Pulling out all the stops

I'm trying to figure out what's going on here, following up from my recent post about a hospital system president who encouraged his doctors and former trainees to register on Doximity so they could influence the US News and World Report hospital rankings.

Avery Comarow, who is in charge of the rankings, offered a comment to me on Facebook to clarify the situation:

For a full explanation of the relationship and how the coming physician survey will be conducted (and why hospitals that try to recruit their doctors to join Doximity won't benefit), see this site.

Look what it says:

If you are a hospital leader, you may be deliberating whether to encourage affiliated physicians to join Doximity and/or participate in the upcoming survey. It’s your call. If an appeal from you increases the number of physicians who participate in the survey, it will enhance our statistical power to calculate reputation scores for all hospitals. But your decision will neither benefit nor penalize your hospital in the reputation survey or in the rankings as a whole, because of the statistical adjustments we will make.

Unlike our nation's imperfect electoral system, which counts the opinions of only those who show up at the polls, the U.S. News reputation survey statistically represents all survey-eligible physicians, including those who don't receive a survey as well as those who receive one and choose not to respond.

If you are a physician, you may be wondering what effect joining Doximity would have on your participation in the survey. Any decision to join Doximity should be made with full awareness that doing so will neither increase nor decrease your net influence on the U.S. News rankings.

But, for some reason, the message has not been received.  Look at today's note from David Battinelli, Senior VP and Chief Medical Officer of North Shore-LIJ Health System:

Dear Colleague,

              

As you know, each year U.S. News & World Report publishes their Best Hospital rankings. Last year U.S. News partnered with Doximity, a web-based physician network, to enable Doximity members to vote online for hospitals they believe provide the best care in their area of board certification.  Online votes from Doximity members, along with paper surveys mailed to a small number of non-Doximity members, determine the Reputation component of the rankings, which accounts for 27.5% of the overall score.  

Similar to last year, all board-certified physicians who are members of the Doximity network are guaranteed an invitation to vote in the coming year’s rankings.  Unlike last year, U.S. News will no longer be using the AMA Physician Masterfile as the source for randomly selecting non-Doximity members to receive paper ballots.  Instead, U.S. News will use Doximity’s proprietary masterfile, comprised of both its members and non-members, including those who’ve never heard of Doximity.   

Therefore, we encourage our physicians to take the following action on the Doximity website prior to the imposed cutoff date of tomorrow, December 5:

• If you are already a Doximity member, find your profile on Doximity.com to ensure your information is still accurate
• If you aren’t a Doximity member, claim your profile and register to have your voice heard in the online voting
• If you choose not to join Doximity, it is still important to view and edit your information on their website for accuracy, since a lottery will be used to identify 4,700 non-members who will receive a paper ballot

So given the US News advisory, why this push for signing up on Doximity?

I can only conclude that these rankings have taken on a life of their own in the minds of hospital executives.  This whole thing has become such a marketing tour de force that the executives don't dare take a chance that--even if meaningless to the outcomes--they haven't pulled out all the stops.

What a stupid use of managerial attention.

People deserve better

After reading my post below about the slow pace of quality and safety improvement in my home state, a reader wrote an in-depth summary of her mother's experience at one of the Harvard teaching hospitals. The care was replete with medical errors, failure to disclose, and unhelpful attitudes.  (The reader is an RN, who then went on for additional education and received an MBA, returning to work in the medical world on quality improvement.)  Here's a portion of the note:

It was a nightmare.

They sent me a bill for hundreds of thousands of dollars.  I wrote back, enclosing the daily notes that I had kept since the beginning, and told them that since the costs were due to their mistakes, I would not be paying them.  In my letter, I offered to work with them to use this case as a teaching tool for their residents.  I actually was so naive that I thought they would jump at the offer--surely the great teaching institution had a rigorous continuous quality improvement program, right?

After several months, I received a letter to the effect that in their munificence, they would waive the charges.  No mention of my offer. The medical records that I received per request, independent of the letter, had only the most superficial documentation of her stays there--no nurse's or doctor's notes.

I can only imagine the rococo channels that my letter and her case traveled throughout the hospital before their determination.

I wish this were the only example I have received, but it is not.  There is an overwhelming degree of arrogance in many of these institutions.  They believe their own propaganda about being the best in the world.  Some of the individual doctors might be the best in the world in particular subspecialties, but the care delivery systems are not.  The people of this region deserve better.

Team-Based care on WIHI

Madge Kaplan writes:

The next WIHI broadcast — The Road to Team-Based Primary Care and Behavioral Health — will take place on Thursday, December 4, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Ed Wagner, MD, MPH, Director Emeritus, MacColl Center for Health Care Innovation; Senior Investigator, Group Health Research Institute
• Robin Henderson, PsyD, Chief Behavioral Health Officer & Vice President, Strategic Integration, St. Charles Health System (Bend, Oregon)
• Parinda Khatri, PhD, Chief Clinical Officer, Cherokee Health Systems (Knoxville, Tennessee)
• Cindy Hupke, BSN, MBA, Director, Institute for Healthcare Improvement (IHI)
• Mara Laderman, MSPH, Senior Research Associate, IHI
  

Primary care practices across the US are facing a number of important challenges right now; prominent among them is doing a much better job at recognizing and helping patients with behavioral health issues. The operative term for this is “integration” — a notion that ranges from, at minimum, co-locating behavioral health services and counselors in primary care settings; to, at best, everyone on staff having greater training and skills to detect and address the mental health and behavioral challenges that may be impacting a patient’s health. And, together as a clinical team, working with patients on ‘whole person’ solutions. Achieving this level of capacity doesn’t happen overnight, but we’re going to discuss why it’s an essential aim on the December 4 WIHI: The Road to Team-Based Primary Care and Behavioral Health.

