Thursday, April 17, 2014

Berwick DID like the UK system after all

In a remarkable show of disinterest by the mainstream media in Massachusetts, it appears that only the Associated Press cared enough about Don Berwick's proposal for a single payer plan to give it the attention of a reporter. Here's the story:

BOSTON (AP) — Democratic candidate for governor Don Berwick on Wednesday called for a ‘‘single health care payment system’’ for Massachusetts.

Berwick, who headed the federal Centers for Medicare and Medicaid Services for 17 months, is one of five Democrats, two Republicans and three independent candidates seeking the state’s chief executive post.

Speaking at Boston University School of Medicine, he praised President Barack Obama’s health care law and the 2006 Massachusetts law that inspired it, adding that Massachusetts can again lead the nation.

But, he said, the state and country can do better by essentially expanding Medicare, which covers the elderly, to include all residents regardless of age.

‘‘We can create and manage a simplified, transparent, efficient, and fully accountable single health care payment system in Massachusetts and we can make it work for the people,’’ Berwick said in a prepared copy of the speech.

That ‘‘single-payer’’ option has long been a dream of liberal Democrats, but has also been considered a political impossibility in a divided Congress.

It was Berwick’s praise for aspects of the British single-payer health care system that marked him for criticism from congressional Republicans, who said it showed his affinity for big government programs. They blocked his confirmation as Obama’s permanent head of the Centers for Medicare and Medicaid Services after his temporary appointment.

Berwick on Wednesday brushed off the criticism of those he called ‘‘naysayers’’ and said a single-payer system would have less ‘‘waste, confusion, complexity, and opacity’’ than the current system, which he said forces patients and doctors to spend time and money sorting out varying coding systems and billing rules.

By contrast, he said, Medicare spends just 1 percent on overhead.

It is ironic that the case made by lots of Republicans against Don for the CMS job was, in fact, based in part on his position on this issue.  Back then, recall, "Republicans . . . seized on remarks he made praising Britain’s National Health Service as an 'example' for the United States to follow." Of course, the Republicans dramatically overstated the issue and would have found any reason to be against him, but time has shown it to be the case that Don actually does support an NHS-like single payer system.

Now, the question is whether this issue will resonate in Massachusetts.

Acts of leadership and courage can be powerful forces for social change

Two lovely articles crossed my desk, and I'd like to share them with you.

The first is by Peter Pronovost, called "The ripple effect." Excerpts:

Cornell University sociologists Milena Tsvetkova and Michael Macy explained how we are much more likely to perform a kind act when we experience or witness one. Experiencing a small kindness is more potent than observing on.

There is a large segment of health care workers who want to do the right thing, to do things differently, but are held back for a variety of reasons. Sometimes they just want to know that there are others who are willing to move forward with them. Someone needs to takes that first step, to set off the chain reaction. Others want to know that if they lead, others will follow.

Take, as a great example, Janet Wall, a support associate on the Weinberg ICU at The Johns Hopkins Hospital. Wall has worked on the unit for 14 years and often jokes that she is “protecting her house” when she sees a behavior that is not consistent with the values that the unit is built around. If she sees anyone neglect to perform hand hygiene before entering a patient room—be it a world-renowned surgeon or a clerical worker—she will immediately remind them to do so. She’s on the unit to save lives, she proudly announces.

Anyone who has worked in health care or been a patient knows how uncomfortable it can be to ask someone else to wash their hands. But Wall took the risk to do something different and hold others accountable. And once she did, other support associates and staff began to follow. Many staff who had never before taken those kinds of risks began to speak up. This social movement has spread around the unit, and even nurses who before did not feel empowered to speak up are doing just that.

Acts of leadership and courage can be powerful forces for social change when they are aligned towards a goal. And as Wall demonstrates, you don’t need a C-suite title to set these in motion. So start a social movement in your unit or clinic. Take that first step—an uncommon act of kindness, generosity or courage. Witness or experience these acts, and then pay it forward, and watch as the world around you begins to change.

And then the next is from Tracy Granzyk at MedStar Health, called "Teamwork and Thinking Differently: Can Healthcare Leaders Do This?" Viewing a terrific instrumental quartet, she observes:

A piano has 88 keys, yet new music is created every day. How can we take what we have to work with in healthcare and see what has yet to be discovered or apply what has yet to be tried — especially when it comes to teamwork.

Wednesday, April 16, 2014

Meanwhile, south of the Massachusetts border

Just when I thought that Massachusetts health care environment was complicated, along comes this story from ConvergenceRI.  Richard Asinof is a tireless reporter who documents the health care comings and goings in the state.  We could use someone of his energy and depth in Massachusetts, someone who connects current events with what has happened in the past--with a healthy dose of similes and an appreciation for irony.

