Monday, March 31, 2008
Our speaker was Dr. Brent James, from InterMountain Health Care. He had a lot of useful things to say about the quality improvements in his system, but the focus of the talk was "Doing Well by Doing Good: The Business Case for Quality."
My main take-away: Within a very few years, we will face a hockey stick pattern of unfunded shortfalls in medical costs paid by the federal government. At that point, there will be four main options: (1) raise taxes; (2) decrease Medicare benefits; (3) shift funds from other programs, like education and national defense; and (4) reduce payments to providers. Which of the four do you think is most likely to be preferred by elected politicians? Number (4), of course. "The money is not going to be there. The business strategy of providers has to be based on managing the cost structure of clinical care." Improving the quality and safety of care is the most efficacious way of doing that.
So, quality improvement has to be a core business strategy for hospitals. Now is a good time to start and learn how to do this. As Brent notes, "It was not raining when Noah built the ark."
Dear hospital colleagues: Do we really need this reason, also, to reduce harm in our hospitals? Well, it can't hurt to be reminded that there is a financial case to be made, in parallel to the humanitarian aspects. Early adopters will do better when the rain starts to fall.
Sunday, March 30, 2008
I mention it also because this is a great example of social media viral marketing, of the type often discussed by David. And, here I am, both telling you about it and participating in it by promoting not only the book, but also linking several types of social media in the course of doing so.
(Disclosure: I have no financial relationship with any of the people mentioned and make no warranties about the material contained in the ebook. I do hope, however, that some of my colleagues with chronic bad breath will read that section of the book.)
Saturday, March 29, 2008
Friday, March 28, 2008
Italy lacks standardized specialty training in emergency medicine. There is no system of national or regional accreditation of the knowledge base or skill set of physicians working in regional emergency departments, which results in variability of emergency medical care delivery not only between hospital EDs but also within individual EDs. To address this need, the Tuscan Minister of Health chose to develop a partnership with emergency medicine specialists from the United States to help expedite the growth of the specialty in Tuscany. The collaboration called the Tuscan Emergency Medicine Initiative consists of the regional health care service, the Tuscan university system, Harvard Medical International, and the Beth Israel Deaconess Medical Center Department of Emergency Medicine.
The program leaders plan to train more than 625 physicians by June 2008.
A new step in the planning stage is to create a pediatric trauma program. To date, no such program exists. Our doctors are working in cooperation with others from Children's Hospital Boston, as well as the Meyer Pediatric Hospital/University of Florence School of Medicine to create one and to enable major pediatric trauma to be consolidated in this new center by creating a regional pediatric trauma referral system.
Both of these programs are examples of the kinds of capability US academic medical centers can bring to other parts of the world. But this is certainly a two-way street, as our doctors also learn a tremendous amount during their time abroad. And, of course, marvelous relationships are created that bring lasting value to all participants.
(The picture above is the view of Florence from Fiesole.)
I welcome your thoughts about the relative ways MGH and BIDMC present this information. As I have often mentioned, these kind of sites are not about competition between and among hospitals: They are most important as a way to hold ourselves accountable to ourselves and to the public. I welcome your help in telling us if our presentation can be improved to achieve those goals.
Thursday, March 27, 2008
Recall that a similar figure for the Netherlands was 2800 Euros per year (and I am not sure it was as all-inclusive as the Tuscany figure.) And the number for the United States is just under $7000. For these purposes, I am assuming comparability in value between Euros and dollars. While exchange rates between countries vary (sometimes inaccurately) and affect the relative price of imports and exports, the local currency represents a reasonably close approximation of purchasing power for domestically produced and consumed services.
We have talked before about some of the explanations for the disparity between the US and other European countries, for example in Iceland. A single payment system that simplifies transactions could be part of it. A strong primary care network that probably helps prevent some diseases and certainly treats many people at the lower end of the acuity and specialty spectrum and thereby reduces the cost of care is probably part of the reason, too. A parallel private system to the public system that provides services that are rationed by the public system -- but is not counted in the public financial figures -- can also be part of it. But what might account for the very low number in Tuscany, even relative to other parts of Europe?
From observation, you can see that there is less obesity and a more foot-dependent lifestyle than in the US -- although I am not sure those characteristics are very different from the rest of Europe. Certainly, too, the food is more healthy, with an emphasis on olive oil, fresh vegetables, less processed food (and consistent consumption of very good Chianti!) (But assuming away the effects of bistecca a la Fiorentina!) Perhaps, too, there is a genetic component attributable to the phenotype of people living in this part of Italy, a population that has been quite homogeneous for centuries.
But there is something else. The doctors in Tuscany get paid very little. An attending physician in a hospital will earn 2500 to 3000 Euros per month. A chief, 4000 to 5000 Euros per month. How can this be? There is a history, but basically it results from government policies years ago that made it relatively easy and financially attractive for people to go to medical school and become doctors. Indeed, the course of study was tuition-free. There are now so many doctors that they actually staff ambulances, rather than the EMTs we would have in the United States.
So, we could hypothesize that this surplus has bid down the wages of the medical profession. (Nurses are paid still less.) And, if you don't have to pay off your debt from school, you can accept lower wages. (In the US, the average amount of medical school debt is about $100,000, but that includes people who have no debt, and it also does not include carry-over debt from undergraduate college. It is not unusual for doctors to have accumulated debt of $300,000 or more by the time they finish residency training.) So, we have to assume that a significant share of the cost of medical school shows up as a underlying component of our overall health care costs, as a necessary component of doctors' salaries.
Also, after undergraduate medical education is over, the cost of residency training in the United States is covered mainly by the federal government as part of the Medicare program, so it is counted in our overall $7000 figure. I am guessing that this portion of the cost of physician training also does not show up in the health ministry book of accounts, so it is not in the 1400 Euros.
