Wednesday, February 28, 2007
I was in the Kenmore MBTA station tonight, looking at the local street map installed inside the station. I think this was installed when the Green Line was upgraded in the 1970s, when I was still in college, and so it is a bit out of date. The current "mistakes" in the map reflect the growth and changes in the academic and medical complex in the Longwood area.
There are some names that are unchanged, mainly the colleges and schools -- Wheelock, Simmons, Emmanuel, Winsor, Boston Latin, Harvard Medical School.
But there are some that no longer exist, in name or at all -- Hospital of the House of the Good Samaritan; Peter Bent Brigham Hospital; Jimmy Fund Research Lab; State Teachers College of Boston; Boston English High School; New England Deaconess Hospital; Beth Israel Hospital; Sears Roebuck and Company; Children's Hospital Medical Center; Boston Lying Inn Hospital; Joslin Clinic.
Today, these hospitals are Beth Israel Deaconess Medical Center; Brigham and Women's Hospital; Dana Farber Cancer Institute; Children's Hospital; Joslin Diabetes Center. And Sears is now the Landmark Center.
Some trivia, as noted by MASCO. The Longwood area is 213-acres formed by the Riverway, Fenway, and Huntington Avenue. More than 37,000 people work within this area, 15,000 students attend school here, and each year more than two million patients visit the area's hospitals for medical care. This small area generates over $3.4 billion in annual revenues. It is truly one of the economic engines of the city and regional economy.
... and apparently, it never stands still.
The little girl on the television screen was brave and determined. She smiled and waved from her hospital bed before surgery at St. Louis Children's Hospital. Her family sat nervously in the waiting room as television news cameras captured 9-year-old Cindy Young's story.
Cindy's surgeon, Dr. Douglas Hanto, also believed Cindy deserved the best. "In this day and age, we cheapen life by saying some people are more entitled for certain types of health care than others," Hanto said on television. "Although Cindy has Down syndrome, she is still a very happy girl who leads a relatively normal life, and I think she deserves the best we can give her."
Before Cindy's surgery in 1987, a St. Louis television station interviewed Hanto, who is now the chief surgeon in the Division of Transplantation at Beth Israel Deaconess Medical Center in Boston. "There have been cases when children with Down syndrome or other serious handicaps were allowed to die" because of debate over how far care for mentally or physically handicapped children should go, he said in the interview.
Tuesday, February 27, 2007
Here are just a few major company CEO blogs:
Jonathan Schwartz, CEO and President of Sun Microsystems -- http://blogs.sun.com/jonathan/
Bill Marriott, Chairman and CEO of Marriott International -- http://www.blogs.marriott.com/
Rick Wagoner, CEO, and assorted executives, General Motors -- http://fastlane.gmblogs.com/
Bob Parson, CEO and Founder of goDaddy -- http://www.bobparsons.com/
David Neeleman, CEO of Jet Blue -- http://www.jetblue.com/about/ourcompany/flightlog/index.html
Of course, someone has created a wiki with a full worldwide list. Other than Nick's blog from Windber Medical Center, listed to the right, I have not seen many from the health care provider or insurance companies.
And, in case any of us need help, Debbie is available to give CEOs advice on how to write blogs!
And, a fellow named Seth, who suggested in 2004 that the last thing we need is more CEO blogs, unless they are based on candor, urgency, timeliness, pithiness and controversy. Golly, I need to work on that controversy part!
Monday, February 26, 2007
I am trying to figure out how well this ad works, and I welcome your thoughts.
Here's my perspective. First, I am a capitalist, and I believe that firms and hospitals and others have a right to advertise, subject to normal societal rules about content and accuracy. So, you won't find me saying that ads of this sort are immoral or unethical -- although I truly understand why some people believe that. Second, I am always curious to understand why an ad has been placed, why it has been designed the way it has, and what the target audience is.
So, I look at this ad for an ICD, and I try to figure out what the point is. Is the ad designed to tell people with heart problems about ICDs? It seems to be written that way -- "If you've had a heart attack, or have heart failure, an ICD could make a big difference" -- but how can that be? Surely, anyone who has severe enough heart disease to warrant an ICD is highly likely to have been told about this option by his or her doctor. Is it worth the money for an ad campaign for the small number of patients who might not have heard about this option?
Is the ad designed to get a patient to ask for a Medtronic ICD from the doctor, as opposed to one from another manufacturer? A minor possibility, I guess, although I am guessing that the MD already has a favored technology that he or she will choose for the patient.
Is it designed to get cardiologists to choose a Medtronic device over another company's? I doubt it, at least in this magazine. Not that cardiologists might not read USN&WR, but I can't see it as their trusted source of information on cardiac devices. Also, this ad is clearly targeted to lay people -- "An ICD can give you more time to do the things you love with the people you love."
Is it designed for the general public, to place a subliminal message in our brain for years hence, when we might develop heart disease, that it is a Medtronic ICD on which we should insist? I doubt it, for I do not believe that ads have that kind of permanence in our memory.
So, I guess I just don't get it, and I am asking for your help. What do you think is the purpose of this kind of ad? And, do you think it is effective in accomplishing that purpose?
(Please, I am really asking these questions because I don't understand. I have no hidden agenda. This is not a critique of this company, this product, or (as mentioned) our economic system! I am hoping that doctors, patients, or manufacturers out there can offer insights to us all.)
Saturday, February 24, 2007
A friend of mine (I'll alternate genders to help maintain confidentiality) recently found herself in this situation. By any measure, this person is an excellent physician. She has impeccable clinical judgment when it comes to both diagnosis and treatment. She has superb interpersonal skills and bedside manner. She is highly respected by her peers, by the nurses, and by all who know her.
Recently he found himself as a defendant in a malpractice lawsuit. The details and merits of the case don't matter all that much. The patient had been under his care for many, many years and was always satisfied with the quality of care offered. After the patient died, the patient's children sued.
Even though she knew that she had done nothing wrong, my friend's main emotional response to the lawsuit was that she was ashamed. She did not want anyone to know about the case -- whether colleagues in the hospital or social friends. I was stunned. Without knowing any of the evidence in the case, I was confident that this doctor had done her best in treating another human being and would be appalled to think she had done anything to create harm. I also knew this person to be as well trained and well intentioned as anyone I could imagine.
And, yet, he felt shame in being named as a defendant in a case that accused him of negligent treatment.
