Not Running a Hospital

Spear (Part 2) at MIT Webiner

2012-01-27T13:00:00.000-05:00

Creative Experimentation: Developing a Skill Critical for Managing Complex Operating Systems (Part 2)

MIT SDM Systems Thinking Webinar Series

Steven J. Spear

Senior Lecturer, MIT Sloan School of Management; Senior Lecturer, MIT Engineering Systems Division; Senior Fellow, Institute for Healthcare Improvement; and author, The High Velocity Edge

Date: January 30, 2012

Time: Noon - 1 p.m. EST

Open to all

A broad-based capacity for experimentation is critical for organizations to succeed because the systems in which people are embedded are increasingly complex and fast. For instance, medical treatment used to be accomplished by "going to the doctor," a sole practitioner supported by a handful of other professionals, who mastered a body of scientific knowledge through steady practice. Now, thanks to the tremendous advances in medical science and technology, diagnosis and treatment span myriad disciplines and countless professionals. Doctors have to be masters in their own fields and masters in coordinating care delivery tailored to individual patients' needs. Experience can no longer be steadily accumulated over time. Rather, teams must experiment off-line so they are prepared for the variety of situations they'll face in real time. The same challenge of having to build knowledge in particular disciplines and learn quickly how to pull the pieces together into coherent efforts is characteristic of manufacturing design and production, services, information technology, and more.

Steven J. Spear's webinar will illustrate this migration from simple and stable to complex and fast, with examples of how organizations have learned to succeed by cultivating a capacity for high-speed, broad-based experimentation. A question and answer session will allow listeners to speculate about what would be involved in developing such a capability in their own organizations.

Broken escalator leads to a crisis

2012-01-27T07:30:00.003-05:00

A friend found this wonderful video in an article by Renskee Visscher at TEDx Maastricht, who notes: "It’s an exaggeration of our dependency on modern technology… at least I hope it still is."

If you can't see the video, click here.

How do we feel about hospitalists?

2012-01-26T20:49:00.003-05:00

I had missed this original MedPage Today column by George Lundberg back in November and so was pleased to catch it as a re-run over at Kevin, MD. George asks the question, "Are Hospitalists a Boon or a Bane, and for Whom?"

A hospitalist, you will recall, is an internist who is the surrogate for your primary care doctor when you have been admitted to the hospital. Before the hospitalist movement started in the mid-1990s-- thanks in great measure to Lee Goldman and Bob Wachter at University of California San Francisco -- your PCP would be in charge of your care at the hospital. S/he would visit early in the morning before taking office appointments and then again in the evening to check in on you. If important issues came up during the day, someone at the hospital would call the PCP to determine the course of action.

The idea of hospital medicine is that these trained doctors are there full-time to check up on you and intervene as necessary in your care. Being on staff, they would know the in's and out's of the hospital, the flows with radiology, physical therapy, laboratories, and the like. They could also explain things to you and members of your family when it was convenient for you, rather than outside of normal business hours.

George notes, however:

I hear many anecdotes of problems such as:

1. Handoffs of patients from the community physicians to the hospitalist and back being fraught with communication gaps and flaws with increasing likelihood of resulting medical errors.

2. Hospitalists having to do the "hospital's bidding," usurping physician autonomy and judgment to the corporate advantage of the hospital.

3. Hospitalists refusing (or being unable) to provide competent and comprehensive care to patients under their responsibility.

4. Hospitalists serving as little more than triage persons, routing every little symptom or finding to this or that specialist (headache to neurologist; tummy ache to general surgeon; heartburn to gastroenterologist; cough to pulmonologist; chest twinge to cardiologist; anxiety to psychiatrist; skin blemish to dermatologist).

I was rally taken aback by this. Maybe my sample is biased, but the experience I have leads me to have the highest regard for hospitalists and for their role in taking care of patients and families. Far from triage persons, they have the time to get to know patients and avoid the need for more costly specialty care. I have found them to be the leaders, too, in process improvement designed to reduce harm and ensure safety. Here's an example from BIDMC, where hospitalist Melissa Mattison developed a protocol for reducing the likelihood of falls among elder patients. And here is hospitalist Julius Yang explaining the fundamentals of Lean process improvement.

Indeed, primary care doctors can no longer carry out those tasks. (The exception is concierge doctors who limit their panel of patients to just a few hundred people.) PCPs are overwhelmed by the demands of their office practices. Were they to try to visit their admitted patients, they would have little time for in-depth assessments. Also, they would find themselves left behind on the latest clinical processes in the hospitals. And they certainly would not be effective in implementing process improvement in the complex hospital environment if they could only be present for a few hours.

But let me pose the question to this audience. The comments on George's initial article and on Kevin's reprint tended to be negative about hospitalists. What has been your experience? If it has been negative, please answer this: How well do you think your PCP could have taken care of you in the absence of the hospitalists? Do you think you would have had a better experience?

Jonathan Byrnes on inventory optimization

2012-01-26T12:14:00.000-05:00

MIT's Jonathan Byrnes presented a terrific webinar last week. His topic -- inventory management -- has a lot to do with all kinds of businesses, including hospitals. I want to summarize some key points for you. (For those who want learn more, Jonathan has his own blog, which I highly recommend.)

The major point of the webinar was that there is a huge difference between inventory optimization and inventory management. Jonathan puts this in terms of a paradigm shift:

In the past, the job of the supply chain manager was to optimize the flow of goods into and out of the storeroom. For example, reducing the inventory of a SKU that lost money was viewed as success. But as Jonathan puts it, "If you optimize something that is stupid, the result is still stupid."

He urged us instead to consider the earning power of inventory, to change from minimizing inventory cost to maximizing its earning capacity. Inventory represents a significant portion of a company's invested capital, and you want to put that investment to its most productive use.

If you look at your task as maximizing the return on invested capital that is represented by inventory, many other aspects come into play. Look at this comparison of the factors which would be considered in the standard model and the one for which he advocates.

In the old model, all those factors in the right-hand column were "somebody else's job." If, instead, you take a broader view, you realize that those factors must be considered, especially relationships with suppliers and customers. Each stage of that value chain should be analyzed.

There is a historical context for this transition. Markets have evolved over the years.

Before mass production, the "market" was how much you could deliver on your horse or in a cart. With mass markets, full-scale and wide-ranging production and distribution became the norm. Now, though, precision markets exist, with finely grained purchase and consumption decisions intimately tied to the needs of suppliers, intermediaries, and consumers. This requires a new view of value creation, one that leads outside the boundaries of the corporation to include the real-time needs of customers.

Jonathan followed with a number of case studies that dramatically illustrated these points.

Autism in France

2012-01-26T08:13:00.005-05:00

A friend, a doctor in the UK, wrote me this:

Just back from France where I was horrified to learn that autism is treated only by psychoanalysis there because it is believed to be caused by lack of maternal bonding in the first year of life. I almost hit a senior pathologist as he held forth. Medicine isn't always as international as we would like it to be.

Could it be, I thought? So I did a little Google searching on the topic. The first item was an article from The Lancet in 2007. Are you ready for this?

In France, autistic children who have psychiatric problems routinely undergo a treatment that has never been tested in a clinical trial and that many parents regard as cruel. Psychiatrists who use the technique claim that it produces positive results, but critics argue that it shows just how far France has fallen out of step with the international medical community in its understanding of the condition.

The therapy, called packing, involves wrapping a child tightly in wet sheets that have been placed in the refrigerator for up to an hour. When children are encased in this damp cocoon—with only their head left free—psychiatrically trained staff talk to them about their feelings. Typically, the treatment is repeated several times a week, and depending on the results and the severity of the child's condition, it can continue for months or even years.

Oh, yes, let's talk about your feelings.

Another report comes from Chantal Sicile-Kira in 2010:

When [my son] Jeremy showed autistic tendencies [in the early 1990s], I was told by the powers that be to take him to see a psychoanalyst. The psychoanalyst concluded that Jeremy was autistic because he suffered separation issues from breast-feeding. This the analyst gleaned from watching him spin round objects (which reminded him of his mother's breasts) and chase after one that he had "lost" when it fell and rolled under a piece of furniture.

Well maybe things have improved? I guess not. A recent movie on the topic, entitled The Wall, begins:

For more than thirty years, the international scientific community has acknowledged that autism is a neurologic disorder that is the cause of a handicap in social interaction. All autists have the same anomaly in one area of the brain, the upper temporal line identified in 2000 by Dr. Monica Zilbovicius. In France, psychiatry, being very largely dominated by psychoanalysis, ignores these discoveries. To psychoanalysis, autism is a psychosis. In other words, a major psychic disorder resulting from a bad maternal relationship.

This confirms the impression received by my UK friend from her French physician colleague.

Now, though, the film's producer is being sued. According to the New York Times,

Three of the psychoanalysts whom Ms. Robert interviewed for the film have sued her, claiming she misrepresented them in the 52-minute documentary, which has not yet been screened in cinemas or on television.

[I]n court filings, Mr. Charrière-Bournazel said the film had been edited to make his clients look absurd. Ms. Robert, he said, presented the project to the analysts as a documentary, though “it was in reality a polemical enterprise meant to ridicule psychoanalysis in favor of the behavioral treatments that are so fashionable in the United States.”

The film makes no pretense of objectivity, juxtaposing interviews with psychoanalysts with scathing criticism of the field’s precepts. Ms. Robert, 44, describes herself as an anthropologist and said she once wanted to be a psychoanalyst herself.

“I would have never imagined what I discovered,” she said of her first few interviews for the film. “Then I thought, wow, what I hear is just crazy.

Yes, it is.

End-of-life preferences on WIHI

2012-01-25T22:52:00.000-05:00

Have You Had The Conversation? Helping Loved Ones
Discuss End-of-Life Preferences
January 26, 2012, 2:00 PM – 3:00 PM Eastern Time

Guests:
Ellen Goodman, Columnist, Author, founding member of The Conversation Project

Ira Byock, MD, Professor, Dartmouth Medical School; Director of Palliative Medicine, Dartmouth-Hitchcock Medical Center

Bernard “Bud” Hammes, PhD, Director, Medical Humanities and Respecting Choices®, Gundersen Health System

Martha Hayward, Lead for Public and Patient Engagement, Institute for Healthcare Improvement

Most of us, if asked, say we care a great deal about will happen to us when we’re at the end of our lives. And yet, because we’d also rather focus on just about anything but death and dying, especially if we’re young and healthy or aging well, we’re all vulnerable to what can transpire by default: spending our last few days in an ICU, even if that’s at odds with our needs and preferences. The reasons for this disconnect are complex but often stem from the fact that individual and family decisions come late, are hashed out during a crisis, and in the very setting – a hospital – that promises high-tech and high-intervention cures for just about everything.

This scenario is slowly starting to change. There are now numerous efforts, some medically-based and many more that are grassroots, successfully promoting alternative perspectives and practices so that people who’d prefer to die at home can do so, and benefit from pain management and comfort over costly and heroic measures. But when you get right down to it, “dying well” is quite personal and, as such, needs to start in a personal place: by having a conversation with the people you’re closest to about how you want to die and how they, surviving friends and family members, can feel okay carrying out your wishes. Equally important: initiating or being open to that conversation, perhaps several conversations, when the circumstances aren’t so fraught and there’s time to digest and reflect and integrate the information.

All of this and more are what’s behind a new initiative getting underway in 2012 called The Conversation Project (TCP), which you’re invited to learn more about on the January 26 WIHI. In collaboration with IHI, award-winning columnist and founding member Ellen Goodman and the project’s team members seek to create a cultural movement with one basic goal: to help every American say what they want at the end of life so that family members and medical providers have the guidance they need to respect those preferences. To get there, TCP wants to normalize discussions that can at times feel “too big to broach” by encouraging loved ones to talk to one another when circumstances aren’t so charged – when everyone is healthy – and the environment is more conducive to a good exchange. Around the kitchen table, for instance, rather than the hospital bed.

To launch a national campaign to bring about this change, Ellen Goodman and members of TCP have turned to many, many experts on death and dying, palliative care, and successful partnerships with patients and families, including two outspoken champions of change on the clinical and community side: Dartmouth’s Ira Byock and Gundersen Health System’s Bud Hammes. With IHI’s Martha Hayward also on board, WIHI host Madge Kaplan invites you to get an early look at a unique initiative in the making from the architects themselves. Increasingly, that’s going to become all of us – having “The Conversation” and telling others how it went and what we learned in the process. It’s hoped that many will benefit, including health professionals who often find themselves at a loss for words, brought up short by their training, and caught in the cross hairs of their own and others’ conflicting emotions and wishes. Spread the word and please join us on the January 26 WIHI.

To enroll, please click here.

Zeno's paradox of hospital prices

2012-01-25T13:26:00.005-05:00

I apologize to my non-Massachusetts readers for having yet another column about the insurance company payment situation here in the Boston area, but I know there is a lot of interest around the country about the first state that put in place the kind of health care reform that was modeled at the national level. Many things are local in the health care world, but the issue of market power is one that is of interest everywhere. Indeed, there is substantial concern about whether the movement to accountable care organizations will lead to abuses of market power by providers and payers. The market structure issues that exist in this state, therefore, are of broader interest.

A few days ago, I wrote about the falsity of so-called "rate reductions" negotiated between insurers and the state's dominant provider group. (How dominant? See here.)

Today WBUR's always thoughtful Martha Bebinger writes a story with unsubstantiated assertions by insurers that they are acting to reduce the disparity in rates between the provider "have's" and "have-not's." Notes one, "[I]t will begin to narrow the gap." Left unstated is how long it would take to end the gap.

Martha gives a potent example of how long it would take to narrow the gap for a particular procedure, based on some existing prices. Answer: Never.

Let me generalize this. Let's assume that one system's overall hospital rates are 15% above another system's. Let's assume that the higher paid one gets annual rate increases of 2.5%. How long does it take for the other to catch up under three scenarios: a 3% annual increase, a 4% annual increase, and a 5% annual increase?

Now, this is not the extreme example posited by Zeno, put this way by Aristotle: In a race, the quickest runner can never overtake the slowest, since the pursuer must first reach the point whence the pursued started, so that the slower must always hold a lead. Here, it takes virtually forever in the first case, eleven years in the second case, and "merely" seven years in the third case.

I know it is really difficult for insurance company folks to just fess up to the fact that they blinked. But why should they admit that when even the Governor doesn't acknowledge the problem? What's his analysis? He falls back again on changing the rate structure, when it is clear that a changed rate structure based on existing differentials will perpetuate those differentials. Here's an excerpt from his state of the state address a few days ago.

The market is moving in the right direction and that's very good news. But it is not enough.

. . . We need to put an end to the "fee-for-service" model. We need to stop paying for the amount of care, and start paying instead for the quality of care. We need to empower doctors to coordinate patient care and to focus on wellness rather than sickness. And we need medical malpractice reform. . . .

I believe that with these tools and the right oversight, we can slow the growth in health care costs significantly.

Martha ends her story:

I wonder if the insurers' efforts to close the gap between higher and lower paid hospitals is one more attempt to show legislators that the market is working without their intervention. Just wondering.

I amend that slightly:

I wonder if the insurers' efforts at pretending to close the gap between higher and lower paid hospitals is one more attempt to show legislators that the market is working without their intervention. Just wondering.

Building Bundling Business

2012-01-24T21:29:00.000-05:00

An intermediate rate design between fee-for-service pricing of medical services and capitated, or global, payments is the concept of bundled payments. Under this scheme, the health care organization gets a fixed fee for a given medical condition. A recent article from Medscape Business of Medicine by Kenneth J. Terry addresses some of this issues arising from this kind of payment scheme. It notes:

There are 3 main types of bundled payment structures:

Bundling of hospital and physician payments for inpatient procedures;
Bundling of inpatient and post-acute care for a time-limited episode; and
Bundling of chronic disease care for a specific condition, usually for a year.

In all cases, if the provider organization can deliver the care for less than the bundled payment, the surplus is available to be shared in some manner between the facilities involved and the doctors. If it can not deliver the care for the budgeted amount, the loss must then be allocated.

I am going to skip the clinical protocols and other aspects of actual care delivery and focus instead a big business issue regarding this kind of scheme. I have mentioned it before, with regard to global payments, but it also applies to bundled payments.

Underneath the global budget, there is still a fee-for-service arrangement establishing the transfer prices among the providers in a network. That GI specialist will still get paid for each colonoscopy. The big thing to work out in this system is the allocation of any surplus or deficit in the annual budget among the various specialists.

This topic is addressed directly in the financial section of the article, "Dividing the Pie." Here it is:

If healthcare organizations can provide care at a cost that's less than the bundled payments, the resultant savings may be divided between hospitals and physicians in a variety of ways. The most common approach is to pay doctors 100% of their Medicare or private insurance fees and add a gain-sharing bonus if they meet quality and efficiency targets or prevent complications.

Eventually, hospitals may ask physicians to share in downside risk as well. But right now, they're reluctant to do that. They fear that community doctors might not participate in such a program because of their bad experiences with HMO capitation.

Simon Prince, MD, a nephrologist in Manhasset, New York . . . dislikes the idea of hospitals being in charge. Hospitals and physicians both support quality improvement, evidence-based-medicine protocols. and care coordination, he says, but the real problem with bundling is that the hospitals get to decide how the payments will be divided. "At the end of the day, they hold the cards. They have all the leverage in the relationship."

Robert Berenson, MD, a senior fellow at the Urban Institute, concurs with that view and says he wouldn't be surprised if hospitals took the bulk of savings because Medicare's hospital payments represent about 85% of the cost for an inpatient episode of care. But [Michael Zucker, Senior Vice President and Chief Development Officer at San Antonio's Baptist Health System] disagrees, noting that bundling would be impossible without physician cooperation.

[At] Baptist Health. . . the physicians and the hospital had equal voices in the organization, and they decided to split the bundling proceeds 50/50 . . . . Baptist saved $2.2 million in the first year of the pilot, mainly due to lower costs for implants, and 78% of the physicians received bonuses.

Reporter's ABM helps shoot down medical armament in Utah

2012-01-24T09:26:00.001-05:00

In this world of medical arms races, it is refreshing to find a reporter who isn't taken in by the latest hype. It is brave when the story is about a hospital or doctors in one's own town. It is also refreshing to see a reporter who doesn't just parrot the press release, but -- like the journalists of a previous era -- finds alternate viewpoints.

Kirsten Stewart at the Salt Lake Tribune wrote this piece. Excerpts:

An independent group of radiation oncologists affiliated with hospitals throughout Utah is hyping the arrival of “the world’s most advanced radiation therapy.”

