Where you stand depends on where you sit

I know from personal interactions that the CEO of Steward Health Care System has an excellent sense of humor.  But he certainly cannot have meant to be funny when he appeared at the state health cost trends hearings hosted last week by the state Health Policy Commission and appealed to the state to enact more health cost containment legislation that would further limit prices for higher-cost doctors and hospitals.  Julie Donnelly at the Boston Business Journal summarized:

The demand for additional regulation is somewhat unusual given that de la Torre is the CEO of one of the few for-profit health systems in the state, a company owned by private equity firm Cerberus Capital Management. De la Torre says that new government intervention is needed to fix a broken market that makes it difficult for Steward to compete.

“We not comparing (the price of) liver transplants, we don’t provide them and we don’t care,” de la Torre said at the hearing. “But CT scans, MRIs, hernias – there’s price disparity that creates unfair competition.”

Wait, I thought that disparity was the basis for the Steward's business model.  Let's look back a few months.  As Bruce Mohl in Commonwealth Magazine reported in July 2012:

At a time when private insurers and state and federal regulators are trying to rein in the cost of health care, Steward thinks its cost advantage over teaching hospitals gives it a significant competitive edge. “Our model is very disruptive to the academic medical centers,” says David Morales, Steward’s vice president of public policy and strategic planning. 

Morales and Murphy, the Steward spokesman, say the only reason the big Boston teaching hospitals are gobbling up community hospitals in the suburbs is so more patients can be referred into Boston “to feed the beast.” By contrast, they say, Steward wants to keep care (and jobs) in local communities where it can be provided more cheaply. Morales estimates community hospitals are 25 percent less expensive than teaching hospitals. “The key for us is the economics,” he says. “Our hospitals, and community care in general, are lower cost.”  

Steward is trying to enhance any cost advantage it has by paring back the cost of services it provides and attempting to reduce how often those services are needed. 

Steward is also positioning itself to take advantage of a shift by insurers toward paying health care providers based on patient outcomes rather than the individual services they provide.

The position taken by Steward this last week might have generated more sympathy if the company had not tried to increase referrals by paying to acquire community-based primary care practices.  Mohl noted:

To steer more patients to its hospitals, Steward is aggressively adding doctors to its physician network, in several instances wooing them away from the networks run by Boston’s big teaching hospitals. 

One way of doing that was by using the padded, front-end loaded global payment contract signed with Blue Cross Blue Shield of MA.  In the early years of that deal:

Steward was left with a contract that brought in revenue that far exceeded its expenses, allowing it to share the wealth with doctors who joined with Steward.

The comments might have also generated more sympathy if Steward had not engaged in an arrangement to send its high-end tertiary care patients to Massachusetts General Hospital and Brigham and Women's Hospital, the highest priced hospitals in Massachusetts, instead of lower-priced but equally capable facilities like Tufts Medical Center, Boston Medical Center, Lahey Clinic, and BIDMC.  Robert Weisman at the Boston Globe reported this in October 2012:

Expanding ties between the state’s two largest medical care providers, fast-growing Steward Health Care System has struck a deal with Partners HealthCare System to send its most severely injured patients from emergency rooms at Steward’s 10 community hospitals to Partners-owned Massachusetts General and Brigham and Women’s hospitals in Boston.

The alliance isn’t the first between Partners hospitals — which have been cited by state Attorney General Martha Coakley as among the most expensive in Massachusetts — and two-year-old Steward, which many in the state health care industry welcomed as a lower-cost alternative.

Last year, Steward teamed with Tufts Health Plan to offer small employers less expensive health insurance that restricted patients to Steward hospitals for routine care. At the same time, it agreed to refer more complicated adult care to MGH and the Brigham and complex children’s procedures to Mass. General’s pediatric branch, MGH for Children.

Finally, the comments might have carried more weight in the absence of high-priced advertising campaigns by this hospital system, including the above-pictured banner attached to one of the passenger bridges at Logan Airport.

The final words in Mohl's article offer a rich irony:

“In a world of Neiman Marcuses, we’re OK being Filene’s,” de la Torre said, according to a report in The Boston Globe. “The key, when you’re a regionally focused, community-based, accountable care organization, is to keep health care local.” 

What was probably lost on the audience in San Francisco was the fact that Filene’s, once an iconic retailing brand of Massachusetts, no longer exists.

But let's turn from humor for a second.  If the business model adopted by Steward turns out to be dependent on state action to help it compete, was this the intent of the private equity firm that bought the Caritas Christi hospital system?  If so, they misrepresented things to state authorities at the time.  If the original business model was not meant to be reliant on that additional state action, but the company turns out to need state help, what does that suggest about the company's valuation to future potential investors when the private equity firm decides to flip the hospitals in an IPO or to another investment group?

Runs in the family

Atul Gawande is not the only superb writer in his family.  His daughter Hattie recently took to the public forum of our community newspaper to support the establishment of a nine-unit home for formerly homeless adults in an old fire station in her section of town.  Her article was beautifully constructed and written.  Like her father, Hattie sets forth a principled position.  This one is on an issue in which our City's mayor has ducked and weaved and made himself invisible, when there was an outcry of opposition from a small number of neighbors.

