Sepsis heroes

Dr. Jim O'Brien reminds me (and now you!) about this important event in New York City On September 12.  Ticket information here.  It will honor the following people:

Gary Black, sepsis survivor and author of “Gyroscope: A Survival of Sepsis.” Gary is one of SA’s first Faces of Sepsis. On his website, Gary describes the book: “GYROSCOPE reveals my entire harrowing experience of cascading to the edge of death from severe sepsis. It explores my mental, physical, and spiritual traumas and triumphs from onset to recovery. It also includes 52 illustrations that express my pain, anguish, dreams, delirium, and personal awakenings, a brief medical glossary, and research references.”

Since publication of his book, Gary has given talks and presentations to many groups about the seriousness and impact of sepsis. Last September, Gary was invited by the Society of Critical Care Medicine to participate in the Post Intensive Care Syndrome (PICS) Stakeholders conference. His point of view as a sepsis survivor is invaluable to the people who work to fight the disease. Read more about Gary here.

Governor Andrew M. Cuomo: New York State Governor Cuomo is the first U.S. politician to directly address the issue of sepsis and the importance of sepsis awareness. During the State of the State address earlier this year, Gov. Cuomo announced that New York State will be the first state to require that all hospitals adopt best practices for the early identification and treatment of the disease. The measures are to be implemented through regulations issued by the Department of Health led by State Health Commissioner Nirav R. Shah, M.D., M.P.H..

These initiatives, together called "Rory's Regulations," pay particular attention to the needs of New York State’s children. Due to the tireless advocacy of Ciaran and Orlaith Staunton, whose 12-year old son, Rory, died of sepsis in April 2012, the proposed regulations will ensure that results of critical tests will be transmitted to parents in easy-to-understand terms upon their child’s hospital discharge. As well, the hospitals will have to post a “Parent’s Bill of Rights,” so parents are aware of the new regulations. Regulations like these enacted by Gov. Cuomo help raise sepsis awareness among both healthcare professionals and the general public and ultimately save lives.

GE Healthcare Education Services. The education arm of GE Healthcare has been in a leader in raising awareness about sepsis among healthcare professionals. Their push for sepsis education in their Nursing Library of Online Education, including their video Communication: Sounding the Alarm for Sepsis, has allowed nurses from all over to benefit from information that they may otherwise not be able to access. GE Healthcare also provides scientific posters and professional education sessions about sepsis at professional conferences, such as at the American Association of Critical Care Nurses. Since nurses are the front-line healthcare professionals, this education and awareness is invaluable.

David Goldhill, author of “Catastrophic Care: How American Health Care Killed My Father--and How We Can Fix It.” David, who is president and CEO of GSN (the Gameshow Network), lost his father to sepsis and after learning more about what happened, he wrote his book. “Catastrophic Care.” David gives many talks about issues regarding health care and he begins his talks by telling the audience how his father died. In March, David was the keynote speaker at a major conference for healthcare journalists – people who need to hear the word “sepsis.” Read more about David here.

Mark Lambert, former president of Sepsis Alliance. Mark was the first president of Sepsis Alliance and was instrumental in helping shape and guide Sepsis Alliance. Mark not only helped put together the team that works behind the scenes, but he was a major force behind developing SA’s mission. He also helped build the board of directors, spearheaded the creation of Sepsis Alliance’s first video, Sepsis: Emergency, and brought together the Merinoff Symposium 2010: Sepsis - Speaking with One Voice – an important turning point in how healthcare professionals around the world viewed sepsis. Read more about Mark here.

Surviving Sepsis Campaign. The Surviving Sepsis Campaign (SSC) was formed in 2002, a joint effort between the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. The SSC has since developed evolving guidelines for the management of severe sepsis and shock, something that had not previously existed. The SSC is committed to collecting data from 10,000 hospitals worldwide, to apply the guidelines to 100 percent of patients in whom the diagnosis is suspected, and developing a strategy to improve the care of septic patients in under-resourced areas. Recently, study findings showed that this is resulting improvement in sepsis care.

DO or MD?

I wrote to an associate, who is a DO (Doctor of Osteopathic Medicine), with the following question:

"I have a young friend who is trying to choose between a DO and an MD.  Would you have advice for her?"

The reply was immediate and strongly felt.  I copy it with permission and seek your responses:

This is really a philosophical choice. I applied to both and got in first to a DO school while wait-listed at a couple MD schools. I had no higher aspirations than to practice medicine and do good for people.

The sad reality is that there is a not so subtle and in many cases flagrant prejudice against DOs. Simply put, MDs and MD institutions discriminate against DOs. Hiring practices in many states or regions discriminate against DOs. I heard of a case recently where there was a sick patient on an airplane flying domestically, not foreign, and the responding doc was a DO. When the doc said we have to go down now in the best interest of the patient the pilot refused because the doc was “just” a DO.

It sounds cruel to say it but the question is similar in many ways to asking whether you want to be white or black, or whether you want to be male or female. As a DO you will be a discriminated against minority. Overall you will make less money, you will not have access to the best paying  or most prestigious jobs, you will unlikely be able to achieve an academic appointment at a prestigious MD led institution and you will constantly be asked to explain yourself. “Just what is a DO anyway, doc?” The good thing is that you will always do good work no matter where or for whom because the education is very good and all American.

If her aspirations are simple then it really doesn’t matter. The philosophy of osteopathic medicine is very appealing and I think most human and appropriate. The education is at least as good as MD, especially in a university affiliated school. But the dark side is that the MD world will always look down on you as something less than adequate or someone significantly less than worthy or competent. If her aspirations are to function in a university setting, maybe do research, maybe aspire to lofty public health goals or something along these lines, forget DO school and go to an MD school even if it is an offshore school. Sadly, it is the letters after her name that will count, not the education. Sure there are a few token DO stars here and there, but the MDs rule and DOs are viewed as second rate, generally speaking, in the towers of medicine, especially in the ivory ones.

My advice? See if you can discern your long term goals. Then make your choice based on that discernment. We are all idealists at first. Try to see past that. It is not an easy task.

Best of luck to her.

How would this play in the US?

The Telegraph reports about the NHS:

The number of patients waiting to be admitted for operations or other treatment in June was a quarter of a million higher than in the same month last year, official figures show. 

The figures come after a report by Monitor, the NHS regulator, which warned that some trusts were cancelling non-emergency procedures to deal with a higher load of emergency cases, resulting in longer waiting times.