I am not suggesting here that the disparity in salaries and other such matters accounts for the entire difference, but this point is emblematic of discussions about national differences in health care costs. As you dig down into the issue, you often find that people are not counting the same things in the same ways.
But, based on recent experience, I will suggest that having a glass or two of Chianti while discussing the topic makes one care less about getting the numbers exactly right . . . .
Tuesday, March 25, 2008
Monday, March 24, 2008
Here are two recent examples along those lines. I am going to present the log reports in "hospital-speak", i.e., as written by the staff, so please accept my apologies if not all the terms are familiar to lay readers; but I think you will get the picture. I think you will also get a feel for how complex the patient care environment is in a large academic medical center. The first case involves treatment of psychiatric patients entering the Emergency Department. There is a general shortage of psychiatric beds in Massachusetts -- having mainly to do with grossly inadequate reimbursement rates for these patients and also a failure of the state to properly care of patients who should be under its care -- and this shortage spills over in hospitals in the way described in this case. We can't solve those broader societal issues, so you will see how the staff cobbled together an appropriate solution to this particular issue. (Note, for example, how the materials on the "Expressive Cart" have to be carefully chosen so the patient cannot intentionally harm himself or herself.)
On March 5, an Emergency Department nurse called out a serious concern: that patients presenting to the Emergency Department (ED) for psychiatric evaluation are often held in the ED for a number of days while a bed search takes place. During that time, the patient is held in seclusion, without the benefit of therapeutic or diversional material.
On March 10, Michelle McCool, Director of Ambulatory and Emergency Operations; Karen Lottatore, ED Practice Manager; and Kathy Fanning, ED Nurse Manager, had a plan in place to purchase some activity materials by March 17, and to have a physician in Psychiatry approve them within five days. In the meantime, Michelle McCool updated the SPIRIT Problem Log, mentioning that long-term solutions are currently under discussion on a governmental level as well as on an internal, interdisciplinary level between the ED team and Psychiatry leadership.
On March 13, Michelle McCool and five others (Mary Anne Badaracco, MD, Chief of Psychiatry; Dyanna Domilici, MD, Psychiatry; Jonathan Florman, MD, HMFP Psychiatry; Tina Gosselin, RN, Psychiatry Nurse Manager; and Sandi Leitao, Administrative Director of Psychiatry) met to discuss improvements in the care of psychiatry patients with extended stays in the ED. They agreed on an extensive action plan that includes the following:
One crank hospital bed will be available to those patients uncomfortable on stretchers;
Michelle McCool will communicate with Central Processing on this.Patients will be offered items from an “Expressive Cart” which will include cordless radio head sets, non-toxic art supplies, books and other items.
After the acute evaluation is complete, if approved by Psychiatry, patients will be offered more comfortable clothing. (Michelle McCool to obtain a supply.)
A daily team meeting will occur, including Nursing and Psychiatry at a minimum. The team will develop a treatment plan which will be documented daily.
Consider other types of consults – possibly Nutrition, Physical Therapy and Occupational Therapy – for patients who have been in the ED for more than 24 hours.
Possible assignment of a case manager to patients requiring disposition. Marsha Maurer, RN, Vice President of Patient Care Services is considering this.
The second case is more typical of a large hospital. Capacity or staffing or continuity of care problems on one floor that require coordination with several other units to resolve.
Problem: At 8:30 a.m. a staff nurse (Lucy Miller, RN) on Farr 9 needed to page the medical house staff with a question about a patient admitted overnight from the Emergency Department (patient arrived on floor between 3:30 and 4:00 a.m.). The nurse paged the resident listed as covering, but that beeper was forwarded to another resident who stated he was not covering. That resident instructed the nurse to call another resident who also stated she was not covering. The nurse paged the attending physician of record who gave the nurse two additional options to page. At this point, John Ryan, RN, Nurse Manager on Farr 9, became involved and paged the Chief Medical Resident for help in determining coverage.In addition, coverage for the SIRS firm, which often covered medical patients on Farr 9, was not easily identifiable through the online paging system like other medical firms such as MERIT or Blumgart. The nurse had to get the SIRS on call resident information by calling page operator.
Person(s) Describing Problem: Lucy Miller, CN2, Farr 9, and John Ryan, RN, Nurse Manager, Farr 9.
Help Chain Contact: Jane Foley, RN, Director of Clinical Operations.
Root Cause: There were a higher number of medical admissions than usual overnight. The patient was assigned to a different medical firm (team of residents, interns, medical students and attending physicians) than the SIRS firm that usually covers Farr 9 patients. The POE order set did not indicate the correct firm coverage. Why? Until recently, Farr 9 had been primarily an inpatient surgical unit. In early February we moved several surgeons that had been admitting to Farr 9 to the east campus. This left available capacity on Farr 9. Additionally we had a couple of surgeons still operating on the west on vacation and high Emergency Department medical volume – thus Farr 9's population shifted to 40-50% medical service patients. Why? The overall increase in medical patients house wide and particularly on Farr 9 led to some coverage issues for the medical firms. Why? In order to safely spread medical firm coverage, patients on Farr 9 were getting assigned to teams other than the SIRS firm which usually covered F9 medical patients.
Solution After Investigation: The immediate issue was fixed and the correct team assignment was notified, but it took 30-45 minutes. On March 5, Jane Foley contacted Sandra Denekamp, Telecommunications, about adding SIRS on call to the online paging system. Completed.
