Two hundred years young

Next year, Massachusetts General Hospital will begin a third century of healthcare leadership and serving the local community. Hospital President Peter Slavin lets Marie Shields in on the plans to mark this important milestone.

“We want to use this as an opportunity to celebrate what MGH has been over the last 200 years, but even more importantly we want to use it as an opportunity to think about how we can do the most for society over the next 200 years.”
-Peter Slavin

Imagine it's 1810, and you're a gentleman or a lady of a certain class in Boston: well-off, living in a comfortable home with a few servants and access to good food and wine - and when you're ill, your personal physician comes to your home to treat you with the latest medicines, for which you are happy to pay.

Now imagine that one day you receive a letter from two doctors, John Collins Warren and James Jackson. In it, they express concern for the many local residents who have no money to pay for medicines, and sometimes not even homes to be treated in. Warren and Jackson propose the founding of an innovative institution - an acute care hospital - that would provide medical treatment to the area's poor. And here's the catch: they're asking you to contribute a sum of money toward its establishment. What do you do?

Luckily, many of those who received Warren and Jackson's letter did agree to fund the new institution, and in February 1811, Massachusetts General Hospital was established by charter. But as current President Peter Slavin explains, the process that followed was not a straightforward one, "It took some time to get the law passed to create the hospital, raise the money and complete the construction on the building - this building we're sitting in right now - and so the hospital opened its doors to patients about 10 years later.

"If you look back at that era, there were similar efforts underway in Philadelphia and New York, and there were hospitals that opened in all three communities at roughly the same time. These were charitable institutions aimed at trying to provide care to the poorest people in society, and what I'm proud of is that that spirit, that initial focus, has not been lost in any way over the last 200 years.

"While we obviously now also provide services to people with means, we are still one of the biggest providers to the poor people of this region and we remain intensely committed to meeting their needs."

Obviously medicine has changed beyond almost all recognition over the last 200 years, and it's a credit to Mass General that it has kept pace with the latest developments while remaining true to its original vision. Clinical care and medical education were clearly part of that: when the hospital opened, it was also planned as a teaching site for students at Harvard Medical School, which was founded before the creation of the hospital.

According to Slavin, one other important mission has been added since then: research, which now makes up about a quarter of what the hospital does. This means dedicating a quarter of its employees and a quarter of its budget to research, giving it the largest research program of any hospital in the United States.

"In many ways the mission of the hospital has remained unchanged over the last 200 years," Slavin says, "although how we go about pursuing the original vision has obviously changed as medicine has changed dramatically.

"Boston has by far the greatest concentration of biomedical research of any community in the world, and I think we're the single largest institution conducting biomedical research in this community. We also have MIT and other parts of Harvard and the other hospitals here in town, as well as a growing number of pharmaceutical and biotech companies. If you want to pursue biomedical research, Boston is the place to be."

With that amount of expertise available in the local area, it makes sense for institutions to collaborate, as indeed they are. In 2003 MIT, Harvard and the Harvard teaching hospitals (with funding from philanthropists Eli and Edythe Broad) created the Broad Institute, arguably one of the leading genetics research institutes in the world.

Another collaboration spans all the Harvard institutions in stem cell research, resulting in the Harvard Stem Cell Institute, which Slavin says has helped make an even greater impact in the field. And last year, MGH created the Ragon Institute, which is aimed at developing a vaccine for HIV, and involves a partnership with MIT and Harvard University.

Celebrating

Slavin sees the bicentennial as a way to mark the past while also looking forward . "We want to use this as an opportunity to celebrate what MGH has been over the last 200 years and the impact it's had on countless individuals and families," he says, "but even more importantly we want to focus on the future and use it as an opportunity to think about how we can do the most for society over the next 200 years. There's every reason to believe that as different as medicine is now compared to what it was in 1811, probably in 2211 it will be even more dramatically different."

As medicine moves on, so must treatments, and by extension, the facilities need to perform them. For this reason, perhaps the most important event of next year's bicentennial celebrations will be the opening of Mass General's Building for the Third Century.

"The thing that we do the most of, and I would argue the most important thing that we do, is take care of patients," Slavin stresses. "In recent years our ability to do that has been hampered by some capacity constraints: we simply on a day-to-day basis don't have enough beds or operating rooms. Our emergency room is undersized relative to the number of patients we are serving there, and so the new building is aimed at trying to provide the hospital with additional capacity in those areas, in very patient-focused modern facilities."

Slavin underlines that the new building is also being designed with patients and their families foremost in mind, meaning that all 150 inpatient beds will be in spacious private rooms.

"When I was a trainee 25 years ago, semi-private rooms and even four-bed rooms seemed like a luxury," Slavin recalls. "We don't have any four-bed rooms left, but we do have lots of semi-private rooms, which don't seem as luxurious as they used to. Increasingly[IS1]  people are expecting to be in private rooms, and this building will significantly increase the number of private rooms that we have available.

"The other thing I would point to in the building is the procedural space. In the old days, we had operating rooms and we had separate imaging facilities. This space will integrate imaging with operative space so that our proceduralists, our surgeons and other clinicians, can use MRI, CT and other imaging modalities while they're doing surgery to more precisely know where they are and what they're doing, and we think that will be a great advantage in our surgical capabilities.

