Time to talk for the common good

Over a decade ago, a common refrain was that there were too many tertiary care/academic medical centers in Boston.  Of course, that comment often came from the dominant hospital system and the most prestigious medical school in town, but not exclusively.  The conversation would then continue to the question of which one was surplus.  BIDMC was in financial trouble, so some assumed it would be the one to go.  Indeed, as I have related, the then-Attorney General was pressuring the organization to sell itself to a for-profit and drop its teaching and research mission.  Others assumed it should be Tufts-New England Medical Center, which also had had financial problems.  Still others assumed it should be St. Elizabeth's Hospital, the flagship of the Caritas Christi system.

By the way, the rationale for choosing "favorites" in this unfortunate race generally had no substantive basis.  All of those centers have experienced and dedicated and highly competent staff and excellent records of clinical care and academic programs.  Indeed, in another city without a tertiary hospital, any one of them would have been considered a highly desirable asset for the community.  But underlying prejudice, arrogance, contempt, and old grudges often formed the basis for many opinions on the matter.

Over the years, the ranking of candidates for extinction changed.  BIDMC has had a successful turn-around and many continuous years of profitable operations and has gained substantial market share, while expanding its research and education programs.  It is clearly out of the woods.  Likewise, strong administrative and medical leadership at Tufts Medical Center has stabilized that organization and created new clinical affiliations with referring physicians in the region.  But St. E's continues to show weakness.  Its clinical volumes are down, and residents reportedly need to go to other hospitals to get sufficient surgical experience to meet their training requirements.

But, none of this suggests that the initial premise was valid, that there are too many such facilities in Boston.  Each of these institutions brings something important to the region.  The question is not whether one should cease to exist.  The question is how to rationalize the mix of clinical care, teaching, and research across all of them to create increased value for the community.  Ultimately, that requires, too, a rationalization of the functions and services of the medical schools in the city, for the teaching activities of these tertiary centers are important components of their added value.

Would it be possible, among these highly competitive hospitals and medical schools, to share resources, to allocate clinical programs for the greater public good, and to engage in truly cooperative undergraduate and graduate medical education?  I don't know, but I am reasonably sure that, absent such a joint effort, the extinction of one of the members of this elite club is likely to occur.  Therefore, the conversation is worth having and should be at the top of the agenda of the university presidents and medical school deans, along with their hospital counterparts.

Jubilee Project offers hope for Red Balloon

Eric Lu and his friends at The Jubilee Project have issued another in their series of warm and touching videos.  This one is entitled Letter of Hope and raises funds for Red Balloon, an organization that uses music to help sick children.

Here's the video.  If you cannot see it, click here.

More Irish eyes are shining! Congratulations, Mr. Dowling.

Congratulations to Michael J. Dowling, president and chief executive officer of North Shore-LIJ Health System (and native of Limerick, Ireland).  He is  the recipient of the National Center for Healthcare Leadership (NCHL) 2011 Gail L. Warden Leadership Excellence Award for bringing innovation and accountability to health care and contributing significant and lasting improvements to the field.  Mr. Dowling was recognized for creating a culture of mentorship and learning at North Shore-LIJ that underscores his commitment to future generations of health care leaders.

North Shore-LIJ is the nation’s second-largest, non-profit secular health system with more than 5,600 beds and a total workforce of more than 43,000 employees. It comprises 15 hospitals and more than 200 ambulatory care centers throughout the region.  The press release reports that, under Mr. Dowling’s leadership, North Shore-LIJ’s achievements have included:

•     The first health care organization to establish a corporate university
•     The first health care organization to name a chief learning officer
•      The first health system to receive the Ernest A. Codman Award from The Joint Commission for its commitment to quality and patient care
•     One of the first health care organizations to volunteer to participate in the U.S. Centers for Medicare and Medicaid Services (CMS) Hospital Quality Incentive
•      Among the first non-profit hospital systems to publicly disclose its hospitals’ CMS quality performance data, patient satisfaction scores, and hospital-acquired infection rates.

Bravo!

Pull out your crayon box

The visual display of quantitative information is a fascinating field.  Here's an example, borrowed from Andrew Gelman's blog, Statistical Modeling, Causal Influence, and Social Science.

First, check out this chart showing the evolution of Crayola crayons colors over the decades.  It's pretty satisfying, no?

But now look at this enhancement.  Doesn't it work much better?

Proving what?  Perhaps that the context for the information provides clues as to the relative effectiveness of various visual displays.

Shirley Fletcher offers a Dance of Difference

You can tell that Shirley Anderson Fletcher is going to be very honest as she explores the nature of prejudice in The Dance of Difference, The New Frontier of Sexual Orientation when she starts the book with this story:

I have been concerned about the oppression of racism and sexism for most of my adult life.  However, I turned a blind eye to the oppression of gays, lesbians, and bisexuals until my fourteen-year-old son confronted me.  I was forty-one years old at the time.  He had overheard his dad and me laughing at a so-called 'gay joke.' He looked us in the eye and asked, "Would you really be laughing if there was someone gay in this room? Do you really think this is funny?"  He looked at us long and hard before striding out of the room.  I was mortified.

