Winter break

It is time for my annual winter blogging break. If you leave comments, they will be moderated when I return.

Happy holidays to all! See you after the new year.

Books to consider -- IV

I end my series of possible gifts more topical than those mentioned below with two books about which I have written before. I hesitate to say that I have saved the best for last, but these two are truly excellent, moving, and inspirational. (And I would say that even if the authors were not friends and if they hadn't blessed me by allowing me to write prefaces for both!)

e-Patient Dave deBronkart's Laugh, Sing, and Eat Like a Pig is a great story about his experience with kidney cancer and his journey to patient empowerment and collaboration with his doctors.

Monique Doyle Spencer's The Courage Muscle, A Chicken's Guide to Living with Breast Cancer is an often humorous account of things to expect and how to prepare for this disease.

Both books are perfect for friends or family members going through all types of cancer (not only kidney or breast cancer), and also for their caregivers.

Books to consider -- III

We continue our series of possible gifts more topical than those mentioned below.

In The Communicators, Leadership in the Age of Crisis, Richard Levick, with Charles Slack, offers forty rules that can help leaders deal with the instantaneous nature of information flows and the challenges and opportunities that emerge from that environment. From rule number one ("Learn to accept death") to number 40 ("People want to be inspired"), there are stories and insights that are engaging and helpfully provocative.

If there is anyone better suited to editing a volume called Lessons Learned in Changing Healthcare . . . and How We Learned Them than Paul Batalden, I am hard-pressed to know who that might be. A dozen knowledgeable and self-reflective practitioners relate the stories of their progress in improving health care, creating a tapestry of thoughtful observations and lessons.

Books to consider -- II

Continuing our attempt to offer gifts more topical than those mentioned below, I offer two more recent books for your consideration. I'm sorry I cannot include all that I have received. Feel free to mention yours in a comment if you want to self-refer.

Lois Kelly, author of Be the Noodle, Fifty ways to be a compassionate, courageous, crazy-good caregiver, starts by noting:

This morning, approximately 50 million people, mostly women, woke up to a job they never wanted and have no training for -- caring for a loved one who is dying.

This little book then provides pithy lessons and helpful suggestions to those in this situation.

Social media practitioners are very familiar with the work of David Meerman Scott. They and social media wannabees will find Real-Time Marketing and PR a valuable tool. He notes, "Awareness of information as it happens, in real time, can give you an enormous competitive advantage - - if you know how to use it." A few chapter headings will give you a sense of what's up in this book to help you get there:

Speed versus Sloth: Dispatches from the Front
Laying Down Some Real-Time Law
Real-Time Attitude
Tap the Crowd for Quick Action
Business at the Speed of Now

Books to consider -- I

In a spirit of Christmas gifts more topical than those mentioned below, I offer today and on subsequent days some recent books related to health care and medicine that might warrant your consideration. I start with two today, one from the patient's point of view and one from a hospital administrator's.

Notes from the Waiting Room, Managing a Loved One's End-of-Life Hospitalization was written by Bart Windrum. I met Bart during the patient advocacy session we helped organize at the recent IHI Annual Forum. He starts by explaining the genesis of the book:

This book is not abstract. . . . I write from my involvement as a son who watched both patients die. . . . In both my parents' cases, their dying process was rife with unnecessary grief. I don't mean the grief that accompanies loss. . . . I write as a layperson for lay people. I expose what causes much of the needless shock (and resulting grief) that can accompany any hospitalization and end-of-life experience.

Chapters include: Be an effective personal representative; Making effective declarations; Care and communication in hospitals; family involvement in hospital care; forecasting and ethical support.

Transforming Health Care, by Charles Kenney, tells the story of Virginia Mason Medical Center in Seattle, which has become famous as the hospital in America that has most dramatically endorsed the Toyota Lean Production System. The senior administrative and medical team, led by CEO Dr. Gary Kaplan, started the process with a visit to Japan and then designed a hospital-wide program to bring greater efficiency to many aspects of the institution's operations. They entitled their program the Virginia Mason Production System and made significant improvements in many aspects of health care delivery.

Lives and times

This is a spectacular visual display by Hans Rosling of the correlation between income and life expectancy, over the decades, for dozens of countries.

If you cannot see the video, click here.

I'm gonna scream!

The New York Times offers this summary of words that were introduced or popular during 2010. I'd like to give my candidate: Gonna.

As in going to.

Look, this has always been a lazy contraction. I remember reading a transcript of my own testimony over a decade ago, certain that the stenographer had misquoted me. But no, I had often slipped into this slurred version of going to. It caused me to train myself not to, and I have pretty much killed the habit.

But none other than our Commander in Chief has now made it acceptable. He uses it all the time. Here's one example.

I argue that his persistent use of the word has now influenced the entire country.

A sign of how pervasive it has become is that I heard it from an NPR radio announcer! OMG, the bastion of good grammar and pronunciation has been corrupted. Are we gonna have to stop listening to Weekend Edition?

Even the spellcheck on this blog service does not recognize it as a mistake.

Please, Mr. President, along with giving up smoking, can you give up gonna?

Good move in Congress

I am very pleased that Congress has now eliminated the ban on gay people serving openly in the US armed forces. I know many gay people who have served with distinction during the last decade, and it always pained me that they could have been discharged if their sexual orientation had been made known. Who knows how many other qualified people chose not to serve because of the previous law.

