On That Day I Left My Boyhood Behind

Susan Burnett, at Imperial College London, writes:

My grandfather, Norman Marshall Woodcock, was called up on the day that war was declared in 1914.  He came home five years later. For fifty years after his return he rarely spoke about what had happened, but he cried each year on Remembrance Sunday.  As he grew old and had time to reflect he began to write, and in time he also began to answer the questions from his grandchildren when we asked him why he was crying.

Susan has now integrated her late grandfather's stories with the historical context, the history of the war in those areas where he was fighting.  The book is called On That Day I Left My Boyhood Behind and is a compelling first-hand account of the Middle East portion of World War I, with a special emphasis on the tragedy and debacle that we now simply call Gallipoli.

I place this book with Emily Mayhew's Wounded on my short list of must-read World War I books (of which there are many in this centennial year.)

Here's one excerpt from Mr. Woodcock's account, as a member of the Signal Corps.  Remember this occurred before the common use of wireless transmitters, so communications across the front were carried out on lines set out and maintained by the Corps:

During one battle the Navy was firing heavy Artillery from the ships anchored offshore towards the Turkish trenches ahead of us . . .

I was in charge of the communications lines that day. One of these lines ran to a Naval observation station, a dugout on the cliff top above W beach where the Lancashire Fusiliers had won five Victoria Crosses for bravery during the landings in April.  The sailors in the observation station sent these messages from the cliff top to the Admiral on the Majestic, anchored below.

Suddenly, a voice rang out "N.O.S. Lineman," that was me, "Line Dis" -- our communication line was disconnected to the Naval observation station, broken, probably damaged by a shell.  I picked up a Field Telephone and hurried out into the heat of the battle to test the line. The fault was not in the vicinity so I ran along the ground looking for where it was broken, falling flat when a shell burst near and hugging the ground to avoid rifle fire. I knew the observation station was the only link between our sea and land forces, so this was important. The line had to be repaired, and quickly.

I couldn't find a break and eventually, panting, I arrived at the observation station. A dreadful sight met my eyes. All eight men were dead. A shell had landed and burst inside the station; it had killed everyone. They were unrecognisable. It was awful. I collected myself as far as I could, and hurriedly connected my telephone, hoping it would still be through to the Signal Office where I had come from.  I held my breath and called.  Yes. To my relief it was in order. Quickly, I described the position, and then a voice came on: "Signal to the flagships. Stop Fleet bombardment. Our ships are firing into our men." I explained I had no signalling flags with me and everything in the dugout was destroyed. The answer: "Find some, it is very urgent, our casualties are mounting."

I thought for a moment as I surveyed the grisly scene, "Where can I get some flags?" and I remembered that further along the cliff was a 60-pounder Battery and they would have some.  I dashed along and explained my need as rapidly as I could to the Battery Commander.  As signallers we wore blue and white armbands wherever we were, and they allowed us to go anywhere without hindrance. The battery was in action and between my panting breaths and the big guns firing he gave an order for the flags to be brought, sending two of his signallers with me, presumably to make sure my story was true.

We set up station by the dugout and I sent the message to the Majestic.  The ships ceased firing and a boat party came ashore. They had gathered something was wrong when the station went quiet. When they saw the dugout there was silence for quite some time.

Then more messages were send describing the scene.  I returned to our Signal Office and learnt that the Navy had decimated our boys with their fire and when the inevitable counterattacks came, were driven off the hill and never recaptured it.

How good ideas get killed

Borrowed from Lucien Engelen on Facebook.  This reminds me of some places I've visited!

How Lean dies

This story was recently related to me about a hospital in which the Lean process improvement philosophy was adopted, with strong support and encouragement by the CEO.  Over several years, it resulted in a significant cultural change in the organization, with resultant improvements in clinical care, employee satisfaction and morale, and finances.

After the CEO left, the board's search consultant interviewed senior clinical leaders and administrators to learn of their hopes with regard to candidates who might serve as the hospital's new leader.  The consistent theme from the senior team was to recruit someone who had a strong commitment to Lean, so the philosophy would continue and be enhanced for the future.

It soon became evident that the search firm had no idea what was being discussed, could not pass along the proper message to the board of trustees search committee, and over time watered down the job description to include typical general language about managing improvement.

As the search continued, the hopes of the senior team were left in abeyance, and a new CEO was brought in with minimal commitment to the Lean philosophy.  While the philosophy stayed in place for a while, without top leadership encouragement and engagement it gradually fell into disuse.  Undoing years of progress, Lean remained mainly in the memories of those who had enjoyed the benefits it had brought for the community.

Up to date in Kansas

Melissa Clarkson, from Kansas, is the relative a patient who suffered serious harm from a series of medical errors, and she writes an occasional blog on her observations.  In this piece, she relates the story of attending a Summit on Quality in Wichita, sponsored by the Kansas Healthcare Collaborative (which is an organization formed by the Kansas Medical Society and Kansas Hospital Association).

While expressing appreciation for the success stories presented in the conference, she raised some doubts.  First, she noticed a paucity of negative reports, ones that would indicate the potential for learning.

I . . . wish that the presenters went a little deeper and talked about times when mistakes were made, when things went wrong, and when patients were harmed. I realize that these are uncomfortable topics, but cheering for successes is not enough. The failures and breakdowns have to be seriously discussed. Not only is there is a great deal to learn from these incidents, but there is value in simply seeing examples of healthcare professionals talking about patient harm.

Patient harm is as real as the successes that were celebrated. I encourage KHC to consider how both can be discussed.

Second, she observed, "There was much talk at the meeting about patient-centered initiatives. But at this meeting the patient’s voice was not only not at the center, it seemed to be completely absent."

