Grateful Nation coming events

A number of grateful patients and families (some seen above) have organized fund-raising events for our hospital. Biking, walking, golf, or tennis: You can find them here. Please join us.

And for those who eschew exercise and just like to shop, here's another one on August 11 at 6pm in Copley Place: David Yurman, America’s renowned fine jewelry and timepiece designer, will host an exclusive shopping event previewing the latest David Yurman collections. A portion of the evening’s proceeds will benefit the Sarcoma Tumor Bank at BIDMC, under the direction of Mark Gebhart, MD.

Presidential swap shop

A pet peeve of mine is how the inventory of office supplies continues to grow in an organization. I have seen this everywhere I have worked and in many places I have visited. I'm talking basic stuff -- paper clips, alligator clips, three-ring binders, pads of paper, pens, and pencils.

And, even though there is a ton of stuff in the building, office managers continue to order more of it.

In a previous place I worked, I put out an order saying that we would no longer permit purchases of paper clips. Guess what? We never ran out. They just kept getting recycled when documents would be sent from one office to the next.

We plan to have a general office supply swap for the hospital soon, but I thought I'd run an experiment in the meantime. It is based on my community experience running a soccer cleat exchange. I created the "Presidential swap shop" in the corridor near my office, which is within eyesight of a highly trafficked thoroughfare. The sign says, "Take what you need, leave what you don't." Already, within a couple of days, there has been a dramatic amount of trading activity.

Those neat red boxes are the containers in which pipette tips arrive at the labs. We use thousands per year. They are perfect storage boxes for all kinds of stuff here and at home. They are flying off the shelf of the swap shop.

You can't see the paper clips and alligator clips, but they are also moving well, as are the three-ring binders. Meanwhile books are coming and going like a lending library.

I hear reports that other swap shops are popping up around the hospital. Maybe it's a movement.

You call this a photo-op, Mr. President?

Hello? Who is doing PR for President Obama? Why would you put this picture -- the President trying out a surgical robot -- on the White House web site?

Look at this post on medGadget for commentary.

So, Mr. Obama provides free nationwide marketing for this device, a machine that is totally counter to what he is trying to accomplish with health reform.

The people at Intuitive Surgical must be gloating today. You can't buy this kind of publicity.

Maybe, next he should be seen piloting an F-22 (photo credit embedded).

Taking care of one of our own

A note from an administrative staff member who became a patient, reprinted with permission:

I wanted to personally send you an email, not send in the BIDMC Patient Survey, regarding my medical care at BIDMC over the last year. (This is my first week back from my one year medical LOA).

July 9th, 2008, after my PCP received blood work results back on me, it was suggested that I go to “a Boston hospital” to have my blood work rechecked. My numbers looked funny. Where else would I go but to BIDMC, where I worked. I drove in myself, went to the ED, where before you know it I was in an isolation room. Little did I know just how sick I really was. I wished I had a family member or friend with me. I never expected the news I was about to hear. A nurse came in (I wish I knew her name but I don’t) and sat with me. I said “I’m really sick aren’t I?” She said “Yes, you are”. I asked if I had leukemia and she said she really didn’t know but oncology doctors would be in to see me soon. The personal treatment that I received from the ED was exceptional. The staff was wonderful and truly caring.

That evening I was shipped up to 7 Feldberg where I spent the next 5 weeks, diagnosed with APML, leukemia. I believe it takes a special person, doctor or nurse, to be a caregiver to a very ill person. There were days that I wasn’t sure I was ever going home, but the staff never let that thought stay in mind for very long. I can’t say enough about “my family” on 7 Feldberg. They made it a point to get to know me and my family personally. Although everyday I hoped and prayed that I would be going home, I couldn’t have been in a better place. The folks on 7 Feldberg have my praise!

I started my outpatient treatment right away. Off to Shapiro 7 I went 5 days a week for 5 weeks. I had a 2 week break and then back in for another round. My good days were really good; my bad days were really bad. But I always went home comfortable physically and psychologically. I really don’t want to point out anyone, any department over another, but I have to in my case. The staff (medical and administrative) on the Hematology/BMT floor is great. It’s scary knowing that you have cancer, but when you walk into the front desk area you are greeted with such compassion, almost forgetting the reason why you are there in the first place. Once again, very special people.

My BMT nurse has been with me through thick and thin. My Oncologist is phenomenal. I have a great NP who was actually one of my nurses on 7 Feldberg. I sent them an email last week on my anniversary date and thanked them for all they do for me. I told them that I appreciate them allowing me to consider them my extended family. I had a standing weekly blood draw at 8am every Monday and saw my NP and doctor shortly after. Since coming back to work, that does not fit into my schedule, so I had to ask them what they could do to help me out. Again they have gone above and beyond. I take the shuttle from my office on my lunch hour once a week. My nurse will fit me in whether I’m 15 minutes early or 15 minutes late, basically making her schedule around mine. The next day I see my NP and doctor after their last appointment. I still can’t believe that they have done everything possible to make my transition back to work a smooth one. I’m here for my staff when I need to be, and they are going out of their way to see me, working around my schedule. Where else would I find that level of service?

In closing, during my inpatient stays and my outpatient appointments, there wasn’t a day that I thought I was in the wrong place. From Food Services, Housekeeping, Social Work, Patient Transport, Patient Accounts, CTscan, MRI . . . I could go on and on but I'd be afraid I would forget someone. What was a tough experience for me was made much easier by all the staff we have here. I’m in remission now, and I’m sure that with the exceptional treatment I receive I will remain that way for a very long time.

Thank you from a very satisfied patient!

