Even the meal tray

As far as I'm concerned, you can take all those posted quality metrics and throw them out the window when you get a letter like this one that I received from a patient:

BIDMC is a special place. The nursing care deflates your stress about being in the hospital. The doctor's talent makes you believe you have the best possible care. The atmosphere makes you feel that people like their jobs and feel invested in them, so you feel that everybody is paying attention, whether they are cleaners, food service, transport, department heads, trustees.

I especially noticed the employees' investment in their jobs. (NURSE: "Doctor, I noticed you are testing Ms. X for TB. If we believe she might have TB, should we institute those protocols now?" TRANSPORT: "The nurses are really busy. I'll reconnect your oxygen so you can go back to bed and I'll tell them that I did." NURSE: Let's not wait for the bed to be changed. I want it to be dry for you when you have these fevers." She changed the bed and me three times that night.)

Symbol of cooperation regardless of rank or function: Nobody left my room without taking my meal tray with them.

Follow-up from Sunday

Once again, for my out-of-town readers, a link to today's Boston Globe story following up on the one published on Sunday.

More from Chicago

Here are some pictures of attendees at the Joint Commission event mentioned below. I think these folks are from Indiana, Wisconsin, New York, New Jersey, and Florida. Over 400 people attended. You should next year!

At the Joint Commission

I'm currently in Chicago, having been invited to speak at the Joint Commission's annual conference on quality and safety, "Safety and Quality Solutions: Driving Sustained Improvements." My talk is about to follow that given by Mark Chassin, President of the Joint Commission (shown in picture). As I sit here waiting, I am summarizing what he is saying for those of you not in attendance. (Apologies in advance if I do not do a completely thorough or accurate job. Please excuse typographical errors, too, as it is tricky to listen, synthesize, and type at the same time.)

Mark described the environment within which the Joint Commission finds itself in the quality field and what kind of improvements are needed. "Despite our best efforts, we still have serious quality and safety problems in all of the domains we try to work in." In addition to the usual areas, there is a particular new focus on overuse, an essential problem to solve if the issue of affordability in the health care system is to be addressed.

But there are models of success, which serve as learning opportunities. Core measures have improved since their introduction in 2002. For example, the average for compliance with acute MI metrics (e.g., aspirin on arrival) is over 70%, with about 95 percent of hospitals having performance over 90% in two key metrics. So it is possible to have success in carrying out important metrics that lead to improved outcomes.

But the value of other metrics is problematic, in terms of achieving actual clinical results. For some, the measure we use doesn't really assess the process that we want to assess (e.g., smoking cessation counseling advice.) For some, the process that is assessed is far removed from the outcome we want to achieve (e.g., oxygenation of left ventricular function assessment). For some, the measure is susceptible to workarounds, more than encouraging the process we want have happen (e.g., heart failure discharge instructions). For some, measures lead to adverse effects (e.g., 4-6 hour timing of the first dose of antibiotic for patients with pneumonia in the face of an uncertain diagnosis).

"We should start withdrawing measures like this that are not excellent," that have these problems. But Medicare needs to do the same thing. It can't just be the Joint Commission's decision.

But let's look beyond the particular measures and find out "where's the beef" in real improvement so we can focus on the most important things. Unfortunately, there is a scarcity of evidence as to what those are, both in the hospital setting and other settings. As health care assimilates new drugs, devices, procedures, and equipment, "the goal posts keep moving" because of the increased complexity of the care system. And, in a time of scarce resources, we need to be cognizant that the Joint Commission itself influences how those resources of used. If we don't have the highest confidence that a measure is excellent, we shouldn't ask you do to it. "We have an obligation to maximize the health benefits of our measures and standards."

There has been a balance between the roles of the government and the private sector in overseeing quality in health care. Two related forces are affecting that balance: (1) bad things are happening even in Joint Commission accredited hospitals, and (2) routine safety process break down routinely and visibly. "Our public stakeholders are losing patient with us." Unless we get better at things, this will lead to a change in the balance between the government and private sector roles.

