How to deal with performance anxiety

Here's a really interesting insight from a musician about one way to deal with performance anxiety.  Or Ben-Natan is a vocalist who sings bass in classical and other music concerts in Israel. At a recent rehearsal with a chamber group in Zichron Ya'akov, his wife made sure that their little granddaughter was sitting near her in the front row to watch the performance.

When we asked Or if this was a distraction, he said that it actually helped him.  "When I am performing, I feel the tension between the anxiety of the performance and the desire to relax and enjoy the music. I know that my granddaughter would immediately sense it if I became too anxious, and so she helps me consciously move along the spectrum towards relaxation and enjoyment of the music."

A remarkable and lovely insight.

Shaking the hubris of the profession

My friend Danny Sands writes a remarkable story about a recent medical problem he faced. It's called "On The Ultimate Loss of Control, Living with Uncertainty, Reflecting on the Future, and Being a Patient."  It is beautifully written and worth a look.

I have been struck by a number of similar types of stories recently in which doctors have become patients or have been with close families members in that situation.  I think it is a wonderful thing that physicians now feel comfortable relating such experiences.  The common theme is one of shock and a new understanding of what it is like to be a "customer" in the health care system, especially when the episode involves an error or near-miss that is made in your treatment.  Here is a "minor" example in Danny's case: 

Because of the uncertainty of the diagnosis, I was prescribed atorvastatin to lower my LDL cholesterol and risk of future strokes. When I asked if they measured it in the hospital, I was told it was 107 (which is rather low already) so I politely declined. Besides, the imaging showed no evidence of plaque in my carotid arteries, my blood pressure was low, and I had no family history of cerebrovascular disease or coronary artery disease.

But--and I mean this with great affection for my colleagues who have written, in that I view them as among the best of their profession--isn't it a sign of the hubris of our profession that these doctors do feel the shock they write about?  After all, they have spent years in training and practice and treated thousands of patients.  In other fields of endeavor, the most important part of being and staying in business is to understand the needs of the customers.  The most successful firms, indeed, are driven by the needs of their customers.

In contrast, look at what Ashish Jha noted after a recent injury brought him to the emergency room:

The biggest lesson for me was that this was not an extraordinary story at all.  When I told my story to colleagues the next day, no one was surprised. We accept that when we walk into a hospital, we give up being people and become patients.  We stop receiving care, the way I did on the bike path.  Instead, we receive services. And when you are in pain, the difference between care and services is stark.

This is why I implore the medical profession to move to the idea of patient-driven care.   

As I have said at some recent conferences, patient-driven care does not mean foregoing the expertise, judgement and experience of clinicians.  Nor does it suggest the abdication of their clinical responsibilities. But we must go beyond patient-centered care, in which the doctors and nurses decide what is best for the patient.  Patient-driven care, in contrast, is based on a partnership between the provider and the customer.

And one thing more, returning again to Ashish's story:

Now that we are measuring patient experience and ER wait times as quality measures, I wondered how Falmouth hospital did.  Out of curiosity, I looked up its ratings. They are fine.  Average. This is not an outlier hospital. My experience was not an outlier experience. And that is the biggest disappointment of all.

I often say, "There is no virtue in benchmarking yourself to a substandard norm." Hospitals have come to accept that a "normal" level of (even just) patient-centered care is acceptable.  It is not.

I am pleased to see the hubris of my doctor friends being shaken by their personal experiences.

In memoriam: Arik Einstein

The story goes that, on his 70th birthday, Arik Einstein was invited to lunch by the president of Israel. "Mr. President," he replied, "please let me stay home."

This week this legendary performer, an icon in the country, died from a ruptured aneurysm at age 74.  The outpouring of grief and appreciation has been truly remarkable.  For example, thousands of people attended hours-long open-air concerts in Tel Aviv, singing the well-known lyrics of dozens of his songs.  The participants?  People of all ages, from teen-agers through the elderly.

Although Einstein had been writing and recording songs into his later years, he had not appeared in concerts for three decades.  How is it that young folks, then, took him into their hearts in such a manner?  After all, their musical heroes tend to be the people who give concerts, dance in sexy clothes, construct music videos, and the like.

One theory is that Einstein embodied the values of "the old Israel," and that this resonates with mutiple generations. Let's face it: Ever since the 1967 war (the Six Day War), this has been a country in which hubris has grown in disproportion to other characteristics.  It was that hubris that likely led to the debacle of the Yom Kippur War in 1973.  It is that hubris that encourages governments to support settlements in the Occupied Territories.  It is that hubris that impedes multiple chances at the peace process.

Meanwhile, in the manner that is the contradiction that is this country, Israel sets a remarkable standard in other respects.  We know, for example, of its reputation as "start-up nation" and other well deserved credit in other realms, like the medical education advances I recently discussed.

But, perhaps the young people responded to the unassuming nature and modesty of Arik Einstein, as exemplified in the story above.  Perhaps the message of Einstein's death is that the next generation seeks that kind of guidance, direction, and example from their national leaders.

Happy holidays!

My friend Lisa Popick Coll offers this version of a Thanksgivukkiah on Facebook.

Reportedly the two holidays will not coincide for another 70,000 years.  More or less. The explanation:

The overlap this year is because according to the Jewish calendar, this is a leap year, meaning that an entire extra month is added to the calendar. Because of that, most major Jewish holidays moved up by nearly a month. Couple that with the extremely late date of Thanksgiving in 2013, and you've got a convergence of holidays that comes once in many, many generations.

Ma, can we go to the hospital mall?

Traveling in Chicago recently, I saw these ads on the side of a major hospital.  I was struck by the idea that advertising for a mall was getting equal billing to advertising for orthopaedic services.  Orthopaedics has always been a high profit item for hospitals.  I guess dining and shopping has now reached that same level.

Remembering Monique Doyle Spencer

A reminder of some of the impact of Monique Doyle Spencer, noted on the second yarzheit (anniversary of her death.)  The Sunshine Girls, a breast cancer support group in Southeast US, with copies of The Courage Muscle. 

We'd often laugh about how she was always misplacing her reading glasses!  Here's part of the collection she maintained by her bedside just in case.