The "referral to treatment" data reveals that waiting lists, which have hovered around 2.5 million patients in recent years, reached 2.88 million in June, the highest level since May 2008. 

However, the figures also show that the median waiting time for treatment is currently 5.7 weeks – the same duration as in June 2012.

I guess the last paragraph is supposed to represent good news. In the US, when you need surgery, you can get it reasonably quickly.  Look at this chart from the OECD for a related statistic, the percentage of people who have to wait four months or more for elective surgery.

Of course, in the US, that's if you have insurance or can otherwise afford the care.

But before you jump to conclusions about the relative gross inequity of that, please note that in the UK, you can get faster treatment if you can afford private insurance or can otherwise pay to go to private clinics or hospitals, where the same doctors who work in the NHS will offer you a different class of treatment.

It might be asserted that the NHS steady-state figures reflect a decision by the government to engage in congestion management to ration care.  Based on my experience in the UK, though, the more likely reason for the delays are work flows that are remarkably un-Lean.  This is hard to fix, but an example might come from our buddies in Saskatchewan.  There, the health authorities adopted the Saskatchewan Surgical Initiative Plan, with a goal of reducing surgical wait times to no more than three months by 2014.

While the results are mixed, the intent is noble, especially when seen in the context of adopting the Lean process improvement philosophy for the entire province.

There's a big difference, of course, in adopting an organizational philosophy for a province of one million people compared to adopting a goal for an organization of 1.7 million people, serving over one million patients every 36 hours!

The process improvement challenges in the NHS represent one of the largest examples I know of a system in need of repair.  All I can offer from this side of the Pond is the observation that improvement is likely to come from the individual hospitals and clinics when the central authority of this massive organization understands that its role is to support the development of learning organizations and not to impose arbitrary targets from above.

This is not courage

Here's a quick follow-up to my post about the traffic configuration blues facing the City of Newton. As mentioned, the Board of Alderman voted to deconstruct a renovation project that was recently completed.

Now comes the latest news that some of the Alderman sent an email to their constituents explaining their vote, using the following subject line: “Admitting our mistakes takes courage."

First of all, as I noted in a comment:

It is really poor form to attribute courage to one’s own actions. Others should always be the judge of what’s courage and what’s something else.

But then, I went further and stated:

IMHO, calling this “courage” is a vast overstatement and denigrates the real meaning of the word, as we would usually apply it, e.g., a firefighter rescuing a child from a burning building. 

Let's stick with this point for a minute.  Merriam-Webster defines courage in this way: "Mental or moral strength to venture, persevere, and withstand danger, fear, or difficulty."

When seen in that light, the Aldermanic vote is just the opposite from courage.  It was a way to avoid difficulty, i.e., the complaints from constituents.  But even if it is a tough vote, use of the terminology in this case weakens its meaning when there are real cases of courage.  I'd like us to retain the purity of meaning so we can apply it in truly inspirational instances: For an act to be courageous, it has to be not only selfless but also at variance with the usual human tendency for self-preservation.  If you want to see courage with regard to a mistake, for example, watch how a distraught doctor who has made an error openly and honestly discloses it and apologizes to a patient and displays his or her vulnerability in the process.

So, I ended my comment by saying:

No, taking these kinds of decisions is actually just part of the job of public officials. Let’s just call it making a judgment call–a good one or a bad one–and leave it at that.

The Aldermen's note is typical of the kind of "grade inflation" used by so many legislators today.  You know, the ones who constantly remind us how "hard they are working" to create jobs for Americans, to protect us from hazards, and so on.  Hey guys and gals, sitting in a legislative chamber and using your brains and abilities to decide which way to vote it not "hard work."  Yes, it is work, and when done right, it takes thoughtfulness, experience, and dedication.  But "hard work" is what many of your constituents do every day. If you want to see hard work, for example, shadow a transporter in a hospital, a nurse in an ICU, or a physician carrying out a delicate procedure. 

The City's legislature at (re-)work

Here is a follow-up to my post about the traffic design wars in Newton, MA. The issue was returned to the city's legislative body for review and consideration.  I guess that was deemed necessary because any changes would require additional spending authorizations.

We neighbors received the following email from the city DPW reporting the results.  I offer it without comment.

As most of you are aware the Board of Alderman voted to restore the intersection of Cypress Street and Centre Street to its original configuation.  As a result, the city will be commencing the following construction activities in Newton Centre.

Dates: August 19, 2013 thru August 30, 2013 (M-F, possible Saturday work)

Time: 7:00 AM to 7:00 PM

Activity: Intersection work (Cypress at Centre)

In addition, the city will be conducting the following roadway milling operations.

Date: August 18,  2013 (Sunday night)

Time: 5:00 PM to 5:00 AM

Activity: Roadway milling

During all construction activities there will be adequate police details to handle traffic and

pedestrian flow.

We thank you for your patience during this construction phase.

Sorry, I understated the problem

When I wrote yesterday's post about the excessive charges collected by the Partners Healthcare System, I thought I had a good understanding of the dimensions of the problem. Apparently not.

In a follow-up story on boston.com, we find the following quote:

“What surprises me most is the difference between Partners and their next biggest competitor,’’ said Áron Boros, executive director of the Center for Health Information and Analysis, which compiled the report. He said Partners has been able to negotiate high prices with all insurers, unlike other systems. “None of them has the consistent success of Partners in driving prices up,’’ he said.

Whew.  Mr. Boros is probably the most knowledgable person in the state when it comes to the rates paid to hospitals and doctors.  In his previous job, he "hosted the annual Cost Trends hearings and presided over the first release of the Division’s All-Payer Claims Database for state agency and research uses."  It was at those Cost Trend hearings that the pricing inequities in the state were first disclosed, based on research conducted by the Office of the Attorney General.  Mr. Boros has continued with similar important activities since taking over CHIA.

Given this expertise, if Mr. Boros admits publicly to being surprised by the results of his agency's study, then I am confident that my assertions about the tax being imposed on the Commonwealth by Partners Healthcare have to be dramatically understated.  Why the head of the Health Policy Commission and other policymakers persist in denying the inflationary aspects of this problem is a mystery.  Partners really has succeeded in pulling the wool over the eyes of the Commonwealth's leaders.

Well, duh.