Our guides on this WIHI include Dr. Ed Wagner, whose work in chronic care and primary care redesign is legendary. Dr. Wagner has most recently been focused on identifying effective practice models around the country as part of the Robert Wood Johnson Foundation initiative known as Learning from Effective Ambulatory Practices, or LEAP. A strong commitment to behavioral health integration is often a standout feature of primary care practice transformation. The St. Charles and Cherokee Health Systems are cases in point. We’ll learn from Robin Henderson and Parinda Khatri about efforts to forge deeper linkages between behavioral health and primary care at their organizations; these efforts have already begun to demonstrate better patient outcomes and lower costs. Finally, we have IHI’s Cindy Hupke and Mara Laderman with us, each of whom has a hand in researching and teaching the programmatic designs necessary to help primary care teams engage in behavioral health integration. We look forward to engaging with you on the topic of behavioral health integration on December 4.

You can enroll for the broadcast here. We'd also appreciate it if you would spread the word about the show via Twitter.

Falling behind on safety and quality in the Hub of the Universe

I'm sitting here in Massachusetts trying to reconcile two stories.  First, this optimistic one put out by AHRQ, reported by Modern Healthcare's Sabriya Rice.  The lede:

The Agency for Healthcare Research and Quality estimates that 1.3 million fewer patients were harmed in U.S. hospitals from 2010 to 2013 amid focused and widespread efforts to reduce surgical-site infections, adverse drug events and other preventable incidents.

The decline represents cumulative 17% reduction and an estimated 50,000 deaths prevented over the three years after the launch of the Partnership for Patients, a public-private collaborative created with funding from HHS.

“This is an unprecedented decline in patient harm in this country,” said CMS Deputy Administrator Dr. Patrick Conway. “This means avoiding costly mistakes and readmissions, keeping patients healthy and out of the hospital and rewarding quality instead of quantity.”

I read that report and said, "Hmm, that doesn't jibe with what I see in Massachusetts." And then I read this less positive report by Kay Lazar at the Boston Globe:

The 1994 death of Betsy Lehman, a Boston Globe health reporter who received a massive overdose of chemotherapy at a prestigious Boston cancer center, galvanized health leaders to reduce errors in medical care.

But two decades later, nearly one-quarter of Massachusetts residents say they, or someone close to them, experienced a mistake in their care during the past five years, according to a survey released Tuesday. And about half of those who reported a mistake said the error resulted in serious health consequences.

The poll of 1,224 residents by researchers at the Harvard School of Public Health found that many people did not report the medical mistakes, often because they did not believe it would do any good, or they did not know how to report it.

“When you are trying to reduce incidents, and 20 years later you still have a significant number of people who report a significant event, it sets off concerns,” said Robert Blendon, a Harvard professor of health policy and political analysis, and the poll’s director.

That story was less surprising to me.  Why?  One of the problems in Massachusetts remains hospitals' stubborn failure to acknowledge the harm they cause.  A few years ago, for example, when I was posting BIDMC's central line-associated bloodstream infection rates, a reporter asked the CEO of one of the other Harvard hospitals when he was going to do the same.  His cynical response;  "We'll post our numbers when we're good and ready . . . but our numbers are better than theirs."

True clinical process improvement does not happen without true transparency--not to compare one hospital against another, but to help hospitals hold themselves accountable to the standard of care they say they believe in.  Endorsement of real-time, relevant transparency by Massachusetts hospitals' clinical and administrative leaders, and their boards of trustees, remains sorely lacking.  What's published is often out of date and put in terms of some substandard national benchmark, rather then being directed at eliminating preventable harm.

There is no virtue in benchmarking yourself to a substandard norm.  I once quoted Catherine Carson, Director, Quality & Patient Safety at Daughters of Charity Health System: 

When the goal is zero – as in zero hospital-acquired infections, or falls – why seek a benchmark? A benchmark would then send the message  - that in comparison to X, our current performance level is okay, which is a false message when the goal of harm is zero.

A colleague from another state noted to me upon reading Kay's story: "I have to say this is pretty shameful for a state dominated by academic medical centers."

Ironically, some of the world experts in these matters are faculty members in our local hospitals. Massachusetts should be a world leader in the science of health care delivery, along with the fields in which it already holds prominence.  But it is nowhere close to holding that title.  The action is elsewhere in the country. The state's hospitals are being left in the dust, to the detriment of thousands of people living here.