The expectation of our public stakeholders is that major adverse events, like wrong side surgeries, should diminish in frequency and be eliminated. If that does not happen, we should expect legislators to pass new laws. The nature of the legislative process is that new laws can often be heavy handed and not recognize the subtleties of these issues. Unfortunately, laws are not the best way to achieve the right results, but it is easy to see why they are passed.

So, how do we got a lot better quickly and document that improvement, to help maintain the appropriate balance between governmental supervision and private sector responsibilities? The first major barrier to this is lack of capacity in the health care system to execute robust process improvement. Secondly, we have not truly adopted a true safety culture.

We need to learn from other industries -- high reliability organizations -- and apply those lessons in the health care system. Those organizations have a commonality in their methods of achieving their excellent results. (My comment: See similar points by Steven Spear.) Mark quoted Karl Weick: "Safety is a dynamic non-event." Mark then went into details on this point, which I will not summarize, as regular readers have seen lots of this topic on this blog.

The Joint Commission wants to work with health care institutions to help them adopt these methods. But, he is also doing this to achieve internal improvements within the Joint Commission. He wants to improve its own customer service, to reduce costs, and to be more effective in carrying out its mission.

On the issue of safety culture, Mark noted that there are three imperatives of a safety culture: trust, improve, and report. On the trust point, the aim is not a blame-free culture, in that there is a difference between small errors (for learning) and egregious errors (for discipline, equitably applied). My note, please review this post for more on this topic.

Learning begins with reporting, especially near misses. "They are free lessons", an opportunity to fix a system before it breaks. A bureaucratic culture celebrates near misses rather than learning from them. High performance organizations react to near misses exactly the same way you would react to an adverse event.

Finally, on the Joint Commission itself, Mark cited improvements over the past five years, but firmly said, "We need to continue the aggressive improvement of our own processes." "We must increase confidence by pruning the measures that don't help, by focusing on and enhancing the ones that do," and by helping to provide useful process improvement tools to the the industry.

Seasonal trauma

News to me. Our chief of surgery notes an interesting "blip" in a certain kind of accidents during this fall season: Broken feet from people falling off a ladder while cleaning out the leaves from their clogged roof gutters. He recently moved to Boston from the Midwest and said it was common there, too.

Have others noticed this?

Time to brag a little

Excerpts from BIDMC and Blue Cross Blue Shield of MA press releases today. (More available here.)

BIDMC TOPS BLUE CROSS BLUE SHIELD MASSACHUSETTS RANKINGS
FOR HEALTH CARE QUALITY AND COST EFFICIENCY

BOSTON – Beth Israel Deaconess Medical Center (BIDMC) topped the list among Massachusetts hospitals in Blue Cross Blue Shield of Massachusetts’ (BCBSMA) Blue Distinction® designation of hospitals making a difference in health care outcomes and value.

BIDMC won the designation for its efforts in Bariatric Surgery, Cardiac Care, Complex and Rare Cancers, and Bone Marrow, Stem Cell and/or Allogeneiac Transplants. The medical center was among 16 Massachusetts hospitals designated by the state’s largest health insurer in a process that involved collaborating with employer groups, providers, and specialty medical societies.

“BIDMC has focused intensively on providing high quality, well coordinated care in these specialized service lines, and it is gratifying to see these efforts manifesting as better outcomes for our patients,” said Kenneth Sands, MD, senior vice president of health care quality.

Blue Distinction is a nationwide program that recognizes medical facilities that meet a national set of objective, evidence-based thresholds for clinical quality developed in collaboration with expert clinicians and leading medical organizations. This designation provides consumers with a credible, easily identifiable means of selecting facilities that best meet their individual specialty care needs.

