AT&T and The Bell System (remember them?)

Steve Bailey, a Boston Globe columnist, offers an interesting column in today's paper about the market power and the behavior of the largest hospital and physician group in the state, Partners HealthCare System. The head of that group makes a cogent and thoughtful comment (as he often does) about the ambiguity in today's society about its desire for greater cooperation among health care providers and its wish for a competitive marketplace.

With respect, though, the comment misses the point that Partners could be more cooperative, still maintain its dominance, continue to be financially healthy, and could also enhance the efficiency of the overall system. Instead, it rationalizes aggressive stances in the marketplace with a supposed need to ensure quality.

What I have learned in my short time in this field, though, is that no single hospital or system has a monopoly on good ideas to enhance quality and efficiency. When one group puts up barriers to cooperation, everyone loses an opportunity to improve.

As a student of other industries, I also humbly suggest that protectionist behavior by a dominant provider also removes a key stimulus -- within its own system -- to encourage behavior that enhances quality and innovation and customer service. Remember Ernestine, Lily Tomlin's telephone operator?

Customer service?

We try really, really hard to be good at customer service. (This is in addition to offering very good medical care!) By customer service, I mean what the patient's experience is like when he or she calls on the phone or comes to the front desk. How well do we help each person navigate the unwieldy system in a big hospital? Often we do well, but sometimes we blow it! Here is an example of the latter:

I want to share a less than optimal experience, just so you know.

I have an appointment Thursday at Dermatology. I've been well reminded: a paper letter with map, two email reminders, and (tonight) a voicemail on the home phone. This is all fine. Clearly taking responsibility for making sure the patient doesn't forget, and doing it all automated, cost-effective.

However, I want to *change* the appointment, and that's not going so well.

Over the weekend I tried using PatientSite. No option to change apptmt.

Today during office hours I didn't get to it. Oops. So on the way home I called in. No menu option to change an appointment, but there's one to cancel. I selected that, to see what I'd get, and I got:

"The cancellation voice mailbox is full. Please call back during normal business hours."

No catastrophe - I'll deal with it, obviously - but not a particularly good customer experience.

Thanks!

So . . . we will keep trying to improve! We do learn from these comments, and we make changes in how we do things. For those of you out there who experience this or any kind of problem, please do not hesitate to write me.

My Congressman

I happened to listen on the radio last night to Congressman Barney Frank's speech last week to the Great Boston Chamber of Commerce. If I heard correctly, one of his points was that the new Congress should make it easier for unions to organize service employees, unlike industrial workers, because creating more unions in service establishments would not result in any competitive disadvantage to the US because those businesses can not move to other countries.

Do any of you out there have a reaction to this?

Isabel's story

Those of you living in eastern Massachusetts may have seen a recent television ad from Blue Cross Blue Shield of MA about a young woman named Isabel and her discovery of and treatment for breast cancer. The whole story is on the BCBS website and is really worth viewing.

Can I confess something? When I first saw the ad, I was a bit annoyed that BCBS was taking credit for this person's treatment, when in fact it was carried out by doctors and nurses at a hospital in the Boston area. (No, I don't know which one.) After all, what right does an insurance company have in owning this story?

But watching the full video convinced me otherwise. BCBS really did make a difference in Isabel's experience by providing an additional level of comfort and support beyond what was given by her caregivers and her family. That is terrific, and the people in the company deserve credit for reaching beyond the traditional role of an insurance company and displaying that extra degree of humanity.

And Isabel, too, deserves a lot of credit for telling her story. I am sure it will be an inspiration to thousands of people. Bien hecho, Isabel!

$8.60

That's the average annual investment per American in cancer research, in federal funding through the National Institutes of Health. The total federal investment per American in cancer research over the last 30 years is about $260.

What has this produced? Thirty years ago, when people were afraid to even mention "the Big C", we were only able to detect large, advanced tumors. There was virtually no early detection. Survival times were short. Only one child in 10 survived cancer. Treatment was highly uncertain and painful and required long hospital stays.

Today, for the first time, annual cancer deaths in the United States have fallen. There are ten million cancer survivors. Early detection and screening are more effective. New targeted, minimally invasive treatments have multiplied. New discoveries make it possible for the first time to "personalize" cancer treatment.