How to ensure a "statistically valid sample"

Here's something to give you even more confidence in validity of the US News and World Report hospital rankings, also the work being done as part of that process by Doximity:

Dear Colleague:

At University Hospitals, we are committed to providing the highest-quality, personalized care to our patients. This approach is validated every day in the feedback we receive from patients and the recognition we earn from fellow physicians.

As a physician with ties to UH Case Medical Center, whether through medical training or as a current or past faculty member, you know that part of our reputation as a national leader in clinical care comes from our strong standing in U.S. News & World Report's annual "Best Hospitals" rankings. In the 2014-15 rankings, for example, UH Case Medical Center was ranked in all 12 methodology-ranked specialties for the third year in a row, with four specialties ranked in the top 20 nationwide.

For the 2015-2016 voting, U.S. News is expanding the number of physicians surveyed about reputation. In addition to the questionnaire mailed or emailed to 3,200 board-certified specialists, U.S. News will survey all eligible physicians who are members of Doximity.com, the secure online social networking site for physicians.

To help spread the word about the superior care available at UH Case Medical Center, please consider registering on Doximity.com no later than Friday, Dec. 5, when data will be sourced for the survey.

If you are registered and are board-certified in one of the relevant disciplines for U.S. News voting, you will be eligible to vote. In early 2015, you will be contacted by email or prompted to complete the survey when you log in to Doximity. The 2015 U.S. News survey represents the first time pediatric specialists who are Doximity members will be surveyed via that website. If you are already a member of Doximity, please update your profile by Dec. 5 to make sure your board certifications are listed correctly.

Thank you for your ongoing commitment and for letting your colleagues know about the exceptional patient care delivered at UH Case Medical Center.

Sincerely,

Fred C. Rothstein, MD
President
University Hospitals Case Medical Center
11100 Euclid Avenue
Cleveland, Ohio 44106

What happened to pairing risks and rewards?

Here's a point of view guaranteed to upset those who religiously believe (nothwithstanding structural flaws) that the move to accountable care organizations with an accompanying shift of risk to providers is the way to transform the US health care system.

Today, the federal government essentially admitted that the move is a failure.

Let's look at the underlying principle:  If we give ACOs a financial incentive to beat an annual patient care budget, they will dramatically shift the way they deliver care to garner the surplus and avoid the penalties.  By pairing risk and reward, we will influence clinical decision-making.

But what if we only offer rewards and take away the risks?  What does that say about the principle?

That's exactly what is now planned.  Look at this report from Jordan Rau at Kaiser Health News.  Excerpts:

Health care systems experimenting with a new way of being paid by Medicare would have three extra years before they could be punished for poor performance, the federal government proposed Monday.

The proposal is one of dozens of changes that the Centers for Medicare & Medicaid Services wants to make to rules governing accountable care organizations. ACOs are affiliations of doctors, hospitals and other providers that jointly care for Medicare patients with the goal of pocketing a portion of what they save the government. Those that spend above Medicare estimates stand to lose money.

In the first year of the program, 118 ACOs saved Medicare $705 million with about half earning bonuses, government records show.  Another 102 ACOs spent more than Medicare’s benchmark, but only one had to repay Medicare because most ACOs have a three-year grace period when they can earn bonuses but are excused from penalties.

The new rule would give ACOs, both new and existing ones, an extra three years before they faced penalties, for a total of six years. Sean Cavanaugh, Medicare’s director, said the change was one of many prompted by concerns raised by ACOs. “The notion that 36 months later you’re going to be at downside financial risk is pretty intimidating,” he said in an interview.

The rule comes because many organizations have withdrawn from the ACO scheme or threaten to do so.  They have concluded that the risks just aren't worth the potential gain.  So now, CMS tries to solve that problem by essentially removing the risks.

This kind of reversal represents a kind of muddied thinking that is an indication of ideological public policy formulation. 

There are so many other things CMS could do to lower health care costs and remove incentives for overuse of unproven or inappropriate technologies.  I wish it would get to work on those rather than persistently trying to hammer a square block through a round hole.

Always visualize the data

Sometimes comments on Twitter offers useful perspectives.  Kris Peeters (@peeterskris), of datamined, tweeted this set of plots along with some excellent advice:

These sets all have the same mean, median and variance. Lesson: Always Visualise.

Of course, Twitter being Twitter, and geeks being geeks, someone named Emil OW Kirkegaard (@Kirkegaard.Emil) shortly thereafter presented a computerized numerical analysis and noted:

Not quite true, but close and the recommendation is good. 

It's during moments like this that I miss being on the MIT faculty!

Meet Dr Olivia! You are in for a treat.

The following might be the most adorable video in the health care world.  The purpose is to help people understand that a visit to the emergency room ("A&E," or "Accident and Emergency," in the United Kingdom) might not be the best path for treatment of certain ailments.  I present it with thanks to Mike Davidge, a Director at NHS Elect.

Here's the caption:

Meet Dr Olivia, Wales' youngest A&E consultant, and her team of 'medical students' as they meet patients in the A&E Department of a busy NHS hospital in South Wales.

(Note:  "Consultant" in the UK is an attending physician.)  Here's the video:

The search is over

Ah, I've finally figured out where change happens.

Have a great Thanksgiving!

Wellness programs are not doing well--or good.