That was twenty-nine years ago.  We made a commitment then to monitor our own prejudices and biases regarding gays, lesbians, and bisexuals.  We've been intentional about building our awareness.  And the reality is we still have a long way to go.

Shirley then employs a model called "Dialogue with Difference" for exploring this prejudice by presenting a transcript of a discussion about sexual orientation with a gay African American colleague, the Rev. Dr. Jamie Washington.  That transcript comprises the middle section of the book, and it is revealing in many ways.  This particular technique is based on the societal construct of dominance and subordination, but it turns that relationship on its head by permitting the subordinated group member in the dialogue to have the opportunity and authority to decide the focus of the discussion.

I was skeptical about this type of presentation but found myself drawn into the discussion and learning a lot about the issue and, like Shirley, my own preconceptions and prejudices.

This is the first of a series of books on prejudice by Shirley, collectively entitled The Dance of Difference.  If you want a break from traditional fluffy summer beach reading, it is well worth your time.

Never blue at Indian Head Farm

Summer is not summer without several visits to Indian Head Farm, in Berlin, MA.  The Wheelers have managed to keep this place open for decades, and the produce is always above average.

We are now into the sixth week of blueberries, and a friend and I were still able to pick two or three quarts in about 20 minutes.  That does not include the ones we ate along the way.  (I always think they should weigh the pickers pre- and post-gathering, in addition to the berries!)

Besides standard fruits, vegetables, and cutting flowers, the Wheelers also grow husk tomatoes, which are described by Culinate as follows:

Husk tomatoes are neither cherries nor gooseberries. Their papery, Chinese-lantern-like husks offer the best clue as to their pedigree. Like tomatillos, husk tomatoes belong to the genus Physalis, which is a member of the Solanaceae family, better known for producing peppers, eggplants, potatoes, and tomatoes.

About the size of a blueberry, a ground cherry tastes similar to a super-sweet cherry tomato, with a hint of — strawberry? Mango? What is that mysterious flavor? You just might keep eating them to find out. Author and naturalist Euell Gibbons declared this elusive essence “so good it doesn’t have to resemble something else.”

MHA does CLABSI right

Here's a great step forward by the Massachusetts Hospital Association, a public presentation  of current data on the rate of central line associated bloodstream infections among its participating members. Here's the current chart:

Let's talk about what's good about this. First, the data are quite current, just a few months old.  Next, the monthly figures, which are subject to minor variations, are smoothed out with a three-month moving average, so you can see the trend.  Third, there are no punches pulled.  When the rate goes up, they say it.

Since each hospital knows it own rate, it can easily compare its progress to others in the state.  N0t for the sake of trying to attract more patients or for other kinds of marketing, but to act as a form of creative tension within the organization to do better. Now, that's the right kind of competition.

Action in Saskatoon

I recently came across the website of the Saskatchewan Health Quality Council and was impressed to see the philosophy and activities of this organization.  The council is an independent agency that measures and reports on quality of care in Saskatchewan, promotes improvement, and engages its partners in building a better health system.

In particular, I love the theme of their most recent annual report:

 

That last point especially -- it's time for greater curiosity and more questions about the way things have always been done -- is the intellectual underpinning for quality, safety, and process improvement.

Look at this point, too, made CEO Bonnie Brossart, in the document:

I am energized by the development of our new 2011-2014 Strategic Plan, Accelerating System-wide Improvement: Transforming Saskatchewan’s health care system. What excites me is the collaborative approach we took in seeking out ideas from our customers about what they need from us over the next three years. While we don’t necessarily have the answers or solutions, we do have curiosity and QI knowledge to help our customers create their own solutions. Our plan reinforces our commitment and desire to play a pivotal role in ensuring the highest quality of health care for every person, every time.

The website, too, is chock full of interesting stories and updates, including links to other blogs, like this intriguing one, Adventures in Improving Access, where urologist Dr. Kishore Visvanathan and his colleagues present:

Their challenges and their victories, their obstacles and their "aha's" - as they work to drive down their backlog and push up the satisfaction of patients, referring physicians, and their own team.

Congratulations to this organization, and best wishes for continued success!

An ad for NASDAQ?

If you have been worrying about your retirement account given the fluctuations in the stock market, here's good news.  You are less likely to survive a downturn.

A recent paper, "Stock Volatility as a Risk Factor for Coronary Heart Disease Death", (European Heart Journal; 2011; 32(8): 1006-1011) explains:

The volatility of financial markets may cause substantial emotional and physical stress among investors. We hypothesize that this may have adverse effects on cardiovascular health. The Chinese stock markets were extremely volatile between 2006 and 2008. We, therefore, examined the relationship between daily change of the Shanghai Stock Exchange (SSE) Composite Index (referred as the Index) and coronary heart disease (CHD) deaths from 1 January 2006 to 31 December 2008 in Shanghai, the financial capital of China.

