What's an ex-President worth?

Did this bother you, or is it just me? A Jim Rutenberg article in yesterday's New York Times presented the story of former Presidents Clinton and Bush addressing an audience in Toronto about their presidential experiences. I'm sure that was a fascinating and worthwhile session.

Here's the part that was troubling to me: "Each earned more than an estimated $150,000 for the appearance."

As far as I can tell, an ex-President gets the following from taxpayers: A $191,300 salary, full coverage for himself and his spouse in the federal health care system, staff for his office, office rental expenses, coverage of all telephone and postage expenses, and certain travel expenses.

I don't begrudge any of that. After all, this is one of the hardest jobs in the world, and ex-Presidents continue to have public obligations even after their term of office ends. And I am pleased if they can make lots of money, too.

But shouldn't we require some kind of offset if an ex-President is able to bring in money by selling stories about his time in public service? For example, Mr. Clinton's speaking fees and book royalties have reportedly amounted to over $50 million since leaving office. What if the first dollars that came in were used to reimburse the taxpayers' contribution to the president's ability to go on the speaking circuit?

The idea of a salary offset is common in business. If a person has a severance agreement, the annual payment is often subject to this kind of offset if he or she receives income from another source during the severance period. Why shouldn't we apply that in this case?

SEIU surveys the residents

This week, residents at our hospital received an email survey request from the SEIU. Does this mean the union is thinking about organizing the residents, or does it hope to obtain responses that would be helpful in a corporate campaign? Some residents wondered how SEIU has the resources to obtain their email addresses and also how it can afford to conduct this kind of survey. The answer, as I have noted before, is because it can.

Dear Residents of Beth Israel Deaconess Medical Center,

As part of its effort to organize hospital workers in Boston, 1199SEIU has been reaching out to residents and attendings to better understand the joys and challenges of working at academic medical centers in Boston. As the end of your residency is near, we would like to give you the opportunity to tell us about your own residency experience. We would appreciate your thoughts on compensation for your residency and a few current healthcare policy issues.

Please consider filling out the following survey; it is brief and shouldn’t take more than 5 minutes. Your name and personal information will be kept confidential. Responses will be compiled in the aggregate.

One resident wrote me the following note:

Should I respond to this survey and tell them the truth how enjoyable it truly is to work at BIDMC, how the salaries are fair for the market, and other generally positive things or would they simply use this to twist any words I said to the negative?

I feel that you have done a better than outstanding job at defending the management of this hospital through the budget crisis across the country and at being in touch with all employees about the day-to-day challenges of running a hospital; very much in the spirit of transparency, I think.

My gut tells me to toss the below e-mail in the garbage with an unsubscribe order, but my heart tells me to tell the positive truth. What should I do?

Of course, I made clear that this is a matter of personal preference. Here's the survey. Anyone can fill it out. I'll help you with the answers I would give:

Q. During your residency at BIDMC did you have the opportunity to negotiate you (sic) salary and/or benefits?
A. I believe that, under the national rules of residency selection, this is not permitted.

Q. Were you required to take a pay cut as part of the [BIDMC] budget cutbacks?
A. No, residents were exempt from any cuts. See here, paragraph 24.

Q. Should residents have been asked to take a pay cut as part of the budget cutbacks?
A. No, but is SEIU advocating a reduction in residents' pay? Ditto, paragraph 25.

Q. Do you think that BIDMC would respect employees' desire to form a union?
A. What do you mean by desire? Do you mean by a secret ballot election? Or do you mean under the SEIU's proposal to eliminate secret ballot elections or limit debate during elections? If the latter, how would you know what the employees' desire actually is?

Happy birthday to the OR staff

Every month, nurse Tere McCarthy makes a cake in honor of OR staff members who are celebrating their birthday that month. Here is this month's version -- Fenway Park. I was lucky to catch this photo before too much was eaten!

Richard Schlesinger on CBS Evening News tells our story

A very nice story tonight by correspondent Richard Schlesinger on the CBS Evening News about our approach to solving this year's budget problems:


Watch CBS Videos Online

McAllen, Texas = Boston, Massachusetts

Thoughts as I go through the night prepping for my regular colonoscopy (OK, more than you want to know!) which allows me to be up even earlier than usual and make some observations. I can't yet blame the soon-to-be administered Demerol for any incomprehensible wanderings, and I promise not to write the next post until that wears off.

Atul Gawande has yet another beautifully written article in the New Yorker about health care costs, this time focusing on a particular city in Texas that has remarkably high costs compared to the rest of the country. Of course, he need not have travelled so far. The points he raises have been published for years by our colleagues at Dartmouth, and have been discussed by Brent James and others. And the kinds of numbers he cites, although perhaps not as extreme, also typify health care costs here in Massachusetts.

Brent summarized some of these issues in a talk he gave here about a year ago:

-- Well-documented massive variation in practice based on local medical myths.
-- High rates of inappropriate care.
-- Unacceptable rates of preventable care-associated patient injury and death. (Hospitals are actually the #4 or #5 major public health problem in this regard!)
-- A striking inability to "do what we know works".
-- Huge amounts of waster and spiraling prices that limit access.

While Atul focuses on national policy in his article, let me bring the discussion back to strategic planning for hospitals in general and academic medical centers in particular. It seems to me that there are three overwhelming public policy trends in America:

1) A desire to set an annual budget per person for health care;
2) A desire to limit the growth of that annual budget to a rate equal to or less than the overall rate of inflation; and
3) A desire to reduce the amount of harm caused to patients during hospitalizations.

The successful hospitals (and their associated physicians) will be those who learn to live within these broad formulations, and the most successful with be those who wholeheartedly embrace them. Further, they will need to create integrated networks of care -- whether by ownership or strategic alliances -- with people in other parts of the health care delivery system who have similar beliefs. Finally, they will need to engage in process improvement of the type discussed by Steven Spear to squeeze waste out of the system on the "factory floor."

In Massachusetts, there is only one integrated delivery system characterized by ownership of enough entities to engage in this kind of strategic approach, but that system has not yet demonstrated an ability to deliver care at a lower cost. Indeed, just the opposite. For a place like BIDMC, we will have to rely on finding multi-specialty groups, community hospitals, and others who share our vision of success through improving the quality and efficiency of our service, delivering care in the most appropriate settings, and constantly striving to be "the best at getting better."