A new article at the Health Affairs Blog by Al Lewis, Vik Khanna, and Shana Montrose evicerates many of the claims of wellness programs offered in the health care marketplace.  Here's how it starts:

During the last decade, workplace wellness programs have become commonplace in corporate America. The majority of US employers with 50 or more employees now offer the programs. A 2010 meta-analysis that was favorable to workplace wellness programs, published in Health Affairs, provided support for their uptake. This meta-analysis, plus a well-publicized “success” story from Safeway, coalesced into the so-called Safeway Amendment in the Affordable Care Act (ACA). That provision allows employers to tie a substantial and increasing share of employee insurance premiums to health status/behaviors, and subsidizes such program implementation by smaller employers. The assumption was that improved employee health would reduce the employer burden of health care costs.

Subsequently, however, Safeway’s story has been discredited. 

They continue:

Now, more than four years into the ACA, we conclude that these programs increase, rather than decrease employer spending on health care with no net health benefit. The programs also cause overutilization of screening and check-ups in generally healthy working age adult populations, put undue stress on employees, and incentivize unhealthy forms of weight-loss. Through a review of the research literature and primary sources, we have found that wellness programs produce a return-on-investment (ROI) of less than 1-to-1 savings to cost. 

More often than not wellness studies simply compare participants to “matched” non-participants or compare a subset of participants (typically high-risk individuals) to themselves over time. These studies usually show savings; however in the most carefully analyzed case, the savings from wellness activities were exclusively attributable to disease management activities for a small and very ill subset rather than from health promotion for the broader population, which reduced medical spending by only $1 for every $3 spent on the program.

They conclude:

In sum, with tens of millions of employees subjected to these unpopular and expensive programs, it is time to reconfigure workplace wellness. Because today’s conventional programs fail to pay for themselves and confer no proven net health benefit (and may on balance adversely affect health through over-diagnosis and promotion of unhealthy eating patterns), conventional wellness programs may fail the Americans with Disabilities Act’s “business necessity” standard if the financial forfeiture for non-participants is deemed coercive, as is alleged in employee lawsuits, against three companies, including Honeywell.

Especially in light of these lawsuits, a viable course of action—which is also the economically preferable solution for most companies, and won’t unfavorably impact employee health—is simply to pause, demand that their vendors and consultants answer open questions about their programs, and await more guidance from the administration. A standard that “wellness shall do no harm” . . . would be a good starting point.

Who let this through at HBR?

Harvard Business Review online often has interesting and thoughtful pieces, but this one is so self-serving as to make me gag--and wonder about the editorial policies that allowed its publication. 

The title seems innoucous enough--"Teaching Hospitals are the Best Place to Test Health Innovation." But this is no rigorous study or presentation of the article's premise.  No, when you read the thing, you discover that is a paean for the Hospital for Special Surgery in New York City and for a product developed by a doctor at the hospital, in which the hospital presumably has a financial interest.

It really would be interesting to analyze and test the proposition about teaching hopsitals versus non-teaching hospitals to see where clinical innovation is most likely to spread.  But this article makes no contribution along those lines.

As a piece of earned media, it is a public relations triumph.  I just never expected HBR to be taken in so easily.

Intensive training on line

I learned today of an impressive on-line educational tool produced by folks at Alfred Health in Melbourne.  It is Intensive, an educational website for doctors and other health professionals training in and practicing intensive care medicine.

This announcement appeared in May of this year:

Alfred ICU is delighted to have Chris Nickson as a senior registrar and he has designed and implemented this blog which will be a resource and repository for all our teaching and education. In the first 3 days since launching on 17/5/14, it has already had 1500 hits, 68% from overseas.

This is a well done venture and great worldwide resource.

Chris is a busy fellow on other fronts, too, involved in such activities as the SMACC (Social Media and Critical Care) conference to be held this year in Chicago.  You can listen to some of his ideas here.

Danish get a pasting

Gary Schwitzer reports on the proliferation of robotic surgery in Denmark, in a publicly financed health care system.  He quotes Frederik Joelving, a Danish journalist:

“What’s interesting is that even though our healthcare system is publicly funded, the development here is largely parallel to what’s been happening in the US: With hospitals competing to take the lead in robotic surgery and using dubious claims to market the technology, it has now become virtually impossible to have an open (let alone traditional laparoscopic) prostatectomy in most parts of the country.

So far, Denmark — a country of 5.5 million — has bought da Vinci equipment for 44 million US$, and the reimbursement for each robotic surgery is between 5000 and 10000 US$ higher than for the traditional approach. What’s more, all except one university-affiliated hospitals have stopped teaching open/laparoscopic prostate surgery. As one of my sources said, What happens when something goes wrong during a robotic surgery and you have to convert?”

Noted Gary:

The global march of the robots continues.

Pursuit of excellence at Alfred Health

I had a chance in advance of some presentations I'll be making this week at Alfred Health to view a number of the clinical process improvements at The Alfred, the system's tertiary referral teaching hospital, based in Melbourne.  The organization has spent years in adopting a culture of continuous process improvement, relying in great measure on the ideas and engagement of front-line staff.

