” he says.

I was so touched to hear about the way that Shon made this family’s experience at the Brigham positive, despite their difficult situation. Shon is a shining example how each one of us, whether or not we provide direct care to patients, can make their experience at the Brigham a good one. 

If you see someone going above and beyond their responsibilities to help a patient, visitor or colleague, please email TheBrighamWay@partners.org so that we can recognize our staff and learn from their example.
 

Inclusion Imperative: BWHers Respond to Community Violence

When a bullet grazed the head of a 15-year-old boy in Jamaica Plain last summer, Jenny Valdez, a member of BWH’s Violence Intervention and Prevention Program, responded to the scene to support the teen and his family.

Valdez is part of the Jamaica Plain Neighborhood Trauma Team (JPNTT), a city-led initiative created last year to address community violence. With funding from the City of Boston, Partners HealthCare and Boston Children’s Hospital, this interdisciplinary group brings together staff from the Brigham’s Violence Intervention and Prevention Program and community health centers with the Boston Police Department, Jamaica Plain Coalition: Tree of Life/Arbol de Vida and other organizations serving local youth and families.

In the days following the incident, Valdez helped the family gather paperwork and evidence to apply for an emergency housing transfer, arranged behavioral health appointments and coordinated transportation, in addition to offering emotional support via regular communication and home visits.

The JPNTT is part of a citywide trauma team network tasked with providing response and recovery services to individuals and communities experiencing trauma due to community violence. The JPNTT is activated when a violent incident occurs in the Jamaica Plain neighborhood. In the past year, the team has directly responded to 38 cases, offering ongoing support for the community through healing circles, referrals to care and community-building events.

Today, the JPNTT is still connected to the family of the 15-year-old boy who was shot last summer, with the mother keeping the team updated about her family’s progress.

Anyone who has experienced community violence in Boston can call the citywide trauma hotline at 617-431-0125. 
 

Safety Matters: BWH Improves Quality Ratings

Quality and safety are always top priorities for us, and we recently saw this commitment validated with improved ratings in two consumer-focused assessments of hospital quality: the Centers for Medicaid and Medicare Services (CMS) Hospital Star Ratings and the Leapfrog Group Hospital Safety Grades.

BWH’s CMS Hospital Star Rating, which is calculated from a variety of patient safety and quality measures, increased to four out of five stars. Our improved score reflects the strong efforts across our institution in preventing deep vein thrombosis and catheter-associated urinary tract infections, among other conditions.

In addition, the Leapfrog Hospital Safety Group awarded BWH an “A” rating and named us a Leapfrog Top Teaching Hospital. This grade gives credence to hospital performance in the domains of preventable harm and medical errors. Our focus over the past few years in addressing hospital-acquired conditions, safety events and patient experience has led to significant improvements in our scores for MRSA, C. difficile infection, retained foreign objects, air embolism and communication with patients around prescribed medications. 

While no hospital quality and safety rating system is perfect, it’s heartening to see the improvements we’re making on key metrics. Thank you for your commitment to providing the highest-quality, safest care with an exceptional patient experience. 
 

Breakthrough Briefing: Finding a Critical Blood Pressure Threshold

Many health care professionals subscribe to the conventional thinking that incremental changes in blood pressure are a normal, expected part of aging. But a new study led by cardiologist Susan Cheng, MD, and her colleagues challenges this logic. Published in JAMA Cardiology, their study reports that a systolic blood pressure (the top number in a blood pressure reading) that regularly exceeds 120-125 mmHg could signal impending hypertension, regardless of age. These results lend support to the updated American College of Cardiology and American Heart Association high blood pressure guidelines, published in November, which redefine high blood pressure as greater than 130/80 mmHg (instead of 140/90).

In a longitudinal cohort study of 1,252 participants from the Framingham Heart Study, Dr. Cheng and her colleagues collected data about patients who developed hypertension in their 40s, 50s, 60s or 70s. The research team found that pressure trajectories leading up to the onset of hypertension appeared to follow a similar pattern. Blood pressure levels were generally stable until they approached the range of 120-125 mmHg, above which blood pressure rose rapidly and into the range of hypertension.

Dr. Cheng and her team are working tirelessly to unravel the sequence of events and changes that occur in the body before the onset of hypertension and to identify a tipping point at which hypertension begins to develop. Their work has the potential to help clinicians determine which patients are at high risk, intervene early and help save patients’ lives or spare them from complications associated with hypertension. I applaud their innovative, rigorous approach and look forward to their continued insights that could help us prevent the progress of cardiovascular disease.
 

News of Note: Lessons from Axolotls

Imagine having the power to regenerate tissue or regrow a limb. The axolotl – a salamander native to Mexico – possesses this remarkable ability, and researchers like BWH’s Jessica Whited, PhD, are studying these creatures to understand why, and translate those discoveries into hope for trauma patients.

Nova Next recently featured Dr. Whited in a story that brings the reader from the outskirts of Mexico City into Dr. Whited’s office here at the Brigham, where she shares her motivation for studying axolotl tissue regeneration and her passion for discovery.
 

Mission Moment: ‘Broken Hearts and Opened Eyes’

Why does it take mass shootings to move our collective outrage?

Our own Associate Chief Medical Officer Charles Morris, MD, MPH, and Jonathan B. Miller, JD, of the Office of the Attorney General in Massachusetts, pose this question in a New England Journal of Medicine perspective following the horrific school shooting in Parkland, Florida. 

In “Broken Hearts and Opened Eyes,” the authors reflect on the far-reaching and devastating effects of gun violence that occurs on a daily basis in this country and what we as health care providers can do to ignite change.

Clinicians have an important opportunity to engage patients and families in discussions and educate them about firearm safety. Last year, Morris and Miller led a team of researchers, clinicians, public health advocates and law enforcement officials to develop a toolkit that helps clinicians start these conversations and “take part in problem-solving with patients about minimizing exposure to unwanted harms, just as doctors do in countless other contexts.”

Normalizing discussions about gun violence is one component of widespread changes that are needed to prevent it. Morris and Miller conclude their piece by applauding the students of Parkland for using their voices to demand change and, we hope, alter the typical narrative that follows mass shootings. 

I was proud to see many members of our staff supporting the students of Parkland and across the country and raising awareness about gun violence as a public health issue on National School Walk-out Day, March 14, when a crowd of physicians, employees and senior leaders gathered in the Fish Rotunda for Healers Stand Against Gun Violence. In addition, on Saturday, March 24, a Brigham Health contingent joined thousands of people on Boston Common as part of March for Our Lives to speak out against gun violence.

We are all too familiar with the shattering effects of gun violence on individuals, families and communities throughout the nation. Our Brigham family’s commitment to making our country safer for all of us – and for the generations who follow – is inspiring.
 
If you have questions, comments or news to share, don’t hesitate to email me at AskDrNabel@partners.org.
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