13.3.13

REALIZING THE PROMISE

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Realizing the Promise
By Mat Edelson

On the evening of April 12th, the Mayor of New York stood before more than 1,400 dignitaries, donors, and doctors. They had all gathered for the dedication of The Charlotte R. Bloomberg Children’s Center, and His Honor, Charlotte’s son, Michael Bloomberg, was in fine form. In tones both hopeful and bar-setting, Bloomberg spoke of the promise of the impressive new 12-story edifice. “If this center will bring the youngest and most vulnerable patients the kind of care and comfort that they need; if it will increase the knowledge and experience of the greatest doctors and teachers; if it will inspire other institutions to do more and do better,” said Bloomberg, “then we all will be happy.” So what will it take to make all those ‘ifs’ go away? And how far can a new Children’s Center take Hopkins down that path?
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Consider what may eventually be called, simply, The Choice. When the history of this clinical building is written in a few generations, of all the decisions which will have woven its hopefully successful tale, perhaps none will have been more critical than the judgment to integrate the new children’s hospital into the existing East Baltimore campus.
            The choice of whether to go freestanding or remain physically part of the medical community was a matter of lengthy debate. According to Johns Hopkins Children’s Center Director George Dover, several off-campus sites were on the table, including a potential “Super Center” that would have combined the institutional knowledge and experience of both Hopkins and the University of Maryland in a central downtown location.
            Dover well understood the allure and prestige of a move to a freestanding structure. He notes that many of the country’s finest care centers for children have stand-alone status, including Children’s Hospital of Philadelphia (CHOP), D.C.’s Children’s National Medical Center, and Wilmington’s (DE) Nemours/DuPont Hospital for Children.
            Dover could have pushed in that direction, but feared that achieving breakaway status would negatively impact the kind of visionary medicine he felt bore the Hopkins stamp. In Dover’s mind, it came down to a single priority: Be the best, or be the biggest. From that vantage point, the call practically made itself. “We never designed this place to be the biggest,” says Dover. “In fact, the number of beds in this building is smaller than D.C. Children’s, CHOP, and DuPont, our major competitors. We didn’t even try to get where they were.”
            Dover says limiting size directly affects quality of care, both now and in the future. Pushing up the bed count strictly to pump up the volume of patients could, in Dover’s opinion, fundamentally alter the Children’s Center’s century-old mission. “If we hired faculty to serve those additional beds, and they were working 100 percent of the time, clinically, they wouldn’t be innovating. They’d just be keeping up with the clinical demands," Dover says. "We still want to hire physicians who can do research and clinical work, but if we grow too big, our faculty won't have the time to do both."
            To Dover, freestanding status would have limited the fertile ground for seeding such breakthroughs, the research equivalent of moving from a beautiful botanical garden to a rooftop herbal planter. Dover cites the thoughts of the last Children’s Center director who opened a new hospital, Robert Cooke. In 1964 Cooke, in his dedication speech, worried that moving into the larger CMSC could trigger rapid growth, create silos, and weaken pediatrics’ long-standing reputation for collegiality with their adult medicine counterparts. “(Cooke said) that the culture depended upon people being close to each other, bumping into each other,” to create and nurture ideas, says Dover. “That without this closeness, the ‘aura’ around pediatrics could be threatened.” That concern resonated a half-century later as Dover contemplated the center’s path. He decided to stay on the road well-traveled.
            “The most important structural thing that will allow us to continue to innovate is being connected to the rest of the hospital,” he says. “Those eight stories that bridge the children’s tower and the adult tower; the fact we’re sitting on the same parcel as the Dome, across the street from the School of Public Health, down the block from the basic sciences and the School of Medicine, across the street from the new Armstrong Education building, and the fact that we stayed in this environment is the major thing that will allow us to innovate. Sometimes it’s not what you do that’s important, but what you don’t do.”
            This continuing connection and sharing with adult medicine can be seen literally at the new hospital’s front door, where the Pediatric and Adult Emergency Departments stand side-by-side. But there’s more than symbolism at work here; there’s a direct benefit to pediatric emergency cases.
