Thanks for engaging gracefully

I want to thank the many people out there who participated in our Thanksgiving weekend blog rally in support of Engage with Grace. When the day began last Wednesday, based on replies we had received, we thought we would have roughly 40 bloggers engaged in this. By Thanksgiving, there were over 80, rising to over 95 during the weekend. If you do Google or Twitter searches on "Engage with Grace", you'll get the idea.

I especially want to thank two of our local media blogs, White Coat Notes on Boston.com, and WBUR's Commonhealth. These blogs are generally outlets for news and commentary, not for causes, and it was exceptionally generous of them to devote their space to this community effort. And, of course, Kay Lazar's wonderful story on the front page of the Boston Globe got the day off to a spectacular start.

We had participation and/or coverage by the circulation giants in the health care blog world, the Wall Street Journal; Kevin, MD; Diabetes Mine (including, of course, our co-conspirator, The Health Care Blog) -- but also in several topically different blogs, like this one from the Caribbean, this one from a Florida sportsman, this one from the Outer Cape, and this one from a religious blogger. And it was great to "meet" these and other people with whom we probably never would have connected: MaryAnne, Cyndi, Xujun, Susie, and even someone from Australia. And special thanks, too, to a related winemaker.

Some people have already written in to ask, "What's next?" Well, I'm a firm believer in enjoying a good thing and letting it sink in for a while before thinking about what might be next. The Engage with Grace blog rally worked because it was a cause in which people of all persuasions could believe, it was translatable into a pretty simple message, and it was timely. Also, I think it gave people something easy to leave on their blogs over Thanksgiving, when they wanted to take a break anyway!

Whether the idea of a blog rally becomes a vehicle for other causes remains to be seen. Bloggers are pretty independent people, and getting them all to publish virtually identical posts at the same time and over the same interval will require a highly motivational cause and the right set of circumstances.

In the meantime, thanks to all who participated.

First signs of ice

Photos from weekend wanderings at the MA Audubon Society's Broadmoor Sanctuary. Just the thinnest layer of ice.

Engage with Grace

Several dozen bloggers in the health care field and beyond are engaged today and through the Thanksgiving weekend in a blog rally*, simultaneously posting the item below to encourage conversation about a topic that's often avoided but needs to be addressed in every family: How we want to die. I've written about this before, with regard to my mother. Please try it, using the slide above as a discussion guide. It's not that hard to have the conversation with your loved ones once you get started.

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We make choices throughout our lives - where we want to live, what types of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we don't express our intent or tell our loved ones about it.

This has real consequences. 73% of Americans would prefer to die at home, but up to 50% die in hospital. More than 80% of Californians say their loved ones “know exactly” or have a “good idea” of what their wishes would be if they were in a persistent coma, but only 50% say they've talked to them about their preferences.

But our end of life experiences are about a lot more than statistics. They’re about all of us. So the first thing we need to do is start talking.

Engage With Grace: The One Slide Project was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences. And we’re asking people to share this One Slide – wherever and whenever they can…at a presentation, at dinner, at their book club. Just One Slide, just five questions.

Lets start a global discussion that, until now, most of us haven’t had.

Here is what we are asking you: Download The One Slide (that's it above) and share it at any opportunity – with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started.

Let's start a viral movement driven by the change we as individuals can effect...and the incredibly positive impact we could have collectively. Help ensure that all of us - and the people we care for - can end our lives in the same purposeful way we live them.

Just One Slide, just one goal. Think of the enormous difference we can make together.

(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team. )

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* In case you are wondering, "blog rally" is a term we invented this past weekend. A blog rally is the simultaneous presentation of identical or similar material on numerous blogs, for the purpose of engaging large numbers of readers and/or persuading them to adopt a certain position or take a certain action. The simultaneous nature of a blog rally creates the ironic result of joining the efforts of otherwise independent bloggers for an agreed-upon purpose. As far as we can tell, this is the first recorded use of a blog rally -- occurring from November 26 through November 30, 2008, in support of a viral movement called 'Engage with Grace: The One Slide Project' -- organized to encourage families to discuss end-of-life care issues while gathered together for the Thanksgiving holiday weekend. This particular blog rally also has a parallel component on Facebook, where many people are donating their status to bring attention to Engage with Grace.

The ad I would buy

I was joking with a friend the other day that the Boston Globe Spotlight team (their investigative group) has managed to become a profit center for the newspaper, rather than a cost center. How so? Well, the main subject of two recent articles, Partners HealthCare, has been buying a series of editorial page ads in anticipation of the articles and today published a full page ad in response to them.

Relying on the placement of MGH and Brigham and Women's Hospital in the top ten of U.S News & World Report the ad notes that:

[T]here are real differences in quality between hospitals. Year after year Partners HealthCare hospitals rise to the top of this list because of investments in teaching, research, safety, and technology. Our patients continue to choose us time and again, especially for complex treatment. And the ultimate measure of quality is that physicians and other hospitals in the area frequently send their most challenging cases to our teaching hospitals.

We realize that there are costs associated with excellence. teaching hospitals, including MGH and Brigham and Women's, care for the sickest patients, the most complex diseases. We subsidize a broad range of service, some of which lose money, such as psychiatry and community health centers.

I can't afford these kind of ads, so I'll offer some thoughts here.

Can we please start by agreeing that these are two very impressive hospitals, staffed by superb physicians, nurses, and others, and deserving of substantial praise in many, many respects? We can also agree that they are destinations for very sick patients and that they subsidize many important services that receive insufficient reimbursement from private and public payers.

But, can we also agree that the differential in rates received by these two hospitals and the doctors working in them is not related to documented, quantifiable differences in quality between them and, say, BIDMC and Tufts Medical Center, two academic medical centers that are also acknowledged for their excellence and that are also destinations for very sick patients and that also subsidize many important services that receive insufficient reimbursement from private and public payers?

