Talking about transparency in Copenhagen

I am in Copenhagen to speak at a conference sponsored by Dagens Medicin, a newspaper for professionals and decisions makers in the medical and health care sector. According to my host, Kristian Lund, editor-in-chief, "The overall purpose of the conference is to inspire decision makers in Danish health care to improve leadership by using quality data. We are especially interested in hearing about your way of working with data and patient safety." As an outside guest, I am joined in a related topic by Johan Kips, Director of the UZ Leuven, the largest hospital in Belgium (2000 beds), who is here to address the attendees on the use of data to direct quality improvement. (Kristian -- another blogger! -- and Johan are in the accompanying photo.)

This is a fascinating topic to discuss in this venue, as the Danish health care system is quite good, but it does face interesting challenges. Here is a part of a summary from the WHO European Observatory on Health Systems and Policies.

Like the other Scandinavian countries, Denmark is characterized by a strong welfare state tradition, with universal coverage including diagnostic and treatment services, is free for all citizens except for certain services such as dental care, physiotherapy and medicine requiring patient co-payment. Equity and solidarity are important underlying values in the system, and surveys show a persistently high level of patient satisfaction. The system has a relatively good track record in terms of controlling expenditure and introducing organizational and management changes, such as transition to ambulatory care, and introduction of activity-based payment.

. . . More generally, the Danish system, like many other European health systems, faces challenges of guaranteeing access and quality while at the same time keeping costs under control. An ageing population and rising expectations regarding service are contributing factors in challenging the sustainability of the public health system.

This gives part of the context for a point Kristian wrote in my letter of invitation, "You will have a unique opportunity to influence Danish health care management in a rare situation since the government is ready to invest more than 5 billion Euro in new hospitals. Denmark is also about to reform the allocation of specialities and we are in the process of re-evaluating the education of specialists."

Here is a bit more background. Denmark currently spends about 8% of its GDP on health care (not counting the educational subsidy to those studying to be doctors and nurses.) There is an expectation that this will be quickly rising, to over 10%, within just a few years. There is pressure on the government to spend more to enhance and expand services. For example, while treatment of heart disease is excellent, cancer care is considered less than adequate by US standards, with less use of imaging and chemotherapy; and there is a desire to upgrade it. There is also a huge building program going on -- eight new hospitals are under construction. Too many hospitals are engaged in high-level procedures, and there is a need to consolidate those, but there is reluctance from those currently engaged in those arenas. I had heard previously that the primary care system was very good, with quick care and integrated electronic medical records. The former is true. It is easy to get an appointment quickly, and the care is excellent. The latter is not. Integrated EMRs are not present at the primary care level, although they are at the hospitals. Finally, there is budget pressure: When the end of the fiscal year arrives and a hospital is behind on its budget, it "manages by congestion," delaying procedures until the next year. A colleague here jokingly said, "I don't know why people from abroad come to visit, thinking our system is wonderful. We think it is awful."

I have talked on several occasions about the convergence of issues and health care design between the US and the nationalized systems of other developed countries. Denmark seems to provide another example of this. As my hosts indicated, we face the same demographic challenges and the same desire on the part of the public for the latest and best in health care technology. It is always helpful to share stories and ideas in pursuit of improved care for all.

The Jubilee Project helps on Hep B

Here's the latest video from the Jubilee Project. As always, when you view it, a donation will be made to a charity. Co-founder Eric Lu sent me a message and press release:

We are happy to announce that The Jubilee Project has released its first music video, "Why I Sing," by Rooftop Pursuit. This video is used to help raise awareness and funds for Hep B Free, an organization dedicated to tackling the problems of hepatitis B. Every view raises 2 cents for Hep B Free, and anyone can choose to become a sponsor by pledging to donate a penny per view. Sponsors may also set a cap if they'd like.

Over half of those infected with chronic hepatitis B in the US are Asian Americans and Pacific Islanders, and one in ten Asian Americans and Pacific Islanders have the disease. It is the only disease where you will find such a huge racial disparity.

"We wanted to be involved in raising awareness for hepatitis B because of the prominence of the disease in the API community and among our own friends and families," said Eddie Lee, co-founder of The Jubilee Project. "We have to end hepatitis B transmission today, and the first step is awareness."

Also known as the "Silent Killer," Hep B currently affects 1 in 10 Asian Pacific Islanders, compared to 1 in 1,000 of the general public, and is the primary cause of liver cancer. Despite this, Hep B can be prevented with by vaccine, and treatments prevent liver cancer.

The Jubilee Project is also seeking sponsors to support this effort. Sponsors offer one penny per view, but can cap how much they ultimately choose to donate, as low as $50.

Funds will be used for national Hep B Free efforts to end Hep B and liver cancer including public awareness, clinician education, screening, vaccination and linkage to care.

"Hep B Free has a multi platform approach to outreach," says Hep B Free co-founder Ted Fang, director of the AsianWeek Foundation. "Not only are we on the ground with person to person connections, but we are also spreading the word and raising money using social media, events, partnerships, foundations and business partners."

For more information about the collaboration, or to pledge as a sponsor, contact Eric Lu at (469) 688-0988 or email to Eric_Lu [at] hms [dot] harvard [dot] edu.

Click here if you cannot see the video.

WIHI on Crisis Management

Reports from the Frontlines of Effective Crisis Management
Thursday, April 7, 2011, 2:00 PM – 3:00 PM Eastern Time

Jim Conway, MS, FACHE, Senior Fellow, Institute for Healthcare Improvement

Anthony A. Armada, FACHE, President, Advocate Lutheran General Hospital, Advocate Lutheran General Children’s Hospital

Michael A. Fisher, President and CEO, Cincinnati Children’s Hospital Medical Center (CCHMC)

Uma R. Kotagal, MD, MBBS, MSc, Senior Vice President, Quality, Safety and Transformation, CCHMC; Executive Director, James M. Anderson Center for Health Systems Excellence

Michelle Hoppes, RN, MS, President, American Society for Healthcare Risk Management; Senior Vice President and National Director for Healthcare Risk Management and Patient Safety, Sedgwick Claims Management Services

It’s every hospital executive’s worst nightmare – a phone call carrying the news that a patient at the facility has died or been seriously injured due to an adverse event. Action is now called for on multiple fronts. Do you have a plan for what to do?

