Two stories about transparency

Here are a couple of stories about transparency of clinical outcomes. I present them for your review and comment.

The first is one from the Los Angeles Times, entitled "'Error-free' hospitals scrutinized." Here are some excerpts:

California public health officials are scrutinizing hospitals that claim to be error-free, questioning whether nearly 90 facilities have gone more than three years without any significant mistakes in care.

Eighty-seven hospitals — more than 20% of the 418 hospitals covered under a law that took effect in 2007 — have made no reports of medical errors, according to the California Department of Public Health.

The high percentage has raised concerns that errors have gone unreported. Some patient advocates say it is an indication that hospitals are unwilling to police themselves. State officials have given hospitals until Tuesday to verify their records as error-free or to report errors, as required by law.

Next, a report from The Health Foundation in the United Kingdom. Martin Marshall, Clinical Director and Director of Research and Development, and the late Vin McLoughlin, Director of Quality Performance and Analysis, have published a paper called, "How might patients use information comparing the performance of health service providers?" It is on the BMJ website. They note:

There is a growing body of evidence . . . describing what happens when comparative information about the quality of care and the performance of health services is placed in the public domain. The findings from research conducted over the last 20 years in a number of different countries are reasonably consistent and provide little support for the belief that most patients behave in a consumerist fashion as far as their health is concerned. Whilst patients are clear that they want information to be made publicly available, they rarely search for it, often do not understand or trust it, and the vast majority of people are unlikely to use it in a rational way to choose ‘the best provider’. The evidence suggests that the public reporting of comparative data does seem to play a limited role in improving quality but the underlying mechanism is reputational concern on the part of providers, rather than direct market-based competition driven by service users.

. . . How should policy makers, managers and clinicians respond to these findings? Some might be tempted to suggest that we should focus only on those who work in the health service and discount patients as important stakeholders. We believe that this would be wrong. The public has a clear right to know how well their health system is working, irrespective of whether they want to use the information in an instrumentalist way. Improving the relevance and accessibility of the data should be seen as a good thing in its own right and may start to engage a large number of people in the future.

. . . That patients might want to view health as something other than a commodity presents a conceptual as well as a practical challenge to those responsible for designing and producing comparative performance information. We suggest that for the foreseeable future presenting high quality information to patients should be seen as having the softer and longer term benefit of creating a new dynamic between patients and providers, rather than one with the concrete and more immediate outcome of directly driving improvements in quality of care.

Sign congestion

Sometimes, with "new eyes," you see things you walk by every day. As I went to visit a sick friend yesterday, not as the hospital CEO but just a visitor, here was the scene I found at the elevator in one of our main lobbies.

Each one of these signs was likely added for good reason. But, in combination, they are problematic -- too cluttered.

Also, they are not culturally competent. The blue sign on the left has several languages. None of the others do.

Perhaps it is time for a Lean rapid improvement event about our signs.

Is this normal?

This is a story about consumer choice using publicly available information. Unfortunately, it is also about the power of suggestion as used by an incumbent provider organization.

The friend who sent me this note is a research fellow at one of the Boston teaching hospitals, so I guess he is more likely than most to do the kind of research he summarizes. Most people would have taken the referral advice offered without question. If they ever did ask to see a different doctor, most would never get past the "need" for asking for "special permission."

Hi Paul,

I had a strange encounter, and I was wondering if you could tell me if this is normal.

A few months ago my primary care physician recommended I see dermatology for my eczema. His clinic recommended the names of two dermatologists within the same health care system. I looked up both dermatologist on healthgrades.com and found that their patients had given them luke-warm reviews. (There were many reviews, so this wasn't a sampling problem). Also, I have been reading the medical literature about eczema, and knew there were a lot of recent advances, so I wanted somebody who had published and was familiar with the research.

I found another dermatologist, Dr. Caroline Kim. Her patients loved her (according to healthgrades.com), she had published articles in dermatology research (from scholar.google.com), and she trained at top institutions: Harvard Medical School and MGH. I made an appointment with her.

I called my PCP and asked for a referral. The receptionist told me Dr. Kim was "out of network" and they would have to ask my PCP for special permission. I thought this was odd because I had Blue Cross PPO insurance (not HMO), so as far as I knew, there was no "out of network".

A month later, my referral had not been sent. I called my PCP again, and asked for them to send it. After I gave her the name and phone number of the dermatologist, this was the conversation.

Receptionist: I am sorry, that is out of network. We will have to check with Dr. X.

Me: What does "out of network" mean? I thought I had PPO insurance.

Receptionist: You won't get the best care if you go out of network.

Me: Is this a [health care system] policy?

Receptionist: We might not know what medications you are prescribed if you go out of network. Your medical records might not get transferred back to our office.

Me: Is this a [heath care system] policy?

Receptionist: Yes.

A week later I had my referral.

It seems like this health care system is using an insurance term -- "out of network" -- to trick patients into going to specialists that work for the same company. Am I wrong?

En route to True North

"True North" is a key concept in Lean process improvement. It might be viewed as a mission statement, a reflection of the purpose of the organization, and the foundation of a strategic plan.

Here are illustrative thoughts from two observers:

The "ideal vision" or "True North" is not metrics so much as a sense of an ideal process to strive for. It sets a direction, and provides a way to focus discussion on how to solve the problems vs. whether to try.

If we don't know where we're going, we will never get there. "True North" expresses business needs that must be achieved and exerts a magnetic pull. True North is a contract, a bond, and not merely a wish list.

Lean is inherently the most democratic of work place philosophies, relying on empowerment of front-line staff to call out problems. The definition of True North, however, does not rely on that same democratic approach. Instead, it is established by the leadership of the organization.

At BIDMC, we have been engaged in a slow and steady approach to adoption of Lean. Our actions have been intentionally characterized by "Tortoise not Hare," as we methodically train one another, carry out rapid improvement events, and integrate the Lean philosophy into our design of work. As you have seen on this blog, staff members have come to embrace Lean and have used it in a variety of clinical and administrative settings.

(For more examples, enter "Lean" in the search box above. I have been presenting them here for some time in the hope that they would be useful to those in other hospitals who are thinking of adopting this approach.)

We have intentionally not, until now, tried to define True North, but things have now progressed sufficiently in terms of our application of the Lean philosophy that the organization is crying out for it. This is just as we had hoped. Establishment of True North before this time, i.e., without an understanding of its role, would not have been as useful in our hospital.

