How our staff gets high

Mount Everest is the background. This was taken two weeks ago from Kala Patar in Nepal. The people are Margie Serrano, RN (nurse manager of Farr 6 and CVICU), Alan Lisbon MD (Executive Vice Chair, Anesthesia), and Judi Deveau RN, NP (cardiac surgery).

Evidence in Medicine

A new blog by David Rind. Very timely.

We are eating ourselves to death

I'm taking a risk of offending here, but I don't mean it that way at all. It could be written about much of this country.

This particular post is prompted by an AP story by Mike Strobbe, pointing out that rates of obesity in the United States are highest in the Southeast and Appalachia.

On my recent incoming flight to Kentucky, an MD from the area who was sitting next to me pointed out that I would notice a large number of people with high body-mass indices. I expressed surprise, and said, "You mean noticeably different?" He said, "Yes."

I mentioned this story upon arrival to a number of my hosts at UK, and they confirmed it. They attributed it to the diet in their part of the world, combined with an increasingly sedentary population. Still I wondered, "How different can it really be?"

Then I noticed the breakfast buffet at my talk (seen here). And then a friend sent me a picture of the breakfast she was served after delivering her baby, with eight pieces of bacon.

There is much talk of the cost of health care in America. That talk tends to focus on the costs of doctors and hospitals, but a growing determinant of that cost is the diet and exercise pattern of our culture. I have previously posted slides from the CDC showing this trend over time. Sure, Kentucky and some other states are in the lead, but the whole country is following suit.

If I had taken pictures of the meals available to waiting travelers at Boston's Logan Airport, you would see similar patterns. A single sandwich with 1500 calories. A 32-ounce drink from the soda fountain with hundreds more.

We are eating ourselves to death.

There is no billing code for compassion

Our Dr. Amy Ship won the Campassionate Caregiver Award from the Kenneth B. Schwartz Center last night. The center conducts programs to educate, train and support caregivers in the art of compassionate health care. It received over 100 nominations for this award, which is designed to recognize people who have exemplified the practice of compassionate care to patients. Here is a background story from NECN television.

Amy's acceptance speech kept the audience in rapt attention. Here are some excerpts. I am hoping to be able to lead you to a video soon. One peak moment was when she emphasized the importance of primary care and bemoaned the current environment that often results in short, unsatisfactory visits. Noting that "there is no billing code for compassion," she called for a restoration of the proper role for primary care doctors.

Optimism? Other options?

This New York Times story by Michael Grynbaum tells of a new transit pass in New York City that has the word "optimism" printed on the reverse. Why?

“God knows people want to feel good, they want to feel up, they want to feel positive,” said Christopher P. Boylan, who oversaw the project at the Metropolitan Transportation Authority. “If I can make a couple of customers smile a day, that’s nice.”

Shouldn't we be more flexible here in Boston? New York is so old. In this high tech town, where social media reigns and where everyone has a status bar on Facebook, shouldn't we have Charlie Cards that give us a choice on any given day?

Optimism, sure.

Next year, absoxlutely.

Still waiting (for my train/bus/trolley), clearly.

Wrong choice (for Monday morning quarterbacks), Patriotically.

Some choice, for Election Day.

Dim sum, for riding on Sunday.

Esplanade, for the Fourth of July.

Your ideas?

Donate Life New England

BIDMC was just presented with this award for its role in promoting organ donations. The sponsor, Donate Life New England, coordinates organ donation programs throughout the region. It has a new website, as well as presence on social media like Facebook and Twitter, to get the word out about how important it is -- and easy it is -- to be an organ donor.

Many people think they have to wait for renewal of their driver's license to become an organ donor, but you can do it at any time. (I actually thought so, and then forgot to do it during my recent renewal!) You can do it on the website. It only takes a minute, and it will be legally binding. And, yes, you can revoke it at any time and also put various conditions in your record.

After going through the adventure below, I was moved to fill out the form. You never know.

Thanks for the rush!

It has been a beautiful fall here in New England, and I have been taking some early morning bike rides. It is dark when I head out, so I have the full panoply of reflective gear and a clear and strong headlight. It is good to be seen by drivers in their cars.

In the picture, I am the "X" just making a right hand turn at a corner in which there is a rotary around which approaching cars from the opposite direction are supposed to go when making a left turn (top black line).

Except, this time, the guy driving a minivan at about 30 mph decides he is at Le Mans and choose to make the left turn by bypassing the rotary altogether and driving in the left lane and cutting the corner (lower line).

He finally wakes up and sees me and swerves and misses me by a foot. Never stopping. But accelerating off as he departs the scene.

I can't tell you how much I appreciated the adrenaline rush. I had been just a little chilly as I set out that day, and this event quickly warmed up my whole body.

A long day

Even with enforced restrictions on duty hours, it can be a long day for residents. Next time, I hope this fellow can find a bed instead of a chair at the end of a corridor. He probably woke up feeling pretty stiff.

Tweeting while you talk?

So, I have been doing a fair number of speeches lately, and you always wonder what people in the audience are thinking. Might they be publishing tweets with their opinions while you talk? Here is a humorous view from Marc Perry at The Chronicle for Higher Education.

Caught between mammograms

Here is a great commentary by WBUR's Rachel Zimmerman about the uncertainties raised by recent articles about mammograms.

Dean Flier offers his views

Harvard Medical School Dean Jeffrey Flier offers a thoughtful and honest perspective on the health care bills circulating in Congress in this Wall Street Journal op-ed. Jeff is not just an academic observer. He is an accomplished physician-researcher-educator with lots of experience in the trenches.

He must know that his column will raise the ire of those on one side or the other of the health care debate, and then what he says will likewise be used in the political debate. I am confident that he raises these issues because he senses a need for someone to speak directly and help our political leaders on both sides of the aisle do the right thing.

He starts with a plain-spoken summary: "As the dean of Harvard Medical School I am frequently asked to comment on the health-reform debate. I'd give it a failing grade."

