Charlie's main message

Charlie Kenney was next at the conference. After telling stories of notable leadership in the quality and safety arena, he concluded by relating a story about Sorrel King asking Hopkins medical students how many had heard about To Err is Human. Among all the first and fourth year medical students present, not one had heard about the study. His conclusion: “There is an ignorance in the medical profession about the quality and safety movement that has to be fixed. We have to do a better job getting the word out there.”

Sorrel's story

The conference began in an intimately personal way, with Sorrel King telling the story of her daughter’s death due to medical errors. “First, I wanted to stick it to Hopkins. I wanted everybody in the hospital to know. I did it out of anger and grief. Then it became destructive, and I didn’t want to talk about it any more.” But, then things evolved, and she now tells the story in the hope of spreading the message that it was a series of simple errors that could have been avoided. She hears from lots of doctors and nurses who thank her for telling the story. She says, “I do it now because it is making a difference.”

The King’s took the financial settlement from Hopkins to create the Josie King Foundation to start and enhance programs to "prevent others from dying or being harmed by medical errors. By uniting healthcare providers and consumers, and funding innovative safety programs, we hope to create a culture of patient safety, together."

The latest project is the Care Journal, a simple way for families to keep track of the progress of patient care for their loved ones in a hospital. Check it out here.

Pursuing the Holy Grail, in real time

Let's try some real-time blogging. I just arrived at a conference organized by the Blue Cross Blue Shield Foundation, entitled In Pursuit of Health Care’s Holy Grail: The Quality Movement that is Transforming Health Care. It is being held at the JFK Library and Museum in Boston and is basically a real-life version of a recent book written by Charlie Kenney, entitled The Best Practice: How the New Quality Movement Is Transforming Medicine. Here's a Boston Globe op-ed article written by Charlie summarizing the main points of the book. It is a compendium of success stories in the quality and safety arena from around the world.

Here's a July 23, 2008 podcast of WGBH's Emily Rooney interviewing Charlie. One thing on which he and I would disagree is his relative emphasis on the need to change the payment system to accomplish quality and safety improvements in hospitals. That view is consistent with Blue Cross Blue Shield's hope to engage hospitals in their so-called alternative contract, which is a major part of their program. Their emphasis is not surprising. When you are an insurance company, your major tool for influencing behavior is pricing, and, as they say, when you have a hammer, everything looks like a nail.

It is interesting to note, though, that the whole range of quality and safety initiatives begun by BIDMC is being done under the traditional compensation system. We get no financial reward from insurers for this program, and yet we find it in our strategic and financial interest to pursue it nonetheless. The plan being proposed by BCBS puts a major insurance risk on hospitals by capitating payments, and the company has yet to address that proposed shift in risk from the insurance company to the providers -- rather than recognizing that there are multiple ways to encourage the quality and safety results they seek. But that is a topic for another day, and will either be resolved or not in the context of our contract negotiating sessions.

The speaker who gets the distance record for this conference is Göran Henriks, Jönköping County, Sweden. His picture is above. You can read about the path taken by the folks in this network of hospitals and ambulatory centers here.

Another notable speaker at the event is Sorrel King, Founder of the Josie King Foundation. Her picture is above, too.

As the day goes along, I'll post any interesting observations that come my way.

Like elephants

I offer the following comment with no sense of joy, sadness, sarcasm, irony or any other emotion. Yes, now I am a Red Sox fan, but that is not why I include it here. After all, I grew up rooting for and admiring the Yankees.* I just think this is one of the best leads for a sports story that I have ever seen, evoking an entire season in about 50 words. It is by Sports of the Times writer Dave Anderson and appeared in the NY Times on September 14.

The Yankees, like elephants, have come home to die. During the homestand that will conclude next Sunday night with the baseball finale at Yankee Stadium, this uninspiring team will almost surely be eliminated from what many of their fans have come to consider an inalienable right — a place in the postseason.