“BCBSMA is committed to delivering on our promise of high quality, more affordable health care by working to eliminate the overuse, under use, and misuse of health care services. Blue Distinction is another way we demonstrate this commitment,” said BCBSMA Chief Physician Executive John Fallon, MD.

“Based on clinical data from hospitals and registries, research indicates that Blue Distinction Centers demonstrate better, more consistent overall outcome with fewer post-procedure complications and lower mortality rates,” Fallon said.

The analysis includes 41,333 patients treated within a facility setting, 22,322 of which were treated at BDC-designated facilities and 19,011 at other facilities. The analysis is based on cardiac events and procedures occurring during calendar year 2006, with follow-up in 2007.

BCBSMA launched Blue Distinction in 2007 with the Blue Distinction Centers for Cardiac Care. In 2008, the health insurer launched three Blue Distinction programs: Transplants, Complex and Rare Cancers and Bariatric Surgery. Due to the high level of success that BDCs have seen with regard to quality outcomes and value, Blue Cross and Blue Shield companies are in the process of expanding the program to additional specialty areas.

NAME				CITY				DESIGNATED FOR
Bay State Medical Center				Springfield				Bariatric Surgery, Cardiac Care
Beth Israel Deaconess Medical Center				Boston				Bariatric Surgery, Cardiac Care, Complex and Rare Cancers, Transplants-Bone Marrow, Stem Cell and/or Allogeneiac
Boston Medical Center				Boston				Bariatric Surgery, Cardiac Care
Brigham & Women’s Hospital				Boston				Bariatric Surgery, Cardiac Care
Cape Cod Hospital				Hyannis				Cardiac Care
Caritas St. Elizabeth’s Hospital				Boston				Cardiac Care
Dana Farber-Brigham & Women’s Cancer Center				Boston				Complex and Rare Cancers
Faulkner Hospital				Jamaica Plain				Bariatric Surgery
Lahey Clinic				Burlington				Bariatric Surgery, Cardiac Care, Complex and Rare Cancers
Lawrence Memorial Hospital				Medford				Bariatric Surgery
Massachusetts General Hospital				Boston				Bariatric Surgery, Cardiac Care
Massachusetts General Hospital Cancer Center				Boston				Complex and Rare Cancers
Mount Auburn Hospital				Cambridge				Cardiac Care
Newton –Wellesley Hospital				Newton				Bariatric Surgery
North Shore Medical Center				Salem				Cardiac Care
Tufts Medical Center				Boston				Cardiac Care, Transplants-Liver
Winchester Hospital				Winchester				Bariatric Surgery

And some more union spending

Speaking of union spending, there apparently will be a TV campaign for the so-called "Employee Free Choice Act" (the one that would eliminate secret ballot elections.) An ad from this campaign, which reportedly will be on CNN and other sources, can be seen here and is explained in more detail here.

Question for Washington insiders and political reporters: Did the Obama team ask the unions to try to generate more support for this bill, or is the campaign an attempt to keep pressure on a new administration that is busy with many important issues to make the bill a legislative priority?

SEIU goes Googling

It is impressive and instructive to note the many ways the SEIU has chosen to spend money on advertising about BIDMC. I mentioned before the hundreds of thousands of dollars spent on radio, television, mobile billboards, and bus stop ads. The latest purchase, apparently to reach the social media audience, is an ad that appears when you do a Google search on BIDMC, Beth Israel Deaconess, and who knows how many other topics related to BIDMC.

Try it. In the upper right hand corner of the search results page, you will see this ad:

Eye On BIDMC
High costs, patient problems
What does Beth Israel have to hide?
www.eyeonbi.org

For those of you who own stock in Google, I hope you see an easy way to enhance your company's revenues. Just do a search for BIDMC and click through on the SEIU ad!

For the record, if you really want to know the many things that BIDMC does NOT hide, including one the most open presentation of clinical outcomes in the country, follow the Google search link to our website instead and click through to Quality and Safety.