The Boston Globe prints as news a story that Partners HealthCare collects a lot of the dollars spent on medical care in Massaachusetts.  It's not news, but I guess later is better than never.  The lede:

Nearly one-third of all the money that Massachusetts insurers spent on acute hospital care last year went to Partners HealthCare, according to a new Patrick administration analysis that underscores the dominance of the state’s largest medical provider.

In addition, Partners-affiliated doctors received 25 percent of the money paid to physicians in 2011. In both cases, Partners received two to three times as much as the providers receiving the next most in payments.

The statements above are rendered less informative without some kind of metric that indicates what percentage of the hospital beds, or discharges, or whatever are owned by Partners.  Or, what percent of  the state's doctors (by specialty) are in the Partners network.  That is nowhere to be seen in the story. (Maybe some of these charts would have been helpful.)

Absent that information, too, the story's reported assertion by the head of the state's Health Policy Commission has no basis.  The story quotes him as saying that the report underlines “why we are the most expensive state in the US. It’s because of the structure of our system,’’ which leads residents to “use expensive teaching hospitals,” including those owned by Partners, more often than people in other states.

What if the explanation, instead, is that the amount Partners' hospitals and doctors receive for patient care--in its academic centers, in its community hospitals, and its physician office practices--has been substantially above the rest of the market for two decades? What if the percentage rate increases granted by the state's largest insurer to Partners exceeded the average rate increases given to other networks, even though the base on which those increases was applied was already well above the state average?

Both of those statements are true but are not part of the news story.  The underlying issue, with due respect, is not that people in Massachusetts use academic centers more than in other states (although that can certainly be a contributing cost factor.)  It's that the dominant provider--which is about to expand its holdings--is paid hundreds of millions of dollars in excess revenue relative to the market.  It's that the dominant insurer has displayed no capacity for taking on that behemoth.

Fortunately, buried in the story is the conclusion by the Center for Health Information and Analysis "that cutting spending on medical care will depend in part on controlling payments" to Partners and other systems that have used market power to extract high prices. You can't control health care costs in Massachusetts without equalizing the rates of pay among the health providers by basing the amounts paid on clinical value received, irrespective of market power.  However, there is no appetite in this state to make that happen.  Since it will not happen, we will simply see periodic reports and news stories about ever rising costs while the industry giants demand more. Meanwhile, hospitals and doctor groups outside of the market drivers will be left with the scraps.  As those latter hospitals slowly decapitalize and those doctors lose income, they will be inevitably drawn into the big systems, allowing those systems to exert still more influence over payment rates. It will not matter if those payment rates are based on fee-for-service or bundling or capitation.  Regardless of payment design, the rates of the monopolistic systems will generate supernormal returns.  Their income is our costs.

How not to play on Kickstarter

My regular readers know that I love the Kickstarter concept and get excited when I see the enthusiasm from ordinary people when they support young entrepreneurs when they have a great idea.  But those who solicit funds through Kickstarter also have a moral obligation to deliver what they promise, in a timely fashion, and when they cannot, to be utterly transparent and clear with their funders as to why not.

One of the most successful Kickstarter solicitations was this one by Formlabs in the fall of 2012.  Aiming to raise $100,000 to introduce a new line of 3-D printers, the company ultimately raised almost $3 million from over 2000 backers.  Most backers were to receive one of the printers, and here's what was said about delivery:

We are already working hard to plan our supply chain and manufacturing operations to make sure you get your Form 1 as soon as possible. We feel comfortable targeting February 2013 for our first full-production shipments in the USA/Canada, and March 2013 for our first International shipments.

The Formlabs team noted:

Many Kickstarter campaigns can encounter problems when taking their prototypes to production. This includes issues finding suppliers and engineering products for mass-production. Smooth execution is absolutely essential to overcoming such risks. We take this lesson seriously and have been working for months negotiating with suppliers, testing component quality, and building a team that can execute on our promises. Our plans are nearly in place, and we now mainly require the resources to execute them.

Well, that didn't work out as planned.  Complaints started to arise, and Formlabs posted a story on their blog on June 30 suggesting that there were quality control problems from their manufacturer:

We won’t let a printer out the factory door if it hasn’t passed our exhaustive calibration and test procedures. This commitment to quality has caused delays in our shipping schedule, but the Form 1 will be better for it.

While there were supportive comments, there was also frustration expressed, including these thoughts from Austin on July 4:

I was slated for March delivery…still waiting. I haven't recieved anything except an email saying my tier was being shipped. But I still haven't recieved any shipping info. Even if they shipped now, I still wouldn't see a printer till August.

On July 21, vinnivanhood said:

It’s time for another update isn’t it?!

And Karen noted this week:

We too are trying to be patient but the replies to our emails don’t give us any more information about shipping than this blog.

We paid for the backing in October 2012 and then was asked to pay shipping in February. Our shipping date was originally April 2013 and our number is #1972. We do not know what tier we are?

Everything just seems to be shrouded in mystery. We have all backed Formlabs and put our faith and trust in you maybe we should have something a bit more concrete like what number you have shipped so we know where you are up to at least.

Meanwhile, the topic has been on the airwaves on Formlabs' community forum, too.

I have a theory that the manufacturer used by Formlabs did not meet the performance specifications set out by the firm and promised by that manufacturer.  I am guessing, but do not know, that this manufacturer was not based in the US, but was probably in Asia somewhere.  I am further guessing that our young entrepreneurs did not have sufficient experience in production processing--and perhaps commercial negotiation with their vendor--to ensure timely and high quality deliveries at the price agreed upon.

The end result is that a great concept and great people have now taken a marketing hit.  I hope that they will work it all out and be successful, but I think there is an object lesson here for others.  I also think this would be a great case study for Harvard Business School to prepare, to show the trials and tribulations that can occur in the new Internet economy.

Teams must have individuals, too

My neighbor Paul Doherty wrote the following sestina after reading my book Goal Play!, which has lot to say about the kind of leadership that promotes effective teams. He noted:

I enjoyed reading your book.  I find it interesting to compare children's sports these days--and I coached youth baseball here in Newton for a dozen or so years--with my own growing up experience.

Before I turn to Paul's poem, I also want to relate a comment I received from a distinguished and thoughtful clinician, in response to my blog post below:

Interesting. I think the profession has bent over backwards to focus on systems contributors in a way of fostering more error reporting, less blame, and greater participation. When I make a mistake it is satisfying to identify systems issues, but ultimately I made the mistake and my skill set must learn to think about that when making decisions. 

