Tuesday, May 31, 2011

Kudos to Glen Cove Hospital

The folks at Glen Cove Hospital are on a roll. Last October, they were listed by the New York State Department of Health as having the lowest central-line associated blood stream infection rate in medical-surgical intensive care units among 113 non-major teaching hospitals in the state. At the time, they had gone over two years without an infection of this sort.

A few week ago, I met Maureen White, RN, from North Shore-LIJ Health System, who told me that the record was now over 2.5 years. This morning, I confirmed that with Jeanine Woltmann, RN, in the Infection Control department.

As of April 30, Glen Cove had gone 1223 ICU patient-days without a central line infection. An outstanding accomplishment by any measure.

How did they do it? Was it some government regulation? Was it incentive payments from the insurance companies or Medicare?

No. They did it because they wanted to do it. Here's the magic solution:

"The superior results at Glen Cove are the result of a collaborative effort between nursing, infection control and physician staff," said Brian Pinard, MD, chief of surgery. "These clinicians have consistently put their motivation and caring into action to reduce the risk of infection while caring for patients."

The culture of patient safety in hospitals has changed dramatically in the last several years, according to Dr. Pinard. He explained that, prior to 2005, there was a common misconception in healthcare that some hospital infections were unavoidable and beyond anyone's control. He said the path to the perfect record began with the hospital's embracing the Institute for Healthcare Improvement's 100,000 Lives Campaign and its emphasis on preventing medical errors and infections.

The hospital's initiatives included communication through daily inter-professional rounds, education, and monitoring of various programs, among them hand hygiene, sterile practices and the use of universal safety protocols. This led to excellent outcomes, improved patient safety, decreased length of stay, a decrease in mortality and cost avoidance, according to Dr. Pinard.

In other words, the people at Glen Cove Hospital do not accept or believe the premise that "these things happen." I again repeat the wise words of Ethel Merman, and also present the original scene from It's a Mad, Mad, Mad, Mad World:

Now what kind of an attitude is that, 'these things happen?' They only happen because this whole country is just full of people who, when these things happen, they just say 'these things happen,' and that's why they happen! We gotta have control of what happens to us.

If you cannot see the video, click here.

Monday, May 30, 2011

Bach and Kocher: Good try. Wrong plan.

Peter Bach and Robert Kocher offer an intriguing but wrong-headed approach to expanding the roster of primary care doctors in America. In a New York Times op-ed entitled, "Why medical school should be free," the authors note:

Fixing our health care system will be impossible without a larger pool of competent primary care doctors. . . . [T]he American Academy of Family Physicians has estimated a shortfall of 40,000 primary care doctors by 2020.

Making medical school free would relieve doctors of the burden of student debt and gradually shift the work force away from specialties and toward primary care.

We estimate that we can make medical school free for roughly $2.5 billion per year — about one-thousandth of what we spend on health care in the United States each year. What’s more, we can offset most if not all of the cost of medical school without the government’s help by charging doctors for specialty training.

[U]nder our plan, medical school tuition, which averages $38,000 per year, would be waived. Doctors choosing training in primary care, whether they plan to go on later to specialize or not, would continue to receive the stipends they receive today. But those who want to get specialty training would have to forgo much or all of their stipends, $50,000 on average.

This is such a convoluted plan that it is unlikely to get much traction, but its proposal is indicative of a more fundamental problem, a huge gap in what primary care doctors and other cognitive specialists get paid under Medicare (and therefore by private insurers) compared to what procedural specialists get paid:

Our plan would not directly address the chronic wage gap between primary care providers and specialists. But efforts to equalize incomes have been stymied for decades by specialists, who have kept payment rates for procedures higher than those for primary care services.

I have discussed this problem here, and it has been documented by others. The rate-setting process used by CMS is deeply flawed. By inaction and secrecy, the agency has chosen to let specialists have the influence cited above. It is indicative of this deeply ingrained pattern at CMS that these two respected folks, high-level participants in the Washington arena,* were unable to use their positions in federal administrations to get the job done in a much simpler fashion.

*Bach was a senior adviser at CMS from 2005 to 2006. Kocher was a special assistant to President Obama on health care and economic policy from 2009 to 2010.

The Infrastructure Chronicles -- Volume 8

In December of 2005, there was a breach of the dam holding back the 50-acre Tom Saulk reservoir in Missouri. This created what was called a mini-tsunami, with 17 foot waves.

The proximate cause of the problem was that a simple water level gauge failed, and so the power company overfilled the dam. There were redundant systems in place to measure the water levels, but they had been bypassed, leaving a single failure mode in place.

The state public service commission investigated the accident and found that the utility's "decision to continue operating Taum Sauk after the discovery of the failure of the gauge piping anchoring system and the consequent unreliability of the piezometers upon which [its] control system was based is frankly beyond imprudent – it is reckless."

The design of safety systems for infrastructure is a science, as it is in hospitals. There is one thing common to both: If you rely on a single point of control to avoid disaster, you are likely to fail. Sometimes catastrophically.

Friday, May 27, 2011

The Infrastructure Chronicles -- Volume 7

Fred Salvucci, transportation engineer extraordinaire in Boston, has often told this humorous story about his grandfather:

When my grandfather was preparing to immigrate from Italy to the US, he was told the streets were paved with gold. He learned three things upon arriving. He learned that the streets were not paved with gold. He learned that the streets were not paved. And he learned that he was going to pave them.

There was a generation of Italian stone and brick workers who constructed many of the buildings and infrastructure projects in this region. Some of them worked on the sewer system. Not much craftsmanship there, you might think, until you remember that the early sewer pipes were made with brick, not pre-cast concrete like today.

I have been inside some of those large old sewer pipes and I have seen the interior construction. The pattern of the brickwork is pure artistry. Many have lasted over 100 years in a environment that is extremely corrosive. Unfortunately (well, maybe you think it is fortunate), you cannot go and tour them. But here are some pictures from the 1902 First Annual Report of the Metropolitan Area Water and Sewerage Board that will give you an idea of what you are missing. The one above is entitled, "Construction of circular tunnel with air compressor and metallic shield, in Centre Street, Jamaica Plain." The one below in Milton required an open cut through the granite that characterizes that region and was then lined with bricks.

