It made me think

A physician friend writes:

Last night I was traveling back from California to Ohio.  As we landed in Denver, there was severe weather in the area--mostly rain and lightning--but also some minor hail.

FAA regulations require that, with any hail, every plane has to be inspected. I heard some of the ground crew bemoaning the fact that they had to do this, that it was a waste of time, as we loaded onto our connecting flight.

After the 30 minute inspection, the pilot explained to us that they found some minor damage on the plane from the hail and, therefore, we would have to get on another plane. Most likely, this damage would have never amounted to anything.

Deplaning at 11:30 at night for people headed east who were tired and grumpy was not a popular procedure. But it was the right thing to do. They were forced to put safety first. It wasn't what any of us wanted last night--but in the light of day, I am much happier being alive and back with my family--even if three hours later than anticipated.

It made me think--how often do we in health care push forward, ignore possible safety/quality issues, out of convenience or concern of causing someone temporary discomfort?

Leaders fail: The blame game continues

Salem witch trial: No defense possible in this court

If hospitals ever hope to create a culture of continuous improvement, the people in charge need to learn how to help people learn from mistakes rather than blaming them when mistakes are made.  Again and again, we hear stories that indicate a failure to realize this fundamental leadership lesson.

Witch hanging:  The result of hysterical blame for ill fortunes

One case occurred last year, an error regarding a kidney transplant at UPMC, where a surgeon was demoted and a nurse was suspended for what was later diagnosed as a series of systemic problems in the organization. Another had a more tragic turn, when a Seattle nurse committed suicide months after being disciplined for administering a fatal dose to an infant, again in an environment with underlying systemic problems.

I quote myself from the blog post describing that last story:

My regular readers know that my former hospital faced a similar issue following a wrong-side surgery. Would we punish the surgeon and others involved in the case? We decided not to, not because they had suffered enough themselves from the error, but because we felt that a "just culture" approach to the issue would suggest that further punishment would not be helpful to our overall goal of encouraging reports of errors and near misses. The head of our faculty practice put it well:

If our goal is to reduce the likelihood of this kind of error in the future, the probability of doing that is much greater if these staff members are not punished than if they are.

Punishment of those involved in this case also would have diverted attention from the failures of senior management in doing its job. As Tom Botts from Royal Dutch Shell commented about deaths on one of his company's oil rigs:

It was a defining moment for us when we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. That gave license to others deeper in the organisation to go through the same reflection and find their own part in the system, even though they weren’t directly involved in the incident.

It also would have diminished the likelihood of widespread interdisciplinary participation in redesigning the work flow in our ORs. By making clear that the error was, in great measure, a result of systemic problems, all felt a responsibility to be engaged in helping to design the solution.

But here we go again.  NBC News reported from Ohio:

A nurse who accidentally disposed of a living donor's kidney during a transplant said she didn't realize it was in chilled, protective slush that she removed from an operating room....

[The hospital] said poor oversight and communication and insufficient policies were factors in the kidney's disposal, which prompted the voluntary, temporary suspension of the hospital's living-donor kidney transplant program and led to reviews by health officials and a consulting surgeon hired by the hospital.

The medical center suspended two nurses after the incident; one was later fired, and the other resigned, the hospital said. A surgeon was stripped of his title as director of some surgical services, and a surgical services administrator put on paid leave has resumed work.

Witch cucking justice: If you survive the dunking you must be a witch

As in the UPMC and Seattle cases, is it possible for anyone working in this hospital to read these three paragraphs and not say, "There but for the grace of God go I"?  Think about how the leadership approach that was employed will drive reporting of errors and near misses underground.

The hospital's actions reflect a failure of the leadership to recognize its role in the problems.  Contrast that with real leaders, like Tom Botts mentioned above, and Paul Wiles, former CEO of the Novant Health system, discussing preventable infants' deaths in one his hospitals:

My objective today is to confess.  I am accountable for those unnecessary deaths in the NICU. It is my responsibility to establish a culture of safety. I had inadvertently relinquished those duties [by focusing instead on the traditional set of executive duties (financial, planning, and such)].

If you cannot see the face of your own relative in a patient, or if you can not see the face of your own son or daughter in the face of a distraught nurse or doctor who has made an error, I suggest that your executive talents would be better placed in other industries.

Marty Makary recently wrote about the persistent level of errors that occur in hospitals, decrying the lack of progress in quality and safety improvement.  When you read stories like this one from Ohio, you have no doubt of one major contributing factor, leaders who don't understand what Wiles has stated so eloquently.

Whose fault is this?

My Facebook friend Carrie posted this photo of a truck pretending to be a sardine can as it went through a Storrow Drive underpass in Boston.  People who added comments were very quick to blame the driver.  It is very easy to do so, as s/he probably didn't notice the sign on the bridge indicating the clearance, but there is a bigger problem here.

I have often told the story of how Bill Geary solved this problem when he was MDC Commissioner in the 1980s. He installed rubber signs and cowbells (yes cowbells, to make noise) at every entrance to Storrow and Memorial Drive. The signs were set at a height just slightly lower than the underpasses. The idea was that your truck would hit a sign and ring the bell and you would not proceed along the drive and get stuck.

Before Bill invented this low-tech solution, there was one accident per week on Storrow or Memorial drive. Afterward, they were virtually eliminated.

One time I told the story, a commenter noted:

Overheight warnings are nothing new, but as you say, they need to be put up (first) and then maintained in order to be effective. 

Signs are fine, but signage at the turn from the Mass Pike Allston offramp to Storrow Drive is a bad example of our Massachusetts tendency to assume that everyone who drives on our roads already knows (a) where they are, (b) where they are going, and (c) how to (or in this case how not to) get there. 