Jim Conway and three co-authors developed the IHI white paper, Respectful Management of Serious Clinical Adverse Events, to guide senior leaders on a comprehensive set of “best practices” not just to handle and respond to unforeseen incidents, but to learn from each incident so that future medical tragedies are less likely. One key is that everyone in the organization has a role to play and no one in the organization is ignored. Transparency with and attention to the needs of patients and families are foundational.

Since the IHI white paper was published in the fall of 2010, thousands of senior and frontline staff have benefited from its clarity of purpose and advice. Not only that, some organizations have turned to its guidance when faced with serious situations. We’re going to hear from two of those organizations – Cincinnati Children’s Hospital Medical Center and Advocate Lutheran – on the next WIHI. Their leaders – Michael Fisher, Uma Kotagal, and Tony Armada – are eager to share what they learned and continue to learn about crisis management. Jim Conway and Michelle Hoppes, a risk management expert, will offer the context in which all of health care delivery must consider its obligations to patients, staff, and the larger community when it comes to safety and principled actions if and when things go wrong.

WIHI host Madge Kaplan hopes you’ll join this important and timely discussion. To enroll, please click here.

Partners in Health of Maine

We have all heard about the good work being done by Partners in Health, but there is another PIH, lesser known, but equally well-intentioned. It is called Partners in Health of Maine. It is a nonprofit, nondenominational organization whose mission is to provide health services, training, education and volunteer opportunities for health care providers in third world countries. Its activities have been limited to Central America, with a focus on Nicaragua and Guatemala. The organization grew around the volunteer work of Dr. Robert Bach, a general surgeon from Maine, and other health care workers who had been volunteering in Central America since 1975. The two PIHs started at about the same time, and I guess both want to keep the name!

Most of the work of PIH of Maine has centered on the Autonomous Atlantic Region (RAAN), Nicaragua’s largest province, which occupies approximately a fifth of the land area and is located on the Northeastern Caribbean coast. This area is inhabited by indigenous Miskito Indians and people of Afro-Caribe and Spanish descent.

A friend of a friend provides some of the color of the Maine organization in a recent email, written after attending a briefing in the US, complete with a story of low-cost innovation by a clever team:

I am going to Nicaragua because I was invited by old friends from Waterville. John and Mary got involved five or six years ago. The work was originally focused on providing medical care to a town on the Atlantic side of Nicaragua. John is a pathologist, and he has been instrumental in writing grants and training Nicaraguan doctors to prepare and read slides in an effort to catch some of the rampant cases of cervical cancer early enough to provide treatment.

In the States, slides are prepared with the aid of a $30,000.00 tissue processor. The machine is massive and the reagents are unavailable in Nicaragua. So the ever-resourceful John invented a way to process slides using a $69.00 microwave oven! He enlisted the aid of his brother-in-law, a retired computer chip engineer, and the two of them figured out a way to program the oven to cycle and hold the kind of temperatures required to "fix" the slides.

And, then some more!

John’s wife Mary is an artist. She was featured on one of the slides shown during the PIHOM presentation...her smiling face lit up the screen and the caption underneath read “I’m an artist...is there anything I can do to help?”

Dr. Bach admitted he groaned a bit inside when she showed up with her offer! And today she has grown into the heart and soul of the tiny grassroots group. Mary has painted colorful and uplifting murals on the hospital walls, she has taken over the newsletter, she writes grants, she teaches English classes. Yes, there was/is a lot she can do to help and her example was a great inspiration to the non-medical folks in the room. "Health" directly translates to "hope" in Arabic and medical care is only one leg of the stool.

This is a lovely example of people helping people. They are looking for volunteers, supplies, and cash. Go to this website for more information on how to help out.

They have heard. Are they ready?

Cheryl Clark at Health Leaders Media offered this summary from a recent conference of the American College of Healthcare Executives (ACHE).

They have heard, and hopefully understand, how important it now is. They are going to have to change their organizations in major, cataclysmic ways especially if they haven't started to do so already.

Tom Dolan, president and chief executive officer of ACHE, says leadership in general is now "much more knowledgeable" about the steps they have to take. "They know they need to reduce costs. They understand they have to adopt Toyota and Lean manufacturing strategies. They know they have to reduce errors, medication mistakes, reduce readmissions and improve quality measures for specific diseases. "They know they have to dramatically re-engineer the way we provide care and can't tinker the way they have in the past."

Here is what I am not sure of, and I mean this with affection and respect. I am not sure that the current generation of leadership in academic medical centers knows how to do what is summarized above. I actually think that leaders of some community hospitals might be better trained in such matters. Why?

Well, the career path of people chosen to be leaders of academic medical centers tends to be based on success in the things valued in the academic medical environment. As is often the case in universities, people work their way up through the ranks of the faculty based on prowess in research and specialized clinical areas. Sure, as they become division and department chairs, they take some courses in business and management, but their promotions tend to be based more on academic achievement than on managerial and leadership skills. And the continuing education courses often do not include strong training in the kind of process improvement techniques and philosophies mentioned by Mr. Dolan.

There are, of course exceptions. I can think of a handful of people who have made the transition and have demonstrated great leadership in instituting these kinds of approaches in an academic medical center. Gary Kaplan at Virginia Mason in Seattle is the prime example.

But maybe I am wrong. Let's give my readers an invitation to offer the names of others they know in this category. This is your chance to brag! Which people in academic medicine are in the vanguard of the kind of change mentioned by Mr. Dolan?

ACO rules: Where's the beef?