Person or system problem, or both?

I am going to do something really wrong, commenting without knowing all the facts. But guessing from a press report, I am betting that this story is not totally a person problem:

A Pennsylvania medical center demoted a surgeon and suspended a nurse who were involved in the transplant of a kidney from a donor who had hepatitis C, a spokeswoman said on Thursday. The University of Pittsburgh Medical Center has also suspended its live-donor liver program as a precaution, though no problems were found with that program, UPMC spokeswoman Jennifer Yates said in a statement. The medical center voluntarily suspended its live-donor kidney transplant program earlier this month after discovering the infected kidney and notified the United Network for Organ Sharing, a national transplant agency. The agency plans to conduct a review.

It will be interesting to follow this story as it develops. It will also be revealing to see if UPMC shares the results of what they learn more broadly with the transplantation community.

In the meantime, will this have an impact on the hospital's ad campaigns?

Addressing scapegoating in North Carolina

Blue Cross Blue Shield of North Carolina is using the humor of an ad campaign to get across the complexities in the health care system. Take a look at their concept, Let's Talk Cost, here. I think it is really nicely done. Here's one of the ads:

If you cannot see the video, click here.

Thursday, May 26, 2011

HSPH students analyze hospital mergers

Those nice students from the Harvard School of Public Health turned in their paper about hospital mergers, and they were kind enough to send me a copy. It is entitled,"Leading by Leveraging Culture in Hospital Mergers," and the authors are M. Marianne Jurasic, Ryota Konishi, and Katherine Sullivan. Their research led them to a number of lessons and recommendations. Here are some excerpts (cites omitted):

If hospital mergers are such great opportunities from an economic perspective, why do many notable failures litter the landscape and the pages of academic journals? Despite similar commitments to patient care, safety, and improving health, no two health care organizations are exactly alike. Thus culture clash between merging organizations is inevitable. It is our contention that one reason many hospital mergers fail is because hospital leadership fails to anticipate and address the impact of culture clash on the outcome. By being aware of the acculturation process in the new organization, management can have a positive influence on the merger process.

We recommend merging entities examine how their cultures differ prior to the merger. The merging entities should consider how much they value the preservation of their own culture and also their perception of the attractiveness of their merging partner. This analysis will enable them to determine whether their cultures will undergo integration, assimilation, separation or deculturation. If the two merging entities agree on their mode of acculturation, there will be less acculturative stress present and a more successful implementation of the merger.

We also recommend the development of a comprehensive plan for cultural integration. Despite the persistence of small and imminent problems, a long term goal and vision for the merged organization is necessary. In order to communicate management’s commitment to this vision, quick and decisive actions regarding any post-merger reorganization and consolidation are required. For example, prior to their merger, HP and Compaq recognized that they had had very different cultures. To address it, they anointed 650 part-time internal "cultural consultants." Early and comprehensive intervention by management provides a way to ensure that a uniform culture develops. Management can exert its influence on culture through socialization activities that include seminars, cultural and behavioral training, and provision of incentives for desired behaviors and social activities.

A final recommendation is that management communicate that voluntary employee departures are a normal part of building a new culture. It is important to accept that some conflict and dislocation is a part of the process, and not to lose focus on overall strategic goals. Mergers are inevitably accompanied by change, and this change can be stressful and frightening. The departure of individuals leads to “wash out” of extreme cultural differences and paves the way for new employees to join the group who are more susceptible to enculturation. Poor communication during mergers may intensify stress among the members of the organization because of the uncertainty they feel regarding their future. It is for this reason that various methods of communication are necessary to ensure there exists exemplary information transfer between all members of the organization.

The cultural implications of hospital mergers is not a relic of the hospital merger frenzy of a decade ago. Rather, ongoing health care payment reform in the United States, which will attempt to shift the payment system from fee-for-service to pay-for-performance or global payments system in order to improve the quality of care and reduce overall medical expenditures, creates a similarly uncertain financial operating environment for hospitals today as existed in the 1980’s and 1990’s. Given the high likelihood of increased hospital mergers going forward, hospital managers now have a the opportunity to learn from past mistakes and address issues of culture clash in the combined entity before, during, and after the merger takes place.

Is it something in the water?

What's going on in Michigan? There seems to be something about that state that prompts sustained and excellent progress in improving the quality and safety of patient care. Here are two announcements from Diane C. Pinakiewicz, President of the National Patient Safety Foundation. Let's bottle that water and send it around the world!

The National Patient Safety Foundation (NPSF) today awarded its 2011 Chairman's Medal to Dr. Robert Connors, president of Helen DeVos Children's Hospital, a member of Spectrum Health System in Grand Rapids, MI.

Beginning with the stated goal of creating "the safest children's hospital in America," Connors spearheaded a patient safety program in 2007 that empowered staff by removing traditional hierarchies and barriers to communication. After completing an intensive training program in safety sciences and armed with error reduction tools and techniques to guide their practice, employees directly involved in patient care gained the authority to raise safety concerns with anyone at anytime. Connors' efforts at the hospital resulted in this program being picked up by the entire Spectrum Health System organization, which includes nine hospitals and 180 care sites.

Among the outcomes:
  • Between 2008 and 2010 safety events were reduced 68 percent.
  • Ventilator associated pneumonias in the Pediatric Critical Care Unit have been eliminated for 19 consecutive months.
  • Hand hygiene has improved from 56 percent to 96 percent for more than a year, helping to reduce hospital acquired infections by 50 percent.
  • Catheter associated blood stream infections in the Newborn Intensive Care Unit were reduced by almost 50 percent.
  • Asthma core measures at discharge achieved 100 percent compliance.
  • Spinal surgery infections were eliminated.
Sustaining the safety transformation has become just as important as launching the initiative. "Safety is now an integral part of our strategic planning and daily operations," said Connors. "We have appointed an executive director of quality and safety, created unit based safety champions and forged partnerships with other leading children's hospitals engaged in safety work best practices."

And . . .

