Windows of Hope

Windows of Hope is our oncology shop, located on the ninth floor of the Shapiro clinical center -- at the corner of Longwood and Brookline Avenues -- near the chemotherapy and other treatment areas. In addition to selling wigs, scarves, book, and other helpful items, it has become a place where cancer patients and families come and talk comfortably and share advice and stories about what they are going through. Linda and Terri, who run the shop, are warm and friendly people. You don't have to be a patient at our hospital to go there. All are welcome. Samples of their wares are in the pictures above.

If it sounds too good to be true

Technology Review has an excellent article by David Talbot entitled "The Fleecing of the Avatars", which deals with the difficulties of consumer protection and regulatory supervision of commerce on Second Life and other virtual worlds. Financial rip-offs are hard enough to avoid in-world, and this article gives a really good description of the issues when virtual currency is in play.

Merry Christmas!

Just to take a break from this current addiction, I'm taking several days off from posting new items (although I will still moderate your comments), and so I wanted to leave you with this nice image at the top of my page. One of our nurse managers insisted that she did not want presents from her staff. They, being the usual strong-minded nurses at BIDMC, nonetheless insisted, but gave a gift in the form of this Christmas tree. Each "mitten" is a warm and kind personal message from a nurse to Sue.

An idea for US News and World Report

Here is an open suggestion for Avery Comarow, the editor of the annual US News and World Report ranking "America's Best Hospitals." Why not add to your algorithm extra points for those hospitals that voluntarily publish clinical indicators of the degree to which they harm patients? I am not talking about the usual hodgepodge of outdated CMS data, which are available anyway. I am talking about substantive clinical metrics, like central line infections, ventilator associated pneumonia, and the like. Or the ultimate, the hospital standardized mortality rate calculated by the Institute for Healthcare Improvement.

I can already hear the arguments against this. Who is going to validate the numbers? Which definition of central line infections should be used? How would you compare from hospital to hospital?

Please, put all that aside. Let's just accept as a premise that hospitals that choose to post these numbers do so not for comparative or competitive purposes, but rather to hold themselves accountable to the public for their efforts in quality and safety improvement. Shouldn't that be worth something in the US News listing?

A fallback, if you don't want to change your algorithm. Just create a special box listing the hospitals that post these kinds of results, along with their url, so people from hospitals around the world can check in and make their own judgments about the usefulness of this approach.

Avery, you have become a force in this field. As noted on your blog, your perspective uniquely qualifies you to observe and comment on the efforts by hospitals and other health care providers to improve care and patient safety. Why not use that influence to push the industry along to greater heights by giving space to those who risk holding themselves accountable in this manner?

Heartsaver

I have linked at right to a blog I just learned about, Corazón Hispano. Here is a note from the author, Juan Jose Rivera, in response to a comment I left:

Saludos from Corazon Hispano blog. Thank you for your comment. It is very important for me that Hispanics have access to essential and practical prevention information. We represent the minority group in the US with the highest percentage of uninsured individuals. A significant number of Hispanics have access to the Internet, but not to a primary doctor.

He provides personal information on his profile:

Pertenezco al departamento de Cardiología de la Universidad de Johns Hopkins en Baltimore, Maryland. Además de mis obligaciones clínicas, me dedico a realizar investigación en el área de prevención cardiovascular. También escribo una columna mensual para el periódico médico nacional estadounidense Today in Cardiology.

This blog is very well written and quite informative. I hope you will pass it along to friends and associates.

Partial Credit

As a former state official, I understand the difficulties of running a state agency and therefore like to give credit where credit is due. This post is to award "partial credit" to the DCR, the state agency that runs the parks.

We had a big snowstorm on the weekend, but this is not unusual in New England. So you would think that the various agencies would be prepared to clear major walkways on public lands, particularly those walkways that lead to major mass transit stations. Not so. My particular T stop is Longwood, which serves thousands of people going to work at hospitals, school, and other institutions -- not to mention patients. A major passageway from the Longwood stop to the medical and academic area is a short walk through a park and across the Muddy River.

As late as yesterday, the walkway was a sheet of ice several inches thick. There had been no effort to clear it or to spread sand on it. It was treacherous.

So, today, I brought a camera to document this condition and send it along to the authorities and -- lo and behold -- the walkway has been plowed and sand laid down. The steps up the little bridge across the Muddy River likewise have been totally cleaned. The pictures above attest to this result.

So, that is the good news. The bad news is that it took so long. Partial credit awarded.

The new Commissioner of the DCR is Rick Sullivan, who used to be mayor of Westfield, MA. He is an honorable, hard-working, and competent person who understands the importance of proper and timely delivery of municipal services. Like his predecessors, though, he is hamstrung by inadequate budgets and, I am guessing, antiquated equipment. I think he is doing the best he can, but until and unless the public puts more pressure on their elected representatives for more adequate funding, the state park system will always be behind -- just as it was this week.

Physician Diversity -- Part 3

You know, if you know where to look, everything is available on the BIDMC website! Here is a report prepared by Rosemary Duda, Director of our Center for Faculty Development, as a guide to the faculty recruitment process, with a specific emphasis on trying to recruit under-represented minorities and women. Pages 40 to 42 of the book has charts showing the relative percentage of different levels of faculty at BIDMC in those categories and -- starting on page 43 -- compares our numbers to Harvard Medical School (including all the affiliated hospitals).

