Saturday, October 31, 2009
We are all familiar with Isaac Newton's outstanding contributions to science and mathematics, but how many know about his career after 1695? In that year, tired of university life at Cambridge, he moved to London to become Warden of the Royal Mint.
There, he ran into another very bright person, in the form of William Chaloner, an accomplished counterfeiter, who was rising through the ranks of the underworld. As he had in other fields, Newton invented methods of investigation and proof, but these were designed to catch criminals.
Mr. Levenson's writing style is engaging, and you find yourself turning pages quickly. The book reads more like a novel than non-fiction, and the factual basis for the story makes it even more intriguing.
Friday, October 30, 2009
Don offered stage-setting remarks for the CEO presentations to follow. He noted that the MA universal coverage law is being used as an example by people in Washington, DC, even though there remains lots to do with its implementation. He termed that law a "moral commitment," but one that requires lots of attention to the offshoots and results of that kind of commitment.
Don said that the work of the Lead group is also path-finding in its own way.
Regarding the current debate in DC, Don suggests that most of what seems to be playing out is an oscillation between two kinds of alternatives: Spend more or do less. The political process has the means to get through this kind of dialectic. But what the CEOs here know is that there is actually a third option: Redesign the care. The quality movement is formed by a kind of optimism. It always can be better; therefore we should stive. "Better is the option: Redesign is the plan."
Until now, it has not been necessary to do this in the health care system, and many parts of the system are still delivering care based on old models. Congress and the Administration don't get this because they don't deliver care. They don't know what the potential is and how to achieve it.
Don suggests that there are other elements in achieving this potential. The first domain of care is inherent in the Institute of Medicine list: Safe, effective, patient centered, timely, efficient, and equitable. He notes that we have gotten better in this domain, and he presented lots of examples across hospitals. "We know a lot, and it can be done."
The second part of the story has to be based on value, a system that we can afford. "I do not regard it as ethical that health care takes up 16% or more of the national economy." This steals wealth from other important causes like education, culture, and infrastructure. The health care system is way overbuilt. "Health care is not entitled to the growth in GDP that it demands." This will not be solved by focus on the IOM domains. We have to use scientific knowledge about process improvements and knowledge of systems to achieve the IHI triple aim: Better care, better health, and lower per capita costs.
There are some high value areas of the US. We brought together 10 of those regions and did a debrief. These places have broken the back of supply-driven demand. They also evidence high degrees of cooperation between medical groups and hospitals, among hospitals, and with payers. In every one of those communities, people in positions of responsibility both inside and outside of the health care system have chosen to exercise that responsibility. The attributes of the executives in the successful markets include: Confidence in possibility; appeal to the heart of the work force; constancy of purpose; alignment of resources for achievement of the long-term aims (money and time -- use a low discount rate in evaluating investment choices); review and reflection; translation into finance (bridge between the world of improvement and the world of money -- the CFO is at the table); management of spread (take pockets of excellence and help them be be pervasive); formats for cooperation ("not love, not even peace, but some way to get together") -- move good news from one place to another; celebration at the community level.
My colleagues in crime in the Lead program are (seated): Vinod Sahney, SVP at BCBSMA; Jeanette Clough, CEO of Mount Auburn Hospital; Helen Streider, CEO New England Baptist Hospital and Maureen Broms, VP of Health Care Quality and Patient Safety at NEBH; and (standing) Eugene Lindsey, CEO of Atrius Health; Craig Melin, CEO of Cooley Dickinson Hospital. Yup, that's Don Berwick standing to Gene's right: More on him in a second.
All of the program materials are, or will be, available online here for providers and here for employers. There are some impressive stories, including how Mount Auburn virtually eliminated medical errors over a period of several months.
The keynote presentation will be given by Don Berwick in a few minutes. I'll try to pick up highlights and get back to you.
Thursday, October 29, 2009
But, no. The sign remained dark for the half-hour I waited for a train tonight.
Well, not totally dark. There was the message, simulcast on the public address system and the LED sign, warning us that fare evasion was a crime and that we could be punished mightily for it.
But not a word about the actual train service.
I have to give the MBTA something for truth in advertising. It describes this capital improvement project (or one like it) as follows: This project will install new LED information signs on the platforms and lobbies of busy subway stations. These signs will provide visual equivalent of audio information on train arrival times and destination information.
In that sense, the signs are the visual equivalent of the public address system on this line, which for years has also failed to give audio information about delays or train arrivals.
This will be my final Reflections as Interim President and CEO. It has been a remarkable year (actually 14 months). To this day, I am proud that the Trustees asked me to take on this responsibility and humbled by the honor. It has been a great privilege to work at the helm of this extraordinary institution where the values of respect, ownership, superior service and excellence result in legendary service being a prominent part of the culture.
These values are some of the reasons that my father, a thoracic surgeon, loved the Baptist, and the reason why I have enjoyed working at this institution, from the time I had a summer job during college, through my service on the Board of Trustees.
I knew as I started to work last August that I would be supported by a talented Executive Team and helped along the way by all who work here, and this proved true. I am proud that we were able to go beyond just holding the fort and accomplish so much together this year.
First and foremost, we continued our journey toward keeping our patients safe by reducing complications such as infections, skin breakdowns and medication errors. All of nursing, health care quality, infection control, environmental services and everyone who washes their hands regularly contributes to this progress. The pharmacy, nursing units, and the PASU learned to solve problems to root cause, reducing medication errors that reached the patient by 33%. To be successful with this process means that we must not blame each other for mistakes, but instead figure out how to change systems to avoid errors. We have learned to be transparent and now know it is safe to call out issues as they arise.
When the economy failed, and we, like so many, lost value in our investments and our pension assets, and our volume declined, the entire staff pulled together and made sacrifices to enable us to make, and even exceed, our budget. Special kudos go to the patient care teams who cooperated in continuous, precise flexing of staff and closing units when volume levels required.
