Remembrance on Passover

As we begin this celebration of freedom tonight, listening to this tape can be a helpful reminder of the strength of this human instinct. This tape was discovered, I think, in the Smithsonian Museum a couple of years ago, and is of a BBC recording on April 20 1945, about 5 days after the liberation of the Bergen-Belsen concentration camp by the British Army.

Busywork is not your job!

A SPIRIT Story:

On March 25, a SPIRIT training team visited the MICU 6. During the 25-minute observation, Pat Boykins, a Unit Coordinator, attempted to order copies of a patient consent form from the Web site of Office Depot Web, which has a contract to print all of BIDMC’s forms. When she entered the BIDMC code for the form (MC1793) she received an error message saying that the SKU – the product number Office Depot associates with the form – was incorrect. There was no other information, and thus Pat could not order the form.

Pat then spent 5-7 minutes making phone calls to hunt down the correct code. She eventually found it: MR1793. When asked at the end of the 25-minute observation if she encountered any problems in her job during that time, Pat said “No.” Why? Because this type of hunting and fetching has become a routine part of her job – a job she does with as much efficiency as possible. When prompted by the SPIRIT team to think of a way to improve the form-ordering process, however, she did make a suggestion that she said would save her a lot of time: find a way for the Office Depot site to provide the correct SKU for an expired or changed form code.

Here’s what happened next:

Pat reached out to her Help Chain Contact, Kristin Russell, Nurse Manager of MICU 6. Kristin spoke with Paula French, Contract Manager, who handles the Office Depot account. Paula said the proposed functionality of the Office Depot database does exist, and that the SKU never changes for a given form, even if its BIDMC code changes. She referred Kristin to Michelle Micale, Project Manager in Health Information Management, the department that handles all forms.

Michelle Micale was very helpful, and in the information she provided, the root cause of the problem was revealed. She confirmed that the form’s internal, BIDMC code had changed recently as part of an overall, ongoing process of reassigning more specific codes to forms to categorize them. Instead of all being Medical Center (MC) forms, they are being recoded as Medical Records (MR) forms, Learning Center (LC) forms, Human Resource (HR) forms, etc.

Michelle is working with Office Depot to ensure that both the old code and the new code for each form will always lead to the same SKU, beginning with the Medical Records forms. This process will take a while. In the meantime, she is available as a resource to provide the correct form number to anyone who needs one. Her e-mail and phone number are on the problem log. David Drew of Patient Care Services has sent this information to all Unit Coordinators.

Batalden updates Machiavelli

"There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order, this lukewarmness arising partly from fear of their adversaries … and partly from the incredulity of mankind, who do not truly believe in anything new until they have had actual experience of it."

This famous quote by Machiavelli is both a hearty warning and a healthy piece of advice to those who seek to change a political or social system. If those in today's health care system were looking for the equivalent piece of warning and advice, they might just have obtained it from Paul Batalden, Professor and Director of the Center for Leadership and Improvement at the Dartmouth Institute for Health Policy and Clinical Practice. He presented it to a small group of us today, in a talk entitled "The challenge of leading the leading of the improvement of health care". I present it with his permission. I think he has nailed the issue and admire his ability to do it so succinctly.

The key slide had the following heading:

“Anchors” of a synergistic culture holding the present in place…

And the following four major observations about why change is so hard to achieve:

Lack agreement about what the common and individual work is (at the behavioral level) that will be necessary to create anything different than the present reality;

We seek and find reinforcement for our self-interests, beliefs in the current payment methods and systems of health care;

Desire to focus on “islands of excellence” (and we love to give “Island Tours”) rather than create and maintain uniformly safe, high quality, good value, reliable and accessible operations; and

A well-developed capacity to rationalize away the newsworthiness of potentially disconfirming data (financial, quality, safety) and external assessments by patients, payers, etc.