You can look at the numbers yourself, but it is clear that we are behind the rest of HMS in all faculty ranks.

Professor Duda's introduction to the book is very well written. Having served on search committees for department chiefs, I know that its recommendations are followed. Likewise, having talked to our chiefs, I believe that its recommendations are also carried out for division chiefs and other recruiting committees.

By the way, to answer comments on earlier posts, her language on page 6 concerning the value of diversity is very compelling: The advantages of a diverse faculty at BIDMC include optimizing our ability to provide high quality medical care for our underserved populations, addressing the issues of health and health care disparity in the underserved populations as these patients are more likely to seek physicians who are similar in ethnicity, culture, race and/or gender, and improving our cultural competency educational efforts and professionalism training. A diverse faculty also brings to the institution an expansion of the research focus that would encompass health issues related to women and underrepresented minorities.

But let us return to the question. If good intentions reign, and I believe they do, why are BIDMC's results less favorable than the rest of the HMS community? I know that a large part of the answer relates to the hospital's troubled period of 1996 through 2002, when many of the existing faculty left the hospital for greener pastures and when many potential young recruits were scared away by the uncertain future of the BIDMC. In fact, our moniker of "financially troubled BIDMC" did not leave the pages of journalism until sometime in 2004. I think this set us back many years, both in terms of new recruits and in creating a pipeline for later professorial advancement.

But let's open this up to those who want to comment, who know this place or know of it. Are there other factors at BIDMC that adversely affect our performance in this matter? Are those factors different from other Harvard hospitals? From other hospitals in Boston? Please dive in and offer your opinions and remedies.

Timely and important advice

Today's Boston Globe has timely and extremely important advice from Monique Doyle Spencer. You will not want to miss this.

Say it ain't so, Joe

I heard a great presentation this morning by Joe Newhouse, from the Department of Health Policy and Management at Harvard Medical School. There was one point that he made that really caught my attention. It was a cite to a 2004 article in the Journal of the American Medical Association (Dimick, et al, JAMA 2004; 292: 849) that presented the issue of how many cases you would need to collect of a certain clinical procedure to be able to make a determination that a given hospital's mortality for that procedure was twice the national average. It turns out that only for CABGs (coronary artery bypass grafts) are there enough cases performed to have statistical confidence that a hospital has that poor a record compared to the national average. For other procedures (hip replacements, abdominal aortic aneurysm repairs, pediatric heart surgery, and the like) there are just not enough cases done to make this assessment. (By the way, if you just want to know if a hospital is say, 20%, worse on relative mortality, you need even a bigger sample size.)

I have copied the basic chart above. Sorry, but I couldn't nab the whole slide. The vertical axis is "Observed 3 year hospital case loads", or the number of cases performed over three years. The horizontal access is "Operative mortality rates". The line curving down through the graph shows the frontier at which statistical significance can be determined. As you see, only CABGs are above the line.

And, as Joe pointed out, this chart is based on three years of data for each hospital. With only a year's worth from each hospital, you surely don't have enough cases to draw statistically interesting conclusions about relative mortality. And remember, too, that this is hospital-wide data. No one doctor does enough cases to cross the statistical threshold.

So, this would suggest that publication of hospital mortality rates for many procedures would not be helpful to consumers or to referring physicians.

Meanwhile, though, you might recall a post I wrote on surgical results as calculated by the American College of Surgeons in their NSQIP project. This program produces an accurate calculation of a hospital's actual versus expected outcomes for a variety of surgical procedures. Unfortunately, the ACS does not permit these data to be made public.

Where does this leave us? Well, as I noted in a Business Week article, the main value of transparency is not necessarily to enable easier consumer choice or to give a hospital a competitive edge. It is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care. So, even if we can't compare hospital to hospital on several types of surgical procedures, we can still commend hospitals that publish their results as a sign that they are serious about self-improvement.

IT Memory Lane

Another snowy day in Boston. Luckily it is Sunday, and this provided a perfect opportunity to go up and clean out the attic.

What should I find but my old class notes from the spring of 1969, a course entitled "Information Systems" -- "1.00," in MIT parlance -- taught by a wonderful professor named Dan Roos who, by coincidence, I happened to run into recently.

We used an IBM 360 computer in those days. It took up an entire room and probably had less memory than your cell phone does today. You would write your program in Fortran -- an example from my final project is shown in the bottom picture above. Then, you would punch Hollerith cards to encode the program on a medium that could be read by the computer. I show several above, along with a diagram they gave us to show what fields were punched by which key on the punch machine. The machine used a hexadecimal numbering system, so we were expected to be conversant in base 16 -- delineated as 0-9 and A-F.

After keypunching, you would hand your batch of cards to the system operator, who would feed them into the computer. Depending on your priority in the queue, you would wait five minutes or an hour for the program to be compiled by the computer, only to discover that you had made a programming error, a keypunch error, or had a hanging chad on one of your punch cards. The problem, of course, is that you didn't know which of the three problems had occurred!

