There is no mystery in Mystery Shoppers

Nobody wants to be thought of like Ernestine, Lili Tomlin's rude telephone operator! We have been trying to improve customer service in our hospital. Academic medical centers are often not great at helping patients navigate their way through their clinics, and we are hoping to set a higher standard at our place.

We have borrowed the concept of "mystery shoppers" from other service industries. We train people to pretend they are patients or patients' family members, and then we send them into a clinic to make observations and take notes. We also do this with our call centers, so we can see how our people serve the public on the telephone.

We then share the results with the chiefs, the clinic managers, and, of course, the front-line staff. As in the case of clinical improvements, we do not engage in the "blame game", but rather we use the shoppers' reports to offer helpful suggestions to people. Often, too, the problem is not with the front-line person, but there is some systemic problem behind the scenes that needs to be fixed.

Curious? OK, here are samples from two of our clinics. In the first, the Emergency Department after a very busy day, you can see areas for improvement. In the second, the more sedate Infectious Disease clinic, things look pretty good. (Excuse the stream-of-consciousness feel of the reports. We ask our shoppers to maintain a running commentary of what they see and hear.)

Remember, these take place in the waiting rooms -- not the patient care areas. These particular surveys are designed to review service quality, not the quality of the medical care offered in the exam rooms.

The Emergency Dept wait area is comfortable, well designed area with corner views of the Medical Center area. It is well lit with natural Department and fluorescent lighting. Area is modern but messy and dirty. On today’s visit, which occurred late in the day after the ED had been on diversion, there was litter strewn about, empty soda bottles on side tables and food crumbs all over the floor. Entryway is free of obstruction to passage. The first group of seating is reserved for patient triage. Security greeted me as soon as I entered and told me where to wait. The guard would not allow me close to the desk area unless I required nursing assistance. I wasn't sure how patients were actually checked-in, since the security guard primarily interacted with the patients who arrived and he asked them to have a seat. There is a large C shaped desk that seemed to be shared by security and nursing that was part of the wait area. Once I took a seat further back in the area I was not acknowledged again. Co-payment and referral signage were not posted. Patient Rights and Health Care Proxy information were available in various languages on a nice turnstile rack that needed restocking. There was no PRC information. Infection control information was posted throughout the area. One box of tissue was on a side table; no Calstat bottles. There is a vending machine in the back along with restrooms. Restrooms needed cleaning. General appearance of the waiting area was messy. At the check-in desk there were soda bottles and a coffee cup. Area was lacking in entertainment reading; there were a couple of old, torn magazines scattered around. Addresses were visible and there were no instructions for coping. Several informative brochures were neatly arranged on a long side table. Area had a plasma screen television which was on, tuned to nightly news. RN triage area is further along the large C shaped desk area and provides for privacy. Ten patients arrived within fifteen minutes of one another and overall the staff managed the patients efficiently through the triage area. Information regarding waits was not provided once in rear wait area. Staff was pleasant and courteous. Name tags were visible. Nursing personnel wore lab coats. At times personal conversations occurred between security and nursing but were not overheard. The security guard was chewing gum. I asked security (my only option) for directions to the cafeteria. He instructed me on how to proceed to the Farr Building then said -- "you’ll find it". My assessment of customer satisfaction in this clinic would be 3.0 -- good patient flow system but lacking in friendliness.