The National Patient Safety Foundation (NPSF) today awarded its 2011 Stand Up For Patient Safety Management Award to Franciscan St. Anthony Health-Michigan City, a member of the Midwest-based Franciscan Alliance.

The Patient Safety Management Award is granted to a member hospital of the National Patient Safety Foundation’s Stand Up for Patient Safety program in recognition of the successful implementation of an outstanding patient safety initiative led or created by mid-level management. The initiative must have demonstrated evidence of patient safety improvement, with involvement of staff at all levels of the organization.

The hospital’s Nuclear Medicine Department designed a process-improvement project to study its lymph node visualization rates. The mammary sentinel lymph node biopsy, or sentinel nodal location (SNL) procedure, plays a critical role in the staging of breast cancer, and information from the biopsies is used to determine how to treat the cancer most effectively. In a study involving 24 patients, health professionals at Franciscan St. Anthony Health-Michigan City found that by reducing the length of the needles used during the biopsies, visualization rates improved dramatically, from 25 percent to 100 percent in 2010.

By optimizing its visualization rates, the hospital has improved the quality of care and safety of its patients by:

· Reducing patient discomfort associated with the SNL procedure

· Reducing surgical time (total procedure time reduced from 3 hours to 1 hour)

· Shortening recovery time

· Increasing access to outpatient surgery bed time (for other patients)

Wednesday, May 25, 2011

Tom Closson rebuts my post about Ontario MDs

Tom Closson, head of the Ontario Hospital Association, has written a blog post finding fault with my interpretation of a lack of interest on the part of doctors to take advantage of a funded program to improve care in the province's hospitals.

The link to his article is
here. But I also reprint it in its entirety to let you decide if he answers the concerns I raised. (I feel like we are talking past each other. See what you think.)

I recently read a blog written by Paul Levy called $33 million (Canadian). Any interest? To read the blog, click here. The blog was Paul’s interpretation and opinion of an article in the Canadian Medical Association Journal written by Lauren Vogel, entitled “Uncertainties Surround New Funding for Most Responsible Physicians”. To read the article, click here.

I was quite surprised to read how Paul thinks that uncertainty surrounding the challenges with physicians participating in Ontario’s MRP Collaboration Incentive Fund implies that Ontario physicians are not interested in improving patient quality and safety. I know this is not the case.

Physicians are often engaged in quality improvement activities. The challenge, however, seems to be the ease of alignment of physician engagement with hospital and government agendas. The Ontario Hospital Association (OHA) recently hosted an event featuring keynote speakers Jack Silversin and Steven Lewis. Both speakers noted that there are many reasons for the lack of involvement of physicians with quality improvement activities, including lack of time, being funded for only fee for service activities, and the lack of training in quality improvement methodology. Put simply - if we want physicians to engage, we need to give them the skills and opportunities to do so and we need to invest in physician leadership. We also need to ensure that provider reimbursement models are aligned with good practice.

The Saskatchewan Medical Association along with the College of Physicians and Surgeons and the Health Quality Council of Saskatchewan have invested in physician leadership so that they are equipped to lead health system transformation rather than just play a part in it. In Ontario, the Ontario Medical Association (OMA) recently launched a Physician Leadership Development Program with the Schulich School of Business and the Canadian Medical Association (CMA).

We are also trying to play our part at the OHA. We recently formed a Physician Provincial Leadership Council aimed at working with physician and hospital leaders to inform health system change. To formally launch this Council, the OHA will be hosting an inaugural Physician Leadership Summit in Toronto on June 9 & 10, 2011 which will focus on physician leadership and the role of physicians in quality improvement. For more information on the Summit, click here.

Quality improvement is hard work and we need to work together to ensure that we are making health care better for all Ontarians.

CMS stifles primary care. Washington sleeps.

Brian Klepper and Paul Fischer take aim at the approach used by CMS to set rates for the various medical specialties. Thanks to ePatient Dave for leading me to this and for reminding me that this was a topic I covered last October, based on a report in the Wall Street Journal and insights from several of the doctors at my hospital. In short, a secret, unaccountable panel makes recommendations to CMS that favor proceduralists over cognitive specialists. These recommendations then get translated into the actual rates paid to the different types of doctors.

In their article on the Health Affairs Blog, Klepper and Fischer note:

We have focused on rallying the primary care and business communities to pressure CMS for change, and are contemplating a legal challenge. But the obvious question is why these steps are necessary. Why doesn’t CMS address the problem directly? Why does it continue to nurture the relationship?

So, while CMS is busy trying to revise impractical ACO regulations and also persists in avoiding pressure on its delegated agency, The Joint Commission, to make public the best practices of hospitals that pay funds to be accredited, it fails to act on this poor process and the resultant skewing of rates. And not a word about this from elsewhere in the Administration or the Congressional leadership.

Tuesday, May 24, 2011

Halamka is a fun guy

It has been very moist here in Boston (and tropically warm today.) Prime season for mushrooms, like this one growing out of a tree stump. Thanks to John Halamka (aka Geekdoctor), we learn that this specimen is "a harmless polypore." Among other accomplishments, John is one of the region's most knowledgeable mycologists. By "harmless," I think he means edible. I was told by folks at Mass Audubon that all tree-growing mushrooms in this region are edible. They are not always tasty and tender, though.

Humorous addendum from John: Instructions for eating a polypore - boil for 60 hours, then enjoy. Tastes like cardboard. Mmmm.

Monday, May 23, 2011

One way to handle a near miss

The Blue Angels, the Navy's elite aerobatic team, have cancelled their annual performance at the Naval Academy's Commissioning Week. Why? Well, they had a near miss during a recent show:

"There was a deviation from the standard flight parameters during the show,” Kelly said.

The performance was halted and the Navy decided the team needed to head back to Pensacola for training and practice.

Let's think about the difference between this and the usual practice in hospitals. A near miss occurs. Most times, no one notices. Many times, no one says a word, even if the event is noticed. Some times, someone says something, and nothing happens. Still fewer times, someone says somethings and reports it up the chain of command, and nothing happens. Fewer times still, after it is reported up the chain of command, a root cause analysis is done. Fewer times still, after the root cause analysis is done, a change in protocol is designed and tested, and, if effective, training is carried out and implementation of the new protocol spreads through the organization.

