Sox show their heart again

A note from Lissa Kapust, one of our social workers who helps out patients with ALS ("Lou Gehrig's Disease"). On July 4, the Red Sox joined with other Major League Baseball teams to commemorate the 70th anniversary of Lou Gehrig's farewell speech. The team's management offered us one of their corporate suites for ALS patients and family members.

I wanted to let you know that the day at Fenway was magical. We filled the Red Sox Executive Box with 25 smiling patients, family members and ALS staff. The day went flawlessly; even sunny skies. The Sox loss was unfortunate, but put no damper on a fabulous day.

Some of our patients made it down to the field as Shilling read the Lou Gehrig "luckiest man alive speech". One patient was given a signed bat from a Sox player (Lugo) which he clung to throughout the game, sitting in his wheelchair, grinning from ear to ear. We had a visit from Sox management, including staff coming by with World Series trophies for our gang to pose with for Kodak moments. Wally [the team mascot] came by for photo ops and hugs. Kait Desmarais [the suite manager] and the food manager came by (and stayed for some time) to take it all in and to be sure there were no problems. The food selections were perfect with special help from the chef who prepared food that would be appropriate for the chewing/swallowing problems for some of the patients.

At the end of the game came a surprise. I went to pay for the food and was told that the Red Sox had picked up the entire tab. I tried to tip the Box attendant, and he refused.

Then the hugs and goodbyes to patients who talked about that we might be able to come back to Fenway again. Pretty hopeful for patients living with ALS.

What the CEO cannot do

This is what leadership looks like. It comes in the form of an email from Michael D. Howell, MD, MPH, our Director of Critical Care Quality and Associate Director of Medical Critical Care, to the ICU nurses, house staff, fellows, pharmacists, respiratory therapists, and attending physicians. Without these kind of champions throughout the hospital, the CEO's job is impossible.

All –

Fifty days. No splashes in any of the nine adult ICUs.

For those I haven’t met (welcome, new interns and fellows!), I’m the Director of Critical Care Quality and one of the ICU docs. In the past, I’ve written about our work to improve patient safety (90% reduction in central line infections, etc), speed delivery of critical medications to our patients (70% reduction in time-to-first-dose antibiotics), and more recently about work we’re doing to improve the experience for patients and families in critical care. Today, though, I’m writing about your safety.

Most of you will have noticed the box in the upper right corner of the Portal [note: our intranet home page] that lists the number of days since an employee injury. You’ve probably noticed that it’s always zero, meaning that one of our colleagues is hurt every day. I’ve been sort of agitated by that, and a few months ago we set it as one of the major improvement priorities for critical care.

As our first target for improvement, we sought the elimination of exposure to bloodborne pathogens by splashes. If you or a friend has ever gotten blood in your eye, you know it’s unpleasant, shocking, and scary. Some of our colleagues have, in fact, even been exposed to HIV and hepatitis this way. We know that nearly all exposures from splashes should be preventable by using personal protective equipment. And yet, before we started our work, someone got splashed about every week or two in our ICUs.

Many of you have participated as we began to try to figure out how to prevent these. Here are a few things we learned:

· ABGs and accessing arterial lines are especially risky procedures. In January alone we had *five* splashes from this mechanism.

· Glasses don’t offer adequate protection. Many people have gotten blood in their eyes (or mouth) while wearing their own eyeglasses.

· Splashes happen at unexpected times: disconnecting a Foley, flushing a PICC line, suctioning an ET tube, and being in the room while someone else was doing as ABG – people have been splashed in all of these ways.

Yesterday, though, we crossed an important threshold -- it has been fifty days since our last splash exposure in any of our nine adult ICUs. That’s definite, meaningful progress. Distribution tells us we’ve more than doubled our mask usage, and in some cases they have even had trouble keeping up with demand. That’s because of your work.

From my own practice, I know that it can be irritating and sometimes challenging to put on a mask and visor every time you’re doing something with a patient. But look at it this way: If we’d done things like we used to, we would have expected three to five more of our colleagues to have gotten blood splashed in their eyes during this time period. Instead, no one did.

I want to make a special request of those of you who are more senior, with lots of ICU experience: Please watch out for your junior colleagues, and if they are forgetting to wear a mask with visor, please remind them. Remember also that you set an extraordinarily powerful example with your own practice. By not wearing a mask, you may unconsciously be training your more junior colleagues to put themselves at risk.