Dealing with a demand for harmful or ineffective treatments

There is often a lot of commentary about physicians' overuse of medical services, using treatments that are unnecessary or wasteful. But there is also the question of how to handle the situation in which a doctor does not want to deliver a treatment s/he believes would be harmful or ineffective when a patient or a patient's family demands to receive such treatments. Our hospital has a policy on this matter, conceived with broad involvement from our faculty and with particular input from our ethics coordinator. I print it in its entirety below in case it might be useful to other places or informative to this general audience. I think it is pretty self-explanatory, but I am happy to help collect responses to questions in case it is not.

Title: Policy On Treatments That Are Harmful or Ineffective

Purpose: To ensure that medical treatment always respects the dignity and integrity of both the patient and any involved health professionals.

Policy Statement: The goal of medicine is to benefit the patient, and the process of delivering medical care should always respect the dignity and integrity of both the patient and the health care practitioner.

It is the policy of the Beth Israel Deaconess Medical Center that no patient should be forced to undergo, nor should any physician or health professional be forced to provide, a treatment that is ineffective or harmful. A medical treatment is ineffective if there is no reasonable likelihood that it will achieve a medical benefit to the patient. A medical treatment is harmful if the likely suffering or risk of other harm caused by the treatment grossly outweighs any medical benefit to the patient.

In undertaking the care of a patient, a BIDMC physician will offer all available medical treatments that have a reasonable likelihood of benefit without an overwhelming burden of suffering. If a point is reached when no further medical treatment offers any reasonable hope of benefit without an inordinate risk of suffering, the physician will continue to care for the patient, ensuring that any suffering is minimized and the patient’s dignity is respected.

Procedure(s) for Implementation:

Patients, families and providers generally agree in applying these principles of medical care to achieve patient-centered goals. In rare cases, significant disagreements may arise over whether a treatment is ineffective or is harmful. In such circumstances, if all efforts to achieve agreement fail, the following series of steps is recommended, each in a timeframe appropriate to the patient’s clinical situation, and with documentation in the medical record:

1. The attending physician should seek a formal, independent second opinion from a physician not currently engaged in the patient’s treatment. If the consulting physician concludes that treatment is not ineffective and not harmful, the attending physician may choose to provide that treatment or the consulting physician (or another who is willing to do so) may take over care of the patient.

2. If the attending and consulting physicians agree that the treatment is ineffective and/or harmful, the patient or family should be offered the opportunity to seek transfer to a facility willing to provide that treatment. The patient or family should be encouraged to seek support and assistance from a BIDMC Patient Relations Representative and/or Social Worker in this and any subsequent steps described below.

3. If the attending physician concludes that these efforts to resolve the disagreement have failed, s/he should notify the administrator on call, who will convene a committee consisting of:

1. Chief(s) of the relevant medical or surgical service(s) or their designees not involved in the patient’s care
2. Chair of the Ethics Advisory Committee (EAC) or designee
3. Representative of the Patient Care Assessment Committee (PCAC)
4. Senior Vice President of Patient Care Services or designee
5. Director of Social Work or designee
6. Director of Pastoral Services or designee
7. Chief of Psychiatry or designee
8. Chief Operating Officer or designee
9. Others deemed appropriate by the committee or its chair

The EAC representative will serve as moderator and chair of the committee. A quorum will consist of a minimum of four members, including at least two physicians, since the committee’s core task is to determine, on medical grounds, whether the treatment under consideration is ineffective or harmful. The quorum must include at least one representative of the relevant medical or surgical service(s), and the representative of PCAC.

The committee will consult with the following parties:

a. The attending physician, who should explain the basis for deeming the treatment to be ineffective and/or harmful. Other members of the treatment team should be asked to add details or to offer different perspectives and interpretations.

b. The patient and/or family spokesperson(s), who should explain the patient’s perspective regarding the treatment under consideration, including hopes or expectations of benefit and views about possible harm(s). A BIDMC Patient Relations Representative and/or Social Worker should be available to the patient and/or family before, during, and after this step.

Following as free an interchange of perspectives as possible, the committee will meet alone to determine whether the treatment is ineffective or harmful.* If the committee does not conclude that the treatment is ineffective or harmful, it may offer suggestions for identifying BIDMC staff that may be willing to assume responsibility for the patient’s care. If the committee does conclude that the treatment is ineffective or harmful, it may offer suggestions to the involved clinical service(s) and BIDMC administration regarding steps that may be taken to ensure that BIDMC staff are not forced to provide the treatment.