So, the clinical and administrative leaders recently met to try to nail this down. The process is not over. Indeed, our Board of Directors has yet to pitch in and offer their thoughts. But, we are far enough along that I thought you would enjoy seeing the draft.

Here it is:

BIDMC will care for patients the way we want members of our own families to be treated, while advancing humanity's ability to alleviate human suffering caused by disease. We will provide the right care in the right environment and at the right time, eliminating waste and maximizing value.

Here is some commentary to help you interpret and deconstruct this. The first sentence is based on the long-standing tradition of our two antecedent institutions, the New England Deaconess Hospital and the Beth Israel Deaconess hospital. The late doctor Richard Gaintner used to refer to the Deaconess as, "A place where science and kindliness unite in combating disease." That could just as well have been applied to the BI. As an academic medical center, our public service mission of clinical care is enhanced by -- and enhances -- our research and education programs. Our mission is to help humanity, not just the people who live in our catchment area.

The second sentence is offered in realization that the Ptolemaic view of tertiary hospitals as the center of the universe is no longer apt (if it ever was!) We need to view ourselves as being in service to primary care doctors, community hospitals, and other community-based parts of the health care delivery system.

On another level, it is also reflective of the fact that society expects us to be more efficient both within our own walls and in cooperation with our clinical partners, adopting approaches to work that do not waste societal resources.

In contradistinction to what I just said about this not being a democratically established statement, I offer our draft to you -- both those within BIDMC and worldwide -- for your criticism and suggestions. I don't know of other places that engage in this form of crowd-sourcing with regard to True North, but readers of this blog are unusually informed about health care matters, and I welcome your observations.

Behind the scenes

Recent international negotiations have reached a very high level. We were able to get security clearance and obtain this picture from behind the scenes. Sorry, but I cannot divulge the location or tell you which countries were involved.

Painfully slow

You can already imagine the responses. "That's just in North Carolina." "Our patients are sicker." "There are problems with the data."

What would prompt that? This New York Times article, citing a forthcoming NEJM study about medical errors in North Carolina. Here's the lede:

Efforts to make hospitals safer for patients are falling short, researchers report in the first large study in a decade to analyze harm from medical care and to track it over time.

The study, conducted from 2002 to 2007 in 10 North Carolina hospitals, found that harm to patients was common and that the number of incidents did not decrease over time. The most common problems were complications from procedures or drugs and hospital-acquired infections.

Other excerpts:

Dr. Landrigan’s team focused on North Carolina because its hospitals, compared with those in most states, have been more involved in programs to improve patient safety.

But instead of improvements, the researchers found a high rate of problems.

. . . The findings were a disappointment but not a surprise, Dr. Landrigan said. Many of the problems were caused by the hospitals’ failure to use measures that had been proved to avert mistakes and to prevent infections from devices like urinary catheters, ventilators and lines inserted into veins and arteries.

And another:

Dr. [Bob] Wachter said the study made clear the difficulty in improving patients’ safety.

“Process changes, like a new computer system or the use of a checklist, may help a bit,” he said, “but if they are not embedded in a system in which the providers are engaged in safety efforts, educated about how to identify safety hazards and fix them, and have a culture of strong communication and teamwork, progress may be painfully slow.”

Exactly right, Bob! What does it take to motivate this profession? What does it take to make process improvement part of medical school and residency training programs.

Painfully slow, and painful or worse to patients.

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Addendum: Dr. Wachter also discusses this study on his blog, here.

Things we are grateful for this year

For three years running now, many of us bloggers have participated in what we’ve called a “blog rally” to promote Engage With Grace – a movement aimed at making sure all of us understand, communicate, and have honored our end-of-life wishes.

The rally is timed to coincide with a weekend when most of us in the United States are celebrating Thanksgiving and are with the very people with whom we should be having these unbelievably important conversations – our closest friends and family.

At the heart of Engage With Grace are five questions designed to get the conversation about end-of-life started. We have included them at the end of this post. They are not easy questions, but they are important -- and believe it or not, most people find they actually enjoy discussing their answers with loved ones. The key is having the conversation before it’s too late.

This past year has done so much to support our mission to get more and more people talking about their end-of-life wishes. We’ve heard stories with happy endings … and stories with endings that could have (and should have) been better. We have stared down political opposition. We have supported each other’s efforts. And we have helped make this a topic of national importance.

So in the spirit of the upcoming Thanksgiving weekend, we’d like to highlight some things for which we’re grateful.

Thank you to Atul Gawande for writing such a fiercely intelligent and compelling piece on “letting go”– it is a work of art, and a must read.

Thank you to whomever perpetuated the myth of “death panels” for putting a fine point on all the things we don’t stand for, and in the process, shining a light on the right we all have to live our lives with intent – right through to the end.

Thank you to TEDMED for letting us share our story and our vision.

And of course, thank you to everyone who has taken this topic so seriously, and to all who have done so much to spread the word, including sharing The One Slide.



We share our thanks with you, and we ask that you share this slide with your family, friends, and followers. Know the answers for yourself, know the answers for your loved ones, and appoint an advocate who can make sure those wishes get honored – it’s something we think you’ll be thankful for when it matters most.

Here’s to a holiday filled with joy – and as we engage in conversation with the ones we love, we engage with grace.

To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team. Please feel free to join our blog rally by copying this post and putting it on your own blog for this holiday weekend.

Checklists ain't all

I am often approached by people who have read Atul Gawande's excellent work and who ask me if we use checklists to improve the quality of care in our hospital. We do, in order to reduce variability where appropriate, but stating the issue in terms of checklists is simplistic. This 2009 Lancet article by Charles Bosk, Peter Pronovost and others, entitled "Reality check for checklists," states it clearly:

The emphasis on checklists is a Hitchcockian “McGuffan”, a distraction from the plot that diverts attention from how safer care is really achieved. Safer care is achieved when all three—not just one—of the following are realised: summarise and simplify what to do; measure and provide feedback on outcomes; and improve culture by building expectations of performance standards into work processes. We propose that widespread deployment of checklists without an appreciation of how or why they work is a potential threat to patients' safety and to high-quality care.

Transparency and "dial tone" to fight market power

Back in August, I raised the question of whether the move to Accountable Care Organizations and capitated payments would lead to market dominance and a resulting reduction in competition in certain geographic areas. The summary of the argument was this:

On the one hand, ACOs offer the potential for a better integration of care across the spectrum of primary care, hospitalization, skilled nursing, rehabilitation, and hospice. If the ACO faces an annual budget per patient under a capitated payment scheme, there is an incentive to avoid unnecessary tests and procedures and also to help direct patients to the most cost-effective component of the health care continuum.

