Hospital rankings: I wasn't cynical enough.

Whenever I think I am too cynical about the business of health care, I learn something that makes me understand that I am not cynical enough.  You may recall my 2011 column about the silliness of the hospital rankings published in one of the national magazines. I said:

US News needs to stop relying on unsupported and unsupportable reputation, often influenced by anecdote, personal relationships and self-serving public appearances.

So, you can imagine my pleasure in learning of the latest rigorous advance in the methodology applied by the magazine, a partnership with the physician network, Doximity.  This will certainly make things more objective and precise, right?  Well, not quite.

Here's a general letter sent out by the Ophthalmologist-in-Chief of one of the nation's eye centers.  It demonstrates how the process can be influenced by hospitals in helping to ensure a self-selected samples of physicians who are then polled to offer their opinions for the annual survey.

And, by the way, how reliable is Doximity in providing unbiased measures of quality? It seems mainly to be focused on networking:

“With over 170,000 physician members, Doximity has become the CV source for physicians researching other physicians—their training, insurers accepted certifications, publications, and other bona fides,” said Jeff Tangney, CEO of Doximity. "We’re excited to work with U.S. News to help patients find the right physician, precisely and reliably.”

Bona fides.  Great.  Until we read the next line:

For doctors, the new collaboration offers an opportunity to accurately represent themselves to the online public. Physicians can control whether certain information is shared publicly.

I wasn't cynical enough.

They should have been given a Miranda warning

Sometimes the exact words that people use to blame others serve as the most powerful indictment of their own ineptitude and culpability.  Imagine if you were to read the following statements from the owner/governing body of any non-profit hospital in America, describing a situation that lasted almost a decade:

[The hospital owner's president] blamed the facility’s debt on administrators who were not forthcoming.

“We were not getting full disclosure. We would ask the questions and we were not getting a full response.”

The hospital’s deficit began in 2006 and . . . its administrators did not reveal it despite being asked numerous times.

“We don’t know why we didn’t get the information. We asked the questions but did not get the answers.”

At one board meeting, trustees inquired about the hospital’s finances and “the board chair said it would be looked into. But at the end of the board meeting, we did not have a clarification.”

"After three years of mounting debt, [we] hired outside auditors who discovered the extent of it. They were using available funds to cover it and were reporting an amount that included those funds. Our consultant showed us the real cash flow deficit before funds were transferred to cover it. Both sets of numbers were legitimate, but ours showed a red flag.”

The debt currently totals $350 million, and [the hospital owner's president] cites the administrators’ carefree attitude towards expenses, as well as viewing the [hospital's owner] as a cash cow that could cover shortfalls, as the reason for the debt.

“The director general would come to the board of the owners, and say I need more money and our board would say, ‘How much?”

“It was a hospital that was run without worrying. If they could buy a pen for $1.50 or pay hundreds for a pen, they would pay hundreds and say it was needed. … We allowed it and they benefitted by it. There came a point that our organization could not allow the hospital to continue spending without a high level of fiscal responsibility. So we now find ourselves with a significant deficit.”

Asked about reports that some of the hospital’s more than 850 doctors had been earning salaries in excess of $1 million a year, [the hospital owner's president] replied: “I have never seen the actual salaries of our physicians.”

Here's the real truth:

Dan Brown, editor of eJewishPhilanthropy, [said] that he is troubled that the [owner] isn’t “willing to admit they have any responsibility for anything that’s happened in the past.”

“I think their mistake is that they were allowing things to happen under their watch,” he said. “It was bad management on their part. Ultimately, as owners and bosses, they’re responsible.”

And how does the owner respond?  By trying to put pressure on the government:

If you have not done so yet, please sign this petition to the Government of Israel in support of HMO. You can say “I stand with Hadassah Hospital and the people of Jerusalem and Israel” by signing on TODAY. Our goal is 10,000 signatures, so please include yours and pass it on to your friends and family! We will present the petition and signatures to the Israeli government in mid-March.

This group--Hadassah Women's Zionist Organization of America--has given up all moral authority to be the owners and governing body of a tremendously important national asset.

In Sickness As In Health

I've just read an excellent book called In Sickness As In Health: Helping couples cope with the complexities of illness, by Barbara Kivowitz and Roanne Weisman.  I recommend it highly. It serves an an excellent reference to people who find they have to deal with the acute or chronic illness of one of the partners in a marriage or other close relationship.  Beyond exploring the three phases of such situations--crisis, balancing act, and regaining equilibrium--it offers thoughtful commentary about a lot of related issues. 

There was one that I found particularly perceptive.  You've been informed by your doctor that something bad has occurred, and s/he offers a prognosis for the illness and thereby implies what it is likely to mean for the physical or mental functionality of the patient.  As the partner, you take this to be true:

All their normal coping skills remain on planet Earth even as they have to immediately learn to breathe in this new atmosphere.  In this unhinged state, they naturally seek a powerful guide, and typically grant omniscient status to the doctor.

The doctor becomes the orientation point in this new and frightening universe.  Her words signify more than educated opinion; they become oracular.

