Thursday, December 18, 2014

Please answer the question.

If you haven't answered the question I pose below, would you please do so as a comment on that article?  It requires no technical knowledge, and I'd value your opinion.  Thanks.

Enforcing AG's agreements with hospital systems

Bruce Mohl at Commonwealth Magazine reports that the state of Massachusetts has started "to assess $1,000-a-week fines on Steward Health Care for failing to turn over to regulators the company’s audited financial statements, with the current tab standing at $12,000"  This story is the latest chapter dating back to August.  Back then I made a suggestion:

Back in October 2010, when the Attorney General recommended approval of Steward's takeover of the Caritas Christi hospital system, she was able to get the following agreement: 

"Steward, and any successor-in-interest to Steward, will, notwithstanding its for-profit status, fully cooperate with any investigation, inquiry, study, report, or evaluation conducted by the Attorney General under her oversight authority of the non-profit charitable hospital industry to the same extent and subject to the same protections and privileges as if Steward were a public charity." 

So all it takes is for the Attorney General to announce to Steward that she wants this information as part of a joint study with CHIA.  Perhaps she will make that offer to CHIA.

The Attorney General is the lawyer for state agencies.  Why her office is not mentioned in the current story as supporting CHIA in this regard is problematic. This seems to be part of pattern of inability to enforce, in that Steward has also acted to close one of its acquired hospitals (Quincy Medical Center) before the allowed period stated in the agreement.

If this simple set of commitments can't be enforced by the AG, imagine how difficult it will be to enforce the much more complicated proposed settlement with Partners Healthcare System.  I hope the AG-elect is watching closely and is learning the lesson, and chooses to withdraw the PHS agreement from the Court.

Wednesday, December 17, 2014

Please answer this question

At a meeting this week of the MedStar Health patient and family advisory council, Rosemary Gibson and Anne Gunderson asked,

"As a patient or family member in a hospital, what are your assumptions and expectations with regard to medical students and residents when it comes to patient safety?"

Please think about that for a moment, and post your answer as a comment here.  (I'll respond afterwards.)

Everyday innovators show the way at U. Mass.

I hear through the grapevine that my July post about U. Mass Memorial Health Care in Worcester was not well received by some colleagues in Central Massachusetts.  I can certainly understand that, as I did not portray an optimistic prognosis.  I certainly hope to be proven wrong, and recent numbers from that quarter look better, as reported in this story by Lisa Eckelbecker at the Worcester Telegram.

But regardless of how things progress, I want to expand on a passing comment in that blog post, which I meant with all sincerity:

Dr. Dickson, by all accounts, is a thoughtful, honest, and effective leader, with a terrific sense of what it takes to improve hospital work and clinical processes.

Eric writes a marvelous blog--Everyday Innovators--that is documenting many aspects of the process improvement journey occurring at U. Mass.  He celebrates the small and the large, giving special attention to the ideas created by front line staff.  Here's an excerpt from one recent example:

Our first Idea of the Week comes from a team who has taken these principles to heart, the Anti-Coagulation Center staff. After reading an article about how patient perception of quality of care begins in the reception area, team member Pam Burgwinkle, a nurse practitioner and manager of the center, brought the subject up at her team’s idea huddle and collectively they examined some of the topics discussed in the article.

Pam was looking for ideas about how they could demonstrate to patients UMass Memorial’s commitment to patient centered care. As always our care givers had lots of great ideas including ensuring the reading materials are current, adding plants to the reception area and making sure the patient education material is fully stocked.

Finally the team came up with their best idea adding a USB port charging station so our patients can keep their phones charged and provide updates to their family and friends. 

Well done! 

It is out of such engagement and creativity that progress occurs.  There is a leadership and team building example here that has value to hospitals everywhere.

Best of luck to Eric and his team at U. Mass.  I hope and trust you will prove my earlier post to be totally off base!

Not really a victory

Quincy city officials and the Attorney General are likely to claim victory in getting Steward Healthcare System to agree to open a "satellite" emergency room at the otherwise shuttered Quincy Medical Center (in addition to an already operating urgent care facility elsewhere). Patrick Ronan at the Patriot Ledger reports:

Amid calls from state and local officials to retain an ER in a city with more than 93,000 residents, Steward announced Tuesday that it has filed a letter of intent with the state’s Department of Public Health to open a satellite ER in the hospital’s existing emergency department at 114 Whitwell St. The for-profit company said it still plans to close the rest of the 124-year-old hospital by Dec. 31.

Steward said the satellite ER will be open 24 hours per day, seven days per week, and it will be staffed with physicians and nurses. There will also be on-site diagnostic radiology and laboratory services. Patients with serious emergencies or who need inpatient services will be taken to other acute-care hospitals.

A word of caution comes from a knowledgeable person:

Deborah Socolar, a North Quincy resident and former co-director of the health reform program at Boston University’s School of Public Health, said she is concerned about how the satellite ER will be staffed. She said some of Quincy’s ER workers were under the impression it would close Dec. 31, so they got new jobs.

Socolar said news of the ER staying open, although welcomed, doesn’t change the fact that Quincy is about to lose its hospital. “It’s obviously still a loss for the city to not have a full-fledged ER that would have operating rooms upstairs and as a result would be able to handle a wider, more diverse array of patients,” Socolar said. 