We found that CHD deaths fluctuated with daily stock changes in Shanghai, suggesting that stock volatility may adversely affect cardiovascular health.

Self-dialysis in Sweden

Ryhov Hospital in Jönköping, Sweden, had a traditional hemodialysis and peritoneal dialysis center. Now they aim to have 75% of patients be on self-dialysis.

Read that again.

When Maureen Bisognano, CEO of the Institute for Healthcare Improvement, told me this story, I was blown away.  How could this happen?  Here are some of her slides from a recent presentation.

In 2005, a patient named Christian asked about doing it himself.  The nurse in charge thought about it and thought that he could pull it off.  She had trained many other nurses in the procedure, so she just trained him in the same sequence.  Then it went viral. 

They currently have 60% of their patients on self-dialysis and hope to reach 75%.  Christian reports:

The nurse leader says:

Did you notice that?  1/2 to 1/3 less cost per patient.  Better outcomes, far fewer complications and infections.

A staff nurse says:

Did you notice that?  Instead of engaging in vulnerable and helpless behavior during treatment, the patients were energized and would exercise.

What does all this mean?

I can already hear the objections.  "Our patients are sicker."  "The Swedes are all the same ethnicity."  "It would never work here."

Right.

What's the story behind the story?

When you read a story and it doesn't make sense on its face, you have to wonder what's behind it.  Today's example is this one from the Boston Globe:

Partners HealthCare System Inc., the state’s largest hospital and physicians network, has signed a letter of intent to acquire Neighborhood Health Plan, a Boston-based nonprofit that insures more than 240,000 mostly low-income residents across Massachusetts.

I am speculating, of course, but there are two ways to look at this.  One is that PHS is trying to lock in a set of relationships and customers for the future; but that doesn't make sense because these patients are poorly reimbursed.  Also, the company has promised that it will not use this new relationship to limit those patients' choice of providers.  So to make that work, it would have to develop new models of care that enable this group of patients to be profitable, notwithstanding Medicaid rates that are acknowledged to be too low.  A worthy, but very hard row to hoe when you operate a high fixed cost network.

The other is that a trade has taken place, related to the fact that the holding company has been facing state and federal antitrust reviews.  It agrees to provide some financial assurance to a financially stressed insurance company and community health centers serving mainly the indigent, in return for being allowed to keep other human resource or geographic assets that might otherwise be subject to a divestiture that would have reduced its market power.

Or maybe they just want to make sure care is accessible to everyone.

Closing? I don't care.

A recent headline in my local newspaper* at first had me wondering at the news sense of the editor:  "Post Office patrons not shocked by possible closings."  What kind of story is this?  A non-reaction to a possible event?  It certainly did not meet the "man bites dog" standard.

But then I read further, and I found that there is a real story here, and a warning for people in health care: You are not as essential as you think.  There are disruptive forces in these fields that can make you obsolete.

The purpose of this story was to document community reaction about the possible closing of some neighborhood post offices, arising from the business problems faced by the USPS.  Here are some of the comments:

Jim Rectra isn’t surprised by the news. The Waltham man said he lives about a mile from the West Newton post office, but uses the service sparingly. “I don’t use the post office that much,” Rectra said. “I try to do everything online.”

At the Lower Falls office on Washington Street, Molly Grant wasn’t disappointed to learn the location might shut its doors. Grant, a Weston resident, said she’s not thrilled with the service at Lower Falls. “I really only come for the convenience,” she said.

Even Barney Frank, the US Congressman, said:  "This one is one where it’s not my opinion that counts, but people in the neighborhood.”  Barney never admits that his opinion doesn't count and never misses a chance to fight for his constituents, but that's only when he is pretty sure of winning the issue and garnering votes thereby.  Here, he knows that neither is likely.

What has happened, clearly, is that the public's perceived need for these facilities and their services has diminished greatly.  Whether it is on-line purchases of postage or bypassing postage altogether by using email, Skype, and other social media, the infusion of new choices has relegated the local post office to the status of the Model T.  Boy, it's nice to see one, but I don't think I need one.

Clay Christensen has reached similar conclusions about general hospitals.  Disruptive forces are at work that should compel hospital administrators to rethink their business model.  This is especially the case for academic medical centers, which are burdened by even more significant overhead costs than a regular general hospital.

I have discussed this before, when I noted:

The lessons here for high fixed cost academic medical centers are clear. Academic medical centers face all of the problems of two stressed industries -- academia and medicine. The future will belong to the efficient. Hospitals that are driven by their senior faculty and hopeful junior faculty to expand buildings and research facilities, that invest in high-cost but unproven clinical equipment, that do not engage in front-line driven process improvement, that fight transparency of clinical outcomes -- and that plan to depend on private and government reimbursements, government grants, and philanthropy to pay for all this -- will not do well. Those that limit capital investment in inflexible fixed assets, that focus on higher quality and reducing waste, that endorse transparency, that invest in the science of health care delivery as much as basic science, and that develop and implement treatment modes that take care to the patient rather than requiring physical visits by patients, will do well.

