Introduction
This work is a brief overview of the evolution of Massachusetts General Hospital (MGH) and its seminal contributions in the field of medicine. It discusses the relevance of its work in relation to the social upheavals of its time. It discusses the institutional framework for adhering to high standards of quality of care and patient safety alongside its utilization of technology to promote equity of access and optimize enterprise wide care processes.
Background
Massachusetts General Hospital (MGH) in Boston is one of the oldest hospital in the United States. Founded in 1811, the prestigious institution boasts of 900-bed hospital and is globally acknowledged for its standards of patient care. Besides, it is the oldest and largest teaching hospital of Harvard Medical School. The annual patient load of the hospital and its network facilities includes 1.5 million out-patient consultations, 44000 in-patients admissions and about 32000 surgical operations. (“Hospital Overview - Massachusetts General Hospital, Boston, MA," 2013)
Track record
Over the last 2 centuries of its existence, MGH has distinguished itself by pioneering countless path breaking interventions that have revolutionized medical practice across the world. From the world’s first ever surgical operation performed under anaesthesia in 1846, to its homegrown state-of-the-art expertise in neurosurgery, oncology and paediatric surgery, MGH has an illustrious history. (Calicott, 2005) (Porter, 2000) Among contemporary institutions in U.S. MGH has the highest funding allocated for research. Its yearly budget for research activities exceeds $786 million. Among the institution’s various accomplishments, the one that stands out in my view is its pioneering work on the social aspect of health care. MGH has a vision of medicine and social services as complementary disciplines with the common objective of advancing health and well being. (Massachusetts General Hospital Department of Social Services. 1958).
Birth of the social imperative in Medical Care
The social work movement in United States gained strength in the early 1900's. (Trattner, 1994) The period saw the birth of the social ideology that sought to address the essential needs of underserved populations like urban poor, immigrants. (Thio, 1997) From promotion of hygiene and occupational health, the scope of issues widened to include improving access to health, housing, medical care, fair wages and life-skills education to the community. Influenced by the birth of the physical sciences, the social intelligentsia in Europe and Americas started recognized the link of poverty and illiteracy with disease. (Goldstone, 1982) (Thio, 1997)
Origins of Social movement in MGH
The first step in this direction was taken in 1905 by Dr. Richard Cabot by bringing social services to his clinic patients at his own expense. The initial focus was to provide social support to tuberculosis patients, cases of teenage pregnancy, and for providing nutrition and hygiene education and care for destitute patients. The institutionalization of this social care imperative as part of health services was formalized in 1907 with the appointment of a registered nurse, Ida Cannon, as a social worker in MGH. This was followed by setting up a supervisory committee to support and finance this non-medical department. (Cannon 1952) By 1910, the concept of ‘social diagnosis’ began to take root as the linkage between social conditions and disease was increasingly getting acknowledged. (Thio, 1997) In 1914, with the formal appointment of Cannon as the first head of social services, the scope of services carried out by social workers broadened to cover all major clinical specialties, like Syphilis Clinic, Genito-Urinary Clinic, Infantile Paralysis Clinic and Neurology Clinic. Influenced by the wider social movement taking place in Europe and the realization of the common goals of social work and health care, institutional work culture in MGH strengthened the physician-social work relationships. (Massachusetts General Hospital Department of Social Services. 1958) The institutionalization was complete in 1914 with formal recognition of social services as an integral department of MGH with its own Advisory Committee. By 1957, the tasks for social workers began to be segregated by different care domains. In 1968 a Transfer Office was created charged with assuring appropriate continuity of care after discharge from hospital and creating linkage with community based services. The scope of work further broadened to include agreements with nursing homes, ambulance companies and day care centres. By 1980, Social Service started screening all admissions using criteria like diagnosis, age, ethnicity and socioeconomic condition, to identify patients who might require community level support after discharge from hospital. (Massachusetts General Hospital Department of Social Services. 1958)
The development of Social Services department kept pace with the system wide changes in the late 20th century. Some of the other notable developments include initiatives like Haven program (1997), Child Protection Consultation Team (2000), and Clinical Recognition Program (2003) developed by the patient care services.
MGH Mission Statement
"Guided by the needs of our patients and their families, we aim to deliver the very best health care in a safe, compassionate environment; to advance that care through innovative research and education; and, to improve the health and well-being of the diverse communities we serve." ("Mission statement in Hospital Overview - Massachusetts General Hospital, Boston, MA," 2013)
A review of available literature shows MGH’s unequivocal emphasis on the quality of health care. Over the years the institution has developed considerable institutional memory and expertise in this respect. There is a systematic and enterprise-wide integration of quality assurance mechanisms at all levels and across all domains and sub specialties under the stewardship of the MGH Centre for Quality and Safety. ("Massachusetts General Hospital: Quality & safety," 2013)
Quality improvement
The institution is guided by the Institute of Medicine’s framework for quality and safety based on six criteria: Safety, effectiveness, patient centeredness, timeliness, efficiency and equity. (Donaldson, 2008) The institution is renowned for its inter disciplinary collaboration among various departments, most notably, in oncology, gastroenterology, cardiology and vascular medicine. Further, the ‘Care Redesign Initiative’ is another collaborative initiative involving multidisciplinary teams of health care providers and administrators for optimizing care, reducing costs and improving outcomes.