I later had a chance to view the slide show presented by the CEO and CNO at the University of Kansas Hospital. There is much positive to be said about the progress of the institution, but--perhaps because of my recent blog post about Magnet hospitals--I was struck by the level of hype about this one's Magnet recognition and also its rankings in US News and World Report.

Every single slide in the 52-slide presentation was framed with emblems from these two organizations. Here's an example:

And here's one that reeks of non-substantive self-congratulation:

Why a hospital would choose to place such emphasis on designations like these when it has so much good to report is beyond me.  I guess it is a statement of the degree to which both Magnet and US News have inserted themselves into the marketing mindset of US hospitals.

The vultures are at work

Two articles in the Boston Globe set forth the view that Gary Gottlieb's leaving Partners Healthcare System was seen "as a way to ease the pain" of the controversy surrounding the big health system as "regulators grew increasingly hostile toward Partners’ desire to expand, tens of millions of dollars in losses piled up at a new in-house health insurance arm, and some doctors and hospitals bristled at a push to standardize clinical practices."

This is typical after-he-left kind of nitpicking in academic medicine.  The comments in the article may or may not have something to do with the real reasons Gary is leaving.  More accurately, each constituency within the organization is now using the Globe, trying to influence the board to pick someone who will protect their interests. 

Overall, to say Partners faced a string of setbacks is ridiculous when we look at the big picture.  They continued in their market dominance and got the state legislature and the AG, both, to accede to laws and rules that will maintain that dominance for years to come.

But whether or not the comments are true, their publication validates my assertions that the board is going to be very timid about bringing in a change agent at this point.  This is a board that does not like to take chances of getting splash-back from the faculty or other inside players in town.  They will hire a low-risk, steady-as-you-go kind of person.  Welcome to the General Motors of twenty years ago.

Who comes after Gary? It doesn't matter.

Boston is abuzz with speculation as to who will be chosen to succeed Gary Gottlieb as he steps down from the helm of Partners Healthcare System.  WBUR's Martha Bebinger notes:

Several internal candidates are being suggested to succeed Gottlieb including Mass. General CEO Dr. Peter Slavin, Brigham and Women’s President Dr. Betsy Nabel and Dr. David Torchiana, CEO of the Mass General Physician’s Organization. Dr. Tom Lee, who left Partners last year, and Dr. Mike Jellinek, who moved from Partners to Lahey Health earlier this year, have also been mentioned as possible candidates.

The answer, sadly, whether it is an internal or external candidate, is that it won't matter much.  If there was ever an example of "a cost structure in search of revenue streams," Partners is one. As I have noted:

No matter how innovative or entrepreneurial a firm might have been at its start, once it is has been in existence for some time and has an established place in the social economy, its goal in life is to persist.  It leaves the world of innovation, often loses its purpose, and exists solely to exist, i.e., to cover its costs.  Often this is a reflection of the corporate hierarchy, where, sadly, leaders lose their sense of providing true value to their customers, intent instead on aggrandizing their own position and preserving their status.  The firm no longer reflects the creativity of risk-taking, becoming a bureaucratic shell of its former glory.

Especially so when the firm has a dominant market position, aided and abetted by government policy, insurance company timidity, and an apathetic business community.

Perhaps change could come from within, but there is little or no interest in change from the faculty within the large academic medical centers at Partners' flagships, Massachusetts General Hospital and Brigham and Women's Hospital.  They are basically content with their exalted status in the world of clinical care, education, and research.  Their clinical practices are fed by an extensive network of primary care physicians and community hospitals.  Their position vis-a-vis undergraduate education at Harvard Medical School and graduate medical education in their fields is secure.  Their laboratories are amply supported by grant funding and/or departmental support from their hospitals.

So, if you are on the board of trustees of Partners searching for a successor, you do not seek an agent of change.  You seek another person who will maintain the status quo with regard to market dominance, finances, faculty relations, and state politics.

The only way this organization will diverge from the path it has maintained is if there is decisive action that forces structural change, that recognizes that the current structure is harmful to the state economy, slow moving with regard to advancement of clinical expertise that would reduce harm to patients, and inimical to the advances that would come from real competition.  Such action would have to come from the government, the insurers, or the business community--or better yet, all of them together.  Until or unless it does, expect a clone to be appointed as the next CEO.

Magnetic forces

A blog post I wrote in 2012 about the quality assertions of the Magnet recognition program developed by the American Nurses Credentialing Center raised the hackles of some close friends and colleagues.  My point, back then, was this:

So, here's the question:  With all that it takes to receive Magnet® status, and with all the assertions by the ANCC about the superior nature of Magnetized institutions, what peer-reviewed data exist that support the assertion that such hospitals do in fact deliver higher quality patient care than the non-Magnetic hospitals?

What prompts me to raise the issue again is a double-full-page ad in the Sunday New York Times. The prominent quote:

Health care organizations that receive the prestigious accolade have proven that they excel at providing high-quality nursing. Magnet-recognized hospitals have improved patient outcomes and satisfaction and attract highly talent nurses, physicians and other health care providers. The designation is widely considered the gold standard of patient care.

Here's the underlying issue, concisely summarized back in 2012 by a commenter, Dr. James O'Brien:

In addition to the financial costs of completing the application and review process for this and other such awards, there is a tremendous opportunity cost. I have assisted some of the nursing committees who spend considerably time completing the application and review process. I wonder what the results might have been had this time been devoted to direct quality improvement. Additionally, if an institutions chooses to prioritize these applications and yet does not appear to provide the same resources and time to direct quality improvement, it sends a clear message to its employees about the true priorities of the organization.

Regarding the issues of the predominant association between such designations and outcome - this would be an easier inference to make if there was a transparent reporting of the data. Ultimately, the costs of these applications must be paid for by health care dollars - therefore, they should have some semblance of cost-effectiveness - with an assessment that includes the man-hour costs of the application and review process.