I am struck by how long it takes for society to overcome its prejudices. As I welcome our new employees each week, I tell them the story of the establishment of Beth Israel Hospital in 1916, which occurred because of discrimination against Jewish doctors and Jewish patients. Young people look at me in incredulity, wondering how a society could be so prejudiced. Well, I know doctors who tell me that such discrimination lasted through the 1960's for them here in Boston, limiting their professional options, or causing them to legally change their names to keep those options open.

I have read that prejudice and discrimination may have an evolutionary basis, rooted in the nature of primate and human subsistence groups. Here's just one example, gleaned from a quick Google search, from a 2004 paper by Harold D. Fishbein, Department of Psychology at the University of Cincinnati:

Our genetic/evolutionary heritage provides the initial push toward prejudice. My essential argument is that three sets of genetic/evolutionary processes that lead to prejudice and discrimination evolved in hunter-gatherer tribes. They were appropriate and necessary for that subsistence mode, which characterizes 99% of human existence.

I guess it is hard to counteract this stuff if it is really wired into our brains as a result of thousands of years of genetic selection. On the other hand, we should be advanced enough not to let us use our evolutionary inclinations as an excuse for inaction or continued discrimination or political grandstanding.

Manly gifts for Christmas

I was listening to Tom and Ray on Car Talk today and heard their suggestions for Christmas gifts for guys. You can listen to that here, show #1051. Suggestions included, "Two words no guy can resist: ratchet and socket." Also, a cordless drill -- "You can never have too many" -- and other manly items.

I was attentive because just yesterday a colleague told me of his household's pattern. My friend who is, shall I say, a boring dresser, each year is given many items of clothing by his wife. His practice has been to unwrap each box, but then store it unopened in his closet.

This year, in the spirit of frugality, he said to his wife, "You know, if you just take the boxes from my closet and re-wrap them, when I open them on Christmas morning, I won't even suspect they are the same gifts, because I never knew what was in the boxes anyway."

This being family television, I dare not describe his wife's response.

Hospital visiting day for Red Sox Scholars

The current class of Red Sox Scholars came to BIDMC today for a visit to our neonatal intensive care unit and our surgical skills and simulation center. You can meet these talented students in this video and get a glimpse of their day.

If you cannot see the video click here.

Two Degrees of freedom

As you know, I don't often write about commercial ventures here, but from time to time, one that has a broader public service mission emerges. Here's the latest, recently announced.

A company called Two Degrees is marketing a new, nutrition bar.* That's nothing special (although it does taste good**), but what is special that for every one they sell, they will produce and distribute -- working with Partners in Health -- a nutritional pack to a hungry child in the world. The nutritional packs themselves are manufactured locally, so the company is creating jobs in the areas being served. Here's more information about those packs.

"Nutrition packs are revolutionary treatments for severe and chronic malnutrition. Known as Ready-to-Use Food (RUF), these nutrition packs have been endorsed by the World Health Organization and treat chronic and severely malnourished children with up to 95% success rates. As convenient packs that do not require water or refrigeration, they have shifted the treatment of hungry children from doctors in hospitals to a community-based model focused on mothers in homes."

--
* Disclosure: My friend Lauren Walters is a founder, but I have no financial interest in the company.
** The other founder's grandmother says: "I can't believe how good this is! I usually don't eat bars unless they have the word 'candy' in front of them."

The Jubilee Project

If this video doesn't warm your heart, you have serious emotional problems. It was produced by The Jubilee Project, a non-profit that that harnesses the power of Internet videos and the spirit of philanthropy. As noted by the founders:

- Our mission is to make videos for a good cause.

- Our core value is to partner with those in our communities to help make these videos possible.

- And our hope is that we can create entertaining videos that will empower, enable, and inspire others to do good as well.

The team prepares videos, posts them publicly, and receives payment from sponsors based on the number of views. This one that has been particularly successful, with about 200,000 views.

Here's their Facebook page. They seek ideas for other worthwhile causes.

If you cannot see the video, click here.

We're all entitled to move

Please check out this story from the PBS NewsHour about how dance can be used to improve the lives of people with Parkinson's disease.

I wrote about a local version of a similar kind of program back in 2008, sponsored by Ed Rudman, one of our former Board chairs. It is wonderful to see this expand to other settings. The group Dance for Parkinson's has "classes right now in about 14 states, from California to Washington State to Texas . . . all the way down to Florida."

My father died of this disease back in 1992, and there was nothing like this available where he lived. As I watch these dancers, I have to express great admiration and appreciation to the professionals and volunteers who have made these programs available.

As noted in the story, "Joy, it's not a quality you associate often with Parkinson's. And, yet, it is what you see here. There are people in this class whose condition limits how they move, but not their smile or spirit."

I say "Bravo!" and "Encore!"

The value of standard work

"The most important thing we can teach our residents and trainees is the value of standard work."

Imagine if that were the philosophy in every academic medical center. It is the philosophy at the Mayo Clinic, according to Dr. Stephen Swensen, Director for Quality. Dr. Swensen commented on these matters during last week's IHI Annual Forum. I was not able to attend his session, but a colleague did go and reported back to me.

For years, I have been hearing about the quality of care given at Mayo and was having trouble learning what distinguishes the place. I should have figured it out. The simple summary of process improvement is that you cannot design and implement improvement if there is too much variability in your process. Why? First, you cannot design an experiment for change unless you are confident that your change is being applied to a relatively uniform "prior." Second, you cannot measure improvement compared to a base case if there is not base case.