For every reported adverse event in a hospital there are at least an order of magnitude, and perhaps two or three orders of magnitude, more unreported events. For every unreported event, there is a similar order of magnitude difference in the number of near misses.

Imagine if we had a standard of care in hospitals equal to that of the Blue Angels.

Nah, it can't be worth it. After all, they have six people to worry about, so many more than go to hospitals.

And the consequences of errors in hospitals are so insignificant.

Nah, it can't be worth it. After all, these things happen.

U of M: How're they doing? Your call.

The University of Michigan Health System has done exemplary work in improving the quality and safety of patient care. Perhaps the most visible success, as part of a statewide effort, was to eliminate central line infections in ICUs for extended periods of time. But UofM has a broad-based program beyond this, which gets support from the senior leadership and participation throughout the organization.

The system is also very open about its clinical outcomes and the status of its process improvement. As noted on this website:

This site shows where we're doing great and where we can perform even better. The site also offers information about quality care, quality measures, and what quality really means to the most important people in our community: you - our patients and families. While quality reports from other sites may be a year old or more, the reports on our website show the most up-to-date measures of quality and safety at the University of Michigan Health System.

People are then invited to explore more deeply. I recently did, but rather than offering my opinions about the site, I thought I would ask you to take a few moments to click through it and offer your views here. Knowing the folks at this system, I am sure they would like to have the benefit of your suggestions and ideas about the content and design of their presentation.

Sunday, May 22, 2011

Professor West goes off-base

Yvonne Abraham at the Boston Globe takes Cornel West to task for couching his criticism of President Obama in racial terms, rather than on the merits of policy arguments or the President's personality. She raises good points, but I feel a need to address another. I offer this in sadness that West thinks that a remark he makes is truthful, and that he thinks that a statement that is so ignorant of historical relationships will be politically effective.

The sentence was this: "He [Obama] feels most comfortable with upper middle-class white and Jewish men who consider themselves very smart, very savvy and very effective in getting what they want."

I address specifically the point about Jews. Why did he include them in his remarks?

This sentence is clearly steeped in prejudice. Can you imagine this being said about any other religious group? (Go ahead: Insert another religion in the sentence to how West's use plays on a certain stereotype.) Can you imagine the reaction on most college campuses if a professor said it about any other religious group?

What is even more sad, though, is that the Civil Rights movement in America was strongly supported by Jewish men (and women). That West has decided that it would be politically effective to decry the President's association with people of this background is a denial of that collaboration.

On the Princeton website it says: "Cornel West has a passion to communicate to a vast variety of publics in order to keep alive the legacy of Martin Luther King, Jr. – a legacy of telling the truth and bearing witness to love and justice." Well, not quite, apparently.

Saturday, May 21, 2011

The infrastructure chronicles -- Volume 6

In our continuing series on infrastructure issues, we turn to water. Almost every part of the world faces limitations in the supply of drinking water, and one of the jobs of a water supply agency is to adopt policies that promote its efficient use. In the early days, pricing was crude, based on the number of families and fixtures you had in your house, as per below:

This 1868 rate schedule for Boston also varied by type of business:

Bakeries: For the average daily use of flour, for each barrel, the sum of $3 per annum; provided that in no case shall any bakery be charged less than $6.

Livery stables, including water for washing carriages: $6. And for each horse over two: $2.*

Later, meters came into use. If we go back 100 years from today, the 1911 Annual Report of the Metropolitan Water and Sewerage Board makes note of progress in this regard, a result of the passage of the Meter Act in 1907.

During the past year 14,099 water services, new and old, in the District were equipped with meters. ...The cities of Medford and Melrose and the towns of Watertown, Milton, Winthrop, Belmont and Swampscott have now meters upon all their services, and the cities of Malden and Chelsea have metered about 94 per cent. of all services. The city of Boston installed an increased number of meters during the past year, but its percentage of the number of its services metered (27.33) is still the lowest in the list.

But as in health care, pricing isn't the complete answer to obtaining efficiency. If the underlying infrastructure is not properly maintained, waste occurs.

It is, however, apparent more than ever that there is a great waste of water in the Metropolitan district which the increasing use of meters does not prevent. ...There is a constant leakage of water due to defective local pipes and bad house plumbing and to incessant flow from the faucets, by which water is wasted to the extent probably of one-third of the entire supply afforded. The situation demands more careful supervision on the part of the responsible authorities of the various cities and towns and the adoption of rigorous measures of prevention.

As noted by the MWSB, a more prudent use of water was "in the interest of economy for the District [by] delaying the time when additional sources of supply must be sought and new and extensive works be constructed, but also in behalf of the remote communities of the Commonwealth whose properties and rights will have to be yielded up for the benefit of the metropolitan District." By the last clause, they meant that new reservoirs would be constructed by damning rivers and flooding communities west of Boston.

When I arrived to run the MA Water Resources Authority in 1987, a similar situation existed in the regional water system. Demand for water from the very large Quabbin Reservoir that had been built in central Massachusetts exceeded the safe yield of that 412 billion gallon lake. Many policy-makers in Boston were convinced that the supply had to be expanded -- by tapping the Connecticut River. This was an idea that found little favor in central and western Massachusetts and downstream in Connecticut. Previously, Connecticut had gone all the way to the US Supreme Court to stop the construction of the Quabbin Reservoir, which tapped two of the river's tributaries. They lost that battle, but they were gearing up for the next.

I was confident that this was an unnecessary fight, that there was plenty of water in the Quabbin system for decades to come, if we just made better use of the resource.

About 25 million gallons a day of water was estimated to be leaking from the 6,700 miles of pipes owned by the 46 cities and towns in the district, and another 4 mgd from the MWRA's 270 miles of aqueducts. Over the next few years, we conducted an intensive leak detection and repair program in conjunction with the municipalities, plus running a series of water conservation programs. In all, we were able to decrease water consumption by 15 percent over a three-year period. This pattern has stayed in place, and there is no longer any talk about diverting river water.

* Quaint, eh? Until you realize that in New York City, rates were based on the frontage of your building (regardless of the building's height) -- until 2009!