And then there was the horrible winter, when Security roared into action getting folk up the hill for their shifts, and the wonderful patient care team spent overnights here and did everything in their power to make sure that they were here to care for their patients (including one nurse who walked up the icy hill in her socks).
We have renewed our alliance with our medical staff by coordinating negotiations with insurers and, in the process, aligned our quality goals with the medical staff metrics.
We reached a milestone in our Master Facility Plan in September as we opened the beautiful new Central Sterile Processing Department and a leading edge OR. The remarkable thing about the construction and facilities team was not only that they accomplished these goals, but met them while keeping disruption to operations to a minimum, and Environmental Services kept us clean and shiny throughout. What a great team!
By the end of the fiscal year our surgical admissions, outpatient visits and radiology volume actually exceeded that of 2008, despite the economic downturn and various other challenges. The increase in volume is due in large part to the efforts of our medical staff to increase their work, and to the incredible efficiency in the OR and perioperative teams. We also were fortunate to have several Harvard Vanguard orthopedists join our ranks in a testimony to their belief in our quality and that this is a place where their patients will have better outcomes. And now, as we are blessed with greater volume, all departments are rising to the challenge of caring for more patients while holding to our high standard of care.
And through all of this, our Food & Nutrition team fed us, catered events with panache, and comforted out patients with room service. They sustained us with that vital coffee and snacks as we dragged into early morning or evening meetings ready to put our heads on the conference table. How would we survive without them?
And what a beautiful tea party they orchestrated for us yesterday. Thanks to all for a lovely afternoon of smiles and to everyone who came to wish me well. And special thanks for my beautiful new chair.
So now Trish arrives on November 2nd . . . and I will be sleeping in! We all are excited about her leadership and look forward to helping her help us be the very best we can be.
Thank you all for a wonderful, exciting and challenging experience and for all that you do for this Hospital.
Dan Jones continued his visit as our Judith and Robert Melzer Visiting Professor in Health Care Quality and Patient Safety with an appearance at Medical Grand Rounds. You see Dan here with his friend and colleague Jim Womack.
The topic was "Realizing the potential of Lean thinking in healthcare." I'll try to hit the highlights.
Joking that, after visiting our hospital, "I'm encouraged because your problems are the same I see everywhere else," Dan set forth the challenge as one of delivering more and better service to patients for less money. He noted that progress in the quality movement can be viewed an complimentary to implementation of Lean approaches. Whereas the quality movement strives to define best practice interventions and to eliminate variation and errors, Lean focuses on the context of the flow of work to eliminate delays for patients, wasted effort for staff, and unnecessary costs. The two movements share a common sceintific-evidence based methodology.
Lean, says Dan, begins with engaging the staff in improving work, liberating the potential to take action. But, he warns, point improvements are hard to sustain without an end-to-end perspective and management systems to support them. There is a need to manage an interdependent process throughout an organization. This requires a different level of engagement, in that making the system more "fragile" and subject to interruption is an inherent characteristic of the lean approach.
Dan illustrated the hospital environment as a set of processes (see above). Usually, nobody can see the whole set of interactions, "but we need to be able to do that," or each segment will just react to events rather than working on the greater good. In the example he gave us, he showed an analysis of patient flow from the emergency room through to discharge. "If demand is generally predictable, why are there so many delays" he asked, "both at the front end in the ER and at the back end, waiting for discharges?"
Based on his work at many hospitals, he noted that there are pioneers who have make progress in each segment of the care process. "Yet, the big opportunity is leveraging the gains of that work by linking the entire system together. The challenge, now that we see the hospital as a collection of processes, and we know how to improve most of them, is to connect all the pieces together."
After a detailed review of one particular case, Dan laid out the conditions for successful implementation of this kind of integrated approach:
There has to be a will to act.
Someone has to be the value stream manager, the person who takes end-to-end responsibility.
That person works to establish the foundations of progress: stability and visibility.
That person has to gain agreement from the team on the right actions, based upon the facts on the ground.
That person has to have the backing from senior officials to resolve conflicts that arise between departments and the overall value stream objectives.
That person, has to be able to deliver results, and yet has to do so with no authority over resources (just like the engineers at Toyota.)
Our doctors and students were engaged and very interested in all of this. Many had been primed by previous activities and instruction from Mark Zeidel, our Chief of Medicine. But, I think the fact that this is a whole new way of thinking about care delivery was evident to the audience. It is an approach that will take lots more practice and thoughtful planning and priority setting for hospital-wide implementation.
Well, it turns out that many employers in the state, including unionized organizations, have employees who rely on taxpayer funded health insurance. Indeed, that was part of the design of Chapter 58, the universal health care coverage law passed a few years ago (the one being used as a model for national health reform). Here is the chart published by the Commonwealth of Massachusetts on this topic. Let's see a sample of which governmental organizations and nonprofits are included: The Commonwealth of Massachusetts itself, City of Boston, U Mass, Salvation Army, City of Springfield, Brigham and Women's Hospital, Bay State Medical Center, Boston University, Boston Globe, Catholic Charities, Action for Boston Community Development, U Mass Memorial Health Care, City of Cambridge, Boston College. As you can see, there is a mix of both unionized and non-unionized organizations included.
The SEIU mailing also decries the fact that our workers last year had cuts in earned time, retirement benefits, and raises. Absolutely true. As has been documented in national and local news coverage, BIDMC was a national example in avoiding hundred of layoffs by asking workers to make a sacrifice for the greater good. And all the while protecting the lowest wage workers by ensuring that they would continue to get raises. This is what happens when workers care for one another. In contrast, how many stories have you heard about where unions have refused to consider this kind of shared approach, resulting in layoffs of their most junior members.
Wednesday, October 28, 2009
Dan and his US counterpart, Jim Womack at the Lean Enterprise Institute, are the instigators of a group called the Lean Global Network. This comprises sixteen organizations around the world that are promoting Lean thinking and leadership and helping organizations with their Lean transformations.
Dan had a great description for how Lean becomes a force in those organizations that carefully plan and design its implementation: "A benign infection for which there is no antidote."