Class 1.00 is still taught at MIT. Here is the description of the 2005 class from MIT OpenCourseWare. Every one of those desktop computers you see in the picture has a gazillion times (whether in base 10 or base 16!) more capacity than the old IBM 360. By the way, Fortran still exists, but these kids get to use Excel and Java instead. Seems a bit too easy to me . . .

Welcome world!

It has been a while since I have taken the time to welcome readers from around the world. I am prompted to do so after glancing at my StatCounter statistics. Among the last 500 visitors I find viewers from Korea, Lithuania, Nigeria, Italy, Finland, Saudi Arabia, Kuwait, Ukraine, Germany, Thailand, Israel, Iran, Singapore, Indonesia, United Arab Emirates, Poland, Switzerland, Philippines, Sweden, South Africa, India, Pakistan, Denmark, Netherlands, Kyrgyzstan, United Kingdom, Turkey, and Canada (including Ontario, Alberta, British Columbia, and Quebec), and 26 states in the USA. (Don't worry. I don't know who you are personally, just the region where your ISP address resides.)

I am honored to have all of you as visitors. I think the issues we face in running hospitals here in the US are not very different from those in other countries, and I welcome your participation in our discussions. Both signed and anonymous comments are welcome, and we encourage perspectives from all over the globe.

Talking Turkish

We recently had a visitor from Turkey, who spent two weeks learning about our hospital. His hospital is about to go through a Joint Commission International survey. And, whaddayaknow, he posted our survey results on his new blog to give his folks an idea of what to expect.

White Christmas Pops

Lots of snowstorm stories from yesterday and last night. Here's one from my wife, who sings in the Tanglewood Festival Chorus and was on the roster to sing in two Boston Pops concerts yesterday. She was smart enough to take mass transit, rather than attempt the drive to Symphony Hall.

I got to Symphony just a little late, only to find something like eight people there ready to sing. It seems that the roads were gridlocked, and people were frozen there (pun intended). One person, for example, was on Boylston Street about two blocks above Symphony for about two hours. Stories were everywhere -- some people took four or five hours to go a few miles, others left their cars on the side of the road and walked or took the train. The record was a violinist who spent more than seven hours in his car. Keith Lockhart was being driven in and the car was stopped for hours in Kenmore Square. He just got out and walked the rest of the way.

They moved the concert up a half hour, and by that time there were about twenty-five singers (out of fifty) ready to do their thing. The orchestra, however, was very, very sparse. There were four first violins, four second violins, no oboes, one bass, no tubas, and no trumpets. It's hard to do a Pops concert without trumpets, and Keith moved around the music making the big trumpet pieces later on the program in hopes that some trumpet player would make it. Finally, we were doing Sleigh Ride (a piece by Leroy Anderson) that has a horse's "neigh" at the end which is done by the trumpet section. We were about half way through the piece when a lone trumpeter in street clothes made it to the stage door, came on stage, and played the neigh by himself!

Keith had the chorus and Santa go down into the seats with the audience to sing the audience sing-along. Needless to say, there weren't very many people there, so it was a cozy and friendly "sing." We were all wearing Santa hats, and one of the tenors gave his hat to a little boy. He kept it on the whole time, despite that fact that it kept falling down his face.

Less? More?

Retailers will hate this post by our CIO John Halamka, especially in these last days before Christmas, but his sentiments are very persuasive.

Community response

Kevin Cullen wrote this moving story in yesterday's Boston Globe. Yesterday afternoon, I received this note from our head of social work:

Even more moving than the story itself is the response that it has generated. We and the Globe have received dozens of calls from people who have seen the story and are offering either a room for this patient, or money to help him pay rent. This is a tribute to this patient, the staff who have worked tirelessly on his behalf and the generosity of strangers.

Is this progress?

Is this progress? You get to vote with your comments.

Three of my friends ate at Legal Seafoods in the Prudential Center last night. At the conclusion of dinner, the server came over and, with great enthusiasm, told them that their restaurant was the first in Boston to have a new feature. (I gather from this article that it has been in use elsewhere.) It was a handheld device, running off a wi-fi system, that permitted the customers to pay their check at the table with their credit cards. (It is roughly equivalent to the one you use at a grocery store checkout.)

Yes, you can still split the bill among two or three credit cards, but you need to calculate the tip in advance from the paper bill so that you enter the right amount into the keyboard for each person.

One of my friends was very excited about this approach. Another could not see why it provided any advantage from the customer's point of view. Her view was reinforced when she mistyped a number, tried to clear and reset it, and received a message saying she should wait for the server.

This approach has been described as a way to minimize credit card fraud because you never hand off your card and have it leave your sight. It also has been described as a way to boost server productivity and speed up table turnover.

What's your take? Good, bad, indifferent? I'll send along your comments to Roger Berkowitz... or maybe he reads this blog.

By the way, this makes me wonder: Should we have a grocery-store type device for collecting co-pays at our clinics? Today, the desk attendant has to complete your transaction for you.

Salgirah Mubarak!

Today is the Aga Khan's 71st birthday, and this year marks his Golden Jubilee celebration of 50 years on the throne of Imamat. The Aga Khan is the spiritual leader of the Ismaili Muslims, and looks after both the spiritual and material/secular well-being of his followers.

It is quite remarkable that any leader fulfills 50 years of service, and this gentleman has made major contributions to world peace and economic development.