It is not unusual, in the aftershock of diagnosis, for patients and their partners to either submit silently to the sentence or pummel the doctor with questions as they desparately seek loopholes through which they can squeeze their fading hopes.  The doctor remains the focal point. Her words at this delicate moment . . . can have fateful impact.

This a superb observation, and the authors quickly explain the fallacy.  The doctor, after all, is making judgments based on personal experience, observation, and general statistics about the illness--but cannot actually predict the course of your particular illness.  What the authors call a "healing doctor," though, will:

call on his own humility and acknowledge that while death or disability are possible, he can't write your next chapters or know the exact trajectory of your illiness.  Healing is being present and promoting hope while presenting the medical perspective, and, at the same time, acknowledging the patient's fears with compassion.

So, how ironic and telling that a book designed to help couples is also an advisory to doctors who serve for and care for those couples!  My advice is that this book should be read by physicians as well as those of us who might need it for our families.

SNFs on WIHI

Madge Kaplan writes:

The next WIHI broadcast — Mobilizing Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations: New Imperatives and New Models — will take place on Thursday, February 27, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Laurie Herndon, MSN, GNP-BC, Director of Clinical Quality, Massachusetts Senior Care Foundation
• David Gifford, MD, MPH, Senior Vice President, Quality and Regulatory Affairs, American Health Care Association
• Annette Crawford, Administrator, Stafford Healthcare at Ridgemont
• Marie Schall, Director, Institute for Healthcare Improvement

In the world of health care improvement, and in society at large, talking about skilled nursing facilities (SNFs) can sometimes be a tough subject. When a loved one moves in to long-term care, they’re usually quite elderly, and it's often the last move they'll make of this kind before dying. So, whether because of this association or because other sectors of health care tend to get more attention, the hard work that’s going on to ensure that all types of SNFs deliver high-quality and patient-centered care, has been somewhat obscured. We’d like to help change this by zeroing in on one aspect of the work.

Please join us for the February 27 WIHI: Mobilizing Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations: New Imperatives and New Models ​where we’re going look at new developments with better coordination and communication between SNFs, local hospitals, and various community stakeholders, to reduce unnecessary transfers of patients to acute care settings. These avoidable admissions or readmissions can come from short-term-stay SNFs or long-term ones, from assisted living residences or rehab facilities.

Unpacking what’s behind unnecessary transfers and what better, safer, actions might be taken has been the focus of IHI’s STAAR initiative and is captured in one of a series of STAAR How-to Guides: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations.

Our guide on the learning and momentum everyone can build upon from STAAR is IHI’s own Marie Schall, who’s also the first to point to the rich activity and resources available from Laurie Herndon and the widely recognized INTERACT program.

Another huge resource is the American Health Care Association, which is mobilizing SNFs across the US to do their part to reduce readmissions within 30 days by 15% by 2015. David Gifford will be on hand to talk about these efforts.

And, then there’s the amazing example of Kitsap County in the state of Washington, where Annette Crawford’s SNF has played a leading role building a new kind of coalition across the continuum of care to ensure that patients get the right care in the most appropriate setting.

What’s your story? Where do SNFs fit in, in the emerging world of ACOs? 

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

Mayhew's "Wounded" as finalist for the Wellcome Book prize 2014

You no longer have to take just my word for it.  Now Emily Mayhew's book Wounded is on the short list for the Wellcome Book Prize for 2014.  For those not familiar with this prize, here's the description:

The Wellcome Book Prize is an annual award, open to new works of fiction or nonfiction. To be eligible for entry, a book should have a central theme that engages with some aspect of medicine, health or illness. This can cover many genres of writing – including crime, romance, popular science, sci fi and history.

At some point, medicine touches all our lives. Books that find stories in those brushes with medicine are ones that add new meaning to what it means to be human. The subjects these books grapple with might include birth and beginnings, illness and loss, pain, memory, and identity. In keeping with its vision and goals, the Wellcome Book Prize aims to excite public interest and encourage debate around these topics.

 Congratulations to Emily!

There is a non-zero chance of problems

In contrast, in a under-performing hospital, they would say, "The data are wrong," and "Our patients are sicker," and then give up.

Back in 2009, I wrote: The fear of transparency clouds all. That still applies in all too many places.

Is there an app for this?

An article in Nature reports:

The publishers Springer and IEEE are removing more than 120 papers from their subscription services after a French researcher discovered that the works were computer-generated nonsense.

Over the past two years, computer scientist Cyril Labbé of Joseph Fourier University in Grenoble, France, has catalogued computer-generated papers that made it into more than 30 published conference proceedings between 2008 and 2013. Sixteen appeared in publications by Springer, which is headquartered in Heidelberg, Germany, and more than 100 were published by the Institute of Electrical and Electronic Engineers (IEEE), based in New York. Both publishers, which were privately informed by Labbé, say that they are now removing the papers.

Labbé developed a way to automatically detect manuscripts composed by a piece of software called SCIgen, which randomly combines strings of words to produce fake computer-science papers. SCIgen was invented in 2005 by researchers at the Massachusetts Institute of Technology (MIT) in Cambridge to prove that conferences would accept meaningless papers — and, as they put it, “to maximize amusement” (see ‘Computer conference welcomes gobbledegook paper’).

Labbé does not know why the papers were submitted — or even if the authors were aware of them.

