Ain't the way to die

Here's a different take on end-of-life issues from ZDoggMD.  Worth watching and perhaps using in your place to get the conversation started.

(Thanks to Dr. Susan Shaw in Saskatoon for the reference.)

An individual and organizational moral obligation

My buddy Jeff Thompson is stepping down as CEO of Gundersen Health System in a few months.  I have commented several times here on Jeff's leadership abilities, which are again demonstrated in a note he sent to his staff this week.  In simple, direct terms he reinforces the narrative that is at the heart of his hospital's purpose.  It could be the same purpose of any hospital in the world, but it is not often set forth so well.  An element of leadership is that the narrative is expressed in so eloquent and elegant a fashion--one that permits all recipients to feel ownership of the privilege and obligation they have been given.

Dear Colleagues,

We are experiencing many changes as an organization. Some are very exciting like Dr. Rathgaber taking over as CEO in September. Others are more of a struggle. There is always going to be change, especially in our business.

But it is not the changes that are the most important.  It is how we respond. How we respond to change as individuals, teams and as an organization is what defines us. It will determine our futures and move us from good to great.

Sounds good, but change can be very scary.

Here’s what won't change: Our mission to improve care, lower cost and improve the health of the community. This rises beyond growth targets, financial goals and facilities plans. It really is an individual and organizational moral obligation.

To take on big responsibility and big changes, it is best to start with a great platform as a base. The solid platform we have should give us great confidence going forward.  In the face of higher quality standards, economic down turns, tons of regulation and increasing competition, you as teams and we as an organization have steadily improved on all of our key strategies.

Going forward it boils down to just a couple of really big things: Take care of our patients and take care of each other.  The "patient" part has expanded to "patients, families and communities" and each other needs to include those well beyond our immediate work groups to colleagues and partners.

Although changes will always cause some struggles, we have no reason to fear them. We need to trust our strong platform, our clear path and a great team to not just survive but truly excel through the change.

I know we are up for the challenges.

Sincerely,

When CEO bonuses are tied to US News rankings

Here's a quiz.  Can you guess who posted the following messages on Twitter?

Any idea how many hospital execs' bonuses are tied to their institution's U.S. News rankings?

When execs confide this arrangement, they expect me to be impressed or flattered. Are you kidding? I'm deeply disturbed.  

In my view it's a symptom the board has abdicated its responsibility to measure, monitor & incentivize quality improvement.

You might be surprised to learn that it was Ben Harder, @benharder, chief of health analysis at US News and World Report, the magazine that publishes "data, rankings & tools to help consumers choose hospitals, doctors, health plans & more."

Probably more than anyone in the country, Ben understands the inherent limitations in any such rankings. More important, he understands that the rankings are designed to advise patients with complex medical conditions.  They are not an indication about the general level of quality of care or safety in an institution.

He certainly knows that hospitals use the rankings in their marketing materials, but he understands that what makes marketing effective is different from what makes it possible for a hospital to deliver the highest level of care and to engage in ongoing clinical process improvement.

Bravo to Ben for putting this out there so clearly. I'm hoping board members take note.

Student observations from Telluride West

Here are some excerpts from just a few blog posts written by medical and nursing students after the first day the Napa version of the Telluride Patient Safety Camp (seen here having lunch!)  I encourage you to read others:

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They would act as though nothing is wrong.

I wrote this quote down on my pad during the Lewis Blackman video that was shown today because I’ve been guilty of this during rotations myself. Hellen Haskell, Lewis’ mother, was talking about the nurse taking care of her son and the fact that nursing notes ultimately revealed that she was indeed deeply concerned about the patient and his deteriorating clinical condition.

 

The truth is I don’t quite know how to act (maybe act is the wrong word) or rather what emotions to show around families. No one ever tells you to show a impassive face, to act as if everything is proceeding according to plan even when your team is struggling to figure out what is wrong, yet this is exactly what one learns observing the behavior of residents and attendings.

 

I suppose I always assumed that it was more comforting for families to feel like the providers had a handle on the situation. However, having heard from the patient and patient family perspective, I recognize how isolating and invalidated it can be to feel as if you are the only one concerned about your loved one’s care. While there is a time, a place, and an extent to which to share one’s emotions with patients and their families, honest communication throughout a patient’s stay can create a foundation of trust that can be critical in the terrible event an adverse outcome occurs.  (Neelaysh Vukkadala)

 

--

 

We started the day with the Lewis Blackman story. It was a very sobering, raw look at what healthcare should not be. Everything that could go wrong did in this case. No one could see the forest for the trees. I felt sad as a provider, devastated as a parent and could not imagine the strength that Helen has to go on and share this with others.

The whole story reminded me of my mother in law (who had cancer). She had epigastric pain & went to the ER. She was told she was constipated from her pain meds-and they missed her massive MI. Mom walked into the ER but never walked out. She lived the rest of her days (2 months) in a nursing home since she could no longer care for herself due to the injury from the missed MI.  She ultimately died from heart failure shortly after her MI-not the cancer she had been battling. We thought she would be with us for about another year-but we got that time stolen from us. In our case, my husband and I talked and decided not to pursue legal action since we knew she likely did not have much time left. He approached someone who he was friends with in hospital administration and let him know about the missed MI. He told him that he didn’t plan to pursue any legal action but did want to talk about how this could be avoided in the future. The guy he thought was his friend suddenly did not take his calls anymore. How sad. There are far too many stories like this.  (Tanya Celia)