But it isn’t new technology, nor is it new to the Salt Lake area. And whether the TomoTherapy brand is “a step above” other systems, as described by Gamma West’s founder and chief medical officer, John K. Hayes, is open for debate.

The trick for patients, of course, is finding which treatments, if any, are right for them — a decision complicated by the soaring cost of cancer care in America.

The rise of high-tech medicine has coincided with a decrease in death rates from cancer. But scientists differ on whether it’s directly responsible for prolonging lives.

“We are very medicalized in this country. We think that every predicament in life is a medical predicament and there’s some miraculous solution,” said Nortin Hadler, an immunologist and microbiologist at the University of North Carolina, Chapel Hill and author of Rethinking Aging and Worried Sick.

[A]bout 80 percent of our increase in longevity is tied to our socioeconomic status — “something about the way we live together, whether that’s job security or education levels,” Hadler said.

Biomedical advances, on the other hand, are responsible for about 20 percent, which Hadler says he’s proud of. But he rails against the overtreatment of patients by an industry that he says has “lost its moral compass.”

Thanks to HealthNewsReview.org for the heads up on this story. As noted by Gary Schwitzer, "Hype. Medicalization. Costs. Informed patient decision-making. She fit a lot into this story and deserves a shout-out for the effort."

Rhode Island Quality Institute seeks help

2012-01-23T21:32:00.000-05:00

Laura Adams, President and CEO of the Rhode Island Quality Institute writes:

The Rhode Island Quality Institute in Providence, RI is seeking its first Chief Medical Officer (CMO) and its first Director, Strategy and Development. Both of these positions report to Laura.

Founded in 2001, the Rhode Island Quality Institute’s (RIQI) mission is to significantly improve the quality, safety, and value of health care in Rhode Island. RIQI is a non-profit and a collaboration of leaders in the Rhode Island community including CEOs of hospitals, health insurers, and businesses, along with leaders of consumer groups, academia, and government. This group is determined to significantly improve the healthcare system in the state by building on the availability and advantages of health information technology.

Chief Medical Officer (CMO) Position (PDF Link).

Director, Strategy & Development Position (PDF Link).

If you know of qualified applicants who may be interested in exploring either of these opportunities, please forward this notice. Resumes should be sent to Michelle Dexter, RIQI Human Resources department at mdexter [at] riqi [dot] org.

The shamans knew

2012-01-23T15:55:00.000-05:00

Thanks to Kevin, MD for reprinting an excellent column by Joe Kosterich entitled, "There is scope for harm when ordering tests." Dr. Kosterich notes:

Most symptoms that we experience are not due to disease. A cough may be a symptom of lung cancer but hardly anyone who coughs has lung cancer. Likewise with a headache and brain tumors.
Most conditions we see today are not acute emergencies and hence can be given time to resolve themselves. You do not always have to run to the doctor at the first sign of any symptom. Listen to your body.
Tests and treatments have an important role but are never free from potential harm. We must always balance the benefits against the risks.
We need to get back to treating people and not numbers so as to please governments and academics.
The process of setting guidelines needs to be cleaned up.

All of this reminds me of some advice I received from an internist a few years ago. He said that the main job of a primary care doctors is to decide not to treat someone's symptoms. I may get the numbers wrong, but I recall him saying that 85% of symptoms just go away after a short time; another 10% can be treated, either simply or in a more complicated manner; and the remaining 5% will not go away even with treatment.

I conclude from this that the shamans and medicine men of olden days had things figured out pretty well. A person shows up with symptoms. In most cases, if you just talk to them, sing some songs, beat a drum or jiggle a rattle, and burn some incense, 85% will get over their symptoms. In other cases, if you administer some herbal remedies -- purgatives, muscle relaxants, anti-anxiety drugs, or anti-emetics -- another 10% will get better. And for the final 5%, you blame a lack of progress on the "evil spirits" or other supernatural forces.

With a 95% success rate, your career and livelihood is assured!

For more on this and related topics, check a new website called The Naked Doctor. An excerpt:

Naked Doctor aims to encourage discussion and awareness of the opportunities to do more for health by doing less. It is a compilation of articles, books and other works that highlight overdiagnosis and overtreatment.

It is a project of Dr Justin Coleman, a GP who works in Aboriginal and Torres Strait Islander health in Brisbane. He holds a Masters in Public Health, and is President of the Australasian Medical Writers Association.

The Joint Commission tries to lead hospital leaders

2012-01-23T08:13:00.000-05:00

I was intrigued to read of a new standard, effective July 1, 2012, adopted by The Joint Commission regarding the need for hospital leaders to create and maintain a culture of safety and quality throughout a hospital. Here it is:

I do not know how to find the previous standard for this topic, so I don't know how different it is. But this one seems to reflect comments made in the past by JC president Mark Chassin that the industry needs to get better creating and maintaining a true culture of process improvement. For example, an article by him and Jerod Loeb in Health Affairs centers on this topic. In a town hall meeting back on April 13, 2011, Mark also noted:

The first premise for taking on this new topic is that I believe we need to do something different in quality improvement. . . . Our public stakeholders are clamoring for much more rapid improvement that extends over more aspects of the way care is provided . . . . So, the fact that we've made some progress is important, but it's not enough.

[W]e can learn from organizations that are outside of health care that have managed to deal with very serious hazards much more successfully than health care has. . . . When we're talking about organizations known in this literature as High Reliability organizations—commercial air travel, aircraft carrier, flight decks, even nuclear power—have much better safety records than health care does. [W]hat they actually have in common is that they have very effective process improvement tools that allow them to create nearly perfect processes and a safety culture that wraps around those very highly performing processes and keeps them working at high levels of safety over long periods of time.

This is an excellent diagnosis of the problem, and the contrast between those industries and most hospitals is dramatic. How, then, to draw the nexus between where hospitals need to be and this newly adopted JC standard? Face it. If this standard were enforced today, most hospitals would not be accredited.

Sure, a hospital could create pro forma policies that would appear to represent compliance with the standard, but that is quite different from establishing a true culture of process improvement. In my former hospital, with a full-fledged effort, it took five years to get to the point that we understood pretty well how to accomplish process improvement. I think if you talked with other leaders like Gary Kaplan at Virgina Mason and Jeff Thompson at Gundersen Lutheran, they would say the same. And look here for the exposition by Jack Billi at the University of Michigan Health System, who modestly explains that, after years of dedicated work, they still have a long way to go.

As I have stated, The Joint Commission has the unenviable task of enforcing the CMS Conditions of Participation, a hugely bureaucratic set of standards. Its surveyors' manual relating to these regulations goes into excruciating detail. Given those requirements, I always found the Joint Commission surveyors to be thoughtful, helpful, and highly experienced people; but to evaluate the new standard copied above will require an entirely different set of assessment skills and personal experience from the surveyors. How will they be trained to be fair and accurate judges of this standard, to know the difference between real progress in a hospital and window dressing? Given that they drop in for just a few days every three years, how will they judge progress over an extended period of time?

Finally, this kind of standard is quite different from, for example, the one requiring 16 inches clearance above shelves in a storeroom. With those detailed standards, when you "fail" enough of them, you need to have improvement plans and you risk loss of accreditation. If a hospital is found not to comply with this new standard, what will be the remediation process?

So, good for the JC in setting for this standard. The jury is out as to how it will be enforced and how meaningful it will be.

Let's move to real-time philanthropy

2012-01-22T18:55:00.001-05:00

I want to present here a somewhat radical view of how large non-profit organizations like hospitals might more appropriately use the financial reserves they have accumulated through philanthropy. In short, I want to suggest that virtually all gifts received by a non-profit of this scale should be considered spendable, to be used -- and used up -- for the strategic priorities for the organization over a short period of time, say five to ten years.*

I offer this thought not in any attempt to be critical of the current policies of hospitals, but in the hope of stimulating some discussion. If this approach were to be adopted, it would require a different viewpoint by boards of trustees and a different approach with many prospective donors.

Some background. Virtually all large non-profit hospitals must engage in fundraising to support their clinical, research, and teaching activities because payments from the government and private insurers are inadequate to cover a portion of those costs. The preponderance of funds received are from individuals and family foundations, from people who believe in the mission of the organization and want to contribute to its success. Some gifts are offered for current use, but that is a small portion of those received. A greater percentage of funds donated are placed in endowment-type accounts, against which the institution applies a payout policy. That policy is usually very conservative, designed to support the perpetual existence and availability of the gift.

It is the word perpetual that concerns me. In treating donated funds in this manner, the institution has decided that there is an overly important inter-generational aspect of its fiduciary responsibilities. I want to question that, both as a matter of philanthropy and as a matter of sound business planning.

Let me first acknowledge that it is a good idea to have some "money in the bank" for untoward circumstances, dips in the economy, and such. Also, of course, there is a need to accumulate some amounts before committing to specific large capital investments. But let me suggest that the amount of money reserved by most places greatly exceeds the need to cover those contingencies and those projects.

As noted, I'd like us to think instead of a policy that directs virtually all gifts received by a non-profit to be considered spendable. Instead of constituting a long-term holding account, the funds would be used -- and used up -- for the strategic priorities for the organization over a short period of time, say five to ten years.

Why? First of all, I do not believe that most donors, were the question put to them in this way, would want their donations put in a decades-long holding account. I think that most donors want to see their gifts put to use today and in the near future, to improve patient care now, to expand research now, and to enhance teaching now.

Second -- and this is the controversial part -- the establishment of large, slow-payout endowment funds reduces the accountability of a non-profit to the society it serves. Non-profits are different in many ways from for-profits, which have to answer regularly to investors and thereby prove their strategic and tactical decisions. The "shareholders" of non-profits are more diffuse, the citizens of the region served. The success of the non-profit, too, is not measurable by a simple profit-and-loss calculation. I think we can all agree that an important measure of the effectiveness and relevance of a non-profit is the degree to which it can persuade people to donate money.

A powerful test of an organization's relevance, therefore, is whether it is able to raise money from each generation. In contrast, the kind of inter-generational transfer of funds represented by a slow-payout endowment accounts weakens the ability of an institution to assess its relevance to the current generation.

I realize that this approach would put non-profits at greater risk. I am suggesting that this is a good thing. It is too easy for the management and board of a hospital to get complacent and comfortable when they have a big bank account and use only a small portion for current expenditures and capital budgets. It is also too easy for them to respond to a turn-down in revenue in a manner designed to preserve those financial assets rather than, for example, to preserve the jobs of people working in the facility. How many times have we seen hospitals conduct major personnel lay-offs while their endowment accounts remains strong? To be blunt, these are often instances of valuing money over people. These kind of decisions can result from overly conservative boards being more focused on the long-run preservation of assets than on an equally important assertion in support of the organization's human capital.

So, let's cut through all that and decide that each generation should be responsible for the financial health of the hospitals in the community. Sure, have a bit of money squirreled away for contingencies, but test the proposition of each non-profit's value to society by expecting those living today to provide support for today's programs and services. If an organization cannot meet that test of relevance, let's not plan to keep it on life-support by using money from previous generations of donors.

---

* This could apply to large colleges and universities, too.

Samsung's Smart Window

2012-01-22T06:57:00.000-05:00

A really neat invention. Thanks to Bertalan Meskó, MD (@Berci on Twitter), who notes, "Such windows would look great in hospitals as well.

Thanks for nothing

2012-01-21T21:11:00.001-05:00

I have been reading and listening to media reports about recent deals between Partners Healthcare System and insurers in Massachusetts and experiencing a case of cognitive dissonance. From the reports, you would think that PHS is reducing the rates it gets from the payers.

Well, that just shows the power of PR spinmeisters. Let's start by recalling that PHS has used its market power for well over a decade to extract payments from insurers that are dramatically above those received by other hospitals and physicians. Those out-of-market rates were built into the contracts that were to extend a year or two into the future, and the annual increases included in those contracts were likewise out-of-market.

So, what has happened is that PHS has agreed to lower the rate increase for the last year or two of those contracts and for the succeeding years to something in the 2-3 percent range. It then claims to produce "savings" of $45 million over two years for Tufts Health Plan and $80 million annually for Blue Cross Blue Shield.

These "savings" mask two phenomena. First, the base upon which those 2-3% rate increases will occur remains substantially above the rates paid to other hospitals and doctors. Second, the rate increases that PHS has received are no lower, and sometimes higher, than those granted to other systems whose base rates were already lower.

In short, the disparity between the PHS rates and those of other providers will not drop an iota as a result of these deals, and is likely to increase.

The only good thing about these announcements is that they provide, for the first time, a sense of the tax imposed by PHS on the region's health care budget. We now see that it can forgo what it has characterized as $345 million in future revenues and still maintain its financial health. Looking back over the past decade, it is not unreasonable to posit that this system has added in the range of two billion dollars to the health care costs paid by the state's businesses and individuals. The newly announced deals change little in that regard, extending that hidden tax for years to come.

Thanks for nothing.

Carrying a lot of baggage

2012-01-20T18:55:00.003-05:00

In contrast to the story below about treating airline priority customers well, let's turn to baggage handling. I recently traveled on American Airlines through Miami en route to Boston. The luggage from my first flight was to be shifted from that airplane to the Boston flight. I had used some mileage credit to get a first-class upgrade so my bags were tagged with a special red marker indicating "priority handling." According to AA, this would ensure special and expedited treatment:

Immediately available system-wide, select American Airlines customers will experience Priority Baggage Delivery. Upon check in, your luggage will be tagged with branded Priority bag tags. And when you arrive at your destination, those bags will be the first ones delivered to the baggage claim area, allowing a swift, convenient exit from the airport.

I got to Logan Airport and waited at baggage claim for 45 minutes until all the luggage had been unloaded. Mine was missing, so I went to the baggage service desk. A very nice person looked up my record and said, "Oh yes, your bag missed the connection and is on the next flight." So the company's baggage tracking information system had worked. They knew where my bag was and had known for several hours.

Query: Why hadn't they notified me upon arrival -- or even before arrival when I was aboard the plane? They knew what plane I was on. Why have me go through a long fruitless wait at the airport? If you have such a powerful information system, why not use it to the benefit of your patrons? Especially your so-called "priority" customers.

Indeed, why can't all customers gain access to the baggage information system on their computers or iPhones? Sounds like that would be better service and possibly save money for those companies, too.

Airline priorities

2012-01-20T18:39:00.000-05:00

First impressions about service issues can sometimes be misleading, especially if you don't understand aspects of traffic flow. Here was my first impression, and then something I learned afterward.

We start with this scene of a Delta airlines gate area. It happens to be at the Atlanta airport, but the same configuration is used elsewhere. (See the Memphis set-up below.) Note the sign indicating two lanes of traffic, "general boarding" and "Sky Priority." Note, too, the special carpet with "Sky Priority" printed on it. As you can see, the two lanes go to exactly the same door.

Here's what happens. When a plane is being boarded, passengers who have the "Sky Priority" status are boarded first and directed to use the right-hand lane. Indeed, a ribbon is stretched across to prohibit entry through the other lane. When those passengers have finished entering the plane, the ribbon is moved over to block the priority lane, and the general boarders use the other lane.

I asked my gate attendant why this was done. She giggled and said, "It is kind of silly, but it makes the Priority passengers feel important."

Priority route

General route

I know this is not a big deal in the scheme of things, but let's calculate how much money Delta spent on those signs, the fancy rugs, the barricades, and so on. I wondered, "Have they really done research to show that passengers care about having a special lane?" Early boarding, sure. But in an industry that never makes a profit, why spend money on something silly like this?

But then I talked to a friend who is on the board of an airline company. He said, "It is all about traffic control at the gate. If you don't have a physical separation for those classes of customers who are entitled to early boarding, everybody else just piles up at the gate. It slows things down, plus the passengers who have paid for or otherwise earned priority status get shoved aside. Those loyal (and mainly full-fare business) passengers are very important to an airline, and they value unfettered early boarding. So, we incur a little extra expense to give them higher quality service."

Inventory Productivity Webinar from MIT

2012-01-20T07:55:00.014-05:00

Inventory Productivity: Missing Link Between Supply Chain Management and Sales

MIT SDM Systems Thinking Webinar Series

Jonathan L.S. Byrnes

Senior Lecturer, MIT

Date: January 23, 2012

Time: Noon - 1 p.m. EST

Open to all

Traditionally, supply chain and sales have been managed relatively independently, despite the critical impact that each has on the other. Systems thinking provides the key to linking these two critical business functions.

Inventory productivity, the return on invested capital in your inventory, is the single systems measure that links these two cornerstone functions. This webinar will: 1) explain the central importance of this critical metric; 2) describe how to measure inventory productivity in a practical way; 3) outline the levers that both sales and supply chain managers can use to radically improve inventory productivity; and 4) describe how leading companies have created core processes for sales and supply chain managers to work together to achieve stunning results.

Routine or rote?

2012-01-20T06:31:00.003-05:00

I am reprinting one of my favorite columns, first posted here on April 26, 2007.

A story for all who have been through the multiple rounds of medical histories upon entering an emergency department.

A good friend found herself in a local ED with symptoms of appendicitis. The first medical history was taken by the triage nurse. Then, another nurse. Then, an intern. Then, a resident. Finally, the attending arrived, and he started the process again, writing while talking and making no eye contact.

By this time, my friend had memorized all the questions, and she figured she could speed up the process by anticipating the next questions and giving the answers in advance of their being asked. "Have you ever had abdominal surgery?" "Yes," she replied, and proceeding to the next as yet unasked questions, offered, "It was a complete hysterectomy, and it was three years ago."

Without pause, and without thinking, he said, "Is there any chance you are pregnant?"

She, feverish and in pain, raises up one elbow, looks directly into his eyes and says, "Either you are trying to introduce some levity into this situation, or that is the dumbest question you ever asked."

He turns deep red and leaves the room without another word.

Moral of the story: In a busy environment like an ED, it is all too easy for providers to go on "automatic pilot" and not really pay attention to what the patient is saying.

Costs of Care essay winners -- Part 1

2012-01-18T18:00:00.003-05:00

Do you remember my post back in September helping to publicize the Costs of Care essay contest? Well, the judges have acted and picked the winners. Organizer Neel Shah writes:

Two of the winners are from Boston, including an internist who described how a pharmaceutical cost-shifting strategy left him unable to discharge his patient from the hospital, and a medical student who described how she was able to treat a patient in her clinic on a $100 budget by avoiding an unnecessary hospital admission. In all, we received more than 100 submissions from patients and providers all over the country that illustrate both challenges and opportunities to improve the value of care.