And then he leads to an important point: "Speeches and news reports can lead you to believe that proposed congressional legislation would tackle the problems of cost, access and quality. But that's not true." Hmm, that sounds familiar and is strongly supported by everything I have heard. He continues, "So the overall effort will fail to qualify as reform."

But, for me, the major insight is this: "Worse, currently proposed federal legislation would undermine any potential for real innovation in insurance and the provision of care. It would do so by overregulating the health-care system in the service of special interests such as insurance companies, hospitals, professional organizations and pharmaceutical companies, rather than the patients who should be our primary concern."

And finally: "So the majority of our representatives may congratulate themselves on reducing the number of uninsured, while quietly understanding this can only be the first step of a multiyear process to more drastically change the organization and funding of health care in America. I have met many people for whom this strategy is conscious and explicit.

We should not be making public policy in such a crucial area by keeping the electorate ignorant of the actual road ahead."

Stories about Harvey Goldman, MD

I reported in April on the death of Dr. Harvey Goldman, one of our beloved and esteemed colleagues (who loved baseball and is here seen with a Red Sox World Series trophy). Today, we honored this eminent pathologist with a memorial celebration and dedication of the Pathology Department Conference Room in his name. Speakers at the event included people from BIDMC, but also Fred Silva, Executive Vice President of the United States and Canadian Academy of Pathology, and Henry Appelman, Harvey's long-standing friend and colleague from the University of Michigan Medical School.

There were humorous and poignant remarks, too, from Robert Najarian, a gastrointestinal pathology fellow at BIDMC. He remarked that there were so many stories he had heard from residents and fellows that he felt badly he could not tell them all. I suggested we might give people a chance to tell those stories right here on this blog.

So, if you have studied or worked with Harvey at any point in your training or career and wish to offer stories or comments here for your friends, colleagues, and the world, please submit them.

The former Speaker speaks

Here are some folks from around the country at the Press Ganey National Client Conference today in Maryland. The "clients" is this case are hospital and physician groups who employ Press Ganey to conduct surveys of their patients. Over 1700 people attended. I was invited to talk at one of the sessions about the issue of using transparency to help create a culture of quality and safety.

The keynote speaker was Newt Gingrinch, former Speaker of the US House of Representatives (fuzzy picture above). Mr. Gingrich and I agree on some things and not on others. For example, his behavior with regard to the issue of so-called "death panels" was, in my mind, despicable. And, even in this speech, he had tendency to introduce partisan divisiveness when not really necessary.

That being said, he made some good points. He implored those in attendance to engage in continuous process improvement in their hospitals and not await government action to improve the quality and safety and cost-effectiveness of patient care. Essential to those improvement programs, he noted, is accurate data about clinical results, with concomitant transparency of those outcomes.

You can review other aspects of his work and ideas at the Center for Health Transformation.

City Sourced, a great app idea

I met a fellow today named David Kralik who is part of a new venture that has developed a wonderful iphone, Blackberry, etc. application called City Sourced. The idea is that, if you see something wrong in your town (a pothole, a broken street sign, or some other unsafe condition), you can immediately send a GPS-ed message with a picture of the problem to the municipality to inform them of the problem.

Just think, if I had had it this morning (and if I still had a Blackberry), I could have reported the problem I saw on the local transit system.

Art on the MBTA

A short while back, I wrote about new uninformative signs and annoying audio messages on the local transit system. Having run a large public agency, I really understand and sympathize with the logistics involved in introducing a new system. But it seems to me that these folks are missing something: If your system is not ready for prime time, don't bring attention to it.

The previous loud message warning us not to be fare evaders has now been joined by a message urging us to follow the safety rules and regulations of the transit system -- as though we might know what those are. It was amusing to be told to be careful riding the escalators, since the stations at which this broadcast was delivered are at ground level.

This morning, too, we had a new feature. Check out the artwork portrayed on the sign. If you click to enlarge the photo, you can see a random pattern of energized LEDs. Thanks to the MBTA for offering this visual treat!

Market failure --> New entrants?

This story by Rob Weisman in today's Boston Globe is about large insurance rate increases being faced by small businesses in Massachusetts. But, it is really about the lack of effective competition in the Massachusetts health care market, both on the provider side and the insurer side.

Although there are many contributors to rising health care costs in the state, one major one is the fact that the largest provider system is paid rates that far exceed the rest of the industry. This is the result of its market power and leverage over the insurance companies during rate negotiations. Yes, part of the problem is a fee-for-service payment regime that encourages overuse; but that is compounded when the dominant system's FFS rates are very high relative to the market. Why? Because it enables that system to recruit community physicians into its network at higher salaries, away from other systems. Those local doctors, in turn, refer their patients to the higher priced hospitals in that same network. This is a vicious cycle of higher rates, leading to network growth, leading to still more bargaining power, leading to higher rates.

Why do the insurers put up with this? Because there is a public perception, unsupported by clinical outcomes data, that the dominant provider must be part of any insurance plan's network. The plans, therefore, are afraid to leave those hospitals out of their insurance products. They also seem reluctant to create a market for insurance products that would charge customers a higher co-pay or add other features that would encourage the patients to go to lower-priced facilities.

The result: Utilization in the network served by the dominant provider grows at a rate exceeding the regional average. And because that utilization is reimbursed at a higher differential rate, the insurance company sees a huge cash outflow, and feels it necessary to raise rates -- especially to the market segment that has the fewest choices.

The second problem is a similar lack of competition in the insurance market itself. In any other industry, a competitor would enter the market and create a niche product -- a plan for small businesses and individuals, based on a limited high-quality, low-cost provider network.

National insurance companies have had a very small market presence in our state. Those who have thought about expanding their share of the Massachusetts market are probably concerned about the relative costs of doing so or about the ability of the insurers in this state to simply underprice their products. Well, we now see evidence that even the dominant insurer might feel it cannot afford to respond competitively to a new market entrant. That insurer, along with the others, is so persuaded of the market power of the dominant provider that it has been reluctant to take on that provider by leaving it out of its product mix or by including it at the premium price necessary to cover its costs.

