Israel visit -- Part 1

I have been on a mission to Israel for several days with a number of Bostonian businesspeople, sponsored by the Combined Jewish Philanthropies. These kinds of programs are always engaging and informative, as an attempt is made to meet with people from a wide variety of political backgrounds, but also to meet with people living their everyday lives.

Whatever your view of the Israeli-Palestinian conflict, I am sure you would agree that schoolchildren are casualties. I hope you agree with me, too, that they are innocent victims. In addition to the chance of being killed, they suffer from other ravages of war.

We visited the Israeli town of Sderot, right outside of Gaza, a town that has experienced daily rocket attacks for many years, sometimes several times per day. As you can see, this school has been reinforced in many ways to deflect and withstand rocket attacks. Nonetheless, the children have grown up in an environment that leads many to suffer from post traumatic stress.

A program was introduced to help children cope with this emotional burden. It is called Havens of Calm, and it comprises pet therapy, pyschodrama, and yoga. The idea is to provide a school-based stress reduction and resilience building service accessible to all children when they need it. The program builds upon the mental health service provided by the education system (counselors and psychologists), as well as bringing in additional services and supplementary expressive therapies. It is funded by the Joint Distribution Committee with support, in part, from the people of Boston through the CJP.

We had a chance to watch the children and their therapists. By the way, note that the buildings built by the children as part of this session tend to have heavily reinforced roof structures, just like their school building. Compare this to what your own children would be likely to build: This is an unconscious result of their experience.

Healthy is . . . skating at Fenway

About 120 BIDMC staff members got a chance to take to the ice rink last week at Fenway Park. The rink was constructed for the New Year’s Day “Winter Classic” match-up between the Boston Bruins and the Philadelphia Flyers. As part of its special relationship as the Official Hospital of the Boston Red Sox and Red Sox Nation, the Sox invited BIDMC staff to have an exclusive one-hour free skate before the rink gets removed. Here's Joanne showing how to stay healthy.

Uncivil behavior within the SEIU?

A few weeks ago, I wrote of issues surrounding morality, power, and union organizing with respect to the SEIU. Now comes this fascinating article entitled SEIU's Civil War by Bill Fletcher, Jr. and Nelson Lichtenstein on a website called In These Times.

I know nothing about the authors or the website, although the site portrays itself as committed to social justice issues. One paragraph of the story struck home and seemed consistent with my post:

Although some SEIU locals have had histories of varying degrees of internal democracy and transformational politics, the SEIU has looked askance at such localist examples of democratic participation—not because the leadership of SEIU is hostile to mobilization or democracy in any formal ideological sense, but because it has had other agendas that all too often seemed to conflict with a decentralized and democratic structure. Efforts to democratize and transform the union controlled and led by rank and file members have been largely absent.

Honoring Dr. King

These are remarks delivered by our COO, Eric Buehrens, this past week at our annual Martin Luther King, Jr. memorial celebration:

It’s a pleasure to be here and to see this community come together in reverence for the memory of Dr. King, his work and legacy.

I hate talking about race in platitudes. It’s perhaps the most difficult, volatile and emotional topic in American social discourse, and so of course we do what we often do when faced with difficult and controversial topics, which is to either not talk about it at all, change the topic, or talk in platitudes.

I’m old enough to remember when Boston was a very different city and when a person of color risked life and limb if they walked on the wrong side of Dorchester Avenue, or got off at the wrong T stop, or as happened to Ted Landsmark, just happened to be walking across City Hall Plaza at the wrong time.

I’m also old enough to remember the heyday of the civil rights movement, the struggles and successes, and the murders of black and white civil rights activists, and then of course the assassination of Dr. King himself.

It would be easy to reflect on those days and then on the man who took office as President of the United States a year ago and deliver a homily on “see how much progress we have made”. And of course we have made progress. As maddening and backward as this great country can be in many, many ways, we change. Too slowly, and often at high cost, but we find a way to have the difficult conversations and we change.

But just last night in this hospital, we had an incident where a group of employees were sitting around at shift change in the locker room, and in the course of chatting and bantering, a white employee made a highly, highly offensive remark to an African American co-worker. Maybe innocently, maybe not with racist intent, but a stupid and thoughtless insult nonetheless.

I was pretty gratified to learn that the supervisor, an old white guy like me, heard about it at home and got in his car and drove in to talk to the employee who was offended as well as the one who made the remark. This supervisor had the presence of mind to know that this was important, and to understand that the only way we change and grow as a community and as a society is to face our history and the legacy of racial division with honesty and a commitment to change. That is this hospital’s commitment to our community and to every one of our employees.

Saying sorry

Natasha Singer writes this interesting article about apology in the health care world in today's New York Times. I'm quoted briefly at the end. Would love your comments.

Transparency? Not here, please.

Our friends at The Health Care Blog have posted a letter from the founder of C-SPAN to Speaker Pelosi asking for televised proceedings of the health care bill conference committee. This has generated lots of comments.

I think this is a bad idea. Maybe this will surprise those of you who know me for pushing transparency. But the world of negotiation requires some privacy.

The C-SPAN fellow confuses transparency of result with transparency of process. Sometimes, the process needs to be held in confidence to build the kind of trust you need to reach an agreement.

Negotiations like this need to be held in private for effective compromises to be reached. For example, part of a negotiation is for each party to discuss how they are going to help the other party persuade his/her colleagues to go along with the negotiated agreement. You can't really talk about such things in public.

If this set of meetings is broadcast, the real negotiations will take place in a quiet room somewhere else on Capitol Hill.

Breast cancer meme on Facebook

I was wandering through my Facebook friends and started to see status bars with colors -- "black", "white," "red." I had no idea what it was about so I posted a query on Twitter and within 20 minutes had tons of replies. A sample: "Women are naming the color of their bras to heighten awareness of breast cancer. Interesting idea.."

Well, it turns out to be somewhat controversial. Here are two articles with lots of comments pro and con. Feel free to post your opinions here or there.

Lean Resolutions

Pat Wardwell, COO of the Greater Boston Manufacturing Partnership suggests ten New Year's resolutions for Lean leaders. The summary:

1. Set aside time each week to actively and openly nurture the Lean journey in your organization;
2. Get out of your office and walk the value stream at least once per week;
3. Resolve to use your eyes and ears more than your vocal chords when on the shop floor;
4. Ask 5 different people who work for you "what can be improved" at least once a week;
5. Participate in an improvement project team meeting, training session or kaizen event at least once per month;
6. Ask to be shown an implemented improvement idea from all areas reporting to you at least once per month;
7. Read at least one new Lean article or book a month;
8. Attend a conference, plant tour or participate in a webinar or podcast on Lean topics once per quarter;
9. Vow to visit at least one external customer or supplier each quarter;
10. Develop your own "Manager's Standardized Work."