We also plan to summarize the lessons learned from the stories we received over the last two years in the form of "quick guides" and educational web-based videos that we will release over the next few months.

I'll print two of the essays in this post and two others by patients below in a separate post. Here is the first one Neel mentioned, by Andrew Schutzbank.

Peggy was in her early 70s and suffered from a terrible lung disease known as pulmonary hypertension. So bad in fact, that she had a pump infusing a medicine under her skin 24 hours a day to keep the blood supply to her lungs open. Once started, this medicine, treprostinil, was known to improve life in those with pulmonary hypertension. Unfortunately, like all continuous infusion medicines of this type, it has the unfortunate side effect of sudden death if stopped for more than 4 hours. Starting it was a difficult choice for Peggy and her expert team of physicians, but her disease had progressed to a point where it was the right decision. As you can imagine, this drug was mighty expensive. We would only find out how expensive later.

On the day that I met Peggy, she was being admitted to the Intensive Care Unit (ICU) not for her pulmonary hypertension, but because she had a bleed in her stomach, which caused her to swallow blood/stomach contents into her already damaged lungs. Once stabilized, our first challenge was to ensure that she continued on the treprostinil. It took a little magic from pharmacy and the drug’s manufacturer, but we were able to get everything together and Peggy was no worse for the wear.

A few days later Peggy was improving, breathing tube out and awake and back to herself. Due to the special nursing needs with treprostinil, Peggy was required to be in the Cardiac Care Unit (CCU), a special type of (ICU), despite her progress. Even though Peggy managed this medicine at home by herself, hospital policy prevented her from transitioning out of the ICU to the general medical floor, at a fraction of the cost. Conceding that point, the decision was made to try and transition Peggy directly to Rehab. But her progress was stalled for one simple reason: treprostinil.

It turns out that if Peggy were to go to a rehab, they have to pay for her medications out of the money they receive to care for her. As it turns out, treprostinil costs $1400 per day. $1400. Now, Peggy does not pay that amount, she has a special arrangement worked out with the company and the state. But in order to make that arrangement work, the company charges full freight for the drug when the patient is institutionalized. Since the drug cost alone would wipe out payment for her stay, no rehab would accept her. So Peggy was stuck in the hospital, and stuck in one of the most specialized and expensive beds in the hospital in the CCU.

Think about that for a moment. A critical care bed was tied up for days for a patient that was well enough to leave the hospital, just not ready to go home. Arbitrage was suggested—would it not make more sense for our hospital to buy the drug for her at rehab, freeing up the CCU bed (which costs far more than daily dose of treprostinil). But we are doctors, not financial engineers. We work in the world of medicines and were unable to orchestrate such an unusual arrangement. So we did the only thing we know how to do. We stopped the expensive medicine.

This was not a financial decision. Peggy had been describing vague body pain, a known side effect of all prostaglandin medicines. Think of treprostinil as a 24-hour infusion of anti-Ibuprofen. Her breathing was actually quite good despite her recent trials in the hospital, so stopping the medicine made medical sense. We monitored her closely during the transition and she quickly improved! She was able to move around more and started on recovery. She was transitioned to a rehab shortly thereafter and continued to improve.

My colleagues’ decision to stop treprostinil was a medical one. But ironically, we would not have considered it if were not for the cost factor of the medicine. Peggy would have gone on for some time on an expensive medicine that was not helping her. At the same time, it was through one party’s insane attempt to “control costs” that simply caused costs to be shifted and multiplied. The entire health care system spent much more on Peggy’s care because no one had the vision or authority to deal with $1400 a day. Pennies compared to the amount wasted, and nothing compared to the risk undertaken by Peggy and her family during this trying time.

And here is the second essay mentioned, by Molly Kantor.

As a third year medical student, I spent one afternoon each week at a health clinic at a community hospital affiliated with my medical school. This health clinic was focused on primary care for patients with HIV, and many of our patients were poor, homeless, immigrants, or uninsured. Many were also living with their diagnosis in secrecy and had to hide their medications and medical bills from family members.

One of my patients, who I will call Clara, was a 65 year old Haitian immigrant who diabetes, heart failure, and depression, along with HIV. Due to her medical conditions, she was unable to work. She had two grown children, but they did not live nearby and did not know about her medical problems, especially her HIV. Her husband, unfortunately, was very ill and lived in a nursing home. Clara somehow managed on her own, but her lack of insurance, poor medical literacy, and limited English proficiency made it difficult for her to stay healthy, and she was constantly coming to clinic for help.

At one visit, Clara seemed unusually tired and revealed that she had been feeling short of breath at home. In my mind, this raised many questions—Could this be a heart attack? Worsening heart failure? A blood clot in her lungs? Pneumonia? I took a history and did a physical exam, and my top concern was that this was an episode of worsening heart failure, what we call a heart failure exacerbation, and this typically occurs because the body accumulates too much fluid that the heart has trouble pumping it all so it backs up into the lungs. Usually, this is a patient who you would send to the Emergency Room (ER) and have them admitted to the hospital so that they could get diuretics (water pills) and slowly lose the extra water—all while being carefully monitored in the hospital. However, Clara refused to go to the ER. “Too expensive,” she stated firmly. “I can’t go into the hospital again.”

We realized the burden this would have on her and her family, so we worked around the problem by getting an EKG done right in the office and getting a chest x-ray. When her EKG and chest x-ray supported our diagnosis, we decided to give her the diuretics as an outpatient and to have her come back for a second office visit in a few days. When she returned, she felt that breathing was much easier, and her physical exam supported the improvement. Instead of this heart failure exacerbation costing thousands of dollars for an ER visit and hospitalization, this cost only a few pills (furosemide 80mg PO costs about $0.29 per pill, and she was prescribed this once daily in addition to her normal medications) plus an extra primary care doctor visit, which runs about $100.

Costs of Care essay winners -- Part 2

2012-01-18T17:58:00.000-05:00

Here are two more of the winning essays from the Costs of Care essay contest described in the post above. These are by patients.

Renee Lux, Connecticut
Patient Cost Anecdote: an unnecessary CT scan raises a patient’s insurance premiums

One morning this May, I woke up with a stiff neck. I applied hot and cold therapy all day and took an Advil before bed. By the end of that week, I was unable to comfortably move my head and I was feeling numbness down my left arm to my fingertips. I saw my doctor within 24 hours of calling his office. After a brief exam, he was sure of my diagnosis, but he scheduled me for a CT-scan at the hospital the next day, “Just to be certain.” A day after the CT-scan he diagnosed me with Radiculitus Cervicalgia- inflammation leading to nerve root impingement. I was prescribed a 10-day regimen of prednisone. By the end of my prescription, the pain was gone and my total out of pocket expense was $55 in co-pays. The unintended result of this diagnosis will cost me $2,220 a year in increased health insurance premiums for the foreseeable future.

Stress and anxiety was likely the root cause of my radiculitus. Stress and anxiety brought on by my search for affordable private health insurance. My husband had been out of work for over a year and our COBRA, with the government’s Premium Assistance Rate (ARRA), was about to run out.

I contacted a health insurance broker and explained that I needed an affordable, high-deductible plan for a family of four with no pre-existing conditions. We are all healthy, all average weight and height, non-smokers, none of us are on medication and we have no issues with cholesterol or allergies and no plans for more children.

The broker found us an affordable plan and sent over an application for underwriting which I carefully filled out. Within hours of emailing it back to her I received a frantic phone call. “You said you had no pre-existing conditions!” she bellowed down the line.

She explained that having had a CT-scan and prescription medication within 30-days of my application made me practically uninsurable. She was adamant that the CT-scan alone would trigger an automatic denial. The broker suggested a high-risk plan, which is very expensive. If I couldn’t afford it, I could apply for Connecticut’s High Risk Insurance Pool, but I would have to be un-insured for 6 months in order to qualify.

“High risk?” I thought meekly. I don’t have diabetes, cancer or HIV. I don’t even have high blood pressure. How can I be high risk when my diagnosis was resolved with $5 worth of prescription drugs?

Now I was frantic! I called my doctor. He was incredulous, insisting that my radiculitus was resolved. He offered to write a letter on my behalf. I contacted a friend of a friend, a medical underwriter in another state. All she would say was that my diagnosis within a month of my application throws up red flags for insurance companies.

I took a deep breath and started over with a new broker- we talked over the phone. When I told him about my recent CT-scan I could hear him sucking in his cheeks. There was a long silence.

Finally, he suggested we apply to three insurance companies at once, in the hope that one would accept me. The underwriting process requires me to state if I have ever been declined health insurance. A denial by one company would trigger automatic denials by other insurance companies.

I filled out three applications and agreed to phone interviews with underwriters for two insurance companies.

Eventually, one company offered to cover my family, but denied coverage to me. One company offered us coverage with an exclusion: “This policy does not cover any loss incurred by Renee Lux resulting from any injury to, disease, or disorder of the cervical spinal column, including the vertebrae, intervertebral discs, surrounding ligaments and muscles, treatment or operation therefor and complications therefrom.”

The third and final insurance company approved my coverage with a premium increase to cover my medical condition, “Cervicalgia/Inflammation of the neck.”

Had I known what the repercussions of that doctor visit were, I would have asked my doctor if the CT-scan was absolutely necessary for my diagnosis. Perhaps even the prescription could have been replaced with a higher dose of over the counter anti-inflammatory. The long-term affect of my “pain in the neck” is an additional $189 a month for the foreseeable future.

Here's the second one.

Court Nederveld, Florida
Patient Savings Anecdote: a frugal patient saves money on routine prescriptions and testing by having a frank conversation with his doctor about costs.

Hypertension was the trigger that forced medical cost awareness to the forefront. My doctor decided that with a rise in blood pressure it would be prudent to proscribe a blood pressure drug and order a nuclear stress test. With only a catastrophic insurance policy with a $5000 deductible it was imperative from our personal financial state that the cost of both the drugs and the procedure be known up front. The prescription was the first thing we faced. The script for Lotrel was written and a trip to the pharmacy revealed an out of pocket cost of $200 for a thirty day supply. This was way beyond my means especially factoring in that this drug would most likely be required indefinitely. Relating this information to the doctor resulted in a prescription for the generic Norvasc and the pharmacy cost was to be $138 for 30 days. Still beyond household finances. I then began to research Lotrel and Norvasc and discovered that they are two old blood pressure medicines, amlodipine besylate and benazepril hydrochloride. I requested that my doctor write the script for these two separate drugs and I now take them daily at a cost of $7 for a thirty-day supply of both drugs.

Having successfully challenged the cost of prescriptions my eyes were wide open as I began the quest for a nuclear stress test. My doctor, fully aware that I would be a self-pay referred me to a colleague in our area. A phone call began with introductions and the statement that because I would be a self-pay patient it was imperative that I know the cost of the procedure before hand. The doctor was unable to immediately provide a cost and after checking with staff requested $2500. I reminded him that I was uninsured. He replied that it could be done for $1900.

I told the doctor that I wanted to be sure I understood. I asked, “if I walked in with a check for that amount I would walk out with the test results?” The physician responded that I would need to come in for a consultation first. Cost $250. I asked again, “if I walked in with $2150 would I walk out with the test results?” Again the reply was that there would have to be a follow up visit to review the results. Cost $250. Hesitation must have been detected in my voice or the doctor detected a possible mark, because the doctor then said that perhaps I didn’t need a nuclear stress test and a regular stress test would suffice. Cost $800. Consultation and follow up not included. I then asked what would occur if the regular stress test revealed nothing. His response was that we would do the nuclear stress test to be sure. The inverse was also true; if the regular stress test revealed any anomaly then a nuclear stress test would be ordered to provide further information. Total cost out of pocket would be $3450.

Feeling much like a cow on a milking machine I began to test the theory that medical procedures were money making enterprises and as such should be available as a commodity. Using the Internet to begin my search, the only specific criteria required was that the location of the facility performing the test be within a short drive from home. It took very little time to find and confirm a company that would provide a nuclear stress test sans consultation, follow up and would willingly and promptly forward the results to my primary care physician. To verify that all was understood I informed then that I would have a check for the exact amount they quoted and no further remuneration would be forthcoming. All was as stated and the procedure was done. Total cost was $938.11.

While these two episodes have been the only challenges faced so far, having related these stories to friends and family, they also have begun to challenge costs and procedures with very similar savings.

It will be several years before Medicare is available to me and until that time I intend to challenge every prescription or procedure as to necessity and cost.

What would Richard do?

2012-01-18T12:54:00.002-05:00

When it comes to hotel service, I have a new standard by which I measure facilities: "What would Richard do?" Richard Caines, you may recall, is director of training at the Gaylord Palms Resort and Convention Center in Kissimmee, Florida. The hotel appropriately prides itself on a very high standard of service, based in turn on a respectful and congenial approach to its staff.

So, today, I am at the Gold Strike Casino Resort, in Tunica, Mississippi, where I will be giving a speech to a group of health care finance people. Hearkening back to my years in Arkansas, I decided to start my day with a good old-fashioned Southern breakfast in the comfort of my room. Now, there was no way I was going to eat all 2000 calories, but I was looking forward to sampling the grits, biscuits, and fried ham steak.

Well, as I dug into the ham, I discovered that it was resting comfortably on a rather long and dark human hair. That quickly ended breakfast, and I called room service to report the matter. The woman who answered was very apologetic and offered to send up another meal. I said that I no longer had an appetite for that and was only concerned that they find the cause of the problem so it wouldn't happen to anyone else. She told me that someone would come up to investigate.

A short while later, a man from Security showed up. He took a picture of the evidence; took a picture of me to document that the hair could not have come from my head, and then asked me write out a description of the event and sign it. He also donned surgical gloves and put the offending hair in an evidence bag. He left behind a card, with contact information for the security department, saying that I could contact them in about five days to learn the results of their investigation. He was polite and helpful throughout.

The way the hotel choose to handle this case made me feel like I felt like a witness at the scene of a crime more than a customer reporting a service quality problem. Yes, both people with whom I was in contact were friendly, concerned and appropriate. Each one asked if there was anything further they could do to help me.

I think Richard and his colleagues at the Gaylord would have handled this differently. I think they also would have apologized profusely. I think they would have offered to refund the cost of my breakfast. I think they would have gone further to make sure I would want to come back to their resort, perhaps even so much as refunding a portion of my room charge or offering me a discount on a future stay. They would not have asked me to fill out an affidavit, which in essence made me feel like the hotel didn't trust my oral report. And they NEVER would have taken a picture of me to substantiate the nature of my complaint -- as though a customer would choose to lift up a ham slice and put a hair underneath. Finally, they would not have left it up to me to contact the hotel in several days. They would have taken it upon themselves to send me a report, along with remedial steps they had taken. I imagine, too, that a senior manager would have come to visit me within an hour or so to apologize again and explain their process improvement plans.

Minor points? Maybe. But in a highly competitive resort marketplace, details matter.

(In health care, too, by the way.)

---

Addendum: A short time after I wrote this, I went to the front desk to check out. The process was taking longer than expected, as the desk clerk stepped away to consult with her supervisor. After some time, she returned, and I asked if everything was all right. "Yes," she said, "we were figuring out how to 'comp' you for your breakfast order this morning." A nice gesture, I thought, but why had no one mentioned it earlier during my talks with the room service or security people? By delaying the gesture, they lost a chance to make a good impression in real time.

De-Magnetizing

2012-01-17T20:45:00.014-05:00

One study does not a trend make, but this one has conclusions that are so direct that it is bound to attract lots of attention . . . and anger from certain quarters. This post, likewise, may prompt additional anger from some of my readers.

C.J. Goode and others have published an article in the Journal of Nursing Administration entitled, "Comparison of patient outcomes in Magnet® and non-Magnet hospitals." You can view the abstract here. Let me give you the highlights:

Non-Magnet hospitals had better patient outcomes than Magnet hospitals. Magnet hospitals had slightly better outcomes for pressure ulcers, but infections, postoperative sepsis, and postoperative metabolic derangement outcomes were worse in Magnet hospitals.

What an indictment of a certification process that the American Nurses Credentialing Center describes as follows:

The Magnet Recognition Program® recognizes healthcare organizations for quality patient care, nursing excellence and innovations in professional nursing practice. Consumers rely on Magnet designation as the ultimate credential for high quality nursing. Developed by the American Nurses Credentialing Center (ANCC), Magnet is the leading source of successful nursing practices and strategies worldwide.

What is the ANCC? It claims to be "the world's largest and most prestigious nurse credentialing organization." Its website explains:

The American Nurses Credentialing Center (ANCC), a subsidiary of the American Nurses Association (ANA), provides individuals and organizations throughout the nursing profession with the resources they need to achieve practice excellence.

For purposes of this post, let's accept that and stay away from credentialing and professional advancement programs for individual nurses and focus on what it takes to receive Magnet® designation. Well, like other types of certification programs in other industries, your organization needs to meet an array of standards based on certain philosophical underpinnings, and you need to "pass" a review by independent surveyors.

You also need to pay a lot of money. There is an application fee, an appraisal fee, a documentation review fee, a site visit fee, and an extension fee if you want to postpone your site visit. In all, the process costs tens of thousands of dollars, paid to the ANCC, not to mention the costs incurred by the hospital on internal organizational matters.

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? We now have one such study that indicates the contrary.

Currently, there are 391 Magnet hospitals. As I look through the list of those from my own state of Massachusetts, I don't see any that offer sufficient public, real-time data about clinical quality to prove the case of higher quality. And given the dearth of transparency with regard to clinical outcomes nationwide, it is hard to believe that one could do so in any other state.

I did a Google search on the topic of "quality of care at Magnet hospitals" and found very little. There was a 2010 thesis by Kelly Scott, a nursing student at the University of Kansas, entitled "Magnet Status: Implications for Quality of Patient Care," Magnet Status: Implications for Quality of Patient Care which said:

In summary, this study did not find evidence to support the expectation that Magnet accreditation directly correlates to lower rates of hospital‐acquired infections. There was evidence to support existing research indicating that nursing workforce characteristics are better in Magnet hospitals. While Magnet accreditation remains the gold standard for nursing work environments, this status does not automatically lead to better patient outcomes.

And in the absence of real data, it seems that a hospital's enthusiasm for the importance of this status can be transitory, at best:

Magnet hospital status was "the ultimate benchmark to measure the quality of care" for the University of Kentucky until it failed to get renewal of the designation.

A hospital official questioned its importance last week. "It is a recognition from a professional society," said Dr. Richard Lofgren, chief clinical officer for UKHealthcare. "You can get recognition from a whole lot of professional societies."