--

* Newton Tab, Vol. 34, No. 15, August 10-16, 2011. Page 1.  The online edition is here, with a different headline.

In memoriam: Thousands from Hiroshima and Nagasaki

On the anniversary week of the first use of atomic bombs at Hiroshima and Nagasaki, it is stunning to watch this video.  Within the first two to four months of the bombings, the acute effects killed 90,000–166,000 people in Hiroshima and 60,000–80,000 in Nagasaki.  Let's hope we never see such devastation again.

Japanese artist Isao Hashimoto has created a beautiful, undeniably scary time-lapse map of the 2053 nuclear explosions which have taken place between 1945 and 1998, beginning with the Manhattan Project's "Trinity" test near Los Alamos and concluding with Pakistan's nuclear tests in May of 1998. This leaves out North Korea's two alleged nuclear tests in this past decade (the legitimacy of both of which is not 100% clear).

Each nation gets a blip and a flashing dot on the map whenever they detonate a nuclear weapon, with a running tally kept on the top and bottom bars of the screen. Hashimoto, who began the project in 2003, says that he created it with the goal of showing"the fear and folly of nuclear weapons." It starts really slow — if you want to see real action, skip ahead to 1962 or so — but the buildup becomes overwhelming.

To build a fire

A short break from health care, as we are in the midst of many people's summer reading pleasure.  Maybe this will prompt some to put aside novels and nonfiction and read some of those great short stories.

I was in Jack London Square in Oakland, CA, a couple of weeks ago, and it prompted me to comment to several family members about London's short story, "To build a fire."  It had made a huge impression on my when I read it as a teenager.  None of them had read the story, and when I described it, some found the idea disturbing -- which, of course, it is.  But it is worth reading.  It is on this website in its entirety.

It is even better than I remember it, a true classic of short story construction.  And for those of us who have spent time in the wilderness, well . . .

Here is the beginning, with full foreshadowing of things to come:

DAY HAD BROKEN cold and gray, exceedingly cold and gray, when the man turned aside from the main Yukon trail and climbed the high earth-bank, where a dim and little-travelled trail led eastward through the fat spruce timberland. It was a steep bank, and he paused for breath at the top, excusing the act to himself by looking at his watch. It was nine o'clock. There was no sun nor hint of sun, though there was not a cloud in the sky. It was a clear day, and yet there seemed an intangible pall over the face of things, a subtle gloom that made the day dark, and that was due to the absence of sun. This fact did not worry the man. He was used to the lack of sun. It had been days since he had seen the sun, and he knew that a few more days must pass before that cheerful orb, due south, would just peep above the sky-line and dip immediately from view....

But all this—the mysterious, far-reaching hair-line trail, the absence of sun from the sky, the tremendous cold, and the strangeness and weirdness of it all—made no impression on the man. It was not because he was long used to it. He was a newcomer in the land, a chechaquo, and this was his first winter. The trouble with him was that he was without imagination. He was quick and alert in the things of life, but only in the things, and not in the significances. Fifty degrees below zero meant eighty-odd degrees of frost. Such fact impressed him as being cold and uncomfortable, and that was all. It did not lead him to meditate upon his frailty as a creature of temperature, and upon man's frailty in general, able only to live within certain narrow limits of heat and cold; and from there on it did not lead him to the conjectural field of immortality and man's place in the universe. Fifty degrees below zero stood for a bite of frost that hurt and that must be guarded against by the use of mittens, ear-flaps, warm moccasins, and thick socks. Fifty degrees below zero was to him just precisely fifty degrees below zero. That there should be anything more to it than that was a thought that never entered his head.

As he turned to go on, he spat speculatively. There was a sharp, explosive crackle that startled him. He spat again. And again, in the air, before it could fall to the snow, the spittle crackled. He knew that at fifty below spittle crackled on the snow, but this spittle had crackled in the air. Undoubtedly it was colder than fifty below—how much colder he did not know. But the temperature did not matter.

Here are the last paragraphs, after he fails to make the fire and tries to keep warm by running around:

He was losing in his battle with the frost. It was creeping into his body from all sides. The thought of it drove him on, but he ran no more than a hundred feet, when he staggered and pitched headlong. It was his last panic. When he had recovered his breath and control, he sat up and entertained in his mind the conception of meeting death with dignity. However, the conception did not come to him in such terms. His idea of it was that he had been making a fool of himself, running around like a chicken with its head cut off—such was the simile that occurred to him. Well, he was bound to freeze anyway, and he might as well take it decently. With this new-found peace of mind came the first glimmerings of drowsiness. A good idea, he thought, to sleep off to death. It was like taking an anaesthetic. Freezing was not so bad as people thought. There were lots worse ways to die.

He pictured the boys finding his body next day. Suddenly he found himself with them, coming along the trail and looking for himself. And, still with them, he came around a turn in the trail and found himself lying in the snow. He did not belong with himself any more, for even then he was out of himself, standing with the boys and looking at himself in the snow. It certainly was cold, was his thought. When he got back to the States he could tell the folks what real cold was....