But it really goes beyond that, doesn't it? Do you really want to give the impression to the public that an ER exists when there is no connection in the building to the kind of services that might be needed for emergent patients? What are the clinical ramifications of the delay associated with accepting a patient for triage and initial treatment in Quincy and then bundling him/her up for transport to another hospital? Some percentage of patients will be better off going directly to a real hospital's ER directly.  Who is going to make that judgement?  If you were an EMT with a patient in your ambulance, what choice would you make?  If you have concerns and you call ahead to the Quincy ER, you are likely to hear, "Best to take the patient directly to a full service ER."


Look at these two maps.  If you need emergent care and live in the north or west part of Quincy, you may well be better off going to BID-Milton from the start (above).  If you live in the south or east part of the city, you may well be better off going directly to South Shore Hospital (below).  In short, a good portion of those 93,000 Quincy residents will not need or want a satellite ER.


Here's my prediction:  After the six-month trial period, this facility will be quietly closed, citing a lack of business.  The ambulance drivers and the public will vote with their feet.

Tuesday, December 16, 2014

CLER as mud

Back in April, I raised the question of why the ACGME was not publishing the results of its surveys with regard to CLER, Clinical Learning Environmental Review.  The program description states:

CLER emphasizes the responsibility of the sponsoring institution for the quality and safety of the environment for learning and patient care, a key dimension of the 2011 ACGME Common Program Requirements. The intent of CLER is “to generate national data on program and institutional attributes that have a salutary effect on quality and safety in settings where residents learn and on the quality of care rendered after graduation.”

CLER provides frequent on-site sampling of the learning environment that will:
  • increase the educational emphasis on patient safety demanded by the public; and,
  • provide opportunity for sponsoring institutions to demonstrate leadership in patient safety, quality improvement, and reduction in health care disparities.
The question remains, months later:  Where is the data that the ACGME collects about this important GME quality and safety curriculum? Why can't medical students who are interested in joining hospitals with vibrant patient safety and quality programs see it during their residency match process?

And fundamentally, why won't the ACGME model the kind of transparency that is needed to bring about clinical process improvement?

How bad is it? It's so bad that . . .

It struck me that this old Dilbert cartoon characterizes many hospitals.  The situation described may present a problem as they try to run ACOs to manage patient care under a risk-sharing model of reimbursement, especially when they must do so across many institutions and physician practices--each of which has the same problem of cost accounting.

Monday, December 15, 2014

All That's White Isn’t Necessarily Propofol

With thanks to Saskatchewan's Health Quality Council Chairperson Susan Shaw for the reference, please check out this short article on a near miss in a large community hospital.

I have only one quibble with the author's choice of language.  She says:

As with any near miss or drug error, there were a series of unusual circumstances that led to this product being placed on an anesthesia table top. 

Actually, many such errors do not require a series of unusual circumstances.  It is the pattern of everyday work that often leads to preventable harm.

Meanwhile, with thanks to Jan M. Davies, Professor of Anesthesia & Adjunct Professor of Psychology, University of Calgary, I add this short video from George Carlin about "near misses."  Enjoy!

Getting the skinny on skin conditions

I usually get nervous when something seems too good to be true, but every now and then the spark of human goodness comes through. Unless I am missing something, here's an example, sent to me on Twitter by Dr. Howard Green, @DermHag, a dermatologist in West Palm Beach.

He wrote:

Here's a first look at Skinstamatic a ground breaking mobile collective sourced medical search app.








Curious, I followed up with Howard:

Very interesting. So the consult is free? Do users get some kind of priority for appts? Often hard to get one.

He replied:

Free. No priority just recognition of Skinstamatic user at this time although identified photobook is available to be viewed by Dr.

All in all, this looks like a generous use of social media capabilities from members of the profession.  What do you think?

Sunday, December 14, 2014

Randi Redmond Oster questions protocol

Back in April, Randi Redmond Oster sent me a copy of her book Questioning Protocol with the following inscription:

My mission is to help make this book obsolete in 10 years!  In the meantime, I hope it helps others navigate the system.

Well, I've finally had a chance to read the book, and it is excellent. The story told is much more than her son's experience with Crohn's disease.  It is a narrative about the the types of things that regularly happen in hospitals.  I'm not so much talking about medical errors, although those occur. No, this is more about a pervasive tendency of participants in the health care system, as noted by Helen Haskell:

“This was a system that was operating for its own benefit.” 

What she meant was that each person in the hospital was unthinkingly engaged in a series of tasks that had become disconnected from the underlying purpose of the hospital. They were driven by their inclinations and imperatives rather than by the patient’s needs. 

Doctors and nurses face an abundance of tasks every day, and they apply their energy, creativity, and experience to those tasks. But, they often neglect to connect with the patients and families whom they are treating. This is a not a case of bad intentions. Indeed, these folks are among the most well-intentioned people in the world.

Randi relates the story of a doctor's failure to contact her before giving the boy a drug, even though there was no emergent reason for doing so and even though the mother had clearly requested to be consulted on such matters:

"No, I did not contact you. I'm sorry. I did what we always do. Dr. Simmon told me you had an issue with steroids but he saw the pros and cons of administering them. Dr. Hughes and I agreed it was the best course of action."