Uh oh, it sounds like a lot of revenue for the ANCC might be at risk unless peer-reviewed articles emerge that document real quality improvement results from this certification process.

Read more here: http://www.kentucky.com/2011/03/07/1660635/nursing-care-designation-doesnt.html#storylink=cpy

Wachter explains private practice in the UK

2012-01-17T09:55:00.000-05:00

Bob Wachter continues to offer thoughtful perspectives on the British health system. The latest is about the role of private insurance and private doctors operating in parallel to the National Health Service. Here are some excerpts:

[F]rom the time of its founding in 1948, the British National Health Service has allowed – and, depending on which party is in power, promoted – a private insurance market. Private insurance in a single payer, government run healthcare system is a funny animal: one part incest, one part conflict of interest, and three parts strange bedfellows. And it’s infinitely fascinating.

The action in the private world stems from occasionally poor access to specialty care in the NHS, both because of limited numbers of specialists and gatekeeping by GPs. The result of these limitations is the famously long NHS queues. . . . [M]any patients still have to wait longer than they’d like in the NHS. Such patients find the private sector’s shorter waits attractive.

Who are the doctors who provide this private service?

There are few purely “private doctors” in Britain – most private care is delivered by moonlighting NHS physician-specialists. . . . [T]he NHS’s 30,000 specialists have had no cap on the amount of money they can earn from private practice, as long as they clock 40 hours a week for the Health Service.

Hmm, doesn't this create a conflict of attention? Yup.

The conflicts play out within the specialists’ practices themselves. One London neurologist told me that he might see a patient in consultation for a neurological disorder and offer a follow-up appointment in several months, assuming there is no urgent clinical need. “But if the patient has private insurance, she can see me tomorrow if she’d like.”

The average specialist in the UK augments his or her income by about 50 percent through private practice, but there are wide variations. Specialists operating in the countryside, where few patients have private insurance, may have no opportunity to practice privately. On the other hand, some London specialists double or triple their salaries through private work.

Isn't this unsustainable?

Yet while they differ at the margins, both parties seem content to allow private practice to exist, and sometimes thrive. I wondered why: doesn’t the private sector siphon off resources – both money and providers’ time – from the NHS? I finally had my aha moment when one NHS manager likened the situation to that of US private schools operating alongside our underfunded tax-based public school system. “All the people using the private system have already paid their taxes, so they are siphoning volume out of the NHS that the system otherwise would have to manage,” he said. “The NHS would come to a grinding halt if private practice went away.”

None of this is surprising. Back in 2007, I wrote about how the US and European health systems will eventually converge.

The health systems in these countries are owned and financed by the government and are often appropriately cited for the quality of care offered to the public. Indeed, in debates here in the US, they are often called out as examples of what we might strive for in terms of universal coverage and a greater emphasis on primary care than we have.

[In a nationalized health system, the] appropriation by the parliament is a politically derived decision. . . . In the face of inevitable limitations on the ability of the national hospital system to offer all services demanded by the public, a growing parallel system is emerging, in which private practitioners offer elective therapies and procedures outside of those supported by the national system.

I predict . . . that the systems will start to look more and more alike over time. Pressure in the US for a more nationally-determined approach. Pressure in Europe for more of a private market approach. It shouldn't surprise us to see this convergence. After all, the countries are dealing with the same organisms, both biologically and politically.

Water interests in hospitals: Spraying infections?

2012-01-16T08:12:00.000-05:00

By now, you may have heard about the outbreak of Legionnaires’ disease in Wisconsin that was linked to a decorative water wall in a hospital lobby. As noted in this Washington Post story:

In 2010, eight people contracted the severe and potentially life-threatening form of pneumonia caused by the bacteria. None had been admitted to the Milwaukee-area hospital at the time of exposure. But they all had walked by the water wall in the main hospital lobby, researchers said.

I wonder how many more people may have been unknowingly infected. The article continues:

The study, published online in Infection Control and Hospital Epidemiology, is the second documented outbreak of Legionnaires’ disease in a health-care setting associated with a wall-type water fountain, a design that is increasingly popular in hospitals, hotels, spas and other public settings, the study said. In 2007, two cancer patients at the National Institutes of Health in Bethesda were diagnosed with the disease after being exposed to a contaminated wall-type water fountain.

I see this as yet another example of an expensive and poorly thought through health care fad:

Decorative water fountains and water walls can be soothing and calming, so many hospitals and clinics included those amenities as a way to be more patient-friendly, said Jan Patterson, a professor of medicine and infectious diseases at the University of Texas Health Science Center at San Antonio.

Here's a lovely example from Carson City:

People probably crave views of water in Nevada

I would go further and suggest that this particular fad was often driven by a desire to persuade rich people to make donations to support hospitals' capital expansion programs. I can see it now: A visit by the hospital CEO to a wealthy potential donor, showing the architect's rendition of a beautiful lobby, complete with "water interest."

Wait! You can see it now, too!

A happy donor, no doubt.

By the way, The Joint Commission has rules about this issue that were prepared in 2003 by Centers for Disease Control and Prevention, Healthcare Infection Control Practices Advisory Committee (HICPAC):

Although not considered a standard point-of-use fixture, decorative fountains are being installed in increasing numbers in health-care facilities and other public buildings. Aerosols from a decorative fountain have been associated with transmission of Legionella pneumophila serogroup 1 infection to a small cluster of older adults. This hotel lobby fountain had been irregularly maintained, and water in the fountain may have been heated by submersed lighting, all of which favored the proliferation of Legionella in the system. Because of the potential for generations of infectious aerosols, a prudent prevention measure is to avoid locating these fixtures in or near high-risk patient-care areas and to adhere to written policies for routine fountain maintenance. [page 47]

Hmm, is a cancer center a high-risk patient area?

But "routine fountain maintenance" may not always work, notes the story in the Washington Post:

The fountain at the Aurora St. Luke’s South Shore hospital was installed in 2008. All visitors using the hospital main entrance passed by it on their way to the information desk. Water flowed down a tile wall about 8 feet wide by 5 feet high, and through a bed of decorative rocks that rested on a spongelike foam material.

Although hospital staff performed weekly and monthly maintenance, “it’s very difficult to clean those things out,” Haupt said. A sampling of a 3-inch by 4-inch piece of the foam material found it had more than 1 million bacteria, he said.

Canadian court to address end of life support

2012-01-15T15:12:00.000-05:00

The Supreme Court of Canada will soon be taking up the issue of whether doctors need consent before taking a patient off life support. As reported here in The Globe and Mail:

The country’s top court has granted leave to appeal to the doctors of . . . a man who has been in a coma at Toronto’s Sunnybrook Health Sciences Centre since October, 2010. His doctors diagnosed him as being in a “permanently vegetative state” and recommended he be taken off life support, but his wife and substitute decision-maker . . . strongly opposed. Now the doctors have turned to the Supreme Court in hopes of disconnecting Mr. Rasouli from the medical machines that are keeping him alive.

The outcome of the case could set a national precedent on protocol for end-of-life care when physicians and families don’t see eye-to-eye. The issue is fraught: Medical technology can now keep patients technically alive, so their loved ones sometimes keep them connected to machines for months or years, even when doctors advise against it.

As it stands, all provinces but New Brunswick require consent from the patient or substitute decision-maker for medical treatment, and Ontario is the only one with a tribunal that makes decisions on a patient’s behalf.

Of course, the ideal is for the patient and family and doctor to have talked through such matters in advance, but where that has not occurred, a clear legal standard will come in handy.

In my former hospital, we had a procedure in place for those instances in which a doctor felt that a patient or family was demanding a harmful or ineffective treatment. But as I re-read that policy today, it seems to be focused on the initiation of such treatment. I am not sure whether it should or could apply to the withdrawal of treatment, i.e., the kind of case being considered here by the Canadian court.

I think, too, in the United States, that these would be matters of state, and not national, jurisdiction. Perhaps readers who are more familiar with the various states' laws on these issues will provide us all with the benefit of your comments.

NPSF listserv

2012-01-14T18:04:00.000-05:00

Many thanks to Dr. David Lawrance, at University of Illinois at Urbana-Champaign, for a lead to a good listserv run by the National Patient Safety Foundation. He notes:

I find a lot of value following the National Patient Safety Foundation's listserv, which has a very ardent group of patient safety professionals. However, there is not enough participation by senior hospital administrators, current, former, or future. The consequence is a frustrating disconnect. I thought you might be interested.

He's right. I joined and took a look around at the conversations. They are thoughtful and professional. You can find more information and join in the conversations here.

Making the constitutional argument

2012-01-14T08:30:00.000-05:00

MA Attorney General Martha Coakley has submitted an amicus brief in the pending Supreme Court case about the national health reform legislation. The brief focused on the "individual mandate" portion of the law. I think it is really well done and I copy the argument summary here:

Having enacted six years ago a prototype of the comprehensive healthcare reform package that Congress would later adopt in 2010, Massachusetts is in a unique position to assess the rationality of the assumptions that underlay both enactments. Specifically, the Court has held that the Commerce Clause empowers Congress to regulate activities that substantially affect interstate commerce. Congress properly exercised that power in adopting a provision in the ACA that requires all non-exempt persons to purchase at least a minimum level of health insurance coverage. Through its legislative findings, Congress rationally concluded that those who fail to purchase health insurance despite their ability to pay for it (“free riders”) not only drain finite State and federal free-care resources, but also negatively impact the availability of privately-issued health insurance policies and the prices at which such policies are sold. Congress further concluded that curtailing the practice of “free riding” would make private health insurance coverage easier for individuals both to procure and to afford.

Having examined data for four years following the adoption of its own individual mandate, Massachusetts can attest to the rationality of Congress’s conclusions. Massachusetts now finds that its efforts to stop healthy people from opting out of purchasing health insurance have increased health-plan enrollment and helped decrease the rate of premium growth. These developments, in turn, prompted a significant reduction in governmental and private free-care expenditures. Because Massachusetts’s empirical experience demonstrates a strong link between eliminating “free riders” and improving access (and reducing costs), Congress acted rationally in drawing the same link as one basis for its regulation of activity affecting interstate commerce.

The Massachusetts experience further demonstrates that Congress was also empowered to enact an individual mandate under the Necessary and Proper Clause. That clause authorizes Congress to
take the steps necessary to implement legislation that falls within a specifically enumerated power. Thus, even if an individual mandate did not fall within the ambit of the Commerce Clause, the broader machinery of the ACA -- provisions broadening access, controlling costs, and eliminating denials based on pre-existing
conditions -- was constructed precisely to regulate the interstate features of the health insurance marketplace. That attacking the “free rider” problem is rationally related to achieving the ACA’s interstate commerce objectives likewise finds strong support in the Massachusetts data.

Finally, while Massachusetts has reaped many benefits as a pioneer in healthcare reform, its experience also demonstrates the limitations on a single State, acting alone. Many aspects of health insurance are the exclusive domain of federal regulators, while innovations by individual States have consequences beyond that State’s borders. This demonstrates both the interstate character of the health insurance market and the need for a coherent federal approach to its regulation.

Earle of the islands

2012-01-12T15:50:00.000-05:00

Earle Nelthropp and daughter Sonya

Here are some stories from one of my ancestral homes, St. Thomas. You may recall a previous one about how the island came to be covered with flamboyant trees.

Today's stories are about an interesting personage from the Virgin Islands, Earle Nelthropp. You met his daughter, Sonya, in an earlier post, in which she presented several sayings from the islands, updated here.

Earle served as Administrator of St. John from 1966-69, appointed by his old friend, Governor Ralph Paiewonsky. In 1970, he took over as manager of the Magens Bay beach authority. But it is his earlier history that offers a sense of the color of the times.

Earle was born in St. Thomas in 1906. In an interview with Sonya in his later years (1988), he reminisced about the arrival of Halley's Comet in 1910:

Halley's Comet in 1910

I was in St. Thomas. I was only four years old at the time. My father and I went out in the evening to see this comet over the town of Charlotte Amalie and from where we were standing, we were facing the town across the Harbor of St. Thomas. It seemed to me at the time that we were standing from one end of the town to the other end. The sight was very spectacular.

Shortly after, Earle was sent to Denmark for his early schooling.

In Denmark, I was enrolled in a boarding school. The schools were very rough on children who did not speak Danish; therefore it did not take me long to learn.

King Christian the Tenth used to ride by the school yard every Thursday on his horse. At that time, 10:00 in the morning, we were out in the play field when he rode by. He would give us a bag of sweets over the fence. That's the kind of King he was. He was 6 foot 6 or 6 foot 7, a big man, a wonderful man.

Apparently, Earle became a bit more mischievous upon returning to St. Croix, attending Mrs. Lauder's School at the corner of Church and Queen Street. A contemporary, Antone Taytoe, relates this story:

One day, Earl N., who was always up to tricks like this, brought to school a large centipede which he had caught and removed its poison fangs. Now, with the fangs removed it was perfectly harmless; but if you did not know that the fangs had been removed it was still very frightening. So, while we were all seated and busy with lessons, Earl removed the centipede from a little box in which he carried it and place it on the floor and called the attention of one of the more timid girls to it. The girl took one look and let out a scream of course and pandemonium broke loose. Earl had to push one boy out of the way just as he was about to stomp on his centipede. Finally Earl got it back in its box and took it outside in the yard ostensibly to kill it, as he said.

Mrs. Lauder cautioned loudly, "Look out, they always travel in pairs, another one might come along at any moment." This gave Earl just the opening he wanted. After coming back into the classroom saying not to worry that he had disposed of the creature, he let a few minutes go by and when things had settled down and lessons resumed, he let his centipede out of its box again to the accompanying shrieks of the children. "See what I told you," said Mrs. Lauder, now a proven naturalist, "They always travel in pairs."

Earl again caught the centipede and was now viewed as a sort of hero. He took his defanged centipede outside and set it free in the garden.

Semester in Israel for undergraduates

2012-01-12T08:46:00.000-05:00

Here is a great opportunity described by Dr. Osnat Levtzion-Korach, Deputy Director, Assaf Harofeh Medical Center. It is for undergraduates with an interest in medicine, pre-med and other health/science students, to take a semester at a highly regarded Israeli institution:

We would like to introduce to you our accredited academic elective program: The Voyage to Medicine in Israel.

The Voyage to Medicine is a five-month program (either fall or spring semester) open to English-speaking undergraduate students who express an interest in the field of medicine. The program is a joint venture between Tel Aviv University and Assaf Harofeh Medical Center.

The course offers participants the unique opportunity to gain experience in one of Tel Aviv area's finest hospitals and medical institutions, under the tutelage of expert physicians in the field. The medical facilities which comprise Assaf Harofeh Medical Center, an 800-bed academic, medical center, treat a broad spectrum of ethnic origins, cultural backgrounds and socio-economic levels of the Israeli population. The program provides the overseas students a wealth and variety of clinical material such as: clinical research, first aid, emergency care, laboratories, adolescent medicine, genetics, psychology and much more.

For additional information please see the link to our site.

End-of-life conversations, as seen by the intensivist

2012-01-11T19:52:00.001-05:00

My recent post on end-of-life care issues, "What if they had had to pay?," generated a lot of comments in the blogosphere and beyond. One intensive care doctor sent me a particularly poignant note. It gives a good sense of what it is like on this person's side of the bed. The note re-emphasizes the need for better end-of-life planning, for the sake of patients, families, and providers.

Here's my day so far. This is my first day of a 7-day stretch in a tertiary ICU. The average census in this ICU is 10, but today we have had to surge to 15.

Let me stop right there. This is doctor (and nurse) shorthand for, "I expect to be very busy, very tired, and very stressed out. I am going to have to make some highly critical clinical judgments, sometimes with very little time to react. I don't know anything about these patients beyond what is in the charts and what our care team sees and hears for themselves."

Two patients today coded in our hospital. One family wants "everything" done, and seemed shocked to learn that I don't think it is right to provide "everything." The other family wished someone from the healthcare team had bothered to ask them what their 89 year old dad would really like to accomplish from his hospital stay before he tried to die. We decided to let him finish dying.

And I had 3 other similar discussions with patients or their families about goals that can actually be achieved. All of them were already in the ICU, having had no real clear previous discussions. One of those patients was admitted last night, but the other 2 had been in our ICU for days....

Removing barriers on WIHI

2012-01-11T13:46:00.002-05:00

Removing Barriers to Better Health and Better Care with
Medical-Legal Partnerships
January 12, 2012, 2:00 PM – 3:00 PM Eastern Time

Guests:

Barry Zuckerman, MD, Chair, Department of Pediatrics, Boston University School of Medicine; Founder, National Center for Medical-Legal Partnership

Robert Kahn, MD, MPH, Associate Professor of Pediatrics and Director, Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center

Carol Beasley, MPPM, Director of Strategic Projects, Institute for Healthcare Improvement

Let’s face it. If someone mentions the words “medical” and “legal” in the same sentence, the next thing we imagine we’ll hear about is a lawsuit. Picture this instead: empowered, proactive social workers, collaborating with health care providers, lawyers, and legal experts, to ensure that the health of indigent patients isn’t undermined by unsafe housing, lack of food, or lack of access to benefits and entitlements. Some people refer to this type of outreach as “preventive law” because it’s directly related to preventive health measures we now recognize are crucial to help people head off disease or better manage chronic conditions.

Doctors and nurses on the front lines have understood for years the role that social conditions play in improving or worsening health. Also, what happens when problems brewing at home, such as domestic abuse, don’t rise to the surface during a routine medical visit. Fifteen years ago, Dr. Barry Zuckerman founded a program at Boston Medical Center to address a swarm of issues affecting the health of low-income children. Six years ago, this initiative became the National Center for Medical – Legal Partnership, focusing on anyone, at any age, in need of the combined power of medical and legal intervention. The effort and the framing caught on and there are now over 200 programs like Zuckerman’s across the US, one of them in Cincinnati.

WIHI host Madge Kaplan welcomes Dr. Zuckerman and Dr. Robert Kahn of Cincinnati Children’s Hospital Medical Center to the show on January 12 to explain and explore the ingredients of an effective medical-legal partnership and how the efforts to date are making a difference in patients’ health and their lives. At Cincinnati Children’s, key prompts to get at social determinants of health are built right into the electronic health record. This helps screen for health-undermining circumstances — for instance, a landlord’s lack of attention to a faulty refrigerator — that might benefit from legal attention. This is just the type of thing Carol Beasley is keeping an eye on as she continues to help spearhead the work of IHI’s Triple Aim initiative. When the goals are improving the experience of care, improving the health of populations, and reducing per capita costs, it’s increasingly essential to form coalitions and partnerships that integrate legal and social service expertise with health care expertise.

