Wednesday, April 30, 2008

What a social worker does . . . and feels

Each year, we give out the Bernice K. Snyder Award for Excellence in Social Work, and this year the recipient was Sarah Porell. In a previous post, I have talked about the essential role of social workers in the hospital. Sarah's acceptance speech, though, was a marvelous "job description" of what a social worker does, along with the doubts and joys associated therewith. Here are excerpts:

I feel like the work we get to do is incredibly privileged, sacred work. To be present to people in their most vulnerable moments is a privilege I pray I never take for granted or stop learning from. And I have to say, quite honestly, that while I am very grateful for my social work education and the skills it has taught me, I really believe that all the schooling in the world cannot fully prepare you for this work. Daily, I continue to fearfully pause at the threshold of patients’ rooms praying for the wherewithal to know how to handle God-knows-what tragic situation I am about to walk into. As we all know, some days are harder than others, and there is always a sigh of relief when all someone wants is a parking sticker.

I remember one of my first weeks back here as an MSW, I got a call from the ICU letting me know there was a 40 year old woman, mother of three young children, dying of cancer. Her parents and husband were at bedside and could I come see them. I PANICKED. I remember cataloguing my brain for the grad school lesson on young dying woman with children and was at a bit of a loss of what to do. It was my first experience of a dying patient, and I was terrified. Thankfully, I had the sense to ask for help and I paged Amy T, who graciously stopped everything she was doing and came to the ICU. We read through the chart, and she gave me a few words of guidance and assured me she would walk me through it. As I nervously followed her seemingly fearless stride into the room, she turned to me and whispered, "Just remember, lead with your humanity." Those profoundly simple yet wise words guide me everyday. And I have to say, some days I do this much better than others.

I think it's both the blessing and the struggle of this work that in addition to (or maybe even beyond) our clinical skills, our greatest asset to our work is who we are and how we use ourselves to connect with the patients, families and staff we serve. I think the clinical term is "differential use of self." When I have the opportunity to watch my colleagues in action or listen to case presentations, I am always amazed and inspired how each of us uses the uniqueness of who were are in our work.

But as we use ourselves, I know for myself, I continually struggle with questioning the efficacy of my work and wonder, when there isn’t anything concrete to measure success, if what I am doing makes any difference. However, I have come to learn through my colleagues that this is a question with which we all struggle and which keeps us humble.

To end, I would like to share with you a quote by Thomas Merton that has really helped me and I really feel speaks to this struggle and the work we all do:

"Do not depend on the hope of results. When you are doing the sort of work you have taken on, you may have to face that your work will be apparently worthless and even achieve no worth at all, if not perhaps, results opposite to what you expect. As you get used to this idea, you start more and more to concentrate not on the results, but in the value, the rightness, and the truth of the work itself. And there too, a great deal has to be gone through, as gradually you struggle less and less for an ideal, and more and more for specific people. The range tends to narrow down, and it gets more real. In the end, it is the reality of the personal relationships that saves everything."

The growth engine continues to rev

I wrote last year about the growth imperative in the health care sector. It continues unabated, as noted in two stories by Tom Palmer in today's Boston Globe. The Longwood area remains an engine of economic growth in the city and regional economy, with tremendous growth in employment and ancillary spin-offs from the clinical and research functions of the hospitals. This, in part, is the other side of the story of the high cost of health care. I am not offering it as an excuse for those cost increases, but mainly to remind folks that there is a benefit associated with that cost.

Tuesday, April 29, 2008

Food in every language!

Excuse me if I start to doze off. Our interpreters' annual lunch just happened, and I was "required" to taste everything from several dozen countries around the world. So, I am experiencing an early afternoon need for a siesta.

My discovery this year was catchupa, a Cape Verdean dish made by Fernanda (in photo). It has corn, beans, carrots, onions, pork, and other things cooked together for an hour or so. It is one of those comfort foods that makes you remember your childhood, even if you didn't come from Cape Verde! Other items today included a gazillion varieties of rice dishes, types of chicken, polenta, dumplings, ceviche, and, yes, "a few" desserts. All surrounded by good cheer and decorations from around the world.

Healthy Work/Healthy Home

Each year at this time, Jane Matlaw (shown at right) organizes a series of events at BIDMC to raise consciousness about steps that people can take to be better stewards of the environment. Part of the celebration is the presentation of Environmental Action Awards to people at BIDMC who have made a difference. Today, we presented a special award to Jane herself for leading this effort for 10 years. Congratulations!
We also had a special visitor, Ian Bowles, Massachusetts Secretary of Energy and Environmental Affairs (photo above). He gave a briefing on recent state initiatives in this area and graciously and thoroughly answered a number of questions from the audience. The key point to me was that we should "get out of the victim mentality" when it comes to rising energy prices and "take control" of our energy use by pursuing energy efficiency opportunities in our travel, homes, and businesses.

Monday, April 28, 2008

How good does this make you feel?

This email is reprinted with permission. I have omitted the person's name and redacted several details of personal and family medical history.

Dear Mr. Levy,

I am a Surgical Technician on the West Campus. I am writing to you to let you know about the truly special group of staff members you have on the fourth and fifth floors of the West Campus. These special people are my co-workers. I refer not just to my fellow surgical techs, but to the nurses, doctors, residents and anesthesia staff I work with every day. As outstanding as they all are in delivering care to patients, and doing so with Compassion, Professionalism, Respect and Integrity, they rise to heights you should be made aware of when it comes to one of their own.

The world should know what a special group of people we have here at Beth Israel Deaconess Medical Center. I remember at my orientation you came by to say "hello", and about a month later recognized me as a new employee and stopped to ask how it was going. That meant a lot then. Your kindness means a lot now. I have worked at the other major hospitals in Boston, and spoken to people from all over. No other place can a Surgical Technician and Nurse walk into an O.R. and have the attending ask how your kid's soccer game was this weekend, or us ask how their family reunion went. The same holds true for Anesthesia with nursing, the attendings with anesthesia, etc.

In most places of this size all the disciplines have their own worlds, their own lounges and spaces that never interact with one another. I hear it all the time. "You had lunch with Dr......!"., "What do you mean you hang out with attendings?", and it goes on and on. As I said, it starts at the top, and we see that in our O.R. (and the locker room) with Dr. Hurst (Note: Acting Chief of Surgery and trauma surgeon). I know many of my co-workers would follow that man into Hell. On some nights we do. Please continue to bring people of integrity like him, Dr. Joe Upton, Dr. Ben Schneider, Dr. Dan Jones, Dr. Ken Rodriguez, Dr. Bernard Lee, and all the rest of the staff we have on board. I could keep naming names. They inspire and encourage us each and every day.

Please allow me a moment of your time to tell you my story. The last year has been pretty much Hell for me and my family. (Details of family medical history omitted.) The world as I knew it had been turned upside down. I cannot begin to express the support from my B.I.D.M.C. family. It was inspiring.

I followed that up with being a patient on the West Campus. No less that 30 people visited with my wife and I in the pre-op holding area. Not only was my wife, a surg tech at (another hospital) was totally impressed by all of this. The other patients in the holding area must have thought I was related to you! My wife got a chance to see the family I speak so much and highly of up close and in person. The post op care was even more impressive.

Sounds like things could not get worse, but unfortunately they did. On Monday of last week, April 21, 2008, I was caring for my mother while my sister took a much needed two week vacation and I had a heart attack. My life and my family were once again rocked to the core. I was rushed to the Lahey Clinic in Burlington. I had three stents placed that day and was scared for my life.