Ten top celebrity health stories

I have written before about a site called Celebrity Diagnosis. Devoted to "teachable moments in medicine," it is well written and informative. Dr. Mark Boguski, in our Department of Pathology, is one of the founders and writers. Here's their list of the 10 most important stories from 2009.

J. Smith auction closes tonight

The online auction to benefit the Joseph Smith Community Health Center closes at 8pm tonight. Get your bids in!

Having trouble reading this? Bid on an eye exam and glasses!

Wanna hamburger with your Celtics tickets? Check this!

How about a hot air balloon adventure?

Maybe you are just hungry.

Or, get ready for the Red Sox spring training with this accessory.

Bean Counters -- Part 1

I guess it is time to start a new series, on bean counters. I am fully aware of the need for fiscal responsibility on the part of health care providers and insurance companies, so please don't take what comes as an invitation for profligate spending. But there are times when, in the name of saving money, places lose their moral compass and engage in behavior that is cruel to patients and families and is often wasteful, to boot.

Here's one, with names left off. A long-term patient was sent to us from a rehab hospital belonging to another health care system. After an appropriate stay in our ICU, we sought to send this ventilator-dependent patient back to the facility from which s/he had come. The facility refused, saying that they would not accept the patient because s/he had used up the annual Medicare allotment for in-patient stays. When we inquired further, we learned that they were trying to put pressure on the family to come up with a cash payment to offset this reduction in government payments.

Eventually, we were able to shame the rehab hospital into taking back this patient, but we were required to board the patient in our ICU for an extra six days.

Mastering the Senate

As a student of politics and government, I love the US Senate. Really. Sure it can be incredibly frustrating, but to watch it in action is fascinating. The best description I have found is in Robert Caro's biography of Lyndon Johnson, Master of the Senate. The tradition of unlimited debate and the associated two-thirds vote requirement for cloture gives each senator a chance to include something for his or her favorite constituency, until the magic number of votes is reached.

For a small picture of how it works, check out this article by Robert Pear in the January 3 New York Times about the health care bill. A summary:

Republicans complained of “sweetheart deals,” payoffs and kickbacks. But the Senate majority leader, Harry Reid, Democrat of Nevada, brushed aside the criticism.

“There’s a hundred senators here, and I don’t know if there is a senator that doesn’t have something in this bill that was important to them,” Mr. Reid said. “If they don’t have something in it important to them, then it doesn’t speak well of them. That’s what this legislation is all about. It’s the art of compromise.”

Here's what it has for Nebraska, and here's the new Lousiana Purchase. And here's a more general description. Mr. Reid probably overstates things when he says that all 100 senators have something in the bill. I think it is more like 60.

Snow angels in the outfield

Several of our folks provided first aid services at Fenway Park on New Year's Day for the NHL's Winter Classic hockey match between the Boston Bruins and Philadelphia Flyers. You see them here on the right.

After the game, when medical responsibilities were over, a game of "Truth or Dare" ensued, and Dan and Cyndi ended up making snow angels in center field.

The next day, at the Bruins Legends Classic charity game, BIDMC staff members again showed up at the park, this time to donate their services for the benefit of the Boston Bruins Foundation, Red Sox Foundation and Hockey Fights Cancer.

A new team assembles

This is the first week for staff members from Atrius Health and BIDMC to work side by side in taking care of patients on our medical/surgical floors. Key players in this collaboration are the case managers who help patients and families with transition of care issues and other matters.

Seen here are Marianne Lille, BIDMC RN; Sue Farrell and Karen MacDonald, case managers from Harvard Vanguard Medical Associates; and Ellen Miller, BIDMC case manager.

Meanwhile, the information systems folks from BIDMC and Atrius have done a marvelous job in integrating our electronic medical records systems. Read more about that here on John Halamka's blog.

$340 million = Old School

This article by Haya El Nasser in yesterday's USA Today presents a remarkable view of the old way of marketing and publicity. The Bureau of the Census is going to spend $340 million on a promotional blitz to "promote the benefits of responding to the 10-question Census."

Beyond a 46-foot trailer and 12 13-foot trailers traveling 150,000 miles, $140 million will be spent on TV, radio, print, and outdoor advertising; and there is another $80 million on ads for racial, ethnic, and non-English speakers in 28 languages.

Promoting the census is very important. After all, it is the basis for representation in Congress and other governmental functions. We certainly want full participation.

But this is so old school.

There is not a single mention in this story about using social media for this purpose. So I looked further. I found this e-newsletter for Census partners and also this toolkit, one of several available to organizations that might want to promote the Census. Each toolkit has common elements, like letters, announcements, brochures, calendars, posters, certificates.

Still pretty old school.

Contrast this with the power of the networked intelligence approach discussed below in two posts. Imagine if the Census Bureau engaged in this kind of crowdsourcing to invent ways to reach out to lots of difference segments of the population. And used the reach of Facebook and Twitter and other sites to carry the message. For a lot less money.

The Obama administration virtually invented social-media-based campaigning during the last election. The company that did a lot of that work has since branched out into lots of other exposure and advocacy functions. Maybe they would offer pro bono service to the government to help get people counted. Or even if they charged for it, I bet they could do it for a lot less than $340 million.

“Somebody screwed up big time.’’

The blame game is ubiquitous in Washington, DC. This quote and others floating around exemplify exactly the wrong approach to improving our country's anti-terrorist system.

Let's think through the problem. Tens of thousands of patriotic Americans work in federal agencies trying to protect our shores. They face a threat of unknown dimensions, involving ten of thousands of possible bad guys who want to hurt us.

Statistically, even if our system worked very, very well, one or two terrorists could slip through and do something dastardly. However, we have to admit that the system may not work so well.

When I go through airport security, I am prompted to mix historical metaphors. Our TSA Red Coats employ a Maginot Line against a group of guerrilla fighters who change venues, clothing, and weapons to penetrate our static defense system.

When they break through, we bolt on a new technical solution. Will full body scanners make a difference? Yes, they can see the outlines of people's bodies, but they cannot see what might have been put in body orifices or what is hidden by flaps of fat, or what might have been swallowed. Do we think that a terrorist will worry about being being physically uncomfortable for a few hours as s/he heads to a suicide mission?