Here is a clip from a Canadian broadcast wishing the Aga Khan a happy birthday. There has been a close relationship between the Ismaili community and Canada since the time Canada served as a refuge for Ismailis who were expelled from Uganda by Idi Amin in 1972.

PFL at MIT

I was recently honored to give the Brunel Lecture at the engineering school at MIT. It was entitled "Process Improvement in the Rarified Environment of Academic Medicine." It is now available for viewing on MIT World. The lecture has similar themes to the one I gave at the National Academy of Engineering. Some of you had trouble downloading that one, and so you can try this one if you are interested.

Physician Diversity -- Part 2

A continuation of my new series about promoting diversity among our physicians at BIDMC. Please take a moment to read the thoughtful comments offered by readers after the last post. One commenter questioned the validity of my premise that we want greater diversity, but I am going to proceed on the assumption that we do. Feel free, though, to offer alternative points of view. And please be sure to read Jon's comments on the topic, which gives a helpful national perspective on the pool of applicants to medical school and the resulting difficulty that presents as we move along the pipeline to residency programs.

I promised I would give you some numbers, and here they are, as of November 2007. Thanks to Dr. Rosemary Duda, the Director of our Center for Faculty Development, for assembling these.

We have 744 clinical residents spread throughout our 13 academic departments. As I mentioned below, the gender mix is excellent, but the percentage of underrepresented minorities is small.

Male -- 370 (49.7%)
Female -- 374 (50.3%)

White -- 464 (62.4%)
Black -- 26 (3.5%)
Asian/Pacific Islands -- 193 (25.9%)
Hispanic -- 33 (4.4%)
American Indian -- 0 (0.0%)
Other -- 28 (3.8%)

Here is the pattern among the 487 BIDMC research fellows. Some of these are MDs, and some are not.

Male -- 280 (57.5%)
Female -- 207 (42.5%)

White -- 215 (44.1%)
Black -- 7 (1.4%)
Asian/Pacific Islands -- 234 (48.1%)
Hispanic -- 17 (3.5%)
American Indian -- 2 (0.4%)
Other -- 12 (2.5%)

Acknowledging these numbers, our graduate medical education (GME) office has encouraged the creation and support of a BIDMC Diversity Committee, which is primarily a resident committee, but also has some faculty membership and mentoring. One of our fine young doctors, Sean Kelly, currently serves as faculty advisor and one of our BIDMC residents, Alden Landry, is serving as Chairman of the committee. They collaborate with the Office for Diversity and Community Partnership at Harvard Medical School and the minority affairs and diversity offices at the other HMS hospitals.

Rather than summarizing all their activities, I'll invite Sean and Alden and any other committee members and any of our other residents and fellows to post their own comments. I also invite people at other hospitals here in Boston or elsewhere to post their thoughts on the matter. What works? What doesn't? Are there success stories from elsewhere that can help inform our programs?

Drugs in the workplace

There was a piece in the New York Times Magazine in November entitled "Dr. Drug Rep" by Doctor Daniel Carlat who discussed the interplay of drug companies and physicians, and his own evolution concerning the appropriateness of aspects of that relationship. I thought it was a fascinating article.

Then, this past week, the Magazine published a letter to the editor from Dr. Amy N. Ship, a superb internist in our hospital's primary care practice. Here it is, in case you missed it. Strongly held beliefs, clearly presented.

Even without Dr. Carlat's delayed recognition of the positive spin Wyeth clearly expected him to put on its product, why did it take a year for him to realize that he was being paid and pampered to sell a product? How could he seemingly miss the obvious: that his M.D. and credentials provided for Wyeth a patina of legitimacy that its drug reps couldn't muster independently? Why did it take him so long (while he amassed $30,000) to see that his position was morally corrupt?

The "lessons" that he reputedly learned are not new or unique. I'm proud to work in a medical practice where pharmaceutical representatives are not permitted.

Downstream impacts

One of the great joys of teaching is to stimulate a student's interest in a topic and then hear, years later, how that might have contributed to career choices and positive impact on the world. Here's one such story. I am not sure there is a direct connection, but I like to think that I planted a seed.

Several years ago, I was asked to teach a group of seventh grade girls about sewage. Yes, I know what you are going to say, but I had just been running the local water and sewer agency, and their teacher wanted to cover an environmental topic, and so there I was. After making sewage in the classroom (details another time if you want them!), we took a tour of a local headworks. This is a facility in which lots of sewer pipes converge into long, open, deep, fast-flowing channels of wastewater en route to the local sewage treatment plant. While viewing this flow, one girl noticed some life preservers hanging nearby, and asked what they were for. I gave the obvious answer.

The next day, I received a note from her father, saying how much the girls learned on the field trip and relating an age-appropriate comment from his daughter, Amy: "Life preservers, Dad! I'd rather die!"

Well, that same Amy has just finished three years working for Environmental Justice for California Water Rights, where she lobbied all over the state for better drinking water for underserved communities. She helped get new water systems for some small Salinas valley communities, and she was instrumental in preserving water rights for the Winnemum Indian tribe in Shasta County. Here is an article describing some of her activities.

Thanks to Peter for the update, and best wishes to Amy and her colleagues in their pursuits.