Then the man drowsed off into what seemed to him the most comfortable and satisfying sleep he had ever known. The dog sat facing him and waiting. The brief day drew to a close in a long, slow twilight. There were no signs of a fire to be made, and, besides, never in the dog's experience had it known a man to sit like that in the snow and make no fire. As the twilight drew on, its eager yearning for the fire mastered it, and with a great lifting and shifting of forefeet, it whined softly, then flattened its ears down in anticipation of being chidden by the man. But the man remained silent. Later, the dog whined loudly. And still later it crept close to the man and caught the scent of death. This made the animal bristle and back away. A little longer it delayed, howling under the stars that leaped and danced and shone brightly in the cold sky. Then it turned and trotted up the trail in the direction of the camp it knew, where were the other food-providers and fire-providers.

And here is a film of the pertinent scene.  It is very effectively done.

If you cannot see the video, click here.

Supporting “The Boshman” in His Recovery

We all know worthy people who have experienced medical hardship who need our help.  Here's one such case and a painless way for you to help, if you'd like.

A friend writes:  On July 2, 2011, Chris Boshar suffered a spinal cord injury. He is currently at The Shepherd Center in Atlanta, Georgia undergoing rehabilitation. As of now, his injury is C4/5 complete. In addition to the medical and rehabilitative help he is receiving, he is in need of many prayers and strong positive energy to get him through this difficult time.

A number of friends are trying to raise money to help the family, and there is a silent auction set up to do so.  They have collected very special items for Bostonians and people who might be visiting here, including some amazing sports tickets.  The auction closes on Friday, August 12 at noon.  You can check the website here, and participate by mailing in a bid to boshfund [at] comcast [dot] net.

Note, the embedded link is sometimes slow loading.  Try instead by cutting and pasting this into your browser:  http://home.comcast.net/~boshfund/boshauction.pdf

Or, if you still have trouble, just email the address above for more details.

Birthday thoughts

The signals arise, and they are not pretty:

As I am entering a state park in California two weeks ago, the gate attendant asks, “The senior discount?” Riding the MBTA to and from Boston, I am offered a seat by someone in their twenties -- in both directions!  Seeing a person in the grocery store, I recognize their face, but draw a blank on whether I know them from work (the most recent job, the previous one?) or soccer (a parent of a girl I have coached?) or some other setting.  (I hope that the first few words in the conversation give the pertinent clue.)  Having my dentist, orthopaedist, ophthalmologist, dermatologist, or gastroenterologist say, “You just have to expect that at your age.”

I have long said, “What you lose in memory, you gain in wisdom,” but who can remember that when the pressure is on?

Here’s what I have really learned:

You don’t get to pick your family, but you do get to decide whether to have them be your family.

Your true friends are a gift, and it is never too late to find more true friends.  That being said, some true friendships come to an end, and it is not necessarily anyone’s fault.

It IS better to give than receive.

A conversation with a person who is dying is humbling and awe-inspiring.

Holding and smelling new babies is the humbling and awe-inspiring bookend.

Watching them become warm, talented, kind, accomplished adults is over the top.

Coffee ice cream at Dresser Hill

It is midsummer and time for a visit to Dresser Hill, my favorite ice cream stand.  About a year ago, I wrote to tell you about a Camp Wamsutta reunion. One memory we discussed was about our counselors, who would go out at night and return with cups of ice cream from this dairy farm down the road.

So, of course, I return whenever I can.  The farm is situated on the top of a hill in Charlton, with a view that extends for miles to the west overlooking the Quinebaug Valley.  It is indeed unusual to have such an expanse.

The place has a long history, with lots of participants.  Here's one from this review page:

Dresser Hill Put 100 Pounds on Me
 I have been going to Dresser Hill since my Mother milked cows by hand and put the steel milk cans in the back of her caddy and delivered it to Arthur! I was about five, and my favorite memory was the day I could finally eat a whole banana boat. Arthur was so tickled, all my banana boats were free that summer! I still have a couple of them in my back pockets!

The portions, as suggested by this reviewer and as you see in this warning, are very large.  I go for the kids size, which is "only" one large scoop.

My favorite back in those camp days was coffee ice cream.  Dresser Hill carried a particularly creamy variety, with an excellent coffee taste.  Also, the color was a nice light shade of tan.  Some nights, I would eat a pint (480 cc's) of the stuff.

I am pleased to report that the ice cream is the same as it was back then.  The first lick brings back memories of a group of boys, sitting quietly in their beds, spooning ice cream, and listening to the crickets of early August outside the screen windows of our cabin.

The coffee ice cream is the same!

Grandma Angelina's cookies are angelic!

I love it when local entrepreneurs reach into their ethnic heritage bag of tricks and create a new product line, especially if it is related to food.  Maybe you remember my post about Eduardo Kreindal and his creation, Giovanna Gelato.  Now I have discovered Michele Ozioli, who dug up some recipes from her grandmother, Angelina, and created pizzette, delicious Italian cookies. Here's the website.