* (Of course, those were different Yankees.)

Carrier pilots do it

A short New York Times article yesterday by Stephen R. Gray, “Flight School,” got me to thinking. Gray describes the work environment for fighter pilots who land their jets on aircraft carriers:

A carrier pilot must ... learn to accept criticism of his or her performance, from both peers and overseers. The landing signal officer on an aircraft carrier administers a public debriefing and critique of every landing, and a grade is assigned to every pass the pilot makes at the deck. These grades ad the pilot’s performance are displayed publicly for all to praise or ridicule. The psychological pressure of this culture is the whetstone that successful carrier pilots use to sharpen their skills -- and the grinder that drives some from the profession.

Now, in medicine, we don’t have anything like this. Yes, while in training, interns and residents receive real-time reviews of their work (often in front of their colleagues) from their more senior residents and from attending physicians. For attending physicians, we hold mortality and morbidity (M&M) conferences when something goes wrong in patients’ care. But, we do not generally conduct peer reviews of doctors’ performance once they are certified as full-fledged physicians.

Our Chief of Neurology, Clif Saper, originated a thoughtful practice along these lines. The doctors in his department do randomly assigned reviews of the case notes of their colleagues, with an eye towards deciding if the process and diagnosis and treatment seem warranted by the facts of the case. Those reviews, blinded by reviewer, are then shared with the attending physician. The idea is a good one, to help all of the doctors do a better job by allowing an objective review of real cases. It is specifically designed not to be threatening, though, and the results are not made public, even within the department.

We also had a similar, more limited experience in our GI department, after it was learned that the speed of removal of an endoscope during a colonoscopy can make a dramatic difference in the likelihood of detecting pre-cancerous polyps. (See this post for more information.) Each doctor in the GI divisions was given a summary of the department’s performance on this metric, along with a confidential summary of his or her performance. Without any public release of data, everyone’s performance soon rose to the desired level.

But do these efforts go far enough?

The difficulty of doing a carrier pilot type of review in a hospital is that no place can afford to have dozens of senior physicians standing around judging the performance of dozens of attending physicians, all day long and all night long. In contrast, one landing signal officer on an aircraft carrier sees every pilot’s pass and can apply a grade to it.

But there are metrics of performance that can be applied to surgical and procedural cases. While not perfect, they could send warning signals of the need for improvement -- or perhaps, at a minimum, create a healthy kind of competition among doctors. For example, you could use unanticipated returns to the OR or incidence of surgical site infections to evaluate surgeons. As mentioned in an earlier post, too, the American College of Surgeons already collects data regarding risk-adjusted actual versus expected outcomes in certain surgical specialties.

For proceduralists, like GI doctors, you might measure the number of adverse events, like perforated colons. These data are already collected by every hospital. So imagine if these kinds of metrics were presented every week to the doctors within each group, with names mentioned.

I know it would be more difficult to assign a good grade to a doctor for treatment of a given patient. After all, some results are not known for days or months, well after the patient has left the hospital. So focusing on problems rather than successes might give an unfortunately negative view of performance, but at least it would help assess each doctor's ability to avoid harming a patient.

I haven’t raised this issue at BIDMC (yet!). I am willing to guess what the reaction would be -- even in a place where transparency is embraced as fully as any hospital in the world. “No way!” would be the response, I think. First, people would say that there is no metric or set of metrics that would be accurate enough to give a full representation of a doctor’s performance. Then, people would say that if we share this data, it will distract people from the “real” issues in patient care and cause them to “teach to the test.” Others might say it would be insulting and a sign of disrespect, especially if the residents and other trainees were allowed to view it.

To which I would say, “You pick the metrics you want to share, the ones you think would be indicative of important aspects of performance. Don’t release them to the world, but use them only in your legally protected peer-review sessions. Tell your residents that you are doing this in front of them to demonstrate that learning and performance improvement never stops. Consider this as an experiment for six months, and see if it changes the nature of the discussions at your faculty meetings.”