I almost hesitate to say so, but the kind of claims placed in the Magnet ad remind me of other New York Times ads, those promoting robotic surgery.  There, too, assertions about the relative benefit of that surgical approach have no documented support and appear to be designed mainly to serve as marketing vehicles for the hospitals mentioned.

Who rounds 2.4 up to 3? Who reports 14 as 29?

Martha Coakley either will or will not be Governor-elect on November 10, but she will still be the incumbent Attorney General when the Court takes up arguments that day on her proposed deal with Partners Healthcare System.

Much has been said about the supposed cost advantages that will result from giving PHS the right to add new hospitals to its already dominant market presence.  The Attorney General has remarkably ignored her own research over the years that demonstrates the excessive rates received by this system because of its substantial market power.  Notably, she dismissed those findings in her proposed settlement, saying those factors were not relevant to the complaint she had filed against PHS.

But I wonder if she and her staff have kept up to date with another set of claims made by PHS with regard to its ability to achieve cost savings.  It's all there in the public record, but let me summarize here in case these items have not made it to the McCormack state office building.

There were five Massachusetts health systems that opted to participate in the Pioneer ACO program run by CMS, the Medicare agency.  The idea was that managing care across the continuum (i.e., practicing population health management) and putting the provider groups at a certain amount of risk would bring about higher quality care and lower costs.

How did Partners do compared to the other Massachusetts P-ACO health systems in the first year?  Just fair.  According to this report from CMS, PHS came in third place in terms of achieved savings:

BIDCO:  4.2%
MACAIPA:  3.4%
PHS:  2.4%
Steward:  1.1%
Atrius:  -1.0%

Remarkably, Partners' press release describing these results says the following:

During the first year of the initiative, Partners HealthCare was successful in slowing the rate of cost growth by approximately 3% as compared with the reference trend that Medicare used to measure Partners’ performance.

Hmm, 2.4% somehow got rounded up to "approximately 3%."

Here's how all of us learned how to do rounding:

So, 2.4% should actually be described as "approximately 2%."

The July 2013 press release also says:

This translates into approximately $14.4 million in shared savings that Partners will receive from Medicare. 

Remember that number.

Now look.  In the company's January 2014 filing to the Health Policy Commission justifying one the mergers, on page four, it repeats the 3% and then goes further:

During its first year as a Pioneer ACO, Partners slowed the rate of cost growth by approximately 3% over CMS's reference trend, translating to nearly $29 million to be shared with Medicare.

Now $14 million has more than doubled, to $29 million.

I can't find any rule for rounding that suggests that kind of exaggeration.

Let's go further and see how PHS stacked up against the others over two years of the program:

Partners ranked 3^rd in Year 1, worst in Year 2, and 4^th over both years combined.

Well, how did PHS describe these results?

Strangely, while Partners proudly announced its results from Year 1, it issued no statement that I could find about its Year 2 performance.

Given these actual results, why would we expect any likelihood of any savings (let alone any savings that get funneled back to payers and consumers) from Partners taking over more hospitals?

Given the looseness with which Partners presents the "facts," how can we be assured that future Attorneys General or the state Court will be able to accurately monitor PHS cost and rate increases and enforce the terms of the settlement deal?

Please, Attorney General Coakley, withdraw your deal with Partners and let your successor revisit the issue.

Please, Attorney General candidates, call upon the incumbent to do so--before Election Day.

---

Addendum at about 9pm.  I just received the following email and post it for your consideration, with thanks to the sender:

I agree that reporting of 2.4% as 3% is inappropriate, but I think the differences in the 14 and 29 are due to reporting the shared savings with Medicare in two different ways.

From your post:

"translating to nearly $29 million to be shared with Medicare."

"This translates into approximately $14.4 million in shared savings that Partners will receive from Medicare. "

So it seems Partners has stated this accurately, although confusingly. The first quote references the total amount of savings before the split with Medicare and the second just refers to the amount Partners will receive.

This sounds like a plausible explanation to me.  If true, then we should perhaps just ask why the company chose to utilize the lower number in one place while emphasizing the higher number in the later HPC document trying to justify the merger.

And the point about substandard performance over two years compared to the other P-ACOs remains.

---

Additional addendum added at about 9pm the next day, repeating a comment posted below:

I'm not sure I see the $29 million anywhere. The CMS website shows $14.4 total, $7.2 is Partners share.

I think the $29 million is incorrect. 

Still using horses and buggies

I recently had to reschedule a routine exam with my hospital-based primary care doctor and so decided to use the supposed rescheduling functionality on the patient portal to carry out this task. 

The appointment was scheduled for September 23, and I sent in a cancellation request on September 14, along with a note suggesting possible substitute dates two weeks hence.

There was no reply.  I later learned that the message was not opened until October 15.

Message Date/Time: 10/15/2014 11:23 AM Subject: We are working on your request

---

We have received your request. We are working on it.

A minute later, a second reply came back:

Sorry taking so long to get back to you but your appt is on Tuesday 1/27/15 at 10:40am.

I replied that I would be out of town on that date, adding:

Instead of just choosing a date, why don't you offer some possible openings, and I'll let you know which would work?

The reply:

The reason why I couldn't just offer some possible openings is because appts go very fast. You can pick which days and times works best for you and we will try our best to fit you in on those slots. Pls email me back and let me know what works for you and I will schedule it.

By this point, I knew things would be hopeless if we continued writing each other:

Why don't I call so we don't go back and forth on email?

Now, compare that with my experience setting up a routine exam for my Subaru.  I go to the website and a full calendar for several months is presented, showing where there are openings for my particular kind of appointment.

I can even tell them if I want to wait for the work to be done, borrow a car, or get a ride somewhere.  I flip through the calendar, make my choice, and a confirmation arrives instantaneously--along with a button to push if I need to make a change.