I can't find a link yet to her guest column in the Newton Tab, but here are highlights from this high school senior:

Waban is considered a "family" neighborhood.  It makes sense, then, that advocates for and against the Engine 6 proposal have been talking about what kind of neighborhood they want to raise their children in.  Parents have pitted heavy words like "diversity" and "compassion" against words like "crime" and "safety."

I thought it would provide a new perspective, however, to speak as a child who also has a vision for the neighborhood.  I have lived all of my 17 years in Newton, half of them in Waban.  The rest of my life will be shaped by the foundation that was built here.  For the sake of all the children whose lives rest on a Newton Foundation, I am asking you to take action in support of Engine 6.

... I want to tell you that the vision of Newton that is more diverse, welcoming, and integrated is the one I want to work toward, as a child growing up here.

... Newton needs to live up to its promises.  We need to recommit to the goal, stated in more than one city plan, in improving the economic diversity of our neighborhoods by opening up more affordable housing.

... Bear this in mind: Keeping Waban the way it is now is harmful to me and all the other children of Newton.  Being sheltered for 17 years, blind to the difficulties of people less fortunate than we are, risks breeding indifference to human beings who need our help.  Frankly, that makes for a poor childhood.  But--if we act now, together, we can begin to change Newton for the better, and not only improve the lives of nine chronically homeless individuals, but my life, and the lives of all other Newton children.

What's a synonym for hypocrite?

Randy Neugebauer.

Watch this clip from NBC, where the Congressman from Texas berates a Park Ranger who--because of the federal government shutdown--has been directed to prohibit people's entry to the World War II memorial in Washington, DC.

Staffing Models for Primary Care on WIHI

Madge Kaplan writes:

The next WIHI broadcast — New Staffing Models for Primary Care — will take place on Thursday, October 10, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Ed Wagner, MD, MPH, MACP, Director Emeritus, MacColl Center for Health Care Innovation, Group Health Research Institute 
• Trissa Torres, MD, MSPH, FACPM, Senior Vice President, Institute for Healthcare Improvement 
• Kirsten Meisinger, MD, Medical Director, Union Square Family Health Center, Cambridge Health Alliance 
• Thad Schilling, MD, Medical Director, Patient-Centered Medical Home, Harvard Vanguard Medical Associates-Medford (MA) 

What does it take to be a high-functioning primary care practice today in the US? Some 30 sites of all  shapes and sizes are in the midst of being studied in hopes of answering this very question. The Robert  Wood Johnson Foundation and the MacColl Center for Health Care Innovation selected these practices  because of their exemplary and innovative staffing models. Figuring out the best ways to delegate  responsibilities and work as a team is one of the central needs for all primary care providers today, and  midway through the project known as LEAP (Learning from Effective Ambulatory Practices) WIHI will get a look at the success factors that LEAP has identified thus far.

Dr. Ed Wagner of the MacColl Center is LEAP’s Project Director (along with Margaret Flinter, APRN, Phd) and he’ll be heading up the discussion on the October 10 WIHI: New Staffing Models for Primary Care. Dr. Wagner developed the Chronic Care Model, which was groundbreaking for office practices in the late 1990s and remains foundational to the creation of patient-centered medical homes today. Changing how providers and staff both divide up the work and share responsibility for every patient is a critical part of this transformation, and Drs. Kirsten Meisinger and Thad Schilling will use their time on this WIHI to share what they’ve been doing that’s earning their sites accolades and, most importantly, achieving better results.

IHI’s Trissa Torres is no stranger to primary care transformation. Prior to joining IHI, Dr. Torres helped pioneer new care models for the Genesys Health System in Michigan and developed the concept and role of “Health Navigators” to help patients build upon an office visit and identify further support in the community. All this and more on this next WIHI. 

I hope you'll join us! You can enroll for the broadcast here.

Are road turnouts part of the National Park system?

OK, I understand that the shutdown of the federal government requires the National Parks and Monuments to be closed.  But I don't understand why officials felt it necessary to block off all the road turnouts leading to Mt. Rushmore and Devil's Tower National Monument with cones.  So, not only could you not visit the parks, but they made it more difficult to safely view the sites from public roads in the vicinity of the parks. 

Unless there is some public safety reason for this, it appears to be a political ploy to make the disruption even more unpleasant.  It is already unpleasant enough (and, of course, totally unnecessary), but why would you want to aggravate people even more?

MA Health Policy Commission posts a report

The Massachusetts Health Policy Commission presented this slide deck at the annual Cost Trends Hearings.  It is a good descriptor of some key performance indicators of the state's health care system.  Here's the key summary page (as I read the report):

In case you can't read it, the summary is that the state spent 36% more than the US per capita average in 2009; that the demographic indicators show an older, wealthier, universally insured population that has lower risk factors and disease prevalence than the average.  The population uses inpatient and outpatient services more than the national average. On the price front, there is significant variation within the state.  Finally, there is an assertion that quality is at or above the US for many measures.

Recent growth in per capita expenses are less than the national average.  For 2009-2012, MA expenses grew at 1.9% compared to a national figure of 3.1%.  For 2000-2009, MA grew at a higher rate than the national average, 6.8% versus 5.7%.

The report does not reach conclusions about the cause for the slowdown.  It asks the following questions:

How can we maintain the progress of the last few years?
Where can we go further on utilization and price?
Where are opportunities for plans, providers, employers, consumers, and the state to play a role?

