Tuesday, August 31, 2010
What is happening? First, the consolidations in other industries, resulting in large, multistate corporations, already mean that many companies self insure their employees. Even many local firms have large enough work forces that they can be self-contained risk pools. (One source I found says that in 2008, 89 percent of workers employed in firms with 5000 or more employees were in self-insured plans.) There is no sense compensating insurance companies for actuarial risk when your employee base is that large. Instead, the insurance companies or other firms are hired solely to administer the benefit plans.
For those insurance markets that still exist, the provisions for transparency under the national health care reform law, and the insurance exchanges that will be set up, will result in the commoditization of insurance products. That commoditization will drive down the profit margins that would otherwise exist in this market segment.
The result is that health insurance companies will become financial services organizations more than insurance entities. Think of them as another form of banking, where minimizing transaction costs becomes imperative, and where the use of derivatives and other hedges makes the difference in who makes money and who doesn't.
This, in turn, also implies that scale matters. Like banks and credit card companies, the larger ones incur a lower cost for each transaction. Several years ago, I was told that the minimum size needed to be a successful insurance company was two million subscribers. That was before the national health reform bill passed.
What does all of this mean for the relatively small insurance companies that serve Massachusetts? The same trends apply, but they have been aggravated by recent state action that limits premium increases for small business and individual policies. That action has explicitly made that business line unprofitable.
What can Massachusetts firms do to maintain their profit margins? (Yes, I know they are non-profits, but even non-profits need a positive bottom line.) There are two basic approaches: One is to grow in size to reduce transaction costs. On that front, is it reasonable to expect some consolidation of companies in this state? (See chart with membership, courtesy of figures reported by Rob Weisman at the Boston Globe.)
The other approach is to find new lines of business. The large national companies are already exploring that. What valued-added services could Massachusetts insurers bring to the marketplace?
Monday, August 30, 2010
While there are some who suggest that a move from fee-for-service to global, or capitated,* payments is the key element in solving rising health care costs, some questions need to be answered as part of the payment reform movement in Massachusetts. If the wrong answers are given, the movement will result in a simple transfer of risk and finances between and among insurers and hospitals, and between and among hospitals. This will aggravate the problem noted above and, with the creation of Accountable Care Organizations, may also lead to greater market concentration in the state.
1) Given the underpayment to hospitals and doctors by Medicare and Medicaid, what margin would private payers need to pay to provide hospitals with an operating margin consistent with maintaining and renewing physical plant and equipment and with providing proper levels of clinical staffing? (Medicare is the largest single payer for most hospitals, and the percentage of patients it covers in hospitals is growing as the baby boomers age.)
2) How is that needed margin consistent with the current actions by the state's insurers to impose rate increases on hospitals and doctors below the rate of inflation -- actions that are based in part on the decision by the state to require insurers to undercharge for small business and individual premiums?
3) As insurers move to capitated rates, do they have any intention of equalizing rates among provider groups in the state to reflect population-based characteristics as opposed to the relative market power of providers? If so, what is their timetable for doing so?
4) As insurers move to capitated rates, shifting actuarial risk to providers, will there be a commensurate reduction in capitalization requirements for those companies? Will there be a reduction in the remarkably constant 10% of premiums that goes to paying administrative costs for those companies? How and when will those savings be passed along to consumers?
5) How will the body politic deal with the inconsistency in payment models between capitated-limited network plans offered by private payers and the open choice (i.e., PPO) model offered by Medicare?
As an economist, I recognize the merits of capitation. But, if it is done with incomplete consideration of these questions, we will have traded one set of problems for another.
* On the more humorous front, the main semantic difference between "global" and "capitated" seems to be that "global" is a softer term, implying inclusiveness; whereas "capitated" brings up memories of the guillotine!
Sunday, August 29, 2010
A friend recently went to the Emergency Room because of some bad symptoms. After a few tests, the attending returned to give the diagnosis. He started out by saying, "I hate it when I have to give this kind of news" and then proceeded to summarize the test results and finally to tell my friend that she likely had a very serious, probably terminal form of cancer.
I think what happened here was that the doctor thought that his introductory clause displayed empathy. But what this patient and her spouse heard was that the doctor was more concerned about what he was feeling than what the patient was feeling. Especially after they found out that, no matter how badly he felt, it was the patient who was likely to suffer and die.
Further, in the extended minutes of explanation before he actually delivered the diagnosis, his introductory comment caused a heightened level of stress. He felt the explanation was important to provide a context for the conclusion, but it mainly served to create suspense.
They would have preferred a more direct, "I am sorry to have to give you some bad news. We believe you have ** cancer. Let me explain why we think so." In their minds, the slight change in wording would still have presented empathy but would have made clear that the doctor's concern was about them and not about how badly he felt. The direct delivery of the diagnosis at the start of the explanation would have relieved suspense.
Some reading this might feel that my friend and her spouse were overly sensitive and were misinterpreting common courtesy. I can only respond that these folks' reaction was immediate and negative. I conclude from this that common courtesy does not always feel like such in a difficult clinical setting.
I claim no expertise in how bad news should best be delivered by doctors. But I have told this story to other people with serious diseases, and they have resonated with the feelings of this couple, often remembering their own moments of diagnoses in a similar fashion.
I would love to get reactions and wisdom from both clinicians and patients on this matter. Please comment.
“It has happened in this country before, but not in recent decades”.
Blue whales are the biggest creatures to have ever lived on Earth. They can grow up to 30 metres and weigh up to 150 tonnes.
Friday, August 27, 2010
A blue whale died and washed ashore. We don't know how it died. It has been dead for awhile...meat rotten and most of the skin was gone. It is on the beach about 30km from Skagaströnd (where I live). The whale will likely be dragged onto the land (the farm is mostly abandoned) and left to nature. It will feed many, many animals for a long time.
The whale is the property of the land owner. In the old days the fat would have been used for fuel.
He is a marine biologist, and therefore adds:
I had to measure it. Cutting into it was even more "fun".