Friday, May 20, 2011

Tablescaping. Not quite the right idea.

I am expanding my previous focus from bottled water to other "amenities" offered by hotels in their conference rooms. This is about "tablescaping." Perhaps you have not heard this term. The contract for a conference I recently attended promises that "all meeting rooms are to be tablescaped, using intriguing metallic sculptures and gems."

Words don't do this justice. See the photo above. A stainless steel circle; a metal sculpture, perhaps representing a person; and the "gem," a diamond shaped piece of cut glass over six inches in diameter. They are comfortably resting on a pebble mosaic tile. Yes, the kind you would use in a bathroom renovation project. (This is a meshed-back product, like these. Instructions: Glue it to the floor with others and fill in with grout.)

I hope I am not offending someone with artistic inclinations, but what on earth is the point of this? We had a set of conference tables set up in a square (seating 20 people), and one of these arrangements was placed on the middle of each table. Not only did they fail to contribute to the meeting, but they actually got in the way of people's lines of sight, while taking up space on the table, too. So, here's where they ended up shortly after the meeting started:

Thursday, May 19, 2011

First, higher education. Next, academic medicine.

Higher education is ripe for the fleecing by new firms with disruptive technology and strategies. For decades, the university world has been jokingly termed an "ivory tower." Well, it turns out that this is an apt metaphor. Let's look at some of the underlying characteristic of the world's great universities: A huge physical plant; an "edifice complex" that pushes construction of new buildings with little consideration for their maintenance and operating costs; a cadre of aging, tenured faculty; a willing supply of wannabe faculty members who have invested hundreds of thousands of dollars in opportunity costs by getting Ph.D.'s in highly specialized areas and taking lower paid junior positions until they get their "union card." All this is supported by ever-rising tuition; philanthropy that is needed to offset the tuition for a growing number of students; and, often, diminishing federally sponsored research that never has paid the full indirect costs of that research.

In short, we have high fixed costs dependent on highly uncertain revenue sources; incumbents who have no reason to work hard and be innovative; junior members of the faculty who need to focus on their research -- rather than teaching -- to get tenure and who, upon receiving tenure, lose incentive to be productive; and tuition that has regularly risen at rates greater than inflation.

You don't have to be Clay Christensen to guess what happens next. Upstart firms enter the education market and cream-skim highly profitable segments by offering specialized schools, modern approaches to teaching using part-time faculty, and pricing their services at rates that are more reflective of the opportunity costs of students.

I recently became aware of two examples. One is the Hult International Business School and the other is a firm called 2tor. They have different business models.

As first blush, Hult might seem like any business school, but check out the differences. Yes, it has a physical campus; but, no, it has five small physical campuses in cities selected for their likely commercial value, i.e., proximity to up-and-coming people in the business world (Boston, San Francisco, Dubai, London, and Shanghai). Teaching staff is drawn from practitioners in the field:

Unlike other business schools that are research-oriented, Hult’s talented pool of faculty are academics who also have significant business experience. Over 80 percent of our faculty have had actual business experience, working for companies like Procter & Gamble, Motorola, Credit Suisse, and Monitor Group—others have started successful ventures themselves.

Results: In 2002, the Economist Intelligence Unit ranked Hult the third best business school in Massachusetts, after Harvard Business School and MIT's Sloan School of Management.

2tor's approach is different, partnering with physical institutions of higher education to deliver rigorous, selective degree programs online. In essence, it takes a campus-based program off-campus, but retains the core competencies and reputation of the host university in doing so. A summary:

2tor supplies universities with the tools, expertise, capital, and global recruiting needed to compete in a space currently dominated by unexceptional programs. 2tor develops state-of-the-art technology platforms that enhance traditional offline curricula to create transformative instruction using the best educational and Web 2.0 technologies. 2tor also develops the human and support infrastructure needed “on the ground” and provides the vital—yet often-overlooked—logistical components of any online program, including comprehensive student support services from enrollment through graduation and beyond as well as practical learning experiences within distant communities around the country.

Notice that we are not talking about degree factories here. The emphasis is on quality, but with an understanding of the need to offer curriculum in a setting that goes to the market, rather than expecting the market to come to them. They make use of new digital technology approaches rather than physical infrastructure. They draw in faculty in a way that is very different from one based on the academic tenure process. As a result, there is more pedagogical flexibility and adaptability to the market over time.

The lessons here for high fixed cost academic medical centers are clear. Academic medical centers face all of the problems of two stressed industries -- academia and medicine. The future will belong to the efficient. Hospitals that are driven by their senior faculty and hopeful junior faculty to expand buildings and research facilities, that invest in high-cost but unproven clinical equipment, that do not engage in front-line driven process improvement, that fight transparency of clinical outcomes -- and that plan to depend on private and government reimbursements, government grants, and philanthropy to pay for all this -- will not do well. Those that limit capital investment in inflexible fixed assets, that focus on higher quality and reducing waste, that endorse transparency, that invest in the science of health care delivery as much as basic science, and that develop and implement treatment modes that take care to the patient rather than requiring physical visits by patients, will do well.

Wednesday, May 18, 2011

Dear CMS: Stop the proton beam arms race

If Medicare payments for proton beam therapy are what is driving the construction of too many such machines, why doesn't Medicare change the reimbursement? That's my simple question for the day.

What prompts it is this story from the Midwest, where University Hospital has entered the proton beam machine arms race with plans to spend $30 million. Here's the story from MedCity News.


Few argue that proton therapy is ineffective, though many would like to see it subjected to rigorous testing. The National Cancer Institute (NCI) in 2009 expressed concern that “enthusiasm for this promising therapy may be getting ahead of the research.” NCI experts worry about a lack of published randomized, controlled trials that show proton therapy works better than standard radiation therapy and increases survival, or improves quality of life for patients.

Cost is also a huge concern associated with proton therapy — and one reason so many hospitals are eager to jump into the proton therapy business. Medicare reimburses proton therapy at about twice the rate of standard radiation therapy, which prompts concerns that patients (or their insurers) could pay twice the price for a treatment that may be no more effective than the cheaper alternative.