Action Plan: Julius Yang, MD, Hospitalist, and Todd Pollack, MD, Chief Medical Resident, worked on solutions with Nurse Manager John Ryan, RN, to prevent issue from occurring again:
· Medical firms reassigned to support increased medical volume on Farr 9. (completed by Yang/Pollack)
· Farr 9 RN staff educated about medical staff coverage – virtual pager for Robinson/Kurland Firm; page #s posted on unit and staff educated on how to find medical call schedule on portal. (completed by J Ryan)· Medical house staff will up date POE order set to accurately reflect team coverage. (completed by Yang/Pollack)
· As a back up, if POE order set is not up-to-date, medical house staff will either evaluate patient if critical issue is occurring or locate correct coverage as opposed to giving RN another intern/resident to page. (completed by Yang/ Pollack)
· On call paging system updated to list SIRS firm by name. (completed by Sandra Denekamp)· Automated paging system (generates an automated page to medical admitting resident once bed assigned for patient admitted via ED) updated to reflect new admitting scheme – (completed by Yang/Pollack/Larry Nathanson, MD, Emergency Department)
Saturday, March 22, 2008
By now I'm sure you have heard that Max passed Thursday afternoon at 4:47. It was as quick and comfortable for him as could be. Everything that could be done was being done, with respect and love beyond words. The people who make the day to day of life and death work are nothing short of amazing and wonderful gifts to the world. They made what could have been all pain, gentle. Their first concern was for his comfort, the second was for ours. I am most grateful to all, for all.
He lived next door and had been there for many years before we moved into the neighborhood. Everyone knew him. He was a handyman and had every tool you might ever need to borrow. As another neighbor noted, "The first day I moved on to the street, Max showed up at my door to let me know there was a neighborhood ladder in his garage, available for all to use."
Max was a handyman, but he loved nothing more than "supervising" other people's work. My brother-in-law, Dave, a contractor of great skill -- and even greater kindness and patience -- would quietly seethe while Max stood over his shoulder watching him work on a project at our house, offering a running commentary on what Dave was doing wrong. But you could never complain because he was such a kind and giving man.
When Max and his wife grew older and moved out of the house into a more manageable apartment, he gave me all his tools, plus dozens of jars of nails, screws, and bolts. He had never thrown anything away.
My daughters grew up with Max. Favorite story: One day, he and Sarah (age 4) decided to pick the blackberries growing in our back yard. She had on shorts and a short-sleeved shirt, and so he volunteered to step into the prickly bushes to hand the berries out to her. She held the Tupperware container. So, he would reach in, pick some berries, and hand them out to her to put into the bowl. She would promptly eat them as they arrived. After ten minutes, he turns and sees an empty bowl. He says, "I thought we were going to share." She says, "We are. You get the pretend ones. Here (and hands him the bowl)!" He laughed and laughed at being outsmarted by a four-year-old.
Friday, March 21, 2008
In 2007, we went live with integrated e-Prescribing within our enterprise electronic health record via the MA-Share rxGateway, our statewide health information exchange collaboration of payers and providers. We had to redefine workflows, cleanup old prescription data and refine the our existing applications to adapt to the new features of e-Prescribing (eligibility checking, formulary enforcement, medication history display and prescription routing).
We started this as a pilot program with our hospital-based primary care doctors. They can now, with the click or two of a computer mouse, send prescription orders to any pharmacy in Massachusetts rather than having to call them in or have the patient deliver a paper order slip. Louise, the practice manager of this group, reports the following benefits, so far:
Significant improvement in efficiency and patient satisfaction in the time for prescriptions to reach the pharmacy. With e-Prescribing, orders travel quickly to pharmacies. Previously, when we called things in it could take up to 2 days for the order to be called to the pharmacy. We have also seen a decrease in medication errors, in terms of wrong patient, wrong medication, wrong dose, in that e-Prescribing has decreased the potential for "communication errors". We are able to track prescriptions more efficiently. With the paper call-in system, orders were all over the department being called in by so many people. Now we can look in WEBOMR and quickly determine where a prescription is in the process (i.e. in queue, transmitted successfully, transmission failed, etc).
Prior to full implementation of e-Prescribing by doctors and NPs, Medical Assistant call-in of prescriptions averaged 350 prescriptions per day. This has now been reduced to 80/day approximately. This will reduce to about 30 once the residents move to e-prescription in April. Each call-in averages 4 minutes per prescription, a savings of 23 hours or approx 3 FTE worth of work per day. The Medical Assistants are now available to more consistency perform the core work required to support the patients, providers, and practice. Previously, inconsistency, the inability to predict if you will have adequate support during your session, had been a major complaint from the doctors and nurses.
Thursday, March 20, 2008
Dr. JudyAnn Bigby, MA Secretary of Health and Human Services, will talk about "Primary Care's Role in Health Reform in Massachusetts" and Dr. Thomas Bodenheimer, from the Department of Family and Community Medicine, University of California San Francisco will address "Preparing Primary Care for Increasing Demands of the Aging Population".
Here's more information, including a registration form. This is open to the public.
Also, a gala fundraising event that night will honor the founders of UMG. The Capitol Steps will be performing. I wonder if they will have anything topical to discuss!
Wednesday, March 19, 2008
Here are two emails I have received on the topic which both offer useful perspectives on the matter.
First, my buddy E-patient Dave writes:
I've caught a couple of errors on my radiology reports, and have had them corrected. Both VERY minor compared to this.
Can there be any doubt that patients need to have access to their records, as PatientSite allows, and need to be aware of their need (and ability) to read them?
Second, from one of our senior surgeons to his colleagues:
As copied below, another high profile event, to remind us how easily error can occur. In this case the consent was wrong when done in the office, and it was the only document used to confirm sidedness at the time out. As you read the article, you will note this tragedy extends not only to the patient but to the entire team, as well as the institution.
I would remind you that we had our own "near miss" here at BIDMC, which was caught by the attending surgeon, and confirmed on reviewing the images. In our case, the patient had confirmed the wrong site to the nurses, residents and fellows involved, so patients are not infallible. To best avoid this we (multiple providers) must use multiple sources of information (including the patient, exam, imaging and documentation), and we must have all OR participants agree actively that the patient ID, procedure, side and site are correct. Also as highlighted by this case, the episode of surgical care and opportunity to err starts the first time we see the patient.