That no answers are given to the questions raised is not unexpected.  I doubt whether there would be a consensus even within the HPC as to the answers, much less across the public.  Those advocating a wide range of public policy and private directions for the future can all find support for their positions in this document.

In short, the report provides a good touchstone and reference report for the future.

New book: Wounded, by Emily Mayhew

It's been over two years since I wrote about Emily Mayhew's excellent book, The Reconstruction of Warriors, and it turns out that she has been busy in the interim.  She's just published Wounded: From Battlefield to Blightly 1914-1918.

Wounded traces the journey made by casualites of the Great War from the battlefield (e.g., the Somme) to a hospital in Britain.  The stories come from the testimony of the people who cared for the soldiers--stretcher bearers, medical officers, surgeons, chaplains, orderlies, and nurses.

This is a powerful book, documenting the best about human beings--compassion, dedication, warmth--in an environment of killing, decay, and despair.

Here's an excerpt about the stretcher bearers, who often carried wounded men on their backs, as well:

On quiet evenings the bearers gathered together in one of their tents. . . . Everyone had a story of madness to tell.  One of them had just been at an aid post where a bearer team had just returned, covered in blood (and worse) literally up to their waists.  It turned out they'd been carrying all night, and at dawn they had got back to the head of  communication trench crowded with soldiers waiting for the whistle [to attack.]  The leading bearer dropped down into the trench and waited for them to move.  None of them did.  Bloodly infantry, he thought.  His team was still up there, becoming a target, as the offensive was about to begin.  He gave the usual call of "Gangway stretcher bearers!" Everyone normally moved for the gangway call, for it meant that a wounded man was on board.  It had no effect.  He tried again: "Make way for wounded!" Still nothing. When he walked over and pushed at the shoulder of one of the men leaning on a trench wall, the soldier's head lolled back. He was dead. It turned out that every last one of them was dead, hit where they stood, the trench too crowded for anyone to have fallen back. The shelling was heavy and they had no choice but to use the trench; leaving the stretcher on top, they started to push the dead soldiers over.  Then they got the stretcher down and told the casualty to keep his eyes shut and not open them, whatever happened.  They set off over the human mound, two of them dragging the stretcher behind them, the other two up ahead, pushing over the corpses to make a path.  They kept tripping up, their legs squishing down into the soft corpses, but they carried on and returned covered in blood.

But there is humor, too. Here's a sample about Major Alfred Hardwick, a regimental medical officer:

When the waters receded (from the trenches), a different plague was sent to try them.  Rats by the hundred scuttled freely around the trenches, feeding on all the rubbish left behind by the flood.  The men loathed them above all else, and one animal in particular, a large specimen that waddled where it liked and chewed with impunity.  Their hearing became sensitised to the smallest of scratching sounds, which indicated that one of the rats was at work on a boot, a carefully saved biscuit or a candle end.  Hardwick was determined to do something about this.

In March he was given a two-week pass, long enough to go all the way home to the West Country to see his family.  When he was there he bought two ferrets and a large cage.  On the train to London, and at his hotel, noses were wrinkled, but Hardwick dusted the cuffs of his uniform and glared back.  The ferrets couldn't have made a better start when they got to the 59th: bombing out of their cages, they returned the giant rat dead at Hardwick's feet.  It was better than getting a medal.

... What would the ferrets do, the men wondered, if the war ever ended.  How could they ever go back to a Cornish farm, now that they had hunted for trench rats in France?

Small favors

In this blog post, Boston Business Journal reporter Julie Donnelly passes along a comment by Partners Healthcare System made for the pending Health Policy Commission Cost Trend Hearings that "it does not expect its prices to rise faster than the rate of general inflation in the next several years."

Excuse me if I am unimpressed.  PHS rates have been above the market for at least fifteen years.  Its most recent rate increase from Blue Cross, the largest insurer in Massachusetts (twice as big as #2 and equal to all the others combined), exceeded the BC statewide average, even though the base on which that increase was applied was already substantially above the other tertiary hospitals, secondary hospitals, and physicians in the state.

It would only be newsworthy if PHS is not able to beat the overall rate of inflation with that kind of head start.

As another party to the hearings notes:

We are concerned . . . that the direction of the Commonwealth’s cost containment efforts could have the unintended effect of institutionalizing significant market disparities and dysfunction in place if we fail to focus on the need for correction of these disparities, and on the cost containment goal as an aggregate goal.

Returning, though, to the point of Julie's article: "But if the government keeps cutting reimbursements to . . . hospitals, it is hard to see how they can survive without shifting more of the burden onto commercial insurers and the employers who buy their health plans."

Almost. If government payers do not do their share, there are two possible results:  Private payers will have to make up the difference, or many of the other providers will suffer decapitalization and losses.  I'm guessing it will be more of the latter than the former.  In which case, PHS market dominance will grow.

The fragmented system of government oversight and regulation created by the Governor and legislature in their most recent legislation, Chapter 224 of the Acts of 2012, continues to serve the powerful.