A follow-up with Dr. Simmon occurs a few hours later:

"I spoke with Dr. Stark today and I understand your concern about steroids. I know you never met her before but she is my partner and I support her medical decision." He blurts this out, stating his position so clearly, that even with a bad [telephone] connection I hear him sharp. The tone in his voice seems like he is concerned about keeping a unified medical front, not about my son.

 "Doctor, Gary is not to have steroids until I understand the justification for taking them. Stop them immediately." I say it strong and clear.

The next day, Dr. Stark says:

"I spoke with Dr. Hughes and Dr. Simmon and since Gary is going to have surgery in three days and he can withstand the pain, he doesn't need steroids. We will not be giving them to him.

I don't think we can expect this kind of scenario to change.  Many in the profession are not ready to change, and they've not been trained to do so. Also, they face innumerable new pressures and obstacles to providing patient-driven care.

Randi learned this during her son's experiences in hospitals.  She therefore developed a series of approaches and techniques to help insert herself into the care regime.  She calls the book Questioning Protocol, and by trial and error, she learned how to do so in a manner that was less likely to cause clinicians to be defensive and upset.  She taught them how to become partners with the patient and his family.

After the episode above, she reports:

Things seem to change in the hospital from this point.  Clearly, they must have written in Gary's records that we are to be made aware of everything and given the opportunity to ask questions.

Now these strangers understand how we operate as a family. I understand they have a well-oiled machine they work in every day.  They move through the machine gears ducking and turning in synchronization with each other, sometimes forgetting that a newcomer might be terrified.  I think they believe that trust in the machine is essential. After all, they know they are the experts.

I feel as if the machine slows down for them when I try to get up to speed.  I see their frustration creep up.  They have other people to process.

The doctors are the first to say they do not have all the answers.  I realize maybe that's why they don't like the questions. But this experience reinforces my resolve: Unless it's life-threatening, I must STOP the machine and understand exactly what is happening.  I'm incorporating these new people into OUR team.

Each chapter of the book contains a portion of her family's narrative, but then ends with two or three or four concrete pieces of advice for people who finds themselves in the clutches of the health care system.  The advice is cogent and clear and helpful.

I highly recommend this book.  I don't think it will be obsolete, as Randi hopes, in ten years.  Buy it now for when you'll need it.  You will.

Pedestrian injuries from cell phones

You will recall the excellent advice of my primary care doctor, Amy Ship, when it comes to using a cell phone while driving.  Don't!

Now comes this story from Governing, about the dangers to pedestrians who are walking and using their cell phones, both talking and texting.  It was brought to my attention by the folks at Commonwealth Magazine.  Excerpts:

Pedestrian injuries due to cell phone use are up 35 percent since 2010, according to federal emergency room data reviewed by Stateline, and some researchers blame at least 10 percent of the 78,000 pedestrian injuries in the U.S. in 2012 on mobile device distraction. The federal Fatality Analysis Reporting system attributes about a half-dozen pedestrians deaths a year to “portable electronic devices,” including phones and music players.

Emergency room visit data analyzed by Stateline are published by the Consumer Product Safety Commission, and incidents caused by distracted walking are likely to be underreported, since the injured party would have to confess to texting or phoning while walking.

A Stony Brook University study in 2011 documented the effect of texting on navigation while walking, finding it significantly more dangerous than talking on a cell phone, leading to a rate of 61 percent navigation errors in simulated situations.

“While talking on the phone is a distraction, texting is much more dangerous because you can’t see the path in front of you,” Jehle said.

Saturday, December 13, 2014

I'll take generic cancer treatment, please


Speaking of insipid hospital advertising in Jacksonville Airport, what's the story about this one from Mayo Clinic?  Who on earth doesn't offer personalized cancer treatment?

And, why does it say "most" insurance plans accepted?  Why wouldn't they accept all insurance plans?

As below, does any of this kind of advertising contribute to the public good?

Friday, December 12, 2014

NowIknowmemorial. Do you really?


Passing through Jacksonville Airport, we saw the advertisement above for a local hospital.  I guess I should be used to ads that suggest that robotic surgery has "quicker recoveries," but this ad made me wonder what other assertions this hospital might make.  What I found is all too typical of the generic, meaningless, and unsupported advertisements hawked by marketing firms and favored by hospital PR departments, CEOs, and Boards of Trustees.

I went to the website to review other aspects of the "NowIknowmemorial" campaign.  Here are the other three images presented.


What does "some of the shortest" mean? Compared to what? Over what time period?  I searched the website and couldn't find those answers.


Of course, OB hospitalists are a valuable service offering, but does it matter that Memorial was the first, if others now have this service?  Obstetrics competition is apprently rife in Jacksonville.  This article notes:

Maternity care is a major marketing tool for hospitals. A nice facility and positive birth experience can mean that the mother, who overwhelmingly makes the health care decisions for the family, will return for pediatric and other care.


And, the ultimate meaningless metric.  But let's say the US News ranking has some validity.  Is this hospital in the Honor Roll of Best Hospitals, one of just 17 out of over 5000 nationwide.  No.  So it's one of the hundreds of so-called "best hospitals."