Lessons on Governance

I recently heard a thoughtful presentation by my colleague Bob DeVore, from the Risk Management Foundation, about the role of governing bodies. He borrowed the slide shown to the left from a book called Governance as Leadership: Reframing the Work of Nonprofit Boards, by Chait, Ryan and Taylor.

The idea is that most boards engage in oversight of management, especially on financial matters. Some go the next step and become involved in strategic planning. But, the more sophisticated boards engage in what the authors call "generative work." They note that "generative thinking produces a sense of what knowledge, information, and data mean," and that this "demands a fusion of thinking, not a division of labor."

I found this to be a useful and descriptive framework. We seek an environment in which lay board members bring their extensive knowledge, experience, and judgment to share with management on the wide range of issues facing our hospitals. While maintaining the distinction between those who govern and those who manage, the partnership that emerges between the two groups is a vibrant and self-renewing source of ideas and approaches. These strengthen our ability to carry out the public service mission of these institutions.

As you read the post below on the involvement of our Boards in safety and quality, I think you can get a sense that they have indeed moved into this category of lay leadership at both BIDMC and BID~Needham.

Spotlight shining in MA

For my out-of-town readers, you'll want to check out this story in the Boston Globe that is likely to be the talk of the town here.

Message to prospective BIDMC interns

A note from one of our senior faculty members in the department of surgery:

Paul,

As I am sure you are aware, we are in the process of recruiting the PGY-I class for 2009. Many of the candidates schedule their interviews so that they can visit all three Boston hospitals on their “swing through town”. During one interview with a spectacular candidate -- AOA, top of the class, and solid research experience -- was the following question: “BI has gotten a lot of bad press lately, could you tell me about it?”

At first she seemed surprised when the reply was, "I would be delighted." She was told that, I as an individual practitioner, and we as a health care organization realize that, as long as medicine is practiced by humans on humans, there will always be the likelihood for errors. She was told that although we all have a zero tolerance policy for errors, when they occur our obligation to the patient, and to the health care organization, is to learn all we can to decrease the likelihood the same error would be repeated. I then gave her several examples from my own practice over the years.

She admitted that the first step in understanding the factors leading up to an error was the admission of same. She then said that she understood the transparency focus. We left this portion of the interview with the following question: “Do you think errors are occurring in other hospitals, perhaps your own, and perhaps even other Boston hospitals? Perhaps they have chosen a different path to resolution?” The question did not require an answer.

I thought you may find the discussion interesting. Thanks.

To which I add the following open letter:

Dear prospective interns and residents,

Please consider coming to our hospital if you would like to join in our quality improvement adventure. We promise a blame-free environment in which all participants (including trainees) are treated respectfully and as part of a team devoted to eliminating preventable medical errors. For reference, please see the post immediately below, as well as this one and this one.

In short, we teach the science of medical care delivery here, as well as the science of disease. We believe that this has become an essential component of graduate medical education and will serve you well in your career. We hope you agree and will find BIDMC an attractive opportunity for the next phase of your training.

No retreat by the Boards

About a year ago, the Boards of BIDMC and BID~Needham met in an educational and planning retreat to decide on their priorities for both hospitals, one a large academic medical center, the other a small community hospital. The result was a four-year commitment to eliminate preventable harm and to dramatically improve patient satisfaction in the two hospitals.

Today, the governing bodies again met to reaffirm these goals, to learn more about how to achieve them, and to plan their agendas for the coming year. They were assisted by some special guests.

First was Steven Spear, Senior Fellow at both the Institute for Healthcare Improvement and the MIT Engineering Systems Division. I have written before about some of Steven's ideas and research. Here, too, he discussed the manner in which the best complex organizations deal with the problem of how to obtain process improvement. He noted that the first step in improving a complex system is being transparent about what is going wrong because "we need to know it's a problem we need to solve." As opposed to a transactional mindset, in which the emphasis is on making decisions because you assume you know enough to make the right choice, he emphasized the value of a discovery mindset. Under this approach, you have to have humility that an educated guess is not likely to be right, but that it provides an opportunity for learning. You also need to be sufficiently optimistic that you will achieve improvement over time, aided by iterative discovery. In short, the key is "humble optimism."