"It happened the way I called it"

I just returned from my annual soccer (football) referee recertification clinic. I have been reffing since 1994 and many years ago upgraded from the entry Grade 8 to Grade 7. As best I can tell, the main difference between the two grades is that I now have to take an annual physical exam and also pass an annual written test. The passing grade for the latter is 85%, which I think means that it is acceptable to be wrong 15% of the time. (Hey, that's not bad. There was a period of time where the passing grade for nuclear power plant operators on the NRC's test was 65%. Let's not think about what that meant! That preceded Three Mile Island.)

One of the things I love about fútbol is that the rules we use are the same throughout the world. Theoretically, that means I could officiate a game in Brasil or Italia or Cameroon or Korea as well as a game here in Massachusetts. I say theoretically because there is no way I could keep up with the players there.

There is a joke among experienced referees that you go through three stages of self-confidence as you get more and more experience officiating matches. The first is when you are starting out and are insecure. A coach complains about a call, and you reply, "I'm doing the best I can."

After a couple of years, you gain self-esteem, and you reply, "I called it the way I saw it."

Finally, when you have the full degree of self-assurance, you reply, "It happened the way I called it."

Actually, though, what was clear among my teachers and colleagues today is that the more experienced referees reach a level of comfort at which they no longer respond so defensively to complaints about their officiating. There is more of an understanding that your job as referee is to make yourself as invisible as possible and let the game flow. In what other sport, for example, is there the equivalent of the "advantage" rule, where you intentionally do not stop play to call a penalty if the aggrieved team's possession of the ball is not harmed by the foul? Soccer is a passionate game for players, coaches, and fans, and it is the referee's job to let many of those passions roll of your back and enjoy the overall experience while ensuring an appropriate level of fair play on the pitch.

Benefit Dance concert in SoHo

LA-based Lineage Dance Company, which holds dance concerts to benefit non-profit organizations, is offering performances tonight and tomorrow in the Joyce SoHo in New York City to raise awareness about Brotherhood/Sister Sol. They will be performing the New York premier of "Dancing Through The Ages," which uses community members of all ages.

Physician diversity -- Part I

As my loyal readers know, I don't hesitate to brag about BIDMC when I think we are deserving, but I also write about areas where we need to improve. This is one of those latter topics. I can't cover it all in one post, so I will follow up with more in coming days and weeks.

Here's the issue. If you were to look at the mix of patients here, it would feel like a mini-United Nations in terms of the racial mix. But, if you look at the medical staff -- full-fledged physicians, fellows, and residents -- it looks different, with under-represented minorities being a very small percentage of our trainees and attending physicians. (By the way, on the proportion of men and women, the story is better.)

This is a general problem in medicine nationally (with little progress notwithstanding well intentioned efforts). It is a bigger problem in Boston than other places, and I believe it may be a bigger problem at BIDMC compared to some other places in Boston. "Why here?" is the question I'd like to explore with you, and I'll give you real numbers and other facts in future posts, along with how we are trying to do better.

For today, let's start with the beginning of the physician pipeline. Harvard Medical School does quite a good job in recruiting a diverse entering class. Here is an article from a few years ago documenting this, showing about 19% minority admissions. Those students spend a lot of their time in the Harvard hospitals (BIDMC, MGH, Brigham & Women's, etc) doing their clinical rotations. I think it is fair to say that they love the time spent at BIDMC because we have great teachers and give them a great educational experience.

Then the students apply for residency programs. The minority students are in great demand, and they do very well in terms of the "match" process that characterizes the residency selection program. Many HMS graduates want to stay in Boston, but there has always been a tendency among them to seek the residency programs that have greater prestige. MGH in particular has always been viewed that way. But the other thing that happened here from 1996 on was the financial disaster following the merger of the BI and the Deaconess. For years, the local pool of HMS applicants that might have been interested in BIDMC, including the minority applicants, essentially dried up. Simply put, they feared that this hospital would not be around much longer. So the primary source of minority medical students that were most familiar with our hospital and comfortable with our faculty basically disappeared. And since residents serve as a major source of faculty recruits going forward, if this pipeline dries up, you start behind in terms of expanding the number of young minority faculty members.

With the financial recovery of the BIDMC and the reinvigoration of our clinical and education programs, we are back to being seriously considered by HMS graduates as they apply for the residency training. That should help. But it does not address the full range of concerns.

In the next postings, I will cover more of this topic and also will move up the pipeline and successively cover junior faculty, senior faculty, and chief-of-service issues.

PFL at the NAE

Well, in case you are not sick of reading my stuff about process improvement in hospitals, you can get a real aural overdose in this speech I gave at a recent symposium at the National Academy of Engineering. It was the first chance I had to publicly consolidate my thoughts on the matter.

Sorry about some nerdy jokes at the beginning, but, hey, it was a talk to a group of engineers! (For ease of reference, the blog post on preventing ventilator associated pneumonia to which I refer in the speech is here. The BIDMC transparency website to which I refer is here.)

Running time is just over twenty minutes. Excellent listening as you catch up on emails . . .