Dr. Swensen talks a lot about the "cottage industry" and "farmers' market" approaches to medicine, as opposed to the Mayo way of standard work, decision support, and forced protocolization. Mayo has a Clinic Clinical Practice Committee that has the authority to set practice standards and methods across the organization. When improvements are discovered, there is rapid diffusion of learning.

When it comes to residents, they must be bronze-certified through Mayo Quality Academy before treating patients. This includes training on simulators before being allowed to practice procedures (like central lines) on patients.

Dr. Swensen also discussed four conflicts in academic medical centers that prevent truly patient centered care:

• Physician Autonomy - As mentioned, a high variation environment is inherently unsafe.
• Financial conflicts - Some care receives higher payments; there are financial conflicts between the doctors and the hospital; and fee-for-service creates conflicts of interest.
  
• Research - The well-intentioned focus on the mission that "we're here to advance knowledge" can interfere with care.
• Education - The well-intentioned view that "we're here to provide training opportunities" lets trainees practice on patients and causes care to be organized around the training program, rather than vice versa.
  

As I heard this, I thought about our place. While we have instituted some standard practices, it is clear that we have not gone as far as we might. On the financial front, we have started to move away from fee-for-service, but there is not a uniform payment system across all of our payors. And his comments about research and teaching are often likely to be valid.

I will state immodestly that we are viewed as one of the leaders among academic medical centers with regard to quality, safety, and process improvement. If we still have so far to go, after several years of concerted effort, the academic medical sector as a whole has miles to travel.

When borrowing is a good idea

There is an element of the economic downtown that unfortunately aggravates the prospects for recovery. In Massachusetts, employers fully fund the state's unemployment insurance fund. During periods of high unemployment, payments made from this fund go up, and employers are asked to help keep the fund balance current.

In this chart from the Associated Industries of Massachusetts, you can see this during the increase in insurance benefits paid during the recessions of the 1970's, early 1990's, 2002, and currently.

During these hard times, when unemployment claims go up, the state faces a deficit in that fund and has to consider whether to raise the unemployment tax. You can see that in this chart.

Massachusetts is currently considering a very large increase -- 40% -- in the unemployment insurance tax, from an average of $638 per employee to $897. Statewide, this would represent an increase over 2010 of $662 million. This would go into effect on January 1.

Of course, a recession is precisely the worst time to raise such a tax. It would be better if accruals into the fund could be timed more smoothly and in a counter-cyclical fashion.

There is an alternative: To borrow from the federal unemployment fund, at zero interest. From the point of view of the state's employers, the alternative is clearly the way to go.

This approach has no adverse impact on the families in the state who benefit from unemployment insurance, but it provides a reasonable opportunity to smooth out the effects of the recession, making it more likely that a recovery will not be stalled.

Will this cause a change?

An article in Lancet sets forth the need to change medical education. It is authored by as auspicious a group as you could imagine.

The indictment has been handed down. This is not news. Will they listen this time?

Here is the introduction:

100 years ago, a series of studies about the education of health professionals, led by the 1910 Flexner report, sparked groundbreaking reforms. Through integration of modern science into the curricula at university-based schools, the reforms equipped health professionals with the knowledge that contributed to the doubling of life span during the 20th century.

By the beginning of the 21st century, however, all is not well. Glaring gaps and inequities in health persist both within and between countries, underscoring our collective failure to share the dramatic health advances equitably. At the same time, fresh health challenges loom. New infectious, environmental, and behavioural risks, at a time of rapid demographic and epidemiological transitions, threaten health security of all. Health systems worldwide are struggling to keep up, as they become more complex and costly, placing additional demands on health workers.

Professional education has not kept pace with these challenges, largely because of fragmented, outdated, and static curricula that produce ill-equipped graduates. The problems are systemic: mismatch of competencies to patient and population needs; poor teamwork; persistent gender stratification of professional status; narrow technical focus without broader contextual understanding; episodic encounters rather than continuous care; predominant hospital orientation at the expense of primary care; quantitative and qualitative imbalances in the professional labour market; and weak leadership to improve health-system performance. Laudable efforts to address these deficiencies have mostly floundered, partly because of the so-called tribalism of the professions—ie, the tendency of the various professions to act in in isolation from or even in competition with each other.

Redesign of professional health education is necessary and timely, in view of the opportunities for mutual learning and joint solutions offered by global interdependence due to acceleration of flows of knowledge, technologies, and financing across borders, and the migration of both professionals and patients. What is clearly needed is a thorough and authoritative re-examination of health professional education, matching the ambitious work of a century ago.

Champy on health care on Kindle -- Free!

Jim Champy, well known for his books on reengineering, has teamed up with Harry Greenspun to write Reengineering Health Care: A Manifesto for Radically Rethinking Health Care Delivery. The book has gotten good reviews, and many of my readers might find it of value.

The good news for Kindle users is that you can download it free, but only between now and December 18. Just go to this site.

North by Northwest Misdirection

It may be worthwhile to deconstruct this section of a recent Boston Globe story by Rob Weisman about the acquisition of two for-profit hospitals by Cerberus Capital Management. You will recall that Cerberus recently took over nonprofit Caritas Christi Health Care last month and converted it to a for-profit business.

I have discussed below the potential for misdirection in press statements about the Cerberus system. Are we seeing it again? Is a system that is reportedly under review for anti-trust issues using this news item as argument against those possible concerns?

But Peter K. Markell, vice president of finance at Partners HealthCare System Inc., the Boston parent of Massachusetts General Hospital and Brigham and Women’s Hospital, said Steward could offer more competition for downtown teaching hospitals if de la Torre is successful in stemming the leakage of patients from Eastern Massachusetts communities to Boston.