I met Michele at the Brighton (MA) Whole Foods this week.  She said she would be back on Monday, from 3pm to 6pm, handing out more samples.  Hmm, I may drop by again.

Come to think of it, crumbling some of those cookies on top of Eduardo's gelato may be the perfect combination.

IHI reaches out to middle managers

I remain impressed with the ability of the Institute for Healthcare Improvement to reach out to various sectors of the health care world and offer useful, affordable, and accessible curricula on quality, safety, and process improvement.  Here's an example, a program designed for middle managers:

A 9-Month Professional Development Program
Begins October 6, 2011

As the link between senior leadership and the front lines, middle managers serve a vital role in converting strategic goals into action. Turning high-level goals into results requires a strong foundation in improvement, yet unfortunately, few opportunities exist for managers to formally acquire the skills necessary to accomplish this.

To meet this need, the Institute for Healthcare Improvement (IHI) is pleased to offer Leading Quality Improvement: Essentials for Managers, a virtual professional development program. Over the course of nine months, expert faculty will teach participants the requisite improvement skills to meet their organizations’ goals of demonstrably better outcomes, safer care, and reduced costs.

For more information, or to enroll, please visit our website.

Meet me at the Coolidge . . . and Make Memories

A Brookline, MA, friend writes:

This is an innovative program for folks with memory loss.  I plan to take both of my parents to this autumn/winter's showings at the Coolidge Corner cinema, 10AM to noon.  If you know anyone who has a family member with dementia, this is a FREE program for caregivers and patients with memory loss that is designed to be both enjoyable and therapeutic.   Feeling very lucky to live in this area where I can take my parents to something designed exactly for their conditions.  "ARTZ: Artists for Alzheimers" is the creator/presenter of this program.  If it is not offered where you live, ask for it to come to your community.

The website explains: 

A one-of-a-kind film experience, designed specifically for people with memory loss and their care partners. Short clips from classic films are shown, followed by audience discussion and reminiscence, guided by a moderator.

This program demonstrates how film can be a form of treatment for some of the symptoms associated with memory loss, Alzheimer's disease and related dementia. The cinema has the power to connect us with our deep-rooted emotional memories - the kind that never leave us.

US Rumor and Hospital Report

It has been almost four years since I commented on the annual hospital ranking prepared by US News and World Report.  I have to confess now that I was relatively gentle on the magazine back then.  After all, when you run a hospital, there is little be gained by critiquing someone who publishes a ranking that is read by millions.  But now it is time to take off the gloves.

All I can say is, are you guys serious?  Let's look at the methodology used for the 2011-12 rankings:

In 12 of the 16 [specialty] areas, whether and how high a hospital is ranked depended largely on hard data, much of which comes from the federal government. Many categories of data went into the rankings. Some are self-evident, such as death rates. Others, such as the number of patients and the balance of nurses and patients, are less obvious. A survey of physicians, who are asked to name hospitals they consider tops in their specialty, produces a reputation score that is also factored in.

Here are the details:

Survival score (32.5 percent). A hospital's success at keeping patients alive was judged by comparing the number of Medicare inpatients with certain conditions who died within 30 days of admission in 2007, 2008, and 2009 with the number expected to die given the severity of illness. Hospitals were scored from 1 to 10, with 10 indicating the highest survival rate relative to other hospitals and 1 the lowest rate. Medicare Severity Grouper, a software program from 3M Health Information Systems used by many researchers in the field, made adjustments to take each patient's condition into account.

Patient safety score (5 percent). Harmful blunders occur at every hospital; this score reflects how hard a hospital works to prevent six of the most egregious types. A 3 puts a hospital among the 25 percent of those that were best in this regard, a 2 in the middle 50 percent, and a 1 in the lowest 25 percent. Examples of the six kinds of medical episodes factored in are deaths of patients whose conditions should not have put them at significant risk and surgical incisions that reopen.

Reputation (32.5 percent). Each year, 200 physicians per specialty are randomly selected and asked to list hospitals they consider to be the best in their specialty for complex or difficult cases. A hospital's reputational score is based on the total percentage of specialists in 2009, 2010, and 2011 who named the hospital. This year some physicians were asked to list up to five hospitals, the rest to list up to 10.

Other care-related indicators (30 percent). These include nurse staffing, technology, and other measures related to quality of care. The American Hospital Association's 2009 survey of all hospitals in the nation was the main source.

Let's see how this pans out for one specialty, pulmonology. We see that the number 1 and 2 ranked hospitals have great reputations but the lowest score for patient safety.  The first hospital with “superior” safety rankings doesn’t appear until number 21.

The reputational data is opaque, as it has to be.  With great respect for the 200 pulmonologists who were surveyed, how much current data have they seen about the outcomes achieved by hundreds of hospitals and thousands of doctors around the country.  Answer:  None.  Why?  Because there is no current data published on such outcomes.  Likewise, there is no current data published about hospital related infections, falls, medication errors and other matters that could affect the treatment of a pulmonary patient, even if the pulmonologists are top-notch.