On the other hand, if an ACO becomes the dominant provider in a region and especially if it has a electronic health record that is not interoperable with others in the region, that ACO will have substantial market power and will negotiate a higher global payment than would occur in a more competitive marketplace.

Robert Pear raises similar questions in an article in the New York Times. Here are some excerpts:

[E]ight months into the new law there is a growing frenzy of mergers involving hospitals, clinics and doctor groups eager to share costs and savings, and cash in on the incentives. They, in turn, have deployed a small army of lawyers and lobbyists trying to persuade the Obama administration to relax or waive a body of older laws intended to thwart health care monopolies. . . .

. . . Consumer advocates fear that the health care law could worsen some of the very problems it was meant to solve — by reducing competition, driving up costs and creating incentives for doctors and hospitals to stint on care, in order to retain their cost-saving bonuses.

A related concern was raised by Attorney General Martha Coakley in a speech last week to the MA Association of Health Plans, as reported by Matt Murphy of the State House News Service:

Attorney General Martha Coakley cautioned Friday against a "full-scale push forward" on global payment reform to address spiraling health care costs without addressing the underlying issue of market clout that has led to a disparity in pricing among providers without any clear link to quality of care.

. . . [S]he has directed her staff to resume its effort of examining the health care market in Massachusetts to study models of care delivery and the associated costs.

. . ."A shift to global payments by itself is not the panacea to controlling costs," Coakley said. "Implementing payment reform without addressing the market leverage issue outlined in our report is like trying to fix the roof on a house without fixing the flawed foundation."

Because anti-trust regulatory action is often ineffective against market dominance, we should focus on self-reinforcing policy initiatives to mitigate against this possibility. Here are two suggestions.

The first is one mentioned often on these pages: Total transparency of rates paid by each insurance company to each provider. In Masachusetts, a good first step along these lines was taken by the Legislature and Governor Patrick this past summer. Only when subscribers can see the actual rates being paid will there be the moral force to ensure that rates are reasonably related to factors other than market power.

The second idea is a simple as dial tone: Complete interoperability of medical records among providers. As long as proprietary electronic medical record systems exist, a given provider network can control the degree to which patients can choose lower priced or higher quality doctors and hospitals outside of that network.

Instead, we need the equivalent of the "magic button" described in this post by our CIO, John Halamka, demonstrating interoperability between our hospital and Atrius, the state's largest multi-specialty practice:

By working with Epic and Atrius, we enabled a "Magic Button" inside Epic that automatically matches the patient and logs into BIDMC web-based viewers, so that all Atrius clinicians have one click access to the BIDMC records of Atrius patients.

If this capability existed among and between all provider systems, consumer choice would be possible. Without it, a dominant network will remain dominant.

A defining moment at Risky Business

Lord Ian Blair led London's Metropolitan Police through the investigations of the multiple bombings of July 7, 2005 and all that followed. His lessons about chain of command and the like are valuable to those who have to deal with disasters and emergencies. He presented this at the Risky Business conference in London this week.

If you cannot view the video, click here.

BP Oil Spill at Risky Business

Here is a very good perspective on what went wrong to cause the explosion on the BP Deepwater Horizon drilling rig and the resultant oil spill, presented by Nick Coleman, VP in charge of Group Safety Performance Reporting until three years before the incident. He is now non-executive chair of the Risk and Safety Committee of Royal Brompton Hospital. He presented this at the Risky Business conference in London this week.

If you cannot view the video, click here.

Everest disaster at Risky Business

Dr. Ken Kamler is a surgeon who also has served as doctor on some of the world's most daring expeditions, including the ill-fated climb up Mt. Everest in 1996. He told that story in this presentation at Risky Business in London this week.

If you cannot see the video, click here.

Reconciliation at Risky Business

Jo Berry is founder of a charity called Building Bridges for Peace. Patrick Magee, PhD, was sentenced to life imprisonment for the Brighton Bomb which he set off as a member of the Provisional Irish Republican Army in 1984. He was released in 1999. For 10 years he has worked for peace with Jo Berry, whose father he killed at Brighton.

They offered this discussion at Risky Business in London yesterday.

If you cannot see the vido, click here.

Sekou at Risky Business

You last met Sekou Andrews on this blog after his performance at last year's IHI Annual Forum. He was back in good form today at the Risky Business conference in London. Here is a video of his presentation.

if you can't see the video, click here.

Pedro Algorta at Risky Business

The Risky Business conference in London just ended. Here's a video of one of the most moving talks of the two-day session. Pedro Algorta was one of the survivors of the Uruguayan rugby team that was on an airplane that crashed into the Andes air crash many years ago (Alive!). Note his elegant and simple style and the wisdom of his remarks.

If you can't see the video, click here.

Risky decision-making

I am back in London for a short stay to attend a conference entitled Risky Business, organized by Great Ormond Street Hospital for Children, the National Health Service, and BMJ Group. Allan Goldman, the conference director, says:

The aim of this conference is to hear from some of the highest achievers in other high risk industries on the topics of risk, human factors, patient safety, teamwork, leadership, and improvement.

The presentations have been among the best I have heard anywhere. There are several I would summarize, but for now, please consider watching this one by Pat Croskerry, Professor in Emergency Medicine at Dalhousie University, Halifax, Nova Scotia.



Croskerry's exposition compares intuitive versus rational (or analytic) decision-making. Intuitive decision-making is used more often. It is fast, compelling, requires minimal cognitive effort, addictive, and mainly serves us well. It can also be catastrophic in that it leads to diagnostic anchoring that is not based on true underlying factors.

Why is it addictive? Croskerry describes the "cognitive miser function," a tendency to get comfortable with the form of decision-making that you find most used and useful.

The problem, of course, is that the overall rate of diagnostic failure is about 15%, and most of those diagnoses are made based on the intuitive approach. Not that the analytic approach is always correct, either. Indeed, in studies of factors contributing to failures to diagnose, cognitive errors alone or in part account for about 75% of the cases.

Croskerry thinks we need to spend more time teaching clinicians to be more aware of the importance of decision-making as a discipline. He feels we should train people about the various forms of cognitive bias, and also affective bias. Given the extent to which intuitive decision-making will continue to be used, let's recognize that and improve our ability to carry out that approach by improving feedback, imposing circuit breakers, acknowledging the role of emotions, and the like.