As I talked to other doctors, I learned that this was a common reaction to such lawsuits. Another friend talked of the scars left from a case 20 years ago. He was found not to be at fault, but he could still vividly recall the weeks of shame he felt while the case proceeded.
What is it that makes doctors respond in this way? Are they so naive about the legal system that they are not able to absorb its brickbats with equanimity? After all, people in other fields are sued all the time, and while they feel many emotions, usually shame is not at the top of the list.
I think it is this. Doctors devote their lives to alleviating human suffering caused by disease. They spend decades in training. They disrupt their family lives to be available to help others. For them, this is a calling. It is not part of their life. It is their life. They measure their worth to their community and ultimately value themselves by their unfettered dedication to this cause -- and by society's appreciation for it.
A malpractice claims shatters this construct. In the doctor's mind and heart, it says, "Society does not value all that I have devoted my life to. They do not believe I am worthy of trust that is granted to me, notwithstanding the effort, energy, and dedication I have given to this calling." And perhaps he even says, "Maybe I am not really as good a doctor or as good a person as I think I am."
For someone who has spent his or her whole life basking in the gratitude and admiration of individuals and society, this can be a devastating experience. Even when the verdict is issued, clearing the doctor of all wrong, it can leave a terrible scar.
As this particular case proceeded, I was really pleased to see an evolution in the doctor's feelings. After watching the opposing witnesses misrepresent the clinical evidence in the case, she got really, really angry. Her sense of shame evaporated. It was replaced by an outrage that the patient's children, the plaintiff's lawyer, and members of her own profession were causing her to spend hours away from the care of other needy patients. With the arrival of anger, her confidence returned.
Sure enough, he was cleared of all allegations. He came back to work, and I was heartened to see that caring smile return to the floors of our hospital. I hope he never has occasion to feel unwarranted shame ever again.
Among the hundreds of emails I get each day, there are inevitably the "funny" jokes and stories people send me, but there are actually some good ones, too.
I am going to take a chance of alienating you, my loyal and/or new readers, with just a few of my favorites. I hope you like them, but I hope you won't hold it against me if you don't. At worse, it will help you understand the underlying personality disorders of this particular hospital CEO . . . .
Reporters interviewing a 104-year-old woman: "And what do you think is the best thing about being 104?" the reporter asked. She simply replied, "No peer pressure."
... at a science presentation by the 8th grade today, we learned that overexposure to helium "can make you die and then have brain damage."
Two diary entries. His & hers.
Tonight I thought he was acting weird. We had made plans to meet at a bar to have a drink. I was shopping with my friends all day long, so I thought he was upset at the fact that I was a bit late, but he made no comment.
Conversation wasn't flowing so I suggested that we go somewhere quiet so we could talk. He agreed but he kept quiet and absent. I asked him what was wrong; he said nothing. I asked him if it was my fault that he was upset. He said it had nothing to do with me and not to worry.
On the way home I told him that I loved him, he simply smiled and kept driving. I can't explain his behavior; I don't know why he didn't say I love you too. When we got home I felt as if I had lost him, as if he wanted nothing to do with me anymore. He just sat there and watched T.V. He seemed distant and absent.
Finally, I decided to go to bed. About 10 minutes later he came to bed, and to my surprise he responded to my caress and we made love, but I still felt that he was distracted and his thoughts were somewhere else. He fell asleep - I cried. I don't know what to do. I'm almost sure that his thoughts are with someone else. My life is a disaster.
Today, the PATRIOTS lost, but at least I had sex.
A lady was picking through the frozen turkeys at the grocery store, but she couldn't find one big enough for her family. She asked a stock boy, "Do these turkeys get any bigger?" The stock boy replied,"No ma'am, they're dead."
A man had 50 yard line tickets for the Super Bowl Game.
As he sat down, a man approached him and asked him if the seat next to him was available.
"Yes," he said sadly, "the seat is empty".
"This is incredible", exclaimed the man. "Who in their right mind would have a seat like this for the Super Bowl, the biggest sports event in the world, and not use it?"
Somberly, the man replied, "Well... the seat actually belongs to me. I was supposed to come here with my wife, but she passed away. This is the first Super Bowl we have not been together since we got married in 1967."
"Oh I'm sorry to hear that. That's terrible. But couldn't you find someone else - a friend or relative or even a neighbor to take the seat?"
Shaking his head he replied, "No. They're all at her funeral."
I recently picked a new primary care physician. After two visits and exhaustive lab tests, he said I was doing "fairly well" for my age.
A little concerned about that comment, I couldn't resist asking him, "Do you think I'll live to be 90?"
He then asked, "Do you smoke tobacco or drink beer or wine?"
"Oh no," I replied. "I'm not doing either."
Then he asked, "Do you eat rib-eye steaks or barbecued ribs, or any of those types of meats?"
I said, "No, my other Doctor said that all red meat is very unhealthy!"
"Do you spend a lot of time in the sun, like playing golf, sailing, hiking, or bicycling?"
"No, I don't," I replied.
He asked, "Do you gamble, drive fast cars, or have a lot of sex?"
"No," I said. "I don't do any of those things."
He looked at me and said, "Then why do you care how long you'll live?"
In honor of Spring Training:
A Red Sox fan used to amuse himself by scaring every Yankee fan he saw strutting down the street in the obnoxious NY pinstripe shirt.
He would swerve his van as if to hit them, and swerve back just missing them.
One day, while driving along, he saw a priest. He thought he would do a good deed, so he pulled over and asked the priest, "Where are you going Father?"
"I'm going to give mass at St. Francis church, about 2 miles down the road," replied the priest.
"Climb in, Father! I'll give you a lift!"
The priest climbed into the rear passenger seat, and they continued down the road.
Suddenly, the driver saw a Yankee fan walking down the road, and he instinctively swerved as if to hit him. But, as usual, he swerved back into the road just in time.
Even though he was certain that he had missed the guy, he still heard a loud "THUD".
Not understanding where the noise came from, he glanced in his mirrors but still didn't see anything.
He then remembered the priest, and he turned to the priest and said, "Sorry Father, I almost hit that Yankee fan."
"That's OK," replied the priest, "I got him with the door."
And, finally, reflecting my MIT nerdish upbringing:
Q--Why did the chicken cross the Moebius strip?
A--To get to the same side.
Werner Heisenberg is pulled over by a traffic cop.
Cop--"Do you know how fast you were going?"
WH--"No, but I know exactly where I am."