So, the reputational survey is likely to based on the following type of "information":

Oh, I like Dr. Smith at ABC hospital.  We were in residency together 25 years ago.  He was a great guy.  I still remember that amazing Christmas party in 1986.

Or, maybe:

That Dr. Jones is at XYZ hospital is terrific. I heard him give a paper at the last meeting of the ATS (or ACCP, or AABIP.)  His Powerpoint presentation about his clinical successes (or research with mouse models) was gripping.

Or, maybe:

Dr. Pebble was trained by Dr. Stone, one of the best in the business in his day (40 years ago.)  That's good enough for me.

Or, even:

I sent a really sick patient to Dr. Good at RST Hospital.  He saved her life.  It was a very tough case, and he deserves a lot of credit.

US News needs to stop relying on unsupported and unsupportable reputation, often influenced by anecdote, personal relationships and self-serving public appearances, and work on real -- and more recent -- data. Maybe that will also cause hospitals to be more willing to report their data so they can be named to the “Honor Roll.” As it is, you are better off keeping things opaque to protect your reputation.

I think it is time to acknowledge that this ranking offers very little in the way of valuable information.  It is mainly a vehicle for advertisements from the pharmaceutical industry, who know that this issue of the magazine gets a lot of attention and high circulation.  As you flip through to each specialty, you are blasted with ads for drugs related to syndromes within that specialty.  Here's the top part of the pulmonology page:

Then, if you click through to "find resources about" a particular disease, you do get some nice content information, but you get sprayed with even more ads.

There would be no market for this magazine survey if the government or insurance companies did their job and displayed real-time clinical outcome data.  But those with the reputational advantage do not want that to happen.  And those who profit from the lack of data also have nothing to gain by a more open presentation of the actual record and qualifications of hospitals and doctors in each specialty.

Product placement?

Seen entering Cambridge, MA on the River Street Bridge.  Is this a revenue raiser for the Highway Department or a rogue placement?

How to keep bike lanes open for bikes

I am so proud of the new bike share program sponsored by Boston's Mayor Tom Menino. But it is time to get even more aggressive about keeping cars from parking in the bike lanes.  Our mayor should take a hint from Mayor Zuorokas of Vilnius, Lithuania.  Here's the video:

If you cannot see the video, click here. (Thanks to @SWGriffith and @ScottKirsner on Twitter for the link!)

Meanwhile, on the Medicaid front

Here's the latest on Medicaid funding in Massachusetts, which seems to be typical of many states.  I guess this is part of the promise of President Obama and others to lower "costs," i.e., appropriations, as part of health care reform.

Note, this came before this week's deficit reduction legislation.

The summary is from The Massachusetts Medicaid Policy Institute (MMPI).

The FY 2012 budget includes $10.4 billion for MassHealth — an increase of just $155 million over current FY 2011 projected spending. The FY 2012 budget assumes significant constraints in the MassHealth program, and relies on significant cuts and savings, most of which were part of the Administration’s original FY 2012 budget proposal. . . . All told, the FY 2012 GAA includes approximately $770 million in cuts and savings to the MassHealth program.

Cutting spending to such a large degree within one fiscal year will be very challenging, particularly as the MassHealth administrative budget to implement such initiatives is also being cut. Furthermore, the federal maintenance of effort (MOE) requirement removes the ability to modify eligibility or cap enrollment as an option to addressing budget gaps, unless

a hardship waiver is sought. This leaves provider and managed care capitation rate cuts and reductions in benefits as the main tools available to quickly achieve the large level of savings needed.

Based on assumptions included in the Administration’s original budget proposal, these savings are to be achieved primarily through new procurement strategies aimed at those currently enrolled in managed care as well as other controls on provider and managed care organization rates and payments. It is important to note that if MassHealth does not meet these savings targets, other significant programcuts might be necessary to stay within budget, or additional funding may need to be appropriated later in the year.

What is the value of $40 million?

As Poo-Bah says, "Merely corroborative detail, intended to give artistic verisimilitude to an otherwise bald and unconvincing narrative:" Let's consider how much $40 million is really worth when you spread the payment over a period of time.

As economists and investors will tell you, there is a time value associated with money.  To prove this, ask yourself whether you would rather receive $40 today or a year from now.  Of course, you would want it today, as you can use or invest it today, whereas its future value is less.  As the person who owes you money, I'd rather pay it to you in the future than today, for exactly the same reason.

There is a formula (above) that tells you the time value of money.  It is based on the interest rate you could otherwise earn on that money.  In the nonprofit world, that is the rate you can earn on your endowment.  In 2010, the average return on endowments was about 12% according to the Chronicle of Philanthropy.*

So, if an organization postponed paying $40 million for a year, it was able to deprive the payee of the right to that money for that period, reducing the effective cost to the payer (and the value to the payee) to $35.71 million ($40 million divided by 1.12).

