Monday, September 29, 2008
When I say that Alan was a reporter, I choose the word carefully. I don't mean journalist, although that could apply, too. I mean that he was a down-in-the-streets reporter, who got news stories and columns the old fashioned way. He would talk to people and ask questions. And they were great questions, probing to the heart of the matter at hand. They could be tough questions, but they were never mean. (Actually, as I think about it, I don't ever recall Alan being mean.)
My first exposure to this guy was in the 1970s when I watched a show called The Reporters on WGBH, the local public TV station. Here's how it worked. Alan and his colleagues would walk around the streets of the city with a still camera and take black-and-white pictures and conduct interviews. The news would then be presented as a voice-over on TV, with the pictures of the interviewees and of the street scenes and other pertinent views. I think I recall that each segment lasted about 15 minutes, but I might be wrong about that. If you have watched Ken Burns' specials, you can get the idea, but this was not a history show. It was a current events news and feature show. It was engrossing, informative, entertaining, and gave as complete and fair a presentation on each story as you could imagine.
I was always sad that The Reporters went off the air. I assume it could not compete with the glitzier news programs that are based on television stations' belief that viewers have attention deficit disorder. But, I actually think there could be a place for such a show even today -- if it were done with the professionalism, depth, and empathy shown by Alan and his colleagues.
I have not met a person in Boston who knew Alan who did not love and admire him. Think of that. A person who conducted investigative journalism in one of the toughest political environments in the country, and he ends up beloved and admired. Over these last few months, as I have talked with other people who knew that he was terminally ill, none of us could mention him without choking up in sadness at the thought of losing him. Now we have lost him, and the tears can flow freely, as they do as I write this on the eve of a holiday that is otherwise wrapped in happiness and hope for the coming year.
I took a beginning Spanish course at the University of Zaragoza, Spain, about ten years ago. One day I was at a local grocery store, picking through some apples and oranges when I noticed several women looking at me with utter disgust. I couldn’t imagine what was bothering them and returned their gaze with an innocent shrug.
“Sucio!” [dirty] uttered one under her breath. And the women shook their heads and pushed their shopping carts away from me in a huff.
My mind went into overdrive trying to figure out what I could possibly have done that was so utterly distasteful. I watched other women at the apple bin and slowly noticed that they had a systematic way of selecting their fruit. First they pulled a plastic bag off the roll, then they opened it and put their hand in it (as if it were an ill-fitting surgical glove), and then they began picking up the apples and oranges one by one to inspect them for defects. When they found one they liked, they simply inverted the bag and kept the item inside, without ever having skin-to-fruit contact.
“Ah hah,” I thought, “that’s why they thought I was ‘dirty.’ I was touching the fruit with my bare hands.” And from that day on, I have used the “surgical glove” approach to fruit selection. It’s a cleaner way to shop.
I was at a local farmer’s market today with my husband, and I noticed him rifling through an apple bin with a bunch of other eager shoppers. True to their “dirty” American upbringing, they were all inspecting the fruit with bare hands. I told my husband about my Spanish experience and asked him if he thought all the hands on the fruit might be spreading E.coli or other bacteria around.
He replied simply, “Well, I’d be more concerned about the foreign farmers fertilizing their plants with human manure than about the grocery store buyers touching the fruit. Besides, we wash our hands in America.”
Well, I’m not sure if the second statement is correct – Paul Levy will testify to just how difficult it is to get hospital employees to wash their hands! My bottom line is – please wash your fruit.
Sunday, September 28, 2008
But the problem with the ad is that it gave the impression that because this discovery was made in one hospital, that hospital can offer superior cancer care to patients. As we know, even if this discovery were ready for clinical application, advances of this sort are made widely available to the world and are not held as proprietary by the discovering institution. (In this case, especially so, in that the discovery is actually part of a multi-institutional cancer research program in which results are widely shared among all participants.)
To be clear, the hospital buying the ad is a superb place to get diagnosis and treatment of cancer. What is objectionable in the ad was the decision to cite a promising research finding and to overstate its relevance to the current delivery of medical care in this hospital. This is particularly troubling in the cancer arena, where patients hunger for new treatments and cures and can easily leap to the conclusion that an experimental finding is already available to them. Perhaps some of you will view this as too fine a line of distinction, but I think we need to be careful here: All of this affects the entire medical community's credibility over time.
Saturday, September 27, 2008
Friday, September 26, 2008
Hospitals prefer to deal with local health plans over their national counterparts. But Bay State providers still want them to try harder to reduce inefficiency and extra costs, according to a new survey released Friday by an industry trade group.
"What we found is that no one plan is really performing at the top at every attribute," said Lynn Nicholas, president and CEO of the Massachusetts Hospital Association. "But all plans have strengths and weaknesses, which provides a great opportunity to learn from those who do it well in an effort to improve the field overall."
...[H]ospital executives said they want insurers to update and distribute more evidence-based clinical guidelines to help promote more cost-effective care. They also want health plans to better educate their members about their insurance and obligations so they can make more informed consumer decisions.
I am sure this report will be viewed as self-serving by the insurance companies, but the points made and the language used are remarkably similar to the comments those companies often make about hospitals. My conclusion: Both segments of the health care industry have a long way to go. Transparency in both sectors would go a long way towards self-improvement.
In that regard, let's do an experiment. Check out the websites of your favorite insurance companies and hospitals. See how many have adopted quantifiable audacious goals for quality improvement, patient satisfaction, or efficiency -- and how many post their actual operating results to hold themselves accountable? (If you find some that do, please submit their links as a comment.)
Thursday, September 25, 2008
Just yesterday, I heard a good one from China: "You can't cross a chasm in two small jumps."
If you would like to post your favorite proverb, please submit it as a comment. Let's see what people come up with.