The Infectious Disease Clinic shares a good size waiting area with the Travel Clinic. Area is up to date, warming, inviting and comfortable. When first entering the French doors you see the water cooler and excess bottles. It does not pose an obstruction to passage. The reception assistants made eye contact with me immediately. I chose a seat in the corner as she inquired how they could be of assistance. There was no posted signage on the walls or framed on desks. Kleenex was on all side/reception tables. One Calstat dispenser was on the wall by the entrance area; no others visible in the area. Appearance of the waiting area was more than satisfactory -- clean, neat and orderly. Plenty of updated reading material for entertainment and infectious disease related. None of the magazines had stickers with copying instructions. Names were blacked out. Most of the magazines were addressed to MDs in the Lowry Building. There was no television in the waiting area, more than adequate seating and no clutter on the reception desk. A small bouquet of fresh flowers was in the room along with several healthy appearing plants. One of the staff members was caring for the plants and making pleasant small talk with those waiting. I would rate the area a strong 5 in the customer satisfaction area. There were 3-4 attendants behind the desk at all times. They spoke quietly, discreetly and professionally. None wore lab coats but were dressed in professional work attire. All had their name tags visible but I was unable to obtain names without further calling attention to myself. Twice 2 different attendants approached me in the corner and asked how they could be of assistance. Therefore, I was addressed/approached a total of 3 times in 22 minutes. One gentleman was seated several chairs next to me the entire time who was never approached. But he seemed content. One patient was identified by their first name but it was clear they had an established relationship. Physicians in the area wore lab coats, walked in the wait area to greet their patient, shook hands and lead them to the exam area. A physician approached one gentleman to offer an explanation of the wait after I was there approximately 15 minutes. As I was exiting the area I asked directions to the bathroom -- interrupting a work related phone conversation. The attendant was extremely pleasant, giving specific directions. As I was exiting the area a physician who heard my request offered additional instructions.

If Jayco didn't exist, we would want to invent it

The Joint Commission (previously known as the Joint Commission on Accreditation of Healthcare Organizations, and still informally called "JCAHO" or "Jayco") has for years assessed quality and safety in hospitals. Previously conducting a somewhat bureaucratic review of files and written rules, Jayco recently enhanced its survey procedures to complete much more thorough investigations of actual clinical procedures and the medical staff's understanding of patient care guidelines.

Also, the Joint Commission now does unannounced surveys, in contrast to the previously scheduled visits. So, a team shows up on a Monday morning and spends the week in your hospital conducting an extensive and intensive review. If they find things wrong, they issue "requirements for improvement", and the hospital must show a detailed plan for making the improvements in a set period of time. If they find enough things wrong, the ultimate sanction is a loss of accreditation, which is bad in many respects, not limited to losing the right to be paid by Medicare.

This is all to the good. Notwithstanding great intentions by well-meaning medical staff and effective supervision by a board of trustees, independent external reviews are helpful in many respects. Our slogan is, "If Jayco didn't exist, we would want to invent it." That is not to say that a visit doesn't make us sweat, and that the prospect of their unannounced arrival doesn't keep people awake each Sunday night. It does.

One of the medical standards currently being enforced by the Joint Commission is something called "medicine reconciliation". Part of this standard means that we are supposed to to discuss with all patients the medications they were taking before entering the hospital, and review their medications again upon discharge. This is supposed to apply to both inpatients and outpatients.

This makes tremendous sense, of course. How can you give thorough and proper care to patients without knowing what medicines they are already taking? But, frankly, it is not always carried out to the full extent. Things happen: A busy clinic, a confused patient, a missing note from the referring physician. But clearly, the goal is full compliance.

This is just one example. It would be the truly extraordinary hospital that gets a perfect score from a Jayco surprise visit on the wide range of patient care standards. But that's just the point, isn't it? Even the finest institutions can improve, and sometimes we all need an objective outside observer to tell us where we should focus our efforts.

The job of hospital management is to use those findings as positive challenges for the institution and help it achieve ever better results for the public. Having talked with my colleagues in the other Harvard hospitals and in the other Boston-based hospitals, I know they share that view. The public should feel good about that shared perspective -- while still holding us accountable for better and better performance.

New links

I have posted some links to other sites on the right. They are really well written, with interesting points of view. Some are brand new and need visitors! Try them out. From their profiles:

Apollo, MD: Apollo is a physician-in-training in an allopathic medical school in the U.S. Drawing from historical perspectives, recent news, and personal experiences during medical training, he hopes to provide perspectives on medicine and health care on the middle ground between patients, physicians, and other forces influencing the delivery of medical care.

Paging Dr. Jess: I'm a fourth year medical student starting internal medicine residency this summer.