Last year around this time I had breast surgery. When I was diagnosed in January of 2007, it did not seem real but it became real when I had my surgery in March. I have to tell you I was very scared that day of surgery and all the support from family and friends could not make me feel at ease.
Three women during my day of surgery made me feel that I had nothing to worry about. I really don't think they realized how they made me feel. I only know their first names and wished I remembered their last names so that I can thank them appropriately. I was hoping with your assistance you can make my appreciation known.
The first woman I want to thank is Rose in Radiology, who pushed me down the halls from pre-op to mri/nuc med. This woman talked to me about different things. I had a book and told her if I had it with me I usually don't wait long for appointments. She made me feel safe and when I went to wait for the Radiologist, I forgot my book and Rose brought it to me and we both laughed.
The second woman was Virginia. When I'm nervous I laugh and talk too much. Virginia was assisting the radiologist with the needle loc. She asked me where I was from and found out we were almost neighbors. A lively conversation ensued and the radiologist thought we were friends for a long time. We weren't, we had just met! It's these little moments that make you get through the big ones. After my needle loc, Virginia wished me well and I was off to mri/nuc med for my injections. Rose was my navigator to my next stop. When Rose was done pushing me around I got a soft hug and a very caring good luck. Rose made that part of the journey easy to get through.
The third woman was Brenda in mri/nuc med. Brenda greeted me and wheeled me into the room. During all this time my boyfriend finally joined up with me and Brenda found him and let him stay for the injections. Brenda told me everything that was going to happen during the injections. Let me tell you, they were very painful but Brenda stood by me counting down the shots and stroking my hand. It didn't hurt as bad when someone you don't know makes you feel comfortable.
I want to thank these 3 women for their sensitivity, caring and understanding and helping me through that very scary day. I feel lucky to have met these women and glad they were there to assist in my care. I want you to know that no matter how good the doctor is, it is the supporting staff that really helps the patient emotionally, and I can't say enough about the goodness these three women put forth on that day. My only regret is that I waited to long to send this to you. I hope in some way you can recognize these women and send them my thanks.
Thank you for giving me the opportunity to send this to you.
Tuesday, March 18, 2008
Works for me. What do you think? Check out this definition in Wikipedia. And here is the geological version, as seen in this satellite map of Houston, caused by overextraction of groundwater. In the current economic case, greed-induced overextension of credit to unqualified investors began the cycle. Now, levels of liquidity fall and cause us to realize that the foundations of our capital markets depend on trust and principles that are easily damaged and that will take time and hardship to restore.
Monday, March 17, 2008
Saturday, March 15, 2008
The authors reviewed 307 closed malpractice claims from four malpractice insurance companies in which patients alleged a missed or delayed diagnosis in the ambulatory setting. I quote from the abstract:
A total of 181 claims (59%) involved diagnostic errors that harmed patients. Fifty-nine percent (106 of 181) of these errors were associated with serious harm, and 30% (55 of 181) resulted in death. The most common breakdowns in the diagnostic process were failure to order an appropriate diagnostic test (100 of 181 [55%]), failure to create a proper follow-up plan (81 of 181 [45%]), failure to obtain an adequate history or perform an adequate physical examination (76 of 181 [42%]), and incorrect interpretation of diagnostic tests (67 of 181 [37%]). The leading factors that contributed to the errors were failures in judgment (143 of 181 [79%]), vigilance or memory (106 of 181 [59%]), knowledge (86 of 181 [48%]), patient-related factors (84 of 181 [46%]), and handoffs (36 of 181 [20%]).
Recognizing that malpractice claims are but a subset of cases that result in medical errors or other patient safety problems, this study to me is nonetheless another indication of an important problem that other observers and I have mentioned. The first line of defense in proper patient care is the primary care system, yet this portion of health care delivery is systematically undercompensated and undervalued in the medical payment spectrum. We have relegated primary care doctors to a triage function, requiring them to see a large number of patients in a short period of time. It should come as no surprise that the kinds of errors mentioned in this article happen when a PCP is expected to spend about 20 minutes with each patient.
Much is often made about the superiority of the health care system in European countries. I believe a big portion of the difference is the relative emphasis put on primary care in those countries compared to our own.
Friday, March 14, 2008
The other night, I overheard someone say, "I can't vote for Obama. I think he really is a Muslim."
This past Saturday, I read a column by Bob Herbert in the New York Times that included the following:
And then there was Mrs. Clinton on “60 Minutes,” being interviewed by Steve Kroft. He had shown a clip on the program of a voter in Ohio who said that he’d heard that Senator Obama didn’t know the national anthem, “wouldn’t use the Holy Bible,” and was a Muslim.
Mr. Kroft asked Senator Clinton if she believed that Senator Obama is a Muslim. In one of the sleaziest moments of the campaign to date, Senator Clinton replied: “No. No. Why would I? No, there is nothing to base that on. As far as I know.”
As far as I know.
Wouldn't it have been refreshing to hear Senator Clinton respond to Kroft by saying, "Steve, I don't know why you are asking that question. It has nothing to do with a person's qualifications, and I am not going to spend time on it or respond to those kind of questions." Instead, she clearly felt that it would be beneficial to her campaign to give the kind of answer she did.
Which is more disturbing, that a candidate feels that such an answer will help her cause and would stoop to such a tactic? Or that such an answer might actually help her cause?
There are lots of ways to count how many people are affiliated with different religions in America, but one thing is clear. People's choice of religion has no bearing on their patriotism, or their qualification for public office. And using a particular religious belief as a code word for the country's concerns about terrorism or some other issue just is not right. Can't we please expect the candidates for the highest office in the land to take these teachable moments to expand the horizons of America's voters rather than helping them descend along despicable paths?