Spear emphasized that one of the jobs of a governing board of a hospital committed to transparency is to stand by the medical and clinical leadership and staff during the inevitable periods in which there will be adverse publicity resulting from this openness. "Watch their back," he advised.

The next session consisted of a panel comprising doctors and nurses from the two hospitals, focusing on their perspective on the progress towards quality and safety improvement and receiving their advice for activities by the Boards that could support these objectives. They were unanimous in their support for the importance of transparency as a key part of process improvement.

Following break-out sessions in which the Boards and their respective committees planned their agendas for the coming six months, they heard from Lee Carter, former Chair of the Board of Cincinnati Children's Hospital, a national leader in hospital quality and safety. He mentioned the key elements of board involvement in the quality agenda:

-- Pay attention and understand what people on the front line are doing so that they know they are appreciated. Improving quality is very difficult and takes extra work. "You need to let them know that you appreciate them."
-- Encourage transparency. "It is powerful and absolutely necessary. Until you identify what you need to improve you never will improve."
-- Establish and maintain a culture of trust, because without it, you cannot obtain transparency.
-- Measure progress, rigorously and accurately. Quoting IHI's Jim Conway, Lee noted, "Some is not a number; soon is not a time." Quantifiable objectives, with specific deadlines, are key, as is measuring progress towards both the objectives and the timeliness of achieving them.

He left the board members with the following lessons from Cincinnati: (1) We are never as good at something as we think we are; (2) it is very hard work to make transformational, as opposed to incremental, change; (3) we always have slower progress than we think we will, and the board needs to understand that and be supportive; (4) it takes persistence, and the role of the board is to support the attempt and be cheerleaders for the transformation. Confirming Spear, he stated that the board needs to let the clinical and administrative leadership know that "I've got your back" during periods of public scrutiny and the adverse publicity that often accompanies transparency. Finally, says Lee, (5), "After all this, it works" and will save lives and will result in better patient care overall.

About 80 lay leaders left the 12-hour session with a renewed sense of purpose and commitment, enthusiastic in their attempt to improve care not only at their hospitals, but also cognizant that they are partners in a national movement to do the same.

The geeks helped out, too!

And here is the computer screen referred to below, which acts in parallel with the time-out checklist to help insure compliance with the protocol. It was specially designed by our able IS team when they realized it would be helpful to this quality improvement effort. John Halamka, our chief "geekdoctor", wrote about an early version of this back in July; but then his folks worked with the clinician task force to modify and expand the concept to produce the screen you see before you. Things like this constantly remind me of the expertise of our IS folks and their enthusiastic willingness to dive in with other staff and help with clinical applications like this.

(Please ignore the space between the top and bottom halves, which does not exist on the actual computer screens. I couldn't quite put together the two images, but you get the idea. Click on either half to get a close-up view of the checklist items.)

Transparency works! Better than you can imagine.

I just saw clear evidence of the importance of transparency with regard to the reporting of important adverse events and medical errors. Bear with me through the details, but I will not keep you in suspense regarding the conclusion: The wide disclosure of a "never" event in a blame-free manner resulted in an intensity of focus and communal effort to solve an important systemic problem, resulting in redesign of clinical procedures, buy-in from hundreds of relevant staff people, and an audit system that will monitor the effectiveness of the new approach and leave open the possibility for ongoing improvement. If you ever needed a clear example of the power of transparency, here it is.

Back in early July, a patient experienced a wrong-side surgery in our hospital because the staff failed to carry out the required time-out. We disseminated the story of this event to all staff in the hospital. There was a full investigation of the matter, both internally and by the state DPH, and some immediate improvements were made in our procedures. But the more important work was being done by a Safety Culture Operational Task Force co-chaired by a nurse, a surgeon, and an anesthesiologist, and engaging almost two dozen other people from a variety of disciplines and positions in the hospital. Its charge and mission:

To implement and embed the Culture of Safety at the point of care in Perioperative Services, with an emphasis on teamwork and enhanced communications.