First stop was the Emergency Department with my guides Rebecca (Bec) Atkins, the Nurse Manager, and ED Deputy Director, Dr. Jeremy Stevens.  As many of my readers know, EDs often suffer from patient flow problems.  The arrival patterns and condition of incoming patients are unpredictable, and many hospitals suffer from extended lengths of stay in the ED for patients who have been admitted to wards on the hospital.  Unfortunately, such patients end up boarding in the ED awaiting available rooms, creating backlogs that work backwards all the way to emergent patient arrivals.

I don't have pictures that can demonstrate the approaches used, but the folks at The Alfred have worked through this problem and have configured the various divisions of the ED for a more uniform and predictable throughput to the rest of the hospital--notwithstanding unpredictable arrival patterns and levels of patient acuity.  Among other things, they use a multi-bed short-stay section very thoughtfully, allowing it to be a resting place for patients who need a bit of extended care and/or observation but are unlikely to need to be admitted.  While the state of Victoria sets a standard that up to 25% of short-stay patients can ultimately be admitted, The Alfred's figure is more in the range of 15%.  This indicates that the triage function and the follow-up care in the ED are well enough carried out to be more precise about which patients are likley to be admitted.

From the ED, we were off to the intensive care units, with guides Dr. Owen Roodenburg, Deputy Director of the ICU, and Sharon Hade, the Nurse Manager.  You see them here in the natural light-enhanced unit, with switchable glass windows that automatically adjust to change their light transmission properties as the sunlight changes on the building.  In addition, the smart glass is used as a divider between the patient bays, where it can be manually switched from translucent to transparent to provide privacy or to allow a sense of openness.

There's lots to report about the ICUs, but one aspect that grabbed my attention was the availability in the family waiting rooms of iPads with useful information for waiting patients.  Developed by one of the staff members and put in place this last July, this application was thoughtful, clear, and very user-friendly.  (It was designated as a finalist in the Australian Mobile and Application Design Awards for 2014.)  What follows are some of the screen shots showing the capabilities of the program.  Their purpose is self evident, so no explanation is needed:

Here's the video tour:

But wait, it gets better!  Look at these scenes presenting--with utter transparency--important metrics of clinical performance: line related infections, hand hygene, and overall mortality.

And, just in case a staff member forgets to employ proper hand hygiene, here's a friendly reminder that patients and families have been encouraged to question them on the issue!

All in all, an impressive showing.  I'm looking forward to the rest of this week's activities.  Stay tuned.

Whac-A-Mole disguised as high-deductible plans

In the zeal to "bend the cost curve," the US health care system has focused on more "consumer-directed" aspects of health care, often in the form of high deductible insurance plans.  As in all such public policy moves, there are unintended consequences.

This has been recognized on the pediatric front, with the American Academy of Pediatrics taking a strong stand, as reported several month ago by Budd Shenkin:

The federal government should consider restricting high-deductible health plans (HDHPs) to adults because the plans discourage families from seeking primary care for their children, according to an updated AAP policy statement. 

But the tsunami is still coming.  Here's the report by Bob Herman at Modern Healthcare.  An excerpt:

“I thought (high-deductible plans) would level off this year and they continue to grow,” said Brigitte Nettesheim, a principal at the Chartis Group who studies the health insurer segment. “They will still be a significant portion of the type of plan designs offered.”

The proliferation of high-deductible exchange plans highlights the core issue of insurance affordability, one of the basic tenets behind the Patient Protection and Affordable Care Act.

Those deductibles already are weighing heavily on Americans. A new survey from the Commonwealth Fund (PDF) found that three in five low-income adults and about half of adults with moderate incomes believe their deductibles are “difficult or impossible to afford.” About 13% of Americans spend 10% or more of their income on out-of-pocket healthcare costs as well.

Bob notes that the trend applies to employer sponsored as well as insurance exchange plans:

These types of plans have taken off in the employer space in recent years as more companies have tried to stem the tide of growing premium costs by putting more of the expense burden on workers. Employers also may be looking ahead to 2018, when the Affordable Care Act will levy an excise tax on so-called “Cadillac” employer health plans that offer generous benefits and little, if any, cost-sharing for employees.

The Commonwealth Fund summarizes the impact on many families:

The results of this survey show that these trends toward greater cost-sharing, combined with little or no growth in median family income, have left many working Americans in the middle and lower end of the income distribution with large healthcare cost burdens. Cost-sharing in health plans is affecting people's medical decisions in ways that should be of concern to policymakers and the medical community.

Here's what the "experts" offer in the way of a solution:

Experts say insurers and providers are the most influential players to educate patients about high-deductible plans and help them determine whether they are a reasonable fit. “If there's anything they can do to talk to patients more, or educate their insured folks more about some of those terms and concepts, they may end up with fewer situations where people are surprised about their out-of-pocket costs,” said Liz Hamel, the director of public opinion and survey research at the Kaiser Family Foundation.

Look, most people can't even understand how to pick a cellphone calling plan that meets their needs. Do you think that people are really going to be able to be that analytical about their health insurance plans?  Even if you are good with humbers, when you choose a plan, you generally have no idea of what your medical needs are going to be for the coming year.  Having talked to many people in this situation, I'd be willing to bet that most people in the middle and lower end of the income distribution are guided by what the monthly premium will be:  That is their only way of judging affordability. No amount of "education" is going to change that.