Can we also agree that, likewise, there is no documented, quantifiable difference in quality between Partners' community hospitals (like North Shore Hospital) and other community hospitals (like Beverly Hospital)? And yet, the rates received by those community hospitals and the doctors working therein are generally higher than the non-Partners community hospitals.

And finally, can we agree that the higher rates received by community primary care doctors and specialists in the Partners system are not related to documented, quantifiable differences in quality between them and non-Partners community doctors?

When you cut through it all, that is what the Globe stories were about. Everybody knows that Partners is able to achieve higher rates from private insurers because it has more market power than others in the Boston area. The Globe simply documented the figures that we have all heard about for years. Who can quarrel with this business model, envisioned at the creation of Partners years ago and executed superbly?

The issue for today, it seems to me, is whether in a region characterized essentially by nonprofit hospitals and nonprofit insurance companies, the government agencies that supervise those charitable institutions should care that this imbalance exists. This is more a question to be asked of the insurers than of the providers.

Now, here's the heart of the question. Is this a zero sum game? Is there some fixed pot of insurance premiums to be allocated, so that if rates for other hospitals were to rise, those for Partners hospitals would have to fall?

Regular readers of this blog know that my answer to this will be, "Wrong question." The correct question is how much money could be saved in the health care delivery system if we were all to invest in quality and safety and other process improvements. The answer is, "A lot." The first step, though, is to move towards basing rates on the quality of care delivered -- to give the proper incentives to make progress in this direction. Sorry, not quality as portrayed by a magazine, but as documented from actual clinical records, the kinds of records maintained by all of us, in real time, every day of the year.

Let's measure improvement in avoiding central line infections, ventilator associated pneumonia, "codes" on medical floors, and other preventable harm. I'm not saying that reimbursement rates should be mainly based on a comparison of hospital A's to hospital B's infection rate. Perhaps it would actually be more effective to emphasize the rate of safety and quality improvement within each hospital as an entity. And, please, let's get away from pay-for-performance reimbursement systems that use process measurements of the type collected (and two years late) by the government. (By the way, some of these have uncertain validity or perhaps harmful clinical results, e.g., 4-6 hour timing of the first dose of antibiotic for patients with pneumonia in the face of an uncertain diagnosis.)

In summary, I don't think Partners needs to defend itself for executing a thoughtful business plan. I think it is the public officials who supervise the nonprofits in the health care sector who should feel some time pressure. They need to figure out, and quickly, how to fix the disconnect between reimbursement rates and the degree to which hospitals achieve quality and safety improvements. It is the pursuit of those improvements that offers us the first and best hope to control the rise in health care spending in Massachusetts.

Laboring in Washington

(1) The Obama team continues to pull in very able people for the new Administration. One announced last week is Patrick Gaspard, executive vice president of SEIU Local 1199, who will be the President's Political Director. One of Mr. Gaspard's tasks now will be to remember to work for the interests of his new boss, rather than his old organization -- especially given the difficulty of persuading the public that eliminating secret ballots (through the so-called "Employee Free Choice Act") as part of union certification drives is consistent with core American values.

See the items below to get a sense of how this issue is likely to be portrayed. If you were the new President, would you make this a legislative priority? The new chief of staff, Rahm Emanuel, is going to have thread this needle very, very carefully or he will jeopardize lots of other priority measures. Don't you think it is interesting that no one in the Administration seems to want to talk about this bill? Do a web search and try to find someone on the inside saying anything about it. If you do, please post the link as a comment.

(2) A friend writes:

I came across a news item whose irony I needed to pass along. Yesterday, the House Congressional caucus voted to replace the powerful chairman of the Energy and Commerce Committee, John Dingell. Since I've known Dingell for over 20 years, I decided to inquire as to the vote to see how close the election was. I was told that that information was not available, since the Democratic caucus members not only vote by secret ballot but also refuse to make public the final tally. Aren't those the same folks favoring the denial of secret balloting in union elections?

(3) A post on a blog on an anti-labor blog called LaborPains.org.

The Employee Freedom Action Committee (EFAC) called on Senate Democrats to replace today’s secret ballot vote over Sen. Joseph Lieberman’s (D-CT) committee chairman status with the public open vote method they would like to implement in union organizing elections.

Democrats are slated to cast a secret ballot vote today to decide whether Lieberman will maintain the chairmanship of the Homeland Security and Governmental Affairs Committee. That stands in stark contrast with their support for the misnamed Employee Free Choice Act (EFCA) which will effectively eliminate the secret ballot vote in union organizing elections. EFCA is expected to be one of the first items on the legislative agenda in 2009.

One of the benefits offered by a secret ballot vote is that Democratic Senators who support their colleague won’t have to fear retribution from left wing activists and bloggers who strongly dislike Lieberman. Similarly colleagues who oppose Lieberman won’t have to fear retribution from the Senator if he maintains his Chairmanship. That same protection from retribution will be denied American workers who will be forced to make a decision on the union in public.

(4) A comment about an SEIU presentation on another blog:

I am a progressive, supported Obama, BNF, DSSC, Al Franken and others with $$ this season - but I cannot support the EFCA. It just seems to be so anti-democratic. Why are we afraid of a secret ballot? Let people decide in private whether they want representation or not. The goal should not be more union members, the goal should be fair treatment for workers. While I admire much of Robert's work - his statement that the EFCA will "effectively restore the middle class..." is just over the top. Support the right to an election, support penalties for anti-union activities but do not support the EFCA.

(5) But then there are those who are ready to take to the streets if Mr. Obama backs off.