A new entrant might feel differently and focus its efforts on a vulnerable market segment, one that would find a high-quality, low-cost network attractive. When you are fighting for your financial life as a small business or individual purchaser of insurance, you are more willing to make different kinds of choices. And, as a small business, you can more easily explain to your employees why you have done so.

To me, this seems like an opportunity for competition.

At the Saturday Club

Rob Velella (the one on the left) wanted to commemorate the 200th birthday of Oliver Wendell Holmes, and so he wrote a one-act play called "At the Saturday Club." The Club, which still exists today, was founded in 1855 and was an informal gathering of the great writers and thinkers of that age. They met at Boston's Parker House for "extravagant meals and even more extravagant conversations."

This play begins in 1892, with Holmes being the last survivor of his generation of writers. In his mind, he travels back to 1860, where he revisits his old friends Henry Wadsworth Longfellow, James Russell Lowell, and Ralph Waldo Emerson. The dialog in the play is taken from the original words of these historical figures.

The play was performed this afternoon at the Massachusetts Historical Society.

Another great soccer season

Another successful soccer season closed out today. Well, not quite. The last game was postponed because of bad weather, but the end-of-season party went as planned. We'll see next week whether we can extend the 7-1-1 record to 8-1-1. In the meantime, the girls and parents fought off the rainy weather blues with the above cake and lots of other goodies.

It was also a chance for me marvel again at how many of the girls' parents are doctors (both MDs and Ph.D.s.) They seem to be endemic to this city. They include the following specialties: psychiatry, internal medicine, infectious disease, endocrinology, neurology, nutrition and aging, and risk management to name a few. We are clearly ready for any medical emergencies that might occur on the field!

Right on Target from The Onion

This is more true than you can imagine. It has happened to me many, many times during TV interviews.

How not to save energy

The second US energy crisis occurred in 1979, after the Shah of Iran was deposed, and oil production in Iran plummeted from 6 million barrels per day to under 2MBD (black line in the chart to the right). Saudi Arabia and other OPEC countries increased production to try to offset this, but the results were uneven. While the overall reduction in supply was only 4 percent, panic resulted, leading to hoarding behavior and shortages.

President Carter responded to this with a package of energy legislation and his now-famous "malaise" speech, in which he discussed an American crisis of confidence and urged people to use less energy.

The most correct thing the President said in terms of energy policy was that "We often think of conservation only in terms of sacrifice. In fact it is the most painless and immediate way of rebuilding our nation's strength." But this lesson was soon lost as the government acted to equate conservation with deprivation.

An example is in the certificate above. The Emergency Building Temperature Restrictions were implemented the day after Carter's speech and set maximum temperature levels for public buildings in the heating season and minimum temperature levels in the cooling season, as well as maximum temperatures for hot water. Specifically, space heating was restricted to a maximum of 65 degrees Farenheit, hot water temperature to a maximum of 105 degrees F, and cooling temperature to a minimum of 78 degrees F.

The damage done to American's understanding of energy conservation was that a policy that could have been equated with efficiency, competitiveness, and improved comfort was instead seared into the public consciousness as sacrifice and discomfort. (It is no accident that the regulations were rescinded by President Reagan shortly after taking office.)

I had seen a similar portrayal during the first energy crisis in 1974, when the OPEC nations imposed an embargo on petroleum sales to the United States and other Israeli allies. Rogers Morton, Secretary of the Commerce at the time said, "Americans don't want to conserve energy. They want to win." At a private meeting at Harvard during that period, as an intense 25-year-old Deputy Director of the MA Energy Policy Office, I rather directly and perhaps a little rudely told Energy Czar Frank Zarb that he was dead wrong when he said that America had reached the limits of possible energy conservation.

Sure enough, investments in plant, equipment, and appliance over the years have changed the underlying structural relationship between energy use and GDP in the US and other countries, and they have done so while preserving and even enhancing the efficiency and comfort of American life.

But reminders persist. The certificate above is today posted in a building at MIT, no longer relevant or in force, but a shadow of a failed policy direction.

There is still tremendous potential for energy efficiency in America and the world, but only if we approach the problem in a way quite different from that adopted in 1979.

Atrius-BIDMC Relationship

We announced yesterday an important partnership between the state's largest multispecialty group practice, Atrius Health, and BIDMC. This is a promising new relationship between a physician practice group and an academic medical center.

Here's the press release. Please note, in particular, the comments by Don Berwick, which help explain the context and significance of this.

While exciting to me, I also know that this will also require a lot of work to pull off, and I expect we will learn much from each other. I would also be happy to hear comments from my readers as to your experiences in similar ventures, and your advice to us to help make this a success.

ATRIUS HEALTH, BETH ISRAEL DEACONESS MEDICAL CENTER WORKING TO CREATE NEW HEALTH CARE MODEL

Atrius Health and Beth Israel Deaconess Medical Center are expanding their relationship to establish a new model of health care delivery between a large ambulatory multi-specialty practice and a leading academic medical center, according to Gene Lindsey, MD, president and CEO of Atrius Health.

The boards of directors from Atrius and BIDMC both voted Wednesday evening to build the expanded relationship. The first step will be that Harvard Vanguard internists from the Kenmore, Copley Square, and Post Office Square offices will send their patients who need emergency care or hospitalization to BIDMC. Over time, Atrius Health will also look to collaborate with BIDMC in ensuring hospital care for patients with more complex needs, including cardiovascular and oncology patients as well as other surgical specialties. The organizations will utilize electronic medical records to help coordinate patient care. Atrius Health will continue all of its existing hospital relationships to serve patients in communities it serves.

Guided by an overarching goal of patient-centered care, Atrius Health and BIDMC also envision a robust agenda of quality improvement and cost efficiency strategies. Both parties have a vision of working together far into the future. Additional details about joint clinical, quality, and cost reduction programs will be introduced over time.