My friends and I just didn't get it. We entered 1 Federal Street in Boston and found this very odd elevator system. You have to punch in the number of the floor to which you want to go on the outside of the elevator. Once you are inside, it takes you there. There is no inside panel of floor buttons. So, what if you made a mistake or want to change your mind after the doors have closed?
Tuesday, October 27, 2009
Some friends of mine are involved in a new company called BiddingforGood. What EBay brings to the world of auctions in general, B4G brings to the world of charity auctions. It is a consolidator, facilitator, and operator of on-line auctions for charitable causes and organizations.
With the help of B4G and some of the BIDMC staff, I will be holding an on-line auction each month to benefit one of the BIDMC's affiliated community health centers or another health care-related cause. You will have a chance to bid on neat items, knowing that the proceeds go to a worthwhile purpose.
The first auction will benefit BIDMC's owned Bowdoin Street Health Center, a wonderful place providing primary care, specialty care, and many support functions to a section of Dorchester in Boston.
Bowdoin Street Health Center was founded in the Bowdoin/Geneva neighborhood of Dorchester in 1972 by community residents to provide affordable, accessible primary care and public health services. The Bowdoin/Geneva community is a widely diverse population. 43% of the patients served at the health center are African American or Caribbean Islanders and 38% are Cape Verdean, while Latino, Vietnamese, Haitian and Caucasian populations make up the remaining base. The health center has experienced continued growth over the past 36 years, leading to several relocations to larger facilities. The current building opened in 1997, and we now care for more than 10,000 patients through 45,000 visits across a wide spectrum of care. Bowdoin Street also has a long history of working in partnership with residents, businesses and organizations on identified issues of importance to the community. A staff of 70+ employees makes Bowdoin Street the largest employer in the Bowdoin/Geneva area.
Specifically, I am trying to raise money to purchase an ultrasound machine for the health center. This would enable pregnant women to have ultrasounds in the community, rather than having to travel several miles to BIDMC for these screenings. I hope you will like the items I am offering and will bid vigorously for them for this cause.
But, wait, there's more. I mentioned that B4G is a consolidator and facilitator. You have the opportunity to offer items of your own to include in this auction. Just go here and click on the button entitled "Sign in to Donate," provide the requested information, and we'll tell you if your item will be included. (You'll need to consult your tax advisor to assess the tax deductibility of a donation.) Or use the blue Donate an Item button on the right side of this blog.
Sample items that typically do well that I’d love to include in the auction include:
Tickets to sporting events (from season ticket holders)
Tickets to entertainment events
Bottle of fine wine
Lunch with a celebrity or a political figure (are you one?!)
This blog has a worldwide audience, so don't think your items have to be based in Boston. On the other hand, I do have lots of Boston-area viewers, so local items are also welcome.
The first auction will run from Monday, November 2 through November 9. I'm planning to run one during the first week of every month.
I hope that you enjoy this new feature and will choose to participate, as a bidder, donor, or both. Please pass along the word to others, too, OK?
The two young men above are Nevan Hanumara and Conor Walsh, Ph.D. candidates in Mechanical Engineering at MIT. You see them here at the current Innovation Congress of CIMIT, being held in Boston. CIMIT is a multi-institutional cooperative venture with the mission of improving patient care by facilitating collaboration among scientists, engineers and clinicians to catalyze the discovery, development and implementation of innovative technologies, emphasizing minimally invasive approaches.
Nevan and Conor work with Professor Alexander Slocum at MIT and Doctors Rajiv Gupta and Jo-Anne Shephard at MGH's Department of Radiology. They came up with a device to help interventional radiologists perform soft tissue probe insertions with greater speed and accuracy and reduced complications and physician strain. They explain more here.
This kind of project research is funded by the CIMIT member organizations, along with federal government and industry sponsors. To the right, you see some of our executive committee members getting a feel for this device.
The organization has published two books, Answering the Call and Advancing Women in Business. The first is a resource for considering the risks and responsibilities of governance. As WBL notes, "This book is a great place to start considering whether board service is right for you or to brush up on your governance-related knowledge." The second book is to help you understand how to get on a nominating committee's radar screen.
In addition, WBL holds annual Summits about serving on corporate boards and considering your first board seat.
This is a great resource for women health care professionals who want to expand their personal and professional horizons. Many corporate boards are seeking to diversify their membership, and the experience offered by health care people can often be applicable to other industries.
Monday, October 26, 2009
A key part of the program, consistent with our transparent approach to process improvement, is that we share data about every floor with every floor, so there is an overall awareness of how we are doing. Our measurements are based on a combination of direct observation and keeping track of quantities of CalStat used on each floor relative to the number of patients on that floor. We are now at the point, as noted below, of increasing our goal.
Here's the form of the message that goes out from Linda M. Baldini, RN, CIC, CPHQ, Infection Control\Hospital Epidemiology, to each floor, all of the Chiefs of Service, Division Chiefs, and many other people at the end of each observation period:
The latest hand hygiene reports for all units are now available. Reports are available on the online Infection Control manual. The link may be found on the new portal.
The most recent report is for Period #25 (7/4/09 – 8/28/09) and is generated using data on usage (counting empty soap and CalStat containers) and census (patient days) for each unit. These data closely mirrors that obtained by direct observation of hand hygiene performance of health care workers during the same period. Note that L&D is considered an ICU in this report due to similar nurse:patient ratios.
The reports available include: ICU hand hygiene reports (all units on one graph) Non-ICU hand hygiene reports (all units on one graph) Average ICU and non-ICU hand hygiene performance over time Individual graphs for each unit over time
Congratulations to L&D, CVICU, MICU 7, 7 Feldberg, 6 Feldberg, 5 Feldberg, 5 Stoneman, Farr 10 for reaching goal this period of ≥80%!
An email reminder will be sent to you after each intervention period, approximately every 9-10 weeks. Please share these data and information with your unit-based staff at all levels and physicians. Feedback of data has been shown to help improve performance.