"Araña" means "spider"

Small world category: While refereeing a boys soccer game recently, I started to talk with the coach and inquired where he was from, and he was of Romanian descent but grew up in Lima, Peru. I said, well, as an exchange student in high school over 40 years ago, I stayed with a Romanian family in Lima, and asked if he knew them.

Of course, it turned out that he was a good friend of one of the boys in the family, and we laughingly talked about the mischief they would do together. The family I lived with owned a textile factory next to their house, and the boys would take used spindles, fill the hollow core with gunpowder, and shoot them over the neighborhood from the roof of the house.

The daughter of the family, aged 4 or 5 at the time, adopted me and would escort me through the garden behind the house. She was the one who taught me the most Spanish, because she would jabber on and on. Total immersion for me! For her part, I think she was surprised that I knew so few "important" words, words that describe things at the eye level of a little girl.

So, to Lisa, I owe the credit for teaching me that "araña" means "spider".

Uncle!

Many months ago, I wrote about the da Vinci Robot Surgical System and expressed doubts about whether there was evidence to support the clinical efficacy of this equipment, as opposed to the marketing efficacy of the company selling it. Well, the time has come to graciously say, "Uncle!"

Without making any representations about the relative clinical value of this robotic system versus manual laparoscopic surgery, I am writing to let you know we have decided to buy one for our hospital. Why? Well, in simple terms, because virtually all the academic medical centers and many community hospitals in the Boston area have bought one. Patients who are otherwise loyal to our hospital and our doctors are transferring their surgical treatments to other places. Prospective residents who are trying to decide where to have their surgical training look upon our lack of the robot as a deficit in our education program. Prospective physician recruits feel likewise. And, these factors are now spreading beyond urology into the field of gynecological surgery. So as a matter of good business planning, concern for the quality of our training program, and to continue to attract and retain the best possible doctors, the decision was made for us.

So there you have it. It is an illustrative story of the health care system in which we operate.

Farr better

Another wonderful application of Lean process improvements on one of our floors, done in conjunction with our BIDMC SPIRIT program. A seemingly simple reorganization of the supply closet. It always seems to prompt the question, why didn't we do this before? Well, the answer is that people are so busy doing work-arounds and getting by that they don't have time to get better. (By the way, the title of this post is a play on words: The work was done on the 5th floor of our Farr building.)

A note from our Lean guru, Alice Lee:

I know there was a comment in your blog asking if RNs should be organizing a supply room. Well, they are among the primary users of the supply room and know best what items need to be co-located, what items can be retired, what additional items need to be added, what the correct par level is (after analyzing usage trends). There is a true sense of ownership with full participation at all levels so the work is sustained.

The RNs and PCTs as well as MDs go in the supply room many times a day and waste many, many minutes a day searching for things, not finding them even if they are, there due to the disorganization and overstock of so many items.

We have a place for everything now that makes sense and locates the most frequently used items at eye level. As we transform each unit, the nurse manager and medical director marvels at how much of a crowd pleaser this is with the staff. Morale boost!

I know there have been comments also about whether the rapid improvement approach is the right one. Most of the work is actually parsed and distributed throughout a month in preparation for the 2 day concentrated effort to make the physical changes needed. It is hard work that is fun and builds a closer team. It brings people together that may have had an adversarial relationship previously (Unit staff & distribution staff). This is not unlike the ED and Lab working together to solve the hemolysis problem.

Even the meal tray

As far as I'm concerned, you can take all those posted quality metrics and throw them out the window when you get a letter like this one that I received from a patient:

BIDMC is a special place. The nursing care deflates your stress about being in the hospital. The doctor's talent makes you believe you have the best possible care. The atmosphere makes you feel that people like their jobs and feel invested in them, so you feel that everybody is paying attention, whether they are cleaners, food service, transport, department heads, trustees.

I especially noticed the employees' investment in their jobs. (NURSE: "Doctor, I noticed you are testing Ms. X for TB. If we believe she might have TB, should we institute those protocols now?" TRANSPORT: "The nurses are really busy. I'll reconnect your oxygen so you can go back to bed and I'll tell them that I did." NURSE: Let's not wait for the bed to be changed. I want it to be dry for you when you have these fevers." She changed the bed and me three times that night.)

Symbol of cooperation regardless of rank or function: Nobody left my room without taking my meal tray with them.

Follow-up from Sunday

Once again, for my out-of-town readers, a link to today's Boston Globe story following up on the one published on Sunday.

More from Chicago

Here are some pictures of attendees at the Joint Commission event mentioned below. I think these folks are from Indiana, Wisconsin, New York, New Jersey, and Florida. Over 400 people attended. You should next year!

At the Joint Commission

I'm currently in Chicago, having been invited to speak at the Joint Commission's annual conference on quality and safety, "Safety and Quality Solutions: Driving Sustained Improvements." My talk is about to follow that given by Mark Chassin, President of the Joint Commission (shown in picture). As I sit here waiting, I am summarizing what he is saying for those of you not in attendance. (Apologies in advance if I do not do a completely thorough or accurate job. Please excuse typographical errors, too, as it is tricky to listen, synthesize, and type at the same time.)

Mark described the environment within which the Joint Commission finds itself in the quality field and what kind of improvements are needed. "Despite our best efforts, we still have serious quality and safety problems in all of the domains we try to work in." In addition to the usual areas, there is a particular new focus on overuse, an essential problem to solve if the issue of affordability in the health care system is to be addressed.

But there are models of success, which serve as learning opportunities. Core measures have improved since their introduction in 2002. For example, the average for compliance with acute MI metrics (e.g., aspirin on arrival) is over 70%, with about 95 percent of hospitals having performance over 90% in two key metrics. So it is possible to have success in carrying out important metrics that lead to improved outcomes.