Another time, someone said:

Your comment on that scene illustrates a principle unfortunately common to governing bodies of organizations (including hospitals) - a problem is fixed, but the solution, over time, is not maintained, often due to changes in staff, apathy, etc. Then the problem inevitably resurfaces and, lo and behold! One must have another whole series of meetings, discussions, etc. to solve it all over again - because everyone has forgotten the previous solution, or downsizing has eliminated the institutional memory. Now THAT also wastes time and resources.

See the next blog post (above) about another case of misplaced blame in the presence of systemic problems.

Pioneering ACOs on WIHI

September 27, 2012: Pioneering ACOs: What Do We Know So Far?
 2:00 - 3:00 PM Eastern Time

Featuring:

Elliott Fisher, MD, MPH, Director, Center for Population Health, Dartmouth Institute for Health Policy and Clinical Practice
Palmer “Pal” Evans, MD, former Senior Vice President & Chief Medical Officer, Tucson Medical Center (TMC)
John Friend, Vice President Business Development & Associate General Counsel, TMC Healthcare; Executive Director, Arizona Connected Care, LLC
 
One of the best-kept secrets about US health care this election season is the degree to which change and transformation are coming, no matter what happens in November. You won’t hear “global payment” or Medicare Shared Savings Program mentioned as often as “individual mandate” in the current political debate, but ask anyone leading a health care organization today which issue keeps them up at night, and it’s definitely payment reform. In general terms, the entire system is shifting from paying for volume – lots of procedures – to paying for value, or how well patients are cared for over time and across the continuum. Accountable care organizations (ACOs) are one critical new reflection of this migration, and they’re being encouraged by public and private payers alike. What do we know about the more than 200 ACOs that have formed in the US thus far? It’s still early in the process, but some smart people are keeping a close eye on ACOs, and we’re going to be talking with a few of them on the September 27th WIHI.
 
As Director of Population Health and Policy at the Dartmouth Institute for Health Policy and Clinical Practice, Dr. Elliott Fisher is leading a major study of the factors enabling ACOs to get up and running and to successfully implement new forms of care delivery. WIHI host Madge Kaplan welcomes Dr. Fisher to the show to share what he and his team of evaluators have learned thus far. He’ll be joined by leaders from Tucson Medical Center (TMC), one of the nation’s earliest adopters of the ACO concept. Dr. Palmer “Pal” Evans and John Friend from Arizona Connected Care both say that one of the biggest hurdles for newly forming ACOs is to let go of the notion that hospitals can and should run the show. That’s not where the future is headed, both say, and they’re learning this in spades in Arizona. They’re also learning how to build will and buy-in from mostly independent physicians, a situation that’s typical of most US hospitals.
 
There are plenty of uncertainties ahead, but Elliott Fisher, Pal Evans, and John Friend agree that ACOs or something similar are likely to be a feature of reform for the forseeable future. They look forward to sharing their perspectives and answering your questions on the September 27th WIHI. For some background on Tucson Medical Center’s entrance into the ACO experiment, please take a look at these Commonwealth Fund case studies published earlier this year. 

To enroll in the broadcast, please click here.

Attempting to block the world's news

A friend works as an analyst at a major investment house in New York City, and wrote the following after I sent the link below about the opening of The Waiting Room in that town:

Thanks. Reminds me that I have to get re-approved to open your blog at work. I had it okayed when I first started here.  Since it is a blog I had to get permission, and it was okay, but then they tightened the rules on what we can access and I got knocked off again.

I responded:

Wow.  Think of that.  You are expected to be knowledgeable about things that could affect securities valuations, and the firm is closing off the major source of information to the world--not my blog, but all of them.

The reply:

We can't access New York Times articles if the paper calls them "blogs" either. I do understand that they are trying to protect us and the system and not have us frittering our time away.

Nonsense.  This is just a Neanderthalic view of the world. First, think of what it says about the lack of trust the firm has for its professional staff.  Second, it is an ineffectual measure, in that people can just bypass the company's server and use their iPhones for the same purpose.

I previously discussed hospitals and other firms that blocked social media on their servers.  This is just plain dumb in the new information age.

---

The sequel!  Just received from my friend:

Yeah, I sold out and upgraded to iPhone 4. So I got to read your blog post after all. Well written. I am in the process now of gathering the approval emails to attach to the Web Site Blocking Exemption Request. Need one from my boss's boss, which he sent quite promptly with a nice GOOD LUCK on it. Now I have to get one back from compliance, and as I don't know the guy from Adam nor he, me, goodness knows how long this is going to take. Plus I am spending half my morning on this, plus the form said it would take 3 days to approve once I submit. And do you know what the crowning glory is? Even if I get approval again I won't be able to open any videos!

My eternal motto is: "Ya can't make this stuff up."

The Waiting Room arrives on the big screen

A note from Peter Nicks and others who produced The Waiting Room, a compelling documentary about patients and staff in Oakland's Highland Hospital.  Here's the trailer.

The wait is over.

The Waiting Room opens this Wednesday in NYC and on Friday in L.A.!  New York Magazine has named the film a critics pick and described it as "the kind of observational doc that manages to say a lot by saying very little— avoiding political grandstanding and instead coolly observing the characters." And over in L.A. The Hollywood Reporter has named it an Oscar possibility in their initial assessment of the Oscars race. Wow! As far as we're concerned that's a huge statement about our little film and inspires us to work even harder to get the stories of the beautiful people in the waiting room heard.