Look at these excerpts, for example:

Like new spring growth in the briar patch, thorny consequences of Prime Healthcare’s takeover of Landmark Medical Center have begun to emerge, less than four months after the deal was finalized that allowed the California-based, for-profit hospital system to purchase the financially troubled nonprofit community hospital.

UnitedHealthcare Insurance Company and UnitedHealthcare of New England have asked the R.I. Department of Health to remove Landmark from its network of hospitals, along with 52 physicians, 32 of which are primary care providers, who have “admitting privileges exclusively” at the hospital. 

The only commercial insurer with an ongoing participating agreement with Landmark is Blue Cross & Blue Shield of Rhode Island – a legal arrangement that was part of the final purchase deal.   

There is a certain amount of irony in the current situation, given the events of two years ago, when in the summer of 2012, it was Blue Cross & Blue Shield of Rhode Island that had requested to remove Landmark from its network of hospitals during its contract negotiations with Steward and Landmark, leading to an aggressive advertising campaign attacking Blue Cross by Steward and Landmark and a lawsuit against Blue Cross by the special master that was later withdrawn.

Failed mediation efforts with Blue Cross involving Rhode Island Attorney General Peter Kilmartin [and leaked confidential letters between Kilmartin and Steward Health Care CEO Dr. Ralph de la Torre] led in part to the breakdown of the proposed purchase of Landmark by Steward, a for-profit hospital system based in Boston and owned by a private equity firm, Cerberus, in New York City.

Amazing. Miraculous. Groundbreaking. Incredible.

Gary Schwitzer from makes this point on Twitter:

A journalist must work hard to fit “amazing, miraculous, groundbreaking, incredible” into 1 robotic surgery story.

He is referring to this piece on Although the entire story is worth reading, I especially like this approach to the scientific method:

The new donation will support the funding of surgeries but also launch a more complete program where patients' results can be tracked. It's hoped those results can be used to promote broader use of robotic surgery and secure more funding, said Dr. Waël Hanna.

It's clear we don't have to wait for the results of those studies!

Three days to help Alex go back in time

Our buddy Alex Green has made good progress on his IndieGoGo project to step back in time and engage in old-fashioned typesetting.  Three days are left, and he's 91% percent of the way there.  Please help bring back a bit of the past. Contribute here.

Tuesday, April 15, 2014

Berwick proposes Medicare for all in Massachusetts

Massachusetts gubernatorial candidate Don Berwick is holding a press conference on Wednesday, April 16, at 7pm at Bakst Auditorium at Boston University's School of Medicine to present his plan called "Medicare for All," a single payer system for the state.  Many will be curious to see what he proposes.

As one of Don's supporters in the Democratic primary race, I don't necessarily agree with all he says, but I love that he stretches the limits in his public policy proposals.  It keeps the race vibrant and gets people engaged.

There is a delicious irony to Don's single payer approach in this state, in that a large argument for it has been provided by the state's largest insurer, Blue Cross Blue Shield--which would be put out of business by the proposal.  Why?  Well, BCBS has been so intent on expanding the use of global payments that it has effectively shifted actuarial risk from itself to the providers who have adopted that payment regime.  One can logically ask the question: "If insurance companies don't bear risk, why do we need insurance companies?"  If all they do is handle transactions and claims, who needs them as plan administrators?  What core competencies do they bring to bear that any well-run financial services organization does not?

I'm being slightly facetious but not a lot.  The state's insurers continue to collect a similar percentage of the premium dollar each year for administrative functions.  They seem unable to realize economies and improvements in that part of their business.  Thus, as premiums have risen, their share has risen proportionately. Indeed, one can argue that they have an incentive for higher premiums and more claims processing.  Hmm, it sounds like they operate under their own fee-for-service reimbursement approach, something they decry as inappropriate for the rest of the industry!

Poke that sleeping lion, Don, and we'll see whether it responds with a roar or a meow!

What happened to the Massachusetts exchange?

In the "people's republic of Massachusetts," the Pioneer Institute often gets a bad rap as a conservative think tank.  The Democratic establishment does its best to ignore it, but I have found the Institute to do good work and raise issues in a thoughtful and rigorous manner.