Boston lab coat review: Working hard every day at one of Boston's major teaching hospitals. Help and healing do not come when we pretend and mask our pain, but rather when we are honest and admit our need.

ER RN: Expanding my horizons, gaining knowledge, having way too much fun along the way.

Tales from the ER and Beyond: To get into medical school, you have to be well-rounded. It's pretty much an admission requirement. Ironically, it doesn't take much time for medical school to beat the well-roundedness out of you.

Everything Health: Dr. Toni Brayer has practiced Internal Medicine in San Francisco for over 20 years.

Diabetes Mine: Inquisitive, perhaps-just-a-tad overly analytical new diabetic based in San Francisco, CA. Diagnosed with Type 1 in May 2003.

Transplant Headquarters: Had a kidney transplant in 2000, watched the field of transplantation swirl around me before and after, decided to start a blog about it.

Better grades on VAP

Good progress on implementing steps to reduce ventilator-associated pneumonia. Recall my story in January on this topic.

Our goal is to make sure we are carrying out the five-part Institute for Healthcare Improvement "bundle" to reduce the incidence of this disease. As I noted back then, if you want to reduce VAP, you institute this bundle of steps. But, like your toughest sixth grade teacher would say, "There is no partial credit!" Unless you carry out all five steps, you do not get a perfect score. Here are the monthly stats:

April 06: 83%
May 06: 74%
June 06: 82%
July 06: 80%
August 06: 76%
September 06: 86%
October 06: 92%
November 06: 85%
December 06: 87%
January 07: 93%
February 07: 98%
March 07: 100% (to date)

In addition, our folks are working on instituting improved oral hygiene for these patients, another aspect of reducing the VAP problem. There we have gone from 58% (in April 06) to 91% (in March 07).

But, I want to make clear that these are process metrics. This differs from the central line infection story I have mentioned elsewhere, where we measure the actual number of cases. My folks tell me that actual VAP rates themselves may not be accurate because it is the most subjective of all nosocomial infections and the most difficult to track. We are currently engaged in refining our methodology for actual VAP surveillance.

Finally, I want to point out that this effort requires a variety of specialties to work together -- several types of doctors, nurses, respiratory therapists, and pharmacists. In this case, 14 people serve in the VAP Working Group. They develop protocols, data monitoring, and training programs and then have to persuade dozens of other people to engage in the program on a sustained basis. As I have noted below, the unique environment of academic medical centers creates interesting challenges in process improvement. These folks deserve a lot of credit for what they have accomplished, but the real test will be to see if they can keep it going. Knowing the people involved, I am optimistic.

This new media stuff is getting me dizzy!

How circular is this?

I run a hospital blog.

The Wall Street Journal runs a heath care blog (link to the right).

They do a story about my blog on their blog -- complete with video:
http://blogs.wsj.com/health/2007/03/16/paul-levy-online-ceo/ .

Now, I do a story about their story about my blog on their blog.

Somebody . . . protect us from ourselves!!!

Play Ball!

You haven't had a chance recently to really criticize my managerial judgment and priorities, so it is time to offer that opportunity. It is after all, Spring Training. Let's talk inside baseball.

Several years ago, a number of hospitals in Boston were vying to become the Official Hospital of the Boston Red Sox. This is a sponsorship arrangement. In return for paying an annual fee, the designated hospital has exclusive naming rights to be associated with the team, both for purposes of outside advertising and for signage in Fenway Park. You also provide first aid to fans in Fenway Park for the 81 (or hopefully more!) home games each season. (Provision of medical service to the players is not necessarily included, as Major League Baseball quite appropriately does not want to require players' treatment decisions to be tied to sponsorship contracts.)

Those of you from other cities and countries are probably already wondering about this. What is the possible advantage to a hospital that chooses to do this? Those people who are citizens of Red Sox Nation (anywhere in the world) already understand the value.

In our case, finding ourselves engaged in a successful turnaround after almost going out of business because of a botched merger between 1996 and 2001, we were looking to remind people in Boston that we were alive and well. We wanted to portray a sense of permanence for our hospital, which had been badly beaten up in news reports and in community perception for several years.