Cost Trends Hearings 2013

From the website of the MA Health Policy Commission:

The annual health care cost trends hearing is a public examination into the drivers of health care costs as well as the engagement of experts and witnesses to identify particular challenges and opportunities within the Commonwealth's health care system. Chapter 224 transferred the responsibility to conduct the hearing to the Commission, in coordination with the Office of the Attorney General and Center for Health Information and Analysis. The hearing is scheduled for Tuesday, October 1 and Wednesday, October 2 at 9:00 AM at the University of Massachusetts Boston Campus Center. The hearing will provide a unique opportunity to evaluate evidence and assess the health care market’s response to the cost growth benchmark and quality, transparency and care delivery innovations required by Chapter 224.

Check out some of the pre-filed testimony to get a sense of what is happening in Massachusetts and how it's being spun by the various participants in the marketplace. 

Animal, vegetable, or fungus?

One of the joys of living in Massachusetts is being able to attend field schools offered by the Massachusetts Audubon Society at their Welflleet Bay Wildlife Sanctuary.  I've reported on some of these before and am pleased to do so again, after a two-day session led by Wesley Price, who, among other things, has organized the Cape Cod Mushroom Club.  Our diverse group of participants was introduced to the many aspects of this field, ranging from the ecological powerhouse represented by this part of the fungus kingdom (distinct from plants, animals, protista, and bacteria) to the details of structure and design of the most common genera.

Wesley is assiduous about documenting the location and setting of his finds.  After just a short time together in the forest, our eyes became trained, and we noticed mushrooms that we would have easily passed by previously.  Below is a pretty Amanita that I found growing among the bearberries.  Some varieties of edible and some are deadly poisonous, including one version that will kill your liver and require you to get a transplant to survive.  Wesley's practice and advise with regard to this genus:  Don't eat any of them.  There are very subtle differences between the good and bad ones, and his view is that it is just not worth the risk.

But then there are the Matsutaki mushrooms, a highly sought after variety, especially in Japan.  They are a bit harder to find, usually hidden under a clump of pine needles or other plant detritus.

At this time of year on Cape Cod, you will often find people of Russian or Eastern European descent searching for Boletes.  Unlike the amanitas, these do not have gills, but rather spongelike tubes and pores.

This sample was taken up with a chunk of the mycelium attached.  This is the major part of the fungus, a network of thin connectors spread throughout the soil.  Indeed, the mushroom that we see is the fruit of the mycelium, which erupts with the sole purpose of spreading spores into the environment to spread the fungus.  The mycelium is often found as a mycorrhizal, a symbiotic relationship with tree roots and other roots under ground, intertwined and helping the plant get moisture and nutrients form the soil.

We were also joined on this class by entomologist Hannah Nadel, Supervisory Entomologist at the US Department of Agriculture Otis Laboratory, who was able to present us with lots of information about the relationships between insects and fungi.

And, in anticipation of your final question, yes, we ate some.  Here was this morning's breakfast, some Cortinarius caperatus, commonly known as gypsy mushrooms, being readied to be sauteed and then served with polenta and avocado.

 

Breaking news: Health care may be becoming a political issue

A very funny article appeared in The Onion about US health care issues: "Area Man Worried Health Care Debate Might Be Getting Political." Read it if you need solace during the Congressional debates!  Opening:

COLUMBUS, OH—Local man Henry Allen, 56, expressed concern Tuesday that the debate over how United States citizens receive health care may in fact be becoming a political issue, sources confirmed.

Close:

Allen stated that, in the end, he believes elected officials know how great their responsibility is to the American people, and that they would ultimately of course never let something as petty as party politics get in the way of that.

Career advice

A young friend writes this letter and asks me to forward it to potential firms in the field.

Subject: Recent [name of undergrad school]/[name of grad school] grad interested in health jobs

Having recently completed a Master of Science in Public Health degree from [name of school], I am now looking for job opportunities in innovation in health sciences. I have experience in both qualitative and quantitative analysis, using software such as STATA and atlas.ti. I also hold a bachelor's degree from [name of school].

As we discussed, I am attaching my CV for your review.
 
A friend who heads up a company responds after I do so:

Thank you Paul. It makes me nervous when people are so proud of their universities. My father used to say the people who are the most worthy of their credentials rarely mention them. 

A word to the wise: Spend time in your cover letter explaining what you care about and what you'd like to learn more about, not relying on credentials.

Negotiating on Purpose

I am honored to post guest blog articles on Athenahealth's Leadership Forum, and the latest one just went live.  I'd be very pleased if you clicked over there to read it.  The title of the article is "Negotiating on Purpose."  Here's the lede:

After her fifteen year-old son Lewis Blackman died from a series of preventable medical errors, Helen Haskell diagnosed the problems in the hospital by saying, “This was a system that was operating for its own benefit.”

What she meant was that each person in the hospital was unthinkingly engaged in a series of tasks that had become disconnected from the underlying purpose of the hospital. They were driven by their inclinations and imperatives rather than by the patient’s needs. Indeed, they were so trapped in that form of work that they could not notice the entreaties of a seriously concerned mother as her son deteriorated.

From there I go into a discussion of the role of a leader in conducting what can be viewed as a negotiation with the doctors and other staff of a hospital to help the institution's constituencies understand that their interests are coincident with the purpose of the organization and to help them jointly decide on the actions needed to carry out that purpose.