Wednesday, September 24, 2008
Note to BIDMC folks: More pictures and more about this story will be posted tomorrow on our portal, and you can also find some more of my pictures now in Facebook on my profile page.
In the picture above, Trustee Jonathan Lee presents Lois with a charm bracelet containing symbols of the various parts of her life related to BIDMC. A well deserved standing ovation followed.
Tuesday, September 23, 2008
To: BIDMC Community
From: Kenneth Sands, MD, Senior Vice President of Health Care Quality
Subject: Updates after Summer Incidents
Over the summer, BIDMC experienced two troubling incidents that received considerable attention, and rightly so. The first was a “never event” (in this case, a wrong site surgery) and the second involved an impaired physician.
We have recently received the results of the investigations by the Massachusetts Department of Public Health into both cases. As always, we fully cooperated with DPH as they reviewed all our documentation and interviewed key staff on-site. We wanted to share with you a summary of what DPH said, and what improvements we have made in light of these cases:
1. In the case of the wrong site surgery, the DPH investigator concluded that BIDMC acted appropriately in reporting the event, discussing the error with the patient and apologizing to her.
The investigator also noted that BIDMC has initiated a corrective action plan that places ultimate responsibility for calling a “time-out” prior to surgery directly on the surgeon who will make the first incision. But the basic principle remains that while the surgeon always needs to initiate this step, it remains everyone’s responsibility to be sure that all safety protocols are being followed. Specifically, if for whatever reason it appears that the surgeon might neglect to call for the time-out, every other person in the OR is encouraged and empowered to mention that fact.
Additionally, a revision to the "Correct Site Universal Protocol Policy" (PSM 100-105) requires that “the scrub person will mount/arm the scalpel after the ‘time-out' has been completed.” This creates a “fail safe” that ensures that a surgery cannot go forward without following the proper procedure. Everyone working in the ORs has been informed of and trained in these changes to the policy.
2. In the second case, the DPH investigator determined “invalid” the allegation that BIDMC “failed to ensure quality care” in a surgical procedure performed by a physician who appeared to be impaired. The medical center was, however, cited for record keeping deficiencies in the case. The conclusions came after a thorough review of our documentation and interviews with clinicians associated with the case.
We are currently working together, with helpful advice from our Board of Trustees, on a new policy to strengthen the medical center’s procedures when a doctor or other caregiver is impaired or otherwise unable to perform his or her duties. This includes improvements in training for staff on what to do should they encounter such a situation. We will let you know what we come up with.
These recent events remind us that we need to remain ever vigilant about our everyday commitment to quality and safety. We continue to identify and tackle problems as soon as they arise and create a culture where talking about problems or necessary improvements is embraced.
All of us at BIDMC have been involved in efforts to make the medical center a safer and more welcoming place for patients and families. At the same time, we have set a new standard for transparency in our work – the good, the bad and the learning experiences have been laid out for all to see.
We know how much each of you cares about the medical center and the patients we serve. You have helped make BIDMC an exceptional place – for high quality and compassion. Always keep that in mind and be proud.
I especially enjoyed this comment by Mark Brooks:
CEOs time is extremely precious. The best way to extract a blog out of a CEO, and keep it colloquial is to interview them twice a week, then transcribe, then edit to something interesting. The time impact to the CEO should be 10 minutes per interview. Transcription and editing and posting time an additional ~60 minutes per interview.
Whew, fortunately, I never had this advice when I started this whole thing two years ago. I might never have started. But at least if I followed Mr. Brooks' approach, someone on my staff would know what is going to be posted before they read it here.
But, poor misled Mr. Brooks, thinking CEO time is precious. In fact, it is the least valuable time in an organization if things are working right. And, if things are not working right, it is even less valuable.
Monday, September 22, 2008
FROM THE SURGEON:
Later that day he was weaned from sedation and awoke neurologically intact...
You can see Bob here holding his cough pillow. When asked if he wanted his picture on this blog, he replied, "That is certainly all right with me. That is a NY Yankees jacket I have on...."
Several thousand people joined together yesterday for Hub on Wheels, a bike ride through the neighborhoods of the City of Boston. The ride is a fundraiser for the Boston Digital Bridge Foundation, a which provides technology training and computer equipment to underserved communities.
We had about 80 people from BIDMC on the ride, and several more of our folks also joined with the people at Cataldo Ambulance Company to provide first aid along the 10 mile, 30 mile, and 50 mile routes. Some of the riders and first aid crew are shown in the pictures above.
We were greeted by Steve Miller, originator of the Hub on Wheels event, and Nicole Freedman, Mayor Tom Menino's bicycle "czarina," both of whom are pictured here as well. I think Nicole was giving me some kind of hint with the sign she is carrying.
What have I learned?
First, public reporting works. It created a strong incentive to improving our quality. Second, responding to the crisis transparently, while more risky, was the right thing to do. At times, even lawyers must lean into the discomfort of transparency. It was the best course for our patients, our staff, and our community. Finally, humility saves lives. There is nothing more humbling than having to suspend a program. But it taught us to never accept the status quo, to know we can always get better, and to highly value a culture of learning and continuous improvement.
Saturday, September 20, 2008
"But then I noticed two problematic items in the document that was about to be approved. Here's the first: It is the responsibility of the physician initiating the procedure to initiate the time-out.... I said, don't we want to expand on this and make it clear that each staff person in the room is encouraged and empowered to question whether the time-out has taken place and/or to remind the physician that it should be."
But then I wrote this:
"Why did I have to suggest these modifications? ... And if not, why wouldn't any other member of the MEC have thought to raise them."
One of the doctors at the MEC meeting later reminded me that he, not I, actually first brought up this point. Shows you how tricky memory is. My only explanation is that I remembered it as being my idea because I did indeed comment on it in the way mentioned, and that I was the one who brought up the second point about patient involvement in the time out. But he is exactly right, and I apologize for presenting it wrong.