Thursday, March 13, 2008
It was about giving up my Blackberry and the benefits therefrom:
The sun rises in the morning and sets at night. Airport lounges are great places to visit with friends or read a book. Red lights are an excellent excuse to stop driving, look around, and see what's happening on the streetscape. People in meetings pay more attention to you if you pay more attention to them. The email that arrived three hours ago is still relevant -- or better yet, no longer matters!
Is this some special kind of cross-over -- a peer-reviewed medical journal footnoting a blog? I imagine it is not the first time this has happened, but it feels like a graduation of sorts. Thanks to Jamie and Allan.
Wednesday, March 12, 2008
It all started when two BIDMC clinician-scientists found themselves in an airport waiting for a delayed flight. They knew each other a bit, but had not had a chance to explore clinical and scientific interests before the bad weather made it possible to spend four hours together in the coffee shop.
One physician, Steve Freedman, is a GI specialist who treats people with pancreatitis. The other, Alvaro Pascual-Leone, is a neurologist who studies the use of repetitive transcranial magnetic stimulation (rTMS) as a therapy in several types of neurological disorders.
While waiting for the flight, Freedman discussed the tragedy of pain suffered by people with pancreatic disease, a type of pain that is among the most debilitating known. He allowed as how interventions in and around the pancreas were often unsuccessful in alleviating this pain. This prompted Pascual-Leone to hypothesize that the perceived pain was instead centered in the brain. Together, they wondered if rTMS could be used to alleviate this type of pain.
Clinical trials ensued, and the two doctors, along with several colleagues, published reports that indicate promising possibilities. Here's one, which to my dismay, is not available without payment, but which I offer for those who might be interested in following up. Here is another, which at least offers a free abstract. Ditto, for another.
But my main point is this: A chance meeting of two highly dedicated physician-scientists creates new avenues for treatment of a debilitating disease. For those of us who spend time trying to raise funds and otherwise support the activities of academic medical centers, this is what it is all about.
Tuesday, March 11, 2008
Bailey, 57, who in his three decades at the Globe has earned a reputation as one of its most dogged reporters and widely read columnists, will move to London to join Bloomberg News as a senior enterprise editor, "finally yielding to his wife's wish" that his family live closer to her home country of France, according to an internal memo by editor Martin Baron announcing the staff changes.
I don't recall the first time Bailey covered a story involving or quoting me. The Globe archive lists one back in 1998, but I think some were earlier. Then, there were regular ones through the present. His questions in preparation for these stories were incisive and thought-provoking and actually made me re-think my position on issues from time to time. You could never tell where this liberal-conservative-socialist-capitalist columnist would come out on an issue. Many people around town claimed to have a policy of never talking to him because of this unpredictability, but they were lying: He had the best Rolodex in town and could always find sources for any story. Why? Because he was utterly trustworthy. Phrases and sentences would not be taken out of context. Also, "off the record" really meant off the record. Bailey would never burn a source. As a result, he was one of very few opinion columnists who would actually break news stories.
Bailey's degree of institutional memory for matters relating to Boston politics and business is extraordinary and his departure leaves the city a bit poorer in that regard. On a personal level, though, what I will miss is those calls, starting "This is Bailey. What do you know about...." and waiting with bated breath to see what would come out in print a day or two later.
Monday, March 10, 2008
This reminded me of a post I wrote several weeks ago about my hope to create the organizational equivalent of a wiki. And, of course, it relates to all the stuff I have been boring you with about BIDMC SPIRIT. The underlying premise is that a democratic approach to problem identification and problem solving is what makes it possible for a complex organization to discover ways to improve. As Steven Spear notes, the alternative method -- trying to design the perfect complex system in advance using the traditional business hierarchical approach -- is unlikely to produce a sustainable and efficacious solution, especially in an environment characterized by structural change.
Can health care institutions learn this approach to adaptation and improvement? The jury is still out.
Sunday, March 09, 2008
PROBLEM: The lab test entered in the lab (Metanephrines) was different than the lab ordered on order requisition (Methemoglobin).
ROOT CAUSE: Why was Metanephrines entered into lab system instead of Methemoglobin? Metaneprines was selected from the list of 9 choices displayed in the blood lab information system when lab assistant typed in "MET". Assistant selected metanephrines (plasma) because asked a coworker what to select was told to pick this one because purple top vial is associated with plasma. Methemoglobin was not an option to select. Why was methemoglobin not an option to select? Assistant was working in blood lab information system. Methemoglobin is a blood gas test and is an option in that system only. Why was the assistant working within the blood lab information system? The requisition that the EP lab sent to the lab was a blood lab requisition not a blood gas requisition. Why did the EP lab send a blood lab requisition? The person requesting the lab test was unfamiliar with the test and did not have the information necessary regarding the type of tube and requisition to use. (Asked 4 people in cath department and lab and received inaccurate information and sent purple top and blood lab req. )
SOLUTION: Design a way for workers to have accurate information regarding which blood tube and requisition to use for each test. (Access to electronic URL that contains the lab resource manual on BIDMC website.)
ACTION: Wayne (Lab department manager) demonstrated the online lab reference to the nurses in the EP lab. Will continue to work with lab and nurses to work on a way for them to have the information that they need when requesting lab tests. Wayne will also work with his staff regarding a way to call out for help when the exact lab test requested is not an option to enter into the system.
Notes: The problem was found serendipitously when looking at a lab requisition for another issue (a half-printed patient plate). Wayne learned as much as he could from his staff then activated the help chain to request help in further investigation in the EP lab. Nurses in EP lab and in our small group were unaware of the online resource available to them and grateful to learn about it. This surprised Wayne. Question for consideration: Are the other nurses in the organization aware of this extremely useful tool and if not how can this be communicated to them?
