Greetings!

Several months ago, we created some new jobs at BIDMC. These folks work at our information desks or stand near the front doors or at critical hallway intersections, with the sole purpose of helping patients navigate their way through our 2 million square feet of clinical space.

Their position is formally called "service ambassador," but we all call them "greeters." The gentleman shown here is Leon Carrington, the solo lady is Lynn Miner, and the smiling pair are Yoly Reyes-Campbell and Zofeen Shujaatullah.

Don't they look friendly? Say "hi" next time you see them.

Our hospital as small town

I really like it when people write me notes complimenting their colleagues, especially those from other departments. Here is a note I received just after the Christmas holiday weekend from one of our senior faculty members in the Radiology Department:

Good afternoon!

I wish to relay to you a short story that illustrates why BIDMC is so special.

Through the magic of our Radiology PACS system, as well as a robust backbone from Information Systems, I have been able to read all of my radiology cases from a home workstation for a number of years. As computer power has increased, I now can display cases faster at home than in some of the older sections of the hospital!

In the last few days, this connection to the hospital PACS system dramatically slowed. I feared that something within the hospital was malfunctioning, as my internet connection speeds (purchased by me to provide the highest downloads available) were perfect. Another user, with the same ISP, was suffering the same problems.

In response to this query, John Halamka, answering emails from me immediately while having an arduous cross country plane flight, assembled a crack team from his dep't, consisting of Mr. Mark Olson, Ms. Michelle Frayman, Mr. John Powers, and Mr. Bill Corzett. From our department, Mr. Jim Brophy and Mr. Phil Purvis also stepped in to help. The IS department thoroughly analyzed their systems. While this work was occurring, another remote user, having a different ISP indicated, to me there were no connection problems. After conversing with my ISP, and spelling out the problem, they located a regional server malfunction, issued me a new IP address, and basically rectified the problem!

The point of this message is that without rigorous analysis of this technical issue by people who gave of their free time on a holiday weekend, the solution would not have been achieved. I believe such dedication deserves recognition. The caring attitude that these people exemplify is the clearest explanation as to why our hospital is so special. High technology doesn't mean anything without the people who are willing to go way beyond their assignments to ensure that caregiving remains optimal. I certainly feel honored to have been a very small part of this effort for more than three decades. While our hospital has grown substantially in this time period, the strong interpersonal relationships that wonderful people engender at BIDMC still create a wonderful "small town atmosphere." This sense of friendliness and desire to help makes BIDMC a very special place to "hang one's hat."

Sincerely yours,

Jonathan Kleefield, M.D.
Radiology Dep't

Can we learn together?

A dramatic cease-fire was announced over the weekend. No, not the one in the Mideast, but rather in the health care market in Massachusetts. As documented in this Boston Globe story by Scott Allen and Jeff Krasner, Tufts Medical Center and Blue Cross Blue Shield of MA reached an agreement on a payment contract. What's the big deal? Well, Tufts had threatened to pull out of the BCBS network when it felt that it was not being offered sufficient compensation for its medical services.

The context was important. The Globe had previously reported that payments to Tufts and its doctors were substantially below those received by, in particular, the hospitals and doctors in the Partners Healthcare System, and often below those received by BIDMC and its doctors. As I have noted below, there is really no justification for these differentials, if one considers the actual quality of care delivered by the major academic medical centers.

Well, I guess Tufts felt that enough was enough and stood its ground in its contract negotiations with BCBS. This was a gutsy move, in that BCBS has more subscribers than all the other insurance companies combined, and Tufts and its doctors stood to lose a lot of business if the dispute was not resolved.

We should all be pleased that the issue was settled, apparently to the satisfaction of both parties. It is difficult to believe that Tufts could have followed this path absent the Boston Globe stories, in that those stories created the moral high ground for a different kind of negotiation. After all, there is no data to support the contention that a patient at MGH or Brigham and Women's Hospital will receive better care than at Tufts.

