Time with a gracious witness

I finished the week with a sobering and also inspiring conversation with Maurice Vanderpol. Dr. Vanderpol survived the Nazi regime by hiding out for 2-1/2 years with his mother in a third floor tenement in Amsterdam. He spends much of his time now teaching school children about the Holocaust on behalf of Facing History and Ourselves. My assistant Gail had organized a session for her town's school several years ago with Dr. Vanderpol, had maintained contact, and had kindly arranged for us to meet today.

The details of the Vanderpol family's survival -- such as hiding in a 1' x 5' compartment behind a hidden wall in the apartment -- are engrossing, but there were other points that he made today that left a bigger impression.

On teaching today: "How can I get 13- and 14-year-olds to get even a remote feeling, when living in a safe country with a predictable life, to understand what it was like when nothing was predictable anymore? Finally, with today's economic dislocations, they are starting to get it."

On situational prejudice and fear of intimacy: "One night -- May 10, 1940 -- our country was invaded. Previously Jewish families had fled from Germany to Holland, and their children were in our classes at school. We didn't like them.... We never asked them what it was like to leave your country. I think we didn't want to know. We were too uncomfortable to ask."

Having faced a survival situation, making life and death choices every day, and yet still looking back and wondering if you did the right thing at key junctures: "You review your life at certain points, certain sticky points, and you feel badly about things you should have done. I didn't join the resistance.... I wish there things that I could have done differently."

More regal than the king

A friend taught me a new word tonight, one she had learned from her daughter. It is myrmidon. Actually it is a pretty old word, but I had never heard it.

From this source, we get the following definition: "A loyal follower; especially: a subordinate who executes orders unquestioningly or unscrupulously."

One of the dangers for a CEO is the tendency for your subordinates to take what you say, sometimes in passing, and execute it to a degree you never intended. Henry II, a pretty high ranking "CEO," discovered this after he said in exasperation one day, "Will no one rid me of this troublesome priest?"

I always try to surround myself with people who will question my assertions and conclusions, but even at BIDMC where (trust me!), very little goes unquestioned, I have had people behave like myrmidons. From time to time, people have assumed that I meant something I did not and then proceeded to design whole systems to make sure it would be implemented, even to the point of ignoring or covering up substantive and documented facts and factors that would make the conclusions impractical or unrealistic. Such is the unintentioned power of the office.

Do you have stories of similar phenomena? Please post.

Chat with Hester

We are hosting an online chat today from 1 p.m. - 2 p.m. on a topic that touches so many people around us. Hester Hill Schnipper, LICSW, will be answering questions on coping with being a caregiver for someone who is ill.

Hester is the Chief of Oncology Social Work at BIDMC. A nationally known speaker, she has written numerous articles for professional journals and has authored two books: Woman to Woman: A Handbook for Women Newly Diagnosed with Breast Cancer and After Breast Cancer: A Common-Sense Guide to Life after Treatment.

Illness and hospitalization can be a stressful and challenging time for patients and their families. There are many emotional and practical issues that a caregiver may have to deal with during a loved ones illness. Hester will answer your questions about caring for caregivers.

Click here join the chat.

The fear of transparency clouds all

I have been worried lately that I may have adopted radical views on quality and safety in hospitals, that I may be out of the mainstream of American life when I suggest that we should jointly determine to eliminate certain types of infections or engage in protocols to enhance patient safety. I was also worried that my insistence on the importance of transparency with regard to these issues was just too outlandish for people to absorb and accept.

Imagine my relief then, to read this editorial in USA Today. Hardly a radical journal, the editors write:

Too many Americans go into hospitals for treatment and end up getting sicker....

A greater sense of urgency is needed....

Why are infections so widespread? In part, of course, because hospitals are full of sick people and germs. But medical professionals, hospital administrators and government regulators are failing to demand adherence to actions they already know will protect patients....

Secrecy allows the problem to fester. Although 23 states require hospitals to report infections to one of four unlinked federal databases, reporting is so scattershot that there's no way to determine whether the problem has been getting better or worse.

On the comments under the post below, some of the world's experts on quality and safety offer their perspectives on this issue. What is it about the medical community that makes it so hard for these views to be accepted? A close colleague writes to me saying, "I imagine the fear of transparency clouds all."

Look at the numbers in the editorial: Tens of thousands of deaths from often preventable infections. We -- and I mean the academic medical centers in general -- rely too much on our reputations. It is beyond time to hold ourselves to a higher standard. As I have said before, if we fail to do so, it will be done for us and to us by legislative and regulatory action, and such action is bound to be less accurate and helpful than the kind of self-reporting I have advocated here.