Also, I had had a chance to meet the owners and top management people at the team, and I discovered that we had virtually identical philosophies of community involvement and stewardship of our respective "franchises."

So, we made a proposal that, yes, included a payment and first aid, but that equally focused on programs we could do together for the community. As an example, one of the showcase programs we proposed to sponsor was the Red Sox Scholars. Each year, 25 economically disadvantaged but academically excellent fifth graders from Boston neighborhoods would be inducted into the program, $5000 put into an interest bearing account towards their college education, assigned a "medical mentor" from BIDMC, and presented with programs designed to enhance their teenage years and encourage them to stay in school and go to college.

Another program combined the resources of BIDMC, the American Red Cross, and the Red Sox to encourage blood donations. By publicizing the "blood donor of the game" and by co-sponsoring a September 11 anniversary blood drive, we have encouraged hundreds of people to give blood that is used by hospitals throughout the city. Likewise, we have sponsored a skin cancer awareness day and an organ transplant awareness day at Fenway Park.

I have received criticism from some for entering into this partnership, but I would do it again in a heartbeat. I will not even try to make a case that spending money in this way brings in more patients to our hospital and ultimately improves our financial ability to conduct research and teach medical students. I will, however, unashamedly make the case that two championship institutions from different lines of business can jointly make wonderful contributions to the life of our city.

Oh, I almost forgot to mention something else. Over the decades, our hospital has been known for success in treating all kinds of diseases. But this was the first time ever that we cured a curse . . . .

My Mom's wishes

In the story below, there is an important sentence: We discussed possible actions with Dr. X and decided to halt all invasive treatments, a course that my family has long agreed to.

I know from personal experience what this simple bit of family planning can mean for the terminally ill patient and for his or her relatives. My Mom's living will had this directive, among others:

That no extraordinary measures be used to prolong my life if in the sole judgment of my daughter and my physician such measures will not restore me to a level of life that is commensurate with the mental and, to a lesser degree, physical standards by which I have been fortunate enough to live. Without limitation, such extraordinary measures include cardiac and/or pulmonary resuscitation, mechanical respiration, tube (intravenous and/or nesogastric) feeding and antibiotics.

She wrote and signed this in the early 1990's, when she was in her early 70's and therefore likely well before it would be likely to be applied. The application of her directive occurred two years ago after an accident left her with a severe head injury and internal bleeding in her brain. When it became clear that, in her words, "the application of life-sustaining procedures would serve only to artificially prolong the moment of my death", my sisters and I were empowered to have a short and decisive conversation to remove the respirator and other measures that were keeping her alive. With no regrets on our part, she died just a few hours later.

Afterwards, the ICU nurse kindly reaffirmed our decision, saying to me: "You, of all people, know that we can keep people alive forever. You did the right thing. She would have spent the rest of her life on her back in a nursing home, unable to talk or move. Surely, she would not have wanted that."

A living will with this kind of advance directive is one of the greatest gifts a parent can give to his or her children. If you don't have one, or your parents don't, please have one prepared and discuss it with your relative while you are both still able to do so.

Dear Mr. Levy, My husband was a patient in your hospital...

When I receive a letter like this, I never know from the salutation if it will be a complaint or something else. This one is clearly something else, and I want to share it with you. Those of you who work in hospitals have doubtless heard similar stories; but for those of you who do not, it provides an insight into the dedication and thoughtfulness of the kind of people who work here and in other places in Boston and throughout the country. It also implicitly provides several pieces of advice to all of us who will go through the experience of terminal illness with a loved one.

Dear Mr. Levy,

My husband was a patient in your hospital in late January through early February 2007. He arrived at BIDMC via a MedFlight from Florida. We, myself, my two sons and their wives, and our BIDMC primary care physician felt that the small community hospital there was not able to deal with the complex issues that my husband seemed to have.