Some might read the article with a view of negotiation as a kind of transaction or a form of haggling.  That is a narrow view of the term.  A more expansive view, and the one I attempt to portray, is a respectful process that provides a means of satisfying parties’ underlying interests by jointly decided action.

I'd welcome your comments, either at the Athenahealth site or here.

I have quit texting while driving

A friend writes:

Your blog post on texting while driving was VERY powerful.

I have quit and shared the video with friends and family I care about. Thanks!

Another said,

I watched that video and, since them, I zip up my cell phone in my purse whenever I get into the car.  I asked the principal of my child's high school to show it to the kids to help them understand.

Please tell me your stories.  Let's keep it going.

Not everyone has gotten the word.  Zoom in on this picture.

Two sides of a coin, or TANSTAAFL

Economists like to say that there is no such thing as a free lunch, or TANSTAAFL, and this phenomenon is showing up in the rates to be charged for new health insurance products that will be offered by exchanges across the US.  Harris Meyer at Modern Healthcare reports:

An eagerly awaited report by HHS released Wednesday on health plan premiums and participation in the 36 states where the federal government is fully or partly running the new insurance exchanges shows that consumers in most of those states will have many plans to choose from and that premiums will be significantly lower than expected in 2014.

The new HHS report, combined with previous reports from states running their own exchanges that showed similar results, bolsters the Obama administration's case that the Patient Protection and Affordable Care Act is achieving its goal of fostering competition in the health insurance marketplace and producing affordable premiums for consumers. 

But now look at a report by Robert Pear in the New York Times:

Federal officials often say that health insurance will cost consumers less than expected under President Obama’s health care law. But they rarely mention one big reason: many insurers are significantly limiting the choices of doctors and hospitals available to consumers. 

From California to Illinois to New Hampshire, and in many states in between, insurers are driving down premiums by restricting the number of providers who will treat patients in their new health plans.  

To hold down costs, insurers say, they have created smaller networks of doctors and hospitals than are typically found in commercial insurance. And those health care providers will, in many cases, be paid less than what they have been receiving from commercial insurers. 

Consumers should be prepared for “much tighter, narrower networks” of doctors and hospitals, said Adam M. Linker, a health policy analyst at the North Carolina Justice Center, a statewide advocacy group. 

“That can be positive for consumers if it holds down premiums and drives people to higher-quality providers,” Mr. Linker said. “But there is also a risk because, under some health plans, consumers can end up with astronomical costs if they go to providers outside the network.”

None of this should be surprising.  As I have mentioned many times:

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.

But the President's decision to hedge this issue during the legislative battle on the act is nothing compared to the cruelty and stupidity of those governors who have decided to deprive their Medicaid-eligible residents of the opportunity to participate in the federally funded health care insurance subsidies under the new law.  And those in Congress who are holding up the national budget and debt ceiling by trying to defund the act are likewise cruelly rolling the dice on the national and world economy by their sore-loser approach to what is supposed to be the approach to compromise in a republican form of government.

A solution to clutter

#GBMP1 Sometimes unexpected proposed countermeasures to problems called out during Lean process improvement efforts come up.  Look at the one proposed here on a suggestion form!  While Lean envisions countermeasures as temporary or iterative or interim solutions to problems, I don't think even the most creative of Lean experts would have come up with this one--even for the short term.

Thanks to Gary Peterson at O. C. Tanner for this humorous example.

Notes from a Lean conference

#GBMP1 I'm currently attending the 9th Annual Northeast Shingo Prize Conference presented by GBMP, a non-profit that is engaged in Lean educational programs.  Entitled, "True North: Set the Course, Make Waves," the conference began with a short introduction by GBMP's president, Bruce Hamilton.  Regular readers will recognize Bruce as the star of Toast Kaizen, a wonderful video illustrating Lean principles in the "production" of toast in a kitchen.  He began with the concept of "True North," which he defined as "the way things should be," but importantly the way things should be for both customers and those providing service to customer.

The keynote speaker was Gary Peterson, EVP for supply chain and production at The O.C. Tanner Company.  "We've made a ton of mistakes" with our Lean journey, he began:

Most of the mistakes we've made centered on our people.  We implemented tools and imposed them on our people.  They worked, but people hated it. We hired "a cop" to enforce use of the tools.  "That should have made it obvious that we were doing something wrong!"

The fundamental principle has to be respect for people, he noted.  He suggested that there are four things that are critical for getting people involved:

(1) Setting a clear vision:  Establishing an understanding of True North (an aspirational vision of what might be achieved--but paradoxically might be unlikely ever to be achieved), provide free flowing information, engage in true transparency.  "By the way," he noted, "Things somehow move from aspirational to the way things are!"

(2) Providing a powerful reason for engagement.  Don't use, "If we don't do this we may go out of business."  Focus on the purpose of the organization, the intrinsic reasons that make daily work meaningful and create a sense of pride.  (By the way, check out his company's blog to get a sense of this.)

(3) Engaging in a thoughtful and good improvement methodology.  Develop people for contribution, particularly helping people evolve into leadership roles that are supportive of the philosophy.  "We want eveyone to become leaders." Minimize rules that control: Avoid systems that get in the way. "Don't act like you are cutting them loose and then have them drag a chain behind themselves." Hire well: Ensure that they believe in the elements of a living culture--safety, continuous improvement, trust, respect for others, we are all in this together, Arbinger principles (avoiding self-deception.)