Friday, February 23, 2007
Blog tests hospital leaders' patience
Beth-Israel CEO jabs competitors
By Liz Kowalczyk, Globe Staff February 23, 2007
There are some things that Boston hospital executives generally believe are best kept quiet. Gripes about competitors are one. The rates of hospital-acquired infections among patients are another, at least at this point.
Then came Paul Levy's blog.
He challenged other hospitals to publicize their infection rates.... The Globe asked several other Boston teaching hospitals if they would release their monthly central line infection rates, which they have collected internally for years. They all said no, at least for now, but added they expect to in the near future.
In his blog, Levy also has needled Partners HealthCare, the parent organization of Mass. General and Brigham and Women's, about their formidable market share of patients, saying they get paid more from insurers because of their size.
Partners executives declined to comment. "What's a blog?" said chief operating officer Thomas Glynn when asked about Levy's blog.
Spokeswoman Petra Langer said that overall, people at Partners are not a blogging group. "They're too busy," she wrote in an e-mail.
Thursday, February 22, 2007
Wednesday, February 21, 2007
More seriously, a state-sponsored website could be set up for a few thousand dollars. In fact, I will donate the time of our Chief Information Officer to design the site. Hospitals could voluntarily post their data on three or four categories of infections (e.g., ventilator-associated pneumonia, ICU central line infections) along with any explanation they would like. The public could then watch each hospital's progress month to month and year to year.
This is not a game to compare hospitals one to the other: It is a crusade to see how each hospital improves its own processes. So, Valerie, you don't have to have a standard across all hospitals. Sure, that would be an added bonus, but if you wait for that, you will wait for a long, long time. And, Nancy, the internet obviates the need to have a one-size-fits-all standard.
Don't you have enough faith in the public to let them see what they will actually experience in our hospitals?
State eyes hospital infection reports
By Jessica Fargen, Boston Herald Health & Medical Reporter
Wednesday, February 21, 2007 - Updated: 04:01 AM EST
Patients may soon be able to shop for the safest hospitals thanks to a new $1 million public health plan that will make rates of deadly infections at Bay State medical centers readily available to the public for the first time.
The Department of Public Health team, which has enlisted 50 experts and surveyed 73 hospitals so far, expects to make recommendations in June on how to reduce life-threatening in-hospital infections and put in a place a plan to make the rates public, officials said yesterday.
Paul Levy, president of Beth Israel Deaconess Medical Center, created a big stir recently when he posted the hospital’s infection rates on his blog and encouraged other hospitals to follow suit without a complicated state mandate.
“Wouldn’t it be easier to try it out voluntarily - see how it goes?” he told the Herald. “My point is these numbers are available in real time. We all keep track of it. All the state has to do is set up a Web site and let us enter our data.”
But public health officials are taking a more measured approach, hiring experts, doing research and surveying hospitals.
“Just the nature of the patients, the case mix of patients means that there is not a one-size-fits-all solution to the problem,” said Nancy Ridley, director of the Betsy Lehman Center, which is leading the project with the DPH.
Massachusetts General Hospital spokeswoman Valerie Wencis echoed that concern, saying the hospital won’t post its rates until it’s mandated.
“You have to have a standard across all the hospitals,” she said. “That’s something that needs to be taken into consideration before rates would be put online or made public.”
Tuesday, February 20, 2007
The da Vinci system combines computer and robotic technologies and takes surgical treatment to the next level. Here's how it works.
As a surgeon prepares to perform a procedure using da Vinci, he or she sits at a console in the operating room that is often several feet away from the patient....
Because da Vinci magnifies images and its robotic arms follow the slightest movement of the surgeon's hands and feet (sometimes used to refocus the camera or adjust a robotic arm), da Vinci enhances dexterity, precision, and control during surgical procedures. da Vince can also scale down hand movements when the tiniest cuts are needed and eliminates hand tremors, which further enhances the technology;s precision.
A doctor at Westside says, "It offers excellent outcomes and a quick recovery, as well as many other advantages for today's on-the-go citizens -- all in the comfort of their community."
da Vinci is being set forth as the state-of-the-art approach to urological surgery, particularly prostatectomy (removal of the prostate.)
In a posting below, I set forth the current knowledge about the relative benefits of laparoscopic versus open prostate surgery. Suffice it to say that there is not a clear winner. Just so, too, in the case of regular laparoscopic surgery versus robot-assisted laparoscopic surgery.
So, in the absence of clinical evidence that the robot is better, what is going on here? Here's the answer, as set forth so clearly by Nancy Schlichting, President and CEO of the Henry Ford Health system in Detroit:
We've seen double-digit increases in the number of prostate cases performed since we introduced the da Vinci Surgical System.
And by the manufacturer:
The following are three examples of hospitals that have captured market share with the da Vinci Surgical System. These organizations have established a leadership position within their communities and have achieved a significant return on investment.
In short, what we have here is a new technology, with no proven advantage in terms of clinical results, that is rapidly moving forward in hospitals because urologists and their hospital administrators have become convinced that their market position depends on owning this robot. It apparently has worked as a marketing plan.
Since its first da Vinci System shipment, Intuitive Surgical has expanded its installed base to more than 300 academic and community hospital sites, while sustaining growth in excess of 25% annually.
Boston has not been immune from this land rush. Boston Medical Center recently bought this machine. The verdict from their surgeon: "Dr. Richard Babayan, chairman of urology at Boston Medical Center, said he's found no difference in continence rates in the 30 robotic cases he's done, compared with traditional surgery."
Notwithstanding the lack of evidence of enhanced clinical efficacy, I have been advised the following by one of our leading doctors:
Due to market forces beyond any of our control, the unfortunate reality is that without a DaVinci robot, BIDMC prostatectomy volume would likely plummet by 2010 and BIDMC would consequently quickly become a non-entity in regional prostate cancer care. This would have dire consequences for BIDMC clinical urology, radiology, radiation oncology, medical oncology, as well as for research in translational oncology. It is unlikely that [we can] fully gauge the breadth and depth of collateral damage that absence of a daVinci robot would bring to our medical center.
Why do I feel like the American Congress several years after President Bush promised them that Iraq had weapons of mass destruction?
Here you have it folks -- the problem facing every hospital, and especially every academic medical center. Do I spend over $1 million on a machine that has no proven incremental value for patients, so that our doctors can become adept at using it and stay up-to-date with the "state of the art", so that I can then spend more money marketing it, and so that I can protect profitable market share against similar moves by my competitors?