Finally, I want to say ‘thanks’ to everyone who is helping with this, and particularly to Sabrina Cannistraro who is helping to lead the project, analyze the data, and coordinate the work. We will keep focused on splashes for the next several months, and once we’ve convincingly eliminated them we’ll begin to focus on needlesticks, lift injuries, and other challenges to our own safety.

As always, feel free to send comments, questions, and rebuttals directly to me, and please forward to anyone I’ve omitted.

Thanks,

- michael

Real competition? Really?

Paul Krugman's desire for advocacy has become so strong that he apparently has let his economist's training slip. Look at these two excerpts from yesterday's column in the New York Times.

Referring to a Senate committee's action, he notes that its plan for health reform:

achieves near-universal coverage through a combination of regulation and subsidies. Insurance companies would be required to offer the same coverage to everyone, regardless of medical history; on the other side, everyone except the poor and near-poor would be obliged to buy insurance, with the aid of subsidies that would limit premiums as a share of income.

This is good and sensible. But then, he slips off the wagon.

And those who prefer not to buy insurance from the private sector would be able to choose a public plan instead. This would, among other things, bring some real competition to the health insurance market, which is currently a collection of local monopolies and cartels.

"Real competition" is when all participants play by similar rules. As I have noted, that could not and would not be the case with regard to a public plan.

It's working!

Still exercising. Check back tomorrow.

New exercise regime

As I take a Fourth of July blogging break, I am pleased to note that Gretchen Reynolds in the New York Times reports on research showing that short, hard bursts of exercise may do as much for you as regular lengthy routines: "Can you get fit in six minutes per week?" Good news. I am canceling the morning bike rides and the soccer games. This will leave lots more time this summer for eating and naps. I'm sure to end up healthier.

See you on the beach, but only under the umbrella: No more swimming. I don't want to undo all the good effects of those very special six minutes. And the latest research shows the beneficial effects of sleeping. Probably more so when a light, warm breeze is blowing.

Gin and tonics are part of the new plan, too. My research shows that limes are an essential food group in the summer.

A real power bar

It's lunch time and time to report that BIDMC has recreated the famous chocolate chip cookie recipe. It is now available for sale in our cafeterias. Click on the image to enlarge and read closely to find the special ingredient.

ENFP or ENTP?

As we move towards a holiday weekend (here in the US), we'll shift to a couple of days of less hefty topics to help you start relaxing. Blogs are pretty narcissistic by nature, but this post is as self-centered as they come. Skip it right now if you are concerned.

I thought it would be fun to take a Myers-Briggs personality test. It has been many years since I did so, and I forgot what I am like, so I asked one of our HR people to set it up for me.

The results are back and are presented above. I appear to be an ENFP, which stands for extraversion, intuition, feeling, and perceiving. But, the third category was a close call, and I might actually be an ENTP, i.e., extraversion, intuition, thinking, and perceiving.

The characteristics associated with ENFP people are: "Warmly enthusiastic and imaginative; see life as full of possibilities; make connections between events and information very quickly, and confidently proceed based on the patterns they see; want a lot of affirmation from others, and readily give appreciation and support; spontaneous and flexible, often rely on their ability to improvise and their verbal fluency."

In slight contrast, the characteristics associated with ENTP people are: "Quick, ingenious, stimulating, alert, and outspoken; resourceful in solving new and challenging problems; adept at generating conceptual possibilities and then analyzing them strategically; good at reading people; bored by routine, will seldom do the same thing the same way, apt to turn to one new interest after another."

I fear that the instrument is flawed. That it reached no conclusions about my suitability for being a CEO is fine. After all, I'd rather not know. But, the diagnosis made no reference at all to my soccer coaching ability. That is an inexcusable omission.

Summer Report to the BIDMC Staff

Regular readers know that I believe in administrative, as well as clinical, transparency in our hospital. I have trouble understanding why this is unusual, but I know that it is. I just can't imagine trying to solve the problems of an organization and having a common sense of purpose and direction unless everybody is aware of what's going on.

Many of you followed our efforts of dealing with a budget shortfall earlier this year. I sent out the following email to the staff yesterday to offer a follow-up.