--

Throughout the day, I couldn’t help but keep thinking about the importance of communication between the healthcare team and the patients that they serve. If there is no transparency, patients and their loved ones (even those well-versed with the medical system) feel like they are left in the dark — during the most stressful time of their lives, they have the added burden of trying to figure out what it is their doctors, nurses, and auxiliary team are actually doing. Lewis Blackman’s story is powerful in that it illustrates the importance of honesty. Watching the video left me with so many ‘if; statements. If the resident or intern working with the nurses had taken pause to discuss Lewis’s worsening condition, could this all have been avoided? What if the doctors and nurses had been more upfront about their lack of understanding of Lewis’s situation? What if Helen had been able to directly contact the attending, would he/she have listened to her pleas and ordered tests to reveal the ulcer? What if there had been a system implemented in the EMR to alert attendings when vital signs were out of whack? As an engineer by training, I believe we should create a framework so that even when humans make mistakes, the system in which we operate is able to provide a safety net to catch that one mistake that could mean life or death.  (Sunny Kung)

---

As students of medicine, we are constantly learning: from understanding how to create a robust differential diagnosis, to figuring out ways to chart a patient’s progress through an electronic health record. We drink thousands of new words from a firehose every day, hoping to eventually master the mesmerizing and powerful medical language. With this constant influx of new information, it is easy to forget perhaps the most important facet of our patients’ care: a meaningful relationship founded upon trust. Regardless of the hours spent memorizing biochemistry textbooks, if we as health care professionals cannot find a way to communicate with our patients, we will fail to provide our patients with high quality care. (Serena Dasani)

--

The general feeling I left the end of Monday with was discomfort. The idea that I will be taking the reins on patient care in three short years is a terrifying thought. I hope that I can draw on lessons from Telluride to remember to stay goal oriented, patient centered, and most of all scared in order to provide safe, quality care. (Alexandra Butz)

--

The corridor faded as her trust weakened
Ending a life, hopes, and dreams
Learning to cope with how we failed her
Leaving her impressions fluid in the rigid system
Unavailable.
Rising and challenging us to remember the center
Instill our pledge in our actions
Demanding change to our discussions
Establishing humanity in our calling  (Natalie Elder)

Yes, even surgeons can learn

The Risk Management Foundation of CRICO recently supported a research program to test the effectiveness of 360 degree reviews in influencing surgeons' communication and behavioral skills.  The results were just published in the Journal of the American College of Surgeons.

The context was important:

The program was deployed as part of a long-standing, surgical chief-led patient safety and quality collaborative. The collaborative had previously constructed a Code of Excellence (COE), an explicit description of behaviors expected of all surgeons within their departments. The 360 degree evaluation process was designed to assess progress towards these standards.

Here's how the study was designed:

Three hundred and eighty five surgeons in a variety of specialties [in the Harvard hospitals] underwent 360-degree evaluations with a median of 29 reviewers each. Beginning six months after evaluation, surgeons, department heads, and reviewers completed follow-up surveys evaluating accuracy of feedback, willingness to participate in repeat evaluations, and behavior change.

Here are the results:

Survey response rate was 31% for surgeons, 59% for department heads and 36% for reviewers. Eighty seven percent of surgeons agreed that reviewers provided accurate feedback. Similarly, 80% of department heads felt the feedback accurately reflected performance of surgeons within their department. Sixty percent of surgeon respondents reported making changes to their practice based on feedback received. Seventy percent of reviewers elt the evaluation process was valuable with 82% willing to participate in future 360 degree reviews. Thirty two percfent of reviewers reported perceiving behavior change in surgeons.

And the conclusions:

360-degree evaluations can provide a practical, systematic, and subjectively-accurate assessment of surgeon performance without undue reviewer burden. The process was found to result in beneficial behavior change according to surgeons and their co-workers.

"This is bad for academic medicine"

When the history of the patient safety movement is told, it will be appropriate that the Association of American Medical Colleges* will be left out.  The recalcitrance of this organization in acknowledging patient safety problems was legendary for the first decade of this century. The AAMC's leadership not only refused to acknowledge the depth of patient harm but also precluded use of the organization's arms in working on the issue.

For example, when an AAMC committee was to be established in the mid-2000's on patient quality and safety issues, the leadership insisted that the word "safety" be omitted from the committee's name and charter.

For example, when people would submit articles on patient safety to the AAMC's main journal, Academic Medicine, they would be summarily refused, refused even the courtesy of peer review.  The authors were told that patient safety was not an issue of public concern and therefore did not warrant space in the journal.

For example, at sessions with the world's experts on patient safety and doctor education (like Don Berwick and Lucian Leape), high officials from AAMC would reiterate their belief that hospitals did not have a patient safety problem.

Things finally changed in 2010, when a new CEO arrived.  In an article, he and the organization's president addressed the issue:

In order to develop a health care culture of safety that leads to clinical improvements, an unprecedented collaboration between medical schools and their partnering health systems is required, according to Drs. Kirch and Boysen. They identify five factors critical to the success of a culture shift: leadership from the top, student involvement, a focus on safety during residency training, health information technology, and teamwork among health professionals. “When combined with a growing investment in comparative effectiveness research, these factors will help physicians improve care at the bedside,” the authors write.

I suppose better late than never, but think about the societal loss caused by the absence of the major academic medical organization from this issue for so long--notwithstanding important findings by the Institutes of Medicine on the topic.

Perhaps the AAMC leadership reflected the views of its membership.  I recall, when I was emphasizing patient harm on this blog and posting clinical outcome data, the Chair of the Partners Healthcare System called the Chair of our system and said, "Can you get Paul to stop publishing those numbers.  This is bad for academic medicine."

Or perhaps the membership took direction from the AAMC leadership, who, after all, were highly regarded in the profession.  Either way, the lack of action on and attention to patient safety was a significant failure and led to the slow inclusion of patient safety curricula in America's medical schools. Let's consider, therefore, that the AAMC contributed for years to the delay in addressing the large number of preventable deaths and harm in America's hospitals.