I know this is sounding like a sad story, but it really is not. You see, this is where my coworkers and your employees once again carried me and my family when we were unable to do so ourselves. That very night my Nurse Manager called me in the hospital to see how I was and tell me not to worry about my job, just focus on what was important: my getting better and my family's well being. The calls started coming in that night to my wife's cell phone and directly to me from more people that I could imagine, all with the same message, " What can we do? How can we help?". I cannot begin to tell you the tears I shed, nor how humbling it is to have so many offer so much in our time of need. The next day once again my coworkers/family had my back. The cards, emails , and calls from surgeons, nurses and techs were non-stop. Offers of transportation to watching our daughter, to surgeons asking who do I call for you, or what can I do? WOW!!!!!!!!!!!!! How Blessed am I to have such a special work family that would go to these extents for me and my family?

I want to let you know that the doctors at the Lahey tell me I was VERY lucky and the stents are in a secondary vessel. The main arteries are unremarkable and there is no damage to my heart that they can see. With a proper diet and exercise I will see my grandchildren grow old. I am 44 and should live at least another 44 years if I follow all the rules. The O.R. staff tells me I am barred from the elevators and my lunches will be scrutinized, so the rest is a piece of cake.

I know this is a long email, and for that I apologize. I could not tell you of the exceptional people you have on the West Campus in just a few lines. I know your day is filled with lots of important business and meetings. I just felt I needed to tell you of a SPECIAL group of people I work side by side with that are my B.I.D.M.C. family. I know you will be as proud of them, as I am indebted, to each and every one. If the world were filled with more people like my co-worker family how special a place it would be.

Say "Hi!"

Please say hello to some of our new staff members, seen here at this morning's new employee orientation. I like to be the first to welcome the new people, to tell them about the history of our two antecedent institutions and the enduring values that drive our hospital. As I have noted earlier on this blog:

The description of the Deaconess -- "where science and kindliness unite in combating disease" -- was also the watchword for Beth Israel. Fortunately, the combined institution that resulted from the merger ten years ago maintains that set of values. BIDMC stands as a place where patients know they will be treated with warmth, friendliness, respect, and dignity. We do our best to treat each person as we would want a member of our own family to be treated. This is not just a saying: It is part of the culture of the place, and we deliver on that promise every day and night in the great majority of cases. We aim to continue to show our patients that level of caring and respect.

We warmly welcome our new staff every Monday morning and try to pass along this sense of purpose and mission, not only during the orientation, but during the weeks and months that follow.

Keep it moving!

Great use of a Segway: Monitoring live parking at the (several hundred yards long) traffic island at National Airport in DC.

Sunday, April 27, 2008

Sunday, Breast Cancer, Washington

Just back from joining Shannon Brownlee, and Dr. Carolyn Clancy at this year's Annual Advocacy Conference of the National Breast Cancer Coalition Fund, “Beyond Ribbons to Revolutions" in Washington, DC. Ours was a plenary session entitled, Quality Health Care: Delivering on the Promise. Alice Yaker did a superb job as our moderator. Perhaps our session is written up on the conference blog, in which case you can read more about it there. (Photo, left to right, is of Alice, Carolyn, and Shannon.)

Thanks to Judi Hirshfield-Bartek and Susan Troyan (other photo), from BIDMC, for persuading me to cut short my regular Sunday morning soccer game to accept this invitation. They may be two of a very small group of people who could do that -- proving again the power of this advocacy group!

Speaking of breast cancer and advocacy, I want to invite people to attend the annual dinner of the Silent Spring Institute on May 15, at Boston's InterContinental Hotel. SSI is a non-profit scientific research organization dedicated to identifying the links between the environment and women's health, especially breast cancer. The dinner will benefit the Susan S. Bailis Breast Cancer Research Fund. We will be honoring Roberta Chafetz and Fredi Shonkoff with SSI's Rachel Carson Advocacy Awards.

Pasxa 2008

Nabbed this mouth-watering photo from a friend's page on Facebook. I don't know if she wants attribution. Will add it later if she does. An explanation of the word "Pasxa" on this blog: "... the passing over of Christ from here on earth to the Kingdom of Heaven."

Happy Easter to my Greek friends!

Saturday, April 26, 2008

Great Horned Owl Nest

As part of today's walk in Natick at the Broadmoor Sanctuary, we had view of a great horned owl, with two chicks, nesting in a great blue heron's nest. We ran into Oktay Kaya, an accomplished wildlife photographer, who had set up his rig to get some shots of these lovely birds. Here's Oktay and a link to his website. Look closely and you can see the owl and a chick in his viewfinder.

Signs of spring in Natick

Back to Mass. Audubon's Broadmoor Sanctuary today for another walk on a beautiful spring day. Photos show that things are finally warming up. Yay!

Friday, April 25, 2008

Lean speech

For some reason, I have been invited to give lots of speeches and classes lately, mainly on the topic of how to achieve process improvement in hospitals to improve quality and safety. I view this as a bit odd since I am just learning this stuff myself. Maybe people like to hear about the process in mid-stream. Anyway, I enjoy these sessions, getting to know new folks who are interested in the topic, but, as often as not, learning more from them than they do from me.

I tend to accept almost all invitations from colleges, non-profits, civic organizations, and also local businesses -- as my part of the educational mission of BIDMC. If I think they can afford it, I ask for a small honorarium to support programs in our hospital. I also get requests from those companies that organize expensive one- or two-day seminars for business people who want to travel. In those cases, I ask for a very, very large fee -- a large multiple of what they charge their attendees -- and then they usually find someone else!

Today's group was the Lean Educator's Conference, organized jointly by Professor Earll M. Murman at the Educational Network of MIT's Lean Advancement Initiative and another university group called LEAN. LEAN is affiliated with Jim Womack's Lean Enterprise Institute -- Jim is flanked in the picture above by Prof. Joe Sussman of MIT's Department of Civil and Environmental Engineering and Prof. Judy Hoffer Gittell of Brandeis University's Heller School. The invitation came because Earll had heard me talk last October at the National Academy of Engineering on "Adapting Process Improvement Techniques to Academic Medical Centers."

Since there may have been repeat listeners, I had to find some new jokes . . .

Thursday, April 24, 2008

Welche Sprache sprechen Sie?

This young lady is Joanna, one of our "greeters" who helps patients and families as they enter the hospital. Joanna and her colleagues answer all kinds of questions, give directions, escort people to their appointments, and are otherwise exceptionally pleasant and helpful.

But, this post is really about the item to Joanna's right, a rotating box with instructions in several languages to help people who do not speak English get the help they need. We have interpreters in over 30 languages. Good communication is not just a pleasantry in a hospital: It can be a matter of life and death.

High grades for all

I had a nice break from the office today when I went over to that liberal arts college in Cambridge and taught a session in a class called "Quality of Healthcare in America." I told the students that I would post a picture of the student who asked the best question, as judged by his or her peers in the class. They decided that the professor, Dr. Warner Slack, had asked the best question! So, the consolation prize is that they all get their picture in this post. Actually, though, I think most of their questions were better than his. I think they were just trying to flatter him into getting better grades.

Observations from Kampala

A note from my good friend, Dr. Honora Englander, who is currently on assignment in Uganda. Very well written, I think, with important observations about us as well as the local scene there. She welcomes your comments, too. (And please go back to these three posts to read about her previous Kenya experience.)