Before I suggest that, though -- and please remember that I would only have authority to suggest it -- I'd like to hear from any of you out there. Do any of you do anything like this in your hospital or your physician group? I am not averse to pushing the envelop on this, but it would be great first to hear the experience of others.

(Photo credit: OK3)

Transparency, a reprise

The Institute for Healthcare Improvement offers an occasional 2.5 day course for hospital senior leadership teams, which they call their Executive Quality Academy. They admit hospital teams to develop action plans to lead quality improvements in their organizations. (The group above is from Winchester Hospital, a very fine community hospital in Eastern Massachusetts. There were also folks from Stanly Regional Medical Center in North Carolina, the Indian Health Service's Red Lake Hospital in Minnesota and North Dakota, and several hospitals in Florida.) Dr Vinod Sahney, one of the faculty members, asked me to come by this last week and talk about the role of transparency in this kind of effort.

As I did, it occurred to me that recent arrivals to this blog might not be familiar with how I have used it to experiment with reporting of clinical results, with the hope of helping to hold our organization accountable for meeting quality improvement metrics. As I said in an article in Business Week about one year ago:

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

Rather than repeating my IHI talk here (boring!), I am just going to list below some key posts to which I referred during my session. (Who needs PowerPoint if you have a website!) If you are interested, you can follow them through and get an idea of the journey we have taken during the past two years. As always, I welcome comments on these, but I am also seeking comments from those hospitals that have also tried this approach, so we can learn from your experiences, too.

These things happen -- a description of the point of view, all to often found in hospitals, that a certain level of harm that occurs to patients is "just the way things are."

We saved one person's life -- one of series of posts on our effort to eliminate (yes, eliminate) central line infections.

Teamwork wins against VAP -- one of a similar series on our efforts to eliminate ventilator associated pneumonia.

Aspirations for BIDMC and BID~Needham -- the story of how our Boards established an overall goal for these two hospitals of eliminating preventable harm over the next four years.

Source material -- Detailed background on the material behind the Boards' votes.

Next stage of transparency -- A link to our website documenting our progress, quarter by quarter, towards the goal to eliminate preventable harm.

The message you hope never to send -- How we used transparency to learn from one of the most egregious errors that can occur at a hospital, a wrong-side surgery.

Sisters Against Ovarian Cancer

A note from a colleague:

Hi Paul,

I went to the most amazing event on Saturday, September 6, at the Stone Zoo. The Sisters Against Ovarian Cancer Walk is the brainchild of a few women who are rallying around their friend, Marie Spinale, who is battling Ovarian Cancer. I met Marie early in 2008. She had participated in the Avon Breast Cancer Walk the year before and wanted to do something similar for her hospital that would ultimately help the type of cancer she is battling. She is one of the bravest women I have met and has the most optimistic outlook on life, despite the fact that her cancer keeps coming back. Today, Monday, she actually started a new clinical trial which she is so excited about (please see her email to me below).

But on to the walk..they had 170 walkers - 150 pre-registered individuals and approximately 40 walk-ons (some registered walkers didn't show up). They raised $30,000 on walk day and more money still needs to be collected. Earlier this year, they held a fundraising event that raised about $14,000 through raffles and ticket sales - I hear it was a party not to be missed. The money they raise will support the Ovarian Cancer Research Fund at BIDMC under the direction of Stephen Cannistra, M.D.

This is a link the website they created!

---

Hi,

I am so happy you were able to be there on Saturday. We were all very excited and pleased with the turnout. I'm sorry I didn't get to spend time with you but I heard you met quite a few people. I never realized how many wonderful people I have in my life until I got sick. Something good comes out of everything.

I was at the hospital today, but I decided to come into work. I got selected to be on the new pills for the clinical trial so I am very happy about that. I didn't want to go home waiting for side effects to kick in so I thought I'd be better off staying busy. I think I'm going to do great!