I think the two are related in a way, and am honored that Paul has allowed me permission to print his piece here:

BASEBALL, BRACKETT SCHOOLYARD, ARLINGTON MA, 1945 

On late spring afternoons, after school and on into the summer,

my friends and I would show up at the schoolyard to play
baseball. Two of the older players, thirteens, would buck up
sides, and the game would begin on that improvised field,
flat rocks or folded jackets for bases, a friction taped ball sometimes
often a taped bat too. Four or five players on each team.

None of us in those days played for a real team;
Little League did not exist that distant summer.
So this was it, and I ask myself sometimes
if any of us could imagine that kids like us might play
some future time on a green and fenced-in baseball field,
parents cheering in the stands, umpires barking “Fair ball,” and “Batter up."

It was our self-asserting captain who decided who was up
when and who would play what position on his chosen team.
Big kids pitched and played short, lesser kids were in the field--
“the daisies” we called it--all that spring and summer,
though if you kept showing up day after day to play,
you might just get to pitch a little sometimes.

When I recall our games as I do more than sometimes,
in my mind what again and again keeps turning up
is just how little time we’d spend in actual play
and how much time we’d spend in arguing--which team
should bat first, fair or foul, safe or out--all summer.
Endless negotiating at that makeshift field.

No grownups ever visited our quarrelsome field
or indicated any interest in our games, not even sometimes.
Most men were away at war--it ended in August that summer--
and no one, in Arlington at least, had yet thought up
the notion, now de rigeur, that parents ought to coach the team
their kid is playing on on. No, we were unorganized in our play.

More than a little ironic even to call it “play,”
for we were clever little Hobbesians at Brackett field.
We learned to fight our battles on our own, not as a team.
We learned to assert sometimes, and to hold back sometimes.
We learned that when our case was lost to just shut up
and live to fight another day that summer.

We learned life lessons at Brackett field that wartime summer,
dark values, but as important, I’ve come to believe, for our growing up
as those nobler ones about sportsmanship and team play we hear sometimes.

Look who is not listening

The Arnold P. Gold Foundation has a  mission is "to perpetuate the tradition of the caring doctor by emphasizing the importance of the relationship between the practitioner and the patient."  The folks there recently posted a infographic that suggest there is some room for improvement in that regard.  These kind of data make me wish that more hospitals and multi-specialty practices would take a leaf out of the Lean book and learn how to redesign work flows.  If these charts represent the steady-state condition of office visits, they are a clear indication that process improvement could improve both patient and provider satisfaction with no additional resources.

And this chart shows the need for physician training on listening and interpersonal relationships.

Kill this monster!

The time has come to drive a stake through the heart of an oft-repeated assertion.

How often have you heard something like the following when those of us in healthcare who want to stimulate quality and safety improvements draw analogies to the airline industry?

"Well, in an airplane, the pilot has an extra incentive to be safe, because he will go down with the ship. In contrast, when a doctor hurts a patient, he gets to go home safe and sound."

At a recent talk to medical residents, medical students, and nurses in training, Terry Fairbanks (Director of the National Center for Human Factors Engineering in Healthcare) put the opposing case forward.  He noted, "No pilot follows safety rules and procedures because he thinks he is otherwise going to crash."

Likewise, I would note, no doctor fails to follow safety rules and procedures because s/he does not care about the well-being of a patient.

What is the difference, then?  Terry summarizes, "There is a pervasive safety culture and set of rules that guides airplane pilots, based on a human factors approach."

He added, "The relative degree of accountability (compared to other industries) is not the underlying cause of medical errors." 

Being in the human factors business, Terry is a whiz at the physical conditions and cognitive errors that bring about harm, and also at the interventions that can help reduce them.  He notes that most errors are skill-based errors, or errors that occur when you are in automatic mode, doing tasks that you have done over and over--indeed tasks at which you are expert.

He explains, "When you are in skills-based mode, you don't think about the task you are about to do. Signs don't work! Education and labeling don't work when you are in skills-based mode. Most medical errors are in the things we do every day."

Accordingly, vigilance and training are not the answer to skill-based errors. Neither is punishment:

"While discipline and punishment has a role when there is reckless behavior, applying discipline to skill-based errors will drive reporting underground and will kill improvement."

Many hospitals approach safety improvement in the wrong way because "most safety-based programs are based on work as imagined, not work as actually done. We need to design our improvement based on real work, not on the way managers believe how work is done."

Interestingly, Terry asserts,"If we just focus on adverse events, we will not make significant progress on creating a safer environment."

Also, he warns: "Don't base safety solutions on information systems. Humans add resilience: Computers do not adapt."

The airlines have noticed this and have adopted solutions that are attuned to cognitive errors.  Recall this summary from Patrick Smith:

We’ve engineered away what used to be the most common causes of catastrophic crashes. First, there’s better crew training. You no longer have that strict hierarchical culture in the cockpit, where the captain was king and everyone blindly followed his orders. It’s team oriented nowadays. We draw resources in from the cabin crew, people on the ground, our dispatchers, our meteorologists, so everyone’s working together to ensure safety.

The modernization of the cockpit in terms of materials and technology has eliminated some of the causes for accidents we saw in the ’70s into the ’80s. And the collaborative efforts between airlines, pilot groups and regulators like the Federal Aviation Administration and the International Civil Aviation Organization, a global oversight entity, have gone a long way to improving safety on a global level.

Here's more about the Commercial Aviation Safety Team, through which virtually anyone who sets foot in an airplane, touches it, or monitors its travel is expected and empowered to submit a report about potential safety hazards.

In summary, it is not the personal risks faced by doctors compared to pilots that kill and harm patients.  It is the fact that the kinds of solutions needed in health care are just at the gestational stage. Facile comments that doctors don't care as much as pilots are just plain wrong and divert attention from the steps that can and should be taken to learn from the airline industry.

Time for respect, not blame, at the NHS

In light of Don Berwick's recent advisory report for the National Health Service, this commentary by the Health Minister and his initiative send the wrong message. The Times of London reports:

Hospitals are to be forced to publish how much they pay for supplies under plans to end “scandalous” overpayments for basic goods. 

Dan Poulter, the Health Minister, said, "We must end the scandalous situation where one hospital spends hundreds of thousands more than another hospital just down the road on something as simple as rubber glove or syringes, simply because they haven't the right systems in place to ensure value for money.

Those of us who have studied procurement in hospitals know that there is nothing "simple" about this problem.