The future of simulation is to be found in Tel Hashomer

Simulation centers have been popping up in hospitals across the world.  These are useful, but for the most part their function is to provide technical training in surgical and other interventional techniques, as well as to practice resucitation and the like. Sometimes, too, they are used to study teams in stressful situations to provide lessons in team dynamics.

Amitai Ziv has a broader view of the purpose of simulation. His goal is nothing less than to use this tool to help in the transformation towards a safe, humane, ethical, and patient-centered medical culture.  As the director of MSR, the Israel Center for Medical Simulation at Sheba Medical Center on the outskirts of Tel Aviv, he is pursuing this goal with passion and energy and the support of his home base, philanthropists, and medical professionals throughout the country.

When an adverse event occurs in hospitals, we sometimes say that "the holes in the swiss cheese lined up" to permit a series of small problems to cascade into a big medical error.  Amitai draws on that imagery to describe "the educational Swiss cheese model."

He sees flaws in several key components that comprise the continuum of education and practice for physicians and other health professionals. He suggests that targeted use of simulation can help address the holes in the continuum, and he and his colleagues are out to test that proposition.

MSR is designed as a virtual hospital, offering a wide spectrum of medical simulation technologies. These include computer-driven physiological mannequins, advanced task trainers for manual skills and live simulated patients played by role-playing actors.  MSR combines these different technologies in "high-risk" scenarios to develop and build crucial clinical and communication skills and enable team training in risk-free environments.  Customized audiovisual equipment and one-way glass facilitates real-time observation and allows effective debriefing and constructive feedback to trainees.

Beyond technical training, MSR:

Enhances communication skills through programs dedicated to teaching challenging tasks, such as delivering bad news, obtaining consent and the detection of domestic abuse.

MSR training in a variety of technical and interpersonal competencies is now required of all medical students in Israel before they start their internships.  Interestingly, the center is also working in collaboration with the Tel Aviv University Sackler Faculty of Medicine to provide simulation-based personality screening of medical school candidates.  The aim is to improve the humanistic quality of medical school candidates by assessing their personal and interpersonal characteristics.

MSR conducts hands-on experiential simulation training in a wide variety of clinical domains such as Anesthesia, Cardiology, OB-GYN, Trauma, Chemical & Biological Warfare Management, and more. MSR is an integral part of the accreditation and licensure process of several of Israel's healthcare professional bodies.  These include competence-based board exams for Anesthesiology Residents and for Paramedics. 

The center also conducts a faculty development program for those interested in developing simulation programs in their home institutions.

In short, this is not a view of simulation as an adjunct to the medical education system.  It is a conception of simulation as being deeply integrated into many of the phases of a physician's career--starting before medical school, leading through that school and residency, and then staying with the person throughout his or her career. This larger vision welcomes the use of simulation by regulators and professional societies, as well as risk management organizations. Beyond a focus on safety, there is an attempt to influence the practice of medicine in many dimensions, consistent with the underlying values of clinicians and the roles expected of them by patients and families.

As someone who has been involved in several aspects of simulations, I will tell you that the MSR vision is expansive beyond anything I have seen.  The future of simulation is to be found in Tel Hashomer.  If I were running a center anywhere else in the world, I would be doing my best to learn from Amitai and his colleagues lest my own center fall behind and fail to meet its potential value to society.

Scott Adams: I hope my father dies soon.

Dilbert's Scott Adams writes an entirely serious (and angrily raw) post about an important topic, doctor-assisted suicide.  Excerpts:

I hope my father dies soon.

And while I'm at it, I might want you to die a painful death too.

I'm entirely serious on both counts.

My father, age 86, is on the final approach to the long dirt nap (to use his own phrase). His mind is 98% gone, and all he has left is hours or possibly months of hideous unpleasantness in a hospital bed. I'll spare you the details, but it's as close to a living Hell as you can get.

If my dad were a cat, we would have put him to sleep long ago. And not once would we have looked back and thought too soon. 

. . .

I'm okay with any citizen who opposes doctor-assisted suicide on moral or practical grounds. But if you have acted on that thought, such as basing a vote on it, I would like you to die a slow, horrible death too. You and the government are accomplices in the torturing of my father, and there's a good chance you'll someday be accomplices in torturing me to death too.

. . .

[Update: My father passed a few hours after I wrote this.]

New medical device emerges

At first, I thought it was an isolated incident.  @Bob_Wachter from UCSF reported on Twitter:

Lines betwn personal/professional contnue 2 blur, as I now use my @iPhone flashlght 2 look into my patients mouths. OK 2 clean it w/ alcohl?

I jokingly responded:

This makes me feel a bit uneasy, Bob. What if the phone rings? Or worse, buzzes! :)

He answered:

Good point, tho its not inside mouth (just outsde). Its 1 more sign of Swiss-army-knife nature of iPhone: 1 less thing 2 to carry

But then @drsusanshaw from Saskatchewan jumped in:

Just the other day I used iPhone flashlight to help surgeon identify bleeding vessel in an ICU patient.

They say it usually takes 14 years for a new medical device or procedure to infuse the market. Is this one faster?  Please comment if you have seen similar examples.

Exploring Lean in Tel Aviv

A colleague and I are in the midst of an introductory training session about the Lean process improvement philosophy at Sheba Medical Center on the outskirts of Tel Aviv, Israel.  We were invited by Dr. Eyal Zimlichman, head of quality management for the hospital (seen here with Jessica Livneh, head nurse of the oncology outpatient unit.) As is often the case, we find highly committed, engaged staff and managers facing the usual assortment of hospital management problems. Their interest in the opportunities offered by Lean is palpable, but part of our job is to explain that adoption of this philosophy takes extensive time and effort. Our hope is that this session will give them a taste of the possibilities so they and their leaders can make a more informed decision about the path forward.

We were honored to be joined by Boaz Tamir, Israel's Lean guru.  You see him here with (from right to left--appropriately!) Yoav Shalem (pharmacist); Dr. Einav Nili Gal-Yam (head of the oncology outptient unit); and Miriam Adam (director of pharmacy services).

Competition matters on both sides of the Atlantic

There is often a lot to learn by comparing the US and UK health care systems, but as often as not we revert to Shaw’s “two nations separated by a common language” when looking for lessons. Let me give one example.