So I think the record is now accurate, and I am pleased that this current revision helps make my original purpose even more complete. The thrust of my first post was meant to present part of the story of our evolution as an organization and of me personally as CEO. As this same doctor later reminded me, "There are many people in our medical center who are thinking and acting in support of patient safety in multiple ways every day. Although we are not yet where we ultimately want to be, our progress should be acknowledged along with our challenges." To put a more finely focused light on this, this whole MEC episode reinforces Göran Henriks' point: "There needs to be trust from the support system that tells the people at the front that we respect what they are trying to do."
Friday, September 19, 2008
Thursday, September 18, 2008
Well, today, for the first time, I heard a radio ad for a hospital that seemed to me to fit in the same category. It was an ad for a certain vascular center, and it suggested that leg cramps, among other things, could be a sign of peripheral arterial disease. The purpose, pretty clearly, was to get listeners to wonder if this and the other symptoms mentioned might be serious enough to warrant a diagnostic visit to this particular vascular center.
As you know, I am not a doctor, much less a vascular specialist of any sort, but I am guessing that the incidence of peripheral arterial disease among the general population with muscle cramps has to be very, very small. It would be one thing to explicitly target the ad to those at greater-than-average risk of vascular disease (e.g., those with diabetes, smokers, high blood pressure, heart disease, or high cholesterol), but this was a general audience ad. I certainly believe that some percentage of people with PAD who should be getting treatment are not getting treatment, but this ad felt to me (and my accompanying car passenger) to be designed to produce fear and/or anxiety beyond a legitimately targeted audience.
As I have mentioned below, many of us in the hospital world advertise our services. Those ads usually talk about our capabilities, our doctors, access or the like. This is the first time I can remember an ad that seems intent on actually stimulating the demand for specific disease-related medical services among the general population. I don't think this is good for us to do. Insurance companies, government, and employers are beseeching us to control health care costs, especially through a reduction in unnecessary utilization of services. They say that we are insensitive to those cost factors, and we give them support for this position if we advertise our services in the manner I heard today on the radio.
Hearing this ad has made me more sensitive to this issue, and I plan to ask our marketing folks to review all of our ads to make sure we have not gone down a similar path. I do not think we have, but I'll let you know in a later post if we find some.
Tom's type of honesty is virtually the only way to splay out for the public this kind of nasty practice. Why? Because these stories are often not considered newsworthy enough by the media, or because they are presented in a manner that spouts unsupported assertions that are impossible to rebut.
Wednesday, September 17, 2008
Part of the policy includes some unambiguous guidelines, like this: The team will stop, pause, and verbally verify their agreement on the identity of the patient, the procedure to be performed, all patient allergies, the site of the procedure, including laterality, the correct position of the patient and radiological exams, if applicable. There was unanimous support among the MEC members about the need for this policy, and it started to move quickly to adoption.
But then I noticed two problematic items in the document that was about to be approved. Here's the first: It is the responsibility of the physician initiating the procedure to initiate the time-out. On its face, there is nothing wrong with this, as it is, indeed, the physician who has final responsibility for what happens to the patient. But, I said, don't we want to expand on this and make it clear that each staff person in the room is encouraged and empowered to question whether the time-out has taken place and/or to remind the physician that it should be. After all, when we had our recent wrong-side surgery case, only part of the problem was that the surgeon was distracted and forget to initiate the time-out. An equal contributing factor was that no one else in the OR thought to remind the doctor or question whether the time-out had occurred.
The second problematic sentence was this: It is not necessary to include the patient's participation in the time-out process as this may not be applicable. Hold on, I said, don't we want to reverse the emphasis and establish a presumption that the patient should be invited to participate, unless it is somehow inappropriate or not possible. Why not involve the person with the most direct interest in the procedure to help out?
In both cases, the doctors and nurses on the MEC immediately agreed and even suggested helpful language that would accomplish these objectives. But I was left thinking, "Why did I have to suggest these modifications? Why wouldn't they be self-evident to the subcommittee that had written the policy? And if not, why wouldn't any other member of the MEC have thought to raise them." In fact, later I was a bit critical of our SVP for Health Care Quality on these points in a private conversation with him.
One of our trustees was observing the meeting, and I also raised these questions with him. "Too much to do, too busy to read," was his commentary about the medical staff members of the MEC. While that is true, it is not a satisfactory answer. After all, it has just been a few weeks since the wrong-side surgery case, and everyone is attuned to this type of error.
My friends in the patient advocacy world will probably say, at this point, that's why you need patients on every committee and working group in the hospital. Patients will see things that the medical staff overlook and bring in a useful perspective. This can be true, but it actually takes a lot of thoughtful planning and time to create a productive environment for that kind of patient advisory input -- and, even then, there will always be some decisions made without patient consultation.
I have a different answer. After the Blue Cross Blue Shield conference yesterday, I asked a question of Sweden's Göran Henriks, who has worked for two decades on improving safety and quality to make Jönköping County's health system one of the best in the world. "Knowing what you now know," I said, "how long would it take your doctors, nurses, administrators and staff to get to your current level of performance if you were starting afresh?" His reply: "Five years."
Old habits and viewpoints, in other words, are deeply embedded. While every sentinel event presents an opportunity for learning and improvement, it is in the everyday tasks that the possibility for continuous and lasting improvement exists. I happened to be the one to call out two examples today. But, it is the marvelous diversity of experience and perspectives of the people in an organization that provides a reservoir of such possibilities. Our goal is to create an environment in which everyone in the hospital will feel empowered and excited to do the same, whenever they see opportunities for improvement. Training people to do that is what takes time, as we each have a unique way of learning.
And so I realized that I was wrong to have criticized the SVP. It's my job to help people to engage in this learning adventure by setting the appropriate example of humility and encouragement, and I blew the chance today with one very well intentioned individual. But tomorrow will certainly provide other chances to do better.
