Major safety threat found in the UK

Thanks to Wait, Wait . . . Don't tell me, I just learned of something I missed last week:  A threat to health care workers everywhere.  Luckily, the NHS is on this and has taken decisive action.

Here's the story on the BBC World News.  I publish the story in a different font and color for emphasis so no one will miss it: 

NHS health and safety chiefs ban ‘dangerous’ metal paper clips

Manchester NHS Trust officials made the decision to stop the use of the metal stationary item after a member of staff cut their finger using one. In a memo to staff, it was warned that the use of metal fasteners was ‘prohibited’ and the offending clips must be ‘carefully disposed of immediately’. ‘Due to recent incidents, NHS Manchester has decided to immediately withdraw the use of metal paper fasteners,’ explained the memo featuring an accompanying picture of a paper clip – just to avoid any confusion. ‘Please ensure any that remain in use be replaced by similar plastic fasteners. The use of metal fasteners is prohibited and must be carefully disposed of immediately. Thank you for your co-operation.’ 

Disclosure training is not a fifty minute lecture

Head over to the Educate the Young blog written by David Mayer and friends for an important series of articles about disclosure of medical errors as part of a medical curriculum.  David created the first longitudinal medical school program in quality and safety at the University of Illinois College of Medicine in Chicago.  He draws on that experience and more in this series, starting with a post entitled "Disclosure training is a process, not a fifty minute lecture."

He then proceeds to the first phase of the training, things covered in the first and second year of medical school.  This is followed with a discussion of the third year curriculum.  He promises that in the final post in the series:

I will share the final component – the capstone – of our four-year medical school curriculum on disclosure of medical errors. It is our belief that educating future physicians about the importance of open and honest communication when patient care causes unintentional harm is most certainly more than a 50 minute, one-time plenary.

What a model David sets forth! You see the rigor and thoughtfulness behind this, as well as the pedagogical excellence inherent in it.  It leaves you wondering why other medical schools have not done the same.

Not warm and fuzzy at BCBS of Rhode island

Facebook friend Nancy Thomas, President of Tapestry Communications, reported from Rhode Island last week:

No one would believe it. Blue Cross has now taken away the seats in their waiting room in the lobby. You have to sign in on a pad of paper. Then you stand in the lobby and wait. When you finally get called in to talk to 1 of the 2 customer service reps, she tells you that you are now being recorded. I asked her where the tape recorder was, astounded to hear her say that, "It's here," holding her hands up.

Not just once.  Again, today:

I had to go down again to turn in some transfer forms as my daughter is now being covered by the firm where she works, and I just wanted to drop it off.  The woman said I had to confirm my information so I said it again - name, address, phone, had to repeat area code! (slow simmer...) and she said it again - "We are recording this."

Apparently the environment isn't so warm and fuzzy either:

No one can go above the ground level at Xanadu. A surreal experience.

This building is affectionately called "Xanadu" by RI media because NO ONE has seen it.  It is supposed to have a garden on the roof and it glows blue at night.

I managed to take some photos of the BC lobby and also found a website that actually shows for the first time that I'm aware of what the building looks like upstairs.  I have a colleague who has an office in the office building next door and she says that when you look in the windows there is no one there - and she watches this one woman doing her makeup and fixing her hair all day - in her windows cubicle.

It just galls me....and I'm a private paying client!

Here is the link to the architect's website.

Minimum disruption on WIHI

August 9, 2012: Minimally Disruptive Medicine
2:00 – 3:00 PM Eastern Time

Guests:
Victor Montori, MD, MSc, Director, Mayo Clinic Healthcare Delivery Research Program; Professor of Medicine, Mayo Clinic

Nilay Shah, PhD, Assistant Professor of Health Services Research, Mayo Clinic
 
One of the most common phrases used to describe patients who are not taking their prescribed medications or following up on the recommendations of their health care providers is “non-compliant.” What if we viewed the behavior as an act of civil disobedience instead? This provocative notion definitely got the attention of health professionals in the audience at IHI’s 13th Annual Summit on Improving Patient Care in the Office Practice and the Community (March 18-20, 2012). It’s the thinking of Dr. Victor Montori, a diabetologist and researcher at Mayo Clinic whose keynote remarks* at the gathering were, in part, intended to shake up common and sometimes negative assumptions about patients with chronic diseases who don’t seem to be holding up their half of the bargain. Dr. Montori invites all of us to consider the work of being a chronically ill patient, and the burden of increased expectations to follow regimens that don’t easily fit into a patient’s daily life, social circumstances, preferences, and more.

What’s the alternative? Dr. Montori and colleagues call it “minimally disruptive medicine,” and WIHI invites you to learn more about this change of mindset and approach to chronic disease and what it can look like in practice on the August 9, 2012, show. Host Madge Kaplan and Dr. Montori will be joined by Nilay Shah, a health services researcher at Mayo Clinic. Both Drs. Shah and Montori argue that with the growth of patient-centered medical homes and numerous other initiatives that assume a greater role for patients and family members in managing chronic conditions, it’s a critical moment to examine what added workload this implies. The two argue that some of the burden on patients can be reduced if approaches to care are married with efforts to reduce unnecessary and costly over-treatment.

Think of it this way, says Dr. Montori: So-called “non-compliance” is actually an alarm system for a health care system that’s failing patients. The goal needs to be shifting and sharing responsibility for chronic disease with patients and families — not shifting the burden.

Please join what promises to be a vibrant discussion on the August 9 WIHI. To learn a bit more about minimally disruptive medicine before the show, check out the story of Susan and John.

To enroll, please click here.

Understanding Patient Safety

Bob Wachter at the University of California, San Francisco, has done so much good for the world--for patients, their families, and his colleagues in medicine--and he recently added to the total.  He published the second edition of Understanding Patient Safety.  The first edition rapidly became the leading primer in the field when it was issued in 2008.  This update and expansion will surely take its place.

The contents are extensive and inclusive, starting with the nature and frequency of medical errors and adverse events, leading to basic principles of patient safety, and thence to issues of safety, quality, and value.  Following this introduction, we are led through the types of medical errors and solutions to them.  As one might expect from Bob, the presentation is interesting, concise, and thoughtful.  If I were a doctor or nurse--newly minted or experienced--I would want this as my key reference. While the book is not really written with the patient community as its main audience, it is readable enough to warrant broad circulation.