While the unit cost of goods purchased is always worthy of attention, it is actually the stocking of excess supplies that is likely to be more wasteful.  I'd wager that, if you visit the stores room in any NHS hospital (or for that matter, any US hospital), you would find an inventory that is far from the amount needed.  Why is that?

In most hospitals, there is a lonely person who has to decide when to purchase the next shipment of gauze pads, or bandages, or whatever.  He makes a personal judgment of this issue based on the speed with which those boxes leave his storeroom to head upstairs to the wards.  He has no formal training in inventory management and often has no data system to support him in his decision-making.  Accordingly, he employs informal rules of thumb for this ordering.  His incentive is to "never run out," and so he will always order more than the hospital actually needs.  He often works alone, and so when he goes on holiday, he orders still more extra supplies so that things will be all right in his absence.

But, it's worse than that, because the stockers on each ward and unit upstairs have exactly the same incentive.  Although there is a recommended par value of goods in each local supply closet and cabinet, his incentive, too, is to "never run out," and so he will always collect more supplies than are necessary from the central stores. His job is complicated by the fact that the local closets and cabinets are often crowded and poorly designed, so the actual inventory on each floor is unclear.

Those of use who teach Lean process improvement techniques know that one of the most likely places to find opportunities for savings is in this sector of a hospital's operations.  It is not uncommon to find that hospitals are over-purchasing by 10, 15, or even 20%. Then, because medical goods have expiration dates, a portion of the inventory is actually thrown out.

How does this all relate to Don's report?  While his report focused on safety, the conclusions actually are generalizable:

NHS staff are not to blame – in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to . . . problems.

Improvement requires a system of support: the NHS needs a considered, resourced and driven agenda of capability-building in order to deliver continuous improvement.

Recognise with clarity and courage the need for wide systemic change. 

Abandon blame as a tool and trust the goodwill and good intentions of the staff. 

Give the people of the NHS career-long help to learn, master and apply modern methods for quality control, quality improvement and quality planning.

Make sure pride and joy in work, not fear, infuse the NHS.

The language used by the minister and the one-size-fits-all type of solution proposed for this particular area exemplify an approach in opposition to the one advocated by Don and his advisory body. It does not consider the root causes of the problem or systemic solutions.  Equally important, the language used is not respectful nor supportive of the hard-working staff in the hospitals.

Walczak creates chances for change

Buried away in his campaign website is an extraordinarily thoughtful idea by Boston mayoral candidate Bill Walczak.  It represents the kind of thinking that can occur at the local level by people willing to think creatively and across disciplines.  This one is about education and health care.  Here's the quote:

Early education works best when parents are prepared and supported in their role as their child’s first teacher, and this needs to start with prenatal care. . . . The challenges that confront young people in many of our neighborhoods in Boston include violence, chronic poverty, poor housing, and unhealthy environments among others. These difficulties spill over into their social and educational experiences. The term applied to these phenomena is “toxic stress.” Strong evidence points to the physical and emotional toll that toxic stress places on children, including compromised brains and bodies.

I strongly believe that connecting our schools and health care providers will help to reshape some of these experiences. Our health care institutions need to become more proactive in integrating the realities of childhood poverty into their interventions. At the Codman Square Health Center, we replicated an approach developed by the Centering Healthcare Institute that includes group visits for expectant parents. This model connects parents to each other, their pediatrician/family physician, and the resources they need to support their children as they grow. One of the results was increased infant birth-weight, an important indicator of a child’s ability to develop, learn and thrive. Connecting this model to early childhood education and expanding the program to infants and toddlers will result in better care for children as they grow. This approach requires no major expense; just a reallocation of how already approved prenatal visits are used. As Mayor I will work with community health centers and other prenatal programs to expand group pre-natal and pediatric visits to include early childhood educators, supporting parents as first and primary teachers. This will build community capacity by linking families with each other and institutions at the early stages of parenthood.

This is good stuff.  Actually, very good stuff.  It's not surprising that Bill, who founded the Codman Square Health Center and served as its CEO for 32 years, would understand the interplay of education and health care.  But he takes that understanding and uses it to come up with a conceptual design for an initiative that would build a stronger sense of community and would not bust budgets.

I don't get to vote in Boston, but I find myself wishing I could. I know who would get my vote.

Cricket vs. Football (Soccer): The obesity wars

Under this headline:

Fitness and the beautiful game -- and football

A letter in The Times of London on August 5:

Sir, I do not agree that football is better than cricket in answering problems of inactivity and obesity (letter, Aug 3). Neither sport will cure obesity, but cricket demands far more physical and mental activity than football, at least where school and casual play are concerned. Indeed, the stamina required by cricketers far exceeds that of the footballer. The batsman's concentration, while defending the stumps and trying to score, is probably unequalled in any sport.  And each fielder must be ready to respond within a fraction of a second. As to the bowler, his every delivery will be watched and judged by one and all. Football is easier to stage and less expensive, but let us not forget the significance of the phrase, "That's not cricket," and despite misgivings about some umpiring, as a lesson for pupils in later life, there can be no better. And anyone who thinks cricket is the preserve of a certain class owing to a lack of equipment and facilities, ought to visit India where mile after mile of land plays host to the game, often with improvised implements, but never lacking in enthusiasm.
JACK LYNES
Pinner, Middx

Whaddayamean? This isn't hard exercise?

WWKS?

What would Dr. Koop say? According to Al Lewis and Vik Khanna, he would not be pleased that people have used his name for an award for a fraudulently described wellness program in Nebraska.

A lesson from Harvard

There are a lot of really bright folks at Harvard, including some of the world's experts in the health care field. How meaningful, then, when the university falls for the marketing plans of health insurance companies and finds itself under a rock.

The New York Times lays out the story:

It [Harvard] dropped its standard deal — a subsidy that rose in line with the price of the insurance policy — and switched some 10,000 workers on its payroll to a fixed subsidy that encouraged them to shop around for care. Families of workers who chose the Preferred Provider Organization offered by Blue Cross/Blue Shield — the most comprehensive plan, with lots of doctors and hospitals on its network — faced a $500-a-year jump in their out-of-pocket spending on health care.

Younger and healthier workers canceled their P.P.O. plans, enrolling in cheaper H.M.O. options or dropping Harvard insurance altogether. Left with a sicker patient base, the P.P.O. raised its premiums further, which prompted the next layer of relatively healthy customers to leave. 