This one would be paid for by a "a mix of capital, bonds and philanthropy," according to Cleveland.com. What an obfuscation. No, it will be paid for with money! All of which has an opportunity cost. Dear Ohioans, you can do better with your money than throwing $30 million into this machine.

Open letter to Don Berwick at CMS:

Please make them stop. You can dry up this source of funds and improve health care and help control its escalating cost. Use the tools you have at hand.

Bret demolishes the '80s and moves on

A young man named Bret Victor is exploring the capacity of new forms of visual displays of data, equations, scientific relationships, and the like. There is a great example in the video below. As you watch, consider the ramifications for health care or whatever field in which you are involved.

I like that Bret presents this work as examples of two core concepts (outlined at 4:57 in the video) ubiquitous visualization (you can see everything -- every variable and every term in every equation) and in-context manipulation (there is a knob on the screen that can be use to change values and coefficients and see the results immediately). He draws the contrast with traditional computer programming to do the same. Here's my favorite line:

That may have been a pretty good way of working in the early '80s, but I think it is time for something better.

Some firm should be very smart and hire this guy before its competitors do.

if you cannot see the video, click here.

Interactive Exploration of a Dynamical System from Bret Victor on Vimeo.

Tuesday, May 17, 2011

Really? A Concussion?

This is an essay written by Aub Harden, a fellow Under-14 soccer coach. It has an important message. Concussions are not just the province of professional football players, and they are not always obvious.

It’s Monday morning and we’ve just received a call with the verdict: "Yes, your daughter definitely has a concussion from her soccer game on Saturday."

Really? A concussion?

Actually, by this time the diagnosis was not really a surprise. After the game my daughter complained of a mild headache which continued to come and go all weekend. On Sunday, when she was trying to do her homework on the computer, it got bad enough that she really couldn’t work. When my wife volunteered to type for her, she had problems concentrating and would repeat herself. This last bit in particular was enough to think that maybe she had been concussed.

My daughter is fortunate enough to go to a school that administers ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) and has a detailed policy for working with students after a concussion. All the students take the ImPACT test in the fall, which provides a baseline for later comparison. So this morning, she went to the school nurse to take the test again. The results of this test were compared with her baseline results from the first test. Concussion. Now she’s home for a couple of days to rest. No schoolwork. No reading. No TV or computer. No soccer tomorrow, this weekend, and maybe the rest of the season. No crew for the rest of the season. (And, the school nurse told her, depending on how things progress, maybe no final exams! She’s not too disappointed about that one...)

The scary thing was how easy this would have been to miss.

Why didn’t her coach pick up on this at the game? Oh, wait. I’m her coach.

Just before the end of the first half, my daughter was pushed from behind— pushed hard enough that her head snapped back. I was talking with my players on the bench, so I didn’t see it happen. A minute or two later, she got hit in the back of the head with the ball. I did catch that, but it didn’t seem bad and she just grinned and kept playing.

Really not much to pick up on.

Hindsight and a Monday afternoon interrogation revealed some additional information that I wish I had known earlier. When she was pushed from behind, the whiplash was enough that she felt light-headed for a moment or two. When she came off the field for half-time, she didn’t eat any of the fruit because she was afraid she would throw up. When we started the second half, she asked not to start— not because she was tired (as I assumed, playing as we were with just a few subs), but because she still felt a bit nauseous.

There were some other signs— some uncharacteristic fights with her younger sister. A bit more tired than usual. Her headache was ‘different’ from others- not necessarily worse, but different.

Now we know.

My daughter will be fine. As far as concussions go, it wasn’t a serious concussion. She just needs to take the time to fully recover.

I’ve written this to encourage coaches and parents to let their players and children know what the warning signs for a concussion can be.

My 7th grade daughter didn’t know that her moment of light-headedness or her vague nausea were significant. As a coach and as a parent, I can’t act on information I don’t have, and when there’s no obvious collision or fall, I wouldn’t have thought to probe any deeper than a general how-do-you-feel.

Be sure that I will be taking the time with my players to let them know that they need to tell me about anything that’s ‘not right’. Whether the cause is a concussion, muscle strain, or heat exhaustion or whatever, it’s usually information that they provide that enables coaches (and parents) to help them.

Concussion information

Concussion information sheet for parents and athletes

Monday, May 16, 2011

The fall and rise of asynchronicity

The daughter of a friend was bemoaning poor connectivity of the internet at a university in Europe. She said, "It's vital since I don't have any other method of communication."

My friend noted, "I was telling her how we only had letters and occasional long distance phone calls in college...."

One of my most widely read blog posts was entitled, "Blackberry Cold Turkey," in December of 2006. The impetus was when my telecomm provider wrote in November to tell me that my bare bones wireless data service was going to be discontinued, but that I could "upgrade" to one with a higher price with more functionality, if I also bought a new device. I decided it was time for a life-changing experience and tossed my Blackberry in the trash. This reminded me of a major functionality of email.

The most important attribute of email is the asynchronicity of the medium: The sender and the receiver do not have to be in contact at the same moment. This enables efficient communication. You can integrate emails into the fabric of your life. You originate a message when you want, and you reply to another's when you want.

Until the "revenge effect" occurs! How does this work? Email was invented. Then Blackberries were invented so we could be sure, when we are away from our computer, to receive emails as soon as they are sent and reply to them immediately. In fact, we feel compelled to read and respond in real time. Asynchronicity disappears.

Now, it is even worse. With iPhones and the like, you not only get email in real time. You see Twitter feeds in real time. You see Facebook updates in real time. You see the news in real time. What you tend to do is to respond quickly and less thoughtfully. Also, you train all your correspondents to expect you to be available at a moment's notice. We have all seen teenagers -- and adults -- walking down the street, side-by-side, focused on their hand-held devices, rather than talking with each other.

What you don't see in real time is the ambient environment. As I noted back then, after my disposal exercise:

I have since discovered marvelous things. The sun rises in the morning and sets at night. Airport lounges are great places to visit with friends or read a book. Red lights are an excellent excuse to stop driving, look around, and see what's happening on the streetscape. People in meetings pay more attention to you if you pay more attention to them. The email that arrived three hours ago is still relevant -- or better yet, no longer matters!