These facts and figures were contained in a recent presentation by Dr. Elias Zerhouni, Director of the NIH.

I don't know about you, but I think that is a pretty great return on investment!

A really good cause

As you can imagine, I am expected to attend fundraisers for many worthwhile causes. One of my favorites, from which I am just returning, is an annual breakfast in support of Health Law Advocates. HLA provides legal assistance to people who are having trouble gaining access or services in the health care system. I urge you to check out their website to learn more about the organization and see if you want to get involved.

In addition to the worthiness of the cause, the HLA breakfast is always a pleasure because of the quality of program (great speakers, music, humor) . . . and because it always ends on time!

Look for the union label

The gubernatorial election will be over tomorrow, so look for an increase in organizing activities here in Boston. The SEIU was an active participant in the elections, supporting some candidates with money, time, and effort.

On the issue we have covered in a posting below, both Deval Patrick and Kerry Healy are on record in favor of elections and said they would not support efforts to substitute a "card check" form of union certification. So, it is unlikely that this tactic will be pursued. But watch closely, and let's see if the union changes the debate slightly. Perhaps now it will be in favor of elections, but not the form of election carried out under the auspices of the National Labor Relations Board. Here is an example of arguments being used in an organizing campaign in Chicago.

Look for the union, too, to cite papers and articles from selected academic think tanks, which may point to successful management-labor partnerships at other hospitals. Of course, that is not the issue, is it? There are both successful and unsuccessful management-labor partnerships in both union and non-union environments. The issue here is the process by which workers get to choose whether they want a union or not.

Finally, if all else fails, look for aggressive tactics to discredit the management and the boards of hospitals who don't give in. All of sudden, the hospitals you have trusted to provide high quality care to all people will be pictured as having low standards, not caring about poor people or minorities, abusive of their workers, wasting federal research dollars, or worse. Trustees -- those generous unpaid volunteer lay leaders -- will find themselves publicly characterized as unworthy of supervising non-profit hospitals.

I can understand why a union might want to change the rules of the game to improve its odds of success. Will hospitals in the state accede to this, in response to pressure from the union and several of their friends in elected positions?

Man of Patients

Please read this lovely story from today's Boston Globe about George Geary, former CEO of Milton Hospital (for 18 years), who recently completed nursing school. George and I overlapped for a while as CEO's, and I was always impressed with his integrity, thoughtfulness, and caring. I am sure he is a great nurse! I wonder if we can recruit him away to join BIDMC . . . :)

More on Cookies

A few weeks ago (on October 18), I published the recipe for the world famous Beth Israel cookies. I received a number of oral comments and emails from people in the Boston area about this. Here is an exchange with one of our doctors, which tells you a lot about the culture of our hospital: (1) Everyone feels comfortable writing me with suggestions and comments; and (2) I take every suggestion seriously; (3) members of the administrative staff are undefensive and honest about steps being taken to improve the place; (4) running a hospital food service is like running a restaurant, with thousands of customers with a variety of taste and preferences; and (5) even doctors and nurses sometimes need a little treat to do the right thing, i.e, get their flu shot!

Dear Paul,
I was reading your blog last week with the old recipe for the much missed and wonderful BI cookies.

Today, I got my flu shot and a reward voucher for a cafeteria cookie, which I decided not to get because I try to avoid trans fats and suspect that the current hospital cookies (and other foods) are made with partially hydrogenated fats.

Is my concern correct? If so, as a health institution should we be asking our cafeteria to avoid using partially hydrogenated fats in the foods they prepare and sell?

Here is the reply from our director of hotel services:

Your message concerning trans-fat foods was forwarded to me; the food service is one of the departments I oversee.

We share your concern and we are taking steps to address it. First of all, the cookie you were offered for getting your flu shot is a trans-fat free product. We are converting to trans-fat fee items whenever possible, but some of our very popular items are not currently offered as such. For example, the jumbo cookies we sell in the cafeteria are not trans-fat free; as soon as they become available we will make the conversion. Earlier this year we began using trans-fat free fryer oil in both our patient and cafeteria programs. We are now offering more trans-fat free cakes, pies and crackers.

Our goal, like many food service establishments is to become totally trans-fat free, it will just take a little time. We will continue to look for and offer healthy options to our cafeteria customers.