One recent topic followed by the Institute concerns the failure of the Massachusetts health exchange.  Recall that this exchange worked quite well for years before the Accountable Care Act, but then it went into a tailspin during the compliance process for the new law.  Analyst Josh Archambault notes:

As a result of the failed Connector website, 160,000 Massachusetts residents are on temporary public Medicaid coverage even though they don't qualify for MassHealth. Failure at the Connector will cost Massachusetts taxpayers over $100 million dollars this year.  So, Pioneer has questions about how Massachusetts went from having a well-functioning Exchange to one of the worst performances of any state in the Union.

This week legislators on Beacon Hill are finally convening a second hearing in the seventh month since open enrollment started under the ACA, on the failures at the Connector.

This follows a recent Congressional hearing featuring the executive director of the Connector, and a February hearing in Boston where legislators simply vented at officials from the Commonwealth.

Yet, even with these two hearings, little information has been released to the public on how the state got into this mess in the first place.

Pioneer asks 100 questions that it asserts, "need to be answered regarding just what happened during implementation"  I include the first 43 here for your perusal.The kinds of questions raised by Josh are essential to conducting a root cause analysis to understand what went wrong, in the hope of doing better on this kind of project in the future.
  1. Why did the Commonwealth decide to completely rebuild its website exchange? Why did it not work off the foundation of its old website?
  2. Why did the University of Massachusetts Medical School hold the contract for the exchange development? Did the Connector and MA HHS shape the Early Innovator Grant application?
  3. Why were the University of Massachusetts Medical School principal leads on the contract both policy experts, not technical experts?
  4. What was the bidding process that led to the selection of CGI? What factors were considered?
  5. What other companies bid on the contract?
  6. What state employees provided technical expertise to design the website contract?
  7. Were any of the website contracts granted on a sole-source basis?
  8. Why did the state's IT department (ITD) play a limited role in implementation and contracting?
  9. It is clear to outside auditors that the original deal with CGI was too ambitious. Did state employees or CGI include the level of bells and whistles in the original contract? 
    (Background: The promise was a Rolls Royce exchange.)
  10. Problems arose early with conversations about scaling back the original contract starting as early as January 2013, when did serious problems first start to emerge? 
  11. How quickly were issues escalated and to whom? What exactly was the escalation process? 
  12.  When did senior staff at UMass Medical School first know about the problems? 
  13. When did Connector senior staff first know about the problems?  
  14. When did Mass HHS senior staff first know about the problems?
  15. When did the Governor first know about the problems?
  16. When did the CMS state officer assigned to Massachusetts know about the problems?
  17. How frequently were these groups updated about the depth of the problems with the website?
  18. Is there a precedent for reworking IT contracts multiple times in the Commonwealth during such a short engagement?
  19. What are the guidelines for reworking state contracts? Were they followed?
  20. Technical staff under contract with UMass Medical were removed from quality review committees because of their critical assessment of CGI's work, why?
  21. Independent reviewers criticized the Commonwealth for being understaffed in multiple areas of this project, and for high staff turnover, why was this the case?
  22. Best practices for project management were not followed. Which were not, and how will things be different going forward?
  23. Why was no firm pull the plug date set for the project?
  24. When was the decision made to go live, even with the well-known lack of basic functionality?
  25. What percentage of the website was expected to be functional on October 1st?
  26. What percentage was functional on October 1st?
  27. Why did the Connector spend significant advertising money in mid-October to increase traffic to the website with all of the known issues?
  28. Why were the Governor and other senior Connector staff denying that the website had major problems until early November 2013?
  29. Was it ever discussed to simplify MassHealth (Medicaid) eligibility rules during the design process? 
    (Background: Massachusetts has over 250 eligibility rules, and has added enormous complexity to the site design.)  
  30. Did state officials mislead the Federal government on the progress of the project at any point? 
    (Background: Independent reports have noted that code was often submitted with limited to no testing, and the Committee on Oversight has raised questions about security protocols being followed during the entire project.)
  31. Were security agreements signed by state officials truthful for the level of security provided by the website to users?
  32. (Background: As one example, a Minimum Acceptable Risk Standards for Exchanges agreement was signed by the executive director of the Connector and the HHS Secretary in September 2013. Yet independent auditors in September listed the lack of a testing schedule to determine the basic security of the system as a major concern. The Chairman of the U.S. House of Representatives Committee on Oversight has raised security concerns about the state connecting to the federal data hub.)  
  33. What was the standard of proof required by the federal government for the state to pass each "gate review" for the readiness of the site?
  34. Why was the Commonwealth habitually slow in turning around the review of CGI code?  
  35. How many citizens have paid for their plan and still lack an insurance card? 
    (Background: At one point the number was over 2,200)
  36. Why were there no basedlined deliverable and baseline dates updates as the project progressed? (Background: Independent auditors document a lack of baseline in August 2013, with the last being submitted in February.)
  37. How many staff who worked on the UMass Medical School contract have been moved over to other departments or contractors still working on the project?
  38. Why was CGI allowed to change delivery dates without consulting state officials? (Background: This has been a criticism by independent auditors.)
  39. Why were changes to the project allowed "without formal approval and assessment of downstream impacts.."? (Background: This has been a criticism by independent auditors.)
  40. Once the severity of the technical problems became overwhelming, why was contingency planning understaffed by both the Commonwealth and CGI? (Background: This has been a criticism by independent auditors.)
  41. Why was the site allowed to go live without any UAT (user acceptance testing), a standard for any IT project?
  42. When did CMS grant the Commonwealth a delay for testing under the CCIIO Blueprint Test Scenarios? (Background: Independent auditors have noted the state missed the 8/23/2014 delayed deadline.)
  43. Why was there no "formal method for holding individuals and organizations accountable for achieving agreed-to deadlines for project tasks"? (Background: This has been a criticism by independent auditors.)
  44. Why was it announced to the public that CGI was being "fired" before the state had developed the terms of that separation? 