Pursuing Perfect Care in Ohio

Several weeks ago, I mentioned the retreat we held with the BIDMC and BID~Needham hospital boards to review the role and scope of the governing bodies of our organizations, as a precursor to establishing audacious quality, safety, and patient satisfaction goals for the two hospitals. In just a few weeks, the two boards will meet again, and I will be able to report to you on the overall direction voted by them. In the following months you will be able track our progress towards exacting, quantified goals.

Several days ago, I had a chance to visit with a board member from Cincinnati Children's Hospital about their self-improvement process, entitled Pursuing Perfect Care. This has been an extraordinary program, pervading the entire institution, and achieving great results. A key aspect of the process has been utter transparency about the organization's progress towards its goals. Check this page for a summary of the operational definitions of the items that are measured and reported upon publicly. As I have noted elsewhere, transparency is not a matter of trying to create a competitive advantage for one hospital versus another. It is a way of holding one's own organization accountable to itself and to the public.

In the last several days, executives from several of the state's insurance companies have made suggestions regarding cost control of medical expenses in Massachusetts. As reported by our friends at Health Care for All, they suggested legislation that would include the following items:

1. Public Reporting of Preventable Errors and Prohibiting Billing for Avoidable Mistakes
2. Strengthening the Determination of Need Process
3. A Special Commission to Study State-Funded Stop-Loss Coverage
4. Allow for the Operation of Limited Service Clinics
5. Medical Malpractice Reform
6. Require Electronic Transmission of Health Care Transactions
7. Repeal Mandated Benefits that are no Longer Effective
8. Comparative Effectiveness Studies of Medical Services
9. Extend the Moratorium on Mandated Benefits
10. Permit Mandate-Lite and Mandate-Free Products
11. Hospital Reporting on Measures to Reduce Duplicative Diagnostic Services
12. Hospitals Reporting on Measures to Eliminate ER Diversions and Overcrowding
13. Make Greater Use of Managed Medicaid
14. Eliminate Duplicative Regulatory Requirements
15. Standardized Reporting Requirements
16. Streamline Administrative Processes
17. Standardize Physician Credentialing

Perhaps some of these might be good ideas in their own right, but they do not get at the underlying structural problem in the delivery of care in hospitals. This is not to say that hospital costs are the sole or main determinant of cost increases in health care, but they are admittedly an important part of the trend. We do not need to wait for legislation to make improvements.

The clear message from my colleague in Ohio was this: THE most significant step hospitals can take to improve cost-effectiveness is to reduce harm to patients in their institutions by adopting aggressive quality and safety goals, measuring their success towards them, and reporting on their progress to the public. Not that we should need an economic argument to do a better job for patients, but it is good to know that two go hand in hand. We intend to pursue this agenda with all due energy at BIDMC and BID~Needham.

Piling On

Someone at the health insurance plan associated with Boston Medical Center did something wrong. As reported by Alice Dembner in today's Boston Globe, BMC gave the impression in a letter to 2600 people that they would lose their ability to be treated at BMC if they didn't sign up with the hospital's insurance plan.

Now, let's all agree that this was a wrong and bad thing to do. (I think most of us would believe that it was the result of some lower level staff person writing a letter poorly rather than some dastardly plot to force 2600 people to use the hospital.) But what is the right response and the right remedy?

BMC immediately apologized and said they would take steps to make sure this doesn't happen again. Seems like enough to me.

But, no, first they get accused of "losing sight" of the purposes of the MA health reform legislation. Someone else asserts that BMC's actions are "all about money and not about health." Then, they have an investigation by the Attorney General to see if they violated the state's consumer protection law? What's next: Financial damages?

Folks, they made a mistake. This is the hospital that has stood tall for care of the indigent for years. If we make (perhaps literally) a federal case about every glitch and error that occurs in implementing a highly complex state law, we only succeed in generating cynicism and ill will that will ultimately undermine this noble experiment.

A note from the interns

For those of you who wonder whether young people who choose medicine still care, please read this note from three of our interns to the nurses on the oncology (including bone marrow transplant) units with whom they worked during their month-long rotation on those floors. (And, of course, it says something really nice about the nurses, too!)

As we're finishing up our last few hours on BMT/OMED, we want to thank you for all your help in the past month. We started with three consecutive code blues in our first week, and it has been a tough five-week block for us interns. But we have learned a lot from the patients and you guys. Thank you for showing us the ropes, for always being the most fervent advocates for the patients, for being so responsible, responsive, and prompt to remind us when we forgot to order labs or TPN. Thanks for your patience, your smiles, and, many times, your food!

We wish we knew more medicine, more ways to relieve pain, more treatment strategies so that our patients could have a few more months with their loved ones. We wish we could have done something differently so that the patients didn't have to spend Thanksgiving evening with us. We wish that we didn't have to tell so many twenty-two-years-old the new diagnosis of lymphoma, that we didn't have to announce so many deaths. We wish we could have helped you guys more in your care for the sick.

Thank you for everything.

Endowment Policies

Here is a thoughtful article on the issue of endowments written in response to suggestions by some in Congress that universities and other large non-profits should be required to spend 5% of their endowment each year. As noted by the authors, this would be bad policy. (Note: I serve on the MIT Corporation, along with Mr. Mead.)