It sounds right, you’re saying to yourself, but how does it really work? Where do you find the resources? And, where do you begin? Bring all these questions and more to the January 12, 2012 WIHI — the first program of the New Year. This topic is the perfect place to start. See you then.

To enroll, please click here.

Good diagnosis, Zeke. Why no cure?

2012-01-10T08:14:00.000-05:00

I really like it when I agree with Zeke Emanuel and never more so than with his recent column in the New York Times about proton beam machines. You will recall that I addressed this topic several months ago.

He notes:

If you want to know what is wrong with American health care today, exhibit A might be the two new proton beam treatment facilities the Mayo Clinic has begun building, one in Minnesota, the other in Arizona, at a cost of more than $180 million dollars each. They are part of a medical arms race for proton beam machines, which could cost taxpayers billions of dollars for a treatment that, in many cases, appears to be no better than cheaper alternatives.

To generate sufficient revenue, proton beam facilities need to treat patients with other types of cancer. Consequently, they have been promoted for patients with lung, esophageal, breast, head and neck cancers. But the biggest target by far has been prostate cancer, diagnosed in nearly a quarter of a million men each year.

There is no convincing evidence that proton beam therapy is as good as — much less better than — cheaper types of radiation for any one of these cancers.

And here's the upshot:

With Medicare reimbursement so generous, and patients and doctors eager for the latest technology, building new machines is sane, profitable business for hospitals like Mayo.

But it is crazy medicine and unsustainable public policy.

If the United States is ever going to control our health care costs, we have to demand better evidence of effectiveness, and stop handing out taxpayer dollars with no questions asked.

So why doesn't the administration, which runs and controls Medicare, change this? Didn't you work in the White House, Zeke? Can you tell us why?

BioInnovations Conference at MIT

2012-01-10T07:34:00.001-05:00

A note from Lamees Hamada, a graduate student at the Sloan School:

The MIT Sloan Healthcare Club is holding its annual BioInnovations Conference, Driving Innovation & Entrepreneurship in a New Era, on February 24th. The conference will feature keynote speakers, Chris Viehbacher (CEO of Sanofi), Phillip Sharp (Nobel Laureate and Co-founder of Biogen and Alnylam Pharmaceuticals Inc.), and George Scangos (CEO of Biogen Idec). Panels will focus on paradigm-shifting trends: personalized medicine that creates more value, new business models that sustain innovation, healthcare financing that nurtures entrepreneurship, and emerging market healthcare that tackles global challenges. The conference will conclude with a networking reception, the BioInnovations Poster Session, which will feature student research from MIT and other universities. Early bird tickets are on sale through January 30th. Please visit the conference website for further information.

The harp delivers and soothes

2012-01-10T06:08:00.002-05:00

One of the most satisfying decisions I made during my tenure as CEO of our hospital was to introduce harp playing. This happened in an unplanned way. I was walking near the building and ran into a family friend, Nancy Kleinman, and asked what she was doing. She mentioned that she was spending a lot of time playing the harp, and I invited her to play in our public spaces. She was willing to volunteer, but I insisted on her being paid because I felt that this would be an important service, one that should be offered on a professional basis. Of course, no insurance company would cover this kind of service, so I paid for her personally for several months. Later a generous donor stepped forward to fund the program on a ongoing basis, and an additional musician was added to expand the program.

Beyond public spaces, the harpists were also asked to play in individual patient rooms. Here is an example.

Here is a more recent one, offered at Boston University's Marsh Chapel recently:

Kindness

One of our dear Marsh Chapel members is in hospital. We visited her on Wednesday at Beth Israel Deaconess. She heals, hour by hour. How grateful we are for the skill and care of doctors and nurses there. The best wisdom of the reason, the finest attention to efficient detail, the steady combat, as in every hospital, against infection—these we again prized, this Christmastide.

After conversation and prayer, the elevator brought us again to the first floor. As the door opened, something…A wondrous note, an audible epiphany, a gratuitous kindness…the sonorous notes of a harp. To the gifts of medicine, there were added the gifts of music. Deep, resonant, lovely. Something else. Something transcendent. A gratuitous kindness, calling us up and calling us out. How fitting that harp note. A gift not strictly necessary, but utterly meaningful.

Walking away, one heard something, something deeply about being human or becoming fully human. We will not reach our height, become who we are, only by rationality and efficiency, as crucial, as saving as they are. To become who we are we shall need a turn to grace, that chord of depth and height and breadth and love, resounding from the nimble fingers of someone making a gift of gratuitous kindness.

-The Rev. Dr. Robert Allen Hill, Dean of Marsh Chapel

Tracking adverse events

2012-01-08T16:18:00.001-05:00

A recent report from the Office of Inspector General at the US Department of Health and Human Services finds, unsurprisingly, that hospital incident reporting systems do not capture most patient harm. A summary of major points:

All 189 sampled hospitals had incident reporting systems to capture events, and administrators we interviewed rely heavily on these systems to identify problems.

Hospital staff did not report 86 percent of events to incident reporting systems, partly because of staff misperceptions about what constitutes patient harm.

Nurses most often reported events, typically identified through the regular course of care; 28 of the 40 reported events led to investigations and 5 led to policy changes.

Hospital accreditors reported that in evaluating hospital safety practices, they focus on how event information is used rather than how it is collected.

And here are the recommendations:

AHRQ and CMS should collaborate to create a list of potentially reportable events and provide technical assistance to hospitals in using the list.

CMS should provide guidance to accreditors regarding surveyor assessment of hospital efforts to track and analyze events and should scrutinize survey processes when approving accreditation programs.

Sorry, but to me this is all somewhat "ho-hum." Virtually all adverse event reporting systems are "bolt-on" additions to hospital clinical information systems. They do not result from a thorough analysis of how work is done on the floors and units of hospitals. They are not designed by the people who actually have to report such events. They are certainly not designed to capture near-misses, which occur 100 to 1000 time more often than actual adverse events, but which are a huge source of information about systemic problems. Filling them out is often considered "extra work" by busy clinicians, not as part of a process of continuous, front-line driven process improvement. Thus the recommendations offered in the report will not, I predict, make a significant difference in the future.

What are also unsurprising are the findings in this article by Downey et al, covering the period 1998 to 2007:

As the patient safety movement enters its second decade, an emerging body of research is finding that safety for hospitalized patients has likely not improved significantly over the past several years. This study, which used the AHRQ Patient Safety Indicators (PSIs) to analyze safety events in 69 million hospitalizations over a 10-year period, also finds no clear evidence of improved safety. Of the 20 PSIs analyzed, 7 increased in incidence over the time period studied, 7 decreased, and 6 did not change. While PSIs are best used for screening purposes and not for direct comparisons between hospitals, they have been used to track system-level rates of safety problems over time. The results of this study and other recent literature provide continued urgency for the safety movement to strive to improve the safety of the entire health care system.

What's going on? Answer: We hear of great work done in quality and safety improvement by hospitals on the leading edge. And that work is often impressive. But those reports distract us from the fact that most hospitals still do not have in place clinical, administrative, and governance leaders who seriously and consistently put process improvement at the top of their strategic objectives. As I have mentioned, I am often approached at my speeches by nurse managers and young doctors who say, "How can I get my CEO/Chiefs/Board to support these kind of activities?"

I have urged here my (former) colleagues in academic medical centers to take the lead in these matters. Many, too, have urged the country's medical schools to incorporate the science of health care delivery improvement into their curricula. Thus far, the pace is way too slow. Let's hearken back to Captain Sullenberger's imperative:

""I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country."

Front page ads hiding as news stories at the New York Times

2012-01-08T11:51:00.000-05:00

The New York Times has now fully blurred its news reporting roles and its and its reporters' commercial forays into book publishing.

Some time ago, I raised this issue with regard to an advertisement for a Times book presented as an article about Bernard Madoff.

Now, we see it again. A front page story by Times reporter Jodi Kantor about Michelle Obama contains this paragraph:

But interviews with more than 30 current and former aides, as well as some of the first couple’s closest friends, conducted for “The Obamas,” a new book, show that she has been an unrecognized force in her husband’s administration and that her story has been one first of struggle, then turnaround and greater fulfillment.

And, at the end of the article, we have this tag line:

This article was adapted from “The Obamas,” by Jodi Kantor, which will be published Tuesday by Little, Brown & Company.

Indeed, the whole article is just a teaser for the book, for it can scarcely be considered front page news. Since when does a reporter get to publish a self-referential story based on his or her book? Since when does a newspaper permit this kind of commercial use of a front page story, whether for its own profitability or that of its reporters?

Physicians study leadership at HSPH

2012-01-07T22:22:00.002-05:00

Each year, I am delighted when Jim Conway invites me to be a guest lecturer in a class on Physician Leadership at the Harvard School of Public Health. The attendees are senior doctors from institutions around the world who come to Boston several times over two years for four-day weekends of classes. Jim, as many of you know, served from 1995-2005 as Executive Vice President and Chief Operating Officer of the Dana-Farber Cancer Institute. After leaving that position, he was senior vice president and senior fellow at the Institute for Healthcare Improvement. During my tenure as CEO of BIDMC, he was a true mentor to me in learning about the process of quality and safety improvement. He also played a key role in helping our hospitals' boards learn how to exercise strong governance over clinical matters. To the extent we were successful as an institution in reducing preventable harm, he was a major contributor.

Jim is accompanied in this teaching course by Ron Goodspeed, former President of the Southcoast Hospitals Group. Another committed practitioner of process improvement, Ron was highly regarded throughout the state. For example, in 2006 he was named President of the Board of Directors of the Massachusetts Coalition for the Prevention of Medical Errors. As noted by Paula Griswold, president of the coalition, he was selected because his "credentials, experience and dedication to quality patient care [were] invaluable as the coalition worked to educate the health care industry about best practices in preventing medical errors."

The topic of the day was the case study written at Harvard Business School about my arrival as CEO of Beth Israel Deaconess Medical Center in 2002 and actions thereafter. As is my practice, I warned class participants that I would take pictures of those who asked really good questions or made particularly insightful remarks. There were many and I don't have space here for them all, so I can only offer prominence to a few. I am especially pleased, though, to include Dr. Holmes (above), who was born at the Beth Israel Hospital and who confirmed again my assertion that all of the babies born in that hospital and the successor BIDMC are above average!

Why such a short reply?

2012-01-06T08:17:00.000-05:00

A physician friend with whom I have been corresponding wrote, after I sent a short reply to an email:

You have perfected the CEO art of short, succinct emails. All CEO's I know can do this. I can't. Do they teach that art in CEO school?

My reply:

It is a post-graduate course.

So, here's my philosophy on email, from the work environment, which tends to run over into personal stuff. I never wanted to be the bottleneck in something that was going on. I always figured that a quickly delivered short, responsive note was better than a delayed expansive one.

Also, when you get 500+ notes a day, it is important to answer each one as you read it. If you hold it to think about, and then read it again, and then respond, you have doubled your intake folder and used up a lot of time. This is a fundamental rule of time management: Whether a paper or electronic letter, or a phone message, deal with it the first time you read/hear it. (Unless it is something that really requires a lot of research or thought.)

Also, email has now changed. Its past virtue was that it was asynchronous. No one expected you to reply right away. Now, everyone has a PDA, and there is an expectation that you will be in touch all the time and responsive immediately. If you don't give an answer, the person sends you another note 15 minutes later, asking if you got the first one. Again, you have now doubled your inbox.

(This is one reason I rather publicly threw away my Blackberry when I was a CEO: I wanted people to understand that I was not always available.)

Unfortunately, this has now carried over into personal emails, too. If I didn't answer relatively quickly, you would wonder if you offended me, or if I perceived you as unthoughtful, or whatever. So, I tend to reply quickly and concisely.

Finally, as friends, we have lots going on back and forth during the day. Just as would be the case if we were together, some responses during the course of the day would be short and some long.

Steve Spear's MIT webinar on January 9

2012-01-06T05:04:00.001-05:00

Here's another great webinar being offered next week by the MIT System Design Management crew:

Creative Experimentation: Developing a Skill Critical for Managing Complex Operating Systems

MIT SDM Systems Thinking Webinar Series

Steven J. Spear

Senior Lecturer, MIT Sloan School of Management; Senior Lecturer, MIT Engineering Systems Division; Senior Fellow, Institute for Healthcare Improvement; and author, The High Velocity Edge

Date: January 9, 2012

Time: Noon - 1 p.m.

Open to all

A broad-based capacity for experimentation is critical for organizations to succeed because the systems in which people are embedded are increasingly complex and fast. For instance, medical treatment used to be accomplished by "going to the doctor," a sole practitioner supported by a handful of other professionals, who mastered a body of scientific knowledge through steady practice. Now, thanks to the tremendous advances in medical science and technology, diagnosis and treatment span myriad disciplines and countless professionals. Doctors have to be masters in their own fields and masters in coordinating care delivery tailored to individual patients' needs. Experience can no longer be steadily accumulated over time. Rather, teams must experiment off-line so they are prepared for the variety of situations they'll face in real time. The same challenge of having to build knowledge in particular disciplines and learn quickly how to pull the pieces together into coherent eff! orts is characteristic of manufacturing design and production, services, information technology, and more.

Rapid response teams and end-of-life care

2012-01-05T11:11:00.001-05:00

How well are end-of-life issues dealt with in emergency situations in hospitals, i.e., when rapid response teams are called in? Researchers in Australia, Canada, and Sweden asked that question and studied the treatment of several hundred patients over the course of a month. Nearly one-third of patients seen by a rapid response team ultimately had limitations placed on their care (such as do-not-resuscitate orders). This is suboptimal compared to making those plans earlier, during less stressful times. Here is the formal conclusion published in Critical Care Medicine:

Issues around end-of-life care and limitations of medical therapy arose in approximately one-third of calls, suggesting a mismatch between patient needs for end-of-life care and resources at participating hospitals. These calls frequently occur in elderly medical patients and out of hours. Many such patients do not return home, and half die in hospital. There is a need for improved advanced care planning in our hospitals.

Tired is bad. A tired organization is worse.

2012-01-04T17:15:00.001-05:00

If stating the obvious were a sign of success, we would have to give The Joint Commission an A+. It issues Sentinel Event Alerts, ostensibly designed to to emphasize pressing safety issues and provide guidelines for organizations on how to address them. The December 14, 2011 topic: "When caregivers are tired, they are more likely to make mistakes."

First of all, this is not a sentinel event. As noted in the paper itself, it is a long-standing and well documented problem. Characterizing it as something new when it is not quickly loses readership and attention.

The paper goes on to make some helpful suggestions about hand-offs, fatigue management, and the like. There is nothing wrong with the ideas. It is just that they do not get to the root problem -- a task-oriented environment in which well intentioned people work beyond their limits. In other words, the suggestions are window-dressing to the real issue, the need to re-design how work is done in hospitals.

I guess it doesn't do any harm to issue such papers, and it might do a little good. But, wouldn't it be great if The JC became an effective leader in transforming health care, rather than restating the obvious? It still doesn't offer open access to its Leading Practice Library, a compendium of best practices from those hospitals it has surveyed. And the agency has made virtually no progress with regard to reducing the rate of wrong-site surgeries.

I think they are tired in Oakbrook Terrace, Illinois.

Or perhaps I am being unkind. After all, the main task facing The JC is ensuring that the CMS Conditions of Participation are met. This is an incredibly detailed list of standards covering all aspects of hospital operations.

Let me give you an example. One part of the COP is the Life Safety Code Certification. Part of that certification is guided by this portion of regulations in the Federal Register. The summary is simple:

The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community.

But then, the surveyors' manual relating to these regulations goes into excruciating detail. Such detail is required, after all, when the regulations say things like this about hand cleansing dispensers:

(9) Notwithstanding any provisions of the 2000 edition of the Life Safety Code to the contrary, a hospital may install alcohol-based hand rub dispensers in its facility if:

(i) Use of alcohol-based hand rub dispensers does not conflict with any State or local codes that prohibit or otherwise restrict the placement of alcohol-based hand rub dispensers in health care facilities;

(ii) The dispensers are installed in a manner that minimizes leaks and spills that could lead to falls;

(iii) The dispensers are installed in a manner that adequately protects against inappropriate access;

(iv) The dispensers are installed in accordance with chapter 18.3.2.7 or chapter 19.3.2.7 of the 2000 edition of the Life Safety Code, as amended by NFPA Temporary Interim Amendment 00-1(101), issued by the Standards Council of the National Fire Protection Association on April 15, 2004. The Director of the Office of the Federal Register has approved NFPA Temporary Interim Amendment 00-1(101) for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the amendment is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD and at the Office of the Federal Register, 800 North Capitol Street NW., Suite 700, Washington, DC. Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02269; and

(v) The dispensers are maintained in accordance with dispenser manufacturer guidelines.

So, to be fair, who at The JC would have the energy and time to focus on the big picture?

Swirling down the drain, ever faster

2012-01-04T12:09:00.000-05:00

Some months ago, I wrote about the deterioration of the Boston area transit system, linking to an article I published in Commonwealth Magazine. We are now witnessing the sequelae of the syndrome I presented there. The Boston Globe reports that the MBTA is seeking major fare increases and service cuts:

The MBTA would raise subway fares by up to 70 cents and dramatically cull bus routes, eliminate ferries, and end weekend commuter rail trains under a plan unveiled yesterday to help erase a projected $161 million deficit.

To be fair, this is not just about Boston. The New York Times recently published an article entitled "The Recession Squeeze on Buses and Trains", documenting similar problems in lots of places. About Boston, the Times noted: "[R]idership is up, but so is debt; last year, virtually every dollar paid by riders went to debt service."

It is a mistake, though, to link these problems with the recession. There are long-lived structural issues at play.

A friend has helped me review the MBTA’s most recently reported statistics (for 2010) to the National Transit Database. These numbers demonstrate that fares collected per boarding (column 1) generally do not cover even the direct vehicle operations plus maintenance costs per boarding (column 2). Those costs, by the way, exclude the amounts needed to maintain fixed infrastructure and cover general and administrative categories.

Commuter Rail	$5.68	$7.41
Demand Response	$1.67	$28.51
Boat	$4.43	$5.23
Rapid Transit	$1.10	$1.33
Light Rail	$1.06	$1.45
Motorbus	$0.72	$2.75
Trolleybus	$0.69	$4.14
SYSTEM TOTAL	$1.30	$2.42

Now, these are average costs, and it is harder to estimate the marginal costs of an additional trip; but there is every reason to believe that those marginal costs exceed the marginal revenues received per trip. In other words, an increase in ridership may actually cause the system's net income to fall. This is a terrible vicious cycle for a transit system.