Too many transplant programs

Long-term readers will recall that one of my pet peeves is the proliferation of solid organ transplant programs in New England. In simple terms, there are too many such programs given the small size of the region and the limited number of organs made available from living and deceased donors. This surfeit results in unreasonable expenditures for the region, and it also results in less than optimum care for those patients served, especially the ones seen by smaller programs.

The Health Resources and Services Administration (HRSA) Best Practices Evaluation, conducted in 2007, states that transplant programs should meet the following six criteria:

①Institutional vision and commitment
-- “Fundamental”.
-- “Hospitals cannot dabble in organ transplantation. They must commit to it fully and provide the resources and support necessary.”

②Dedicated transplant team
-- Attracting & retaining dynamic, dedicated and skilled specialists who consistently function as a team.
-- Collegial and nonhierarchical team provides the best care.

③Aggressive clinical style
-- For the care of patients before, during & after transplant is central to making best use of organs that are chronically in short supply.

④Patient- and family-centered care
-- Organize care around needs of patients and families, instead of around the needs of the institution.
-- Streamlining processes to reduce paperwork burden on patients; increasing educational opportunities for patients and families about lifelong care of the transplant; creating comfortable spaces in the hospital that do not isolate the patient from his/her family.

⑤Financial intelligence
-- Rigorously detailed accounting of program finances, sound financial management, and excellent payer relations.

⑥Protocol-driven results
-- Leading centers consistently conduct improvement-oriented performance reviews based on protocols, data-driven quality control methods, innovation, and research.

The chart above shows the number of adult abdominal organ transplants for all the centers in New England through October of 2008. I am going to go out on a limb here and assert that a substantial number of these programs would not meet the HRSA criteria. I do not say this to insult anybody, but objective observers throughout the country would surely reach the same conclusion.

We hear over and over again from state officials and insurance company executives that they want to rationalize health care in the state, increase efficiency, reduce costs, and make it more patient-centered. Question: When are the state regulators and/or insurance companies going to step in and shut down some of these programs?

ICU, but do I feel for you?

We've been thinking a lot about our intensive care units (ICUs) and how we could make them more comfortable, welcoming, and friendly -- not only for the patients, but more for their families. Last week, the three people here (Wendy McHugh, RN; Dr. Michael Howell; and Barbara Sarnoff Lee, our chief of Social Work) presented a report on this work in progress to our Board of Directors.

We serve 5500 adult ICU patients each year, in 9 separate units with 77 beds. Staff for these units comprise dozens of types of specialists and virtually every department in the hospital. The theory of the case for our working group is that the patient and family experience is an outcome that must be managed and improved. Thus, this is not a project. It is an attempt to understand the experience to great depth, looking at both quantitative and qualitative factors. We are aided in this process by a volunteer advisory group of patients and family members who have had ICU experiences.

A symbol of the "old way" is seen in the picture above: Hardly a welcome greeting! Another symbol was the existence of visiting hours in the ICUs. Why do they exist? Well, our working group decided to eliminate them. They decided that allowing loved ones to be in the ICU at all hours would actually be helpful to all parties. Since the patient is often unable to communicate well, who better to explain things to the medical staff and hear from the doctors during their rounds than a family member?

The group is also focusing on how to improve communication in this environment, making it more predictable and consistent. Another area of attention is how to improve the transition from the ICU to the regular floors, often a stressful period as the patient goes from continuous nursing care to more episodic care.

Since the usual patient satisfaction surveys don't really address the ICU experience, the team is also working with a survey designed for this audience of patients and families. In addition, Wendy engages families in real time to get their reactions to the environment and other issues.

I am sure the team would welcome thoughts from readers about your experiences in this kind of process improvement. Please post them here.

Feeling small

I write this post with a bit of temerity that it will prompt all kinds of defensive reactions, but I am not doing it to criticize the protagonists -- rather to give an example of the kinds of market forces at work here in eastern Massachusetts. I am actually not sure as to whether the moral of the story is "That's life. Get used to it" or "This is an unsustainable situation." I let you be the judge and offer comments.

For the last several months, I have been hearing from friends at Norwood Hospital, a small community hospital south of Boston affiliated with the Caritas Christi system, that they were really afraid of a new ambulatory care center being built nearby by Partners Healthcare System for their flagship hospitals, MGH and Brigham and Women's. I frankly attributed the concerns to the usual kind of overstated fears you often get in this business, and so I discounted them.