This new expanded relationship comes amid the current statewide and national debate on cost control and health care reform, and the move toward global payments in Massachusetts. The collaboration will be built around a strong emphasis on primary care and a continuum of care from the ambulatory setting to the hospital and beyond.

“The goal is to demonstrate that by working together, the two organizations can provide the highest quality, best service, and lowest cost health care in the Commonwealth.” Lindsey said. “We have the utmost respect for the progress BIDMC has made towards eliminating preventable harm and doing so with transparency,” he added.

The collaboration is also part of a larger Atrius hospital strategy to work together to improve quality and reduce costs with hospitals that share their vision and want to work on lowering cost and improving quality. Atrius Health and BIDMC have a long history together and both were involved in the Blue Cross Blue Shield of Massachusetts LEAD program for process and quality improvement.

“We intend to establish the model for health care delivery in the Commonwealth,” said BIDMC President and CEO Paul Levy. “That model offers a full spectrum of health care services that are patient-centered, compassionate, integrated, and evidence-based. Fundamental to our model will be an emphasis on primary care, alignment of the organizations, and transparency. Atrius Health has demonstrated leadership in all these areas, which is why we are so excited to be working and learning together.”

“Almost for certain, the American health care system is on the threshold of a leap into a new era of integrated, coordinated care. Patients as individuals and society as a whole badly needs that leap to achieve better quality at lower total cost. That re-forming of care will require new, highly cooperative relationships between foresighted hospitals and progressive medical groups,” according to Don Berwick, MD, MPP, President and CEO, Institute for Healthcare Improvement. “I cannot think of two organizations better equipped to welcome that reinvention, and to succeed at it, than BIDMC and Atrius Health. Each has a strong and distinguished track record of innovation, and their combined efforts will blaze a trail for many others,” he added.

The goals of the new relationship follow many of goals and principles outlined by the Massachusetts Health Care Quality and Cost Council, the Massachusetts Payment Reform Commission, the Mayor’s Task Force on Improving Access to Primary Care in Boston, and the Institute for Healthcare Improvement (IHI), including: Putting primary care at the center of patient’s care; Making sure that physicians work together as a team with nurses, technicians, and other allied health professionals; Enhancing and further integrating electronic medical records; Advancing health equity and ensuring a diverse, culturally competent, interdisciplinary workforce; Preventing and reducing medical errors and being transparent about results; Improving the efficiency of health care delivery by continuous process improvement as exemplified by the Lean methodology; Empowering patient involvement in the design of the health care delivery system through advisory councils, secret shoppers, patient satisfaction surveys, and other mechanisms.

Harvard Vanguard and its predecessors have a long history with BIDMC. Harvard Community Health Plan originally formed as a combination of a Brigham & Women’s practice and a Beth Israel practice, and benefited from the relationships with both of these outstanding institutions. Today, Atrius Health has existing relationships with BIDMC for obstetrics and oncology.

How to make health care remarkable

An excellent interview with e-Patient Dave here on Phil Baumann's blog.

The harp soothes the soul again

A few months ago, we established an "online community of gratitude" called Grateful Nation to give patients and family members an outlet for feelings of gratitude they might have about a doctor, nurse, housekeeper, transporter, or other member of our medical staff. Items can also be sent in by mail.

Here's one that arrived this week. I have written about the harp before. This is another affirmation of the power of music in a clinical setting. The 7th floor is our oncology clinic.

Following Ruth

I love this video of our archivist Ruth Freiman giving a tour of the BIDMC archives, containing items from the BIDMC's antecedents, the New England Deaconess Hospital and the Beth Israel Hospital.

Caller-Outer of the Month Award #9

Our Board of Directors awarded this month's caller-outer award to Tinea Simpson, Practice Representative in our GI department.

GI staffers on Tinea's floors are practicing a “Leaner” way to conduct their day to day business thanks to her call-out, and the resulting reorganization that came from her work with Resource Nurses Mary Ellen Johnson and Christine Hunt.

As you may know, there is a patient packet for every procedure that happens in a hospital. For the past several years BIDMC volunteers have assembled these packets covering the entire demand of our GI unit – over 100 procedures a day.

As medical practices are revised and forms become obsolete or go unused, the end result can be a tremendous waste of paper and money. These three women evaluated the situation, decided what forms were necessary and what were not, and with the help of Volunteer Services, took action to correct the packets and reduce the use of hundreds of forms.

They created a path of action to include creating new sample packets for volunteers to follow and purging forms that were no longer warranted. Congratulations to Tinea for demonstrating the concept that each person should feel encouraged and empowered to recognize and go about seeking solutions to inefficiency and waste that he or she sees in the workplace.

Translation Service

A friend sent me this training page that appears to be from the SEIU. The link to the website from which it was obtained is disabled. Maybe someone from the union can point us to the document's new location. Maybe not. It was entitled, "For internal use only -- Not for distribution."

Veterans Day Thanks

An idea we have adopted for Veterans Day. Have you considered a similar thing for your hospital?

To: BIDMC Community

From: Paul Levy, President and CEO

Eric Buehrens, Chief Operating Officer and Executive Vice President

Subject: Veterans’ Day Thanks

BIDMC pays tribute to those who serve our country through military service.

It is our privilege to say, “Thank You,” to the many employees who are among the 24 million living American veterans – as well as the numerous staff and family members who are on active duty now. We appreciate their service and honor them for their sacrifices.

Tomorrow, Veterans Day (Wednesday Nov. 11, 2009) employee veterans and United States Armed Forces active duty personnel will receive a free meal (breakfast, lunch or dinner) in the east or west campus cafeterias. Just present your BIDMC ID badge and let the cashier know you are a veteran or active duty personnel member.

Also, if you would like to have a prayer offered for any veteran or active duty member of the military, please send the name and details you wish to include to either the Pastoral Care mailbox (select Pastoral Care from the dropdown menu in the “To” field of the e-mail) or directly to Rev. Julia Dunbar, Director, Pastoral Care and Education, at [email excluded here].