Although the UK has had a single payer, nationalized system for over six decades, there also exits a small but vibrant private sector system. In this sector, private insurance companies—supported by premiums paid by individuals or corporations (on behalf of employees)—contract for services from private hospitals and consultants (i.e., doctors.) The system operates in a similar fashion to the US private care system. Insurance companies negotiate with the provider groups as to the rates that will be paid for the various clinical services.

As in the US, there are some private provider groups that have sought to obtain geographic dominance in certain markets. One purpose of that dominance is to have monopoly-like leverage over the insurance companies to obtain super-normal profits.

In the US, when this kind of dominance occurs, it is—for the most part—ignored by public policy makers and regulatory officials. Indeed, it is explained away by assertion that such ACOs (as we now call them) are better able to coordinate care for their patients and thereby achieve efficiencies that will lead to lower costs. As best I can tell, no one with training in economics believes that such an offset is likely to be the result.

Recent rulings by the Competition Commission in the UK have given the lie to those kinds of hopes.  The CC found that dominant private health care networks, particularly by not exclusively those in major metropolitan areas, were able to extract monopoly rents from the insurance companies. The regulatory response: Requiring the divestiture of a sufficient number of hospitals to enable competition to emerge.  The specifics remain to be decided, and portions of the ruling are likely to be contested or appealed, but the logic of the CC will remain intact: Too much market concentration is bad for consumers.

I am struck by how this differs from the situation in the US.  Even Don Berwick, one of the most informed candidates for public office when it comes to health care, avoids the market power issue in his recent platform statement—notwithstanding how many times it has been documented that the dominance of one health care provider network in Massachusetts single-handedly accounts for a substantial portions of the state’s high health care costs.

The CC’s report should be required reading for US health care policy-makers. The UK has a lot to teach us if we can learn to understand our common language.

IWantGreatCare advances the Lean agenda

I don't think Neil Bacon (of IWantGreatCare* fame) meant to reinforce one of the main tenets of Lean process improvement in a recent blog post, but he did do so. I also don't think Neil meant to enhance the Lean philosophy by adding a new key dimension, but he did that, too.  Let's start with his story from University Hospitals Morecambe Bay Trust:

The senior nurse from the surgical unit recounted to her colleagues how last week an elderly patient had used his iPad, from his hospital bed, to provide feedback on his care, highlighting a problem and concern he had using the iWantGreatCare pages for the hospital.

The nurses on the wards are able to receive instant alerts if there are concerns that need addressing for their ward – and thus the nurses were instantly made aware of a problem. Interestingly, in his comment the patient said something along the lines of “this needs sorting at some point, but I don’t want to interrupt anyone now”. Whilst the comments on iWantGreatCare are anonymous there were not many elderly patients sitting in bed with iPads! Thus the nurse was able to go directly to the patient and say “Let’s solve that problem now”.

I am told that the patient (who is still in the hospital) was completely amazed, not really expecting anybody to do anything ever, let alone seconds after he had given his feedback – this was not what he had come to expect from the NHS! Not only was the problem fixed, but the patient has been telling all his visitors and family about the incredible hospital and how the staff really listen, really care and get things fixed. His confidence is high, as is the morale of the staff who see people talking about the great care they deliver.

Lean is about front-line driven process improvement.  We encourage staff to call out problems they see in their work environment, and then managers "swarm" on those call-outs--in real time--and invent experiments that might improve the situation.

Here, though, we've gone a step further.  Here, the patient has been added to the front-line team by being given a simple technological approach that permits him/her to be empowered to make the call-out.

Whether Neil knows it or not, he just advanced the science of process improvement in the health care environment by one great leap forward. Well done!

--
* Think TripAdvisor for health care to get the concept.

"Wounded" comes to America

Emily Mayhew's book Wounded, about which I wrote in early October, is now available in the United States through Amazon.  This is simply the best book I have read about World War I, the 100th anniversary of which occurs this coming year.  It tells the intimate stories of doctors, nurses, and other medical personnel assigned to the front during this terrible war.

Terry Wise shares

Terry Wise is an extraordinary person--wise, empathetic, warm, thoughtful, and vulnerable.  She shares all these attributes with us in her book Waking Up, but she shares the benefit of her work with others through The Missing Peace Foundation:

The Foundation provides financial assistance, public speaking and other resources to entities that lack funding to advance their efforts to help those confronted with mental and physical health issues. Qualifying recipients include organizations, communities, schools, and other associations who aspire to raise awareness and educate others on topics related to long-term caregiving, grief, depression, mental health, suicide prevention, and the process of recovery.

Please check out the website to see if the foundation might be able to help your organization, or whether you might feel moved to contribute money to help the work of the foundation.

How the British Empire lives on

From The Times of London, a new type of Advent calendar!

Leadership Skills on WIHI

Madge Kaplan writes:

The next WIHI broadcast — New Leadership Skills for Better Health and Health Care — will take place on Thursday, November 21, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Gary R. Yates, MD, President, Sentara Quality Care Network; former Senior Vice President and Chief Medical Officer, Sentara Healthcare
• Lee Sacks, MD, Executive Vice President & Chief Medical Officer, Advocate Health Care; Chief Executive Officer, Advocate Physician Partners
• Derek Feeley, Executive Vice President, Institute for Healthcare Improvement
• Andrea Kabcenell, RN, MPH, Vice President, Institute for Healthcare Improvement

IHI has been doing a lot of thinking of late about leaders and leadership… in particular the skills, behaviors, and outlook necessary to steer today's health care organizations toward a very different future. A new IHI white paper (working title: High-Impact Leadership) will be out before the end of the year that captures this complex transition. Among other things, it offers a new framework for leaders who are not just responsible for making change manageable, but enthusiastically supported by all staff. You can get an early look at the new leadership framework on the Nov. 21 WIHI: New Leadership Skills for Better Health and Health Care. One of the goals of this WIHI is to describe the interdependence between the growing focus on population health, the shift from volume to value, and the corresponding leadership skills required to address these challenges. 