Here's the actual page from the rankings.  First, let's see how many services were ranked by US News.  Well, none:


Now, let's see how the hospital compares to its peers with regard to patient satisfaction:


Oh dear, below both the state and national average with regard to likelihood to recommend, and above average with regard to unlikelihood to recommend.

Look, I don't mean to pick on this hospital.  Its campaign is emblematic of so many others being run around the country.  I think it's reasonable to ask: Does any of this kind of advertising contribute to the public good?

Thursday, December 11, 2014

When they lose their way

This story by at Bloomburg News shows what often happens in "make your numbers to make your bonus" organizations.  Summary:

Cracks in the foundation of Wal-Mart’s retail business in China have been developing for years, hidden by questionable accounting and unauthorized sales practices.

Let this be a lesson to boards of trustees of health care systems who focus too much on CEOs' achieving corporate financial objectives.

Two leaky lifeboats strapped together?

Priyanka Dayal McCluskey and Robert Weisman at the Boston Globe report that Boston Medical Cemter and Tufts Medical Center are considering a merger, "a deal that, if approved, would be the biggest union of Boston teaching hospitals in nearly two decades."

They note:

A merger would link two nonprofit hospitals that both treat many low-income patients and have endured financial struggles.

While such conversations are worth pursuing, the issue facing the institutions is whether they would be stronger together than they are separately.  If not, this could be a case of strapping two leaky lifeboats together, leading to a faster demise than if they remained apart.

What are the obstacles to success?  First, one of the consequences of the Affordable Care Act has been a diminution in public support for safety net hospitals, like BMC.  There's no indication that government policy will change on that front.

Second, TMC has the weakest referral base of all the teaching hospitals in Boston and, despite best efforts on that front, it remains behind the other big hospitals on that front.

Third, BMC has a large number of unions (is it 14?) that, in the words of a prior CEO, "make it impossible to manage."

For a merger to succeed financially, we need to look for accretive value.  Would it be possible to eliminate layers of overhead, achieve economies of scale in purchasing and other functions, and negotiate better contracts with insurers?

Is it possible to rationalize areas of clinical care?  For example, both hospitals have kidney transplant programs that are, frankly, too small to justify in the own right.  By combining them, costs could be reduced and outcomes likely improved.  Might there be other examples?

But it is often  difficult to accomplish such rationalizations, in that the doctors in each hospital might feel a proprietary interest in their programs.  Someone would have to negotiate a new clinical leadership agreement.

Which brings up the biggest issue of all:  Most mergers are not mergers.  They are takeovers by one party.  The BIDMC example is apt.  A so-called merger of New England Deaconess Hospital and Beth Israel Hospital in the mid-1990's was actually a takeover of the former by the latter.  This led to resentment, alienation, and near bankruptcy.  (In contrast, the successful "merger" of MGH and Brigham and Women's Hospital to create Partners Healthcare System was not a clinical merger at all.)  The cultural issues associated with mergers reign supreme, and I trust that the parties at BMC and TMC are thinking through those aspects as well as the clinical and business aspects.

Interestingly, the Globe story notes that while Tufts is connected with Tufts University School of Medicine and BMC is affiliated with Boston University School of Medicine, "the medical schools . . . would not be part of the deal."

A question to ask is, why not?  We don't need to consider a merger of the two medical schools to rationalize their undergraduate medical education and graduate medical education programs.  There might be efficiencies to be garnered there.  And with the weakness of its other education affiliate, Steward Healthcare, perhaps Tufts Medical School should be considering more of a strategic alliance with its colleagues at BU to ensure the strength of its medical education program.

Wednesday, December 10, 2014

HealthNewsReview lives on!

Many of us are extremely pleased to hear that Gary Schwitzer and his colleagues at HealthNewsReview have received a major grant from the the Laura and John Arnold Foundation:

Stuart Buck, JD, PhD, the Vice President of Research Integrity for the Arnold Foundation, said:
“With a ‘publish or perish’ mentality, researchers are incentivized to produce findings that are striking enough to grab headlines and citations, even though such findings may be exaggerated. News organizations often pass along such findings uncritically, without carefully considering how a study was conducted and whether the results are based on accurate science. We are pleased to provide funding so that Gary Schwitzer and his team can help the media to evaluate medical studies and press releases with a skeptical eye.”
Among other things, the grant will permit Gary and friends to:

Add new systematic reviews of health care news releases (from sources including medical journals, drug/device manufacturers, academic medical centers). This is the most important new feature made possible by the new grant, allowing us to critique news releases that are often the faucets that turn on health news. 

HNR is one of those examples of social media that validate the medium, offering unvarnished reviews of claims in a field where unverified claims are commonplace.  This grant is a terrific contribution to the public good.  

Tuesday, December 09, 2014

Commoditizing patients

This report on BetaBoston made me uneasy.  I'm almost reluctant to comment because my colleagues in the industry may see it as a part of a pattern to criticize a certain health system, but I would say the same thing regardless of what company might be involved in this venture.  See what you think.  Here are key excerpts from the article:

The Center for Connected Health at Partners HealthCare has created a secure survey tool to help medical product makers and investors get feedback from patients and customers. The new mobile app and Web-based survey tool called cHealth Compass will charge companies for the service and pay survey takers for their time.