As many of you know, I have spent much of the last year thinking, learning about, and further developing work around humanism in medicine curriculum for African students. The basis for it came out of work that I started with Kenyan students to explore the personal challenges of providing care in a resource poor setting with high mortality from HIV/AIDS and other treatable diseases. "The Art of Medicine" in Kenya was based on a discussion series that we had while I was a resident at OHSU, where we discussed cases focusing on the personal aspects of providing care, instead of the typical clinical focus. The experience was meaningful and powerful for the Kenyan students, and many of them are eager to further pursue it. Seven of the Kenyan students have arranged to come to Kampala for an away rotation, in part to continue the conversation that we started a year ago. They arrive next week, and I am delighted to see them again. It is exciting, and as I return to East Africa I am reminded of the importance of these themes.

I hesitate a bit to write to you all about some of the things that are the hardest about being here. I have not yet sorted out my complex feelings about the dynamics and culture of care on the hospital wards, but I will share some of my early thoughts. My sense is that most, if not all, Westerners who work in a setting like this feel a certain frustration, and at times desperation, from the intensity of disease, limited resources, and the relatively slow pace to dealing with what they perceive as emergencies. There are critical labs that get drawn but not run, and life-saving treatments that get delayed until it is too late. Often in the afternoons and late evenings there are no doctors on the wards that are filled with ailing patients. I see many Westerners complaining, exasperated, and angry, about shortcomings of the system. And I hear repeated criticism about the "lack of accountability" and "professionalism" amongst local providers. I understand and see what people are talking about, but I feel that there is so much more to it all. And I worry about the effect that these critical voices from abroad have on an institution and a culture. These voices are hard to escape, and come with strong undercurrents of implicit assumptions and judgments made by visitors. And while I am grateful to be here, I do question the value and the harms of short-term visits by people from wealthy countries…. These questions are not new for me, but they are freshly revisited. I suppose they are what motivate my interest in promoting discussion amongst Africans around the art of practicing medicine, and also in encouraging a more thoughtful approach on the part of US collaborators and educators who send so many students and physicians overseas…

Wednesday, April 23, 2008

Yesterday's newspapers are today's . . .

. . . fish wrapping. So, what is yesterday's newspaper sidewalk box? Large litter in the MBTA right-of-way near the Longwood Avenue bridge.

Dan Kennedy wrote of the demise of BostonNOW last week. As he notes, this "free commuter rag" never lived up to its billing, "a state-of-the-art meld of print and Web, with readers setting up blogs that would be excerpted in the paper." Too bad.

Too bad, too, that they couldn't at least have picked up their trash before they folded.

Tuesday, April 22, 2008

Celebrating Quality and Safety at Work

As my regular readers know, in December of 2007, the Board of Directors of BIDMC formally voted to support two audacious, long-term goals for improving the quality and safety of care for our patients.

The first is to eliminate preventable harm by January 1, 2012.

The second is to achieve patient satisfaction that places us among the top 2% of hospitals, also by January 2012.

These are not easy goals. Achieving this degree of excellence requires the ability to evaluate performance, implement changes, and evaluate again – in multiple small ways and across all departments and disciplines.

In preparation for the First Annual Silverman Symposium for Quality and Safety in April, staff from across BIDMC were invited to summarize their improvement work in a standardized format that captures the essence of the project in a single page.

I think you will be impressed with the variety of problems, approaches, and solutions represented by these project summaries. (The box on the left of the embedded web page has a list you can click.) While BIDMC has a small and very fine staff of quality improvement professionals to facilitate projects, the vast majority of the work occurs by health care workers dedicating special time and effort to create change. I hope you will agree that this collection demonstrates that BIDMC is a place where evaluation and improvement occurs every day.

Of course, we are happy to share more details of any of these programs with other hospitals. Just let me know if we can be helpful to your place.

Award for Non-Profit Governance

Congratulations to Harold Hestnes, Chairman of the CareGroup Board, for receiving the Leadership in Non-Profit Governance Award from the New England Chapter of the National Association of Corporate Directors. (CareGroup is the holding company that comprises BIDMC, BID Hospital~Needham, Mount Auburn Hospital, and New England Baptist Hospital.) We are pleased to have someone Harold's stature and wisdom at the helm and to get confirmation that he is widely recognized for his accomplishments in non-profit governance.

Here's the excerpt from the announcement:

Leadership in Non-Profit Governance Award: Harold Hestnes, Former Partner, Wilmer Cutler Pickering Hale & Dorr. For more than 40 years, Hestnes practiced general litigation with an emphasis on public law issues, particularly antitrust and regulatory matters affecting the oil, gas and electric power industries. He retired from active practice in 2007. Hestnes is a prior chairman of the Greater Boston Chamber of Commerce, director and secretary of the Massachusetts Business Roundtable, and is past chairman and a member of the Boston Coordinating Committee. He has served as chairman of the Board of Selectmen for the Town of Weston, and as director and chairman of the Massachusetts Taxpayers Foundation. He is also the Chairman of the Board of Directors of CareGroup and a board member of MassINC.

Flash! SPIRIT lowers high blood pressure!

What's one of the most common things a nurse does upon entering a patient's room? Check the blood pressure. So just imagine the work-arounds that were happening over and over again before this problem was called out as part of BIDMC SPIRIT. I post the results from the problem log.

Type of Problem -- Save Time; Improve Patient Care
Campus -- East
Setting -- Inpatient Ward
Location of Problem -- 12 Reisman
Problem -- Many of the patient rooms missing blood pressure cuffs and/or parts.
Person Describing Problem -- AnnMarie Grillo, RN

Root Cause
Many of the nursing staff unaware of storage location of BP cuff and extra parts (kept in a closet at the end of the hall). Because of this, missing cuffs and parts not getting replaced.

Solution (after investigation)
Change storage location to more central area.

Action Plan (who, what, by when)
1) Immediately -- room rounds done and all missing cuffs and parts replaced. (Done by AnnMarie Grillo and Gina Murray.)

2) Moved storage location of BP cuffs and parts to a drawer in the medication room at the nurses' station. Labeled drawer and notified the staff. (Done by AnnMarie Grillo and Gina Murray.)

3) Obtained current list of BP cuffs and supplies from Bill Pyne in Distribution. Posted this list in medication room above BP supply drawer for staff to make re-ordering easy. (Done by Kerri Petraitis and Gina Murphy.)

Investigation -- Closed (Complete w/ root cause, solution, action plan complete)

Hug a lab worker! And say "Thank you," too!

This is National Medical Laboratory Professionals Week, which is celebrated to provide the profession with an opportunity to increase public understanding of and appreciation for, clinical laboratory personnel. This activity takes place during the 4th week in April each year, and is coordinated by a collaborative committee with representatives from 10 national clinical laboratory organizations.

Here at BIDMC, we are marking the occasion with seminars, raffles, tours, and -- of course -- food, including a bake-off.

But, mainly, we are marking it by expressing our appreciation for these quiet and extremely professional heroes of our hospital, without whom the modern practice of medicine would be impossible.

In Memoriam: Hendrik Houthakker

Hendrik Houthakker was known for big things in the field of economics, including being on two presidents' Councils of Economic Advisers. For me, he was a kind person when I showed up after taking the Number 1 bus up to Harvard from MIT in 1973 to ask for advice on my Master's thesis, which was an econometric study of the residential demand for electricity in New England. My MIT advisor, Karen Polenske (no slouch herself in the economics world) had suggested I do so. We only met once, but I remember his gracious manner as he spent a half hour with an unknown student to check out my proposed methodology.