Dear BIDMC,

Back in March, I promised I would report back to you on budget and financial issues in June. Here we go:

First, here are the details of our progress in the current fiscal year. As a result of the steps we all took together, we expect to break even for this year. What could have been a $20 million loss has been eliminated. With your help, what could have been 600 layoffs was reduced to 70 layoffs. With your extra help, we were able to insulate our lower wage staff members from what could have been particularly bad news. BIDMC has received national acclaim for our approach to solving these budget problems, and our story has caused many organizations and institutions around the country to think of more humane ways to deal with the economic downturn.

When I asked for your help back in March, I was confident of the response. But I honestly did not understand the enthusiasm with which it would come. I knew that we viewed ourselves as a family here. But I did not fully understand the degree of affection and mutual commitment that underlays our hospital. We together lived through something very special, and I was especially honored to be your CEO during those weeks.

What now? I will talk about next year's budget, but first want to give an overview, at least as I see it. First, some "business school" type of background. I apologize if this is a bit dense and financially technical, but it will be helpful for you to understand the overall picture. I have also provided embedded links to my blog on some of the topics I mention, in case you want to delve into them further. Stick with me through this, please -- even if some of the terminology is new to you -- because I would really like you to understand the financial environment in which we carry out our important societal missions of patient care, research, and education.

As an academic medical center, we have been engaged in a successful business strategy that is composed of five elements: (1) create a broad referral network of trusting primary care doctors, specialists, and community hospitals; (2) emphasize those high level tertiary and quaternary specialties in which we excel, where we can gain market share, and which are highly reimbursed; (3) create a thriving environment for clinical care, research, and education that makes us attractive for the world’s leading clinicians and researchers; (4) negotiate favorable insurance reimbursement packages with insurance companies; and (5) pursue unrestricted philanthropy and gifts directed at clinical, research, and educational priorities.

We have had specific financial targets during this period. To renew and replace infrastructure in our buildings, to stay up to date with the latest clinical equipment, and to invest in our research enterprise, we should be prepared to make annual capital investments in the range of 130% of depreciation, or about $90 million per year. To generate this kind of cash, we need to earn a sustained operating margin of at least 4% supplemented by philanthropy directed specifically to capital purposes. In the years following the merger of the Deaconess and the BI, the hospital’s finances suffered, and capital investment did not meet this standard. Following the turn-around in 2002, we were able to earn a sufficient margin to start to make up for this shortfall, and by FY2008, we had substantially narrowed the gap on a cumulative basis.

There is nothing on the national or state political and economic scene to suggest that the coming years will offer good news for us and for other hospitals. Unless we act decisively, it is reasonable to expect a slow and steady deterioration in our capital position, our ability to compete, and ultimately our ability to carry out our mission in a manner that meets the standard of excellence we demand for ourselves. Putting aside the ups and downs of the economy, there are two major reimbursement factors that are likely to come into play. First, the rate of increase in reimbursements from both the government and private insurers will, at best, rise at the overall rate of consumer spending (not medical sector inflation). Academic medical centers like ours will especially see this. Second, there will be a tendency on the part of both types of insurers to move more to a capitated or bundled form of insurance that will require allocation of revenues and risk between the hospital and its affiliated doctors, but also between those two groups and other institutions in continuum of health care delivery (e.g., skilled nursing facilities and rehabilitation centers.) In others words, there will be something like an annual budget per person for health care, as opposed to the current fee-for-service type of pricing, where we get paid for each diagnosis and procedure and treatment we offer.

So, notwithstanding several years of success based on this business model, we need to recognize that the coming period will introduce new pressures on BIDMC. It is hard to envision exactly how we should respond to those changes. But we know, directionally, what we need to do:

1) We need to retain and enhance our focus of safety and quality and eliminating harm to patients. Beyond the obvious humanitarian reason for doing that, there is also a business imperative. We should anticipate that there will be greater public policy pursuit of quality and safety improvements, most likely characterized by failure to pay for certain procedures with adverse outcomes (e.g., “never” events and returns for follow-up surgery). There is also likely to be discounting of the capitated rates referred to above for failure to meet defined safety and quality metrics. These punitive steps add impetus to the existing business incentives for pursuing quality and safety improvement. Those incentives are expansion of market share from referring sources who value quality and safety and the dollar savings that accrue to the hospital by avoiding costs associated with patient harm.