But where does that leave the state? On its face, the Tufts-BCBS deal seems to contradict the hopes of Governor Deval Patrick, who, it is reported, wants the hospitals and insurers to slow down the growth rate in health care premiums. BCBS, for its part, has been pursing adoption of a capitated insurance reimbursement approach to control those costs, and adoption of that plan was announced as part of the Tufts deal. But clearly some compromise must have been reached. The plan offered to Tufts had to be more generous than the one previously offered, or the deal would not have been done.

We have been discussing this alternative contract idea with BCBS for several months, too, and both parties are trying to figure out how it might be designed to work in the environment of our medical center and our physicians. One key issue is that such a plan transfers a portion of the insurance risk of health care to the providers and away from the insurance company. Some element of this risk-sharing is probably essential to align incentives between the providers and the insurer, but the specific design and implementation plan is important, lest the hospital and doctors find themselves with a major revenue loss at the end of any given year. After all, providers do not have the kind of financial reserves that insurance companies have.

Another important issue is that we do not control the delivery of the full spectrum of care, from primary care to hospitalization to skilled nursing facilities. A capitated contract requires some kind of relationship among providers across that spectrum, so that risk can be appropriately monitored and shared.

Nonetheless, people of good will can work through these issues, and I am hopeful that we can, too. In the meantime, as I have noted often on these pages, there are many steps that hospitals and doctors can take in the current fee-for-service reimbursement environment that also help to control cost increases. My passion for reducing harm that you have seen repeatedly on these pages is an important part of that process. See below, for example, the post about reducing ventilator associated pneumonia. That program not only saved lives: It saved millions of dollars in medical costs. That most of the savings went to the insurance companies did not preclude us from adopting this standard of care. Our job, simply, was to reduce harm and save lives.

As you can tell from my post below, I am frustrated that the medical profession in this city has not adopted an aggressive and transparent approach to this kind of quality improvement. As noted by one or more comments under that post, in its delays, the profession risks abdication on these matters to governmental authorities, who will impose standards that will inevitably lack the subtlety and effectiveness of those that the profession could otherwise design for itself.

Also, on these pages you have seen an emphasis on BIDMC Spirit, our process improvement program based on the Toyota production system. We engaged in this program to improve the work environment for our staff and to improve patient care, but it also has the effect of controlling costs and improving efficiency. Again, a great portion of the cost savings will flow through to the insurance companies, but we still pursue the effort because of its advantages to the organization. I want to acknowledge here that our progress on the front was greatly aided by technical support and assistance from BCBS, as part of a pilot program involving five hospitals in the state. The program gave us exposure to people and ideas and resources that we might have encountered otherwise, but that probably would have been delayed by several years.

As a result of these joint efforts with BCBS and with other helpful people like the Institute for Healthcare Improvement, we find ourselves to be in the vanguard with others around the country in the implementation of these approaches. Through this blog and other presentations, we are doing our best to share what we have learned. As I have often stressed, quality and process improvement and transparency is not a matter of gaining competitive advantage.

As long as the distribution of health care reimbursement revenues is viewed as a zero sum game, the likelihood of cooperation across the hospital and medical community is likely to be minimal. If Tufts Medical Center got more, must everyone else get less? No. My hope is that the presentations here and elsewhere of what we and others have learned will help people understand that it is not a zero sum game. Society as a whole can benefit from the kinds of quality and safety and other process improvements with which we have been experimenting. But we need all participants to shed their defensiveness and fear of disclosure, to acknowledge the areas needing improvement, and to share what they have learned for the greater good.

January 19 and 20

As this weekend ends, three thoughts:

I love living in a country that created a holiday to honor a person who devoted his life to promoting civil rights.

And, as inauguration day approaches, I am reminded to appreciate the fact that I live in a country that has peaceful transitions of government and has managed to keep that concept going for over 200 years.

But, as I view both events, I am also reminded that Thomas Jefferson said, "The price of freedom is eternal vigilance." I worry about the financial troubles facing the country's newspapers, gradually undermining their ability to do the kind of investigative reporting that makes governments and corporations uncomfortable. While social media like this kind of forum help to offset some of those losses, who is going to pay for the depth of investigation and reporting that has proven so important over the years?

Jambu!