BID~Needham construction progress

Speaking of videos, click here to watch an update of the construction project at BID~Needham hospital. This video shows you the outside of the new emergency department and walks you through the new inpatient unit. The grand opening is planned for this fall.

The latest on pumps

I've been meaning to post this for a while, as an update to the effort to solve our problem with distribution and maintenance of pumps. Here's the latest video describing what was done. In discussions with the nurses, I am told that this has made a real difference in their day-to-day lives.

American Adipose Act

And now for something a little less serious . . . or maybe it is serious. You choose:

Many observers of national politics worry about the establishment of new entitlement programs and the lack of fiscal discipline that can accompany them. That may account for a lot of the current discourse about the President's proposed public insurance plan.

A colleague has come up with a scenario that would help ensure that the number of people subscribing to a public plan would be kept to a minimum -- and would be consistent with other societal health and well-being goals.

The idea would be to create the American Adipose Plan ("AAP"), the public insurance plan. Only citizens with a body mass index above a certain number would be eligible for insurance from AAP. Because overweight people tend to have more difficult and expensive health care needs, and would therefore draw more public subsidies, Congress would have an incentive to try to minimize the number of people in this plan. Thus, goes the theory, they would be less likely to fund certain programs that undermine public health by promoting obesity. For example, subsidies for corn and sugar, two of the major federal programs that have contributed to excessive calories in fast food and school lunches, would be seen as less desirable by Congress. A positive feedback loop could result, saving money in both arenas, while contributing to the entire nation's health.

Perhaps, too, the government's Food Pyramid would be revised to reflect the actual nutritional value of food groups, as opposed to the financial clout of various sectors of the food industry.

In the best of Washington traditions, lobbyists who wish to advocate for this plan are free to do so.

Re-making up is hard to do

This article by Kevin Sack in the New York Times provides an excellent description of person-on-the-street reactions that explain why change in health care is hard to do. Note, this is not ideological stuff. It is just normal people's reactions.

The President tried hard from the outset to sell the proposition of providing access, controlling costs, and enabling consumer choice. He decided he had to stay away from terms like rationing and general tax increases. But people understand that you can't give everything to everybody without taking something away from somebody or asking for general sacrifices. As the debate over health care reform continues after the summer, it will be interesting to see how the various plans are modified and explained.

Some people have asked what I would do if I had the magic wand. Here's the simplified list of my major recommendations. My goals would be: Providing access and security to people; covering the costs of that access in a broad-based manner consistent with a national priority; limiting the expansion of uneconomic new technologies; and shifting the payment regime to the part of the health care system best able to control costs in the long run. I have tried to pick ideas that are properly jurisdictional at the national level, only preempting state jurisdiction where necessary for the sake of uniformity.

1) Eliminate the nasty practices of insurance companies by requiring them to take all applicants, eliminating pre-existing condition restrictions, and the like. In essence, provide a preemptive overlay of national regulation of health care insurers above state regulation. This would provide assurance to people that, when they changed insurance providers, they could maintain coverage. Do not create a public insurance plan.

2) Provide subsidies to people, based on income, to enable them to purchase insurance. Under the national regulatory scheme mentioned above, require a spectrum of insurance packages so people could have choice of several levels of coverage, from basic to advanced. Require people to enroll in one. (These provisions are the core of the Massachusetts access model.)

3) Pay for the subsidies by eliminating the current pretax treatment of insurance benefits and applying new taxes in areas that would, themselves, contribute to a healthier population (cigarettes, sugar content, and the like).

4) Create a national standards board that would review new medical diagnostics and therapies and equipment for cost-effectiveness, to supplement the efficacy determinations made by the FDA. Do not prohibit non-cost effective remedies, but make them ineligible for insurance coverage.

5) Revamp the payment system to shift emphasis to primary care providers so that they no longer serve in a mere triage function, but in fact have the time to properly manage a patient's care. Whether this is done by shifting payments within the fee-for-service environment, or moving to capitation, or a combination, would be subject to regulation by each state for the private insurers. For Medicare, the determination would have to be for the country as a whole.

I am not wise enough to judge the political acceptability of this package in Congress, but friends I have talked with so far have indicated that they like the themes. I'm happy to get your comments.

Son of spam

For the last few weeks, I have been taking the time to unsubscribe myself from the dozens of computer generated messages that clog up my email. These are sent by organizations and companies that could be relevant -- as opposed to the truly junky or obscene kind of spam that our IS department automatically filters out. But most are not of interest, and so I am doing an experiment to see if I can reduce their number.

Here's one I tried to kill. My alumni email account at MIT has a feature that sends an automatic update every day (see above) with a list of incoming emails that have been put in a spam quarantine holding folder on MIT's server. I have no need to get this daily email update, so I clicked on FAQs and found the following:

Q. Is there a way to turn off receipt of the Spam Quarantine Summary email?
A. Unfortunately there is no way to set this at the individual level at this time. A workaround is to set up a filter in your email program that will place the summary emails in your trash or other folder.

Unfortunately, indeed.

In the Congo

Also, worth seeing, but quite different from below. The experiences of some of our doctors and others in the Congo.

"My mother was smiling"

This is a really well done segment from WCVB, Channel 5, regarding end-of-life care. Maureen Bisognano of the Institute for Healthcare Improvement, who appears in the video, is one of the nation's health care quality leaders.

Going full circle

The post below represents a major change in views for me, and it merits further explanation. For years, I regulated the state's utility companies, and I came to learn how regulation often impedes innovation and promotes inefficiency. I was in favor then, and am now, of permitting markets to work where they can deliver a better result for consumers and society.