I welcome advice from those of you out there who care about the cost and quality of health care, but also from those of you in other business sectors who make choices like this all the time.
Monday, February 19, 2007
Saturday, February 17, 2007
Here is my view. First, let me address the last point. I plead guilty to being highly competitive, but I took over a hospital that was almost driven out of business, both by bad internal management and by aggressive actions taken by other hospitals in town. I think the people at BIDMC -- and I mean everybody -- doctors, nurses, techs, housekeepers, transporters, and food service workers -- have something important to offer the community. I dearly want our place to thrive so they can deliver on that promise, and I will look for a competitive advantage where I can find it.
John McDonough, on the Health Care for All blog, has suggested that high quality care can be a competitive advantage. Maybe, maybe not. I do know, however, that some other hospitals in town can ride on their reputation, rather than on their comparative performance. I also know that some other hospitals in town are reimbursed by insurers based on market share, rather than on quality of care. If people are given accurate data on quality and safety, and if these perceptions and patterns shift as a result of that transparency, so be it.
But I believe that the more important issue for all of us running hospitals, and especially academic medical centers, is that our standing as institutions in American society is in jeopardy. In many respects, people do not trust that we are there to serve them carefully and efficiently. Some think, too, that we do not have proper respect and concern for our workers. Some also think that we do not have sufficient involvement in the community. Here in Boston, the hospitals are now the largest corporations in the city, in terms of staffing, revenues, physical facilities, purchasing, energy use, and the like. By virtue of that standing, we are now expected to meet a higher public standard than has ever been the case.
I know that the people at BIDMC are trying to meet that higher standard. We may falter, and we will make mistakes (sometimes really bad ones), but we are setting ourselves to carry forth the legacy of our two antecedent institutions, the New England Deaconess Hospital and the Beth Israel Hospital.
The description of the Deaconess -- "where science and kindliness unite in combating disease" -- was also the watchword for Beth Israel. Fortunately, the combined institution that resulted from the merger ten years ago maintains that set of values. BIDMC stands as a place where patients know they will be treated with warmth, friendliness, respect, and dignity. We do our best to treat each person as we would want a member of our own family to be treated. This is not just a saying: It is part of the culture of the place, and we deliver on that promise every day and night in the great majority of cases. We aim to continue to show our patients that level of caring and respect.
But this has to be combined with excellence in the delivery of patient care -- and particularly minimizing the probability of causing harm to patients. Clinical quality emanates from the judgment and experience and skills of world-class doctors working with world-class associates like nurses and technicians. But even that expertise sometimes needs help and new management approaches to overcome systemic problems in the organization. As I have tried to reflect in the postings below, we have aspirations to be as good as we can possibly be in that arena. We believe that public disclosure of our progress is one tool in reaching those aspirations.
I hope you agree that more widespread disclosure by all the Boston hospitals would enhance the performance of us all and would build public confidence in the great academic medical centers in our community. I like to think that we will eventually live up to the expectations set forth so clearly by Patient Dave in his heartrending comment on the posting below:
NOBODY has more right to that information than the patient in need. NOBODY.
This is REALLY personal, believe me. If we can easily get info on the best used cars (hardly a matter of life and death), we certainly ought to have free access to information on who has high and low outcomes and accident rates.
We owe it to ourselves and the community to make sure Dave and all other patients get what they need.
Friday, February 16, 2007
This month's figure covers 1853 patient days. If we had had our previous average of "3" in January, five to six people would have had an infection. Statistically speaking, one would have likely died. It could have been anybody's mother, father, sister, brother, daughter, or son. It is MUCH better this way! Let's see if we can keep it going.
Month ----- Infection Rate
Oct 05 ----- 1.67
Nov 05 ----- 1.28
Dec 05 ----- 2.43
Jan 06 ----- 3.07
Feb 06 ----- 1.40
Mar 06 ----- 1.07
Apr 06 ----- 0.00
May 06 ----- 0.59
Jun 06 ----- 1.15
Jul 06 ----- 0.57
Aug 06 ----- 3.03
Sep 06 ----- 2.50
Oct 06 ----- 0.00
Nov 06 ----- 2.38
Dec 06 ----- 1.87
Jan 07 ----- 0.00
Can I ask a question? If I can post these rates for BIDMC, why can't people from other hospitals? Cleve, Charlie, and Jim: Why can't the insurance companies (Blue Cross, Harvard Pilgrim, and Tufts) post them? Governor Patrick and Secretary Bigby: Why can't the state of Massachusetts? And, where are the public health advocates on this topic? As I have shown, the data are collected regularly. I am seeking no competitive advantage here. This is an attempt to get past a culture of blame and litigation and persuade people that transparency works: Real-time public disclosure of key indicators like this (not the untimely publication of "process" metrics) can be mutually instructive and can help provide an incentive to all of us to do better.
Wednesday, February 14, 2007
From our VP for Human Resources:
One of our employees met with me yesterday to tell me about her experiences at Newton-Wellesley Hospital. I thought I would pass them on to you:
-- All central scheduling. One phone number for all appointments (!)
-- Appointments ran on time, and when they didn’t someone told you what was going on and what to expect.
-- There were bud vases with flowers in each ladies room, with a card that said “Thank you for choosing Newton-Wellesley”.
-- There was a person at the entrance with a button that said “Ask Me”, who would escort you as needed.
-- When an appointment was cancelled after she arrived because a provider was sick, she was offered her choice of a $10 gift certificate to the gift shop or free parking.
-- After patient satisfaction surveys, someone got back to say what actions were taken.
Bravo to Newton-Wellesley Hospital. Lovely ideas, and well executed. We plan to steal some of them!
From a patient who had flown in from another state to see one of our hand surgeons:
Just wanted to take a minute to share with you some of my observations and experiences as a recent patient in the orthopedic department at BIDMC. In essence, I found myself a bit shocked – in a pleasant sense – by the patient-centeredness and thoughtfulness of the personnel there. I use that adjective because it is certainly not what I am used to in a medical and particularly orthopedic setting. I found the staff in orthopedics to be proactively concerned with meeting my needs as a patient – for example when I arrived substantially early for an appointment, trying to get me in on a timely basis. I also found Dr. Day and his resident physicians to work closely as a team, to exude a sense of integrity and forthrightness, and again – to be very patient-centered in their approach.
You might take such things for granted, but I assure you that much of the medical world does not come close to approximating these good standards.