            “We put CT scanners, MRIs, and trauma bays between the Adult ED and the pediatric unit,” says Dover. “We don’t have enough patients coming solely to the pediatric unit to justify that, but when you combine the adult patients and pediatric patients it makes sense. So we can actually take some of the present technology and bring it closer to the bedside because we’re willing to share it with our adult colleagues.”
            The structure also offers a unification of sorts, which could well amp-up synergies between pediatric specialties. Between the modern David M. Rubenstein Child Health Building, opened in 2006, and the bridge-connected Bloomberg Children’s Center, nearly all of pediatric clinical services have been joined together, or as Dover puts it, consolidated in a more focused fashion. “When you decide to build a building across the street exclusively for pediatric outpatients (Rubenstein), when you decide to build a tower exclusively for pediatric inpatients, one of the things you do is bring the pediatric community even closer together," Dover says. "Giving a sense of identity to pediatrics which will attract all these wonderful people into our building is a great idea, and because we’re so close to the adult side, we’re not separating ourselves. Once we made that choice, we began to see the opportunity to do some remarkable things.”

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In 2001, just as plans for the new Children’s Center were in their embryonic stages, the Institute of Medicine laid down a formidable gauntlet. Their report entitled: Crossing the Quality Chasm: A New Health System for the 20th Century, didn’t mince words. It condemned American medicine for being unresponsive to patient needs, uncoordinated in its application of care, and unnecessarily unsafe.
            The IOM’s report challenged institutions to improve in six areas and created a new buzzword for hospital administrators and faculty: Patient-Centered Care, or as the IOM put it, “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.”
            To say that the phrase—adapted to the more universal “Patient-and Family-Centered Care”—has become the single guiding principle of the design and function of the new Children’s Center would be neither understatement nor hyperbole. There’s a microeconomics term called “The Second-Mover Advantage” which may best explain where the Bloomberg Children’s Center stands as it opens its doors. Though Hopkins never claimed to be the first institution to practice patient-and family-centered care, they’ve used their “second-mover advantage” to learn from others' successes (and mistakes) in the field. Pediatric faculty, staff, and administrators made numerous trips to facilities across the country, gleaning a multitude of ideas and creating a master “wish-list” of patient-centered initiatives.
            The result at this moment may well be the gold standard of Patient-and Family-Centered Care. Beautiful? Yes, so far as that term can apply to any structure made of concrete, steel, and glass. Lots and lots and lots of light-giving glass. But what’s most impressive, from its outer skin to its inner wiring, is how form and function combine to create a third, far more powerful element: Opportunity.
            It’s impossible to discuss the new building with faculty and not have words such as “opportunity” and “promise” pepper their conversation. To a person, they see the structure through their professional prism and glimpse new ways of healing. Call it the potential beyond the amenity, but it’s everywhere one looks. For Child Life Director Patrice Brylske, those playful, oversized sculptures, the hundreds of pieces of fascinating art that dot the walls, the colorful playrooms on each floor, are more than just a delightful aesthetic; each is a potential conversation starter with a child, an entree for building trust and taking fear out of the hospital experience, which leads to better healing.
            “The old building restricted a lot of the lovely things we wanted to do for patients and families, but this environment is so stimulating, so rich, it feels so freeing,” says Brylske. “Now we challenge ourselves to use what’s in this beautiful building to support our work.”
             Part of her vision involves using the Great Room—a two story gym-size facility on the 11th and 12th floor—and other open spaces to expand Child Life’s creative arts program. “We have such diverse space now that we can accommodate a menagerie of artists, from music and art to dance, poetry and drama, elements that we didn’t have the space for before, to have that quality interaction with patients and families.”
            Brylske also mentions the private rooms that are the standard accommodations as being of great benefit to engaging children in play, especially those who aren’t mobile. The 205 private rooms are cited time and again by staff as perhaps the key central element in improving all aspects of patient care. Many are quick to point out the family-friendly details such as on-demand room service, family lounges with microwave ovens and overnight beds. Pleasing amenities to be sure, but purposeful as well; keeping families on-site longer and close to their loved ones has numerous ancillary benefits.
