It on the System
Mistakes happen. In the case of medical errors,
finger-pointing doesn't solve much.
The death of his father from a hospital error has influenced his whole
career in medicine.
Peter Pronovost has
his reasons for being a zealot about patient safety, and he isn't shy
about sharing them. When Pronovost was in his fourth year of medical school
at Johns Hopkins, his father died as the result of an error made by a
hospital in New England. It colored everything-his choice of careers (critical
care medicine) as well as his research interests.
Since then, the young associate professor has built a reputation around
Hopkins as the person to go to for anything pertaining to patient safety.
The timing of his interests was providential. The convergence of a number
of factors-an eye-opening, national report two years ago on medical errors
in hospitals, a crackdown on hospitals by regulatory agencies, and unquestionably
the death of a research subject at Hopkins in June 2001-propelled safety
to the top of Hopkins' priority list. "It's the No. 1 issue," says Beryl
Rosenstein, the Hospital's vice president for medical affairs.
Pronovost, mind you, doesn't preach perfection. Fallibility is part of
the human condition, he acknowledges, and is not something that can be
changed. But we can change the systems under which people work, he argues,
thereby reducing the risk of errors.
It's a concept that goes against the medical culture, Rosenstein says.
"Physicians and nurses are trained from their earliest days in school
that health professionals don't make mistakes, and if you do, you don't
talk about it."
And so, when Peter Pronovost takes on a unit, he begins by measuring the
"culture of safety," that is to say, he asks pointed questions of the
people who work there. How comfortable are they at disclosing errors?
Do they ever make mistakes?
The medical-error problem is huge, and it is global, Pronovost tells them.
In the United States alone, 7 percent of patients in academic medical
centers experience a mistake with their medication resulting in up to
98,000 deaths a year. Those numbers are mirrored in Australia and the
Once a staff has drawn up a list of concerns about the unit, they are
assigned a Hopkins leader who conducts executive walk rounds each month.
The executives, who include Dean Miller, JHU President William Brody and
Hospital President Ron Peterson, get to see first-hand where the problems
One memorable example of the effect this can have involved the intensive
care units, which the safety program targeted first, because errors there
have a higher probability of being life-threatening. During rounds, the
potential danger of having inadequately trained employees transport very
sick, ICU patients around the hospital for tests came through loud and
clear. What if the intern accompanying Mr. X to his MRI wasn't familiar
with the dosages of medication this patient was being infused with to
control his heart rate? Here was a safety issue, and the nurses knew it.
They'd been asking for a transport team-the breed of ICU nurses specially
trained to do just this sort of job during interhospital transport-for
"The next morning," says Pronovost, "the transport team started.
I don't know where the money came from, but the good will that generated
was tremendous." The transport team is now available to all the ICUs.
Despite the inevitable extra work it causes, the safety program has been
much more enthusiastically received than other programs of its ilk. "This
isn't about an administrative thing, there are no hidden agendas," says
Pronovost. "This is, patients shouldn't be harmed. And that makes people
feel good, because it's what we all went into health care for."
Mary Ellen Miller
Steps Toward a Spiffed-up Campus
Research Building takes shape. When it opens next year, it will provide
380,000 square feet of new space, including a state-of-the-art mouse
facility and a home for the Institute of Cellular Engineering (ICE).
Time and events change
how we see the future. And so it's been for Johns Hopkins Medicine. In
the nearly 10 years since Hopkins Hospital drew up its last master plan,
managed care has shaken up the health care industry, nearby Church Hospital
has closed its doors, Hopkins bought that property and swapped it with
the city for an eight-acre adjacent parcel of land fronting on Orleans
Street, and now Baltimore's mayor is proposing to erect a biotech park
just north of the medical center. By late last year, it was clear it was
time for a new master plan that would encompass the entire campus.
To shape the project, the Hospital along with the Schools of Medicine,
Nursing and Public Health and the Kennedy-Krieger Institute called in
the New York-based architecture and urban design firm Cooper, Robertson
& Partners, which has done work for medical campuses like Duke, Yale,
Columbia-Presbyterian and Texas Medical Center.
David McGregor, managing director at Cooper, Robertson, caught his first
glimpse of Hopkins from his train window in a cab from Penn Station. "You're
down in this valley," says McGregor, pointing out that there's a
20-foot difference in grade from Monument to Madison streets, and another
20 feet from Madison Street to Ashland Avenue. "You're looking straight
up the hill and there's this thing up there."
His first impression?
Forbidding, he admits.