Dr. V continues to be our primary care doctor even though we moved to Florida. We communicate to him via PatientSite and have our annual visits with him each summer and he was constantly aware of my husband's condition while in Florida. He arranged for a hospital-to-hospital admission. We arrived very late on Wednesday January 24th. My husband underwent many tests on Thursday and Friday. We were given a diagnosis on Friday evening.

The diagnosis was not one we wanted to hear; lung, liver and bone cancer, but a course of action was set in place. My husband was to have radiation therapy starting on Monday January 29 to reduce his back pain. The nurses who took care of him were all professional and kind to him and kept me continually informed. They made sure that he was heavily medicated before the transport through the hospital and in radiation treatment, which sounds like a trivial compliment but was actually of utmost importance to minimize the suffering caused by the bone cancer and exacerbated by movement. The nurses in radiation oncology were wonderful and did whatever they could to reduce his pain and make him as comfortable as possible.

On Friday, February 2nd, it became apparent to myself and my sons that my husband was not doing very well, and a CAT scan was scheduled to determine if he had pancreatitis. We asked for a meeting with Dr. X, the hospitalist, to tell us what his condition was at that point. I am sure this type of situation is never easy for a doctor, but Dr. X very clearly and compassionately indicated to us that my husband only had a few days or weeks left to live due to the cancer in the liver being so aggressive. We discussed possible actions with Dr. X and decided to halt all invasive treatments, a course that my family has long agreed to. Dr. X also set up a meeting between us and the palliative care team for later that afternoon. Seemingly within minutes Dr. X had the wheels in motion. All scheduled tests and treatments were cancelled, IVs were stopped and, most importantly to us, had us moved to a private room. Her action was stunning, and we cannot say enough about how fortunate we were to have her during this most difficult time.

We met with RN L that same day. The palliative care folks seem to be a special breed of people doing an incredibly difficult job with kindness and compassion. L promised us that pain relief strategies could be altered such that my husband was not in a drug-induced stupor yet still be relatively pain free. She also stated that we should use the window of opportunity to have friends and family visit as much as possible while he was clear headed because it was all going to be a façade and the cancer would be working just as aggressively though it would not appear so. She was eventually proven correct on all counts.

When my husband woke up Saturday morning he was quite clear-headed for the first time since we arrived back in Boston. We all got to talk with him, and he got to enjoy his children and most importantly, his grandchildren. The private room was wonderful, as we could just close the door and have fun with the grandchildren. He seemed so well that we all expected to see him get up and walk home, giving us pause to our decision to stop treatment. L and Dr. X reminded us, however, that this was just a fleeting condition and that we were doing the right thing. We just cannot write enough times in this letter how great these folks were to us.

L had delivered what she said she would, some very quality time with my husband. Also, I want to stress that because he was able to be on palliative care, his last week at BIDMC was less stressful for both of us. This is an incredible service that makes a very difficult time as humane as possible. These people deserve all possible accolades for their incredible efforts. In general, everyone from the cleaning staff, dietary staff, transporters, medical assistants and nursing staff, were kind and wonderful. So much for the thought of the impersonal big city hospital.

My husband was moved to a nursing home on Friday February 9th. He passed away on Sunday February 11th. Thanks to the efforts of the team, we were at least able to enjoy our final week with our husband and father and he was clear-headed and joking until the day he left BIDMC. We will forever be grateful for that.

Paying it forward

A note from Alabama, from James Noland RN, MSN, CEN, Clinical Education Specialist, Huntsville Hospital Emergency Department Office.

"On November 20, 2006, a tragic school bus crash occurred in Huntsville, Alabama. More than thirty students were brought to Huntsville Hospital. Among the injured were four young women who sustained major head injuries and later died. This tragedy made national news.

"In Boston, MA, at Beth Israel Deaconess Hospital Emergency Department, nurses heard about the tragic event and performed the most honorable gesture. The nurses from Beth Israel Deaconess Emergency Department bought the staff of Huntsville Hospital Emergency Department lunch the next day. Yes, on November 21, 2006, around 11:30am several pizzas arrived with a note attached that read to: all emergency room nurses from: your Emergency nursing colleagues at Beth Israel Deaconess Hospital in Boston, we are there with you, keep up the good work. This was such an honorable gesture.