Harvard has not been alone in facing this predicament.  I laid out the commercial logic of this pricing scheme a few months ago:

Notwithstanding public pronouncements to the contrary, it is evident that insurers have persuaded plan fiduciaries (i.e, companies who offer health insurance to their employees) to adopt plan designs that are priced to diverge from the rates that would be based on actuarial calculations.  Plan designs for high-cost subscribers are subsidized by plan designs for low-cost subscribers.  I believe the insurers do this for strategic reasons, to migrate customers to those plans that create the most income for the insurers.  The plans that create the most income for insurers are the ones that generate growth in claims:  Insurers want larger groups to insure and they want to insure unhealthy populations.  After all, claim adjudication is the major source of income for the insurance companies.

The purpose of the Times article is to explore whether a similar phenomenon might occur under Obamacare or whether there will be enough competition among insurers to keep a lid on "the death spiral of adverse selection" and rate increases. Of course, that national issue is more complicated than the one facing a single employer.  The problem, as I have noted, is the growing lack of competition on the supplier side, a trend that is encouraged by the administration's desire for Accountable Care Organizations that will be large enough to bear a larger portion of the actuarial risk of population groups.  Indeed, that consolidation can more than offset the hoped-for competition in the insurance market.  From the Times:

“The more health plans compete for insured in a local health market, the more fragmented the payment side of the market will be vis-à-vis the ever more consolidated supply side,” Uwe Reinhardt of Princeton, a contributor to The Times’s Economix blog, wrote me in an e-mail. “And the higher prices for health care will be.”

We need to accept the fact that there is really very little in the national health care legislation that is likely to control the ascent of costs. We have the country's underlying demographic trends and other factors like the medical arm's race; requirements on insurers for guaranteed issue and expanded coverage; and greater concentration in the provider market.  The drafters of the legislation knew this to be the case and assumed that the higher costs would be met by new taxes during future administrations.  The logic and need for universal coverage of the population is incontrovertible, and it needs to proceed. But as I said many, many months ago, when the President promised the nation access, choice, and lower costs, he was misleading us.  You get two out of three, not all three.

Quick, arrest that senior intelligence official!

In a post below, I make note the point that the boundaries of security clearances are extremely elastic and will be used by any administration to suit its purposes.

I also decry the media, saying:

The story-hungry press lets them get away with this with impunity, often citing "Administration sources who could not be identified because of the sensitivity of the information" or some such silly moniker. 

Little did I know that a few hours later the New York Times would publish this story, with a full explanation of NSA data-collecting algorithms and other information.  It contains the following words:

To conduct the surveillance, the N.S.A. is temporarily copying and then sifting through the contents of what is apparently most e-mails and other text-based communications that cross the border. The senior intelligence official, who, like other former and current government officials, spoke on condition of anonymity because of the sensitivity of the topic, said the N.S.A. makes a “clone of selected communication links” to gather the communications, but declined to specify details, like the volume of the data that passes through them. 

Who has the higher ethical lapse here, the administration or the newspaper?

In any event, if Edward Snowden deserves arrest for what he disclosed, what about this person, who provided detailed information on the same topic?

The teachable moment

Tweets are flowing about George W. Bush's annual stress test and the resulting angioplasty and stent insertion.  Why? Because the care provided to our last President is inconsistent with current evidence-based medicine recommendations. Indeed, hospitals would risk non-payment from the government and private insurers for the type of treatment received by Mr. Bush.

Here's a full description from Burt Cohen's Stent Blog.  He links to a number of tweets from people, including Eric Topol, who says:

Relative to Pres Bush, here are the @ACCinTouch recommendations against stress testing http://www.cardiosource.org/News-Media/Publications/Cardiology-Magazine/choosing-wisely.aspx

Burt Cohen notes:

Was a CT angiogram necessary?

This test is not currently covered by Medicare or most insurance providers for this indication, mainly because it’s considered one of those “over-used unnecessary tests.”

He follows:

Was a stent necessary?

Or could Bush’s coronary artery disease have been managed with optimal medical therapy. 

Noting the absence of public comments about this from many prominent health care experts and commentators (Dr. Oz, Sanjay Gupta, Atul Gawande, Don Berwick, ex-Surgeons General, AARP, Brian Williams, the American College of Cardiologists), a friend summarizes:

You and me, and everyone who gives a hoot about the health care system talks of the adult conversation and the teachable moment.  Look in the mirror.  I would call what we have in front of us a whopper.  

If W did indeed have a screening stress test, mind you--in an incredibly fit, teetotaling, non-smoking Texan, then who will be a immune from over testing and misuse of resources?

We have a root cause of system ills right in front of us, but the A in RCA, i.e, the analysis caboose, has seemed to decoupled from the engine.

 

Indeed, where are the mainstream media and the advocates?  Are you afraid to challenge this type of care because it involves a member of the country's ruling class?  In doing so, do you implicitly advocate a two-tiered system of care for the country? One where the rest of us pay for "royalty" to receive a more costly level of care than the rest of us?

Where you stand depends on where you sit

Pro Publica (@ProPublica ) has published a wonderful article entitled, "The Surveillance Reforms Obama Supported Before He Was President". It is worth reading.

By the way, have you noticed that this and previous Administrations feel quite free to disclose their chosen tidbits of secret information when it is politically expedient to do so.  The story-hungry press lets them get away with this with impunity, often citing "Administration sources who could not be identified because of the sensitivity of the information" or some such silly moniker.  Like the one this week about Al Qaeda threats discovered in secret ways:

It is unusual for the United States to come across discussions among senior Qaeda operatives about operational planning — through informants, intercepted e-mails or eavesdropping on cellphone calls. So when the high-level intercepts were collected and analyzed this week, senior officials at the C.I.A., State Department and White House immediately seized on their significance.

“This was a lot more than the usual chatter,” said one senior American official who had been briefed on the information but would not provide details.

And then look at the complicity of the media:

At the request of intelligence officials, The New York Times withheld some details about the intercepted communications.  

Note how the Administration discloses certain details to select newspapers on the condition the information is not released. It extends special privileges to some reporters to make them feel like they are on the "inside." These favors are returned over time.

Just saying, the boundaries of security clearances are extremely elastic and will be used by any administration to suit its purposes. But these guys will never be prosecuted for doing so.