Monday, April 14, 2014

Elton John praises hospitalists!

I never knew that I knew Elton John, but then he showed up in this video to sing a song in honor of hospitalists.  I suspect--and I mean this without criticism--that this rendition is highly unlikely to top the charts.  As I post it right now, it has had 689 views.  With your help, maybe we can get it up into the four digit range!

Sunday, April 13, 2014

7,100,000 is less than 7,000,000

Excellent Saturday Night Live spoof of Fox TV coverage of health insurance sign-ups by the statutory deadline.  Here's the video.

Invitation: Patient and family engagement virtual meeting

Linda Kenney from MITSS says, in asking me and you to pass along this notice:

"I thought you might be interested, or you can pass along to PFAC members or other patient and family members you think might be interested."

Virtual PFE Network Meeting:  Please Join Us on Wednesday, April 16 at 4:00 p.m. EDT.

Patient and family engagement (PFE) is a critical element in improving patient safety and reducing harm.  Consumers, patients, families and patient advisors, as well as providers of care, have a role to play. They must be supported to ensure integration of PFE into all patient care. Please join us on Wednesday, April 16, from 4:00 – 5:00 p.m. EDT for the Patient and Family Engagement (PFE) Network Meeting.

This meeting of the PFE Network will provide an opportunity to convene the group in conversation about patient and family engagement. We will recap the PFE work that is under way as a part of the Partnership for Patients, and discuss priorities to move forward. We will also seek input from you about needed training sessions and other resources that would be useful. More information can be found in the PFE Network Meeting Flyer by visiting this link. We hope you will join us, and please invite friends and colleagues who may be interested.To register, please visit: Virtual PFE Network Meeting.

Saturday, April 12, 2014

The feet that won the game

My team of 12-year-old soccer players asked me to take this picture in honor of a well-played 2-1 victory today.

Thursday, April 10, 2014

It took 400 years to sell the movie rights

A throw-back, seen in the used book section of a book store. The movie probably could have helped Shakespeare to become well known, but it only got a rating of 7.9 out of 10.  No doubt the dialogue needed rewriting.

Wednesday, April 09, 2014

Empathy on WIHI

Madge Kaplan writes:

The next WIHI broadcast — Reclaiming Empathy: Best Practices for Engaging with Patients — will take place on Thursday, April 10, from 2 to 3 PM ET, and I hope you'll tune in.
Our guests will include:
  • Helen Riess, MD, Director, Empathy and Relational Science Program, Department of Psychiatry, Massachusetts General Hospital
  • Stacie Pallotta, MPH, Senior Director, Office of Patient Experience, Cleveland Clinic
  • Martha Hayward, Lead for Public and Patient Engagement, Institute for Healthcare Improvement
Enroll Now

Empathy is not the same thing as sympathy. In the first instance, we feel seen and truly heard; sympathy tends to maintain a distance between two people, often deliberately so. One of the best explanations of the distinction, and why empathy can be so much more powerful, is an online video narrated by human vulnerability expert Dr. Brené Brown. And then there’s the Cleveland Clinic’s video about empathy, directed at health professionals. This moving reminder of the stories behind the faces of patients that pass through health care every day has been viewed on YouTube over a million times.