Many of you have watched our progress here on this blog and on our corporate website as we feel our way along this path. One of our management techniques is transparency. It is based on a philosophy that you can't get better and you can't hold yourself accountable unless you are exceptionally public about what you do wrong, as well as what you do right. As I have noted elsewhere:

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.

In this sense, transparency is a necessary but not sufficient element in bringing about transformational change in an organization. But the actual implementation is not easy. You've seen our stories about BIDMC SPIRIT and Lean process improvement here. We view ourselves as babes in the woods in these arenas, but we view part of our role as an academic medical center to share what we have learned with others. We will also ruthlessly borrow good ideas from others in our quest to do better for our patients but also for ourselves as an organization facing the three policy imperatives set forth above.

Lucy and Ethel discover gemba

Lean training for our senior executive group continued apace this week. As always, a segment was a return to gemba, the place where work happens and value is created for the customer. Here, SVP for Health Care Quality Ken Sands visits with radiology staff members Michael Hogan and Caitlin Buchsteiner to learn about what visual signals exist in the workplace that give a sense of the status of the pace of diagnostic radiology exams. One part of the Lean theory is that it should be easy for staff members to get at-a-glance information on the status of a given work flow or process.

The classic example of a system in which the workers are disconnected from the upstream aspects of production system is found in this episode from the I Love Lucy show. How many examples of this can be found in your hospital? We find them all over. As always, this is not a case of ill-intentioned people working in a bad environment: Rather it is the all-to-common case of really good people working in an environment that has not been designed to reduce waste. The result is work-arounds, wasted effort, errors, and staff who go home more tired each day than they really need to.

Simply stated, the goal of Lean is to train people to see these examples and also to have the team learn how to address them in a comprehensive and thoughtful way. The idea is not to solve for the complete perfect solution all at once, but to be "very good at getting better."

3-1-1 > 0?

Many months ago, I wrote a post about a series of ads for medical devices, wondering "Is this ad effective?" It is time to ask the question again.

Going through the airport's security system the other day, I noticed this handy bag being offered as part of the TSA 3-1-1 program. A nice convenience, I thought, for those who had forgotten to separate their small vials of liquids.

But then I noticed that the bag was an ad from Johnson & Johnson for an atrial fibrillation (AF) catheter. I have no doubt this is an efficacious product, but how many people who need electrophysiology (EP) to diminish AF will be influenced by the placement of this ad on this medium? Let's look at the decision tree involved: Perhaps some people who are taking beta blockers or other drugs may choose to place their drug vials in this particular bag, and then if their AF is refractory to the drugs, they might remember seeing this ad, and then they might say to their cardiologist just around the time they are planning an EP treatment, "Gee, last time I was in the airport, I picked up a 3-1-1 bag at security that suggested that a particular catheter was real cool. Are you planning to use that catheter?"

Sound likely? Not to me. I therefore ask the questions I have posed before:

So, I guess I just don't get it, and I am asking for your help. What do you think is the purpose of this kind of ad? And, do you think it is effective in accomplishing that purpose?

(Please, I am really asking these questions because I don't understand. I have no hidden agenda. This is not a critique of this company, this product, or our economic system! I am hoping that doctors, patients, or manufacturers out there can offer insights to us all.)

Almost the Academy Awards

Sometimes the most prestigious awards are inexplicably not covered by the major media. Here's one example.

Thanks to Amanda Russell, RN, seen at left with a very young staff member at her feet, for inviting me and for her explanation:

This is the Third Annual Farr 2 Awards where the Housestaff and the Nurses come together to recognize each other and the work we do. We have many categories of awards, including the Golden Washcloth, and Nicest General Orders. The nurses vote for the interns and the interns vote for the nurses! It's just a fun way to end the intern year.

Congratulations to all the winners and to the great teamwork they all display on this floor of our hospital.

Blog Rally to help design the Healthcare X PRIZE

A message from Scott Shreeve, MD, Senior Health Advisor at the X PRIZE Foundation as part of a blog rally to publicize the existence of this prize and to solicit ideas in its design. Please pass this along and also feel free to post it on your own blog.

We are entering an unprecedented season of change for the United States health care system. Americans are united by their desire to fundamentally reform our current system into one that delivers on the promise of freedom, equity, and best outcomes for best value. In this season of reform, we will see all kinds of ideas presented from all across the political spectrum. Many of these ideas will be prescriptive, and don’t harness the power of innovation to create the dramatic breakthroughs required to create a next generation health system.

We believe there is a better way.

This belief is founded in the idea that aligned incentives can be a powerful way to spur innovation and seek breakthrough ideas from the most unlikely sources. Many of the reform ideas being put forward may not include some of the best thinking, the collective experience, and the most meaningful ways to truly implement change. To address this issue, the X PRIZE Foundation, along with WellPoint Inc and WellPoint Foundation as sponsor, has introduced a $10MM prize for health care innovators to implement a new model of health. The focus of the prize is to increase health care value by 50% in a 10,000 person community over a three year period.

The Healthcare X PRIZE team has released an Initial Prize Design and is actively seeking public comment. We are hoping, and encouraging everyone at every opportunity, to engage in this effort to help design a system of care that can produce dramatic breakthroughs at both an individual vitality and community health level.

Here is your opportunity to contribute:

1. Download the Initial Prize Design
2. Share your comments regarding the prize concept, the measurement framework, and the likelihood of this prize to impact health and health care reform.
3. Share the Initial Prize Design document with as many of your health, innovation, design, technology, academic, business, political, and patient friends as you can to provide an opportunity for their participation

We hope this blog rally amplifies our efforts to solicit feedback from every source possible as we understand that innovation does not always have a corporate address. We hope your engagement starts a viral movement of interest driven by individual people who realize their voice can and must be included. Let’s ensure that all of us - and the people we love - can have a health system that aligns health finance, care delivery, and individual incentives in a way that optimizes individual vitality and community health. Together, we can ensure the best ideas are able to come forward in a transparent competition designed to accelerate health innovation. We look forward to your participation.

Reality TV and then some

E-patient Dave sends me a note about this article in the New York Times about Methodist University Hospital in Memphis webcasting brain surgery as part of its marketing campaign.