Don't Require Colleges to Spend More of Their Endowments
By DANA G. MEAD and JEREMY M. JACOBS
Chronicle of Higher Education
November 9, 2007

The demand for higher education and academic research ­and the costs of providing them has risen in recent years, and the search is on for easy answers to limit the financial burdens on families and the government. The most recent suggestion has been to require colleges and universities, especially large and prestigious ones, to spend more of their endowments. Congress, for example, is considering a proposal to require institutions with big endowments to spend at least 5 percent of that money each year, the same percentage that nonprofit foundations are required to spend.

So why don't universities spend as much as they can of their endowments to stop tuitions from rising, or to allow more low-income students to attend college, or to reduce the need for federal investment in scientific research?

The short answer is, they already do.

We serve as chairmen of the boards at two of our nation's most-important research universities. As taxpayers, business people, parents, and citizens, we strongly support the goals of making college affordable, aiding low-income students, and conducting research. And as board chairs, we know that endowments are used for precisely those purposes and more. Last year alone, America's colleges and universities spent more than $15-billion from their endowments to subsidize tuition, make college inexpensive or free to millions of students, raise the quality of education, conduct research, and otherwise improve the services that they provide to students and society. On average higher-education institutions spent 4.6 percent of their endowments last year.

Why don't we spend more? In part, it is because we can't. We have a legal and moral responsibility to honor our donors' wishes and ensure that our institutions' endowments are at least as strong 10, 20, and 50 years from now as they are today, so that they can serve the needs of students and society then as they do now. We take few of our responsibilities more seriously than the stewardship and strengthening of our institutions' endowments.

Indeed, for more than three centuries, endowments have helped colleges and universities assist students, conduct research, construct new facilities, hire faculty members, and carry out a host of other activities that would not have been possible had they relied solely on tuition and government support.

An endowment is typically made up of numerous different funds contributed by separate donors. Individuals, businesses, foundations, and others are exceedingly generous to colleges and universities; in the 2006 fiscal year alone, they provided $28-billion in contributions. People contribute for a variety of reasons: out of loyalty, because institutions are an important part of their community or state, or simply because they believe in the missions that the colleges are supporting.

Most of those donors are, in fact, fairly specific about their objectives. They might direct the money to research on a specific disease, to the establishment of a faculty position in a particular area of studies, or to financial aid for students. Institutions appreciate their generosity, and they are legally and ethically bound to honor a donor's intent.

Moreover, donors also usually specify that they want their generosity to produce benefits for many years to come. They want their contribution managed so that some of the earnings are spent, while the rest are reinvested to ensure that the endowment rises enough to let the annual payout keep pace with rising costs ­ in good economic times and in bad.

For example, a donor contributes $1-million to create a permanent fund for cancer-related research. She wants the fund to produce research support that keeps up with inflation, regardless of the markets' performance. To do that, the fund must grow larger, even as it is paying out a steady stream of research dollars. Recall Joseph's advice to the Egyptian pharaoh to store grain during the coming seven years of abundance to feed his people during the drought that would follow. Endowment managers reinvest revenues earned during years of abundance to ensure that spending can keep up with inflation during the lean years, when markets are not so friendly.

The issue is not only one of donor intent, however. Between us, we have served on dozens of corporate, university, foundation, and other boards. In each of those positions, we have shared with our colleagues management and fiduciary responsibilities for multimillion-dollar or even multibillion-dollar corporations and other institutions. An essential part of our stewardship of those institutions has been to ensure that they are at least as strong in the future as they are today. Robust endowments are crucial to sustaining colleges' high-quality education and research.

Endowments are, in fact, providing increasing support for current activities. Among the colleges with large endowments, about one-third of annual operating revenue comes from endowment spending ­ and at Harvard, for example, that figure has grown from 21 percent just 10 years ago, while at Yale it has almost doubled.

For many higher-education institutions, endowment spending is the single largest source of revenue ­ more than tuition, research grants, and clinical income from medical schools. Some institutions with large endowments have undertaken bold initiatives on student aid; Princeton University, the University of Pennsylvania, and the University of Virginia, for example, have made a college education virtually free for students from low-income families, as well as those from many middle-income ones. Endowment revenue is also indispensable for investments in academic programs that make American universities the envy of the world.

Endowments have grown significantly in recent years, despite what they spend, and that is a good thing. It helps ensure that colleges and universities have the resources to continue to improve and contribute to the well-being of our society. Much of the growth has been a result not only of increased donations but also of sound financial management. But to update Joseph, and paraphrase the warning investors have heard many times, recent growth of investments is no guarantee of future performance. Indeed, average endowments declined nearly 10 percent between 2000 and 2002. Institutions would be irresponsible if they assumed that investment returns will always grow rapidly. And endowment managers are under no illusion that they will.

Strengthening higher education and research in both the short term and the long term is important to our nation's well-being. Forcing endowments to spend more quickly might help in the short run, but it's a recipe for long-term weakening of a major national asset. Too often we see the government ignore long-term needs to address short-term goals. It shouldn't force us to do the same.

Dana G. Mead is chairman of the Corporation of the Massachusetts Institute of Technology, of which he has been a member since 1996. He was chairman and chief executive officer of Tenneco Inc. from 1994 to 1999. Jeremy M. Jacobs is chairman of the Council of the University at Buffalo, State University of New York, and chairman and chief executive officer of Delaware North Companies.