--

* As noted in its materials: The Association of American Medical Colleges is a not-for-profit association representing all 144 accredited U.S. and 17 accredited Canadian medical schools; nearly 400 major teaching hospitals and health systems, including 51 Department of Veterans Affairs medical centers; and nearly 90 academic and scientific societies. Through these institutions and organizations, the AAMC represents 148,000 faculty members, 83,000 medical students, and 115,000 resident physicians.

Telluride goes to Napa

A hearty welcome to the newest participants in the Telluride Patient Safety Summer Camps, taking place this week in Napa, CA.  Here's a sample of the medical students and nursing students who are attending:

Man has to have feelings and then words before he can come close to thought

Back in 1962, John Steinbeck published Travels with Charley, a series of stories and observations from interactions with people across America.  I happened to pick it up yesterday to re-read it, about 50 years after the first time it was assigned to me in junior high school.  Early in the book Steinbeck relates a discussion he has with a New Hampshire farmer about what was still a major post-World War II concern, the recent development and spread of nuclear power and weapons.

The farmer says,

"Take my grandfather and his father.  They knew some things they were sure about. They were pretty sure give a little line and then what might happen.  But now--what might happen?"

"I don't know," responds the author.

"Nobody knows. What good's an opinion if you don't know. My grandfather knew the number of whiskers in the Almighty's beard. I don't even know what happened yesterday, let alone tomorrow. He knew what it was that makes a rock or a table. I don't even understand the formula that says nobody knows. We've got nothing to go on--got no way to think about things."

The farmer leaves and Steinbeck reports (my emphasis):

"I found I couldn't read, and when the light was off I couldn't sleep.  The clattering stream on the rocks was a good reposeful sound, but the conversation of the farmer stayed with me--a thoughtful articulate man he was. I couldn't hope to find many like him. And maybe he had put his finger on it. Humans had perhaps a million years to get used to fire as a thing and as an idea. Between the time a man got his fingers burned on a lightning-struck tree until another man carried some inside a cave and found it kept him warm, maybe a hundred thousand years, and from there to the blast furnaces of Detroit--how long?

"And now a force was in hand how much more strong, and we hadn't had time to develop the means to think, but man has to have feelings and then words before he can come close to thought and, in the past at least, that has taken a long time."

Now, look at this article about genetic engineering from Wired.  Excerpts:

140 scientists gathered here in 1975 for an unprecedented conference. They were worried about what people called “recombinant DNA,” the manipulation of the source code of life. It had been just 22 years since James Watson, Francis Crick, and Rosalind Franklin described what DNA was.

Preeminent genetic researchers like David Baltimore, then at MIT, went to Asilomar to grapple with the implications of being able to decrypt and reorder genes. It was a God-like power—to plug genes from one living thing into another. Used wisely, it had the potential to save millions of lives. But the scientists also knew their creations might slip out of their control. They wanted to consider what ought to be off-limits.

At the end of the meeting, Baltimore and four other molecular biologists stayed up all night writing a consensus statement. They laid out ways to isolate potentially dangerous experiments and determined that cloning or otherwise messing with dangerous pathogens should be off-limits. A few attendees fretted about the idea of modifications of the human “germ line”—changes that would be passed on from one generation to the next—but most thought that was so far off as to be unrealistic. Engineering microbes was hard enough. The rules the Asilomar scientists hoped biology would follow didn't look much further ahead than ideas and proposals already on their desks.

But then:

Earlier this year, Baltimore joined 17 other researchers for another California conference. The stakes, however, have changed. Everyone at the Napa meeting had access to a gene-editing technique called Crispr-Cas9, [which] makes it easy, cheap, and fast to move genes around—any genes, in any living thing, from bacteria to people. “These are monumental moments in the history of biomedical research,” Baltimore says. “They don't happen every day.”

Using the three-year-old technique, researchers have already reversed mutations that cause blindness, stopped cancer cells from multiplying, and made cells impervious to the virus that causes AIDS. Agronomists have rendered wheat invulnerable to killer fungi like powdery mildew, hinting at engineered staple crops that can feed a population of 9 billion on an ever-warmer planet. 

Bioengineers have used Crispr to alter the DNA of yeast so that it consumes plant matter and excretes ethanol, promising an end to reliance on petrochemicals. Startups devoted to Crispr have launched. International pharmaceutical and agricultural companies have spun up Crispr R&D. Two of the most powerful universities in the US are engaged in a vicious war over the basic patent. Depending on what kind of person you are, Crispr makes you see a gleaming world of the future, a Nobel medallion, or dollar signs. 

The technique is revolutionary, and like all revolutions, it's perilous. Crispr goes well beyond anything the Asilomar conference discussed. It brings with it all-new rules for the practice of research in the life sciences. But no one knows what the rules are—or who will be the first to break them.

Now, think back to Steinbeck:

"And now a force was in hand how much more strong, and we hadn't had time to develop the means to think, but man has to have feelings and then words before he can come close to thought and, in the past at least, that has taken a long time."

In the past, it was the military-industrial complex, now it's the medical-industrial complex. Driven by ego of people who are too sure of themselves and the greed of those seeking to park their cash, the likelihood of effective and thoughtful controls is likely to proceed at too slow a rate to protect us from ourselves. Now here's an issue worthy of attention by the multitude of presidential candidates: Will any step up to address it?

Everyone likes to think they are doing better

Tissue plasminogen activator

I recall a wonderful story from Amitai Ziv, the director of MSR, the Israel Center for Medical Simulation at Sheba Medical Center on the outskirts of Tel Aviv.  He relates how Israeli fighter pilots would return from their missions and debrief how things went.  The self-reported reviews of performance were very good.  Then, the air force installed recording devices on the planes, and it turns out that the actual performance was not nearly as good as had previously been reported.  The conclusion: It's not that people are poorly intentioned or attempt to mislead about their performance. It's just that we tend to think we are doing better than we actually are.