But the value of other metrics is problematic, in terms of achieving actual clinical results. For some, the measure we use doesn't really assess the process that we want to assess (e.g., smoking cessation counseling advice.) For some, the process that is assessed is far removed from the outcome we want to achieve (e.g., oxygenation of left ventricular function assessment). For some, the measure is susceptible to workarounds, more than encouraging the process we want have happen (e.g., heart failure discharge instructions). For some, measures lead to adverse effects (e.g., 4-6 hour timing of the first dose of antibiotic for patients with pneumonia in the face of an uncertain diagnosis).

"We should start withdrawing measures like this that are not excellent," that have these problems. But Medicare needs to do the same thing. It can't just be the Joint Commission's decision.

But let's look beyond the particular measures and find out "where's the beef" in real improvement so we can focus on the most important things. Unfortunately, there is a scarcity of evidence as to what those are, both in the hospital setting and other settings. As health care assimilates new drugs, devices, procedures, and equipment, "the goal posts keep moving" because of the increased complexity of the care system. And, in a time of scarce resources, we need to be cognizant that the Joint Commission itself influences how those resources of used. If we don't have the highest confidence that a measure is excellent, we shouldn't ask you do to it. "We have an obligation to maximize the health benefits of our measures and standards."

There has been a balance between the roles of the government and the private sector in overseeing quality in health care. Two related forces are affecting that balance: (1) bad things are happening even in Joint Commission accredited hospitals, and (2) routine safety process break down routinely and visibly. "Our public stakeholders are losing patient with us." Unless we get better at things, this will lead to a change in the balance between the government and private sector roles.

The expectation of our public stakeholders is that major adverse events, like wrong side surgeries, should diminish in frequency and be eliminated. If that does not happen, we should expect legislators to pass new laws. The nature of the legislative process is that new laws can often be heavy handed and not recognize the subtleties of these issues. Unfortunately, laws are not the best way to achieve the right results, but it is easy to see why they are passed.

So, how do we got a lot better quickly and document that improvement, to help maintain the appropriate balance between governmental supervision and private sector responsibilities? The first major barrier to this is lack of capacity in the health care system to execute robust process improvement. Secondly, we have not truly adopted a true safety culture.

We need to learn from other industries -- high reliability organizations -- and apply those lessons in the health care system. Those organizations have a commonality in their methods of achieving their excellent results. (My comment: See similar points by Steven Spear.) Mark quoted Karl Weick: "Safety is a dynamic non-event." Mark then went into details on this point, which I will not summarize, as regular readers have seen lots of this topic on this blog.

The Joint Commission wants to work with health care institutions to help them adopt these methods. But, he is also doing this to achieve internal improvements within the Joint Commission. He wants to improve its own customer service, to reduce costs, and to be more effective in carrying out its mission.

On the issue of safety culture, Mark noted that there are three imperatives of a safety culture: trust, improve, and report. On the trust point, the aim is not a blame-free culture, in that there is a difference between small errors (for learning) and egregious errors (for discipline, equitably applied). My note, please review this post for more on this topic.

Learning begins with reporting, especially near misses. "They are free lessons", an opportunity to fix a system before it breaks. A bureaucratic culture celebrates near misses rather than learning from them. High performance organizations react to near misses exactly the same way you would react to an adverse event.

Finally, on the Joint Commission itself, Mark cited improvements over the past five years, but firmly said, "We need to continue the aggressive improvement of our own processes." "We must increase confidence by pruning the measures that don't help, by focusing on and enhancing the ones that do," and by helping to provide useful process improvement tools to the the industry.

Seasonal trauma

News to me. Our chief of surgery notes an interesting "blip" in a certain kind of accidents during this fall season: Broken feet from people falling off a ladder while cleaning out the leaves from their clogged roof gutters. He recently moved to Boston from the Midwest and said it was common there, too.

Have others noticed this?

Time to brag a little

Excerpts from BIDMC and Blue Cross Blue Shield of MA press releases today. (More available here.)

BIDMC TOPS BLUE CROSS BLUE SHIELD MASSACHUSETTS RANKINGS
FOR HEALTH CARE QUALITY AND COST EFFICIENCY

BOSTON – Beth Israel Deaconess Medical Center (BIDMC) topped the list among Massachusetts hospitals in Blue Cross Blue Shield of Massachusetts’ (BCBSMA) Blue Distinction® designation of hospitals making a difference in health care outcomes and value.

BIDMC won the designation for its efforts in Bariatric Surgery, Cardiac Care, Complex and Rare Cancers, and Bone Marrow, Stem Cell and/or Allogeneiac Transplants. The medical center was among 16 Massachusetts hospitals designated by the state’s largest health insurer in a process that involved collaborating with employer groups, providers, and specialty medical societies.

“BIDMC has focused intensively on providing high quality, well coordinated care in these specialized service lines, and it is gratifying to see these efforts manifesting as better outcomes for our patients,” said Kenneth Sands, MD, senior vice president of health care quality.

Blue Distinction is a nationwide program that recognizes medical facilities that meet a national set of objective, evidence-based thresholds for clinical quality developed in collaboration with expert clinicians and leading medical organizations. This designation provides consumers with a credible, easily identifiable means of selecting facilities that best meet their individual specialty care needs.

“BCBSMA is committed to delivering on our promise of high quality, more affordable health care by working to eliminate the overuse, under use, and misuse of health care services. Blue Distinction is another way we demonstrate this commitment,” said BCBSMA Chief Physician Executive John Fallon, MD.

“Based on clinical data from hospitals and registries, research indicates that Blue Distinction Centers demonstrate better, more consistent overall outcome with fewer post-procedure complications and lower mortality rates,” Fallon said.