Markell said that Mass. General and Brigham and Women’s are also community hospitals for residents in and around Boston.

If the Steward network draws away routine health care services, it could drive up the cost of the more complex medical care offered at Partners hospitals, he warned.

“Any competition is always a threat,’’ Markell said.

How does ownership by Cerberus make the competition vis-a-vis the Partners hospitals more real? Is there an indication that there is currently a large outflow of routine (as opposed to tertiary) care from these two community hospitals to Boston and specifically to MGH and the Brigham?

The two hospitals, Merrimack Valley and Nashoba Valley, are in Haverhill and Ayer, respectively. The former is 26 miles north of Boston. This takes 43 minutes to traverse in average traffic, along a route that never has average traffic. (See map to the right.) The latter is 29 miles northwest of Boston, with a travel time of just over an hour in average traffic, along a highway that most people would rather avoid. (See map below.) It is hard to imagine that the residents of these communities are opting to go to Boston for most secondary care that can be treated locally.

Perhaps Partners is suggesting that such tertiary referrals as will be sent to Boston will now go to the Cerberus-owned St. Elizabeth's Medical Center, rather than the Partners hospitals. Maybe to some extent. But the jury is still out on that front.

For example, to the extent there are currently referrals from Nashoba Valley, they are just as likely to go to U. Mass. Memorial Medical Center in Worcester, 24 miles away, and 41 minutes on lightly traveled roads. (See map to the right.) Some other referrals also come to BIDMC. If Cerberus succeeds in diverting those referrals to St. Elizabeth's, that is not a shift in market share away from Partners.

But the really surprising quote is this one: If the Steward network draws away routine health care services, it could drive up the cost of the more complex medical care offered at Partners hospitals.

Is this a suggestion that secondary care subsidizes tertiary care in the Partners system? I have never seen data from other tertiary hospitals that would support the proposition that low acuity care is more profitable than high acuity care. On the other hand, perhaps the differential in insurance payments that Partners receives offers benefits along these lines that are not representative of other hospitals. As always, a transparent presentation of such data would help evaluate whether the statements made in this story are valid.

In any event, isn't the whole point of current public policy to deliver the right care in the right setting? If Cerberus is truly able to make it more attractive for low acuity patients to be served in a lower-cost community setting, that would seem like the right thing to do.

Application for writ of possible simcha

A very funny pleading in court a few weeks ago, and a thoughtful ruling by Judge Kimba Wood. The full story is here.

Antikythera Mechanism, Lego version

Thanks @kaythaney, my inner nerd loves this, a modern-day Antikythera Mechanism made out of Legos. Here's the story.

If you cannot see the video, click here.

Tell me the news up front

I have previously discussed the difficulty of presenting bad news to a patient. How you give good news is also important.

A friend received a preliminary diagnosis of cancer, based on a pathology sample that was reviewed by a general purpose commercial laboratory. Her doctor suspected differently and asked one of our BIDMC pathologists, who is a specialist in this particular area, to review the samples. He concluded that there was no cancer.

The doctor thoughtfully called the patient as soon as he heard the news. Here is a transcript of the voicemail message he left (reprinted with her permission, with names changed):

Betty, hello, this is Dr. Smith. I'm calling you back again. It is Saturday. I have some important information to share with you prior to your MRI on Monday. Please give us a call at 617-632-****. You will reach the page operator. I am not the doctor on call but you can ask that I am paged. And if they give you a hard time, tell the other physician that I want to talk with you, and she'll pass the message along to me.

By now, about 35 seconds had passed, endlessly in her mind. You can imagine her distress.

It's good news. I hope to speak to you soon.

She starts to scream with joy.

All's well that ends well, but imagine if he had started with: It's good news. I hope to speak to you soon.

Carey and Stuart talk payment reform

As a supplement to the story covered below, please see this excellent interview between Commonhealth's Carey Goldberg and Dr. Stuart Rosenberg, CEO of the Beth Israel Deaconess Physicians Organization.

BID doctors and BCBS go global

This story by Martha Bebinger at WBUR relates the fact that our physician group has joined with Blue Cross Blue Shield of Massachusetts in a new form of payment contract. Instead of being based on a fee-for-service rate structure, it is based on an annual average budget per patient, with bonuses offered for specific quality metrics and specific patient satisfaction scores.

As noted by BCBS CEO Andrew Dreyfus in the video below, BIDPO is the largest physician organization in the state to sign such a contract. Its membership includes all of the faculty at BIDMC, but also hundreds of primary care doctors and specialists in several community hospitals, private practice, and community health centers. Getting this variety of doctors to reach a consensus on the desirability of such a contract took education, time, and patience on the part of the BIDPO leaders, and particularly Dr. Stuart Rosenberg, the group's CEO. Stuart strongly felt that the BIDPO doctors should take the lead in delivering care based on a strong foundation of primary care, local delivery of service, and controlling the growth in costs.

One of the impacts of this kind of contract will likely be a reduction in certain services provided by BIDMC, either eliminating them altogether or delivering them at lower cost sites in the community. This makes sense from a societal point of view, and we welcome that result. Our business plan is not based on carrying out more and more procedures per patient: It is to become the destination of choice for patients who truly need tertiary care, but who want it delivered in a safe, high quality, and efficient environment -- a place that can substantiate its progress on those fronts by publication of clinical outcomes and other metrics for all to see (as below) -- and a place that closely coordinates care with our clinical partners in the community.