Ruth Francis, UK head of communications at Springer, says that the company has contacted editors, and is trying to contact authors, about the issues surrounding the articles that are coming down. The relevant conference proceedings were peer reviewed, she confirms — making it more mystifying that the papers were accepted.

The IEEE would not say, however, whether it had contacted the authors or editors of the suspected SCIgen papers, or whether submissions for the relevant conferences were supposed to be peer reviewed. “We continue to follow strict governance guidelines for evaluating IEEE conferences and publications,” Stickel said.

MedStar maintains the focus on transparency

MedStar's David Mayer addresses an important process improvement imperative--transparency--in this recent post and gives an example of how his institution is trying to overcome inertia and fear on the matter:

An important part of this journey includes creating a learning culture built on transparency that many in healthcare are still uncomfortable with. Overcoming these barriers requires consistent and repetitive role-modeling and messaging around core principles that help instill and reward open and honest communication in an organization. One of the ways we continue to reaffirm these important messages is through our “60 Seconds for Safety” short video series, which highlights different high reliability and safety principles. Each week, a video from the series is attached to our “Monday Good Catch of the Week” email, delivered throughout our system. The video highlights one important safety message all our associates can become more familiar with, and hopefully apply as they go about their daily work that week. Similar to starting every meeting with a safety moment, we want all of our associates to start each new week with an educational message reminding us that safety is our number one priority. The videos are available on MedStar’s YouTube Channel, under the Quality & Safety playlist. Please feel free to use any of these videos in your own Quality & Safety work — and please share ways you are getting the quality & safety message out to your front line associates.

Not "Not Running a Hospital"

For those interested, I have gradually copied posts related to transparency and Lean process improvement to my other blog (aka, "Not Not Running A Hospital") to serve as an archive and resource to people in hospitals who might want to review the experience at Beth Israel Deaconess Medical Center and other hospitals and apply lessons to their own institutions. 

I've also included stories from training programs I've conducted around the world on this topic.  What a pleasure it has been to meet thoughtful and well-intentioned people in other countries who are interested in enabling their hospitals to become learning organizations.

I just did an update, adding many dozens of posts from the last two years. (You can also search "Lean" and "transparency" here on my main blog and find most of these, but the search engine is not always complete, so you might find the other blog a more useful place to review those posts.)

Hope is on its way

As we consider the imperatives for a health care system that Gene Lindsey espouses, we have to wonder who will get us there.  Clearly it will not be the government, for the government is paralyzed by the conflicting interests of those who seek to extract their share (or more) from the 18% of GDP represented by the health care system.  Legislators and presidents are not very good at resolving what they view as zero sum game.  In that world view, any changes are viewed as what we negotiators call value claiming:  "If I get more you get less." It's hard to build a coalition for change if you view the world in that manner.

While value claiming is part of any set of transactions, the more satisfying part of negotiation is value creation.  Here, we focus on the underlying interests of the parties and satisfy them by engaging in packages of trades that are of low cost to one party and high value to another.  Instead of zero sum, both parties gain.  A coalition for change is created, and blocking coalitions are held off.

Gene's marvelous list is rife with opportunities for value creation.  Look at it again:

1) Care based on continuous healing relationships: Care should be given in many forms not just face-to-face encounters. The system should be responsive 24 hours a day. 
2) Customization based on patient’s needs and values. 
3) The patient as the source of control. Encourage shared decision-making. 
4) Shared knowledge and the free flow of information: Unfettered access to medical records with effective communication between patients and clinicians. 
5) Practice should not vary illogically from clinician to clinician.
6) Safety as a system property.
7) The need for transparency. 
8) Anticipation of need. 
9) Continuous decrease in waste. 
10) Cooperation among clinicians. 

As I have noted:

My view is that inspiration comes from within and is tied to those ethical standards and good intentions that caused people to enter the health care professions in the first place. The leader’s job, then, is not to inspire. It is to use his or her influence to help create a supportive environment that permits the waiting reservoir of such intentions to be tapped.

This kind of leadership has been demonstrated in a number of progressive parts of the industry to date. Who's going to do this on a broader scale?  I'm not sure, but I am carefully watching the growth of several cadres of doctors who believe in the elements in Gene's list and are acting on them.  As one example, I refer to a number of young doctors in CIR (the Committee of Interns and Residents.)  This union, in addition to focusing on the regular economic issues of its members, has placed an emphasis on quality and safety, process improvement, sharing what has been learned, and patient partnership for its members and their hospital workplaces.  These doctors understand that these imperatives are not part of a zero sum transaction, but instead add value to all parties.  I've had a chance to interact with many of them at the Telluride program, but I've also now see many of them in action in their localities.  If this group is indicative of the classes coming up through residency training, we'll be heading the right way.

Indeed, these young doctors go well beyond their workplace in acting to make the world reflect Gene's list.  Here's one example, Kate McCalmont, who wanted New Mexicans to have a better chance of getting health care coverage under the Affordable Care Act. She invented a way to help them. You can see the TV news report here.

Why should our industry expect success?