We hope you can make it to one of these screenings, but fear not if you hang your hat in another city. We will be announcing more dates over the next couple of months in the Bay Area, Boston, DC, Houston, Seattle, and Minneapolis just to name a few.

Tickets available here:

IFC Center (New York City)
Laemlee Theaters (Santa Monica, Pasadena & Claremont)

Hope to see you there!

With the boards at Gundersen Lutheran

I was honored and pleased to be invited to make several presentations today to the governing bodies of the Gundersen Lutheran Health System in La Crosse, Wisconsin.  This is an exemplary health system, with a wonderful focus on quality and safety and process improvement, but also with an expanded focus on issues of community concern, like environmental stability.

It is to illustrate this latter front that I am breaking protocol and giving top billing not to the CEO, but to Becky Hamit, his administrative assistant.  You see her here sporting a bag made from the recycled material of the cloth that is used to wrap surgical instruments in the operating rooms.  Ordinarily, this material is disposed of into landfills, and it is a high quality fabric that does not break down easily.  At Gundersen Lutheran, the staff has gotten used to looking for all kinds of ideas to reduce energy use and improve the institution's environmental footprint.  They have cooperated with a group of senior citizen volunteers, working through the RSVP organization, to take the fabric and sew it into these handy bags.  Some are used to provide clinical information packets to patients, and some are used in other ways.  A small example, yes, but illustrative of Gundersen Lutheran's focus on constant improvement.

Ok, now back to Jeff Thompson, CEO of the system, seen here presenting to his Board of Governors and Board of Trustees.  As you see from the photo above, Jeff doesn't pull punches with his board about the status of quality and safety issues and other strategic matters facing the board.

My job, after Jeff's update, was to present some thoughts about likely future trends in the industry and what attributes will be needed by high performing organizations.  The board members then broke into working groups to discuss risk assessment and mitigation in light of these thoughts.  I was not surprised, given this health system's leadership position in the country, to hear extremely thoughtful observations from the board members.

A highlight of the day was a presentation on servant leadership by Dave Skogen, founder and former CEO of Festival Foods.  Dave quoted with displeasure Henry Ford:  "All I want is their hands and feet.  I don't want them telling me how to run the company."  Dave stressed the importance of leadership in making feel people appreciated and engaging them in process improvement in an organization.  He reminded the group:  "The customers want us to serve as their agent for quality, price, and service."  But, he said, "You don't manage people.  You lead people.  Management is what we do.  Leadership is who we are.  What is it about me that others would change if they could?"

Dave suggests that the first question that should occur in an employee's performance review should be, "How am I doing as your boss?"  Only if the leader is serving the staff member well is he or she doing the job right.  A wonderful thought from a great leader and coach.

Unaccountable

Many of you may have seen the recent article by @DrMartyMD, Marty Makary, in the Wall Street Journal, "How to Stop Hospitals from Killing Us."  The lede:

When there is a plane crash in the U.S., even a minor one, it makes headlines. There is a thorough federal investigation, and the tragedy often yields important lessons for the aviation industry. Pilots and airlines thus learn how to do their jobs more safely.

The world of American medicine is far deadlier: Medical mistakes kill enough people each week to fill four jumbo jets. But these mistakes go largely unnoticed by the world at large, and the medical community rarely learns from them. The same preventable mistakes are made over and over again, and patients are left in the dark about which hospitals have significantly better (or worse) safety records than their peers.

The article is drawn from Marty's recently published book Unaccountable.  This trailer will give you a sense of the themes.  He notes:

It does not have to be this way. A new generation of doctors and patients is trying to achieve greater transparency in the health-care system, and new technology makes it more achievable than ever before.

I hope so, but I don't know.  For several years, I have joined Marty, Peter Pronovost, Brent James, David Mayer, Lucian Leape, Jim Conway and others in advocating for changes in medical education, in clinical process improvement, in transparency of clinical outcomes.  Those changes are all necessary conditions for a transformation of this industry, not only in the US but in all developed countries.

Unlike these people, I come to this field with a background in other industries, much more than in health care.  I have seen and participated in the transformation of other sectors, where the hope was that changes in technology would render previous industry patterns unsuitable.  Whether with gentle or forceful steering from the government, it was hoped that the disruption in those industries would result in more customer choices, greater value for each dollar (or pound or peso) spent by consumers, and an overall improvement of efficiency for society.  The results in those other fields have been mixed, as is perhaps inevitable when any major sector with extensive vested interests is perturbed.  But we can often see some change in the hoped-for direction.

But I have yet to encounter a field that is as recalcitrant to change as health care.  While filled with people of the best intentions, intelligence, and extensive training, it is also characterized by self-satisfaction, denial of the underlying problems, and arrogance.  Thus far, too, the patient advocates who have tried to cause improvement have not been unified or effective in purpose and plan.  Thus, there does not yet appear to be a solid, sustained constituency for the result Marty predicts.

Sometimes, I remind myself to be patient.  It is hard to change the medical system quickly.  But, more often,  I find myself agreeing with the words of Captain Sullenberger:

"I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country. We have islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety."

O'Reilly offers Strata Rx

O'Reilly Media has a new conference, Strata Rx, that will be of interest to people who want to bring data science to the healthcare world.

The folks at O'Reilly note:

Big data holds great promise for the advancement of personalized and predictive medicine. Used wisely, it can lead to significant cost savings, and even point to entirely new products and markets. If the conference  tagline, "Leverage the Power of Big Data in Healthcare," gets you excited, you'll want to join them in San Francisco on October 16-17.

The company has offered a 25% discount to readers of this blog. To claim it, use my name as a discount code (PAUL) when reserving your seat. Early registration expires today, September 20, and the price goes up thereafter.  Click here.