Then, this past Friday, I was in Foxboro at Gillette Stadium to give a speech to a group of hospital finance people, and I was stunned to see a very large building (pictured above) adjacent to the stadium. I later checked it out and learned that the new center is 75,000 square feet and will offer the following specialties: Primary Care, General Surgery, Plastic Surgery, Orthopaedic Surgery, Cardiology, Cardiac Diagnostics, Dermatology, Diagnostic Imaging, Women’s Health, Rheumatology, Rehabilitation Services including Cardiac Rehab, Physiatry and Pain Management.

I now understood why my colleagues at little Norwood Hospital were nervous. Their website says they offer the following services, among others: Surgery, Obstetrics, Cardiology, Dermatology, Radiology, Neurology, Orthopaedics, Gastroenterology, Cancer Care, and Pediatrics. Not a complete overlap, but quite a bit.

As you can see on the MapQuest graphic, the two facilities are merely 8.5 miles apart, making them indistinguishable to many patients in terms of transportation access. Since insurance companies pay community doctors in the Partners system substantially more than those in the Caritas Christi system, it will be easier to recruit physicians to offer services in Foxboro than in Norwood. Does this difference in reimbursement rates reflect a documented difference in the quality of care between the community-based doctors in the two systems? No.

Now, let's acknowledge that MGH and the Brigham are powerful brands. To the extent patients are influenced by that reputation or other factors to migrate to the PHS facility from Norwood Hospital, the overall health care bill for the state will rise for no documented additional value to those patients or society.

The Boston Globe recently reported about similar expansions by PHS to the west and north of Boston. As I have said before, I offer no criticism about the business accomplishments of any hospital system. But when a differential in reimbursement rates that has no basis in quality or outcomes creates a market opportunity for one system vis-a-vis all the others, the effect is simply to raise overall costs to society.

Not the Staten Island Ferry

I have had requests for more details about the Mumbai-Goa charity bike ride I joined a few weeks ago. In particular, people want to know about the ferry rides. Folks from the ride have now posted lots of their photos on Facebook, and I have borrowed a compendium to share with you.

The one that might need some explanation is the huge ore loader, one of several parked in parallel on one side of an inlet. We walked our bikes across the first few, and loaded ourselves on the bow of the one furthest into the inlet. (If you click on the aerial view of the ore loaders, you can see us grouped on the bow.) The "ferry" service provided was when the pilot gunned his engine, turned the boat sideways across the inlet and ran aground on the other side, whence we could climb down on the opposite beach. He then had to wait till the tide came back in to pull off the sand bar and return his ship to the other side.

Mutt be true

A message I just received:

Good morning!

Two weeks ago, tomorrow, Sunday, my sweet little mutt bit me on the chin as I tried to pick him up to put him in my friend's truck cab after a lovely walk in the Maine woods. I thought nothing of it, as the same thing happened several years ago after he had surgery and I was lifting him into my car. He is a rescue dog, and I think young children picked him up as a pup and teased him, and the flashback is not pleasant.

In any event, I thought nothing of it, as the first time there were no repercussions. Not so this time! By Monday evening at 9:30PM, I had a 103 fever and swelling in my face such that my right eye was virtually closed. "Get thee to the BI emergency ward," says my primary care physician, and so I did, arriving about 10:15PM, with a temperature of 105 and a closed right eye.

The care was superb, in the ER, and on the bariatric and pancreatic surgery floor, kind, professional, sometimes funny, always serious of purpose. I was there for two and one half days, as the intravenous drip did its thing. Congratulations on a sensational staff and a fine operation. BIDMC is the BEST! And I am your most earnest advocate!

Near misses matter

A story published on our hospital intranet from our BIDMC SPIRIT group, with the aim of spreading this kind of discovery to other areas:

The recent case of an exploding light bulb and near miss injury in the Neonatal Intensive Care Unit (NICU) serve as a good example of the kind of quick, positive change that can happen when near miss incidents are treated as serious safety threats.

Last month, NICU nurse Sarah O’Neil, RN, was using a250-watt warming light to prepare an infant scale for weighing a newborn patient when she heard a loud “POP!” – as if something exploded. “I turned around and saw a small flash, and then smoke was rising out of the top of the warming light,” she said. “The flash and smoke extinguished within seconds. Then I noticed there were small shards of glass all over the top of the scale, and a small amount on myself.” Neither the patient nor O’Neil was injured by the incident. “It scared me to know that the patient and I could have been affected much differently had the incident happened minutes later,” said O’Neil.