While you are at it, check out the video of this presentation by Duncan Murrell, who employs intuitive decision-making while photographing humpback whales -- sometimes in the middle of a feeding frenzy -- from a kayak in Southeast Alaska. (You can see the photographs up close here.)

If you can't see the videos, click here.

MLB praises Red Sox Scholars program

Here's some very nice recognition by Major League Baseball for the Red Sox Scholars program, for which BIDMC is the Presenting Sponsor. Here are some excerpts from the announcement:

Major League Baseball announced today that the Boston Red Sox have been named the recipient of the inaugural Commissioner's Award for Philanthropic Excellence. Created by Major League Baseball and chosen by a Blue Ribbon Panel comprised of Commissioner Allan H. (Bud) Selig and MLB Executives, the award recognizes the Red Sox extraordinary charitable programs, run by the Red Sox Foundation, which have resulted in significant and sustained community impact.

Commissioner Selig presented the club with the award today at the Industry Meetings in Orlando, FL. . . .In singling out the Red Sox for this prestigious award, the Commissioner praised the depth of the Red Sox charitable programs and specifically the impact of the Red Sox Scholars program, the educational cornerstone of the Red Sox Foundation.

... said Commissioner Selig. "I congratulate the entire Boston Red Sox organization, and particularly the Red Sox Foundation, for their commitment to the future of hundreds of young people from the inner-cities of Boston."

... Each year, the Red Sox select 25 academically talented, economically disadvantaged Boston Public School students in 5th grade as Red Sox Scholars. Through the program, run by the Red Sox Foundation, the Scholars receive tutoring, mentoring, after school enrichment opportunities, summer camp assistance, and other leadership development activities. Red Sox Foundation staff members work with the Scholars intensively in 6th through 12th grades and each Scholar is awarded a $10,000 college scholarship redeemable upon graduation from high school with enrollment in an accredited college, and on condition of continued good citizenship. There are currently 200 Red Sox Scholars with members of the first class selected in 2003 now college freshmen.

The Red Sox Scholars program is presented by Beth Israel Deaconess Medical Center (BIDMC), the Official Hospital of the Boston Red Sox. Over the years, almost 200 BIDMC physicians, nurses, medical technicians and administrators have been individually paired with the Scholars as Medical Champions. BIDMC also hosts "Shadow Days" for the Scholars each year, giving them an opportunity to visit the Neo-natal Intensive Care Unit, the Simulation Center and Skills Lab, and other parts of the medical center to be exposed to a variety of careers in medicine.

ED report card

An emergency department in an academic medical center has an important educational role in training the next generation of emergency medicine doctors. There are at least two measures of how well it is doing. The first is how desirable the program is viewed by potential residents. The second is how well those residents do in their annual examinations.

Here is the trend in our place. Each year we admit about a dozen residents. Note the growth in applicants year to year in the top chart.


And the chart underneath shows their performance on the standardized examination. Nicely above average year after year for all three classes of residents.

The US dialysis program -- How good and how bad?

A recent article in ProPublica by Robin Fields contains a number of strong criticisms of the US dialysis program for people with kidney disease. Here's an excerpt:

Now, almost four decades later, a program once envisioned as a model for a national health care system has evolved into a hulking monster. Taxpayers spend more than $20 billion a year to care for those on dialysis -- about $77,000 per patient, more, by some accounts, than any other nation. Yet the United States continues to have one of the industrialized world's highest mortality rates for dialysis care. Even taking into account differences in patient characteristics, studies suggest that if our system performed as well as Italy's, or France's, or Japan's, thousands fewer patients would die each year.

NPR's Terry Gross recently interviewed both Robin Fields and Barry Straube, Chief Medical Officer for Medicare. The interviews are worth hearing or reading. Here's an excerpt from Dr. Straube's interview:

I believe that Robin's article, although pointing up some very important issues that this agency and the Department of Health and Human Services is aware of and trying its best to fix, that it overstates significantly the degree of the problem out in the real world. It makes it sound like any dialysis unit that a patient would walk into is subject to these problems and that's simply not true. The vast, vast majority of the units are not as described in the several examples, which are completely true examples but not illustrative of most dialysis units.

I think my main quibble with the article is that it sounds as though one would not want to have dialysis in the United States. This is a life-saving treatment that the vast majority of people are being treated very well in very clean facilities that hopefully make very few mistakes. And the examples there are not indicative of most dialysis units.

I conclude, having read and heard both, that there are elements of truth in the article about this kind of care and need for improvement. However, the magnitude of the problem seems to me to be less than reported. I welcome your thoughts.

Middle school explorers in BIDMC Labs

Harvard Medical School's Office for Diversity and Community Partnership created the Explorations program to enhance science and math curricula outside the classroom. The program links faculty, research associates, and medical students with Boston and Cambridge sixth, seventh and eighth grade students. They get hands-on exposure to research laboratories and get to hear about science career paths. The hope is to get them excited about the sciences.

Four students from the William Barton Rogers Middle School in Hyde Park spent a morning at BIDMC with Parameswary Muniandy, PhD, a pathology research fellow studying brain cancer. “Early exposure to science and how research works really helps them develop an interest in science,” said Muniandy. She helped the students feel like real researchers by putting on lab coats and gloves.

You can watch the excitement in this video. If you can't see the video, click here.

Some grades are in

In a comment below, Jim Conway offers some data from the Commonwealth Fund that sheds light on the question posed. I have copied the summary above.

Recall that the proposition was: "There is lots of evidence that Massachusetts health care is the best in the country." We get excellent grades for access and equity. This is not surprising given the state's universal insurance coverage law.

We do well on "healthy lives," too, but I do not know how much of that derives from the health care system as opposed to relative lifestyle (smoking, obesity, and the like) in the Bay State.

But we clearly have a problem when it comes to overuse of the hospital system. Also, the performance with regard to standard indicators of care is not exemplary.

Prove it!

A well regarded local hospital administrator last week said, "There is lots of evidence that Massachusetts health care is the best in the country." The context was a discussion in which it was pointed out that health care costs in Massachusetts are above the national average, even adjusted for wage differences. The statement was made to suggest that it is worth paying a bit more if what we actually get is better.

I was taken aback. I have never seen any evidence to support this conclusion. Would anyone care to offer quantitative support for the proposition -- or against it?