One or more representatives of the committee will communicate the committee’s conclusion, any related suggestions, and its reasoning to the concerned parties, with documentation in the medical record.

If the patient or family are not in agreement with a determination by the committee that the treatment is ineffective or harmful, and are unable or unwilling to arrange for transfer to another facility, they should be informed of their options for seeking, within a reasonable timeframe, court involvement. Unless there are legal barriers to doing so, however, BIDMC administration shall take steps to support implementation of the committee's conclusion.

---

* Finding a treatment ineffective or harmful is a positive finding; in the absence of a clear consensus, the committee should conclude there was inadequate evidence on which to decide that the treatment was ineffective or harmful.

Straight talk about SPIRIT

After each full-day training session for managers and others about BIDMC SPIRIT (almost 600 people now), there is a debriefing session. The comments that emerge are helpful to us in refining both the training program and our plans for calling out and solving problems throughout the hospital. To give you a sense of the issues raised, I am posting the comments from the last session. Remember, this is early in the process, not like at Toyota and other places where similar approaches have existed for decades. So, we are still feeling our way. I love that people are so open and clear about what they find reassuring and what they find troubling. That, in itself, is an important aspect of what we are trying to accomplish.

BIDMC Spirit Orientation
Participant Concluding Reflections
April 15, 2008
These reflections were invited by Ken Sands, our SVP for Health Care Quality. He started by saying, "We heard earlier today from a colleague about how logging of items about their unit had been used as a metric that wasn’t positive." Responses follow:

That was me. I did get a call from someone above me who said in effect, "There are a lot of call-outs in your area there must be some real problems there; what’s going on?" when it’s 4 out of 450 and I know we are trying to encourage call outs. I wanted to say that I’m a big supporter of this process, but it has been confusing regarding are we supposed to deal with things as they are called out and up "the help chain" or by getting calls from people above us or reacting to an e-mail from the log monitor? Are we supposed to scan it everyday? It’s not clear and it’s hard to know how to prioritize. We talked about it earlier today, and we discussed how we are all learning together including the leaders, but it’s important to be aware of this dynamic because it creates pressure and anxiety.

Thanks for saying that. The other day we had an issue and I ended up talking about it with the other manager by saying, "Maybe we can do a problem solving without logging it." And we actually had a phenomenal response; fastest ever. But there’s something about the log, it’s very visible, monitored, punitive potentially. It just feels like a difficult environment for me to call out in, at least at this stage.

The last five years have seen a great focus on greater accountability. We just don’t want to slip into blame.

I wanted to say that SPIRIT does empower us to deal in areas where we’ve struggled … it makes it much easier to engage on issues we’ve struggled with. I do have a suggestion about the training; make it easier to make a personal connection in the set-up, with phone numbers etc. Finding time was hard for me, so you send an email and you hope for a response but it’s not to anyone in particular.

I’ve been to a lot of trainings like this. The bigger challenge than training is how to keep it going. How does the organization reinforce this; how do we get reinforcement? Reflecting on today, I’m not sure I would have been as persistent and nice in working with the people involved. It’s a discipline. It needs to be reinforced/mentored. This is a cultural change!

My comment is about language. If we changed what we say from "problem" to "opportunity" it might help. Because that’s what they are – opportunities – and even the word problem seems to connote something negative.

It was inspiring to see people on the front line involved in solutions and being asked for their opinion, not just told. Being asked, "What do you think about this?" and "How would this idea come across to your peers if we rolled it out?" That was totally inspiring.

Facebook followup

As mentioned below, Johnny Diaz at the Boston Globe was working on a story about Facebook in the workplace, and his story is in today's paper. As he noted, for those wanting to avoid total disclosure about personal details, "Last month, the company introduced new privacy options. Users can now distinguish who can view their personal details by classifying people into specific groups such as friends, co-workers, classmates, or relatives, each category granting a different level of access. In other words, Facebook members can allow their close friends to see their vacation snapshots but restrict co-workers or relatives from the same access."