At Advocate Health Care, Dr. Lee Sacks has been hard at work learning by doing, with the help of other physician leaders. He’ll explain in concrete terms what his team’s leadership practices look like day to day, including those needed to lead an Accountable Care Organization (ACO). Sentara’s Dr. Gary Yates will spend his time on WIHI outlining key leadership behaviors that signal to staff how change is going to come about and what’s expected of everyone. If leaders want to alter the perception that they alone have all the answers, hashed out in some corner office, they must become a regular, approachable, and authentic presence throughout the organization. Discussions in the hallways talking with staff, and learning from patients and patient stories, need to become the norm.

Fresh from his leadership perch at NHS Scotland, IHI’s Derek Feeley has been thinking hard about what’s applicable and relevant to the US context and in many other countries seeking better health and health care for their citizens. He, along with Andrea Kabcenell, will discuss how leaders can better manage and prioritize all the tasks necessary to succeed. WIHI host Madge Kaplan invites you to put on your leadership cap wherever you reside in your organization, and take part in this next discussion on Nov 21. Tell us what you’re doing to lead differently, with a different future in mind, and what impact this is already having.

I hope you'll join us!  You can enroll for the broadcast here.

I have no way of knowing whom I may have hurt

A colleague writes with a thought-provoking story:

As is often the case, learning the meaning of something can happen well after the actual events that precipitate our own maturation.  So it was for me when my mother developed a growth on her esophagus just before her stomach, in the fall of 2009.

My mother was scared and my father was trying not to appear scared.  Together, they were preparing themselves to be lead by the healthcare system in the discovery of exactly what my mother was afflicted with and how it would be treated.  Having started my life in healthcare 29 years ago, working then as an X-ray Technologist, it took no time for me to launch into an effort to assist my mother and father in navigating through this event.  The reflexive urge I felt to help is well known by all those who work in healthcare.  As healthcare professionals of all disciplines, we know, that despite the best intentions and the best training in the world, there is no predicting how a health episode will go.  Nor is there an outcome that can be reliably delivered.  

After some phone calls by me, my mother was seen, biopsied and got her results well ahead of the typical time frame for these millstones of care.  She also had the benign growth removed well ahead of what would have been normally scheduled.

When I recount my efforts to help my family, with my friends and acquaintances, who also work in healthcare, every person affirms they would do the same for their spouse, children, family members and friends.  Normally, this affirmation is heartily expressed like those who are part of an exclusive club.  It was not until earlier this year that I was struck with a profound sense of guilt as I reflected on my actions.  I most certainly delayed the care that would have otherwise been given to someone with a malignant growth.  Someone who my mother and father, knowing her growth was benign, would have gladly had go ahead of them.  I have no way of knowing whom I may have hurt or if my actions had no consequence at all.

Aim for muscle fitness

My friend, colleague, and neurologist Seward Rutkove has invented several new fascinating medical devices.  One of these--Aim--is designed for the general marketplace (as opposed to medical clinics.)  He and his partner have started an Indiegogo campaign through which you can support the introduction of this device, plus get one for yourself.  What does it do?

Press Aim against any major muscle to measure the fat percentage and muscle quality (MQ) for that muscle.

• Each measurement takes less than a second and results are immediately displayed
• By measuring four muscles (biceps, triceps, abs, and thigh), you get an accurate estimate of your total body fat percentage and MQ
• Aim sends your results to an online dashboard via Low Energy Bluetooth
• You can review your results on the online dashboard to track progress and get tailored fitness advice

Expanding our horizons as teachers

Bradley Flansbaum tells an amusing story about an international medical graduate he was mentoring and then concludes:

Watching an international graduate take his first step assimilating into a new professional role, American style, opened my eyes once again to the valuable guidance we provide as teachers.  I consider moments with them as prized as the interactions with my patients.  What is the difference really?  In both instances, you provide the knowledge and comfort the other side lacks.

The learning is a two way street however, and I get as much as I receive.  Over the years, I have absorbed distant perspectives on religion, the roles of gender and family in the home, and viewpoints on sickness and death.  As a result, I believe my connection with trainees from other countries has made me a better person.

A lovely, concise, and perceptive observation.

Coaching as a leadership theme

Dr. Brian Wong has written a book called Heroes Need Not Apply.  A number of friends have recommended it to me.  I've not read it yet, but I did watch Dr. Wong's video in which he answers the question: "In your book, why does coaching become such an important leadership theme?"  I found his answers thoughtful and compelling and recommend the short video to you.  I'll look forward to reading the book some day.

Sweet to be mentioned. Thanks!

How lovely to have this blog listed as one of the "100 Important Sites for Healthcare Leaders and Executives" on the MHAPrograms.org website. They note: "Blogs, news sites and magazines in the healthcare industry often dedicate articles to covering the latest news on health leadership, promoting upcoming leadership conferences, and sharing advice that administrators can use to improve the efficacy of their organization."

Indeed, one of my hoped-for audiences is current and future health care administrators, and I am honored to be included.

Patty Skolnik adds "author" to her credentials

Congratulations to patient advocate Patty Skolnik in her new role as co-author in an international journal, Teaching and Learning in Medicine.  The title of the article is "Patient Safety Education: What Was, What Is, and What Will Be?" You can find it here.

The abstract:

Patient safety is an important topic that has been receiving more attention in the current health care climate. Patient safety as a curriculum topic in medical schools has only become apparent in the late 1990s, and much more needs to be done. This article summarizes patient safety curricular content as it occurred (or did not occur) in medical education circles in the past (pre-1990s), and present. It also makes some recommendations for the future of medical education curricula in the area of patient safety, using a framework for the development of expertise using the Dreyfus educational model.

Schwartz Center brings all together again

Petra Langer reminds us of an event that has become a mainstay of the New England healthcare community.  This may be one of the few places where the intensely competitive actors in the region join forces in total unanimity!

More than 150 doctors, nurses and other hospital staff who treated those injured in the Boston Marathon bombings will be honored at the 18th annual Kenneth B. Schwartz Compassionate Healthcare Dinner on Thursday, November 21, at the Boston Convention Center. Adrianne Haslet-Davis, a professional dance instructor who lost her lower leg in the bombings, will speak at the event beginning at 7pm. More than 2,000 people are expected to attend. 