But this is between friends, so let's put that aside, and start all over with $40 million, looking forward from today.  What if the organization reduces its insurance reimbursements by $40 million over the next year or two?  We divide the $40 million by 12 or 24 months, apply the relevant monthly discount factor (12% divided by 12 or 24) and discover that effective cost to the payer (and the value to the payee) has dropped to about $38 million.

Meanwhile, the company has already taken a charge against earnings of $40 million.  That this is the appropriate accounting treatment should not be doubted.  But accounting treatment is not concerned with the time value of the money.  It deals in nominal dollars.

But remember how you felt, above, knowing in your heart that a check today is worth more to you than one of the same amount next year.

---

* We can quibble about the appropriate discount rate.  Perhaps we should be using the interest rate faced by small businesses or individuals on their credit cards or other lines of credit.  Perhaps we should consider the inability of some small businesses to borrow at any rate, implying an infinitely high cost of money.

Chutzpah, timidity, prediction, policy

What do you call it when a hospital and physician system gets to collect an extra, say, $200 million per year in insurance payments for a decade and a half?  What do you call it when that system promises a one-time donation of $40 million towards a crisis in individual and small business insurance premiums, but then says, "We didn't necessarily mean cash" -- but preferably a negotiated offset to a previously unspecified and unknowable level of future rates?

Chutzpah.

What do you call it when the Commonwealth has the legal authority to publicize the data it has already collected and to take actions to moderate the payments made by insurance companies to this hospital and physician system, but chooses not to?

Timidity.

What do you call this?

The parties agree to experiment with bundled payments for certain diseases and procedures, staying far away, though, from a full system of capitation. The parties agree to a general rate increase of just a few percent. Together, they will say, this will "bend the cost curve" for this large group of doctors and hospitals. There won't be much talk about the fact that the base upon which the bundled payments and other fee-for-service payments is set remains far above market.

End result: Continued use of market power as the prime determinant in setting reimbursement rates.

A pretty accurate prediction.

What do you call it when all this is happening before our eyes?

Massachusetts health care policy.

Five years running

Today marks the fifth anniversary of this blog.  Little did I realize when I offered my first post that it would evolve into a personal compulsion.  Even less did I understand the power it would have as a leadership tool within my hospital and the impact it would have  more generally in the health care field.

I started this blog because I had an interesting job (CEO of a hospital) in a fascinating field.  Being new to the field myself, I thought that other people might like to have an insider’s view of what was going on in an academic medical center.  The blog would also require me to think clearly about what I was learning so I could synthesize things for my readers.

What readers?  At the beginning, there were a few, mainly the lawyers and press people in my hospital who had an underlying fear that I would say something illegal, inappropriate, or downright dumb.  I knew they had nothing to fear on the first two points, but on the third, they had every right to be nervous!

I learned how to generate traffic for my blog.  First, I sent an email to my 500 closest friends, letting them know about it and asking them to tell others.  Second, I created linkages to other health care bloggers.  Third, I tried to write something interesting so people would come back for a second visit.

The breakthrough moment, though, came when Boston Globe business reporter Chris Rowland wrote an article about the blog in his newspaper.  Privately, he also told me that my posts were a bit boring and that I needed to spice things up a bit.  From then on, it was off to the races, as you can see in this traffic report from the days right after his story. (In those days, I eagerly counted page loads in the hundreds rather than thousands!)

When I left my job at the hospital this past winter, quite a number of you wrote to me and expressed hope that I would maintain the blog.  Because of you, I did so, and I have been pleasantly surprised to see that viewership has continued to grow.  My topics have become less Boston-centric (except where Massachusetts offers broader lessons).  Also, of course, I no longer present inside stories about my former hospital.  I now consider myself an unabashed advocate for those causes mentioned in the masthead.  In that capacity, I am more free to be even more direct than before (if that is possible!) about things that matter to patients and families, and also to doctors, nurses, and other people involved in the delivery of care.

I have found, too, that many of you are eager to join in by sending me story ideas from your regions -- events and concepts that you know are important to your constituencies and more broadly.  I welcome those suggestions and promise to maintain your confidentiality as I rewrite them for the general audience.

The blog has also turned into a bit of a magazine over the years, with other topics of interest to me and, I hope, to you.  You don’t have to stick with me very long to know of my passion for soccer, infrastructure, civil rights, effective government, good food, and nature.  I hope that the articles on those topics provide a nice break for you, as they do for me.  After all, you can’t talk about health care all the time!

It is traditional, on this kind of anniversary, to cite those blog posts that have generated the most interest, in terms of traffic and/or comments.  I demur on that point.  Each of you has your favorites -- and the ones you hated -- and it serves no purpose to give you my summary right now (although that may come in a future book on the value of social media for those in leadership positions.)

For now, I simply offer my thanks to you -- regular readers, occasional readers, newly arrived readers -- for allowing me the privilege to let this site provide useful, informative, or entertaining content in your lives.

And for my colleagues in arms, the other health care bloggers out there, a special thank-you for your friendship, collegiality, support, and good humor as we together try to transform the health care system into what we would want for members of our own families.  There is a long way to go, but there is no more worthwhile endeavor.