I'm sorry, but I just don't get it. Last week, CMS announced proposed regulations about setting up Accountable Care Organizations. Here's the statutory background and the theory of the case, as set forth in the March 31 Medicare Fact Sheet:

Section 3022 of the Affordable Care Act, added a new section 1899 to the Social Security Act (the Act) that requires the Secretary to establish the Shared Savings Program by January 1, 2012. This program is intended to encourage providers of services and suppliers (e.g., physicians, hospitals and others involved in patient care) to create a new type of health care entity, which the statute calls an “Accountable Care Organization (ACO)” that agrees to be held accountable for improving the health and experience of care for individuals and improving the health of populations while reducing the rate of growth in health care spending. Studies have shown that better care often costs less, because coordinated care helps to ensure that the patient receives the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors.

Here's the introductory paragraph from the CMS summary:

ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities. The Medicare Shared Savings Program will reward ACOs that lower growth in health care costs while meeting performance standards on quality of care and putting patients first. Patient and provider participation in an ACO is purely voluntary.

How will this work? And, will it work?

Let's dig in.

The proposed rule would require providers participating in an ACO to notify the beneficiary that they are participating in an ACO, and that the provider will be eligible for additional Medicare payments for improving the quality of care the beneficiary receives while reducing overall costs or may be financially responsible to Medicare for failing to provide efficient, cost-effective care. The beneficiary may then choose to receive services from the provider or seek care from another provider that is not part of the ACO.

. . . Medicare would continue to pay individual providers and suppliers for specific items and services as it currently does under the fee-for-service payment systems. The proposed rule would require CMS to develop a benchmark for savings to be achieved by each ACO if the ACO is to receive shared savings, or be held liable for losses. Additionally, an ACO would be accountable for meeting or exceeding the quality performance standards to be eligible to receive any shared savings.

So, the PPO character of Medicare would not change: "The provider may not require a beneficiary to obtain services from another provider or supplier in the same ACO."

How can you be held accountable, as a provider group, if you cannot control the management of care of your patients? I'm not blaming CMS for this contradiction. The agency is simply implementing what Congress and the President ordered it to do. There is no way Congress will limit choices among the Medicare population.

Real cost savings will not result from ill-conceived government laws and regulations: They will occur when physicians and other health professionals redesign the work that takes place in their offices and hospitals. Attempts to generate that redesign by government regulations, especially self-contradictory ones like this, will fail.

Career advice sought

A friend writes below. She is in the municipal bond world, working as an associate in public finance at an investment bank. As indicated below, she is currently contemplating where she wants to go in her career. She seems to want more from life than being an investment banker. Perhaps you would like to offer advice in your comments?

I'm thinking I'd like my next job move to be health care focused. Given my interest in policy and my desire to work in a field that I feel is socially important"and yet also challenging, health care seems to fit my needs.

I am curious. Do you have any recommendations for the types of roles that are interesting in health care finance today? Since I'm getting my CFA [Chartered Financial Analyst, a designation for investment professionals] it needn't necessarily be public finance. I am wondering what type of job I could pursue now that could transition into working for a policy think tank or a not-for-profit advocacy group down the line. I just wanted to do some exploring. Recommended reading for keeping up on health care would also be great!

More signs in the Athens of America

Back to our occasional review of signage seen in public places. The infrastructure geek in me likes to evaluate them for efficacy. The one above is from the Kennedy School at Harvard. Really terrible jokes and scenarios come to mind.

And here is part of a very clever ad for a restaurant search engine, seen on the Boston transit system.

This is no eggsageration!

In a previous post, I made the point that meal components and serving sizes are contributing to a huge increase in obesity in the US. With no offense meant to my friends in the South, this especially seems to be the case in that part of the country.

While waiting for an airplane at the Tampa airport last week, I decided to order the vegetable omelette for breakfast, figuring it would be the healthiest thing on the menu at the Sam Snead Tavern near my departure gate. What showed up was this behemoth!

Sam could never have done so well if he ate this way!

Learn the MIT physics curriculum in one hour

I am an unabashed MIT fan. Here's why. It is hard to imagine this happening elsewhere, and with such good humor.

From:
Date: Fri, Apr 1, 2011 at 8:04 AM
Subject: 5-Minute Physics Lectures, 8 pm tonight
To:

Want to learn 144 units of physics in 1 hour? Neither do we, but at least there'll be free cookies/cocoa/tea!

If you're curious to sample the entire Course 8 curriculum from 8.022 to Quantum Field Theory II at ultrarelativistic speeds, come to 8-329 tonight at 8 pm to experience each class losslessly compressed into 5 minutes or less by your friendly neighborhood Physics majors. To quote Chancellor Grimson's recent email, "This is not some dry 8.01 lecture."

Also featuring Prof. John Belcher TEACHING HIS OWN CLASS (8.07).

Part of Physics Exploration Week, hosted by Undergrad Women in Physics.

---
Explanatory notes: A "unit" for an MIT class is equivalent to an hour per week of class time or expected homework. A 12-unit class at MIT is roughly equivalent to 4 credit-hours elsewhere. "Course 8" means the Department of Physics. At MIT, a course is a department. A class is a course. Classes are designated with the course number first, and then the class number after that. They roughly rise in degree of difficultly based on the digits. 8.01 is thus a lower level course than 8.07. Buildings and rooms at MIT are designated by numbers, too. Room 8-329 is on the third floor of building 8. The building numbers tell you where you need to go on campus. Building 8 would be between Vassar Street and the Charles River, relatively close to the river, to the right of the large dome in the middle of the MIT campus (as you face that dome from the river.) Clear?

Crowdsourcing for his book

Mark Graban, an expert on the use of Lean process improvement in hospitals, has opened up his own process as he prepares revisions of the "Visions of a Lean Hospital" ideal state chapter in his book, Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction.

He notes on his blog:

I’ve shared the first chapter of the book for those who signed up on my book’s site. Now as I’m making revisions, I’d like to get your input and ideas around the final chapter – “A Vision for a Lean Hospital.” I think the chapter has some good ideas, but given my audience here, I’m not going to pretend I have all the answers for hospitals. So I’d like to hear what you think in the comments for this post, or email me. What’s missing? What’s confusing? What’s wrong?