Lucien Leape described the book as "a true gem, destined to be a close companion for all of us who strive to make health care safe."  Lucien was absolutely on target.  This book represents the best that medicine can be.  It adds to my gratitude for knowing Bob and having the opportunity to learn from him again and again.

First, assume a ladder

A distinguished local health care economist was giving me a hard time about some of my statements about the Massachusetts health care market.  I had talked with him about the importance of removing disparities in the amount paid to the dominant provider group and other topics covered in this blog.  He said, "You're wrong.  I've been looking at this a long time.  Just get the pricing right, and it will get better.  Get rid of fee for service and move to global payments."

This reminded me of the old joke.  An engineer and an economist were walking through the forest when they fell into a deep pit in the ground.  It had vertical sides, and they could not climb out.

"This is hopeless," said the engineer.  "We'll never be able to get out.  No one knows we are here.  We will die before we are found."

"Not so," said the economist.  "There is no problem."

"What do you mean?  How could that be so?" replied the engineer.

"It's simple," said the economist.  "First, assume a ladder."

My economist colleague was doing the same thing.  He was assuming that market conditions exist in the state that will allow a different pricing regime to make a substantial difference in the pattern of health care cost increases.  There is no evidence for this proposition in a state with a dominant provider group and a dominant insurance company. 

Josh Archambault, Director of Healthcare Policy at the Pioneer Institute, has thought things through more clearly.  He says, of the legislation signed by the Governor today: 

Rather than provide financial incentives for individual patients to take charge of their own medical care, this legislation rearranges the system based on accountable care organizations (ACOs) and governmentally-imposed changes in payment methods.  Real-life evidence that these approaches contain costs is mixed at best; as a result, the law misses the mark by a long shot and will not lead to long-term, sustainable containment of health care costs.

The government will impose caps in healthcare cost increases, which will lead to further consolidation in the market--exacerbating one of the causes of the predicament we are in today. The law will also lock in place current inequalities of provider reimbursement levels, as everyone will grow at the same rate, but not everyone is starting from the same place. Then just to add salt to the wound, the government is ensuring that healthcare will cost us all a lot more, by adding hundreds of millions of dollars to the system through new surcharges, fees, and penalties. Make no mistake about it, these costs will be passed onto consumers.

By the time this is evident, the current governor and many current legislators will no longer be around to help dig the state out of its new hole.

The Great Train Robbery, version 2.0

A few years ago, at a meeting of business executives and the leaders of the Executive and Legislative branches of the Massachusetts state government, a representative of MA Blue Cross Blue Shield made a presentation advocating capitated, or global, payments for health care providers in the state.  This was presented as the most effective way of lowering the rate of growth of health care costs in the state.

The people from Partners Healthcare System were quiet during the presentation.  The CEO of Tufts Medical Center pointed out that effective cost control was impossible as long as the disparities in reimbursement rates among provider groups remained in place.  She pointed out, too, that overlaying global rates on a rate system based on market power would just perpetuate the existing problem.

I took a different tack.  I pointed out that instituting global payments would represent a huge shift of actuarial risk from insurance companies, which are structured and compensated for taking risk, to providers (doctors and hospitals), who are not.

I recall one of the top three state officials turning to me in surprise and saying, "Really?"

Well, we can see how much influence the CEO of Tufts Medical Center and I have had on the public policy debate.  As I have noted, the state has gone whole hog in assuring that the competitive price advantage enjoyed by Partners persists into the future.  The recent legislation also provides tremendous encouragement for the spread of capitated rate plans.  The former is a victory for Partners, the latter for BCBS.

Think of it.  The firm, in the face of little or no empirical proof, has persuaded an entire state to adopt a rate-making approach whose main value is to shift risk from it, the dominant insurance company.  Now, risk does not disappear.  Usually in society, we pay people to assume more risk.  Also, people from whom risk is shifted usually expect a lower return.  Here, the risk is shifted, but the insurance company gives up nothing.  Indeed, it is secure in pricing its product because it knows exactly how much money it will pay out in medical claims.  Meanwhile, the percent of premiums it collects to cover administrative costs remains remarkably constant, even as revenue grows.  The capital reserves that it has accumulated over the years to cover actuarial risk remain untouched, even thought the degree of risk assigned to it has fallen.

In contrast, doctors who take on risk contracts must secure that risk with their salaries.  If they are good at case management, i.e., meeting the arbitrary targets set by the insurer (and now the state), they might make a bit of a surplus to share among themselves.  (Recall, though, that how that surplus is shared remains a tough question. Who gets it?  The primary care doctors or the specialists?)  If they are not good at case management, or if something goes awry in the actuarial forecast that is the basis for the contract they have signed, their salaries go down.  There are no cash reserves to help them meet the deficiency, except their personal bank accounts.

Hospitals that take on risk simply face the prospect of higher or lower income, ultimately improving or diminishing their balance sheets and their ability to fund renewal and replacement of important capital assets used in providing care to patients.  As with the doctors, there are no cash reserves dedicated to risk management.  The hospital's endowment or working capital gets depleted as necessary to cover its losses.*

And the state official said, "Really?"

Really.  Even if you believe that capitated contracts are the best thing that could happen in health care, you should not and cannot believe that the transfer of risk inherent in such contracts should go unrecognized.  The state's failure to account for this gift to the insurance company represents an example of incomplete policy-making.

Oh wait, since the state intends to apply this kind of rate-making to Medicaid patients, it is also a beneficiary of the shift in risk.

Combined, the "gift" from providers to the insurer and the Commonwealth is this year's version of the Great Train Robbery.

--
* Hmm, if I am the CPA firm doing the annual financial audit of such a hospital, shouldn't I require it to reduce current income to create a new reserve account for this risk? It may be a year or two or more before the actual surplus or deficit is known.

Cure for the heat: Boston Harbor Islands

Here's some hot weather escape advice for tourists and locals in the Boston area, the Boston Harbor Islands.  There is regular ferry service to and among the islands, starting at Long Wharf on the waterfront.  From there you might want to go to Spectacle Island, where a former landfill and horse rendering plant have been transformed into a lovely park, using the dirt from the new underground central artery highway.  You can easily walk up to the top of one or both recently heightened drumlins and if your eyes are sharp, you might find this reward on the way down:

There is a small but well-maintained and supervised, lifeguard protected swimming area.  The water is nice and cool.  Well, ok, cold.  But clean, thanks to the Boston Harbor cleanup project.