Wednesday, August 25, 2010
Science is the topography of ignorance. From a few elevated points, we triangulate vast spaces enclosing unknown details. We cast the lead and draw up a little sand from the abyss we may never reach with our dredges.
And from Jules Verne, Journey to the Center of the Earth:
Science, my boy, is composed of errors, but errors that it is right to make, for they lead step by step to the truth.
I think you would be hard-pressed to find recent graduates from medical schools who would not understand these quotes and find them inspirational. After all, medical students are steeped in the scientific method. Those who go on to academic hospitals apply that method in their scientific research.
Then they enter the clinical setting, and many put aside that method. They rely on judgment, memory, expertise, instinct, creativity, and anecdote in treating their patients.
Brent James has put it this way:
We continue to rely on the "craft of medicine," in which each physician practices as an independent expert -- in the face of huge clinical uncertainty (lack of clinical knowledge; rapidly increasing amount of medical knowledge; continued reliance on subjective judgment; and limitations of the expert mind when making complex decisions.)
The scientific method relies on establishing a base case against which hypotheses are tested. The base case often does not exist in the clinical setting because there is a large degree of variation in clinical practice. How can a hospital or group of doctors test new approaches of care delivery for efficacy relative to a base case where the base case does not exist?
"These things happen" is often the result. A certain number of cases of harm to patients are viewed as an irreducible statistical percentage. There is no scientific validation that that number is, in fact, an irreducible number. By anecdote, it becomes the standard of care.
In this way, our finest doctors betray their own training as scientists. Perhaps it is not their fault, in that the medical schools do not explain that the same method that is used in basic science research can be applied to clinical process improvement. As the Lucien Leape Institute notes: "[M]edical schools and teaching hospitals have not trained physicians to follow safe practices, analyze bad outcomes, and work collaboratively in teams to redesign care processes to make them safer.
The "bad outcomes" are the errors that Jules Verne urged us to make and learn from. For two years, the IHI Open School has been taking comments about the wrong-side surgery that took place here at BIDMC and about our decision to broadly publicize that surgery to our entire staff. My colleague Deepa posed the following question: "What do you think of the way the hospital responded to the error?"
I have been watching the replies over the last two years, and I have been pleased by the near unanimity and enthusiasm for the transparency with which we dealt with this issue.
Here are three recent comments:
Disciplining may work in some cultures, but we as a society learn from our mistakes. The culture that is developing may seem new to some people who have been in the profession for many years and have become accustomed to doing things a certain way. To change that view and have them realize that making a mistake and holding their hands up to it is not a punishable act. It is something that we can learn from, and by taking the steps that have been laid out for them with new patient safety protocols they can lower mistakes.
My work culture is changing, but I can remember times when we were afraid to make mistakes because we didn't want to be "the example." Now we are looking into errors from a systems approach and are creating a more transparent culture. We are trying to create an information board . . . which we hope will show staff and guests that safety and quality are our priority and that mistakes do happen. From all the changes we have made so far, I do see a difference in morale.
When an error is shared everyone benefits by knowing what not to do. The patient and patient's family also feels as if the institution was not trying provide a cover-up for the error. This approach allows all to learn valuable lessons, while admitting to the patient that there was an error and trying to make the wrong right.
Dr. Ernest Codman propounded this approach in the early 1900s. An article in 2008 noted:
...A century later, the medical profession is still struggling with the same issues as though they were new. Dr. Codman was right then, and he is right now. Fundamental to the quality movement and American medicine in the 21st century are the same peer review, standardization, systems engineering, and outcome measurement issues. Publishing results for public scrutiny remains a controversial topic. We should embrace transparency as a component of our tipping point strategy to ignite the change we all need to transform our organizations and our profession.
The path is clear: Reduce variation, admit errors, test out new approaches to clinical processes, measure and publish the results. Repeat until done.
P.S. You are never done.
*With thanks to HMS Dean Jeffrey Flier, who reminded me of these quotes in a recent testimonial to one of his predecessors, Dan Tosteson.
“The idea is to take existing supplies which, for one reason or another, are not being used and give them a new life where they can be used,” says Aviva's supervisor, BIDMC’s Sustainability Coordinator Amy Lipman. “Sharing these items keeps them out of landfills and helps save money throughout the medical center.” We do this twice a year, and the events have made paper, hanging folders, file folders, binders, unused toner cartridges, envelopes, labels, desk organizers and other useful office items available for free to all staff. (Regular readers will remember that I also ran my own version of this last year.)
You see Aviva and Amy in action in the video below, where they have set up the freecycle station in a corner of our cafeteria.
If you cannot view the video, click here.
If you can't see the video, click here.
We asked them to summarize what they did and what they had learned from the experience. I've excerpted the latter portions of their remarks to present to you in this video. I hope you enjoy their comments as much as we all did.
If you cannot view the video, click here.
Tuesday, August 24, 2010
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.
As noted here:
The federal Patient Protection and Affordable Care Act is looking for $500 billion in savings over the next decade to help pay for extending coverage to 32 million uninsured Americans. Yet it doesn’t address the problem of market concentration -- and may make it worse, said Robert Berenson, a physician and policy analyst at the Urban Institute in Washington D.C.
I suspect that the tools used by the Federal Trade Commission will be ineffectual in most regions. For one thing, ACOs will not always be created by corporate consolidation, the usual vehicle for FTC review. For another, the usual metrics used to study market dominance, like the Herfindahl-Hirschman Index, are not particularly effective in evaluating a market characterized by many discrete lines of business. Medicine is not one service. It has multiple pathways for patient entry and egress, covering a huge number of clinical conditions.
Here in Massachusetts, we have a dominant provider that has been able to demand high reimbursement rates because even the dominant insurer has been unable to withstand its market power. We have seen little political will on the part of the government, or commercial interest on the part of insurers, to attack that source or use of market power.
How much stronger will the dominant firm be allowed to become once insurers and the government encourage it to be an ACO? What if it enters into a referral relationship with the second largest provider network, combining the market power of the two largest groups? What will stand in the way of that dominant provider, alone or with its new affiliate, from demanding a global payment in excess of other market participants?