I admit that such systems have some deterrent effect, but they can be bypassed. And usually with low-tech approaches.

The problem facing our security services is how to encourage and enable all their loyal employees to act in a cooperative and creative fashion. Fast moving targets like terrorists change their stripes often, but they will leave traces -- digital traces, physical traces, relationship traces (think of that Nigerian father). Our security folks need to feel the freedom to follow those traces and to report them within and among the national agencies. They need a culture that thanks them for following gut instincts and calling out problems and near misses.

I admittedly don't know much about the culture of these agencies, but I can guess that a predominant motivation is CYA. I say this because I know how large organizations work, and it is the very unusual one that rewards people for calling out problems. We see the opposite in hospitals, financial services, and manufacturing. And we see it big time in the government, where the body politic, with quotes like the one above, tends to encourage that kind of motivation.

I have spent a lot of time in these blog pages exploring how to achieve continuous process improvement in a complex organization. I gave the example of Tom Botts at Royal Dutch Shell, who realized that the fault behind two fatalities lay with the leaders of the company, not with the workers who strayed to the wrong part of an oil rig. I summarized, too, the approach of John Toussaint and others in the hospital arena and Paul O'Neill at Alcoa, and forwarded advice from Steven Spear.

Contrast those lessons with what you are hearing in Washington, DC.

I'd like to see Mr. Obama help the agencies get past the blame game that is going on right now and focus on organizational, along with technological, strategies that enhance their ability to ameliorate terrorist threats. He clearly has the leadership ability to do that.

But here's the rub, and it is both a political one and a personal one. The political one is this. He has to persuade our citizens that he is strong-willed enough and competent enough to fight the terrorism that heads our way, but he would also need to persuasively reframe the manner in which he intends to carry this out.

The personal one is this. Our President has never run a complex organization. Does he know how to do it? Does he have advisors who do? I hope so, or we will just see a replay of this blog's headline sometime in a year or two.

Online auction for J. Smith Community Health Center

There's a new online auction to benefit the Joseph M. Smith Community Health Center.

JMSCHC provides high-quality, comprehensive, culturally-competent and affordable primary health care and selected specialty services to families and individuals in Allston, Brighton, Waltham and surrounding communities. All are welcome – children and adults, the insured and uninsured, the employed and unemployed, long- and short-term residents and recently arrived immigrants.

Bids will be accepted until 8pm on January 7. As always, there are great items for yourself or for gifts. Here is a sampling:

Eye exam and glasses from the Joseph Smith Center.
Celtic tickets, along with a Fuddruckers gift certificate (Jan 18).
A trip for two to Washington, DC.
Custom made box by a woodworking instructor from the Eliot School.
A hot air balloon ride for two (almost anywhere in the country!)
Membership at the Equinox Fitness Club.
Caviar.
One dozen brownies from Emily's Brownies.
Private cooking instruction from TaylorMade Meals.
Red Sox memorabilia.
Overnight stay at the Courtyard by Marriott in Cambridge, MA.
Concert tickets for Luciana Souza Trio (Jan 22) and Carolina Chocolate Drops (Jan 23).
Tours of the MSPCA and WGBH.
An interior design consult from Brenda Be.

Please bid often and pass this along to your friends.

Medical wisdom

A note from a friend:

I asked my doctor today, during my annual physical, if I look fat.

His response: "I’ve been married a very long time, and you’ve got another think coming if you think I’m going to tell any woman she looks fat. That includes you."

Auction sneak preview

A new online auction begins tomorrow to benefit the Joseph M. Smith Community Health Center. The auction will run from January 1 to January 7. You can sneak a preview here, but you can't bid until 6am on New Year's Day.

Engage with Grace hits the Top 10

Health Leaders Media lists Engage with Grace as one of 10 phrases that became part of the health care lexicon in 2009. I'm sure our blog rally propelled it up there. It is a lot more useful than most of the other expressions, I say.

What referees do in the off-season

This is for soccer players, parents, fans, and, of course, referees. There are few things more challenging that officiating a game with 22 players running across a field that is larger than 5000 square meters, lasting at least 90 minutes, where your job description is to decide in real time whether a foul is meaningful enough to warrant your interrupting the flow of the game. (Compare this to other games with more umpires on a smaller field, where a foul is always called and then, during the stoppage, a judgment is made as to whether a penalty will be awarded.)

Soccer referees take an initial course to become certified, are regularly assessed during games, and then are required to take an annual recertification course during the off-season. Here's a video clip of a course last weekend. Segments of the class include a written test, followed by discussion of the possible answers. Then the group breaks up into smaller groups to evaluate a particular scenario and report back to the full group. During breaks, you can go to the Soccer Spot table and purchase supplies and equipment for the next season.

Everybody's favorite part, of course, is watching film clips of actual game situations and judging the appropriate call. I have given you some to watch, and you can make the call. They start at minute 2:23 of the video.

I'll give you a hint about one. The scene in clip 3 (minute 2:50) is not a foul. Think about explaining that to the coach of the striped team or to the parents of that young lady lying on the ground.

If you cannot view the video, click here.

Mid-winter beachcombing, bay side

The next day, after the walk on the ocean side, beachcombing continued on the bay side of Cape Cod. This time it was a dolphin who had met its end on the beach.

Mid-winter beachcombing, ocean side

As the surfers took advantage of winter waves at Head of the Meadow Beach, I went beachcombing. Here are some scenes from the ocean side of Cape Cod.

The bird is a northern gannet, with distinctive yellow feathers on its head.

There are long shadows at this time of year at this latitude, even late in the morning.

The next day, I went to the bay side.

Bike4Life anniversary

A note from a fellow rider from last year's charity bike ride in India:

Happy Anniversary to all....how time flies....it's been a year since we first put foot to pedal in Mumbai ! What wonderful memories!

Best wishes for 2010.

This year's event is a hike in Uganda. Sorry to miss it.

Prints in the snow

Deer prints but no moose prints at Mass Audubon's Moose Hill Widlife Sanctuary.

Have I got a guy for you!

Very funny status update on Facebook from my Indian friend and comedienne, Dhaya:

Stay tuned for craziness. Parents arrive tomorrow. They are bringing "The Mister". After a moment of potential arranged marriage panic, I realized they were referring to a recently acquired humidifier they want to give me. Mist away Mister!

First, feed the residents

Our Chief of Medicine, Mark Zeidel, and his wife, Dr. Susan Freedman, have a tradition of holding Christmas morning breakfast with the residents on duty at the hospital.