But the kids seems to find other things to do.

Meanwhile, over on George's Island, you can take a ranger-led tour of Fort Warren, built in 1850 and enhanced over the years.  It was used as a prisoner-of-war camp during the American Civil War, for both southern soldiers and northern deserters.  Here is our guide, Jerry, showing the bakery, with ovens large enough to feed hundreds of people their daily ration of bread.

The views from the islands are spectacular.  Here are some folks looking for distant landmarks.

Why there are fewer images being made

David Lee from GE Healthcare and Frank Levy from MIT have published a thoughtful article in Health Affairs entitled "The Sharp Slowdown In Growth Of Medical Imaging: An Early Analysis Suggests Combination Of Policies Was The Cause." The authors noticed that, well before implementation of bundled or global payments, the growth in usage of certain radiological modalities had moderated (see chart above).  They were curious why.

The abstract:

The growth in the use of advanced imaging for Medicare beneficiaries decelerated in 2006 and 2007, ending a decade of growth that had exceeded 6 percent annually. The slowdown raises three questions. Did the slowdown in growth of imaging under Medicare persist and extend to the non-Medicare insured? What factors caused the slowdown? Was the slowdown good or bad for patients? Using claims file data and interviews with health care professionals, we found that the growth of imaging use among both Medicare beneficiaries and the non-Medicare insured slowed to 1–3 percent per year through 2009. One by-product of this deceleration in imaging growth was a weaker market for radiologists, who until recently could demand top salaries. The expansion of prior authorization, increased cost sharing [i.e., with patients], and other policies appear to have contributed to the slowdown. A meaningful fraction of the reduction in use involved imaging studies previously identified as having unproven medical value. What has occurred in the imaging field suggests incentive-based cost control measures can be a useful complement to comparative effectiveness research when a procedure’s ultimate clinical benefit is uncertain. 

The hypothesis:

We hypothesize that prior authorization policies, higher deductibles, and lower reimbursements worked to offset strong nonmedical incentives, such as physicians’ fear of malpractice litigation or a desire to generate revenue to order imaging studies. Furthermore, we speculate that the slowdown may have included a meaningful proportion of procedures with marginal or unproven medical value, as discussed below. If our hypothesis is correct, what has occurred in the imaging field is evidence that reducing nonmedical incentives to perform a procedure is a useful cost-control strategy, where a procedure’s ex ante clinical benefit is uncertain and clinical guidelines are hard to write.

The conclusions:

Logic suggests that the growth in use of advanced imaging would have slowed eventually, but interviews and available evidence point to several policies that slowed the growth in utilization beyond any exhaustion of trend.

These authors identify these as prior authorization, increased cost sharing, reimbursement reductions in the deficit reduction act of 2005, and fear of radiation.

Just a bit off, Dr. Gupta

As well intentioned and thoughtful as he is, Sanjay Gupta nonetheless misses the point in his recent New York Times op-ed "More treatment, more mistakes."  The theme of the chief medical correspondent for the Health, Medical & Wellness unit at CNN is:

Certainly many procedures, tests and prescriptions are based on legitimate need. But many are not.... This kind of treatment is a form of defensive medicine, meant less to protect the patient than to protect the doctor or hospital against potential lawsuits. 

Herein lies a stunning irony. Defensive medicine is rooted in the goal of avoiding mistakes. But each additional procedure or test, no matter how cautiously performed, injects a fresh possibility of error.

With a quick aside in admiration of Peter Pronovost's approach to harm reduction and some other process improvements, he then says:

What may be even more important is remembering the limits of our power. More — more procedures, more testing, more treatment — is not always better.

And then, remarkably, he presents M&M conferences as a remedy:

One place where I have seen these issues addressed is in Morbidity and Mortality, or M and M — a weekly gathering of doctors, off limits to the public, which serves in most hospitals as a forum for the discussion of mistakes, complications, deaths and unusual cases. It is a sort of quality-assurance conference where doctors hold one another accountable and learn from one another’s mistakes. They are some of the most candid and indelible meetings I have ever attended.

Having a consistent gathering to talk about the mistakes goes a long way toward that goal, and just about any institution, public or private, could benefit from a tradition like M and M. 

OMG.  Dr. Gupta has inadvertently given us a wonderful exposition about a lack of understanding of the nature of quality and safety process improvement in hospitals. Most harm is not caused by a doctor making an error of commission, i.e., an extra test or an unnecessarily executed procedure. The number of reported adverse events from such instances is dwarfed by other forms of harm -- hospital acquired infections, falls, failure to rescue, pre-39 week induced labor.  Many of these are not even reportable as harm.

Dr. Gupta's presentation reflects no knowledge about the science of process improvement.  Peter Pronovost's check list is not just a good idea.  Brent James' introduction of clinical protocols is not just a good idea.  These are approaches that introduce the use of the scientific method into the clinical setting.  In contrast, M&M conferences are essentially anecdotal reviews of an incredibly small number of adverse events.  I would not understate their importance as teaching tools (when they are conducted in a pedagogically appropriate manner), but they do not deal with systemic problems, with near misses, with the manner in which communication fails.

As Lucien Leape and others have stated, and as Dr. Gupta makes clear in a way he certainly did not intend, the medical profession needs to have dramatically improved training in the science of process improvement as part of the undergraduate and graduate medical education curricula.

CampaignZERO empowers patients with knowledge

As an adjunct to Martine's book, summarized below, check out the website from CampaignZERO.  It provides the actual check lists that should be employed in a number of clinical situations.  As an informed patient or family member, you can participate in a positive way to help reduce the likelihood of preventable medical errors.

There's a page, for example, about ventilator associated pneumonia, giving things a loved one can look for during the treatment of the patient, along with early warning signs of trouble.  That is just one of several conditions covered.

The organization lists its goals as follows: 

CampaignZERO delivers safety strategies to patients and their family-member advocates to prevent medical errors.

We know that family members especially can be empowered to help zero out those errors—and we’re here to help guide the way.

Our mission at campaignZERO is to foster collaboration among patients, their advocates and health care team. We believe this will result in better quality care and support for medical staff, especially nurses who serve on the front line in every hospital.