You can see the data, too, on our corporate website. As I have often mentioned, we believe that public presentation of our performance data stimulates internal improvement by helping to hold ourselves accountable to the standard of performance for which we stand.
But back to the game idea, here's the latest campaign, announced last week:
To: BIDMC Community
From: Ken Sands, MD, MPH, Senior Vice President of Silverman Institute for Health Care Quality and Safety
Sharon B. Wright, MD, MPH, Director, Infection Control/ Hospital Epidemiology
Subject: Raising the Bar on Hand Hygiene
Starting with the new observation period that begins Oct. 24, BIDMC will increase its hand hygiene compliance goal from 80 to 90 percent across the medical center. To help roll-out this new initiative we will introduce a fun new incentive program to help inpatient unit staff improve their hand hygiene compliance.
BIDMC Bowl-O-Rama (Knock Down The Germs) will use a bowling-themed scoring grid to communicate unit performance in each measurement period. Those units meeting the new goal will receive rewards such as bowling shaped cookies and coffee to winning units at the halfway mark (April, 2010), and a big party with raffles during Infection Prevention Week in October 2010.
Our grand prize will be a Wii game system, including the sports/bowling program, as well as other bowling-themed prizes, gift certificates to area bowling alleys, custom made bowling shirts (for select Hand Hygiene advocate champions), and movies such as and “The Big Lebowski.” Unit-based bowling trophies will also make the rounds to highlight and reward compliance.
To learn more about this new initiative, please join us at the Infection Prevention Week informational fairs in the east and west campus cafeterias on Oct. 21 and 22, from noon to 1:30 p.m. The fairs include free prizes and Wii bowling.
So that's what Sam and Pat did. They are not trained clinicians and have frankly not spent all that much time in clinical settings. But they have good eyes. For many hours, they sat in patient rooms and watched as people entered and left, keeping track of potential sources of infection.
Here's a short excerpt of what they noticed, just the part focusing on hand hygiene. Please remember this was not meant to be a statistically valid sample. Some of the observations have been helpful to our infection control people as they design changes to improve compliance with this important aspect of the hospital. In other cases, the recommendations might be deferred because different approaches have been found to be more effective. See the post directly above this one for an update on the entire issue.
Over the course of 4 weeks, we spent approximately 25 hours observing interactions in inpatient rooms to evaluate what passes the perimeter of the infection zone. We were able to compare notes from our observations and categorize our findings into five categories.
1. Physical space
3. Hand hygiene
4. Use of gloves
5. Outside visitors
Major inconsistencies with staff using Cal Stat upon entering and exiting patient’s room.
This observation includes: nurses, co workers, food services, physical therapy, family members, couriers and Phlebotomist.
Further training in targeted work groups and visitors (see list above).
All visitors must sign in at front desk before entering patient’s room at that time.
Educate or give visitor a hand hygiene pamphlet that explains the importance of this
Involve the patient; include an antibacterial wipe/napkin on food trays along with an educational reminder to use before eating.
Empty Cal Stat – people were still going through the motions even if nothing was coming out.
1. Monitor Cal Stat usage
2. Install empty warning alerts
3. Flag – visual identifier
4. Blinking red light
5. Beeping sound
No standard protocol for when to wear gloves and when not to (medication delivery, checking wounds, etc.)
Establish best practices; undergo refresher training for all staff.
Use educational humor, display slogans in certain areas of the institution, i.e.
“Spread the word not the Germs”.
During our visits we observed that there is no designated work space for staff within the patient room. Caregivers are often observed using the soiled linen cart as a place to check and/or update the patient chart or they use the space to regroup before coming into the room, or moving on to the next patient room. Also, often times, equipment or charts would move back and forth from the clean bed to the patient bed increasing risk for infection. Floors, chairs, patient bed, and patient tray were used as work spaces to hold phlebotomist cart, charts, medications, and even urinals.
One recommendation is to create a designated space in the room that gets sanitized – perhaps one of those tables that fold down from the wall? If there is no space within the room, it could exist immediately outside the room. In some situations such as the phlebotomist, a rolling work station might be appropriate.
The cleanliness of the rooms also presented some risk. We observed dirty gloves on floor next to trash can; empty drain hanging out of trash can; and dirty paper towels on floor. Additionally, we observed a coworker who cleaned the patient’s belongings while wearing the same gloves used when she cleaned the patient.
Perhaps an easy fix for trash could be to buy taller trash cans. The trash cans are quite short and are often placed in a far corner of the room. If the cans were taller, there might be less likelihood of missing the can. Additionally training is recommended for all staff that is responsible for cleaning and sanitizing the room to educate on the various ways that infection can be transferred.
Some equipment is used on multiple patients – this includes tourniquet, stethoscope, and blood pressure cuff. Not all equipment was wiped properly before being used on the patient.
Some of the items could be assigned to each individual upon arrival – such as a tourniquet or blood pressure cuff. Communication and education around the importance of cleaning stethoscopes may help with consistent cleaning prior to use on patients.
Saturday, October 24, 2009
I like this set of comparisons.
Banning social media in the work place is:
- Analogous to banning the Internet
- Analogous to banning the phone because you might make a personal phone call
- Analogous to banning paper and pens because you might pass a note that is not related to class or work
- Could potentially signal to current workers and future recruits that your company just doesn’t “get it”
Thursday, October 22, 2009
Our mission is to transform the culture of medicine to be more participatory. This special introductory issue is a collection of essays that will serve as the 'launch pad' from which the journal will grow. We invite you to participate as we create a robust journal to empower and connect patients, caregivers, and health professionals.
This is free, online journal dedicated to documenting how healthcare encourages, supports and expects active involvement by all parties, and leads to improved outcomes. An interdisciplinary publication founded, written, edited, and reviewed by health professionals, patient advocates, and researchers, the journal will explore how participation affects outcomes, resources, and relationships in healthcare; which interventions increase participation; and the types of evidence that provide the most reliable answers.