(4) Inspiring a desire to continue to do it and stay engaged.  Make it fun to learn and safe to venture into unknown territory.  Above all, "Show me you value my efforts."  Help people believe: "There is no secret ingredient."

One is too many

An excellent story here about Jordan Hospital's success in avoiding catheter-associated urinary tract infections (CAUTIs).  Note the important elements of process improvement, starting right with the governing body.  Note, too, the lack of acceptance of industry benchmarks: The aim is zero. Zero is achieved!

Excerpts:

An intensive education program involving the hospital's Board of Trustees and personnel in the Emergency Department, Critical Care Center (CCC) and other units throughout the hospital, has been followed by daily and even hourly assessments of patients with catheters.  The surveillance, discussion, and effort to curb infections are unending and are now ingrained within the hospital's culture.

"We began with the premise that anytime you insert anything into a person's body that they didn't come into the hospital with, it increases their susceptibility to infection," says Kathleen M. Mercurio, R.N., infection preventionist at Jordan.  

The challenge at Jordan was threefold - to reduce catheter associated urinary tract infections in the Critical Care Center (which is what Jordan calls its ICU); to decrease the number of days a Foley catheter stays in a patient (hence decreasing the chance for infection); and to promote alternatives to Foleys that are non-invasive. 

Nurses on each shift have to enter computerized documentation, answering, among other items: When was the catheter inserted? Where was it put in? (In the ED, CCC or on a med/surg floor) and why was it inserted.  To answer the "why," a nurse has to check off on the computer screen one of the CDC-approved guidelines.  Those same questions are answered for each patient when a new shift begins, demonstrating that for a quality-improvement strategy to work, repetition of many tasks is imperative.

"We had to create new strategies and processes easy for everyone involved. Using and incorporating a new process into their daily workflow requires a systematic, sensible approach," Mercurio says.

"Anytime you want to change a person's habits, you have to give that person a reason for the change - a reason that hits something inside of them that makes them value the change," Mercurio says.  For the different cultures throughout the hospital, the reasons she gave varied.


In July and November of 2012 and January and February of 2013, Jordan Hospital had one patient in each of those months who developed a CAUTI.  That's not a terrible track record, but as Mercurio says, "One is too many. One is someone's dad getting an infection."

But from March through August 2013 (the latest full month recorded), Jordan Hospital has had zero CAUTIs. 

And, the number of Foley catheter days - that is, the number of days that patients had catheters - steadily dropped, evidence of the strategy of removing them as soon as possible. The decrease in Foley catheter days occurred even as patient days in the CCC increased. That is, more patients, less days with them having catheters, and less chance of them getting an infection.
 

Gettting older? What can we count on?

"Advanced Old Age in America: What Can We Count On?"

Join Senator Mark Warner (D-VA) and Senator Johnny Isakson (R-GA) as we focus on health care reform and elderly Americans living with frailty in their last years, addressing questions such as:

• How serious are the shortcomings in services and the expected growth in costs as the population ages? How much time do we have to make arrangements for the coming increase in numbers?
• What should we promise to individuals living with frailty in old age and their families? How does this differ from the current trajectory?
• Half of those who live past 85 years old will have cognitive failure. What health care, social supports, and financial arrangements would serve people touched by this challenging situation?
• Which of the current reforms and trials offer prospects of moving us toward a workable set of solutions—that is, more appropriate and desirable services, at lower cost? Are there additional strategies that should be tested and developed?
• What role might local coalitions, commissions, and communities have?

Speakers at the Roundtable:

• Joseph Antos, Wilson H. Taylor Scholar in Health Care and Retirement Policy, American  Enterprise Institute
• Shannon Brownlee, Senior Vice President, Lown Institute; Senior Fellow, New America Foundation; Instructor, The Dartmouth Institute for Health Policy and Clinical Practice
• Suzanne Burke, Chief Executive Officer, Council on Aging of Southwestern Ohio
• Susan Dentzer, Senior Health Policy Adviser, Robert Wood Johnson Foundation (Moderator)
• John Feather, Chief Executive Officer, Grantmakers In Aging
• Jennie Chin Hansen, Chief Executive Officer, American Geriatrics Society
• Sen. Johnny Isakson (R-GA)
• Joanne Lynn, Director, Altarum Institute Center for Elder Care and Advanced Illness
• Anne Montgomery, Senior Policy Analyst, Altarum Institute
• John Rother, President and Chief Executive Officer, National Coalition on Health Care
• Mimi Toomey, Director, Office of Policy Analysis & Development, Administration for Community Living
• Sen. Mark Warner (D-VA)

Final opportunity to register!

Click here to register to attend the September 26 Roundtable in person or to join via Webcast.
(For individuals registering to join via webcast, an email confirmation will be sent with further instructions.)

What:       
    Advanced Old Age in America: What Can We Count On?
When:       
    September 26, 2013 from 8:30 a.m. - 12:30 p.m. ET
     Webcast: from 9:00 a.m.-11:30 a.m. ET
Where:     
    The Pew Charitable Trusts Conference Center, Washington, DC

Melody from Jubilee

The team from the Jubilee Project have done it again, producing a touching and warm video, entitled Melody.  I will not spoil it by describing it in any way. Just watch.