"We have a neurologic intensive care unit where patients suffering from very severe brain diseases are cared for. Currently, when those patients  need an imaging test, they need to travel to a different unit downstairs and then be transported back upstairs, and that is an incredible logistical undertaking when they're so sick and on various machines. In our new neurologic intensive care unit there will be an MRI and CT scanner right on the same floor."

Learning

In planning the new building, the MGH team reached outside the organization to learn from what others have done recently in constructing hospital buildings. Taking a lesson from the hospital's own history, the new building is also being built with flexibility in mind, because as Slavin points out, the medicine being practiced when the building opens next year will be different from the medicine that will be practiced 10, 20 or 50 years from now. "If we want this building to continue to function, there will inevitably have to be renovations and so we're building it to make that as easy as possible. We want to make sure that this building serves future generations of leaders of this institution and patients and clinicians.

"This includes making sure that there is ample floor-to-ceiling height, because when some of our older buildings were built, the floor-to-ceiling height was maybe 10 or 11 feet. Back in those days there wasn't much in the way of wires, air handling or other things that needed to go into the ceiling and still leave enough height for people to walk around.

"The amount of material that now needs to go into the ceiling has dramatically increased; therefore the floor-to-ceiling heights have to be greater in order to accommodate it all. We've erred on the side of having even higher floor-to-ceiling heights, because who knows what will be in those ceilings 10, 20, 50 years from now. That's just one way that we're trying to plan for the future."

With an eye on our modern concern with environmental sustainability, the new building has been constructed to the LEED Gold environmental standard, the second highest level of 'greenness' that a building can achieve.

The building's heating and air conditioning systems and the insulation have all been designed to minimize the amounts of energy needed to ensure patients and staff are comfortable.

Slavin gives as an example the glass used in the building, which is designed to allow sunlight to partially heat the building, while at the same time ensuring it is sufficiently insulated so that it doesn't let heat escape. The entire roof will be covered in greenery, to consume carbon dioxide and release oxygen into the atmosphere, and materials needed for construction have been sourced as close to home as possible so that the carbon footprint associated with constructing the building can be kept small.

Leading

Anniversaries are a time for looking not just backward, but also at what lies ahead, and Slavin sees a bright future for his hospital, as it continues to be a leading light in the healthcare community: "I hope in the future our role is similar to the one we've played over the last 200 years. At least from my perspective, MGH is a place that over that period of time has done everything it possibly can to meet the needs of individual patients and families, and at the same time try to advance the field of medicine to benefit not only our own patients, but patients around the world.

"Exactly how we'll go about doing that in the future is hard to know, because it's not clear where the opportunities to advance care will be or what exactly care will look like at any point in time. I hope that continues to be the spirit and the identity of this place, both providing the most advanced and compassionate care to patients on a day-to-day basis, but at the same time trying to advance care so that we come up with better answers for our patients and their families that improve care in the future."

Peter Slavin on EHR

"I'm delighted that the government is taking a leadership role on electronic health records. At MGH, we currently have virtually all of our outpatient records in electronic format, and all orders for inpatients in the hospital are done electronically, and there's no doubt in my mind that that is a safer way to practice medicine.

"It's also more efficient. Where once a physician would have to generate a letter after an outpatient visit, now all that happens electronically, and any other physician who's involved in the care can see that note immediately.

"The records also check for quality on a real-time basis, so if a physician orders a dose of a medication that seems out of range, the system will immediately alert the physician to the potential error.

"I'm very bullish about the use of electronic records and I'm glad the government is providing some carrots and sticks to get other providers across the country online."

Peter Slavin on home-based care

"It is a very positive development. If I compare how we treat medical conditions now compared to when I was in training here, it's dramatically different. A lot of what was done on an inpatient basis is now done in doctor's offices or at home.

"Our goal as a healthcare institution is to keep people healthy and out of the hospital, so if we can do more outside of a hospital setting, that's all the better from my vantage point.

"The best test of our success would be if we could go out of business because nobody needed to be in the hospital anymore. We could declare a victory at that point, although I don't see that happening in the near future."

Peter Slavin on HAIs

"We have a number of programs aimed at trying to minimize the rate of hospital-acquired infections, one of which is a very aggressive hand hygiene program. We have spies who wander around the hospital and watch individual clinicians to see if they wash their hands or use an alcohol-based hand cleaner before going into a patient's room and after coming out, and we track those findings by patient care unit.

"Five years ago hand hygiene happened 50 percent of the time. Now it happens well over 90 percent of the time. And we've seen our rates of the common infections that are associated with lack of hand hygiene go down significantly.

"We've also been very focused on central line infection rates, and those have come down dramatically as well. Those are just two examples of what we're doing. We're taking it very seriously, and I wish that the entire healthcare industry was doing the same."

Peter Slavin on health reform

"I'm delighted that health reform passed a few months ago and that we're going to join the rest of the civilized world and provide access to healthcare to almost all of our citizens.

"One of the greatest remaining challenges facing our healthcare system is cost. There are a lot of opportunities in healthcare in the US to provide better care at lower cost, and  that's one of the things we will be working on as hard as possible here, and I hope that people throughout this country come to that challenge in a very constructive way.

"If we don't do it we're either going to create a great economic challenge for our country, or we're going to deliver suboptimal care. I hope by being innovative and relentless in our pursuit of ways to deliver better care at lower costs that we can avoid either of those two other alternatives."

 [IS1]use "increase" twice, perhaps say "More and more, people are expecting.."