Several of us are lucky to be on a weekly email message list from Gene Lindsey, former CEO of Atrius Health, the largest multi-specialty group in Massachusetts. Drawing on a variety of life situations, Gene is always able to make connections and comments about the state of our health care system. Although he generally refers to issues in the US, his comments are applicable to other jurisdictions as well. This week, he asks and then answers a question, and then he offers a concise summary of the attributes needed in health care delivery organizations. Let's consider his advice after reviewing two descriptions I have offered elsewhere:

After her fifteen year-old son Lewis Blackman died from a series of preventable medical errors, Helen Haskell diagnosed the problems in the hospital by saying, “This was a system that was operating for its own benefit.” 

What she meant was that each person in the hospital was unthinkingly engaged in a series of tasks that had become disconnected from the underlying purpose of the hospital. They were driven by their inclinations and imperatives rather than by the patient’s needs. Indeed, they were so trapped in that form of work that they could not notice the entreaties of a seriously concerned mother as her son deteriorated.

Or that of a Harvard business professor who described the financial imperatives of many hospitals in a less personalized, but analogous fashion. He called hospitals “business cost structures in search of revenue streams.” 

What he meant was that the business strategies of the hospital had become detached from the humanistic purposes that had led to the creation of the hospital. There was thus a parallel to the individuals’ behavior noticed by Helen.

Gene put it this way:

Why should our industry expect success when we consistently put our own concerns and fears before the needs of our patients? At a minimum, we must align our skills with their problems even if our motivation is pursuing our own interests and financial well being. This is a truth that real service industries take as a given. Many in the traditional professions like medicine, education, law, and even the clergy are beginning to see the need to approach their relationships in a way that is more cognizant of the concerns of their customers who are now armed with enough information to have the courage to push back and ask “why." 

And then he offered the following, taken from Crossing the Quality Chasm:

The Ten Descriptors of A Better Health Care Organization

1)    Care based on continuous healing relationships: Care should be given in many forms not just face-to-face encounters. The system should be responsive 24 hours a day.

2)    Customization based on patient’s needs and values.

3)    The patient as the source of control. Encourage shared decision-making.

4)    Shared knowledge and the free flow of information: Unfettered access to medical records with effective communication between patients and clinicians.

5)    Evidence based decision making. Practice should not vary illogically from clinician to clinician.

6)    Safety as a system property.

7)    The need for transparency.

8)    Anticipation of need.  

9)    Continuous decrease in waste.

10) Cooperation among clinicians.

Medicine for Managers and Entrepreneurs at MIT

I was pleased to be invited by Dr. Richard J. Cohen, Whitaker Professor in Biomedical Engineering, to address a new class he is offering at MIT, called "Medicine for Managers and Entrepreneurs." The goal of the course is to teach a bit about medicine to individuals who have a career interest in starting or managing a biomedical company.  The students in the course are a mix of MBA students and graduate students in various science and engineering departments at MIT.

As always, I promised (threatened?) students who asked good questions or gave good answers that they might end up on this blog.  I don't have room for them all (and, sorry, but some pictures were blurred) but here's Sahar Hashmi,  a soon-to-be Ph.D. and the teaching assistant for the class, who not only had good questions but also had a number of excellent observations about how to bring about change in the health care environment.

And here's Samantha Simmons who is working on a fascinating start-up called Curative Orthopaedics, which designs comfortable orthopedic wear to promote the recovery of broken bones, the healing of musculoskeletal injuries, and the reduction of fibromyalgia pain.

It was privilege to be invited, and I'm sure that the people shown here and their colleagues will make important contributions to the field.

Nominations for the John Q. Sherman Award for Excellence are Now Open

Jim Rattray wrote and asked me to let you know:

Here's your opportunity to spotlight the exceptional work that your organization is doing to advance patient and family engagement! Nominations are now open for the John Q Sherman Award for Excellence in Patient Engagement. Full details are available here. Visit now to review award criteria and to download the official award nomination form.  Standard Register Healthcare in partnership with the National Patient Safety Foundation's Lucian Leape Institute will be conferring an award on one individual and one healthcare organization at the 16th Annual NPSF Congress in Orlando this May. Put yourself, a colleague or your institution in the spotlight!  The website notes:

This year, Standard Register Healthcare is establishing the John Q. Sherman Awards for Excellence in Patient Engagement. The award program is being created to recognize those individuals and healthcare provider institutions that are changing the face of healthcare. 

We want to shine a spotlight on the innovative programs and approaches that are increasing patient and family engagement, and with it, delivering better, safer care and improved outcomes.

The deadline for award submissions is March 28, 2014.

Good luck - hope we see you in Orlando!

MITSS Tweet Chat

Medically Induced Trauma Support Services, Inc. (MITSS) is a non-profit organization whose mission is to support healing and restore hope to patients, families, and clinicians who have been impacted by adverse medical events.  They invite us all to the following:

Join us for a live Tweet Chat on Thursday, February 27th, from 6:30 to 7:30 pm EST

Supporting patients and families following medical harm -- it's the right thing to do, but is healthcare missing the boat?  MITSS held an educational program this past November dealing with this important topic.  Click here, then scroll down if you would like to view the presenters' slides from that program.  For those of you who were able to attend, we'd like to keep the conversation going.  For those who were unable to be there, this is a great opportunity to join in.