Sometimes a call-out is just a sign of initiative and caring. It might not result in a new process, but it might help confirm that something that has been put into place is working well. Such was the case here.
Dave is a pharmacist who helps nurses and other staff learn to use our sophisticated medication-delivery pumps. During a pump's testing phase, he will sometimes distribute a few pumps to people in training and then collect them before the full roll-out occurs.
He did this recently and found one pump was missing, having disappeared. Previously, finding one pump on the dozens of floors in the hospital would have taken forever, during which time it might have been misused or create other problems. Here, Dave immediately called Pam Dicapua in our clinical engineering department. That group had recently installed an RFID system and labeled hundreds of medication pumps. This particular lost pump was located within 37 minutes of Dave's query to Pam. It had traveled downstairs from one floor on our West Campus, across the street three blocks away, and then upstairs to a floor on our East Campus.
In short, good heads up thinking and initiative by Dave, and excellent follow-through by Pam at clinical engineering, using the latest systems put in place by her and her colleagues.
Dave says he has renamed RFID to mean "Really Finds Infusion Devices"!
Wednesday, October 21, 2009
I just returned from a session for minority students at Harvard Medical School where I joined my Harvard hospital CEO colleagues in addressing the students on the topic of "Why Boston? Building your Career in Academic Medicine in Boston." You might be interested to know that, decades ago, Boston was considered one of the friendliest places in America for African Americans to live and advance professionally. Unfortunately, that reputation was tarnished greatly in the 1970s and 1980s (thanks in part to this image) when the controversy over school busing to integrate the public schools divided the city in so many ways. More recently, civic, academic, and corporate leaders in the region have reached out in an attempt to revive that older, more tolerant and friendly view of the city.
A lovely moment in tonight's program was the presentation of an "Excellence in Mentoring Award" to Dr. Johnye Ballenger (seen here). Johnye is a instructor in pediatrics at Children's Hospital, and she has spent the last 20 years tutoring and mentoring HMS students. In accepting the award, she said to the students, "It has been my passion to be part of your lives," and received a standing ovation.
DeWayne reports: "At the end of that session the head coach, assessing my season’s performance, told me that I could probably have a good career in medicine." Then, "I’ll be in a little late tomorrow. I’ve got a physical therapy appointment lined up."
A pertinent quote:
"Medical care is more fragmented in most hospitals, with many doctors self-employed or working for independent groups, and insurance provided by separate companies. That pits those groups against one another economically. In a fully integrated system, like Geisinger's, everyone benefits more easily from holding costs down and improving care, experts said."
Question: How much is due to the common bottom line between the MDs and the hospital, and how much is owning the insurance company? Also, how much of this is transferable to other settings that do not have the dominant market position enjoyed by Geisinger?
Glenn and colleagues, can you please reply?
Tuesday, October 20, 2009
I am not allowed to play favorites, but I will tell you that this group includes many of my most favorite people in the hospital. They are wise, engaged, thoughtful folks with a great sense of team spirit and a marvelous sense of humor that develops from the technically demanding responsibility that surrounds their jobs.
Here is a slide show that was produced to honor them at the luncheon. I dare you to watch it and not share my affection and appreciation for these very fine people.
I'm somewhat sympathetic to Dr. Gleicher's point about a government-imposed clinical review process, but he overstates the case about a current free market of ideas. Individual insurance companies and Medicare currently make payment decisions with regard to therapeutic judgments every day. How are they informed, and what are their sets of vested interests? Much of that remains hidden from public view.
Meanwhile, too, doctors and hospital practice what Brent James calls "regional medical mythology," patterns of care divorced from scientific evidence, based as much on the local supply of specialists and what they learned from their predecessors as any other factors.
Perhaps what Dr. Gleicher is trying to avoid is the replacement of this array of unscientific medicine with the establishment of a centralized panel of unscientific medicine. In essence, he is suggesting that it is worse for the federal government to get it wrong for the whole country at once than for the individual participants (payors, MDs, and hospitals) to get it wrong each in their own way.
Seriously, though, one can apply some analytical rigor in support of Dr. Gleicher's thesis. Just as a diversified investment portfolio does better over the long haul in terms of risk mitigation, so too might the country do better over time with a diverse set of views as to appropriate diagnostic tests and therapies.
Monday, October 19, 2009
Shown left to right are Moderator Jessica Lipnack, CEO of NetAge; Thomas Gensemer, Managing Partner of Blue State Digital, LLC; and G. Scott Greenberg, Director of Sahale Snacks, Inc., InSpa Corporation, and Calidora Skin Clinics, Inc., and Senior Partner at K&L Gates, LLP.
Jessica started us off with an electronic survey of the audience:
Does your Board uses websites for purposes of meeting management and board communication:
No: 54% Yes: 46%
Do you personally keep a blog?
No: 97% Yes: 3%
Do you read blogs as part of your Board work?
No: 68% Yes: 32%
Do you participate in Facebook, Twitter, or other social media sites?
No: 35% Yes: 65%
How would you place yourself in the "digital continuum" relative to your colleagues?
Novice: 17% Competent: 64% Out-in-front: 19%
Much of Scott's presentation dealt with the pervasive presence of digital media and with the tools available to boards for meeting preparation and management and board communication.
Thomas talked about the essential elements of a social media strategy: Timeliness; transparency; authenticity; and personalization of messages. As one of the brains behind the Obama internet campaign, he had a particularly vivid experience upon which to draw.
My topic was the value of transparency in building trust with customers and other constituencies. I drew on our experience at BIDMC and also the approach used by Salesforce.com.
Jessica ensured that our presentations would be short and focused, leading to an extensive and engaging question and answer period.
Here's the initial compelling question on the site:
"In an average American community with 500,000 people, what three changes in the health care system (organizations, resources, personnel, etc.) would contribute most to simultaneously reducing the per capita costs of care and improving care outcomes and health status?"
Sunday, October 18, 2009
In any event, the first snow always makes me recall this story.