If you would like me to add yours, please send me the url, and I will be happy to consider it.
Tuesday, February 13, 2007
In that vein, I learned this week of a clinical trial being undertaken by the World Health Organization as part of a collaborative effort with several institutions around the world. The trials derive directly from the research described in Jerry's article. The idea is to determine whether simple urine and blood tests can be used to identify women at risk for this disease. The trial is being carried out in several countries, and the hope is to evaluate this procedure in over 12,000 women who have risk factors for the disease.
The idea is straightforward. If simple tests during early pregnancy can indicate which women are more likely to get the disease, their pregnancy can be closely monitored and their symptoms alleviated rapidly when they occur -- reducing the chance of death or injury to the mother and the baby. As noted in the summary:
If as we hypothesize, this large prospective study convincingly demonstrates that urinary ... and serum ... bio-markers predict preeclampsia, with a high degree of sensitivity and specificity, and weeks prior to overt disease, we will focus on the best way to implement the use of these easily performed and affordable tests in developing nations.
Read through the minutes of the cooperative group to get a sense of how these scientists are designing the trial and the considerations they must examine to make sure it is scientifically valid and useful. The minutes give you a feeling for the enthusiasm with which these doctors approach the trial and also for their underlying wish that it will be successful.
It is always tempting to have great hopes for clinical trials, and we shouldn't permit ourselves to get ahead of the results. That being said, if this trial is conclusive, this is a big deal for the entire world. We all wish them great success.
Sunday, February 11, 2007
The full board's involvement is often entrusted in the first instance to its patient care assessment committee (PCAC). This is a combined trustee/medical staff committee that reviews adverse events, the procedures used by the medical staff to investigate errors and omissions, and the range of programs in the hospital that are designed to reduce medical errors and otherwise enhance quality. The PCAC reports on a regular basis to the full board.
In our place, we supplemented the PCAC reports with a monthly report on the quality indicators that are collected and posted by our accreditation body, by Medicare, and by other insurers (e.g., the percentage of heart attack patients who receive aspirin upon arrival). This "dashboard" covers a variety of such measures and provides a quick visual scan of how the hospital is doing relative to national benchmarks on each one. On the dashboard, measures that are in compliance are shown in green, those with slight trouble are in yellow, and those that are substandard are shown in red. In addition, we would have a presentation by doctors and nurses about particularly interesting quality or safety initiatives.
Our board was not satisfied with this. To them, it did not answer the underlying questions: How well are we doing on quality and safety? Where could we do better? Is the place safe? They asked us to bring in an outside visiting committee of national safety and quality experts to offer an assessment of our programs and advice on how they, as board members, could make sure they were doing their job as well as possible. We did this, and here is what we learned.
We learned that our policies, procedures, and actual quality and safety programs were quite good, with a supportive corporate culture and sound underlying systems and knowledgeable and enthusiastic people who wanted to move things up a notch and get even better. But we were advised that a change in focus was needed to reach our potential. And, interestingly, the key to our success would be to change the relationship with our governing body. While there were several detailed suggestions, here were the two main ideas:
First, said our advisers, the board of trustees is seeing too much green. Don't bother showing them a quality dashboard that mainly displays your success in complying with detailed national quality metrics. That is distracting and boring and an ineffective governance and management tool. Instead, focus the board's attention on where you are doing harm to patients, and tell them how you are going to stop injuring and killing people.
Second, do more to tap the intelligence, skills, and experience of the board members to prompt them to offer advice from their own personal and professional lives that could be useful in designing, implementing, and monitoring progress. During discussions of quality and safety, board members are often intimidated by their lack of medical expertise. Give them the means to participate in thoughtful discussions on these topics. They are bound to have many good ideas. If the board is not spending as much, or more, time on quality and safety as on hospital financial and other business matters during their meetings, something is wrong.
As is often the case, these two simple themes have changed our perspective. At all levels in the organization, we focus less on detailed compliance with regulatory standards and more on how to eliminate harm. This rises up from the units in the hospital, to the divisions and departments, to the medical executive committee, to PCAC, and to the full board. You have seen some examples on this blog: My postings on central line infection and ventilator-associated pneumonia are drawn directly from the work and presentations in the hospital and include many of the same details seen by our board.
The second point is also being implemented. More meeting time is devoted to these topics. Even better, the presentations we have made during the last several months have, indeed, prompted more board discussion and insights from the board members themselves. They have become confident that they can be as "expert" on quality and safety issues as on business issues. They have found this to be engaging and useful, as have the staff.
In summary, we are all learning how to do this better. There is no monopoly on good ideas. I welcome comments from those of you out there who want to share your own experiences.
Thursday, February 08, 2007
First, we noticed that people who wanted to see neurologists on a semi-emergent basis, i.e., in a day or two, were finding an appointment lag of several weeks. Why? Because all the doctors were booked well in advance. So our chief of neurology instructed his faculty to leave their schedules open for a portion of each session, to be available for last-minute patient requests. The doctors were worried, though, that they would have wasted clinical time during their days, that those reserved open hours would never be filled.
What happened? Just the opposite. The reserved open hours were always filled with patients with more immediate needs. And, those patients had a much better record of actually showing up for their appointments than people who had made appointments several weeks in advance. And, doctors had a chance to see patients while they were freshly suffering from neurological symptoms, instead of hearing about those symptoms weeks after the fact. End result: Happier patients, better clinical diagnoses, and more productive doctors.
Second, every hospital has a "mortality and morbidity" conference procedure to review cases with adverse outcomes. But what about the normal, day-to-day cases? How do you audit for quality control? I don't mean questions about proper documentation. I mean review of the doctor's decision-making. Even the best of doctors will make mistakes and omissions in the course of treating a patient, most of which are not crucial, but many of which can be instructive if they are pointed out. Here, too, our chief of neurology put in place a simple idea, which he calls a "biopsy" of the medical record. Here's how it works.
Each faculty member in the department, from most junior to most senior, is asked to anonymously review the patient record of a colleague. He or she then offers a "grade" on the quality of the diagnosis and treatment, with minimal or extensive commentary depending on what he or she finds. That written review is then shared with the attending physician on the case.
What is going on here? Let's remember, first, that these doctors are extremely well intentioned and quite expert and really don't need an incentive to treat patients as well as possible. Through this gentle, non-threatening, but direct, peer review process, they are told by an equally expert colleague how they can do better. The reviewer, too, benefits by thinking through an interesting case and reflecting on his or her own practice. Since everybody gets to be a judge and part of the review team, the likelihood of defensive behavior or denial is reduced.