Is this all a good idea or a bad idea? We regularly use live webcasts as teaching tools. The most notable one is a worldwide CME course offered by Doctors Ram Chuttani and Doug Pleskow and others, in which they present two days' worth of endoscopies in real time. This kind of course is extremely valuable to doctors and nurses.

But broadcasting live to the public raises ethical concerns, particularly if and when things go wrong. Read these excerpts as to how MUH handles things and see if you share Mr. Morreim's view.

Mr. Ferris said: “One concern is what happens if something goes wrong — you’re making this public in a very real-time way. Our general plan is we would gently take a break from the twittering if the situation became very dire. You don’t necessarily want to be tweeting that somebody might be dying on the table, and God forbid the patient’s family learns about it that way.”

Methodist Hospital records an identical surgery on another patient, so if “something unforeseen happens and you need the camera to cut away from the surgery, you can fall back on your previous surgery,” Ms. Fazakerly said.

E. Haavi Morreim, an ethicist at the University of Tennessee College of Medicine, said “If you don’t show the bad along with the good, people can end up misinformed or with excessively optimistic expectations.”

Happy Memorial Day weekend

(Back next week.)

Caller-Outer of the Month Award #5

Our Board of Directors yesterday presented this month's Caller-Outer of the Month Award to Susan Adams and Lora Morgan, whose near-miss call-out I have previously described. Susan was the ICU nurse mentioned in that story, and Lora was the clinical pharmacist. Please recall that this award is presented by the Board to reinforce the underlying concept of BIDMC SPIRIT -- that each person should be encouraged to call out problems in the workplace and be recognized and appreciated for his or her contribution to safety, quality, efficiency, and a better work environment.

Following #charitytuesday

A feature of Twitter is the hashmark listing, which makes it easy for viewers to keep track of certain topics.

Yesterday (Tuesday!) I received this helpful tweet: "Have you heard about #charitytuesday? Maybe it can help increase awareness of #BIDMC on twitter."

Here's an article that describes this more fully, citing this one by John Carnell, which I offer here to be helpful to other non-profits who might either be on Twitter already or might be wondering why it would be useful to be on it.

Gemba calls again and again

The training sessions for the senior management in Lean philosophy and techniques continue, in an effort to integrate that approach with the ongoing BIDMC SPIRIT program. Each session involves a visit to a front-line process or clinical area. Here you see Suzanne Albright, a recruiter in our human resources department, explaining the steps in recruiting, screening, interviewing, and hiring to Mark Gebhardt, Chief of Orthopaedics.

Above, you also see the group at play, with a simulation of a meeting to discuss process improvement. Each person is labeled with a characteristic -- unknown to him or her -- that causes the other participants to treat him or her in a stereotypical fashion. The lesson is clear within just a few minutes: If you draw assumptions about your colleagues with regard to their ability to participate fully in process improvement, it is a self-fulfilling prophecy. The result is a diminution of the ability of the group and the organization to learn from one another and achieve the best results.

For Tall People, "Now" Is Really The Past

As a teenager, my daughter often accused me of living in this past, and this NPR story by Robert Krulwich suggests she had scientific evidence on her side. Excerpt:

It may be that our sensory perception of the world has to wait for the slowest piece of information to arrive, Eagleman says.

"Given conduction times along limbs, this leads to the bizarre but testable suggestion that tall people may live further in the past than short people."

It also gives me the perfect excuse for never being quite as good as others in soccer:

Because for the taller person it takes a tenth of a second longer for the toe-touch to travel up the foot, the ankle, the calf, the thigh, the backbone to the brain, the brain waits that extra beat to announce a "NOW!" That tall person will live his sensory life on a teeny delay (at least as regards toe-touching). This, of course, could apply to all kinds of lower-extremity experiences — cold or heat against the skin, tickles, rubs, hitting a soccer ball — the list goes on and on.

You suggest, therefore you do

Have you noticed the tendency of people who serve on community-based non-profit boards to say, "Someone should do something about this," and then wait for someone else to do it?

Many years ago, when I was president of our town's soccer club, a volunteer organization, I was inspired at a board meeting to invent a new rule. It went like this: If a member of our Board proposed that we should do something, it became that person's responsibility to get it done. This became codified as "The Levy Rule," and it has been passed down from generation to generation.

Last week, I was refereeing a soccer game, and I saw one of the coaches from another town who serves on the board of the regional soccer organization. He gave me a friendly welcome and then said, "You know, we still follow your rule." "My rule?", I said. "Yes, The Levy Rule, where if you suggest something at a board meeting, you have to do it."

Little did I know that my influence had spread. Anyway, I offer it to you now, for your consideration. It is an excellent way for a community organization with limited resources and volunteers to vet new proposals!

Dave is up in lights!

E-patient Dave gets good coverage in today's Boston Globe.

The whole story about health care IT

Wow, this is really good. (Listen closely for the reference to our CIO, John Halamka.)

Request for personal stories

In Massachusetts, there is legal protection for gay and lesbian people from being fired for reason of their sexual orientation. I was just asked by a respected associate to get involved in supporting Massachusetts legislation that would expand that protection to protect people from being fired for gender identity or gender expression. She notes, currently, "a person can be fired because they are transgendered (identity) or because they do not express their gender in a way that is pleasing to their employer (gender expression). " The bill would also expand the definition of hate crime to include if a person is physically attacked, beaten or killed because they are transgendered.

I have been strongly supportive of civil rights in the arena of GLBT rights, but it is a sign of my ignorance that I was not aware of this particular problem or how widespread it might be. As I evaluate how involved I want to get in this issue (yes, like others, CEOs have to decide where to put their political efforts among lots of worthwhile causes), it would be helpful to me if readers out there would submit stories of any experiences they might have had in Massachusetts that suggest how necessary this law is.

4 simple questions

As the Administration and some in Congress push forward on ways to make it easier for unions to organize health care workers, and as the President seeks reforms because of a compelling need to control costs and improve the quality of health care, shouldn't reporters or others ask the following questions -- to draw a connection between the two issues?