I know there are subtleties that sometimes require personal attention when making medical appointments, but many appointments require no human intervention from the doctor's office.  It is frustrating to think that it is easier for me to schedule a routine car service event than a routine physical exam.  It is also a waste of human resources in a cost-constrained health care environment.  For all I know, my doctor was left with an unfilled appointment back in September.  Perhaps another patient with an urgent need could have seen the doctor during that block of time.  It makes me think that some hospitals have a long way to go before they get out of the horse and buggy era.

Return from South Africa

You’ve already read some health care stories from my recent trip to South Africa, but now please permit me some general summations of other things I learned.

I imagine I am somewhat typical of my generation in the United States, in terms of my limited understanding of the recent history of the country.  Many of us felt tremendous admiration for Nelson Mandela and his colleagues after the multi-year struggle against Apartheid, but it was difficult from afar to understand the brutality of the regime under which that social, economic, and legal policy was enforced.

Apartheid was not just white domination of blacks, although that was harsh enough.  The legal system at the time also deprived other non-whites, i.e., “colored” people, of their rights.  Among other insults, the government produced the Group Areas Act, permitting the government to forcibly relocate over 150,000 black and colored people from their Cape Town homes.

One area so affected was District Six, home to some 60,000 colored people.  In 1966, District Six was declared a “white” group area, and over the next 15 years, this vibrant, mixed neighborhood in the middle of the city was systematically razed, forcing the residents to move to new depressing and physically inadequate townships on the outskirts of the city.  (Some of the streets on the Cape Flats, cynically, were named for those destroyed in District Six.)

At the District Six Museum, there is a heartfelt story that captures the loss to this community:

Let us not let the topic of this story minimize the human hardship.  Rather, it is precisely its elegant simplicity that gives a hint of the sadness of the time and the inhumanity of the regime.  Here is a portion of the 300 meter long memory cloth on which former residents of the District have written their testimonials:

At a visit to the prison on Robben Island, we heard from this gentleman, who had been brought to the island as a 25-year old political prisoner in 1981.  Upon arrival, he was intent on meeting “the old men,” Mandela and the others who had already been imprisoned for many years.  He eventually succeeded in entering their cell block and upon meeting Mandela asked, “So what are we accomplishing by being locked up here?”

Mandela replied, in essence, “It is all part of our plan.  The day will come when the power of our cause and the pressure of our allies around the world will force the government to accede.”

It took many years before that was to take place.  Mandela was finally freed in 1990 after 27 years in prison.

I asked the gentleman, “So, was Mandela really seen by all of you as the leader, or is that just a mythical impression we get from abroad?”

“Oh no,” he replied.  “He was the acknowledged leader, a man of great character, modesty, and kindness.  He had the respect of all here, prisoners and guards alike.”

Year later, when Apartheid was ended, Mandela visited the judge who had sentenced him to life imprisonment at Robben Island.  The judge described him as “a saintly man.”

Many topics I cover on this blog rise or fall on the issue of leadership. Whether or not Mandela should be described as “saintly” is not the point.   He was, after all, a human being with his own flaws.  But by any measure, he was an extraordinary leader.  How many of us would have the patience and perspective to say, while sentenced to life imprisonment, “It is all part of our plan?”

People of this stature come along very infrequently.  Gandhi, King, Mandela.  While they hope to succeed in their cause, they also are prepared to give their lives in the knowledge that they have moved events forward. 

I don’t know if any of them read the Pirkei Avot, teachings of Jewish sages of old.  There is one lesson that seems to apply to their struggles:

You are not obligated to complete the work, but neither are you free to desist from it.

Dear health care folks, I don’t mean to equate what we do with what these great people experienced. However, those of you who are involved in trying to save the hundreds of thousands of people preventably killed and harmed in hospitals every year may feel great frustration at the slow pace of your work.  And, while we don’t risk our own lives in our daily work, we do often face the calumny of our colleagues and the disrespect or disengagement of those whose attention is placed instead on the business aspects of the profession. Apathy often reigns, too, within the profession and among the public.

So whether you are in South Africa, the US, or elsewhere, when you feel it is just too hard to remain passionate about your cause, please be assured that your leadership makes a difference.  Again, please remember:

You are not obligated to complete the work, but neither are you free to desist from it.

View from above

Some final thoughts from South Africa.  The picture above from Kruger National Park is just to get your attention!

Here's the more serious photo from the Best Care Always quality summit last week.  Thabiso Bale (right), soon to earn his masters degree in nursing, was chosen to present a poster during the conference.  You see him here with Gary Kantor, BCA co-founder and Discovery Health advisor, going over his findings.

The findings were troubling and an indication of the kinds of issues facing hospitals worldwide as they seek to infuse medical treatment with a higher level of quality and safety.  Thabiso's preliminary topic was to evaluate nurses' understanding of the VAP bundle (designed to reduce the incidence of ventilator associated pneumonia for patients in ICUs.)  Not surprisingly, there were differences among the nurses that correlated to their years of experience.  The hope, though, would be that the VAP protocol would be uniformly understood and applied regardless of tenure.

More seriously, Thabiso documented that the rate of pneumonia did not correlate to the reported adherence to the VAP bundle in the ICUs.  In other words, the staff's documentation that they had carried out the bundle was inaccurate.

In my view, this kind of result is indicative of not only incomplete understanding but also incomplete buy-in by the clinical staff.  Ultimately this is derivative of a lack of leadership from "on high" in the organization.  Such a phenonemon does not only occur in Africa.  I have seen examples throughout the world, including the US.

In a comment to the post below, my regular correspondent "nonlocal MD" noted the poor safety record of some hospitals in Texas:

Interesting concept, and I am not at all surprised about Texas. It again raises the question that you and I debate, Paul - will hospitals do the right thing of their own accord or is it necessary to demand accountability from an outside source? And when you answer with the word 'leadership', I ask then, how will we find those leaders? They seem to be in short supply. 