New enrollees get a flat $50 when they register and $110 per year to take monthly surveys. Other opportunities from individual vendors could pull in between $20 to $50 per survey.

“We currently have several hundred people, and are actively enrolling more,” said Jethwani. The goal is to enroll 2,000 patients from Massachusetts by summer 2015, and then expand to include residents from other parts of the United States.

Client companies will pay a fee for the service, depending on how many questions are included in their surveys and how many patients they intend to reach.

My first reaction is that the health system has just found a new way to commoditize patients.

My second reaction is that this effort is designed only to help companies. It is not designed at all to help patients.  The press release doesn't even pretend that it is otherwise.

My third reaction concerns the potential for bias that is created when responders are paid.

If there were a way for patients to find value by participating in surveys, outside of money--like in this case--that approach might lead me to a different set of conclusions.

Only at IHI!

The Annual Forum run by the IHI always has some surprises.  The best one for me this year:  Only here could you be in the ballroom watching a keynote address by Atul Gawande while exercising on a treadmill!

A just culture at work

The health care world is abuzz with a report from Oregon about a woman who died from a drug administration error.  There are many details about what went wrong and why, but I was extremely pleased to see this statement from the hospital:

"While human mistakes were made in this case, we as a health system are responsible for ensuring the safety of our patients," the health system said in a statement. "No single caregiver is responsible for Loretta Macpherson's death. All of us in the St. Charles family feel a sense of responsibility and deep remorse."

Saddened, they also went right to work to fix underlying problems:

The health system said in a statement that it has put several measures in place to make sure the mistakes aren't repeated. It's enforcing a "safety zone" in its pharmacies so workers can complete medication verifications with fewer distractions, and it's bringing in an external pharmacy expert to provide recommendations.

The hospital system is also looking at changes in how patients are monitored after medication is administered.

Although newsworthy, this event is not unusual. There are many such errors that occur in hospitals, all too frequently.  Also, there are many times more that number of near misses that go unreported, each one of which offers the potential to uncover and remediate systemic problems.

Monday, December 08, 2014

Behind the scenes at the World Center Marriott

Starting with the end of the day first, you see here Melissa Hayes, Regional Director of New York's HELP/PSI Inc. summarizing observations from day-long excursion at the IHI National Forum in which a group of us had a chance to go behind the scenes of the Orlando World Center Marriott.  The purpose was to learn how the resort handles the flow of large volumes of visitors and delivers high levels of customer service in the front office, adheres to schedule in the banquet kitchen, manages daily housekeeping operations, runs a golf club, and tends to a multitude of details in events and convention services.  Our goal was to see if there were lessons from this kind of business that might be applied in health care settings.  Participants on the tour came from a variety of organizations in the US, Singapore, New Zealand, Scotland, Norway, Canada, Iceland, and the UK.

It was figuratively and literally a "soup to nuts" tour, with presentations on site from a variety of program managers.  Here you see New Zealand's Helen Mason with James Rothier, the senior banquet chef.  He gave a detailed view of the food preparation process for the thousands of meals served every day, whether for large conventions of the size represented by the IHI Forum (over 5000) or for smaller business and personal events that take place during the year.  We focused on food safety issues, but also worker safety in a busy work environment characterized by sharp knives, hot water and oil, cooking fires, and large movable containers.

On another front, a visit to the lost and found provided a reunion for Scotland's Michael Kellet with Sydia Dawkins, who, on the previous day, had returned to him a Blackberry he had lost in the seat cushions of one of the hotel's restaurants.  Sydia's boss, Mike Cord, explained the procedures followed when items were lost in the hotel (a common problem in hospitals, too!)  In a place the size of the Marriott, this amounts to thousands of objects per year, and they are kept in storage for up to six months on the chance that travelers will be delayed in claiming and retrieving them.

And so on, through many back corridors of the hotel, as we heard of the logistical challenges in a place of this size, many of which paralleled the service issues facing hospitals. At the debrief, my colleagues Marie Schall and Deborah Bamel (left) and I asked the participants to meet in small groups to compile and categorize their observations of key aspects of the hotel's procedure and to try to draw lessons for their home environments.  The categories shown on Melissa's group's sheet were echoed by the others in the room:  A strong focus on customer satisfaction; intensive and extensive training of staff in standardized approaches to the work environment; strong communication within and across operational divisions; an unending pursuit of high quality; a culture of collaboration, respect, and caring; and, above all, a commitment to associates' recognition and empowerment.

Janet Reeder from Kaiser Sunnyside Medical Center offered a visual summary of the latter point by capturing this hall of honor of associates who had been recognized for extraordinary work by their peers and supervisors.


I'm hoping other participants in the excursion will offer comments about the experience and expand on my brief summary.  Stay tuned over the next day or two as they arrive below.

Sunday, December 07, 2014

Shrink to grow

I want to make an outrageous proposal to the board of trustees of Partners Healthcare System (PHS) as they go about deciding on their next CEO:  Hire someone to split up your health care system so that it can productively grow.

This is a matter of good management and good public policy.  Let me explain.

From the beginning, the creation of PHS was never intended to result in a clinical integration of the flagship hospitals, Massachusetts General Hospital (MGH) and Brigham and Women’s Hospital (BWH).  The two organizations have disparate cultures and have always suffered from mutual jealousies, sometimes rising to the level of disdain.  The senior leadership of PHS recognized early on the futility of clinical integration and instead focused on back-office functions—purchasing, information systems, and negotiations with insurers.  On those fronts, they were relatively successful, achieving some economies of scale and other financial gains.