I arrived in the hospital world eight years ago, and people would sometimes ask me if I thought the current unregulated facility planning and pricing regime in Massachusetts should be replaced by state regulation of hospital capital expansion and rate-setting. I would answer that the inefficiencies of regulation were likely to far outweigh the inequities and inefficiencies of the marketplace.

Having now watched the unregulated hospital system at work in this state, I reach the opposite conclusion. There is little in the Massachusetts health care environment that encourages efficiency, that encourages wise purchasing decisions with regard to expensive plant and equipment, and that enables effective competition. The current marketplace in the state is dominated by a major player on the provider side, which has leveraged its market power to achieve substantially higher reimbursement rates, enabling dramatic expansion of facilities to further expand its market reach, along with major investments in capital equipment. Other providers grub around for the crumbs that are left behind, yet also feel the need to invest heavily in expensive devices and the like to retain market share. Indeed, there is a slow decapitalization of that sector of the industry as it fights a medical arms race while trying to keep up with societal needs. Meanwhile, there is virtually no mechanism that properly encourages improvements in the quality and safety of patient care.

This is a system that is ripe for regulation. It is needed to protect the industry from itself. It is needed to protect the public.

The report of the Payment Reform Commission cited below provides the logical framework for moving in this direction. If we are moving to a system of capitated, or "global," payments and the associated close networks (accountable care organizations) that are needed to manage care, there will be an inevitable concentration of the health care industry in the state. Over time, there are likely to be two, three, or maybe four integrated networks serving the state. Given barriers to entry by other participants, that will not be enough to provide the kind of contestable market that is needed for real competition, especially if one of the networks enters the fray with rates that are much higher than the others.

If I am correct in my assessment of this situation, it is time to consider hospitals and the accountable care organizations of which they will be a part to be more like utilities. Let's reinvigorate an effective system of rate and facility regulation to provide a level playing field among these organizations, to provide a brake on unnecessary capital investments, and to encourage competition based on the right factors. Those systems that do well in the regulated environment will do so because of the quality and value they offer to society, which will be a function of how well they treat their workforce, how efficiently they organize their work, and how safely and effectively they treat patients across the continuum of care.

The next step in payment reform

Much has been made of the recent report of the Massachusetts Special Commission on the Health Care Payment System. This is an interesting and thoughtful report and well worth reading in its entirety. The commission's main conclusion -- a move to a capitated (or "global") form of health care payments -- is based on the following principles:

1. As currently implemented, fee-for-service payment rewards service volume rather than outcomes and efficiency, and therefore other models should be considered.
2. Health care payments should cover the cost of efficiently provided care, support investments in system infrastructure, and ensure timely access to high quality, patient-centered care. Additional payment should reward and promote the delivery of coordinated, patient-centered, high quality health care that aligns with evidence-based guidelines where available, and produces superior outcomes and improved health status. Performance measurement should rely on reliable information and utilize uniform, nationally accepted quality measures.
3. Provider payment systems should balance payments for cognitive, preventive, behavioral, chronic and interventional care; support the development and maintenance of an adequate supply of primary care practitioners; and respond to the cross-subsidization occurring within provider organizations as a result of the current lack of balance in payment levels by service.
4. Differences in health care payments should reflect measurable differences in value (cost and quality). Payments should be adjusted for clinical risk and socio-economic status wherever technically possible, and should promote greater equity of payments across payers and providers, to the extent that this is financially feasible.
a. Differences in health care payments should be transparent, including across different payers.
b. Costs associated with desired investments in teaching and research should be paid outside of base payments, and should require provider accountability for how such payments are spent.
c. Costs associated with desired investment in special “stand by” capacity should be accounted for in the payment system.
5. The health care payment system should be structured in such a way as to minimize provider, payer and patient administrative costs that do not add value.
6. Payment reform must consider how:
a. Some payment methods may require certain organization of the service delivery system, and
b. Health benefit designs either support or limit payment reform.
7. Health care per capita costs and cost growth should be reduced, and providers, payers, private and public purchasers and patients should all share in the savings arising from payment reform.
8. The health care payment system should be transparent so that patients, providers and purchasers understand how providers are paid, and what incentives the payment system creates for providers.
9. It will be necessary to consider the diversity of populations, geography and providers across the Commonwealth when designing payment reform to ensure high quality, patient-centered care to all populations and geographic regions in the Commonwealth.
10. Implementation should be phased over time with:
a. Clear and attainable deadlines;
b. Planned evaluation for intended and unintended consequences; and
c. Mid-course corrections.

It seems to me that a logical conclusion that follows from these principles and recommendations is that the capitated rates to be collected by the providers should be set by state regulation rather than by the current negotiations and market forces at play in the state. Why? Well, there are simply no reasons beyond the factors mentioned above to account for any difference in the per-person-per-month charge collected by different providers.

Today, rates that are established by negotiation between insurers and providers are mainly based on the relative market power of the two organizations. Note that this factor is totally absent from the principles set forth above. If it were allowed to come into play in a capitated world, what would happen?

Well, for example, we know that the doctors and hospitals in the Partners Healthcare System currently get fee-for-service payments about 30% greater than other providers. If a capitated rate were established for PHS providers today based on this differential, it would perpetually reward this health care system for its market dominance, to the detriment of the other public policy imperatives mentioned above. The differential would cement Partners' standing as the dominant provider group in the state, enabling it to recruit doctors and absorb hospitals by offering its new captives a higher rate than they could previously receive.

So, it seems to me that the job of the state in this new order is to establish risk-adjusted annual health budgets for the different risk categories of the public; to weight them by geographic cost-of-living factors; and to apply the appropriate adders for medical education and the other factors mentioned above. This would then become the rate schedule to be used by every insurer with every primary care doctor in the state, regardless of what provider network that doctor was affiliated with.