If you cannot see the video, click here.

Dr. Vollmer and team continue to tell all

Transparency of clinical outcomes has now become part of the culture at BIDMC, and that is nowhere as evident as in our outcomes for pancreatic resection surgery. These are difficult procedures, where surgical skill matters, but where use of a standardized plan of care (or clinical pathway) makes a large difference.

Our website contains a clear exposition of the results in our hospital. As noted by Doctor Charles Vollmer in our Department of Surgery,

"This summary reflects our initiative for total transparency of the real outcomes from our practice which are available to anyone through our institutional website. We believe this is a unique approach in our specialized field of pancreas surgery, and I would even contend it is rare to see anything like this for any general surgical domains around the country."

Credit for this approach also clearly goes to Dr. Mark Callery, chief of our general surgery division, and also a major practitioner in this particular field.

You can find the website here. The new numbers are about to be posted. Here is a sneak preview, showing the changes from 2007 through 2010.

Volume of Procedures: 82; 73; 86; 89
Mortality Rate: 1.2%; 0%; 3.5%; 1.1%
Length of Stay (Median): 7.5 days; 8 days; 8 days; 7 days
% of Patients Requiring Admission to an ICU: 8.5%; 12.3%; 17.4%; 11.2%
Blood Loss During Surgery (Median): 300ml; 300 ml; 275 ml; 200 ml
% of Patients Requiring Post-Op Blood Transfusions: 14.6%; 26%; 12.9%; 19.1%
Reoperation Rate (within 3 Months): 6.0%; 6.8%; 7%; 3.4%
Readmission to Hospital (within 90 days) Rate: 13.4%; 25%; 29%; 11.2%
Central Venous Line Infection Rate: 0%; 0%; 1.2%; 1.1%
% of Patients Receiving Immunizations Prior to Discharge (for Splenectomy): 100% (all years)

As I have said previously with regard to another topic, if we can post these rates for BIDMC, why can't people from other hospitals? Why can't the insurance companies post them? Where are the public health advocates on this topic? The data are collected regularly by all hospitals. We must get past a culture of blame and litigation and persuade people that transparency works: Real-time public disclosure of key indicators like this (not the untimely publication of "process" metrics) can be mutually instructive and can help provide an incentive to all of us to do better.

Some people have argued that transparency will lead to doctors trying to avoid the high risk cases. I know from personal knowledge of some of their patients that such is certainly not the case with Dr. Vollmer and his colleagues. Note, too, that they make no attempt to risk-adjust the metrics above. These are all-in figures.

BIDMC Holiday Party

It's the time of year for holiday parties, and we are no exception. Our active and creative Employee Involvement Committee did the planning for this one. (The bluegrass group came from the Berklee School of Music.)

If you cannot see the video, click here.

Push pins give a safety and quality update

#IHI It is not a scientific survey, but these push pins give a sense of what's working and what's not in process improvements in the health care field. The boards were posted at the IHI Annual Forum. Forum participants were asked to use red pins to indicate processes "that continue to challenge you" and green pins are the ones "for which you have demonstrated success." If you compared these year to year, you could get a sense of the general progress of process improvement in hospitals and physician practices. I include just a few examples.

The oatmeal chronicles -- Part 3

#IHI Just when you thought it was safe to have breakfast, the oatmeal chronicle offers another chapter.

In the post below, Joe Wright offered the following suggestion:

Two fixes that require no extra labor, and no new equipment:
1. don't serve oatmeal
2. do serve oatmeal, but use tapered soup bowls instead of those vertical-side breakfast bowls.

The problem as you laid it out previously was the bowls being too small for the ladle, right?--so you can change the ladle size or the bowl size. Easier to change the bowl size, because the hotel should have tapered-side bowls for soup or salad already without having to purchase, store, and maintain new bowls, new ladles or a new oatmeal dispensing system. In fact, if they can be washed quickly between breakfast and lunch services it means that the inventory is being used more efficiently as the bowls will be used 2x-3x/day rather than once, as with these breakfast bowls.

Given the low cost of oatmeal relative to other breakfast options, even if this might lead to guests taking a slightly larger quantity of oatmeal on average, it would still likely be worth it.

So imagine my surprise when, this morning, I see a waiter bringing a tray of larger bowls for use by the oatmeal servers. I say, "Those will be easier." He says, "Those are the backups, in case we run out of the smaller ones."

Snatching defeat from the jaws of victory. The solution was not only evident, but actually presenting itself.

Poster session @ IHI Annual Forum

#IHI The poster session at the IHI Annual Forum is a cornucopia of quality and process improvement projects from dozens of hospitals and physician groups. I filmed a few of the presenters and offer them here to give you a sense of the variety.

If you cannot see the video, click here.

Maureen sets the tone

#IHI Maureen Bisognano has just welcomed the 6000 delegates here and 15,000 watching around the world at the opening session of the IHI Annual Forum. The CEO's address establishes the theme for the Forum and for IHI's activities for the coming year and is a highlight of the conference.

Maureen's empathy and kindness come through in all she says and does, and so it was not surprising that her address focused on the patient experience. Some excerpts:

When [my nephew] Robbie was four months old, my sister took him back to his doctor for another routine check-up. During the visit, the doctor told my sister he would be giving Robbie his 4-month DPT shot. My sister asked, “Don’t you remember what happened last time?” The doctor paused. My sister described the hospitalization after the last shot, and the doctor told her that the illness was unrelated. He hesitated for a moment and then said, “I’ll give him half a dose,” and then administered the vaccination. Robbie died within 24 hours.