Not a big deal, you say? Maybe not. On the other hand, it is a thoughtful and effective process that is respectful of the expertise of the faculty while providing a gentle nudge towards more consistent clinical excellence. I like how it works, and I like what it stands for: A underlying value system of collegial behavior in service to the patients.
Wednesday, February 07, 2007
The biggest managerial conundrum facing hospital administrators is how to bring about constructive and lasting change in these large, complex organizations that are known as academic medical centers. People often say that AMCs are behind the times with the application of managerial techniques that are in wide use in other kinds of organizations. That may be so, but I do not think it is an accident or for lack of trying. I think there is something fundamentally different about these hospitals that requires a different point of view and approach.
The first difference is that we do not produce a single product or service. Every patient is different, and every patient expects and deserves personalized service and individualized attention. Not so different, you might argue. There are plenty of businesses that offer service tailored to the individual, and they have learned how to provide that service consistently and efficiently. And it is true that, in medicine, there are general rules and appropriate clinical responses for many patients with one or another disease. For example, I have discussed below the use of clinical pathways to make care decisions more routine, and I have discussed protocols that can be used to avoid ventilator-associated pneumonia, central line infections, and other harm. But, at its core, effective treatment really does require due attention to the individual biology of the patient, his or her state at the exact time of treatment, as well as related factors like family and home situations. It is as much art as science.
The second difference is that the key players in the delivery of medical care -- the doctors -- are not employees of the hospital. They are essentially independent contractors who have chosen one or another AMC for a particular mix of clinical care, research, and teaching that gives them personal satisfaction. Further, they have been taught through medical school, residency training, and their history of academic professional advancement that they will ultimately judged by the results of their personal efforts, not by the progress of the institution within which they work. In baseball parlance, they are all free agents. I do not say this with any inclination to diminish the dedication, expertise, or integrity of these doctors. I offer it, though, as a sociological context for their perspective on the world. (And please, I recognize that I am generalizing a bit here, so I am shortening the description of what is a broad continuum of individuals.)
Red Sox fans know what I mean when I say, "That's Manny being Manny." Our left-fielder is a brilliant baseball player who sometimes lets his individual inclinations interfere with the well-being of the team, but who is admired, respected, and even beloved for his overall contributions on the field. Even when his actions confuse and confound and annoy us, we put up with him because he is a hard-working person usually devoted to doing the best he can -- and because his results in the batter's box can be stunning and change the course of a game or even a season.
Doctors in AMCs are not all "Manny being Manny", but they are thoroughbreds in their own way. Sometimes their behavior can be confusing and even infuriating to hospital administrators. But let us remember: Even those doctors who truly care about the interests of the hospital must make individual decisions in the batter's box when seeing a patient. They know they will ultimately be judged by others -- and by themselves -- for their specific performance in an exam room, an operating room, or on a patient floor. The same holds true for their performance in the research lab and in instructional sessions with medical students or residents.
The rest of us in other jobs think we are being judged as acutely for our own performance, but our performance is often measured in terms of our effectiveness as team members or by our interpersonal skills or by the overall progress of our organization. But now think of how we expect our own doctors to get results. How often have you heard, "Well his bedside manner isn't very good, but he is a great surgeon. If I have to choose, I want a great surgeon." It is not that we intentionally are enablers of bad behavior: It is that we selfishly want good results for ourselves or our loved ones -- and we expect the doctor to deliver it notwithstanding the economics of the health care system, the productivity of the hospital, or any other ancillary concerns.
Here at BIDMC, we are engaged in an experiment, trying to mold the hospital to your expectation of a great hospital experience. As one of my folks put it yesterday, we are trying to be "aggressively patient centered" so that every person is treated as though he or she were a member of our own family. How can we do that, you might ask, if what I say above is true? The answer lies in part in our own history as an organization, a legacy of the underlying values of both the New England Deaconess Hospital and the Beth Israel Hospital. But there was another factor.
Because our hospital went through an exceptionally bad period after the merger that created BIDMC and then almost literally rose from the ashes, those doctors, nurses, and others who stayed with us and have since joined us have an extraordinary degree of loyalty, optimism, and enthusiasm about our ability to work together to deliver the kind of care I describe above. They are collaborative to an outstanding degree. Yes, the doctors are still free agents, but they recognize that even their individual advancement can be enhanced by teamwork and cooperation.
In the postings below entitled "What Works", I have given some examples of their attempts and accomplishments. But here is the key message: Not one of those initiatives was driven by me or other members of the senior management team. The desire for change and improvement came from within, from those very free agents who are viewed by some industry observers as so troublesome.
So here is the five-year takeaway. My management philosophy is remarkably simple. My job as CEO is to help create an environment and provide the resources within which the native creativity of our doctors and other staff can flourish. I don't practice an iota of medicine, but when I do my job right, they are better able to do theirs right.
There is a joke that, "You've seen one AMC, you've seen one AMC." Maybe what I say would not apply elsewhere. We will also get to see if it works even here for the next five years! The jury is still out, but so far, we appear to be headed in the right direction.
Tuesday, February 06, 2007
Monday, February 05, 2007
Here is one of the most lyrical descriptions I have seen of the nature of scientific research:
Science was all about failure, and bench work consisted primarily of setbacks. Conducting biological research was like climbing up a downward-moving escalator that then multiplied and divided and unzipped itself into a thousand new mutating walkways. The challenge was not to move upward or forward, but often only to stay upright. How satisfying, then, and how amusing when objects stayed in the same place, and forms and colors suddenly behaved predictably. These were the unexpected rewards of scientific life, the odd consistencies.
And the following marvelous insight about a researcher who falsifies data and who is unable to admit it to a colleague:
He didn't see. His guard was up again. Once more he maintained he had done nothing wrong. She wanted a confession, but he had nothing to confess. After all, he could not confess to [her] what he would not confess to himself. What he told himself about his work was not exactly what he had done. What he had done, not exactly what it should have been. Still, [his] own perceptions of his actions were coherent, internally consistent. He clung to his defense for safety.
Perhaps his work ... had been more about ideas than concrete facts; perhaps his findings had been intuitive rather than entirely empirical. He had not followed every rule.... He had not chosen to discuss every piece of data, but had run ahead with the smaller set of startling results he'd found. Still, aspects of his data were so compelling that in his mind they outweighed everything else. He had sifted out what was significant, and the rest had floated off like chaff.