After unplugging the equipment and securing the area, O’Neil filled out an incident report that immediately triggered the involvement of Rich Stroshane, Product Recall Technology Coordinator; Steve Fairbrother, Biomedical Technician 3, and Cecil John, Biomedical Technician 2, from Clinical Engineering; Mary Ward, Health Care Quality; and Gary Schweon, Director, Environmental Health and Safety.

“When we went and looked at this warming light, we decided to look at all the other warming lights in use on the units,” said Schweon. “For safety, all of the lights have protective screens in front of the bulbs. This was intact in this case. We surmised that the glass shards came out the top of the lamp housing. “What we also noticed was that the bulb that exploded and all the other bulbs, except for one, looked the same. One bulb looked very different from the others – it had plastic-type sheathing around the bulb.”

Turns out that this was the only Teflon-covered shatter-proof light bulb in the 12 warming lights in use throughout L&D and NICU. Unfortunately, the bulb that shattered, as well as all the others – except one – was a regular bulb. Since there was no protective coating on the bulb that blew, it had not prevented glass shards from exploding outward and upward, he said. “At that point we pulled all the lamps out of service until we could get the newer shatter-proof bulbs, which we did within 12 hours," said Schweon.

Searching for a root cause, the group’s focus quickly turned from light bulbs to warmers. “I never thought of these bulbs as being a potential danger, but some of these warmers are pretty old,” said Jane Smallcomb, RN, Nurse Manager, NICU. “I’ve been here 16 years and they were here when I got here.” Schweon believes that at the time of purchase, shatter-proof bulbs had not been invented and not identified in the user manual.

The team reached out to senior leadership, presented the problem as an urgent need, and is seeking funds to purchase new warming lights to replace the older models. In the interim, the oldest warmers have been removed from service and all warmers in use have had shatter-proof bulbs installed, said Smallcomb.

“I have to say the scariest part about what happened was the possibility that five minutes later a baby would have been lying on that scale,” said O’Neil. “I’m just so thankful that the patient was not harmed in this situation. I’m also grateful that the bulbs have since been switched to a shatter-proof bulb, so that something like this is prevented from happening again. It's great to see that such quick action was taken to resolve the cause of the incident.”

Schweon says there is an important lesson all staff can learn from this incident. “We were able to take quick corrective action on something that posed a serious safety risk to both patients and employees, but only because someone treated a near miss as a reportable incident,” said Schweon. “NICU Nurse Sarah O’Neil gets a lot of the credit for making this happen because she saw this threat and filled out the incident report that set these wheels in motion.”

If you witness a dangerous condition relating to equipment in the course of your work, please stop and take the following actions:
1) Immediately take the equipment out of service and report the malfunction to your manager;
2) Contact the appropriate service group (Maintenance, Clinical Engineering, etc …) if known;
3) Complete the incident report;
4) Fill out a red “Equipment Management Program” tag, indicate that the device was involved in an incident and/or that an incident report was written, and sequester the device in a safe, secure location;
5) Remember that if it can happen to one piece of equipment then it’s possible it can happen to all other like pieces of equipment.

Good news at Dimock

The pictures here are of today's ribbon-cutting ceremony at Dimock Community Health Center for a new pharmacy that will offer low-cost and no-cost drugs to the patients of this facility in Roxbury. This should help low income people have a better chance to adhere to the drug regimens suggested by their doctors. We at BIDMC were pleased to contribute funds to Dimock for renovation of the new facility, beginning inventory for the pharmacy, and support for launching an e-prescribing program. Our hope is that the pharmacy will lessen the burden of the all-to-common choice of "eat, heat, or treat" for people served by this health center.

One photo shows Myechia Minter-Jordan, Dimock's chief medical officer, making a presentation, with the pharmacy in the background. The other shows Dimock's president, Ruth Ellen Fitch, with Delores Pickett, a fourth generation health center patient, cutting the ribbon.

Caller-Outer of the Month Award #2

It was time last night for the second Caller-Outer of the Month Award, given by our Board of Directors to an employee who exemplified the principles of BIDMC SPIRIT in pointing out a problem that was interfering with the staff's ability to do their jobs. This one went to Sharon O'Donoghue, clinical specialist in the medical intensive care units, seen above.

Here's the story. Last spring, based on observations from several ICU nurses, Sharon called out a frustrating problem: Inpatient nurses were unable to read many consult notes or follow up on tests because they did not have access to webOMR. WebOMR displays results and provides access to notes and other documentation. Instead, the nurses had to waste time searching in different locations for labs, imaging and plans of care.