“The Marathon bombings seven months ago cast a bright spotlight not only on the courageous first responders and volunteers at the scene, but also on the extraordinary people who work in healthcare in the Boston area,” said Julie Rosen, executive director of the Schwartz Center for Compassionate Healthcare, a Boston-based nonprofit that works to strengthen the relationship between patients andtheir healthcare providers. “We’re thrilled to honor them. Their professionalism and compassion have been critical to the collective healing of our community.”

The Schwartz Center will also celebrate the 15th  anniversary of its prestigious Schwartz Center Compassionate Caregiver Award®. The award was established in 1999 to honor healthcare providers who display extraordinary compassion in caring for patients and families. Past recipients will be in attendance, and this year’s recipient will be announced at the dinner.

A modest proposal

I’m going to offer an idea that is so outrageous it might actually have merit.  This concerns the Boston area health care market, but my readers from other regions might also find it of interest.

There are two health care entities in Massachusetts that face uncertain futures.  One is Tufts Medical Center, a relatively small but highly respected academic medical center with a notable history, going all the way back to its antecedent’s founding by Paul Revere and other patriots. The other is Steward Health Care, a chain of hospitals purchased from the Boston Archdiocese several years ago by a private equity company, which converted it into a for-profit organization.

Not withstanding superb executive and board leadership over the past dozen years and a dedicated medical staff, Tufts remains trapped by the lack of an extensive referral network of doctors and community hospitals.  It suffers, too, from some bad luck going back to leadership decisions made several decades ago.  For example, although located in Boston’s Chinatown neighborhood, the community health center serving that densely populated neighborhood decided to affiliate itself with another academic medical center several miles away.  When people in Boston say, as they sometimes do, that there are too many academic medical centers in town, Tufts is the one that is most often suggested for elimination.  Such facile comments are, of course, unfair, in that the quality of clinical care, teaching, and research at Tufts is excellent: Were this institution to close, the community and the world would suffer a true loss.

Nonetheless, in the changing world of healthcare, a lonely academic medical center surrounded by other such centers with large (and growing networks) is at a disadvantage.  Tuft’s inability to keep and create significant strategic alliances with physician groups and community hospitals is a major vulnerability going forward.

Steward Health Care presents a totally different performance problem.  Owned by a private equity firm, the hospital system’s leadership has done what private equity managers do.  Assets have been stripped away to create cash flow for the owner. Actions have been taken to increase the top line performance of the company: Acquire, at high price, physician practices to increase referrals; sign front-ended loaded global payment contracts with the largest insurance company; sell (and lease back) real estate; sell clinical laboratories (and enter into a long-term vendor relationship with the purchasing firm); and minimize capital investment in the system, to produce earnings before depreciation that look robust.

But even those steps cannot hide the fact that actually running a hospital system in the Massachusetts market is not a highly profitable enterprise.  Payment increases from private insurers, Medicare, and Medicaid seldom rise at rates greater than overall inflation. Meanwhile, service worker unions expect wage and salary increases to exceed that rate of inflation. Renewal and replacement of capital facilities and medical equipment by far exceeds the original cost of such investments. A for-profit firm faces the additional challenges of relying on taxable debt rather than tax-exempt debt; having to pay sales tax, local property taxes, and the like; and being unlikely to attract philanthropy to support its programs.

The private equity business model calls for a sale (or flip) of purchased companies within a short time frame. Indeed, the investors in private equity funds are promised such terms.  In general, two types of sales are envisioned: An initial public offering, in which the company’s shares are offered to the general marketplace; or a secondary sale to another firm in the private equity market. In either event, the selling entity needs to create a colorable story that the enterprise has a high chance of financial success, meeting the hurdle rate of the new investors.

From reports I see in the media, it is unclear to me that Steward has much to offer to new investors.  As mentioned, its financial strategy seems to have been tied to stripping cash out, leaving questionable value for the next investor. Profitability seems difficult to achieve. Indeed, we can imagine the current firm seeking concessions from its labor unions and perhaps even asking for property tax relief from municipalities if its earnings deteriorate significantly. Such actions would be a precursor to a loss of political support.

There is talk of selling Steward to one of the large American private hospital companies.  But what can Steward’s owners truly expect such a company to offer in the way of a purchase price, when the likelihood of the system meeting a private market’s hurdle rate is so small? If I were the current owner, I would be searching for a way to get out—to take solace in the cash I have been able to extract, and to avoid the possible future costs of running the system.  Indeed, I might even be willing to give away the investment to cut future losses and report a reasonably successful investment result to my private equity fund participants.

It is that thought that swiftly leads me to today’s modest proposal. I suggest that Tufts and Steward would both be better off if they reach an agreement under which Steward sells itself to Tufts for $1and in which the hospitals in the Steward network are re-established as non-profit institutions within a greatly expanded Tufts network of physician groups and community hospitals.  Overnight, Tufts would become the second or third largest health care network in the state, with outposts throughout the Boston metropolitan area.  It would thereby enhance its ability to negotiate with the private insurance companies.  Steward’s tertiary referrals, which today go to the high-priced Partners Healthcare System, would instead be treated at Tufts’ main campus in Boston, offering lower priced care of equal quality. As non-profits, the community hospitals could again return to their tax-exempt status, saving millions in costs over the coming years and benefitting from the generosity of local donors. And, by the way, the two hospital systems are already part of the Tufts Medical School training program, so there are benefits of better coordination for graduate and undergraduate medical education.

How crazy is this? If you think through the alternatives for the two parties, the approach I outline doesn’t look so bad—and could look quite good.  The public policy ramifications are also positive: Beyond solving the sentimental problem of keeping Paul Revere’s legacy alive, the proposal offers the potential for the entry of a third vibrant competitor in a health care marketplace that is looking more and more like a duopoly.  Contestability in this sector requires at least three competitors.  This proposal could help make that scenario more likely.

A normal day at the NHS

Those of us in the US who have been overwhelmed lately by overly excited health care stories in the media look fondly across the Pond. We are confident that we can find a much calmer discourse about these issues in the UK.  After all, a single payer system, well established, and held in fond regard by the populace can’t be very controversial.  Well maybe.