The business case for Lean

Does Lean pay?  CFOs always want to know!  Joshua Rapoza at the Lean Enterprise Institute, Inc.writes:

I want to invite you to our latest webinar, The Business Case for Lean, with Michael Ballé, taking place at 2:00 p.m. Eastern on October 10, 2012. This is a one hour, free webinar.

"Executives have been asking about the ROI of Lean programs forever. Lean practitioners answer that it's the wrong kind of question. They are absolutely right, but we must get better at showing the business benefits of Lean. That's where I can help." - Michael Ballé.

Ballé is the award winning author of The Lean Manager and The Gold Mine, as well as the writer of the very popular Gemba Coach Column on lean.org.

Click here to register for this free webinar, and don't forget to invite your colleagues as well.

While you are on lean.org, take a minute or two to learn about Ballé’s upcoming (one time only) workshop of the same name at LEI's Cambridge headquarters this November.

A fine is not fine

Regular readers know of the patient quality and safety troubles faced by Parkland Memorial Hospital, as made broadly public last summer.  A new chapter has now unfolded. As reported by Patient Safety and Quality Healthcare:

Parkland Health & Hospital System has reached a settlement agreement with the Department of State Health Services (DSHS) that resolves and discharges all potential litigation and enforcement actions for compliance issues prior to May 31, 2012.  Under the agreement with DSHS, Parkland will be assessed $1 million for violations that occurred prior to June 1, 2012. $750,000 will be payable within 30 days of the execution of the agreement. $250,000 will be held in abeyance subject to Parkland’s compliance with the terms of the agreement.

I understand the need for a closely supervised quality and safety improvement program, but I cannot understand the purpose of a fine, especially when the institution being fined is a non-profit hospital.Why would you take resources away from a hospital when what is needed is for it to invest in an extensive and intensive quality and safety program?

I could even see requiring Parkland to spend this amount on quality and safety programs, but I don't see the point of hurting them financially.

Your thoughts?

In appreciation: John Auerbach

It is a sign of the times that one of the most able, experienced, and thoughtful of our state's public administrators has had to take the fall for a series of events that would have been virtually impossible for him to prevent.  John Auerbach has been serving as Commissioner of Public Health in Massachusetts for six years.  Previously he served as head of the City of Boston Public Health Commission.  He has been a calm voice of reason and has received virtually unanimous praise for his dedication and professionalism.

For those of you from out of state, the scandal that erupted related to a scientist at the state's crime laboratory, who had falsified evidentiary reports for many years.  This has likely led to overly harsh judgments and criminal sentencing for a number of alleged criminals.  The state will now have to go through thousands of case records and work with prosecutors and defense counselors to sort out the mess.

In today's political world, there seems to be a need to assign blame when something like this happens.  Whether it might just have been a rogue scientist, or whether there may have been inadequate procedures in the laboratory, or both, is something worthy of review and correction, of course.  But the idea that the Commissioner, sitting astride a huge organization of departments and divisions, should be held accountable for this is ridiculous.

Here's the current organization chart for the state DPH.  Good luck even finding the division in which this scientist used to work.

John, being the ultimate gentleman and stand-up guy, issued this statement:

It is with deep regret and with a sense of responsibility to uphold the high ideals Governor Patrick demands that I announce today my resignation as Commissioner of the Department of Public Health. 

It is clear that there was insufficient quality monitoring, reporting and investigating on the part of supervisors and managers surrounding the former Department of Public Health drug lab in Jamaica Plain -- and ultimately, as Commissioner, the buck stops with me.

But the "high ideals" he cites of the Governor apparently do not include the concept that this could have happened in any administration (and indeed apparently started well before John's tenure).  Those ideals apparently do not include the concept that someone who has been an exemplary public servant deserves a chance (if he wanted) to try to remedy the underlying problem of the agency.  Those ideals apparently do not include any self-blame for the people still higher in the administration, who filed the extremely tight budgets for this agency for several years that may also have contributed to an inability to conduct proper oversight.

No, we seem need to find someone to punish . . . and quickly, to get through the news cycle and put this story behind the administration.  The Governor said:

Today, I accepted Commissioner John Auerbach’s resignation. The failures at the Department of Public Health drug lab are serious and the actions and inactions of lab management compounded the problem. The Commissioner recognizes that, as the head of DPH, he shares accountability for the breakdown in oversight.

Boston Mayor Thomas M. Menino said, “For all the wonderful things he did over the years, his career should not be blemished by this one incident.”

Let's be clear, Mr. Mayor.  This is not a blemish on John's career, and to call it so misconstrues the nature of what has happened here.  They needed a fall guy, and he was gracious enough to accept the role without complaint.  We citizens owe him a debt of gratitude for years of dedicated public service.  Knowing John, I am sure that he will continue to make contributions to the public good wherever he goes and whatever he does.

Meanwhile, though, the Massachusetts political system goes on and eats its young.

With Professor Restuccia at BU

Professor Joseph Restuccia runs a terrific course at the Boston University Graduate School of Management entitled "Health Services Delivery: Strategies, Solutions, and Execution."  He has been kind to invite me each year to meet with the students and tell how we were able to transform the culture of my former hospital to instill a great emphasis on the safety and quality of patient care, based in large measure on front-line driven process improvement.

I attended last night again and, per habit, told students who gave particularly perspicacious answers to my questions that they might find themselves featured on this blog.  So here they are.  I include their names so potential employers will know whom to contact when they are looking for recruits!

Dear HMS, Here's what it could look like.