And, finally, the dilemma of running a lab:
The postdocs answered to [the principal investigator], but she depended on them for the truth of their answers. She could not monitor them every minute of the day.
I have had the privilege of meeting many science researchers here and throughout the Boston area. Their dedication is inspiring, and their patience and fortitude is exemplary. This book presents a great story about the self-imposed and external pressures on scientists and their good and bad all-to-human response to those pressures. I recommend it highly.
Sunday, February 04, 2007
Have you ever noticed that a hospital will not offer comments to newspapers and other media when there is a story on a patient complaint, a lawsuit, or other such matter? This is not part of a p.r. strategy to stonewall the reporter. It is because we are not permitted, under state and federal law, to comment on patient-specific matters.
The federal law that governs this, known as HIPAA, has very strict privacy provisions and very large penalties for those who violate them. In Massachusetts, there are even more stringent state statutes that supersede some of the federal rules.
Hospitals hold training sessions for new employees, interns, residents, and doctors on this stuff. Many of us also have electronic audit procedures in place to make sure that people who look at patient records are (1) authorized to do so and (2) are doing so for legitimate reasons. Here at BIDMC, only authorized people have access to our patient medical records system. And for these people, when they log into our view a record, there is an electronic "trail" that records when and why they did it. These audit results are regularly reviewed by our compliance people.
By the way, when a celebrity is in the house, we will often assign a fake patient name to the person. We will not confirm to the media that the person is a patient. Also, no enterprising fan or gossip columnist can slip through and call the hospital operator and ask to be connected to that person's room. We did have an amusing case in which we had done all of that to protect the privacy of a celebrity - who then called the media to make sure reporters would get a picture of him as s/he left the hospital!
(Of course, if a reporter wants to publicize his or her own hospital experience, that is a different matter. This can often result in an impressive program that helps educate thousands of people.)
But our rules go further than that. If you are a TV or newspaper photographer -- or even just a patient or visitor -- and want to take images on our property, you need to get prior permission and you need to be accompanied by one of our staff people when you are videotaping or photographing. Why? Because we do not want you to inadvertently capture the image of any patient and be able to display publicly the fact that that person was a patient.
One of the more sensitive questions occurs when one of our employees is a patient in our own hospital. Clearly, co-workers want to know enough offer support and encouragement and to visit their colleague. Here, too, we must be acutely sensitive of the desire to protect his or her privacy. Our folks always err on the side of confidentiality. But if the person happens to say, "You can tell people I am here and would like visitors", you can bet that there is a stream of well-wishers to that room!
To get back to the media, it can be frustrating to a hospital when a lawyer suing the hospital on behalf of a patient goes to a reporter to get a human interest story to engage public support that person's claim. We just cannot comment even if the claim is totally frivolous. We can't even comment if we think the claim is legitimate and that we have learned from the specific medical error. So, the TV or newspaper story can end up appearing one-sided -- and the hospital can look like it is stonewalling.
The better reporters and more responsible media outlets understand this and often will choose not to run stories of this nature. They know that they can be manipulated by a clever attorney in a heart-rending case with great human interest -- and they refuse to be used that way. Other media outlets will run the story anyway, even knowing that one side is legally handcuffed in its ability to respond.
I don't want this to change, notwithstanding the occasional discomfort to hospitals. In a society that is moving more and more to open access about all of our detailed life history, finances, habits, and other characteristics, let's hope that our medical history and experiences are kept behind an opaque veil.
Friday, February 02, 2007
There is a lot of talk about how hospitals are in the age of the abacus when it comes to information systems. BIDMC is not. Our CIO, Dr. John Halamka, and his team have built a set of administrative and clinical applications in our place that lead the country. Here is part of his semi-annual report, the part dealing with just the clinical matters. Tell me if your place comes anywhere close to this!
As I have done in previous years, the following is a mid-year progress report about our FY07 major IS initiatives.
Clinically, we are focused on quality improvement, patient-centered care and pay for performance projects.
We have built and gone live with a Perioperative Management System for Operating Room scheduling and workflow enhancement in all BIDMC surgical locations. In December, we added Specimen Tracking to the OR to ensure all tissue removed from patients is delivered to pathology, analyzed, and reported back to the appropriate clinician. In the Spring, we will add OR charging by exception and later this year, we will implement perioperative provider order entry (POE) in the OR holding area and begin work on adding large LCD dashboard displays to our ORs.
We have implemented our ambulatory medical record, webOMR, to all HMFP and BIDPO practices eligible for a hospital-based electronic health record. webOMR now includes e-Prescribing and we are one of the first hospitals in the country to automate prescription routing. In the next few weeks, ePrescribing will include formulary checking to ensure that clinicians choose medications that are covered by the patient's insurance. We have also implemented an automated results notification system that alerts ordering physicians to new laboratory, pathology and radiology results. We have chartered a Users Group to prioritize future webOMR enhancements.
We have launched a new intranet portal at which offers single sign on and remote access to most applications, news feeds and customizable links for research, clinical, education, human resources and departmental content. We are working with Corporate Communications to replace the BIDMC external website and add many advanced web features.
We have developed a strategy for providing a hosted electronic health record for non-owned clinicians at non-BIDMC sites of service. This system includes the ability to view all BIDMC clinical data and order tests from within a commercially developed electronic medical record/practice management system, eClinicalWorks.
We designed and implemented an innovative Oncology Management System, which automates all aspects of chemotherapy ordering and treatment. We have also developed a medication reconciliation system which enhances patient safety and complies with JCAHO best practices.
To help improve inpatient vaccination rates, we developed a new system of prompts and reminders for influenza vaccine, and we will enhance the existing system for pneumovax. Also, to improve safety, we developed and deployed an adverse events tracking system in collaboration with Healthcare Quality. As part of our ongoing work to automate inpatient documentation, we will begin work this year on a suite of automated clinical documentation tools.
We are completing our MetaVision Critical Care System pilot this year and if the pilot is successful, we will replace our existing critical care application. This new system provides multidisciplinary clinical charting and tools for measuring quality. Examples of such measurement include Central line infection, ventilator associated pneumonia, and real time alerts based on clinical protocols.
We have obtained funding for expansion of the automated labor and delivery application, OBTV, to the Emergency Department and will be installing the upgrade this Spring. This will further enhance patient safety by providing remote real-time fetal tracing surveillance and alerting of ED patients by Labor & Delivery experts.