A mission to a tiny country

This week, doctors from the BIDMC Division of Urology are heading off to the Cape Verde Islands to provide a much needed service and to teach for future improvement in this area of care. Dr. Michael Kearney is leading the group.

The goal of this mission is to do an initial assessment of the need for urological specialty care, while diagnosing and possibly treating a number of patients while there. The team believes they will be seeing approximately 100 patients over 4 days.

But what I really like, too, is that our Interpreter Services Department offered to join in, selflessly concluding that this would be a great opportunity to assist in the development of this service.

In all, three BIDMC Cape Verdean interpreters, two Chief Residents from BIDMC, and one doctor from the Miriam Hospital, are joining Dr. Kearney on this mission.

Through the generosity of the Cape Verdean consulate in Boston, TACV airlines, the clinics in Cape Verde to be visited, and Nobidade TV media, expenses for travel will be kept to a minimum.

Please join me in wishing them all well.

Rolling Thunder

Newton Girls Soccer team Thunder ended the fall season with a triumphant 7-1-2 record, clinching the championship of their section of under-14 players. Congratulations to all!

What does "true essence" taste like?

Continuing my admittedly obsessive occasional series about the water served in hotel conference rooms, I now present this Norwegian one from a meeting today. This one had to travel 3500 miles. But unlike the decantered blueberry water or the plastic bottled water from the other side of the globe served at other hotels, this water is shipped thousands of miles in a glass bottle.

How about that bottle! We learn from the company website that the designers "utilized the depth of their experience from the cosmetic industry in understanding how to create a brand personality that differentiates itself through the entire experience, reflecting the true essence of the brand."

Cost: $2 per bottle for about 12 ounces, roughly the cost of 350 gallons of tap water in Boston.

After a taste test last year, our hospital switched from bottled water to tap water for meetings. We decided that the "true essence" of bottled water did not add to its taste.

Bravo, Dr. Ring!

Health Care on MSNBC.com reports about a recent article in the New England Journal of Medicine about a surgeon's operating room error in Boston. What makes the article unusual is that it was written by the doctor who made the mistake.

Dr. David Ring from MGH presents a clear and understandable summary of the case, what went wrong, how he handled the disclosure to the patient, and many other important details.

He says, “Just imagine the worst thing that’s ever happened to you and that’s how it feels. I don't want anybody to make the same mistake I made."

In writing this article, Dr. Ring follows in the footsteps of Dr. Ernest Amory Codman, an MGH doctor from decades ago: "Dr. Codman made public the end results of his own hospital in a privately published book, A Study in Hospital Efficiency. Of the 337 patients discharged between 1911 and 1916, Dr. Codman recorded and published 123 errors."

Congratulations to Dr. Ring and to MGH for taking this step. As we have found in our own case, wide disclosure of such errors is the best way to learn from them and help avoid them in the future. It also sends a clear message to other clinicians that reporting of errors will be handled in a just manner.

Addendum to my original post (now edited), with still more thanks to Dr. Ring:

As another interesting twist to this, the first web article about this was a case of "wrong-site journalism" which unfortunately I got caught up in as well. The first article implied that this was a wrong side surgery. But it was the wrong surgery on the correct side, not wrong side surgery. The MSNBC.com piece has a disclosure of the error on the top of the page now. Oddly enough, I wrote my original post with the wrong interpretation -- even though I read the NEJM article. Apparently I got trapped by my own bit of cognitive anchoring by reading the earlier MSNBC.com article! As Dr. Ring says in a note to me: "To err is clearly human, which only helps emphasize the points that we all believe are so important to make."

Do I hear someone kicking a can?

Robert Lowes, in Medscape Medical News (sorry, password protected) reminds us:

Physicians face a 23% cut in Medicare rates on December 1 and another on January 1 that pushes the total to roughly 25%. Both are triggered by the controversial sustainable growth rate (SGR) formula that Medicare uses to set physician pay. Put simply, the reductions represent the program's attempt to collect several hundred billion dollars that it has overpaid physicians since 2002. This debt has built up because every year Congress has postponed SGR-mandated reductions. The cost of merely freezing current Medicare rates through 2020 as opposed to cutting them as planned would amount to $276 billion, according to the Congressional Budget Office.

Kaiser Health News says:

If Congress fails to overturn the cuts this time, doctors could reconsider taking new Medicare patients* or change how they participate with the program, (AMA President) Wilson warned in an interview with Kaiser Health News. "What we're saying to them and what we want seniors to say to them is, 'You're threatening our access to care. If physicians cannot keep their doors open because Medicare now only pays about half the direct cost of running a practice, then we're going to lose access to care,'" Wilson told Kaiser.

Another article notes,

The AMA is campaigning for a 13-month extension, rather than a shorter extension until Congress reconvenes next year, taking advantage of the completely Democratic Congress. The Democrats will put the cuts on the legislative agenda this month.

Of course, the trade organizations for every physician group are also at work on the issue, from optometrists to family practice doctors to hematologists.

Most people think that Congress will just kick the can down the road a bit more with a short-term postponement. Why? Because a permanent fix would bust the federal budget rules. A reminder, too: The Congressional Budget Office analysis of the recently passed health care bill assumed that this reimbursement reduction would go ahead as planned.

I don't know what long-term fix will be used for this problem. Thoughtful observers like BU's Austin Frakt have come up with proposals, but such plans are unlikely to be adopted during a lame-duck session.

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* I do not believe this option is open to private practice doctors in Massachusetts. Can someone validate that for me? In any event, though, hospitals and doctors working in hospitals cannot exercise this option.

Extra security

Being a security guard at a hospital brings with it unexpected situations and challenges that call on one's training, skills, and composure. Here's a note from last Friday to our chief of security from a nurse who happened to be near our front entrance at the right time:

Hi,

I am a nurse on 5/6 Feldberg who was in the Feldberg Lobby yesterday afternoon when a Code Blue* was called -- Location Feldberg circle outside the front door on the sidewalk. I ran out the door and found a man in a wheel chair being helped out of a car by two Public Safety Officers, Marianne Hughes and Platini Pontes. They both said "He is not breathing."

Immediately the three of us jumped into action. We put the patient onto the sidewalk from the wheelchair. Marianne started doing chest compressions immediately. I was trying to get the man's clothing off to be able to do better compressions. Platini was trying to manage the crowd and initial surge of people rushing towards the patient. Marianne did compressions for a while, and then I relieved her.