On the east side of the campus, the spread consisted of bialies, bagels, and smoked salmon from Kupel's Bakery in Brookline. Shamshad Zahoor, from Environmental Services, jumped in unasked to help clean up the table. Mark then made the rounds telling people on each floor that breakfast awaited. Not surprisingly, they responded.

If you cannot view the video, click here.



Meanwhile, on the west side, a crew had begun to make pancakes for their colleagues. Residents Kelly Bodio and Stephanie Mueller called in reinforcements, Stephanie's husband Matt Ledoux, to keep up with the demand. Violet, dressed for the season, patiently awaited her portion.

If you cannot view the video, click here.

Christmas Dinner with Helen

Helen, seen here, is 97. Get her started on how to make filo dough, or any other topic, and you are in for a story. Her specialties tonight included pastitsio (Greek lasagna) and baklava. Her daughter Joan is no cooking slouch either, with a lobster shepherd's pie based on an old recipe from The Elms Inn, in Ridgefield, CT. Other guests brought the salad with pine nuts and the kumquat tarts. An excellent feast!

Santa arrives early to Boston

Santa, accompanied by some kind of reindeer, was seen this afternoon on Commonwealth Avenue. This is the real thing: Listen closely when about 53 seconds have passed and you will clearly hear his "Ho, Ho, Ho, Ho!"

If you cannot see this video, click here.

Birth of Twitter

Philip Kaplan (aka @pud) posts this old article from 2006 about the introduction of Twitter. Thanks to Matthew Holt (@boltyboy), author of The Health Care Blog, for retweeting.

The article was wrong about one thing, perhaps reflecting a social-media induced change in social morays with regard to privacy:

There is also a privacy issue with Twttr. Every user has a public page that shows all of their messages. Messages from that person’s extended network are also public. I imagine most users are not going to want to have all of their Twttr messages published on a public website.

Holiday cookies arrive, too

I had just about digested the gelato when these cookies arrived today from a friend. His note said, "The tin is filled with handmade cookies made by an artist friend of mine in P'town. This is a reward for all your biking and exercise, so enjoy!"

The baker is Frank Vasello, who runs a place called Relish.

So, do you think the cookies will last long enough to share with our nurses tomorrow?

Gelato for the holidays

Continuing our non-health care holiday theme, it's time to focus on food. I have lost track of the holiday parties during these last two weeks -- seemingly one for each department in the hospital, not to mention the various affairs around town. All these represent a difficult obligation for us CEOs. But with practice, you adapt.

In a non-institutional vein, I take pleasure in reporting on an intimate dessert party last night at the home of Eduardo Kreindel, Gelato Master of Giovanna Gelato. Eduardo gave up a career in architecture to learn authentic Italian procedures for making gelato and sorbet. He grew up in Argentina, which has a huge Italian population, and he is now fulfilling a dream designing and producing lots of flavors.

Here is a picture of Eduardo in his kitchen, where he explained the equipment and ingredients he uses. The cookies are not part of that. They are an Argentinian treat called "rumbas," which go very well with gelato.

Eduardo often conducts tastings at local grocery stores. Bostonians and Rhode Islanders can find samples next week at the Harvest Coop in Jamaica Plain on December 28 and the East Coast Market in Providence on December 29. Click on the photo to get details of the tasting list! ("DDL" = dulce de leche.)

Longwood dashes: The full story

Professor Peter Furth, transportation systems engineer from Northeastern University, provides a full technical explanation for the dashes on Longwood Avenue in a comment below.

This Old House in Roxbury

Easing into the holiday week, a change in topics from health care. One of my favorite shows on television is This Old House, and in that I am joined by lots of people who have watched the show for 30 years.

My administrative assistant somehow wrangled a way for my wife, my brother-in-law, and me to visit the current TOH site in Roxbury, a neighborhood of Boston. We were hosted by VP for TV Operations Michael Burton and welcomed by developer David Lopes. Seen here flanking the family members are Senior Series Producer Deb Hood and director David Vos. The renowned Norm Abrams is in the middle.

We had a chance to see the filming of a short segment regarding the installation of a mantle and an old-style cast iron front piece that would be used for a coal-burning fireplace (in this case an ornamental one only). I prepared this short video to give you a sense of the logistics involved in what will be just a short segment. I am sure this doesn't compare to the camera work of TOH cameraman Dino D'Onofrio! You can compare this to the final production when the show is aired in late January.

If you cannot see the video, please click here.

Forming bonds between Atrius Health and BIDMC

Last week, I sent this staff email following up on our earlier announcement about the new clinical partnership between Atrius Health and BIDMC. It gives you a sense of how we are preparing for this joint venture, but also provides the broader context. Gene Lindsey's comment holds even more power in light of the direction of recent legislative activity in Washington, DC.

Dear BIDMC,

As you may have read a few weeks ago, Atrius Health and BIDMC have entered into a new patient care partnership. Starting January 4, patients from the Harvard Vanguard Kenmore, Copley, and Post Office Square Centers will be coming here for emergency care and tertiary care. We have had teams from both organizations working for months on the logistics and planning for this, and we are in good shape to proceed. (For example, read John Halamka's blog for details of some of the items involved in the IT arena.)

We had a welcoming reception last night in the Shapiro lobby, and it was a great chance for clinicians, administrators, and board members from both institutions to get together and to celebrate the work that has gotten us this far. It was striking how many of these folks already had relationships, some dating back to their training days.

Over the coming days and weeks, you will see some new people from Atrius on our floors as this rolls out, especially hospitalists and case managers, but also people in specialty areas. I know you will make them feel welcome. And I am absolutely confident that patients from Atrius will see the same level of care we strive for all the time, the kind of care we would want a member of our own family to receive. But, we want this to be more:

Gene Lindsey, the Atrius CEO, and I have met with each other's senior management team, and we have a simple and a hard message for both organizations. We aim for this partnership to set a new standard for patient care in the region. As a tertiary center, we plan to be exceptionally responsive to the primary care-centered model of care exemplified by Atrius (and also enhancing how we do so with our own superb primary care practices at Healthcare Associates, APG, and the community health centers). Together, we look forward to setting higher bars in safety and quality, aided by transparency. We will also work together using the philosophy, measures, and techniques of the Lean process to improve the work environment for all.