I confess that I do not understand many of these ads. I'm not saying that I don't understand why I get them. I am saying that I literally don't understand most of the terminology. Here are some excerpts from a small sample of those I received yesterday. I guess the one I really need is the last one listed . . .
Billing Success Secrets -- Live audio conference
In Dec. 2007, UnitedHealthcare adopted the Centers for Medicare & Medicaid Services' Correct Coding Initiative (CCI) edits -- but not all of them. And for you pediatric coders out there who aren't familiar with CCI edits, that's not all. The insurer has also interpreted CCI bundles and extrapolated CMS' rationale to apply to additional codes. And as anyone knows who's dealt with CCI edits before, the system it is vital for proper payment and anti-fraud protection.
Get up to speed on how UHC is bundling your services during this can't-miss audioconference with expert speaker Jennifer Godreau, BA, CPC. In one hour, she'll uncover which common pediatric services UHC bundles, when the payer allows a modifier to override the edits, and other reimbursement policies.
Red Flags That Could Lead the Feds Right to Your Door
Physicians and Practice Managers: Do you live in fear of the day the Feds march through your front door, ask your staff to step away from their desks, and seize all your computers and practice records? If an indictment follows, you could be in for the fight of your life.
Fraud accusations don't just happen to criminals. They can, and DO happen to honest, upstanding physicians ... just take it from speaker and expert witness Barbara Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC. In this one-hour audioconference, Barbara will share shocking real-life scenarios that took unsuspecting physicians by surprise. Find out why they were accused, how they defended themselves, and what they could have done differently so that you can prevent this from happening, or if it does happen, optimize YOUR practice's defenses.
Esophogeal Dilation CPT Code Surprises
Error-proof esophageal coding requires a solid understanding of dilation procedures and the nuances of medical necessity. In just one hour, certified gastroenterology coder Carol Pohlig will teach you everything you need to know about esophageal dilation coding: from the reasons for the dilations to the techniques and their CPT codes.
Become a leader in the coding industry by being certified as a Professional Coder. Let our AAPC certified instructors help you get prepared to pass the American Academy of Professional Coders' CPCÂ® Exam with flying colors. It is as simple as it sounds! CPCÂ® Training Camps are small intensive preparation courses. You will get one-one instruction from our AAPC certified presenters. There are only 10 limited spots available. It is first come, first serve so reserve your spot today.
Tuesday, September 16, 2008
His focus was on what’s left to do, rather than what’s already been done. There’s a lot to be done. There is a big gap between what we have and what we could have. Looking at what is spent in the US on health care, we see that we spend a lot, and we do not get our money’s worth -- either in terms of access or results. We need to grapple with the fact that we have a low value system.
It is also a system characterized by extreme variation in spending, over $3000 per capita in Medicare spending between the lowest quintile and highest quintile parts of the country. There is no positive correlation between spending and results. In fact, it is a negative correlation. In other words, this is $3000 of negative return.
We don’t have one big problem here. We have two, and this requires a sophisticated and parsed solution with two separate paths.
One path is about getting better care when you are sick. This is based on achieving the following dimensions of excellence when you are sick and need care: Safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. This is done by designing better processes and deploying them.
The second problem has to do with the drivers of the low value system. On the high cost side, this derives from the constant entry of new technology, drugs, and the like without documented relationships to outcomes; no mechanism to control costs; and supply-driven demand. On the low-quality side, it comes from over-reliance on doctors for things that non-doctors can do; no foreign competition; and undervaluing system knowledge.
Berwick’s approach to this is defined as the “Triple Aim”: Improve the experience of care + raise the level of the health status of the population + control the per capita cost. He states that the root of the problem is that the business models of almost all health care organizations depend on keeping these aims separate. Berwick proposes a system that will focus on individuals and families; offers strong primary care services; provides population health management; imposes a cost control platform (i.e., a strict population budget); and enforces system integration to make this all happen.
First, an exchange with Göran:
Q. What are the top three tactics to get past inertia (among the medical staff)?
A. People in medicine like to be the best. You have to talk about people about what they love to be best in, not about something unrelated to their own desires.
You cannot win everybody. You have to be patient. In the meantime, they need to feel that there is a context that believes in them, so that when they come around, they will feel supported.
Support systems (HR, Finance, etc) are all services for the front, i.e., where the actual value is delivered to the patient. There needs to be trust from the support system that tells the people at the front that we respect what they are trying to do.
And, another answer from Uma, to a related question:
We instituted a daily failure reporting system. We conduct a same day investigation of daily events, followed by implementation of improvements on a continuous basis. This makes it part of the culture to report problems on a current and regular basis.
Louise explained the implementation of the electronic medical record system at Kaiser. Göran talked about the learning environment in Sweden in general, gaining knowledge from the success of others. He also discussed the use of physician extenders and real-time monitoring to create better access and results in the orthopaedic arena. Uma explained her hospital’s success in treating children with bronchialitis, focusing on the lack of evidentiary support for what had been the standard practice for treating patients, and modifying it to institute more efficacious approaches to the management of this disease -- which included a much closer relationship with community physicians to keep children out of the hospital in the first place.
What works, asked Larry, that could inform this conference audience? This is a continuing learning process, even for us, said all three. Göran said it well: “We need to meet systems that have energy in this field, so we can be refueled in our own efforts.” "If you hear about something good, get on a plane and find out!", said Uma.
The King’s took the financial settlement from Hopkins to create the Josie King Foundation to start and enhance programs to "prevent others from dying or being harmed by medical errors. By uniting healthcare providers and consumers, and funding innovative safety programs, we hope to create a culture of patient safety, together."
The latest project is the Care Journal, a simple way for families to keep track of the progress of patient care for their loved ones in a hospital. Check it out here.