"So, when the tornado swept across Enterprise, Alabama, and the bus crash occurred in Atlanta, Georgia, the ED nurses from Huntsville Hospital collected money and bought pizza for the staff at Medical Center Enterprise in Enterprise, Alabama, and the ED staff at Grady Memorial Hospital in Atlanta; we decided to pay-it-forward.

"There is a spotlight section on the Beth Israel Deaconess Medical Center website that says 'BIDMC is making a difference in Boston and around the world...' and they certainly are. Thank you BIDMC for what you did and the difference you are making."

And thank you, Huntsville, for paying it forward!

Soliciting organ donations

Our chief of transplantation, Dr. Doug Hanto, has strong opinions about the ethical issues surrounding solicitation of organs for transplant. He recently set those forth in an article in the New England Journal of Medicine. Here is a summary from the Boston Globe's White Coat Notes.

Dr. Hanto has built a very successful solid organ transplantation program at BIDMC. We are proud of the work he and his colleagues have done. I am also proud that he has chosen to engage directly in these very controversial subjects. I also agree with him. Check it out and see if you do, too.

A story from our harpist

Sent by our harpist:

I want to share a short and poignant story from yesterday in the lobby (names are changed).

As I was playing, two distraught-looking women were drawn into the harp's music. I asked if everything was okay and Nancy told me her husband was upstairs actively dying.

I asked if she would like me to play for Paul and she was simply thrilled. I said it was my job here and my pleasure. Nancy told me her daughter, who was in the room, is a music therapist.

As I began to play, everyone started to cry. Nancy got onto the bed with Paul and everyone actually sang along to any familiar music I played. When I finished with Danny Boy, the daughter followed me out to thank me and hug me saying that everything I played had meaning for the family. She was so grateful and appreciative.

I told her the music was a gift from the hospital and that the greatest gift was surrounding her father with such love and peace at his final hour.

These things happen

I was reminded of this by our Chief of Medicine. In the movie, It's a Mad, Mad, Mad, Mad World, Ethel Merman, playing Mrs. Marcus, says:

Now what kind of an attitude is that, 'these things happen?' They only happen because this whole country is just full of people who, when these things happen, they just say 'these things happen,' and that's why they happen! We gotta have control of what happens to us."

I am struck by the relevance of this to running a hospital.

Several years ago, we had that attitude in our hospital with regard to certain types of medical outcomes. For example, we were content with our level of central line infections because we were below the national average. After all, these things happen. Then our chiefs of medicine and surgery said, "No, they don't have to happen. When they happen, people die. We are going to insist that we achieve zero central line infections." And then they got to work. As I have noted below, it is not an easy problem to solve, but it is worth the effort, and you can improve.

One way to encourage organizational improvement is to publicize the results of your program. I have done that below for our hospital, and I have made the suggestion that others in the city could do the same. As I noted, I did not make the suggestion for competitive purposes -- after all, I don't know if our numbers are better or worse than those of other hospitals -- but because public exposure of all our efforts will drive all of us to do better. Also, it will build, rather than erode, public confidence in the academic medical centers in our city.

The response, as you have seen from the press reports, ranges from simple recalcitrance to technically sophistic arguments about comparability of data. Please, does anyone argue that the goal should not be zero? If it is zero, it does not matter whether the data is measured in cases per thousand patient-days, cases per thousand catheter-days, or just the raw number of cases.

We all keep track of these numbers in some form or another. We could easily post them in real time voluntarily on a website maintained by the state or an insurance company, along with our own explanations of how and what we measure. (And perhaps, over time, we will agree on what single metric is most useful.)

People can and will understand this. They already spend hours on the Internet reading medical websites. Why do we give them so little credit? It will demonstrate to the public that we care about this problem, and will show our individual progress towards our ultimate goal.

Finally, it will enhance the reputation and credibility of all of the academic medical centers, two aspects of our character that will be more and more under siege because of the broader problems of the health care system.