(In that regard, I am officially declaring the end of BIDMC SPIRIT, which was an inward-looking approach to process improvement. SPIRIT was based on Lean principles, and we learned a lot from it. But we now start to enter a different phase of process improvement, one based on JOINT action with our clinical partners, starting first with Atrius. In the last few months, Alice Lee and her team have been teaching us more about Lean. Many of you have participated in rapid improvement events and other training. That will continue, but, in Atrius, we have a partner who has been engaged in similar training, and we aim to learn from one another and apply this philosophy to our joint operations.)

More broadly, Gene recently addressed aspects of our mutual goal in a newsletter to his staff. He noted:

“How do we reform healthcare?” That is a big tough question. This week I heard Don Berwick from the Institute for Healthcare Improvement point out that the question in Washington has shifted toward, “How do we reform health insurance?” By changing the question, the President is indicating his understanding of the limits of legislation. He understands that politicians can change the way people access care, or how care is financed, but they cannot change how care is delivered and legislators will always find it difficult to create quality.

Politicians can increase the funding of health care, but a reform of the practice of healthcare is our domain. Only we, the community of practice, can improve quality and change the systems of care in such a way as to improve the experience of care for individuals, improve the health of the nation and end the extortion of much needed funds from the other categories of our collective societal experience. Only we, the good people who provide the care, can create the solutions that end the fragmented, mediocre and unsafe experience of care that is the experience of so many of our citizens.

We control the experience of health care for our patients far more than we might want to admit. Since so often they do exactly what we tell them to do when we suggest a test, or a surgery, we need to be very sure that we try to see the world as they do as we give them our counsel. Being patient-centered is the hardest task we have because for many of us it means trying very hard to convince patients that they should do what we think is best.

What gets done is usually what we order. The options that most patients have are the ones that we offer. Their experience of care is the experience we provide. If we care about our patients, the first question that must be answered is “What do they really really want?”

Note that the focus here is what patients really want. They do not want MRIs, CT scans, or procedures. They want to live happy and healthy lives. They want us to listen to them and understand their needs. This was put so clearly by Dr. Amy Ship, when she recently accepted the Compassionate Caregiver Award from the Schwartz Center. Please take 8 minutes to watch and listen to Amy's speech, here.

Gene and I are excited about the Atrius-BIDMC partnership because we think it provides a vehicle for learning how to do this and for spreading the word to our community. We invite you to join this adventure and be active participants.

Sincerely,

Paul

Longwood dashes: Mystery solved!

Michael Sandman posts an answer to the question: What are those dashes on Longwood Avenue? Find his comment here. Thanks, Michael!

Good news from Bowdoin Street

Many thanks to those of you who participated in my recent auction to benefit the Bowdoin Street Health Center. Remember that we were trying to raise money for an ultrasound machine, so pregnant women could have ultrasounds in their neighborhood setting rather than having to spend time and money to travel to BIDMC for this service.

I received good news today from Adela Margules, who heads the center:

I wanted to let you know that I received notice today that we have received a grant from the MA Health and Educational Facilities Authority to help purchase an ultrasound machine for our ob/gyn practice. (HEFA has a competitive grants program each year for health centers, and we were one of 14 funded.) This grant award, coupled with the funds raised through the Red Sox raffle* and the auction on your blog, allows us to move forward and purchase the machine.

* Note: We raffle off tickets to the baseball playoff games.

Good work!

Thanks to the MBTA and DCR (our transit and parks agencies, respectively) for beautifully clearing stairways after the snowstorm in anticipation of this morning's commute.

On accountability

A "benefit" of being a CEO is that publishers send you copies of all the new management books, presumably so you will recommend them to your colleagues. Most are not very good. If you are lucky, a book will have one good idea that is stated in the introduction or first chapter. Then they fill the book with poorly edited repeats of the same concept. Often, they use a large font so the book will have more bulk.

This week's book is by Quint Studer and is called Straight A Leadership: Alignment, Action, and Accountability. (Fire Starter Publishing, Gulf Breeze, FL) I skipped the first two topics but found the chapter on the third. I have been thinking a lot about accountability and was curious to see what he said. The crux of his case was, "What we find is that most organizations fully grasp the importance of accountability, and they put guidelines into place to hold people accountable to -- but somehow, they fall short of closing the loop."

Over the past few months, I have come to a conclusion about accountability that is at variance with most management guidance on the subject. That guidance suggests, as in Studer's book, that a successful organization depends on holding people accountable to do good quality work in support of corporate objectives. I'll assert instead that it is not only impossible to hold people accountable in an organization, but trying to do so is a misallocation of managerial attention.

You say, "What? How will you make sure people are performing up to spec if you don't hold them accountable?"

I view the job quite differently. I view the leader's job as helping to create an environment in which people are so comfortable with their role in the organization, and are given the right tools for doing their job, that they hold themselves accountable. After all, most people want to do well in their job and want to do good in fulfilling the values of the enterprise. Why not trust in their inherent desire to be successful personally and collectively? Instead of focusing on measuring their performance against static metrics, why not create a setting in which they use their native intelligence, creativity, and enthusiasm to solve problems in an inevitably changing environment? Then, spend your time praising them and making sure they get credit. (See John Toussaint's and Paul O'Neill's thoughts here for variations on this theme.)

People who have heard my speeches know that I often make analogies between running a hospital and coaching a girls soccer team. (Regular readers know this all too well!) Your purpose as coach is not to criticize by pointing out errors and areas of deficiency. The players (workers) already know when they have made a mistake or are not performing up to par. Your task, instead, is to give them the chance to learn tools that enable them to meet a high standard, both individually and as a team.

I'll stop here for now on this topic and take your comments on my premise and on how it feels to work in your organization. Do you know what your role is, individually and with respect to the institution's objective and values? Are you respected and treated with dignity, regardless of your position in the organization? Are you given the tools you need to do the job? Are you recognized for what you have done?

I'll be the first to admit that our hospital leadership team still falls short in many respects. We are trying hard, but we are neophytes in this new mode of management. We need to learn to listen better so that we can be better coaches. Our goal, though, is to make it possible for each person to answer these four questions with a resounding "Yes." If we can do that, there will be no need to hold people accountable.

Killer app! Texting while driving

Yvonne Abraham's column in today's Boston Globe is a great reminder. An excerpt:

A lot of us are otherwise pretty sensible - even risk-averse - people. So what happens to us when we get behind the wheel?

I put that question to Dan Ariely, a behavioral economist at Duke University, and the author of a book called “Predictably Irrational.’’ Last semester, he asked the 200 students in his class if they ever texted while driving. All but three raised their hands - and one of those three is blind.