Why? Because the original version of webOMR was optimized for outpatient workflows and was initially rolled out to outpatient providers. It had never been offered to the inpatient nurses or authorized to them as part of their information system log-in credentials. In fact these nurses first learned about the existence of the system when they happened to look over the shoulders of some doctors! Absent this access, the nurses had to use older programs that were not as complete, were not web-based, and were not as easy to use. This situation had existed for years.

Within a couple of days, Larry Markson, MD, Vice President, Clinical Information Systems, provided a simple way to give read access to webOMR to the inpatient RN staff, fitting the inpatient workflow. The result was enhanced patient care and improvement in the day-to-day lives of our 1400 nurses.

Sharon received a congratulatory letter, plus two super tickets to a Red Sox game of her choice this spring.

Greetings!

Several months ago, we created some new jobs at BIDMC. These folks work at our information desks or stand near the front doors or at critical hallway intersections, with the sole purpose of helping patients navigate their way through our 2 million square feet of clinical space.

Their position is formally called "service ambassador," but we all call them "greeters." The gentleman shown here is Leon Carrington, the solo lady is Lynn Miner, and the smiling pair are Yoly Reyes-Campbell and Zofeen Shujaatullah.

Don't they look friendly? Say "hi" next time you see them.

Our hospital as small town

I really like it when people write me notes complimenting their colleagues, especially those from other departments. Here is a note I received just after the Christmas holiday weekend from one of our senior faculty members in the Radiology Department:

Good afternoon!

I wish to relay to you a short story that illustrates why BIDMC is so special.

Through the magic of our Radiology PACS system, as well as a robust backbone from Information Systems, I have been able to read all of my radiology cases from a home workstation for a number of years. As computer power has increased, I now can display cases faster at home than in some of the older sections of the hospital!

In the last few days, this connection to the hospital PACS system dramatically slowed. I feared that something within the hospital was malfunctioning, as my internet connection speeds (purchased by me to provide the highest downloads available) were perfect. Another user, with the same ISP, was suffering the same problems.

In response to this query, John Halamka, answering emails from me immediately while having an arduous cross country plane flight, assembled a crack team from his dep't, consisting of Mr. Mark Olson, Ms. Michelle Frayman, Mr. John Powers, and Mr. Bill Corzett. From our department, Mr. Jim Brophy and Mr. Phil Purvis also stepped in to help. The IS department thoroughly analyzed their systems. While this work was occurring, another remote user, having a different ISP indicated, to me there were no connection problems. After conversing with my ISP, and spelling out the problem, they located a regional server malfunction, issued me a new IP address, and basically rectified the problem!

The point of this message is that without rigorous analysis of this technical issue by people who gave of their free time on a holiday weekend, the solution would not have been achieved. I believe such dedication deserves recognition. The caring attitude that these people exemplify is the clearest explanation as to why our hospital is so special. High technology doesn't mean anything without the people who are willing to go way beyond their assignments to ensure that caregiving remains optimal. I certainly feel honored to have been a very small part of this effort for more than three decades. While our hospital has grown substantially in this time period, the strong interpersonal relationships that wonderful people engender at BIDMC still create a wonderful "small town atmosphere." This sense of friendliness and desire to help makes BIDMC a very special place to "hang one's hat."

Sincerely yours,

Jonathan Kleefield, M.D.
Radiology Dep't

Can we learn together?

A dramatic cease-fire was announced over the weekend. No, not the one in the Mideast, but rather in the health care market in Massachusetts. As documented in this Boston Globe story by Scott Allen and Jeff Krasner, Tufts Medical Center and Blue Cross Blue Shield of MA reached an agreement on a payment contract. What's the big deal? Well, Tufts had threatened to pull out of the BCBS network when it felt that it was not being offered sufficient compensation for its medical services.

The context was important. The Globe had previously reported that payments to Tufts and its doctors were substantially below those received by, in particular, the hospitals and doctors in the Partners Healthcare System, and often below those received by BIDMC and its doctors. As I have noted below, there is really no justification for these differentials, if one considers the actual quality of care delivered by the major academic medical centers.

Well, I guess Tufts felt that enough was enough and stood its ground in its contract negotiations with BCBS. This was a gutsy move, in that BCBS has more subscribers than all the other insurance companies combined, and Tufts and its doctors stood to lose a lot of business if the dispute was not resolved.

We should all be pleased that the issue was settled, apparently to the satisfaction of both parties. It is difficult to believe that Tufts could have followed this path absent the Boston Globe stories, in that those stories created the moral high ground for a different kind of negotiation. After all, there is no data to support the contention that a patient at MGH or Brigham and Women's Hospital will receive better care than at Tufts.