Here's your chance to be a ghost writer!

How the veterans are winning the war

At a seminar last night at the Center for Public Leadership at Harvard's Kennedy School, one of the students asked a question along the lines of, "How do you know when you have done too much with regard to transparency?" My answer was that the question presupposed the wrong approach to transparency, that it was being driven by the CEO without proper attention to the efficacy and appropriateness of what was being measured and disclosed. Instead, I suggested that it should be driven by the leadership of the organization, but based on metrics that were viewed as useful and appropriate by the clinical staff. In such an instance, transparency serves the function laid out by IHI's Jim Conway, as summarized here in an article discussing the BIDMC experience:

[P]ublic reporting created what management guru Peter Senge calls creative tension, a key in getting an organization to change. Announcing a daring vision — the elimination of patient harm — combined with honestly publicizing the problems, fuels improvement, he said.

I expressed the concern last night that the general recalcitrance of the medical profession about engaging transparency will inevitably lead to fiats about disclosure from government regulatory agencies. The problem with those fiats is that they will be grossly constructed and force hospitals and doctors to focus on the wrong things, in a manner not consistent with widely established principles of process improvement. (See, for example, this approach in Maryland.)

Now comes the Veterans Administration, proving the case with panache! You may recall my complimentary post on the VA back in January. Thomas Burton's article this week in the Wall Street Journal -- "Data Spur Changes in VA Care" -- documents this in more detail. Some excerpts:

Hospitals serving U.S. military veterans are moving fast to improve care after the government opened a trove of performance data—including surgical death rates—to the public.

The information was released at the urging of VA Secretary Eric K. Shinseki. Among other things, it presents hospitals' rates of infection from the use of ventilators and intravenous lines, and of readmissions due to medical complications. The details have been adjusted to account for patients' ages and relative frailty.

"Why would we not want our performance to be public? It's good for VA's leaders and managers, good for our work force, and most importantly, it is good for the veterans we serve," Mr. Shinseki said in an emailed statement.

At VA hospitals in Oklahoma City and Salem, Va., the rate of pneumonia acquired by patients on ventilators was shown last fall to be significantly higher than the national VA average. The Salem hospital says a relatively low number of patients on ventilators skewed its infection rate higher, but staff members at both facilities say the numbers prompted action.

Seeing the data helped, says the Salem hospital's chief of surgery, Gary Collin, because "you can become kind of complacent."

In contrast, notes the article:

This unusually comprehensive sort of consumer information on medical outcomes remains largely hidden from the tens of millions of Americans outside the VA system, including many of those in the federal Medicare system.

And, as I reported last month,

A November 2010 report from the Health and Human Services inspector general concluded that one in seven Medicare patients is harmed by medical care, nearly half of those avoidably.

Conway is right. Senge is right. The veterans have figured out how to start winning the war for patient safety and quality and process improvement. The rest of the profession is in retreat and is letting the wrong people design the battle plan.

Conversation at the Center for Public Leadership

Many thanks to the Center for Public Leadership at Harvard's Kennedy School for inviting me to meet with the Zukerman and Dubin Fellows tonight. The Zuckerman Fellows are graduate students or professionals from the fields of law, business, or medicine who are pursuing a second degree in health, education, or public policy in order to broaden and deepen their understanding of public sector issues. The Dubin Fellows are master's degree students at the JFK School who have demonstrated strong character, academic excellence, the ability to thrive and lead in the face of adversity, and a commitment to making a transformative impact on the communities they serve.

My topic was about lessons from leadership positions, with a particular focus on engaging front-line staff in process improvement, building constituencies in the complex environment of academic medical centers, and the importance of transparency in both clinical and administrative matters.

I promised to post the pictures of those who asked especially good questions, but everyone did! I don't have room here for all, but I include a few. Special thanks to Laura Burke (bottom right), a resident in Emergency Medicine at BIDMC, for her role in organizing tonight's event.

It's not "nothing" -- Accepting gratitude

A friend and I were discussing the point that effective communication is most likely to occur when the other person feels that you understand his or her situation. This is an underlying premise of negotiation theory: You are more likely to be successful at a negotiation when you understand the other person's underlying interests and when you make it clear to that person that you do. To do otherwise, whether in negotiations or other settings, is likely to lead to speaking at a person, rather than to the person. Not because you mean to, but because the other person will not value what you say, compared to when they think you really "get it."

One of the things I learned in my hospital days was how to accept gratitude. A hospital can be an uncomfortable place for patients and family members. It is a strange physical environment, where people are anxious because of feared or actual medical conditions or forthcoming procedures or tests. In that situation, when you do something kind for someone, the person is truly grateful. It can be as simple as offering directions, or picking up a fallen object, or something much more serious.

When I started working in the hospital, when someone would say "Thank you" to me, I would often answer, "It's nothing," or "No problem." Wrong! I was taught that such an answer devalues the gratitude that the other person is feeling. A more appropriate response is, "It is my pleasure," or "I am so pleased I was able to help." That indicates that you understand their feelings.

Over the years, I trained myself to do this. Lo and behold, once I got rid of the "It's nothing" conversation stopper, people would jump in and continue the conversation even further. I was able to learn so much more about people's fears, expectations, experiences, and hopes and then help translate those into improvements in the clinical environment.

Try it. It's not "nothing."

A mentor hospital

The Institute for Healthcare Improvement gives the following update. How impressive! And how generous of Columbia Regional to offer to share what they have learned. What a shame that The Joint Commission has not followed this lead by making its best practice library available to all.