The Take-Charge Patient

In one of those ironies that sounds implausible, author Martine Ehrenclou found herself suffering from debilitating, chronic pain during the research for her book The Take-Charge Patient: How you can get the best medical care.  So she got to try out her own advice.  I am sure that helped strengthen the book and expand her already empathic view of the world.  She notes, "I never expected to live each chapter of this book, but it did prove to me just how invaluable this information is."

This is a very good book, loaded with helpful suggestions and advice for patients (and families) of all types. This is no excoriation of the medical profession.  Its premise is that a strong partnership works best.  The theme: "Taking charge of yourself as a patient is essential in order for your doctors and other medical professionals to serve you in the way they know best.  Your health care is a team sport."

I found the style to be approachable and readable.  The substantive content is excellent, as well.  Whether you are currently a patient or will be one, this is an excellent addition to your bedside table.

Well done, Partners!

John McArthur must be smiling.  But even the former Dean of Harvard Business School--the brains behind the concept of creating a provider network "too big to exclude" from any insurance company's product line-- could not have anticipated the degree to which the state's body politic would stand by and watch the aggrandizement of economic power that has occurred since the Partners Healthcare System was created in the early 1990s.  Indeed, beyond watching, the state is now poised to assist in a continuation of that trend.

The ability of Partners to demand and receive above-market payment rates from insurers has been well documented.  There is the apocryphal-sounding story of CEO Sam Thier saying to the head of Blue Cross Blue Shield, when the latter balked at a PHS rate request, "Bill, this is what good health care costs."  Bill paid it.  Then there was the attempt of Tufts Health Plan, a second tier insurer (in terms of size), to pay less.  Partners started a million-dollar marketing campaign to inform Tufts subscribers that they would no longer be able to go to Massachusetts General Hospital or Brigham and Women's Hospital.  Those subscribers threatened to leave the insurer in droves.  "Tufts surrendered in little more than a week."

But that is just a well-executed business strategy.  The real accomplishment of Partners has been its ability to persist in the exercise of such market power even after the disparity in payment rates was clearly documented--even after business leaders (i.e., subscribers) and government officials (i.e., protectors of the public interest) were led to understand that the Partners rates were, in effect, a tax on the state economy in the range of $200 million per year.  The body politic was told, in simple direct sentences:

Price increases, not increases in utilization, caused most of the increases in health care costs during the past few years in Massachusetts. Higher priced hospitals are gaining market share at the expense of lower priced hospitals, which are losing volume. The commercial health care marketplace has been distorted by contracting practices that reinforce and perpetuate disparities in pricing.

The latest evidence of the degree to which the company's political strategy has been effective is in the passage of legislation by the House and Senate this week.  The bill, now on the Governor's desk, has been erroneously described by one news report as "setting the stage for Massachusetts to become the first state to ­establish a target limiting how much providers and insurers spend on medical care."

Of course, it does no such thing because the horse has already left the barn.  Recall that just a few months ago, the state's largest insurer awarded Partners a rate increase larger than the statewide average, on a base that was already substantially above that of other provider networks. The goal was to ink this deal before legislation might pass that would limit such increases, as I noted several months before the contract was signed.

The figment of cost control in the new legislation has no effect on this result.  Why?  The bill, says the same news report:

would allow health spending to grow no faster than the state economy overall through 2017. For the five years after that, spending would slow further, to half a percentage point below the growth of the state’s economy, although leaders would have the power under certain circumstances to soften that target.

Providers and insurers that do not meet the spending targets would have to submit “performance improvement plans’’ to a new state commission. Failure to implement their plans could lead to a fine of up to $500,000.

The problem, of course, is that a provider network like Partners with costs well above the state average will find it easier to meet the governmental targets than those with lower costs.  Why?  Because each hospital or network will be judged on its percentage increases.  If you have a higher base, you can increase the absolute number of dollars being spent to a much greater extent than those with a lower base and still meet the percentage target.  Ironically, again, the state is acting to increase the disparity in costs between the have's and the have-not's.  It is enhancing Partners' market power.

Some will point to the fact that a new commission "would be required to conduct a 'cost and market impact review' of certain providers, including those that want to expand or do not meet the state’s spending benchmarks."  You can be sure that Partners will handle its accounts in such a way as to never be the target of such a review.  On the expansion front, in a strategy of burying the money, it has already invested heavily in new facilities.  This provides a twofer, avoiding future constraints on its ability to expand without state review while further increasing the cost basis against which future percentage increases will be measured.

The ability of Partners to succeed in the political domain has allowed it to get state authorization for mechanisms that will guarantee its market dominance for decades to come.  This all represents a superb execution of its business strategy.  Staying on message--persistent advertisements and press releases and speeches setting forth the assertions of a concern with cost control--wears people down.  In any event, such messages receive no rebuttal or rigorous analysis by the media.  Sprinkling money in support of worthy causes buys complacence or acquiescence by advocacy groups.

The overall context in the state makes this easier.  The local business community fails to be organized around these issues even though the current situation has a huge impact on their bottom line.  Indeed, one business group strongly opposed even the limited amount of government intervention contained in the bill.  Further, a one-party state offers no chance for loyal opposition in the halls of the legislature.

Well done, Partners.

Check out the FMLM blog

I just came across this blog from the Faculty of Medical Leadership and Management in London.  The purpose:

The Faculty of Medical Leadership and Management is a new UK-wide organisation that aims to promote the advancement of medical leadership, management and quality improvement at all stages of the medical career for the benefit of patients.

The idea of the blog:

The FMLM blog publishes original articles on a range of issues relating to medical leadership and management.

Our blog authors are FMLM members and invited guests from a variety of grades, specialties, backgrounds and geographical locations, each with a unique perspective on leadership and management issues.

I have paged through and found a number of thoughtful articles and am pleased to recommend it for your perusal.  I have also added it to my blog roll.

Attitudes are one thing, behavior is another

A recent article in Medical Education, "Changes in intern attitudes toward medical error and disclosure," compares the results of a survey conducted ten years apart:

Two cohorts of interns for the academic years 1999, 2000 and 2001 (n = 304) and 2008 and 2009 (n = 206) at a university hospital were presented with two hypothetical scenarios involving errors that resulted in, respectively, no permanent harm and an adverse outcome. The interns were questioned regarding their likely responses to error and disclosure.