And here's a tree and fruit called jambu, in Sri Lanka. A very pretty tree. the fruit has a texture almost like an apple or pear, with a slight flavor of pear with something else mixed in. Those who have tried it can offer their opinion.

Tropical trees

From the Peradeniya Botanical Garden in Kandy, Sri Lanka come these pretty trees, part of a huge collection from around the world. The big bud is on a tree called Rose of Venezuela (Brownea Kewensis), and is from South America. The one that looks like a mobile (with a closeup of the flower) is called Queen of Flowering Tree (Ahnerstia Nobilis), and is from Burma.

Leeches, too

Continuing to ease this blog back into the medical world, here's more about Sri Lanka. I include a report of my visit to the Sinharaja Forest Reserve, a UNESCO World Heritage site, a truly unspoiled region in the southern part of the country. There was lots of wildlife, including this millipede, a hump-nose lizard, a colony of poisonous caterpillars gathered on a tree, and many pretty waterfalls, including the one below called Kakuna Ella.

And then there were the leeches. They lay on the forest floor and propel themselves onto your shoes and ankles as you walk by. If you slow down to knock them off, more join in. Meanwhile, the early arrivals travel upwards to, shall we say, the warmer areas.

So by the time you get home and take off your shoes, you discover blood covered toes and ankles, where the satiated leeches have either dropped off or been crushed inadvertently.

My fellow blogger Ramona Bates discusses the current use of leeches by the medical profession.

For my part, I didn't detect any lasting damage, but I did have a craving for protein after the hike . . .

It's voting time

If you have not already, please take the time before Sunday night to vote for the best medical blogs in several categories at Medgadget.com. There are so many good ones that you will have a hard choice. I nominated a few, including Life as a Healthcare CIO (vote here), Beating Social Anxiety (vote here), Notes of an Anesthesioboist (vote here), and Scan Man's Notes (vote here).

I want to tell you about a particular one, though, that is also very compelling. It is called Running for My Life: Fighting cancer one step at a time and is in two categories, Best Literary Medical Blog and Best Patient Blog. Here's a summary from my friend Margaret Pantridge:

The blogger is my close friend Ronni Gordon, a 54 year-old journalist and mother of three from South Hadley, who was diagnosed in 2003 with Acute Myeloid Leukemia after feeling unaccountably winded by a 10K road race. She has relapsed and is currently stuck in the hospital awaiting her fourth bone marrow transplant on January 30. Ronni has been plagued by headaches, a fever and - needless to say -- worry. But she continues to write her eloquent blog, describing in unflinching detail the difficult treatments, her roller-coaster emotions and the unusual lifestyle cancer imposes upon those it strikes.

As she puts it, "This blog is about falling down and getting up, coping and coming back." Though a bit bashful about her nomination, Ronni is getting a kick out of it. As friends check in with her and her vote total climbs, she is enjoying a pleasant distraction from platelet counts and transfusions. Would you mind casting a vote for Ronni? She has the best chance in the Literary category, where there are fewer nominees, but I hope you'll consider voting for her in the Patient category as well.

What does it take?

I take a short break from my travelogue to get back to medical issues. A vacation is supposed to help you get perspective and calm down, but I find myself pretty upset.

What follows is not criticism of any particular hospitals. I repeat, it is not criticism. It is an observation about this medical system in which I find myself a participant. It is a statement of frustration about the lack of will within this profession to change itself in a timely fashion.

Here's the setting. There is a great story by Liz Kowalczyk in today's Boston Globe about the work that Atul Gawande and others have done to document the effectiveness of a pre- and post-surgical checklist. They were able to show that use of the checklist has real benefit in reducing the likelihood of medical errors during surgery. Atul himself said "that in his own operations, the checklist catches a potential problem about once a week."

A number of commenters to the Globe story expressed surprise that surgeons had not previously adopted this approach. One person noted, "It is quite shocking that something like this is considered an innovation. I would have thought that it was a common practice long ago. It makes me wonder what else is going on in hospitals that could use the application of common sense."

A good point.

So, the question I raise is, what does it take to implement changes like this in a profession that is so steeped in the practice of giving individual physicians the prerogative to do their work the way they want to?