Why the seemingly sudden need to draw the attention of doctors and nurses to the humanness of the patients before them? Is it because, as some fear, empathy is becoming harder and harder for health professionals to feel or express in the course their jobs? Could be, but there’s nothing inexorable about the loss of empathy in health care today. And, as we’ll learn on the April 10 WIHI: Reclaiming Empathy: Best Practices for Engaging with Patients, there are effective ways to help today’s busy and often overwhelmed caregivers reconnect with their own feelings and the feelings of others, namely their patients.

At the Cleveland Clinic, Stacie Pallotta is part of a team that’s looking at empathy as one important part of an overall strategy to improve patient experience. Dr. Helen Riess, who specializes in the neuroscience of emotions, is turning her findings into “empathy education” for health professionals. She’s also found that if students’ empathy towards patients tends to erode over the course of their medical training, as evidence suggests, new research shows that additional training can either disrupt or reverse this process.

Is there something that patients and families can do if the doctors and nurses and staff they encounter are having a bad day or are so stressed by being pulled in million different directions that they can’t seem to register much more than a weak smile? We’ll ask IHI’s lead for public and patient engagement, Martha Hayward, that question. And we want to know what you think, too. Please join us for this discussion about the value of empathy and human connection to improving health and health care, on the April 10 WIHI.
I hope you'll join us! You can enroll for the broadcast here.

Time for Compassionate Caregiver Award nominations

The Schwartz Center Compassionate Caregiver Award is an opportunity to recognize extraordinary caregivers in our midst. The award is one of the region’s most prestigious honors in healthcare.  Nominations for this year's award are now open and are due by May 9, 2014.  The details are here.

For an example of an extraordinary caregiver, click back to this award ceremony in 2009.

The quarterbacks of the health care system

Here's a great article in Commonwealth Magazine about the buying and selling of physician practices in Massachusetts.  Author Bruce Mohl notes:

In many respects, primary care doctors are the quarterbacks of the new health care system, the marquee players that every team is scrambling to sign. Some work under contract, others under lease arrangements, and more and more are becoming employees of the teams. The financial details of these employment arrangements are tightly held secrets, but rumors abound of signing bonuses, lavish incentives, and big paydays. The health networks—the teams—scoff at such reports, but many of them quietly whisper that their competitors are offering physicians outlandish deals.

As the state’s health care industry consolidates, regulators and the media have focused most of their attention on high-profile hospital mergers and acquisitions. But the pursuit of primary care physicians may eventually have a more profound impact on health care. Those networks that control the most doctors will control the most patients, and with them will come more revenue, more referrals, and more leverage in negotiating reimbursement rates with insurers. 

Tuesday, April 08, 2014

"Good" news: It's not just people

Source: Sunday Telegraph
The UK Sunday Telegraph reported this week:

The waistlines of Britain’s pets have expanded to ever greater dimensions, with a new report revealing that almost half of cats and dogs are now regarded by vets as obese. The new study suggests the numbers of overweight animals has soared in the last five years, and claims that the cost of treating pets for obesity-related conditions is now around £215 million a year.

The problem is worst in dogs, with vets reporting that 45 per cent of those they treat are obese or overweight. The situation is little better in cats (40 per cent), while it was also noted in almost a third of small animals, like rabbits, hamsters and guinea pigs (28 per cent). Even pet birds now suffer with their weight, with problems observed in 15 per cent.

Is this about exercise? Mainly not:

One in three owners admitted feeding their animals “human” food, while the numbers giving them leftovers had risen by 28 per cent in the last five years. Vets believe this is the leading cause of pet weight gain – responsible for eight out of ten cases in dogs. 

Is that all?  No:

[S]ome experts have started to blame pet food manufacturers themselves for making obesity problems worse. David Jackson, a former pet industry nutritionist, has set up a website – – where he analyses the contents of various brands. 

It discovered salt, sugar, oils and fats in a number of leading brands and found chicken dinners containing just four per cent chicken. Some pet nutritionists and behaviourists argue that, just as with children’s junk food, pet food today is at least partly responsible for an epidemic of animal obesity, as well as some behavioural issues. 

I don't know even how to begin thinking about this. How does all this make you feel? Should we care? If so, what's to be done?

Monday, April 07, 2014

Ah, so we STILL need a showing of efficacy, safety and cost effectiveness

I am often amused by the "expertise" of Wall Street analysts.  It's particularly instructive to compare the first one below, a person who hopped on the bandwagon driven by the company, compared to the second one, who retained a more rigorous standard of review.