On the other hand, maybe everything will turn out fine.
But Lisa also has a blog, Reports from a Resident Alien, which is also worth reading. Here's a lovely excerpt:
Most neurotypicals (who aren't artists or children) will probably never notice the beauty in the patterns on a cracked sidewalk, or the gorgeous way the sun reflects off an oil slick after the rain. They'll probably never know what it's like to immerse yourself in a subject and learn everything about it, and the beauty of having all those facts lined up. They'll probably never know what it's like to flap their hands in happiness, or lose yourself in the feel of a cat's fur. There are lovely things about being autistic, too, just as there must be about being neurotypical. Oh, make no bones about it: It's difficult. The world's not set up to operate with autistic people in mind; and autistic people and their families face prejudice every day. But being a happy autistic person isn't "being brave" or "making the best of it". It's quite simply being happy. You don't have to be normal to be happy.
This is a blog event I am hosting on my blog to allow everyone to share their story on life with CHD, connect with other heart families and chat live on my blog. Check out my blog for all the details and spread the word!
You can go to her site, "When life hands you a broken heart," and see a compendium of stories from lots of people on this topic. She provides simple instructions as to how to link your story to her page.
Thanks to Mary Ellen Mannix for giving me the heads up about this event.
Monday, August 23, 2010
Radboud University Medical Center in Nijmegen has built an emergency Augmented Reality display that allows you to look through your mobile phone's camera view and locate the nearest automatic external defibrillators (AEDs) located in a public place. It's the first independent database of AEDs in the world operated by an Academic Hospital. Data is collected by crowdsourcing and validated on-site by The Dutch Red Cross. Besides augmented reality also iPhone, Android and iPad apps are provided free. Focus is now Netherlands, soon broadened to Europe and then Global. Also, as an academic hospital, research is part of it of course. Coverage, usage, outcome etc.Click here if you cannot view the video.
When you grow up in a large family the responsibilities that come with each age are very specific. Rule number one: You always watch out for the ones younger than you. If my two younger brothers got into something on my watch, it was pretty much my fault. There once was a time that we rolled my younger brother Rob down a hill while packed inside a 50 gallon drum. To this day I can still hear my mother’s voice when she discovered he was a little bit unconscious after his ride: “You should have been watching more closely!” (I was the one who pushed it.)
Then there was the time we tickled him until he stopped breathing. I thought for sure we were bound to be goners if she found out we ended his life by tickling, but my mother just gave me a good tongue lashing: “You lead by example! If you do it your brothers are going to want to do it.” If he was to follow my example my younger brother would have loved women, but it didn’t work out that way. The children in my family turned out 2 for 7. That is 2 GLBT children and 5 "Straight" children. Where were our role models?
When Robert came out I wasn’t paying attention. He didn’t come out to me or to his best friend or to the rest of his family. He turned to men, looking for answers he had no one else to ask. It was the 1970s, and, in those days any gay social life came from the bar scene—hence the reason I know that disco is the music of my people. Imagine if bars and clubs were your only social circle. Is it any wonder, then, that gay people of my generation have a history of substance abuse and risky behavior?
My brother was found to be HIV positive in 1999, the year of my first PMC. I still hear my mother’s voice telling me to look out for him. In my memory I hear her at the end of her life, calling from the nursing home demanding that I fix the impossible. I can fix your door or change your locks or hang shutters, but I still cannot divert a hurricane.
In my mother’s last days we discovered among other things, that she had lymphoma. Cancer had metastasized to all her major organs. She was 75, an age that somehow no longer seems old to me. She wasn’t a sick a day in her life, nor did she ever see the point in yearly check ups. Not if she was well. She didn’t want to be a “burden on society” a tax on the system that she had contributed to her entire life through children and labor. And herein lies the rub. Had she had regular check ups, had she had a primary care doctor who advised her to have the most basic of cancer screenings, we might have intercepted and reversed the cancers that killed her.
I am not a very good sister. Nor am I very good daughter for that matter. How could it be that I work in one of the top three cancer hospitals in the world and yet my own mother escapes basic screenings? When I walk by the Blum van I could kick myself. Such a basic and elemental thing, the DFCI Blum van. Going into underserved communities and giving basic screenings—or at least raising awareness that it is a good idea to have check ups.
As my mother was dying, the last thing she said to me was that she loved my house. If you had said to me in 1975 that I would grow up someday, have a job where it is less of an issue to be out, have a house and a wife, and even a child, I would have thought you were crazy. Yet here it all is. A sequence of little miracles spanning the years.
My brother has zero T cells this month and I still cannot help him. I cannot ride like Lance Armstrong. Nor can I ride like Greg LeMond whose name is emblazoned on my shiny red bike. You can’t make me want to go to France, though my wife would be gone in a flash if (and when) given the opportunity. What I can do is work here. Fix the doors, make sure they close and open. I can participate in the ride knowing that maybe, just maybe the little that I can do adds to the greater of the whole. Research and clinical trials will continue. The Blum van will pull out of 44 Binney Street. We all might live longer and be healthy and happy while we are at it.
Sunday, August 22, 2010
Why don't the insurers in Massachusetts require the hospitals here to report their HSMRs (hospital standardized mortality rates) -- in private, with no publicity -- to them, the insurers, as a condition of being in the payers' networks?... [I]f the results are out of whack with industry norms, or otherwise indicate quality or safety problems, the insurers could then require remediation plans to remain in good standing.
Dumb idea, it turns out. As Liz Kowalczyk reports in the Boston Globe, an expert panel that has been studying the measurement of hospital mortality rates has found that the "current methodology for calculating hospital-wide mortality rates is so flawed that officials do not believe it would be useful to hospitals and patients."
Researchers evaluated software of four companies for measuring hospital mortality. "The problem was that researchers came out with vastly different results when they used the various methodologies to calculate hospital mortality between 2004 and 2007 in Massachusetts, and they could not tell which company's results -- or if any -- were accurate."