One answer has been given by my colleague Dave Mayer, head of quality and safety at Medstar Health, who jokingly responds: "Educate the young . . .  and (when necesaary) regulate the old."

Humor aside, Dave may have the right thought.  While trying to infuse quality and safety training into the curriculum of young doctors and nurses, there is likely a need for oversight from regulators or other outside bodies--if for no other reason, than to get the attention of the senior admininstrative and clinical leadership.  That being said, unless those senior leaders truly believe in the need for process improvement and act on that belief every day, the horrendous status quo with regard to unnecessary deaths and harm documented by Michael Millenson will continue.

A new look at "safe seats"

Michael Millenson, President, Health Quality Advisors, writes:

 

Working with data analytics colleagues, I've produced a report on safest Congressional districts looking not at political safety (whose seat is secure) but the physical safety of constituents getting care at hospitals in that district. 

We used 20 different measures to rank each district, seven of which were measures of infection control or prevention and divided districts into good, fair and poor. Using the most conservative and evidence-based estimates, we translated those results to the political environment. We found that 59 House districts were less safe than the norm and 114 districts were safer, with measurable consequences. (I also took a look at the home districts of Obama, Biden, McConnell and Reid, plus House leadership.)

In each Congressional district ranked “poor” on safety, preventable medical errors cause an average of 553 deaths and 4,148 injuries annually; in “fair” districts, the average toll of preventable harm is 469 deaths and 3,518 injuries each year; and in “good” districts, preventable errors cause an average of 385 deaths and 2,888 injuries each year. Put differently, on average 14 more individuals die every month and 105 are injured in hospitals in districts rated “poor” on safety than in those rated “good.” Even in “good” districts, however, at least one individual dies unnecessarily every day and another eight are harmed. We also looked at Republican versus Democrat: when it comes to patient safety, there is no red America or blue America, only the United States of America: there was no difference between the parties.

You can look at the report, and your district, at www.safedistricts.com.

Separately, as you may know, there's an infection that kills up to one in five of those who contract it, costs the nation billions of dollars to treat. And yet the CDC thinks hospitals can take more than a decade to dramatically reduce it, even though a paper in the NEJM by Peter Pronovost showed what to do back in 2006. Did laxity by the Centers for Disease Control and Prevention in eliminating central-line associated bloodstream infections (CLABSIs), which are caused by hospitals, leave the way open for infection control lapses that are hurting the Ebola fight?

See my analysis at Forbes.com: http://t.co/3a7Ao7vbG3. Retweeting appreciated.

Oh: the Congressional district in which Texas Health Presbyterian Hospital is located scored "poor." In addition, the only two districts of 436 (including DC) we could not rate, because their hospitals did not report enough information, were in Texas.

Both of these, by the way, are anchored in the medical literature, although the blog post has links, not footnotes. :-)

Hope you find this useful in your own good works.

Rainbow nation

"Rainbow nation" was the term coined by Archbishop Desmond Tutu to describe post-apartheid South Africa, after the country's first fully democratic election in 1994.  I was privileged to participate with a number of people this past week who ably represent the hopes and dreams of the country in trying to improve its health care system. They came from all parts of the country, included a variety of clinical and administrative specialties, and represented all racial and ethnic backgrounds.  Best Care Always was the predominant theme of the conference held by the Hospital Association of South Africa, with support from Discovery Health (the country's major private insurance funder), the country's private hospital firms, and various other organizations involved in clinical care, medical education, and health care policy.

And how fitting to receive the above going-away gift as I drove along the highway after leaving this exemplary meeting!

New word: "maieutikos"

Among the joys of teaching Lean process improvement with people like the Lean Institute Africa's Norman Faull are the unexpected language lessons. Today at a Best Care Always workshop in Johannesburg, Norman posted the slide seen above.

Maieutikos?

I'll let you read the slide to get the meaning and context.  Your homework assignment is to now use it in a sentence during the next 24 hours!

Beyond that item, Norman related a conversation he once had with John Shook, of the Lean Enterprise Institute.  John speaks Japanese and Norman was confirming with him that gemba means the place (e.g., the factory floor) where work is done and value is created for the consumer.

John said, that while true, in Japan gemba is often used to mean "crime scene."  In that sense, going to gemba is equivalent to investigating the crime, trying to put the pattern together.  Think of Columbo, the TV detective, visiting a crime scene and slowly and persistently teasing out the evidence to find the guilty party.

Your Lean task, in going to gemba, is to discern the pattern of evidence about a flawed production or service process.  You then divine from that investigation possible experiments that will help solve the riddle of your next step of process improvement.

For want of a nail . . . the battle was lost

The Health Minister of South Africa, Dr. Aaron Motsoaledi joined the HASA and Best Care . . . Always quality improvement summit and gave a thoughtful overview of the challenges facing this country. Hearing one of his remarks took me back to a public hospital visit I made earlier in the week.

Here was his comment:

We have an extremely under-resourced public health care system that is serving 78% of the population, struggling to meet quality standards.

You may recall my praise for the work of several staff members at Charlotte Maxeke Johannesburg Academic Hospital.  Their focus has been on reducing ventilator associated pneumonia in the neuro-ICU.

One aspect of the VAP bundle implemented by Phindi and her staff is too enage in "closed suctioning" of the ventilator to remove biological material in which infections can breed.  This is accomplished with the kind of apparatus seen here.  It simply attaches to a port on the tracheal ventilator tube.

If the closed suction equipment is not used, an "open suction" approach is used, which requires removal of portions of the ventilator.  While the literature suggests that both approaches are equally efficiacious, experience in this hosptial suggests otherwise.  Simply put, in this hospital's environment, it is difficult to respect general precautions in the sanitary-epidemiological regime and barrier nursing techniques.