As the system grew, with acquisition of physician groups and incorporation of outlying community hospitals, the clinical split between the flagship hospitals was reinforced.  To this day, physicians and community hospitals refer their patients primarily either to MGH or BWH.  Researchers in each flagship hospital have no special interaction with those in the others, compared to interaction with the other non-PHS Harvard hospitals.  Education programs—undergraduate medical education and residency programs both—likewise are physically and culturally separate in most respects.  Quality improvement programs, to the extent they exist, are hospital-centric.  Development of new clinical initiatives occurs in one place or the other, but seldom in both.

Beyond that, each hospital has used its influence at the PHS headquarters to impair some of the creative energies in the other.  There are plenty of stories, for example, of times an initiative at BWH might have the potential to be truly competitive with an established program at MGH, and only to find itself quashed at the corporate level.  These were not cases of rationalizing care delivery: They were simply opportunities for ego-flexing.

Likewise with regard to philanthropy.  Donors are identified early and separately as MGH targets of opportunity or “BWH people.”  Never the twain shall meet, and their identities are carefully guarded until the gifts are secured.

So this is not truly an integrated health care system, and it will never be.

On the business side, too, the existence of economies of scale has clearly reached a point of diminishing returns.  Look, for example, at the recent $1 billion information systems contract with Epic.  I am willing to bet that disparities in the models of care and administrative requirements between the two segment of PHS are causing that IT system to have higher costs than would occur if it were being constructed for two separate and more culturally distinct organizations.

Likewise, there is little or no advantage in purchasing contracts for this large system that would not be available for two somewhat smaller, but still very large systems.

Further, the centralized PHS corporate office with high salaried people in the high-rent Prudential Center is quite properly viewed with resentment as mere overhead by those both on Fruit Street and Francis Street.

The one thing that might be argued is that PHS has had effective and extreme power in its negotiations with insurance companies, leveraging its network spread to demand higher rates than almost all in the region.  But, even there, a case can be made that the leverage was based on geographic dominance in each subregion—a dominance based either on the presence of the MGH-affiliated branch or the BWH-affiliated branch—as much as the system as a whole.

Meanwhile, though, the size of Partners makes it a target for opponents when it seeks to grow.  Witness the recent objections to the acquisition of community hospitals to the north and south of Boston.  What might make sense from a public policy point of view, with regard to suburban-to-urban secondary-to-tertiary clinical integration, gets squashed or subject to burdensome regulatory requirements.

Everybody interested in health care in Eastern Massachusetts—government officials, business customers, and consumers—seeks to bring about cost savings, service improvements, and a drive to higher quality care.  Notwithstanding lots of recent state legislation, there is a growing recognition that the only way to achieve this is a greater level of competition in this marketplace.  As things stand, Lahey, BIDMC, Tufts and the others can only nibble at the edges, and they scarcely make a difference in the overall results in terms of those desired areas of improvement.  Meanwhile, Steward Healthcare System is showing signs of rapid decline and irrelevance.  Boston Medical Center, too, remains in its safety-net niche, scraping by with diminished state and federal resources.

The best way to generate real competition is to split PHS so that MGH and its network and BWH and its network have separate corporate identities and bottom lines.  This would acknowledge the de facto clinical separation of the two components of the PHS system and give each organization a real incentive to grow—but this time through excellence in care delivery rather than corporate heft.  Each, too, might seek new clinical alliances with the aforementioned Lahey, BIDMC, Tufts, Steward, and BMC, offering the potential for rationalization of care and better use of financial resources.

Would the Partners board have the nerve to dismantle a system they assume is working well?  Frankly, not likely.   But this is not a case of having to worry about accretive value for shareholders or private equity investors.  There are no shareholders here.  The only audience of concern should be the public.  The board owes it to that public to review the twenty-year history of the corporation and objectively determine whether the region is better off for the creation of Partners Healthcare System, and whether the future is better served by one entity or two. Indeed, any potential CEO worth his or her salt should be asking the question before taking the job.

(Note to Attorney General-elect Maura Healey:  Might they be more likely consider a breakup if you tossed out the wrong-headed proposed agreement negotiated by your predecessor and threatened a true antitrust lawsuit jointly with the US Department of Justice?  This is a moment for a great negotiator, and you have the power to set up the situation for an agreement that is truly in the public interest.)

Saturday, December 06, 2014

Tracy Granzyk tells stories

Tracy Granzyk, a key member of the Telluride Patient Safety Camp faculty, has published an ebook called Using Stories to Influence Change in Healthcare: Lessons From the Frontlines of Educate the Young. Look for it here.

She notes:

As long as there are patients who fall victim to preventable harm in healthcare, there are healthcare professionals who also have a story rich in learning material from the other side of the bedrail. Both sides of the patient harm story will need to be embraced by healthcare leadership in order to achieve the delivery of reliable, high-quality, safe care everyone desires. Because the numbers harmed by healthcare have at the very best plateaued, an urgent need to pick up the pace for change remains. Sharing the stories of patients and healthcare professionals on a larger and more strategic scale throughout the industry will allow others to learn vicariously from mistakes as well as successes, building upon the positive momentum found when utilizing storytelling as a medium for change. Our stories can provide the guiding light leading us into a new world for healthcare—where the patient voice is welcomed, and healthcare professionals are allowed to speak their truth.