He also was struck by how densely the campus is built ("There is
no relief") and by the aging inpatient facilities. "Medicine
is new, it's changing," McGregor says. After interviewing more than
120 faculty and staff members, he is convinced that all patient rooms
should be private, and big enough to bring more equipment to the bedside
or for family members to stay overnight.
Modernizing the clinical space is a priority, according to Sally MacConnell,
the Hospital's vice president for facilities. Plans for two new patient
buildings-the children's and maternal facility and the adult bed tower,
which will connect with the cancer center and back into the rest of the
Hospital-haven't changed appreciably from the master plan of the early
1990s. MacConnell anticipates that both buildings will be complete "well
within the next decade," although they are largely dependent on philanthropy.
Plans for expanded laboratory space are more fluid, given the breakneck
pace at which research is growing. A replacement for the Preclinical Teaching
Building also is being planned that would remain geographically close
to the basic sciences. "We've tried to identify a number of places
where research could go that are close to where it's going on now,"
says McGregor. His firm will supply Hopkins with a budget and plan looking
out 25 years and also an analysis of what could get done when.
Meanwhile, support services-an additional power plant, garage, loading
docks-will be clustered together on the eight-acre site on Orleans Street.
There was a conscious decision not to erect any major clinical, research
or educational facilities there. "The most important resource we
have here is people's time," says McGregor, "so you have to
bring the (similar) facilities as close together as possible."
From the eight acres will arise a parking garage (to replace the one that
will come down when the new clinical buildings go up) and a patient and
family residence where people visiting the Cancer Center can stay. There's
also talk of putting a new kitchen there, where patient meals would be
cooked and chilled, then be delivered and heated right on the units. The
site also might include residential buildings for medicine, nursing and
public health students.
"A lot of things you can't do until you do something else,"
explains McGregor. "For example, you can't empty the Jefferson Street
(old Oncology) Building-where the adult bed tower will go-until at least
the Broadway Research Building is opened.
"We know we don't need the new buildings plus all of the old buildings,"
MacConnell says, "nor can we afford, quite frankly, to occupy and
operate all that square footage." Therefore, selective demolition
of the older buildings along Monument Street may be in the future. The
result would be open, green space. "I know people work hard here.
I've seen that," McGregor says. "But you also need three minutes
a day sitting under a tree."
Up the Block
Neighborhoods in old American cities like Baltimore can die over time.
And then after 50 years or so, astonishingly, they can rise again in entirely
unforeseen reincarnations. Who would have thought, for example, that Harborplace,
with all its shops and eating places, would emerge out of the rotting
wharves and rusting barges that listed along Baltimore's southern shores
in the 1950s?
And now, if a group of civic leaders has its way, something no less miraculous
will materialize right here in East Baltimore. Last April, the city announced
plans to redevelop an 80-acre parcel of land just to the north of the
Hopkins medical complex in a blighted area known as Middle East. The $200
million project calls for hundreds of new and rehabilitated housing units,
all anchored by a 22-acre biotechnology research park.
More than half the properties in the space targeted for redevelopment
already are vacant. An estimated 300 homeowners who will be displaced
will be compensated for their homes and receive generous cash incentives
to stay in the area. The redevelopment plan guarantees minority participation
in all contracts and aims to attract and foster minority-owned, start-up
companies and retail businesses. With 2 million square feet of space for
emerging biological research and small-scale manufacturing companies,
the biotech park could provide 8,000 jobs.
Although Maryland boasts nearly 300 biotechnology companies, attracting
sufficient venture capital for such enterprises has so far not been this
region's strong suit. The park's connection to Hopkins, which has committed
to leasing up to 30,000 square feet of lab space (worth about $1 million
a year) for 10 years, may prove key in attracting investment.
Baltimore Mayor Martin O'Malley has hailed the project as a chance "to
move past the distrust and stagnation of the past and embrace the possibilities
of the future. This effort is not going to be a sad chapter of urban renewal,"
he promised. "We have the opportunity here to rebuild a neighborhood
from the ground up."
Anne Bennett Swingle
The Johns Hopkins Hospital continues to lead U.S. News & World
Report's list of top hospitals. For the 12th year in a row, Hopkins
placed #1 in the magazine's Best Hospitals issue, out each July. Meanwhile,
in that same magazine's spring ranking of the nation's medical schools,
the School of Medicine once more took the runner-up spot. As far as USN&WR
was concerned, it was Harvard then Hopkins, just as it's been ever since
those rankings began.
in the Balance
Joanne Pollak spent her Christmas holiday last year curled up at home
with a weighty volume put out by the U.S. government. Some of what the
general counsel for Johns Hopkins Medicine read caused her alarm.