Good government?

Now that all of you have teached me how to use this blog, I decided to try another one in a different arena. I was recently asked by the mayor of my city to chair a citizen's commission on municipal budget and finance issues.

I suggested to my fellow volunteers that it might be useful to the commission members and the public to have a blog in which people could exchange views and stay up to date on the activities of the commission. They agreed and have already used the blog for a healthy exchange of views on several issues. So far, we have not heard much from the public, but I am confident that will pick up steam.

So, if you are interested, take a look and see if this kind of site might be useful to you in similar activities.

Choices (for men only)

You learn you have prostate cancer, and you have been told that you need to have a radical prostatectomy to remove the diseased gland. You have a choice of an "open" procedure or a laparoscopic procedure. (By the way, we offer both at BIDMC.) How do you choose? What are the pro's and con's?

I attended a recent seminar of this topic -- yes, you get to do this kind of thing when you run a hospital -- and I was surpised to learn from our Chief of Urology that the case is not at all clear cut. I had thought that the laparoscopic procedure would be a clear winner on many counts, but there are arguments to be made on both sides.

I am giving my layperson's interpetation of what I learned, so please don't rely on this. Check with your doctor or the literature for a more accurate reading on the matter. Medicine being an inexact science, there are bound to be lots of opinions.

Since men only are reading this posting -- hold on, maybe some women readers joined us and are interested in this question, too -- I know that your first question will be about potency rates after the surgery. The answer: Similar results.

OK, what about effectiveness in removing the cancerous tissues? Similar results.

What about returning to regular life activities? With open surgery, doesn't the open incision mean a longer recovery time? No, postoperative pain is comparable in the two cases, and men can return to activities just as quickly despite an incision.

And so on, and so on. Are you surprised like I was?

Here's my pitch, instead

If Alice (below) can sell useless plaques, let me instead try again to sell something more practical. For those of you arriving recently, I repeat my posting from several weeks ago. (If enough of you buy this, I won't have to clog up my blog with repeated advertising!)

"A couple of years ago, we published a wonderful book on the subject by Monique Doyle Spencer, which is designed to help people who have the disease understand and cope with many aspects of the treatment process. We published the book because it is funny, and commercial publishers felt that it was inappropriate to have a humorous book dealing with cancer. We thought it deserved public exposure. It is called, 'The Courage Muscle, a chicken's guide to living with breast cancer.' After my mother-in-law read it, she said, 'I wish I had had this book to read during my treatment.' Many others have said the same thing, and the book's reputation has spread by word of mouth and occasional newspaper columns and Monique's interviews on television and radio.

You can buy it from Amazon, but if you buy it from the hospital instead, the proceeds go to support Windows of Hope, our non-profit oncology shop that sells wigs, scarves, and other supplies for cancer patients. Just send a check for $16.95 to Windows of Hope, 330 Brookline Avenue, Boston, MA 02115, and we will mail you a copy. Or call 617-667-1899."

I thought I had seen it all

We have a very good email system that intercepts a lot of the spam being sent out, but sometimes things slip through. As you can imagine, companies are trying to sell us all kinds of this. This morning, one arrived that I never could have imagined.

Here's the text:

Congratulations Paul on being recognized by The Chronicle of Philanthropy as one of The Philanthropy 400!

We prepared an online preview of your handcrafted special edition plaque for your review. Click here to personalize, customize and preview your plaque. Only 3 business days left to SAVE $30 on your order (order by Nov 6th, 2006).

If clicking on the link doesn't work, please copy and paste the entire address into your web browser or follow these simple instructions:
Click to the following website: www.amreg.comEnter Preview Code: 3262340

Now, with just a few clicks of your mouse you can prepare your plaque exactly the way you want it:
* PERSONALIZE the wording, font size or style.
* CUSTOMIZE your favorite wood finish and choose gold or silver for the wood trim.
* PREVIEW the plaque exactly as it will be delivered.