Perhaps an insurer could be permitted to offer different rate incentives or disincentives from other insurers for differences in measurable quality outcomes, but these, too, would have to be uniform across all providers for each insurance company.

The Commission may or may not have considered this option in their planning, but it should certainly be front and center when the Legislature considers the next step.

Caller-Outer of the Month Award #7

Continuing our series, our Board of Directors awarded this month's caller-out award to Marylou Conant, RN, who works in our PACU (i.e., post-op area.) Regular readers will 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.

Marylou's call-out was related to the availability and location of Calstat hand cleansing pumps. She noticed that hand hygiene in the PACU was being impaired. Why? The issue is that patients in the PACU are in bays that are close together, and you approach the patient from the foot-end of the bed. The Calstat dispensers are mounted at the head of the bed, on the wall, a location that does not support ease of good hand hygiene. But each bed does have a mobile bedside table that you pass on your way to the patient. Marylou and her colleagues figured out that you could "set a location" for a Calstat dispenser on every mobile bedside stand. They came up with a simple but elegant solution that provides both a visual cue as well as a slip-proof location on the mobile table using simple magnetic strips.

Marylou received a congratulatory letter, plus second row dugout tickets to a Red Sox game of her choice.

Careful now . . .

There is a fine line between being Populist-in-Chief, a strong advocate for your policy prescriptions, and allowing yourself to be played by the opposition in a way that undermines your credibility as Chief Executive, to the detriment of your objectives.

When President Obama made health care reform a priority, he put forth a set of objectives -- "control costs, expand coverage and ensure choice" -- that are mutually incompatible. What we have seen in the last few weeks is that these desired outcomes are, in fact, coming into conflict with one another during the Washington debate. Even a government dominated by one party is hearing from constituents (like the Governors) that they are worried about the draft plans wending their way through Congress.

Just in the last few days, I have seen hints that the administration is starting to blame insurers and other interest groups for the failure of these plans to move more quickly. Not that Mr. Obama needs advice from me, but I see danger of repeating a worrisome pattern. Years ago, when the Clinton's proposed their health plan and it ran into opposition, Hillary quickly turned from being a thoughtful policy advocate to demonizing those (including insurance companies and pharmaceutical companies) who opposed her proposal. I worry that President Obama could go over the line and do the same thing.

I am not being naive in suggesting that all interest groups are acting in the national interest, nor that they are not being selfish about their concerns. (I recall raising some here, for example, but of course those are legitimate!) As I have noted before, "One person's costs are another person's income." But we also have to respect that most opposition is based on legitimate fears or philosophical objections, not the result of venality. Thus, it will be very hard to craft a coalition for this bill, and therefore the President and his people have to be cautious in their words. Stridency or demonization mainly act to help the opposition congeal and get more support.

The President did not exercise that kind of caution during the AIG bonus episode. Indeed, his behavior at the time sounded more like a member of Congress than a President, and later he had to back away from his rhetoric. This topic is a lot more complicated than that one. Its resolution will take a unity of purpose that only Mr. Obama can create and sustain by keeping people inside the tent. The best negotiators treat their opponents with the same respect as their allies and try to address their legitimate interests and create value for all constituencies.

AHA-McKesson award announcement

We are very pleased to have been designated as one of three hospitals in the country to receive recognition by the American Hospital Association-McKesson Quest for Quality Prize® committee for leadership and innovation in quality, safety, and commitment to patient care. Here's a copy of the press release from the AHA. Congratulations, too, to Bronson Methodist Hospital in Kalamazoo and Duke University Hospital in Durham.

Lean: Tortoise not Hare

Here's an update for those of you interested in our process improvement efforts at BIDMC and our preliminary thinking about the next stages. Back in March 2008, we rolled out our BIDMC SPIRIT program, our first formal experiment with staff-based call-outs based loosely on the Totoya Production System, aka "Lean." It has accomplished some good stuff, and we have learned from it. (Search "BIDMC SPIRIT"and "Caller-Outer" on this blog to see a collection of those items.)

From the very beginning, we said that BIDMC SPIRIT would itself evolve, and now we are at the latter stages of thinking through how to do it. This process included some in-depth training of several of our senior clinical and administrative leaders, a cadre of the next organizational level of directors, and several of our medical trainees. Beyond training us, those sessions served as test beds for the specific curricula developed by our staff, in cooperation with and building on materials from the Greater Boston Manufacturing Partnership. Meanwhile, too, Steve Spear invited several of our folks to audit his process improvement class at MIT, where they have had more advanced exposure to Steve's work but also healthy interactions with people from other industries.

As the graphic above displays, we view ourselves at the very beginning of a long journey to full implementation of Lean principles in our hospital. Others, exemplified by Gary Kaplan and his colleagues at Virginia Mason Medical Center in Seattle, and John Tuissaint at Thedacare, started earlier and are further along.

As I was discussing with Jim Womack the other day, it is an interesting paradox that while an important part of the Lean philosophy is the concept of standardizing work (to avoid waste and unnecessary variation), when it comes to implementation of Lean, each organization is essentially sui generis. That is, the plan for diffusing the concepts of Lean in an institution like ours has to be cognizant of the people and the culture of the place, an environment that has evolved over decades.

The idea here is to be slow and steady -- "Tortoise not Hare" -- in both planning for implementation and executing the plan. I present, for your viewing, a simplified chart of the roll-out proposal we are currently thinking about and will be sharing with our leadership groups and staff. You can click on that chart and expand it. You might not get all the points, but you can see the major themes: Lots of training; application by the trainees of what they have learned; focus on broad system work across the hospital, but also specific project work in high priority areas; and a small, nimble governance structure to keep track of things and make mid-course corrections.