Friday, March 07, 2008
Pat suggested I share the email below with you regarding my initial impressions of the Spirit program. As background, I was a longtime “old BI” nurse and left clinical practice back in the 1990s to do writing and other projects, which led to launching a consulting business a number of years later. However, after 11 years, I found I missed clinical practice, and I chose to return – albeit on a very limited basis (about 20 hours a month). This is becoming a lot of background - - but! - - folks in nursing were amazing in helping me get back on my feet, providing many hours of re-training and encouragement – just wanted to mention that also! I spend most of my time in the ED, and my email to Pat was following my shift last evening.
I think Spirit is fantastic; thanks for creating the environment where this is possible.
And her note to Pat, one of our SPIRIT organizer/trainers:
Just a quick note to say I think the SPIRIT website is fantastic. I used it last night to log my first “problem.” As you and I have discussed, as someone re-entering practice, and as someone who doesn’t work a whole lot of hours, I think I have a vantage point that is free of what you have called “tolerance of deviance” - - -I haven’t built up that tolerance, so some of these issues are just glaring me in the face. I am so pleased to have a way to share them.
That said, I’m a little worried about posting too many things!! Let’s discuss more when we talk next.
It is interesting to see the range of things posted. The few skeptics who are posting are disheartening, but I predict that attitude will die out quickly.
Here is a quick anecdote from my shift last night - - one that I think shows that just having this in place may help people become more aware of problems that they will then just solve on their own. Several people came through the ED looking for pillows. It is a chronic problem – lack of pillows. My tech had said to the pillow-searcher, “We don’t have any. We never have any.”
I was talking to my tech about this, and about how this could be logged into Spirit. (He was initially skeptical of the whole idea of SPIRIT but, I think, warmed to the idea!). Anyway, as I was showing him the program and encouraging him to log it in, he said, “Well, you know, we can call for pillows any time we want.” You could almost see a light bulb going off over his head - - saying, “Well then, why don’t we??”
I think the whole discussion of the idea of SPIRIT ratcheted things up for him to say, “Wait a second, I don’t have to live with no pillows, I can actually call for more and I think I will.”
Kind of a silly example, but I think the program will have this power.
That’s it, just sharing! I think it is very exciting.
Thursday, March 06, 2008
Well, my photos of Jonathan Papelbon and Dustin Pedroia are not as graphic as the video clips on Boston.com, but you get the idea. The fundraising cause was the Mike Lowell Foundation at an event organized by the Red Sox Foundation last weekend in Florida. Mike explained that he started the foundation to enhance the resources available to cancer patients and their families. For example, he told a heartwarming story about how the foundation had enabled a single father to be able to afford daycare for his small children while another child was undergoing cancer treatment.
Bidding in support of the charity at a live and silent auction was fierce -- no doubt stimulated by the dancing contest!
Wednesday, March 05, 2008
Blue Cross-Blue Shield's directors are ... paid, unlike those at most nonprofits, earning from $47,400 to $53,900 a year.
At Harvard Pilgrim Health Care, ... [d]irectors earn from about $20,000 to $30,000 a year.
Tufts Health Plan... [d]irectors earn between $11,500 and $29,000.
I think Mr. Krasner is correct that trustees and directors of most non-profits do not get paid, but there are exceptions. I personally serve on the board of one that does pay its directors. This is ISO-New England, the non-profit that supervises transactions within and reliability of the region's electric utility transmission system. ISO recruits board members with strong business background from around the country -- the kind of people who would ordinarily serve on for-profit companies -- and requires them to travel from their home cities at least once a month to Holyoke. Therefore, like the other regional ISOs in the US, it pays board members fees of the sort they might receive on a for-profit board. (Rest assured that I immediately endorse all checks I receive for this service, along with any other fees or honorariums I receive for any other outside activities, to BIDMC.)
I suppose one could make the same argument with regard to compensating board members of the insurance companies. While I do not believe that most of those members travel from outside of the region, they are the caliber of people who could easily have served on for-profit boards, and so there is an opportunity cost for them in the amount of time they devote to these non-profit corporations.
But -- and this is the big "but" -- the people who serve on the BIDMC Board and the boards of the other major hospitals in Boston are also of that caliber, i.e., major business and community leaders who incur an opportunity cost by spending time in service to those non-profits. They are expected to carry out their governance responsibilities with the same standard of care with regard to financial matters, senior executive compensation, audits, and compliance as those serving on insurance company boards, but also with special responsibility for the quality and safety of patient care.
I think we would think it somehow untoward if hospital board members were compensated. Going further, we would certainly be offended to learn that board members of other public charities like religious institutions, colleges and universities, day care centers, or town sports leagues were compensated. And yet, in each case, we expect those board members to meet a high standard of care with regard to their fiduciary responsibilities.
I do not write this to give any sense that I begrudge the insurance company board members their annual retainer and meeting fees, but I wonder how the custom evolved that they should be paid. Has it always been such, or is this a recent development? Is there is anything special expected of them in return for that payment that we do not expect of unpaid board members serving other non-profits? Looking forward, should we extend this compensation practice to other major non-profit organizations that demand a high standard of care from their board members?
Tuesday, March 04, 2008
The story is told by Betsy, a manager in the Radiology Department, to the Techs and Associates in her department. The problem being called out was that Techs arriving to administer a portable chest image for patients on the cardiology floor would often find a patient missing. A wasted trip, and frustrating for these very busy people, who then also would wonder why the patient couldn't just have been sent to the Radiology floor to have the imaging done there.
Our first BIDMC Spirit call out was entered yesterday for portable chest ordered on Farr 6 when patients are off the unit. As many of you may have encountered arriving for a portable on Farr 6 - to find the patient is off the floor (usually in dialysis). So the SPIRIT was looking at why this was happening and what could be done. We learned a couple of things:
* This is a cardiology set-down unit.
* The person entering the order does not know the patient's schedule for the day.