Accordingly, the staff at Charlotte Maxeke hospital have concluded that the closed suction approach is preferable.

Here's the rub.  A closed suction device of the sort shown above costs 150 rand (about $15).  After a certain amount of time during the budget year, the hospital runs out of them and cannot afford to buy more.  The rate of VAP seen by Phindi and her staff correspondingly rises.  This is the case notwithstanding that the avoidance of VAP brings financial benefits to the hospital well in excess of that price (reduced length of stay, avoiding antibiotics, and so on)--but the budget decisions for these supplies are centralized in a purchasing agency that is subject to other pressures.

So here's a concrete example of Dr. Motsoaledi's remark, "an extremely under-resourced public health care system . . . struggling to meet quality standards."

--

My headline reference quotes Benjamin Franklin:

For the want of a nail the shoe was lost,
For the want of a shoe the horse was lost,
For the want of a horse the rider was lost,
For the want of a rider the battle was lost,
For the want of a battle the kingdom was lost,
And all for the want of a horseshoe-nail.

I felt like I was back home

While I made presentation at a quality summit sponsored by Discovery Health, as usual I learned more than I imparted.  The similarities between the South Africa health care environment and that of the US are remarkable.

Jonathan Broomberg, Discovery CEO, led off with a description of the challenges facing the South African private health care system (which operates in parallel to the public system).  He noted that medical costs are growing at a rate exceeding overall inflation; that there is a rising burden of noncommunicable (i.e, lifestyle) diseases; and that there is high variability in the quality and value of care to patients.

Later, he provided examples of this variability. Looking at the treatment data from 139 hospitals, Discovery has found that in-patient (case-mix adjusted) antibiotic defined daily dosages vary from 39 to 177 per 100 bed days.  There is also a significant variation in the cost of end-of-life care among the country's regions.

Jonny noted that medical inflation costs are not largely driven by the units costs of care.  Rather it is the growing volume of services that is the critical cost driver.  He noted that insurance premiums rose at an average rate of 11.5% between 2009 and 2013.  Of that, 7.05% (or just 0.3% above inflation) was attributable to tariff increases, but 4.5% was attributable to utilization.

The supply-side drivers, he posited, are a fee-for-service physician payment environment; fragmentation of care along the spectrum of care; the construction of new hospitals; and new technologies and procedures.  He singled out the use of the daVinci surgical robot, noting its increased cost over traditional prostate removal techniques.  "It takes the premiums from 10,000 healthy members to fund 400 prostate cases" using the surgical robot, he noted.

Demand-side drivers come from an aging population; an increased disease burden; and adverse selection. The last item occurs because there is no individual mandate for insurance coverage.  Therefore, a large percentage of young adults between age 20 and 30 choose not to buy insurance--until or unless they need it.  If insurance were mandatory, premiums could be reduced by 15%, he pointed out.

Jonny summarized that a sustainable solution requires an equilibrium with no trade-offs among access, quality, and costs, but that a key aspect of the solution must be an effort to educate and empower patients.  Even among the well educated and relatively prosperous South Africans who purchase private medical insurance, there is virtually complete disempowerment in clinical settings.

After I presented a complementary talk on reduction of harm in hospitals and approaches to process improvement, a panel discussion ensued with representatives from a number of health care sectors, including two of the large private hospital chains (left).  There was remarkable consensus among the panelists as they riffed off of the earlier themes and addressed the questions posed by the moderator (below).

As I listened to it all, the conversation seemed quite similar to those I have heard in the US over the last decade: Well-intentioned people who understand they have a high degree of interdependency.  As in the US, the question will be whether the various stakeholders will decide that their differences separate them or or whether those differences offer the potential for trades that satisfy individual corporate and sectoral interests and create value for society as a whole.

Not so different after all

I'm so pleased to be in Johnannesburg to present some sessions in association with the Hospital Association of South Africa at a quality improvement summit hosted by Best Care . . . Always!

As summarized on their website:

BCA campaign supports South(ern) African healthcare organisations as they implement specific, internationally recognised, evidence-based interventions that enhance patient safety and constitute current best practice in hospital care. BCA is inclusive and enrolls hospitals from both private and public sectors. There is no fee to join. Participating hospitals should be willing to make evidence-based changes at a faster pace, share ideas with others, measure results and report on progress.

In preparation for the event, I had a chance to tour two local hospitals, Wits Donald Gordon Medical Center and Charlotte Maxeke Johannesburg Academic Hospital.  They are just this far apart, 1.2 kilometers, physically:

But institutionally, they exemplify different worlds, as Gordon is a private hospital with under 200 beds, running profitably with payments from individuals and private insurance companies. Under national law, the doctors are not permitted to be employees of the hospital.  Maxeke is a large public tertiary hospital with over 1000 beds and 4000 admissions per month, with tight finances supported by government funding. The doctors are public employees.

But I discovered a hidden commonality between the two places.  First I met these two women at Gordon, Winnie and Ronel. They are part of a cadre of folks who have implemented quality and safety protocols, training, and documentation in several wards and units in the hospital.  They have focused on reducing the incidence of central line infections, ventilator associated pneumonia, catheter-associated urinary tract infections, and other such issues.  Although they are quick to point out they still have a lot of room for improvement, the results are clearly showing.

The team employs a "Welsh cross" as a visual cue to their staff as to progress.  Every month, the cross is posted in a highly visible location showing on which days an infection has occurred.  (In this case, for example, there was one blood stream infection on August 24, and 2 respiratory tract infections on August 12 and 14, and one other infection on August 25.)   The cross acts as a reminder of the need to be vigilant but is also a way to provide positive feedback to the staff about the efficacy of their actions.  The women noted, "We're not satisfied unless every day is green!"