But where does that leave the state? On its face, the Tufts-BCBS deal seems to contradict the hopes of Governor Deval Patrick, who, it is reported, wants the hospitals and insurers to slow down the growth rate in health care premiums. BCBS, for its part, has been pursing adoption of a capitated insurance reimbursement approach to control those costs, and adoption of that plan was announced as part of the Tufts deal. But clearly some compromise must have been reached. The plan offered to Tufts had to be more generous than the one previously offered, or the deal would not have been done.

We have been discussing this alternative contract idea with BCBS for several months, too, and both parties are trying to figure out how it might be designed to work in the environment of our medical center and our physicians. One key issue is that such a plan transfers a portion of the insurance risk of health care to the providers and away from the insurance company. Some element of this risk-sharing is probably essential to align incentives between the providers and the insurer, but the specific design and implementation plan is important, lest the hospital and doctors find themselves with a major revenue loss at the end of any given year. After all, providers do not have the kind of financial reserves that insurance companies have.

Another important issue is that we do not control the delivery of the full spectrum of care, from primary care to hospitalization to skilled nursing facilities. A capitated contract requires some kind of relationship among providers across that spectrum, so that risk can be appropriately monitored and shared.

Nonetheless, people of good will can work through these issues, and I am hopeful that we can, too. In the meantime, as I have noted often on these pages, there are many steps that hospitals and doctors can take in the current fee-for-service reimbursement environment that also help to control cost increases. My passion for reducing harm that you have seen repeatedly on these pages is an important part of that process. See below, for example, the post about reducing ventilator associated pneumonia. That program not only saved lives: It saved millions of dollars in medical costs. That most of the savings went to the insurance companies did not preclude us from adopting this standard of care. Our job, simply, was to reduce harm and save lives.

As you can tell from my post below, I am frustrated that the medical profession in this city has not adopted an aggressive and transparent approach to this kind of quality improvement. As noted by one or more comments under that post, in its delays, the profession risks abdication on these matters to governmental authorities, who will impose standards that will inevitably lack the subtlety and effectiveness of those that the profession could otherwise design for itself.

Also, on these pages you have seen an emphasis on BIDMC Spirit, our process improvement program based on the Toyota production system. We engaged in this program to improve the work environment for our staff and to improve patient care, but it also has the effect of controlling costs and improving efficiency. Again, a great portion of the cost savings will flow through to the insurance companies, but we still pursue the effort because of its advantages to the organization. I want to acknowledge here that our progress on the front was greatly aided by technical support and assistance from BCBS, as part of a pilot program involving five hospitals in the state. The program gave us exposure to people and ideas and resources that we might have encountered otherwise, but that probably would have been delayed by several years.

As a result of these joint efforts with BCBS and with other helpful people like the Institute for Healthcare Improvement, we find ourselves to be in the vanguard with others around the country in the implementation of these approaches. Through this blog and other presentations, we are doing our best to share what we have learned. As I have often stressed, quality and process improvement and transparency is not a matter of gaining competitive advantage.

As long as the distribution of health care reimbursement revenues is viewed as a zero sum game, the likelihood of cooperation across the hospital and medical community is likely to be minimal. If Tufts Medical Center got more, must everyone else get less? No. My hope is that the presentations here and elsewhere of what we and others have learned will help people understand that it is not a zero sum game. Society as a whole can benefit from the kinds of quality and safety and other process improvements with which we have been experimenting. But we need all participants to shed their defensiveness and fear of disclosure, to acknowledge the areas needing improvement, and to share what they have learned for the greater good.

January 19 and 20

As this weekend ends, three thoughts:

I love living in a country that created a holiday to honor a person who devoted his life to promoting civil rights.

And, as inauguration day approaches, I am reminded to appreciate the fact that I live in a country that has peaceful transitions of government and has managed to keep that concept going for over 200 years.

But, as I view both events, I am also reminded that Thomas Jefferson said, "The price of freedom is eternal vigilance." I worry about the financial troubles facing the country's newspapers, gradually undermining their ability to do the kind of investigative reporting that makes governments and corporations uncomfortable. While social media like this kind of forum help to offset some of those losses, who is going to pay for the depth of investigation and reporting that has proven so important over the years?

Jambu!

And here's a tree and fruit called jambu, in Sri Lanka. A very pretty tree. the fruit has a texture almost like an apple or pear, with a slight flavor of pear with something else mixed in. Those who have tried it can offer their opinion.