            Sally Radovick, Director of Pediatric Endocrinology, sees the private rooms as offering the ideal educational space for parents who suddenly have to cope with a child’s life-changing illness. She points to children admitted because of life-threatening diabetic ketoacidosis, often the first sign that they have Type 1 Juvenile Diabetes.
            “An important aspect, during the acute phase, is to begin teaching (chronic disease management),” says Radovick. “Learning about insulin dosing, what type I diabetes is, nutritional support…it’s critical for this initiation of self-care for the chronic state. Now, parents can stay with their child in a single room round the clock, and they can learn from the nursing staff and diabetes educators how to take care of this child, how to give the insulin injection, and participate in carbohydrate counting each meal, which was potentially more difficult to do in a room with two or more children.”
            Director of Pediatric Nephrology Barbara Fivush also credits the private rooms for fostering better staff-family/patient conversations. In just the short time the hospital has been open—the official start date was May 1st—Fivush says she can see and hear the change.
          “Our service has many chronically impaired patients with complicated emotional problems…the conversations can get pretty detailed, and I think we felt uncomfortable (in multi-family rooms) talking about their care," Fivush says. "Now we have the privacy to really get to spend time with our families, which promotes the ability to communicate better because you don’t have to be concerned about who is listening and who else is in the room. And you don’t have to stand in the hall to talk.”
            She adds, “I’ve just been on service in the new hospital this week, but I’m very impressed with the conversations we’re having, about non-adherence, why they got kidney failure from a certain drug, why that drug was given to them in the first place…so many topics that are not naturally easy to discuss unless the environment is open to that.”
            Private rooms also increase patient safety, a key element of the IOM’s pivotal report. “With private rooms, you don’t worry about cross-infection from roommates,” says pediatric pulmonologist Beryl Rosenstein, former long-time Vice President for Medical Affairs at Johns Hopkins Hospital. In the old building, “we had to move patients around because of infection control issues. Now it’s simple; every patient is in their own little cocoon.”
            And many systems have been built around preserving the sanctity and safety of that little cocoon. Marlene Miller, Director of the Division of Quality and Safety, notes that drug delivery has been completely revamped from stem to stern. The pediatric pharmacy is five times larger than its predecessor, there are separate rooms with separate pass-throughs for IV meds, and quiet space for the pharmacists to do their dosing calculations without being disrupted. Also, the medication distribution system has been redesigned with more frequent delivery of meds, more frequent removal of the discontinued meds, and bedside delivery of medication so there’s less distraction for the nurse. 
            "She’s not in a med room with five other nurses all getting meds for their patients," says Miller. "Her patient’s meds are right by the bedside.”
            Keeping the nurse with their patients, especially those who are critically ill, is a win-win result of another amenity, Clinical Customer Service Representatives (CCSR). In the past, PICU and NICU nurses would often be called away from their patients to meet families and instruct them on proper safety protocols before entering the rooms. Now, they can stay by the bedside, as the CCSR staff greet families at the entrance to each unit and prep them for their visit.
            “The CCSR is going to welcome the family in, show them how to wash their hands, and walk them down to the patient room,” says NICU nurse Christy Richter. “It’s what we’ve always wanted to do, but in the past it wasn’t ideal; you had to have somebody else watch your patient while you got the parent. That wasn’t really welcoming for anyone. But now their anxiety level will already be lower when they enter the room. And their hands will already be washed so we can get right to ‘here’s what’s going on with your baby.’ The continuity is just going to be better.”
            Continuity. Safety. Quality of care, notably Patient-and-Family Centered Care. Modern medicine lives by these buzzwords; together they form the mantra by which the new Bloomberg Children’s Center will attempt to create a standard of care that would make the IOM proud.
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That’s as of today. But what about medicine 10, 20, 50 years from now? Will the new Bloomberg Children’s Center still be going strong when our children have children, or will time have passed it by? Put another way, will the faculty and staff have made their mark on medicine in Bloomberg's Children Center, much as they did in the CMSC and Harriet Lane clinic? Or could this next era for the Children's Center become a grand experiment that ultimately yields disappointing results? If history is any indication, it’s hard to imagine the latter, especially given the thousands of planning hours put into envisioning the future of pediatric medicine. Still, playing clairvoyant is a daunting task.