Next month: Helping The Borum

Thanks to those of you who visited my auction site to support the Bowdoin Street Health Center, whether you chose to bid or not. Next month's auction, starting December 1, will benefit the Sidney Borum Jr. Health Center.

I have already received some great auction items, including many that are just right for holiday gifts -- whether you live here in Boston or anywhere in the world. Visit the auction before you go to the mall!

Located at 130 Boylston St, across from the Boston Common, the Sidney Borum Jr. Health Center opened in 1994 to serve the health care needs of homeless youth and young adults, many of whom engage in unsafe sex with adults in exchange for money, food or a place to sleep.

The Borum provides primary medical care as well as mental health and substance abuse counseling, HIV counseling, testing and risk reduction reinforcement, as well as other clinical and social services. Its primary focus is on young people who have been unable to gain acceptance in more traditional health care settings for a variety of reasons, including homelessness and involvement in street life and the sex industry.

Through the online auction on this blog, The Borum seeks support for its linen service and grooming/hygiene products that help patients live with the dignity they deserve.

Please donate items at any time and stay tuned here for the latest auction details.

Bourbon, neat

OK, I have to admit that not all of the time in Lexington, Kentucky (see below) was spent on health care issues, unless we consider bourbon a therapeutic substance. I had a little time to visit the Bourbon Trail with some friends, and we toured the Four Roses distillery. Here is a picture of our tour guide offering samples and a video of the fermenting mash.

With the Wildcats

I just attended a session run by the University of Kentucky's Program for Quality, Safety & Patient Rights in the Center for Enterprise Quality and Safety. The director of the program is Dr. Joe Conigliaro, who related stories of meeting Bostonians during his matriculation at Harvard Medical School. "How's your brother/cousin?" he would be asked, even though he was not related to Tony.

But that's not the main point of this post. UK, in cooperation with the Lexington Veterans Administration, has a keen interest in patient safety. My role in the morning plenary session was to lay out legal, ethical, and practical implications of disclosing adverse events. Participants then attended concurrent sessions, one on transparency and disclosure evaluation through incident reporting, and the other on historical perspectives on transparency and disclosure.

My last event of the day was a panel discussion on these topics with: Dr. Steven Kraman, Vice Chairman of Internal Medicine at UK College of Medicine and Margaret Pisacano, Director of Risk Management (seen above). Unfortunately, I had to leave before hearing from State Representative Tom Burch, who I am sure gave an insightful perspective from the public policy point of view.

It is so satisfying to be with advocates and practitioners of patient quality and safety and to learn from one another's experiences. Wait, did I tell you they have a blog, too! It is hosted by Ann Smith, chief administrative officer at UK Albert B. Chandler Hospital, and jointly written with some of her colleagues. Please check it out and submit comments.

Tempus fugit

Just 15 more hours left to bid on great items and services at my auction to benefit Bowdoin Street Health Center.

Hybrid Vigor, or Heterosis to you

I am extremely fond of many of our staff, but Dr. Rafael Campo is near the top of my list. He is an excellent physician . . . and poet . . . but also head our Office of Multicultural Affairs. He has written a credo for this office, and I wanted to share part of it with you. I cannot think of a better way to explain the importance of diversity and inclusiveness in a hospital setting. I also love the way he stretches the use of a term from another field, "hybrid vigor," as a metaphor for what we hope to accomplish. See what you think.

The Office of Multicultural Affairs . . . is an embodiment of BIDMC’s belief that the best possible medical community is one in which the maximum diversity and inclusiveness is found. We believe that the best research and medical care occurs in a context where differences are highly valued; that "hybrid vigor" is not just relevant but fundamental to the structure and optimal functioning of human groups. We do not advocate a sublimation of our differences, however. Our inherent tendency to cluster into our group identities is also essential to the preservation and nurturing of each of our unique cultures. Multiculturalism is the search for an appreciation of the richness gained by the co-existence and mutual respect of our differences, as well as an acknowledgment and embrace of our similarities. We feel that these values are essential to the development of outstanding physicians and the delivery of extraordinary patient care.

Monique exclusively for you

The last time Monique Doyle Spencer gave a talk at a corporate retreat, the CEO reported that it was the single most motivational event in all of his years with the company. She has donated her time for a session for your company or civic organization to my online auction to benefit Bowdoin Street Health Center.

Here's some background:

Spencer believes in humor as a powerful force in restoring the human spirit under any conditions. She is a three-time cancer survivor who has used laughter to reach wide audiences, to teach people how to survive and even thrive under challenges. Whether the audience has been women in prison, business groups, firefighters, cancer patients or grieving spouses, Spencer’s unique approach has inspired countless people to find their personal courage and restore joy in their lives.

Spencer is a contributing columnist to the Boston Globe. Her Globe columns also appear on NYTimes.com and in the International Herald Tribune. She is author of The Courage Muscle: A Chicken’s Guide to Living With Breast Cancer; and How Can I Help? Everyday Ways to Help Your Loved Ones Live with Cancer. Her third book, The Real Life Body Book, will be available in March, 2010.

Rational choice?

I'm trained as an economist, and I understand the theory of comparative advantage, but I still have not figured out how the world's economic system makes it possible for this bottle of water to find its way from Fiji to Boston, a distance of about 8000 miles. It is not just the water, it is the plastic bottle, which is either manufactured somewhere and imported to Fiji, or the raw ingredients of which have to be imported to Fiji and made into a bottle there. Then, the bottle and the water both have to be shipped around the world to this market.

But what I really don't understand is why anyone would buy this water. (I acquired this bottle at a hotel in Boston, where I was attending a conference. Do they really think that we make choices about hotels based on which bottled water is served?)

A 24-pack of the Fiji 500 ml bottle weighs 27 pounds and costs $38.00 on this website. That's 12 liters for $38.00, or over $3 per liter.

A comparable pack of San Pelligrino from Italy costs $26.00, or a little over $2 per liter.