Let's turn to health care.  Here's a recent story by Lisa Rapaport at Reuters that portrays a problem and--as in the Israeli example above--demonstrates the importance of transparency--providing staff in a hospital with actual data about their clinical performance. The lede:

Many hospitals overestimate how quickly they give stroke patients a clot-busting treatment designed to help minimize damage, a U.S. study suggests.

Researchers asked hospital staff how fast they administered an intravenous (IV) therapy known as thrombolysis to dissolve clots and compared the answers to stroke registry data with the actual times.

Only 29 percent of hospitals had an accurate sense of their own speed.

“Everyone likes to think that they are doing better,” senior study author Dr. Bimal Shah, a researcher at Duke University School of Medicine.

The slowest hospitals were also the ones most likely to be inaccurate about their results.

The gap between perception and reality was far bigger for hospitals that were generally slower.

Among the lowest-performing hospitals, staff surveyed generally thought that at least 20 percent of treated patients got the therapy within an hour. In reality, none did.

Despite their lack of speed, 85 percent of the low-performing hospitals reported their performance as average or above, with almost 5 percent of them ranking themselves as superior in comparison with other hospitals nationwide.

Those of us who are Lean adherents believe in the idea of visual cues, providing data about an organization's performance in real time to those working in an area.  That information helps a place monitor its performance and look for ways to improve and sustain improvement.

It looks like stroke centers and their patients could benefit from such real-time reporting.  As Dr. Shah notes, “Not acting quickly makes the prognosis for stroke patients worse.”

Cups half full and half empty

I've been enjoying an exchange over at Twitter with Ben Harder, @benharder, chief of health analysis at US News and World Report.  As he notes, "We publish data, rankings & tools to help consumers choose hospitals, doctors, health plans & more."

In previous posts, I've expressed major reservations about the methodology used by the magazine.  Regular readers might recall my 2011 column where I said:

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

To his credit, Ben has been working on creating a more objective basis for his magazine's rankings, but there is a still a major component that relies on doctors' opinions.  I wish him well in continuing to make this whole exercise more scientific. (By the way, as the magazine notes, their ranking is not for patients with "normal" levels of acuity, but rather is designed to focus on which hospitals best handle the more complex cases. You'd never know that based on how hospitals use the rankings in their advertisements.)

Meanwhile, it has been revealing to focus on other comments in the Twitterverse and blogosphere that have attacked as unconscionable recent stories from ProPublica in which Medicare data on readmissions were used to describe complications rates for America's surgeons.  Oddly, I cannot recall any of the authors of those diatribes taking on any methodological aspects of the US News rankings.

My guess is that the US News rankings have become such an important part of the marketing campaigns of America's hospitals and doctors that any such problems fall away in the eyes of the profession.

But back to our interchange.  Ben notes, with optimism:

Thru NSQIP & PQRS, @AMCollSurgeons "has begun the long, arduous process of [public] quality assessment" of surgeons.

Surgeons' work on "assessing and improving surgical outcomes...will take some time. It’s complex."

I responded:

NSQIP has existed for years. No indication that it will be used for public reporting. Ever. [Note: More on that here.]

I also noted:

Also c new AUA data effort: "By urologists. For urologists." Public disclosure not contemplated. U c progress. I c recalcitrance.  [Note:  Check here for a description of the American Urological Association Quality Registry inititaive.]

His reply:

You may be right. But the winds of change are blowing. Growing # of surgeons want  #NSQIP to open up.

I offered:

Winds of change? More like gentle whispers. As we say in politics, count the votes. Inertia's winning.

He answered:

You see cup empty. I see rain clouds.

I added:
 
In short, the medical priesthood prevails: "You are not worthy to judge us."

He answered:

Priests will be priests. The congregation is losing its religion.

To which all I can now do is respond by saying, "We shall see."  I see nothing on the horizon that suggests that the public's need to know is as yet offsetting the profession's desire to hold things close to the vest.  When the numbers suit them, the profession extolls the results.  When the numbers don't suit them, it's back to: "The data are wrong.  My patients are sicker."

Care to discuss Faulkner?

I happened to be looking through an old Doonesbury collection and found this one.

Human factors and EHRs

Perhaps you don't want discouraging news about electronic health records. If that's the case, browse on to another site.  However, the authors of this new paper have some important things to say.  And they have the expertise to be credible, being part of the National Center for Human Factors in Healthcare.

The short version is that EHRs have not been designed with sufficient attention to human factors and therefore are likely to be not as usable as they should be and--I extrapolate--have the potential to cause harm.

First, some background on the topic:

The usability of any device or system can be broken down into two major categories: basic interface design (human factors [HF] 1.0) and cognitive support of the user (HF 2.0). The basic interface design should follow well-established principles that ensure information is clear and readable, such as font size and color, while also providing adequate contrast between text and the background. Focused on the cognitive support of the user, HF 2.0 entails much greater detail and a deep understanding of the workflow and cognitive needs of the user. Designers focusing on HF 2.0 principles seek to understand how users accomplish their work in the context of their actual work environment (e.g., observations, task analysis, and other ethnographic techniques) and engage in iterative user testing of the interface throughout the development process.

Next, an assessment of the "state of the art:"

We are . . . concerned about the lack of progress in addressing HF 2.0 challenges. Nearly all EHR vendors, both large and small, struggle with the challenge of designing for numerous permutations of workflows, clinical specialties, and physical environments in which their EHRs are deployed.( Yet these systems must be designed with the cognitive needs of the frontline users in mind for each specialty and each user role (physician, nurse, tech, clerk, etc.). For example, an HF 1.0 patient discharge tool may have the necessary textbox fields that allow the provider to enter all of the important discharge instructions. But an interface incorporating HF 2.0 design principles would ensure easy access and display of relevant nursing notes, changes in patient status and vital signs, automatically highlight abnormal test results, and suggest follow-up information based on those results. In current systems, abnormal findings and change in a patient's status are easily missed during the discharge process, despite the fact that the information is contained somewhere in the EHR, just not presented in a meaningful way to the user.