We have completed the first phase of our Positive Patient ID wrist band project and currently 80% of all patients have bar codes to ensure positive identification when receiving medication or giving blood samples. We will pilot a process to bar code employee badges and plan the bar coding of medications this year. These initiatives lay the foundation for the creation of an electronic medical administration record in the near future, replacing the current paper process and implementing bar coding technology in support of patient safety initiatives already underway.
We are implementing a new lab system which includes chemistry, hematology, pathology, blood bank and microbiology lab support. This new system will be one of the first systems to utilize the bar coded wristbands generated by the Positive Patient ID initiative. It will track specimens from the time they are ordered to the time results are made available for viewing and will streamline lab operations. Results generated from inpatient glucometer measurements will also be available on-line.
We are implementing and supporting several department specific quality registries as prioritized by the new Registry Committee.
We are in the final stages of selecting a new radiology information system (RIS). We’re also working collaboratively with all departments at BIDMC to develop an enterprise-wide image management (PACS) strategy. Areas of focus include identification of technical commonalities among various systems that could create economy of scale benefits for the medical center, comprehensive back-up and disaster recovery planning for all PACS data and a consolidated approach to ensure all images are available to all clinicians.
Within Radiation Oncology, initiatives underway include interfacing electronic charting software to the medical center’s billing system to ensure accuracy, implementing WebOMR within the department to reduce paper charting errors, and aligning all our IS efforts to ensure we provide optimal support for the entire cancer care process.
We have implemented the 3M System for Case Management, DRG Nurse Reviewers, Audit/Denial Management and will soon implement abstracting for coding. The system enables case managers to use Interqual criteria to make decisions about medical necessity and continued stay on inpatients and observation visits. The DRG Nurse Reviewers using 3M have the ability to e-mail physician queries directly from the system regarding documentation improvement for coding.
The Lab Scanning Pilot went live in November 2006 for scanning Lab Requisitions viewable via a web application on the intranet portal. The next step is to implement Dermatology clinical documentation and Heme/Onc external lab reports scanning for viewing in webOMR. Our eScription voice recognition team is implementing new portable handheld devices and template processing in Orthopedics.
Medical Library services collaborated with Health Information Management to standardize medical abbreviations at BIDMC. We are currently investigating how to integrate "Do Not Use" and "Approved" abbreviations into webOMR.
Enough! Now, you see why I love this guy.
Hospital CEOs are expected to do a good job running their hospitals. They are also expected to be leaders in their community. How well do we carry out those ancillary roles?
Several months ago, Ian Bowles, then heading MassINC and now a cabinet secretary in the new Deval Patrick administration, wrote an editorial pointing out that leaders of the non-profit sector in Boston, and the health care sector in particular, had a civic duty to become more engaged in public policy issues and other community activities. Ian echoed a theme that had been expressed earlier by Curtis Johnston and Neil Pierce, writing for the Boston Foundation.
They noted that the non-profits are now the largest corporations in Boston and, therefore they had to take on more of this mantle, which previously had resided with banks, insurance companies, and large manufacturers (many of which have since merged with national companies and moved their corporate headquarters elsewhere.)
I think Ian, Curtis, and Neil are right, but I think they neglected to mention that many hospital folks were already doing what they were suggesting. Here are some representative examples -- this is the butt-kissing part!
- Jim Mongan, President and CEO of Partners Healthcare System, served as chairman of the Greater Boston Chamber of Commerce; has served on the board of the Kaiser Family Foundation; and was arguably one of the most important participants in the development of the recent health care reform legislation in MA.
- Gary Gottlieb, President of Brigham and Women's Hospital, co-chaired Mayor Menino's Task Force to Eliminate Ethnic and Racial Health Disparities, as well as working on a variety of other assignments for the City.
- Mike Jellinek, President of Newton-Wellesley Hospital, chaired a citizen's commission for the Mayor of Newton on the future of that city's high school.
- Ellen Zane, President and CEO, of Tufts-New England Medical Center, has been a director of Fiduciary Trust Company and a director of the John F. Kennedy Library Foundation.
- Elaine Ullian, President and CEO of Boston Medical Center has served as chair of Conference of Boston Teaching Hospitals and on the boards of Greater Boston Chamber of Commerce and Citizens Bank of Massachusetts.
That being said, these articles actually caused me to rethink my level of civic involvement and expand it. Fortunately, our hospital was also through its financial turn-around, so I had more time to engage in such things. So here is a list of my extracurricular activities, most of them new in the last two or three years: This is the self-serving part!
- Board member of the MIT Corporation, the Institute's governing body.
- Board member of the Celebrity Series, the largest local performing arts organization.
- Board member of A Better City, a business group advocating for enhanced city transportation, parks, and other quality-of-life development.
- Board member of ISO-New England, the regional electricity transmission organization.
- Chair of a citizens' commission reviewing the city budget for the Mayor and Aldermen of Newton.
For all of us, these activities are personally rewarding and informative. I know that I take no risk in saying on behalf of my colleagues that, to the extent we can contribute to the overall advancement of our city and region, we are grateful for the opportunity to be of service.
Thursday, February 01, 2007
Hospital -- 2004 -- 2005 -- 2006
BIDMC -- 124 -- 138 -- 86
MGH ---- 102 -- 153 -- 81
NEMC ---- 81 --- 65 -- 56
Lahey ---- 70 --- 75 --- 54
UMass --- 63 --- 71 --- 43
Children's - 20 -- 26 --- 26
Yale NH -- 63 -- 64 --- 62
Brigham --- 67 -- 65 --- 51
BMC ------ 29 -- 29 --- 27
RI Hosp --- 73 -- 76 --- 40
Maine MC - 66 -- 53 --- 52
DHMC ---- 36 --- 40 --- 43
Total -----794 -- 855 --621
There are multiple issues here, as I have discussed repeatedly (and probably ad nauseum to some of you!) One I have not mentioned is that smaller programs sometimes reject organs that are more problematic but usable because they don't have the technical expertise to handle the harder transplants -- and/or because they don't want to take the chance of harming their overall mortality statistics. This means patients listed in their locality have to wait longer for organs. So, is a small, local program always a good for the community? We often find ourselves in the position of being able to successfully use organs that have been rejected by less technically adept and/or more risk-averse transplant centers.
(By the way, although I include figures from Children's Hospital here, I recognize that pediatric transplants are a very special case and in no way would suggest that their program is too small.)