By the way, the idea that providers will offer such education is laughable. During your next 18-minute visit, just try asking your primary care doctor to opine on insurance plans. Watch his/her eyes roll in frustrated ignorance.

And given the state of the insurance exchanges, can we expect the people at the end of the phone call to have the time and expertise to help consumers truly evaluate their personal needs?

Beyond the sad impact on individual families in any given year, I fear that the economic backlash of these policies will be a deferment of needed health care treatments and a resulting future bulge of cost increases.  We're playing Whac-A-Mole here.

Iron filagree enhances Melbourne

I'm breaking from health care today, with a throwback to my training as a city planner.  I'm spending several days in Melbourne, Australia, and had a chance to visit some of the old neighborhoods. We spent some time walking around Drummond Street, in the Carlton section of the city, and came across an incredible collection of terraced houses from the Victorian and Edwardian eras.  Fortunately, they have been preserved, and now the district is legally protected from redevelopment.

Wikipedia explains:

In the first half of the twentieth-century, terraced housing in Australia fell into disfavour and the inner-city areas where they were found were often considered slums. In the 1950s, many urban renewal programs were aimed at eradicating them entirely in favour of high-rise development. In recent decades these inner-city areas and their terraced houses have been gentrified. Terrace houses are now highly sought after in Australia, and due to their proximity to the CBD of the major cities, are often expensive.

The most noticeable characteristic of these row houses is the cast iron filagree work.  It is present on the overhang underneath balconies, where it also serves as a sunlight diffuser.  It is also used decoratively on the blaconies themselves.  My host noted that the iron originally came from pig iron that was used as ballast on the incoming ships from England and elsewhere.  (On the outgoing routes, the cargo served as ballast.) Wiki says, "Today Melbourne has more decorative cast iron than any other city in the world."

Another predominant feature is the use of polychrome brickwork.  Some of the houses have been painted over, but the original bricks are visible in quite a few.  Check out this marvelous specimen below:

What's up with the residency programs at St. Elizabeth's?

I've written about the financial difficulties leading to the closure of Quincy Medical Center and have suggested that these almost inevitably resulted from the business model employed by the private equity firm that owns this hospital system.  But are there other somewhat hidden consequences of this style of ownership?  One worth reviewing might be the system's commitment to residency training programs.

St. Elizabeth's Medical Center is the major training hospital within the Steward Health Care System.  How is it doing with regard to the long-standing and clinically important graduate medical education program that resides there?

Not so good.

The ACGME is the governing body that accredits residency programs.  It has a public website on which the status of each program is listed.  As we go through the site, we see the following programmatic problems at St. Elizabeth's in three of its largest training programs.  (The fourth, Anesthesiology, is currently accredited but up for renewal soon.)

Surgery

Internal Medicine

Psychiatry

Getting a warning or probationary designation is a very big deal.  For example, of the 9,527 programs that were ACGME accredited in 2013-2014, only 279 programs (under 3%) received such designations.  Here's the chart:

A warning is serious, but probationary status is applied when the ACGME concludes, following a site visit and review, that a program or sponsoring institution has failed to demonstrate substantial compliance with ACGME requirements. 

What's behind the St. Elizabeth situation? While the details behind these designations are not published, in general, the largest number of such citations come from persistent violations of the ACGME duty hours requirements.  Recall that, several years ago, the ACGME imposed strict limits on the number of hours per week that residents were permitted to work. These rules came about from Congressional pressure and an acknowledgement that it was not healthy for the residents, patients, and members of the public for trainees to get too little sleep (resulting in "impaired neurocognitive performance, including reduced memory consolidation, and deterioration of waking performance marked by increased rates of attentional failures.")

I have a hypothesis that when a hospital like St. Elizabeth's suffers from financial distress, there is an inclination to use residents as low-cost labor (relative to nurse practitioners and physician assistants) and assign them to extra hours of work in taking care of patients.  I'd be happy to have this hypothesis disproved, but that would require disclosure by St. Elizabeth's of the reasons for the warning and probationary ACGME designations.  The hospital is very unlikely to provide that to me!

But is there any inclination on the part of the Attorney General, the state official with authority to monitor the performance of the Steward Health system, to look into this matter?  If residents are, in fact, violating duty hours, there is the potential for harm to the public.  If residents are being assigned to cover the work that would otherwise go to paid staff, is that consistent with the employment promises made during the take-over of the system from its previous owners?

(There is also another possible reason for poor reports from the ACGME--a lack of training opportunities.  For example, if the volume of patients is too low, surgical residents don't get enough cases on which to practice. Might that being going on at St. Elizabeth's, too?)

It is too late to save Quincy Medical Center, but it is not too late for the state to review these matters and intervene.

Lean is not a program

Over two years ago, I wrote a post saying, You don't "do Lean."  Beyond suggesting that there should be a form of medical malpractice lawsuit against those consulting firms that promise hospitals that they will teach them how to "do Lean," I summarized the main point:

Lean is not a program.  It is a long-term philosophy of corporate leadership and organization that is based, above all, on respect shown to front-line staff.  There are two essential aspects, training front-line workers to be empowered and encouraged to call out problems on the "factory floor," and training managers to understand that their job is to serve those front-line workers by knowing what is going on on the front lines and responding in real time (when problems are fresh) to the call-outs.