Process improvement is a guiding framework for MGH Centre for Quality and Safety which includes overlapping themes of quality & safety, service and efficiency. (Leape 2005) The center has its own Process Improvement Working Group and Steering Committee guiding the various initiatives. There is also a dedicated Disparities Solutions Center that systematically seeks to address racial and ethnic disparities and promote equity. Additionally, MGH has a culture of forming viable partnerships with communities. It is a founding member of Partners HealthCare, an integrated health care delivery system that includes the two founding academic centers, hospitals, primary health care facilities, specialists, physicians and community health centers. The Adult Foster Family Care Program was initiated to provide viable alternatives to nursing home care for elderly patients. The program later expanded in scope to address needs of disabled and HIV infected individuals.
Historically, the social workers at MGH were the first professionals to perform a comprehensive analysis of tuberculosis in the United States. The institution was the first to fully integrate social support in the medical treatment of polio, cancer, cardiac care, venereal disease and tuberculosis. (Porter, 1997) Moreover, the institution supports patient education and actively promotes peer support networks. (Massachusetts General Hospital Department of Social Services, 1958).
Overall, with a due focus on competence, social relevance, evidence backed practice, the institution has effectively responded to contemporary challenges like rising health care costs, complexity of payer-provider relationship, legislative reform and rising needs. It allowed greater integration of social aspects in medical care. There is a renewed emphasis on care that is responsive to the patient’s socioeconomic condition, addresses psychosocial issues and provides for continuity of care at the community level. (Massachusetts General Hospital Department of Social Services, 1958).
Embracing technology as an enabler
The first Hospital Computer Project contract at MGH was funded jointly by the National Institutes of Health and the American Hospital Association in 1962. The initial efforts were focused on the development of an admission discharge census system, a laboratory reporting system, and a drug ordering system. (Barnett, 1967) (Greenes, 1967) The next major development was that of a "modular" approach that focused on individual information processing units to provide well-defined and clearly bounded computer systems which provided for integration into clinical care systems. (Greenes, 1970) Currently the organization has an enterprise wide health informatics system that provides seamless integration of data related to different aspects of care process. There is a state of the art electronic medical record system in place that is integrated with clinic decision support systems and facilitated by real time integration between clinic OPDs, in-patient departments, operation theatres, pharmacy, emergency departments, blood banks, etc. The patients can access a copy of their EMRs for sharing it at any other health institution. There are in-built safety checks to minimize errors in the care processes.
References
Barnett GO, Castleman PA (1967). A timesharing computer system for patient-care activities. Comp Biomed Research. 1967; 1:41-50.
Calicott R W (2005). “This Is No Humbug!": Reminiscences of the Department of Anesthesia at the Massachusetts General Hospital; Bulletin of the history of Medicine 79.1 (Spring 2005): 162-163.
Cannon, Ida. (1952). On the Frontier of Medicine: Pioneering in Medical Social Service. Harvard University Press. Cambridge, MA.
Donaldson MS (2008). An Overview of To Err is Human: Re-emphasizing the Message of Patient Safety. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 3. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2673/
Greenes RA, Pappalardo AN, Marble CW, Barnett GO (1969). Design and implementation of a clinical data management system. Comp Biomed Research. Vol. 2:469-485.
Greenes RA, Barnett GO, Klein SW, Robbins A, Prior RE (1970). Recording, retrieval and review of medical data by physician/computer interaction. NEJM. Vol. 282:307-315.
Leape LL, Berwick DM (2005). Five years after To Err is Human. What Have We Learned? JAMA. 2005;293:2384–90
Massachusetts General Hospital Department of Social Services. (1958). Selected Papers and Reports: Fiftieth Anniversary Celebration of the Social Service Department at Massachusetts General Hospital. Boston, MA
Trattner, Walter. (1994). From Poor Law to Welfare State; A History of Social Welfare in America (5th edition). The Free Press. New York, NY.
Massachusetts General Hospital: Quality & safety. (2013). Retrieved from http://qualityandsafety.massgeneral.org/
Thio, A. (1997). The essence of social life. In Sociology: A brief introduction (3rd ed., pp. 4-24). New York, NY: Addison Wesley Longman, Inc.