Addendum (November 2010): Here's the video clip from the movie:

Just learning to crawl

It has been a bit over half a year since I started this blog. It is time for a retrospective.

Here are the favorite (or most provocative?) postings, based on number of comments received:

October 20: How am I doing?
December 18: Blackberry Cold Turkey
January 28: Do I get paid too much?
February 20: DaVinci decoded -- Or, surgical robots unite!
February 23: If man were made to fly...
February 24: The shame of malpractice lawsuits

Here are the most popular postings, based on Statcounter.com statistics:

->The Blackberry story, which was picked up by dozens of other blogs and read by thousands of addicted users with sore thumbs.

->The salary question, whose popularity needs no explanation, which is still being forwarded among bloggers and on which I am still receiving comments.

->The series of stories on disclosure of clinical results (like infection rates), which not surprisingly indicates tremendous public interest in this matter. These are receiving national attention and commentary, with overwhelming support for the kind of disclosures I have included and for which I have advocated.

I can't paper over this story any longer

Back on January 15 I posted a piece about our misadventures with new paper towel dispensers.

Hundreds of you have demanded an update on this dramatic story. Here it is, in the form of an email from our manager of environmental services. We are all pleased that the problems have been solved. But, please Mark, did you have to call it a "roll-out"?

On March 5, 2007, we will expand to the East Campus our program to replace mechanical paper towel dispensers with battery-powered, "hands free" dispensers. These new dispensers reduce the chance of cross contamination and thus facilitate improved infection control.

As you know, we faced problems with the initial roll-out on the West. These were mainly related to the specific kind of paper towel we started to use. We have switched to a paper towel comparable in quality to the one we had always used. These new paper towels have been in place with the new dispenser for six weeks on the West and have been considered appropriate and acceptable.

We are now moving forward to replace dispensers on the East Campus and will be starting with replacing those that currently use a "hand lever". This should take about one week (i.e., 3/5-3/9).

You don't have to say you're sorry

You don't have to say you're sorry
But I sure do wish you would, I wish you would
(With apologies to Vanessa Williams)

My recent posting on malpractice cases prompted several comments to the effect that, if doctors did a better job disclosing errors and apologizing for mistakes, there would be fewer malpractice claims. That issue has been debated back and forth for some time, and it is difficult to prove one way or the other.

The Harvard hospitals, under the guidance of Dr. Lucien Leape, have endorsed general principles that could result in more disclosures and apologies when medical errors are made, but it will be up to each hospital and ultimately the hundreds of physicians therein to decide how to operationalize these principles. Similar discussions are going on around the country.

In the meantime comes a thoughtful and useful program at Mt. Auburn Hospital, in Cambridge, MA. The folks at Mt. Auburn noticed that individual doctors and nurses were often unsure if a given situation merited a disclosure and/or an apology and, if so, how to most compassionately and effectively deliver it. So, they created a team of administrators and doctors who are on call to help a doctor or nurse who might have committed an error. This team eliminates the isolation felt by a doctor or nurse in that uncomfortable and awkward position; provides a third-party perspective on the particular case; and can often make helpful suggestions of how to talk with the patient and family members.

We are currently reviewing the Mt. Auburn program to see if it or some variant would be helpful to our care providers and thereby to our patients and families. If you know of a similar program, I would be interested in learning about it.

Our favorite author

It is time to reintroduce another author, one of a completely different genre from the gentleman below. Monique Spencer was treated for breast cancer at our hospital and has written this funny, perceptive, and helpful book for people who are going through the same thing -- or who are experiencing other types of cancer.

We published the book because commercial publishers thought it was inappropriate to have a funny book about cancer. I agree that not everyone wants to laugh -- but there are many who find humor to be a helpful part of the treatment process.

An excerpt:

This morning I saw yet another article about an amazing cancer superstar. . . . [S]he runs a business, chairs a few hundred charities, takes care of a few sick friends, and the interview takes place in her "immaculate home."

Oh. My. God.

I have deep respect for people with immaculate homes, I really do. Every two weeks, after the cleaners come, my house is immaculate, too. Then school lets out. Here come the kids with their friends. . . .