But this is an even better one. It is a public service announcement to being shown in the UK to schoolkids. Warning: It is VERY graphic.

Please show it to your kids. Please watch it yourself.

Now, try this out. Look in your rear view mirror during an average commute and see how many people driving behind you are texting. You might be surprised.

Snow chickens

My young neighbor Miriam is raising chickens in her backyard. With the blizzard arriving, her dad Jason had to do some emergency reinforcements of the chicken pen. I paid a visit this morning and picked up these images of the farming life going on just down the street in our suburban community.

If you cannot see the embedded version of the video here, you can follow this link to view it on You Tube.



You can also learn more at Miriam's blog, here.

The egg, by the way, was delicious.

Dashes in Brookline

Regular readers know of my odd fixation about infrastructure. I can't help it. I just notice things about the streets, bridges, pipes and power line and wonder how and why.

Here's the latest, and I am hoping someone can explain. The Town of Brookline recently repaved Longwood Avenue. Then they painted these dashes on the road. I can't figure out what they are for. They clearly do not delimit a bike lane. Are they meant to provide a guide to drivers as to the appropriate position in this lane? If so, they don't quite work, as seen in the video. If you cannot view this embedded video here, you can use this link to YouTube.

Any theories from my readers, serious or humorous?

I think you're a hypocrite

I'll say one thing for the SEIU. It is consistent in its ability to be inappropriate to the situation and to resort to personal disparagement when it fails to persuade.

The setting: An annual Christmas party at which a group of us former members of the Boston Symphony's Tanglewood Festival Chorus get together with other friends and relatives to eat, drink, and sing Christmas carols.

A man introduces himself as a neighbor who works for the SEIU. We start with a little repartee about Blue Mass Group, where he notes that I was taking some hits for recent comments. I say how I love BMG as a democratic place where anybody can participate. He looks at me oddly.

He then sidles into the topic of, "When are you going to let your employees form a union?" I respond with, "When are you going to let them have elections with debates?" And the race to the bottom is on. Pretty quickly, I say, "Look, I'm here for a party with friends, not to discuss this stuff."

He says, "I think you're a hypocrite."

Let's see. We have known each other for about 90 seconds. We have quickly figured out that we are not going to persuade each other on the merits of the issue. So he resorts to a character slur.

I'll admit that my response at that point consisted of a rude, physically impossible, autoerotic suggestion. (I then apologized to my host for swearing at one of his guests.)

The rest of the evening was entirely pleasant, with lots of joyful singing. This fellow didn't join in.

Peer reviewed? Not quite . . .

An email from Nebraska to our research librarians. I love this! The blog takes precedence over medical journals.

From:
Sent: Thursday, December 17, 2009 3:33 AM
To: Research,Medical
Subject: iv blood draw study

In our E/R, we routinely draw blood for lab work off of IV starts. We do this to speed results and to spare the patient an unnecessary stick.

Our administration recently asked us to write a policy to define our procedure and best practices. In an extensive literature search, I came across a piece about this very topic in Paul Levy's "Running a Hospital" Blog. ("Fixing bad blood tests", dated 11/5/2008)

We will probably do an internal study similar to that described in the blog. Any information about the procedures or data from your study would be helpful to me. If you formulated a formal policy as a result of the study, I would very much like to get a copy.

Can you help me, or refer me to the people at your hospital who conducted the study?

Any assistance you can give me would be greatly appreciated.

Thanks,
--
[named omitted] BA RN EMT-P CEN
Emergency Department
Saint Elizabeth Regional Medical Center
Lincoln, NE

Part way to Lean in the SICU

Here is an in-progress report from Jean Campbell, nurse manager of our surgical intensive care unit, to all of the people in those units on the status of her Lean team's rapid improvement event in the SICU supply rooms.

Hi Team,

As you could see, there was a lot of activity in the clean supply room this week. The Lean team from the President’s Office, Distribution plus Anna (PCS), Sabrina (Health Care Quality), Martha (11 Riesman), Tim (MICU), (Fin4), and Kristin Russell worked with the SICU team to redesign the clean supply room for better flow.

We received training on key Lean principles and Smart Placement which taught us that spending time searching and fetching items means less time spent on real work – time with our patients. Even when we can easily find an item, does it make sense for us to put items out of reach, i.e. too high or too low? Why not imitate the supermarkets that place frequently purchased items, like bread, at eye level!

Lean calls these non-value added steps, “waste”. We spent the week removing as much waste out of the clean supply room process as possible. A few weeks ago we counted the par stock right after it was fully stocked, then counted again the next day before it was restocked. This gave us a single day usage quantity and was used to determine the amount needed on your supply room carts (called the par number). Our aim was approximately a 3-day supply (for weekends). We realized we had more stock than we needed in some cases and not enough in other cases based on this count, so we removed all excess stock as well as added additional stock where needed.

Once we regained additional space, we organized the stock logically by function and for flow. For example, you will see we now have carts for IV/Lab/Syringes/CRRT; GI/GU/Wound Care, ADLs, Procedures, and Respiratory. We then placed the most frequently used items at eye level to reduce bending and reaching and items used together are placed together. For example, you'll find benzoin on the respiratory cart because it's used when securing ET tubes. Most items are now in bins and the bin sizes indicate the amount of stock needed. The bins have 3 labels: the “common name or AKA (also known as) label” on the front of the bin – what most of you call the item, the “picture of the item label” on the bottom of the bin to tell you when that bin is empty what belongs there, and finally the “reorder label” also on the bottom of the bin that tells you the J number, cost & the ordering amount so when you are out of an item, you have the information needed when calling distribution. On the front of the shelves are the bar codes that distribution uses to facilitate reordering.

Some examples of changes:
Procedure supplies that were formerly housed in cabinets in front of the nurses' station are now on the procedure cart (neuro on bottom shelf);
Oxygen delivery items now have pictures to clearly show which mask is in each bin so you don't have to search very long;
Wound care supplies were moved from the small carts in the middle of the unit to the supply carts. An added benefit is that it clears some of the corridor space - helping us meet CMS fire/safety guidelines;
By placing procedure supplies and wound care supplies on the carts in the back, the UCo and RN don't need to worry as much about inventory and restocking. The exceptions will be items with pink AKA labels. Those must be special ordered; they don't come from distribution;
IV Fluids with KCL have a highlighted AKA label to make it easier for you to find them;
Med rooms and kitchens have also been reorganized.