Our hospital's head of health care quality, Dr. Ken Sands, was on the panel. He is quoted in the story as saying:
"In every year there were at least a couple of hospitals ranked as having low mortality with one vendor, and high mortality with another. That hospital could either be eviscerated or rewarded depending on which vendor you choose."Fortunately, there are other metrics that can reliably measure aspects of the quality and safety of hospitals. Death will just have to wait.
Friday, August 20, 2010
Regular readers know that I am a biking aficionado. I will tell you, in no uncertain terms, that a bike rider with earphones is oblivious to the sounds of the road and is a hazard to himself and to others. It is hard to imagine a more dangerous way to ride, except for riding blindfolded.
I have presented, in other posts, data on the dangers of driving while on a cellphone. The neurological issue behind that danger is that human beings are not really that good at multi-tasking. I am not contending that such is the issue here. The issue here is that you simply do not hear things in the ambient environment when you are wearing earplugs.
While biking, I have approached people on the road and have called out the expected, “On your left,” as I prepare to pass them. People listening to music do not hear me. Then, as I pass, many of them swerve from the surprise. When I see those earbuds, I give extra berth because I know they might swerve into me. But sometimes, they swerve towards the curb where there can be road grates or other hazards. I have passed couples riding and listening together, who have almost collided with each other as I passed them.
Ok, so my voice is not very loud, but I have also witnessed bike riders who do not hear approaching trucks and buses as they listen to their iPods.
I am not talking here of people who blast the music at high volumes, like the ones you can hear across the aisle in a subway car. I am talking about normal music volumes.
So, please ride your bike with both ears open. Listen to music in another setting.
So my brother's 67th birthday is tomorrow and he just received a Happy Birthday email from -- Medicare! No kidding!
After they wish him happy birthday they tell him to check on his eligibility for screening for:
PSA (which, recall, is now not recommended in all guidelines)
Abdominal aortic aneurysm
Zowie, look what we have to look forward to! My mind is blown!
Thursday, August 19, 2010
Wednesday, August 18, 2010
Today at Medical Executive Committee, we were voting on approval of procedures and therapies. The topic was adult intraosseus device use. This is a gizmo that screws into a bone that permits the delivery of medication into the marrow. It is for those cases in which access to blood vessels is not possible. I am told that this doesn't happen often, but that it is good to have the devices in reserve for emergency department and ICU situations.
Well, the group got to talking about what these devices look like now and how they compare in functionality and cost to ones used in prior years. Finally, our Chief of Anesthesiology summarized the discussion by saying, "So now we have a new expensive device that is just as good as the old cheap one."
In health care, plus ça change, plus c'est la meme chose.
Speaking of which, I am told of an article in the New England Journal of Medicine by Barbash and Glied, entitled "New technology and health care costs - the case of robot-assisted surgery." Aug. 19, 2010 pp 701-704. A friend sent an excerpt:
"... [R]obotic technology may have contributed to the substitution of surgical for nonsurgical treatments ... increased both the cost per procedure and the volume of cases treated surgically.... The evidence suggests that despite the short term benefits, robotic technology may not have improved patient outcomes or quality of life in the long run."
We can all agree that more nursing time spent directly with patients results in better patient outcomes. But mandated nurse to patient ratios, which Suzanne Gordon advocates in her Aug. 5 op-ed “Critical care,’’ are the wrong way to achieve this goal.
Those of us applying proven improvement methods in health care, such as Lean and Six Sigma, have learned what the manufacturing world has long known. We need to free nurses from the administrative burdens, inefficient activities, and wasted steps that do not directly add value for patient care.
In an environment of rapidly expanding health care costs, legislatively mandated nurse to patient ratios are unsustainable.
Yes, we need more nursing time spent directly with patients. But we must achieve this by aggressively applying improvement techniques to remove waste from our workflow. This is the only sustainable way to both control costs and improve patient safety.
Marsha L. Maurer
Senior vice president, Patient Care Services
Chief nursing officer
Lois E. Silverman Department of Nursing
Beth Israel Deaconess Medical Center
Tuesday, August 17, 2010
As noted in this story, we continue to find this a very important way of meeting our patients' expectations:
Sherry Calderon, manager of ambulatory services at Beth Israel, says: “I really feel like this kind of regular checking has driven change here that nothing else has.”
Monday, August 16, 2010
My readers got early word of this book here.
Friday, August 13, 2010
But that was before I read the exchange of comments on Kevin's blog. At least one commenter took offense at her perception that Dave was glorifying the role of hope in the treatment of cancer, and in so doing might be disparaging people who do not experience that hope, suggesting that they are somehow weak and inadequate. As you read through Dave's response and that of other observers, it becomes clear that he certainly did not intend to suggest such a conclusion. Indeed, by comment #15 or so, the exchange had gone on sufficiently long that the participants had come to a rapprochement on the issue, in part because of the respect they showed for each other's opinion.
During this last 8+ years that I have been CEO of a hospital, I have had occasion to talk to lots of people with cancer. Truthfully, I had never done so before because I was too uncomfortable to do it. To this day, for example, I regret not spending time with my good friend Leah as she was dying from breast cancer about 20 years ago. As I suspect is the case for many of us, I just found it too scary and uncomfortable. I now have started to appreciate what I lost as a result, and I also have learned how helpful I could have been.
Each person faces cancer in his or her own way. There is nothing right or wrong about the different approaches people take. Denial or acceptance is not a statement about someone's character. Having hope or not does not always come from an explicit decision to be hopeful; it often just happens one way or the other. Likewise, the spectrum from stoicism and strength to dependence and, yes, even weakness, are reactions that are unpredictable until you are actually faced with the disease. Too, how one feels can change over time -- whether minute to minute, day to day, or year to year. So, one thing I have learned is not to be judgmental about how a person responds to cancer.