Here’s a synopsis of one day’s news coverage about the NHS from The Times and The Daily Telegraph.  Make sure you read all the way to the last one.  My head is spinning.

•A hospital trust whose staff were allegedly forced to alter waiting times of cancer patients has been put in “special measures” by Monitor, the health regulator.  An “improvement director” will be appointed by Monitor to ensure the [Colchester Hospital University NHS Foundation Trust] turns itself around. “The leadership of the trust will be reviewed as part of our scrutiny of the trust’s governance arrangements and, if necessary, further regulatory action will be taken.”

•Hundreds of teenage girls have had genital cosmetic surgery on the NHS, prompting doctors to call for an end to state-funded “designer vaginas.” Internet pornography has driven a five-fold increase in female genital surgery in the past decade and more than 2,000 women a year now have the procedure on the NHS.  Ruptures are reported in up to a third of cases and NHS surgeons report seeing women with complications caused by surgery in the private sector. There is no evidence that the surgery improves women’s lives.

•Nine of the world’s biggest pharmaceutical companies have warned that innovative new medicines are being blocked from use in the NHS and are calling for an overhaul of the commissioning process.  They said that, since 2005, the National Institute for Health and Clinical Excellence (NICE), the body that selects drugs for use in the NHS, has approved “fewer than one-in-three medicines” and needs to be given a new mandate to make the UK a world leader in innovation. In a statement, NICE said the companies had “wildly underestimated” the proportion of drugs approved and it “supports more than 80pc of the drugs appraised. The NHS needs to be confident that the treatments it buys with its increasingly stretched resources are both clinically and cost effective.”

•Wider use of statins will have minimal benefit and could needlessly expose thousands to severe side-effects, a leading doctor has claimed following a change in US prescription guidelines. Dr. Aseem Malhotra, a cardiology specialist registrar at Croyden University Hospital, south London, said he would be “disturbed” if Britain followed America in changing prescription guidelines to widen use of statins. Side-effects experienced by up to one in five patients include severe muscle aches, memory disturbances, sexual dysfunction, cataracts and diabetes.

•And here are two presentations of the same story:

The Daily Telegraph story, headlined, “Return of ‘proper family doctors:’”

A new contract for GPS will see the return of “proper family doctors” responsible for out-of-hours care for the elderly, Jeremy Hunt, the Health Secretary, announced today.  The deal agreed with the British Medical Association reverses changes introduced by Labour that allowed family doctors to abandon responsibility for care outside office hours. Mr. Hunt says that the changes are crucial because the failure to care for older patients is behind a crisis in NHS emergency care, with millions of patients admitted to hospital because they cannot get help in time from their GPs.

The Times headline was, “GPs told to reveal their pay:”

Family doctors will have to reveal their salaries from next year, under changes to be outlined today by the Health Secretary. Jeremy Hunt said that he had secured the agreement of the British Medical Association to publish the pay of GPs, in return for waiving a series of targets and handing nearly £300 million of performance-related pay directly to doctors.

[Hunt said,] “Transparency is always uncomfortable. People will get used to it, but it needs to be linked to outstanding performance.”

Both stories talk about the elimination of 40 percent of GP performance targets.  Here’s the Telegraph quote:

Under the targets framework, doctors have been paid for improving their handwriting, or ensuring staff undergo training, or for asking their patients how often they take part in activities such as DIY, cooking or gardening.

And the Times quotes Dr. Chaand Nagpaul, chairman of the BMA’s GP committee, applauding the change as:

Freeing up resources for GPs to use their clinical judgment—not a checklist—when treating their patients.

And finally:

•GPs are seeing up to ten patients a day who are lonely rather than ill, according to research. Three quarters of GPs questioned said it was usual to see between one and five patients a day in their surgeries primarily because they were desperate for human contact. However, some doctors had even higher rates of patients suffering loneliness with one in ten saying that they saw up to ten patients a day who came in for the company. Half said they were not confident about whether they could help their lonely patients.

What's your QI IQ?

Here's an excellent program for residents and attending physicians in the New York City area who are interested in enhancing their quality improvement skills.  It is offered jointly by CIR/SEIU Healthcare.

A summary:

This is a great educational opportunity for residents and attendings who are interested in taking their QI project to the next level and plan for publishing their work. Publication of a manuscript is a process that starts when you think of a QI topic, and requires thoughtful planning and execution. You will learn from leaders and national experts in the field of QI how to plan, execute and publish. Interactive and hands-on activities comprise a large part of this conference. 

What:  What's Your QI IQ? How to be Scholarly in Quality Improvement
When: Saturday, November 23rd, 2013 from 9:00am - 3:30pm
Where: New York Academy of Medicine
  1216 5th Ave, New York, NY 10029
Who: Housestaff, Faculty, Administration
Cost: Complimentary
Register here: bit.ly/QIIQNov23

Sportsmanship supreme

You don't have to be a soccer fan to enjoy this video clip.  Summary:

Al Nahdha's goalkeeper Taisir Al Antaif was about to make a clearance early in the second half with the score still at 2-2 but noticed that his shoelace had come undone, and was clearly nervous about his boot coming off as he kicked.

The opposing striker bearing down on him, a Brazilian by the name of Jobson, noticed what was going on - but instead of trying to take advantage, he ran up to his opponent and did his shoelace for him.

Al Antaif slapped his new friend on the back as thanks, and gave him a high five afterwards before getting on with the game.

But, here's where it turned sour, with the referee penalising the keeper for taking too long with his clearance.

He awarded an indirect free kick inside the area, and the home side lined up, clearly fearing the worst as Al Ittihad's strike force discussed their attacking options.

But in one of the most subtle and greatest insults given to a match official, Al Ittihad did the decent thing and merely passed the ball safely off the pitch. Even the supporters cheered at the gesture.

In a single stroke, the players managed to endorse a magnificent moment of sportsmanship between two opponents, while highlighting what an idiot the referee had made of himself.

Different priorities

A thought for the day from the world of coaching girls soccer, with thanks to a colleague at Northwestern Medicine in Chicago.

After a soccer game between two teams of seven-year-old girls:

Frustrated coach:  Your heads were just not in the game! Where were they?