And, you never know where things will lead. Several months later, when I went to interview for my first job, the thesis would come in handy. Henry Lee, the incoming director of the MA Energy Policy Office, had spent a year off getting a master's degree at Harvard at the Kennedy School. He hired me, in part, because my thesis had been on the reading list for a class he took! (Other than that, and in a few footnotes elsewhere, the thesis has fallen in oblivion.)

Monday, April 21, 2008

CarePages at BIDMC

A suggestion from e-Patient Dave after his treatment at our hospital last year prompted us to start offering Carepages to our patients. The idea is to make it easy for people to create and update a private and personalized web page where they can share their latest news with friends and family and receive messages of support. There is no charge to the patient for this service.

Similar services had been available to patients if they made an effort to find them, but Dave was right to suggest that we offer it directly. For some reason, we were a bit behind the times on this matter, and I am glad he pointed it out to us.

Proving again that patients really have good ideas about how to make life better for patients. Duh!

Bill Bryson on Darwin

It's Patriots' Day weekend here in Massachusetts, and also in Maine. (Apologies to readers in the UK!) As you can see, I'm using the occasion to offer some non-hospital-related items. (See below, as well.)

Bill Bryson is one of my favorite authors, and I am belatedly in the midst of reading A Short History of Nearly Everything (Broadway Books, New York 2003). As the title suggests, it covers a lot of ground. For those of us interested in the study of the human genome, there is a marvelous paragraph (on pages 3-4) about the random directedness of evolution. I think Darwin would have liked it:

Not only have you been lucky enough to be attached since time immemorial to a favored evolutionary line, but you have also been extremely -- make that miraculously -- fortunate in your personal ancestry. Consider the fact that for 3.8 billion years, a period of time older that the Earth's mountains and rivers and oceans, every one of your forebears on both sides has been attractive enough to find a mate, healthy enough to reproduce, and sufficiently blessed by fate and circumstances to live long enough to do so. Not one of your pertinent ancestors was squashed, devoured, starved, stranded, stuck fast, untimely wounded, or otherwise deflected from its life's quest of delivering a tiny charge of genetic material to the right partner at the right moment in order to perpetuate the only possible sequence of hereditary combinations that could result -- eventually, astoundingly, and all too briefly -- in you.

What we have here . . .

Note on her mother's wall from a 15-year old, after her mom has consistently not responded to previous messages:

mom, this is pathetic. you defeat the purpose of facebook completely.

Sunday, April 20, 2008

Dad, that twee is bwoken!

Mrs. L and I had a chance today to enjoy a beautiful spring day in Boston with a walk through one of our favorite Mass. Audubon sanctuaries. Lots of families were out in the woods, including one with a little boy between two and three years old. He had just passed by this tree that had been uprooted by a storm, lying on the ground with a full set of roots showing, and it clearly made an impression. He kept repeating, in the manner of little boys, "Dad, that twee is bwoken!" until he got a proper acknowledgement from his parent. A perfect moment.

Worth mentioning again

For this second night of Passover, please click over to this post and follow the link embedded there.

Saturday, April 19, 2008

Let's adopt the Knutson Plan

I was going to make this proposal, but I got distracted by other things, and so I was beat to the punch by Mandy Knutson, of Nashua, NH, in a letter to the editor in the today's Boston Globe:

I have an idea that would solve the shortage of workers on Cape Cod ("Cape employers left scrambling," Page A1, April 11). I read in a subsequent edition of the Globe about a possible shortage of jobs for teenagers in Boston as companies and nonprofits are cutting back ("Summer jobs may be at risk for teens," City & Region, April 16). Why not hire and house teenagers from the Boston area on the Cape? Just a thought.

I have had this same thought every year when I am on the Cape and restaurant owners and others tell me about their difficulty in getting foreign workers when the federal government puts limits on the number of work visas. Even when they can get workers, they have to pay hefty fees to agencies to recruit the workers and pay their airfares. Each year, a different country seems to provide the most young adults. Sometimes Poland, sometimes Bulgaria, and so on.

I don't begrudge young Eastern Europeans a chance to get to know America and earn some money. In fact, it is probably good for the US to have these folks get to know us in a way other than what they see in the movies and television shows. It is also good for us to learn a bit about their countries.

But, I am struck by the fact that teenagers and young adults in Boston, Quincy, Fall River, and New Bedford have persistently high unemployment rates, and yet no job creation agencies or foundations or Cape Cod employer groups seem to have thought about training and recruiting them to do jobs that pay reasonably well and are much closer to home than Bulgaria. An advantage, too, is that you would have all winter and spring to schedule the training so they could be ready to take on their job responsibilities upon arrival.

Thank you, Mandy Knutson, for making the suggestion. Maybe someone will pick up on it.

Remembrance on Passover

As we begin this celebration of freedom tonight, listening to this tape can be a helpful reminder of the strength of this human instinct. This tape was discovered, I think, in the Smithsonian Museum a couple of years ago, and is of a BBC recording on April 20 1945, about 5 days after the liberation of the Bergen-Belsen concentration camp by the British Army.

Friday, April 18, 2008

Busywork is not your job!


On March 25, a SPIRIT training team visited the MICU 6. During the 25-minute observation, Pat Boykins, a Unit Coordinator, attempted to order copies of a patient consent form from the Web site of Office Depot Web, which has a contract to print all of BIDMC’s forms. When she entered the BIDMC code for the form (MC1793) she received an error message saying that the SKU – the product number Office Depot associates with the form – was incorrect. There was no other information, and thus Pat could not order the form.

Pat then spent 5-7 minutes making phone calls to hunt down the correct code. She eventually found it: MR1793. When asked at the end of the 25-minute observation if she encountered any problems in her job during that time, Pat said “No.” Why? Because this type of hunting and fetching has become a routine part of her job – a job she does with as much efficiency as possible. When prompted by the SPIRIT team to think of a way to improve the form-ordering process, however, she did make a suggestion that she said would save her a lot of time: find a way for the Office Depot site to provide the correct SKU for an expired or changed form code.

Here’s what happened next:

Pat reached out to her Help Chain Contact, Kristin Russell, Nurse Manager of MICU 6. Kristin spoke with Paula French, Contract Manager, who handles the Office Depot account. Paula said the proposed functionality of the Office Depot database does exist, and that the SKU never changes for a given form, even if its BIDMC code changes. She referred Kristin to Michelle Micale, Project Manager in Health Information Management, the department that handles all forms.

Michelle Micale was very helpful, and in the information she provided, the root cause of the problem was revealed. She confirmed that the form’s internal, BIDMC code had changed recently as part of an overall, ongoing process of reassigning more specific codes to forms to categorize them. Instead of all being Medical Center (MC) forms, they are being recoded as Medical Records (MR) forms, Learning Center (LC) forms, Human Resource (HR) forms, etc.

Michelle is working with Office Depot to ensure that both the old code and the new code for each form will always lead to the same SKU, beginning with the Medical Records forms. This process will take a while. In the meantime, she is available as a resource to provide the correct form number to anyone who needs one. Her e-mail and phone number are on the problem log. David Drew of Patient Care Services has sent this information to all Unit Coordinators.

Thursday, April 17, 2008

Batalden updates Machiavelli

"There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order, this lukewarmness arising partly from fear of their adversaries … and partly from the incredulity of mankind, who do not truly believe in anything new until they have had actual experience of it."