Here's one aspect of this, where certain Congressman are trying to protect medical device companies located in their states. And here's another summary, showing the interplay among several groups of constituents:
Doctors are expected to win a $240 billion boost in reimbursement rates that would shield them from a 21 percent pay cut next year for treating Medicare patients. Women who now pay higher insurance premiums for caesarean sections would be protected under antidiscrimination provisions. And although Congress is strongly considering a tax on high-cost “Cadillac’’ insurance plans, the charge is likely to be imposed on a smaller number of health plans, appeasing angry labor activists.
None of this should be a surprise. It is the legislative process in action, based on a republican form of government that was written into our Constitution by John Adams and his colleagues to assure that minority interests are considered.
In similar fashion, we should really ignore non-stories like this one in today's Washington Post. It contains complaints that the final negotiations are being held by a small group of people as opposed to the "big table" approach promised by the president during his campaign. This has been standard practice for decades, and it is necessary to actually get the final work done. It does not, by the way, guarantee full approval by either house of Congress, but without a small working group at some point in the legislative process, you never get close to a conclusion.
All that has really changed recently is that the sausage-making aspects of legislation are now more visible for the world to see.
What it will mean for the final bill, though, is that health care reform will not satisfy the President's three-part test of offering more access, lower costs, and consumer choice, but those in all segments of the industry have known since the start that this was not possible. In my view, the most important things that will be accomplished are eliminating nasty practices of insurance companies; establishing a national requirement for people to have health insurance; and subsidizing at least some of those who need it. The first will give security to those who have insurance but who fear losing it. The second will cause those healthy people who choose not to buy insurance to do so, helping to assure that they do not end up being a burden on all of us when they show up at the Emergency Room. The third will help some portion of the population get insurance and more access to preventative and diagnostic care.
We will find out months and years from now what our Congressional buddies horse-traded away to get this package. Some of it will not look pretty. Some of it will actually harm the underlying causes of more access, lower costs, and consumer choice. There will have been missed opportunities to rationalize the health care system, too. But all of that, I submit, is the nature of the legislative process, where the reality that "one person's costs are another person's income" gets transmogrified into a bill that gets enough votes to pass.
Saturday, October 17, 2009
Here, the Commonwealth of Massachusetts decided to put money into a solar energy company:
The incentive package from the state included nearly $21 million in direct grants to the company, $22.6 million in tax incentives, $13 million in grants to build roads, upgrade electrical transmission lines, and upgrade other infrastructure to support the 450,000-square-foot Devens plant, a $1-per-year lease for 23 acres at Devens worth $2.3 million, and $17.5 million in loans.
There are two types of risk associated with this kind of investment. The first is that the firm might fail, taking with it millions of dollars in state assets. That is particularly likely in the energy field, where changes in world oil prices and advances in technology or unexpected competition can quickly make mincemeat of a firm's business plan.
In this case: A big problem is the price of solar panels, which keeps dropping, in part because of sinking demand and competition from China. The U.S. Synthetic Fuels Corporation, staked with billions of dollars in federal support, was another casualty of these kinds of market forces.
The second risk is that political bodies have trouble with the concept of sunk costs. Private firms consider past investments as fiscally "gone" for purposes of evaluating future investments. But the government often behaves as if investments have a carry-forward risk of embarrassment, so it is more likely to throw good money after bad.
This part of the story demonstrates the latter point:
...After its efforts to borrow elsewhere failed, the company recently asked MassDevelopment for a new $5 million loan. ...MassDevelopment staff members warned last month that the company does not currently generate enough cash to pay it back, and gave it the highest score possible for risk, 6 out of 6. The $5 million request is also double the $2.5 million limit allowed under MassDevelopment’s own guidelines. Nevertheless, MassDevelopment’s board unanimously approved the loan at a board meeting Sept. 17.
Some Governors and Presidents like to believe that they are more able than the private markets to evaluate and support technologies and companies consistent with their policy agendas. The problem is that they use our money in support of their hunches, changing the private sector's risk-reward calculus that is essential for a proper evaluation of the investment's value.
Friday, October 16, 2009
Meanwhile, just this week, a friend reports that, in honor of Diwali, the company where she works is serving Tamarind Masala Meatloaf. Really. Picture included. Hopefully, the White House was a bit more culturally correct.
Each year, the Society of Critical Care Medicine (SCCM) selects one (and only one) hospital or ICU for its Family-Centered Care Award, the purpose of which is to "recognize innovation that improves the care provided to critically ill and injured patients and their families." If you’re not familiar with SCCM, it is the largest multiprofessional organization focused on critical care, with more than 14,000 members in 80 countries. This is an international competition.
I am very proud to announce that BIDMC has received the award, which will be presented in January.
As Dr. Michael Howell, Director of Critical Care Quality, explained to our staff:
Why did Critical Care at BIDMC win this award? Because of your work. Literally hundreds of people have made small, incremental changes to help improve the experience of critical care for our patients and families. Anyone who has had a family member an ICU knows that it’s an extraordinarily trying time. From simulated family meetings for the medical residents, to family pagers in the SICU, to transition-out-of-the-ICU work in CVI, to pro-active rounding of chaplains, there have been a tremendous number of improvements over the past year and a half. Family satisfaction data (which we have meticulously collected) supports this as well. Today, families are more than twice as likely to report that they are completely satisfied with their decision-making role than they were when we started in April 2009, and we’ve seen improvements in other areas as well.
I also want to give special thanks to IHI's Maureen Bisognano, who had a special role in stimulating our activities in this arena. Maureen had a friend in our ICU for some time. Afterwards, she said that the medical care had been extraordinary, but that other aspects of our care were substandard and outdated. She was absolutely correct. Beyond that criticism, she has been a loyal guide in our work.