The first known longitudinal patient safety curriculum that I know of was instituted at the University of Illinois College of Medicine.  This was rigorous and thoughtful approach to patient safety, integrated into the undergraduate medical education program.  A capstone was a four-week elective that, as David Mayer notes, became increasingly popular as time passed.

Dave recently published two blog posts summarizing this course, here and here.  Here's the part I like best:

Students were asked to address 1-3 specific research questions around each patient safety topic, and to share 2-3 relevant articles from a literature search that addressed the questions posed. Responses to each question (no less than 400 words) were then posted on the course blackboard site so others could then read and respond to their peers’ conclusions as appropriate. Answers to the questions were required to demonstrate critical thinking and scholarly investigation, and to be taken from peer-reviewed literature and referenced appropriately. The interactive, adult-learning format allowed for discourse via the blackboard around the posted answers. The course provided a forum for each student to gain substantial knowledge in patient safety, as well as prepare students for the responsibilities of residency.

These were no easy questions.  Look at these, for example:

1. What are the key risk management concepts non-medical industries use to manage their high-risk operations?
2. What is a safety culture and how can it help enable creating reliable and patient centered care?
3. What can we learn from HRO research that can help inform patient safety practices in healthcare?

The course also contained several opportunities for personal reflection, again shared with other classmates. Adding this humanistic tilt to the course presents a great opportunity to break down the interpersonal barriers so often found in medical school and later in the practice of medicine.  Here is the summary:

Individual student reflection were assigned for Day 5 of each week, and designed for students to reflect on the week’s discovery and learning. Reflections were due on Saturday, and students were instructed to post comments and reactions to one another’s posts. The reflections addressed the following questions:

1. How would you apply what you have learned this week to your professional life?
2. What are the concepts that made you think differently than before and why?
3. What’s your greatest “take away” learning from this week? Why?
4. What unanswered questions remain?
5. Any additional comments and thoughts?

Found in Translation

I was so pleased to receive an informative note from Maria Vertkin, founder and executive director of Found in Translation.  This organization has a terrific dual purpose: "To help homeless and low-income multilingual women to achieve economic security through the use of their language skills; and to reduce ethnic, racial, and linguistic disparities in health care by unleashing bilingual talent into the workforce". The website notes: 

Our 12-week Medical Interpreter Certificate course is offered at no cost to income-eligible women and includes common-sense supports such as on-site childcare and assistance with transportation. Upon successful completion of the course, graduates are qualified to be hired as medical interpreters at hospitals, clinics, and other medical settings.

As a budding non-profit,  Found in Translation can use your help in funding.  If you are in the area, you can join in their fall fundraiser on November 16, 2012 from 6:00 PM - 9:00 PM at the Microsoft NERD Center, Cambridge.  The event will "celebrate our inaugural year, our graduates' accomplishments, and the diversity of our community!"  The celebration will include:

- Ethnic cuisine

- Music

- Dance performance

- And auction of fabulous items.

This event requires registration, here.

L'shanah tovah!

This little diamondback terrapin entered a new world as the New Year began.  Let's wish him/her success in a rough environment and remind him/her that sticking your neck out is often--but not always--a good way to make progress.

(Thanks to naturalist Molly at Mass Audubon Society's Wellfleet Bay Sanctuary for her introduction!)

Take the credit, Mr. President!

One of the mysteries of electoral politics is why President Obama doesn't take more credit for those aspects of the Affordable Care Act that are popular, that represent a reduction in anxiety for a portion of the public.  It's as if he lets the other guys define the issue in the most negative way.

I recently wrote about one, the guarantee of insurance coverage when someone has pre-exisiting conditions. But an equally attractive feature of the law is the provision that allows young adults to stay on their parents' insurance policy until age 26.  For years, many people would graduate college or otherwise enter the work force without health insurance coverage.  While these people are, on average, healthier than the general population, the average hides a lot of variation.  Plus, this is the time of life when getting used to preventative care is a good habit.

The new law has made a difference.  The Commonwealth Fund recently reported on data from the Census Bureau:

Young adults made strong gains in coverage, continuing a trend that began in 2010 with the passage of the Affordable Care Act. The percentage of uninsured young adults ages 19 to 25 without health insurance declined by 2.2 percentage points in 2011, to 27.7 percent, down from 29.8 percent in 2010 and 31.4 percent in 2009. This nearly 4 percentage point decline in the share of young adults who lack health insurance over the past two years reverses the growth in the uninsured in this age group over the past decade, and is likely attributable to the Affordable Care Act; young adults under age 26 may now stay on or join their parents' health plans. About 1 million more young adults had insurance coverage in 2011 compared with 2009, prior to the passage of the law.

Mr. Obama's opponents have made it clear that they would repeal this provision.  The Huffington Post reported back in July:  "Rep. Paul Ryan (R-Wis.) said Republicans would not require parents' health insurance plans to extend eligibility to adult children if Obamacare is repealed."

Hey, I am rank amateur on campaign strategy, but I would think that emphasizing these points would be attractive to many voters across the political spectrum.

Sleep apnea diagnosis shirt

Thanks for the lead from @tgranz (Tracy Granzyk) via TechCrunch Disrupt SF 2012.  There are tons of college students and recent graduates inventing new health care gizmos here in the Boston area.  Here's a summary of one of them, a new approach to monitoring a person to detect sleep apnea.  They made the prototypes using a 3-dimensional printing machine, finding that they could not get the quality or price they wanted from regular production houses.

A infant sleep monitor is coming next!

Take a couple of minutes to watch the video.  I think you will be impressed.  (Click here if you cannot see the video.)