This famous quote by Machiavelli is both a hearty warning and a healthy piece of advice to those who seek to change a political or social system. If those in today's health care system were looking for the equivalent piece of warning and advice, they might just have obtained it from Paul Batalden, Professor and Director of the Center for Leadership and Improvement at the Dartmouth Institute for Health Policy and Clinical Practice. He presented it to a small group of us today, in a talk entitled "The challenge of leading the leading of the improvement of health care". I present it with his permission. I think he has nailed the issue and admire his ability to do it so succinctly.

The key slide had the following heading:

“Anchors” of a synergistic culture holding the present in place…

And the following four major observations about why change is so hard to achieve:

Lack agreement about what the common and individual work is (at the behavioral level) that will be necessary to create anything different than the present reality;

We seek and find reinforcement for our self-interests, beliefs in the current payment methods and systems of health care;

Desire to focus on “islands of excellence” (and we love to give “Island Tours”) rather than create and maintain uniformly safe, high quality, good value, reliable and accessible operations; and

A well-developed capacity to rationalize away the newsworthiness of potentially disconfirming data (financial, quality, safety) and external assessments by patients, payers, etc.

Wednesday, April 16, 2008

Dealing with a demand for harmful or ineffective treatments

There is often a lot of commentary about physicians' overuse of medical services, using treatments that are unnecessary or wasteful. But there is also the question of how to handle the situation in which a doctor does not want to deliver a treatment s/he believes would be harmful or ineffective when a patient or a patient's family demands to receive such treatments. Our hospital has a policy on this matter, conceived with broad involvement from our faculty and with particular input from our ethics coordinator. I print it in its entirety below in case it might be useful to other places or informative to this general audience. I think it is pretty self-explanatory, but I am happy to help collect responses to questions in case it is not.

Title: Policy On Treatments That Are Harmful or Ineffective

Purpose: To ensure that medical treatment always respects the dignity and integrity of both the patient and any involved health professionals.

Policy Statement: The goal of medicine is to benefit the patient, and the process of delivering medical care should always respect the dignity and integrity of both the patient and the health care practitioner.

It is the policy of the Beth Israel Deaconess Medical Center that no patient should be forced to undergo, nor should any physician or health professional be forced to provide, a treatment that is ineffective or harmful. A medical treatment is ineffective if there is no reasonable likelihood that it will achieve a medical benefit to the patient. A medical treatment is harmful if the likely suffering or risk of other harm caused by the treatment grossly outweighs any medical benefit to the patient.

In undertaking the care of a patient, a BIDMC physician will offer all available medical treatments that have a reasonable likelihood of benefit without an overwhelming burden of suffering. If a point is reached when no further medical treatment offers any reasonable hope of benefit without an inordinate risk of suffering, the physician will continue to care for the patient, ensuring that any suffering is minimized and the patient’s dignity is respected.

Procedure(s) for Implementation:

Patients, families and providers generally agree in applying these principles of medical care to achieve patient-centered goals. In rare cases, significant disagreements may arise over whether a treatment is ineffective or is harmful. In such circumstances, if all efforts to achieve agreement fail, the following series of steps is recommended, each in a timeframe appropriate to the patient’s clinical situation, and with documentation in the medical record:

  1. The attending physician should seek a formal, independent second opinion from a physician not currently engaged in the patient’s treatment. If the consulting physician concludes that treatment is not ineffective and not harmful, the attending physician may choose to provide that treatment or the consulting physician (or another who is willing to do so) may take over care of the patient.
  1. If the attending and consulting physicians agree that the treatment is ineffective and/or harmful, the patient or family should be offered the opportunity to seek transfer to a facility willing to provide that treatment. The patient or family should be encouraged to seek support and assistance from a BIDMC Patient Relations Representative and/or Social Worker in this and any subsequent steps described below.
3. If the attending physician concludes that these efforts to resolve the disagreement have failed, s/he should notify the administrator on call, who will convene a committee consisting of:
    1. Chief(s) of the relevant medical or surgical service(s) or their designees not involved in the patient’s care
    2. Chair of the Ethics Advisory Committee (EAC) or designee
    3. Representative of the Patient Care Assessment Committee (PCAC)
    4. Senior Vice President of Patient Care Services or designee
    5. Director of Social Work or designee
    6. Director of Pastoral Services or designee
    7. Chief of Psychiatry or designee
    8. Chief Operating Officer or designee
    9. Others deemed appropriate by the committee or its chair

The EAC representative will serve as moderator and chair of the committee. A quorum will consist of a minimum of four members, including at least two physicians, since the committee’s core task is to determine, on medical grounds, whether the treatment under consideration is ineffective or harmful. The quorum must include at least one representative of the relevant medical or surgical service(s), and the representative of PCAC.

The committee will consult with the following parties:

a. The attending physician, who should explain the basis for deeming the treatment to be ineffective and/or harmful. Other members of the treatment team should be asked to add details or to offer different perspectives and interpretations.

b. The patient and/or family spokesperson(s), who should explain the patient’s perspective regarding the treatment under consideration, including hopes or expectations of benefit and views about possible harm(s). A BIDMC Patient Relations Representative and/or Social Worker should be available to the patient and/or family before, during, and after this step.

Following as free an interchange of perspectives as possible, the committee will meet alone to determine whether the treatment is ineffective or harmful.* If the committee does not conclude that the treatment is ineffective or harmful, it may offer suggestions for identifying BIDMC staff that may be willing to assume responsibility for the patient’s care. If the committee does conclude that the treatment is ineffective or harmful, it may offer suggestions to the involved clinical service(s) and BIDMC administration regarding steps that may be taken to ensure that BIDMC staff are not forced to provide the treatment.

One or more representatives of the committee will communicate the committee’s conclusion, any related suggestions, and its reasoning to the concerned parties, with documentation in the medical record.

If the patient or family are not in agreement with a determination by the committee that the treatment is ineffective or harmful, and are unable or unwilling to arrange for transfer to another facility, they should be informed of their options for seeking, within a reasonable timeframe, court involvement. Unless there are legal barriers to doing so, however, BIDMC administration shall take steps to support implementation of the committee's conclusion.

* Finding a treatment ineffective or harmful is a positive finding; in the absence of a clear consensus, the committee should conclude there was inadequate evidence on which to decide that the treatment was ineffective or harmful.

Straight talk about SPIRIT

After each full-day training session for managers and others about BIDMC SPIRIT (almost 600 people now), there is a debriefing session. The comments that emerge are helpful to us in refining both the training program and our plans for calling out and solving problems throughout the hospital. To give you a sense of the issues raised, I am posting the comments from the last session. Remember, this is early in the process, not like at Toyota and other places where similar approaches have existed for decades. So, we are still feeling our way. I love that people are so open and clear about what they find reassuring and what they find troubling. That, in itself, is an important aspect of what we are trying to accomplish.

BIDMC Spirit Orientation
Participant Concluding Reflections
April 15, 2008
These reflections were invited by Ken Sands, our SVP for Health Care Quality. He started by saying, "We heard earlier today from a colleague about how logging of items about their unit had been used as a metric that wasn’t positive." Responses follow:

That was me. I did get a call from someone above me who said in effect, "There are a lot of call-outs in your area there must be some real problems there; what’s going on?" when it’s 4 out of 450 and I know we are trying to encourage call outs. I wanted to say that I’m a big supporter of this process, but it has been confusing regarding are we supposed to deal with things as they are called out and up "the help chain" or by getting calls from people above us or reacting to an e-mail from the log monitor? Are we supposed to scan it everyday? It’s not clear and it’s hard to know how to prioritize. We talked about it earlier today, and we discussed how we are all learning together including the leaders, but it’s important to be aware of this dynamic because it creates pressure and anxiety.