Is there independent evidence to suggest that in hospitals in which the SEIU or other unions are represented:

1) Care is delivered with greater quality and less harm to patients than in comparable non-union hospitals?
2) Care is delivered at lower cost than in comparable non-union hospitals?
3) Patient satisfaction is better than in comparable non-union hospitals?
4) Worker satisfaction and morale is better than in comparable non-union hospitals?

Parent Connection reaches 10 years

Ten years ago, some folks in our Obstetrics Department had the idea of creating a group of experienced mothers who could be mentors to new mothers. With some encouragement and support from the Jewish Family and Children's Service, the Parent Connection was born.

Over the next ten years, over 300 volunteers were trained to be mentoring moms as part of the only hospital-based program of its kind in the Boston area. The program pairs veteran mothers with first-timers who give birth at BIDMC for weekly telephone support and advice during the baby's first three months of life. In addition the program has five support groups for any mothers (not just BIDMC patients) who cover a variety of typical infant care issues to surviving as a working parent to raising kids in a gay or lesbian household. The gay and lesbian group meets in Jamaica Plain, the working mothers group meets in Dedham, and the general support groups meet in Lexington, Needham, and Chestnut Hill.

Congratulations to all who have been involved in this lovely program.

Tale of two tales

Thanks to A Letter a Week for posting a really nice story of a great experience in our Labor and Delivery unit.

What a great irony that this post also contained a Google ad from the SEIU for "Eye on BI: High Costs, Patient Problems -- What does Beth Israel have to hide?" SEIU buys these ads to show up when BIDMC is a topic of a search or a website.

What's the difference between the two items on the same webpage? The parents were moved to write their story because of their actual experience in the hospital. Their only motivation in posting the article was gratitude. For example: "Our experience at Beth Israel was amazing. We would like to thank all of our nurses and doctors for making it that way." SEIU, on the other hand does not participate in patient care here and has another motivation.

Disparities in Transplantation

In previous posts, I have addressed the clinical benefits that come if organ transplantation programs are of sufficient size. There are also knowledge benefits that accrue to society when programs are large enough to support research. Here's an example, a recent article investigating the sources of racially-correlated treatment disparities in this field -- a serious and important public policy issue.

The article, in the American Journal of Transplantation, is entitled "Framing Disparities Along the Continuum of Care from Chronic Kidney Disease to Transplantation: Barriers and Interventions." It was prepared by Keren Ladin, James Rodrigue, and Douglas Hanto, from our Center for Transplant Outcomes and Quality Improvement and Harvard's Department of Health Policy. I'm sorry that only the abstract is available without a subscription. I've copied a portion of the article above to give you a feeling for it. Here is the abstract:

Research in renal transplantation continues to document scores of disparities affecting vulnerable populations at various stages along the transplantation process. Given that both biological and environmental determinants contribute significantly to variation, identifying factors underlying an unfairly biased distribution of the disease burden is crucial. Confounded definitions and gaps in understanding causal pathways impede effectiveness of interventions aimed at alleviating disparities. This article offers an operational definition of disparities in the context of a framework aimed at facilitating interventional research. Utilizing an original framework describing the entire continuum of the transplant process from diagnosis of chronic kidney disease through successful transplant, this article explores the case of racial disparities, illustrating key factors predicting and perpetuating disparities. Though gaps in current research leave us unable to identify which stages of the transplant pathway adversely affect most people, by identifying key risk factors across the continuum of care, this article highlights areas suited for targeted interventions and presents recommendations for improvement and future research.

Nonprofits learning to help themselves

This is Geeta Pradhan, Director of Programs at The Boston Foundation, making a presentation yesterday on the fiscal fitness of and the challenges facing nonprofits in Massachusetts. She summarized a report on this topic -- Passion & Purpose: Raising the Fiscal Fitness Bar for Massachusetts Nonprofits -- produced by the foundation a few months ago.

Yesterday's session built on this report to discuss the topics of restructuring, repositioning, and reinventing the Massachusetts nonprofit sector. TBF President and CEO Paul Grogan reminded a full room that the current economic conditions can be an opportunity to "utilize the utility of trouble." I was honored to serve as a member of a panel to offer perspectives on these matters. Here were the other panelists: Alex Cortez, Manager, The Bridgespan Group; Hubie Jones, Founder and President, The Boston Children’s Chorus; Patrice Keegan, Executive Director, Boston Cares; and Michael Weekes, President and CEO, Massachusetts Council of Human Service Providers.

If there was one dominant theme, it was that nonprofits need to do a better job in rigorously identifying how effective they actually are in delivering the services they were created to provide. Absent that kind of accountability, they will fail to generate sufficient support from a wide constituency.

About Harvard

I don't know the origin of this inside story about Harvard, but I felt I should share it with my loyal readers. (Click to expand and read it more easily.)

BOA sequel, and lessons for here

Dave, the Bank of America Twitter guy, was really helpful on the phone. He not only arranged for a provisional credit of my deposit (remember the three checks that were eaten by the ATM?), but he also explained that the clerk with whom I talked really was obliged under federal electronic banking laws to take my claim -- even though she refused to because I was not able to tell her exactly how much each check was written for. He also confirmed the point I had made with her that there must certainly be a reconciliation by the bank of the checks in the ATM and the total deposits made that day -- and so my three checks would show up in that daily audit. And, since the checks have my name and address on them, tracking them back to me shouldn't be that hard.

While I was walking in NYC today, (see post below) I was relating all of this while phoning my friend Lisa in Boston. Further, I mentioned that I was lucky to have had cash in my wallet for my day trip to the City, because the new debit card was going to take five days to arrive. "Oh," she said, "They didn't tell you that they could produce a new one immediately for you if you had gone to a teller at the bank?" Er, no, in fact, the first clerk I talked to made no mention of that option.

Dear readers, I report all this to you not to cast aspersions on this bank or the people working there. I understand, from my own organization, that the provision of consistently high service quality can be difficult. But the problem I encountered at the bank is not unique or even unusual. Both people with whom I talked had a clear view of all of my account information and could see that my account was in good order and that I was a long-term customer of the bank. Both were also extremely pleasant and polite. But neither one helped me to the extent they might have, and, in fact, both led me astray and left me dissatisfied with the experience -- even to the point of wondering whether I should switch my banking to one of those local community banks where they promise to know you personally.