Meanwhile, though, many people sometimes get tried of all the applications and invitations they get from their friends, just wanting to use Facebook for basic communication. A friend of mine posted the following humorous and poetic note on her site to send a message on this topic to her friends:

dear every one, i appreciate the thoughts, however, I am not interested in being super poked super sideways double reach around video wall posted, live music player hosted, double dutch instant messenger facebook chatted, quadruple application mounted vip amazing friends list added. I hate to love facebook just like the next guy, but i'm not succumbing to this level of application installation carpal tunnel wrist numbing add me please action, you hold me too long online it's off i'm trying to sign, so cut the crap, this macbook is burning my lap.

A way with words

I just had the pleasure of being on a panel discussion at U. Mass Boston with three wonderful colleagues: Stephen Crosby, Dean of the McCormack Graduate School of Policy Studies; Jim Sabin, Director of the Harvard Pilgrim Health Care Ethics Program; and Marc Roberts, Professor of Political Economy at the Harvard School of Public Health. The topic was "Health Care Rationing: The Elephant in the Room." Of course, the topic eventually swayed over to the improper incentives built into the current health care reimbursement system -- at which point Marc began to discuss the pigs of Provence who use their snouts to root underneath oak trees in search of truffles. The audience was lost for a moment until Marc drew the analogy with me and my fellow hospital administrators, whom he termed "truffle-seeking pigs" rooting through the reimbursement system to focus on those service lines that generate the most margin for our institutions. I am not sure how I feel about the animal he chose, but it was a superb image!

Help wanted . . . and found

A lovely editorial in today's Boston Globe about use of the Workforce Competitiveness Trust Fund, created by the Legislature in the economic stimulus bill of 2006. Thanks to this appropriation, BIDMC, Children's Hospital Boston, and the New England Baptist Hospital jointly created a two-year Medical Lab Technician program with Bunker Hill Community College. As noted in the editorial, "There's a high demand for these workers, whose responsibilities can include handling specimens and running blood tests. Classes are held at Beth Israel, after work. During the last six months, participants go to labs for hands-on training. And they still get their salaries, making the training affordable."

How can this be?

As first, I couldn't believe that this story was true, but it has now shown up in several on-line stories and was also in today's Boston Herald, whose story started, "DEARBORN, Mich. - Outraged nursing union members claim they were attacked by purple-cloaked members of a rival union which stormed their conference." (Sorry for not providing a link, but according the Herald site, this story is no longer available on line.)

Homesourcing

Several months ago, I read about Jet Blue's use of homesourcing in Thomas Friedman's book , The World is Flat. The idea is simple and elegant. For some staff functions, those relying mainly on computers and telephone, why not allow people to work from home and avoid the mess of commuting? Also, people who are otherwise tied to home for physical or family reasons can be active members of the workforce and get better jobs if they are permitted to work from home.

We decided to run a pilot for some of our coders (the people who review medical procedures to provide proper billing formats for the insurance companies), and our CIO, John Halamka, writes about the experience in CIO Magazine. As you can see, doing this for a hospital is a bit more complicated that for an airline, because there are major and important concerns about privacy that have to be met. As John notes in the article, "If employees are to access sensitive health data from their homes, I need to investigate biometric devices, re-examine application time-outs, strengthen surveillance of audit logs and ensure end-to-end security from data center to the home."

The results overall were very positive on many fronts. "The flexible work arrangements improved employees' quality of life. They're not stressed or tired from commuting so much, and they're saving money on parking and gas." Also, "Coders are challenging to hire in Boston due to the large number of hospitals competing for a small number of qualified employees, so flexible work arrangements enable us to hire without geographic restrictions. Given the IT job market and the difficulty of recruiting replacements, the benefit of such flexibility cannot be overstated when you have a seasoned employee who knows your systems well. We were able to retain a coder who moved and we included her in our pilot."

But it is important to be sensitive to and respectful of individual preferences. As John notes, "One coder who lives by herself said she felt distracted at home and missed the social interaction with coworkers. Another coder who also lives alone loved working at home since she experienced no interruptions and got more done."