Recommendatons:

To do this well, EHR vendors, health care systems, and frontline health care workers need to partner so that all can deeply appreciate the intersection between the technology and the users and design the system accordingly. These efforts must leave adequate time for testing the systems during the development process, and should not be rushed after the system is built and ready to be implemented. 

From our experience in studying EHRs and their implementations, we believe that health care systems and vendors would be well served by a library of lessons learned and use cases that they can draw upon to design and install their systems. Too often, health care systems undertaking a new EHR installation find themselves reinventing the wheel and repeating the same mistakes and missteps that another institution made previously. This is neither sustainable, nor desirable when it comes to implementing safe and efficient health IT systems. 

VITAL link at Highmark

Highmark Health has started a new program to introduce innovative products to doctors and patients.  Here's the summary:

"Technologies that have received regulatory approval from the FDA often lack sufficient scientific data to convince commercial insurers to pay for them. Without support from commercial payers, it is difficult for new innovations to influence the practice of medicine.

"VITAL’s mission is to leverage Highmark Health's position as one of the largest integrated health care delivery and financing systems in the nation to accelerate the pace with which novel technologies and services are made available to our customers. In doing so:
• Members and patients will be afforded access to safe new technologies without undue financial burden.
• Payers will be able to understand the full impact of new technologies on their members without changing insurance medical policy prematurely.
• Providers will gain early access to novel technologies and a first-hand understanding of their impact on patients.
• Technology vendors will have the opportunity to prove the benefits of their new innovations to patients, providers and payers.

"The VITAL innovation program is essentially a test bed designed to facilitate early use of technologies that have received regulatory approval and are being used for their intended purpose within the approved patient population but are not yet covered by most commercial insurers. VITAL is designed to provide the missing link between FDA approval of an innovative technology and its full reimbursement."

This is interesting.  I view this program as a mechanism to moderate the tension between a desire to get new technologies out quickly and analyzing the clinical efficacy and cost effectiveness of those same technologies.  This will be a good one to watch over the coming months and years.

$300 million misplaced in NYC

If you were going to invest $300 million in the health care of New York City residents, how would you spend it?  In an era of "population health," would you spend it on a single 115,000-square-foot project to provide proton beam therapy?

Well, that's what Memorial Sloan-Kettering Cancer Center, Montefiore Medical Center, Mount Sinai Hospital and ProHEALTH, a multi-specialty physician group practice, are doing.

Construction of the VOA Associates-designed complex will begin this summer with the first patient expected to receive treatment in the spring of 2018. Goldman Sachs and JPMorgan Chase & Co. provided financing.

The beat goes on. How many more of these do we "need?"

Great Scott! David's right again.

I met David Meerman Scott many years ago and was impressed with his perspicacity regarding social media.  He was a man ahead of his time in understanding the potential for these new platforms to reach out inform, and entertain--as well as to waste your time!

Even now, he regularly produces gems of insight.  Here's one from just a few days ago. A teaser:

Social networks are a great place to share content, to interact with others, to listen in on what’s happening, and yes, if approached carefully, social networks can be a way to get the word out about you and your business. However as I review people’s business-related social streams I find way too much selling going on.

As a way to think about your social activities, I’d suggest you should be doing 85 percent sharing and engaging, 10 percent publishing original content, and only five percent or less about what you are trying to promote.

If you are trying to sell, it's well worth your while to read the rest. 

Do we really learn from our mistakes?

Please click over to this new article I have published on the athenahealth Leadership Forum.  I'm hoping you will post comments.  Thanks.

An excerpt:

It’s often said that we learn from our mistakes. Indeed, many a business course in leadership offers that premise as a given. I’ve glibly repeated this often in my classes, speeches, and advisory work.

“You don’t learn from your successes,” I point out, “but rather from your errors.”

But do we really learn from our mistakes as a matter of course?

My friend and colleague Michael Wheeler, in his wonderful book The Art of Negotiation, warns us that it is "all to easy to be overconfident about our ability to observe and learn."

Huddling in Saskatoon

Let's talk about huddles.

They have been used to great effect in dozens of human endeavors.

From restaurant kitchens, to flight operations on aircraft carriers, to sports, we have come to understand the value of taking a few seconds as a team to review the current situation, agree on a plan of action, and identify possible contingencies.

In addition, this moment of face-to-face intimacy reestablishes the human connections among the team members.

 
Paradoxically, it both reinforces the chain of command and re-empowers all of the team members to call out concerns.

Health care, though, has been late to this technique.  How pleasing then to read of yet another hospital setting in which it has become part of the standard work.



This report from the Saskatoon Health Region relates the story of "bullet rounds," their form of huddle.  Excerpts:

It’s 11 am. In Clinical Teaching Unit (CTU) 6200, a medicine unit at Royal University Hospital, a group begins to gather near the whiteboard. Listening to the conversation, you quickly realize they are a diverse group with doctors, nurses, a speech pathologist, a physiotherapist, a pharmacist, an occupational therapist, a social worker, and a representative from client-patient access service (CPAS), to name a few.

Each are handed a list. “Good morning everyone,” says one individual. “We have 20 minutes. Let’s get started.”

For the next 20 minutes, CTU Team ‘Blue’ moves through the unit and reviews care plans for the day for patients as a team. It’s a process you will see repeated later in the hour by CTU Team Red and CTU Team Silver.

How's it working? 