But the main reason I am writing this is to provide a reminder to our staff here at the hospital and to those of you in other places like ours. When a patient presents you with a problem or concern, "Tag, you're it!" Listen closely, and then do what it takes to satisfy that person's issues or complaint. Each of us is an ambassador for our institution. It can take only one bad experience to sour a person's view of the place, even after years of positive treatment.

Elvis, too?

Seen today in midtown Manhattan on a movie set trailer.

Returning to Gemba

You may recall that I discussed the Lean training program being taken by our senior management group. A second session was held this week, and we returned as a group to Gemba, the place where work happens, where value is created for consumers. Today's visit was to the pharmacy. SVP Jayne Sheehan, seen above in her "bunny suit", and I observed how things are done in the clean room.

We watched Rena Lithotomes (left), a trainee, and Rosmara Harvey (right), a pharmacist, as they carried out the incredibly precise and important work of preparing dosages of a wide variety of drugs used in clinical settings.

Later in the classroom setting, we compared notes to refine our observational skills and ability to see opportunities for reductions of muda, mura, and muri in our work areas. These concepts have often been used in other industries, but not so much yet in the health care industry. Probably the best example is Virginia Mason Medical Center in Seattle, where CEO Gary Kaplan has made this the hallmark of his administration for several years. We are earlier on the path to adoption of this philosophy in our hospital, merging it into our BIDMC SPIRIT program in a more systematic way over the coming months.

Recognizing Nurses

We held our annual Nursing Awards ceremony, hosted by the Red Sox at Fenway Park. This is part of our celebration of National Nurses Week. We award over $100,000 in scholarships, but we also recognize people for outstanding performance.

Lots of folks showed up, including Sox VP Sam Kennedy and Wally the Green Monster (the Red Sox mascot), seen here with nursing supervisor Phyllis West. Healthy food is offered, especially Fenway Franks!

Many of our clinical chiefs of service attend, too: Here you see our new chief of Anesthesia, Brett Simon, standing to the right of Alan Lisbon, a member of his faculty who served as interim chief during the HMS search process. Nurses from the PACU are regular attendees, including two Mary's here flanking Dr. Eswar Sundar, another of Brett's faculty members.

The event's main organizer is Laurie Bloom, seen with COO Eric Buehrens. Donors show up, too. Al Tanger, seen with son Woody, sponsors a scholarship with his wife Brenda in honor of Maggie Fermental, a beloved young nurse who suffered a serious stroke a few years ago. Maggie, seen seated and smiling broadly, now runs support sessions for stroke victims and their families.

More from BoA: Who was that masked man?

A lone ranger at Bank of America responded to my post yesterday. He wrote me on Twitter, saying: I work for Bank of America, please send me a DM with your contact information so I can call you to help. Thank you.

Who is this stranger called @BofA_help? He claims to be David Knapp, from Phoenix. The "Future Banking Blog" tells us more here.

David's home page says: Official BofA Twitter rep to help, listen, and learn from our customers. To ensure your privacy, never share account information in unsecured locations.

I appreciated the contact from David and didn't want to discourage him, but I felt it necessary to reply (as I was concerned about security issues): If you really work for the Bank you already have my contact information.

Let's see what the next chapter is. David, you can reply here with a direct line phone number. I won't post that comment.

Service Awards

We held an event to congratulate the BIDMC staff members and doctors who were celebrating their 20th, 25th, 30th, 35th, and 40th anniversaries at the hospital.

Here are are some pictures of those honored. From the top: Sherry Lee (25 years); Elaine Sweeney (30) and Clarisa Joseph (20); David Feinstein (20) and Frank McCaffrey (20); Kenute Reid (20), Marcia Bennett (20), and Debra Bennett (20); Jonathan Critchlow (30); and Susan Dorion (35). And here's a short video of 40-year veteran Emily Carmen giving an enthusiastic thank-you.

Bank of America = Catch-22

How I spent my lunch hour.

Dear Bank of America,

Your bank has invented a Catch-22 that even John Yossarian would find amusing. I deposited 3 checks totaling about $200 in the ATM at your Newton Centre office on Sunday evening. Halfway through the deposit, the machine went dark, keeping my debit card and the three checks.

Upon calling the bank, I was told to hold on for the claims department, to make sure I got credit for the deposit. After I gave the date and time and location of the deposit, the person asked how much each check was for. I said I didn't know, but that the total deposit was about $200. I offered to tell her who had made out the checks, and also pointed out that each of them had my name and address on them. She said, "I can't file a claim without the specific amount of each check."

I said, "I don't have the checks. Your machine ate them." She said, "I can't file a claim without the specific amount of each check. Can you tell me exactly what the total deposit was?"

I said, "Your new automatic deposit mechanism for checks no longer requires an envelope, so I don't have an exact total, and I no longer have the checks." She said, "I can't file a claim without the specific amount of each check."

"Perhaps you should contact the makers of the checks. They can give you an amount, and then you can call back. If you do, it can take 45 days for a claim to be processed. Maybe you can have new checks made out more quickly."

Right . . . .

Special note to Harvard students

With the arrival of beautiful weather, there are lots of Harvard (HMS and HSPH) students riding their bikes in the Longwood area. Many do not follow traffic rules, and many do not have helmets.

Dear Students:

Today's quiz: What do we call a Harvard student who rides a bicycle in the wrong lane without a helmet?

Answer: An organ donor.

I thought it was still spanning the East River

The Boston Globe reports:

Healthcare industry to offer cuts of $2 trillion: Pledge boost goal of system overhaul

WASHINGTON - Volunteering to "do our part" to tackle runaway health costs, leading groups in the healthcare industry have offered to squeeze $2 trillion in savings from projected increases over the next decade, White House officials said yesterday. . . . Representatives from half a dozen health industry trade groups are scheduled to make a formal offer today in a White House meeting with President Obama. . . . The trade groups making the pledge represent a broad spectrum of healthcare interests, including the American Medical Association, the Pharmaceutical Research and Manufacturers of America, America's Health Insurance Plans, and the Service Employees International Union. . . . The groups will have to streamline administrative costs, better coordinate care and bundle payments to achieve the projected savings.

What, the Brooklyn Bridge isn't available for sale anymore?

Gotta love the last line in particular. See discussion below on these very points. We can continue to try to portray health care reform as lowering costs, providing greater access, and maintaining consumer choice, but there is no evidence that all three are possible.