Our healthcare stories also serve many masters. When patients share their story of illness, they heal. When families tell stories of loss, they grieve. When healthcare professionals relate stories of guilt or near misses, they unburden their souls and can fix what is broken in health systems, enabling them to once again care for others as intended. Freedom to tell our story has always been a way to health and happiness.


It is a terrific compendium. Tips from expert storytellers on how to craft good stories, as well as a glimpse into the science of story, round out this collection.

It's a tax, whatever you call it

The Massachusetts Hospital Association is rightfully upset that that state's hospitals are being assessed to pay a growing amount from the state agency at the forefront of healthcare cost control efforts – the Center for Health Information and Analysis (CHIA).  CHIA has seen its budget increase 21% and 6% in the past two fiscal years (FY2014 and FY2015, respectively) and is currently funded almost entirely by the healthcare entities whose finances CHIA tracks as they attempt to meet the state’s healthcare cost benchmarks.

MHA notes:

Hospitals and ambulatory surgical centers (ASCs) are now funding 50% of CHIA’s annual budget, with “surcharge payers” (mainly health insurers) paying the other 50%. In the current fiscal year (FY2015), the tax on hospitals to fund the operation of CHIA is 16.5% higher than it was in FY14.  However, when one-time credits for unused prior year funding are taken into consideration, the expenses of the agency actually grew by 30%. 

In a letter to CHIA Executive Director Aron Boros, MHA wrote: “MHA believes that the work performed by CHIA is a valuable resource for the commonwealth and its mission should be supported. However the recent increase is unprecedented and also conflicts with the commonwealth’s goal to control growth of healthcare costs as this increase is assigned to healthcare entities subject to the state’s cost growth benchmark.”  MHA also noted that the budget of CHIA and its predecessor, the Division of Healthcare Finance and Policy (DHCFP), have grown at a rate significantly above the overall state budget increases over the past 10 years.

MHA explains further:

Chapter 224, which created CHIA out of the former DHCFP, mandates that hospitals/ASCs and health insurers pay at least 33% of CHIA’s expenses.  The other third was intended to be paid by state government and federal revenues Massachusetts receives.  But because of the changing role of the agency, CHIA no longer receives federal matching revenue it used previously for its 33% share. Yet the state’s general fund continues to receive the matching money, meaning, as MHA noted in its letter, “the commonwealth is now profiting from the transition of DHCFP to CHIA.”

CHIA is doing an excellent job: That's not the issue.  There is a long tradition of "creative revenue accounting" in the state Legislature. Even when a regulatory function is an important aspect of public protection, it's so much easier to hide a tax by assessing it on the regulated industry.  Here, as MHA points out, the hidden tax is in direct contradiction to the stated public policy objective of controlling health care costs.

Friday, December 05, 2014

From Elaine

Brian Klepper recently reminded many of us about a beautiful essay written by his now departed wife Elaine Waples, as they faced the inevitablity of her death from cancer.  Here it is.

Here's the part I like best:

There is no bucket list. There are no plans to see the great pyramids, kiss the Blarney Stone, or throw a party in Times Square. We look to the small things we have known for decades that have become precious to us now: a walk on the beach, a Saturday matinee movie, sharing a bowl of ice cream, holding hands as we go to sleep at night.

Thursday, December 04, 2014

The Upside of Down

A short while back, I introduced you to Catherine Crock, who heads up the Australian Institute for Patient and Family Centred Care. While I was in Melbourne, she handed me a book and said, "You are going to like this."

"This" was The Upside of Down, a memoir by Susan Biggar (Kindle edition here.)

On one level, and an effective one at that, this is the story of parents raising two children with cystic fibrosis, and all that entails (including a choice to have the second baby even after genetic testing guaranteed that he would have the disease.)  Susan summarizes:

This is a story of belief, a story about learning that sometimes joy is a decision. The Upside of Down is a memoir about illness, yes, but it’s also about the reward and frustration of parenting, the hard work of resurrecting a marriage and the upheaval of cross-cultural life. This book celebrates today because we can’t always count on tomorrow.

So read the book for that reason alone.  But there is another reason related to topics often discussed on this blog. Susan and her husband Daryl and the children had a chance to experience the differences in medical care in the US, New Zealand, France, and Australia. The shock of Paris, for example, is seen in this excerpt about Oliver's hospital stay:

The efficiency and hygiene at the hospital are astonishing. Nurses are highly skilled and meticulous, though not at all chummy.  The physios barely acknowledge me yet perform very effective physiotherapy. Our doctor, the Professor, arrives only once in the week with a fifteen-strong flock of subordinates. He briefs them on the case, nods at me and is gone. Other white coats pass through fleetingly, again with little conversation.