Meanwhile, less than two kilometers away in the Maxeke public hospital, these two women work.  They are Constance and Phindi.  They, too, have started a program in quality improvement, focusing first on reducing VAP in the neuro-intensive care unit.  Following the same bundle of care used at Gordon, there has been a substantial reduction in pneumonia cases.  And, lo and behold, look at what's posted on the wall of their ICU! The women noted, "We're not satisfied unless every day is green!"

Coincidence? Well, no, because BCA has been holding training sessions for hospital folks--public and private--across the country. They offer advice on protocols, staff training, and the kind of institutional infrastructure and tools need to support patient quality and safety programs.

But these four women have never met one another.  While they are separated by a short distance, they live in two different worlds of patient care.  Yet, in a way, if they traded places tomorrow, they would all feel at home with the sense of purpose and passion inherent in their clinical improvement work.

Maura Healey bobs and weaves off the court, while John Miller takes a shot

Maura Healey is a thoughtful and serious candidate for Massachusetts Attorney General, offering years of legal experience.  One thing she likes to mention is that part of her biography includes a stint as a point guard on a professional basketball team.

Well, there's a problem when a candidate brings her sports abilities to a serious economic and legal issue.  Watch this performance at a recent debate at Stonehill College (from minutes 13:50 to 21:20.)

Under direct questions from one of the reporters, Republican candidate John Miller gives a direct answer: No, he does not believe the deal between the incumbent AG and Partners Healthcare System should be approved.  He offers a cogent legal theory in support of his answer.

Healey, in contrast, offers no answer to the questions, and instead bobs and weaves all around the issue.  She then says she doesn't have enough information to have an opinion on the matter.  That is hard to fathom given this summary from the same biography:

For seven years, Maura helped lead the Attorney General’s Office, ultimately overseeing more than half of the office’s 500 employees. She began as Chief of the Civil Rights Division and went on to direct two of the office’s most prominent divisions: the Public Protection & Advocacy Bureau and the Business & Labor Bureau. She knows firsthand how important the Attorney General's work is for Massachusetts families and businesses. 

What's in the Public Protection & Advocacy Bureau?  Here's the summary from the state government website:

The Public Protection and Advocacy Bureau uses investigation, litigation, and other advocacy to enforce laws protecting the Commonwealth. The Bureau works towards meaningful economic recovery for Massachusetts by tackling the economic and mortgage foreclosure crisis with a multifaceted and aggressive strategy. The Bureau works to protect consumers from unfair and deception activity, enforces state and federal civil rights laws, ensuring access and equal opportunity for all residents, advocates for protection of our environmental resources, pursues complex insurance and finance cases on behalf of residents or government entities, works towards affordable, high-quality health care for all, and enforces antitrust laws.  The Bureau is supported by a team of skilled civil investigators.

Divisions within the Public Protection and Advocacy Bureau include: 

• Consumer Protection Division
• Civil Rights Division
• Environmental Protection Division
• Health Care Division
• Insurance and Financial Services Division
• Antitrust Division

Oh, health care and antitrust, with consumer protection thrown in for good measure.

It is a sad state of affairs when such an able person--who had policy oversight of these divisions for an extended period of time--feels she can not offer a direct answer about the most important health care and economic case pending before the Court.

But perhaps we should believe her.  If Healey really feels she doesn't know enough to have an opinion on the matter, she should immediately ask the incumbent AG to request a delay of the proceeding from the scheduled November 10 session to sometime after the inauguration of the new AG in January.  Maybe, by then, she would have time to form an opinion on the case.

Lazarus lives again in Massachusetts, but at what cost?

There was a lot of coverage last year about the glitches and extra costs associated with the federal government's health care exchange website.  Must less was said about the problems faced by Massachusetts in its execution of the state portal.  In fact, Trudy Lieberman at the Columbia Journalism Review wrote an article about the paucity of local coverage of this issue.

Much of the public exposure on the delays and cost overruns has been produced by a local policy think tank, the Pioneer Institute.  It has assiduously outlined flaws in the project management and has provided the press and the public with material that raised serious questions about the competence of the state administration in this arena.

Bruce Mohl at Commonwealth Magazine offers an excellent summary of the issue here.  The Governor's folks are claiming that the costs are one number, but Pioneer folks remind him that it is not right to leave out the additional federal costs associated with the mess-up.  As Mohl writes:

Stergios urged the Patrick administration not to focus just on the state costs associated with the failed website but to also incorporate federal expenses into the mix, just as officials did with cost overruns on the Big Dig.

"The media and public did not divide that important project's costs into 'the state share' and 'the federal share.' The case of the Health Connector should be viewed through the same big picture lens, especially since the Commonwealth could easily have opted to join healthcare.gov at little or no cost to the state, or to stick with a somewhat modified version of the original website, which was working well pre-Affordable Care Act," Stergios wrote. 

Mohl's piece is well worth reading in its entirety, from the starting sentence on:

The state's health care exchange website is about to return from the dead, but the cost of resuscitation remains far from clear.

Mental health in hospitals on WIHI

Madge Kaplan writes about some of my most favorite people from Contra Costa!

The next WIHI broadcast — Mental Health Care in the Hospital: Preventing Harm, Promoting Safety — will take place on Thursday, October 9, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Kelly McCutcheon Adams, LICSW, Director, Institute for Healthcare Improvement
• Anna Roth, RN, MS, MPH, CEO, Contra Costa Regional Medical Center & Health Centers
• Teresa Pasquini, Mom/Advocate, Chair, Behavioral Healthcare Partnership, Contra Costa Regional Medical Center and Health Centers
• James F. O’Dea, PhD, MBA, Regional Director, Hartford Healthcare Behavioral Health Network
• Richard Wohl, MSW, MBA, President, Princeton House Behavioral Health; Senior Vice President, Princeton Healthcare System

With all the discussion going on about the integration of behavioral health with primary care in the outpatient setting, we don’t want to ignore what’s happening in the hospital for patients with psychiatric conditions and needs. Safety has been one of the major issues identified in recent years… safety for individuals in crisis, for the staff caring for them, and for family members. Those who’ve identified effective improvements are often the patients themselves.