The joys of coaching soccer

I currently coach a group of 11- and 12-year old girls. At practice this weekend, I introduced the concept of thinking about what you plan to do with the ball before it arrives at your feet. It is difficult, in neurological terms, to make that decision once the ball has already arrived, so the idea is to think ahead.

Shortly after this, Margaret one-touched a ball into no-man's land, nowhere near any of her teammates. I said, "You weren't thinking in advance." She replied, "Yes, I was thinking. I just hadn't reached a conclusion."

Cognitive Bias

My friend Phil Shapiro, CFO of Babson College, led me to this website. It lists the common forms of cognitive bias.

Each time I look at it, I see another that is prevalent in hospitals. Confirmation bias is certainly one that is found in clinical decision making, as noted by Jerry Groopman. Status quo bias occurs in every walk of life. I bet that CFOs like Phil often are faced with reminding people about sunk cost bias. I particularly like the concept of survivorship bias, forgetting to include firms that no longer exist in research reports when strategic planning takes place!

In the body politic, the bandwagon effect is well known....

Move to the side of the road

A Friday diversion from work: As the weather improves and exercise beckons this weekend, fellow bikers might appreciate this situation.

Temporary Art along the Muddy River

A nice surprise yesterday as I walked from the T to the hospital, an art exhibit called "Nature and Artifice: Temporary Art along the Muddy River." It is presented by Studios Without Walls and hosted by the Brookline Parks and Recreation Department. The idea is to "draw attention to the beauty of this locale and the much needed Muddy River Restoration Project of the Emerald Necklace Conservancy."

Here are some pictures of works by Phyllis Ewen, Muriel Angelil, and Joe Fix that I nabbed with my cellphone as I wandered to work. The exhibit will be in place until June 28. On that day, there will be a closing celebration featuring the Joel Press Combo at 3pm, near the Carleton Street Bridge.

Concert in aid of kids with cancer

Mohan Sundararaj, a graduate student at Harvard, sent me this announcement:

FUNDRAISER CONCERT IN AID OF KIDS WITH CANCER
AT THE HARVARD SCHOOL OF PUBLIC HEALTH
featuring 37 musicians in 24 eclectic performances
in an Open Bar Event at the Kresge Cafeteria
Friday, May 8th 6:30pm

We (Musicians@HSPH) are pleased to announce that "Rhythm Therapy II - Return from the Deep" will be organized at the Harvard School of Public Health as a concert fundraiser for kids with cancer.

Featuring student and community musicians from Harvard and area schools in an eclectic array of genres including electronic, opera, choral, pop and many more.

As told by a Harvard Kennedy School student who attended our event in November:

"...had a great time last night. What a great range of music as well as talented people playing it! Not sure if there has ever been a transition from Chopin to people getting down on the dance floor before in the history of music :-)"

Tickets are $20 with valid Student ID, $30 all others. All alcoholic and non-alcoholic beverages and snacks are complimentary. Click here to order tickets online. Or contact Sarah Aroner: saroner [at] hsph [dot] harvard [dot] edu.

Provider payment considerations

An article in today's Boston Globe about a state commission reviewing changes in the way doctors and hospitals are paid for delivery of care (from fee-for-service to a global payment) has prompted a huge number of comments on the newspaper's website. Here's mine:

Assuming this is the right thing to do, it would represent a shift in actuarial risk from insurance companies, which maintain cash reserves for such things, to doctors and hospitals, which do not. Does the Commission propose to make a change in accounting rules for insurance companies, so that their required revenues -- from the people and companies who pay for insurance -- are reduced to compensate for this shift?

Also, does the Commission have proposals to change the design of insurance products so that consumers know in advance that their choices might be diminished -- that they will be encouraged or directed to be cared for by physicians and hospitals within the orbit of the provider receiving the "global payment?"

The point is that, if this is the right way to go on payment for health care services, you need also to fix the insurance side of things to garner immediate savings for the public. You also need to let the public know what the new environment will be for their care so doctors and hospitals are not caught in the middle, the way it happened during the last experiment with managed care. If the Commission does half the job in its recommendations and leaves the rest to be fixed in the future, it will leave us will a lot of unintended consequences and will undermine the good that might otherwise come from a new payment scheme.

Beyond this, many of my colleagues at other hospitals have pointed out the importance of including mental health in this picture, if we are to go down this route. In the past, mental health services have often been "carved out", leading to underpayment and relegating these diseases to second class status. Dennis Keefe, CEO of Cambridge Health Alliance, states it elegantly:

The results of these systematic underpayment practices on mental health and substance abuse services is what we are seeing today in the Commonwealth; i.e. a growing and continuing shortage of bed capacity; bed capacity that greatly varies across regions and the State; poor access to these services within communities, particularly for the uninsured/underinsured; all of which results in the continued marginalization of services to this population when compared to individuals having other "medical" needs. This, to me, is particularly ironic, as I have often asked the question to groups and others, "who amongst you does not have a friend, colleague, or family member who has not had to cope with mental illness and/or an addiction"? I have never seen a hand go up......

Because it can

There are sightings of a new mobile billboard hired by SEIU to burn fuel through the neighborhoods of Boston. Add to that the likely rental of bus and trolley stop ads, the ubiquitous internet ads, on top of purchasing full paid ads in the local newspapers. I am sometimes asked, "Why does the SEIU do this?"

As you all know by now, the ads have nothing to do with organizing workers. They are meant to denigrate the reputation of the hospital as part of a corporate campaign. Even if any of the accusations made in the ads were to be accurate, why would the existence of problems at BIDMC be an argument for unionization? By that logic, what would one conclude from certain types of problems at the SEIU?

SEIU believes that spending hundreds of thousands of dollars in a periodically renewed ad campaign is effective. It has an endless source of funding for these ads from the dues it collects every week. In this environment, keep in mind which is David, and which is Goliath.

So, the answer to the question asked above -- "Why does the SEIU do this?"-- seems mainly to be the punch line to the old joke, "Because it can."

Looking up

Steve Cannistra is one of our fabulous oncologists. In addition, he is a very accomplished astrophotographer. Look at this sample of his work.

Halamka unwired, er, untagged?