The other thing I have learned, I think, is how to be helpful. I'm not talking about bringing over dinner or giving someone a ride to chemotherapy or other such logistical support -- although that is helpful. No, I have learned how to have a conversation with a cancer patient and hear what he or she needs to tell me. I have learned how to answer and, equally important, when not to answer. I have learned that a lot of the protective layers that we include in our day-to-day conversations fall away when someone knows that he or she might be dying.
I always wondered how people could choose to be oncologists. I used to imagine that it would be the most depressing field of medicine, in that a fairly high percentage of the patients die of their disease. I have come to understand the happiness that a doctor feels when he or she helps a patient beat the disease outright or gain several more years of life. But, I have also come to understand the deep connection that can occur between an oncologist and a patient, especially when the disease is terminal.
Several years ago, one of our beloved hospital employees lay dying with cancer. I went to visit her at the bedside and hold her hand. We talked quietly. She said she was concerned about how her children and grandchildren would do without her. Deeply religious, she was really wondering how they would choose to live their lives. I listened and then I said, "You have to trust that you have given them an upbringing that will lead them the right way. Now, it's time for you to stop worrying about them and just think about yourself." She sighed and smiled and said, "I suppose you are right," and I could see her body relax right then and there. What a gift we had given each other in that moment.
So, now I want to express my appreciation to Kevin, Dave, and Dave's publisher for giving us a chance to eavesdrop on one of those conversations. I want to thank them for giving us a chance just to witness first hand the bared souls of people who have faced this disease in whatever way is best suited to them.
Thursday, August 12, 2010
Here's an excerpt from the introduction:
With few exceptions, [government policy] debaters assume that healthcare costs are fixed, that America's proud history of medical care and innovation comes with a staggering bill.
We know different.
Governments can tweak payment systems and probably get some temporary fiscal relief. But until we focus reform efforts on where most of the money goes, which is healthcare delivery, we will remain stuck in a revolving door of near disaster and narrow escapes. To get to the point where all people have access to high-quality healthcare, affordably, we must focus our attention on how the healthcare delivery system determines costs and quality. Then we need to change that delivery model entirely.
In fact, hospitals, physicians, and nurses -- all of healthcare -- must change. First, we must emphasize the science of medicine over the art. This means turning to evidence-based medicine, which is already underway in some sectors. But we are also talking about evidence-based delivery, work that has barely begun.
And then, they go on and explain how to do this.
You can get a sense of the message in this video produced by the Lean Enterprise Institute, which also published the book. If you can't see the video, click here.
Maybe I missed them in the document, but I didn't find central line infections, ventilator associated pneumonia, spread of MRSA, failure in timely recognition of patient deterioration, failure to diagnose, and other conditions that can result from systemic flaws in the delivery of care. If so, the number is understated.
For example, we found remarkable cost savings resulted from avoiding ventilator associated pneumonia in our hospital alone. As discussed below:
Preventing 744 cases over three years -- at a treatment cost of about $20,000 per case -- translates into a societal savings of $14.9 million during this period.
Whether $20 billion or more, the report presents yet another compelling reason to eliminate preventable harm in our hospitals.
Tuesday, August 10, 2010
(The trade-offs between the dangers associated with tired doctors and those associated with increased hand-offs has been well discussed elsewhere, and it is not my purpose here to argue the case. For the former, you find serious medical errors, medication errors, diagnostic errors, car crashes, depression, and burn-out. For the latter, you find longer lengths of stay, medication errors, and more adverse events, especially those associated with communication failures.)
Three years ago, the Risk Management Foundation published an edition of its Forum entirely devoted to the subject of how to reduce risks during hand-offs. It remains a good summary of the issues, and you can view it here.
Last year, one of our Senior Residents, Kelly Graham, decided to use the research phase of her residency to test out some interventions to see if they could reduce the likelihood of hand-off related errors. She compiled the following baseline assessment for BIDMC (which, as noted, was similar to a previous assessment at Brigham and Women's Hospital):
Kelly decided to focus on three aspects of hand-offs: The systems in place, the written communications, and the oral communications. Her hypothesis was that by taking a systematic approach to intervening in each component of the patient hand-off, we could improve the quality of sign-outs, patient safety, and intern satisfaction.
The "prior" that Kelly was trying to change is the age-old system: Interns learn how to do hand-offs on the floors by watching their senior residents. Process improvement folks reading this know that is a recipe for a high degree of variation in practice and for a systematic transmittal through time of bad habits and approaches that increase the likelihood of harm.
So, Kelly's aims were to provide resident physicians and patients with safe hand-off practices; to promote a “standard operating procedure” for hand-off; and to take hand-offs out of the hidden curriculum of medical training and make it part of our formal education process.
On the system side of the equation, she noted that many hand-offs actually did not occur between the doctor leaving the service and the doctor arriving. Instead, an intermediary person often took the information from the departing doctor and later relayed it to the arriving doctor. Like the old game of telephone, this increased the likelihood of flawed information transfer. (In fact, prior studies indicated a loss of 22% of the desirable information that should be passed along at the time of transfer.)
The alternative was to require direct communication between the departing intern and the arriving intern, in a standard location (the house officer lounge). Doctor-to-doctor interaction increased from 25% to 100%.
The next intervention was designed to present a common template of information to be transferred. Pull-down menus on the computer helped to ensure that standard categories would be discussed, and standard language would be used as much as possible to reduce variation in the transmittal of patient data.
And the final intervention, the one that is likely to raise eyebrows among my lay readers, is the idea of teaching how to do a sign-out in the classroom before arriving on the medical floors. Huh?
Well, the baseline assessment was that interns are not prepared for hand-offs during medical school. 91.3% of interns at BIDMC reported no hand-off training prior to residency; and 92% interns nationally report no hand-off training prior to residency. So Kelly designed and implemented a case-based, interactive, sign-out workshop during the interns' orientation.
As the year went along, she surveyed the residents and also kept track of patient data. She reached the following conclusions:
Interns are ill-prepared for transitions of care; “double hand-offs” may reduce work hours slightly, however the trade-off is that they may be unsafe for patients; involving the primary team in the hand-off process has a powerful effect of patient safety and physician satisfaction; electronic templates are reliable tools to ensure sign-outs are complete; and interns respond well to incorporating hand-off training into their education.