When persistence doesn't pay

A high ranking friend at a hospital sent me this thread of emails:

First the unsolicited invitation to a sales conference:

Space is limited and last year's events were packed so register to save your seat now.

My friend responds with an email with "pls delete me from your e-mail list" in the subject line.

He replies:

We work with a number of healthcare and assisted living companies today. We've been able to demonstrate huge returns for them in the millions by improving on internal processes, greater efficiencies, and driving overall OPEX down.

Given the blueprint of [hospital name], your vertical, employee headcount (3,000) and revenues ($280m+) I would predict you have approximately $70m in addressable spend per year that you and your team is trying to manage. Because of our model, user adoption rates and the ability to control all of this spend by 90% I would anticipate being able to save [hospital name] $150k per month.

I will be more than happy to take you off our email list. With your permission and based on your thoughts given the information I've shared with you today I would welcome a call to discuss how I cam (sic) up with this 15 minute analysis. I believe with your candid feedback and more accurate numbers the number I shared with you would be greater. 

She responds:

Do others find this an effective sales approach?  I asked you to take me off your list and you then write me back trying to still sell me services.  If I wanted to talk to you, I would not have asked you to take me off your e-mail list.

He replies:

I've taken you off any future email campaigns from Marketing, apologies. I sent you a personal email as I'm simply doing my job here.

Most employees I speak with that are tasked with improving operations with tools that drive down costs, improve efficiencies, and provide greater visibility into the organization typically welcome a discussion to learn more.

ConvergenceRI is born

@ConvergenceRI Welcome to the birth of ConvergenceRI, a new online subscription newsletter offering news and analysis at the convergence of health, science, technology and innovation in Rhode Island. It is the brainchild of Richard Asinof @RichardAsinof, who says,

“ConvergenceRI will fill a critical information need, covering Rhode Island’s innovation ecosystem in a cohesive, cogent and comprehensive fashion.”

“Rhode Island’s knowledge economy is on the cusp of a major growth spurt,” Asinof continued. “Its size, its connective sense of neighborhood, its embrace of health care reform and patient-centered changes in health care delivery, its maturing life sciences, biosciences and med-tech sectors, its emergence as a new hub for brain research, and its investment in transforming Providence’s former Jewelry District into a Knowledge District are all critical factors.”

The online newsletter will be published weekly every Monday, 48 times a year, with two-week breaks at the end of December and at the beginning of July.

A palindrome for patient safety

Thanks to David Mayer at MedStar Health for sharing this video by Victoria Nahum.  Well worth two minutes of your time:

No more visitors at Contra Costa

Check out this note from Anna Roth, Chief Executive Officer, Contra Costa Regional Medical Center.

I’m excited to tell our staff and Contra Costa County residents that Contra Costa Regional Medical Center (CCRMC) is eliminating the concept of visitors in our medical center and health delivery system. On September 17^th, 2013, CCRMC will remain accessible 24 hours a day to family and loved-ones of those receiving care in the medical center.

Recognizing that family and loved-one presence supports safe and high quality care, we have worked over the last year to replace our “visitor policy” with this Welcoming Policy. Though we have carefully planned the introduction of this change, we remain open to ideas to enhance and improve our Welcoming Policy and will place it and all supporting documents on the CCRMC web page for your review, comments and suggestions for improvement.

And, then an update a few days later.  A learning organization at work!

We started on September 17, 2013 at 8:30pm. Our first night we welcomed 13 family members/care partners (and a pizza delivery person who brought pizza to a hungry family member). The second night we welcomed 18 family members/care partners and the third night we welcomed 15. That totals of 46 family members/care partners that had the opportunity to participate in the care of their loved one. It also means that we at CCRMC had 46 opportunities to learn from family members and loved ones about how improve the care we deliver and how to improve our Welcoming Policy.

Each night the team learned, modified and improved the steps of the process to better support the family members/care partners. Most of the challenges faced by the testing team on the first night were related to logistics of the process - small details really matter! For example, we had some challenges with language barriers. We have modified our signs and are testing use of the health care interpreter video machines (HCIN) at check in. Timely updates are given to the Nurse Program Managers who have been present at night to support the staff and address any concerns they may have. The manager for Admission and Registration also worked on the night shift to support the staff. The security staff have been fully engaged and critical in the implementation as well. We have conducted huddles daily to support rapid improvements of our process and support the staff and our community in this exciting change. 

Bravo to all!

"This is not about me. It’s about the coat."

Photo by Webb Chappell, Boston Globe

A wonderful, marvelous, lovely (enough said?) story by my friend Cynthia Thomas in today's Boston Globe Magazine.  It's about a coat.

Read it.  That's all I have to say.

Problems of psychology and engineering, not of medicine

There is a superb (and open access!!) article in BMJ Quality and Safety about how human factors engineering can help reduce medical errors.  Well worth reading.  I like, in particular, its summary of fact and fiction.  Here are excerpts:

Human error in medicine, and the adverse events that may follow, are problems of psychology and engineering, not of medicine.