2) We need to improve the way we organize work at the hospital to make it more efficient and less expensive. We have taken some baby steps in this direction with BIDMC SPIRIT. This program incorporates "Lean" type of thinking by encouraging people to call out problems in the work place, analyze those problems to their root cause, and invent solutions. If done right, this kind of continuous process improvement makes a safer and more pleasant workplace for our staff. When I started up SPIRIT, I told you that the design and approach of the program itself would change over time as we learned from it. Many of you joined in with enthusiasm and accomplished some great things, but then you felt that the effort had reach a plateau and sagged over time. Indeed it did because we recognized that we had not done sufficient training -- particularly of managers -- to give them the support they need to make it work. So stay tuned for more on that front.

3) We need to create stronger relationships with the insurers (especially Blue Cross, Harvard Pilgrim, and Tufts Health Plan) to ensure that our quality control and efficiency programs are recognized by them and rewarded in reimbursement methodologies.

4) We need to enhance and expand our clinical relationships with community hospitals and multi-specialty groups to provide a specific focus on quality and safety, to ensure that patients get the right type of care in the right place, but also to provide a dramatic improvement in the communication about patients' needs and the status of their care.

What does this mean this summer as we prepare our budget for FY2010? There are lots of moving parts. We will soon announce some new clinical affiliations in the community, and those will bring additional patients and revenue to BIDMC. But the reimbursement changes that are headed our way mean that we cannot just continue to spend money in the historical way to serve those patients. We need to organize our work differently to reduce overuse of testing and clinical procedures, some of which have been profitable in the past. We need, too, to be attentive to the levels of staff we need in various functional areas -- increasing some and diminishing others -- but doing so in a way that incorporates your suggestions for improving work flow and creating a safer environment. Because of financial pressures on the clinical side of the house, the margins that have traditionally supported research have shrunk, and so researchers too will have to meet more explicit financial targets. We will be gradually redesigning our education program so that efficiency, quality, and safety in clinical functions is more explicitly supported by our house staff, something that will also enhance the academic value of our training programs.

I recognize that these are just generalities at the moment, and you probably want to know, "What does this mean for me?" The nature of these global changes is that we all will see effects on our work lives, but they cannot be predicted exactly. Some people find that exciting, and some people find that scary. It will be a little of both. What I can promise you as we go through this is that we will do it together, with everybody sharing all the same information, with lots of opportunity for consultation and participation. The truly great organizations, like ours, are not afraid to face the future when we know we are doing it together.

Sincerely,

Paul

Paul F. Levy
President and CEO

Please come clean on the public health plan

A few days ago, I wrote about the inconsistencies in the President's and Congressional descriptions of a public health insurance plan and suggested that it had other purposes than the ones they were describing. I now find a kindred spirit in Clive Crook at The Atlantic, who notes:

[I]t is surely disingenuous to say that a public plan can be just another competitor. How can just another competitor "keep them [the private insurers] honest"? If the public plan makes a difference it will be because of its market and political power, and because of its ability to attract subsidy--in short, because it is not just another competitor. If in turn it exerts those pressures, Obama's pledge that nothing will change for Americans who have private health insurance they like will be impossible to honor.

As I note above, if Congress wants to do this, it must be for the express purpose, first, of giving access to insurance to people at a lower cost, thereby reducing the amount of appropriations needed for subsidies of lower income people. And, second, over time, using those cost advantages to cause more and more people to migrate to the public plan. Perhaps those are the right answers for the country, perhaps not. But let's debate those directly, instead of using fuzzy arguments.

Scene from Fair Oaks

This picture was just too cute not to post it, to carry you through the weekend. Here is the explanation from the mother about her son's first "official run."

We live in Fair Oaks, in which our "Old Village" area features a little park that's populated by a band of chickens. There are many varieties, and some of the roosters have spectacular, colorful plumage. We go to the park and feed them, and they wander around the Village, even at the fine outdoor restaurant. It's our trademark; although some would prefer that our oaks, bluff, and beautiful reach of the American River would take precedence. In the festival's running events, the children are escorted by two adult runners wearing outrageous chicken costumes.

In memoriam: Don Lowry

Robert D. "Don" Lowry, former CEO of the New England Deaconess Hospital, passed away peacefully at his home in Chelsea late Monday, June 22, at the age of 95. Don Lowry made innumerable contributions to this hospital, but I will miss him most for his quiet and calm demeanor, and his kind generosity of spirit. What follows are excerpts of our notice to staff this week.