Please read the article for a full description and see if this might make sense for your organization.

Return of the house call?

Please read this op-ed by Dr. Elizabeth Kass, from Urban Medical, and our Chief of Medicine, Mark Zeidel.

11 minutes of pleasure

A year ago, I wrote about our use of mystery shoppers to help guage whether we were meeting standards of customer quality in our clinics. We still do this and find it a good way to help the staff at the front desk staff do better and better for our patients. Here's a call, though, that shows exemplary service. (The call lasted 11 minutes. You can't rush quality.) Note the immediate feedback to the staff member from the secret shopper, too.

Nephrology
After one ring, Kerry Falvey answered my call by enthusiastically stating the name of the practice, her own name, and asking, "How can I help you?" I explained that I needed to make an appointment, but I had never seen a Nephrologist before. I had seen a Urologist recently because of recurrent UTIs who said I had high creatinine levels. My PCP and this Urologist both suggested I see a Nephrologist. Kerry said that she could definitely help me with scheduling an appointment, and asked for my name and date of birth. She confirmed that I had never been to BIDMC then explained that as a new patient, she would need to start a profile for me. She then collected all of my demographic information and confirmed that my PCP was the referring physician. She also asked if there was a particular doctor I'd be interested in seeing, and I said there was not. Kerry then explained that she would check for the first available appointment. She mentioned that their new patient policy was to provide an appointment within seven business days. The first appointment she found for me was for Tuesday, February 26th (6 days) at 10:30a with Dr. Walter Mutter, whose name she spelled for me. She confirmed that this appointment date and time would work with my schedule and confirmed that the reason for my appointment was because of high creatinine. Kerry then explained that she would check if I needed a referral. She clearly explained that depending on my insurance and PCP, I may not need a referral because of certain agreements between BIDMC and certain insurance companies. She explained that since I had Harvard Pilgrim insurance and my PCP was a BIDPO doctor, I would not need to obtain a referral. She then explained that she would check if they could access my PCP's records. Since she discovered that they could not electronically access the records, she said that they would contact my PCP, with my permission, to obtain any pertinent notes. Kerry asked if I knew where their office was located, and I said I did not. She explained that there would be a letter coming in the mail with details on directions, parking, etc, but that she would give me the location anyways. She provided me with the address, name of the building, and floor on which I could find Medical Specialties, which is where their practice is located. She asked if I needed directions to the medical center, and I said I should be fine. Kerry then repeated the date, time, and doctor I would be seeing for my appointment. She provided me with the practice phone number and explained that I could call with any questions and that any of their three staff could help me. She asked if she could help me with anything else before transferring me to registration.

Kerry's facilitation of my call was nothing less than exemplary. I mentioned to her that her tone of voice was very pleasant, and she was easy to speak with, making for an enjoyable conversation. I also commended her clear explanations throughout the call, including why she needed to collect my information, the fact that she would schedule me an appointment then transfer me to registration, and her description of the referral exception which my insurance allowed. I also thought she was very accommodating, since she was able to check right then and there whether I needed to call my PCP for a referral and since she offered to obtain the medical notes from my PCP. I also mentioned to Kerry how helpful it was that she repeated the reason for my appointment, indicating she understood my request, and that she repeated my appointment date, time, and doctor at the end of the call. I also mentioned to Kerry that it seemed like she provided me with all the information I needed and asked all the questions she should have. The only suggestion I could think of for Kerry was for her to mention something about parking along with the location of the practice.

It was very uplifting speaking with Kerry, even for something as mundane as scheduling a doctor appointment. Even on this Friday afternoon, Kerry's spirits were still high, which certainly lifted my own mood. This call truly sets the bar for the customer service that all of our schedulers should aspire to reach. Kerry received a 5 (excellent) out of 5 for this call.

Welcome, Citizen Abraham!

A funny and lovely column by Yvonne Abraham in today's Boston Globe about the penultimate stage in becoming a US citizen. Reminds me of the hilarious Jay Leno routine in which native-born US citizens on the street are immediately shoved into an INS van and deported if they cannot answer the questions expected of new arrivals.