They adopted the following principles of patient safety:
-- Building in redundancies and cross checks
-- Standardization
-- Simplification
-- Forcing functions
-- Empowering the grassroots to lead change

They set forth a number of objectives, the first of which were to assure compliance with the time-out Universal Protocol; to script the time-out; and to design and oversee time-out audits. In so doing, they wanted to review and adopt not only the WHO Safety Checklist, but also to incorporate forthcoming 2009 Joint Commission regulations.

The result is pictured above. The document above is the check list that went into use today for all surgical procedures in our hospital. Not shown above is a corresponding computer screen version of the checklist that will be filled out in real time by the circulating nurse as the time out proceeds.

Responsibilities and the order of events is clearly laid out, even to the point of requiring that any radio in the OR is shut off during the time-out so as to avoid aural distraction. Note the forcing function at the very top of the form: No blades, needles, specula or bronchoscopes can be within reach of the surgeon until the full time-out is completed. Also, a system of "secret shoppers" has been set up to quietly audit compliance with these procedures. These are people from a variety of disciplines who normally work in the ORs who have been given this additional job responsibility.

This material was presented today in interdisciplinary grand rounds attended by about 300 people -- doctors, nurses, surgical techs. The response was enthusiastic, as everyone realized the vast improvement this would make in patient safety. And yet, even at this last moment, there were suggestions from the floor that made the process even better.

And then, I just attended a meeting of our Chiefs of Service and senior administrators. I suggested that this kind of effort and the responsiveness seen by our staff would not have happened if they had adopted the traditional approach to a "never" event -- i.e., a quiet discussion among the leadership with a directive to avoid the problem. The response from the three Task Force co-chairs was unanimous: It was because our leadership had the confidence in our staff to go public with this event that the improvement process took on life and energy.

One of our nurse managers today told me that the American Academy of Orthopaedic Surgeons reports that in a 35-year career, an orthopaedic surgeon has a 1 in 4 chance of performing a wrong-side surgery. Three years ago, people in our hospital might have said, "These things happen." We have now learned that they only happen because we let them happen. We let them happen because of our own silence and fear.

No longer.

What did you say?

Speaking of ethnic and cultural diversity, but this time focusing on patients, I thought you might be interested to see the difference in the distribution of languages served by our staff interpreters between 2001 and 2008. Note, for example, the reduced percentage of Russian-speaking patients and the increase in Spanish-speaking patients. Anyone want to offer theories about why these or other changes have happened? Is this just random variation, or does it reflect some other cause during this eight-year period?

The "other" category also shows some interesting changes. See below.

Did you understand me?

Getting into greater detail from the charts in the post above, here is the breakdown in the "other" language groups, comparing 2001 (on top) and 2008. Notice the relatively large increase in Thai speakers and the decline in Farsi speakers. Again, I welcome your theories for why the relative percentages of the groups might have changed.

East comes West

I just finished speaking at a seminar at the China Senior Health Executive Program run by the Harvard School of Public Health. Attendees comprise officials from the national Ministry of Health, but also regional health officials from Beijing, Shanghai, Xin Jiang, and Guang Dong. There was tremendous interest in our approach to process improvement and transparency at BIDMC. The attendees have a full program, and we are happy to welcome them to Boston.

It's the economy

Several months ago, I wrote about what it is like to construct a budget for a hospital like ours. Well, all that careful planning goes out the window when the economy tanks the way we have seen in the last few months. See some examples of particularly hard-hit hospitals here and here and here.