Here are excerpts from the results:

For both scenarios, the percentage of interns who would be willing to fully disclose their mistakes increased substantially from 1999–2001 to 2008–2009.... 

About two thirds of fully disclosing interns in both scenarios believed ‘the patient’s right to full information’ to be the primary reason for their disclosure.

Prior training about medical mistakes increased more than four-fold between the cohorts.

The conclusion:

This comparison of intern responses to a survey administered at either end of the last decade reveals that there may have been some important changes in interns’ intended disclosure practices and attitudes toward medical error.

"Hold on," says my colleague David Mayer, who has been at the forefront of medical student and residency training programs in quality, safety, communications, and disclosure.  He warns us to be wary about believing attitude data:

We all say the right thing – we are not prejudiced about race or religion, we love mom and apple pie, etc. But what do we do when no one is watching is what makes the difference. Behaviors are much more important than attitudes.

An example is in reporting of adverse events, near misses, and unsafe conditions:

People say it is important for safety, but how many reports do people submit? AHRQ data say the vast majority of care givers submit none or a rare one that has to be submitted because of seriousness of harm.

He also reminds us to distinguish between real training and a lecture:

Medicine loves to give a 50 minute lecture on something and then call it training and part of a curriculum. We do this with ethics, professionalism, human factors, etc.

He elaborates:

The question I would have liked to see studied is (1) how many had serious training and (2) saw a disclosure role modeled in the real world by an MD/organization, and (3) then went to work in a place that made disclosure part of their culture (e.g. Michigan, UIC). That would be interesting because I believe most students would say the education and TRAINING (heard real patients describe how bad they were treated when lied to, got to do a simulated disclosure with an SP, appreciated how difficult a conversation it is to do, got feedback through debriefing, etc) helped them prepare for the time they had to do the disclosure communication. That is how we train students to give other bad news (e.g., telling patients they have cancer) and there is lots of data that shows the educational model is beneficial to them later when they have to have that conversation. I believe that is how you change culture…and behavior (not attitude).

Bravo, Ipswich! (And I don't mean the Tractor Boys.)

John Watson, director of operations at Ipswich Hospital NHS Trust in the UK, included the following message in this week's staff newsletter.  Going to gemba is at the heart of Lean.  This is a great start!

Many hospital managers find their time tied to countless meetings, reviews of performance targets and other duties that take them away from the ‘front line’. We lose contact and understanding. However, what we know is once we spend more time out where the work is being done watching what is going on we will be surprised what we learn. We learn that the jobs we are asking our staff to do every day are often not do-able because there are not stable and reliable processes to support them. It helps managers to know what the problems are every day that are preventing our staff delivering waste-free care because we can then prioritise our work.

Therefore we have started a weekly process where a group of 20 senior Trust managers block every Tuesday morning to just go out to the front line and respectfully watch what’s happening. Each week we plan to place these managers, myself included, into 20 different areas. This is not checking up on colleagues. This is watching to learn and see where we can better help.

Last week I observed Sarah Willingham undertaking the receptioning of the Ophthalmology Outpatient clinic. I was struck by her calmness and professionalism despite the relentless pace of how her job needed to be done. I noticed small things that we simply haven’t designed properly to help such staff. Her phone was on another desk and she had to get up repeatedly to answer it or use it to chase notes. My hope is that gradually we find ways to learn from such observations and correct the countless little things that our dedicated staff have to find a way through.

If you have an area you would like us to come and watch or if you would like to be involved please let me know. If you have to deal with a work process that you think could be made better and have an idea please let me know or ask us to come along and observe how you try to work with it. This is a simple but small yet crucial step into how we think and act differently.

Will the NHS medal?

I am guessing that many Americans who watched the opening ceremonies of the Olympics were, at best, confused by the presence of National Health Service nurses during the choreography.  Here's a video of a portion of the show:



Indeed, Los Angeles Times sports writer Diane Pucin tweeted, "For the life of me, though, am still baffled by NHS tribute at opening ceremonies. Like a tribute to United Health Care or something in US."

This prompted a response by @swaldman: "Well, maybe, if United Health Care were government-run and a source of national pride."

And another by @MaxwellLeslie: "The NHS is one Britains greatest & most loved Institutions, reinforcing the ignorant American stereotype very well with that tweet."

Remember when Don Berwick was nominated to head up CMS, the US Medicare agency?  One of the strikes against him by conservative opponents was that he had expressed admiration for the British health system.

This is what Don actually said on the occasion of the NHS' 60th birthday:

The National Health Service is one of the truly astounding human endeavors of modern times.  Just look at what you are trying to be: comprehensive, equitable, available to all, free at the point of care, and – more and more – aiming for excellence by world-class standards.  And, because you have chosen to use a nation as the scale and taxation as the funding, the NHS isn’t just technical – it’s political.  It is an arena where the tectonic plates of a society meet: technology, professionalism, macroeconomics, social diversity, and political ambition.  It is a stage on which the polarizing debates of modern social theory play out: between market theorists and social planning, between enlightenment science and post-modern skeptics of science, between utilitarianism and individualism, between the premise that we are all responsible for each other and the premise that we are each responsible for ourselves, between those for whom government is a source of hope and those for whom government is hopeless.  But, even in these debates, you have agreed hold in trust a commons. You are unified, movingly and most nobly, by your nation’s promise to make good on an idea: the idea that health care is a human right.  The NHS is a bridge – a towering bridge – between the rhetoric of justice and the fact of justice.

And then he moved on to say:

Is the NHS perfect?  Far, far from it.

[I]n improving its quality, two facts are true: the NHS is en route, and the NHS has a lot more work ahead. 

How can you do even better?  I have ten suggestions:

And then he went on to outline those, summarized by columnist Ezra Klein, as follows:

Conservatives have convinced themselves that the NHS is a terrible system, which I guess is their right. But insofar as Berwick is actually offering recommendations to government-run health-care systems -- and that's what he's doing here, and what he'll be doing at CMS -- his guiding principles seem fairly inoffensive.