And, now look at the clinical efficacy of the experiment. There was a dramatic reduction in adverse events, near misses, and data omissions. In fact, the first two interventions were so powerful that it was not possible to fully evaluate the strength of the last one -- but the training did help to improve interns' job satisfaction.
The interventions are now embedded in our Department of Medicine's system of training and care. The interns who just arrived don't know enough to know that they are doing something different from the past because they never experienced the ad hoc system that was in place before. Congratulations to Kelly and her colleagues for demonstrating how an academic medical center can contribute to the improvement of clinical processes, something just as important as our contributions to basic and translational research about disease.
A key component of GRACE is its integration with our computerized provider order entry system. Here is a recent article on that from Scientific American, which in turn is based on an (unfortunately subscription-required) article in the Archives of Internal Medicine. Here's an excerpt, quoting Doctor Melissa Mattison on our staff:
"Our study found that when doctors were alerted that the drugs they were ordering could pose a danger to older hospital patients, the orders dropped almost immediately," said Mattison, who was the first author on the study.
After the new CPOE function was installed at BIDMC in 2005, the orders for potentially inappropriate medication (PIM) for older adults dropped—and stayed—some 20 percent lower than what they had been (down from an average of 11.6 a day to 9.9 a day).
"Many drugs commonly used today have not been tested in seniors or elderly patients," Mattison said. "As a result, a dose that is appropriate for a younger adult may lead to potentially harmful side effects in older individuals, who tend to metabolize medications more slowly."
I have written several times about the ongoing saga between the state administration and the health care insurers in the state concerning premiums for small businesses and individuals. Over the last several weeks, several insurers have reached settlements with the Division of Insurance. At least one has not and has prevailed at the appeals board because the rates forced upon it by the state were not actuarially sound. Where settlements have been was reached, they were not based on actuarial principles: They was based on a desire to get past this impasse and provide some stability to customers.
Here's a quote from one company official:
Blue Cross spokesman Jay McQuaide said the organization agreed to accept “less-than-adequate rates’’ — which he said are too low to cover its costs — to resolve the uncertainty for customers.
The disturbing aspect that remains is a lack of understanding by some state officials of the issue. There appears to be a presumption that hospitals and doctors are somehow taking advantage of the situation to raise their costs. But that is at variance with what hospitals are actually doing and facing.
Here, for example, we see one hospital facing huge losses and another one laying off staff in the face of financial pressures.
There are sophisticated observers of the scene, however, who continue to offer thoughtful views. Here is an op-ed in today's Boston Globe by Robert Pozen entitled "A bitter health care pill." An excerpt:
[T]he perfect is often the enemy of the good in health care. Instead of taking a decade to move from fee-for-service to a capitation system, the state should implement two relatively significant cost-saving measures: Reduce the number of mandatory coverage items and charge higher copayments for using the highest-cost providers.
Monday, August 09, 2010
Here's what it really shows. It shows that some people are really insensitive and don't understand the privacy laws.
Is Facebook the cause of this? No. Does it facilitate the publication of pictures of all kinds? Yes.
As noted here, breaches of patient confidentiality can happen in many ways. Apparently, a common problem is when patient data is faxed to the wrong telephone number. And then there are the occasional cases where a portable computer with patient records is lost.
I know the counter-argument. These other examples are minor lapses and don't cause patient data to be spread to thousands of people instantaneously.
But here is the point. If you block Facebook on the hospital server, will it nonetheless be used in the wrong way by misguided people? Yes. They will use their iPhones or some other such handheld devices.
I know this sounds like the pro-gun argument, "Guns don't kill people. People do." However you might feel about that issue, this one is different. By blocking this medium on your hospital server, you will remove a highly effective communications tool, all because you are fearful that a few misguided people will misuse it. You trade the illusion of security for a loss of community.
Our head of operations writes:
This picture shows how Brendan's team showed this plant a little TLC. His team will continue to give it special treatment!
Sunday, August 08, 2010
Rättskiparen (The Referee) is short documentary about Martin Hansson, the referee who missed Thierry Henry's handball. A Swedish television program had already committed to this project before the infamous incident which kept Ireland from going to South Africa. The station's plan had been to track the country's top ranked referee in the months leading up to the 2010 World Cup - as fate would have it, the story of course got more complex with that one game. It's an incredible portrait - part of a wave of films looking at referees. This one has an unusually personal quality to it.
If you cannot see the video, click here.
Saturday, August 07, 2010
Heads up, a rogue tomato plant is growing outside Shapiro, sidewalk side of the soup or salad patio. It's amazing it survived as long as it has, but it has flowers, and likely will soon have tomatoes, well if it is not kicked, pulled, or weeded.
I surmise that someone dropped a tomato while eating a salad for lunch.
There is a problem once you learn the Lean philosophy and techniques: Every setting prompts you to imagine how much better it could be if these principles were adopted.
Earlier this week, a friend gave me a sample of some marvelous cranberry bread from a new bakery in Wellfleet, PB Boulangerie. She warned, though, that the place has long lines and that I should be prepared to wait, unless I arrived at the 7am opening time. I arrived at 7:05 and found a line of 20 people. Here is a picture of the ones behind me after I had been there ten minutes.
Now, it is summer on Cape Cod, and who really cares if you have to wait? You meet people from all over and compare notes about beaches, restaurants, and the like. But, then we noticed that the line was scarcely moving. Earlier customers set up their coffee and pastries at a nearby table, and they were practically finished eating by the time I approached the front door.
Once inside, the problem was made evident. There were plenty of serving people (four), but the bakery was rife with batch processes. Two people were in charge of taking orders for bread and pastries; one person was in charge of coffee orders; and one person was the cashier. After the bread person took your order and put it carefully in bags, s/he would place the order on a low shelf, under the counter near the cashier. Meanwhile, the coffee person would hand you your coffee directly.