I hope, by presenting these materials here, to encourage others of you who have been through this kind of transformation to submit comments to share your experiences, and to encourage those who are thinking about doing this to reach out to others who are in mid-stream. As the US considers its options with regard to health care reform, the real action will remain in each hospital and physician group. Public policy instruments are blunt and imprecise. Unless we take charge of the manner in which we do our work, the broad general policies being considered in Washington, DC will make very little difference in the quality of care and the efficiency with which it is delivered.

Dave did good. We are all happy.

My friend Dave deBronkart, aka e-Patient Dave, called me early in 2007 to let me know that he had been diagnosed with late-stage renal cancer and that he could be expected to die within just a couple of months. I told him that this was unacceptable, in that we were scheduled to have our 35th college reunion that June, and that he needed to be there. Well, things turned out quite well. He not only showed up at the reunion, but at many other important events.

Here's a note sent today from Dave to his BIDMC doctors and NPs (David McDermott, Andrew Wagner, Mee Young Lee, Gretchen Chambers, and Megan Anderson), reprinted with his permission:

Medicos,

This week marks two years since my last bit of treatment from any of you. I continue to be well, sleeping well and loving life. I'm so well that, as some of you know, my weight has returned to "entirely too normal." :-) But I'm countering that: for the first time since high school I've become a regular bike rider. (Not getting up at 5 a.m. to do it, like SOME executives, but you gotta start somewhere.)

I tell people about you everywhere I go, which these days includes conferences and policy meetings. I've begun (unskillfully) doing recorded interviews with Dr. McD and Dr. Wagner to make the world aware of what you offer that's not available everywhere; I hope to do more, when you docs say there's more news to share. (Next time around I'll let YOU talk more...)

Ginny and I are having a fabulous summer, making the most of life. Yesterday we decided that next summer we'll celebrate our tenth wedding anniversary with a trip to Switzerland and Germany, where she went many years ago. Gonna get us some Alps! And on May 31 I got to walk my daughter down the aisle, and next weekend is Mom's 80th birthday party. Needless to say, it is a JOY to be present for these events.

Thanks for making all this possible. You're wonderful. (Pass the word to anyone else who worked on my case - too numerous to recall. And all of Stoneman 7.)

Dave

How much we could change

My colleague Gene Lindsey, CEO of Atrius Health, appeared twice in the Boston Globe in the past few days, once as the author of an op-ed, and once as the subject of an interview in the business section. As always, Gene offers thoughtful observations on current matters, and he comes to these issues with a wealth of personal and institutional experience.

I'd like to focus on a few of his points and explore the implications for an academic medical center like BIDMC. With regard to the movement towards capitated (er, now, "global") payment schemes, Gene perceptively notes that:

There needs to be a way to connect patients to primary-care physicians so that payment is made to the organization providing the care. Optimal Accountable Care Organizations will need to have a scale large enough to accept the risk of providing care on a fixed budget and the expertise and infrastructure to manage risk.

This is consistent with the message I sent to our staff a few weeks ago, where I noted:

We need to enhance and expand our clinical relationships with community hospitals and multi-specialty groups to provide a specific focus on quality and safety, to ensure that patients get the right type of care in the right place, but also to provide a dramatic improvement in the communication about patients' needs and the status of their care.

If Gene is right about primary care doctors having an ever-increasing role in managing the continuum of care in the future, the structure of the institutional relationship between primary care organizations like those in Atrius Health and the tertiary care organizations exemplified by BIDMC matters a lot. One model, which could be functional but not very interesting, is that the tertiary center would serve as a vendor to the primary care practice. In essence, this is mainly a commercial role, with a focus on the rates charged by the hospital for the services it "sells" to the PCPs.

A more vital role, though, is a true partnership, in which the medical and administrative staff in both organizations constantly seek ways to improve the patient experience. While there will always be the business aspect of who gets what percentage of the global payment, the real time and effort would be spent on improving communication of patients' clinical information, on enhancing modes of treatment based on the latest evidence, on taking steps to reduce the possibility of harm to patients at all stages of their treatment, and on helping staff in both settings redesign their day-to-day work to make it more rewarding and efficient .

In Gene's words, the latter approach reflects a commitment not to focus on "how little we need to change [but] rather [on] how much we could change." That sounds just right, but it is fair to ask tertiary hospitals how good they are at change and how well they have endorsed change in the past. Our place has learned a lot about change during the past few years -- first out of necessity when we had the near-death experience of the post-merger debacle -- later out of choice when we established audacious goals for patient quality and safety and satisfaction, when we committed ourselves to unprecedented levels of transparency of clinical outcomes to hold ourselves accountable, and when we adopted a staff-driven approach to process improvement.

The main thing we have learned about change is to be modest about what you know and what you don't know. We look forward to the opportunity to learn from Gene's group and others in the state as we pursue the creation of accountable care organizations that are truly accountable, truly care, and truly are organized.

Genders' discrimination

An email recently arrived from Europe, with two descriptions of the same three weeks of travel. The contrast would make Deborah Tannen's mouth water.

Her's:

Paris: croissants
Marseille: bouillabaisse
Nice: pan bagnats
Cinque Terre: pesto, anchovies, focaccia
Venice: marinated octopus
Florence: gelato, gelato, gelato, gelato, gelato

Oh yeah, saw some cool stuff, too.