What if they had had to pay?

2012-01-04T06:36:00.002-05:00

A true story, with changes made to protect privacy. A 89-year-old man with dementia, a heart condition, and other serious medical conditions fell in his Arizona apartment and broke his hip. His children, wanting the best possible care, arranged for him to be air-lifted to New York. There, the orthopaedic surgeon advised them that the chance of their father surviving hip surgery was very low, but he would do as the family wished. The man's three children could not agree. Two would have avoided the surgery, but a third felt very strongly that everything that could be done for the father should be done. The other siblings, out of guilt and respect for the third, acceded. The surgery took place, and the father spent three days in the ICU before his heart gave out.

Here's the terrible and hard-hearted question I pose: If the costs of this procedure and hospitalization had not been covered by Medicare, would the man's children have proceeded along the chosen path? I am guessing not. I don't know the total bill incurred, but it was certainly in the range of tens of thousands of dollars.

In the US, we don't have a good societal process for making these decisions. In the United Kingdom, though, they do, as reported by Bob Wachter in a recent blog post. Here are some excerpts:

[D]uring my six months on sabbatical in London, when I asked British physicians or hospital administrators who have spent time in the US about their main impression of our healthcare system, I nearly always heard some version of, “You people don’t know how to say no to anything.”

In the UK, they have built an organization that makes these tough decisions: the National Institute for Health and Clinical Excellence (NICE). I was lucky enough to spend several hours with its leaders last week in the organization’s London headquarters. NICE is awesome, not just for what it does, but for what its existence says about the maturity of the British political system when it comes to healthcare.

I asked Sir Michael [Sir Michael Rawlins, NICE's founding chairman] what it was about the culture of the British people and the NHS that allowed NICE to function, when America has such problems saying, and accepting, a forthright “no.”

“The man on the street gets it,” he replied. “They know that there is a finite amount of money. And politicians get it as well — they know that someone is going to have to make these tough decisions, and they’d rather it be us than them.”

Imagine that.

Bob concludes:

Decisions over setting limits are invariably wrenching, but our failure to create a transparent way to make these decisions just means that rationing occurs implicitly and haphazardly.

Ultimately, silly season will end, our society will come to grips with the need to choose, and we will begin looking for a method of making these thorny decisions. When that day comes, it’s nice to know that we have a model to learn from.

Blog takes on CNN. Wins.

2012-01-03T18:46:00.000-05:00

It isn't often that I scoop a major network, but my story about the use of UV light as a disinfectant at Cooley-Dickenson Hospital in Northhampton, MA beat CNN's story by a month. But they do have some neat video.

Efficiency matters even in a high fixed cost industry

2012-01-03T10:31:00.001-05:00

I have so much respect for the people at the Dartmouth Institute for Health Policy and Clinical Practice and the excellent work done there that I hate to quibble with their work. But I fear that Stephen S. Rauh, Eric B. Wadsworth, William B. Weeks, and James N. Weinstein have overstated an argument, and their view needs correction.

The problem is in a Perspective article in the New England Journal of Medicine, "The Savings Illusion — Why Clinical Quality Improvement Fails to Deliver Bottom-Line Results". (Aside, thank you, NEJM, for allowing public access to articles of broad public interest. When will others, like JAMA?) Here is the argument in a nutshell:

[The] management and organization [of the typical health care setting] create a rigid cost structure that is relatively insensitive to small changes in patient volume, resource use, or the severity of patients' health conditions. This fixed-cost dilemma leaves most health care costs insensitive to changes in volume and utilization, so clinical quality improvements typically create additional capacity rather than bottom-line savings. An examination of the different cost layers highlights the distinction between variable costs, such as supplies and medications, where reduced use produces true savings, and fixed costs, such as facilities and ancillary services, where the costs persist despite reduced use.

Because of the rigid cost structures, incremental reductions in resource use are unlikely to generate cost savings for either a health care setting or the health care system. The most meaningful way to achieve savings is to focus on overall reductions in utilization rates for health care services and to eliminate the associated unnecessary capacity.

The mistake the authors make is in presenting a static and incomplete view of cost savings and the financial interests of an individual firm, and also a narrow view of the societal advantages that are produced when an industry leader accomplishes cost reductions. Indeed, by their logic, no firm in any industry characterized by high fixed costs would ever invest in efficiency programs and measures.

Two years ago, I gave an example from my former hospital's ICUs. Our staff had accomplished a marvelous reduction in the rate of ventilator associated pneumonia. We admittedly reduced clinical revenues for that "book of business" as a result. If we had focused on that financial outcome, though, and chosen not to carry out the VAP reduction program, we would have been too limited in our view. By reducing lengths of stay, we were able to avoid a huge bolus of new fixed costs: The clinical capacity we created solved a growing congestion problem and enabled us to avoid the new fixed costs of an expanded ICU, along with the essentially fixed-cost staff, equipment, and supplies that would have been required for that addition. Every firm faces capital constraints, and alleviating those constraints is as important a financial focus as what might be a short-term reduction in income.

By the way, on the societal front, we could and did see more patients who would have otherwise gone to higher cost competitors. That is also a common result in many industries.

We don't know how to make a decision

2012-01-02T14:51:00.000-05:00

Twenty years ago, I went to Prague as part of US AID advisory group to help the Czech government make some decisions about wastewater planning. I had just come off a stint as executive director of the state's water resource authority, and someone figured that I might have expertise that would come in handy. As I am not an engineer, I had my doubts, but I thought I wouldn't do any harm. Plus I had always wanted to visit Prague.

I had been told that there was a major dispute among the planners and engineers in the city. They agreed that there was a need for a new sewage treatment plant, but there was a disagreement as to whether the new plant should be built at the site of the existing facility on Cisarsky Island in the Vltava River (left) or at a new location in the suburbs.

I did what any self-respecting consultant would do and asked every person I met for his or her opinion. To my surprise, everyone agreed that a new treatment plant in the suburbs would be the way to go.

So, I asked my host the obvious question: "I was told that there was a difference of opinion on this matter, but I see that you have a consensus." His reply, "Yes, we have a consensus, but we don't know how to make a decision." You see, after 40 years of heavy-handed Communist rule by the USSR, the newly freed nation had not developed the decision-making capability required of an independent country.

From there, I went to Bratislava, on the Slovak side of the country, to conduct a seminar for municipal officials about financing infrastructure facilities. I introduced the concept of using revenue bonds to finance power plants and the like, with the cost of debt being paid by the users of the facilities. For the past several decades, such facilities had been financed by the Soviets, and the underlying costs had been hidden from consumers, built into an arcane revenue model of the central government.

"If consumers have to pay for the full costs of the power plants, the price of electricity will be inappropriately high," was the first reaction from a person in the group. I explained that there are two ways to recover such costs, from the taxpayers or the ratepayers. I asked, "Wouldn't it be better for consumers to have a proper price signal as to the value of the electricity they use?"

I might as well have been an alien from outer space. People either shook their heads, "No," or I received blank stares. The premises of capitalism were utterly foreign to this group.

Let me draw some parallels with health care. "We don't know how to make a decision" might apply to the millions of patients in the world who are treated like serfs in the health care system. Health care professionals often prescribe and order, without helping their patients become full partners in the treatment planning and decision-making process. People like e-Patient Dave and others are trying to conduct their own Velvet Revolution to remedy this kind of attitude.

The parallel on the cost side is equally apt. We have no idea, as health care consumers, what it costs to treat us. Those costs are hidden in a dense fabric of insurance inclusions and exclusions, charge masters, contract allowances, co-pays, and the like. The current interest in establishing global payments as a substitute for fee-for-service pricing is an ineffective way of solving this problem. It mainly shifts risk from insurers to providers, leaving the providers as gatekeepers and middlemen in care decisions. As a solution to the problem of uninformed consumers, it is lacking.

Other parts of the economy thrive with relatively efficient fee-for-service pricing because those sectors are characterized by transparent presentations of choice, quality, and prices. There is a need for a radical disintermediation of insurance companies in health care to allow a similar direct connection between consumers of health care and their providers. With that in place, we would all learn "how to make a decision."

If the business model of the future is accountable care organizations that provide a full range of medical management services in their catchment areas, the value of stand-alone insurance companies diminishes. Instead, each ACO could offer a combination of insurance and care to its subscribers. Interestingly, if you consider those systems in the US that are viewed as most successful, several already have that model.

A new blog

2012-01-01T17:56:00.002-05:00

Some time ago, I acquired the url for "notrunningahospital" in case there was confusion about the name of this blog. That way I could refer people over here if they ended up at the wrong place.

But then I realized that a blog address is a terrible thing to waste and wondered if I could do something useful with the other one. Here's what I came up with: I have been gradually copying posts related to transparency and Lean process improvement from this blog to the other serve as an archive and resource to people in hospitals who might want to review the experience at Beth Israel Deaconess Medical Center and other hospitals and apply lessons to their own institutions.

What you see documented on that blog is a consistent and decided institutional commitment to transformational change at BIDMC and several other places. It takes a long time and with constant reinforcement from the top folks to fight inertia and entropy and build sustained momentum for this kind of change. Personal involvement and interest of the CEO and clinical leaders is essential.

I hope you find the new site to be a useful resource. (You can also continue to search "Lean" and "transparency" on this blog and find many posts on those topics, but the search engine is not always comprehensive, so you might find the other site to be a more useful place to review those posts.)

I also continue to search for success stories in these arenas from around the world. If you have some to share, please let me know.

Dhaya helps with the transitive property

2011-12-29T21:30:00.001-05:00

I want to help you end the year with some warm laughter, and the best vehicle I can find is this wonderful story by my friend Dhaya Lakshminarayanan about teaching mathematics to her mother -- and about the American dream. It appeared on Snap Judgment in August.

If you cannot see the video, click here.

Verizon: "Your session is now closed. Thank you, have a nice day."

2011-12-29T06:24:00.000-05:00

I again break my holiday blogging break because I can't wait till the New Year to share this story with you.Verizon sent an email offering a special rate on a new two-year contract for the FIOS internet, telephone and television service to which I subscribe, and I wanted to know how it compared with my existing rate. Here's the actual chat transcript after I clicked on the icon above. I couldn't make this up:

A Verizon Service Representative will be with you shortly. Thank you.

Agent Stephen has joined.

Stephen : Chat ID for this session is 12281146501.

Stephen: Hello. Thank you for choosing Verizon and visiting our Verizon chat service. How can I help you place your order?

You(21:01:30): I am looking at the $104.99 2-year contract. What am I paying now?

Stephen(21:02:30): let me send you a link to check your bill.

Stephen(21:02:40): https://www22.verizon.com/ForYourHome/BillView/MyBillNew.aspx?

Stephen(21:02:50): Please click on the above link to check your bill after logging into your online account.

You(21:03:47): I don't recall my user name or password, and when I clicked on the link to retrieve them, nothing happened.

Stephen(21:04:22): Do you have a paper bill whch you can look?

You(21:05:35): No, I don't. The site responded, and I asked for both. The next screen is blank, so far. Stay tuned!

Stephen(21:06:35): Let me provide you with the number to call and get this infromation, as online being into the sales department, we don't have the internal access to look into your account.

Stephen(21:06:50): Please contact our Consumer Solutions Center directly at: (800) VERIZON or (800) 837-4966, 24 hours a day, 7 days a week.

You(21:07:27): I called the number before i tried this live chat, and it said no one is on duty at this hour -- even though it claims to be available 24x7.

Stephen(21:08:37): I understand. In that case, I recommend that you try back later or come back online during the business hours. So that the online account specialists are available during that time.

You(21:09:47): So 24x7 doesn't actually mean 24x7?

Stephen(21:10:27): It should be 24 X 7, because most of our customers do get it available 24 X 7.

Stephen(21:11:22): Do you have any other questions for me today?

You(21:11:35): I guess I am special! As I went through the menu on the phone, it asked whether i wanted to talk about FIOS internet, Phone, or TV. I have all 3. I picked internet and then got that message. Would I do better picking some other choice?

Stephen(21:12:05): Let me send you a link to contact Verizon via email about it, and get it resolved within 24 hours.

Stephen(21:12:25): http://www22.verizon.com/content/ContactUs

Stephen(21:12:31): Please click on the above link to contact Verizon via email.

You(21:12:50): About what, my initial question about the 2-year contract, or how to talk to a representative?

You(21:13:38): Meanwhile, the online request for my user id and password stopped functioning.

Stephen(21:14:04): I am sorry, but per your first statement, you just asked question about your existing bill. Could you please be more specific on your initial question that you are trying to ask?

You(21:14:51): I am trying to compare the offer you have on your website, for a two-year contract, with what I am currently paying.

Stephen(21:15:21): Which Verizon services do you currently have?

You(21:15:35): FIOS internet, phone, and TV.

Stephen(21:16:15): You can go for our Verizon FiOS Triple play with FiOS Prime HD 15/5Mbps Internet FiOS Digital Voice Unlimited calling for $104.99 a month with two years price guarantee.

Stephen(21:16:30): If you are out of the contract or under the last 60 days of the contract, then you'll get $300 Visa reward card.

You(21:17:21): I understand that offer. What I do not know is what I am currently paying, so I can compare the offer with my current rates. I don't even know if i have a current contract.

Stephen(21:17:51): Like I said, you need to login into your online account to see your bill, or check your paper bill.

Stephen(21:17:56): Can I assist you with anything else from my end?

You(21:19:09): And, I keep telling you that your website which is supposed to help me get online by restoring my user id and password is not working. And your 24x7 phone line is also not working, telling me to call back during business hours.

You(21:19:50): Is this some kind of cruel joke? I am interested in the product you are offering, and you are making it impossible for me to evaluate it.

The chat application is experiencing connectivity trouble. Your chat will be re-assigned to another agent and will be given high priority. We apologize and Thank you for your patience. (21:20:41)

Agent Valentina has joined. (21:20:41)

Your session is now closed.

Thank you, have a nice day.

---

A Verizon Service Representative will be with you shortly. Thank you.

Agent Jacob has joined. (21:23:03)

Jacob : Chat ID for this session is 12281147492. (21:23:03)

Jacob(21:23:03): Hello. Thank you for choosing Verizon and visiting our Verizon chat service. How can I help you place your order?

You(21:23:23): I was just chatting with Stephen when I got this message:

You(21:23:38): The chat application is experiencing connectivity trouble. Your chat will be re-assigned to another agent and will be given high priority. We apologize and Thank you for your patience. (21:20:41)
Agent Valentina has joined. (21:20:41)
Your session is now closed.
Thank you, have a nice day.

Jacob(21:24:38): I sincerely apologize for all the inconvenience caused to you. How may I assist you today?

You(21:26:12): I am interested in the $104.99 two-year contract. I would like to compare it, though, to my current FIOS charge for TV, internet, and telephone service. I do not recall my user name and password, and your website does not function to restore those to me. I tried calling the 24x7 800 number for customer service, but it was not available.

Jacob(21:26:32): Let me assist you here.

You(21:26:40): My simple question is whether you can tell me what I am currently paying, so i can compare your offer with my current charges.

Jacob(21:26:45): Could you please let me know, if you have UserID and Password for Verizon service account?

You(21:27:14): Did you see my note above? "I do not recall my user name and password, and your website does not function to restore those to me"

Jacob(21:28:09): I do apologize for that. Let me assist you with the link to check the plans and price for the service.

Jacob(21:28:19): https://www22.verizon.com/ForyourHome/Registration/Reg/OrLogin.aspx
Please click on the above link and enter your Home phone number.

You(21:29:10): That site says: "Enter your Verizon home phone number if only adding a bundle or new Internet or TV service. You will not be able to see or modify existing services."

Jacob(21:30:10): Yes, you would need to register online for the UserID and Password.

Jacob(21:30:21): Could you please let me know, if you do not have Home phone service?

You(21:30:32): I have home phone service.

Jacob(21:31:02): Great! Please enter the Home Phone number and you would be able to view the service.

You(21:32:26): I have done that, but no, I cannot view the service. It asks me to select a plan I might be interested in. It does not show me my existing plan or charges.

Jacob(21:33:01): Yes, you would be able to select the Triple bundle at $104.99/month, you would need to select Prime HD TV plan, Internet plan with speeds up to 15/5 Mbps and Unlimited calling plan.

Jacob(21:33:11): About the Existing service, you would need UserID and Password.

You(21:33:55): I am trying to compare that offer to what I am currently paying. As I explained to you already, I do not know my user id or password.

Jacob(21:35:15): Yes, I do understand your concern and as you do not have UserID and Password, it would not be possible to check the existing service.

Jacob(21:35:30): You would be able to view the new plans and price listed on the Build Bundle page, that you can opt for.

You(21:36:20): Is this some kind of cruel joke? I am interested in the product you are offering, and you are making it impossible for me to evaluate it.

Jacob(21:37:50): Let me assist you with the link to retieve your UserID and Password.

You(21:38:21): I have already explained to you that that link does not work.

You(21:39:27): Perhaps, instead, you could send me the link to RCN or Comcast . . .

Jacob(21:40:32): I sincerely apologize here for the inconvenience caused to you.

Jacob(21:40:53): I would recommend you to try the link and let me know, if you are able to retrieve your userID and Password.

You(21:41:57): Jacob, I already tried that. I am sure none of this is your fault, but this has been an extremely frustrating interchange. Perhaps we should just call it a night.

Jacob(21:42:52): https://signin.verizon.com/sso/ForgotUserIDPassword

Jacob(21:43:12): Please try to proceed with this link and check, if you can retrieve your userID and Password.

You(21:45:25): The link doesn't even load now. Last time, it loaded and did not work to deliver the Id and password. I think you should move on to help the next customer.

Jacob(21:46:50): In this case, I would recommend you to call our Local Verizon Office and get the UserID and Password for Verizon service account.

You(21:47:16): What is the number for the local office?

Jacob(21:47:51): You may please call The Local Verizon Office at 1-800-837-4966 between 8:00 AM and 6:00 PM EST from Monday to Friday. I assure you the best assistance.

You(21:49:24): Oh yes, that is the number that promises service 24x7...

You(21:49:34): Good night.

Early terms news arrives late in MA

2011-12-27T07:37:00.003-05:00

(Yes, I know I was going to take a holiday break, but is it my fault if an engaging radio story caused me to backslide?)

WBUR, NPR, and Kaiser Health News have teamed up to produce radio and "print" health care related stories, and the reporting partnership brings together some excellent capabilities. I especially like the open source aspect of the stories. They even include this note: "All original KHN material – articles, graphics and videos – can be used for free, if you credit us and link to us." (Er, note to The Joint Commission!)