Medicine is devoted to human health and healing, but the science behind why errors occur, and how to reduce the likelihood of preventable harm to individuals, are well described in human factors literature. Human factors—a science at the intersection of psychology and engineering—is dedicated to designing all aspects of a work system to support human performance and safety. The goals of human factors in healthcare are twofold: (1) support the cognitive and physical work of healthcare professionals and (2) promote high quality, safe care for patients.

Fact #1: Human factors is about designing systems that are resilient to unanticipated events.

Fiction: Human factors is about eliminating human error. 

Fact #2: Human factors addresses problems by modifying the design of the system to better aid people.

Fiction: Human factors addresses problems by teaching people to modify their behaviour. 

Fact #3: Human factors work ranges from the individual to the organisational level.

Fiction: Human factors is focused only on individuals. 

Fact #4: Human factors is a scientific discipline that requires years of training; most human factors professionals hold relevant graduate degrees.

Fiction: Human factors consists of a limited set of principles that can be learnt during brief training. 

Fact #5: Human factors professionals are bound together by the common goal of improving design for human use, but represent different specialty areas and methodological skills sets.

Fiction: Human factors scientists and engineers all have the same expertise. 

Summary:

Human factors is an established body of science that is positioned to assist with the challenge of improving healthcare delivery and safety for patients. Human factors and healthcare professionals can work together to identify problems and solutions that may not be apparent by traditional means. While human factors does not promise instant solutions for healthcare improvement, it can provide a wealth of scientific resources for sustainable progress.

Deadline approaching for IHI early-bird special

Oct 1 is the early-bird deadline for the 25th National IHI Forum. Registering by then saves $100.  My blue-shirted buddy Amanda Swiatocha notes:
 

Here are some exciting highlights about this year’s National Forum:

·         We have over 350 presenters representing over 80 organizations teaching over 100 sessions (!!) on lots of great new—and tried-and-true—topics.

·         We just announced our fourth keynote – it will be Nancy Snyderman, interviewing her patient (and two-time cancer survivor) Lindsay Beck. We also have some pretty exceptional special interest keynotes listed on here, too.

·         This year, we’re offering attendees the chance to virtually visit over 8 best-practice organizations including Kaiser Permanente and North Mississippi Health Services (2012 Baldrige Winner).

·         We have a nifty new session picker on our website, which allows people to browse topics by title, keyword, presenter, track, and more.

·         We’re offering a new Forum Excursion to LEGOLAND as well as a new Leadership Excursion to Darden Restaurants.  (Paul's note:  I am helping to run that one.  Join me!)

·         It is our 25th National Forum, and yes, we’ll be celebrating with all the attendees during a special event on Tuesday evening.

The right way to handle a quality issue

Kudos to Trillium Health Partners in Ontario for this above-board, open, and honest public communication after they found problems in the work done by one of their radiologists.  The press release:

The web site notice:

88 feet per second

"I only text on the highway," was the comment overheard the other day.  Huh?  I guess the thought was that there is more traffic on local streets, along with pedestrians.

But really?

At 60 miles per hour, your car is going 88 feet per second.  In the time it takes for you to read a text message, say, 5 seconds, you have traveled 440 feet when you look up and see you need to stop.  That's over 100 yards.  And then you put on the brakes.  At 60 mph, "a driver could stop the described vehicle in a total of 6.87 seconds (including a 1 second delay for driver reaction) and your total stopping distance would be 302.28 feet, slightly more than a football field in length!"

In total, two football fields. And that's if you are just reading.  If you are writing, the result is worse.

Please don't.  You are going to feel very stupid if you say, "I killed that person in order to read (or write) a text message."

Watch the video.

 

How to keep Lean while eating

One of the dangers of becoming a Lean aficionado is that you see opportunities for process improvement everywhere.  Also, you feel an affinity for people who are able to go to gemba (the place where work is done) and, either by training or by intuition, look at work flows and find ways to improve them.  You have sympathy for them when their supervisors are unable to recognize their helpful suggestions or respond approrpriately.

I was giving a talk at a conference in Connecticut today and walked up to the lunch buffet table when I heard one of the servers say to her supervisor, "Shouldn't we move the chocolate cake closer to the coffee? Then, the potato chips can be closer to the sandwiches, too."

Of course, she was right.  Look above.  The flow of customers gathering their main course is from right to left, using a large plate (not seen here) for their sandwiches, using the condiments, and adding a bag of chips to their plate.  The flow of customers getting desert would be from the far end of the table, moving left to right, getting their coffee or tea and picking up some cake using the small plates. As the table is organized, when the two flows get busy, they would interfere with each other.

Her supervisor said, "No, the cake has to be near the B&Bs [the bread and butter plates], so we can't move it."

Well, as you can see, it would be possible to switch the chips and the cake and reconfigure things slightly to still allow the B&Bs to be near the cake.

Sure enough, as lunch proceeded, traffic jams ensued between the people who were picking up their main courses and the ones who had already progressed to coffee and dessert.

I offer this not as a treatise in the proper placement of luncheon foods on a buffet line.  I offer it more as an example of a manager who quickly dismissed a suggestion from a staff member without engaging in a reasoned discussion of the alternatives.  We see this all the time in hospitals and other organizations, where a manager becomes blindly wedded to "the way we've always done it," and in so doing discourages front-line staff from offering suggestions for process improvement.