Pollak with the weighty HIPAA tome.
The compendium Pollak was going through contained the proposed patient-privacy
regulations for the federal Health Insurance Portability and Accountability
Act (HIPAA). And deep inside page after page, she found directives that
would make it nearly impossible for academic medical centers to keep on
doing such basic activities as clinical research and fund raising. Today,
Pollak is one of a band of medical center administrators who helped persuade
the government to rethink some of these policies.
Congress passed HIPAA in 1996 to ensure that employees could "carry
with them" their health care coverage from one employer to the next.
It fell to the Department of Health and Human Services to address the
privacy issues that would occur when a patient's medical information was
electronically transferred among health plans, doctors and employers.
HHS laid out a series of regulations. Even a patient's name, age, address,
Social Security number or date of treatment became restricted material.
The new rules went so far as to decree that if someone called from home
to make an appointment with a physician, no discussion of the patient's
problem could take place until a signed privacy consent form had been
delivered to the health care center.
Especially troubling to academic medical centers were the way the proposed
rules would affect research: one regulation required several lengthy,
separate authorizations to be signed before an individual's information
could be used in a research trial-even if the person had already consented
to be in the trial.
And fund raising: in asking grateful patients to support medical programs
or research for a disease they had been treated for, the proposed rules
forbade any mention of the physician or medical service the patient had
been involved with unless a lengthy authorization had been signed beforehand.
Pollak, who's a firm believer in patient privacy, was equally convinced
the rules went too far. Of the proposed stipulations for fund raising,
she says, "It's the service or the physician that patients are grateful
to. This is how Hopkins raises almost all of its funds to support important
To try to soften the privacy requirements, Pollak testified before the
committee that advises HHS on such regulations and enlisted the support
of large groups like the Association of American Medical Colleges in connection
with revising some of the proposed rules.
"We learned that no one had a full understanding of the impact these
privacy regulations could have on academic medical centers," Pollak
says. "By pooling our concerns, we got the message out. But it wasn't
until Hopkins pushed on the issues related to fund raising that other
organizations finally recognized that we were on to something."
On Aug. 14, HHS published its final guidelines. Included were amendments
to its most restrictive rules, several of which had been recommended by
Hopkins: eliminating the prior consent requirement, permitting the privacy
authorization and the research consent to be combined and eliminating
onerous recordkeeping requirements for research.
But the fund-raising issues still haven't been addressed. That step, administrators
hope, will come in a second round of revisions, to be discussed during
the next 12 months. One thing's clear, though: Pollak's made an impact.
Notes Tom Etten, Hopkins' chief Washington lobbyist: "Through Joanne's
doggedness on HIPAA, she corralled people's attention across the country
and got them engaged."
Katharine Hepburn, It All Began at Johns Hopkins
by Tom Chalkey
Long before Katharine Hepburn starred in "The Philadelphia Story,"
her parents starred in a romance-their own. It was set in Baltimore, at
Hopkins in fact, and began one day in 1903 with a friendly fencing match
between students at the School of Medicine. Afterward, Tom Hepburn of
the class of '05 saw his classmate Edith Houghton home to a St. Paul St.
building, where she shared an apartment with her sister Kit. Kit Houghton
took one look at her sister's brawny, red-headed friend and fell into
a swoon. "He's the most beautiful creature I've ever seen,"
she's reported to have announced.
Tom was slow to catch on. During a series of afternoon teas with Kit and
walks in the park over the next few months, he never even hinted at romantic
intentions. "He's more of a sitter," Kit once complained, "than
a suitor." But Tom finally did pick up on the cues, and the two were
married in 1904. After graduating from the School of Medicine the following
year, he accepted an internship at Hartford Hospital, and ran a practice
there for the next five decades. (At the time, Hartford was the wealthiest
city in the nation.) Along the way, he became Connecticut's first urologist.
Kit, meanwhile, in what spare time she had while raising six children,
dedicated herself passionately to supporting the causes of women's suffrage
and reproductive rights.
By 1930, Tom and Kit's daughter Katharine was in her early 20s and announced
her intention to become an actress. Biographies of the great Hepburn recount
that Tom told her, "I'll give you $50 to help pay your expenses for
a couple of weeks until you recover from this madness, but that's the
last penny you'll get from me until you do something respectable."
Katharine, however, persevered, and in the years to come, she never had
one bad word to say about her upbringing. "The single most important
thing anyone needs to know about me," Hepburn once said, "is
that I am totally, completely, the product of two damn fascinating people
who happened to be my parents."