My sister asked me three questions that changed my life. She asked:

Why did the doctor not have the hospital records on hand?
How did he not know what the right care was?
Why didn’t he listen to me?

[Referring to some 220 patient and family histories for 34 different diseases and conditions taped by the New York Times' Karen Barrow:] I’ve been comparing the burden of illness, the voices of the patients in these videos, the experiences of patients and families I meet traveling around the country, to the clinical encounters I see. The conversations are really quite different, in many cases. I see empathy and technical excellence, but the conversation is medical, focused on the disease and often not on the total burden.

[Citing from Henry Ting and Victor Montori at the Mayo Clinic:] When we can’t lessen or ease the burden of illness, we can redesign to lessen the burden of treatment – they call this “minimally disruptive medicine.”

An ideal health system balances the contributions of science and the strengths and needs of the individual; and most important for achieving the specific outcomes with the patient, it has a robust learning system “for the patient”; “for the science” at all levels to modify plans when changes will help, and to leave things as they are when tampering is expensive and ineffective.

Then there is the personal part of caring and healing. How do we best teach new nurses and physicians, clinicians and leaders, how to care and how to improve?

Sometimes caring is minimally invasive technology that optimizes great advancements in the tools of care and minimizes pain and the length of time a patient has to stay in a hospital. Sometimes caring is minimally disruptive processes that are designed to care with and for the patient. Sometimes caring is just standing there. And sometimes, caring is partnering.

Rather than thinking about our work as caring for illness, Antonovsky offers a model of a continuous variable – a “health-ease” instead of a “dis-ease” continuum. A major factor in producing health is resilience – a sense of control and understanding. This will require new and deeper partnerships between patients and families and their provider teams. For years, we’ve had providers with empathy and a strong sense of caring. But what I’m adding today are processes and new designs to support and accelerate the conversations and to build resilience.

Together, our destination is the Triple Aim. It won’t be easy. It’ll take courage, new leadership skills, new care models, new business models, a commitment to equity, and new assumptions:

-- Health care systems can be sustained with modest annual cost increases; and
-- There is enough capacity in the systems to provide equitable, high-quality care to all; and
-- Solutions to national problems will be designed and implemented at the local level.

The theme of this year’s Forum is Taking Care. With a focus on our health, we’ll be better able to take care of those who rely on us. We’ll be better partners with our patients and families. We’ll take care when we need to strengthen our capacity. We’ll take care of the precious resources of our time and our spirit. We’ll take care of our system. And with the new models we’ll build and share in 2011, I can call my sister and answer her questions about Robbie....

Welcome to the 22nd Annual National Forum. Take care, everyone.

The oatmeal chronicles -- Part 2

#IHI The oatmeal chronicles continue, with the folks at the Marriott displaying impressive responsiveness to the process problems noted yesterday. As you can imagine, revamping things overnight for a crowd of 6,000 people is not easy.

We arrived at the food area this morning to find friendly people serving the oatmeal. You can't expect a hotel to replace all the bowls and serving utensils at the drop of a hat, so this was a successful fix for the time being.

A member of the management nabbed me and graciously thanked me for pointing out the problem yesterday. "That's the best way for us to improve," she noted. "Thank you." A very good attitude!

So, for my readers, what would you do next on this issue? Is this the optimum solution? Is there a way to fix the underlying problem that is not so labor intensive? What else would you consider, and how would you do it?

Something tells me that this is going to be a case study at the next hospitality association annual meeting!

Dancing with the Safety Stars

#IHI Speaking of fun videos to promote safety, here's one produced by the folks at the Carondelet Health. Thanks to Scott Kashman, CEO of St. Joseph Medical Center, for reminding us that you don't need the resources of Universal Studios to produce an engaging, helpful guide for your staff. As he notes on his blog:

There was great participation in the making of the video, and while it's entertaining, it also carries serious reminders about the importance being safe in the care we provide to our patients. It is played to Men Without Hats' popular 80's song, Safety Dance.

If you cannot see the video, click here.

Universal safety

#IHI The transformation of health care from a cottage industry characterized by the artistic efforts of individual practitioners to a self-improving system of care delivery will be aided by lessons from other high performance industries. The IHI Annual Forum recognizes the potential for this learning opportunity. So, before the formal sessions start, the organizers arrange excursions to some local businesses in the Orlando area.

What does a theme park like Universal Orlando offer to clinicians and health care administrators? Well, it turns out that the resort has an exemplary safety record, both for the tens of thousands of daily visitors and for the actors and stunt people who perform every day. A group of us spent the better part of today in a conference room at the park, learning of the firm's principles and techniques. The lessons were a direct parallel to those I have discussed on this blog: Framing issues in the context of the purpose of the organization; standardization to avoid variability; encouraging front line staff to call out problems and near misses; prompt reporting of adverse events; and use of root cause analysis when failure occurs.

In the slide shown, note the parallel between the phrase, "No such thing as an accident," and Joe Gavin's comment from the Apollo space program, "There is no such thing as a random failure."

Each organization must adopt techniques that support these goals, techniques that are consistent with the culture of the organization. In the case of Universal, for example, "safety bucks" are handed out to staff members who report safety hazards. These coupons can be used to purchase food at the staff grill.