Goodbye, Mr. Snowden

Last month I wrote a piece about Edward Snowden in which I suggested that his decision to flee the scene and not face punishment after disclosing secret US intelligence information was inconsistent with the country's long history of dissent and civil disobedience. I further suggested that such actions would tend to undermine his moral standing on the issue. Many of you offered comments agreeing or disagreeing.

Now, Mr. Snowden has gone a step further along this path by accepting asylum from Russia. As the New York Times notes in an editorial:

Asylum is for people who are afraid to return to their own country because they fear persecution, unlawful imprisonment or even death because of their race, their ethnicity, their religion, their membership in particular social or political groups, or their political beliefs.

Mr. Snowden undoubtedly fears returning home because he would be arrested and prosecuted. But those fears do not qualify him for asylum. 

Mr. Snowden has unfortunately made a mockery of his principles.  The Times further notes:

And does he really feel safer in a country where Mr. Putin, an increasingly authoritarian leader, has jailed and persecuted his critics?

I'm not saying it would be easy for him back in America.  The Administration will surely throw the book at him to deter others who might consider similar acts.  But we do have a vigorous and independent judiciary, with multiple levels of appeal, as well freedom of speech and press that could be harnessed to build a political coalition in support.  But, by accepting the help of a despotic regime without those structures, Mr. Snowden has forfeited any chance of using the resiliency of the American judicial and political system to help him and his cause.

Berwick advice to the NHS is universal

Several months ago, Don Berwick was asked by the government of the UK and the senior leaders of the NHS to assemble an advisory board to review problems within that organization and make recommendation for the future.  The report has been issued and contains the following broad conclusions.  While some may appear especially applicable to the national health care delivery system that is under the jurisdiction of the NHS, they are actually equally applicable to health care institutions and delivery systems in the US and much of the rest of the developed world.

From the Executive summary:

The following are some of the problems we have identified:

Patient safety problems exist throughout the NHS as with every other health care system in the world.

NHS staff are not to blame – in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.

Incorrect priorities do damage: other goals are important, but the central focus must always be on patients.

In some instances, including Mid Staffordshire, clear warning signals abounded and were not heeded, especially the voices of patients and carers.

When responsibility is diffused, it is not clearly owned: with too many in charge, no-one is.

Improvement requires a system of support: the NHS needs a considered, resourced and driven agenda of capability-building in order to deliver continuous improvement.

Fear is toxic to both safety and improvement.

To address these issues the system must:

Recognise with clarity and courage the need for wide systemic change.

Abandon blame as a tool and trust the goodwill and good intentions of the staff.

Reassert the primacy of working with patients and carers to achieve health care goals.

Use quantitative targets with caution. Such goals do have an important role to progress, but should never displace the primary goal of better care.

Recognise that transparency is essential and expect and insist on it.

Ensure that responsibility for functions related to safety and improvement are vested clearly and simply.

Give the people of the NHS career-long help to learn, master and apply modern methods for quality control, quality improvement and quality planning.

Make sure pride and joy in work, not fear, infuse the NHS.

The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.

We have made specific recommendations around this point, including the need for improve training and education, and for NHS England to support a network of safety improvement collaboratives to identify and spread safety improvement approaches across the NHS.

Our ten recommendations are as follows:

1. The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning.

2. All leaders concerned with NHS healthcare – political, regulatory, governance, executive, clinical and advocacy – should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement and support.

3. Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts.

4. Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS’s needs now and in the future. Healthcare organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well-supported.

5. Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals, including managers and executives.

6. The NHS should become a learning organisation. Its leaders should create and support the capability for learning, and therefore change, at scale, within the NHS.

7. Transparency should be complete, timely and unequivocal. All data on quality and safety, whether assembled by government, organisations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.

8. All organisations should seek out the patient and carer voice as an essential asset in monitoring the safety and quality of care.

9. Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction.

10. We support responsive regulation of organisations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to willful or reckless neglect or mistreatment.

Less than two years

#TPSER9 It would take less than two years to fill Arlington National Cemetery with the victims of medical harm. Less than two years to fill a cemetery that holds over 100 years' worth of US Military casualties and their family members.

This is an excerpt from a lovely post by Tracy Granzyk relating part of last week's "Telluride East" training program for residents, medical students, nurses, and others at Georgetown University.  In a break from the classroom activities:

As we made our way across Washington DC, organic conversations between students and faculty grew throughout the largest Telluride gathering in nine years. I was fortunate to get to know a number of students on the walk to and from this national landmark, many of those conversations each deserving a blog post all their own. Like Rose Ngishu for example–a nurse and mother of four from Kenya now in Galveston, TX, and in her third year of medical school. Rose shared how she knew at 7 years old, living in a country where any healthcare was a luxury, that she wanted to become a doctor and change the conditions in her country of origin. A woman, who despite many personal obligations, continues to push stubbornly toward her goal of improving the lives of those less fortunate and become a physician.

Saturday’s hike culminated on the hill beneath Robert E. Lee’s house with Dave Mayer and Rosemary Gibson centering the group around the fact that it would take less than two years to fill Arlington National Cemetery with the victims of medical harm. Less than two years to fill a cemetery that holds over 100 years worth of US Military casualties and their family members. Rosemary then encouraged us to break up into groups of 3-4 and remember by name, if possible, patients or family members that we personally knew affected by medical harm. The group then came back together and honored those we had discussed in our smaller groups. A new Telluride tradition began this week–one that connected the head with the heart, patient with provider.

I was pleased to be part of the faculty again for this event, conducting a session on negotiation.  Here's a nice summary by Ben Fisher at the Washington Business Journal.

Monkeys and Bananas

Did you ever wonder how things develop to the point of, "We don't do it that way here?"  This phrase often works as the stop sign that impedes process improvement.

Well, here's one cogent explanation, in the form of a video entitled "Monkeys and Bananas."


Thanks for this lead go to Australia's Sarah Dalton, a Fullbright Scholar studying the development of clinical leadership programs at Anne Arundel Medical Centre and throughout the US.

A misguided initiative petition

One of the problems when you criticize a union proposal is that you are at risk of being tarred as "anti-union."  I'm not.  But I'll take the risk of that response in criticizing one union's plans for a referendum here in Massachusetts.

The Massachusetts Nurses Association, which represents about 20% of the state's nurses, is preparing a petition that would impose nurse staffing ratios on the state's hospitals. This kind of proposal, akin to one in place in California, has been rejected many times by the state Legislature, which realizes that such matters are best determined by the clinical and administrative folks in hospitals rather than by regulation.  California is the only state that has these kind of rules, based on a 1999 law, and there have been many unintended consequences.