Player: I was thinking about princesses and puppies.

Northwestern Medicine learns from patients and families

I had the pleasure of making a presentation at a leadership meeting at Northwestern Medicine today. Afterwards, while sitting through some other business sessions of the team, I saw this simple graphic representation.  It is emblematic of the types of changes that can occur when patients and families help set a health system's priorities.  Northwestern has convened a patient-family advisory council and was discussing with them the various metrics the hospital uses to portray progress on several clinical fronts.  The PFAC members made a persuasive case that the evaluative framework employed by the health system, and the corresponding set of metrics to measure progress along that framework, had a number of gaps. What evolved was the new framework shown above.  Over the next couple of years, NW will design and add metrics to their corporate scoreboard to fill in the gaps noted by the PFAC.

This is a fine example of the kind of partnership that can develop between a health care system and the people it serves.

Chutzpah

The classic definition of chutzpah is provided by the man who kills his parents and then pleads for mercy from the sentencing judge on the grounds of being an orphan.

Now, we have a story by Julie Donnelly in the Boston Business Journal about the CEO of a hospital system who bemoans the fact that "any savings from layoffs in the health care industry are constrained by labor agreements that often force hospitals to lay off the youngest, cheapest workers."

Let's recall that it was this CEO who aceded to a neutrality agreement to facilitate the ability of the SEIU to organize his hospital system back in 2009 and who then was responsible for negotiating and approving the collective bargaining agreement with that union.  Such an agreement contains the seniority rules that govern the order in which layoffs occur.  At the time, some of us thought of these as steps along the way to ensure that union's support in front of state officials when the non-profit system's acquisition by a for-profit entity required state approval.

But now, the gentleman pleads for mercy.

The word from Mt. Sinai

There’s some good stuff happening at Mt. Sinai Hospital in downtown Toronto, and I thought I’d take a moment to share examples with you. I was there because the folks at the hospital had invited me to give grand rounds and also to participate in some sessions with senior leadership and with their quality improvement champions. As is often the case, I learned more than I imparted, and I walked away impressed with the organization’s commitment to quality and safety improvement, transparency, and staff engagement.

Here’s one example. While I had heard about the concept of a patient navigator before today, including at my own former hospital, the navigator service was usually designed to help people of different cultural backgrounds maneuver through the complicated labyrinth of the tertiary care system. At Mt. Sinai, they have taken the concept to its logical conclusion, providing patient navigators for all general internal medicine, surgical oncology, and inflammatory bowel disease patients.

Here, for example, is Heather Siekierko, a navigator assigned to the “D” group of doctors and nurses serving patients in the general internal medicine area. When a patient arrives on the floor from the emergency department, Heather is already on the case, handling a multitude of tasks that previously would have taken time away from nurses or other clinical staff. Heather’s academic training? Fine arts!

With one navigator assigned to each of the four clinical teams, there used to be some confusion as to which person was assigned to which team. A doctor might spend time asking, “Are you in our group?” The problem was solved when a doctor suggested creating simple badges indicating each navigator’s group affiliation.

This program is supported by philanthropy, as the payment regime from the province of Ontario does not include funding for this kind of service. It is so effective, though, in terms of patient satisfaction and clinical improvement, that the hospital is working on a way to provide sustainable funding.

Here’s a second example, implementation of the Releasing Time to Care™ approach developed by the UK’s National Health Service. The focus is on team huddles, design of work flows, and attention to key clinical indicators--most importantly characterized by empowering front line staff to identify concerns and drive improvements themselves. As folks at Mt. Sinai have noted:

RTC is about changing the way we manage and do our work--it is not an "add-on" improvement initiative but rather a fundamental strategy that is embedded in the core works of our units and our team.

The program is supported and enhanced by a remarkable degree of transparency. Take a look at these charts—presented for all to see—on the walls of the clinical care floors. There’s no holding back when things do not go according to plan. Everyone is aware.

As you can see from these two falls-related pictures from two different floors, these presentations are not necessarily high-tech computer-generated graphs working off sophisticated databases: They are filled out by hand or constructed by the staff on the floor. People’s participation in creating the visible displays of key metrics is part of the process. They own the numbers, and when the numbers indicate problems, the team swarms on the issues and creates experiments of possible solutions. The feedback on the effectiveness of those experiments is quickly and clearly displayed to all in real time.

So that’s it for now. Two examples of thoughtful attention to the issues facing many hospitals. To the Mt. Sinai folks, this is a good start, but they are modest in their assessment of what has been accomplished. From my vantage point, this is truly front-line driven process improvement, enhanced by support from the senior leadership and from members of the Toronto community. The momentum has been building, and I, for one, expect to see great things in the future.

Southlake offers positive change

I shared a delightful day with people from Southlake Regional Health Centre, in Newmarket, Ontario.  I found a (large) community hospital that has dramatically updated its service lines over the past few years and has also made real efforts to improve quality and safety.  You could see signs of staff engagement throughout the hospital, including this visual reminder regarding daily safety huddles.

I include, for lighter review, a video with a key aspect of the automated wayfinding system the hospital has installed, clearly delineating the path to the Tim Hortons coffee shop! (It also leads people to the various clinical departments and physicians.)

Extreme unusualness

I'm in Toronto to meet with the staff about quality and safety progress at Southlake Regional Health Centre and Mt. Sinai Hospital and am very much looking forward to that.  Meanwhile, I get to read the Toronto Star, which has a story about the return to work of Mayor Rob Ford, "who ignited a firestorm last week when he admitted to smoking crack cocaine" and "will try to go back to business-as-usual."

Here's the quote of the day, the best I have seen about a leader in a long time:

"There's no 'business as usual' with Rob Ford. In a way there hasn't been for awhile, but now it's at the point of extreme unusualness," said Nelson Wiseman, a University of Toronto politics professor.

Learning from the sewers

The Fowl Meadow today

The basic stages of building infrastructure--plan, design, build, and maintain--apply equally well to information systems and physical infrastructure like pipes, roads, and power systems. Over the years, the science of project management has developed many tools to help such projects stay on schedule and on budget, yet many projects fail to meet their timelines and their financial milestones. Why a project fails is often viewed as a sui generis combination of internal management and technical glitches and external forces. But there is often one common factor: A failure of the organization's leadership to adopt a supervisory approach that helps keep the project on track. Oddly enough, this can occur even when the leader of the organization is strongly committed to its success.