Poland Spring water from Maine costs $7.49 per pack, or less than $1 per liter.

Tap water in Boston costs $6.oo per 1000 gallons, which is roughly 3780 liters, for a price of .16 cent per liter.

Another part of economics is the theory of rational choice, which basically says that people consider the costs and benefits of their actions before making purchases or taking other economic steps.

Right.

Tired?

Direct Tire offers a service package (including oil and filter change, tire rotation, and more at any of its locations (Watertown, Norwood, Peabody and Natick) in my online auction to benefit Bowdoin Street Health Center.

Sleepy, too? Maybe you have guests coming to town? Don't forget to bid on an overnight at the Courtyard by Marriott in Cambridge.

Spreading the word to CEOs on transparency

The VHA Foundation is a 501(c)(3) that aims to improve individual and community health by promoting and diffusing new, effective models of health care. It has a program called the Health Care Safety Network for hospital CEOs to help them accelerate their patient safety leadership skills in an environment where they can learn from their peers and national safety experts.

I had a pleasant visit last week from Dr. Peggy Naas, vice president and leader of Physician Strategies for VHA. She was in my office to tape a session about BIDMC's efforts to improve the safety and quality of patient care, with a particular emphasis on our view of the importance of transparency as a management tool in this journey. This video will be shared with the CEOs in the Health Care Safety Network.

I hope our experience proves useful to my colleagues and that it will make them feel more comfortable in sharing their clinical outcomes and process improvement successes and failures with others.

Sweet tooth?

Cookies, gelato and more at my auction to benefit Bowdoin Street Health Center, courtesy of Dancing Bear Baking Company and Giovanna Gelato.

Great dance

A new auction item has just come in, a dance performance by the Trey McIntyre Project at the ICA theatre on Friday, November 20. It is courtesy of World Music/CRASHarts and is available here at my auction to benefit Bowdoin Street Health Center.

Cooley-Dickinson vanquishes VAP

About a year ago, I wrote about the great progress made by Cooley-Dickinson Hospital in Northhampton, MA with regard to eliminating ventilator associated pneumonia. I now hear from Daniel J. Barrieau, RRT, CPFT, Director of Respiratory Care Service, that "we are now counting our time between incidences of Ventilator Associated Pneumonia in YEARS instead of days. This week we passed the 2 year mark and took a moment to celebrate the milestone. Here is a pic of the cake. . ."

Congratulations!

Zip-a-Dee-Doo-Dah

Find custom made jewelry made from zippers! Really. Courtesy of ZipBling's owner and designer, Louise Loewenstein. Check out my auction to benefit Bowdoin Street Health Center.

Working with a family advisory council

The concept of patient and family advisory boards to hospitals is gaining currency. The idea is to integrate the perspective of patients and families into decisions about clinical practices, space, priorities, and the like. We have had a Family Advisory Board for our Neonatal Intensive Care Unit (NICU) for some time. Here is its mission statement:

The mission of the BIDMC NICU Advisory Board is to touch the lives of each NICU family in a positive and lasting way. Our goal is to complement the NICU's outstanding clinical care and embrace the hospital's commitment to Family-Centered Care with programs and initiatives that acknowledge and support the family in a time of crisis, and to extend the relationship between the family and hospital well beyond discharge. The NICU Advisory Board will support this mission through representative feedback on existing and future programs, facility and policy enhancement, staff/family relations, development and fundraising, and other issues related to the needs of NICU families.

If you are going to create an advisory body like this, you need to share key information with them. I am showing here a few slides of a presentation delivered yesterday by Dr. DeWayne Pursley, chief of service. Among other things, the presentations contained a full exposition of progress on the metrics by which the NICU judges its success with regard to family interactions, along with a statement of initiatives in the various dimensions of care. This kind of transparency leads to a greater sense of involvement, and it also prompts discussions that often lead to good ideas.

In a post below, I wrote about some recent success in our adult ICUs. That success was dependent on involvement by a similar patient and family advisory council. Our experience with the NICU council helped us design the adult council, but it also gave the medical staff some confidence that the effort involved in creating and meeting with the council would be worth the effort. Clinicians and hospital administrators are often skeptical on this point. Let's hope that such skepticism gradually erodes as the good work of these councils becomes more widely known.

Feeling the need to wine?

A limited edition, new California wine from Je Suis is available at my auction to benefit Bowdoin Street Health Center.

Help for migraines

Here's a short and excellent discussion about migraine headaches on the FOX25 Morning News with Dr. Carolyn Bernstein, a headache expert with BIDMC's Arnold Pain Management Center. She is the author of The Migraine Brain: Your Breakthrough Guide to Fewer Headaches and Better Health.

Need inspiration?

Planning a meeting for your company or civic club? Hire one of three great inspirational and informative speakers at my auction to benefit Bowdoin Street Health Center. Look under "Unique Experiences."

Want to see a masterpiece theatre?

WGBH is offering tours of its studios in my online auction to benefit Bowdoin Street Health Center. Look under "Unique Experiences."

Interlocking circles and cycles

Still relatively new to the medical field, I am often struck by the interplay among generations of patients and doctors, and between doctors themselves. I have not seen it to this degree in other industries with which I have been associated. It makes the field intensely personal, with constantly interlocking circles and cycles of life.

Here's a microcosm. Dr. Harold Solomon learned about hypertension from one of the leaders in the field, Dr. Norman Kaplan, Clinical Professor of Internal Medicine, University of Texas Southwestern Medical Center at Dallas. Dr. Kaplan's book, Clinical Hypertension, is the standard in this area. Harold built a practice with an emphasis on this field, but also focused on delivering high quality primary care in general.

One of Harold's patients, Harvey ("Chet") Krentzman, died a few years ago. In recognition of the excellent care provided by Harold to her husband, Chet's wife Farla decided to lead an effort to fund a lecture series at our hospital in his name. One of the guest lecturers invited by Harold was Dr. Kaplan, in appreciation for his stature in the field and for his influence on Harold's own career.