Everyone has his Lambaréné

There are certain iconic moments in life that serve to motivate people. I am not talking about traumatic events like Pearl Harbor, JFK's assassination, or 9/11, although these are unforgettable and can lead people to take particular paths in life. No, I am talking about the power of an image or series of images.

In October 1947, Life magazine published a photo essay about Dr. Albert Schweitzer and his medical mission in Lambaréné, Gabon. It was entitled "The greatest man in the world." I have not been able to find a copy, but it most certainly included pictures like the one here. It has a bit of a Mona Lisa quality, crossed with a Pieta -- He is looking directly into the camera with an expression that is engagingly kind and direct but simultaneously deep in thought and focused well beyond the camera.

The pictures and the story in the magazine, I have learned, served as an inspiration for many young people of that era to devote themselves to service. The most famous is that of William Larimer Mellon, who left a wealthy life style to go to medical school and establish a hospital in Haiti. Schweitzer would say, "Example is not the main thing in influencing others, it's the only thing." Certainly that was the case with those of the generation who saw that edition of Life Magazine. I am guessing that the pictures in that magazine were imprinted in their minds.

Yesterday, I attended my first meeting as a board member of the Albert Schweitzer Fellowship, which is devoted to reducing disparities in health and health care by developing "leaders in service" -- individuals who are dedicated and skilled in helping underserved communities, and whose example influences and inspires others. ASF supports 175 fellows a year from schools of medicine, dentistry, nursing, optometry, and pharmacy, who pledge themselves to devote 200 hours to community based organizations like clinic, senior centers, schools, and shelters. The program works in 11 cities in the US and is considering expansion to others. There is an cadre of 1785 "fellows for life" who are alumni of the program.

Please contact the Fellowship if you are interested in becoming a fellow, or if you would like to make a donation to this worthy cause. If you are on Facebook, you can find it listed as a cause.

It's not Passover yet . . .

. . . but these chickens are relaxing in a Jacuzzi in anticipation of the holiday next week.

Save Time; Improve Patient Care; Improve Work Life

Direct and unedited from our problem log, a great example of a call-out and problem solving from BIDMC SPIRIT:

Type of Problem -- Save Time; Improve Patient Care; Improve Work Life
Campus -- West
Setting -- Inpatient Ward
Location of Problem --Farr 7

Problem
I could not find a pulse oximeter to check my patient's oxygen saturation. There were none in the equipment cubby which is a section of our breakroom remote from patient care rooms. I wasted a lot of time going from patient room to room until I found one.
Suggested Solution -- Define a specific location that is more convenient to the nurses' and pcts' work flow
Person Describing Problem -- Beth Morrison

Root Cause
Why were none available? It is not a supply issue, there are 7 pulse oximeters for the floor. Why could Beth not find a pulse oximeter? None were in the storage area. Why are the oximeters not returned to the storage area? It is in an inconvenient location. Why when the oximeters are used are they not returned to the storage area? In the past we had a locked equipment room that was centrally located. On our new floor Farr 7, we do not have an equipment storage room and have designated a small cubby hole in the staff breakdown to store equipment. It is inconvenient in relation to the work area. Also, it is in the breakroom so sometimes it is difficult to move past staff who are sitting eating a meal.

Solution (after investigation)
A cubby hole in the nurses's station is not being used. It's location in very convenient for small equipment storage. Electrical outlets and shelving need to be installed. Once that work is complete, I will apply LEAN principles and outline with black tape and label each area for the specific equipment.

Action Plan (who, what, by when)
1. Kathy Hussain met with staff to brainstorm new, convenient location. Complete.
2. Kathy worked with her Operations Coordinator Debbie McGrath to discuss needed work. Complete.
3. Kathy discussed renovation with her director Jane Foley. Approval given to move forth with project. Complete
4. Kathy and Debbie met with Brendon Raftery and Chris Kimball on March 17th to scope the work. Complete.
5. Electrician installed 20 electrical outlets. Complete
6. Carpentry measured and ordered required shelving.
Complete
7. Currently awaiting installation of shelving.
8. Once shelving installed- will outline placement of equipment so that each piece of equipment has a designated and corresponding location.