Sending lots of love.
Ciao,

His:

Paris: Bike Velib: 20,000 bikes for public use. A shame American credit cards don't work in the system...
Marseille: Chateau D'If, and hidden beach on the next island
Nice: Tour De France!
Cinque Terre: 4 towns hiked in 3 hours.
Venice: Watching the kayakers make a stand against a city dominated by motorboats.
Florence: Da Vinci Museum with full scale replicas of his work.

Wowza.

Mind the Gapminder

A friend sent a link to an application called "Gapminder." It provides an amazing display of comparative quantitative information. Go play with it.

Blog from Children's Hospital Boston

My friend Jim Mandell, CEO of Children's Hospital Boston, sends me notice of a new blog:

Last week, Children's Hospital Boston launched the first health and science blog from a pediatric hospital in the country. Called Thrive, it will cover breaking pediatric news at Children’s, as well as commentary about issues or new treatments in pediatric care that would benefit from our expert opinion.

Blog entries include a link to an interview with Children’s pediatrician Judy Palfrey, MD, the president-elect of the American Academy of Pediatrics, about how health reform might impact children. Last week, there were entries on our autism research and the NIH’s new stem cell guidelines, a wonderful posting from a parent whose child benefited from treatment for a rare disorder and a commentary from David Ludwig, MD, PhD, director of Children's Optimal Weight for Life Program, about how federal stimulus funding could be used to improve the health of all Americans.

Gratitude is good for you

Emergency Departments are busy places, and, even in the best organized ones, people have to pull together in unexpected ways to make things work well. As you can see above, our folks decided to create an opportunity for staff to say "thank you" to one another to recognize those small and large moments when people made an extra effort for their colleagues and patients. Here is a sample of some of the messages, including one from a patient who noticed the form and submitted it:

Sue J. (RN): What a Gal, the most gentle, courteous, pleasant nurse in the ER. Thank you for giving me Sue as my Nurse. Patient John Smith [name changed]. Keep up the good work.

Julie & Janice (Tech): Thank you for your help on Tuesday 6/30. Dynamic Duo!!!

Kim & Catherine (Reg): Thank you Ladies for holding down the Core Desk when I needed a break on Wednesday.

Lisa C. (RN): I want to thank you for the encouraging words that you gave me the other day. It made me look at my role here in a whole new light. Your advice also made my week goes a lot smoother and I was able to smile. Thank you!

Mary Jane (OBS): Thank you for your astute observation while sitting for a patient in yellow yesterday. You kept him safe before he was admitted. I informed the nurses upstairs. Thanks again.

Jill M. (RN): Thank you Jill for starting my patients IV Tuesday and getting his blood. You are so sweet!

Ana G (Tech): Thank you so much for all your help over the years, and for sharing all your goodies especially the artichoke–spinach dip. Also you are great!

Maggie (RN): You are a gift! You give a whole new energy when you are here. You seem to have endless supply of energy. It is a pleasure to work with you!

Claire (RN): Thanks for helping me with that IV today. Sometimes I feel funny asking for help when I know how busy everyone is. I appreciated your ready willingness to help my patient. Thanks again.

Canadian Lean is bakin'

My virtual and occasionally in-person friend, Farhan Merali, (Harvard Medical School MD 2011 and Harvard Business School MBA 2011), sent along this link to an excellent introductory article from Healthcare Quarterly about application of Lean principles in the Canadian health care environment. It was prepared by Dr. Dante Morra and associates from the University of Toronto and Toronto General Hospital. As you will see, Lean principles and philosophy are independent of geographic setting.

MITSS HOPE award nominations are open

I'm posting this at the request of Winnie Tobin at Medically Induced Trauma Support Services:

Nominations are now being accepted for the Second Annual MITSS HOPE Award. The MITSS HOPE Award was established in 2008 to recognize people -- patients, families, healthcare providers, hospitals (or teams or departments therein), academic institutions, community health centers, grass roots organizations, EAP programs, etc. -- who exemplify the mission of MITSS: Supporting Healing and Restoring Hope to patients, families, and clinicians impacted by adverse medical events. The winner will receive a $5,000 cash prize to continue their work.

Nominations are due by September 14, 2009, and the award will be presented at the MITSS 8th Annual Dinner to be held at the Boston Marriott Copley Place on Thursday, November 12th, 2009, from 5:30 to 9:30 pm.

For more information about the award, or to nominate someone, visit us on the web; call Winnie Tobin at (617) 232-0090 or e-mail wtobin [at] mitss [dot] org; or, mail us at MITSS, 830 Boylston Street, Suite 206, Boston, MA, 02467.

Costs are not the same as rates

Many "old" media outlets do not identify the authors of their editorials. Thus, when an opinion is offered, you have no way of knowing who wrote it or what their qualifications are. Your only recourse when there is something unsupported or absurd used to be to send a letter to the editor, where you have about a 0.5% chance of being chosen for publication. And they would edit what you sent in. Then, blogs were invented.

This thought was prompted last week when I read a New York Times editorial entitled, "Financing Health Care Reform." Here's the quote in question:

Meanwhile, it will be important to get some guaranteed fast savings from the health care industries by cutting and reallocating hundreds of billions of dollars from projected spending on Medicare and Medicaid, as the Obama administration has proposed and Congress is considering. Just to be sure, Congress ought to establish a fail-safe mechanism that could impose additional cuts after a few years if savings are less than projected.

Since I don't know the author(s) or whether he/she/they actually know anything about Medicare and Medicaid, I am uncertain how to respond to this suggestion. Except to say: "Are you out of your mind?" Medicare rates just barely cover costs today, and Medicaid rates have not covered their costs in years.