Let's try some real-time blogging. I just arrived at a conference organized by the Blue Cross Blue Shield Foundation, entitled In Pursuit of Health Care’s Holy Grail: The Quality Movement that is Transforming Health Care. It is being held at the JFK Library and Museum in Boston and is basically a real-life version of a recent book written by Charlie Kenney, entitled The Best Practice: How the New Quality Movement Is Transforming Medicine. Here's a Boston Globe op-ed article written by Charlie summarizing the main points of the book. It is a compendium of success stories in the quality and safety arena from around the world.
Here's a July 23, 2008 podcast of WGBH's Emily Rooney interviewing Charlie. One thing on which he and I would disagree is his relative emphasis on the need to change the payment system to accomplish quality and safety improvements in hospitals. That view is consistent with Blue Cross Blue Shield's hope to engage hospitals in their so-called alternative contract, which is a major part of their program. Their emphasis is not surprising. When you are an insurance company, your major tool for influencing behavior is pricing, and, as they say, when you have a hammer, everything looks like a nail.
It is interesting to note, though, that the whole range of quality and safety initiatives begun by BIDMC is being done under the traditional compensation system. We get no financial reward from insurers for this program, and yet we find it in our strategic and financial interest to pursue it nonetheless. The plan being proposed by BCBS puts a major insurance risk on hospitals by capitating payments, and the company has yet to address that proposed shift in risk from the insurance company to the providers -- rather than recognizing that there are multiple ways to encourage the quality and safety results they seek. But that is a topic for another day, and will either be resolved or not in the context of our contract negotiating sessions.
The speaker who gets the distance record for this conference is Göran Henriks, Jönköping County, Sweden. His picture is above. You can read about the path taken by the folks in this network of hospitals and ambulatory centers here.
Another notable speaker at the event is Sorrel King, Founder of the Josie King Foundation. Her picture is above, too.
As the day goes along, I'll post any interesting observations that come my way.
Monday, September 15, 2008
The Yankees, like elephants, have come home to die. During the homestand that will conclude next Sunday night with the baseball finale at Yankee Stadium, this uninspiring team will almost surely be eliminated from what many of their fans have come to consider an inalienable right — a place in the postseason.
* (Of course, those were different Yankees.)
A carrier pilot must ... learn to accept criticism of his or her performance, from both peers and overseers. The landing signal officer on an aircraft carrier administers a public debriefing and critique of every landing, and a grade is assigned to every pass the pilot makes at the deck. These grades ad the pilot’s performance are displayed publicly for all to praise or ridicule. The psychological pressure of this culture is the whetstone that successful carrier pilots use to sharpen their skills -- and the grinder that drives some from the profession.
Now, in medicine, we don’t have anything like this. Yes, while in training, interns and residents receive real-time reviews of their work (often in front of their colleagues) from their more senior residents and from attending physicians. For attending physicians, we hold mortality and morbidity (M&M) conferences when something goes wrong in patients’ care. But, we do not generally conduct peer reviews of doctors’ performance once they are certified as full-fledged physicians.
Our Chief of Neurology, Clif Saper, originated a thoughtful practice along these lines. The doctors in his department do randomly assigned reviews of the case notes of their colleagues, with an eye towards deciding if the process and diagnosis and treatment seem warranted by the facts of the case. Those reviews, blinded by reviewer, are then shared with the attending physician. The idea is a good one, to help all of the doctors do a better job by allowing an objective review of real cases. It is specifically designed not to be threatening, though, and the results are not made public, even within the department.
We also had a similar, more limited experience in our GI department, after it was learned that the speed of removal of an endoscope during a colonoscopy can make a dramatic difference in the likelihood of detecting pre-cancerous polyps. (See this post for more information.) Each doctor in the GI divisions was given a summary of the department’s performance on this metric, along with a confidential summary of his or her performance. Without any public release of data, everyone’s performance soon rose to the desired level.
But do these efforts go far enough?
The difficulty of doing a carrier pilot type of review in a hospital is that no place can afford to have dozens of senior physicians standing around judging the performance of dozens of attending physicians, all day long and all night long. In contrast, one landing signal officer on an aircraft carrier sees every pilot’s pass and can apply a grade to it.
But there are metrics of performance that can be applied to surgical and procedural cases. While not perfect, they could send warning signals of the need for improvement -- or perhaps, at a minimum, create a healthy kind of competition among doctors. For example, you could use unanticipated returns to the OR or incidence of surgical site infections to evaluate surgeons. As mentioned in an earlier post, too, the American College of Surgeons already collects data regarding risk-adjusted actual versus expected outcomes in certain surgical specialties.
For proceduralists, like GI doctors, you might measure the number of adverse events, like perforated colons. These data are already collected by every hospital. So imagine if these kinds of metrics were presented every week to the doctors within each group, with names mentioned.
I know it would be more difficult to assign a good grade to a doctor for treatment of a given patient. After all, some results are not known for days or months, well after the patient has left the hospital. So focusing on problems rather than successes might give an unfortunately negative view of performance, but at least it would help assess each doctor's ability to avoid harming a patient.
I haven’t raised this issue at BIDMC (yet!). I am willing to guess what the reaction would be -- even in a place where transparency is embraced as fully as any hospital in the world. “No way!” would be the response, I think. First, people would say that there is no metric or set of metrics that would be accurate enough to give a full representation of a doctor’s performance. Then, people would say that if we share this data, it will distract people from the “real” issues in patient care and cause them to “teach to the test.” Others might say it would be insulting and a sign of disrespect, especially if the residents and other trainees were allowed to view it.
To which I would say, “You pick the metrics you want to share, the ones you think would be indicative of important aspects of performance. Don’t release them to the world, but use them only in your legally protected peer-review sessions. Tell your residents that you are doing this in front of them to demonstrate that learning and performance improvement never stops. Consider this as an experiment for six months, and see if it changes the nature of the discussions at your faculty meetings.”