I've seen quite a bit of advice about managing daily life while you have cancer. This is my favorite: "ask your older children to assume chores while you are recovering from treatment." Trot this one out in the chemo area and watch the older parents roar. . . .

All parents know that the only way to get kids to do chores is to make the younger ones do it. Don't waste your time on those hateful teenagers . . . . Read up on your Dickens if you don't believe that small children can do chores.

You can buy the book 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 $20 to Windows of Hope, 330 Brookline Avenue, Boston, MA 02115, and we will mail you a copy. Or call 617-667-1899.

In Memoriam: Arthur M. Schlesinger, Jr.

Along with Richard Hofstadter and C. Vann Woodward, Arthur Schlesinger offered a perspective on American history that was invaluable. He died last week. (Photo taken from CNN.com.)

I was reminded of a radio interview he had with Chris Lydon a few years ago. (I am sorry I cannot find the cite.) The final Q&A went something like this:

CL -- After all these years of studying American history, what is the most important lesson you have learned?

AS -- Never underestimate the ability of the American public to become xenophobic.

On-line checkups

Good story in today's Globe about a thoughtful telemedicine experiment between Partners HealthCare System and EMC Corporation. They will test the proposition that more accurate reporting on blood pressure via electronic means from home will lead to better long-term results than the usual reporting by patients to physicians.

As I understand it, most telemedicine to date has occurred in remote locations, where people have trouble driving to their doctor or a clinic -- or to enable a consult from a specialist to a hospital without that specialty.

But there have also been programs of the sort being tried by PHS and EMC. Here is one from Colorado dated 2003. Here is a more recent one from New York.

This is all part of the "earth flattening" cited below. It will require adjustments by insurance companies to avoid the current perverse incentive of the health care system, in which doctors usually only get paid when a patient physically visits them. If this kind of system results in better results, more convenience, and the advantages of asynchronous communications, the insurance companies that figure out how to reward it will gain a competitive advantage.

Man bites dog: Newspapers are alive!

Dan Kennedy reports on a new newspaper/blog concept called BostonNOW. The idea: Bloggers sign up with this new newspaper-based and online journal authorizing them to reprint/republish the blogs. They sell ads. You get a cut of their profits.

Is this good news for newspapers, which have seen declining circulation? It seems to suggest that these folks think there remains a market for paper-in-the-hand media. But, like a no-frills airline that figures out how to reduce labor costs, there is little room in this new business for paid, trained reporters.

I guess this is a logical extension of the convergence between traditional and new media.

Hmm, I'd better sign up and see if they will direct my share of the profit to my hospital . . .

Tufts versus Tufts

It may have been a little confusing for viewers last night on Emily Rooney's Greater Boston television show on WGBH. There we had a doctor from Tufts Health Plan debating a doctor from Tufts New England Medical Center about the insurer's decision to put restrictions on bariatric surgery.

This has been a controversial move by the health plan. I usually don't get into the "who won the debate" game, but four of us watching the show thought the Tufts-NEMC doctor won the night. In particular, he noted that THP's program conflicted with the recommendations of an expert panel convened by the Betsy Lehman Center for Patient Safety and Medical Error Reduction. This had been previously pointed out by Nancy Ridley, associate commissioner for the state DPH and director of the Center. The health plan MD was put in the position of saying, "Well, our evidence-based medicine is better than yours" -- not very persuasive against an expert panel than had met for months to review the situation.

Also, people are less inclined to believe an insurance company on such matters, anyway. Maybe that's not fair. But a friend viewing the show with me said, "They just want to make money by denying payment for treatment. That's all insurance companies ever want to do." Knowing the folks at THP -- and let's remember they are a non-profit with a long reputation for progressive policies in health care management -- I believe they have much better intentions than that. But this tv show demonstrated how difficult it can be for an insurer to win the public debate in these matters.

(Disclosure: BIDMC carries out bariatric surgery, and Dr. George Blackburn from our staff was intimately involved in the Lehman Center report.