This is all part of a general confusion about cost savings versus appropriation savings, a point I made back in March:

On the cost front, the president for now seems to be confusing underlying costs with how much the government chooses to pay. His budget proposal apparently would reduce Medicare payments to doctors and hospitals as a way of building a savings account for greater access. Reductions in appropriations might reduce costs to the federal government, but they do not reduce the underlying costs of care. With 50% of American hospitals operating at a deficit right now, it is hard to imagine how a reduction in federal payments for Medicare patients deals with the cost problem.

If we have a desire, which I support, to provide greater access to health care, let's consider it a national priority and pay for it directly. But a fear of using the dreaded "T" word -- taxes -- is causing the executive and legislative branches to force cuts in services. And meanwhile, the President doesn't want to us to use the word rationing because he knows the negative political ramifications of that (even though we certainly ration care today, mainly by family income). But what do you think will happen if you cut revenue to health care institutions and doctors?

Readers here know that I strongly support improvements in the quality and safety of patient care and the reduction of inefficiencies in the provision of care. Washington seems to think you are more likely get those improvements by underpaying hospitals and doctors for the care they deliver. You will not.

How you get there is not simple, but it involves transparency of clinical outcomes and rate structures so employers and workers can see the actual value offered by different health care providers. This would stimulate competition, too, in that insurance companies could then offer plans and products that reflect providers' relative value propositions to their subscribers. Meanwhile, let's pay primary care doctors and other cognitive specialists rates commensurate with their real importance in the health system. Then, they could take the time needed to care for patients appropriately and not just act as a triage way station to higher cost specialties and invasive procedures.

Isn't it revealing that Medicare and Medicaid could today set an example for all by requiring this kind of transparency and these payment changes, but there has not been the will to do so?

So, instead, we take a political shortcut, one that will have adverse consequences for years to come.

Cape Cod seals return

The seals are back, at low tide on a sand bar about 1/2 mile northwest of Head of the Meadow Beach.

Nessie arrives on Cape Cod?

No, it's not the Loch Ness monster. It is a sturgeon that washed up ashore from Cape Cod Bay earlier this week at Great Hollow Beach in Truro, MA . The locals suggest that this fish from the ocean found itself entrapped in the bay, whence it ran aground. Length = 22 feet, as you can see from the tape measure. The video gives you a sense of the whole animal. It's no longer there: The Town hauled it away before it fully decayed.

You can imagine where these came from

A weekend return to our lighter summer theme: I present excerpts from a cookbook prepared by our daughter as a gift to her mother. A key section is called "Tools and Tips: Lessons learned along the way." Some have particular relevance to this season, while others have universal applicability -- notwithstanding their autobiographical origin.

1) Do not use the microwave to make chocolate cake or hard boiled eggs.

2) While picking blueberries in Truro, do not crouch in poison ivy.

3) Never make mashed potatoes in the food processor.

4) Avoid eating ice cream cones while driving in convertibles on hot days.

Global Music-Medicine Project

A note from my virtual friend Mohan Sundararaj about a new project called The Global Music-Medicine Project, whose goal is "to globalize evidence-based music therapy," especially in developing countries.

While music is not the cure, we do believe that it barely takes its rightful role within humanity, global policy or medicine beyond candid and superficial discussions.

Sox show their heart again

A note from Lissa Kapust, one of our social workers who helps out patients with ALS ("Lou Gehrig's Disease"). On July 4, the Red Sox joined with other Major League Baseball teams to commemorate the 70th anniversary of Lou Gehrig's farewell speech. The team's management offered us one of their corporate suites for ALS patients and family members.

I wanted to let you know that the day at Fenway was magical. We filled the Red Sox Executive Box with 25 smiling patients, family members and ALS staff. The day went flawlessly; even sunny skies. The Sox loss was unfortunate, but put no damper on a fabulous day.

Some of our patients made it down to the field as Shilling read the Lou Gehrig "luckiest man alive speech". One patient was given a signed bat from a Sox player (Lugo) which he clung to throughout the game, sitting in his wheelchair, grinning from ear to ear. We had a visit from Sox management, including staff coming by with World Series trophies for our gang to pose with for Kodak moments. Wally [the team mascot] came by for photo ops and hugs. Kait Desmarais [the suite manager] and the food manager came by (and stayed for some time) to take it all in and to be sure there were no problems. The food selections were perfect with special help from the chef who prepared food that would be appropriate for the chewing/swallowing problems for some of the patients.

At the end of the game came a surprise. I went to pay for the food and was told that the Red Sox had picked up the entire tab. I tried to tip the Box attendant, and he refused.

Then the hugs and goodbyes to patients who talked about that we might be able to come back to Fenway again. Pretty hopeful for patients living with ALS.

What the CEO cannot do

This is what leadership looks like. It comes in the form of an email from Michael D. Howell, MD, MPH, our Director of Critical Care Quality and Associate Director of Medical Critical Care, to the ICU nurses, house staff, fellows, pharmacists, respiratory therapists, and attending physicians. Without these kind of champions throughout the hospital, the CEO's job is impossible.

All –

Fifty days. No splashes in any of the nine adult ICUs.

For those I haven’t met (welcome, new interns and fellows!), I’m the Director of Critical Care Quality and one of the ICU docs. In the past, I’ve written about our work to improve patient safety (90% reduction in central line infections, etc), speed delivery of critical medications to our patients (70% reduction in time-to-first-dose antibiotics), and more recently about work we’re doing to improve the experience for patients and families in critical care. Today, though, I’m writing about your safety.

Most of you will have noticed the box in the upper right corner of the Portal [note: our intranet home page] that lists the number of days since an employee injury. You’ve probably noticed that it’s always zero, meaning that one of our colleagues is hurt every day. I’ve been sort of agitated by that, and a few months ago we set it as one of the major improvement priorities for critical care.