What were those radical suggestions?  Well, as I read them, they would apply just as well to the health system of the United States and every other developed country I have visited:

1.  First, put the patient at the center – at the absolute center of your system of care.

2.  Second, stop restructuring. 

3.  Third, strengthen the local health care systems – community care systems – as a whole.

4. Fourth, to help do that, reinvest in general practice and primary care.

5.  Fifth, please don’t put your faith in market forces. 

6.  Sixth, avoid supply-driven care like the plague. 

7.  Seventh, develop an integrated approach to the assessment, assurance, and improvement of quality. 

8.  Eighth, heal the divide among the professions, the managers, and the government. 

9.  Ninth, train your health care workforce for the future, not the past.

10.  Tenth, and finally, aim for health.

So, my take is like Don's.  Both beloved and berated by the British citizenry, the NHS is a marvelous social experiment that is nowhere near the finish line.  With a most dedicated and caring staff and bureaucratic beyond belief, both, it carries the torch forward.  In the former colonies (the US), we take on the task in a different way, but we face the same issues.  Indeed, as I have noted, "After all, the countries are dealing with the same organisms, both biologically and politically."   The two types of systems have a tendency to converge in many ways, "Suggesting that -- in all systems -- a concerted focus on quality, safety, transparency, and process improvement would be well worthwhile."

Bills, laws, and consequences

Here are two news items that reflect the inclination of public officials to play fast and loose with the issues when it comes to health care legislation:

(1)  The New York Times reports that a result of the new federal health care law is that hospitals serving uninsured immigrants are likely to face budget stresses since those people are not eligible to participate in the health care insurance exchanges envisioned by the law, nor are they eligible for Medicaid.  This comes as no surprise to students of the new law, but the response from the President's folks is off-point and misleading:

The Obama administration said the Affordable Care Act supported safety-net hospitals in other ways, pointing to measures that raise payments for primary care and give bonuses for improvements in quality. 

Raising rates for primary care doctors does nothing for this population and also does nothing for hospital finances.  As for bonuses for quality improvements, they are accompanied by penalties for such things as relatively higher readmission rates.  Recall this conclusion from a study conducted at Brigham and Women's Hospital:

Among 905 764 discharges in our sample, patients discharged from public hospitals (27.9%) had higher readmission rates than nonprofit hospitals (25.7%, P<0.001), as did patients discharged from hospitals in counties with low median income (29.4%) compared with counties with high median income (25.7%, P<0.001).

Conclusions—Given that many poor-performing hospitals also have fewer resources, they may suffer disproportionately from financial penalties for high readmission rates.  As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care.  (Circ Cardiovasc Qual Outcomes. 2011;4:53-59.)

(2) Meanwhile, at the state level, the Governor shows up as a late arrival on the issue of the disproportionate rates paid to certain health care systems, a pattern regularly documented by the Attorney General.  Under the misleading headline, "Patrick offers a plan to control care costs," a story reports:

The governor’s plan requires the administration to conduct a “cost and market impact review’’ of any medical provider it suspects is engaging in or plans to engage in anticompetitive behavior.

The reporter lets the administration off the hook by never addressing why it needs legislative authorization to do what it already has the authority to do.  Until now, the Governor has carefully ducked the issue whenever it has been brought up.  His administration has been MIA, notwithstanding the AG's presentation of her annual findings to one of his line state agencies under previously approved legislation.

By the way, even with no teeth, the proposal has opposition:

[The] president of the Massachusetts Taxpayers Foundation, said the plan is “an open invitation for unaccountable bureaucrats to go on a witch hunt.’’

As if those bureaucrats would be any more unaccountable than the people involved in secret negotiations between the dominant provider and the dominant insurer.

Lucia's Kitchen: Not your beachside clam shack

Several years ago, Lucia Velasco-Evans started business in a small roadside stand.  Her vision was to offer foods from or inspired by her home land of Mexico.  Things went well, and she expanded into this larger quarters.

If you are traveling on Route 1 through York, Maine, and are looking for a change from fried clams and other beach food, this is the place to go.  Our favorite was the budín azteca: layers of corn tortillas, pulled chicken, mole sauce and cheddar cheese.

In addition to sit-down and takeout service, Lucia offers catering.  Here is the website.

I asked when the cookbook would be published.  She claims not to have time to do that.  The world is less for that, and I am hoping she writes one some day.  I suggested she start with Tastebook to make it easy.

Canada stories

I have just returned from a very pleasant camping and touring trip to New Brunswick and Nova Scotia, two beautiful provinces with lovely and interesting people.  As much as I try to put health care and process improvement behind me during vacations, they somehow manage to impinge, often for unexpected reasons.  Here are three anecdotes and observations that arose.  I offer them for what they are worth.  Again, please understand that the context was always one of warm and caring people, but people who face systemic and societal issues--just like south of the border.

Low tide in Alma, on the Bay of Fundy

The first story is a humorous one that comes from a seafood restaurant in Alma, NB, on the Bay of Fundy.  They were serving a linguini and sea food dish (with scallops, shrimp, and haddock), and I asked the waitress if I could please add a lobster tail to the dish.

"No," she answered, "all of our ordering is by computer, and there is no button to push to add lobster."

"What if you were to talk to the chef and ask him to add it?" I inquired.

"It is easy for me to talk to the chef.  We talk all the time," she said, "but he can't do it either because there is no button he could use."

Hmm, not a very customer-centric or Lean process!  While I was tempted to try a Five Easy Pieces approach to the problem, it seemed simpler to just order something else.

Scallop fleet in Digby, NS

The second story comes from a community hospital in Nova Scotia.  A member of our party had taken a dive into the surf and had been thrashed into the sand by a crashing wave.  He bumped his head badly and jarred his neck, and he needed emergency care.  Beyond the possible concussion, there was a clear danger of spinal cord injury or broken neck bones.

The Canadian health care system is quite good, and we knew we could expect good treatment.  What we did not understand is that a person from another country has to personally register and prove his or her ability to pay before going through the ED triage nurse.  So, this injured patient was sent to walk to another part of the hospital and spend a good amount of time filling out paperwork--including a promise to be bound by the legal system of the province in the event of a malpractice claim--before being evaluated.  Once this was over and the patient could be seen, the doctor immediately fitted the person with a neck brace, just in case there was serious spinal injury.

In the US, for all of its health care system problems, no such patient would have been sent to another part of the hospital and required to fill out such forms before being immediately seen in the ED.  Also, a family member would have been permitted to fill out the required forms.