“The evidence (behind bullet rounds) is strong. (Daily interprofessional collaboration) decreases the patient’s length of stay, decreases hospital errors and decreases hospital admission costs,” Prystajecky says. “We also know there are other positive outcomes of collaboration including enhancing team communication and team building.”

And here's a follow-up story, summarizing with the all important continuous improvement goal:

“I am excited to see where this goes,” [Christina Sparrow, CTU nurse coordinator] says. “It’s a great process, and . . . I am excited to see how we will continue to change and improve to get better.”

Well done, Saskatoon!

Silent and inconspicuous supervision in an atmosphere of relaxation

In 1945, Leah and Sam Sleeper, educators from Worcester, MA, started an overnight camp for boys on a piece of land they owned in Charlton.  On the 15th anniversary in 1960, they noted:

[Camp] Wamsutta has always operated on the principle that busy boys are happy boys, and if the "busyness" is channeled into healthy and wholesome areas of activity, busy boys are learning, developing and growing into happy and well-adjusted manhood.

The next year, they noted:

The aim of a well-directed camp program is to achieve order without regimentation; organization without restriction; and excitement and enthusiasm without the pressures of competition.  The ideal is silent and inconspicuous supervision in an atmosphere of relaxation.

And in 1962:

Counsellors have competed with each other in developing interesting projects to motivate the campers. The campers in turn have settled down to a well-regulated and healthy pattern of living.  Their experiences have been many and rich. They have grown in physical, mental, and moral stature.

It was only upon "preparing" for our camp reunion this past weekend that I pulled out these quotes from camp yearbooks that had lain in an old trunk in my attic for several decades.  Several dozen of us met on the shore of Buffumville Lake and reminisced with Marty Sleeper, one of the three sons of the camp founders, who had been intimately involved in camp planning and activities.

Marty himself went on to a career in education, becoming the beloved principal of a school in Brookline and later joining Facing History and Ourselves, where he remains as Special Advisor.

It never occurred to me that the Sleeper's had an educational philosophy for their camp.  I just went to camp and played ball and other activities and had a great time for eight weeks each summer from 1959 to 1964.  I certainly never considered the impact of the Sleepers' educational philosophy on my own development or my own approach to teaching and coaching.

But, then as I read through the yearbooks, I realized that I had internalized many of their lessons and adopted the principles in my own leadership roles--whether running an academic medical center or coaching girls soccer.  "Lead as though you have no authority" is one of my mantras.  Trust the people with whom you work, and understand that a key component of your job is to help enable their personal and professional development.  Your job is to develop new leaders, not persistent dependence on your supervision.

So, with a belated thank-you to Leah, Sam, and Marty, I engage in a midsummer reflection that we never know when mentors' lessons will take hold or where inspiration will arise.

The scalpels are out

The knives, er scalpels, are out in force, attacking the methodology used by ProPublica in setting forth conclusions about America's surgeons.  Here's a piece from Justin McLachlan, essentially accusing ProPublica of journalistic malpractice.  Here's another one by Benjamin Davies, calling the work "clickbait."

Let's see, absent access to the secret NSQIP data, which admittedly does not exist for of all surgeons, what are we left with?

What are we left with if I am a referring doctor who wants to send a patient to the best possible surgeon?

What are we left with if I as a patient want to check out the performance record of several surgeons?

What statistically valid methodology is available to me?

I'll tell you what methods are currently in use:

Anecdote. Bias. Personal friendships between doctors. An unsupported feeling that "Dr. Smith does a really good job."

Justin and Benjamin and others, what exactly are you proposing should supplant the entirely subjective and unreliable sources of information currently available?  How soon will your idea (if you have one) become feasible and be put into the public domain? Or do you simply propose that we should have less information about picking a surgeon than we do about virtually any other consumer choice we make?

Well, maybe it doesn't matter.  Maybe all surgeons are equally competent and have similar records of success. Maybe the personal stakes to me as a patient are too insignificant to matter.

Right.

The entire thing was iatrogenic*

Are falls preventable? Here's a case of inappropriate care by the medical community that caused them. Note my friend--even as a doctor--was unable to get the proper care for her mother:

I have to tell you about my 93 year old mom:

For years at the nursing home they kept adding blood pressure medicines to treat her recalcitrant blood pressure. She was falling more than once a day, disoriented and largely wheelchair bound since the staff found using the chair prevented falls. (They would wheel her to meals, etc.) She spent most of her days in bed.

Shortly before she moved to the dementia unit the doctor came to see her and said she was on too much blood pressure medication.  He noted that old people needed higher pressures, something I had been trying to tell her previous doctors for a couple of years.

Bottom line--he stops all but one blood pressure medication. I ask them to put her on an antidepressant, and she is now walking around without even a walker. We even took her to IHOP and the grocery store and she had more stamina than ever before. She is happy. 

The entire thing was iatrogenic! 
--
*Definition:  Induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures.

We have a better way, but it's secret

A number of experts and other folks have criticized the methodology used by ProPublica to indicate the relative rate of complications for surgeons across America.

Here's the issue in a nutshell, as I see it.  There is a rigorous methodology available for evaluating surgical outcomes.  It is from the American College of Surgeons, and it is called NSQIP.  It is indeed the "leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in the private sector."

Look at what the program offers to surgeons:

Surgeons who use ACS NSQIP receive:

• Better data for more targeted decision-making:
  • Peer-controlled, validated data from patients’ medical charts lets surgeons quantify 30-day, risk-adjusted surgical outcomes, including post-discharge, when nearly 50 percent of complications occur.
  • A variety of program options tailored to your hospital’s size and quality improvement interests.