So, dear college student in Europe, learn to love your freedom. Not only the freedom from your parents, but also your freedom to absorb all that you see, taste, smell, hear, and touch in real time. Those electronic messages that used to seem so desperately important will fade away asynchronously in the face of the synchronous real world.

The Whac-A-Mole school of health care policy

Boy, if you ever needed a summary of how messed up our health care system is, check out this story by Robert Pear in the New York Times. Entitled, "Nursing Homes Seek Exemptions From Health Law," the essence is that nursing homes want to be exempt from the employer requirement to provide health care benefits to their staff because the payments nursing homes get from Medicare and Medicaid to deliver care to patients are too low to provide enough cash to those institutions to offer those benefits.

I am sorry to beat a dead horse, but this is a direct result of political figures -- Democrats and Republican -- who give the impression that we can have it all. I don't know what the President meant when he said that he would deliver access, choice, and lower costs. But I always felt that by "lower costs," he meant "lower appropriations" by the federal and state government for Medicare and Medicaid payments.

This feels like the government equivalent of Whac-A-Mole. Pass a law-- Bam! Reduce government payments -- Bam! Exempt employers -- Bam! Add more people to government subsidized insurance plans -- Bam! Reduce government payments -- Bam!

Sunday, May 15, 2011

Myth Romney on health care

It is entertaining to watch Mitt (aka Myth*) Romney try to thread the political needle as he explains his support of the Massachusetts health care reform bill that he signed as Governor back in 2006. While he attempts to distinguish his law from the one enacted under President Obama mainly as an issue of state versus federal jurisdiction, the big issue he has to overcome with the Republican primary audience is the individual mandate.

Why do you need an individual mandate -- or as Romney calls it, "personal responsibility"? Well, you don't unless you also want to require insurance companies -- as he does -- to cover all patients. As I have said before about the federal law, which also applied to the situation in Massachusetts:

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

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

So, Romney is correct on this point, even though some people hate to admit it.

But Romney is also a bit loose with some facts. While claiming it is possible to design a state-by-state approach that does not rely on new federal funding, he leaves out the fact that the MA law was dependent on -- and in fact, was designed to secure -- over $300 million in federal funding. To a great extent, it was possible to achieve a political consensus on this bill in MA because of the need to save the so-called "Medicaid waiver." I guess you could assert that the $300 million was not "new" federal money, but it was scheduled to expire.

I had a chance to meet with Romney as governor during the period of the bill's pendency. You would be hard-pressed to find a governor more knowledgeable and engaged in the details of the proposed legislation. He, like others, felt it important not to squander the opportunity for compromise that was provided by the budgetary "gun to the head" of losing this amount of federal support.

What a shame now that he can't admit that such political compromise is the sign of smart governing, rather than weakness.

Where Romney and Obama agree, sadly, is in promising the American public that they can have it all -- access, lower costs, and choice. That seems to be the deceptive mantra that is needed in the body politic. Both men ignore inconsistencies in their own legislative frameworks between that mantra and reality. Note that Romney, for example, looks favorably on the removal of fee-for-service pricing, ignoring the reduction in choice implicit in such pricing. (Minute 16:32 of the video below, where capitated rates have "a lot of promise.")

Here's his speech. If you cannot see the video, click here.

* I give credit here to the blogger over at Massachusetts Liberal, who may have introduced this term back in February of 2007.

Friday, May 13, 2011

The infrastructure chronicles -- Volume 5

I offer the next in my occasional series on infrastructure. In the old days, they knew how to make them both functional and beautiful. Here's an example.

From the Brookline Historical Society, we learn that the Fisher Hill Reservoir was designed Edward Philbrick, Boston water systems engineer, who planned two rectangular underground reservoirs. Built in 1875 on a 4.5-acre site, the reservoirs were filled with water pumped from the Charles River, and served as a back-up water supply for the town. The other reservoir on the hill was built by the city of Boston in 1884. The 10-acre site includes a stone gatehouse that was probably designed by Arthur Vinal, Boston's city architect.

Let's talk about that gatehouse. This was the Richardsonian Romanesque period in New England architecture. (Think of Trinity Church in Copley Square.) Two or three or more types of stone were often used in the construction, creating a pattern of color and texture that was quite special. Intricate carvings were also included as design elements, like this sandstone leaf and vine pattern.

The meticulous attention to detail that was present in the construction of buildings and facilities was also evident in the day-to-day work of those running the metropolitan water system. Here, for example, is the hand-drawn diagram showing the rainfall and daily average consumption for each month for several years, including the period during which these reservoirs were built. It is taken from the Twenty-Fourth Annual Report of the City Engineer, Boston, for the Year 1890.

Medscape Physician Compensation Survey

Here are the latest headlines from an annual salary survey of over 15,000 US physicians representing 22 specialties conducted by Medscape:

The demand for primary care doctors continues to grow, but specialists still earn the most money.

The highest earning medical specialties are orthopedic surgeons and radiologists (median compensation: $350,000), followed by anesthesiologists and cardiologists ($325,000).

If they had to do it all over again, primary care doctors were least likely to choose the same specialty (43%).

More than one fourth of primary care physicians (29%) spend between 13 and 16 minutes with each of their patients.

Women doctors reported a 2010 median income of $160,000 compared with men's $225,000. Possible reasons set forth by Medscape: (1) Female physicians on average spend fewer hours per week seeing patients than their male counterparts do, the likely result of their efforts to juggle multiple familial and professional commitments. (2) Fewer women than men are represented in some of the higher-earning specialties, such as orthopedic surgery, cardiology, and gastroenterology.

When it comes to where doctors earn more, the North Central US is the nation's Gold Coast.

Internists and family physicians in small towns and rural areas with populations under 25,000 actually earned more in 2010 than their big city colleagues did: With fewer specialists to refer to, small town and rural physicians simply refer less and do more, from minor excisions to more complicated procedures.

Would you do it again?

Given a mulligan . . . most physicians, specialists as well as primary care doctors, would chose the career of medicine again.