Also, the patient needed a CT scan, which was not offered in the local hospital.  The staff at the local hospital called ahead to the regional hospital and said someone would be waiting for us.  We drove to that hospital, about 20 minutes away.  Not only was no one waiting, but the person at the front desk wanted the patient to go through all the paperwork again.  After persuading that person that the forms were already filled out, the patient was sent to radiology, where the door was locked and no one was visible.  Rousing a custodian, the patient finally found the way to the CAT scanning area and found a technician.

Again, the actual medical care at each step of this process was excellent, and the clinical staff were attentive, friendly, and professional.  And we were through the whole diagnosis in under four hours.  I found myself, though, comparing the process with that in the US, where EMTALA rules the day when a patient shows up in an ED, requiring immediate care without regard to legal status or ability to pay.

Hodo Cookies at the St. John (NB) City Market

The third story relates to obesity.  I have come to understand that this a worldwide problem in developed countries, and the US is a prime example.  I did not expect, though, to see it in the Maritimes.  More frightening than in the adults, the rate of teenage and young adult obesity was clearly visible.  This made me think that Canada, which has done so well in controlling its health care costs, is in for an inevitable uptick over the coming decades.

Triples on WIHI

July 26, 2012: Triple Perspectives on Triple Aim in a Region
2:00 – 3:00 PM Eastern Time

Guests:
Craig Brammer, Director, Beacon Communities, Office of the National Coordinator for Health Information Technology, US Department of Health and Human Services

Shelley B. Hirshberg, MHSA, Executive Director, P2 Collaboration of Western New York; Project Director, Western New York Aligning Forces for Quality(AF4Q), Robert Wood Johnson Foundation

Carol Beasley, MPPM, Executive Director of Strategic Projects, Institute for Healthcare Improvement

Katherine Browne, MBA, MHA, Chief Operating Officer, National Program Director, Aligning Forces for Quality, Robert Wood Johnson Foundation
 
There’s a lot of interest in the Triple Aim in the US, Canada, and several European countries. And it’s no wonder. Ever since IHI conceived of the framework of the simultaneous pursuit of better health, better health care, and lower per capita costs, a whole array of strategies have opened up for health care improvers. Some of the most interesting and groundbreaking strategies have built as much on insights from outside health care as within. And, just imagine if the various communities making headway with the Triple Aim started to think regionally? Well, many are and that’s the evolution we’re going to learn about on the July 26 WIHI, tapping into three related but unique endeavors: IHI’s Triple Aim Initiative (with special focus on recent regional work), the Beacon Community Program (a project of the Office of the National Coordinator for Health Information Technology), and the Robert Wood Johnson Foundation’s Aligning Forces for Quality (AF4Q).

These three efforts combined have already impacted nearly 200 communities, to the point where many now realize that thinking regionally is the logical next step. Among other things, a regional focus forces an examination of cross-cutting social issues that affect more than a single community – issues such as unemployment, education, transportation, and crime. One community’s solutions to the needs of an aging population, people with chronic conditions, and individuals with complex social problems might benefit the community next door. Further, a regional outlook necessitates building even broader coalitions, drawing on the expertise of health systems operating in multiple locations, state and municipal leaders, public health experts, urban planners, economic developers, and more.  

Our guides for the July 26 WIHI are Craig Brammer, Katherine Browne, Carol Beasley, and Shelley Hirschberg from AF4Q’S initiative in western New York. This effort alone has some 270 partners and a portfolio of projects, including health information technology, that point to what’s possible when one starts to act regionally as well as locally. We’ll be identifying other emerging regional “movers and shakers” as well. We look forward to your interest and your ideas on this next WIHI. See you then!

To enroll, please click here.

Time off

I'm taking a blogging break for a few days.  See you later in the week.

No hype on Lean

I sometimes hear skepticism from hospital CEOs who are presented with the idea of adopting the Lean philosophy for their institution.  "Why does this feel like a religious sect?"  "I have no interest in learning Japanese."

Putting aside the ethnocentric context for the latter statement, in that the philosophy was actually introduced to the Japanese by W. Edwards Deming, let's admit that Lean is not for everybody.  But let's also acknowledge that it can make a huge difference for hospital staff and patients when it is undertaken carefully and in good spirit, with commitment from senior leaders.

Here is a short and thoughtful summary of some experience to date, an article in Hospitals and Health Neworks by Steven Garfinkel based on research conducted for the Agency for Healthcare Research and Quality.  The bottom line:

At every institution, staff at all levels reported improved employee satisfaction. They cited opportunities for front-line involvement in problem solving, employee collaboration across ranks and units, efficiency improvements, opportunities to spend more time with patients, and improved patient experience. 

Not surprisingly, cost-benefit ratios and return on investment were never explicitly considered when the organizations we studied adopted Lean. Instead, senior executives were committed to improving quality and efficiency. They adopted Lean because it was tractable — particularly when reliable estimates of cost and benefit were difficult to make. Once leaders adopted Lean, none paid much attention to implementation costs. Top managers saw Lean as part of an array of available quality-improvement tools. All said they were pleased with Lean's results. They viewed Lean as yielding long-term process and quality improvements that enhanced their institution's efficiency and financial viability.

We cannot be sure that Lean is more effective than other process improvement techniques. But we did find that Lean can be successfully adapted from manufacturing to fit the complexities of health care.

Cost structures in search of revenue

A colleague recently quoted a Harvard Business School professor (I forget which one), who said “Businesses are cost structures in search of revenue streams.”  I don’t know this professor or what he had in mind exactly, but I want to offer my interpretation.  I believe that what he was suggesting that, no matter how innovative or entrepreneurial a firm might have been at its start, once it is has been in existence for some time and has an established place in the social economy, its goal in life is to persist.  It leaves the world of innovation, often loses its purpose, and exists solely to exist, i.e., to cover its costs.  Often this is a reflection of the corporate hierarchy, where, sadly, leaders lose their sense of providing true value to their customers, intent instead on aggrandizing their own position and preserving their status.  The firm no longer reflects the creativity of risk-taking, becoming a bureaucratic shell of its former glory.