The folks at the MA Hospital Association have correctly noted:

The arcane concept of applying ratios is especially disturbing in the rapidly evolving Massachusetts reform environment that is centered on rewarding hospitals and other providers based on quality of care delivered and patient satisfaction. Integrating care across the care continuum depends on continually changing patient care and assessment decisions arrived at by a full care-giving team, and not by inflexible, government regulation.

Here's a copy of the instruction sheet being handed out to the MNA members.  It is interesting to note that nurses are instructed not to collect signatures from other bargaining units (i.e., other unions) in their hospitals.  Might that be because a rigid nurse staff ratio could cause other unionized clinical assistants--who are valued members of the care delivery teams--to have fewer jobs?

Two gun stories

I live in Massachusetts, so there are some things I just don't understand.  Here are two examples from elsewhere in America:

A friend who does lobbying in Texas explained to me that people entering the Capitol building have to go through metal detectors.  Except people who have a CHL--concealed handgun license--who can bypass the metal detector by showing the license to the security guard.

The New York Times confirmed this in a story this past spring, noting:

Texas lawmakers . . . described carrying weapons in the Capitol as a personal security habit, doing what they did elsewhere in the state, whether shopping, dining, praying or driving. They also wear their weapons, they said, for the same reason they keep jacks in their vehicles and fresh batteries in their smoke detectors at home. They said there was a difference between being paranoid and being prepared.

So only the people who don't have guns have to go through the metal detectors.

In California:

A KGO-TV news crew was robbed at gunpoint of camera equipment while accompanied by a security guard in West Oakland in broad daylight.

A station official did not respond to a request for comment.

 I'm kind of a loss for words myself.

May you never see the difference

A lovely Facebook post from Jack Sullivan, Senior Investigative Reporter at Commonwealth Magazine:

We were at the Y pool the other day and Gwyni was pointing out the goggles on one of the kids in the pool.
 

"Which one?" I said.
 

"The kid with the brown hair," she said.
 

"Where?" I asked.
 

"Right there, the boy with the brown hair and blue bathing suit," she said exasperated.
 

The fact that the kid she was pointing out was the only black kid in a pool of about 10 other kids never occurred to her. I love my color-blind grandchildren.
 

Happy 9th Birthday, Gwyni. May you never see the difference.

Seven years of blogging!

I'd like to take this opportunity to acknowledge the seventh anniversary of this blog. On August 2, 2006, I took the leap with this short post, noting:

The other day, I was reading a NY Times article that menitoned that only 1 CEO of a Fortune 500 company had a blog. I don't run a Fortune 500 company, but I do run Beth Israel Deaconess Medical Center, a large academic medical center in Boston. I thought it would be fun to share thoughts with people about my experience here and their experiences in the hospital world. 

Truly, I had no idea where this would lead.  Would anyone be interested in what I said? Would there be enough topics to write about?

As you might expect, thing started slowly.  After a couple of weeks, I did a Google search for my blog, and it didn't show up! Why? Not enough traffic to stimulate the search algorithm.  So I sent an email to my 500 (!) closest friends telling them about the blog, asking them to read it, and asking them to tell their friends about it.  I also started linking my blog to others in the health care field and creating relationships with other bloggers by commenting on their posts.  Shortly thereafter, I showed up in the search engine.

Things really broke open, though, when the Boston Globe's Chris Rowland wrote an article about it on October 6. Privately, too, Chris suggested that my writing style was a bit boring and proposed that I make my articles a bit more edgy and controversial.  As regular readers know, I took that to heart.

Cross-linking to other social media over time was also an important way to gain readership.  When Facebook opened up to nonstudents, Nick Jacobs--the first hospital CEO blogger--suggested I join.  He said, "I think you'll have fun with it."

I owe Scott Hensley, one of the authors of the Wall Street Journal Health Blog, "thanks" for leading me to the addiction that is known as Twitter. Shortly after, I confessed my dependence, quoting Bob Coffield, who writes the Health Care Law blog: "Facebook was the gateway drug that led me to the crack that is Twitter."

Over time, the blog evolved into something that I never predicted. The kinds of stories I wrote morphed into a wide variety of commentary on things happening in my hospital to issues of wide social import.  Along the way, I "invented" transparency as a management tool by posting actual infection rates and other clinical outcomes from our hospital, in real time, for the world to see. I did not understand that doing so would help result in a transformation of care in our hospital, as we adopted a goal of eliminating preventable harm and holding ourselves publicly accountable for the standard of care we delivered.  Little did I realize, too, the pervasive impact that doing so would have on the health care profession as a whole, indeed beyond the borders of the US.

I documented, too, our learning experience with Lean process improvement, offering stories of success from the front-line staff.

Meanwhile, I helped expose the inequities in the hospital pricing environment in Massachusetts, where market power--rather than quality--rules the roost.  Over time, this issue got the attention of newspaper columnists and eventually the body politic.  It clearly riled some politically powerful people, who were used to getting their way and who took the matter very personally.

I also must mention the very important series of about 50 posts over a five-year period in which I exposed the corporate campaign being run against our hospital by an aggressive union that sought to infringe the rights of our workers. This led to my book, How A Blog Held Off the Most Powerful Union in America.

I also tried to take on the medical arms race, pointing out how marketing by suppliers and mispricing by Medicare results in the expansion of the use high cost equipment, with no regard to medical efficacy.

For a while, I devoted my Wednesday columns to answering questions posed by students. Among the most-read posts, to this day, is the one from 2007 entitled, "For Students: Don't collect degrees." In it, I answered this question: As someone who is in on the business/medical/policy of today's health care system, what do you think about the career prospects of those pursuing a joint JD/MPH? Is it worth it?

And, of course, there were the occasional columns about my passion, coaching girls soccer and refereeing youth games.  These led to my book, Goal Play! Leadership Lessons from the Soccer Field.

Along the way, I would often get the question of how much time I spent on the blog and other social media.  As noted here, I suggested that this was the wrong question: That's like asking how much time you spend talking with people. 

When I left the hospital in early 2011, I briefly considered ending the blog, but persisted out of habit and upon the suggestions of some loyal readers.  The name changed.  A highlight was being introduced to a doctor in California a few months later who said, "Oh, you're Not Running a Hospital!"

As I noted two years ago:

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!

I repeat 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.