National Forum Preview on WIHI

September 13, 2012: Special Preview of IHI's National Forum
 2:00 - 3:00 PM Eastern Time

Featuring:

Gilbert Salinas, BS, MPA, Director of Patient-Centered Care, Rancho Los Amigos National Rehabilitation Center (Los Angeles); 2012 National Forum Co-Chair

Laura Adams, President and CEO, Rhode Island Quality Institute (RIQI)

Leonard Berry, PhD, Distinguished Professor of Marketing, Texas A&M University

Katharine Luther, RN, MPM, Vice President, Hospital Portfolio Planning and Administration, Institute for Healthcare Improvement (IHI)

Karen Baldoza, Director of Operations, Continuum Portfolio, IHI

One of the most important events of the year for IHI and for the health care improvement community is the National Forum. The theme for this year’s conference (December 9-12 in Orlando, Florida) is Defining Moments. It’s meant to suggest the critical challenges and opportunities before health care right now — for providers, payers, and patients — that will shape the future of health care quality. In other words, “seize the moment” and great things can happen — but only if we act, and act now.

For the 24th year in a row, IHI wants to help with your challenges. That’s why we’ve secured a big space, and cleared our calendars, in order to provide you with as many keynotes, Learning Labs, Minicourses, workshops, Forum Excursions, virtual site visits, storyboards, symposiums, and exhibitors that we can pack into a few days … knowing that you need the latest knowledge and the energy of others who are passionate about patient care to take the next steps. Who might you meet? What might you learn?

WIHI host Madge Kaplan is gathering some talented people together to walk you through the 24th Annual National Forum experience and to give you an idea of who’s speaking, who’s attending, and all the networking possibilities in store. IHI’s Karen Baldoza will provide a concise overview of the conference; National Forum Co-Chair Gilbert Salinas will share his thoughts about the patient’s perspective; Laura Adams, Len Berry, and Kathy Luther all have sessions they’d like to tell you about but, even more, to explain why they attend the IHI National Forum every year. This year’s gathering feels especially timely (and defining) to them, too.

Finally, we are eager to answer your questions and to explain how you can get the most out of IHI’s 24th Annual National Forum on Quality Improvement in Health Care. No question too small or insignificant. Please join us for this special National Forum preview on the September 13 edition of WIHI.

To enroll, please click here.

2000 avoided infections, 500 lives, $34 million

I am just going to copy this article because it so good.  It has been picked up by a number of places.  

A unique nationwide patient safety project funded by the Agency for Healthcare Research and Quality (AHRQ) reduced the rate of central line-associated bloodstream infections (CLABSIs) in intensive care units by 40 percent, according to the agency's preliminary findings of the largest national effort to combat CLABSIs to date. The project used the Comprehensive Unit-based Safety Program (CUSP) to achieve its landmark results that include preventing more than 2,000 CLABSIs, saving more than 500 lives and avoiding more than $34 million in health care costs.

The agency and key project partners from the American Hospital Association (AHA) and Johns Hopkins Medicine discussed these dramatic findings at the AHRQ annual conference today in Bethesda, Md., and introduced the CUSP toolkit that helped hospitals accomplish this marked reduction.

“CUSP shows us that with the right tools and resources, safety problems like these deadly infections can be prevented,” said AHRQ Director Carolyn M. Clancy, M.D. “This project gives us a framework for taking research to scale in practical ways that help front-line clinicians provide the safest care possible for their patients.”

CLABSIs are one type of healthcare-associated infection (HAI). HAIs are infections that affect patients while they are receiving treatment for another condition in a health care setting. HAIs are a common complication of hospital care, affecting one in 20 patients in hospitals at any point in time.

The national project involved hospital teams at more than 1,100 adult intensive care units (ICUs) in 44 states over a 4-year period. Preliminary findings indicate that hospitals participating in this project reduced the rate of CLABSIs nationally from 1.903 infections per 1,000 central line days to 1.137 infections per 1,000 line days, an overall reduction of 40 percent.

The CUSP is a customizable program that helps hospital units address the foundation of how clinical teams care for patients. It combines clinical best practices with an understanding of the science of safety, improved safety culture, and an increased focus on teamwork. Based on the experiences gained in this successful project, the CUSP toolkit helps doctors, nurses, and other members of the clinical team understand how to identify safety problems and gives them the tools to tackle these problems that threaten the safety of their patients. It includes teaching tools and resources to support implementation at the unit level.

The first broad-scale application of CUSP was in Michigan, under the leadership of the Michigan Health & Hospital Association, where it was used to significantly reduce CLABSIs in that state. Following that success, CUSP was expanded to 10 states and then nationally through an AHRQ contract to the Health Research & Educational Trust, the research arm of the AHA.

“This partnership between the federal government and hospitals provides clear evidence that we can protect patients from these deadly infections,” said AHA President and CEO Richard J. Umbdenstock. “Hospitals remain committed to curtailing CLABSIs and enhancing safety in all clinical settings. Tools such as CUSP go a long way toward accomplishing that goal.”

CUSP was created by a team led by Peter J. Pronovost, M.D., Ph.D., senior vice president for patient safety and quality at Johns Hopkins Medicine. “It is gratifying that this method has become such a powerful engine for improving the quality and safety of care nationwide,” said Dr. Pronovost. “It is a really simple concept; trust the wisdom of your front-line clinicians.”

Marty Makary suggests transparency

I haven't read the book yet, but this review of Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care by Dr. Marty Makary makes it look like something worth reading.