Mentor Hospital Goes 5 Years Without a VAP

Staff at Columbus Regional Hospital in Columbus, IN, recently celebrated an amazing accomplishment. They have gone five years without a single incidence of a ventilator-associated pneumonia (VAP). These deadly pneumonias used to be considered an unfortunate reality in ICUs. As a participant in IHI's 100,000 Lives and 5 Million Lives Campaigns, the hospital took aim at reducing VAP by implementing the IHI Ventilator Bundle, evidence-based care guidelines that, when reliably applied, can drastically reduce and even eliminate these infections. One of the enduring legacies of the Campaigns is a robust registry of mentor hospitals, facilities that have outstanding track records in improvement in Campaign-related topic areas that have generously agreed to provide support and clinical expertise to hospitals seeking help with their implementation efforts. Columbus Regional has been a mentor hospital since 2006 for the topics of VAP, Rapid Response Systems, the Central Line Bundle, and Heart Failure Core Processes. IHI congratulates Columbus Regional on their tremendous achievements.

Please nominate for Schwartz Center Award

I am pleased to post this at the request of the Schwartz Center. Please see below and consider people or groups of people who might be worthy recipients of this award:

Nominations Open for Schwartz Center Compassionate Caregiver Award®
New England Caregivers Sought Who Demonstrate Extraordinary Compassion for Patients

Boston, MA (March 22, 2011) – The Schwartz Center for Compassionate Healthcare, a nonprofit organization dedicated to strengthening the patient-caregiver relationship, is seeking nominations for its 2011 Schwartz Center Compassionate Caregiver Award®. For the first time since the program began in 1999, caregivers from all six New England states are eligible.

The winner will receive $5,000 and be honored at the Kenneth B. Schwartz Compassionate Healthcare Dinner on November 17^th at the Boston Convention Center. Last year’s event attracted more than 2,000 attendees. Four finalists will also be recognized and receive $1,000 each. Nominations are due April 22, 2011. Information on how to nominate a caregiver for this prestigious award is available on the Schwartz Center’s website.

The center and award are named after Ken Schwartz, a Boston healthcare attorney who died of lung cancer in 1995 and came to believe that medicine is about more than performing tests and surgeries, or administering drugs. As he wrote in an article published in the Boston Globe Magazine, “These functions, as important as they are, are just the beginning. For as skilled and knowledgeable as my caregivers are, what matters most is that they have empathized with me in a way that gives me hope and makes me feel like a human being, not just an illness.”

Nominees must work in a health-related organization or practice, such as a hospital, physician office, outpatient clinic, community health center, visiting nurse or home health agency, nursing home, or hospice organization. Any paid caregiver or team of caregivers with direct patient contact in Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island or Vermont is eligible. Nominees may include physicians, nurses, physical and occupational therapists, social workers, psychologists, nurse practitioners, physician assistants, certified nursing assistants, home health aides, and chaplains – as well as interdisciplinary teams. Nominations may be made by patients or healthcare professionals.

In 2010, the Schwartz Center Compassionate Caregiver Award® was given to the Haitian Mental Health Team at Cambridge Health Alliance in Massachusetts. In 2009, the award went to Dr. Amy Ship, an internist in the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center in Boston. [My note: Listen to her speech here.]

The winner and finalists will be selected by a regional review committee based on how well the individual or team embodies the characteristics of compassionate healthcare, which are defined by the Schwartz Center as follows:

• Showing respect for the patient, the patient’s family, and those important to the patient
• Conveying information in a way that is understandable
• Treating the patient as a person, not just a disease
• Listening attentively to the patient
• Striving to gain the patient’s trust
• Always involving the patient in treatment decisions
• Apologizing to a patient if a caregiver makes a mistake
• Communicating test results in a timely and sensitive manner
• Comfortably discussing sensitive, emotional or psychological issues
• Considering the effect of an illness on the patient, the patient’s family, and those important to the patient
• Expressing sensitivity, caring and compassion for the patient’s situation
• Spending enough time with the patient
• Striving to understand the patient’s emotional needs
• Giving the patient hope, even when the news is bad
• Showing understanding of the patient’s cultural and religious beliefs

The Schwartz Center for Compassionate Healthcare was founded in 1995 by Ken Schwartz, a prominent Boston healthcare attorney who died of lung cancer at the age of 40. Based at Massachusetts General Hospital in Boston, the center sponsors programs to educate, train and support caregivers to provide compassionate, patient-centered care. Its signature program, Schwartz Center Rounds, has been adopted by 215 hospitals, outpatient centers and nursing homes in 32 states and reaches more than 60,000 clinicians a year.

The Schwartz Center Compassionate Caregiver Award is made possible in part by the generosity of AstraZeneca, a leading pharmaceutical company.

Cheaper than newspaper ads, I guess

You can tell it is spring in New England when your yard gets pelted with these. They are advertisements for landscaping companies. The proprietors drive through the neighborhoods tossing out plastic bags weighted down by pieces of pea gravel.

These seem to be about as effective as hospital advertising -- which is to say, not very -- if we are to judge from the fact that most of them lie untouched for weeks.

Two Degrees delivers

You may remember my post about Two Degrees, a company that donates a packet of food supplement for each nutrition bar they sell. Well, they recently went to Africa and made their first delivery -- 10,800 nutrition packs to malnourished children in Malawi. Here is a picture of co-founder Will Hauser and a local community health worker preparing to disburse the Two Degrees/Valid Nutrition RUTF packs. You can read more about it on Will's blog post. You can also follow this activities of this innovative company on their Facebook page.

Remember, the food supplement is produced locally, so jobs are created, also.

The company is seeking companies, colleges, schools, and other institutions who might want to distribute and sell the bars in company cafeterias and snack bars and other corporate settings. I will vouch for the taste and nutrition (as they helped me and some friends get through a bike trip in the Atlas Mountains), the integrity of the founders, and the good cause. (I have no financial interest in the company.)

Choosing to stop dialysis

I know there has been a lot written about assisted suicide, but this is in the category of a patient choosing to forgo treatment when he or she knows it will lead to death. It comes from a friend who writes about a relative, noting, "I think this is an interesting situation, with a lot of moral threads hanging from it." There are no children involved or living parents.