* These patients have telemetry - so when they leave the unit they must be accompanied by a nurse. This takes a nurse off the unit, so they try to limit the time away - hence the portable order.
Solution - call the unit first to see if the patient will be there. The unit will be happy to help!
Thanks to everyone who was involved looking into this …see, there was a reason for the patient to be portable and a reasonable solution!
(Email yesterday to the BIDMC Community, formally kicking off this adventure.)
Today we begin BIDMC SPIRIT across the medical center. Don’t expect flag-waving, speeches or any fanfare like that. This week is about first steps.
Why do we need to do this? Please read the following situations from some of our SPIRIT training sessions over the past few weeks:
The lights are too bright over my telemetry work station so it’s hard for me to read my screen, but if I turn off the switch it is too dark for the nurses at the rest of the nursing station.
When I mail a prescription to a patient and drop it in the BIDMC outgoing mail box it can take up to 10 days to get to the patient. We have resorted to buying our own stamps, hand-addressing the envelopes and dropping them in a US mailbox.
We are looking for a patient to bring down to angio. We have already searched in the day care unit and on the inpatient unit where we thought he was – but we found out that he went home yesterday!
I needed an IV pump in my recovery bay and I searched all over for one before I found out that we had none.
Think back to your first day of working here: Was it your goal to deal with situations like these? Probably not! But we all acknowledge that it happens every day. No matter where you work at BIDMC, you probably spend a chunk of your time hunting for things, tracking down something or someone you need, and fetching materials. You are well-intentioned, hard-working, creative and industrious. You have found ways to provide excellent patient care or support for patient care in spite of the challenges. Often you create “work-arounds” to simply get your work done. The problem with work-arounds, though, is that underlying systemic problems don’t get fixed. Now, with BIDMC SPIRIT, we aim to fix them.
My hope is to have us improve the quality of the time you spend here so you can focus on the things that matter instead of working around the problems you encounter. We know from other places that this can happen. They key is to empower every single person to call out problems, participate in solutions, and be appreciated for his or her contributions.
I will promise you one thing, though. During the first few weeks of SPIRIT, activities may feel clumsy – and perhaps chaotic. The number of problems called out will certainly exceed the number that can be worked on in real time. Not all of our managers have been formally trained, but we can’t wait for the timing to be perfect. We have to get started. So be please patient with each other – and especially me! -- as we get this going.
You probably have lots of questions. To learn more about how SPIRIT works, please read this Q and A (Note: This linked to the document below.). There are posters and flyers around in four languages so we can make sure that staff who don’t use computers or those for whom English is a second language are involved.
I also ask you to visit the general portal and click on the BIDMC SPIRIT logo some time this week. You’ll find a problem log up-and-running. Real-life, BIDMC problems and solutions from the first SPIRIT trainings are already there for everyone to see and learn from. It’s a great way to see what SPIRIT is.
You will be hearing much, much more about BIDMC SPIRIT in the coming weeks and months through e-mails, newsletters and the BIDMC SPIRIT site on the portal. Also, I will be documenting our progress for the world to see on my personal blog, www.runningahospital.blogspot.com.
Finally, many thanks to Andrew French, Research Administrator, who came up with our program’s name, BIDMC SPIRIT: Solutions Promoting Improvement, Respect, Integrity and Teamwork.
And here is the Q&A that is referenced in the message above:
Frequently Asked Questions
The lights are too bright over my telemetry work station so it’s hard for me to read my screen, but if I turn off the switch it is too dark for the nurses at the rest of the nursing station. On…off…on… off. It doesn’t make sense. We need help!
When I mail a prescription to a patient and drop it in the BIDMC outgoing mail box it can take up to 10 days to get to the patient. We have resorted to buying our own stamps and dropping the envelopes in a US mailbox. Is this extra hassle really doing any good? We need help!
We are looking for a patient to bring down to angio. We have already searched in the day care unit and on the inpatient unit where we thought he was – but we found out that he went home yesterday! What a waste of time! We need help!
I needed an IV pump in my recovery bay and I searched all over for one before I found out that we had none! There has got to be a better way to do this! We need help!
What do these scenarios have in common?
They are all “call-outs” – BIDMC staff declaring that something is keeping them from doing their jobs in the best way possible. The call-outs above are real situations that came up in the first wave of manager training sessions for BIDMC SPIRIT.
What is SPIRIT?
SPIRIT stands for Solutions Promoting Improvement, Respect, Integrity &Teamwork.
You probably remember the e-mail from Paul Levy around Thanksgiving in which he challenged each member of the BIDMC community to be part of a new way to consistently identify barriers to care and implement system-wide solutions as close to real time as possible.
As Paul said in his message: While the goal is simple, the solution is not. We want a solution that will identify and start to solve problems on the floors as they occur. We want a solution that will uncover and fix underlying problems, not result in yet another set of work-arounds.
The goal of SPIRIT is to make the work lives of all of our staff easier and more gratifying. To begin, we must all see and think about what we do every day in a new light. Chances are we all have work-arounds that we do every day without thinking. Or we waste time fetching and hunting for materials or resources we need and we may not even notice.
Once you identify a problem, the basic steps are:
-- Call out a problem to your manager/shift leader.
-- Work together to identify the root cause of the problem and solve it as soon as possible – in real time.
-- Log it. (see below)
-- Use the Help Chain, if necessary. (see below)
Less time hunting and fetching can mean more time spent on patient care – which will have a major impact on our goals of higher patient satisfaction and improved safety.
When and how will we start?
We intend to launch the BIDMC SPIRIT program the first week of March.
We have been busy orienting supervisors, managers, directors and vice presidents to the basic concepts of real time problem solving. We are working with a group of consultants from a company called Value Capture. They have experience in leading system wide change at the international manufacturer Alcoa and leading similar change initiatives at several academic hospitals.
How will it work?