Here at BIDMC, we learned the hard way about the importance of this kind of checklist and instituted it after a bad experience with a wrong-side surgery. I think it is fair to say that institutional and personal embarrassment, along with our decision to be very open about this error, stimulated the change.

But even at the Brigham, where one of the world experts in this field has carried out this important work, the progress is evolutionary: "The Brigham, which was not part of the study, began using the checklist a month ago in general and cardiac surgery and plans to roll it out to other specialties over the next several months."

And of course the story implicitly raises the question about the other hospitals in Partners HealthCare (e.g., MGH, North Shore, and Newton Wellesley), a system characterized as an integrated delivery system? Where are they on this matter?

But this is not just a Partners issue. Look at the non-response to my challenge to all the Massachusetts hospitals on this matter a few weeks ago? I don't think I am being egotistical to expect at least one hospital administrator or someone from the state hospital association to contact me and say, "Yes, let's try it." Or even have one of them say, "That's a dumb idea." No, the response is silence.

Meanwhile, I hear public officials and insurance companies and businesses express concern about the high cost of health care. They say we need new models of compensation and regulation to control those costs. Everyone in the field knows that a major contributor to costs is preventable harm that occurs in the hospitals. It should not take a new alternative contract from Blue Cross Blue Shield or from anybody else to institute these kinds of changes. Failure to implement is not the result of economic pressures or the design of reimbursement. The check list takes about 90 seconds, not enough time to make a whit of difference in the day's OR schedule -- and, I am guessing that it will even accelerate a number of cases.

No, the imperative must come from within the profession. It has to be based on the underlying set of values to which doctors pledge their lives: avoiding harm to patients. The story about Atul's study unfortunately says, in so many words, that there is much lacking within.

Next time you put on rubber gloves

...think back to where they started.

Sumedha's estate in Sri Lanka also covers 35 acres of rubber trees. In this video, you can see one of the latex collectors at work, while Sumedha offers commentary in the background. Each collector taps 350 trees per day, slicing the bark at just the right angle, placing the sap cup, and later collecting the product. The plastic apron around the tree keeps rainwater from diluting the latex.

Healing Hands for the children

While Sumedha runs the tea estate and supervises the pluckers and factory workers, his wife Kumari is busy trying to save the next generation. On many of these estates, the children are left alone all day to fend for themselves. The older ones take care of the babies and toddlers and run the household until the parents come back from work. As a result, they do not attend school and they suffer great privations in many respects. Then, at young ages, they have their own families and do as their parents did. Kumari is trying to break that cycle by running schools on her estate and another, providing nutritious food, medical care, and education for the children.

She organizes this work through a group she founded called Healing Hands Women's Organization. There is a story there, too. She started the group after the tsunami devastated the Sri Lanka coast several years ago. Her own home and children just missed being destroyed, and Kumari felt that she was left alive to accomplish some special good in the world. She started by organizing a women's sewing circle, to provide a setting for women to band together, learn a trade, and share their experiences. The work then spread to the children, and the women produce special boxes of tea bags and other crafts to raise funds for those efforts.

The children walk several kilometers to school each day, often carrying their younger siblings who cannot be left home alone. While the little ones are cared for in a nursery, the older ones learning reading, writing, and arithmetic. With tooth decay being a epidemic, children are taught about dental care, and they start each day by brushing their teeth. Breakfast and lunch are served daily, too. As an incentive to their parents to let them continue in the school program, each family receives a bag of foodstuffs for every 18 consecutive days their children attend school.

Kumari knows she cannot change the world with this work, but she figures that if she can create opportunities for even a few of these children, she will have done something important. If you click on the tea box in the post just below, you can find their contact information if you want to send donations. Even a little money goes a long way in this setting. Need convincing? Keep scrolling through to the kids, themselves, who look a lot healthier than they were when they were scrounging for themselves.

How you can help Kumari

Here's that tea box. Click on it for the email and other contact information.

The kids, themselves

Pictures of a few children and a welcome performance at one of Kumari's schools.

How about a nice cuppa?