The analysis includes 41,333 patients treated within a facility setting, 22,322 of which were treated at BDC-designated facilities and 19,011 at other facilities. The analysis is based on cardiac events and procedures occurring during calendar year 2006, with follow-up in 2007.

BCBSMA launched Blue Distinction in 2007 with the Blue Distinction Centers for Cardiac Care. In 2008, the health insurer launched three Blue Distinction programs: Transplants, Complex and Rare Cancers and Bariatric Surgery. Due to the high level of success that BDCs have seen with regard to quality outcomes and value, Blue Cross and Blue Shield companies are in the process of expanding the program to additional specialty areas.

NAME				CITY				DESIGNATED FOR
Bay State Medical Center				Springfield				Bariatric Surgery, Cardiac Care
Beth Israel Deaconess Medical Center				Boston				Bariatric Surgery, Cardiac Care, Complex and Rare Cancers, Transplants-Bone Marrow, Stem Cell and/or Allogeneiac
Boston Medical Center				Boston				Bariatric Surgery, Cardiac Care
Brigham & Women’s Hospital				Boston				Bariatric Surgery, Cardiac Care
Cape Cod Hospital				Hyannis				Cardiac Care
Caritas St. Elizabeth’s Hospital				Boston				Cardiac Care
Dana Farber-Brigham & Women’s Cancer Center				Boston				Complex and Rare Cancers
Faulkner Hospital				Jamaica Plain				Bariatric Surgery
Lahey Clinic				Burlington				Bariatric Surgery, Cardiac Care, Complex and Rare Cancers
Lawrence Memorial Hospital				Medford				Bariatric Surgery
Massachusetts General Hospital				Boston				Bariatric Surgery, Cardiac Care
Massachusetts General Hospital Cancer Center				Boston				Complex and Rare Cancers
Mount Auburn Hospital				Cambridge				Cardiac Care
Newton –Wellesley Hospital				Newton				Bariatric Surgery
North Shore Medical Center				Salem				Cardiac Care
Tufts Medical Center				Boston				Cardiac Care, Transplants-Liver
Winchester Hospital				Winchester				Bariatric Surgery

And some more union spending

Speaking of union spending, there apparently will be a TV campaign for the so-called "Employee Free Choice Act" (the one that would eliminate secret ballot elections.) An ad from this campaign, which reportedly will be on CNN and other sources, can be seen here and is explained in more detail here.

Question for Washington insiders and political reporters: Did the Obama team ask the unions to try to generate more support for this bill, or is the campaign an attempt to keep pressure on a new administration that is busy with many important issues to make the bill a legislative priority?

SEIU goes Googling

It is impressive and instructive to note the many ways the SEIU has chosen to spend money on advertising about BIDMC. I mentioned before the hundreds of thousands of dollars spent on radio, television, mobile billboards, and bus stop ads. The latest purchase, apparently to reach the social media audience, is an ad that appears when you do a Google search on BIDMC, Beth Israel Deaconess, and who knows how many other topics related to BIDMC.

Try it. In the upper right hand corner of the search results page, you will see this ad:

Eye On BIDMC
High costs, patient problems
What does Beth Israel have to hide?
www.eyeonbi.org

For those of you who own stock in Google, I hope you see an easy way to enhance your company's revenues. Just do a search for BIDMC and click through on the SEIU ad!

For the record, if you really want to know the many things that BIDMC does NOT hide, including one the most open presentation of clinical outcomes in the country, follow the Google search link to our website instead and click through to Quality and Safety.

Lessons on Governance

I recently heard a thoughtful presentation by my colleague Bob DeVore, from the Risk Management Foundation, about the role of governing bodies. He borrowed the slide shown to the left from a book called Governance as Leadership: Reframing the Work of Nonprofit Boards, by Chait, Ryan and Taylor.

The idea is that most boards engage in oversight of management, especially on financial matters. Some go the next step and become involved in strategic planning. But, the more sophisticated boards engage in what the authors call "generative work." They note that "generative thinking produces a sense of what knowledge, information, and data mean," and that this "demands a fusion of thinking, not a division of labor."

I found this to be a useful and descriptive framework. We seek an environment in which lay board members bring their extensive knowledge, experience, and judgment to share with management on the wide range of issues facing our hospitals. While maintaining the distinction between those who govern and those who manage, the partnership that emerges between the two groups is a vibrant and self-renewing source of ideas and approaches. These strengthen our ability to carry out the public service mission of these institutions.

As you read the post below on the involvement of our Boards in safety and quality, I think you can get a sense that they have indeed moved into this category of lay leadership at both BIDMC and BID~Needham.

Spotlight shining in MA

For my out-of-town readers, you'll want to check out this story in the Boston Globe that is likely to be the talk of the town here.

Message to prospective BIDMC interns

A note from one of our senior faculty members in the department of surgery:

Paul,

As I am sure you are aware, we are in the process of recruiting the PGY-I class for 2009. Many of the candidates schedule their interviews so that they can visit all three Boston hospitals on their “swing through town”. During one interview with a spectacular candidate -- AOA, top of the class, and solid research experience -- was the following question: “BI has gotten a lot of bad press lately, could you tell me about it?”

At first she seemed surprised when the reply was, "I would be delighted." She was told that, I as an individual practitioner, and we as a health care organization realize that, as long as medicine is practiced by humans on humans, there will always be the likelihood for errors. She was told that although we all have a zero tolerance policy for errors, when they occur our obligation to the patient, and to the health care organization, is to learn all we can to decrease the likelihood the same error would be repeated. I then gave her several examples from my own practice over the years.

She admitted that the first step in understanding the factors leading up to an error was the admission of same. She then said that she understood the transparency focus. We left this portion of the interview with the following question: “Do you think errors are occurring in other hospitals, perhaps your own, and perhaps even other Boston hospitals? Perhaps they have chosen a different path to resolution?” The question did not require an answer.