The lack of discussion and involvement in decisions leaves both Daryl and me questioning the care. We may have relatively little medical knowledge but more "Oliver knowledge" than anyone else. Is that not relevant? Isn't there a role for us to play in helping him improve? I am physically present with Oliver, but otherwise feel invisible. The role allocated to parents is minuscule with "someone else" deciding everything about his treatments, meals, baths and even visitors. I am routinely put out of the room for dressing changes and procedures, despite Oliver's wild protests. For the first time since we started on this journey with illness I begin to feel like a victim, a powerless player caught up in a life that is moving in ways I can't control.

A sojourn in California offers a difference:

It's culture shock all over again at the hospital. The nurses are amazingly effervescent and friendly: I have five new best friends by lunch. They wear clip-on teddy bears on their stethoscopes and Bear in the big blue house pins on their shirt collars.  When my tears seep out they offer full-on hugs and tissues, even the occasional shoulder rub.

[When she calls in during a break from the hospital, Daryl notes:] "The menus are amazing and all the extra food we can order for him. Plus everyone is so much more helpful and friendly than in France. It makes a big difference to the whole experience."

But even warm and laid-back can have its downsides. The daily routine is unpredictable and harder to work around. Medications and treatments are sometimes late and Oliver is less settled with the slightly topsy-turvy routine. Hygiene etiquette, though probably perfectly satisfactory, feels dodgy after the French hysteria about sanitisation. Oliver is not allowed out of the building at all, even for a quick walk in the stroller.

Finally, the family settles in Melbourne, and the hospital care is excellent and humane, but Susan notes a common trait--from New Zealand to France to the US to Australia:

Looking back, I'm convinced that all the staff we have known were trying to provide safe, efficient care while trying to meet all of the other hospital criteria. It has never been an intentional excluding of us. But because there's not a tradition of including patients and families in policy decisions or putting them on committees, hospitals are often flying blind about how to blend quality and safety with patient and family satisfaction.

And finally, the realization that empowerment begins with self-empowerment:

Cath and I find ourselves talking regularly about how to broaden our scope [beyond serving on the hospital's Family Advisory Council] and link together the many like-minded people across the country already working to improve healthcare. The group begins with small research and clinical projects, encouraging a culture of engagement and partnership between staff, patients and families--with the aim of creating a safer, more patient and family-friendly system. After a year of meeting together, with passion and numbers increasing, an organisation--the Australian Institute for Patient and family Centred Care--is born and a movement towards improved partnership in health is launched.

So, The Upside of Down is not, after all, just about one family.  It is about a pattern seen worldwide, the disenfranchisement of patients and families in the delivery of health care. In the end, though, it is about the ability of normal people to overcome the inertia in the system and work to create a partnership with the well-intentioned people who have made health care their lifelong passion.

Yes, Cath, I liked the book.

Pulling out all the stops

I'm trying to figure out what's going on here, following up from my recent post about a hospital system president who encouraged his doctors and former trainees to register on Doximity so they could influence the US News and World Report hospital rankings.

Avery Comarow, who is in charge of the rankings, offered a comment to me on Facebook to clarify the situation:

For a full explanation of the relationship and how the coming physician survey will be conducted (and why hospitals that try to recruit their doctors to join Doximity won't benefit), see this site.

Look what it says:

If you are a hospital leader, you may be deliberating whether to encourage affiliated physicians to join Doximity and/or participate in the upcoming survey. It’s your call. If an appeal from you increases the number of physicians who participate in the survey, it will enhance our statistical power to calculate reputation scores for all hospitals. But your decision will neither benefit nor penalize your hospital in the reputation survey or in the rankings as a whole, because of the statistical adjustments we will make.

Unlike our nation's imperfect electoral system, which counts the opinions of only those who show up at the polls, the U.S. News reputation survey statistically represents all survey-eligible physicians, including those who don't receive a survey as well as those who receive one and choose not to respond.

If you are a physician, you may be wondering what effect joining Doximity would have on your participation in the survey. Any decision to join Doximity should be made with full awareness that doing so will neither increase nor decrease your net influence on the U.S. News rankings.

But, for some reason, the message has not been received.  Look at today's note from David Battinelli, Senior VP and Chief Medical Officer of North Shore-LIJ Health System:

Dear Colleague,
              
As you know, each year U.S. News & World Report publishes their Best Hospital rankings. Last year U.S. News partnered with Doximity, a web-based physician network, to enable Doximity members to vote online for hospitals they believe provide the best care in their area of board certification.  Online votes from Doximity members, along with paper surveys mailed to a small number of non-Doximity members, determine the Reputation component of the rankings, which accounts for 27.5% of the overall score.  

Similar to last year, all board-certified physicians who are members of the Doximity network are guaranteed an invitation to vote in the coming year’s rankings.  Unlike last year, U.S. News will no longer be using the AMA Physician Masterfile as the source for randomly selecting non-Doximity members to receive paper ballots.  Instead, U.S. News will use Doximity’s proprietary masterfile, comprised of both its members and non-members, including those who’ve never heard of Doximity.   

Therefore, we encourage our physicians to take the following action on the Doximity website prior to the imposed cutoff date of tomorrow, December 5:


So given the US News advisory, why this push for signing up on Doximity?

I can only conclude that these rankings have taken on a life of their own in the minds of hospital executives.  This whole thing has become such a marketing tour de force that the executives don't dare take a chance that--even if meaningless to the outcomes--they haven't pulled out all the stops.

What a stupid use of managerial attention.