Taking advantage of proximity to Goa, a friend and I hopped over after the bike ride to Sri Lanka, where we were hosted by Sumedha and Kumari Kulatunga. That's Sumedha presiding over a tea crop. He took over operation of the family's tea estate in Morawaka this past June, after a varied career in hotel management, including stints in Boston (hence the familiar hat!) He has about 85 acres of tea plants (Camellia sinensis) under cultivation. Here's a picture of the bud and upper two leaves that are used for tea, along with a photo of a couple of the women doing the plucking.

Sumedha gave us a tour of his tea factory. The tea is first laid out and "withered" in long, aerated bins. Then it is put through rolling machines, and the fermentation process changes the chemical composition and the color. Then there are lots of steps sorting the tea by size, shape, and color, before it is packaged and sent to market, where the price has been determined by auction.

This is a very labor-intensive process, although increasing degrees of automation are being introduced. For example, a Japanese machine uses optical scanning to separate leaves by color and send them to different bins. This would have been done manually in the past. Even leaf plucking may become more automated in the future. The Kulatunga's have great concern for the workers on their estate. They know that this largely uneducated group of people need to receive help to adapt to what is likely to be a greatly changing economic environment. I'll describe some of their efforts in a following post.

Faces from Konkan

Some people encountered during the bike ride mentioned below.

The nuisance of stray dogs and cattle

(I am taking a break from hospital-related stuff to catch up on personal activities during the Christmas-New Year break. I hope you enjoy the next several posts.)

"Be alert on the roads due to the nuisance of stray dogs and cattle especially on the turnings." Regular readers know that I often participate in charity bike rides, but I do not recall any that included this type of advice to the bikers. The occasion here was Bike4Life, a six-day 550 kilometer ride along Konkan, the western coast of India. The route led from just south of Mumbai to Goa along the narrow strip of land between the Sahyadri range and the Arabian Sea. About 70 of us participated in this fundraiser for Focus Humanitarian Assistance, an international disaster relief and prevention organization affiliated with the Aga Khan Development Network. Our group came from Canada, the US, the UK, France, and India to support this worthy cause. Beyond that purpose, we were all curious to travel through this part of India by bicycle, getting a unique perspective on these communities and the terrain.

If you want to trace the route on your own map, we started in Alibaug, a small coastal place 160km south of Mumbai, and ended on the border of Maharastra and Goa at a place called Terekhol. Intermediate stops were Diveagar, Ladghar, Gandpatipule, Madbhan, and Bhogue. Because the coast is characterized by peninsulas, we often boarded ferries (often small rickety ones) and continued our ride on the opposite shore. Sites included pristine beaches, tiny villages with varied cultures and colors, and sea forts. We had a most memorable New Year's eve at Madbhan, where local folks entertained us for two hours with a display of acrobatic dancing, as well as a musical drama based on the Hindu legend of Bhimasur, who fell just short of marrying 1600 women in his quest for immortality. I include a short video of local lads doing a sword dance, along with other scenes from the ride, yes, including one of those pesky cattle.

A fan is born!

Excerpts from a very sweet letter:

Dear Paul,

I have worked as a nurse at BIDMC for the past 4 and a half years. Due to some life circumstances (all positive and happy), I am relocating to Los Angeles just after the holidays. Although my heart is joyfully a-flutter in anticipation of my California adventure, it makes for a bittersweet departure from such a gem of an organization and the beloved city that I have called home all my life. These final weeks up have brought on a lot of reflection. And with that reflection, I realized I never thanked you personally for an interaction we had two baseball seasons ago.

I had reached out to you for help with my sister-in-law. For her birthday, I had purchased standing room tickets to a night Yankee game during a pre-season lottery. At the time of the ticket purchase, she was not pregnant. In the weeks before game time, not only was my sister-in-law six months pregnant, but she had been admitted to BIDMC for complications of her pregnancy. She was released but had restrictions. I had inquired with Fenway security if there was anyway we could get a folding chair for her at the game…the answer was uncertain. When the security representative realized I was a BIDMC employee, he suggested I send you an email. With a glimmer of hope for a sole folding chair, I sent you a message to see if you could put in a kind word on my behalf. You in turn contacted folks at the ballpark and almost instantaneously the night become one to remember – we were given complimentary roof deck seats with a food and beverage credit, and I passed the standing room tickets over to my friends at BIDMC.