Among the 22 groups of specialists surveyed, 69% said they would take the same career path, 61% said they would choose the same specialty, and 50% said they would choose the same practice setting. Primary care doctors were just as certain as the specialists about their choice of career and practice setting, but they were less certain than their specialist colleagues about choosing the same specialty again. Indeed, 43% of PCPs said they would, while a significant 58% either said No or they weren't sure.

Of those in either the specialties or primary care who said they would not choose a career in medicine again, business, law, teaching, and finance, in that order, are the most popular alternative careers. Other choices included chef, computer sciences, musician, pilot, and journalist. One respondent said he'd like to be "An assassin -- of insurance company executives."

Thursday, May 12, 2011

"Our Choice" app -- A stunner!

Every now and then you see a really good use of the interactive graphics capability of Ipads and the like. Take a look at this trailer for Al Gore's latest e-book. It is exceptional. Here is a description of it by David Pogue. You can buy the app for $5.

Citing confirmed: ACO rules don't work

The validity of Cheryl's report over at HealthLeaders Media, and my earlier post, about the unworkability of the proposed ACO rules, got confirmation in this story today on AP:

In an unusual rebuke, an umbrella group representing premier organizations such as the Mayo Clinic wrote the administration, saying that more than 90 percent of its members would not participate, because the rules as written are so onerous it would be nearly impossible for them to succeed.

As I noted, not all the problem lies with CMS. Congress put a "poison pill" into the concept because it was afraid to limit customer choice.l This is all a holdover from the manner in which the President characterized health care reform -- as offering access, choice, and lower costs -- but also because Congresspeople believe that changing Medicare significantly is the third-rail of American politics.

Wednesday, May 11, 2011

Cheryl et al report on CMS ACO regulations

Cheryl Clark and her colleagues at HealthLeaders Media have put together a special report on the industry's response to CMS' proposed Accountable Care Organization regulations. This a helpful survey that supplements unsupported comments from people like me.

Let's start with a reminder of the general scope of the regulations:

Groups of ACO professionals with a minimum of 5,000 beneficiaries would be permitted to apply for one of two risk models in order to benefit from shared savings over the three-year program. In the first model, providers would share savings of 50% in all three years, but would be at risk in year three for any losses that exceed 2% of the benchmark established by the Centers for Medicare & Medicaid Services.

In the second model, ACOs could receive a higher percentage of shared savings, up to 60%, but would be at risk of absorbing losses in each of the three years if their expenditures exceeded the CMS benchmark.

Beneficiaries would be retrospectively assigned to the ACO, to reduce the possibility that providers would avoid patients with multiple diagnoses.

There are a variety of comments from among the most progressive health care leaders in the country, but here is one that to me, says it all:

Jay Cohen, MD, executive chairman of Monarch Healthcare in Orange County, CA, says . . . the negatives on the flip side . . . outweigh the positives in the proposed regulations, and may prevent his organization from opting to be an ACO. “The way the proposed regulations are written will not work,” he says.

Notes Cheryl in conclusion: "Industry leaders expect the regulations will be modified once CMS hears the volume of concerns during the comment period."

Tuesday, May 10, 2011

$33 million (Canadian). Any interest?

Last year, the Ontario government made a decision to allocate funds to encourage physician engagement in improving service and quality in hospitals in the province. In all, $11 million was made available in 2010, with another $22 million allocated to 2011.

According to the province, participating MRPs ("most responsible physicians") must commit to ensuring “24/7/365” coverage for unscheduled patients, developing and implementing a quality improvement plan, and reviewing their performance on key indicators, such as average length of stay, emergency department wait times, readmission rates and patient satisfaction.

This article suggested that the criteria for receiving funds were unclear:

“It’s all kind of vague. All I’m seeing is that MRPs have to engage in some kind of quality improvement program, but there are no metrics laid out for what that will look like, and no real deliverables.” Dr. Richard McLean, vice-president of medical affairs and quality at Hamilton Health Sciences in Ontario. “Beyond the money, doctors don’t know what they’re signing up for and whether or not it’s worth the hassle.”

I understand that much of the money from 2010 remains unclaimed. My sources tell me that, in addition to Dr. McLean's points, the big problem appears to be that there is little interest among the doctors in improving patient quality and safety.

After all, that's such a hassle.

In that regard, the Canadian and US health care systems seem to have some commonality.

I wonder if there will be an analysis by the province as to the reasons for non-participation. I wonder if that analysis will be made public. I wonder if the Ontario officials will compare notes with the officials at CMS in the United States, to see if they can learn from one another.

Monday, May 09, 2011

Let's just keep killing and maiming them

Old patterns die hard. Back in March 2010, I posted a chart from the ACHE that Jim Conway had sent me showing a decrease in the ranking of quality and safety among priorities reported by hospital executives.

Now comes an article in Health, Medical, and Science Updates about a study by the Beryl Institute, entitled "The State of Patient Experience in American Hospitals." Of those places surveyed, 51% were individual hospitals and 49% were hospital groups or systems. There was an even mix of urban, suburban, and rural facilities.

As in the prior ACHE survey, 69% of hospital executives rank things other than quality and patient safety as top priorities.

Any way you look at it, this is quite simply a failure of leadership and governance in American hospitals. There is a strange adherence to the view that "these things happen," an apparent belief that a certain level of harm that occurs to patients is just the way things should be. It is as though the medical profession, hospital administrators, and hospital trustees have decided that the current amount of harm is the statistically irreducible level.

In contrast, I quote again from Captain Sullenberger, who notes that such an attitude is impossible to imagine in other fields, like air transport:

"I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country."

Those of us who have participated in systematic improvements in the way work is done in hospitals understand that America is nowhere near the "statistically irreducible" level of harm. As Sully notes,

"We have islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety."

There are thousands of people at lower levels of authority in hospitals who want to improve the situation, but they are stymied. I can't tell you how often nurses, nurse managers, and junior physicians have come to me at conferences and said, "How do I convince my hospital leadership to take an interest in this and support us?"

The leadership for improvement has to come from the top: Hospital CEOs, clinical chiefs of service, and boards of trustees. To date, the American hospital leadership is failing in this regard. Maybe they should be required to say every day, "Let's just keep killing and maiming the patients. After all, they are just statistics, not real people."