Michael Millenson reports on second thoughts from our CIO, John Halamka, about implantable chips for patient medical information. John is quoted as saying, "The implanted RFID chip is not as a society where we’re going.” There always was that problem, too, about being designated as a garden hose when he would walk out of Home Depot!

Bravo to John for always pushing the envelope and for his honesty about the efficacy of attempted innovations in the IS arena.

Calling out the near miss

A story posted by Margaret Bernier, in our Health Care Quality Department, to provide lessons learned from our BIDMC SPIRIT program [Addendum on May 7: Margaret graciously tells me that the article was actually prepared by Pat Folcarelli and Andrew Zaglin]:

On a busy shift in one of our ICU’s, a Staff Nurse was tending to a patient who had an order for 2 grams Magnesium Sulfate. The Nurse accessed the automated medication dispensing system to retrieve the medication, housed in its own specific bin. Immediately, the nurse sensed that the medication bag containing the drug was slightly heavier than usual, but on first glance the color and look of the label was exactly what she was used to seeing for 2 grams Magnesium.In conducting the essential steps of medication administration at that time (right medication, right dose, right time, right route, right patient), she discovered that the medication was labeled as 4 grams Magnesium and not 2 grams.

The Nurse immediately reported this to the Clinical Pharmacist and her Nurse Manager. The Pharmacy immediately investigated this concern, and made a complete sweep of the location of Magnesium Sulfate in the Medical Center. The Pharmacy located 23 of the 24 received bags of the drug, and that the 24th was the one from the ICU that potentially could have been given to the patient in error. The Pharmacy ultimately discovered that when the shipment of this drug was originally received, the bar code for the Wholesaler’s information was scanned from the box containing the drugs, but not that for the Manufacturer (both are on the shipments). The Wholesaler’s bar code was incorrect, listing the shipment as Magnesium Sulfate 2 grams, when indeed it was 4 grams. The Manufacturer’s bar code had the drug listed as the correct 4 grams. If the two bar codes had been scanned at the time of initial inventory, the discrepancy between the information on the two bar codes would have led this potentially impacting error to being discovered at the time of delivery, before the inaccurate drug made its way to our medication dispensing system.

A key to help understand how the error was missed is that the Pharmacy stopped carrying Magnesium 4gm bags quite awhile ago because of the concern that this type of error might occur. Instead, BIDMC orders several cases of Magnesium 2gm bags at a time. In this case, our wholesaler made a mistake when they filled our order and shipped one case of the wrong strength product along with several cases of the correct strength. The Pharmacy immediately changed their practice, and now both the Wholesaler’s and the Manufacturer’s bar code information are scanned together when received and inventoried by the department.

Lessons Learned

One essential lesson is simply this: when it comes to medication administration, the machine is not always right! Our automated medication dispensing machines are now organized so that they point clinicians to a single bin or cube where they should expect to find the medication as suggested by the computerized screen. Since the right medication is in the right place the majority of the time, we become less likely to check that what we remove is what we intended. Safe medication administration is still dependent on looking at the label on the actual dose.

Another essential lesson is that the near miss call–out is essential! Thanks to this call-out we were able to prevent the wrong dose of Magnesium Sulfate from getting to our other patients. The Nurse also took the important step of reporting this safety breach in our safety reporting system so that the event could be captured to help with trending of these types of issues.

In addition, our Pharmacy was able to rigorously look at their current practices to make an essential process improvement so the same type of situation and potential error does not happen again.

Sustaining health care reform in MA -- for students

Dan Kennedy was kind to send me notice of the following session by the Rappaport Institute for Greater Boston. This is one of a series called Boston 101, informal discussions about the people, institutions, and customs that make Greater Boston what it is. The series brings in notable figures from a variety of fields. These events are open to all, but are specifically geared towards students in Greater Boston who are just getting to know this great region.

The Challenge of Sustaining Health Care Reform in Massachusetts
Thursday, May 7 from 8:30 a.m. to 11:30 a.m.
Federal Reserve Bank of Boston, 600 Atlantic Avenue, Boston

RSVP TO Polly O'Brien at 617-495-5091 or polly [at] rappaportinstitute [dot] org. THE EVENT IS FREE BUT YOU MUST REGISTER. Government-issued photo ID is required for admittance to the building. Please allow sufficient time to pass through security. A light breakfast will be available at 8 a.m.

Opening Remarks
The State of Healthcare Reform in Massachusetts
Dr. Judy Ann Bigby, MA Secretary of Health and Human Services

Overview Presentation
Can We Use Local Benchmarks to Reduce the Cost and Improve the Quality of Healthcare in Greater Boston?
Katherine Baicker, Professor, Harvard School of Public Health
Amitabh Chandra, Professor, Harvard Kennedy School

Panel Discussions

Can We Implement Opportunities to Improve the Value of Healthcare?
Sarah Iselin, Commissioner, MA Division of Health Care Finance and Policy
Stephanie Lovell, VP and General Counsel, Boston Medical Center
Delia Vetter, Sr. Director of Benefits, EMC Corp.

Moderated by David Cutler, Acting Director of the Harvard Program for Health Systems Improvement and Otto Eckstein of Professor of Applied Economics

Can We Build Support for Opportunities to Improve the Value of Healthcare?

Jarrett Barrios, President, Blue Cross/Blue Shield Foundation
Jon Kingsdale, Executive Director, Commonwealth Connector
Amy Slemmer, Executive Director, Health Care for All

Moderated by David Ellwood, Dean, Harvard Kennedy School

Closing Remarks
David Ellwood, Dean, Harvard Kennedy School

Prostate Health Information

A note from Dr. Marc Garnick:
I am very pleased to announce the launch of a brand new Harvard Medical School website for issues dealing with prostate diseases and prostate cancer. Through the generosity of several philanthropic families, we are able to make this site available completely free of charge to anyone who has internet access. I would urge you to both use it and pass the link on to those who may need information related to prostate health.

Another approach?

Here's a proposal for a different approach to a political issue currently facing the Commonwealth of Massachusetts, one that would enhance the stature of the Governor and would also achieve the result most people think is correct.

The issue is this, as outlined in a Boston Globe editorial today.