Here is the more detailed explanation from our award application:
DECIDING WHAT TO IMPROVE: MOVING THE LOCUS OF CONTROL TO PATIENTS AND FAMILIES
Strategically, we believed that how we chose what to improve was tremendously important. To be truly patient/family-centered, patients and families should set our improvement priorities. We therefore developed two initiatives to address this critical issue:
ICU Patient and Family Advisory Council
We believed that ongoing, longitudinal guidance from our patients and families was critical. We therefore assembled the ICU Patient and Family Advisory Council, a group of former ICU patients and family members (of both survivors and non-survivors). Each Council member serves for one to two years. The group meets bi-monthly.
As the first advisory council for our hospital, we consciously sought a model that could be emulated by others. After we identified potential Council members, we had a thoughtful selection process, including in-person interviews by a social worker and by a member of the Critical Care Quality staff. This selection process resulted in a group of patients and families who provides exceptional advice and guidance.
To elicit the best possible guidance, each Council meeting is facilitated using careful focus group methods. Each session focuses on a different aspect of the ICU experience. Examples of topics include (among others): emotional support in the ICU, family meeting curriculum design, waiting room revitalization, overall prioritization of improvement opportunities, and others.
FS-ICU: Family Satisfaction in the Intensive Care Unit
Traditional hospital-wide patient-satisfaction tools (e.g. Medicare’s HCAHPS; Press Ganey) have significant limitations in understanding the ICU experience. However, the FS-ICU is emerging as one of the potential gold standards in assessing families’ ICU experience.1 This rigorously developed survey instrument captures key domains of the ICU experience and has undergone multicenter validation. In addition, the survey has three open-ended questions designed to solicit opportunities for improvement. The FS-ICU is administered to families of ICU survivors within three days of transfer out of the ICU; it is mailed to families of non-survivors several weeks after the patient’s death.
We began administering the FS-ICU in April 2008 (i.e. just over one year after the multicenter FS-ICU’s publication) and have surveyed nearly 400 families to date. Quantitative analysis allows us to detect targets for improvement and to follow improvements over time. Qualitative assessment of the open-ended questions ensures that our Advisory Council’s advice resonates with a broader sample of patients. In addition, because we administer surveys in-person and in near-real-time, our team can perform real-time problem solving and address issues as they arise.
GETTING BETTER: A PORTFOLIO OF FAMILY-CENTERED CRITICAL CARE
Based on themes and specifics gathered from our ICU Patient and Family Advisory Council and the FS-ICU, we began the journey toward comprehensive, meaningful patient- and family-centered critical care. Below is a selection of activities, limited by space:
Simulated Family Meetings: Residents provide a great deal of direct patient care, but the optimal way to train them how to conduct family meetings is not known. We have implemented a program in which all medical house officers (>150 physicians) now rotate through our Simulation Center, receiving didactic and high-fidelity simulation sessions on conducting family meetings. The ICU Advisory Council provided major input into the curriculum for this educational program.
Transitioning out of the ICU: The move from an ICU to a regular floor can be very stressful. Now, when patients transition from the Cardiovascular ICU (CVICU) to the floor, RNs from both areas perform a hand-off with the patient in the room with a focus on pain management requirements. Patients have a direct say in their care and in how their pain is managed.
Including Families on Multidisciplinary Rounds: For several years, families have routinely been invited to stay in the patient’s room during the exam and discussion in many of our ICUs. However, we believe this involvement should be expanded. In October of this year, we will begin a pilot to actively invite and include families on multidisciplinary work rounds. In order to help in moving the field forward, we are planning a meticulous effectiveness evaluation of this strategy, using time/motion analyses and the FS-ICU as outcome measures.
Standardized Communication at ICU Admission: Our Advisory Council provided guidance on what kinds of information was most helpful in the first day of a patient’s stay. This new introductory brochure covers information on staff roles in the ICU as well as the day-to-day logistics of visiting (such as parking). It also provides pointers to additional information and information about how family members should take care of themselves during this trying time.
Spiritual Care: Chaplaincy staff now actively solicit patient/family needs by pro-actively rounding in the ICUs. Spiritual care satisfaction scores have more than doubled (p =0.005). Our chaplaincy was recently covered in a major metropolitan newspaper.
Improving the Critical Care Experience
Waiting Room Revitalization: Our Advisory Council and FS-ICU results identified the waiting room as an important factor in satisfaction and a major opportunity for improvement. In spite of the economic challenges of the past year, our hospital dedicated capital to renovating a waiting room serving three of our ICUs. The renovation was designed with active input from our Patient/Family Advisory Council. Thus, the waiting room (now “Family Room”) included functions that are meaningful to our family. Opened in July 2009, we have seen marked improvement in the FS-ICU scores for the waiting room (p = 0.04).
Family Sleep Room: Providing the ability to stay close to loved ones is important. In tandem with our waiting room revitalization, we created two rooms to provide overnight accommodations for our families.
Eliminating Visiting Hours: Our Critical Care Executive Committee voted unanimously to support open access for families, eliminating formal visiting hours. This helps accommodate family members who work late and allows loved ones to visit at their convenience, rather than at ours.
Untethering Families from the ICU
Family Pagers: Our Advisory Council pointed out the feeling that they had to stay in or near the ICU at all times, in case anything happened. We now provide pagers (think Olive Garden) to families that allow them to go to the coffee shop, cafeteria, and nearby shops with the confidence that we can page them if they are needed. These have received rave reviews from families, nurses, and doctors alike.
Computers for ICU Families: Many families use email and social networking to update extended families and friends. Access to the web and email also allows some family members to keep up with some work/employment duties while being close to loved ones. In addition to ubiquitous wireless internet, we now provide public computers in our revitalized family room. These computers open a customized ICU website which includes links to online medical resources such as SCCM’s Official Patient and Family website.
CarePages: Our hospital contracted with Carepages to provide an infrastructure to support patient- and family-created blogs about their health challenge. These private and personalized web pages allow families to share the latest news with friends and family and receive messages of support, without the time and effort required to call large numbers of people.