Before I suggest that, though -- and please remember that I would only have authority to suggest it -- I'd like to hear from any of you out there. Do any of you do anything like this in your hospital or your physician group? I am not averse to pushing the envelop on this, but it would be great first to hear the experience of others.
(Photo credit: OK3)
Saturday, September 13, 2008
As I did, it occurred to me that recent arrivals to this blog might not be familiar with how I have used it to experiment with reporting of clinical results, with the hope of helping to hold our organization accountable for meeting quality improvement metrics. As I said in an article in Business Week about one year ago:
There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.
Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.
Rather than repeating my IHI talk here (boring!), I am just going to list below some key posts to which I referred during my session. (Who needs PowerPoint if you have a website!) If you are interested, you can follow them through and get an idea of the journey we have taken during the past two years. As always, I welcome comments on these, but I am also seeking comments from those hospitals that have also tried this approach, so we can learn from your experiences, too.
These things happen -- a description of the point of view, all to often found in hospitals, that a certain level of harm that occurs to patients is "just the way things are."
We saved one person's life -- one of series of posts on our effort to eliminate (yes, eliminate) central line infections.
Teamwork wins against VAP -- one of a similar series on our efforts to eliminate ventilator associated pneumonia.
Aspirations for BIDMC and BID~Needham -- the story of how our Boards established an overall goal for these two hospitals of eliminating preventable harm over the next four years.
Source material -- Detailed background on the material behind the Boards' votes.
Next stage of transparency -- A link to our website documenting our progress, quarter by quarter, towards the goal to eliminate preventable harm.
The message you hope never to send -- How we used transparency to learn from one of the most egregious errors that can occur at a hospital, a wrong-side surgery.
Thursday, September 11, 2008
I went to the most amazing event on Saturday, September 6, at the Stone Zoo. The Sisters Against Ovarian Cancer Walk is the brainchild of a few women who are rallying around their friend, Marie Spinale, who is battling Ovarian Cancer. I met Marie early in 2008. She had participated in the Avon Breast Cancer Walk the year before and wanted to do something similar for her hospital that would ultimately help the type of cancer she is battling. She is one of the bravest women I have met and has the most optimistic outlook on life, despite the fact that her cancer keeps coming back. Today, Monday, she actually started a new clinical trial which she is so excited about (please see her email to me below).
But on to the walk..they had 170 walkers - 150 pre-registered individuals and approximately 40 walk-ons (some registered walkers didn't show up). They raised $30,000 on walk day and more money still needs to be collected. Earlier this year, they held a fundraising event that raised about $14,000 through raffles and ticket sales - I hear it was a party not to be missed. The money they raise will support the Ovarian Cancer Research Fund at BIDMC under the direction of Stephen Cannistra, M.D.
This is a link the website they created!
I am so happy you were able to be there on Saturday. We were all very excited and pleased with the turnout. I'm sorry I didn't get to spend time with you but I heard you met quite a few people. I never realized how many wonderful people I have in my life until I got sick. Something good comes out of everything.
I was at the hospital today, but I decided to come into work. I got selected to be on the new pills for the clinical trial so I am very happy about that. I didn't want to go home waiting for side effects to kick in so I thought I'd be better off staying busy. I think I'm going to do great!
We raised $30,000 on Saturday! That is not counting what we already turned in and what might trickle in later. I couldn't be happier!!! Thank you for all of your help.
(reprinted with her permission)
Wednesday, September 10, 2008
Here's an abstract of the actual study. A quote:
The results of two studies indicate that people who are high in openness to new experience and high in neuroticism are likely to be bloggers. Additionally, the neuroticism relationship was moderated by gender indicating that women who are high in neuroticism are more likely to be bloggers as compared to those low in neuroticism whereas there was no difference for men. These results indicate that personality factors impact the likelihood of being a blogger and have implications for understanding who blogs.
I dare not comment on the accuracy of this analysis with regard to this author. It would be a HIPAA violation.
Tuesday, September 09, 2008
This really cute kid just above is Kevin Pierro, a 5 year-old Red Sox fan from Norfolk, MA who was born at Beth Israel Deaconess Medical Center on May 15, 2003. The significance of that day is that it was when the record Red Sox 456 sold-out game streak began. Kevin was invited to throw out the ceremonial first pitch at last night's game.
The four other kids shown above Kevin were also born that day at BIDMC and are shown ready to yell "Play ball!" at the start of the game. From the left, they are Christian Trodden, Teddy English, Michael Gunning, and Abigail Weiss. (The photos were taken by Will Nunnally from the Red Sox.)
May I point out, too, that BIDMC became the official hospital of the Red Sox in April, 2003. Query to John Henry, Tom Werner, and Larry Lucchino (shown above): Any connection?
Monday, September 08, 2008
As I have made clear here many times (like here and here), we respect the rights of our employees, including their right to discuss whether or not they wish to be represented by a union. But BIDMC, like many other large organizations with lots of public access, has a solicitation and distribution policy which clearly spells out that non-employees (whether from a union, a company, or anywhere else) may not hand out literature or material on hospital property at any time.
After our folks confirmed that the people distributing the literature were not BIDMC employees, we politely asked them to leave. One group readily agreed and dispersed to a public area where they continued to speak with people. A second group chose to ignore our admonition that they were trespassing and chose to remain until sworn members of the BIDMC Police escorted them out of the building.
The union members violated another BIDMC policy by taking pictures in areas where patients were eating lunch, exposing them to the possible violation of their rights to privacy.
Now, shortly after all of this, the union issued a press release entitled, Beth Israel Deaconess Medical Center Confronts Union Supporters with Armed Security Officers. The subtitle was, Contrary to BIDMC’s CEO’s stated commitment to transparency and openness, administration uses heavy handed tactic to end conversations about unionization.