If you read through the Washington Post's summary of the path taken to construct the federal health care insurance exchange system, you can find lots of explanations for the project's failure.  Some are internal to the agencies involved, while others may have derive from intense political opposition or fear of that opposition.  Nonetheless, it seems incredible that such could have occurred when the President's commitment to the program was unquestioned, and when the stakes were so high for him personally and for the country.

I'd like to suggest that one reason was that the President simply did not understand how to supervise this kind of project in a manner that would identify implementation problems in real time and would help ensure that they were dealt with expeditiously and effectively.  I am not saying this critically.  There is no point in piling on.  I am saying it because the experience offers lessons for future leaders, whether at the federal or state and local level.

The solution is remarkably easy and is illustrated by a town official and a sewer project. When I was executive director of the MA Water Resources Authority, we had literally dozens of water and sewer construction projects in our, er, pipeline.  One project was designed to repair structural and hydraulic deficiencies in an old sewer line that were causing sewage overflows into a wildlife area called the Fowl Meadow in the towns of Canton, Norwood and Milton, which also threatened the water supplies for Canton, Dedham, and Westwood.  The project was complicated, involving tons of permitting issues because we were building through a wetland, because of the overlapping municipal jurisdictions, and because of numerous technical issues.  The project would ultimately comprise 17,000 feet of 48-inch diameter force main sewer line, a 50 million gallon per day pumping station, and 10,000 feet of 48-inch diameter gravity sewer.  Physical challenges included five pipe jacking crossings at major highways and railroads, a siphon crossing of the Neponset River, a pumping station foundation, controlled blasting removal of bedrock, dewatering of silts and fine sands, and sewer bedding and backfill. In addition, it was necessary to protect the unreinforced 48-inch pipe immediately adjacent to the old sewer line throughout the construction period.

At that time, the town manager from Norwood, John Carroll, served as one of the MWRA board members.  John had been commissioner of public works for Massachusetts and had years of experience in managing construction projects there and in his own town. Of all the dozens of projects facing the MWRA, this one was John's pet. His goal was to stop the disgusting overflows of sewerage which were wreaking environmental damage in his town. He understood the long-lived nature of such projects and wanted to implement a supervisory approach that would keep the project on track. He asked me if I would please arrange a status meeting between him and the project team every six weeks. He said, "I just want them to tell me how it's going, what problems they are facing, and how they are planning to solve them."

John knew that sometime before the team met with him--maybe around week four--they would start preparing for their next session.  They never wanted to come to the meeting unprepared. If they had encountered a problem, they wanted to show up with an idea as to how they would solve it.  It's not that John was trying to impose his judgment on the team. He never did that. He would just ask simple questions. He was always supportive of the team, encouraging them to tell him everything.  Knowing that he would ask those questions was not only enough to keep the team on track, but also made them feel comfortable telling John about their problems. They knew he was an advocate for them and could use his involvement more broadly. In particular, John's well-known interest in the project gave the team the status it would need to acquire support from other parts of the agency. After all, no project team has all the answers. There is always a need to get help from other parts of the organization, but there has to be a way to encourage those other divisions to cooperate, to take time away from other projects they might be working on.  The result: The multi-year, multi-million dollar project stayed on track, helping to enhance the entire community. You see the result in the pictures here.

Now, the WaPo article makes clear that President Obama had regular status meetings with his subordinates:

For months beginning last spring, the president emphasized the exchange’s central importance during regular staff meetings to monitor progress. No matter which aspects of the sprawling law had been that day’s focus, the official said, Obama invariably ended the meeting the same way: “All of that is well and good, but if the Web site doesn’t work, nothing else matters.”

I wasn't there, but I'd like to hypothesize that the President's approach was not the same as John's. For one, he probably had the wrong people in the room. I bet he didn't have the actual project team. For another, I bet he did not portray an atmosphere of support. More likely, he demanded results--“We’ve got to do it right"--and he comes across to me as a person who is not interested in excuses. I'm guessing that people would not have wanted to give him bad news.  Hence the October surprise:

Only during the weekend after HealthCare.gov’s Oct. 1 opening did the president’s aides begin to grasp the gravity of the problems, the White House official said. Obama soon began getting nightly updates on the performance of the Web site, which has still been unavailable to Americans for hours at a stretch over the past week.

Too late, as it turned out.

I don't mean to suggest that a sewer project is the same as a massive information system, but there are similarities and lessons to be learned.  I've seen John Carroll's approach used in many organizations that faced high priority complicated physical and information system infrastructure projects, including those loaded with technical and political challenges (and bigger than HealthCare.gov.) The simplicity of the approach is deceptive: This is a powerful management technique. The leader's expectation of high performance by the project team is fulfilled not by appearing to hold them accountable or by making the technical decisions for the team. Instead, the leader appears as an interested and engaged project advocate, curious about obstacles and successes, empathetic to the concerns of the team. Information is shared in real time throughout the pendency of the long-lived project. The team thereby holds itself accountable to a high standard of performance. Success emerges.

Helping in Haiti

My good buddy Cherie Abbanat is CEO of Haiti Projects, Inc., a 501(c)(3) corporation with a mission to empower women in rural Haiti to lift themselves out of poverty, become self-sufficient and build community. Haiti Projects is located in the town of Fond des Blancs, where it is the second largest employee in the region where over 35,000 people live with no electricity or public services.

They run an artisan cooperative that employs 95 women; a health clinic that conducts over 4000 patient consultations; a library with 700 members, daily newspaper, and Cyber Café, and many educational programs for adults and young people.  And did I mention the girls soccer team, with over 60 players at this time?

The organization is currently trying to meet funds to match a Kellogg Foundation grant, and they need to raise $93,000 this year.  Luckily, it is easy for you to help.  Of course, you can send cash, but you can also go here to buy this year's Chanukah and Christmas presents for your friends and family.  The handiworks are lovely and very well made, like the embroidered tulip nightgowns to the left.  Here's the site for the on-line store.