This comprehensive, family-guided program focused on improving the family-centeredness of critical care in our nine adult ICUs. We believe there are two measures of evaluating its effectiveness:
Organizational commitment: In this challenging environment, hospitals cannot commit resources to ineffective programs. Besides being featured on our CEO’s blog, our medical center has supported this key effort in several ways. First, a half-time critical care nurse helps lead this work. Without this, our program would not have been successful. In addition, the Division of Critical Care Quality focuses the resources of the Director of Critical Care Quality (an MD) and a Masters-trained Critical Care Project Manager. Finally, we were fortunate to receive the capital support required for our waiting room revitalization.
Improvement in Outcomes: The FS-ICU provides an opportunity to rigorously measure family-centered outcomes of our work. In addition to statistically significant improvements in spiritual care and waiting room scores, we have seen consistent improvements in families’ rating of overall satisfaction with decision-making, which we believe represents a true outcome measure of our improvement work. In the baseline period (n=45 surveys), 40% of families reported complete satisfaction with their decision-making role. In the past six months, 66% of families report complete satisfaction with decision-making (n=95); in the past three months, 82% of families report this highest level of satisfaction (n=34). Mean decision-making satisfaction scores have correspondingly increased from 3.7 to 4.85 (p=0.005 for Spearman correlation between month and mean decision-making score).
1. Wall RJ, Engelberg RA, Downey L, Heyland DK, Curtis JR. Refinement, scoring, and validation of the Family Satisfaction in the Intensive Care Unit (FS-ICU) survey. Crit Care Med. Jan 2007;35(1):271-279.
Remember the 5S component of Lean process improvement? Well, it applies in all kinds of settings, not just clinical areas. Here are some examples from our Human Resources staff. Laurie reported: "A small group of us in Staffing took this Columbus Day to discover not a new land, but to reclaim our offices through 5S!"
Thursday, October 15, 2009
I just finished participating in a panel discussion at BlogWorld & New Media Expo at the Las Vegas Convention Center. Except I was in Boston. We had hoped to have a video link, but that didn't work out, so I joined by telephone.
Here's a picture of our panel, provided by Dr. Val Jones, entitled, "The value of blogs to hospitals, news organizations, and industry." Shown are moderator Gary Schwitzer (Health News Review), Marc Monseau (Johnson & Johnson's JNJ BTW Blog), Bob Stern (MedPage Today), and me. I offer the closeup of me in case it is unclear in the top picture.
Update on October 20: Here's a video clip from Dr. Anonymous. October 22: An another on You Tube.
A certain US Senator approached Robeson and addressed him as "Professor." Robeson, confused, said, "Senator, I am not a professor. Why do you call me that?"
The reply, "Well, normally, I would call you nigger, but I can't use that term in this White House, so I'll just call you Professor."
Note: Picture courtesy of Wikipedia.
Wednesday, October 14, 2009
Thyroid cancer survivors and families from around the United States, as well as Canada, Brazil, and United Kingdom, will gather in Danvers, Massachusetts, on October 16-18, 2009, to learn from expert physician specialists about the latest research in thyroid cancer, during the 12th International Thyroid Cancer Survivors' Conference.
Speakers at the more than 100 sessions at the Sheraton Ferncroft Hotel at 50 Ferncroft Road, Danvers, Massachusetts, include more than 30 medical professionals, mental health professionals, an attorney, other specialists in well-being, and thyroid cancer survivors and caregivers. There are speakers about each type of thyroid cancer (papillary, follicular, medullary, anaplastic, and variants), for people of all ages at all phases of testing, treatment, and follow-up.
This educational and supportive event is FREE to anyone who requests a scholarship to cover the $50 registration fee (or $30 for one day). Walk-in attendees are welcome.
For the complete program schedule and further conference details, click here, call 1-877-588-7904, or e-mail to thyca [at] thyca [dot] org.
Last night, the folks at South Cove kindly sponsored a welcoming celebration for our new chief of Obstetrics and Gynecology, John Yeh. Here's a picture of some of those attending. From left to right, they are: Dr. Hee Man Chie, OB SCCHC; John; Helen Chin Schlichte, BIDMC Board of Directors; Dr. Steven Tang, SCCHC Founder and Board Member; April Tang, SCCHC Founder and Board Member and BIDMC Overseer; and Cindy Chen, SCCHC Board Member.
Judith Kurland, Mayor Menino's Chief of Staff, offered greetings on behalf of the Mayor. John presented his plans for the OB/GYN department and for continued close collaboration between BIDMC and South Cove. And, of course, the food was delicious!
MITSS holds one major fund-raising event each year, and it will be held on November 12 at the Boston Marriott Copley Place. Proceeds from the event will be used to fund support groups for patients, families, and clinicians; individual counseling; phone support and referral assistance. MITSS also work with health care organizations to assist them in setting up an internal process for supporting their clinicians.
The keynote speaker for the event is Susan E. Sheridan, Co-founder and President of CAPS, Consumers Advancing Patient Safety, which focuses on creating a partnership between consumers and providers of care.
MITSS is an organization worthy of support. For more information, click here.
Why? Because many insurance plans adopted as part of collective bargaining agreements would be covered by the Senate-proposed tax. There will be no such provision in the House bill.
As reported by the Commonwealth Fund, members of the House are already gearing up on this issue.
It would be a odd policy choice, indeed, if the Democratic majority gives a special exemption to union health plans while taxing non-union benefits.
A more democratic approach and one that takes advantage of the existing progressivity of the US tax system would be to eliminate or scale back the current tax exemption for all employer sponsored insurance plans. Higher income taxpayers (whether union members or not) with higher marginal tax rates would pay proportionately more under that kind of proposal.
But I predict that you will not see a real public debate on this issue. It will be decided in the closed door sessions of the conference committee and placed before both houses as an understated component of the final bill. It will be a bargaining chip that the House uses in returning for giving up the public option insurance plan. The Obama administration, which feels it owes its existence to major financial and organizational support from the SEIU and other unions but has been unable to deliver on explicit pro-labor bills, will be quietly lobbying in this manner.