Whether you are a patient or family member, clinician and healthcare provider, healthcare administrator, or anyone who has been touched by medical harm, we'd like to hear from you.  Linda Kenney, MITSS's Founder and Executive Director, and Susan LaFarge, PsyD, Clinical Psychologist, will be our guests for this special event.

To participate in the conversation on Twitter, search for the hashtag #mitss, and you may find it helpful to use a tweet chat service like Tweetchat.com or Tweetdeck.com.  As we get closer to the chat date, we will be sending out a list of specific topic items.

So, mark your calendars - Thursday, February 27th, 2014, from 6:30 to 7:30 pm.   We're looking forward to it!

A commendable record in dealing with conflict of interest issues

I received the following message today from Bill Burton, Interim Associate Chancellor for Public Affairs at the University of Illinois, presumably in response to my blog post concerning the propriety of the Dean of Medicine being on the board of Novartis, and specifically my question: How can this person exercise a proper duty of care and loyalty to both institutions, not only in terms of time commitment, but also in terms of the overlapping scientific research and clinical interests of the two organizations?

The following statement is issued on behalf of the University:

"Dean Dimitri Azar has adhered to various policies set out by the University and the state, including a University Policy on Conflicts of Commitment and Interest; a University Code of Conduct; and the Illinois Ethics Act (all online at www.uillinois.edu). Provisions are made within all these policies for active participation by academic staff members in external activities. The University of Illinois views Dean Azar’s service on the Board of Director of Novartis as appropriate, given that the conflict of interest and commitment is well-managed. The UIC leadership and Dean Azar have commendable records of integrity and in dealing with conflict of interest issues associated with external activities."

This is a specially pertinent comment in light of the following excerpt from today's Chicago Tribune story:

Benedetti, the head of surgery, sought advice and permission from Jerry Bauman, interim vice president for health affairs, and Dr. Dimitri Azar, dean of the College of Medicine, according to an Oct. 23 email obtained under the Freedom of Information Act.

"On one side it would be a lot of free publicity for our program, on the other side we could be criticized to be included in an industry generated campaign," Benedetti wrote. The two responded separately that the visibility would be good for the program.

The Chicago Tribune reports on the University of Illinois

Karisa King and Jodi Cohen at the Chicago Tribune have published an excellent story about how some doctors and admininstrators decided to use the name and reputation of the University of Illinois in support of a medical device company.  With access to internal emails, it becomes clear that an explicit decision was made to do so by very high-ranking officials:

Benedetti, the head of surgery, sought advice and permission from Jerry Bauman, interim vice president for health affairs, and Dr. Dimitri Azar, dean of the College of Medicine, according to an Oct. 23 email obtained under the Freedom of Information Act.

"On one side it would be a lot of free publicity for our program, on the other side we could be criticized to be included in an industry generated campaign," Benedetti wrote. The two responded separately that the visibility would be good for the program.

Others apparently had doubts:

After receiving a Jan. 10 email from Benedetti, in which he forwarded the group picture and congratulated the team for the "important recognition," Dr. Bernard Pygon forwarded the email to a colleague and wrote: "Interesting that he calls this recognition — it's an ad for a for profit company."

On the financial front:

The Tribune also found that some doctors pictured in the ad did not initially disclose their financial ties to the company that makes the robot, Intuitive Surgical Inc., as required by the university's policies on conflicts of interest.

But it appears that the lessons have yet to be learned.  Without regard to the facts that might arise from an ongoing investigation of these matters, and without regard to the lack of scientific evidence in support of a statement about medical outcomes, the University does not hesitate in drawing premature conclusions:

Hardy, the university spokesman, said participating in the ad was "a good faith effort" to promote expertise that has "demonstrably beneficial outcomes for patients," but the execution was perhaps not well thought-out.

"In hindsight, the effort could have been better, or perhaps should not have been undertaken at all," Hardy said. "Although the ad may not have violated policy, a decision was made immediately to pull it and to conduct a review of the circumstances involved with the aim of correcting any mistakes that might have occurred."

Zack Berger explains what noncompliance means

Dr. Zackary Sholem Berger offers a pithy definition of patient noncompliance.  Excerpts:

Noncompliance means I think the patient should do it this way and the patient didn’t do it this way. 

“Noncompliance” makes no effort to figure out why the patient did what they did, or what alternatives they might have selected instead.

“Noncompliance’ makes no effort to figure out if the alternative suggested (or: mandated) by the doctor was the best of all possible alternatives in the first place.

She refuses to say "bibbidy-bobbidi-boo"

While the overall goals of the Affordable Care Act are spot on, there are various unintended consequences.  As the Administration tries to fix some of these, others are left standing.  I think what people find frustrating is that there seems to be little transparency about the process and the standards by which some changes are permitted and some are not.  As is often the case, complaints arise not so much because of the decision that is made as the process by which it is made.

An example concerns a request by Massachusetts, summarized in a recent blog post by the Associated Industries of Massachusetts:

Massachusetts employers are living through a twisted version of Cinderella in which the federal fairy Godmother helps everybody but the one who needs to get to the Ball.

The ACA limits to four the rating factors used to calculate small group health insurance premiums, while current Massachusetts law allows for additional consideration of factors such as industry, participation rate, group size, intermediary discount and group purchasing cooperatives.