From my first day at BIDMC almost seven years ago, I have held to a policy that the entire staff has a right to know about all these things, with current and accurate information. Here's the staff email that I sent out yesterday on this topic:

Dear BIDMC:

A few of you have written me or grabbed me in the hallways to ask about the effects of the current economic mess on our hospital. From stories we read in the newspapers and see on television, we now all recognize that this is the most serious economic downtown in many years. Our hospital is not immune to its effects. Here are the main impacts on BIDMC:

Just a few months ago, our Board of Directors approved a budget for the 2009 fiscal year that has a projected 2% operating margin (or about $18 million dollars). But it is already clear that it will be very difficult to meet that 2% target. And the problem with not meeting the target is that we have fewer dollars available for capital spending for the hospital. (This is because our operating margin is the main source of funds for investments in medical and research equipment, computers, building repairs and maintenance, and so on.) For those of you who keep track of these things, you will note that the FY '09 target this is below previous years, when we have earned between 3% and 4%. For example, our preliminary results for FY 08 are about $37 million. The main difference for the current year is our need to pay rent in our new research space at the Center for Life Sciences.

What will make achieving the 2% margin difficult? First, the state government has announced a cutback in Medicaid reimbursements to hospitals. This affects every hospital. We believe this will reduce our Medicaid payments by approximately $7 million.

Second, the income from our endowment will be lower because of the poor performance of the stock market. Also, the endowment itself has suffered a reduction in value, just like all stock and bond portfolios. Accounting rules require us to record a portion of that reduction as a loss on our income statement.

Third, we can expect that some companies who owe us money will start to pay their bills more slowly, and some people who have made charitable gift pledges to us will also be forced to slow down their payments, and some people who would have donated money to us will decide to hold off for a while until their own financial picture is clarified.

How can we deal with this? As you recognize, most of our spending is in the category of people and supplies associated with taking care of patients, and most of those patients continue to arrive regardless of the economy. So, for the sake of maintaining high quality patient care, we cannot cut back very much in those categories.

However, the new budget included a number of new positions in other categories and, of course, vacancies occur every week as people retire or leave their jobs for other reasons. Effective immediately, every new opening will be reviewed before it is posted to be filled. Eric Buehrens, our COO, and Steve Fischer, our CFO, will lead this process. We will distinguish between those needed for safe patient care, those needed to support volume growth, and those needed for other reasons.

We will closely examine requests for overtime work for existing staff as well. In some cases, those requests will decline if patient volumes decline. In other cases, those requests will increase if we choose to delay filling certain positions.

On supplies, we will bring the very successful multidisciplinary process that physicians and hospital managers have used in the OR Supply Committee to standardize supplies and streamline purchasing to other areas of the hospital – specifically to procedure areas across the hospital, where we use a lot of devices and supplies. The OR Supply Committee has shown us that we can save millions annually while improving safety and outcomes – we will do the same in procedural and other areas.

We will ask every manager in every department to exercise great care about discretionary expenses: travel, food, consulting, memberships, and the like. We don’t spend lavishly in these areas now, but we are asking everyone to ask themselves if these expenses are absolutely needed.

Finally, we will continue to run LEAN rapid improvement events and respond to BIDMC SPIRIT call-outs to look for ways to make enhancements in our processes. We have learned that these events and ideas not only improve the work environment, but also often result in financial savings.

We plan to watch the numbers very, very carefully. Steve Fischer will bring a monthly dashboard of revenue and cost variances to our Operations Council so that the Vice Presidents can solve problems early and aggressively when they appear. We will have the same discussion monthly with the Chiefs of Service. If we aren’t hitting targets for revenue and expenses, we will act quickly to correct the situation. In line with our policy of transparency in so many areas, we will keep you up to date, as well, so that all people working here will know how things are going.

You have probably read about layoffs in other hospitals in Massachusetts. A number of hospitals already find themselves in worse shape than us, and they have responded by reducing the number of staff. You have probably noticed that this is also true for many other types of businesses in the region. As of now, we do not think we will be forced to do that, and we will do our best to avoid that result. Many of us lived through the dark days of 2002, when I eliminated a number of jobs, and no one wants to repeat that experience.