Investigation -- Closed (Complete w/ root cause, solution, action plan complete)

Comments
Beth- thank you so much for calling out this problem. Your willingness to discuss this has lead to more efficiency and less wasted time. As a side benefit, the relocation of the equipment will allow us to recapture space in the breakroom, relieving the crowding and giving the Farr 7 staff a more pleasant breakroom.- Kathy

Throw off the crutches of ppt!

The most important line in a recent post: Jessica got a round of applause for not using any PowerPoint slides.

The time has come for the world, with cries of "Hallelujah!", to throw away the crutches of PowerPoint.

Sure, a good ppt presentation can be special, but how often do you see a good one, or one that even contributes to the reservoir of human knowledge? Instead, what usually happens?

1 -- The machine doesn't work, and the audience is left sitting while the speaker pushes buttons and pulls cables and finally calls in the house AV person, who pushes buttons and pulls cables. What better way to show lack of respect to your audience and lose their engagement by keeping them waiting for your talk?

2 -- The slides are filled with text. The speaker tries to put up too much information, instead of using a few words on the slide to create emphasis.

3 -- The slides are filled with Excel spreadsheets with tiny cells. How often have you heard this: "I know you can't read this from your seat"? Well, why put it up on a screen if people can't read it?

4 -- The speaker turns away from the audience to look at the screen whenever a new slide comes up (yes, even when there is a computer on the podium!), losing eye contact with the audience.

5 -- Oops, did I say "eye contact?" That was already lost when the lights were dimmed for the presentation.

6 -- There are too many slides. A new one arrives on the screen every 15 seconds, so if you are trying to take notes (in the dark!), you never finish one before the next appears. (Then, halfway through, the speaker says, don't worry about taking notes. I'll hand out a copy after the presentation.)

7 -- The speaker reads the slides. Need I say more?

Wrong question

A very good friend and colleague who runs a nonprofit advocacy group sent me an email with the subject line, "New technologies/Social networking" and asked the following:

I wanted to ask for some advice. We are looking at new ways to reach members and potential members. We are considering everything from blogs to Facebook to YouTube. I was warned that blogs can be very time-consuming, and judging by the quality of your blog, I assume it is. Can you give me a sense of how much time you spend on your blog?

My response:

Wrong question. That's like asking how much time you spend talking with people. We should talk.

Here's a more complete answer. As head of an advocacy group, I would be looking to build strong, engaged constituencies to support our goals. In the days before social media, I would have used a variety of tools to do that -- radio, television, print media of various types, community meetings, legislative meetings, and so on. You should view social media tools in the same way. They are likely to reach slightly different segments of the community but are no less important -- and perhaps more so -- than the traditional media. Indeed, there are certain groups of people, especially idealistic younger folks likely to take on a cause, who get much of their information from social media. Look at what Obama has done with these media in his campaign.

Writing a blog does not take much time. After all, how long does it take to write 400 words? But, to achieve effective outreach with a blog, you need to invest the time in creating links with others and reading their posts and commenting on them. Your goal --- does this sound familiar? -- is to create a sense of community with potential constituents who happen to like this medium.

Ditto for Facebook. The time you spend on Facebook is infinitely expandable, as you invite friends, create groups, create causes, and the like. But here, too, your goal is to create a sense of community with potential constituents who like and use that medium.

The big advantage of social media over traditional media is that the interactions can be asynchronous. You don't have to make an appointment, the way you do with a legislator. You do not have to respond in the moment, like when a reporter on deadline calls and needs a comment. You participate when you want to, and you can do so as a "fill-in", between your other tasks. In that sense, these are actually more time-efficient media than the traditional ones.

Another advantage is that you totally control how much time, overall, you want to spend in the media worlds. Except -- and this is important -- you need to spend enough time and be sufficiently attentive that you stay engaged with your constituents and have fresh messages from time to time. How much time is that? Well, it depends on the news cycle of your own organization. If you are facing public policy crisis every day and trying to organize people to engage on short-lived issues, you need to be online almost constantly. But for most advocacy issues, you can probably write a blog post two or three times per week. But, set up the blog to notify you by email when comments are submitted, and respond as quickly as possible to each comment. And use Statcounter, Technorati, and/or another counting programs to see where hits are coming from and what other blogs are referring to yours. Then, read what they are saying and submit comments on those blogs, and, if appropriate link them to yours and let the authors know you have done so.