We raised $30,000 on Saturday! That is not counting what we already turned in and what might trickle in later. I couldn't be happier!!! Thank you for all of your help.

Love,
Marie

(reprinted with her permission)

In memoriam

I take a break today to honor the memory of those killed on September 11 seven years ago.  Let us remember, too that not only Americans were victims, but also people from over two dozen other countries in the world, reflective of the melting pot that America still represents.

Don't tell Woody Allen

Can you believe this? Someone actually did a study of the personality traits of bloggers? Thanks to GruntDoc for the heads up. He picked it up from this blog.

Here's an abstract of the actual study. A quote:

The results of two studies indicate that people who are high in openness to new experience and high in neuroticism are likely to be bloggers. Additionally, the neuroticism relationship was moderated by gender indicating that women who are high in neuroticism are more likely to be bloggers as compared to those low in neuroticism whereas there was no difference for men. These results indicate that personality factors impact the likelihood of being a blogger and have implications for understanding who blogs.

I dare not comment on the accuracy of this analysis with regard to this author. It would be a HIPAA violation.

456 sell-outs at Fenway Park

This really cute kid just above is Kevin Pierro, a 5 year-old Red Sox fan from Norfolk, MA who was born at Beth Israel Deaconess Medical Center on May 15, 2003. The significance of that day is that it was when the record Red Sox 456 sold-out game streak began. Kevin was invited to throw out the ceremonial first pitch at last night's game.

The four other kids shown above Kevin were also born that day at BIDMC and are shown ready to yell "Play ball!" at the start of the game. From the left, they are Christian Trodden, Teddy English, Michael Gunning, and Abigail Weiss. (The photos were taken by Will Nunnally from the Red Sox.)

May I point out, too, that BIDMC became the official hospital of the Red Sox in April, 2003. Query to John Henry, Tom Werner, and Larry Lucchino (shown above): Any connection?

Visitors in the cafeteria

Well, we had heard that all of the 200+ SEIU organizers and other staff reported to be based in Massachusetts were busy working on the Presidential and Congressional campaigns or were otherwise involved in various union matters, but there were a few around last week. They dropped by our hospital to distribute leaflets, and in so doing violated two sets of our rules.

As I have made clear here many times (like here and here), we respect the rights of our employees, including their right to discuss whether or not they wish to be represented by a union. But BIDMC, like many other large organizations with lots of public access, has a solicitation and distribution policy which clearly spells out that non-employees (whether from a union, a company, or anywhere else) may not hand out literature or material on hospital property at any time.

After our folks confirmed that the people distributing the literature were not BIDMC employees, we politely asked them to leave. One group readily agreed and dispersed to a public area where they continued to speak with people. A second group chose to ignore our admonition that they were trespassing and chose to remain until sworn members of the BIDMC Police escorted them out of the building.

The union members violated another BIDMC policy by taking pictures in areas where patients were eating lunch, exposing them to the possible violation of their rights to privacy.

Now, shortly after all of this, the union issued a press release entitled, Beth Israel Deaconess Medical Center Confronts Union Supporters with Armed Security Officers. The subtitle was, Contrary to BIDMC’s CEO’s stated commitment to transparency and openness, administration uses heavy handed tactic to end conversations about unionization.

So, now we get to see another tactic from the corporate campaign playbook in action. Create a setting that requires a response by the security forces of the institution you are attacking in a corporate campaign, by knowingly violating sensible rules or regulations. Use hyberbole and misinformation to give the impression that there is intimidation or some violation of workers' rights.

By the way, it doesn't matter if you happen to get media coverage on the story at that time. In fact, you might not even care if the story is not written, because a good reporter will always give both sides. It is more useful to recycle it later in your own publications to prove a "record" of intimidation. Perhaps later, too, it will even be fed to and used by some of those politicians you supported when there is a hearing on the legislation that would take away workers' rights to a secret ballot election.