Tropical trees

From the Peradeniya Botanical Garden in Kandy, Sri Lanka come these pretty trees, part of a huge collection from around the world. The big bud is on a tree called Rose of Venezuela (Brownea Kewensis), and is from South America. The one that looks like a mobile (with a closeup of the flower) is called Queen of Flowering Tree (Ahnerstia Nobilis), and is from Burma.

Leeches, too

Continuing to ease this blog back into the medical world, here's more about Sri Lanka. I include a report of my visit to the Sinharaja Forest Reserve, a UNESCO World Heritage site, a truly unspoiled region in the southern part of the country. There was lots of wildlife, including this millipede, a hump-nose lizard, a colony of poisonous caterpillars gathered on a tree, and many pretty waterfalls, including the one below called Kakuna Ella.

And then there were the leeches. They lay on the forest floor and propel themselves onto your shoes and ankles as you walk by. If you slow down to knock them off, more join in. Meanwhile, the early arrivals travel upwards to, shall we say, the warmer areas.

So by the time you get home and take off your shoes, you discover blood covered toes and ankles, where the satiated leeches have either dropped off or been crushed inadvertently.

My fellow blogger Ramona Bates discusses the current use of leeches by the medical profession.

For my part, I didn't detect any lasting damage, but I did have a craving for protein after the hike . . .

It's voting time

If you have not already, please take the time before Sunday night to vote for the best medical blogs in several categories at Medgadget.com. There are so many good ones that you will have a hard choice. I nominated a few, including Life as a Healthcare CIO (vote here), Beating Social Anxiety (vote here), Notes of an Anesthesioboist (vote here), and Scan Man's Notes (vote here).

I want to tell you about a particular one, though, that is also very compelling. It is called Running for My Life: Fighting cancer one step at a time and is in two categories, Best Literary Medical Blog and Best Patient Blog. Here's a summary from my friend Margaret Pantridge:

The blogger is my close friend Ronni Gordon, a 54 year-old journalist and mother of three from South Hadley, who was diagnosed in 2003 with Acute Myeloid Leukemia after feeling unaccountably winded by a 10K road race. She has relapsed and is currently stuck in the hospital awaiting her fourth bone marrow transplant on January 30. Ronni has been plagued by headaches, a fever and - needless to say -- worry. But she continues to write her eloquent blog, describing in unflinching detail the difficult treatments, her roller-coaster emotions and the unusual lifestyle cancer imposes upon those it strikes.

As she puts it, "This blog is about falling down and getting up, coping and coming back." Though a bit bashful about her nomination, Ronni is getting a kick out of it. As friends check in with her and her vote total climbs, she is enjoying a pleasant distraction from platelet counts and transfusions. Would you mind casting a vote for Ronni? She has the best chance in the Literary category, where there are fewer nominees, but I hope you'll consider voting for her in the Patient category as well.

What does it take?

I take a short break from my travelogue to get back to medical issues. A vacation is supposed to help you get perspective and calm down, but I find myself pretty upset.

What follows is not criticism of any particular hospitals. I repeat, it is not criticism. It is an observation about this medical system in which I find myself a participant. It is a statement of frustration about the lack of will within this profession to change itself in a timely fashion.

Here's the setting. There is a great story by Liz Kowalczyk in today's Boston Globe about the work that Atul Gawande and others have done to document the effectiveness of a pre- and post-surgical checklist. They were able to show that use of the checklist has real benefit in reducing the likelihood of medical errors during surgery. Atul himself said "that in his own operations, the checklist catches a potential problem about once a week."

A number of commenters to the Globe story expressed surprise that surgeons had not previously adopted this approach. One person noted, "It is quite shocking that something like this is considered an innovation. I would have thought that it was a common practice long ago. It makes me wonder what else is going on in hospitals that could use the application of common sense."

A good point.

So, the question I raise is, what does it take to implement changes like this in a profession that is so steeped in the practice of giving individual physicians the prerogative to do their work the way they want to?

Here at BIDMC, we learned the hard way about the importance of this kind of checklist and instituted it after a bad experience with a wrong-side surgery. I think it is fair to say that institutional and personal embarrassment, along with our decision to be very open about this error, stimulated the change.

But even at the Brigham, where one of the world experts in this field has carried out this important work, the progress is evolutionary: "The Brigham, which was not part of the study, began using the checklist a month ago in general and cardiac surgery and plans to roll it out to other specialties over the next several months."

And of course the story implicitly raises the question about the other hospitals in Partners HealthCare (e.g., MGH, North Shore, and Newton Wellesley), a system characterized as an integrated delivery system? Where are they on this matter?