By the time you got to the cashier, she had become a bottleneck. She would reach under the counter and grab the closest order, and lift it up and place it on the counter and say, "Did you have two baguettes?" and you would say, "No, I had the brioches," and she would bend down and replace the first order with your order. Meanwhile, some independent process would be going on for the coffee.
The person next to me was a process engineer, and so you can imagine the conversation we started to have. What if there had been a continuous process, with visual cues, all focused on the needs of the customers? The possibilities were endless.
In this case, though, the elapsed service time, start to finish, was 55 minutes.
But, here are the almond paste and raspberry brioches, along with the cheese bread and cranberry bread. Worth the wait!
Friday, August 06, 2010
Well, it turns out that there is a tomato-free form of gazpacho in Spain, called ajo blanco, based on almonds, bread, and garlic. It appears to be of Arab origin. Here's the recipe.
Now, while we are at it, what did the Italians use on their pasta before tomatoes arrived? And reaching back, what did they use for a starch before pasta arrived? (No, Marco Polo did not bring noodles to Italy. It appears that the Arabs had something to do with this, too.)
Thursday, August 05, 2010
Wave was perhaps the prototypical Google product: Technically advanced, incredibly ambitious and near-impossible to use.
Its demise is the canary in the coal mine for Google's social networking plans: Facebook is destined to build the Web's next wave, as Google continues to tread water.
Meanwhile, let's take a look at what is going on at Facebook and elsewhere, courtesy of EduDemic. I offer #6 (regarding Facebook) and #10 (regarding Twitter) especially for those hospitals and other companies who choose to block these media on their servers, in the hope they will consider how fruitless that is.
1. The average Facebook user has 130 friends.
2. More than 25 billion pieces of content (web links, news stories, blog posts, notes, photo albums, etc.) is shared each month.
3. Over 300,000 users helped translate the site through the translations application.
4. More than 150 million people engage with Facebook on external websites every month.
5. Two-thirds of comScore’s U.S. Top 100 websites and half of comScore’s Global Top 100 websites have integrated with Facebook.
6. There are more than 100 million active users currently accessing Facebook through their mobile devices.
Over at Twitter:
1. Twitter’s web platform only accounts for a quarter of its users – 75% use third-party apps.
2. Twitter gets more than 300,000 new users every day.
3. There are currently 110 million users of Twitter’s services.
4. Twitter receives 180 million unique visits each month.
5. There are more than 600 million searches on Twitter every day.
6. Twitter started as a simple SMS-text service.
7. Over 60% of Twitter use is outside the U.S.
8. There are more than 50,000 third-party apps for Twitter.
9. Twitter has donated access to all of its tweets to the Library of Congress for research and preservation.
10. More than a third of users access Twitter via their mobile phone.
As I noted below, the bill's provisions about transparency of rates, costs, and clinical outcomes are noteworthy. But there are other important features, too.
If you do a web search, you find some mention of the bill. Here's a piece from an insurance web site. The head of the retailers association, a person who was not timid in past months about the need for a bill, is quoted:
Jon Hurst, president of the Retailer's Association of Massachusetts, said the bill will enable small businesses to obtain premium prices that large employers use their market clout to secure.
"This is the most important reform small businesses have seen in 20 years designed to give them and their employees' health insurance premium relief and equal rights under the law and in the marketplace," Hurst said.I offer no opinion here on the gambling bill, but I am confident that whatever its economic impact might or might not have been, the economic impact of the health care bill will be more pervasive for years to come.
Wednesday, August 04, 2010
Excellent example of actualization of purpose versus a mission statement not so well actualized. (Radiology)
I love it, thanks. I have always tried to live by, "Treat others as you would have them treat you" and have raised my children as my parents raised me. My daughter now works as fitness trainer working with the elderly (many of whom remind her of her now deceased grandparents) and my son found his passion working to integrate those with special needs. To know that I work for such a special organization makes coming to work even more enjoyable.
Working with women in OB/GYN, I try to treat each on as I would want my mother, sister, or daughter treated. It makes no difference to me when I am informed that a patient is a doctor or wife of one. No one gets special treatment, because I feel everyone that comes here gets SPECIAL treatment!
I have always believed by giving some control back to the patient, it helps eliminate high anxiety and make the patient feel respect. Thank you for your thoughts. (Med/Surg)
As a nurse on labor and delivery I just wanted to say that was a wonderfully put statement. As you know we on L&D form very strong emotional bonds with our patients and their families sometimes repeatedly with additional children . We form a certain kind of interdependence relying on each other in a way that is truly unique. Thanks for the "heads up." We appreciate it, and it made total sense. Also made me smile.
Hi Paul...this is a great message from you, and I look forward to hearing more, as time goes on. You may remember several years ago when you hosted small groups for dinner, we spoke about treating patients as we would want our own families and loved ones to be treated. As part of my interviewing process, since I began in this position, I have always referenced that message. What I tell applicants (and anyone else who will listen to me!!) is, "I need people who treat everyone, but I will concentrate on patients now, as they would want to be treated or how they would want their families or loved ones to be treated." If we don't do this, then when our time or their time rolls around, and it does roll around for all of us sooner or later, we have no right to expect more than we've given. And even if it feels like it isn't happening, that's okay, do it anyway because it's the right thing to do!
Your statement, "It is very different from the training received by doctors, and even that received by many nurses. Beyond being respectful, empathetic, and compassionate, it requires us to be ever modest about our knowledge and in our demeanor."
This is key! Until and unless we all recognize and appreciate that we all need the next person in order to be successful, to make the clock tick, we will never rise to the level we otherwise might. The surgeon needs the housekeeper to clean the OR, the housekeeper needs the equipment to accomplish the work, the manager needs a strong staff, and on it goes. I have always believed that no one is more important than the next, and that, in medicine, patients must be listened to with great attention; if not, we've lost a great deal in the process and will never reach the heights that we are capable of reaching - together. The crush is on in health care, all around! (Gastroenterology)
Thank you very much for sharing with us the airline industry story. it is so true that we can never forget what we are working at BIDMC for. We are here to carry a big mission in delivery -- the best and safe care for our patients and their families.