We'll be establishing a location for distribution pick-up and drop-off - more to come on this. It will be an area where distribution can place items that are special requests and we can place items that need to be returned. You'll have an alphabetical index by Friday. Names of the carts are on the wall above them, so that will help you figure out where to start looking. It's meant to be intuitive.

Please let us know if there are items that are running low; this will be especially important on the weekends. We'll be doing regular audits to help us identify items that may be over or understocked and adjusting levels accordingly.

Help us help YOU! There's a piece of paper inside the supply rooms where you can provide feedback. Please include the date and your name so we can follow up if we don't understand and to let you know what the Lean team decides re: suggestions.We're also soliciting ideas with what to do with drawers/cabinets cleared through this event. We're investigating the possibility of placing monitors on shelves and using drawers/cabinets to sort cables.

Any other brilliant ideas out there?

Sustaining the gains: Lean taught us that this is a continuous improvement process so please give us your feedback and we will continue to improve. All of us own this process and keeping the Clean Supply room neat and tidy depends on all of us.

Thanks to Anna Bratslavskaya, Barbara Buckley, Joanna Aseltine, Kelly Farren, Kristina Minahan, Marissa Kaslow, Mary Lavieri, Pat Sorge, Raysa Acosta, Ryan Erskine, Sabrina Cannistraro, Samantha Ruokis, Sophia Shoot, Sue Emerson-Nash, Suzanne Joyner, Tad Mendes, Tim Teves.

Amtrak: Too quick or too slow?

For trips between Boston and New York, there is nothing like the Amtrak Acela Express. It is convenient to downtown in both cities, comfortable, reliable, and quick.

Well, maybe too quick.

Several days ago, I posted a comment on Universal Hub and a helpful person replied with the website for Amtrak customer relations. So, I sent in the following note:

I am worried about the driver of the 4pm NYC-Boston Acela train exceeding the speed limit on the segment between Providence and Rte 128. It is a running joke among the porters that he is always in a hurry to get home. I have now seen this happen several times on that train. Last week, when I took it (Dec 1), you could actually smell the asbestos in the back car as he had to jam on the brakes before going over one of the bridges. I hope someone looks into this before the NTSB has to do so as part of an accident investigation.

Here was the response:

Thank you for contacting us. We have forwarded your e-mail to our Customer Relations Department. They will contact you as soon as possible in the order that the e-mail was received. Due to higher than normal volume, please allow up to 4 weeks for a response.

Four weeks = 28 trains. Thousands of passengers. A potential safety hazard.

Four weeks?

Too quick, or too slow?

What more could I pray for for a loved one?

From the spouse of a patient. This hit home to me in that my mother died several years ago of a similar injury while on this anticoagulant. Although we didn't have a harpist while we awaited her death at New York-Presbyterian, we had a similar experience with marvelously caring staff. We, too, were grateful.

C's fall early in the morning was unwitnessed so I cannot say whether a dizzy spell or loss of balance caused it. He hit his head very hard against a sheetrock wall and the Coumadin regime proceeded silently to steal him away from me. The final 24 hours arrived with shocking suddenness. C was restless in bed and within fifteen minutes his eyes closed and he was unresponsive. The emergency crew arrived minutes after. From home to [the local hospital]; then by helicopter to Beth Israel Deaconess, arriving there around 9:30. I had to crawl my way through Boston commuter traffic and arrived at C's bedside at 11:00am. From that point forward the end was known, and I kept a vigil with my beloved until his passing around 2:45am the next morning.

The staff at Beth Israel Deaconess were wonderful. Every possible comfort was provided for C and me, including a harpist in our private sanctuary/room. She is a social worker and very gifted on the Celtic harp. C loved good music and after a half hour or so of beautiful selections C's breathing settled into a more accepting rhythm. Given the givers, it became a fairly stressfree death. What more could I pray for for a loved one?

A short video of our harpist follows. If you cannot view the embedded video here, you can follow this link to see it on YouTube.

The blue glove medical record

From a close friend, about an experience in another hospital:

So, Mom is taken to the ED over the weekend for treatment of an infection. On one side of the room is the computer terminal for EMR access, with ever-changing screen savers touting the benefits of using the electronic record: safer, faster, more accurate, easier for the provider, better for the patient, etc. On the other side of the room, connected to Mom, is the electronic vital sign monitor: heart rate, blood pressure, oxygen, etc.

Half a dozen times, the tech came in to record her vitals. The procedure is: Put on one blue latex glove, take a Sharpie, write down the vital signs on the back of the gloved hand, leave the room, repeat a few hours later.

Does the blue glove go into the paper record? I dunno, but I guess the fancy EMR and the fancy electronic monitor don't talk to each other, because we have to rely on double manual transcription to record vital signs.

By the way, they use the same procedure up on the floor. Plenty of opportunity for improvement in health care.

TFC @ BIDMC

In addition to the Marshfield High School performers, we were fortunate also to have a visit this week from members of the Tanglewood Festival Chorus, who performed some holiday songs in one of our public spaces. Here is an excerpt of an unusual version of the The Twelve Days of Christmas. While listening, try to catch a glimpse of my wife Barbara, a veteran chorus member, who arranged for the performance to be held for the benefit of our patients and staff. (If you cannot view the embedded video here, follow this link to see it on YouTube.)

Listening to the staff

Many people around the country followed the dramatic story last March when our employees generously gave up salary increases and benefits to help save hundreds of jobs of their fellow workers. A key part of that process was that staff members had multiple paths to contact me with suggestions and reactions to various proposals. Thousands of people did that, and it was very helpful as I made decisions on these matters.

Several months have passed, and our financial situation has improved. We hope to be close to the time when we might restore salary increases and/or benefits. I needed to know which of those items would be most important to our workers, to help set the priorities for restoring them. It was time to check in again.

Two emails follow. I sent out the first just before Thanksgiving and the second one yesterday.

As I have talked about all this with people around the country, many have expressed surprise that, as CEO, I would "take the risk" of consulting our staff on these matters. For some, this is considered an odd ceding of executive authority. My view is just the contrary. If a CEO cannot rely on the judgment and opinions of those doing the work in an organization to help him/her make the final decisions on matters affecting those very people, what does it say about the level of mutual respect in that institution?

Here's the first email:

Dear BIDMC,

As Thanksgiving approaches, it is good to remember that we are blessed to work in a place devoted to healing and characterized by mutual support. Our collective decision in March to adopt a different approach to balance our budget to avoid what might have been hundreds of layoffs is consistent with our deeply held values. It brought national and regional acclaim to our hospital and to those of you who work here. I am proud of your participation in making those decisions during that difficult time.