Don was employed at the Deaconess for 30 years. He became its Chief Executive Officer in 1954, a position he held until his retirement in 1976. He remained on the Board of Directors for several years thereafter, and when the hospital later merged to become Beth Israel Deaconess Medical Center, he was named a Trustee for Life.

The Lowry Medical Office Building at 110 Francis St., was named to honor Don’s many accomplishments during his tenure at the hospital. He was beloved by his employees for his humility, his friendliness and his willingness to pitch in and do whatever he asked of others. An enthusiastic supporter of nursing education, he was admired and highly respected by the nursing staff, the physicians, and the trustees, many of whom became close friends. Under his popular leadership, the Deaconess grew from 298 beds to a 482-bed specialty referral hospital known throughout the world for the treatment of diabetes, heart disease, and cancer.

"Don had the reputation of being a great builder – but being a builder of buildings was not what made him a great leader,” notes his friend and former colleague Joanne Casella, Chief Administrative Officer, Department of Medicine. “It was that he was a builder of trust."

Don had extraordinary warmth and empathy for people of all ages and positions, and he made everyone comfortable in his presence. Many friends and employees were drawn to share their problems with him because, even if he were unable to find a solution, he would leave them feeling comforted, respected, and less lonely and discordant. He loved the people he worked with. As one trustee said at his retirement dinner, "Don's talent has been to bring people around to his way of thinking. He never argued. But soon I'd find myself doing what he wanted me to do...and happy to do it...and thinking it was all my own idea."

Don was born and raised on a farm in Doniphan, NE, a town of about 300. His father later became a grocery store owner and Postmaster. His mother had been a school teacher. After graduating from Doniphan High School, Don worked for several months in a commercial photography studio in Hastings, Nebraska, before moving to California in 1931 where he attended Sacramento College.

In March of 1941 he was drafted into the U.S Army and, when World War II was declared in December of that year, his nine-month stint was extended to five years. In the Army, he helped to set up an X-ray department and trained X-ray technicians at the Station Hospital in San Luis Obispo, Calif. He was commissioned in the Medical Administrative Corps in 1942 and, as a Captain, served as adjutant to the 102nd Station Hospital in Australia as well as in New Guinea, the Netherlands East Indies, and the Philippines, eventually leading to his life's work in hospital administration.

Photography remained Don’s avocation for many years. And, his other great joy in his "off" time from the Deaconess was his 34-foot cabin cruiser, "The Sequester," on which he spent many happy hours entertaining family and friends during the summer months, often serving them a unique sandwich he called the "Sequester Special."

While leading the Deaconess Hospital, Don served terms as President of the Massachusetts Hospital Association and President of the New England Hospital Superintendent's Club. He was an active member of the New England Hospital Assembly, the National League for Nursing, and numerous other hospital-related groups, and remained a Life Diplomate of the American College of Healthcare Executives. Upon his retirement from the Deaconess, he was honored by a vote of the physicians to be named an Honorary Member of the Medical Staff.

Don also was a board member of the Morgan Memorial and in the 1950s a founding member and senior warden of St. John's Episcopal Church in Westwood, and head of its Building Committee. For several years in the late-1970s and early-1980s, he served on the governing board of the Old North Church in Boston where he was a lifelong member of the congregation.

He leaves his wife of 30 years, Eleanor (Clapp) Lowry (a longtime Volunteer Surgical Liaison), family and many friends.

Interns Learn Lean -- They get it in two days!

With medical education focused so heavily on the cause of disease, diagnoses, and therapies, an area that is usually neglected relates to the science of care delivery and process improvement. We're trying to make some inroads here. I told you about one below, and here's another.

Three of our interns (Maryanne Kazanis, Nina Nandy, and Paul Bailey) are participating in a pilot educational experience in quality improvement. As noted by Dr. Julius Yang, who is coordinating the effort, "This is not yet standardized for all new interns, as we are trying to learn from these three whether this is worth expanding to a larger group in the future. The pilot experience is an outgrowth from our participation in the ACGME Educational Innnovation Project, where we are attempting to incorporate continuous health systems improvement skills in the standard training for all our residents."