A recent article by Emmanuel Jallas takes this theme a step further, based on a visit to a manufacturing facility.  Excerpts:

Fake Lean can be very smart. Or rather, I should say convincing at first glance.

I was visiting a facility of a great manufacturer with well known and respected products. I was told by my host, a manager at this facility, that every problem reported by associates is fixed by the team itself within five days, or by the support team under supervision of the facility manager. It all sounds impressive, right?

Maybe not.

While my guide left me alone to go speak with the factory manager, I took five minutes to just watch a team member working in this facility. At the end of this time I had 10 kaizen ideas, least four of which had to do with this person’s safety. She was bending her torso backwards every 20 seconds in order not to hit a screen with her head. She twisted her body 180° several times per minute in order to discard plastic bags in a trash bin which was right behind her. She was raising her shoulder over its normal height because of the length of her screw gun. And so on. Maybe things weren’t going so well after all.

So what is happening in this factory?

Upon further reflection and discussion with its leaders, it occurred to me that Lean was "put in place" here without any consideration for or effort made toward creating a lean culture.

The team member I observed has no chance to speak with leadership about her true problems. Not only this, she hasn’t been helped with how to see and understand them. As a result, she’s focusing less on her work and more on not hitting her head several times per minute.

He summarizes:

Taiichi Ohno was famous for asking managers to "step inside the circle" in order to develop problem- seeing, not just problem solving. Steven J. Spear has written in greater detail about this kind of skill development for managers in "Learning to Lead at Toyota" at Harvard Business Review, but coaching others to help them learn to see problems is really what this lean stuff is all about. No matter how much an organization boasts about their lean practices, or your own company does, it’s this ability to see problems that you really want to be looking for.

The die was cast for Quincy Medical Center in 2011

I wish I could say that it was unexpected, but the current story around the closing of Quincy Medical Center in Massachusetts, after its purchase by a private equity company several years ago, was so predictable.  Short version:  The Attorney General is powerless in making the company stand by its original promises.  She can "offer to negotiate" and other elected officials can bluster all they want, but the closure is done.

Here's the original prediction:

So your private equity firm offers to buy the property, making promises to regulators and stakeholders in the community.  Few objections are raised and the deal is approved.  The private equity firm, new to health care, gives an unprecedented level of authority and autonomy to the CEO.  He rewards your confidence by executing the key elements of the business plan.  Assets are sold for short term gain, with little concern for the downstream costs: After all, the hospital properties will be flipped in a few years anyway.  The hospital system's laboratories are sold to a private laboratory service company, in return for a long-term contract to use that company.  Real estate is sold and leased back.  The system agrees to a front-end-loaded risk-based reimbursement contract with the largest private insurer, one that calls for substantial reductions from the trend of medical expenses in future years.  Physician practices in the community are purchased at above-market prices to create an increased flow of referral business to the hospitals. 

But then the money falters.  Revenues take a tumble and days in accounts receivable grow during an extended transition to a new centralized billing system that was designed to take the place of the billing systems run by each hospital.  The risk contract with the insurer starts to limit annual price increases.  Medicare and Medicaid rates are constrained by the federal and state government.  Top line revenues fall, EBIDTA falls, cash flow falls.  Finally, the private equity partners are nervous. 

They turn off the spigot and impose cash constraints on the system.  Normal maintenance of building systems is deferred.  Medical equipment expenses, too, are kept to a minimum.

The only place to save money is on staffing.  He must make dramatic cuts in the upper management levels but will also be forced to make other cuts in the clinical support and lower administrative staff. Band-aid capital spending will be permitted when unsafe conditions exist, but the hospitals will start to fall behind on upgrades of important medical equipment and devices.  He will be in a race against the clock.  Can he hold it together long enough to permit the investors to get a return in the flip?  Finally, he will realize that closing one of the hospitals has to be part of the answer.  Investors will be relieved when he does so, but the community and governmental constituencies that supported the initial acquisition will get worried. 

[It] would be around this time that regulators would begin to understand that the corporate guarantees that might stand behind the private equity firm's acquisition of the hospital system are a nullity.  The owners' resources are legally separated from those of the hospital system.  It would take years of litigation to pierce that corporate veil.  Thus, the commitments that have been made to the governmental and private constituents in the community are supported solely by the financial resources of the hospital system itself.  But that hospital system faces high debt service costs and obligations, other long-term cost commitments, and increasingly difficult revenue restrictions.

One f***ing tree!

Image by Simon Stevens

Thanks to Janice Lynch Schuster for forwarding me this terrific article about stereotypes, in this case visual stereotypes about Africa.  The story is emblematic of our country's lack of understanding of other parts of the world.  I encountered this from friends and colleagues before, during, and after my recent trip to South Africa.  The lede:

Last week, Africa Is a Country, a blog that documents and skewers Western misconceptions of Africa, ran a fascinating story about book design. It posted a collage of 36 covers of books that were either set in Africa or written by African writers. The texts of the books were as diverse as the geography they covered: Nigeria, Zimbabwe, South Africa, Botswana, Zambia, Mozambique. They were written in wildly divergent styles, by writers that included several Nobel Prize winners. Yet all of books’ covers featured an acacia tree, an orange sunset over the veld, or both.