M (age in mid-60s) is stopping dialysis because his quality of life is too sucky for him to want to continue. He is legally blind and can't read or watch movies for more than a short time per day. As far as I know there is no physical pain. He did have a long time dealing with infection from a botched surgery, about a year, which might be influencing his thinking, but I don't know.

I have mixed feelings. He is relatively young, but I know you join me in wishing him the least painful way out.

Neither I, nor you, dear readers, have a right to judge the actions of the patient. (Remember that Art Buchwald did the same thing?) Perhaps, though, we can offer advice to my friend as to how to handle the situation now and afterward, for he feels he will have to explain to other friends and relatives that he knew what was coming but could not reveal it.

That will be a marvelous kiss!

Although I have talked before about the tendency for medical priorities to be based on the "rule of rescue" rather than more cost-effective reasoning, who cannot be moved by this recent surgical success at Brigham and Women's Hospital? Excerpts from the Boston Globe story by Kay Lazar:

[A] 25-year-old Texas man suffered horrific burns in a 2008 electrical accident that obliterated his lips and most of his other features, but last week he received the nation’s first full face transplant.

“Dallas is looking forward to giving his daughter a kiss again,’’ Dr. Bohdan Pomahac, director of the Brigham’s burn unit and the plastic surgeon who led the transplant team, said in an interview after yesterday’s announcement. “It’s such a simple human function that we take for granted.’’

To modify a quote from The Princess Bride:

“Since the invention of the kiss, there have only been five kisses that were rated . . . the most pure. This one will leave them all behind.”

Indeed. Congratulations to the team!

Maryly proceeding off course

Maryland, the only state with a hospital rate-setting process, also has an interesting financial incentive program related to quality indicators. It is described here. Some excerpts:

This initiative, which commenced July 1, 2009, links payments to hospital performance on a set of 49 Maryland Hospital Acquired Conditions (MHAC) across all-payers and patients in the State.

During fiscal year 2008, these hospital-based preventable complications were present in approximately 53,000 of the State’s total 800,000 inpatient cases and represented approximately $500 million in potentially preventable hospital payments.

The MHAC methodology provides a system of payment incentives based on a hospital’s actual number of complications versus a statewide target rate for each of the 49 MHAC categories. Under this approach, hospitals face strong financial incentives to reduce complication rates. They will also be armed with a sophisticated data analysis tool that will enable them to systematically help achieve this collective goal of reducing complications.

The Washington Post recently (March 19) published a letter to the editor from Robert Murray, the Executive Director of the state's Health Services Cost Review Commission, which offered more detail:

The [MHAC] method of applying hospital rewards and penalties is based on measuring each hospital's performance and determining whether the complication rates are lower or higher than, or on par with, expected rates. The expected rates of complications for each hospital are calculated using statewide average rates for the type and severity of illnesses of the patients treated by a given hospital. Therefore, hospitals with more complex patients are not disadvantaged because their expected complication rates would be higher than those hospitals with less complex patients.

The MHAC approach to funding the rewards and imposing penaities is revenue-neutral and does not raise money for the state through fines; for poorer-performing hospitals, a portion of their approved increase in prices for the current year has been withheld and redistributed to the better-performing hospitals based on performance in the previous year.

In this article, you can see some of the objections to this scheme:

The head of the Maryland Hospital Association says the complication list is too broad and that part of a reported drop last year in the overall rate of complications may simply have been hospitals doing better record-keeping. One leading patient safety expert says the Maryland program – and other national efforts – are moving forward despite insufficient evidence to truly measure and verify the types of preventable complications that should be targeted.

"There is so much pressure to drive down cost and improve quality that politics have gotten ahead of the science," says Dr. Peter Pronovost, a professor at Johns Hopkins University School of Medicine and winner of a MacArthur Foundation "genius grant” for his work on improving hospital safety, often through the use of simple checklists. "There’s a gap between regulators, who say the measures are good enough and clinicians, who say they’re not."

From this vantage point, I am hard-pressed to see how a "focus" on 49 metrics makes much sense. That is unlikely to stimulate a sensible approach to process improvement. Also, the dollars at stake are de minimis -- 0.5% of total inpatient hospital revenue in the state or about $60M -- unlikely to act as much of a financial incentive. Dr. Pronovost has it right. Government regulation of this sort is invariably crude and off-point. It would be much better if the medical profession demonstrated that it is capable of self-regulating in a way that persuasively exhibited a commitment to quality and safety and to patient involvement in the design and delivery of care.

Medical innovation grows in Boston

Now that I am free of the day-to-day responsibilities of running a hospital, I have had more chance to meet people working on new medical diagnoses, therapies, and services in the Boston area. There are a slew of them, as this is a hotbed of innovation and invention because of the concentration of hospitals and research universities. From time to time, I will tell you about some of these.* In particular, I will try to focus on innovations that, in my opinion, have the potential to decrease the cost of health care or provide more patient-centric care.

Here's one I learned about recently, a new company called Novocure. (I have no financial interest in this company.) They have developed a potential non-invasive treatment for solid tumors. Mild electrical currents are applied from an external source through the skin into the body, with the idea of interfering with the growth mechanism of cancer cells. The most promising arena is currently brain tumors, glioblastoma multiforme.

Of course, there is an extensive FDA-guided clinical trial regime to go through, as there is with all such inventions. Last week, the FDA's Neurological Devices Panel Advisory Committee met to review the company's application for recurrent GBM and provide guidance to the agency on approval. The panel voted in favor of the treatment, bringing the company one step closer to being able to offer this treatment option to GBM patients. You can read more here and here.

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* I will only report publicly available information. I will, of course, disclose if I have a personal financial interest. I will no longer comment on any financial interest of my previous employer or staff there, as I in no way represent them; nor do I keep track of such matters and therefore neither can I speak knowledgeably about them.

Insurance companies dancing without touching

A story in the Washington Post talks about health insurance companies seeking new lines of unregulated business as the profitability of health insurance falls and as more and more requirements are placed on that line of business as a result of the federal health reform law. Here's an excerpt: "Insurers have moved into technology, health-care delivery, physician management, workplace wellness, financial services and overseas ventures in wide-ranging efforts to mitigate the new rules imposed by the law."