The first analyst said this:

Shares of ISRG are up today following the announcement that the FDA had cleared the newest version of the company's surgical robotic system, the da Vinci Xi, for sale in the United States. According to the company, the da Vinci Xi Surgical System has broader capabilities than prior generations of the robotic system and can be used across various minimally invasive surgical procedures. Importantly, the company noted that the system has been optimized for complex, multi-quadrant surgeries. ISRG will begin marketing the Xi system immediately and intends on seeking regulatory clearances in major markets around the world.

We think that the approval timing for the da Vinci Xi is perfect as ISRG's largest trade show, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), starts this week in Salt Lake City, Utah. The SAGES annual meeting is oriented toward minimally invasive surgery and last year drew in nearly 2,500 surgeons. A new da Vinci system won't be a panacea for all that ails the company -- pressure on system sales, pressure on procedure volumes in dvH and dvP, confusion about the risk/benefit of robotic surgery, to name a few -- but there will be new upgrade revenue to factor in going forward.

A key feature of the da Vinci Xi surgical system is the overhead boom architecture which allows for enhanced manipulation of the four arms of the robotic system to achieve anatomical access from virtually any position. The robotic arms can even be disconnected and reconnected in 1-2 minutes for better repositioning during the surgery. Moreover, the Vinci Xi is designed to accommodate the Firefly fluorescent imaging system. While the FDA has yet to approve Firefly for use with the Xi, ISRG said it plans to seek clearance for the imaging technology. 

The second analyst said this:

Given the near-term headwinds facing the company, we are hard pressed to get constructive on ISRG until we have greater clarity on adoption trends for the new system, as well as visibility for a next-generation single-site system. Thus, we maintain our HOLD rating and $423 price target.

Shares of ISRG surged following the announcement that the company received FDA approval of the da Vinci Xi Surgical System, reflecting investor sentiment that a new product cycle may help reaccelerate the anemic growth plaguing the company over the past 18 months. While the new system should help the company re-engage potential customers who do not yet have da Vinci, and could also drive an upgrade cycle at some existing customers, we do not believe that the Xi system represents a panacea for below average procedure growth trends. Indeed, we note that the Xi system 1) is an incremental improvement over current iterations that was designed to improve access and ease of use, i.e. not a next generation single-site system; and 2) does not mitigate the cost effectiveness debate that is at the core of the growth deceleration in the overall business over the past 18 months.

We believe that prospective data showing efficacy, safety and cost effectiveness would be the most significant catalyst to growth in this evolving healthcare environment. Additionally, ISRG is launching Xi without the advanced instruments currently found on earlier versions of da Vinci – Firefly, vessel sealer, and stapler – which could limit adoption in the near term.

This last paragraph seems to suggest that what the scientists said in 2008 is still understood to be the case [emphasis added]:

Radical prostatectomy is an effective form of therapy for patients with clinically significant prostate cancer; however, outcomes are highly sensitive to variations in surgical technique. Because of the risks of perioperative complications and urinary and sexual dysfunction, which appear to be as great with robotic-assisted prostatectomy as with any other technique, patients with low-risk cancer, especially those >60 years, might be attracted to more conservative alternatives, including active surveillance, radiotherapy, and focal ablation.

Friday, April 04, 2014

A thoughtful approach to public safety

A friend reports from the Algarve (the northern Portuguese coast):

At the westernmost point of Europe, fishermen sit at the edge of the cliffs across the bay and cast their rods into the waters below. While we were here, a marine policeman came around and administered breathalyzer tests to the fisherman. Apparently, after a morning of fishing, they have lunch out on the cliffs, often with wine. Sometimes, they have a bit too much, and someone will get tipsy and topple over the cliff edge! Then, the coast guard helicopters have to be called in for a search and rescue. Much better to prevent it!

Thursday, April 03, 2014

Annette teaches patient safety in a way we can learn

A key concept in Lean is that of standard work, but it goes beyond Lean.  A major cause of harm to patients worldwide is the large variation in how common medical procedures are carried out.  By definition, if there is a lack of standardization, not all approaches can be based on the best available clinical evidence.  We seek then, to adopt protocols that embody the best knowledge about how to do something right.

Brent James explained this a few years ago:

1 -- Select a high priority clinical process;
2 -- Create evidence-based best practice guidelines;
3 -- Build the guidelines into the flow of clinical work;
4 -- Use the guidelines as a shared baseline, with doctors free to vary them based on individual patient needs;
5 -- Meanwhile, learn from and (over time) eliminate variation arising from the professionals, while retain variation arising from patients.