The absurd state law that allows legislators turned out of their jobs by the voters to collect enhanced pensions is bad enough. Now Globe reporter Sean Murphy has found that 10 former state lawmakers were able to snare early pensions without having lost election, thanks to favorable arrangements with the state Retirement Board. The 1950 law allows enhanced pensions for legislators if they lose an election or fail to qualify for the ballot. But the 10 legislators in the Globe report who got retirement benefits - most when they were in their 40s - left their seats voluntarily.

Imagine the following. Each of those 10 former legislators receives the following call from the Governor's office: "I'm calling to let you know that at 3pm this afternoon, Governor Patrick is going to call on you and the other nine former legislators to voluntarily relinquish this pension benefit. He would be honored to have you stand by him during this press conference to announce that you have agreed to do so -- to give you a chance to receive credit for a selfless act that sends a signal to the people of the state that former public officials realize that this kind of benefit undermines public confidence and current efforts to balance the state budget and retain important services."

The second part of the conversation, to be held in reserve pending the reaction to this request, would be the following:

"I'm sorry to hear that you feel this way. The Governor want me to let you know that, in that case, we will display a picture of you with the amount of payments you will receive in your lifetime both at this press conference and in every public appearance the Governor makes and on his websites, where hundreds of thousands of people will see this until the situation is legally reversed. He would prefer not to do that because he appreciates your years of public service, but there is something more important at stake here."

Now, perhaps those ten people wouldn't care about this, but I am guessing that their reputation in their community matters to them. Maybe that would help them to do the right thing.

Whether they did or did not, it would give the Governor additional moral authority to pursue appropriate legal action to undo this benefit and achieve other reforms. It would set him apart in the public eye and help in pending budgetary and pension fund matters.

(By the way, imagine if President Obama had done a similar thing with the AIG bonus holders. I bet 90% of them would have voluntarily given up their bonus for a chance to stand by the President and receive the approbation of the entire country. And it would have likewise enhanced his moral authority.)

They're baaaack!

Now that the SEIU appears to have failed in its attempt to secure passage of federal legislation to eliminate secret ballot elections, the union has come back to its local activities. This morning's Boston Globe and Boston Herald both contained full-page advertisements saying negative things about our hospital.

Regular readers will remember that this is part of a corporate campaign. Recall that the purpose is not actually to organize workers, who tend to be offended by the ads. For example, one nurse wrote me today: "I was appalled to see a full page SEIU ad in the Boston Globe this morning against BIDMC! What kind of smear campaign is this?" No, the purpose is to denigrate the reputation of the hospital, its lay leaders, and its management in the hope of creating public pressure to provide concessions that would make it easier for the union to organize workers here.

Readers of this blog will also know that I have a great concern about the future viability of the Globe, so I am pleased that the paper has received this ad revenue, which is in the range of $30,000 to $40,000 for the one-day run. The good news for our colleagues at the newspaper is that they can expect more ads like this from the SEIU. The ads will tend to focus on areas where the union hopes to create a sense of vulnerability for the hospital.

Bittersweet good-bye's

We recently offered an early retirement program to our staff, and the time has now come to say good-bye to many long-standing and loyal employees of the hospital. This has lead to series of small receptions in various locations. Pictured here are three people from our food service group: Mary Hayles, Bill Rochelle, and Andre Casimir. As you might expect, their colleagues provided a delicious cake for the occasion! Also seen is Ginny Ferrenberg, a 30+ year veteran of our emergency department.

Harvard vs MIT: Who has the better sense of humor?

Check this out. I am an MIT alum working at a Harvard hospital. Now I know why I don't fit it.

In Memoriam: Marsom Pratt

I first met Marsom Pratt in 1974. I was 24 and working in the state energy office and was assigned to be the staff person for a gubernatorial blue ribbon panel, the Public Power Corporation Study Commission. It was created by Governor Frank Sargent and kept going by his successor, Michael Dukakis, to evaluate whether Massachusetts should take establish a public authority to take over the power generating functions of the privately owned electric utilities.

This was done in response to a move by Congressman Michael Harrington to put the question before the public as a referendum. The question was ultimately defeated, in part because of compromise legislation enacted by the Legislature to enhance the authority of the MA Municipal Wholesale Electric Company to enable municipal light departments to build and finance their own power plants. That Governor's Study Commission report provided the rationale for this approach, versus the broader state takeover of the private utilities' power generating functions. (By the way, for the record, one of the members of the Commission was Stephen Breyer, later to become an Associate Justice on the US Supreme Court.)

For a young person right out of college, Marsom was good company and a good mentor. Plus, he was just the right commission chairperson for someone on a small salary: He would often take me out to Maison Robert, a fancy place located in Boston's Old City Hall, for a working lunch. His office on Court Street was just a few steps down from MR, and we would inevitably find ourselves walking over. He was a regular: "Good afternoon, Mr. Pratt," would say the maitre d'. I become one, too, learning to ask for the items that I liked that were not on the menu that day. And then, there was the famous upside-down apple tart served with fresh whipped cream. Heady experience for someone who usually brought in a peanut butter sandwich for lunch!

His wife's comment in the obituary is exactly on target: He was "unconventional, but he didn't directly defy convention." He was superb on public finance, and a gentleman who held our study commission together, notwithstanding strong advocates within that group. I had occasion to see him a few times recently when he was a patient in our hospital. A kind and gentle person who will be missed.

Sidi Goma -- The Black Sidis of Gujarat

Just back from a great performance of Sidi Goma -- The Black Sidis of Gujarat, at the Somerville Theatre. From the program notes we learn that this is a tribal Sufi community of East African origin which went to India eight centuries ago and made Gujurat their home. "They carried with them their exceptionally rich musical tradition and kept it alive and flourishing through the generations, unknown to the rest of the world. Their native African music styles, melodic and rhythmic structures, lyrics and musical instruments have mingled with local influences to form this unique symbolic representation of African-Indian identity."

The program had two sections, the first being an overview of ritual calls to prayer. The second half was a staged ritual performance of a damal. "While the music gets more rapid and excited, the dances unfold with constantly evolving solo and group acts of satirical imitations of animals and other creature, culminating in a coconut-breaking feat." You can see that excerpt below (and a longer one on my Facebook page.)

The performance was offered by World Music/CRASHart, whose Executive Director is Maure Aronson, seen here with his son Jesse.