So that’s the whole story. Please do your part to help us uncover opportunities for efficiency and savings – consistent with quality care for our patients and safety for our staff. Also, this is a good time to pay special attention to providing good service to patients and referring doctors. To the extent we maintain and improve service quality, we are more likely to see increases in the number of patients we see.

Thanks in advance for your cooperation and assistance as we all work through this difficult time together. As always, please feel free to contact me with ideas and suggestions.

Sincerely,

Paul

Paul F. Levy
President and CEO

United Nations, Longwood style

Every Monday morning, I welcome our new employees in their orientation session. It is always a pleasure to meet new folks and sense their enthusiasm at taking on a new job.

I have been struck by the diversity among those being hired. As one indicator of that, I want to provide you with the last names of a recent group. Take a gander at this worldwide assortment:

Agosta, Arroyo, Baronian, Barros, Barry, Beaton, Brown, Daniels, Doherty, Dominguez, El-Nazer, Falardeau, Fallon, Flynn, Ghosh, Gibson, Green, Hudson, Ingram, Jones, Kopcow, Laing, Lacy, Lee, Leonard, Lewis, Li, Mack, Mendles, Mercilus, Nadadur, Nagel, Nistal, Nugent, Ornego, Paruchuri, Perez, Perna, Phin, Pilo, Poelstra, Powell, Qiu, Quintero, Regis, Rick, Rivera, Salko, Schultz, Servis, Silver, Smith, Snyder, Sun, Tadini, Valdez, Valente, Wang, Watanabe, Watson, Watts, Xu, Yeroshalmi, Zipse.

One "game" I play at orientation is to ask people to raise their hands in response to the following consecutive questions: 1) Raise your hand (and keep it up) if you were not born in the United States; 2) raise your hand (and keep it up) if at least one of your parents was not born in the US; and then 3) raise your hand if at least one of your grandparents was not born in the US. By the end, 95 percent of the people in the room have a hand in the air. A marvelous statement about how the US remains a melting pot for the world!

Which is David? Which is Goliath?

I raised the question last week of whether the SEIU, in light of numerous critical issues facing the new President and the discomfort many people have in eliminating secret ballot elections in union campaigns, would do Mr. Obama the favor of compromising on this aspect of labor reform legislation. Well, the answer - -"No" -- is very clear in today's New York Times, in a story written by Steven Greenhouse, entitled "After push for Obama, unions seek new rules."

As this issue proceeds through Congress, the SEIU will portray itself as David in Goliath-like struggles to organize hospitals and businesses of all kinds. But, let's look at some clues that indicate otherwise. The Times story notes that the unions spent $450 million in the Presidential race to support Mr. Obama. (Please understand that this is not included in the $600+ million spent by the Obama campaign itself.) This level of spending is indicative of tremendous resources, replenished every month by union dues.

Here in Boston, well before SEIU has even started to organize workers in any particular hospital, it has spent hundreds of thousands of dollars on advertisements of all kinds. This is just the first hint of the marketing ability provided by the reported $20 million it has budgeted to organize hospitals.

That no single hospital or other firm can match this kind of spending should be clear to any observer. Neither can anyone match the many dozens of people SEIU has already hired and the hundreds of workers who will be brought in from other jurisdictions to help in an organizing campaign. So, as you read stories and ads over the coming months, think about who is really Goliath here, and who is really David.

Anyway, back to the legislation. It is clear that the strategy will not be to have the union legislation stand alone. Rather, it will be attached to another bill that has broad support. It will fly through the House of Representatives. Then, a group of Senators will face immense pressure as they attempt a filibuster. They will be supported by many, many business groups, non-profit organizations, and others who find the concept of ending elections to be anathema. But they will be portrayed as holding up progress on the other aspects of the bill. This should be dramatic politics indeed.