A good friend of mine, a retired doctor, has been pestering me for years on this topic, saying that this is what has happened to many of the formerly great hospitals in America, particularly the academic medical centers.  She views this as a relatively recent phenomenon.  She does not assert that the doctors and nurses are any less caring or dedicated, but rather that the leaders of these centers have become calcified with regard to their social mission.  They focus instead on expanding market share, growing margins, and attracting philanthropists to contribute to unnecessary and flamboyant edifices.  They have no real interest in reducing costs, but rather in obtaining and securing revenue streams to cover ever-increasing costs.  Most importantly, they neglect the harm they cause to patients in their facilities, preferring to assert that they deliver high quality care without being willing to be transparent with regard to actual clinical outcomes.  When they are shown data that indicate that their levels of care are no better than others, or perhaps worse, they answer that “the data are wrong” or “our patients are sicker.”

I have been agnostic with regard to my friend’s assertions.  For one thing, my experience in the medical field is of more limited duration, so I could not ascertain whether the change she suggests has occurred.  For another, I am more optimistic in nature than she, and so I tend to see half-full glasses rather than half-empty ones.  Also, I have been lucky to spend lots of time with hospital leaders like Paul Wiles, John Toussaint, Gary Kaplan, Jeff Thompson, and Ora Pescovitz who represent the vanguard of those focused on the things of most value to the communities they serve.

But this week, I was informed of an event that has shifted me more into my friend’s camp.  In response to a top ranking by US News--a ranking that, as I have discussed, has virtually no probative value--a local hospital actually organized a celebratory parade of an amphibious tour boat (Duck Boat).  In the past, such parades (admittedly more extensive) have been used to promote the championship seasons of local sporting teams (like the 2007 Red Sox, above), thereby giving fans a chance to yell and scream and applaud their athletic heroes.

Now, I am all for celebrating accomplishments.  At my hospital, we, too, used to be happy about favorable media ratings, even if we knew they were fundamentally meaningless.  But to spend thousands of dollars on a self-aggrandizing circuit (as well as on the right to use the US News logo in publicity) seems to me to reflect exactly the kind of behavior suggested by my friend.  How does this kind of activity promote anything good or useful about the provision of high quality and safe health care in the community?  It appears to be mainly a commercial activity designed to garner market share and otherwise stimulate revenue growth for an entity that, as I have noted, could do so much more to demonstrate a commitment to the kind of care that some of its own faculty and that of other institutions has been shown to save lives, reduce morbidity, and lower costs.

This Duck Boat rally is especially noteworthy when you read the actual words of the editor at US News who notes that the rankings are "to help those who need an unusual degree of skilled inpatient care decide where to get it, especially when there's time to make a choice."  Indeed, the parade is essentially celebrating a nullity when it comes to the day-to-day needs of the community in which this hospital is located.

I yearn for the day when the hospitals in Boston get together and jointly demonstrate progress in eliminating preventable harm, adopting a consistent approach to front-line driven process improvement, and engaging in truly patient-driven care.  Now, that would be something worth celebrating (although I would still omit the Duck Boats.)  For models of that kind of behavior, look west to Ohio, Wisconsin, Washington, and Michigan.  The hospitals there have been hard at work on that approach--with modesty, dignity, and class--literally leaving many "top" Boston institutions in their wake.

Quality without science and research is absurd

If there were something called a Nobel Prize in Medicine, it would be awarded to Peter Pronovost for the number of lives he has saved by his applied research in quality improvement.  Oh wait, there is a Nobel Prize in Medicine, but they will never award it to Peter because the way he saves lives is based on the scientific method.  Oh, wait the Nobel Prize in Medicine is based on applying the scientific method to questions of broad human health import and is awarded "to the person who shall have made the most important discovery within the domain of physiology or medicine." So, they will never award it to Peter because he applies the scientific method in clinical settings and saves lives today as opposed to engaging in reductionist research in laboratories that may never save any lives.

Who knows?  Maybe someday the Nobel Prize committee will review the evidence and decide that scientifically conceived experiments and programs in clinical process improvement are worthy of their attention.  When that day comes, they need only read Peter’s book Safe Patients, Smart Hospitals to find the source material for the award presentation.

But in the meantime, every person involved in the delivery of care in hospitals should read this book.  I am not so keen on the subtitle--”How one doctor’s checklist can help us change health care from the inside out”--because that is a highly simplified shorthand for the many lessons contained in the book.  Sure, there is the checklist story, first applied to eliminating preventable central line infections.  But, as Sullenberger notes, "A checklist alone is not sufficient. What makes it effective are the attitude, behavior and teamwork that go along with the use of it."  A checklist applied to an organization that has not engaged in a cultural change that promotes respectful relationships among the clinical staff--described by Peter as a comprehensive unit-based safety program--will fail.  Peter’s contribution is explaining how to create such an environment and in telling the story of his successes and failures along the way.

My favorite story is about the CEOs of the Michigan hospitals and how they learned they could help in the statewide effort to eliminate central line infections.   One CEO said, “You do not get to be CEO without having answers to questions.  Yet I do not have a clue what to do to improve safety. I am not comfortable admitting that.”

Peter admitted that he did not have all the answers either, but that a show of commitment from the CEOs was essential to programmatic success.  “What if I made this easy for you?  What if we were to send you one simple task for you to do each month, would that help?”

They liked the idea.  Our first trial run came when we learned most of the hospitals used an antiseptic solution called Betadine to clean the skin prior to placing a central line . . . [but] chlorhexadine had been proven to be 50 percent more effective at reducing infections.  Even though the two cost about the same, only 20% of the hospitals in Michigan stocked chlorhexidine....

We went to the doctors and nurses and encouraged them to change the antiseptic solutions . . . but the staff didn’t know how to make this happen. . . .  So we sent all the CEOs a memo asking them to make sure that, within on e month, every hospital stocked chlorhexidine in their central line kits. . . .  In one month it was done.

Every hospital can accomplish the kinds of changes described by Peter in this book.  But they have to want to.  To quote Jim Womack, "Whether you think you can or you think you can't -- you're right."

But accomplishing change is not the same as wishing it were so.  Process improvement is a discipline.  At one point in the book, Peter expresses frustration at the lack of data collected by several hospitals participating in the improvement program.  A colleague says, “This is not how quality is done in this country.  Quality is a concept that has never been viewed as research or science.  As long as hospitals are doing projects they think will make patients safer, they believe patients are safer.”

Peter makes the case strongly:  This is unacceptable.  “Quality without science and research is absurd.”

Right.  Now let’s get back to that Nobel Prize committee.