Spring/Summer 2002

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Blame It on the System
Mistakes happen. In the case of medical errors,
finger-pointing doesn't solve much.

Peter Pronovost: The death of his father from a hospital error has influenced his whole career in medicine.
Peter Pronovost: 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 United Kingdom.

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 lie.

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 two years.

"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

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First Steps Toward a Spiffed-up Campus

The Broadway 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).
The Broadway 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."


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Meanwhile, 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

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On Rankings

U.S. News & World Report

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.

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Privacy in the Balance

Joanne Pollak with the weighty HIPAA tome.
Joanne Pollak with the weighty HIPAA tome.
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.

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 research."

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."

Patrick Gilbert

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For Katharine Hepburn, It All Began at Johns Hopkins

Katharine Hepburn's mother, Kit Houghton, with Tom Hepburn
Illustration 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."

Jim Duffy

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How Faculty Salaries Stack Up

Do medical faculty salaries at Hopkins compare well with what other institutions pay?

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."


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Anatomy Transformed

Chris Ruff with a few specimens from Anatomy's bone collection.
Chris Ruff with a few specimens from Anatomy's bone collection.
The light-filled 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 mind.

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."


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She Was One Powerful Woman

Artist Brece Honeycutt's sculpture

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 College.

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 through September.


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