I thought you may find the discussion interesting. Thanks.

To which I add the following open letter:

Dear prospective interns and residents,

Please consider coming to our hospital if you would like to join in our quality improvement adventure. We promise a blame-free environment in which all participants (including trainees) are treated respectfully and as part of a team devoted to eliminating preventable medical errors. For reference, please see the post immediately below, as well as this one and this one.

In short, we teach the science of medical care delivery here, as well as the science of disease. We believe that this has become an essential component of graduate medical education and will serve you well in your career. We hope you agree and will find BIDMC an attractive opportunity for the next phase of your training.

No retreat by the Boards

About a year ago, the Boards of BIDMC and BID~Needham met in an educational and planning retreat to decide on their priorities for both hospitals, one a large academic medical center, the other a small community hospital. The result was a four-year commitment to eliminate preventable harm and to dramatically improve patient satisfaction in the two hospitals.

Today, the governing bodies again met to reaffirm these goals, to learn more about how to achieve them, and to plan their agendas for the coming year. They were assisted by some special guests.

First was Steven Spear, Senior Fellow at both the Institute for Healthcare Improvement and the MIT Engineering Systems Division. I have written before about some of Steven's ideas and research. Here, too, he discussed the manner in which the best complex organizations deal with the problem of how to obtain process improvement. He noted that the first step in improving a complex system is being transparent about what is going wrong because "we need to know it's a problem we need to solve." As opposed to a transactional mindset, in which the emphasis is on making decisions because you assume you know enough to make the right choice, he emphasized the value of a discovery mindset. Under this approach, you have to have humility that an educated guess is not likely to be right, but that it provides an opportunity for learning. You also need to be sufficiently optimistic that you will achieve improvement over time, aided by iterative discovery. In short, the key is "humble optimism."

Spear emphasized that one of the jobs of a governing board of a hospital committed to transparency is to stand by the medical and clinical leadership and staff during the inevitable periods in which there will be adverse publicity resulting from this openness. "Watch their back," he advised.

The next session consisted of a panel comprising doctors and nurses from the two hospitals, focusing on their perspective on the progress towards quality and safety improvement and receiving their advice for activities by the Boards that could support these objectives. They were unanimous in their support for the importance of transparency as a key part of process improvement.

Following break-out sessions in which the Boards and their respective committees planned their agendas for the coming six months, they heard from Lee Carter, former Chair of the Board of Cincinnati Children's Hospital, a national leader in hospital quality and safety. He mentioned the key elements of board involvement in the quality agenda:

-- Pay attention and understand what people on the front line are doing so that they know they are appreciated. Improving quality is very difficult and takes extra work. "You need to let them know that you appreciate them."
-- Encourage transparency. "It is powerful and absolutely necessary. Until you identify what you need to improve you never will improve."
-- Establish and maintain a culture of trust, because without it, you cannot obtain transparency.
-- Measure progress, rigorously and accurately. Quoting IHI's Jim Conway, Lee noted, "Some is not a number; soon is not a time." Quantifiable objectives, with specific deadlines, are key, as is measuring progress towards both the objectives and the timeliness of achieving them.

He left the board members with the following lessons from Cincinnati: (1) We are never as good at something as we think we are; (2) it is very hard work to make transformational, as opposed to incremental, change; (3) we always have slower progress than we think we will, and the board needs to understand that and be supportive; (4) it takes persistence, and the role of the board is to support the attempt and be cheerleaders for the transformation. Confirming Spear, he stated that the board needs to let the clinical and administrative leadership know that "I've got your back" during periods of public scrutiny and the adverse publicity that often accompanies transparency. Finally, says Lee, (5), "After all this, it works" and will save lives and will result in better patient care overall.

About 80 lay leaders left the 12-hour session with a renewed sense of purpose and commitment, enthusiastic in their attempt to improve care not only at their hospitals, but also cognizant that they are partners in a national movement to do the same.

The geeks helped out, too!

And here is the computer screen referred to below, which acts in parallel with the time-out checklist to help insure compliance with the protocol. It was specially designed by our able IS team when they realized it would be helpful to this quality improvement effort. John Halamka, our chief "geekdoctor", wrote about an early version of this back in July; but then his folks worked with the clinician task force to modify and expand the concept to produce the screen you see before you. Things like this constantly remind me of the expertise of our IS folks and their enthusiastic willingness to dive in with other staff and help with clinical applications like this.

(Please ignore the space between the top and bottom halves, which does not exist on the actual computer screens. I couldn't quite put together the two images, but you get the idea. Click on either half to get a close-up view of the checklist items.)

Transparency works! Better than you can imagine.

I just saw clear evidence of the importance of transparency with regard to the reporting of important adverse events and medical errors. Bear with me through the details, but I will not keep you in suspense regarding the conclusion: The wide disclosure of a "never" event in a blame-free manner resulted in an intensity of focus and communal effort to solve an important systemic problem, resulting in redesign of clinical procedures, buy-in from hundreds of relevant staff people, and an audit system that will monitor the effectiveness of the new approach and leave open the possibility for ongoing improvement. If you ever needed a clear example of the power of transparency, here it is.

Back in early July, a patient experienced a wrong-side surgery in our hospital because the staff failed to carry out the required time-out. We disseminated the story of this event to all staff in the hospital. There was a full investigation of the matter, both internally and by the state DPH, and some immediate improvements were made in our procedures. But the more important work was being done by a Safety Culture Operational Task Force co-chaired by a nurse, a surgeon, and an anesthesiologist, and engaging almost two dozen other people from a variety of disciplines and positions in the hospital. Its charge and mission:

To implement and embed the Culture of Safety at the point of care in Perioperative Services, with an emphasis on teamwork and enhanced communications.