Revisiting the Stark Laws

David Whelan, at Forbes, has posted a very interesting interview with Congressman Pete Stark about the "Stark laws" passed in 1989 and 1995. These laws control many relationships between and among doctors and hospitals. The interview is worth reading. I think it is really hard to write legislation in the health care arena that does not have some unintended consequences. The field is so complex that it is unlikely that even a well written bill won't have unforeseen effects in one or another sector.

French Toast Alert

The French Toast Alert graphic on the right is a gift to the blogging world from AdamG at UniversalHub.com. It is spreading to websites throughout the region, as we all make our contribution to the health and security of the Greater Boston area in the face of the dastardly threat of (ohmygosh!) snow in New England. Please click and read so you and your loved ones will be prepared.

Darn, too late to vote for Pier Paolo!

Our own Dr. Pier Paolo Pandolfi, a world expert in cancer research, was nominated for the Italian periodical Home Men's Health Man of 2008 competition. His rivals included model David Gandy, "surfista" Ryan Heavyside, basketball player Danillo Gallinari, Olympian Andrew Howe Besozzi (shown here) -- and other hulks. As well as assorted folks from other fields.

Unfortunately, I received word of this too late to vote -- and, more importantly, too late to ask all of you to vote also and create a landslide.

Please note that the periodical's subtitle is "il piacere di essere uomo", which Alta Vista translates as "the pleasure of being a man." I have not asked Pier Paolo if that is his personal motto, but we have nonetheless inscribed it over the door of his laboratory, as our belated tribute to his being nominated. Congratulazioni!

Hook, line, and sinker

Restaurateur Ana Sortun led a small group of us on a shopping tour today of several of Watertown's Armenian groceries. (She generously donated her time as a prize in a charity auction we had attended for one of Boston's great music ensembles.) While we were keeping warm in the back of Sevan Bakery, Ana led us through her shopping list and explained the variety of spices, vegetable, dried goods, canned goods, frozen foods, dairy, and deli that we were about to see, feel, smell and taste.

First, though, she offered us a prosaic* depiction of spices, explaining that each particular mix of spices in the world's cooking provides an arrow in the atlas in terms of the food's location and culture. She also depicts each particular mix as the "source of craving" that we might have for different types of food -- Middle Eastern, Greek, Mexican, and so on.

Then, to prove the point, we were told about and got to experience za'atar, the wonderful blend of herbs -- with distinctive varieties from Jordan, Syria, Israel, Turkey, Lebanon and elsewhere. Za'atar also refers to one of the herbs itself, a hyssop related to thyme, but with a flavor that is a cross between thyme and oregano. It is dried and blended with sesame seeds and sumac, which itself is cured with salt. The resulting flavor, notes Ana, catches you "hook, line and sinker" and is one of those things that creates cravings ever after. There was total agreement in our group after our taste test!

That being said, my favorite was muhammara, a mixture of crushed red pepper, ground walnuts, pomegranate molasses, and olive oil. Put that on your pita bread and taste it.

Did I mention that Ana has a cookbook, appropriately entitled Spice: Flavors of the Eastern Mediterranean? If you are really lucky, you live in a city like Los Angeles or Boston, where there are large Armenian communities where you can readily find the ingredients.

*Eek! See comment below and offer substitutes for this word, please!!!

Supporting the Troops

One of our staff members had a great idea, which we immediately put in place. Here's the description below in my email to the entire hospital. I post it here (without the actual link) as a suggestion to other organizations, hospital or not, as to something that you might want to consider. (I am also posting some of the first comments back from staff so you can see reactions.)

Subject: Holiday Letter Campaign to Support the Troops

The holidays are a time when families come together. But for active military personnel deployed overseas the holidays can be especially lonely and difficult.

Many of you support the troops on your own, but here’s a chance for BIDMC to help brighten the season for our colleagues and family members serving overseas. Let’s gather the names and addresses of all BIDMC employees and staff, as well as any of our family members, who are deployed on active military duty. We can then make that list available on the portal for anyone interested in sending out a holiday greeting.

We need to act fast to make this happen.

If you know the name and mailing address of a colleague or family member serving in the military, please click this link to fill out a form that includes the full name and mailing address of the service person being honored, as well as what department you work in and your relationship to this person.

This form will also be available in the BIDMC Today news section on the BIDMC Portal where we will post the names, addresses and information (we will start the postings early next week.) The rest is up to you.

Thanks to John Donaher, RN, Deac-4, for suggesting such a great idea.

Here are three replies:

Although I don’t have a loved one serving in the military I think this is a wonderful gesture and I hope many will rise to the occasion. I recently heard a piece on NPR about the recent push to email military holiday greetings and the press officer being interviewed stated that many personnel will never see those emails and the old fashioned letter is warmly received by those on active duty. For me, I will get names from the BIDMC Today next week to ask my 4th grade Girl Scout Troop to write letters at our meeting next Tuesday.
Ideas like this make BIDMC all the more human.
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Thank you Paul, this is a wonderful idea. As a former military member this will really mean a lot to anyone who receives a greeting. Thanks!
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What a wonderful idea. I am blessed to not be personally impacted with family there but will happily send some cards & get my kids to do some art work. Thanks for the avenue to make it happen.