• Robust reports that provide performance information to guide surgical care and identify areas for improvement for the greatest return and highest impact:
  • Continuously updated hospital performance reports and benchmarking analyses available in real time.
  • Nationally benchmarked and risk-adjusted reports provided semiannually.
  • Maintenance of Certification (MOC) Part IV credit for all surgeons at hospitals participating in the program.
  • Best practices tools, including Case Studies and evidence-based guidelines developed by ACS.
  • Opportunities to participate in regional and virtual collaboratives with other hospitals.
  • Preoperative risk calculator:
    • Online tool helps clinicians make evidence-based decisions, and helps set reasonable patient expectations.
    • Takes into account patient risk factors like age and BMI for a growing number of common surgical procedures.
    • Better predictive ability than most other models.

Ideally, ProPublica or others could publish the NSQIP results, except for one thing.  Under the ACS rules, the evaluations must be held confidential.

So there we have it. We could all have a rigorously derived comparison tool, but since the profession chooses not to make it available, we must have a surrogate of the sort that ProPublica used in its article. Or nothing at all. What would be your choice?

ProPublica and the surgeons of America, together . . . or apart

Well, this is worth looking at:

ProPublica analyzed 2.3 million Medicare operations and identified 67,000 patients who suffered serious complications as a result: infections, uncontrollable bleeding, even death. We report the complication rates of 17,000 surgeons – so patients can make an informed choice.

No doubt the doctors with poorer statistics will say the usual: (1) "The data are wrong" and (2) "My patients are sicker."  Some experts offer their own opinions.

Will the information really help patients make an informed choice? The jury's out on that. It depends on whether primary care doctors use the data to guide their referrals or whether they will continue to rely on friendships and anecdotes--all reinforced by the financial pressures of being in the same ACO as those surgeons.

Brad helps define super-utilizers

Brad Flansbaum (again) offers a thoughtful exposition on an important topic, this time frequent flyers (aka super-utilizers) in the emergency room. He notes:

Those individuals present week after week with innumerable complaints, sometimes pedestrian, sometimes critical–always finding themselves back on the ward for weeks at a time.  As expected, they have weak community support and comorbidities in need of TLC, often requiring services not available in their neighborhoods (mental health and substance abuse counseling come to mind). The local house of worship, community center, or corner bar have limits, and they only offer so much spiritual renewal or sustenance.  We all struggle to find a balance for these folks.  We see them a lot. And thus, the ER becomes their second home.

After presenting some important data (above), he concludes:

Super-utilizers require a more individualized, unique approach.  We need to consider the needs of these patients separately.

It's time to sue the trustees

I’m not a health care person by training. Much of my background is in the public policy arena—starting first in energy and then branching out to telecommunications, and thence to water and wastewater. In parallel, I’ve also run large organizations and managed thousands of people and billions of dollars in capital and operating budgets. I’ve been a regulator and I’ve been regulated. When I offer opinions and illustrative stories on this blog, I am mainly driven by what I see as failures, and I try to offer approaches that might work to improve things.

In that sense, for almost nine years, the blog has presented a series of advocacy documents. Regular readers know that I have seldom pulled my punches: There are enough people who try to be diplomatic in what they say and how they say it. When it comes to saving lives from preventable harm, I am too impatient to be overly considerate about people’s sensibilities.

In all this, I’ve had to decide my own role, beyond what I do to make a living (providing negotiation training and advice to companies in many sectors around the world.) I’m honored to be invited by hospitals and others to provide stories, training, and maybe even some inspiration as they pursue their journeys towards patient-driven care. Those journeys rely on creating learning organizations, characterized by respectful treatment of the staff and transparency to achieve process improvement to deliver high quality and safe care. I’ve chosen to interact mainly with those hospitals that we have come to view as “islands of excellence in a sea of mediocrity.” I don’t spend time in places that are not committed to the quality and safety journey because I only have so much time available and because I don’t find much merit in hitting my head against a wall.

Admittedly, that’s a luxury on my part, hanging out with the 5% or 10% of institutions that “get it.” But what becomes of the rest, the vast majority of hospitals that don’t get it? My buddy Dave Mayer likes to say that the answer to achieving greater quality and safety and transparency is to “educate the young and (when necessary) regulate the old.” Beyond the humor, there is an element of wisdom in Dave’s construction of the argument.

I’ve spent a lot of time on this blog carping about the lack of rigor that has gone into the design of health care regulation, so I don’t want to spend time on that today. Suffice it to say that the hand of government is often roughly applied, and we can only hope that officials get better at designing and implementing policies.

But recent remarks by Bob Galbraith at our student and resident training program (Telluride East) reminded me that the heart of professional activities must be self-regulation. He posited that the medical profession has failed in this regard—avoiding discipline of their members who are clearly impaired, incompetent, and negligent. So, he suggests, fix this they must, or some one will step in and do it for them.

Bob’s right on his particular point, but we know that most medical harm does not derive from the individual actions of doctors. It derives from the work patterns and systems that are in place in hospitals. These are not organizational aspects in which most doctors and nurses have been trained. They are trainable with some time, effort, and resources—but those in a position of authority must encourage and demand that it happen. The “those” in this case must be the boards of trustees, the governing bodies of the hospitals.

But it is in this arena that we have a public policy lacuna. While trustees often have a statutory responsibility for the quality of care given in their hospitals, they are never held accountable for that care. The history of involvement by lay governing bodies is heavily centered on the social and community aspects of governance, including fund-raising. Clinical decisions are left to the clinical staff, as they should be, but oversight of clinical activities by the governing body is often rudimentary at best.

It’s time to change this pattern and, where necessary, force greater engagement by trustees in quality and safety issues. Given the stature of trustees in the community and their political influence, I don’t expect legislators to do much on this front. But there is a group that could take advantage of the current situation and give those trustees a real incentive to learn how to effectively govern safety and quality.

That group is the medical malpractice plaintiff bar.