Here's are some excerpts from the review:

Though concepts such as “accountability” and “transparency” have been trotted out from time to time, Makary believes that medicine is still a closed shop. In Unaccountable, he specifically targets hospitals, arguing that they need to gather, analyze, and publish information vital to prospective patients. They should keep precise tabs on patients’ surgical outcomes, the rate of hospital-borne infections, and other measures, and then put the statistics out where the public can see them (including on the Internet). Doing that would encourage hospitals to hold themselves to higher standards. They would be forced to rehabilitate, train, or weed out physicians and other professionals who need to do better, Makary says, and the practice of medicine would be greatly improved. By focusing only on best practices, hospitals would also reduce the cost of care. 

Meanwhile, hospitals see little gain in presenting statistics about their performance, Makary says—another impediment to better treatment. “Their thinking is, ‘What if we have a bad year?’ They’d rather keep the steady stream of money coming in. They know that people view them as a beneficent entity, almost a charity.

While many hospitals highlight glitzy new cancer centers, Makary believes they should emphasize safety at least as assiduously. “Advances in patient safety will save more lives than chemotherapy this year,” he says.

For all the brewing hubbub, Makary insists he’s not so much a single-minded activist as a messenger. “I didn’t create this movement,” he says. “We’re at a turning point in American medicine now. There is a new generation of physicians that believes medicine should be transparent, that is tired of the old b.s., and wants to change things.” But the old guard isn’t far behind—which gives Makary even more hope. The Institute of Medicine, a vaunted research entity that often investigates best practices, and the American Board of Internal Medicine are starting to take accountability seriously. Even the doctor-protective American Medical Association has taken notice. “Doctors are monitoring exactly what they do. They’re researching and questioning it,” he says. “It’s unprecedented.” 

"Myth" re-redefines his position

The New York Times reported on statements made by Mr. Romney on NBC's "Meet the Press:"

I’m not getting rid of all of health care reform. There are a number of things that I like in health care reform that I’m going to put in place. One is to make sure that those with pre-existing conditions can get coverage.

I read this and surmised that he said this because he had come to understand a major cause of anxiety among the public in an employer-based health insurance market.  Without guaranteed issue provisions, i.e., protection against exclusion for pre-existing conditions, people are at risk for losing health care coverage when they change jobs or if they have not had insurance at all or during an interim period of unemployment.

I was surprised by the comment because in making it, Romney failed to mention something Governor Romney made oh-so-clear to me in a meeting in 2005, as he was advocating for the Massachusetts health reform bill.  A concomitant of guaranteed issue is the individual mandate.  If people can choose not to buy insurance until the moment they get sick, the broad risk pool of subscribers that is needed to fund insurance benefits will be harmed by a process of adverse selection, raising premiums for all.  Absent an individual mandate, a moral hazard is created that guarantees coverage to those who have decided to save money.  They then become a burden on society, being bailed out when illness strikes without having paid their actuarial share.

But almost immediately the campaign "clarified" Romney's remarks.  As reported by folks at CommonWealth Magazine, the plan he really believes in would prevent those with pre-existing conditions from being denied insurance if they have had “continuous coverage,” or if they’ve paid for insurance every month and then enroll in a new plan. It would not include people who have not had insurance at all or for an extended period of unemployment.

Ah, so he is so concerned about not having an individual mandate (something for which he argued strenuously in Massachusetts) that he cleverly proposes to restrict the restriction against denying coverage for pre-existing conditions!

No Myth.  This is absolutely clear.

Modest or bragging?

Heard at MIT:

Professor A:  "What do you know about quantum replication?"

Professor B:  "What I know could be put on the head of a pin."

Stop setting the benchmark at the state average

Ashish Jha, of the Harvard School of Public Health, recently commented on a Massachusetts report about stroke treatment in the state's hospitals.  He explained:

The report is about 1,082 men and women in Massachusetts unfortunate enough to have a stroke but lucky (or vigilant) enough to get to one of the 69 Massachusetts hospitals designated as Primary Stroke Service (PSS) in a timely fashion. Indeed, all these patients arrived within 2 hours of onset of symptoms and none had a contradiction to IV-tPA, a powerful “clot busting” drug that has been known to dramatically improve outcomes in patients with ischemic stroke, a condition in which a blood clot is cutting off blood supply to the brain.

So what does this report tell us?  That during 2009-2010, patients who showed up to the ER in time to get this life-altering drug received in 83.3% of the time.  Most of us who study “quality of care” look at that number and think – well, that’s pretty good.  It surely could have been worse.

Pretty good?  Could have been worse?  Take a step back for a moment:  if your parent or spouse was having a stroke (horrible clot lodged in brain, killing brain cells by the minute) – you recognized it right away, called 911, and got your loved one to a Primary Stroke Service hospital in a fabulously short period of time, are you happy with a 1 in 5 chance that they won’t get the one life-altering drug we know works?  
  
So what might state and federal policymakers do if they wanted to get serious about improving these rates?  There are lots of potential solutions, including greater training, more oversight, even robust pay-for-performance.  I have a simpler request:

Stop setting the benchmark at the state average.

Ashish is right on point.  In several earlier posts, I have talked about how the use of benchmarks can be inimical to clinical quality improvement, stating a preference instead for absolute targets, like zero or 100%. For some reason, many state and federal agencies persist in comparing hospitals to the norm.

Regardless of what the government agencies are doing, though, hospitals can do better.  The NHS' Jim Easton put the job on the leaders of hospitals:

[We] need to improve ourselves as leaders. [We need to] be intolerant of mediocrity, to hate it. [We must] reject normative levels of harm.

It is not ok to be in the middle of the distribution of the number of people we are killing.

I have told the story of being at a hospital where the CEO said directly to his senior management and clinical leaders that his goal was to be “just above average” when it came to quality and safety metrics. A CEO who has chosen not to do that has, in essence, said that the loss of hundreds of lives at his institution is acceptable.