Thanks for saying that. The other day we had an issue and I ended up talking about it with the other manager by saying, "Maybe we can do a problem solving without logging it." And we actually had a phenomenal response; fastest ever. But there’s something about the log, it’s very visible, monitored, punitive potentially. It just feels like a difficult environment for me to call out in, at least at this stage.

The last five years have seen a great focus on greater accountability. We just don’t want to slip into blame.

I wanted to say that SPIRIT does empower us to deal in areas where we’ve struggled … it makes it much easier to engage on issues we’ve struggled with. I do have a suggestion about the training; make it easier to make a personal connection in the set-up, with phone numbers etc. Finding time was hard for me, so you send an email and you hope for a response but it’s not to anyone in particular.

I’ve been to a lot of trainings like this. The bigger challenge than training is how to keep it going. How does the organization reinforce this; how do we get reinforcement? Reflecting on today, I’m not sure I would have been as persistent and nice in working with the people involved. It’s a discipline. It needs to be reinforced/mentored. This is a cultural change!

My comment is about language. If we changed what we say from "problem" to "opportunity" it might help. Because that’s what they are – opportunities – and even the word problem seems to connote something negative.

It was inspiring to see people on the front line involved in solutions and being asked for their opinion, not just told. Being asked, "What do you think about this?" and "How would this idea come across to your peers if we rolled it out?" That was totally inspiring.

Facebook followup

As mentioned below, Johnny Diaz at the Boston Globe was working on a story about Facebook in the workplace, and his story is in today's paper. As he noted, for those wanting to avoid total disclosure about personal details, "Last month, the company introduced new privacy options. Users can now distinguish who can view their personal details by classifying people into specific groups such as friends, co-workers, classmates, or relatives, each category granting a different level of access. In other words, Facebook members can allow their close friends to see their vacation snapshots but restrict co-workers or relatives from the same access."

Meanwhile, though, many people sometimes get tried of all the applications and invitations they get from their friends, just wanting to use Facebook for basic communication. A friend of mine posted the following humorous and poetic note on her site to send a message on this topic to her friends:

dear every one, i appreciate the thoughts, however, I am not interested in being super poked super sideways double reach around video wall posted, live music player hosted, double dutch instant messenger facebook chatted, quadruple application mounted vip amazing friends list added. I hate to love facebook just like the next guy, but i'm not succumbing to this level of application installation carpal tunnel wrist numbing add me please action, you hold me too long online it's off i'm trying to sign, so cut the crap, this macbook is burning my lap.

Tuesday, April 15, 2008

A way with words

I just had the pleasure of being on a panel discussion at U. Mass Boston with three wonderful colleagues: Stephen Crosby, Dean of the McCormack Graduate School of Policy Studies; Jim Sabin, Director of the Harvard Pilgrim Health Care Ethics Program; and Marc Roberts, Professor of Political Economy at the Harvard School of Public Health. The topic was "Health Care Rationing: The Elephant in the Room." Of course, the topic eventually swayed over to the improper incentives built into the current health care reimbursement system -- at which point Marc began to discuss the pigs of Provence who use their snouts to root underneath oak trees in search of truffles. The audience was lost for a moment until Marc drew the analogy with me and my fellow hospital administrators, whom he termed "truffle-seeking pigs" rooting through the reimbursement system to focus on those service lines that generate the most margin for our institutions. I am not sure how I feel about the animal he chose, but it was a superb image!

Help wanted . . . and found

A lovely editorial in today's Boston Globe about use of the Workforce Competitiveness Trust Fund, created by the Legislature in the economic stimulus bill of 2006. Thanks to this appropriation, BIDMC, Children's Hospital Boston, and the New England Baptist Hospital jointly created a two-year Medical Lab Technician program with Bunker Hill Community College. As noted in the editorial, "There's a high demand for these workers, whose responsibilities can include handling specimens and running blood tests. Classes are held at Beth Israel, after work. During the last six months, participants go to labs for hands-on training. And they still get their salaries, making the training affordable."

Monday, April 14, 2008

How can this be?

As first, I couldn't believe that this story was true, but it has now shown up in several on-line stories and was also in today's Boston Herald, whose story started, "DEARBORN, Mich. - Outraged nursing union members claim they were attacked by purple-cloaked members of a rival union which stormed their conference." (Sorry for not providing a link, but according the Herald site, this story is no longer available on line.)


Several months ago, I read about Jet Blue's use of homesourcing in Thomas Friedman's book , The World is Flat. The idea is simple and elegant. For some staff functions, those relying mainly on computers and telephone, why not allow people to work from home and avoid the mess of commuting? Also, people who are otherwise tied to home for physical or family reasons can be active members of the workforce and get better jobs if they are permitted to work from home.

We decided to run a pilot for some of our coders (the people who review medical procedures to provide proper billing formats for the insurance companies), and our CIO, John Halamka, writes about the experience in CIO Magazine. As you can see, doing this for a hospital is a bit more complicated that for an airline, because there are major and important concerns about privacy that have to be met. As John notes in the article, "If employees are to access sensitive health data from their homes, I need to investigate biometric devices, re-examine application time-outs, strengthen surveillance of audit logs and ensure end-to-end security from data center to the home."

The results overall were very positive on many fronts. "The flexible work arrangements improved employees' quality of life. They're not stressed or tired from commuting so much, and they're saving money on parking and gas." Also, "Coders are challenging to hire in Boston due to the large number of hospitals competing for a small number of qualified employees, so flexible work arrangements enable us to hire without geographic restrictions. Given the IT job market and the difficulty of recruiting replacements, the benefit of such flexibility cannot be overstated when you have a seasoned employee who knows your systems well. We were able to retain a coder who moved and we included her in our pilot."

But it is important to be sensitive to and respectful of individual preferences. As John notes, "One coder who lives by herself said she felt distracted at home and missed the social interaction with coworkers. Another coder who also lives alone loved working at home since she experienced no interruptions and got more done."

Please read the article for a full description and see if this might make sense for your organization.

Return of the house call?

Please read this op-ed by Dr. Elizabeth Kass, from Urban Medical, and our Chief of Medicine, Mark Zeidel.

Sunday, April 13, 2008

11 minutes of pleasure

A year ago, I wrote about our use of mystery shoppers to help guage whether we were meeting standards of customer quality in our clinics. We still do this and find it a good way to help the staff at the front desk staff do better and better for our patients. Here's a call, though, that shows exemplary service. (The call lasted 11 minutes. You can't rush quality.) Note the immediate feedback to the staff member from the secret shopper, too.