They adopted the following principles of patient safety:
-- Building in redundancies and cross checks
-- Standardization
-- Simplification
-- Forcing functions
-- Empowering the grassroots to lead change

They set forth a number of objectives, the first of which were to assure compliance with the time-out Universal Protocol; to script the time-out; and to design and oversee time-out audits. In so doing, they wanted to review and adopt not only the WHO Safety Checklist, but also to incorporate forthcoming 2009 Joint Commission regulations.

The result is pictured above. The document above is the check list that went into use today for all surgical procedures in our hospital. Not shown above is a corresponding computer screen version of the checklist that will be filled out in real time by the circulating nurse as the time out proceeds.

Responsibilities and the order of events is clearly laid out, even to the point of requiring that any radio in the OR is shut off during the time-out so as to avoid aural distraction. Note the forcing function at the very top of the form: No blades, needles, specula or bronchoscopes can be within reach of the surgeon until the full time-out is completed. Also, a system of "secret shoppers" has been set up to quietly audit compliance with these procedures. These are people from a variety of disciplines who normally work in the ORs who have been given this additional job responsibility.

This material was presented today in interdisciplinary grand rounds attended by about 300 people -- doctors, nurses, surgical techs. The response was enthusiastic, as everyone realized the vast improvement this would make in patient safety. And yet, even at this last moment, there were suggestions from the floor that made the process even better.

And then, I just attended a meeting of our Chiefs of Service and senior administrators. I suggested that this kind of effort and the responsiveness seen by our staff would not have happened if they had adopted the traditional approach to a "never" event -- i.e., a quiet discussion among the leadership with a directive to avoid the problem. The response from the three Task Force co-chairs was unanimous: It was because our leadership had the confidence in our staff to go public with this event that the improvement process took on life and energy.

One of our nurse managers today told me that the American Academy of Orthopaedic Surgeons reports that in a 35-year career, an orthopaedic surgeon has a 1 in 4 chance of performing a wrong-side surgery. Three years ago, people in our hospital might have said, "These things happen." We have now learned that they only happen because we let them happen. We let them happen because of our own silence and fear.

No longer.

What did you say?

Speaking of ethnic and cultural diversity, but this time focusing on patients, I thought you might be interested to see the difference in the distribution of languages served by our staff interpreters between 2001 and 2008. Note, for example, the reduced percentage of Russian-speaking patients and the increase in Spanish-speaking patients. Anyone want to offer theories about why these or other changes have happened? Is this just random variation, or does it reflect some other cause during this eight-year period?

The "other" category also shows some interesting changes. See below.

Did you understand me?

Getting into greater detail from the charts in the post above, here is the breakdown in the "other" language groups, comparing 2001 (on top) and 2008. Notice the relatively large increase in Thai speakers and the decline in Farsi speakers. Again, I welcome your theories for why the relative percentages of the groups might have changed.

East comes West

I just finished speaking at a seminar at the China Senior Health Executive Program run by the Harvard School of Public Health. Attendees comprise officials from the national Ministry of Health, but also regional health officials from Beijing, Shanghai, Xin Jiang, and Guang Dong. There was tremendous interest in our approach to process improvement and transparency at BIDMC. The attendees have a full program, and we are happy to welcome them to Boston.

It's the economy

Several months ago, I wrote about what it is like to construct a budget for a hospital like ours. Well, all that careful planning goes out the window when the economy tanks the way we have seen in the last few months. See some examples of particularly hard-hit hospitals here and here and here.

From my first day at BIDMC almost seven years ago, I have held to a policy that the entire staff has a right to know about all these things, with current and accurate information. Here's the staff email that I sent out yesterday on this topic:

Dear BIDMC:

A few of you have written me or grabbed me in the hallways to ask about the effects of the current economic mess on our hospital. From stories we read in the newspapers and see on television, we now all recognize that this is the most serious economic downtown in many years. Our hospital is not immune to its effects. Here are the main impacts on BIDMC:

Just a few months ago, our Board of Directors approved a budget for the 2009 fiscal year that has a projected 2% operating margin (or about $18 million dollars). But it is already clear that it will be very difficult to meet that 2% target. And the problem with not meeting the target is that we have fewer dollars available for capital spending for the hospital. (This is because our operating margin is the main source of funds for investments in medical and research equipment, computers, building repairs and maintenance, and so on.) For those of you who keep track of these things, you will note that the FY '09 target this is below previous years, when we have earned between 3% and 4%. For example, our preliminary results for FY 08 are about $37 million. The main difference for the current year is our need to pay rent in our new research space at the Center for Life Sciences.

What will make achieving the 2% margin difficult? First, the state government has announced a cutback in Medicaid reimbursements to hospitals. This affects every hospital. We believe this will reduce our Medicaid payments by approximately $7 million.

Second, the income from our endowment will be lower because of the poor performance of the stock market. Also, the endowment itself has suffered a reduction in value, just like all stock and bond portfolios. Accounting rules require us to record a portion of that reduction as a loss on our income statement.

Third, we can expect that some companies who owe us money will start to pay their bills more slowly, and some people who have made charitable gift pledges to us will also be forced to slow down their payments, and some people who would have donated money to us will decide to hold off for a while until their own financial picture is clarified.

How can we deal with this? As you recognize, most of our spending is in the category of people and supplies associated with taking care of patients, and most of those patients continue to arrive regardless of the economy. So, for the sake of maintaining high quality patient care, we cannot cut back very much in those categories.

However, the new budget included a number of new positions in other categories and, of course, vacancies occur every week as people retire or leave their jobs for other reasons. Effective immediately, every new opening will be reviewed before it is posted to be filled. Eric Buehrens, our COO, and Steve Fischer, our CFO, will lead this process. We will distinguish between those needed for safe patient care, those needed to support volume growth, and those needed for other reasons.