But not in Basel

Monique Doyle Spencer's article about the use of henna to counteract the hand-foot syndrome that is a side effect of the Xeloda cancer drug continues to make the rounds around the world. Here it is in the Khaleej Times from the United Arab Emirates. And here it is on a blog that I think emanates from Estonia.

But it hasn't seemed to make any impression in Basel.

Thanks, Tom!

A very successful ride yesterday organized by cancer survivor Tom DesFosses to raise funds for BIDMC's cancer programs. It was beautiful weather, following a tropical storm Saturday night, and a great family and community event. The picture shows Erica pacing part of the group at the start.

Residency work hours

There is a good story by Liz Kowalczyk in today's Boston Globe about the difficulty we have had in enforcing the work hours rules for surgery residents. As in other areas of our hospital management, we have tried to be open and above-board about areas of deficiency and how we attempt to remediate those. So when the reporter called us on this issue, we disclosed all of our information, even though the Accreditation Council for Graduate Medical Education does not even release names of programs that are under review.

The fact that "9 percent of the total number of programs, including 19 surgery programs" around the country have faced similar programs is not an excuse for our failure to meet this national standard, and we believe we have taken actions now that will ensure our compliance.

Perhaps those of you involved in running residency programs who are reading this would like to comment on your successes and failures in meeting the ACGME standards. Perhaps, too, some residents out there would like to comment on how it feels from your side.

Rara avis

Speaking of birds (below), a friend of mine named Alvin Powell has written a book that is worth your consideration. Here's the story from the press release announcing the book, which is available on Amazon. By the way -- to keep this related to this blog -- I am told that the final bird got a fair amount of health care right at the end of its life!

A new book chronicling the decline and likely extinction of an American forest bird draws lessons for future conservation efforts as the world faces a growing extinction crisis.

The Race to Save the World’s Rarest Bird: The Discovery and Death of the Po‘ouli is a fast-paced scientific adventure story of heartbreaking importance. Part Shakespearean tragedy, part case study, it details the struggle of biologists to save a small, black-masked bird in treacherous, soaking forests thousands of feet up the steep sides of Maui’s Haleakala volcano.

The bird, called a po‘ouli, a Hawaiian name meaning "black-faced," was discovered in 1973 by college students studying the volcano’s dense, unexplored rain forest. In the mid-1990s, with just three individuals remaining, it became the world’s rarest bird. The last known of these quiet, inquisitive birds died in a breeding center in 2004.

"We’re in the midst of a global extinction crisis," said author Alvin Powell. "Thousands of species are declining and in danger. If we can learn from history and understand why we failed to save this species, we have a better chance to succeed with others."

Powell is a veteran journalist and senior science writer at Harvard University. In researching the story, Powell visited the bird’s forest home with a team of biologists and interviewed dozens of people who crossed paths with it, including those who discovered it, tried to save it, and were there when it drew its final breath.

Though the po‘ouli (pronounced poh-oh-OO-lee) was declared endangered soon after it was discovered, years went by before it was the focus of meaningful conservation efforts. During those years, the bird was beset by introduced rats, pigs, and disease-bearing mosquitoes. By the early 1990s, scientists realized the bird was on the brink of extinction and stepped up efforts to study and conserve the species. They fenced in miles of tangled, inaccessible forest, a task some thought impossible. They poisoned invasive rats and trapped the birds in hopes of encouraging the last few to breed. The last known po‘ouli died in captivity awaiting a mate.

"Biologists used all the tools available to them but not in time," Powell said. "It was first too little – for years nothing was done – and then too late. The most important lesson to draw from the po‘ouli’s story is to act now. Species that are similarly endangered around the world can’t wait for us to get around to taking action. The forces squeezing these species out of existence – invasive plants and animals, loss of habitat, environmental change – are not taking a break while we think about what to do and whether to do it."