The company has also prepared an introductory safety video for its staff. It makes ample use of the movies and actors from the firm's cinema productions. It also has a good dose of humor thrown in, consistent with the desire for all activities to support an environment of fun in the park. Here is an excerpt from the Safety Man film.

If you cannot see the video, click here.

Oatmeal, the movie

#IHI Following up on the post below, here is a short video demonstrating one work-around that was invented to deal with the misdesigned breakfast serving system at the IHI Annual Forum. Notice that the inventor preferred to call it "innovation!"

My sources tell me that things will be different tomorrow morning. Stay tuned.

If you cannot see the video, click here.

Oatmeal work-arounds

#IHI Even at a process improvement conference, you encounter failed processes. Have you ever noticed, in a cafeteria or buffet line, that the serving ladle for oatmeal is often too large for the bowl into which it is being put? Such is the case at the Marriott in Orlando here at the IHI Annual Forum.

I captured this problem this morning at breakfast. What's interesting is to see the rapid development of work-arounds. One person abandoned the ladle and used a coffee cup to extract the oatmeal. In so doing, she put her fingers in very close vicinity to the food that would be taken by the following persons. And she then left a goopy, oatmeal covered coffee cup on the table -- in the way of the next person and too dirty to be reused. Other people tried different serving techniques, but they ran into problems because oatmeal just doesn't flow very well!

In the manner of some surgeons who resist acknowledging systemic problems, one person said that he is able to overcome the design problem because he has "a steady hand."

Getting a hug

Our new Chief of Surgery, Elliot Chaikof, is featured in this short interview. He has lots of interesting things to say, but my favorite answer starts at 1:17, in response to the question, "What's your favorite part of the job?"

If you cannot see the video, click here.

Patient advocates band together

#IHI Back in July, I wrote about a new effort by IHI to help patient advocacy organizations. The summary:

Here's how it will get started. IHI wants to invite 35 to 50 patient advocates to its Annual Forum this December in Orlando, FL. The invitees will attend a special session at the beginning of the conference, and then they will attend the entire Forum as the week progresses. Their conference fee and travel expenses will be completely borne by IHI.

Our hope is to provide these folks with a terrific educational experience, but also use this first get-together as an organizational session for a "trade association" of patient advocacy groups. With planning and luck, we think we will be able to build an organization that will provide technical, educational, and marketing support to these small non-profits.

Well, thanks to the generosity of a number of hospitals and others, the group assembled today for the first time in a "Leadership Summit for Patient Activists and Partners in Quality and Safety." I have dropped by for part of the session. On the right, you see Dr. Steve Pratt, from BIDMC, who worked with Linda Kenney from MITSS, on the concept for this session. He is accompanied in this picture by Dale Ann Micalizzi.

The meeting started with a "tweet" from each attendee, telling their personal story that led to their current patient activities. Among them was Helen Haskell, Director of the Empowered Patient Coalition and Mothers Against Medical Error, seen here (right) with IHI's Madge Kaplan (left).

The person in the picture at the top of this post, Regina Holliday, is a medical advocate muralist. She is using paint and brushes to promote health reform and patient's rights. She was on hand to memorialize today's session.

No such thing as a random failure

#IHI Joseph Gavin, Jr., who died in November, was an aeronautic engineer who was intimately involved in the design of the first manned craft to land on the moon. He was also a key player in the rescue of the Apollo 13 astronauts. He was a remarkable fellow, and I had a chance to hear a tribute to him during this past week's meeting of the MIT Corporation. (He was in the class of 1941.)

One of the quotes ascribed to him during the presentation was, "There is no such thing as a random failure."

In this discussion board, a commenter says, with regard to that quote, "Amazing when you look at things now, that in the avionics industry of the time 'random' failures were acceptable! As he says, there is (almost) no such thing as a random failure... Everything has a cause, and in a safety critical system (or one-shot system like this), every failure cause has to be designed out..."

It strikes me that there is a parallel with medical care. I have discussed the problem of "These things happen" that often characterizes the delivery of care. I noted:

Several years ago, we had that attitude in our hospital with regard to certain types of medical outcomes. For example, we were content with our level of central line infections because we were below the national average. After all, these things happen. Then our chiefs of medicine and surgery said, "No, they don't have to happen. When they happen, people die. We are going to insist that we achieve zero central line infections." And then they got to work. As I have noted below, it is not an easy problem to solve, but it is worth the effort, and you can improve.

The science of process improvement can be applied to the delivery of care, as it has been to other high performance service and manufacturing industries. I hope my readers will excuse the degree to which I focus on this topic, but I cannot imagine a more important subject to cover.

This week, several thousand people will be attending the IHI Annual Forum to learn and trade information and stories along the theme of Taking Care. Maybe, if we learn well enough, we can say that "these things" no longer happen.

Here's Ethel Merman, to make the point in her own way. (If you cannot see the video, click here.)

BCBS of MA offers lower cost choices

In a comment on the post below, Barry Carol notes:

I keep hearing from numerous sources that tiered in-network insurance products have lots of potential to create countervailing power against hospitals that currently command high prices because of their market power and not their care quality.

Well, Blue Cross Blue Shield of MA has announced it will offer a product along those lines, but not based on an exclusive network, called Hospital Choice Cost Sharing. The description is here, with the following plain English introduction:

With Hospital Choice Cost Sharing, your choice of hospital and other related facilities determines what you pay for hospital care.

• Lower Cost Share ($) applies to hospitals and related facilities that have met our quality benchmarks and are lower cost. You pay less when you get care at these hospitals.
  