As our first target for improvement, we sought the elimination of exposure to bloodborne pathogens by splashes. If you or a friend has ever gotten blood in your eye, you know it’s unpleasant, shocking, and scary. Some of our colleagues have, in fact, even been exposed to HIV and hepatitis this way. We know that nearly all exposures from splashes should be preventable by using personal protective equipment. And yet, before we started our work, someone got splashed about every week or two in our ICUs.

Many of you have participated as we began to try to figure out how to prevent these. Here are a few things we learned:

· ABGs and accessing arterial lines are especially risky procedures. In January alone we had *five* splashes from this mechanism.

· Glasses don’t offer adequate protection. Many people have gotten blood in their eyes (or mouth) while wearing their own eyeglasses.

· Splashes happen at unexpected times: disconnecting a Foley, flushing a PICC line, suctioning an ET tube, and being in the room while someone else was doing as ABG – people have been splashed in all of these ways.

Yesterday, though, we crossed an important threshold -- it has been fifty days since our last splash exposure in any of our nine adult ICUs. That’s definite, meaningful progress. Distribution tells us we’ve more than doubled our mask usage, and in some cases they have even had trouble keeping up with demand. That’s because of your work.

From my own practice, I know that it can be irritating and sometimes challenging to put on a mask and visor every time you’re doing something with a patient. But look at it this way: If we’d done things like we used to, we would have expected three to five more of our colleagues to have gotten blood splashed in their eyes during this time period. Instead, no one did.

I want to make a special request of those of you who are more senior, with lots of ICU experience: Please watch out for your junior colleagues, and if they are forgetting to wear a mask with visor, please remind them. Remember also that you set an extraordinarily powerful example with your own practice. By not wearing a mask, you may unconsciously be training your more junior colleagues to put themselves at risk.

Finally, I want to say ‘thanks’ to everyone who is helping with this, and particularly to Sabrina Cannistraro who is helping to lead the project, analyze the data, and coordinate the work. We will keep focused on splashes for the next several months, and once we’ve convincingly eliminated them we’ll begin to focus on needlesticks, lift injuries, and other challenges to our own safety.

As always, feel free to send comments, questions, and rebuttals directly to me, and please forward to anyone I’ve omitted.

Thanks,

- michael

Real competition? Really?

Paul Krugman's desire for advocacy has become so strong that he apparently has let his economist's training slip. Look at these two excerpts from yesterday's column in the New York Times.

Referring to a Senate committee's action, he notes that its plan for health reform:

achieves near-universal coverage through a combination of regulation and subsidies. Insurance companies would be required to offer the same coverage to everyone, regardless of medical history; on the other side, everyone except the poor and near-poor would be obliged to buy insurance, with the aid of subsidies that would limit premiums as a share of income.

This is good and sensible. But then, he slips off the wagon.

And those who prefer not to buy insurance from the private sector would be able to choose a public plan instead. This would, among other things, bring some real competition to the health insurance market, which is currently a collection of local monopolies and cartels.

"Real competition" is when all participants play by similar rules. As I have noted, that could not and would not be the case with regard to a public plan.

It's working!

Still exercising. Check back tomorrow.

New exercise regime

As I take a Fourth of July blogging break, I am pleased to note that Gretchen Reynolds in the New York Times reports on research showing that short, hard bursts of exercise may do as much for you as regular lengthy routines: "Can you get fit in six minutes per week?" Good news. I am canceling the morning bike rides and the soccer games. This will leave lots more time this summer for eating and naps. I'm sure to end up healthier.

See you on the beach, but only under the umbrella: No more swimming. I don't want to undo all the good effects of those very special six minutes. And the latest research shows the beneficial effects of sleeping. Probably more so when a light, warm breeze is blowing.

Gin and tonics are part of the new plan, too. My research shows that limes are an essential food group in the summer.

A real power bar

It's lunch time and time to report that BIDMC has recreated the famous chocolate chip cookie recipe. It is now available for sale in our cafeterias. Click on the image to enlarge and read closely to find the special ingredient.

ENFP or ENTP?

As we move towards a holiday weekend (here in the US), we'll shift to a couple of days of less hefty topics to help you start relaxing. Blogs are pretty narcissistic by nature, but this post is as self-centered as they come. Skip it right now if you are concerned.

I thought it would be fun to take a Myers-Briggs personality test. It has been many years since I did so, and I forgot what I am like, so I asked one of our HR people to set it up for me.

The results are back and are presented above. I appear to be an ENFP, which stands for extraversion, intuition, feeling, and perceiving. But, the third category was a close call, and I might actually be an ENTP, i.e., extraversion, intuition, thinking, and perceiving.

The characteristics associated with ENFP people are: "Warmly enthusiastic and imaginative; see life as full of possibilities; make connections between events and information very quickly, and confidently proceed based on the patterns they see; want a lot of affirmation from others, and readily give appreciation and support; spontaneous and flexible, often rely on their ability to improvise and their verbal fluency."

In slight contrast, the characteristics associated with ENTP people are: "Quick, ingenious, stimulating, alert, and outspoken; resourceful in solving new and challenging problems; adept at generating conceptual possibilities and then analyzing them strategically; good at reading people; bored by routine, will seldom do the same thing the same way, apt to turn to one new interest after another."

I fear that the instrument is flawed. That it reached no conclusions about my suitability for being a CEO is fine. After all, I'd rather not know. But, the diagnosis made no reference at all to my soccer coaching ability. That is an inexcusable omission.