Here's the story by Martha Bebinger about recent efforts by Massachusetts hospitals to avoid early term Caeserian section births. (If you prefer, you can listen to the radio version.) Here's the lede:

There are lots of reasons why an expectant mother and her doctor might choose to deliver the baby before its due date: the health of mom or baby, the doctor's schedule, the demands of work, or even to hit or avoid a specific birthday. But if that perfect day falls before the 39th week of pregnancy, and there’s no medical reason for an early delivery, many hospitals in Massachusetts are saying no, you have to wait.

She goes on to explain that pre-39-week deliveries result in more complications for the babies:

"Early-term infants have higher rates of respiratory distress. There are also issues with feeding," says Dr. Lauren Smith, medical director at the state Department of Public Health. "The most recent evidence shows that babies born before 39 weeks may also have developmental issues, so when you add up the increased risks and you weigh that against a situation when it’s purely elective, then you really can’t justify it."

What is sad about this story is that while it is considered news among the medical community here in Massachusetts, it is "olds" elsewhere in the country.

A decade ago, the folks at Utah's Intermountain Health instituted a protocol to reduce the number of early term C-sections. Within just a few months, they were seeing major results. Brent James and Lucy Savitz provided a description in Health Affairs:

[I]n 2001 the Intermountain pregnancy, labor, and delivery leadership dyad focused on the induction of early labor as a target for improvement. They created a shared baseline that identified when elective induction is medically appropriate and deployed it across the entire Intermountain system, which performs more than 32,000 deliveries each year. When an expectant mother arrived at the hospital for an elective induction, nurses completed an electronic check sheet that summarized appropriateness criteria. If the patient met the criteria, the induction proceeded; if not, the nurses informed the attending obstetrician that they could not proceed without approval from the chair of the obstetrics department or from a perinatalogist—a specialist in high-risk pregnancies.

Elective inductions that did not meet strong indications for clinical appropriateness fell from 28 percent to less than 2 percent of all inductions. The length of time women collectively spent in labor fell by roughly thirty-one days per year. As a result, Intermountain is now able to deliver about 1,500 additional newborns each year without any additional beds or nurses. The new protocol reduced the rates of unplanned surgical delivery (cesarean section) and the attendant higher costs. Intermountain’s overall rate of deliveries by cesarean section is now 21 percent, while the national rate is approaching 34 percent. The protocol also reduced admission rates to our newborn intensive care units, reducing their costs as well.

We estimate that the Intermountain elective induction protocol reduces health care costs in Utah by about $50 million per year. If applied nationally, it would lower health care delivery costs by about $3.5 billion annually.

(A more technical description is offered in this article in Obstetrics and Gynecology by Oshiro, et al.)

What other innovations in the delivery of health care have yet to arrive in Massachusetts? The state's academic medical centers are tops at scientific research but often lag with regard to adopting process improvement and applying the scientific method in care delivery. In so doing, they cause harm to patients and permit waste and extra cost to persist in the state. I hope Martha and her team have a chance to focus on that question.

Happy holidays!

2011-12-22T17:48:00.000-05:00

With this view of winterberry in the field behind my house -- on a sunny, warm and decidely not winter-like day in Boston -- I leave you for a blogging break through the New Year. Thanks for your loyal readership, and best wishes for a lovely holiday season for you, you families, and your friends. Let's also give thanks to our colleagues in the health professions, the most well intentioned people in the world, who devote their lives to alleviating human suffering caused by disease.

Stay tuned. Lots more to come in 2012!

To turn or not to turn

2011-12-22T10:26:00.000-05:00

A colleague informs me that 98% of people who are reading a story on the New York Times on-line version do not "turn the page" when the story jumps to a second page. If that is the case, it presents a crystal clear rationale for redesigning the website, taking advantage of the flexibility one has in graphic design to make it more likely that people will read more of the high quality content that The Times offers.

Let's do a little crowdsourcing here. How would you design the web version of the newspaper to encourage and enable subscribers to read more of these stories?

My simple answer, although I don't know if it is technically possible, is to have the story automatically expand as it senses your cursor reaching the last paragraph on the first page.

Thanks to John and Kathy

2011-12-22T09:42:00.000-05:00

How like John Halamka to share with the world his and his wife's experience with breast cancer. John believes that knowledge is power, and shared knowledge even more so. Tune in on his blog every Thursday for an update.

Better than printing money

2011-12-22T06:08:00.000-05:00

John McDonough, one of the health care experts in Massachusetts, writes on his blog about the three-year renewal of the state's Medicaid waiver. John presents a history of the waiver and notes that it provides the "green glue," i.e., the infusion of federal cash, that makes possible the health care reform process approved by this state several years ago.

The details are impressive. $26.7 billion over three years, a $5.69 billion increase over the prior waiver, and bringing $13.3 billion federal dollars to the state; $120 million for safety net hospitals such as Boston Medical Center (BMC) and Cambridge Health Alliance (CHA); a pilot project to improve pediatric asthma care; a first-in-the-nation express renewal process for MassHealth, the state's Medicaid program; enhanced early intervention services for Autism Spectrum Disorders, and more.

There are many similarities between the Massachusetts health care access legislation and the federal plan passed by Congress -- individual mandate, guaranteed issue of insurance, an insurance exchange with minimum coverage standards, and subsidized insurance plans for lower income people. The big difference is that a substantial part of the costs of the state plan are covered by this Medicaid waiver, offsetting appropriations that would otherwise be needed from the state treasury. The federal government, in contrast, has no higher level of government to provide funding for its program. It was well known when the federal bill passed that the financial projections showing zero budget impacts were wrong, ignoring, for example, the annual multi-billion dollar override of the SGR adjustment for physician salaries. Since the legislation really did not provide comprehensive ways to address those cost increases, they will remain a political battle in coming years.

Heavyweight development

2011-12-21T14:02:00.000-05:00

Boy, did I underestimate the capital capacity of the Partners Healthcare System when I wrote a post suggesting that plans by Brigham and Women's Hospital to spend roughly $500 million for new clinical and research space would be problematic. I said:

I write it as a citizen watching the unfolding of a business plan that seems to me to be building in future health care cost increases for our region, or worse, potentially weakening one of the country’s great hospitals.

I underestimated by a factor of two, for now the hospital has filed a notice of intent with the Boston Redevelopment Authority to develop 360,000 square feet of research and wet laboratory space and 355 to 455 parking spots.

I am not current with construction costs in the highly congested Longwood area of Boston, but I believe it reasonable to assume at least $1000 per square foot for lab space. Underground parking spots, requiring slurry wall construction in these high water table soil conditions, come in at $80,000 each if not more. So, the total price tag, assuming room for 400 cars, not counting demolition and clearance costs of the existing structure, is about $400 million.

This takes your breath away. A billion dollar construction program, in the face of the end of the federal stimulus program for NIH research and likely flat funding going forward. The capital accumulated must therefore derive mainly from margins made on the clinical business. If anything gives the lie to the idea that the recently signed contract with Blue Cross Blue Shield was not overly generous, you have it here.

That white stuff is not baby powder

2011-12-21T07:23:00.000-05:00

People in the UK who use public baby-changing units might want to use those baby wipes on the changing surface, as well as on the baby. This story in The Telegraph reports:

More than nine in 10 baby-changing units in the North West have tested positive for traces of cocaine. The tests, carried out by using specialist wipes, found that 92 per cent of the 100-plus units examined carried traces of the class A substance. They included facilities based in public toilets in shopping centres, hospitals, police stations, courts and churches.

Police stations? Courts? Churches?

I know that talcum powder is not longer recommended for babies, but isn't this going a bit too far?

Short memories

2011-12-20T10:38:00.000-05:00

When the health care reform bill was pending, and the Congressional Budget Office was asked to opine on its financial impact, one of the "givens" in the cost equation was the annual sustainable growth rate (SGR) formula included in the 1997 Balanced Budget Act. The was a provision that would reduce physician Medicare rate schedules each year. The SGR adjustment was to save hundreds of millions of dollars during the ten-year analysis period used by the CBO. It was included in the calculation because it was a sure thing prescribed by law.

The problem is that, since 2003, Congress has postponed the rate reduction. Each year, thousands of doctors from around the country, directly and through their trade associations, lobby hard -- and they are successful.

The SGR formula works this way: If spending due to increased use of services by Medicare patients rises faster than the nation’s gross domestic product, Medicare must compensate by cutting reimbursement rates for physicians enough to bring spending back in line with GDP growth. This year, the SGR adjustment would hit doctors with a 27.4 percent pay cut for their Medicare patients in January unless Congress steps in. As noted in this Washington Post article:

Postponing the cuts . . . would cost $21 billion for a one-year delay and $38.6 billion for two years. Fully repealing the formula would add nearly $300 billion to the deficit, according to the Congressional Budget Office.

Rest assured, the cuts will be postponed again, kicking the can further down the road.

But this year, the whole thing is mixed up with the controversy about extending the payroll tax cut. Here is an explanation from Politico that should make the whole thing clear:

After a very long Monday, House Republican leaders announced last night they would not hold an up-or-down vote on the Senate’s two-month payroll tax cut and SGR patch. Instead the House plans to take a series of mostly show votes today, including one on the motion to reject the Senate's version and instruct conferees, and another on a "majority resolution" that restates the House Republicans' priorities when it comes to a two-year "doc fix" and other parts of the year-end package. Little is certain, and GOP leaders were careful not to overpromise on the slate of votes today. Majority Leader Eric Cantor (R-Va.) said the endgame is to appoint a conference committee "so we can actually work the differences out." He added: "We can resolve this situation and the people of this country can get what they deserve — certainty on tax policy and health care policy going forward." Minority Leader Nancy Pelosi said she would not appoint members to a conference.

Legislative battles

2011-12-19T21:45:00.000-05:00

As financial pressures impinge the health care system, the various players sometimes seek legislation to protect their interests. I have heard of two such situations in Massachusetts, and I offer them for your consideration and your comments.

The first involves emergency ambulance service. Earlier this year, several of the major insurers in the state stopped reimbursing out-of-network ambulance providers, and instead started to send the checks to patients who used those ambulances. Those ambulance companies now have to try to collect from people for payments, and they are losing hundreds of thousands of dollars.

(This only relates to emergency calls, not routine transfers. For routine transfers, ambulance providers already agreed to be reimbursed at agreed-upon rates with insurers and municipalities.)

I can understand why the insurers want to use lower cost ambulance services, but I have trouble imagining a more cruel thing than approaching a patient or a patient's family after an emergency situation (which perhaps led to long-lasting disability or death) to collect funds that the insurers have sent to the family. It is also inherently inefficient and adds costs if the ambulance companies have to try collect funds from hundreds of individual patients rather than the few insurance companies.

Rep. Jim Cantwell of Marshfield has filed a bill to force insurers to pay EMS providers, and it has a cost-control provision that would give ultimate rate-setting power to local selectmen. The Fire Chiefs Association, Massachusetts Municipal Association and Massachusetts Hospital Association support this bill. This sounds like one that, in legislative parlance, "ought to pass."

Then there is a proposal that comes out of the growth of tiered networks, in which insurers charge higher co-pays or otherwise limit coverage to patients who choose higher cost providers. Well, it turns out that some of those high-cost providers are seeking legislation that would require insurers to include them in the low-cost tier of the network. The two fields at play are pediatrics and cancer care. The providers' argument is that they offer essential services not available at other providers, or that they offer similar services but at higher quality.

Given the current absence of current and publicly available quality and outcome data, it is hard to make a persuasive argument for this exemption from the tiering system. If I were a legislator, I would want to see the numbers and be assured that the stated services are indeed not available from other lower-cost providers or that they are not the same quality. And, yes, if then persuaded that these are essential and of higher quality and are being allocated away from poorer people because of the pricing regime, legislation might be warranted. But the burden of proof should lie with the providers requesting such an exemption. Also, since things change over time, the process for such exemptions should rest with a regulatory agency rather than having specific providers' names being written into the law.

I welcome your thoughts on both of these matters and wonder, also, if people are seeing similar issues arise in their states.

It moved into my path!

2011-12-19T11:10:00.000-05:00

For those who think texting while driving is dangerous, let's consider how many people hit regular mailboxes while driving! The USPS is clearly a public safety hazard.

Really, the most significant?

2011-12-19T09:17:00.000-05:00

Medscape Today has an article featuring "The Most Significant Medical Advances and Events in 2011." The list includes things like some FDA drug warnings; the fact that the Supreme Court will review the health care reform law; some finding about cellular phone use and brain activity; withdrawal of propoxyphene from the market; and new listings of top hospitals.

To which I say, "Bah, humbug!" Most of the things mentioned have had and will have little or no impact on you, me, our relatives and friends as we seek to get care or avoid care.

What are the most significant advances and events? They are the ones that have occurred by communities, patients, and clinicians in their home towns or their home regions that demonstrate the potential for real improvement in clinical care. These are the ones that save lives now. These are the ones that empower patients to be true partners with their caregivers and vice versa. These are the ones that have nothing to do whatsoever with government mandates, accreditation actions, and the like.

These are the ones that occur because, by strategy or opportunism, well intentioned and thoughtful people modestly work together to reorganize the work in hospitals and other settings.

Examples from this blog are:

1 -- A patient named Christian who persuaded a nurse to allow him to administer his own dialysis, and who then trained others, transforming care in a Swedish hospital.

2 -- Peter Pronovost and colleagues document that reducing central line infection rates in Michigan also lowered costs.

3 -- Glen Cove hospital achieves 1223 patient days without a central line infection.

4 -- The one million people of Saskatchewan allocate $5 million per year of government funds to establish and maintain a Health Quality Council, an independent agency that measures and reports on quality of care in Saskatchewan, promotes improvement, and engages its partners in building a better health system.

5 -- The University of Michigan Health System demonstrates the power of adopting a Lean process improvement philosophy and generously shares its experience with the world.

6 -- Jeroen Bosch Hospital in the Netherlands celebrates the opening of a new building by enthusiastically endorsing transparency of clinical outcomes.

7 -- Aided by the Vermont Oxford network, thousand of neonatologists create state consortia to to set statewide targets and objectives, compare best practices, and understand the variability in clinical practices across and within institutions.

8 -- The SCAD ladies band together and influence the direction of medical research.

9 -- The Sepsis Alliance presses for greater awareness of this deathly clinical syndrome.

10 -- The Manukau District Health Board in New Zealand propounds the following philosophy:

What we need to do if something goes wrong is pull back from the instinct to place blame and instead think more deeply about the contributing factors. We need to think about how the system got us to where we are and where the faults in it lie.

Synthetic Biology Explained

2011-12-18T19:10:00.001-05:00

This is a short, clear, and fascinating video about the basics of genetic manipulation and, by extension, the use of engineering principles to create new organisms. As the squib says:

From selective breeding to genetic modification, our understanding of biology is now merging with the principles of engineering to bring us synthetic biology. Written, animated and directed by James Hutson, Bridge8.

Well worth the six minutes it takes to watch. If you cannot see the video, click here.

The latest from the Jubilee Project

2011-12-18T06:32:00.001-05:00

Eric Lu and his friends from the Jubilee Project are back with this funny skit, supported by students from Harvard Medical School. As always, every time someone views the video, a contribution is made to a worthy cause. Look for a cameo appearance in this one by Dr. Nancy Oriol, HMS Dean for Students.

If you cannot see the video, click here.

What they say versus what they do

2011-12-16T10:24:00.001-05:00

I thought it might be instructive to compare the various wordles below, showing the strategic priorities of the hospitals, with what the CEOs say are their priorities. So, I took this chart of top issues hospital CEOs say they face from a while back and made a wordle out of it. I rounded off the percentages and repeated the word in the wordle application one time for each ten percentage points (e.g., MD/hospital relations at 25% became 3). Here's what you get:

Now, compare that with any of the ones below. Here's Emeline's, representing a number of academic medical centers, to remind you:

Hmm, seems like there is not much correspondence between corporate missions and how leaders spend their time.

Baltimore time is Pepsi time

2011-12-15T23:46:00.002-05:00

Andrea Walker from the Baltimore Sun reports:

PepsiCo has signed a deal that allows employees and dependents across the nation to get certain surgeries at Johns Hopkins Hospital — a cutting-edge arrangement that could grow in popularity as companies look to provide better health care and contain costs.

The world's second-largest soda company will pay for workers and their dependents — about 250,000 people — to travel to Baltimore for cardiac or complex joint surgeries, such as correcting problems in a previous knee replacement. PepsiCo will also cover the deductible and coinsurance for the procedures.

It's a free country, so PepsiCo can do as they like, but I wonder what the basis is for choosing Hopkins instead of another hospital. Is it that it can demonstrate superior outcomes compared to other hospitals around the country? No it cannot, but there are no published figures that would enable that kind of comparison.

So, the answer has to be that PepsiCo negotiated a really good price for these services:

Hopkins in turn will charge Pepsi a set rate for the surgery, rather than separate fees for physician charges, preoperative testing and other related services. The arrangement was announced last week.

As this is mainly incremental business for Hopkins, I am willing to bet that the price offered is substantially below that charged to local residents going to the hospital, whether covered by Medicare or private insurers. In a large, fixed-cost institution like Hopkins, as long as you don't have to add new physical facilities and expensive equipment, you can price just high enough to cover your short-term marginal costs and come out ahead.

But I wonder if PepsiCo considered other institutions or conducted a taste test? That would have provided a real challenge.

The wordle from the Hub academic medical centers

2011-12-15T18:34:00.000-05:00

And the final one in our series of wordles, this one based on the mission statements of the Boston academic medical centers (BIDMC, Brigham and Women's Hospital, MGH, Tufts Medical Center, St. Elizabeth's Hospital, Boston Medical Center, Children's Hospital, Mass Eye and Ear Infirmary, Dana Farber Cancer Institute, and Joslin Diabetes Center.)

Dr. Shaw offers Canadian hospital and health system wordles

2011-12-15T14:19:00.001-05:00

And one more post continuing our theme of visual representations of hospital mission statements, we have these submissions by Dr. Susan Shaw, in Saskatoon, Saskatchewan. She writes:

I wondered if things might be different in Canada. We don't really have Academic Medical Centers in the same manner as the US system. But I picked some of our largest teaching hospitals or networks that partner with Canada's largest medical schools.

I also made a second wordle using all the mission statements of our Saskatchewan health regions for a comparison.