But that does not mean everything is easy. Here is a representative note from Carol:

I am writing you to express my concerns after reading the Annual Operating Plan where it says that we want to "Create and implement programs to recruit and retain an outstanding and diverse workforce including competitive benefits and compensation programs, career development programs to prepare employees for jobs in areas facing skills shortages, and leadership development programs to enhance the strength and capabilities of our managers."

My concern is that it may become harder to recruit and retain “outstanding people” with the loss of benefits. Everyday we all go to the grocery store, the gas station and pharmacy and pay more for the things that we need, not want but need. I would appreciate any feedback in regards to the time frame of reinstituting some our lost benefits.

In talking to my colleagues I find that I am not alone in these concerns. At this point it seems that the surrounding hospitals are better compensated then we are. The difference between them and us is that we have a dedicated and loyal staff.

Here was my short answer, but I am writing to give you a longer one and, once again, to ask your advice:

Thank you, Carol. We are working to restore the benefits as soon as possible. More to come on that front. I do not believe our compensation is out of line with other hospitals, but I do know that we laid off many fewer people than those hospitals because of the sacrifices that everyone here participated in. That was the choice before us, for which we and the staff here received tremendous credit. If I were to make the choice again, I would do the same thing.

So, what's going on and what are our plans?

What's going on is that we ended the fiscal year on September 30 with a $10 million operating margin for the year, much better than the $20+ million loss we were projecting in March. Frankly, through the spring and summer we were just on a pace to break even, but then we had a few lucky one-time events in September (like a commercial dispute that went our way) that were pleasant surprises.

For FY2010, we are budgeting for a 2% operating margin, or about $30 million, but that is based on retaining the same sacrifices in salary and benefits that we discussed back in March. That margin is less than we would like, in terms of our investment needs in physical plant and equipment, but we can get by.

Here's the issue we face right now. The economy still stinks, with a 10% unemployment rate, reduced consumer spending, and the like. It is really hard to know how we will fare in that kind of environment. Is there really an economic recovery about to happen, or will the region slide further down? Will the governor be forced to cut Medicaid payments again? What will Congress do with Medicare as part of health care reform?

So, how do we answer Carol's question? When should we go back to business as usual and restore salary and benefit cuts?

We have an agreement with our Board that we can start to restore those cuts if our operating results for the year show a consistent pattern that is better than our budget. A consistent pattern is something we would see in mid-January, based on our operating results through December.

Let's assume the best! In preparation for what might be, I'd like your help to plan our actions.

The question is this. If and when we are able to start to phase in the things we took away, which would you like to get back first?

Restoration of ET time
Restoration of the 401(k) match
Restoration of the annual merit salary increases

...You can write me directly, but also please respond on this survey instrument so we can get the overall view from lots of people. Click here between now and Monday at 5pm: [link omitted]. I'll post the results on our portal. Your opinions will be one input into my decision on the matter.

I will let you know that decision, and I will also provide you with the specific financial metrics that would trigger the decided-upon restoration of benefits and/or salary increases. I will keep you informed as the weeks go by of our progress towards those metrics, and you will know -- as soon as I do -- when things will be restored. That seems most fair to me: You have a right to know as much as I do on this matter, and you have my commitment that everything will be presented to you in a clear and open way.

Best wishes for a happy holiday for you and your family.

Sincerely,

Paul

Here's the follow-up email:

Dear BIDMC,

I hope you and your family had a happy and safe Thanksgiving holiday. Back before the holiday, I asked you to help me decide which of the salary and benefits you would like to have restored if and when the hospital's financial picture rebounds. Remember that back in March, I told you not to expect any restoration through all of FY 2010, so the fact that I am even bringing this up now should be viewed as a relatively positive sign.

Almost 2000 of you responded (a third of those working here), and results were overwhelming:
Restore annual salary increase: 65%
Restore 401(k) match: 21%
Restore full ET accruals: 14%

Thanks for your help in setting our priorities: So that will be our goal, to restart annual salary increases. Here's how I would like it to work. We will look at our financial results late in January and if we are at or better than budget, we will start up raises again. We would do that effective April 1, the date raises stopped last year. That way, it would be much easier to keep track of everything, and everybody would have faced exactly the same period (one year) without an increase. The amount of increase would be 3% if everything goes according to plan, and you would receive it on your regular anniversary date, thereby keeping everyone on par with those who received a 3% increase in the October through March period last year. Managers and supervisors who had their raises revoked as of April 1, 2009 would have them restored effective April 1, 2010.

Regardless of what happens for the larger group of staff, employees in grades 1-4, who received their 3% raise throughout last year, will continue to receive the additional 2% raise announced earlier this year, consistent with our desire to protect those staff members from any gap in salary increases over this time period.

Where are we right now, relative to budget? Well, October was a strong month, and November was a slow month, and December thus far seems about on target. I am cautiously optimistic, but we live in uncertain times, and I am not guaranteeing that we will be able to do this. I will keep you informed over the coming weeks about whether we are able to meet our goal of restoring increases as of April 1st. This does not mean we are giving up on restoring other benefits, but my hope is to start with the salary increases.

I wish everyone an enjoyable holiday season and prosperous New Year.

Sincerely,

Paul

Marshfield High School @ BIDMC

Students from Marshfield High School visited BIDMC yesterday for brief holiday concerts in several of our public spaces. Thanks to them for taking the time and gracing our halls! (If you cannot view the embedded video here, follow this link to YouTube.)

Harnessing the wisdom of the crowd

This follows up on the post below about using networked intelligence to solve complex problems. Our Chief Academic Officer, Vikas Sukhatme, told me about two websites based on this concept.

One is called Innocentive and the other is called Topcoder, the first for inventions of a general nature, the second for software solutions. The idea of formally using the wisdom of the crowd, stimulated by prize money, to solve problems is fascinating and powerful.

Pay your fare! Or else! Unless you can't.

Back on October 29, I told you the story of the uninformative signage on the MBTA's Green Line and also mentioned the stern warnings about fare evasion presented to the public on those signs. Well, now I have my new Flip videocam and have documented that warning. But stay tuned till after the warning. Then you get a view of the fare box in my train. The dollar bill payment slot is not functioning, so the driver has inserted a dollar bill into the slot to prevent people from using it.

And who says MTBA riders are not honest? Even as the train pulls away several stops later, you can catch a glimpse of the dollar bill hanging out of the machine, having been left in place by dozens of ethical riders. (If you cannot view the embedded video here, you can follow this link to see it on YouTube.)