Please do not hesitate to call or email me with any questions. I would be happy to walk you through the simple steps of customizing your plaque.
Alice Sydney
1-866-964-0866 x8330
asydney@amreg.com

Here would be my response to Alice Sydney:

Dear Ms. Sydney,
America is a great country, full of entrepreneurial ideas. I guess your company figures there are people out there who would actually buy a plaque to commemorate the fact that their hospital raised a lot of money. Personally, I am extremely grateful to generous people in our community for their contributions to our clinical programs, our teaching, and our research. We could not survive and thrive without their help. But I am hard-pressed to figure out why anyone would buy this and where one would hang such a plaque. I guess some CEOs find comfort or excitement in this kind of self-congratulatory pat-on-the-back that could be placed in their offices; but if I had the spare cash to buy your plaque, I would instead donate it to the hospital.
Sincerely,
Paul Levy

And, by the way, did you notice that the sales pitch has the wrong name of our hospital . . .

:)

Clean Hands

The disk on the left shows bacteria colonies that grew from my hand before it was washed with a disinfectant. The disk on the right shows the number of colonies that grew from my hand after it was cleaned with the waterless, alcohol-based antiseptic that is in dispensers outside every patient room in our hospital.

It has been well documented that many infections in hospitals occur because of bacteria transferred from one patient to another when nurses or doctors do not wash their hands between seeing patients.

The New England Journal of Medicine published an article on this topic in July, 2006, entitled "System Failure Versus Personal Accountability -- The Case for Clean Hands," by Doctor Donald Goldmann at the Institute for Healthcare Improvement. His conclusion: "Each caregiver has the duty to perform hand hygiene -- pefectly and every time." "Yet, compliance with hand hygiene remains poor in most institutions -- often in the range of 40 to 50 percent."

It is inconceivable to those of us who are not doctors or nurses that caregivers would not follow simple standards for hand hygiene. We wonder why it does not occur. The article provides good background information on this topic.

Our clinical chiefs and senior adminstrators know that our hospital needs to have high performance in this arena, and we are strengthening our encouragement for this behavior through both positive reinforcement and penalties. As an example, our Chief of Medicine recently wrote the following to his staff:

Appropriate patient care requires that immediately prior to and following each patient encounter anyone having contact with the patient will cleanse the hands thoroughly, using either hand washing or the alcohol-based hand cleansers that are available everywhere in our environment. Anything less than perfect compliance with this standard (except in the case of a patient emergency requiring immediate intervention) represents substandard care which we will not tolerate.

To make this more clear: Everyone (including students, trainees, and faculty who may not expect to touch the patient when they approach) who enters a patient room or an exam room must clean their hands immediately before and immediately after the encounter. In addition, we are all responsible for ensuring that everyone on the healthcare team -- from attending physicians to environmental services personnel --practices scrupulous hand hygiene. Our task is to lead by example through good practice, to notify other healthcare workers if they forget to perform hand hygiene, and to respond respectfully when others do the same.

Please help us to ensure the finest care for our patients by adhering to and insisting upon proper hand hygiene.

Again, we lay people might wonder why it is necessary to provide such advice and reminders to people who have been trained in medical school; but since it is apparently necessary, my colleagues at BIDMC and other hospitals will continue to do so.

The Week Before

The week before the drug company supplement in the NY Times Magazine, there was a glossy insert called "National Hospital Guide, a reference tool for health-conscious consumers". It portrayed itself as "designed to help you better manage your health care needs".

Of course, the major entries in the booklet were those hospitals that had shelled out the money to buy an ad in the same booklet. But then, a few others were included, too, including a few in Boston. When we inquired how the selection was made of those hospitals, the publisher told us that they had a selection process, but could not or would not tell us the criteria for selection. One group of hospitals included in that manner is a major purchaser of advertising space in the Boston Globe, which is owned by the New York Times. In the absence of public criteria for selection in the Times brochure, it is unreasonable to assume that there is some carryover influence from the Globe ad placement?

The point is this. Advertising is advertising. A selection process based on supposed clinical excellence is another. Shouldn't we expect the media to distinguish between the two when they are "guiding patients to better health"?

Offensive

Like everybody else, I have gotten used to the unfortunate number of ads in which drug companies encourage consumers to push their physicians to prescribe the latest in expensive new therapies. But, the NYTimes Magazine had a supplement this weekend that, to me, was really offensive.