Tonight, on the eve of tomorrow's lecture, a group of Harold's patients and physician colleagues joined to express their appreciation and affection for all three people. You see them above.

The gold standard

Our pathology labs receive accreditation from the College of American Pathology and the American Association of Blood Banking. Inspections are every two years and cover about 3000 separate standards. The reviewers are pathologists and technologists from other participant organizations.

We just completed an inspection conducted by a 15-member team, a group with very impressive qualifications.

I am proud to say that, not only did we pass with flying colors, but one surveyor said, "I have been doing inspections for 30 years and if any place has a gold standard, this place is It"!

As noted by Dr. Jeffrey Saffitz, our Chief of Pathology, "In more than 35 years in academic pathology, I have not witnessed such an extraordinary level of commendation and praise from a team of peer reviewers. Almost without exception, these seasoned, experienced inspectors indicated that they learned a great deal from us and they intend to implement many of our policies and practices in their own institutions. Many also expressed a desire to take some of our people back to their home institutions! The cooperation, trust, work-ethic, dedication and commitment to excellence by our lab personnel is absolutely unparalleled."

Congratulations to the entire team!

Hallelujah!

Craving culture? Check out Boston Baroque's Messiah and also their New Year's Eve concert at my auction to benefit Bowdoin Street Health Center.

And, why not combine it with a one night's stay at Boston's most romantic inn, the Charles Street Inn? Look for this newly arrived item under "unique experiences" on the auction site.

Urine my thoughts

I am always on the lookout for water saving techniques . It comes from having focused on this while running the metropolitan area's water system.

I, er, encountered this at MIT -- along with the handy sign that you can read while....

Back at the hospital, I inquired of our facilities folks whether we should have these in public restrooms at the hospital. A rather lengthy stream of information ensued from Mark Lutisch, our utility manager. I'll include most of it, for those of you who might be interested as you consider this in your own facilities.

Waterless urinals can save a lot of water and be fairly clean, with minimal odor. As waterless urinals don’t flush, there may be a reduction in bacteria or pathogens that are transported in aerosols to users. However, waterless urinals are not a set-and-forget plumbing fixture.

Prior to a waterless urinal retrofit project in older facilities, it is highly recommended that facilities 1) ensure that the slope of the drain line is ample, and 2) route drain lines to avoid problems such as sediment build up and 3) check drain heights are appropriate to the brand to be purchased. 4) Heavily corroded pipework should be replaced with PVC pipes. Facilities are far less likely to encounter problems with retrofit projects if these preparations are made.

A special and often-patented trap assembly that requires a special lighter-than-urine liquid must be added to the regular bathroom maintenance schedule. The trap assembly and the trap liquid must be added to the list of consumables that need to be purchased and resupplied for the life of the fixture. Maintenance staff require training in the proper care and feeding of all waterless urinals. Once the plumbers are gone, it’s up to the building staff to maintain the fixtures, and they still need daily cleaning and disinfecting, waterless or not. It may be necessary to clean urinal pipework before installing waterless urinals.

Toilets account for about 20% of BIDMC's water usage, urinals about 1%. A study by Water Management Inc. in 2007 recommended a focused fixture replacement program that zeros in on the fixtures with “the most bodies per potty”. They proposed to replace fixtures that have high per use flows and receive consistently high usage. These fixtures are generally located if common area and staff restroom facilities. Some plumbing fixtures would be excluded from the project scope based on low usage profiles. The cost was estimated at $380K with a 4.5 year payback. Because the energy budget did not have $380K for this measure, and the 4.5 year payback was not as good as other projects, toilet and urinal replacement was excluded from the water conservation project.

Instead of installing waterless urinals, Water Management Inc. recommended simply modifying the flush valves on 50 high use urinals to reduce the volume used per flush to 0.8 gallons per flush, saving about 282,000 gallons and $4K per year. Replacing the flushometers (possibly with infrared no touch sensors) is a cost effective way of reducing urinal wastewater.

In FY12 the energy plan will request funding for toilet and urinal replacement, along with a study on rainwater harvesting, greywater harvesting, and irrigation scheduling. However, we may pilot low flow toilet fixtures sooner in several high use bathrooms.

Thanks for your support,
Mark Lukitsch
Utility Manager, BIDMC

Sleepy? Amorous?

Which side (of the river) do you prefer? Win a hotel room in Boston or Cambridge for a visiting friend or relative . . . or for that romantic night out. Courtesy of the Four Seasons and the Courtyard by Marriott. Bid at my auction for Bowdoin Street Health Center.

Tom Sellers --->> DC

My friend Tom Sellers has fled Boston and taken a new position as President & CEO of the National Coalition for Cancer Survivorship. (Locals here will know that Tom led the fundraising, community relations, and development activities for a $30 million American Cancer Society project to build a 50,000 square foot Hope Lodge in Boston to provide free lodging to over 1,000 cancer patients annually. Before that, he worked at the United Way and in the MA state government.)

He is very excited about this and tells me that there are nearly 12 million cancer survivors living in the United States and that NCCS is the oldest survivor-led cancer advocacy group in the country. This group advocates for quality cancer care for all Americans and provides tools that empower people affected by cancer to advocate for themselves. It was founded by and for cancer survivors more than 20 years ago. Its governance requires at least half of the Board members to have had a cancer diagnosis some time in their lives, and many staff members are cancer survivors, so they speak from experience.

Tom says, "One of our newest initiatives is the Journey Forward program, which is targeted to health care professionals and patients. Upon completing treatment, many cancer survivors find themselves wondering, “What’s next?” The Journey Forward program, is a collaboration of the NCCS, Wellpoint, UCLA Cancer Survivorship Center, and Genentech. It helps survivors with the transition from uncertainty to the next stage of survivorship through the use of treatment summaries and follow-up care plans that summarize cancer treatment and give clear steps for follow-up care and monitoring.