Governor Deval Patrick requested a rating-factor waiver on September 3, noting that “a waiver of rating factor requirements will avoid increases in health insurance premiums for a large segment of our small-employer population and their employees.” Secretary of Health and Human Services Kathleen Sebelius denied the request on September 26.

A study by health insurance companies indicates that the rating changes have raised or lowered rates for small companies by up to 57 percent, on top of average increases of 3.7 percent in their base insurance premiums.

The federal government has already granted more than 1,200 ACA waivers and made numerous administrative modifications to the law. Except on the rating factor issue.

Helping the underdog

We all like to support the underdog, and Patricia Salber, host of The Doctor Weighs In, gives us a chance.  She writes:

I am trying to support some Hopkins engineering undergrads who are competing in the Qualcomm Tricorder XPrize against the big well-funded guys, like Scanadu:  They are trying to raise a small amount of money (10K) on Indiegogo.  If you could help spread the word, it would be terrific.

Here's her story.

Or you can go directly to the Indiegogo page, here.

25 days to go in Illinois

In 25 days, the president of the University of Illinois is due to receive the report from the Vice President for Research that will evaluate the circumstances surrounding the use of the University's name and reputation in support of a private medical equipment supplier.  Recall that the VP was charged to "conduct a methodical assessment of policies, guidelines, procedures and practices, and where corrective changes are required we will take the appropriate action."

I know how things are sometimes left to the last minute in academia, so I thought I'd offer now some suggested questions that might be answered in this report.

1) Were the individuals in the advertisement told that their images would be used for that purpose?
2) Did they sign a release form clearly delineating that purpose?
3) Was each individual given the opportunity to not appear in the ad?
4) Who was the photographer who took the picture that appeared in the ad and the other pictures that were taken at this time? Was this person a University employee?
5) Where are the images stored? Are they in possession of the University or a private company? If the latter, does it retain the right to use the photographs?

6) The Executive Director of University Relations said: Our request [to ask Intuitive to suspend the ad] was based on a business decision; we were concerned that the ad was not benefiting UI Health. This suggests that someone at the University previously decided that the ad would benefit UI Health. Who was this person? What was the process used to make this business determination? What approval process was used to allow the private company to use the University's name and reputation?  How did the process address--and get an exception from--the specific language from the Campus Administrative Manual:

In general, the University cannot permit its image to be used in any commercial announcement, in a commercial or artistic production, including the World Wide Web or in any other context where endorsement of a product, organization, person, or cause is explicitly or implicitly conveyed.

7) Were there other advertisements, beyond the New York Times ad, of a similar nature?  What were they, and where did they appear?  If so, as above, who was this person who decided that the ads would benefit UI Health? What was the process used to make this business determination and reconcile it with the University's rules and regulations concerning use its name and reputation?

8) What is the full range of compensation and other financial support received by individuals, the department of surgery, or other departments at the University from Intuitive Surgery? Include direct payments; research grants or other support; education grants or other support; donations of equipment and supplies; discounted prices for equipment and supplies; and payments of honoraria, speakers' fees, and travel expenses for appearances by UI faculty at other conferences in the country supported in whole or in part by Intuitive surgery.

9) Is there any advance review of such financial support?  If so, what is the process for such review?  Are all these amounts reported in public reports? If so, where? What is the process to ensure that those reports are accurate and complete? Who is the responsible individual for such matters? Does the Internal Audit office, or another independent office, ever review compliance with these matters?

10) To what extent is the University's emphasis on robotic surgery responsible for the fact that the surgical residency program at UIC is currently under probation by the ACGME, the national accreditation body?

11) How will the report address the issue of the propriety of the Dean of Medicine being on the board of Novartis, specifically: How can this person exercise a proper duty of care and loyalty to both institutions, not only in terms of time commitment, but also in terms of the overlapping scientific research and clinical interests of the two organizations?

12) Has the President made a commitment to release this report publicly to the University community, the state's elected officials, and beyond?  If not, under what grounds would the report be withheld from the public?

Jim Dougherty emphasizes culture as part of the business model

Here's a very nice blog post by entrepreneur Jim Dougherty about the importance of cultural issues in a firm.  He titled it "Company Culture is Part of Your Business Model."  Key point:

Culture, in my mind, is the single most important attribute to successful companies.  Inevitably, when things don’t go well for a company, the culture is what has a lot to say about whether or not you make it.

I think leaders should think of their culture as the first and most important business model that they create.  It is the platform from which the more traditionally thought of business models emerge.  A great culture enhances your ability to create great business models (and execute on them too!)

Tile will find your lost keys, or whatever

Every now and then, a really clever device hits the market.  I just saw this one, Tile.  It is a small plastic square that can be attached or hooked onto something you don't want to lose--keys, computer, backpack, bicycle.  When you need to find the item, your iPhone acts as a homing device--visual and oral.

You can also use the gizmo to report a lost item, at which point everyone else's Tile acts like a detective agency to find it and report back to you.

I guess I missed the launch back in 2013, but this will surely be on my gift list for the future.

Thanks to Carla Berg, at the Society for Participatory Medicine, for writing about this on Facebook.