After one ring, Kerry Falvey answered my call by enthusiastically stating the name of the practice, her own name, and asking, "How can I help you?" I explained that I needed to make an appointment, but I had never seen a Nephrologist before. I had seen a Urologist recently because of recurrent UTIs who said I had high creatinine levels. My PCP and this Urologist both suggested I see a Nephrologist. Kerry said that she could definitely help me with scheduling an appointment, and asked for my name and date of birth. She confirmed that I had never been to BIDMC then explained that as a new patient, she would need to start a profile for me. She then collected all of my demographic information and confirmed that my PCP was the referring physician. She also asked if there was a particular doctor I'd be interested in seeing, and I said there was not. Kerry then explained that she would check for the first available appointment. She mentioned that their new patient policy was to provide an appointment within seven business days. The first appointment she found for me was for Tuesday, February 26th (6 days) at 10:30a with Dr. Walter Mutter, whose name she spelled for me. She confirmed that this appointment date and time would work with my schedule and confirmed that the reason for my appointment was because of high creatinine. Kerry then explained that she would check if I needed a referral. She clearly explained that depending on my insurance and PCP, I may not need a referral because of certain agreements between BIDMC and certain insurance companies. She explained that since I had Harvard Pilgrim insurance and my PCP was a BIDPO doctor, I would not need to obtain a referral. She then explained that she would check if they could access my PCP's records. Since she discovered that they could not electronically access the records, she said that they would contact my PCP, with my permission, to obtain any pertinent notes. Kerry asked if I knew where their office was located, and I said I did not. She explained that there would be a letter coming in the mail with details on directions, parking, etc, but that she would give me the location anyways. She provided me with the address, name of the building, and floor on which I could find Medical Specialties, which is where their practice is located. She asked if I needed directions to the medical center, and I said I should be fine. Kerry then repeated the date, time, and doctor I would be seeing for my appointment. She provided me with the practice phone number and explained that I could call with any questions and that any of their three staff could help me. She asked if she could help me with anything else before transferring me to registration.

Kerry's facilitation of my call was nothing less than exemplary. I mentioned to her that her tone of voice was very pleasant, and she was easy to speak with, making for an enjoyable conversation. I also commended her clear explanations throughout the call, including why she needed to collect my information, the fact that she would schedule me an appointment then transfer me to registration, and her description of the referral exception which my insurance allowed. I also thought she was very accommodating, since she was able to check right then and there whether I needed to call my PCP for a referral and since she offered to obtain the medical notes from my PCP. I also mentioned to Kerry how helpful it was that she repeated the reason for my appointment, indicating she understood my request, and that she repeated my appointment date, time, and doctor at the end of the call. I also mentioned to Kerry that it seemed like she provided me with all the information I needed and asked all the questions she should have. The only suggestion I could think of for Kerry was for her to mention something about parking along with the location of the practice.

It was very uplifting speaking with Kerry, even for something as mundane as scheduling a doctor appointment. Even on this Friday afternoon, Kerry's spirits were still high, which certainly lifted my own mood. This call truly sets the bar for the customer service that all of our schedulers should aspire to reach. Kerry received a 5 (excellent) out of 5 for this call.

Welcome, Citizen Abraham!

A funny and lovely column by Yvonne Abraham in today's Boston Globe about the penultimate stage in becoming a US citizen. Reminds me of the hilarious Jay Leno routine in which native-born US citizens on the street are immediately shoved into an INS van and deported if they cannot answer the questions expected of new arrivals.

Saturday, April 12, 2008

Everyone has his Lambaréné

There are certain iconic moments in life that serve to motivate people. I am not talking about traumatic events like Pearl Harbor, JFK's assassination, or 9/11, although these are unforgettable and can lead people to take particular paths in life. No, I am talking about the power of an image or series of images.

In October 1947, Life magazine published a photo essay about Dr. Albert Schweitzer and his medical mission in Lambaréné, Gabon. It was entitled "The greatest man in the world." I have not been able to find a copy, but it most certainly included pictures like the one here. It has a bit of a Mona Lisa quality, crossed with a Pieta -- He is looking directly into the camera with an expression that is engagingly kind and direct but simultaneously deep in thought and focused well beyond the camera.

The pictures and the story in the magazine, I have learned, served as an inspiration for many young people of that era to devote themselves to service. The most famous is that of William Larimer Mellon, who left a wealthy life style to go to medical school and establish a hospital in Haiti. Schweitzer would say, "Example is not the main thing in influencing others, it's the only thing." Certainly that was the case with those of the generation who saw that edition of Life Magazine. I am guessing that the pictures in that magazine were imprinted in their minds.

Yesterday, I attended my first meeting as a board member of the Albert Schweitzer Fellowship, which is devoted to reducing disparities in health and health care by developing "leaders in service" -- individuals who are dedicated and skilled in helping underserved communities, and whose example influences and inspires others. ASF supports 175 fellows a year from schools of medicine, dentistry, nursing, optometry, and pharmacy, who pledge themselves to devote 200 hours to community based organizations like clinic, senior centers, schools, and shelters. The program works in 11 cities in the US and is considering expansion to others. There is an cadre of 1785 "fellows for life" who are alumni of the program.

Please contact the Fellowship if you are interested in becoming a fellow, or if you would like to make a donation to this worthy cause. If you are on Facebook, you can find it listed as a cause.

Thursday, April 10, 2008

It's not Passover yet . . .

. . . but these chickens are relaxing in a Jacuzzi in anticipation of the holiday next week.

Save Time; Improve Patient Care; Improve Work Life

Direct and unedited from our problem log, a great example of a call-out and problem solving from BIDMC SPIRIT:

Type of Problem -- Save Time; Improve Patient Care; Improve Work Life
Campus -- West
Setting -- Inpatient Ward
Location of Problem --Farr 7

I could not find a pulse oximeter to check my patient's oxygen saturation. There were none in the equipment cubby which is a section of our breakroom remote from patient care rooms. I wasted a lot of time going from patient room to room until I found one.
Suggested Solution -- Define a specific location that is more convenient to the nurses' and pcts' work flow
Person Describing Problem -- Beth Morrison

Root Cause
Why were none available? It is not a supply issue, there are 7 pulse oximeters for the floor. Why could Beth not find a pulse oximeter? None were in the storage area. Why are the oximeters not returned to the storage area? It is in an inconvenient location. Why when the oximeters are used are they not returned to the storage area? In the past we had a locked equipment room that was centrally located. On our new floor Farr 7, we do not have an equipment storage room and have designated a small cubby hole in the staff breakdown to store equipment. It is inconvenient in relation to the work area. Also, it is in the breakroom so sometimes it is difficult to move past staff who are sitting eating a meal.

Solution (after investigation)
A cubby hole in the nurses's station is not being used. It's location in very convenient for small equipment storage. Electrical outlets and shelving need to be installed. Once that work is complete, I will apply LEAN principles and outline with black tape and label each area for the specific equipment.

Action Plan (who, what, by when)
1. Kathy Hussain met with staff to brainstorm new, convenient location. Complete.
2. Kathy worked with her Operations Coordinator Debbie McGrath to discuss needed work. Complete.
3. Kathy discussed renovation with her director Jane Foley. Approval given to move forth with project. Complete
4. Kathy and Debbie met with Brendon Raftery and Chris Kimball on March 17th to scope the work. Complete.
5. Electrician installed 20 electrical outlets. Complete
6. Carpentry measured and ordered required shelving.
7. Currently awaiting installation of shelving.
8. Once shelving installed- will outline placement of equipment so that each piece of equipment has a designated and corresponding location.

Investigation -- Closed (Complete w/ root cause, solution, action plan complete)

Beth- thank you so much for calling out this problem. Your willingness to discuss this has lead to more efficiency and less wasted time. As a side benefit, the relocation of the equipment will allow us to recapture space in the breakroom, relieving the crowding and giving the Farr 7 staff a more pleasant breakroom.- Kathy

Throw off the crutches of ppt!

The most important line in a recent post: Jessica got a round of applause for not using any PowerPoint slides.

The time has come for the world, with cries of "Hallelujah!", to throw away the crutches of PowerPoint.

Sure, a good ppt presentation can be special, but how often do you see a good one, or one that even contributes to the reservoir of human knowledge? Instead, what usually happens?