In contrast, heed these words of Paul Wiles, former CEO of the Novant Health system, discussing preventable infants' deaths in one his hospitals:

My objective today is to confess.  I am accountable for those unnecessary deaths in the NICU. It is my responsibility to establish a culture of safety. I had inadvertently relinquished those duties [by focusing instead on the traditional set of executive duties (financial, planning, and such)].

If you cannot see the face of your own relative in a patient, or if you can not see the face of your own son or daughter in the face of a distraught nurse or doctor who has made an error, I suggest that your executive talents would be better placed in other industries.

Join Tom for a ride

It's not too late to participate in Sunday's Reason to Ride, a biking fundraiser for cancer research in Danvers, MA.  Organized by brain cancer survivor Tom DesFosses, this annual event gives participants the option of 10-, 25-, or 50-mile bike rides through beautiful farm land in Massachusetts' north shore (Danvers, Wenham, Ipswich, Essex, Gloucester, and Topsfield). Registration is $25 per child, $50 per adult, and $150 per family to benefit cancer care and research at Beth Israel Deaconess Medical Center. The family-friendly event also features a trike-a-thon for kids, a Fuddruckers cookout, raffles, music, and much more.

Once again, this year’s presenting sponsor is Fuddruckers. Support for the ride also comes from The Print House, Beverly Cycles, Kelly Fiat, Jungle, and People’s United Bank.

The ride is on, rain or shine, although the weather promises to be lovely.  Registration starts at 8am.  The 50-mile ride starts at 8:30; the 25-mile starts 9:30; and the 10-mile starts 10:30.  Meet at the Liberty Tree Mall in Danvers. 

New website for Adenoid Cystic Carcinoma

"Small" diseases, those occurring to a very small percentage of the population, are often ignored by the research funding agencies.  But sometimes people overcome this problem by creating their own advocacy organizations to raise funds and sponsor research outside of the normal grant-making process--and also create a community of interest among patients, health care providers, and researchers.  Social media makes this more possible than ever.

Such is the case with Adenoid Cystic Carcinoma (ACC), a rare cancer of secretory glands, typically originating in the head and neck region.  ACC is diagnosed in only about 1200 cases per year and afflicts about 10,000 people in the US.  The disease often afflicts young and middle-aged patients. The median age at diagnosis for ACC patients is a decade younger than for all cancer patients. ACC’s progression is typically gradual and sometimes relentless. The disease has a tendency to grow along nerves and metastasize to the lungs.

My friend Marnie Kaufman was 38 years old, with four sons under the age of 10, when she received her diagnosis of ACC. Frustrated at the lack of ongoing ACC research, she and her husband, Jeff, formed the Adenoid Cystic Carcinoma Research Foundation in 2005. This has been a well run and thoughtful organization, and they now note the establishment of a new website:

The website serves a pivotal role as a clearinghouse of high quality information for both patients and researchers. For patients, we have reorganized the navigation to make it simple to find information related to each stage of disease or a particular treatment. For researchers, we have presented a centralized inventory of research resources. And for the entire ACC community, we have summarized past and ongoing ACC research projects. 

Realshare for young people with cancer

Lucien Engelen @lucienengelen reports on the creation of realshare, a  new social network for young people with cancer, aged 16-25, who live in the South West part of the UK.  A collaborative program with SouthWest NHS and the Youth Cancer Trust, the site offers the following introduction: 

You may not get to meet many other young people in your situation where you are, so realshare gives you a chance to link up with others all over the South West from Bath to Barnstable, Torquay to Truro. realshare also provides information about treatments and support, events in the area, and even includes a Game Zone if you just want to chill out.

 

Unlike other social networks realshare is closed to members only. You might find it easier to talk about things with other people in a similar situation to you. The forums are moderated by local outreach nurses who treat young people with cancer.

Lucien is Director Radboud REshape & Innovation Center at Radboud University Nijmegen Medical Centre. His favorite topic is the power of social media in helping patients learn, navigate, and collaborate in the context of a health care environment with rising demand, shortages of skilled staff and restrictive budgets.  Check out this article in the Guardian:

We tend not to use the biggest resource in healthcare – the patients themselves. So I'm trying to figure out possible uses for digital technologies like Facebook but also real-life social networks to improve healthcare provision. 

Over the past decades we have tended to take healthcare away from the people themselves. This started with bringing people into hospitals rather than caring for them in their homes. Healthcare has become centralised in institutions, rather than in networks as it was in the old days. But new technology is enabling us to reverse that, while keeping the same high standards. 

30-30 rule for lightning

Living next to a soccer field has many advantages, but sometimes you also see things that are troubling.  Today, as storms approached and lightning and thunder were clearly in close range, the coaches of our boys and girls teams kept practicing with the children.

Referees are taught the 30-30 rule when it comes to lightning, and coaches should obey it, too.  It is as simple as this:  Go inside if you hear thunder within 30 seconds of a lightning flash. Wait at least 30 minutes after you hear thunder before going back outside.

Here are the top ten myths about lightning safety.  The most pertinent one, given today's lapse of judgment, is this:

Myth:  If it's not raining, or if clouds aren't overhead, I'm safe from lightning.
Truth:  Lightning often strikes more than three miles from the thunderstorm, far outside the rain or even thunderstorm cloud.

Here is a great quiz about lightning prepared by the National Weather Service.  It has only ten questions, and you are bound to learn something new. 

Let's start with Leominster

For the new students in Boston, an oldie but goodie video with a pronunciation guide from the folks at BU.

Click here if you cannot see the video.