So, now we get to see another tactic from the corporate campaign playbook in action. Create a setting that requires a response by the security forces of the institution you are attacking in a corporate campaign, by knowingly violating sensible rules or regulations. Use hyberbole and misinformation to give the impression that there is intimidation or some violation of workers' rights.
By the way, it doesn't matter if you happen to get media coverage on the story at that time. In fact, you might not even care if the story is not written, because a good reporter will always give both sides. It is more useful to recycle it later in your own publications to prove a "record" of intimidation. Perhaps later, too, it will even be fed to and used by some of those politicians you supported when there is a hearing on the legislation that would take away workers' rights to a secret ballot election.
But it hasn't seemed to make any impression in Basel.
A very successful ride yesterday organized by cancer survivor Tom DesFosses to raise funds for BIDMC's cancer programs. It was beautiful weather, following a tropical storm Saturday night, and a great family and community event. The picture shows Erica pacing part of the group at the start.
Sunday, September 07, 2008
The fact that "9 percent of the total number of programs, including 19 surgery programs" around the country have faced similar programs is not an excuse for our failure to meet this national standard, and we believe we have taken actions now that will ensure our compliance.
Perhaps those of you involved in running residency programs who are reading this would like to comment on your successes and failures in meeting the ACGME standards. Perhaps, too, some residents out there would like to comment on how it feels from your side.
Friday, September 05, 2008
A new book chronicling the decline and likely extinction of an American forest bird draws lessons for future conservation efforts as the world faces a growing extinction crisis.
The Race to Save the World’s Rarest Bird: The Discovery and Death of the Po‘ouli is a fast-paced scientific adventure story of heartbreaking importance. Part Shakespearean tragedy, part case study, it details the struggle of biologists to save a small, black-masked bird in treacherous, soaking forests thousands of feet up the steep sides of Maui’s Haleakala volcano.
The bird, called a po‘ouli, a Hawaiian name meaning "black-faced," was discovered in 1973 by college students studying the volcano’s dense, unexplored rain forest. In the mid-1990s, with just three individuals remaining, it became the world’s rarest bird. The last known of these quiet, inquisitive birds died in a breeding center in 2004.
"We’re in the midst of a global extinction crisis," said author Alvin Powell. "Thousands of species are declining and in danger. If we can learn from history and understand why we failed to save this species, we have a better chance to succeed with others."
Powell is a veteran journalist and senior science writer at Harvard University. In researching the story, Powell visited the bird’s forest home with a team of biologists and interviewed dozens of people who crossed paths with it, including those who discovered it, tried to save it, and were there when it drew its final breath.
Though the po‘ouli (pronounced poh-oh-OO-lee) was declared endangered soon after it was discovered, years went by before it was the focus of meaningful conservation efforts. During those years, the bird was beset by introduced rats, pigs, and disease-bearing mosquitoes. By the early 1990s, scientists realized the bird was on the brink of extinction and stepped up efforts to study and conserve the species. They fenced in miles of tangled, inaccessible forest, a task some thought impossible. They poisoned invasive rats and trapped the birds in hopes of encouraging the last few to breed. The last known po‘ouli died in captivity awaiting a mate.
"Biologists used all the tools available to them but not in time," Powell said. "It was first too little – for years nothing was done – and then too late. The most important lesson to draw from the po‘ouli’s story is to act now. Species that are similarly endangered around the world can’t wait for us to get around to taking action. The forces squeezing these species out of existence – invasive plants and animals, loss of habitat, environmental change – are not taking a break while we think about what to do and whether to do it."
The Race to Save the World’s Rarest Bird also examines the debate about captive breeding as a conservation tool and highlights the successes and failures of the Endangered Species Act, one of the most significant conservation laws in U.S. history. The fate of hundreds of species rests on the act’s successful implementation.
Thursday, September 04, 2008
Here's the summary:
Clinicians should advocate for single-patient rooms in any new hospital construction, expansion, renovation, or redesign. Single-patient rooms are permanent physical features that potentially could improve safety and patient satisfaction without the need for ongoing staff training, audits, or reminders. Money spent on capital costs to improve patient care may be more efficient than money spent on changing hospital culture and the behavior and attitude of health professionals. It is not necessary to wait 50 years for existing hospital structures to deteriorate before the full potential of single-patient rooms can be realized.
I do not disagree about the attributes of single-patient rooms, in terms of infection control, patient satisfaction, and optimal use of rooms for a diverse mix of patients. Also, they are strongly recommended in guidelines of the American Institute of Architects. I believe they will result in higher capital costs (and therefore higher annual carrying costs), but I do not think it likely that they will generate savings or efficiencies commensurate with those capital costs. In other words, they may not have a good rate of return, in strict financial terms, but they clearly will be the standard for new construction and renovations.
But, I think that Doctors Detsky and Etchells are off-base in their conclusion about single-patient rooms obviating the need for improved staff performance in the quality arena. The idea that increased capital investment in this arena will result in a noticeable and sustained improvement in reducing harm in hospitals -- absent ongoing and dedicated training, measurement, audits, and reminders -- seems to me to be counterintuitive.
I am not sure why the authors felt they needed to reach so far with their conclusion. It ends up sounding like they really feel that the "behavior and attitude of health professionals" is perfectly fine and that it has been the existence of multi-patient rooms that has been the source of safety and patient satisfaction problems in those rooms. This type of conclusion does harm to the quality and safety movement in that it could be used as an excuse that would distract people from investing time and effort in process improvements that are almost universally acknowledged as being long overdue.
One person's costs are another person's income.
Wednesday, September 03, 2008
I tried the henna remedy for chemo-induced Hand-Foot Syndrome last night and it worked!
Granted, my feet had already begun healing, so there were no more open bleeding or pus-oozing wounds, but the skin was still very thin, raw, and tender (and peeling off in small patches), that I was still having some trouble walking.