Joe Colucci sends the wordle for nonprofit hospitals

2011-12-15T14:12:00.001-05:00

Continuing our theme of visual compilations of mission statements from hospitals. Joe Colucci, Research Associate at the Health Policy Program of the New America Foundation, compiled a wordle from the mission statements of about 50 nonprofit hospital systems across the country. He notes that if you zoom in on the image, there's quite a lot of detail -- small words that only recur a few times.

Here's the wordle for academic medical centers

2011-12-15T06:16:00.001-05:00

Responding to my post below, a Facebook friend, Emeline Aviki created -- faster than you can say "AMC"! -- this wordle based on the missions statements from seven leading US academic medical centers.

She notes: "The most concerning words that are missing from this image are 'sustainability' and 'efficiency.'"

In a comment to my original post, Bruce Ramshaw offered a perceptive thought before he even had a chance to view Emeline's work product:

Many are learning the words and including them in their mission statements: patient-centered, world class, team-based care, value, quality improvement, etc. etc. But unfortunately, other than individuals leading extraordinary efforts (like Peter Pronovost and others), the academic medical center leadership and overall organizational design continues to persist in an increasingly outdated mindset, and in an organizational hierarchy with vertical department silos that actually prevents implementation of the improvements described by the words in their mission statements.

What would this look like for academic medical centers?

2011-12-14T18:26:00.000-05:00

A colleague in the arts sent along the following:

"An analysis of the mission statements of leading US art museums yields some surprising results," By András Szántó. From Art Basel Miami Beach daily edition; Published online: 01 December 2011.

The graphic above shows most frequently used words in 60 museum mission statements. The bigger the word, the more often it appears.

Quick. What do the following terms have in common? Beauty. Values. Discussion. Contemplation. The answer: none of them figures prominently among the institutional imperatives of US art museums—at least in light of their mission statements.

In fact, if you scanned 60 mission statements of prominent museums that exhibit contemporary art, you would find that each of the words above appears exactly once. Other words found missing from 59 of 60 mission statements: advocate, progressive, ambitious, ethical, intelligence, strategic, video.

If we were do the same for the nation's academic medical centers, what words would predominate? Which would be missing?

Please provide your answers in the comments below.

Wellness Challenge at the Gaylord Palms

2011-12-13T18:21:00.001-05:00

#IHI You may recall my post below about staff recruitment, orientation, and engagement programs at the Gaylord Palms in Kissimmee, Florida. Here's another I liked a lot, which could be easily replicated by any employer. The goal is to promote employee health and wellness, but not in a heavy-handed way. Consistent with the leadership philosophy of the Gaylord Palms, they made it fun.

The prize is $1,000. You take your "bingo card" (above) and have each box in the bottom half certified when you carry out the measure, e.g., physical exam, blood drive, flue shot, etc. If you complete 10 of the 16 squares, you are entered to win in the drawing for the grand prize. If you complete 12, you get two chances to win; 14, three; and 16, four.

I think this is a painless and enjoyable way to promote employee health. I am also willing to bet that participation in the program reduces the company's health care bill by well more than the cost of this incentive program.

We, robots

2011-12-13T13:10:00.000-05:00

First we have robots that you take home after going to the hospital, and now we have robots before you leave the hospital to go home. An excerpt:

[Brian] Jack and his colleague Timothy Bickmore of Northeastern University have enlisted “Louise,” an avatar, or virtual discharge advocate. She appears on a computer-like screen that is rolled up to patients’ hospital beds to walk them through the discharge process.

Louise can spend 40 minutes or more with every departing patient. She is never distracted and can create well-targeted discharge summaries using information about each patient. Louise can communicate using synthetic speech and through a touch-screen display. And patients actually like her, says Clancy, “some . . . better than real, live nurses.”

Oh, come on. Let's take some of the energy that went into this kind of programming and direct it to adopting Lean process improvement so that real, live nurses or case managers have the time and energy to carry out these functions.

Meanwhile, recall this scene from I, Robot.

Sonny (a robot): What does this action signify?
[winks]
Sonny: As you walked in the room, when you looked at the other human. What does it mean?
[winks]
Detective Del Spooner: It's a sign of trust. It's a human thing. You wouldn't understand.

Big announcement today!

2011-12-13T06:26:00.000-05:00

Are you ready for this?

More on Lean from Michigan

2011-12-12T17:01:00.001-05:00

I want to add a couple of more items to the post below about John Billi's MIT-sponsored webinar about Lean at the University of Michigan Health System.

When the Lean approach was first adopted at UMHS, there were some notable successes which I would term "projects." For example, a rapid improvement event was held to redesign the carts used for blood draws, using the 5S approach that I have often referenced on this blog. Here's the "before" view:

And here's the "after" view:

This is all good stuff, but it is not a full-fledged implementation of an organizational philosophy. What UMHS found out is that the cultural change inherent in Lean takes a long time to become embedded in the firm. At BIDMC, we used to talk about "tortoise not hare" when we described that. In essence, the process of adopting Lean becomes a Lean process itself. It is one of modesty and constant learning. Look, for example, at what John presented for the coming agenda for his institution.

The other point John made is when a map is constructed to enable all to all aspects of the value stream, "it's not the map that's valuable. It the process of mapping, which produces a shared understanding of the value stream and which enables the front-line team to design improvement experiments together."

Lean progress at the University of Michigan

2011-12-12T13:23:00.001-05:00

I just listened to an extraordinarily well done webinar from MIT, presented by Dr. John E. Billi, associate dean for clinical affairs at the University of Michigan Medical School and associate vice president for medical affairs at the University of Michigan. John leads the Michigan Quality System, the University of Michigan Health System’s business strategy to transform clinical, academic, and administrative functions through development and deployment of a uniform quality improvement philosophy.

As noted in the webinar summary, the University of Michigan Health System (UMHS) has been on the lean journey for the past six years, creating the Michigan Quality System. UMHS has 20,000 faculty, staff, and trainees. The goal is to create 20,000 problem solvers who are finding and fixing root causes of problems they face daily. Dr. Billi described UMHS’ initial approach, results of early experiments, what leaders learned, and how they adjusted. The discussion covered the transition from scattered projects led by coaches to an integrated approach that incorporates people development and process improvement.

John's presentation was one of the best I have heard on this topic. His slides, too, were clear and descriptive. I'd like to show you all of them, but let me pick a few. The thing I liked best was the modesty and transparency demonstrated. Even after years of doing this work, John felt comfortable starting with this slide, showing where is system still needs work:

That he would feel the need to do so is even more striking when you look at some of the successes. Here are some results from cardiac surgery:

I liked the story about increasing mobility of ICU patients. Here's the summary chart:

But even better than the substantive results was the fact the Lean approach resulted in pull-based authority. Having achieved a broad consensus on objectives and experiments, the front-line team was able to exercise their discretion in how to carry out the improvement. You see them here accompanied by the grandson of a patient, another key participant.

John summarized other key lessons. The first is about how authority must devolve to make Lean work. "Leaders have to show respect, which means trusting people to solve their own problems if they are given the tools."

Finally, to reach the goal of having 20,000 problem solvers, you need to design brilliant processes, based on creating standard work.

I have some more observations in the post above.

I didn't mean it, HAL.

2011-12-12T10:21:00.000-05:00

HAL: Look Dave, I can see you're really upset about this. I honestly think you ought to sit down calmly, take a stress pill, and think things over.

I remain impressed with the tendency of the health care industry and those new ventures who hope to sell to that industry to invent high-tech, high-cost approaches to problems that can be solved for much less money. Take this new robot described in a Boston Globe article by Jay Fitzgerald. Here's the lede:

When Erin Tally took Aidan, her 2-year-old son, home from Children’s Hospital Boston on the day after his urinary surgery, she brought along a new friend: a 4-foot-6, 17-pound, two-wheeled robot that would help deliver care to her recovering child.

Over about two weeks that included five video consultations, the robot, made by Vgo Communications Inc., of Nashua, eliminated the need for Tally to drive Aidan into Boston every three days for post-surgical checkups.

Photo by Bill Greene, Boston Globe Staff

With cameras, advanced audio gear, and a video screen on its “face,’’ the robot allowed Aidan and his parents to talk with nurses and doctors in Boston. They could see and communicate with Aidan and his parents, take close-up photos of his surgical scars for doctors to review, and help determine what type of medications he needed.

Let's acknowledge that it would be inconvenient for a parent to drive the child in for follow-up appointments and could be a discomfort to the child. Is there another, less-expensive way to use technology to "see and communicate with Aidan and his parents, take close-up photos of his surgical scars for doctors to review, and help determine what type of medications he needed?"

I think so. The devices that could be used include a telephone, email or secure patient site, Skype or FaceTime, a camera, and/or an iPhone or other like device. Why spend $6,000 on a robot and more money for 4G service when the elements of a solution already exist? And please don't tell me that the answer is HIPAA.

Uh oh, have I now annoyed the robot???

----

** Headline source -- 2001, A Space Odyssey:

Dave Bowman: Hello, HAL. Do you read me, HAL?
HAL: Affirmative, Dave. I read you.
Dave Bowman: Open the pod bay doors, HAL.
HAL: I'm sorry, Dave. I'm afraid I can't do that.
Dave Bowman: What's the problem?
HAL: I think you know what the problem is just as well as I do.
Dave Bowman: What are you talking about, HAL?
HAL: This mission is too important for me to allow you to jeopardize it.
Dave Bowman: I don't know what you're talking about, HAL.
HAL: I know that you and Frank were planning to disconnect me, and I'm afraid that's something I cannot allow to happen.
Dave Bowman[feigning ingorance]: Where the hell did you get that idea, HAL?
HAL: Dave, although you took very thorough precautions in the pod against my hearing you, I could see your lips move.
Dave Bowman: All right, HAL. I'll go in through the emergency airlock.
HAL: Without your space helmet, Dave? You're going to find that rather difficult.
Dave Bowman: HAL, I won't argue with you anymore! Open the doors!
HAL: Dave, this conversation can serve no purpose anymore. Goodbye.

Lean thinking webinar from MIT

2011-12-12T06:19:00.000-05:00

This looks like a really good webinar today. Here's the link to register.

Taylor's thinking clearly on health care

2011-12-12T06:05:00.000-05:00

#IHI Hey, check out this new and thoughtful blog, Clear Thinking on Health Care, by a young man named Taylor Christensen. We met at the IHI Annual National Forum. He notes:

I am now in medical school, where I am doing an M.D./Ph.D. in Health Care Organization, Outcomes, and Policy. From there, I’ll be a physician/business strategist/health policist–my dream job! And my career goals are (1) to be an amazing physician and (2) to fix the health system, probably in that order.

It's nice to see someone with ambition! Let's give him lots of feedback as he opines on the issues of the day. Here's a recent post on leadership.

Andy, we hardly knew ya

2011-12-11T17:06:00.001-05:00

When Andy Rooney died a while back, I wondered. Now, thanks to William Heisel, at Reporting on Health, for spreading the word about a piece written by Pat Mastors (seen here.) It is written in the style that might have been used by Mr. Rooney, himself. Here's her lede:

I died last week, just a month after I said goodbye to you all from this very desk. I had a long and happy life - well, as happy as a cranky old guy could ever be. 92. Not bad. And gotta say, seeing my Margie, and Walter, and all my old friends again is great.

But then I read what killed me: “serious complications following minor surgery.”

Now what the heck is that?

Indeed.

What's wrong with this picture?

2011-12-11T06:06:00.001-05:00

A nice effort to engage patrons in reporting problems, but a bit of "a slip 'twixt the cup and the lip."

The Inheritance of Loss

2011-12-10T20:40:00.001-05:00

I just read The Inheritance of Loss by Kiran Desai (Grove Press, NY 2006), and felt great appreciation and not a little envy at her ability to write descriptively. I recommend it highly. The story takes place in West Bengal near the Himalayas. Here is a sample from pages 278-279:

She passed by fields and small clusters of houses, became confused in a capillary web of paths that crisscrossed the mountains, perpendicular as creepers, dividing and petering into more paths leading to huts perched along eyebrow-width ledges in the thick bamboo. Tin roofs promised tetanus; outhouses gestured into the ether so that droppings would fall into the valley. Bamboo cleaved in half carried water to patches of corn and pumpkin, and wormlike tubes attached to pumps led from a stream to the shacks. They looked pretty in the sun, these little homes, babies crawling about with bottoms red through pants with the behinds cut so they could do their susu and potty; fuchsia and roses -- for everyone in Kalimpong loved flowers and even amid botanical profusion added to it. Sai knew that once the day failed, through, you wouldn't be able to ignore the poverty, and it would become obvious that in these homes it was cramped and wet, the smoke thick enough to choke you, the inhabitants eating meagerly in the candlelight too dim to see by, rats and snakes in the rafters fighting over insects and birds' eggs. You knew that rain collected down below and made the earth floor muddy, that all the men drank too much, reality skidding into nightmare, brawls, and beating.

When is a protocol not a protocol?

2011-12-09T16:59:00.000-05:00

Answer: When people don't follow it? Better answer: When people don't think they should follow it? Still better answer: When people don't follow it and people are harmed.

Lola Butcher (could we have picked a better teaser of a last name?) writes in Hospital and Health Networks that, according to the head of The Joint Commission, "surgeries on the wrong side of the body, the wrong site or even the wrong patient continue to occur an estimated 40 times every week." She notes that the JC "first highlighted the problem of wrong-site surgery in 1998." Further:

The Joint Commission already requires accredited hospitals and surgery facilities to use a universal protocol that covers preoperative verification, marking of the surgical site and taking a time-out by all members of the surgical team immediately before the procedure begins. The extent to which the protocol is followed varies widely.

While things sounds like a prima facie case of failure on the part of the accreditation body, it is more than that. The clinical director of the Pennsylvania Safety Authority notes that there have been some successes in the country, but:

"When you subtract out the 50 facilities that have been in those collaborations, we don't see any change at all in the remaining facilities," Clarke says. "We do think we have made a difference, but it's only when hospitals actually make a commitment to change their systems.""

The simple truth is that many doctors don't buy in to this. I've heard of some anesthesia writings that cite the statistics indicating the errors continue as evidence that the checklist protocol does not work! These observers completely ignored whether the protocol was actually being followed or not.

Let's go back to The Joint Commission. As I have discussed, failure to pay for such "never" events is not effective. While I am not keen on regulatory interventions, it is possible to use a light, but effective hand that could make a difference. How about starting by publicizing all cases on the public JC website, with the name of the hospital? Keep them in the public eye until a root cause analysis has been done and a remediation plan put in place. Then, share those success stories widely, as opposed to hiding them behind the JC paywall.

If that approach doesn't start to get results, adopt a policy of putting the hospital on probation, in terms of its accreditation, until a root cause analysis has been done and a remediation plan put in place.

This is what dominance looks like

2011-12-09T08:04:00.000-05:00

Sometimes, as they say, a picture is worth a thousand words. This is a chart from a recent investor presentation showing the market share of the dominant provider group in Massachusetts.

As I have said before, this represents excellent execution of a business strategy formulated in the mid-90s, when this system was founded by a corporate affiliation of Brigham and Women's Hospital and MGH. It has resulted in a behemoth, and the state's largest insurer has said publicly that it does not have the ability to withstand the resultant market power -- and acts that way, too.

The chart shows only tertiary discharges, reflecting the 4,000 licensed beds and 6,560 physicians in this system, with operating revenues of $8.5 billion in fiscal year 2011. So, when you read a story about this system being vulnerable to the poaching of a 90-doctor group by a cash-laden private equity firm, you really have to wonder. Especially when the story notes: "Compass doctors send many of their patients to the Brigham for advanced care, and doctors intend to continue that relationship."

How convenient, though, for the dominant player when such an event happens. It can spin the story and assert that this shows how market forces are at work.

In other regions characterized by similar market dominance (e.g., Utah with Intermountain Health; parts of Wisconsin with Gundersen Lutheran, parts of Pennsylvania with Geisinger), the local provider systems have demonstrated an agenda of controlling the growth of health care costs by focusing on improving quality and safety and process improvement. This Massachusetts system could have and still could exercise similar leadership, but not if it continues to execute the old growth model.

Private equity buys the human resource equity

2011-12-08T09:34:00.002-05:00

A story in today's Boston Globe again misconstrues the business plan of Steward Health Care System in acquiring a physician group that was part of the Partners Healthcare System.

Compass Medical includes 90 doctors in eight offices between Braintree and Taunton, and over time, doctors there probably will refer more of their thousands of patients to nearby Steward-owned community hospitals for care, including Quincy Medical Center, Good Samaritan Medical Center in Brockton, and Morton Hospital in Taunton.

The change is a loss for Partners, a powerful provider network that includes Massachusetts General and Brigham and Women’s hospitals, which has been affiliated with Compass for 16 years.

The Steward plan does not divert patients from PHS hospitals. If anything, it is an attempt to divert them from the other community hospitals in those regions, like Milton and Brockton Hospital. PHS does not have community hospitals in that region. Remember, too, that Steward is using MGH as its tertiary center.

This whole thing, though, is really part of the usual private equity strategy during the years leading up to an IPO or other flip of the Steward network. The name of the game is to show investors a pattern of market share and revenue growth. The profitability of such moves is secondary, in the investment world, to an increase in scale. When viewed that way, it doesn't matter what Steward pays to acquire these physician groups for just a few years: There is no way, though, that the incumbents can match the acquisition price, as they have to plan to stay in business for years to come.

Something we'd rather not need

2011-12-08T08:26:00.000-05:00

Imperial College in London has opened up a new research center to assess the effects of roadside bombs on British troops. The Royal British Legion is providing £5 million to establish the center. As noted in this article in the International Business Times:

The Royal British Legion Centre for Blast Injury Studies at Imperial College will plan the new tools that will develop better ways of protecting British troops.

"The Centre for Blast Injury Studies aims to improve treatment and recovery for those injured serving their country, as well as to reduce the number and extent of blast injuries in the first place," Chris Simpkins, Director General, The Royal British Legion, said in a statement.

This is an excellent idea. One of the often untold stories of these wars is the resulting long-term damage to soldiers who are in vehicles. Even when they are not maimed physically, they can often suffer brain damage from the concussive effects of these explosions. There are many soldier who return with live-long migraine headaches, for example. They are forced to live a life of heavy medication and disability.

The Times story continues:

"We now need to assess the effects of blasts on survivors. We urgently need to know more, so that we can protect and treat people more effectively. This Centre can make a real difference to the survival and quality of life of those serving in conflicts," Anthony Bull, Professor at Department of Bioengineering at Imperial College, said.

Exactly.