The Race to Save the World’s Rarest Bird also examines the debate about captive breeding as a conservation tool and highlights the successes and failures of the Endangered Species Act, one of the most significant conservation laws in U.S. history. The fate of hundreds of species rests on the act’s successful implementation.

Single rooms

An August 27 JAMA article by Toronto doctors Michael Detsky and Edward Etchells is entitled, "Single-Patient Rooms for Safe Patient-Centered Hospitals." Extract here. (As usual, JAMA does not allow free access to public policy articles. When will they start to do that, I wonder?)

Here's the summary:

Clinicians should advocate for single-patient rooms in any new hospital construction, expansion, renovation, or redesign. Single-patient rooms are permanent physical features that potentially could improve safety and patient satisfaction without the need for ongoing staff training, audits, or reminders. Money spent on capital costs to improve patient care may be more efficient than money spent on changing hospital culture and the behavior and attitude of health professionals. It is not necessary to wait 50 years for existing hospital structures to deteriorate before the full potential of single-patient rooms can be realized.

I do not disagree about the attributes of single-patient rooms, in terms of infection control, patient satisfaction, and optimal use of rooms for a diverse mix of patients. Also, they are strongly recommended in guidelines of the American Institute of Architects. I believe they will result in higher capital costs (and therefore higher annual carrying costs), but I do not think it likely that they will generate savings or efficiencies commensurate with those capital costs. In other words, they may not have a good rate of return, in strict financial terms, but they clearly will be the standard for new construction and renovations.

But, I think that Doctors Detsky and Etchells are off-base in their conclusion about single-patient rooms obviating the need for improved staff performance in the quality arena. The idea that increased capital investment in this arena will result in a noticeable and sustained improvement in reducing harm in hospitals -- absent ongoing and dedicated training, measurement, audits, and reminders -- seems to me to be counterintuitive.

I am not sure why the authors felt they needed to reach so far with their conclusion. It ends up sounding like they really feel that the "behavior and attitude of health professionals" is perfectly fine and that it has been the existence of multi-patient rooms that has been the source of safety and patient satisfaction problems in those rooms. This type of conclusion does harm to the quality and safety movement in that it could be used as an excuse that would distract people from investing time and effort in process improvements that are almost universally acknowledged as being long overdue.

Good biking weather predicted for Sunday

Please don't forget Tom's fundraising bike ride on Sunday, September 7.

Too cynical?

Political prognostication is a risky business, but here is one that might be elegant and accurate. As the country prepares for a new President, a colleague of mine offered the following analysis as to why neither Barack Obama nor John McCain will be successful in obtaining legislation that would reduce the nation's expenditures on health care:

One person's costs are another person's income.

Monique 1: Roche 78,000. She wins!

While we patiently await a substantive response from Roche Pharmaceuticals on this topic, thanks to Monique Doyle Spencer, the word is spreading about a simple antidote to the painful and disabling hand-foot syndrome side-effect of the company's important cancer drug, Xeloda. Look at this example, from someone named Shin. An excerpt:

I tried the henna remedy for chemo-induced Hand-Foot Syndrome last night and it worked!

Granted, my feet had already begun healing, so there were no more open bleeding or pus-oozing wounds, but the skin was still very thin, raw, and tender (and peeling off in small patches), that I was still having some trouble walking.

I'm scheduled to start a new chemo regimen in two days, so I was worried that my feet weren't ready to take the new onslaught of chemo and Hand-Foot Syndrome, but after just one night with the natural henna remedy, my feet feel ready to take it on!

So Monique, with no financial resources and just the power of an op-ed article and her own blog, seems to have had more influence in spreading the word about this antidote to a painful and disabling side-effect than Roche Pharmaceuticals. For fun, do a Google search on any combination of Xeloda, henna, hand-foot syndrome, and see for yourself. After the original journal article by some scientists from Turkey, most references to this topic derive from Monique's initiative.