I'm scheduled to start a new chemo regimen in two days, so I was worried that my feet weren't ready to take the new onslaught of chemo and Hand-Foot Syndrome, but after just one night with the natural henna remedy, my feet feel ready to take it on!
So Monique, with no financial resources and just the power of an op-ed article and her own blog, seems to have had more influence in spreading the word about this antidote to a painful and disabling side-effect than Roche Pharmaceuticals. For fun, do a Google search on any combination of Xeloda, henna, hand-foot syndrome, and see for yourself. After the original journal article by some scientists from Turkey, most references to this topic derive from Monique's initiative.
I am trying to be considerate in how I write this, because I know that pharmaceutical companies do marvelous things in terms of drug development and availability, and I also know that they are subject to all kinds of regulatory constraints and legal concerns. But is there anybody at Roche among its 78,000 employees who cares about this topic as much as this cancer patient from Boston?
Tuesday, September 02, 2008
An article by Edward Dolnick in the New York Times gives us a hint of how we “know” that one place is better than another. Because we expect it to be.
Huh? Well, as con artists know, you can take advantage of people’s expectations. Dolnick summarizes a test in which 32 volunteers were asked to sample strawberry yogurt, in the dark. Then the subjects were given chocolate yogurt. “Nineteen of the 32 subjects praised the strawberry flavor.”
When it comes to hospitals, we can measure “better” according to a variety of metrics, ranging from decor and food to the friendliness of the staff to the clinical outcomes achieved for different kinds of diseases. I don’t know about you, but the one I like the best is the likelihood that I will not be harmed during my time in the hospital. After all, hospitals are one of the leading public health hazards in America, and when I go to one, I would like to leave feeling better than when I arrived.
But, you may have a different set of criteria. That’s OK. Each of us knows what is really important to us, right? But I am guessing that most of us fundamentally care about something related to the actual quality of medical care offered.
Here’s a test for those of you who live in the Boston area (or New York or London or New Delhi or wherever). Which is the best hospital according to the criteria that you hold dear? Write down that answer.
Now, what evidence do you have for your conclusion? If you are basing your choice on clinical outcomes, do you have statistically valid data? Without knowing what metrics you have chosen, I will tell you categorically that you do not. There may be some publicly available data about some clinical outcomes and medical processes, but I will assert that it is many months or years out of date, and not necessarily reflecting the service you will get. In short, that data currently gives an impression of precision that is not valid.
(Yes, there are differences in culture and approach in the various hospitals, and those might make you feel more or less comfortable and happy, but do you mind if we focus right now on the measurable outcomes of clinical care?)
The truth is probably that you think your chosen hospital is the best because your primary care doctor, whom you trust, referred you there. But how does your doctor know which is the best? Well, you say, “He is an expert.”
To which Dolnick notes, “Experts make the best victims because they jump to unwarranted conclusions.”
As mentioned below, Brent James from Intermountain Health makes a persuasive case that the variation in medical care from region to region is not based on scientific evidence, but is a function of “medical mythology," lessons of habit passed down from one generation of doctors to the next. I haven’t asked him, but I would guess that he would also support my proposition that referring doctors often make medical judgments for their patients based on unsupported expectations about the relative efficacy of treatment between hospitals. (I put aside issues of personal relationships and financial integration and gain for purposes of this discussion, but we know those are important determinants of referral patterns.)
Now, before you fret too much about what I have just said and start to worry that you are not being sent to the “best” place, I will make another categorical assertion. I will confidently state that, with very few exceptions, you will get comparable care in most if not all of the hospitals in your home city.
Since “the best” is an elusive goal, on what should you focus? Wherever you go, the most important thing you can do is to bring along a trusted family member or friend to be your advocate, to help you keep track of what is going on, ask pertinent questions, and to help make sure that the plan of care is carried out properly. (Read Nick Jacobs’ book for more advice on this front.)
Another thing you might want to consider (he says, in a totally self-serving manner!) is whether the hospital you are visiting has made an institutional commitment to quality and safety improvement and reduction of harm -- and whether it is willing to hold itself accountable by publishing current clinical statistics as to its progress in meeting audacious goals in that domain. A hospital that is aggressive in setting quality and safety expectations; is modest in how much it knows and how much it needs to learn; and shares it successes and failures with others throughout the medical world, should give you some satisfaction that they are thinking about you more than about themselves.
We had a great summer and a wonderful breakfast celebration. Each intern was asked to speak about his or her experiences this summer. One of the interns, Taliah, worked in my office this summer. Here are some excerpts from her essay, and you can see her above speaking at the farewell breakfast. These internships are less important for the specific projects on which the students work than to give them exposure to the professional work environment and some mentoring along the way.
Hi my name is Taliah. This summer I worked as an intern at The Office of The President. I enjoyed every second that I worked. I met a lot of new, exciting people who have helped me a lot as a person and a student. I worked on a few projects during my time at BIDMC such as I organized all of the files in the office, I organized the supply closet, and I worked on updating the Board Member Handbook for FY2009, and in the Development Office, I worked with on several different projects.
I am very grateful for this position, it exposed me to a little bit of the business part of running a hospital. I’ve seen the meetings and the people that both Paul Levy (President) and Eric Buehrens (Chief Operating Officer) go to and meet with to keep the hospital running smoothly.
I have met a lot of wonderful people while working at the hospital and I have learned a lot from them. Gail Serra is the coolest. She is Paul Levy’s Executive Assistant and she helped me choose my college essay topic and has helped me with preparations for my senior year in high school. Mary Chan has helped me get ready for my senior year also. Stephanie Huang has introduced me to a lot of people who work and are associated with the President’s Office and Development Office. She has also helped me with college scholarships and tips on college. They have all given me words of encouragement and guidance to help me on my path to college. I want to thank everyone who has made my experience a great one.