We sat amongst players from the famed ’67 Red Sox, who were being honored that night. It was so above and beyond a folding chair; we were thrilled and humbled and astonished both by the generosity of the Fenway staff and how you personally acknowledged and took interest in my inquiry. Technically, that was my soon-to-be niece’s first trip to Fenway. She was born at BIDMC later that summer, and my brother and sister-in-law had nothing but positive experiences during their time here. She is now 1 ½ years old, running and laughing and getting into all sorts of mischief as one should at that age. One of her early words was “Reh-saw,” which clearly translates to Red Sox. She’s working on “Beth Israel Deaconess Medical Center,” but hasn’t quite perfected it. Attached you will find a picture of her this past Father’s Day standing on the dugout at Fenway. There is a picture of us all at the game that night…but it fell victim to a faulty digital camera.

I’ll never forget how you helped create such a lasting memory for my family to share - simply by opening an email and then sending an email. And although a late thank you is not quite the BIDMC way, I do not think it is ever too late to express heartfelt gratitude. Please know how thankful I am, and how much I appreciate how you look after and listen to your employees.

Thank you for keeping BIDMC a place that I will consider home, no matter how far away I move.

With deepest gratitude and a fond farewell,

Sharp numbers

I cut out an article last March from one of those free magazines you get while flying. This was on a flight from London in a magazine called BusinessLife, and the piece was by Tony Thorne at King's College London. The title was "Sharp Practice". (Sorry, I can't find a link.) I had meant to write about it at that time, but I just found it buried on my desk.

This is about precision heuristics. One application is in the pricing of goods and services.

More generally, we tend to think that "claims expressed in numbers ('78.6 per cent effective') appear to be objective -- based on empirical data -- while claims expressed in words ('finished to the highest technical standards') tend to be judged as subjective. The same distinction operates between round figures or round numbers, often suspected of being guesstimates, and sharp numbers, assumed to show verifiability."

I can already hear some of my colleagues in health care saying, "I told you that transparency of clinical outcomes is misleading! You give the impression of precision when the measurement of the quality of medical care is inherently subjective."

Sorry, guys, don't even try it. I have addressed that before, saying:

We have learned from studying other industries that have engaged in and achieved process improvement that such improvement requires an approach to the organization of work that is very different from that seen in most hospitals. But it also requires measurement and transparency. While even the best calculations and data don't tell all, they do tell a lot, and they are the only way we have for an organization to hold itself accountable.

But those in the medical profession sometimes fall into the trap of believing that because measurement is an inherently reductionist and mechanistic act, it can never be sufficiently accurate to reflect the overall realities of patient care. The paradox is that without it, we can inadvertently fall into the trap of self-congratulatory statements about our good intentions. Only with it can we demonstrate that we actually have a "relentless determination to do best by each patient."

So, sure, let's watch out for the traps of precision heuristics, but let's also watch out for the traps of imprecision, unsupported generalization, and unsubstantiated reputation.

Freedom to Move

My friend Brian Hughes is one of those creative entrepreneurs. His current project is to sell modification kits to Segways that make them useful for handicapped people. The idea is to mount a comfortable seat on the machine, from which the person can easily reach the controls and transport himself or herself around. This would be an alternative to hand-powered wheelchairs or even electric wheelchairs.

This is still in early development, but here's his website. You can watch a video and see some test runs. If you have ideas for how Brian might be able to move this concept along, or of particular groups of people who might benefit from this kind of product, please get in touch at brian (at) segsaddle (dot) com. Or if you live in San Antonio, go visit and give it a try.

Just checking in on your Rx

An idea I heard somewhere:

A week after a prescription is ordered, an automatic email goes from the doctor to the patient saying:

"It has been a week since I ordered a prescription for you. Please call me if you have had any problem filing the prescription, or if you have had any unexpected reactions to it, or if you have any questions whatsoever."

Is this a good idea? Is anyone out there doing it? Do you have any results you would like to share?