It was entitled "From cause to cure, a patient's guide to advances in mental health" and presented articles about Alzheimer's, bipolar disorder, epilepsy, and schizophrenia -- fully intermingled with full page ads from drug companies pushing their products which, by the way, were often featured in the articles themselves. I can't tell you how relieved I was to know that Bristol-Myers Squibb thinks that "treating bipolar disorder takes understanding"; that UCB is "the epilepsy company" that lets you have "life on your terms"; that Pfizer is "working for a healthier world"; that AstraZeneca is wants us to know that "sometimes there is another side to depression" -- and offers a postcard we can send in on which we list our diagnoses and what medications we are currently taking.

The articles and ads were illustrated by manipulative photos of people in various stages of sadness, thoughtfulness, and happiness. I believe that this kind of approach to reaching people -- especially those with mental illness -- and their family members is so cynical as to be offensive.

But, maybe I am just out of date and should learn to expect and accept this form of advertising. What do you think?

Please understand that I highly value the work these companies do: My problem lies in the way they deliver their message.

Sweet Music

A few months ago, I asked a friend of mine, Nancy Kleiman, to play her harp in several places in the hospital, just as an experiment. The reponse was so positive that a donor funded the program, and we have made it a regular thing. The comments from patients and staff have been very positive. Here is the latest note from Nancy, which tells some marvelous stories:

Dear Paul,
There has not been one day since I've begun to play the harp at the BIDMC that I haven't had a significant experience to record in my journal. But in this past week alone, the events that have occurred have been so overwhelming that I wanted to take a moment to describe for you how your vision and investment are making a difference in our community.

It began when a patient in a wheel chair, on her way to an appointment, approached me to say that she was a classically trained harpist who could no longer play her pedal harp because of her MS. During our chat, I invited her to return and try a small harp I owned that she could hold in her lap with the help of a bar that rests under her legs. This Monday when she met me in the Shapiro lobby people gathered around to watch and listen to us play a duet! A social worker looking on wept at this remarkable site. The harpist was so thrilled to be able to play the harp again that she plans to purchase a similar one. I have invited her to a harp workshop I am hosting next weekend where another of your employees, a harpist in your sleep clinic, is speaking about her work. Already, Barbara [chief of social work] and I are talking about getting this harpist involved in the hospital's support for other MS patients.

Thursday as I was playing, a social worker was about to begin a workshop to address self-care for other social workers and asked if I would come and speak about my work and be the "experiential" part of her workshop. She had the social workers close their eyes and simply relax as I played for them. She had attended another workshop where a harpist colleague of mind who started the MGH program spoke and performed this way. As we were chatting, a patient - also a musician - came over to tell me that as she entered the lobby she could tell instantly that what she was hearing was live music. She said she looked up at the harp and was no longer in a hospital.

Although I usually do not come in Friday, I checked my email and had an urgent request from a harpist at the GentleMuse program at MGH. A family of a dying patient at the Brigham and Women's had called for a harpist to do a "death vigil" for their mother who had been expected to die the day before. Of course, I called the family and they were thrilled that I could be there immediately. I simply took out my harp in the Shapiro lobby and walked it across the street. On the way, three employees at the Brigham and Women's asked for my card! One commented, "Why does the BIDMC and MGH have a harpist but not us?" I could not have been received with more welcome and warmth than by the nurses on the 12th floor and everyone else in my path. And what more wonderful example of hospital cooperation than what happened yesterday!

There are so many other stories I could share. A day does not go by that someone doesn't ask me to teach the harp. At least five of your staff - including a physician - have seriously asked me to do so! And even the Starbucks manager is begging me to play in the mornings when her lines are out the door! Since I have already been asked to provide harp music by chaplains to play for a dying patient and by the nurses in Farr 9 and the psychiatric unit, I am envisioning a time when your harpist is available to respond to such requests. I have retired from teaching to make myself available on a volunteer basis to do just that because I believe that this service is a vital and compassionate role to be filled. Paul, that I could do so to serve your community is my ultimate dream!

Nancy

CareGroup -- Part 2

Shortly after arriving as Administrative Dean at Harvard Medical School in the fall of 1998, I was invited to attend a three-day strategic planning retreat for the senior managers and clinical leadership and lay leaders of CareGroup. They were kind enough to invite me, as someone new to the medical field, to get an intensive briefing on the inner workings of part of the Harvard hospital system. It was a fascinating experience, and I learned a lot.