All employees will be asked to participate by “calling out” to their local manager/shift leader to report a problem related to hunting and fetching activities that are causing you to do work-arounds. Your manager/shift supervisor will help you to meet immediate patient needs as soon as possible. We call this “restoring the system.” Together, you will then log the problem into an electronic SPIRIT problem log (click on the SPIRIT logo on the general portal.) Your manager/shift leader will use real time problem solving strategies to facilitate a solution for the problem. Because you are the one who knows your work the best, you will be involved in the steps of finding a solution whenever possible. The goal for us is to have these call-outs addressed within 24 hours. The solutions will also be logged in the SPIRIT problem log.
I do most of my work in a patient care area, but I report to another department. To whom should I call out a problem?
You have two choices:
a) The unit’s nurse manager
b) Your departmental supervisor
When you call out a problem, ask yourself who makes the most sense to provide help. (You don’t need to spend too much time deciding this – there’s no ‘wrong’ answer.) Here is some guidance:
Is the problem related to patient care or work done on the unit? Call the unit’s nurse manager.
Example: While seeing a patient on Farr 7, a Case Manager finds that discharge paperwork isn’t ready at the right time. After solving the problem for the immediate patient, she calls out the problem to the Farr 7 nurse manager – because this problem involves the Farr 7 doctors, nurses and physical therapists and makes sense as part of the Farr 7 Unit Team.
Is the problem specific to your work, but not to the unit you’re working on? Call your usual supervisor.
Example: While seeing a patient on Farr 7, a Case Manager notices a serious bug in the case management software. It doesn’t make sense to call the Farr 7 nurse manager as part of the help chain for this problem, so she calls her supervisor in case management.
What is the SPIRIT problem log?
The SPIRIT problem log is a click away on the portal – just click on the SPIRIT logo on the top of the general portal. It provides a public space for you and your manager to log your “call-outs” and for us to track the various “call-outs” across the medical center. The SPIRIT log is not a notification system. Problems and work-arounds should be called out in person to your manager/shift supervisor whenever possible. At times when no one is available (night shift for example), go ahead and log it into the system anyway. Your manager will get back to you to involve you in problem solving if time allows. The SPIRIT log is visible from any public work station on the portal. The log will also track solutions. This will give us an opportunity to share the knowledge about fixes in one area that may be easily adapted for another area.
For patient safety reports or any report that requires the use of specific patient information, please continue to use the Patient Safety Reporting or Adverse Drug Alert or Adverse Event Management systems. The SPIRIT problem log does not provide the privacy protection needed when reporting patient related events.
What is the HELP CHAIN?
Every department is specifying the components of its HELP CHAIN. The chain flows from the local manager to the director to the VP to the President’s office and then to the Board of Directors of the medical center. We are creating a comprehensive list of departmental manager HELP CHAIN contacts so that your manager will know the name of a manager in another department who can be called when the problem “call-out” and subsequent root cause and solution involve more than your home department. We imagine that this is going to be the case for many of the “call-outs.”
How will I know how it’s going?
Information will be updated on the SPIRIT section of the portal. There will be weekly Friday e-mail updates about SPIRIT with a focus on stories about staff who are doing the work.
What about people who don’t use computers?
For staff who don’t use computers, the preferred way to call out problems is still to talk to their managers/shift leaders. If a manager isn’t available, there is a special SPIRIT phone number, (66)7-7474, for staff to call in a fetching or hunting problem. Information from the weekly Friday e-mails will be collected and put into to a print newsletter.
What about staff for whom English is a second language?
For staff whose primary language is not English, the preferred way to call out problems is still to talk to their managers/shift leaders. If a manager isn’t available, the special SPIRIT phone number, (66)7-7474, allows staff who speak Spanish, Portuguese or Haitian Creole to leave a detailed message in their first language. Staff from Interpreter Services will transcribe the messages and pass them on for the SPIRIT log. The print newsletter will also be translated into Spanish, Portuguese and French/Haitian Creole.
How can we possibly solve all of the problems called out?
We know that this is not going to be perfect on day one! We are all going to learn this together. There will probably be many more problems called out than can be solved in real time. Having said this, the important thing is that we begin by trying to solve some – everyday. This is the main priority for our work this year. Solving more problems in real time and involving those closest to the work will result in smarter solutions and less formal problem solving meetings over time. Remember, to reach our potential for greatness, every employee should be able to answer the following questions with a resounding “YES!”
Am I treated with dignity and respect by everyone I encounter, regardless of role or rank in the organization?
Am I given the knowledge, tools and support that I need in order to make a contribution to my organization and that adds meaning to my life?
Did somebody notice I did it, i.e., am I recognized for my contribution?
Monday, March 03, 2008
Many thanks to Senator Moore, Senate President Therese Murray and all of the members of the Senate for this honor.
Sunday, March 02, 2008
Polling suggests that at least 9 of every 10 voters in November will be insured. Many will not see universal coverage as a matter of self-interest. The complex economic argument that the uninsured impose hidden costs on everyone else may be difficult to convey in sound bites.
And the electorate may be less receptive than participants in the Democratic primaries and caucuses. A December poll by the Kaiser Family Foundation found that 42 percent of Democrats said their top health policy concern was expanding coverage for the uninsured, while 35 percent said it was reducing costs. The priorities flipped when Republicans and independents were added to the mix, with 41 percent of all polled saying they cared most about reducing costs and 31 percent citing coverage for the uninsured.
This is consistent with polling that I have read over the last six years. When you add in the vested interests involved in the debate surrounding any new legislation, it might explain why it is so difficult to generate a political consensus at the national level on these issues and why no President since Bill Clinton has really tried to do anything significant in this arena.
What do you think? I am not asking you whether you think there should be legislation, so please don't offer a speech on that topic. I am asking whether you think there will be strong political pressure resulting from the general election -- even if a Democrat wins -- to provide the impetus major legislation would need to move forward.