Better than buying ads

I meant to cite this article about the use of social media in health care settings several weeks ago. It's main focus is marketing, but I think the ramifications extend beyond that topic.

On the marketing front, a friend (Lisa Pollack at Denterlein Worldwide) suggests:

Mr Maruggi talks about guidance and professional information as two key uses of social media in the health care industry, and I would add to that the power of trust in a social network. Facebook/MySpace/LinkedIn et al are made up of networks of people pre-selected to trust each others’ opinions. Tapping in to that trust network could be a remarkable step forward to a hospital wishing to build its brand.

I remember talking about hospital advertising about a year ago. I know that many people are put off at the idea of a hospital spending lots of money on media buys to enhance its image. Maybe social media offers a more cost-effective and socially acceptable way to do that, plus a forum to offer material that has a clinically educational content.

Merry Christmas & Happy New Year

Taking a blogging break through New Year's, plus a little more. You are welcome to submit comments, but there may be a delay in moderating them.

See you on the other side . . .

What if?

Just thinking, along the lines of a New Year's resolution. What if all of the hospitals in the Boston metropolitan area -- academic medical centers and community hospitals -- decided as a group to eliminate certain kinds of hospital-acquired infections and other kinds of preventable harm? And what if they all committed to share their best practices with one another and to engage in joint training and case reviews in these arena? And what if they all agreed to publicly post their progress on a single website for the world to see?

Let's start simply. My candidates:

1 -- Eliminating central line infections (Metric: The number of CLIs, as defined by the CDC. Goal = 0)
2 -- Adopting the IHI bundle to help avoid ventilator associated pneumonia (Metric: Percent compliance with the bundle. Goal = 100%)
3 -- Adopting the WHO protocol developed by Brigham and Women's Hospital's Atul Gawande for surgical procedures (Metric: Percent of surgical cases in which the pre-op, time-out, post-op checklist has been followed. Goal = 100%)

The medical community in Boston likes to boast about the medical care here, but we don't do a very good job holding ourselves accountable. This would be a terrific way to prove that we are serious about reducing harm to patients and that we can cooperate across hospital lines for the greater good.

"Shehekeyanu" meets "Woo pig sooie!"

We bought this menorah many years ago from the artist, Katya Apekina, who had just arrived from Russia. She was still pretty unknown. Since then, she has become quite famous, with works in many places. Here's her website.

The tray under the menorah has a different provenance. It was one of many hog-themes gifts we received from friends when we moved from Little Rock, Arkansas in 1981.

Is it kosher to put pigs under a menorah?

Regardless: Happy Chanukah!

Thanks again, Grant

Lots of milestones today. Here's one about soccer. Each year, registered soccer referees have to take a recertification class. At the session this morning, we had a nice surprise. Those of us who have been officiating for 5, 10, 15, and 20 years were given tokens of appreciation from the MA State Referees Committee. The gold whistle was for serving for 10 years, and the pin was for reaching 15 years.

Of course, being the compulsive sort, I have a record of every game I have officiated, going back to that first Under-10 girls game on April 23, 1994, and listing the other 514 since then.

I have written here about the differences between officiating girls and boys games, the relationship between referees and spectators and coaches, and the evolution of confidence in soccer referees. What I have not mentioned so much is the camaraderie that develops among those of us who are referees. It is independent of age or gender, and it is a great part of the game.

Our girls soccer league created a scholarship award that is awarded each year to the girl referee who "has achieved high standards of maturity, sensitivity, good humor, and sound judgment in managing play to promote the great game of soccer." It is named in memory of Grant Balkema (shown in photo), one of our friends and fellow referees, who died suddenly about four years ago.

Here is a portion of the eulogy I delivered at his funeral:

"I have an image imprinted in my mind, one that has popped up dozens of times in the last few days: I am greeting Grant as he is walking off a soccer field after having refereed a game. He is always smiling. He loved to referee. He never took himself too seriously, and he always did what he could to help make the game fun for the children or young adults playing the game. He was the perfect ref, in that he understood that the best game was the one in which people forgot that there was a referee on the field."