“In short,” the post said, “the covers of most novels ‘about Africa’ seem to have been designed by someone whose principal idea of the continent comes from The Lion King.”

Like most Americans, book designers tend not to know all that much about the rest of the world, and since they don’t always have the time to respond to a book on its own terms, they resort to visual clichés. 

The diagnosis:

We’re comfortable with this visual image of Africa because it’s safe. It presents ‘otherness’ in a way that’s easy to understand.   

Change comes slowly. One day, Mendelsund [Peter Mendelsund—who is an associate art director of Knopf] predicts, there will be a best-selling novel by an African writer that happens to use a different visual aesthetic, and its success will introduce a new set of arbitrary images to represent Africa in Western eyes. “But right now, we’re in the age of the tree,” he says. “For that vast continent, in all its diversity, you get that one fucking tree.” 

Millions of healthier lives on WIHI

Madge Kaplan writes:

The next WIHI broadcast — 100 Million Healthier Lives by 2020 — will take place on Thursday, November 20, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Soma Stout, MD, MS, Executive External Lead for Health Improvement, Institute for Healthcare
  Improvement (IHI)
• Erin Healy, JD, Director, Knowledge Sharing, Community Solutions
• Kevin Barnett, DrPH, MCP, Senior Investigator, Public Health Institute
• Ninon Lewis, MS, Director, Triple Aim for Populations, IHI

When IHI first introduced the framework of the Triple Aim in 2008, we couldn’t have imagined how much it would resonate with health and health care improvers all over the world. Six years and much on the ground experience later, this pursuit of better experience of care, better health, and lower costs, is taking a new, exciting turn and we want to tell you about these developments on the November 20 WIHI: 100 Million Healthier Lives by 2020. 

The title of the show reflects the ambitions and visions of a new Guiding Coalition that was launched this October by IHI and some 30 founding partners with the goal of making a demonstrable improvement in the health of communities on a global scale… starting in the US. One of the driving principles behind the effort — which over 200 individuals and organizations from across public health, community health, health care, policy, and more have already signed on to — is to learn from and support community innovations and initiatives that are right now having an impact on people’s health. Millions stand to gain if what’s effective is better understood and spread. 

But how does change of this sort happen in measurable ways…especially to achieve the goal of improving the health of 100 million people over the next five years? And, how can hospitals and health care organizations not just say they want to support and strengthen community efforts around health, but actually become part of the fabric and infrastructure and two-way learning that makes it possible? That’s where our guests come in. From direct experience, each has a piece of the picture of the steps needed, fueled by the belief that the time has come to put health care and health together in one strategic frame to achieve results on an entirely new level. 

Your thinking and experience and participation in this effort are needed, too! Soma Stout, Erin Healey, Kevin Barnett, Ninon Lewis, and WIHI host Madge Kaplan look forward to engaging with you on the November 20 WIHI. 

You can enroll for the broadcast here. We'd also appreciate it if you would spread the word about the show via Twitter.

Integrating art into patient quality and safety

Well, I discovered a veritable treasure trove of health care quality and safety advocates here in Melbourne, some of whom I have "known" for years on social media and some new encounters.  We all had lunch together, organized by Marie Bismark, and I was brought up to date on some of the things happening here.  I'll just mention a couple for now, with more to follow.

Catherine Crock (seen here with Marie) heads up the Australian Institute for Patient and Family Centred Care.  As noted on their website:

The Australian Institute for Patient & Family Centred Care brings patients, families and healthcare professionals to the table together, to transform people’s experience of healthcare. We aim to achieve this through a three-fold approach:

1. Develop partnerships between patients, their families and health professionals
2. Create a culture that is both supportive and effective
3. Improve healthcare environments through high-quality integrated art, architecture and design.

There are two programs of note that I'd like to share.  One is Hear Me, a 40-minute HealthPlay written by playwright Alan Hopgood.  The play focuses on the importance of patient and family involvement and empowerment as partners in their own health care.  AIPFCC makes the play available to requesting health care institutions and performs it for them.  Catherine notes:

There is enormous potential for improving the quality and safety of healthcare by encouraging communication and partnerships between patients, families and health professionals and fostering an employee empowerment culture. The play can have a significant and novel role in the education of patients, families and staff.

Following the performance, the audience participates in a stimulating facilitated discussion forum (30 minutes), led by a trained facilitator, on team communication, clinical incident disclosure and patient centred care. The forum is a critical component of the play, allowing for debrief, practical application and ideas for change. 

The play has been performed in many locations in Victoria, with excellent reviews.

The other program is called Hush, and comprises a series of musical pieces. Catherine introduced music into The Royal Children's Hospital in Melbourne, to reduce the stress of hospital procedures for the children, Catherine recognised the effectiveness of involving patients and their families in the treatment program.  Now, a large number of CDs (some shown above) are available for people to use in their own settings.