Julius reports about the first two days: After a whirlwind morning introduction to the field of health care quality and “lean practice” (facilitated by a video that features making toast in a less wasteful way), this group spent an afternoon with clipboards and stopwatches (on day 1 of internship) to observe our current discharge process – using their “uncommitted eyes” to watch the process from the perspective of both nursing and physician workflow. They then spent the next day generating a “future state” concept of what attributes would comprise the ideal discharge process, complete with very near-usable “checklists” (one for the patient, one for the physicians) to help standardize the process.

To give you a sense of the perspicacity of our new doctors, here are just a few excerpts from their observations (some of which paralleled our senior management visit to gemba). Not bad for two days on the job!

GOALS:
To highlight the less efficient aspects of the patient discharge process from a nursing perspective.
To provide a standardized patient discharge protocol for the nursing staff.
To explain why the recommendations implemented in a more standardized discharge protocol would lead to a more efficient discharge process overall.

ASPECTS REQUIRING IMPROVEMENT:
Waiting:
Discharge orders are often entered by the MD at a time that is later than ideal for the nursing staff. This especially contributes to a less efficient overall process when nurses have multiple discharges to complete at once, and when the patients to be discharged are particularly complicated and require more time/teaching by the nursing staff.

Another issue that arises with later discharge order entry is that patients are left to wait 8 hours or more from the time they are told about discharge in the morning to when they are actually free to leave the hospital. This leads to increased questions by the patients to the nursing staff, pages to the MD, potentially displeased patients, and fewer beds available for new patients awaiting admission from the ED.

Forms:
The completion of online forms at this time is redundant with nurses cutting and pasting much of the same information into the patient’s copy of the discharge summary that the MD completed for the permanent medical record. In addition, some online forms include default information that is not relevant to all patients and require frequent deletion by the nursing staff.

Medication reconciliation:
At the time of admission, ED physicians are not consistently completing the handwritten carbon-copy version of the medication reconciliation form and filing it in the patient’s chart. As a result, nurses are required to transcribe by hand this information onto the carbon-copy form which can be quite time consuming.

Obtaining and recording vital signs, removing IVs, and completing medication reconciliation:
At the current time, nurses are often making multiple trips back and forth to the patient’s room to do these items at separately. This leads to inefficient use of time walking back and forth, and may potentially lead to errors in excluding an important part of the discharge protocol.

Dear Governor Patrick

A short excerpt from a more extensive letter to Governor Deval Patrick from the President of the Massachusetts Hospital Association. The idea that coverage under the Massachusetts universal coverage law would be taken away from legal immigrants is deeply disturbing.

Dear Governor Patrick:

The Massachusetts Hospital Association (MHA), and its member hospitals and health systems urge your veto of section 121 of HB4129, the legislature’s FY10 state budget proposal. This section represents a significant step backward in the Commonwealth’s health care reform initiative by eliminating Commonwealth Care Coverage for 28,000 special status legal immigrants currently enrolled in the program.

...We believe health coverage should extend to all legal immigrants, not just those that meet an arbitrary time period of residency. ...[B]eyond the deviation from our goal of near universal coverage, this action also moves us in the opposite direction to better control healthcare costs. These 28,000 people would have less access to prescription drugs and preventative care, including that provided by independent primary care physician practices and mental health providers. The primary access point to medical care for these patients will again become the hospital emergency department, one of the more expensive settings in our system. And while the legislature’s proposal assumes a $130 million state financial savings, the Commonwealth’s true savings will be much less. That is because hospitals and health centers will continue to provide the care they currently do and will pick up the added care associated with loss of coverage from other medical providers and services.

Sincerely,
Lynn Nicholas, FACHE
President and Chief Executive Officer
Massachusetts Hospital Association

Health Care for All explains more here. A summary:

- These Commonwealth Care enrollees are legal, working, tax-paying residents of our Commonwealth, deserving access to services like the rest of our neighbors.
- This is a counter-productive cut, consigning people to the unmanaged, episodic Health Safety Net for services.
- The cut will place additional burden on our beleaguered community hospitals and health centers.
- Eliminating coverage will reduce access to care and reverse the incredible gains we have made through health reform.

I believe that this is a test of the state's resolve to deliver what was promised in Chapter 58. And, while the President and Congress place great faith in our experiment, the resolution of this issue will also send a broader signal to those involved in the national debate.