I raised some of these issues several months ago, where I also suggested that a merger of the Number 2 and Number 3 Massachusetts health plans might be forthcoming. Well, they tried, but decided not to, as they announced a few weeks ago.

Meanwhile, Blue Cross Blue Shield of Massachusetts is clearly laying the groundwork to shed its non-profit status. And, really, why not? It is in no way a charitable organization of the sort envisioned in earlier years, and the constraints of being a nonprofit bind in a number of ways.

When the HPHC and Tufts merger fell through, the operative statement was: "We have now determined that we are stronger as individual competitors than one company."

I predict that will turn out to be a strategic error. In the new world order, scale matters. This statement is, to me, revealing in its own way: "Our operations are very different and, in many important aspects, not fully compatible without significant changes to existing processes and applications." In other words, they chose not to merge because it felt like it was not currently cost-effective to change. This suggests that the operations of the two plans as presently configured are not scalable. But if they don't merge, they will be left behind by those with stronger market power. For now, that is BCBS of MA. In the future, as the business becomes less about taking on insurance risk and more about other services, it could well include some major national players as well. Now, rather than later, would be a better time to consolidate assets and use the cash on hand to make the investments that will be needed to grab market opportunities in the future.

Probably right, or wrong

In the post below, I ask you to make a diagnosis of a medical condition. Most people get it wrong, probably because the actual diagnosis is far removed from the setting presented. People apply their inductive forces to a new problem, based on probabilistic inferences from other situations with which they are more familiar.

I attended a seminar on Friday at which MIT's Joshua Tenenbaum presented a theoretical basis for this learning process. If you subscribe to Science Magazine, you can read his recent article on the topic: "How to Grow a Mind: Statistics, Structure, and Abstraction."

It turns out that people are reasonably good at inference, from a very young age, as Joshua notes:

Generalization from sparse data is central in learning many aspects of language, such as syntactic constructions or morphological rules. It presents most starkly in causal learning: every statistics class teaches that correlation does not imply causation, yet children routinely infer causal links from just a handful of events, far too small a sample to compute even a reliable correlation!

In a more theoretical section, the author describes a probabilistic, or Baysian, model to explain this learning process:

How does abstract knowledge guide inference from incomplete data? Abstract knowledge is encoded in a probabilistic generative model, a kind of mental model that describes the causal processes in the world giving rise to the learner's observations as well as unobserved or latent variables that support effective prediction and action if the learner can infer their hidden state. . . . A generative model . . . describes not only the specific situation at hand, but also a broader class of situations over which learning should generalize, and it captures in parsimonious form the essential world structure that causes learners' observations and makes generalizations possible.

Except when it doesn't work! As several of you demonstrated below, that same probabilistic model can lead to cognitive errors.

I summarized Pat Croskerry's explanation below:

Croskerry's exposition compares intuitive versus rational (or analytic) decision-making. Intuitive decision-making is used more often. It is fast, compelling, requires minimal cognitive effort, addictive, and mainly serves us well. It can also be catastrophic in that it leads to diagnostic anchoring that is not based on true underlying factors.

Why the dichotomy? How can a learning process that works so well in some cases led us awry in others? I asked Joshua, and he suggested that it might have to do with the complexity of the issue. For those functions that were important in an evolutionary sense as humans evolved -- e.g., recognizing existential threats, sensing the difference between poisonous and healthy plants -- a quick probabilistic inference was all that mattered.

Now, though, in a complex society, perhaps we get trapped by our inferences. The sense of tribalism that led us to flee from -- or fight -- people who looked different and who might have been seeking to steal our territory or food becomes evident now as unsupported and destructive racial or ethnic prejudice.

Likewise, the diagnostic approach to illness or injury that might have sufficed with simple health threats 10,000 years ago no longer produces the right result in a more complex clinical setting. Think about it. If you were a shaman or healer in a tribe, most conditions or illnesses healed themselves. You recognized the common ailments, and you knew you didn't need to do much, and whatever herbs or amulets or incense you used did no harm. If you couldn't cure the disease, you blamed the evil spirits.

In contrast, as a doctor today, you are expected to apply an encyclopedic knowledge to a variety of complex medical conditions -- cancer, cardiovascular disease, liver and kidney failure -- that were relatively unknown back then. (You were more likely to die from something more simple at a much younger age!) Many cases you see today have a variety of symptoms and multivariate causes and different possible diagnoses. It is no surprise that your mind tries to apply -- in parsimonious form -- a solution. The likelihood of diagnostic anchoring is actually quite high, unless you take care. As I note below:

Croskerry thinks we need to spend more time teaching clinicians to be more aware of the importance of decision-making as a discipline. He feels we should train people about the various forms of cognitive bias, and also affective bias. Given the extent to which intuitive decision-making will continue to be used, let's recognize that and improve our ability to carry out that approach by improving feedback, imposing circuit breakers, acknowledging the role of emotions, and the like.

Eye couldn't guess!

Quiz for doctors and lay people out there: What is your diagnosis for this eye condition?

Be honest and put your answer as a comment below before looking at this article.

In their boats . . .

There is an old joke about a university with a certain ethnic background (mine) that decides to set up a rowing team. After months of practice, the crew arrives at the Head of the Charles Regatta to compete. They are demolished -- recording by far the worst time of any 8-person boat.

Discouraged, the coach sends out the captain of the team to visit with other college teams to figure out how to get better at the sport. Hours later, Sam comes back and says, "Coach, I figured out the secret of their success!"

"What is it?" asks the coach.

"In their boats, eight people row and only one person talks!"

Apropos of that, please see the photo below of a sculpture from Jaffa, Israel, which seems to exemplify the lesson:

Those who have worked in hospitals already see the relevance of this story, but I present it more to provide a warning of what I see happening in the Massachusetts state government.