The patient did get a heart beat back and was transferred to the ER. When the code was over I went looking for the two of them, as I wanted to tell them what a great job they had both done. I was only able to locate Marianne. She was a little upset as this was the first Code Blue she had ever participated in. I told her that she performed outstandingly, as did Platini.

One of the most important things in a cardiac arrest is prompt CPR, which we initiated immediately. Quick thinking on the officers' parts contributed to this man coming back to life. I can not praise their actions enough. I hope you can acknowledge their performance in a special way as they definitely deserve a commendation.

Pam McBurnie, RN

The chief replies:

Pamela:

I appreciate your taking the time to provide such positive feedback on Marianne Hughes and Platini Pontes.

I am very proud of them. Marianne said that you were terrific and so supportive.........so thank you too.

Chris

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* Code Blue = A message announced over a hospital's public address system, indicating that a cardiac arrest requiring CPR is in progress.

I'm sorry, Doctor Famous is busy

What happens when a referring doctor insists that "Doctor Famous" see his or her patient, even when other physicians on the staff can do the job just as well? In Lean terms, waste is introduced into the system. As diagnosed below: The minute an additional seemingly unnecessary step is added to the flow it adds a huge delay. Here's an example:

A patient needed a certain kind of ultrasound. The hospital-based surgeon helpfully made the appointment call for the patient, telling the scheduling attendant that the procedure had to be done by one of two specific radiologists. Those radiologists only schedule those particular scans for a few hours a week, so the attendant quite properly replied that the next available times would be a few weeks hence.

The patient later wrote me to complain: Why would this all take so long to get scheduled?

I passed along the complaint to our chief of service, Jonathan Kruskal, who wrote:

I just wanted to get back to you about the patient complaint about scheduling an anal fistulogram. You may be interested to know that we have reviewed the actual telephone discussions that took place during the scheduling. (I am enclosing the tapes - How's that for an analytical tool!)

We developed this technique here at BIDMC and are the recognized authorities in the US. All of our ultrasound faculty can do this procedure, which takes less than 5 minutes to complete. The process issue here is that this physician only wanted Bob Kane or me to do this.

Obviously, Bob and I are not scheduled to work in ultrasound every day. To rectify this I trained all our staff to do this so that the studies can be scheduled every day. If the doc had simply scheduled the study it could have been done on any day the patient chose, and Bob or I would happily have reviewed the study even if we had not actually done it. As we all know from work flow analyses, the minute an additional seemingly unnecessary step is added to the flow it adds a huge delay, which is what happened here. We have spoken to [the surgeon] about this, but s/he still prefers to have Bob or me do these.

We do these studies from 1-2:30pm because they can only be done on a single machine (no other local hospitals have these dedicated anal imaging machines) that requires time for setup and probe cleansing. It is this same ultrasound unit that we use for guiding liver biospies (by hepatologists) in day care each morning and for intraoperative ultrasound, so we need to keep it available during mornings when these typically take place.

We've been doing this for over 15 years. Patients are usually thrilled that we offer this unique high quality service. I've never had anybody complain about access before, especially since these are never urgent studies.

Protons killing cancer and our budget

Proton beam therapy is an effective modality for killing certain types of cancer cells. New England and the Northeast are fortunate to have a proton beam machine at Massachusetts General Hospital, where it has been in use for some time effectively treating patients. This is a valuable resource, serving the entire region and beyond.

But what happens when everyone wants one? Well, we see the medical arms race at work again.

These are huge (see graphic below) and very expensive machines, costing upwards of $150 million dollars. At that price, there should only be a very few in the entire country. Yet, as noted in a recent paper by Anthony Zietman, Michael Goitein, and Joel E. Tepper in the Journal of Clinical Oncology, "In the United States alone, seven centers are in operation and at least 10 more are likely to come into operation in the next decade." J Clin Oncol 28:4275-4279

Here's the map of existing facilities and others currently under development or construction, as posted on the web site of the National Association for Proton Therapy (NAPT). What will this look like in a few years?

There is no way this makes sense. As noted, the main value of these machines is in treating certain distinct forms of cancer. The problem occurs when one is purchased as a prestige item. Since there is not enough demand for its use for the appropriate cases, it starts to be used for other types of cancer that would ordinarily be treated with traditional forms of radiotherapy. The article notes:

Protons were used historically to treat relatively rare tumors that were located close to radiation-sensitive normal tissues. Recently, however, much more common cancers are also being treated with protons, notably prostate cancer and non–small-cell lung cancer. The published clinical data on proton therapy have been reviewed in several recent publications. These reviews have underlined the lack of level I evidence for a superiority of proton therapy.

In short, the purchasing hospital needs to figure out a way to amortize the cost, and so it starts using the machine for cancers that were more cost-effectively treated in other ways. The authors explain:

Because of the high capital cost of a proton therapy facility, when a hospital invests in a proton therapy center (or any other expensive new technology), it takes a very substantial financial risk. It has likely elected to reduce its investment in other important areas of health care, it needs to amortize its costs rapidly, and it needs ultimately to generate a profit. Thus, the use of protons becomes as much a business decision as a clinical one; creditors and investors may drive the utilization and potentially the patient mix.

Because of its prevalence, and because of the simplicity and hence economy of its treatments, prostate cancer has become the economic driver for many new proton facilities. Aggressive marketing and high rates of reimbursement mean that the treatment of prostate cancer with protons can be highly profitable. The pressure to undertake such profitable treatments is exacerbated when the success of the business model requires a high throughput of patients.

Who provides the money for these investments? Some is from philanthropists, but the major source is noted in this Forbes article by David Whelan and Robert Langreth:

Most of the $1.5 billion that has been sunk into or committed to building proton centers has come from investors hoping to make a profit. Even the proton center at the august M.D. Anderson Cancer Center in Houston is mostly owned by various investors.

And it appears that the reimbursement system may aggravate the situation, as Forbes notes:

Medicare pays twice as much for a round of protons as for X-rays: $34,000 for eight weeks of therapy versus $16,000.

And then elected officials get involved, too:

The centers have become magnets for politics. In Michigan the Beaumont hospital chain struck a deal with ProCure in 2007 and applied to the state for a license. Other hospital systems, including the University of Michigan and Henry Ford, protested, arguing instead for a consortium-run center. State regulators agreed. But Beaumont and ProCure refused to join and lobbied Michigan Governor Jennifer Granholm, who overruled the regulators last year.