Fun while getting fitted

Fit testing is required at BIDMC and other hospitals to help insure that health care workers who could be exposed to airborne infection have the correct mask to use and thereby minimize the risk of exposure. The testing involves a series of exercises while being exposed to a "bitter" or "sweet" tasting spray of solution. If the mask is fitted correctly you should not taste the solution that is sprayed into the yellow hood.

Each department has a designated person who does the testing. Nurse Judi Hirshfield-Bartek, shown here, makes this important task more fun by adding a few exercises like jumping jacks and silly things that make people laugh. Also, since some people find the test a bit claustrophobic, the games distract them and help them get through more easily.

Grand Rounds is up

Barbara Olson published a great version of Medical Grand Rounds here. Please check it out.

Front row syndrome

Here is a picture of our entering class of residents at their orientation session. What, you don't see anybody? Well, it is because these are the rows at the front of the auditorium. There seems to be some kind of Darwinian imperative -- perhaps based on their experience in undergraduate medical education -- for trainees to sit in the back rows. If you go back a few rows, you can find people, like these three new Emergency Department residents, seen with Dr. Sean Kelly, head of our graduate medical education program.

Notwithstanding their seating proclivities, this is a great group of trainees, and we are happy to have them with us for the coming years. My major points of advice to them? Wear bicycle helmets. And, help us eliminate preventable harm in the hospital by being vigilant caller-outers.

Pig -- Part 1

One of the lessons of Lean is that if you standardize work, you not only reduce variation, but you improve the quality of the product or service. This is known to be true in the delivery of medical care, but it is often not practiced in hospitals. Instead, hospitals remain cottage industries, with each craftsperson (doctor) plying his or her craft (clinical care) on the basis of experience, intellect, and creativity rather than on the basis of scientific evidence. This leads, nationwide, to extension variation in practice patterns (and cost). More locally, it leads to greater potential for harm. What we need, instead, is a greater reliance on standardized practices in those portions of medical care than can and should be standardized -- still leaving to doctors their ability, creativity, and craftsmanship for those circumstances that truly demand those attributes.

This pig game demonstrates the value of standard work flows. It's fun and illustrative of the concept. Find some friends on whom you can experiment. We'll start with this posting in round one, and then rounds two and three follow below. First, prepare standard size pieces of paper with the grid shown above -- one per participant. (If you click on the picture of the grid, you will get an enlarged version you can print out on paper.)

Now, read the following instructions to your friends: You'll probably have to repeat the instructions.

1) Draw the side profile of a pig, centered on the page.
2) Make sure the pig's head is facing left.
3) The pig should be drawn large enough so that a piece of it is in every box EXCEPT the top right.
4) You have 2 minutes to draw your pig.

Now, have everyone show their pig drawing to everyone else. OK, go to round two, below.

Pig -- Part 2

Now we turn to round 2 of the pig game. This time, hand out the instructions above, along with another copy of the grid, and ask people to draw another pig. Again, have everyone compare their results. Now go to the next step, below.

Pig -- Part 3

And, finally round three of the pig game. Hand out this set of instructions, along with another grid. Now, compare the results of the participants.

I'm guessing you will see higher quality pictures and more uniformity. All right, I know this is not a clinical procedure, with all of its potential complications, but the lesson is nonetheless powerful. After our residents took their Lean training course, several of them said this was the most powerful lesson they learned. They now apply it in clinical settings, looking for "pigs" to standardize their work where appropriate.

Remember, we are not trying here to standardize those parts of patient care that should not be standardized; but we are trying to do so for those elements of care than can be and, most importantly, should be to reduce and eliminate harm. In our hospital, we have done so in the following arenas among others. This has saved lives and reduced other harm, plus making life better for staff and patients:

Clinical pathways -- obstructive sleep apnea; Whipples;
Central line infections;
Ventilator associated pneumonia;
Rapid response teams;
Surgical time-outs.

Quality and Cost Council annual meeting

IHI's Jim Conway asked me to post this announcement:

The Commonwealth of MA Health Care Quality and Cost Council will be holding its Annual Meeting on June 25 from 8:30 am to noon.