You may recall a post from a few months ago in which I set forth great hope about the usefulness of an all-payer claims database. Here's an excerpt:

Over the coming months, in accordance with an act passed last summer, the Division [of Health Care Finance and Policy] will be constructing an all-payer claims database (APCD). It will comprise medical claims, dental claims, pharmacy claims, and information from member eligibility files, provider files, and product files. It will include fully-insured, self-insured, Medicare, and Medicaid data. It will also include clear definitions of insurance coverage (covered services, group size, premiums, co-pays, deductibles) and carrier-supplied provider directories.

The Commissioner noted that the result will be "a dataset that allows a broad understanding of health care spending and utilization across organizations, population demographics, and geography." In my view, it will be a moving force in rationalizing payments to providers across the state....

One of the things then-Commissioner David Morales promised was that the database would be widely accessible, so that independent researchers, policy analysts, advocates, market participants, and others would be able to manipulate it to test hypotheses and assumptions. Well, the Commissioner has since announced he is leaving his post, and it already has become evident that there is no one in the government who is steering the boat along the lines he so clearly presented. Instead, there appears to be the classic bureaucratic situation: Too many people involved, none with authority, and certainly no one exercising the leadership needed to make this incredibly useful tool available to the public.

It is time for one person in the Executive branch to talk, and for the others to row, to make sure the Legislature's intent with regard to the transparent presentation of these claims data occurs in a timely and useful fashion.

The Inspector General observes

A recent report by the Massachusetts Inspector General raises a thoughtful concern about the implementation of global payments in the state.

In the effort to contain health care costs, much discourse has centered on moving from a predominantly fee-for-service system to one based mainly on global payments to providers organized as Accountable Care Organizations (“ACO”). There is little doubt that fee-for-service reimbursements create incentives for providers to increase utilization of health care services, with obvious inflationary consequences. But moving to an ACO global payment system, if not done properly, also has the potential to inflate health care costs dramatically.

There is nothing inherent in the current marketplace that would cause an ACO-based global payment system to contain health care costs. The evidence, in fact, suggests the opposite conclusion. For the past two years, the primary experiment with global payments in the private insurance market in Massachusetts has been the Alternative Quality Contract (“AQC”) popularized by Blue Cross Blue Shield of Massachusetts (“Blue Cross”). The payments to providers under this contract are made on a global capitated basis. The capitated amounts are determined by starting with the previous year’s experience of the population of lives covered by the specific AQC. That entire amount becomes the base year from which all future payments are derived. Therefore, the AQC embraces and adopts any excessive or wasteful payments in that base year, including all overutilization resulting from over a decade’s worth of fee-for-service provider contracts. Implicitly, the premium increases of that decade, which overall were well in excess of 100%, are made a permanent part of our health care system’s cost structure.

Once the base year is determined, any excessive provider costs from that year are trended into the future. And the rate of the trend is alarmingly high. While specific details of individual AQCs are kept confidential by Blue Cross and the contracting providers, the OIG estimates that increases in reimbursements to providers over the five-year term of an AQC could be in the 50% range.

The IG's remarks are especially apt in that the first global contracts contained very good deals for those providers who signed on, as rewards for being early adopters. The big problem he identifies, as I have mentioned before, is the lack of transparency surrounding this issue. Absent an open presentation of rates and practice patterns, we will never know how effective this payment regime really is. Meanwhile, the Governor and other policymakers have chosen to proceed, blindly trusting a path that has huge ramifications for patients.

I know of no other arena in public policy in which so many decisions are being made with so little substantive support and so little data-driven debate. Reporters, too, seem willing to accept relatively unsupported and undocumented assertions that global payments are working -- parroting statements made by stakeholders who have tremendous financial interests -- while demanding no independent verification.

Radio gets it right on end-of-life issues

Here is an excellent interview with WBUR's Sacha Pfeiffer and Dr. Lachlan Forrow about the Massachusetts Expert Panel on End of Life Care report I cited below.

It is deeply disappointing that the newspapers in Boston did not cover this important report, one of the most thoughtful pieces of work in the health care field.

No MRI in the Emergency Department

At a major hospital in Israel, one with a very extensive emergency department, they do not have an MRI for the ED. Why? The payment for an emergency room visit is a flat rate, and a low one at that, regardless of diagnosis. While they have X-Rays and CT scanners, they cannot justify the cost of an MRI. Besides, noted my host, "How often do you really need an MRI for an emergency room visit?"

What a contrast with the US, where an MRI in each hospital's ED is de rigueur. But the same question could be asked, "How often do you really need an MRI for an emergency room visit?" Not, how often is one used? This article, for example, shows a tripling of MRI and CT usage in the ten years after 1998. The JAMA abstract is here. (It doesn't separate the two modalities.) During this same time period, there was a small increase in the prevalence of life-threatening conditions; but there was no change in prevalence of visits during which patients were either admitted to the hospital or to an intensive care unit. Visits during which CT or MRI was obtained lasted 126 minutes longer than those for which CT or MRI was not obtained.

So, how often is an MRI really needed? At what cost to society?

Jubilee Project benefit concert

You have seen me post productions here from the Jubilee Project. This is a a non-profit that that harnesses the power of Internet videos and the spirit of philanthropy. As noted by the founders:

- Our mission is to make videos for a good cause.

- Our core value is to partner with those in our communities to help make these videos possible.

- And our hope is that we can create entertaining videos that will empower, enable, and inspire others to do good as well.

Eric Lu, one of the founders, now informs me of a fundraising event in Harvard Square on March 26. Here's the invitation. Bands include: Rooftop Pursuits, Sophia Moon, Courtney Ateyeh & Hilary Reynolds, The Extra Fingers. It looks like fun, and you should order tickets soon, as they are likely to sell out. Details are also available on Facebook.

Addendum: The Jubilee Project added a new video for relief for Japan following the big earthquake there. Here's a message from Eric on that topic, followed by the actual video.

Click here if you cannot see the videos.