  
• Higher Cost Share ($$) applies to hospitals and related facilities that have met our quality benchmarks and are higher cost. You pay more when you get care at these hospitals.
  

These costs apply to services such as:

• Inpatient Care
• Outpatient Day Surgery
• Outpatient Diagnostic High-tech radiology
• Outpatient Diagnostic Lab Tests
• Outpatient Diagnostic X-rays, and other imaging tests
• Outpatient Short Term Rehabilitation therapy

These cost levels don't apply to emergency care. If you get care at a hospital during an emergency you will pay the lower cost share, no matter where you go. This also applies if you're admitted to the hospital from the emergency room.

How much of a higher cost? Here are some examples:

And then a list of the hospitals is provided, indicating whether they are in the higher costs or lower cost category. Here is part of the list:

Lower cost non-hospital imaging providers and laboratories are also provided.

Customers are offered a simple worksheet to help them make choices, and a toll-free number to call with questions:

It will be revealing to see the degree of acceptance of this new plan over the coming months. According to the article cited above, "Businesses who join the Hospital Choice plan would see an average premium increase of 4.5 percent on Jan. 1, compared with nearly 10 percent if they continued without any change."

In the past, such plans might not have received favor, but times have changed. Congratulations to BCBS for testing the market and for offering consumer information that is clearly presented and understandable.

Wrong sites, wrong costs

I heard an excellent presentation by David Morales, Commissioner of the Massachusetts Division of Health Care Finance and Policy, a few weeks ago. He presented these two charts, one (above) showing the spread in payments to hospitals for childbirth, and the other (below) showing the sites of service, differentiated by those same payments.

The perverse nature of the current utilization and reimbursement system is evident. Higher priced facilities have a larger market share than lower priced facilities.

Over the coming months, in accordance with an act passed last summer, the Division will be constructing an all-payer claims database (APCD). It will comprise medical claims, dental claims, pharmacy claims, and information from member eligibility files, provider files, and product files. It will include fully-insured, self-insured, Medicare, and Medicaid data. It will also include clear definitions of insurance coverage (covered services, group size, premiums, co-pays, deductibles) and carrier-supplied provider directories.

The Commissioner noted that the result will be "a dataset that allows a broad understanding of health care spending and utilization across organizations, population demographics, and geography." In my view, it will be a moving force in rationalizing payments to providers across the state, allowing policymakers and businesses to address the market-power driven system of reimbursements that has evolved over the years.

Glad we could help!

No further comment needed.

Enthusiastic transparency

The State of Washington posts a variety of information about hospital infection rates. The latest addition to this is the publication of surgical infection rates. The website provides data on infections following three important types of surgeries: cardiac, orthopaedic, and hysterectomies. The Washington State Legislature required the data to be collected and made public in House Bill 1106 in 2007 and House Bill 2828 in 2010. Here is a section of the press release from the Washington State Hospital Association:

“Washington’s hospitals are enthusiastic participants in providing this new information about surgical infection rates,” said Carol Wagner, vice president for patient safety at the Washington State Hospital Association. “We believe that public reporting helps hospitals improve, assists consumers in making good decisions about hospital care, and creates collaboration between hospitals and quality experts.”

“Hospitals are dedicated to the care and comfort of our patients. In most cases, the data show good results, though there are also areas for improvement. Our member hospitals are working hard to implement changes to stop surgical infections, and we expect the results to get better and better,” concluded Wagner.

Washington State’s infection reporting program is considered a national leader. The National Conference of State Legislatures highlighted Washington, along with nine other states, in its recent report, "Lessons from the Pioneers: Reporting Healthcare-Associated Infections."

Note, too, the publication of central line infection rates and ventilator pneumonia infections.

I like the sound of that: enthusiastic participants. Congratulations to the WSHA for their part in helping bring this about and to the Washington legislature for their leadership.

New site: Care and Cost

I'm passing along this announcement.

Today, David Kibbe and Brian Klepper are launching a new forum for health care professionals, Care & Cost (C&C), that we hope you’ll consider adding to your regular diet of health care information and thought.

We’ve tried hard to design C&C to appeal to health care practitioners from every part of the industry, from imaging, benefits and medical management to law, physicians and palliative care. Every day we’ll run one or two think pieces, as well as interesting charts and images. Our goal is to provide a marketplace of practical ideas that provokes questions and comments. Under the heading “Urgent Science,” we’ll publish refereed review articles that lay out the scientific arguments, with citations, for implementing new approaches into clinical practice. And, from time to time, we may also re-publish articles run elsewhere in the past, simply because they are still relevant.

The articles on C&C will broadly explore two overarching themes. One is the health care cost crisis, which remains very much with us and threatens the stability of both the industry and the US economy. The other is the countervailing trend, the explosion in innovative solutions - tools, programs and designs - aimed at making health care better, cheaper and more available.

We’ve already recruited a couple dozen well established health care writers. At the same time, we’d be delighted to entertain articles from anyone with an insight or something to say to the health care community.

In the interest of keeping the discussion most engaging, we’ve decided to do three things.

· First, we’ll require commenters to use their names. If it’s worth saying, it’s worth owning up to saying it.

· Next, we’ll demand courtesy and professionalism. Insulting or abusive language won’t be published.

· Third, comments should be on point. Entries that simply show up to, say, make a political diatribe, won’t make it either.

We hope you’ll visit early and often and join in the fray.

Please pass this announcement along to colleagues you think might also be interested.

Best regards.

David C. Kibbe and Brian Klepper

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.