Grant received his referee certification a few years after me, and so I think he would have received recognition today for having passed the 10-year mark. So, on behalf of all of us who knew him and officiated with him, I am taking this moment to offer that recognition in a different way.

Post #1001

Hard to believe, but since starting this blog in August of 2006, I have written 1000 posts, making this #1001. For those who have been there from the start, thanks for your loyalty. For new arrivals, I hope you will visit often. For those who have arrived somewhere in between, or who have come and gone, or left and come back, thanks for gracing me with your time and attention.

Now, to the point of this post. Please meet Garry Dunster, night nurse in our Emergency Department, arriving yesterday to BIDMC in record time despite the snow and a few minor mishaps. Gary rides to work every day. (He reports: "My commute is 32 miles one way from Upton, if I'm on one night I'll ride both ways. If I'm on a couple of nights together, I'll make my big cycle in, then sleep at my mother-in-law's in Belmont before cycling home again on the last morning. I hope I can be an inspiration to a few others to give up the car and look for a greener alternative for the commute to work. Although the summer is perhaps the time to start!!!)

Regular readers know that I like to bike ride, too, but I have a firm belief in the importance of friction (between the wheels and the road), something sorely lacking in this weather. Maybe Gary has those special snow tires with embedded studs . . . .

"someone may just end up dead"

A blogger named Bongi from South Africa gives a sense of what it feels like to be a surgeon. For those of us who are not, this is an important insight. It must be considered if we are interested in process improvement and better teams in the ORs:

i try to refer away whatever i feel is not in my scope but once the knife goes through the skin you become suddenly very alone. it is too late to think there is someone else who can do the job better than you. you must be the best for that patient at that moment. this becomes more acutely true when something goes wrong and you have to dig yourself out of a difficult situation. the thing about difficult situations in my line of work is if you handle them not too well someone may just end up dead. somehow to believe you are the best does seem to give just that little more of an edge.

i am not justifying surgeon's arrogance and i hope never to be arrogant. but i can't imagine being able to do what i do without just a little more than the normal amount of self confidence.

Medgadget Best Blogs

Many thanks to those who have nominated this blog for "best" categories of medical blogs at Medgadget, best medical weblog and best health policies/ethics weblog. I was honored to win in these two categories last year. With so many regular writers of excellent blogs, I think this friendly competition will be even greater this year.

If you have favorites in these categories, please make nominations. It is okay to renominate some who are already nominated, as the folks at Medgadget will narrow down the list in each category to a few finalists based on several criteria -- and I am guessing that repeat nominations count in their calculations.

The categories for this year's awards are below. I also list the blogs I have nominated so far, but I welcome other suggestions. In particular, I don't recall who might have started up his or her blog during 2008, for the second category.

-- Best Medical Weblog

-- Best New Medical Weblog (established in 2008)

-- Best Literary Medical Weblog: Look me in the Eye; Notes of an Anethesioboist

-- Best Clinical Sciences Weblog: Scan Man's Notes; Pallimed

-- Best Health Policies/Ethics Weblog

-- Best Medical Technologies/Informatics Weblog: Life as Healthcare CIO

-- Best Patient's Blog: Pregnant Stephanie; Beating Social Anxiety; The new Life of e-patient Dave; Look me in the Eye

"Carefully tend to those kinds of moments"

There is a weekly segment on NPR called “Story Corps”. Today’s recording made me think of what great people work in hospitals.

Load 'em up! Move 'em out!

As promised below, more pictures and narrative from Bruce Wahl showing the truck loading for our Holiday Lights gift program: "Here are some photos from today's Holiday Lights activities. At around 3 pm Jacquaetta Hester-Walker started taking the 12 + carts down to the Loading Dock 1 at a time.... They were fairly heavy being that they were overflowing with gifts. We called upon the Service Ambassadors and a few of my Media colleagues. Many hands make light work. We loaded the 25 foot box truck to capacity and sent it on its way. When I returned upstairs to the staging area gifts had continued to arrive. There will be at least one more "smaller" trip out tomorrow AM. I was truly overwhelmed with the amount of gifts and the efficiency with which they are being handled."