We should never forget how lucky we all are that we are not standing the other side in needing that care but using our skill and knowledge in helping the others. (Peri-Operative Services)
I was thinking precisely the same things about airlines and customer service as I flew back to Boston on a crowded flight on Saturday. I always check Southwest first, not because they're necessarily cheaper, but because I like their ethic, and the tension on other airplanes due to carry-on baggage simply doesn't exist there.
Not too long ago, I asked a flight attendant at another airline how they coped with the increased carry-ons. She surprised me by saying that their cabin crew were not actually logged in as "at work" until the flight took off. Any arranging of bags and assisting of passengers before take-off was quite literally done on their own time. So, apparently, it's the customers and the staff who are suffering from the checked-bags policy.
Compare that with our ethic here at BIDMC - treating patients "as we would like ourselves and our families to be treated". This is so often the way to make the patient experience simpler, more efficient, and crucially - more welcoming. A motivated staff understand and agree with the reasons for doing what they do. That's a large part of what we Mystery Shoppers encourage among our terrific front-line BIDMC staff.
Thanks for a thought-provoking message. (Ambulatory Services)
Tuesday, August 03, 2010
Stick with me through some background that might seem irrelevant. Then, I hope you like where it leads!
A few weeks ago, I heard a talk by Roy Spence, the author of It's Not What You Sell, It's What You Stand For: Why Every Extraordinary Business Is Driven by Purpose. As suggested by the book's title, his proposition is that truly excellent organizations are those characterized by a common sense of purpose. This is different from having a mission statement or corporate objective, which state a business direction. It is more about having a desire to change the world for the better.
An example Roy gave was Southwest Airlines, who purpose is to give people the freedom to fly. You could probably quote the tag line: “You are now free to move about the country.” I listened as he talked about the airline’s actualization of this sense of purpose. One example occurred when the entire airline industry decided to start charging for baggage. Southwest was advised by its financial people that doing the same would save millions of dollars and make millions of dollars. The company decided, though, that charging people for luggage would conflict with its purpose and so -- contrary to all advice -- not only decided not to charge for luggage but to begin a now famous Bags Fly Free advertising campaign. “We love bags!” proclaimed actual baggage handlers on the tarmac.
Sure enough, the company did not save or make millions of dollars from this decision. It made billions of dollars, as the public responded by shifting gobs of business from other carriers.
I hadn’t thought about this much until today, when I got on an American Airlines flight and noticed virtually every passenger board a full flight with a “rollerboard” style suitcase to put in the overhead bins. They were all trying to avoid the $25 fee for checking their bags.
The tension was palpable among the passengers and the flight attendants. Passenger who boarded later peered ahead in the aisle wondering when the next open spot would be for their bags. Flight attendants were alternating between repacking each overhead bin to maximize its carrying capacity and hurrying passengers along so we could have an “on-time departure.”
The result: Airline employees were devoting all of their emotional energy to the baggage. If you had questions about anything else, they could not make eye contact because they were scanning the bins for empty spaces.
Another result: Passengers’ relative comfort with the flight had already been diminished, and we hadn’t even taken off yet. Categories were created between the “have’s” and “have not’s”. Those of us who arrived earlier (because of “priority access”) felt the calm superiority of secure overhead bag placement, while those who arrived after felt like they had missed something. One person actually asked me how I had managed to get on board before her.
To think, this all started with a different sense of purpose. For Southwest’s staff, everything is about wanting to give us the freedom to fly, and because of that, the airline’s customers never have a doubt.
I realized that I’d be hard-pressed to know American Airlines’ purpose. I opened up the magazine in the seat pocket to see if I could find it. There is a letter from the CEO which says something about “all my AA colleagues all over the world who put their hearts and souls into taking you wheresoever you want to go in the world.” At first blush, you might say that is the same thing Southwest says, but it is not quite the same. The AA line is about their doing something for you, not your doing something for yourself. It is not liberating: It is creating a dependence.
Let’s switch to medicine and hospitals now. As you all know, at BIDMC, we have a long-standing purpose. It is not a business objective in our strategic plan or mission statement, but it is deeply held: “To treat patients and their families as we would want members of our own family treated.” Achieving this purpose is a full time endeavor for all of us who work here -- including those involved in research and teaching as well as clinical care.
In the last eight years, we have accomplished a financial turn-around, successfully implemented a strategic plan and gained market share, dramatically enhanced patient quality and safety, come together as a community during economic hard times to save jobs and to protect our most vulnerable staff members, and begun an approach to process improvement (Lean) that is highly respectful of one another.
And, through it all, we took great care of patients and their families.
Notwithstanding these great successes, we have begun to learn that we cannot satisfy our purpose if we make all the decisions for patients and their families. In the ICUs and elsewhere we have established patient and family advisory councils that bring in the wisdom of our clients in logistics, space planning, and even clinical protocols. Several months ago, I wrote about one such effort in our ICUs that actually received international recognition.
Of all the lessons we have learned here at BIDMC, this may be the hardest. It is very different from the training received by doctors, and even that received by many nurses. Beyond being respectful, empathetic, and compassionate, it requires us to be ever modest about our knowledge and in our demeanor.
This kind of approach is most successful when it is a partnership, where dependence in one direction is transformed into bidirectional interdependence. I'm not writing today to provide lots of details, but to give you a heads up: Over the coming months, look for an expansion in our engagement with these advisory councils and other outreach to our patients and their families. We also plan to work with the Institute for Healthcare Improvement to encourage and enhance the activities of patient-run organizations in Boston and beyond.
If we can learn to be full partners with our patients in carrying out our purpose, the sky’s the limit.
Thanks, as always, for your involvement, support, ideas, passion, and encouragement.
Sunday, August 01, 2010
"Laughter and giggling and levity are the spirit of life. It’s what we need and what we all crave. Wangchuk had it and it was natural and graceful.’’