Here's the video.

An open letter to the Israeli government

Dear friends and colleagues,

With everything else you face, the last thing you needed on your agenda was the financial collapse of the country's major academic medical center, Hadassah (comprising two hospitals in Jerusalem.)  That the disruption in patient care, research, and education--not to mention the financial hardship of the doctors, nurses, and other staff--might have been avoidable is of little solace right now.  It will take weeks of thoughtful negotiations and difficult decisions to sort things out and put the medical center back on a good path.  But rest assured that there is a path to long-term success and restoration of this crown jewel. It will be hard, though, for the environment inside an academic medical center is as complex as any; and the forces impinging on the institution likewise are complex.

It is about one of those forces that I now write.  Recently the head of the Hadassah Women's Zionist Organization of America--the owner of the hospital--started a petition drive in which she states:

Financial problems, largely a result of the crisis in the national health system, have beset the hospitals and have resulted in an operational deficit. 

We call on you all to join with us in raising our voices to guarantee the future of Hadassah and Jerusalem as a beacon of medical excellence.

As of this writing, the petition has 5000+ signatories, many with heartfelt reasons for signing the document.

I understand from colleagues that your government feels this petition as a great source of pressure from the American Jewish community and that this perceived pressure might influence the manner in which you work on this problem.

I'm writing to offer my view that is no such pressure or engagement from the American Jewish community at large. 

Health care issues, in general, are exceedingly complex and multi-faceted.  Most of us in America have trouble understanding even the situation in our own community. To think that a large number of Americans truly understand the issues surrounding Hadassah would be ridiculous.  To think that many American Jews would devote their political capital to trying to influence how you handle this problem is even more silly.  With all of the existential issues facing Israel, to the extent we in America raise concerns, it is about the broader issues of survival, relationships with your neighbors, and relationships with the world community.

As I have stated before, this petition drive by HWZOA is a smokescreen for its own failures as a governing body of this hospital:

That HMO has reached the point it has indicates a failure of governance.  Financial and existential crises do not develop overnight.  The current situation has been years in the making, and the inability of the board to acknowledge the trends in a way that would have enabled countermeasures to be put in place indicates a problem in the structure, focus, activities, and perhaps people on those bodies.

I am appalled and embarrassed that, with all the incredibly serious issues facing the relationship between the United Stares and the State of Israel, HWZOA would tap the political capital of American Jewry to solve a problem that is essentially of its own making.  By conducting this petition drive, HWZOA confirms that it should cede its ownership and control of this organization and let it be owned and operated by the Israelis.

Yes, you have generic issues about the funding of health care in Israel that deserve attention, and, yes, some of those aggravated the situation at Hadassah; but the last thing you should consider is a bailout of Hadassah before there is an agreement on the structural changes needed within the institution--and on its ownership.  HWZOA, as well intentioned and generous as it has been in the past, simply does not have the expertise and ability to own, operate, and govern this institution in a health care environment that has grown increasingly complex.  To the extent it wishes to do so, its attitude reflects a tired and out-of-date colonial viewpoint.  It offers nothing to the institution that Israel cannot achieve with internal ownership.  A severance arrangement is timely, with three major provisions:  A commitment by HWZOA to restore all or a portion of the restricted funds that it spent on operations; a transfer of ownership to a new Israeli entity; and a commitment to retain the Hadassah name as a lasting tribute to its founders.

Follow-up to the white coat issue: Enclothed cognition

A few weeks ago, I wrote that the robotic surgery advertisement acceded to by the University of Illinois in support of a private company made inappropriate use of the image of white coats.  I argued that it did so to bring greater credibility to the advertisement:

The public . . . views that symbol as emblematic of that sacred trust.  We look up to and respect people wearing the white coats.  We know they have devoted themselves to our well-being and have engaged in extensive training for our good.

In this ad, for example, an administrative person was clothed in the white garb along with the medical staff.

This point was greeted with disagreement by some. Maria, for example, said:

It [the white coat] seems to have lost some of its meaning. It's not quite the ordeal it's made out to be when other professions/occupations borrow it.  

I responded:

I disagree, Maria, when it is used by a commercial firm to make an advertisement appear to be full of clinicians in support of their product.

If you think the white coat has no meaning in that setting, why didn't the firm just show this person wearing regular business clothes? I believe they knew exactly what result they were trying to achieve in the public eye. 

But the issue keeps coming up.  In a comment on a new Charles Ornstein column on the UI ethics issues, Joannie writes:

I find it amusing that a hospital executive thinks that only physicians* wear white coats. Must have spent most of his time in his office.

Jdr Inca properly responds:

Yes, that's true. But why would the administrative director don a white coat for the picture? Because the white coats are meant to imply that they are all surgeons (the word used 4 times in the text). The administrative director should be holding a pile of paperwork which proves Intuitive's claim that the higher cost of the Da Vinci surgery is offset by better outcomes and fewer days in the hospital. Except that that claim was not supported by this study http://jama.jamanetwork.com/ar... published in JAMA. The add is deliberately deceptive and UI employees should not have participated in it. Furthermore, the add ran in a publication which is not targeted to medical professionals. It was meant to appeal to patients who might be fooled by the white coats.