But this is not just a Partners issue. Look at the non-response to my challenge to all the Massachusetts hospitals on this matter a few weeks ago? I don't think I am being egotistical to expect at least one hospital administrator or someone from the state hospital association to contact me and say, "Yes, let's try it." Or even have one of them say, "That's a dumb idea." No, the response is silence.

Meanwhile, I hear public officials and insurance companies and businesses express concern about the high cost of health care. They say we need new models of compensation and regulation to control those costs. Everyone in the field knows that a major contributor to costs is preventable harm that occurs in the hospitals. It should not take a new alternative contract from Blue Cross Blue Shield or from anybody else to institute these kinds of changes. Failure to implement is not the result of economic pressures or the design of reimbursement. The check list takes about 90 seconds, not enough time to make a whit of difference in the day's OR schedule -- and, I am guessing that it will even accelerate a number of cases.

No, the imperative must come from within the profession. It has to be based on the underlying set of values to which doctors pledge their lives: avoiding harm to patients. The story about Atul's study unfortunately says, in so many words, that there is much lacking within.

Next time you put on rubber gloves

...think back to where they started.

Sumedha's estate in Sri Lanka also covers 35 acres of rubber trees. In this video, you can see one of the latex collectors at work, while Sumedha offers commentary in the background. Each collector taps 350 trees per day, slicing the bark at just the right angle, placing the sap cup, and later collecting the product. The plastic apron around the tree keeps rainwater from diluting the latex.

Healing Hands for the children

While Sumedha runs the tea estate and supervises the pluckers and factory workers, his wife Kumari is busy trying to save the next generation. On many of these estates, the children are left alone all day to fend for themselves. The older ones take care of the babies and toddlers and run the household until the parents come back from work. As a result, they do not attend school and they suffer great privations in many respects. Then, at young ages, they have their own families and do as their parents did. Kumari is trying to break that cycle by running schools on her estate and another, providing nutritious food, medical care, and education for the children.

She organizes this work through a group she founded called Healing Hands Women's Organization. There is a story there, too. She started the group after the tsunami devastated the Sri Lanka coast several years ago. Her own home and children just missed being destroyed, and Kumari felt that she was left alive to accomplish some special good in the world. She started by organizing a women's sewing circle, to provide a setting for women to band together, learn a trade, and share their experiences. The work then spread to the children, and the women produce special boxes of tea bags and other crafts to raise funds for those efforts.

The children walk several kilometers to school each day, often carrying their younger siblings who cannot be left home alone. While the little ones are cared for in a nursery, the older ones learning reading, writing, and arithmetic. With tooth decay being a epidemic, children are taught about dental care, and they start each day by brushing their teeth. Breakfast and lunch are served daily, too. As an incentive to their parents to let them continue in the school program, each family receives a bag of foodstuffs for every 18 consecutive days their children attend school.

Kumari knows she cannot change the world with this work, but she figures that if she can create opportunities for even a few of these children, she will have done something important. If you click on the tea box in the post just below, you can find their contact information if you want to send donations. Even a little money goes a long way in this setting. Need convincing? Keep scrolling through to the kids, themselves, who look a lot healthier than they were when they were scrounging for themselves.

How you can help Kumari

Here's that tea box. Click on it for the email and other contact information.

The kids, themselves

Pictures of a few children and a welcome performance at one of Kumari's schools.

How about a nice cuppa?

Taking advantage of proximity to Goa, a friend and I hopped over after the bike ride to Sri Lanka, where we were hosted by Sumedha and Kumari Kulatunga. That's Sumedha presiding over a tea crop. He took over operation of the family's tea estate in Morawaka this past June, after a varied career in hotel management, including stints in Boston (hence the familiar hat!) He has about 85 acres of tea plants (Camellia sinensis) under cultivation. Here's a picture of the bud and upper two leaves that are used for tea, along with a photo of a couple of the women doing the plucking.

Sumedha gave us a tour of his tea factory. The tea is first laid out and "withered" in long, aerated bins. Then it is put through rolling machines, and the fermentation process changes the chemical composition and the color. Then there are lots of steps sorting the tea by size, shape, and color, before it is packaged and sent to market, where the price has been determined by auction.

This is a very labor-intensive process, although increasing degrees of automation are being introduced. For example, a Japanese machine uses optical scanning to separate leaves by color and send them to different bins. This would have been done manually in the past. Even leaf plucking may become more automated in the future. The Kulatunga's have great concern for the workers on their estate. They know that this largely uneducated group of people need to receive help to adapt to what is likely to be a greatly changing economic environment. I'll describe some of their efforts in a following post.