President Eisenhower warned us about the military-industrial complex. We are have now entered the era of the health care-finance industry complex.


(Graphic is from the Forbes article cited above.)

Playing for Change

A grateful patient of ours has created a benefit featuring Playing for Change live in concert on November 17th at Symphony Hall. All proceeds will support lung cancer research here at Beth Israel Deaconess Medical Center.

The patient writes:

I am Judy Roberts, a BAC lung cancer survivor and grateful patient of BIDMC. Lung cancer survivorship comprises a small group, and in an effort to change this, we are “orchestrating” a music event at Symphony Hall on Wednesday, Nov. 17, at 8 p.m.

In 2006, my life hit “black ice” when I received a cancer diagnosis whereby the force of terror was palpable. Further, as a lifelong non-smoker, being called “an enigma” did not serve to quell my fears. Soon after, surgery stimulated me to boldly attempt to mold the face of lung cancer, create awareness/disturbance through illustrating the stunning contrast between lung cancer statistics versus all other cancers, hoping to contribute in changing its trajectory.

The concert is “Playing for Change," based on Grammy Award winner Mark Johnson’s music documentary where street musicians from around the world not only are playing for change$$, but playing TO change their community, the world. The symmetry of this world music and its mission aligns with the towering research that lies ahead for Dr. Costa [my doctor] and others. It all starts with change.

It’s not what we have, but what we give that defines us in life.

For tickets, click here.

SOS: Morse code does not predict well

Expanding on last week's post on falls, Marsha Maurer, our chief nursing officer, reports:

We've achieved fall rates at BIDMC on par with those noted in the JAMA article by using an algorithm, fine tuned over the past few years based on root cause analysis of each fall. The algorithm guides nurses to an individualized safety plan for each patient identified as "at risk" on the Morse falls tool. Of note, delirium has its own leg on the tool. It was a series of root cause analyses which identified the upstream impact of delirium on a subsequent fall that led both to this leg in the tool and the GRACE work.

We have found, however, that the Morse is a blunt tool. It over-predicts who will fall, and entirely misses some people at fall risk; for example otherwise alert, oriented and ambulatory oncology patients who become weakened over the course of chemotherapy and who overestimate their own strength. Given this, our departments of Nursing and Health Care Quality are working with the Institute for Healthcare Improvement on the next frontier of assessment and intervention -- a falls bundle. It is in pilot use now. The bundle dictates three interventions for all patients regardless of fall risk status: 1) Bed in low position -- with a clear visual cue that this is so; 2) the infusion pump on the side of the bed where the patient will exit; and 3) the call light in reach.

Concurrent with this is the use of a more clinician-friendly simple risk question: "Is this patient willing and able to RELIABLY use the call light to get help?" If the answer is "no" this puts the patient in a high risk category for falls, and additional falls prevention strategies will be implemented.

We are hopeful that this will provide a more specific and meaningful risk identification process and ultimately a reduction in the overall fall rate.

Epilogue

This work at BIDMC and the work cited in the previous post from Brigham and Women's Hospital are exemplary and clearly complimentary. But what is striking is the lack of coordination between the two efforts. Two Harvard teaching hospitals, separated by only a few blocks (see map), both concerned about patient safety, have had virtually no contact on this topic.

I hope I am misinterpreting, but I am concerned that this may be one of those instances in which the competitiveness among the Boston hospitals has spilt over into the safety arena. For sure, there are other areas in which information about quality of care is shared and protocols are examined together. But wherever there is a lack of discourse, opportunities for collaboration are lost. In contrast, remember our colleagues in Ohio, where the rule is, "We compete on everything, but we don't compete on safety." We owe it to our patients to adopt the same approach.

Really patient-centered!

Check out this story.

An issue, guaranteed

I don't mean this in a partisan way, but it is really distressing to read this New York Times article about Republican plans to dismantle parts of the recent health care bill by using the appropriation powers of the House of Representatives. I say this because of the unintended consequences that will result if they are successful in this approach. Let me give an example.

I think one of the most important aspects of the law is "guaranteed issue" of health insurance: Insurance companies will no longer be permitted to use pre-existing medical conditions as a bar to coverage. A concomitant of guaranteed issue is the individual mandate, the requirement that all people purchase health insurance. Why?

Left to their own, insurers will impose pre-exisiting conditions types of restrictions because they understand the moral hazard aspect of insurance. Healthy people provide an actuarial balance to sick people. If people only buy insurance when they need care, the risk profile of the insured population rapidly swings, upsetting the actuarial calculations used to establish premiums. So, if these restrictions are outlawed, everybody needs to be in the risk pool. Accordingly, you have to ban optional insurance.

But look at this quote from the article cited above:

Republican lawmakers said, for example, that they would propose limiting the money and personnel available to the Internal Revenue Service, so the agency could not aggressively enforce provisions that require people to obtain health insurance and employers to help pay for it.

I think the Republicans know that guaranteed issue is popular with Americans, and so they do not directly want to repeal that provision of the new law. But what will happen if healthy people start to opt out of getting insurance, only to return when they get sick? The system will quickly get out of balance. Ironically, this will only cause premiums to rise. I don't understand why the Republicans would want that to happen, and I fail to see a strategic political advantage arising from that result.

This makes me wonder if they have thought this through completely and whether they understand the unintended consequences of their proposed actions.

Turn left, then jet ski across the ocean

You can count on Google maps to give you the best possible route between two places. See, this, for example, to go from Japan to China. Found on Flickr, here.

Good "advice" here

A friend sends a link to this site, The "blog" of "unnecessary" quotation marks. He notes that it is for when italics, underscore, uppercase, or larger point size just won’t “do.”

Can you hear me now?

A discussion on Medscape Physican Connect begins as follows:

My patient's cell phone rang in the middle of his medical visit yesterday. I was fully expecting him to react as I would in such a situation: apologize and turn his phone off. Instead, he jumped up off the exam table, flipped open his phone and proceeded to talk to his wife for several minutes while I waited to resume the exam. This is a patient I have a good rapport with and have known for a long time. I asked him to please turn his phone off during our appointments from now on. However, I can't help but think: isn't that just common sense? I know patients talk on their cell phones in the waiting room, but am I crazy to think that cell phones have no place during a medical exam? I am tempted to post a sign in my office room saying "All cells phones and guns must be checked in at the door". Has anyone had any similar experiences? If so, what has helped you to curb this rude behavior among your patients?