How Faculty Salaries Stack Up
Do medical faculty salaries at Hopkins compare well with what other institutions
The answer, according to a comparison done by the dean's office, is a
qualified yes. Using data supplied by the Association of American Medical
Colleges, the medical school administration compared salaries by rank
and degree at Hopkins with mean salaries at all 125 medical schools in
the nation, as well as with a group of 20 peer academic medical centers
(places like Harvard, Duke, UCSF and Emory).
Hopkins stacked up reasonably well. Clinical assistant professors here
earn a mean of $108,000, while nationally they earn $92,200 and at peer
institutions it's $87,900. Similarly, a Hopkins associate professor with
a Ph.D. in the basic sciences pulls down $82,200, while counterparts nationally
receive $76,100, and at peer schools, $78,400.
That's the good news. When total compensation (which includes things like
pensions and insurance) is used, the comparison is less favorable, especially
among M.D.s in clinical departments. Hopkins' mean salary for clinical
assistant professors is $117,400. At all medical schools it's $150,400,
and at peer institutions, $149,800.
Basic-science junior faculty compare better. The mean for a Hopkins assistant
professor stands at $66,600, while at peer schools it's $64,500. Basic-science
full professors at Hopkins, however, earn around $10,000 less than their
counterparts in the peer group.
Janice Clements, vice dean for faculty, admits it's no secret that Hopkins
faculty aren't among the best paid. "In fact," she says, "when
faculty are asked why they chose to come here, salary is usually third
or fourth on their list. It's common knowledge within medical academia
that our faculty are here because of Hopkins' prestige and reputation
for collegiality and research opportunities. So, when they're recruited
away, other institutions have to pay more to get them."
corner suite the Anatomy faculty now calls home, complete with labs, offices
and study space for grad students, is a far cry from the crowded, ground-level
corridor in the Physiology Building, where this group once toiled. But
that was back in the bad old days when Anatomy was part and parcel of
the Department of Cell Biology and Anatomy. Back then, the anatomists,
most of whom at Hopkins are trained as paleontologists, worked in converted
cell biology wet labs that were never built with anatomical research in
Ruff with a few specimens from Anatomy's bone collection.
Then, a few years ago, a search for a new director of the joint department
ended up with Cell Biology deciding to go it alone. But where to put Anatomy?
In an increasingly cellular and molecular medical school world, says Chris
Ruff, "there's just no natural department for us."
Remaining aligned with the basic sciences was paramount, Ruff says. "After
all, we teach one of the biggest basic science courses in the medical
school." (That would be Human Anatomy, the rite-of-passage course that
year-one students take each fall.) "And they are great teachers," says
Physiology Director Bill Agnew. Plus, says Ruff, the medical school always
should have an entity that contains a certain, time-honored word. And
that, of course, would be "anatomy."
And so, for the moment, after much discussion and soul-searching, Anatomy
has been sent out on its own. No longer a department or even a part of
a department, it has become the grandly named Center for Functional Anatomy
and Evolution. One look at its spacious new quarters and you understand
just how little in common this discipline has with its erstwhile partner,
Cell Biology. The Center's lab benches and pull-out shelves are lined
with bones-long and short, thick and thin. There are paws and jaws, arms
and legs, and hundreds, if not thousands, of teeth-all of which have been
unearthed by the paleontologists in places like the jungles of Costa Rica,
the savannahs of Africa, and the Badlands of Wyoming.
"We're all thrilled at the way everything's evolved," Ruff says.
"For the first time in years, we feel like we know who we are."
Was One Powerful Woman
Mary Elizabeth Garrett used her money to get what she wanted. Late in
the19th century, as the prime mover behind the group called the Women's
Medical School Fund, she established the endowment that allowed Hopkins
to open its medical school on the condition that it admit women. She also
helped endow both Baltimore's Bryn Mawr School for Girls and Bryn Mawr
It was Garrett's spirit of innovation that Washington artist Brece Honeycutt
sought to capture as she set about creating a sculpture for the biennial
outdoor exhibition of large-scale works for the grounds of the Hopkins-owned
Evergreen estate. On seven old-fashioned standing desks made from forged
steel, Honeycutt placed sheets of copper, like pages in a loose-leaf notebook.
There, she etched excerpts from Garrett's papers outlining her plans for
the medical school as well as the names of the people from 15 cities who
donated money, even if only 50 cents, to the Women's Medical School Fund.
The sculpture, which the artist titled "Silence," was on display