1 -- The machine doesn't work, and the audience is left sitting while the speaker pushes buttons and pulls cables and finally calls in the house AV person, who pushes buttons and pulls cables. What better way to show lack of respect to your audience and lose their engagement by keeping them waiting for your talk?

2 -- The slides are filled with text. The speaker tries to put up too much information, instead of using a few words on the slide to create emphasis.

3 -- The slides are filled with Excel spreadsheets with tiny cells. How often have you heard this: "I know you can't read this from your seat"? Well, why put it up on a screen if people can't read it?

4 -- The speaker turns away from the audience to look at the screen whenever a new slide comes up (yes, even when there is a computer on the podium!), losing eye contact with the audience.

5 -- Oops, did I say "eye contact?" That was already lost when the lights were dimmed for the presentation.

6 -- There are too many slides. A new one arrives on the screen every 15 seconds, so if you are trying to take notes (in the dark!), you never finish one before the next appears. (Then, halfway through, the speaker says, don't worry about taking notes. I'll hand out a copy after the presentation.)

7 -- The speaker reads the slides. Need I say more?

Wrong question

A very good friend and colleague who runs a nonprofit advocacy group sent me an email with the subject line, "New technologies/Social networking" and asked the following:

I wanted to ask for some advice. We are looking at new ways to reach members and potential members. We are considering everything from blogs to Facebook to YouTube. I was warned that blogs can be very time-consuming, and judging by the quality of your blog, I assume it is. Can you give me a sense of how much time you spend on your blog?

My response:

Wrong question. That's like asking how much time you spend talking with people. We should talk.

Here's a more complete answer. As head of an advocacy group, I would be looking to build strong, engaged constituencies to support our goals. In the days before social media, I would have used a variety of tools to do that -- radio, television, print media of various types, community meetings, legislative meetings, and so on. You should view social media tools in the same way. They are likely to reach slightly different segments of the community but are no less important -- and perhaps more so -- than the traditional media. Indeed, there are certain groups of people, especially idealistic younger folks likely to take on a cause, who get much of their information from social media. Look at what Obama has done with these media in his campaign.

Writing a blog does not take much time. After all, how long does it take to write 400 words? But, to achieve effective outreach with a blog, you need to invest the time in creating links with others and reading their posts and commenting on them. Your goal --- does this sound familiar? -- is to create a sense of community with potential constituents who happen to like this medium.

Ditto for Facebook. The time you spend on Facebook is infinitely expandable, as you invite friends, create groups, create causes, and the like. But here, too, your goal is to create a sense of community with potential constituents who like and use that medium.

The big advantage of social media over traditional media is that the interactions can be asynchronous. You don't have to make an appointment, the way you do with a legislator. You do not have to respond in the moment, like when a reporter on deadline calls and needs a comment. You participate when you want to, and you can do so as a "fill-in", between your other tasks. In that sense, these are actually more time-efficient media than the traditional ones.

Another advantage is that you totally control how much time, overall, you want to spend in the media worlds. Except -- and this is important -- you need to spend enough time and be sufficiently attentive that you stay engaged with your constituents and have fresh messages from time to time. How much time is that? Well, it depends on the news cycle of your own organization. If you are facing public policy crisis every day and trying to organize people to engage on short-lived issues, you need to be online almost constantly. But for most advocacy issues, you can probably write a blog post two or three times per week. But, set up the blog to notify you by email when comments are submitted, and respond as quickly as possible to each comment. And use Statcounter, Technorati, and/or another counting programs to see where hits are coming from and what other blogs are referring to yours. Then, read what they are saying and submit comments on those blogs, and, if appropriate link them to yours and let the authors know you have done so.

On Facebook, I would check your page once a day for messages and the like. If requests and other items have piled up, then increase the frequency to twice a day.

Oh, and did I mention that this is all free? Other than a bit of your time, the cost of these social media to your organization is absolutely zero.

So, what does this sound like? Maybe an hour a day, interspersed with your other activities? Does that sound like too much? I think if you compare its efficacy against your traditional activities, you will find that you make more contact with interested audiences in that hour than you do with any other activity in which you are engaged. This may cause you to reevaluate the relative time you spend with other media, but is good to do that from time to time anyway.

Wednesday, April 09, 2008

A big chair for the little ones

Congratulations to Dr. DeWayne Pursley, our chief of neonatology, who just a few days ago was named Chair-Elect of the American Academy of Pediatrics Section on Perinatal Pediatrics. DeWayne and his crew take care of our smallest patients. I have written before about their focus on safety and quality. It is a remarkable team of people, as warm and caring as anyone could imagine. DeWayne sets the tone and clearly deserves this national recognition.

Tuesday, April 08, 2008

Is "non-profit business" an oxymoron?

An April 4 article in the Wall Street Journal, entitled "Nonprofit Hospitals, Once For the Poor, Strike It Rich" has prompted a slew of comments on I think they are worth reading and do not intend to summarize them here. Some accused the Journal and the quoted politicians of grandstanding. Others said the story was right on target.

The issue of the type and degree of benefits provided by non-profit hospitals is a legitimate and important one. Our institutions are given certain privileges by the government, and the government has a right to supervise our performance in carrying out our public service functions. Recently, the Massachusetts Attorney General announced a review of certain of these activities, those relating to community benefits. This is a healthy step, in that as times change, the standards of behavior and reporting should likely change, too.

The WSJ's story contained examples of non-profit behavior that many will find excessive. I think some examples chosen are unusual and not reflective of most hospitals. But I imagine that a detailed review of Massachusetts hospitals would find some items of a more modest level that at least some people would find troubling.

On this blog, I have written posts on several of the commercial aspects of running a hospital -- for example, one on the growth imperative, another on advertising. I have also told about what it was like when this hospital was very close to closure because of a failure to mind its financial ways. Finally, you have seen posts on the special role of our Board of Directors in setting standards for a non-profit institution like ours.

In reviewing this issue, it seems to me that there is not always a bright line between the business behavior of a non-profit and a for-profit company. Both need to operate in the black to carry out their purpose. Both need to determine how to compete in a marketplace to achieve that. The strategies employed to do that might look quite similar. Both need to attract qualified people in both supervisory and line positions. The salaries and benefits offered, therefore, might be somewhat similar. Both depend on the vigilance of a Board of Directors to monitor management's performance and behavior. So the structure and functions of the boards overlap in several ways (but not totally, given the pertinent legal requirements). And, as a final level of control, both have regulators to ensure that appropriate community standards are maintained and enforced.

But there is a fundamental difference. The non-profit does not have shareholders who benefit financially from its operations. Its fundamental constituency is the community it serves. For a small community hospital, it is literally the local community. For an academic medical center like BIDMC, it is the local community, but it is also a regional, national, and indeed international community that benefits from the research and educational programs of the hospital.

Is this a difference without a distinction? I think not. I know that our Board and I would be making very different decisions about patient care, research, and training expenditures if we operated under a for-profit rubric. While we always have to be prudent about which services we offer, many more areas that do not generate a profit or that result in perpetual losses would likely be cut or eliminated if we were not a non-profit. As a matter of strict business, many of these could be jettisoned and provided by others outside of our hospital. But we believe that we owe to our patients and to the nurses and doctors who we are training to offer these as part of our public service mission.

As health care costs continue to rise and consume a greater percent of our national economy, we can expect further debates on these issues. Those debates are normal and appropriate and help hold all parties accountable to their constituencies.