Part of adopting protocols is to enable people to learn them, and it is here that there's "many a slip 'twixt the cup and the lip," as the old proverb goes.  In many hospitals that have adopted protocols, the sequence of steps is presented in written form in a hospital manual or on its intranet site.  Perhpas a nurse or resident is taught the protocol on the floor, but the teaching is uneven--sometimes not reflecting the entire protocol--and many times it occurs once, and then the clinician is left to try to remember it. Variation sneaks in and standard work is eroded.  Patient safety problems emerge.

It is our nature to vary from the protocol we are taught, especially if the training occurs in just a few episodes and especially if the training material that remains is only in written form.

Annette Koning from the hygiene department at Jeroen Bosch Ziekenhuis in the Netherlands realized this was a problem with regard to the hospital's protocol for cleaning and maintaining central lines.  So, with a colleague, she prepared this short video as a teaching tool, but also as a reminder tool for the staff.  I think it is an elegant presentation, and I offer it to you as an excellent example of (1) a Lean appraoch, where every person feels empowered to engage in process improvement; (2) quality and safety instruction; and (3) pedagogical excellence.  I hope you enjoy it and will consider using it or a similar approach in your hospital.

These people are not camels

Dr. Victor Trastek is a thoracic surgeon at the Mayo Clinic.  To his surpise, an important part of his professional education came from a nurse, Shelly Olson, well after he became an attending physician.  They tell their story in this video.

Congratulations to Shelly for having the guts to stand up to an abusive and powerful member of the medical staff.  Congratulations to Vic for having the guts to tell the world an embarrassing story about himself--for the purpose of helping others see the way.

Wednesday, April 02, 2014

We never stop getting better

A sign of a learning organization (e.g., those which have adopted a Lean philosophy) is the unending commitment to getting better.  When you go to one of these hospitals and say, "How are you doing?" the answer is inevitably something modest like, "Pretty well, but we have so much too learn."  Also, such hospitals are keen to celebrate the improvement activities of their front-line staff and managers. One such example is Gundersen Lutheran Medical Center in LaCrosse, Wisconsin, under the leadership of CEO Jeff Thompson.  Every Friday, 200 managers and staff gather at 8:00am to celebrate and recognize recent improvement activities, and then a written summary is distributed throughout the hospital.  Here's last week's summary:

March 28th Improvement Event Recap:

At last week’s Improvement Event there we saw three examples of our Staff’s passion, initiative and talent!  Here’s a few highlights:

·         Shawn Stevenson (Business Development and Marketing) presented on “Managing Staff Workloads and Stress”.  Being unsatisfied with his department’s EPS Results, Shawn decided to take some unique and effective steps.  In working with his staff, he determined an imbalance in workload was the primary driver of increased stress and lower than desired engagement scores.  He worked hard with is team to fix this.  Using the A3 tool and the PDSA (Plan, Do, Study, Act) process he’s expecting big things in the next employee survey!  Check in with Shawn if you didn’t get a chance to see one of the tools he invented – THE STRESS-O-METER!
o   Observation:  Some would say “Attitude is Everything”.  Poor attitudes in our staff can be a result of being Overwhelmed – and that one is on us!  Shawn did a great job in recognizing this and doing something about it!

·         Lynn Dosch (Purchasing) and Michelle Tilson, RN (Wound Center), teamed up to present on “Reduction in Rental Equipment Expense”.  They noticed a significant increase in the use of Low Air Loss Overlays for the prevention of Pressure Ulcers.  They wondered whether we were truly using these rented overlays only when they would help our patients, or if their use had become routine.  As a result of asking the question, and deciding to take action together (using a PDSA data-driven process) they were able to reduce expenses by more than $23,000 per year while seeing improved outcomes.
o   Observation:  If every leader at the improvement event found similar savings in their departments we would reduce expenses by $4mil!  This is a great example of what we can accomplish when Supply Chain and our Clinical Areas work together!  Go team!

·         Alan Eber (Facility Operations) and Tammy Anderson (Inpatient Psychiatry) presented on the “New Inpatient Behavioral Health Building”.  We saw a great example of how the Process Improvement Tools, when applied collaboratively between Facility Operations and Clinical Operations can make a lasting impact!  As a result of this kind of collaboration, we now have a beautiful facility that fosters a “best-in-class” healing environment for our patients and is one of the most energy efficient buildings of its kind in the world!
o   Observation:  With an annual energy cost savings of ~$50,000 and a 50-year building design life, we will be “stuck” with saving millions of dollars over the coming decades.  Imagine what we would have been “stuck” with if we did not have such a talented team working together to bring this kind of value to our patients and our community!

And remember:  “The best way to predict the future is to create it!”  I am very excited to see the future we will create together!