We will closely examine requests for overtime work for existing staff as well. In some cases, those requests will decline if patient volumes decline. In other cases, those requests will increase if we choose to delay filling certain positions.

On supplies, we will bring the very successful multidisciplinary process that physicians and hospital managers have used in the OR Supply Committee to standardize supplies and streamline purchasing to other areas of the hospital – specifically to procedure areas across the hospital, where we use a lot of devices and supplies. The OR Supply Committee has shown us that we can save millions annually while improving safety and outcomes – we will do the same in procedural and other areas.

We will ask every manager in every department to exercise great care about discretionary expenses: travel, food, consulting, memberships, and the like. We don’t spend lavishly in these areas now, but we are asking everyone to ask themselves if these expenses are absolutely needed.

Finally, we will continue to run LEAN rapid improvement events and respond to BIDMC SPIRIT call-outs to look for ways to make enhancements in our processes. We have learned that these events and ideas not only improve the work environment, but also often result in financial savings.

We plan to watch the numbers very, very carefully. Steve Fischer will bring a monthly dashboard of revenue and cost variances to our Operations Council so that the Vice Presidents can solve problems early and aggressively when they appear. We will have the same discussion monthly with the Chiefs of Service. If we aren’t hitting targets for revenue and expenses, we will act quickly to correct the situation. In line with our policy of transparency in so many areas, we will keep you up to date, as well, so that all people working here will know how things are going.

You have probably read about layoffs in other hospitals in Massachusetts. A number of hospitals already find themselves in worse shape than us, and they have responded by reducing the number of staff. You have probably noticed that this is also true for many other types of businesses in the region. As of now, we do not think we will be forced to do that, and we will do our best to avoid that result. Many of us lived through the dark days of 2002, when I eliminated a number of jobs, and no one wants to repeat that experience.

So that’s the whole story. Please do your part to help us uncover opportunities for efficiency and savings – consistent with quality care for our patients and safety for our staff. Also, this is a good time to pay special attention to providing good service to patients and referring doctors. To the extent we maintain and improve service quality, we are more likely to see increases in the number of patients we see.

Thanks in advance for your cooperation and assistance as we all work through this difficult time together. As always, please feel free to contact me with ideas and suggestions.

Sincerely,

Paul

Paul F. Levy
President and CEO

United Nations, Longwood style

Every Monday morning, I welcome our new employees in their orientation session. It is always a pleasure to meet new folks and sense their enthusiasm at taking on a new job.

I have been struck by the diversity among those being hired. As one indicator of that, I want to provide you with the last names of a recent group. Take a gander at this worldwide assortment:

Agosta, Arroyo, Baronian, Barros, Barry, Beaton, Brown, Daniels, Doherty, Dominguez, El-Nazer, Falardeau, Fallon, Flynn, Ghosh, Gibson, Green, Hudson, Ingram, Jones, Kopcow, Laing, Lacy, Lee, Leonard, Lewis, Li, Mack, Mendles, Mercilus, Nadadur, Nagel, Nistal, Nugent, Ornego, Paruchuri, Perez, Perna, Phin, Pilo, Poelstra, Powell, Qiu, Quintero, Regis, Rick, Rivera, Salko, Schultz, Servis, Silver, Smith, Snyder, Sun, Tadini, Valdez, Valente, Wang, Watanabe, Watson, Watts, Xu, Yeroshalmi, Zipse.

One "game" I play at orientation is to ask people to raise their hands in response to the following consecutive questions: 1) Raise your hand (and keep it up) if you were not born in the United States; 2) raise your hand (and keep it up) if at least one of your parents was not born in the US; and then 3) raise your hand if at least one of your grandparents was not born in the US. By the end, 95 percent of the people in the room have a hand in the air. A marvelous statement about how the US remains a melting pot for the world!

Which is David? Which is Goliath?

I raised the question last week of whether the SEIU, in light of numerous critical issues facing the new President and the discomfort many people have in eliminating secret ballot elections in union campaigns, would do Mr. Obama the favor of compromising on this aspect of labor reform legislation. Well, the answer - -"No" -- is very clear in today's New York Times, in a story written by Steven Greenhouse, entitled "After push for Obama, unions seek new rules."

As this issue proceeds through Congress, the SEIU will portray itself as David in Goliath-like struggles to organize hospitals and businesses of all kinds. But, let's look at some clues that indicate otherwise. The Times story notes that the unions spent $450 million in the Presidential race to support Mr. Obama. (Please understand that this is not included in the $600+ million spent by the Obama campaign itself.) This level of spending is indicative of tremendous resources, replenished every month by union dues.

Here in Boston, well before SEIU has even started to organize workers in any particular hospital, it has spent hundreds of thousands of dollars on advertisements of all kinds. This is just the first hint of the marketing ability provided by the reported $20 million it has budgeted to organize hospitals.

That no single hospital or other firm can match this kind of spending should be clear to any observer. Neither can anyone match the many dozens of people SEIU has already hired and the hundreds of workers who will be brought in from other jurisdictions to help in an organizing campaign. So, as you read stories and ads over the coming months, think about who is really Goliath here, and who is really David.

Anyway, back to the legislation. It is clear that the strategy will not be to have the union legislation stand alone. Rather, it will be attached to another bill that has broad support. It will fly through the House of Representatives. Then, a group of Senators will face immense pressure as they attempt a filibuster. They will be supported by many, many business groups, non-profit organizations, and others who find the concept of ending elections to be anathema. But they will be portrayed as holding up progress on the other aspects of the bill. This should be dramatic politics indeed.