"Cancer care plans put survivors in a better position to advocate for themselves, monitor their health, and participate in decisions about their future care. Journey Forward’s custom-made Survivorship Care Plan Builder is available to any oncologist, and the electronic Medical History Builder allows patients to easily record their own health history. Journey Forward’s survivorship toolkit currently offers templates that include information specific to survivors of breast and colon cancer, and a generic model that is applicable to survivors of many cancer types will soon be available.

"The program is completely free, and more information about how you can develop a plan is available here."

Hungry?

Head downtown for a great lunch or dinner at the Chinatown Cafe on Harrison Street, courtesy of proprietor Hing Soo Hoo. First, though, bid on a gift certificate at my online auction to benefit Bowdoin Street Health Center.

Who cares if it is off-season?

Take 10 friends for a tour of Fenway Park, courtesy of our Red Sox partners. Or have lunch with Executive Vice President Sam Kennedy. Bid at my auction to benefit Bowdoin Street Health Center.

If you visited yesterday, check out some new items today.

GRACE: Will it be amazing?

Our folks are working on an important new project. It derives from a number of adverse events, cases in which elderly patients fell and were injured. Our review process often indicated that the staff had done just the right things with regard to fall prevention and supervision of patients. Using the "5 Why" process of Lean, they kept digging into the cause of these falls. A hypothesis emerged: Perhaps we were contributing to the likelihood of falls by over-medicating geriatric patients or missing important parts of their supervision and therefore causing them or allowing them to be disoriented.

Our group began to construct a new "geriatric bundle" of care. (You have seen this be tremendously effective in other arenas, like avoiding Ventilator Associated Pneumonia.) But what should it look like, and what should it include? Well, we have just started rolling it out on an experimental basis, and we will report the results as things progress. Here's a summary from the staff:

The Geriatric Bundle now has a new name - GRACE (Global Risk Assessment and Careplan for Elders). This program is designed to improve the care of all hospitalized elders admitted to the BIDMC, with the hope that we will reduce the risk of delirium, falls, pressure ulcers, functional decline, etc.

There are three main components of the initiative:
- Provider Order Entry (POE) enhancements
- Improved Pharmacy/Medication safety
- Bedside care protocol

The bedside care component is a major piece and through the diligent work of many is well on its way to implementation. A tool is a GRACE bedside flow sheet that will be used for all patients 80 and older each day. You can see it and the other elements at this link to Slideshare, where you can read the entire presentation that was shared with our clinical staff on several floors.

Online Auction to Benefit Bowdoin Street Health Center

I am starting a new feature on this blog. I hope you enjoy it and participate.

Some friends of mine are involved in a new company called BiddingforGood. What EBay brings to the world of auctions in general, B4G brings to the world of charity auctions. It is a consolidator, facilitator, and operator of on-line auctions for charitable causes and organizations.

With the help of B4G and some of the BIDMC staff, I will be holding an on-line auction each month to benefit one of the BIDMC's affiliated community health centers or another worthwhile health care-related cause.

This week's auction will benefit BIDMC's owned Bowdoin Street Health Center, a wonderful place providing primary care, specialty care, and many support functions to a section of Dorchester in Boston. I am trying to raise money for an ultrasound machine, so pregnant women can have ultrasounds in their neighborhood setting rather than having to spend time and money to travel to BIDMC for this service.

Just click here to enter the auction site. There are some great items -- travel, food, concerts, sport events, art, and memorabilia. Also, some very special people are offering to provide inspirational and informative presentations at your civic organization or company. Finally, there are a couple of special items from our partners, the Boston Red Sox.

Bid early, bid often, and bid high! You have until 8pm on Monday, November 9, to submit bids.

Also, if you would like to offer items or services for this or future auctions, please click here or on the "Donate" button on the right side of this blog.

In the interest of total disclosure, I want you to know that bidding in this auction will place you on a mailing list for future auctions, both mine and others around the country. You can have yourself taken off that list at any time.

Please let me know what you think about this idea and the B4G site.

And, good luck!

Out of line

Depending on your point of view, competition is either the strong point or the underside of Boston's spectacular collection of hospitals and physicians. It does produce an exceptional desire to succeed, to deliver the highest levels of clinical care. But it also has the potential to be rather juvenile and wasteful of resources. But here is an unusual case where it got downright ugly and out of line.

The story is documented yesterday in a Boston Globe article written by Liz Kowalczyk. The case involves a request for a restraining order against their former hospital physician organization by two doctors who chose to join another hospital's network. Why would they need a restraining order? I have seen the court complaint. Here is a representative part:

Defendant Caritas Christi Physician Network, Inc. ... has failed and refused to send a timely notice to patients presently under the Plaintiffs’ care with respect to the change in affiliation and Plaintiffs’ new contact information. Notwithstanding this failure, Defendants have further refused to agree to remedy the situation by permitting the Plaintiffs to maintain temporary custody of their active patient files until such time as patients have been fully informed of the change and given the opportunity to continue care with Plaintiffs. Without regard to the needs of Plaintiffs’ aged and chronically ill patient population, Defendants propose to remove forthwith ... all active patient files, with the exception of those patients who have a scheduled appointment with Plaintiffs in the next two weeks. Defendants also have failed and refused to agree to ensure that Plaintiffs’ new contact information will be provided to everyone who calls that number, notwithstanding that Defendant is keeping the phone number Plaintiffs have had for over thirty years.

The judge granted the restraining order. The legal standard for a restraining order is that the moving party has "a likelihood of success on the merits of its claim and, without the requested injunction, risks suffering irreparable harm." I'll leave you to read the story, but I want to respectfully disagree with Liz's characterization in one part of it.

She notes, "The disagreement highlights the intense competition among hospitals in the Boston area to hire and retain established physicians, especially primary care physicians." Not so! This is something altogether different.

This is out and out cruelty to patients by attempting to restrict their doctors' access to them and their medical records. I can't recall any other hospital system behaving in this manner when a doctor chooses to join another network, no matter how competitive the environment.