Mark E. Platt
SVP Business Services

Tuesday, April 01, 2014

How NOT to set an example

[First, a bit of a rant:  Why can't JAMA allow its articles of general interest to be viewable by the public? Other journals, like NEJM, do so. Now, on to the substance.]

JAMA has just published a research letter entitled "Academic Medical Center Leadership on Pharmaceutical Company Boards of Directors," in which it presents a list of deans and other high officials from academic medicine who are on the boards of directors of the top pharma companies.

Since we can't read the article, we go to the reports of two health care journalists to find out what's up.

John Fauber from the Milwaukee Journal Sentinel provides a more appropriate title: "Medical school leaders cash in on drug company boards."  Excerpts:

While university doctors who moonlight for drug companies have faced intense scrutiny in recent years, new research suggests much larger sums of money are being paid to their bosses — the leaders of medical schools and hospitals who serve on drug company boards.

Looking at the world's 50 largest drug companies, reseachers found that 40% had at least one board member who held a leadership position at a U.S. academic medical center — including medical school deans, chief executive officers, department chairs and university presidents.

The average annual compensation from the drug companies was $313,000, according to the paper published today in JAMA.
"These relationships present potentially far-reaching consequences beyond those created when individual physicians consult with industry or receive gifts," the researchers wrote.
He quotes an national expert on such matters:
"I don't know how they can manage a conflict like that," said Susan Chimonas, an expert on conflicts of interest in medicine. "My gosh, there is so much money they are making for a little side job.

Serving in dual roles raises so many potential conflicts that it would be wiser to eliminate them, said Chimonas, associate director of research for Columbia University's Center on Medicine as a Profession.
And also me:
"You cannot serve two masters, even if you are highly intelligent. In fact, if you are highly intelligent, you will rationalize the problems away by saying that you cannot be personally corrupted."
Charles Ornstein at ProPublica offers another take: "Leaders of Teaching Hospitals Have Close Ties to Drug Companies, Study Show."  Excerpts:

Pharmaceutical company payments to doctors extend far beyond rank-and-file clinicians — and deep into the leadership of America’s teaching hospitals, according to a study published today in the Journal of the American Medical Association.

All told, the research team found that 41 of the companies’ 2012 board members held leadership positions at academic medical centers. Six of the 41 were pharmaceutical company executives who served on hospital boards of directors or held other leadership posts. 

Excluding the industry executives, the academics earned an average of nearly $313,000 that year for their board service.

As board members of drug companies, academic leaders take on a fiduciary duty to those companies’ success. That can “conflict or compete” with their other responsibilities, the study says. 

“Given the magnitude of competing priorities between academic institutions and pharmaceutical companies, dual leadership roles cannot simply be managed by internal disclosure,” the authors conclude.

Here's the list.  I think it is humorous (and maybe hypocritical) that JAMA decided not to include the names of the board members since the whole article is about transparency and since the names are available from the web sites of all of the companies.  For example, one notable board member of Alnylam Pharmaceuticals--not listed below--has been Victor Dzau, who is leaving his position as chief executive officer of the Duke University Health System to head up the Institute of Medicine. (He was also on the Medtronic Board.)

Life isn't fair

Joe Carlson over at Modern Healthcare has written a nice piece about some discussions that took place in Denver this last week at the Association of Health Care Journalists.  The topic was the forthcoming disclosure that would be required of industry payments to doctors and hospitals.

He relates a touching moment (really, I'm not being sarcastic), when a doctor expressed frustration at the idea that a legitimate commercial relationship between his hospital and a pharmaceutical company might now be viewed with suspicion.  After all, federal law encourages such relationships to help commercialize and spread the clinical advantages of NIH funded research:

"It seems to me that transparency has morphed into a form of bias," said Dr. Paul Offit, director of the Vaccine Education Center at the Children's Hospital of Philadelphia. "Everyone gets painted with the same brush."

Offit noted in a different session that his hospital has received money from the drugmaker Merck. He said the money consisted of royalties paid for the RotaTeq vaccine, which was developed at his hospital and sold to the drugmaker. In the past he has declined to say what share of the royalties went to him personally.

[Susan] Chimonas [from Columbia University] countered Offit's argument by recalling the case of Dr. Charles Nemeroff, who secretly accepted more than $800,000 from drugmaker GlaxoSmithKline while managing a $9.3 million study on depression at the National Institutes of Health. GSK is the maker of the popular antidepressant Paxil.

"Unfortunately, those guys have poisoned the well for you," panelist and former Boston hospital CEO Paul Levy told Offit. "Life just isn't fair."