I am trying to be considerate in how I write this, because I know that pharmaceutical companies do marvelous things in terms of drug development and availability, and I also know that they are subject to all kinds of regulatory constraints and legal concerns. But is there anybody at Roche among its 78,000 employees who cares about this topic as much as this cancer patient from Boston?

Which hospital is better?

Many of us live in cities with more than one hospital. And, in most cities, one hospital is considered better than the other(s). Why?

An article by Edward Dolnick in the New York Times gives us a hint of how we “know” that one place is better than another. Because we expect it to be.

Huh? Well, as con artists know, you can take advantage of people’s expectations. Dolnick summarizes a test in which 32 volunteers were asked to sample strawberry yogurt, in the dark. Then the subjects were given chocolate yogurt. “Nineteen of the 32 subjects praised the strawberry flavor.”

When it comes to hospitals, we can measure “better” according to a variety of metrics, ranging from decor and food to the friendliness of the staff to the clinical outcomes achieved for different kinds of diseases. I don’t know about you, but the one I like the best is the likelihood that I will not be harmed during my time in the hospital. After all, hospitals are one of the leading public health hazards in America, and when I go to one, I would like to leave feeling better than when I arrived.

But, you may have a different set of criteria. That’s OK. Each of us knows what is really important to us, right? But I am guessing that most of us fundamentally care about something related to the actual quality of medical care offered.

Here’s a test for those of you who live in the Boston area (or New York or London or New Delhi or wherever). Which is the best hospital according to the criteria that you hold dear? Write down that answer.

Now, what evidence do you have for your conclusion? If you are basing your choice on clinical outcomes, do you have statistically valid data? Without knowing what metrics you have chosen, I will tell you categorically that you do not. There may be some publicly available data about some clinical outcomes and medical processes, but I will assert that it is many months or years out of date, and not necessarily reflecting the service you will get. In short, that data currently gives an impression of precision that is not valid.

(Yes, there are differences in culture and approach in the various hospitals, and those might make you feel more or less comfortable and happy, but do you mind if we focus right now on the measurable outcomes of clinical care?)

The truth is probably that you think your chosen hospital is the best because your primary care doctor, whom you trust, referred you there. But how does your doctor know which is the best? Well, you say, “He is an expert.”

To which Dolnick notes, “Experts make the best victims because they jump to unwarranted conclusions.”

As mentioned below, Brent James from Intermountain Health makes a persuasive case that the variation in medical care from region to region is not based on scientific evidence, but is a function of “medical mythology," lessons of habit passed down from one generation of doctors to the next. I haven’t asked him, but I would guess that he would also support my proposition that referring doctors often make medical judgments for their patients based on unsupported expectations about the relative efficacy of treatment between hospitals. (I put aside issues of personal relationships and financial integration and gain for purposes of this discussion, but we know those are important determinants of referral patterns.)

Now, before you fret too much about what I have just said and start to worry that you are not being sent to the “best” place, I will make another categorical assertion. I will confidently state that, with very few exceptions, you will get comparable care in most if not all of the hospitals in your home city.

Since “the best” is an elusive goal, on what should you focus? Wherever you go, the most important thing you can do is to bring along a trusted family member or friend to be your advocate, to help you keep track of what is going on, ask pertinent questions, and to help make sure that the plan of care is carried out properly. (Read Nick Jacobs’ book for more advice on this front.)

Another thing you might want to consider (he says, in a totally self-serving manner!) is whether the hospital you are visiting has made an institutional commitment to quality and safety improvement and reduction of harm -- and whether it is willing to hold itself accountable by publishing current clinical statistics as to its progress in meeting audacious goals in that domain. A hospital that is aggressive in setting quality and safety expectations; is modest in how much it knows and how much it needs to learn; and shares it successes and failures with others throughout the medical world, should give you some satisfaction that they are thinking about you more than about themselves.