            “You go into (the process) with a lot humility and insecurity, really, about where the world is going, but you learn lessons for the future from the lessons from past experiences” admits veteran pediatric administrator Ted Chambers. "One of the advantages that Dr. Dover and I have is that we've been here for some time, so we've built up experiences that lead you to how you would shape the building and the future of the Children's Center."
             Indeed, a consulting group hired early in the process strongly suggested that Hopkins build a far smaller inpatient children’s hospital than what Dover and Chambers eventually delivered. The consultants based their recommendation on national data which showed pediatricians across the country were doing a better job at keeping kids from getting sick, and inpatient admissions were dropping.
            They thought they were seeing the big picture; Dover and Chambers thought otherwise. Pediatric cases, especially chronic ones, were getting more complicated. Numerous specialists and services were required, often beyond the scope and resources of most pediatric centers, but not Hopkins. So, by their thinking, while many centers will be seeing less inpatients in the years to come, Bloomberg Children’s Center will thrive by offering top-notch care to the most complex of cases.
            Physically that means having a building with the flexibility to handle those cases now and in the future. Expanded dedicated pediatric OR suites, designed to fit the specific needs of subspecialties including neurosurgery and cardiology, are both state-of-the-current-art and adaptable to technology that at least has been glimpsed on the horizon.
            “We’re going to be able to integrate robots into the system; the rooms are made to accommodate those kind of advances,” says neurosurgeon Ben Carson. “The only reason we don’t use robots right now in neurosurgery is they’re not quite fine enough. But once they become fine enough and delicate enough, the kinds of things we’ll be able to do will be mind boggling.”
            Even the air that’s breathed throughout the hospital has the future in the mind. “The whole building is HEPA (high-efficiency particulate air) filtered. The air is cleaned in a way we never had in the old building,” says Chambers. Such filtering not only lets immune-compromised children stay safer, but it’s vital to emerging therapies. 
           “The way the air handling system works, you can administer a drug in a certain room and it doesn’t leak out into the corridor or other areas," says Chambers. "With gene transplantation, one of the lessons we learned is we needed a very special air handling system to administer the gene, because you didn’t want these genes just floating around anywhere.”
             There’s little doubt that as technology evolves, so too will the concept of the traditional children’s hospital. Expertise that is regionally based is on the verge of having a national and global reach, and Bloomberg Children’s Center is set-up for that emerging world of telemedicine. Cardiologist Philip Spevak has built a NASA-esque imaging command center that coordinates numerous imaging modalities both in-house and to satellite sites to come.
            “This lab is really set up with good hardware and software that has the capacity of seeing an image anywhere, at any time, from anyone,” says Spevak. “That’s important in clinical care because expertise varies from center to center and pediatric cardiology program to program, and you even have expertise here in say, congenital heart cardiac imaging. So we can be an expert consultation service (to other centers) in a minute. We’re also using our center to train technologists at other hospitals.”
            Ben Carson sees a similar technological outreach from OR to overseas coming down the road: “The new operating rooms are very technologically advanced. I did nine cases last week, and to be able to record what you’re doing, with just a simple maneuver, have it sent to a central source where you can then upload it to your computer in your office, make slides, do various presentations, makes access to this information to other people much greater, so now it’s not just what you’re learning, it’s what you’re able to transmit to others…the fact that we’ll be able to communicate with medical centers in Nigeria, in Israel, in Dublin, in South America, in New Zealand, this is the wave of the future.”

            “The opportunity to show current and future residents that the space in which they would be caring for patients conveys the high level of respect that this building does for patients is a wonderful message for us to be sending to applicants,” says Julia McMillan, vice chair for Education and director of the Pediatric Residency Program. “And for the residents who are here, now (through the transition from the CMSC) it says we knew the old space didn’t convey the respect we felt for our patients, and we fixed it. It took us a while, but now we’ve fixed it; it isn’t just something we talked about, it’s something we actually did.”
            It’s a change that could make history.
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