On Facebook, I would check your page once a day for messages and the like. If requests and other items have piled up, then increase the frequency to twice a day.

Oh, and did I mention that this is all free? Other than a bit of your time, the cost of these social media to your organization is absolutely zero.

So, what does this sound like? Maybe an hour a day, interspersed with your other activities? Does that sound like too much? I think if you compare its efficacy against your traditional activities, you will find that you make more contact with interested audiences in that hour than you do with any other activity in which you are engaged. This may cause you to reevaluate the relative time you spend with other media, but is good to do that from time to time anyway.

A big chair for the little ones

Congratulations to Dr. DeWayne Pursley, our chief of neonatology, who just a few days ago was named Chair-Elect of the American Academy of Pediatrics Section on Perinatal Pediatrics. DeWayne and his crew take care of our smallest patients. I have written before about their focus on safety and quality. It is a remarkable team of people, as warm and caring as anyone could imagine. DeWayne sets the tone and clearly deserves this national recognition.

Is "non-profit business" an oxymoron?

An April 4 article in the Wall Street Journal, entitled "Nonprofit Hospitals, Once For the Poor, Strike It Rich" has prompted a slew of comments on wsj.com. I think they are worth reading and do not intend to summarize them here. Some accused the Journal and the quoted politicians of grandstanding. Others said the story was right on target.

The issue of the type and degree of benefits provided by non-profit hospitals is a legitimate and important one. Our institutions are given certain privileges by the government, and the government has a right to supervise our performance in carrying out our public service functions. Recently, the Massachusetts Attorney General announced a review of certain of these activities, those relating to community benefits. This is a healthy step, in that as times change, the standards of behavior and reporting should likely change, too.

The WSJ's story contained examples of non-profit behavior that many will find excessive. I think some examples chosen are unusual and not reflective of most hospitals. But I imagine that a detailed review of Massachusetts hospitals would find some items of a more modest level that at least some people would find troubling.

On this blog, I have written posts on several of the commercial aspects of running a hospital -- for example, one on the growth imperative, another on advertising. I have also told about what it was like when this hospital was very close to closure because of a failure to mind its financial ways. Finally, you have seen posts on the special role of our Board of Directors in setting standards for a non-profit institution like ours.

In reviewing this issue, it seems to me that there is not always a bright line between the business behavior of a non-profit and a for-profit company. Both need to operate in the black to carry out their purpose. Both need to determine how to compete in a marketplace to achieve that. The strategies employed to do that might look quite similar. Both need to attract qualified people in both supervisory and line positions. The salaries and benefits offered, therefore, might be somewhat similar. Both depend on the vigilance of a Board of Directors to monitor management's performance and behavior. So the structure and functions of the boards overlap in several ways (but not totally, given the pertinent legal requirements). And, as a final level of control, both have regulators to ensure that appropriate community standards are maintained and enforced.

But there is a fundamental difference. The non-profit does not have shareholders who benefit financially from its operations. Its fundamental constituency is the community it serves. For a small community hospital, it is literally the local community. For an academic medical center like BIDMC, it is the local community, but it is also a regional, national, and indeed international community that benefits from the research and educational programs of the hospital.

Is this a difference without a distinction? I think not. I know that our Board and I would be making very different decisions about patient care, research, and training expenditures if we operated under a for-profit rubric. While we always have to be prudent about which services we offer, many more areas that do not generate a profit or that result in perpetual losses would likely be cut or eliminated if we were not a non-profit. As a matter of strict business, many of these could be jettisoned and provided by others outside of our hospital. But we believe that we owe to our patients and to the nurses and doctors who we are training to offer these as part of our public service mission.

As health care costs continue to rise and consume a greater percent of our national economy, we can expect further debates on these issues. Those debates are normal and appropriate and help hold all parties accountable to their constituencies.