The best comment:

I had a family come in all texting on their own phones during the visit. The girl continued texting during the exam, even on her back during the abdominal exam. The mother finally told her this was rude. I really think they were texting each other.

There is no free lunch in genetics, either

Martin Pollak, our chief of nephrology, sends along a link to a recent podcast in which he is interviewed. He summarizes:

Basically, we have sorted out why African Americans get so much more kidney disease than other groups. It is related to the development of genetic resistance to sleeping sickness in Africans about 5000 years ago. Specific genetic differences that protect against sleeping sickness increase the risk of kidney disease.

Check Science Magazine Vol 329, 13 August 2010, at page 841 for the full printed version, and for a commentary article, in Vol 329, 16 July 2010, at page 263.

Trying to make falls always out of season

Patricia Dykes of Brigham and Women's Hospital and and her colleagues published an interesting article in JAMA about preventing falls. Falls are a tough problem to solve, and these folks experimented with using a computer-assisted algorithm to design individualized fall protocols. The results were promising.

Most places use the Morse Fall Scale (MFS) to assess each patient's risk for falling. However, the linking of an individual patient's risk profile to a fall prevention plan is not usually standardized.

In contrast, this group used a "Fall TIPS" toolkit that automatically tailors each patient's fall risk profile (as calculated using the MFS) to a fall prevention plan that is based on the patient-specific determinants of risk.

I was curious to learn more, and Patti kindly explained to me in a note:

The interventions that we programmed into the toolkit are based on what we learned from our focus groups with professionals/paraprofessionals/patients/family members are both effective and feasible in acute, short stay hospitals. The Fall TIPS toolkit places this tailored plan within the work flow of all team members, including patients and family members.

This is really nice work. Recall that we are experimenting with a different set of ideas in our GRACE protocol. Eventually, as we all share results, the number of falls everywhere will diminish.

love shrinks tumor and other miracles

This is a beautiful entry by Marilyn Kass on The Momo Blog.

CHCs + BIDMC = Healthier communities

Our hospital is honored to be affiliated with a number of community health centers in the neighborhoods of Boston and surrounding communities (and also one on Cape Cod). Our folks recently produced the following video to provide a representation of how we jointly offer services to people in those communities. I think you will enjoy getting to know the people involved as you watch the video.

If you can't view the view, click here.

Way to go, Mary Jo!

Congratulations to Captain Mary Jo Majors, US Naval Reserve, who today is receiving the Outstanding Woman Veteran Award at the Massachusetts State House. Mary Jo is Director of Clinical Operations at South Cove Community Health Center. Well, she is more than that at South Cove! She is also Director of Nursing, the Emergency Preparedness Coordinator, and the Quality Assurance and Quality Improvement Coordinator. (South Cove CHC has 3 clinics and serves the health care needs of a population of almost 25,000 primarily Asian patients with limited income and resources.)

The award is presented by the Massachusetts Women Veterans’ Network. Previous award recipients are listed here. Mary Jo joins a very distinguished group!

Here is the summary of her own accomplishments:

Captain Majors has been selected for this award because she is a woman veteran who has chosen to continue to serve with honor in the Navy and give back to her country for over 41 years.

Captain Majors made a commitment to join the Navy as an officer candidate while in college to take advantage of the scholarship program to complete school and serve her country following the sudden death of her father, a WWII Army veteran. She was the first in the family of five to serve on active duty and began serving her country during the Vietnam War. She has continued to serve in the Navy since then and to provide leadership, education, mentorship, and care to service members and their families in both the active duty and reserve components during her many duties and assignments over the years.

She puts “service to others” first and has demonstrated this throughout her career whether it was providing direct nursing care to the many returning wounded Vietnam War veterans at the Naval Hospital in Tennessee, or on special reserve orders to assist with the deployment of active duty staff for assignment to the Hospital Ship Comfort and the arrival of medical reservists to Bethesda Naval Hospital during Operation Desert Shield and Storm, or serving in the Pentagon to help improve the medical and dental programs and benefits offered to members in the reserve or those already retired. She continued this personal commitment to help others in the reserve force during OIF/OEF with support to the reserve command in Quincy.

She also spends many hours every month working with young women who are in various stages of a military career, whether it be as an applicant to become an officer in the Navy or a Midshipman at the Naval Academy; a NROTC Nurse Corps Midshipman attending a local Boston college; a newly commissioned NC officer; or those currently serving their country by providing guidance and letters of recommendation to enlisted hospitalmen to attend nursing school or obtain a NC candidate scholarship, or preparing junior nurse corps officers for career planning and selection boards. She utilizes her skills as a senior woman officer to mentor, educate, and be a role model to guide these women and encourage them to further develop as leaders and outstanding members of the Navy.

She has the reputation of performing her duties with total enthusiasm, engagement, exceptional ability, personal initiative, and dedication to duty and has received recognition of such with additional requests for her service, such as with future involvement with the Yellow Ribbon Family Service Support Center and the Naval Reserve Returning Warrior Weekend programs.

We are aware of the beauty of life

From the ridiculous below to the sublime, please watch this incredible video about Alice Herz-Sommer, a 107-year old Holocaust survivor/musician. I hope you are able to watch it all the way through and see the context for these very moving final comments:

I never hate. Hatred brings only hatred.

I was born with a very, very good optimism. And it helps you when you are optimistic, when you are not complaining. When you look at the good side of our life, everybody loves you.

Only when we are so old -- only -- we are aware of the beauty of life.

If you cannot see the video, click here.

Fresh. Slow. Too Close. Not Yummy.

Let me start by saying that I enjoy the Longwood Galleria and its restaurants and am a regular patron and encourage others to go there. But what did they have in mind by hiring this billboard truck to drive through the Longwood area to advertise?

Why would anyone elect to send a truck through the intersection of Longwood and Brookline Avenues, one of the most congested intersections in the City of Boston?

Traffic congestion is measured by Level of Service, as reflected in the chart below.As you travel down Brookline Avenue on the route taken by this truck, you approach the intersection of Longwood Avenue. It is rated as Level F in the morning and level D in the evening. Here's what the Level F ranking looks like.

It shows an average delay of over 80 seconds (often over 5 minutes), a volume/capacity ratio greater than 1.0, and a queue of almost 400 feet of vehicles waiting to get through the intersection.

There has to be a better way to generate business for these excellent restaurants than by contributing to the congestion.