For the last year the QCC has worked to:
• Establish statewide goals for improving quality, containing costs, and reducing racial and ethnic disparities ; and demonstrate progress toward achieving those goals. Areas of focus have included chronic and end of life care, patient safety, and building a road map for cost containment. Info on each can be found at the QCC website.
• Disseminate, through a consumer-friendly website and other media, comparative health care cost, quality, and related information for consumers, health care providers, health plans, employers, policy-makers, and the general public. Updates to and enhanced community education about the website occurred.

The keynote speaker will be Cathy Schoen, Senior Vice President at the Commonwealth Fund, and lead researcher on the Commission on a High Performance Health System’s State Scorecard. Ms. Schoen will be speaking about health care system redesign and aligning outcomes with payment reform while sharing new data from the Commissions’ 2009 State Scorecard. A panel of local reactors will feature Senator Richard Moore, Dr. Charlotte Yeh of AARP, Dr. Randy Wetheimer of Cambridge Health Alliance, and Eileen McAnemy of Associated Industries of Massachusetts. The Council will set its agenda and priorities for FY10 in small work groups with audience members.

The meeting will be held at the Hoagland-Pincus Conference Center at UMASS Medical School. A light breakfast will be available for $5 a person. Please register here.

Tufts Summer Institute course

Lisa Neal Gualtieri, Ph.D., Adjunct Clinical Professor, Tufts University School of Medicine asks me to post the following announcement:

Enroll in the Tufts Summer Institute on Web Strategies for Health Communication, to learn how you can help health care organizations develop and implement Web strategies to drive the success of their online presence. Health care organizations are faced with an ever evolving choice of Web technologies that make it challenging to create a coherent and justifiable Web strategy. At the Tufts Summer Institute, you will learn how to select, use, manage, and evaluate the effectiveness of Web technologies for health communication.

Learn from Tufts faculty and distinguished guest speakers how to:
• Use the Web to communicate with and connect to patients.
• Develop a coherent and justifiable Web strategy for health communication.
• Select and manage Web 2.0 technologies to create a Web presence that provides a rich user experience.
• Accelerate your online presence through the use of social media sites and tools such as Facebook, twitter, ning, and Wordpress.
• Employ research-based methodologies such as persona development and formative evaluation to increase the effectiveness and reduce the risk of Web development projects.
• Learn the best practices employed by leading health Web sites including WebMD.com, MayoClinic.com, CDC.gov, TuDiabetes.com, WeightWatchers.com, Livestrong.org, CureTogether.com, Roadback.org, and ABC News Health.

Web Strategies for Health Communication runs July 19-24, 2009. The course meets at the Tufts University School of Medicine campus in Boston from Sunday, July 19, from 5-8 p.m. and on Monday-Friday, July 20-24, from 9 a.m. – 5 p.m. It is offered through the Health Communication Program at Tufts University School of Medicine.

Enroll in the Summer Institute. Registration costs $1000. Tufts affiliates and alumni pay $800.

What a public plan is really for

The current Washington debate about creating a public health plan has a lot of fuzzy arguments. I think everybody can agree that a government insurance company would have lots of cost advantages over private insurers -- lower or no reserve requirements; avoiding regulatory requirements of the states; and, with regard to the for-profit companies, not paying taxes and trying to meet the expectations of equity shareholders.

So, if Congress wants to do this, it must be for the express purpose, first, of giving access to insurance to people at a lower cost, thereby reducing the amount of appropriations needed for subsidies of lower income people. And, second, over time, using those cost advantages to cause more and more people to migrate to the public plan.

If the purpose were just to provide access to people, the existing insurers could be ordered to provide it in much the way the Netherlands has, and also the way Massachusetts has. Then, the full amount of public subsidies for low income people would require appropriations and would be evident to all.

So, I think the proponents of a public health plan really want two things. They want to hide the cost of universal health care access. And, ultimately, they want a greater and greater percentage of the population to be on the public plan.

Thus, the arguments you see about a public plan being set up to encourage more competition among health insurers just don't hold water. So, let's be more direct about the real purposes and vote those up or down.

Do we really spend too much for health care?

Not according to this analysis, led to us by Greg Mankiw's blog.

A less serious view, here (with thanks to Nurse Ausmed for the reminder about this skit):

Take a nap, we'll be there soon

Happy Father's Day!

(Would like to credit the artist for this, but I can find no record of his or her name. Anyone know?)

David, we hardly knew ya!

Michelangelo's David has been on loan in US museums, in an exhibit sponsored by America's fast food restaurants.