As usual in the health care world, we can actually find an academic article on a related topic.  The Journal of Experimental Social Psychology published one called "Enclothed Cognition," which demonstrated the effect that a white coat has on the wearer!

We introduce the term “enclothed cognition” to describe the systematic influence that clothes have on the wearer's psychological processes. 

► We show how clothes systematically influence wearers' psychological processes. ► Three experiments demonstrate that wearing a lab coat increases attention. ► Attention did not increase when the coat was not worn or associated with a painter. ► Attention only increased when the coat was a) worn and b) associated with a doctor. ► The influence of clothes thus depends on wearing them and their symbolic meaning.

If wearing a white coat can have an effect on the psychological processes of the person wearing it, might we extrapolate to the effect it has on an observer?  I am not going to attempt to answer that scientific question here.  I am, however, going to agree with Jdr Inca:

The add is deliberately deceptive and UI employees should not have participated in it. Furthermore, the add ran in a publication which is not targeted to medical professionals. It was meant to appeal to patients who might be fooled by the white coats.

---
* Note: I didn't say "physicians." I said clinicians, which includes all the clinical personnel in the ad.

Lean-ing nicely in Den Bosch

I had a chance today to visit one of my favorite hospitals, Jeroen Bosch Ziekenhuis in the Netherlands, and spend time with a number of managers who have been exploring a wider application of the Lean process improvement philosophy.  Frans van de Laar, who runs the blood and urine laboratory, recently introduced one of the simplest and most effective examples of standard work, a morning huddle with the staff who collect the daily flow of samples from inside an doutside of the hospital.

You see Frans here with the white board, around which the staff huddles each day.  After talking about projected workload and staffing responsibilities, one component of the huddle (seen below) is to identify a problem of the week that the group will attempt to solve or a situation which they will attempt to improve.

Below that item, the group decides on an inspirational slogan for the week.  This week is was: Treat a patient like you would want yourself to be treated.

Frans was pleased to note that the huddle has changed a bit since he introduced it, with comments and suggestions from the staff being the impetus for modifications.  Beyond the more serious changes, there was the addition of this humorous priority item in the huddle summary:  Friday + [pictured] coffee and apple pie with ice cream!

Another item adopted by Frans and his team is this voluntary assignment board for minor tasks that need to be done around the lab.  Items are coded by whether they need to be done monthly, quarterly, half-yearly, or on an ad hoc basis and put in the left-hand slots. When a person has a lapse in regular lab work, s/he can volunteer to do the job.  Once finished, the tag is moved to the right-hand side, with notes documenting when it was completed.

One can imagine the alternative, spending time assigning people and monitoring their compliance with these items, possibly creating resentment at being assigned humdrum tasks.  Instead, people volunteer during their slow work periods and feel a sense of contribution to the team effort.

These two examples demonstrate that Lean is a state of mind and a philosophy:  Small improvements, engaged front-line staff, and a manager who views his/her job as one of empowerment and service to the team.

Equity on WIHI

Madge Kaplan writes:

The next WIHI broadcast — February 13, 2014: Working Toward Health Equity — will take place on Thursday, February 13, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Tessa Kerby, MPH, Manager, Measurement and Organizational Improvement, HealthPartners
• Yvonne Coghill, OBE, Senior Program Lead – Inclusion and Coaching, NHS Leadership Academy
• Dave Johnson, MBA, Regional Clinic Director in Primary Care, HealthPartners Medical Group
• Don Goldmann, MD, Chief Medical and Scientific Officer, Institute for Healthcare Improvement
• Andrew Loehrer, MD, General Surgery Resident, Massachusetts General Hospital
  

In theory, quality improvement has the built-in capacity to reduce health care disparities and bridge gaps in outcomes and in the experience of care across race and ethnicity. After all, if you’re reliably implementing proven and effective care processes for patients suffering a heart attack, or having a stroke, or dealing with depression, or struggling with obesity, shouldn’t these interventions lift all boats? Would that it were that simple. Decades of research on health care disparities continue to point out how entrenched the problems are and how often even the most well-intentioned efforts miss the mark. However, we’re also now learning that where health care equity across race and ethnicity has improved, strategies have been truly pressure-tested and are multi-faceted.

What are some of these strategies, and what kinds of fresh thinking underpin them? Please join the next WIHI on February 13, 2014: Working Toward Health Equity, to hear about progress that’s being made to reduce health disparities in ways that everyone can learn from. At HealthPartners, innovative and deliberate processes are dramatically closing gaps between white patients and patients of color undergoing breast and colorectal cancer screenings. Dr. Andrew Loehrer and colleagues are documenting powerful connections between insurance coverage and more equal access to certain surgeries. Yvonne Coghill and others at the NHS are demonstrating the critical need for a diverse workforce and, as important, making sure that diverse workforce is treated equitably and fairly. This, by any measure, helps ensure that all patients are treated fairly, too.

IHI’s Dr. Don Goldmann will join our conversation to talk about how we move from an era of mountains of crucial and valuable research documenting lack of equity and health care disparities, to one that is solutions-focused and anchored by cultural competency in word and deed. I and all the guests invite you to be part of this important discussion. See you on February 13.

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