Currently, plaintiffs’ attorneys sue the doctors or nurses or the hospital when someone is harmed and negligence is alleged. The main argument is that the standard of care was not met, and the focus is usually on the specific actions or non-actions by the clinical staff.

But it’s time for a broader definition of negligence: Negligence today is found in a hospital that has not used the wealth of data and experience garnered around the world by the “islands of excellence,” those thoughtful hospitals who have created a new standard of care by the manner in which they have organized work and by the existence of a culture of continuous process improvement. All of those hospitals, too, have boards that are assiduously engaged in appropriate governance of quality and safety.

I call upon the plaintiff bar to expand their reach in medical malpractice cases. Name the individual trustees as defendants. Depose them as to the extent of their activity and oversight with regard to quality and safety improvement. Ask them if they have established a corporate goal of eliminating preventable harm. Find out how they measure and monitor harm in their hospitals. Ask them how much time in each board meeting is devoted to the topic compared to, say, financial matters.

Counselors, I think you will find—all too often—a prima facie case of governance negligence, a factor which is highly likely to support the underlying contention in your particular litigation.

And think more broadly than individual patient lawsuits. Curious about targets of opportunity? The CMS Hospital Compare website might provide guidance. Simply look for those hospitals that have an incidence rate for, say, central line infections or surgical site infections or urinary tract infections that is above the national average. Given the standard of care for such items, if a place has been persistently below average, it’s likely that something is awry. You might even find that you have the basis for a class action lawsuit in those hospitals, as their poor performance is a composite of hundreds of patients.

I have no interest in seeing trustees being held financially liable at a personal level for their lapses, and, after all, insurance will protect them from that. But I do have an interest in having them squirm under the questioning of an experienced malpractice attorney about their failure to carry out their most important fiduciary responsibility, the well-being of patients in their institutions.

Serious business at Telluride East

The Telluride Patient Safety Summer Camp has continued this week, with a new group of students and new residents joining together with the faculty in Maryland. After a full couple of days in the classroom--often characterized by good-hearted banter as well as hard work--the group boarded a bus for a visit to Arlington National Cemetery.  Here, Rosemary Gibson, author of The Wall of Silence and other important works about the health care system, pointed out that the cemetery holds over 300,000 members of the military and their families.  She noted, "The military is very good about keeping track of its members, noting everyone who is wounded or killed."  The contrast with health care is vivid.  In the US, 400,000 people die from preventable harm in the country's hospitals, which would require the construction of a new national cemetery every year.  Also, unlike in the military, the victims of medical harm are essentially anonymous.  We don't always keep track of the individual cases, and often we don't learn from them.

Rosemary asked the attendees to think about people they had known who had suffered from medical errors and to pay them tribute.  Some spoke out, but all seriously considered her words.  Here are some of the faces of our faculty and participants.

Norbert and Richard address incentives

Norbert Goldfield is one of the more sophisticated and deep thinkers on the topic of integrating financial incentives with patient care improvement.  He and Richard Fuller recently addressed the issue of the segmentation of different kinds of patients under such programs.  Here's a teaser:

"It is evident that mental health issues drive increased utilization and, particularly within Medicaid programs, increase the likelihood of readmission. Poorly constructed penalties, apparent in many earlier health management efforts, look at the frequency of readmission at an institution, typically a hospital, and conclude that the hospital patient population as a whole has high rates and therefore the hospital performance merits a penalty. The result is a push to exclude and dilute the impact of patient populations that generate this loss, while the providers that treat them are seen as “loss centers.” The resulting mindset is a pervasive fear in which complex, high-needs patients that require more resources will uniformly experience higher rates of adverse outcomes, leading to them being identified as a problem.

"Exclusion from incentive programs may remove patient populations from the radar of cost-cutting administrators but will also ensure that attempts to improve their care will not be a top priority.

"But, with better crafted policies this need not be the case – in fact the reverse is true."

Where's Ralph?

Back in 2011 and 2012, the CEO of Steward Health Care System was prominently covered in the media for his prowess in orchestrating an alliance of the Boston Archdiocese, Democratic elected officials, the Service Employees International Union (SEIU), and community organizers to support the sale of the Caritas Christi hospital system to a private equity firm, and meanwhile, too, for hosting a campaign fund-raising event for President Obama.  Commonwealth Magazine noted that Boston magazine, in its April “power issue,” put the CEO on its cover, ranking him 12th among the 50 most powerful people in Boston, right behind his counterpart at the much larger Partners HealthCare.

In recent months, the CEO has disappeared.  When Quincy Medical Center was shuttered, for example, it was another corporate official who took center stage.

But now, we face a new set of issues calling for executive leadership, as set forth in the New York Times:

The CVS Health Corporation said on Tuesday that it would resign from the U.S. Chamber of Commerce after revelations that the chamber and its foreign affiliates were undertaking a global lobbying campaign against antismoking laws.

CVS, which last year stopped selling tobacco products in its stores, said the lobbying activity ran counter to its mission to improve public health.

Last week, Harvard health policy expert John McDonough said that the Chamber deserves "shame and disgrace" until the group stops its work on behalf "global merchants of death."

Where's the CEO?

The chief executive of the Steward Health Care System, Dr. Ralph de la Torre, serves on the board of the chamber. In a statement last week, Brooke Thurston, a spokeswoman for Steward, said: “If the chamber is in fact advocating for increased smoking, we do not agree with them on this public health issue.”

That's it?

Steward's owner Cerberus faced some tough public policy and financial issues in the past with its ownership of a major gun manufacturer.  Ater the killing of Connecticut schoolchildren, it promised to divest those assets.

Tobacco sales are not synonomous with guns, but tobacco is widely recognized as a major public health hazard.  It should be pretty easy for the CEO to say that Steward wants no role in encouraging the use of tobacco products or in supporting an organization that opposes reasonable controls on tobacco sales.