We’re going to venture into the acute care setting for the October 9, 2014, WIHI: Mental Health Care in the Hospital: Preventing Harm, Promoting Safety. IHI’s Kelly McCutcheon Adams is going to set the scene for a terrific panel of guests who are working hard on partnering with patients and families to improve their overall experience in the hospital; the prevention of patient harm and staff injuries; the redesign of physical environments; better management of medications; and heading off crises in the making.

Contra Costa’s Anna Roth and parent Teresa Pasquini have a powerful story to share about collaboration, starting with transforming the experience of the psychiatric emergency. Richard Wohl from Princeton House Behavioral Health wants to share what goes into creating a state of the art, safe, inpatient facility and environment for patients in need of psychiatric hospitalization. The features and attributes will resonate with many. James O’Dea from Hartford Healthcare Behavioral Health Network will tell us about “the three-legged stool” that frames his team’s improvement work, and new efforts to get further upstream with patients to help avoid the need for sudden trips to the ED and the hospital.

I'm looking forward to learning from our guests and from you, our listeners. See you on October 9. You can enroll for the broadcast here.

An expanded view of a pediatrican's role

Budd Shenkin, looking at some of the recent NFL news, offers an interesting perspective on the role of pediatricians.  I had never considered this aspect of the profession and offer it for your consideration.

He starts:

So much starts at the beginning. As a pediatrician I'm used to looking at the long curve of life, and trying to help people adjust that curve for their kids at the beginning. We promote physical health – exercise! – and we prevent physical disease – immunize! But beyond the body, we try to promote and prevent with behaviors as well as physical health.

We try to direct our parents and their kids to positive interactions, to positive child rearing, to verbal self defense and explanation.

P4P: The bureaucracy of documentation

Way back in 2010, I raised serious doubts about the efficacy of the pay for performance metrics that were being imposed on hospitals by private and public payers.  After listing the multitude of such metrics, I asked:

If you were in a management position and were trying to direct quality and safety improvement efforts, how would these guide your behavior? If your were a nurse or doctor and were trying to be responsive in focusing on quality and safety improvements, what would this variety of measures tell you?

Let me jump to the answers: The large number of overlapping measures, often with different definitions among payers, can cause confusion rather than offer guidance to hospitals in directing improvement efforts. That is especially the case because many of the items are "roll-ups" of several metrics in themselves.

In this respect, P4P measures are not always the most useful management tools by which to focus attention on the fundamental elements of process improvement: reduction in variation, redesign of work, and communication in clinical settings -- all in collaboration with patients and families. 

Well, a new JAMA report reaches conclusions that are even more strikingly set forth.  The commentary notes:

The findings of a study presented in this issue of JAMA Internal Medicine reinforce concerns about the unintended consequences of public reporting and pay for performance and also suggest a gap between quality improvement activities and patient care. Lindenauer et al surveyed hospital leaders (chief executive officers and executives responsible for quality) about publicly reported quality measures required by the CMS. Although most respondents said that they used the measures extensively, more than half were concerned that the measures encouraged teaching to the test, and almost half reported trying to maximize performance primarily through changes in documentation and coding. Also important is that half or more believed that the CMS measures did not meaningfully distinguish among hospitals or accurately reflect quality of care, even for conditions specifically targeted by the measures. In short, the study findings suggest that many hospital leaders doubt the clinical relevance of these measures. This skepticism is consistent with national data: studies of public reporting and pay-for-performance programs in the United States have failed to demonstrate a clear connection to improved quality.

Indeed, as you see from this excerpt, there is concern that P4P metrics actually distract the hospital and doctors from the things that matter, by focusing on the bureaucracy of documentation.

Where does this leave us?  Well, we need to go back to the underlying values that motivate doctors and nurses, a desire to alleviate human suffering caused by disease.  As I concluded back then:

People who have studied how to achieve change in organizations point to the need for an overarching, audacious set of goals that are highly motivational.

In our case, the most important established goal is to eliminate preventable harm, one endorsed by our Board of Directors. This goal is combined with a strong commitment to transparency, so we hold ourselves accountable to the standard we have set. So, while we will always do our best to meet P4P requirements . . . we do so within an overall context that is meant to transform the organization. 

CFOs join surgeons in quest for robots

This analyst's report from BTIG tells you all that is wrong with health care in some US academic medical centers today.  An excerpt, with emphasis added:

Subject: Hospital CFO Dinner Takeaways: Two NYC-area Academic Centers Highlight What They're Willing to Spend On, and Where They're Cutting Back

Robotics, imaging, personalized medicine and smart tools are areas of investment, while reducing inpatient care offers savings.

  *   Overall, both hospital CFOs seemed much more positive than a few years ago. One noted his center is running at a 9% operating margin this year and both noted HC reform has not had a major negative impact this year as many had previously feared.

  *   Robotics: These administrators have found that ISRG's (BTIG Neutral Rated) robot helps extend the careers of older surgeons (who may be losing hand steadiness) while helping younger surgeons improve more quickly. They noted that minimally invasive robotic procedures save costs with faster discharge. Both CFOs said their centers profit from robotic surgery and both now have credentialing programs in place. Both seemed more open to additional adoption than a few years ago.

  *   The robot is currently used for urology, gynecology, and cardiology procedures, but surgeons are asking to use it for general surgery. One CFO would like to see more profitable reimbursement rates. This particular center's robots are at capacity, so a new robot would need to be purchased for use in general surgery. A request for an Xi is being evaluated. The other CFO noted that they are in the process of buying four new robots for a new center.