I was struck by the sense of unity and purpose of all those attending to create a vibrant and strong CareGroup integrated health care delivery network. Nonetheless, within a short time, I noticed that it wasn't working.

First of all, the merger of the BI and the Deaconess was well into several years of bad results. What had been portrayed as a merger of equals was actually a takeover of the Deaconess by the BI. A look at the clinical and administrative leadership of the BIDMC made it clear that the BI folks had the overwhelming role in running the place. This, along with other misteps, left the Deaconess people feeling left out and alienated and undervalued. Doctors left, nurses were disgruntled, referring physicians changed loyalty, and lay leaders from both the BI and the Deaconess in the community became disenfranchised. Operating losses grew year after year, into the tens of millions of dollars.

The CareGroup holding company, meanwhile, made clinical judgments that further weakened the BIDMC -- most noticeably a commitment to moving the preponderance of orthopaedics to New England Baptist. For a general hospital like BIDMC to lose this specialty meant a significant hit and loss of potential growth to its bottom line.

As BIDMC weakened, both the Baptist and Mt. Auburn, the two other major hospitals in the system, feared for their financial future -- because the debt issued under the CareGroup name was a joint and several obligation of all of the hospitals. How could the two hospitals raise philanthropic donations, for example, if donors thought that funds would be used to bail out the Medical Center?

Meanwhile, the system's three small community hospitals in Needham, Waltham, and Ayer were suffering from the usual woes of community hospitals in Massachusetts, and the Baptist and Mt. Auburn also fretted about the financial impact of those hospitals. The CareGroup board ultimately voted to close the Waltham hospital, but it had to remove the local board to do so, because that local board refused to accede to this action. This use of reserve powers by the holding company board sent a shock wave throughout the system: While everybody knew that the CareGroup board had this authority, it had never been used so dramatically.

You can imagine why this series of events led to a lack of cooperation and collaboration among the Caregroup hospitals. All hope for an integrated health care delivery system was shattered. Eventually, at the behest of the hospitals, the CareGroup board voted to reduce its authority over the member institutions, removing itself from clinical matters and focusing instead on its fiduciary responsibility to the bond holders.

Are there any doctors out there?

If so, I can't imagine that you don't have an opinion about my comments on Transplants, below. In that posting, I am suggesting that not all hospitals should be permitted to do all kinds of clinical procedures. Are you going to let a non-MD like me make a clinical judgment like that -- unchallenged? (I got more comments on the cookies!!)

How magic happens

The magic of academic medical centers occurs at the intersection of clinical care, basic science research, and clinical research. The excerpt below is from an article written by Dr. Jerome Groopman and printed in The New Yorker this past July. If you have chance to read the whole thing, you will find a wonderful story of how a young scientist, working in collaboration with others in the hospital, developed a theory that might end a disease.

The Preeclampsia Puzzle (The New Yorker)
In June, 2000, Ananth Karumanchi, a thirty-one-year-old kidney specialist at Beth Israel Deaconess Medical Center, in Boston, read an article in Nature about preeclampsia, a poorly understood disorder that affects about five per cent of pregnant women. In the developing world, preeclampsia is one of the leading causes of maternal death; it is thought to kill more than seventy-five thousand women each year. In the United States, where treatment is more readily available, few women die of the disease, but complications -- including rupture of the liver, kidney failure, hemorrhage, and stroke --can cause lasting health problems. (In rare cases, patients with preeclampsia develop seizures or lapse into a coma; this is called eclampsia.) The only cure is delivery. "If a woman develops preeclampsia near term, then she is induced to have a delivery or undergoes a Cesarean section," Benjamin Sachs, the chief of obstetrics and gynecology at Beth Israel Deaconess, told me. "In most cases, as soon as she is delivered we know she will get better. But, if preeclampsia develops early in the pregnancy, then we have a huge challenge, because we have two patients: the mother and the baby. If you deliver the baby early to spare the mother, then you put the baby at risk for the complications of prematurity; if you wait, then the mother can have severe complications and go on to eclampsia."
http://www.newyorker.com/printables/fact/060724fa_fact