An excellent op-ed in today's Wall Street Journal by MIT President Susan Hockfield.
(Disclosure: I serve on the MIT Corporation.)
Tuesday, October 20, 2009
Sorrel King @ HCFA
Deb Wachenheim at Health Care for All reminds us that Sorrel King, a nationally-known patient safety advocate, will be speaking at HCFA at 1:00pm today. Sorrel has important things to say, and I urge you to hear her.
Who should tell your MD what to do?
In this Wall Street Journal op-ed, Norbert Gleicher suggests that expert panels won't improve health care because the the quality of the research on which they would base their physician practice guidelines is not reliable. Instead, he suggests that our system can self-correct when experts lead us astray. He asserts that we have a "well working free market of ideas in health care, where effective therapies can rise to the surface and win out."
I'm somewhat sympathetic to Dr. Gleicher's point about a government-imposed clinical review process, but he overstates the case about a current free market of ideas. Individual insurance companies and Medicare currently make payment decisions with regard to therapeutic judgments every day. How are they informed, and what are their sets of vested interests? Much of that remains hidden from public view.
Meanwhile, too, doctors and hospital practice what Brent James calls "regional medical mythology," patterns of care divorced from scientific evidence, based as much on the local supply of specialists and what they learned from their predecessors as any other factors.
Perhaps what Dr. Gleicher is trying to avoid is the replacement of this array of unscientific medicine with the establishment of a centralized panel of unscientific medicine. In essence, he is suggesting that it is worse for the federal government to get it wrong for the whole country at once than for the individual participants (payors, MDs, and hospitals) to get it wrong each in their own way.
Seriously, though, one can apply some analytical rigor in support of Dr. Gleicher's thesis. Just as a diversified investment portfolio does better over the long haul in terms of risk mitigation, so too might the country do better over time with a diverse set of views as to appropriate diagnostic tests and therapies.
I'm somewhat sympathetic to Dr. Gleicher's point about a government-imposed clinical review process, but he overstates the case about a current free market of ideas. Individual insurance companies and Medicare currently make payment decisions with regard to therapeutic judgments every day. How are they informed, and what are their sets of vested interests? Much of that remains hidden from public view.
Meanwhile, too, doctors and hospital practice what Brent James calls "regional medical mythology," patterns of care divorced from scientific evidence, based as much on the local supply of specialists and what they learned from their predecessors as any other factors.
Perhaps what Dr. Gleicher is trying to avoid is the replacement of this array of unscientific medicine with the establishment of a centralized panel of unscientific medicine. In essence, he is suggesting that it is worse for the federal government to get it wrong for the whole country at once than for the individual participants (payors, MDs, and hospitals) to get it wrong each in their own way.
Seriously, though, one can apply some analytical rigor in support of Dr. Gleicher's thesis. Just as a diversified investment portfolio does better over the long haul in terms of risk mitigation, so too might the country do better over time with a diverse set of views as to appropriate diagnostic tests and therapies.
Monday, October 19, 2009
Digitizing Directors
Shown here are my fellow panelists from a session today at the 2009 Corporate Governance Conference of the National Association of Corporate Directors in Washington, DC. Our session was entitled, "Transparency & Technology: Directorship in a Digital Age."Shown left to right are Moderator Jessica Lipnack, CEO of NetAge; Thomas Gensemer, Managing Partner of Blue State Digital, LLC; and G. Scott Greenberg, Director of Sahale Snacks, Inc., InSpa Corporation, and Calidora Skin Clinics, Inc., and Senior Partner at K&L Gates, LLP.
Jessica started us off with an electronic survey of the audience:
Does your Board uses websites for purposes of meeting management and board communication:
No: 54% Yes: 46%
Do you personally keep a blog?
No: 97% Yes: 3%
Do you read blogs as part of your Board work?
No: 68% Yes: 32%
Do you participate in Facebook, Twitter, or other social media sites?
No: 35% Yes: 65%
How would you place yourself in the "digital continuum" relative to your colleagues?
Novice: 17% Competent: 64% Out-in-front: 19%
Much of Scott's presentation dealt with the pervasive presence of digital media and with the tools available to boards for meeting preparation and management and board communication.
Thomas talked about the essential elements of a social media strategy: Timeliness; transparency; authenticity; and personalization of messages. As one of the brains behind the Obama internet campaign, he had a particularly vivid experience upon which to draw.
My topic was the value of transparency in building trust with customers and other constituencies. I drew on our experience at BIDMC and also the approach used by Salesforce.com.
Jessica ensured that our presentations would be short and focused, leading to an extensive and engaging question and answer period.
Cab, buddy?
Regular readers know that I have an obsessive interest in infrastructure, city services, and the like. Well, here's a taxi cab meter that I saw today while visiting Washington, DC. Look at the attributes. In addition to a very clear display of the fare, and credit card reader, it has a GPS map of the route you are traveling. You won't always see this if you are in DC. These are only available in Alexandria (VA) based cabs.
Don and Tom's marvelous adventure
In preparation for a day-long mini-course at the 21st Annual National Forum on Quality Improvement in Health Care in Orlando, Florida (December 6-9, 2009), Don Berwick and Tom Nolan at the Institute for HealthCare Improvement are asking for your input on how to design a low-cost, high-quality health care system for the future. To learn more, submit your ideas and stories, and engage in a conversation about health system transformation, click here.
Here's the initial compelling question on the site:
"In an average American community with 500,000 people, what three changes in the health care system (organizations, resources, personnel, etc.) would contribute most to simultaneously reducing the per capita costs of care and improving care outcomes and health status?"
Here's the initial compelling question on the site:
"In an average American community with 500,000 people, what three changes in the health care system (organizations, resources, personnel, etc.) would contribute most to simultaneously reducing the per capita costs of care and improving care outcomes and health status?"
Sunday, October 18, 2009
First Snow in Boston
View just taken of the back yard and the park behind our house. I know it has snowed earlier than this in Boston, but it has been a long time since I remember one this soon. There was a Columbus Day about 7 years ago, as I recall. And then one snow squall earlier in October in 1970. I remember both of those because I went out bike riding on a sunny morning on both of those days, totally unprepared for the change.In any event, the first snow always makes me recall this story.
Not bad. Did you really expect more?
Several weeks ago, I suggested that the debate on national health care issues had moved from policy to politics. We are now at the point where real horse-trading has begun to get the requisite number of votes in the Senate.
Here's one aspect of this, where certain Congressman are trying to protect medical device companies located in their states. And here's another summary, showing the interplay among several groups of constituents:
Doctors are expected to win a $240 billion boost in reimbursement rates that would shield them from a 21 percent pay cut next year for treating Medicare patients. Women who now pay higher insurance premiums for caesarean sections would be protected under antidiscrimination provisions. And although Congress is strongly considering a tax on high-cost “Cadillac’’ insurance plans, the charge is likely to be imposed on a smaller number of health plans, appeasing angry labor activists.
None of this should be a surprise. It is the legislative process in action, based on a republican form of government that was written into our Constitution by John Adams and his colleagues to assure that minority interests are considered.
In similar fashion, we should really ignore non-stories like this one in today's Washington Post. It contains complaints that the final negotiations are being held by a small group of people as opposed to the "big table" approach promised by the president during his campaign. This has been standard practice for decades, and it is necessary to actually get the final work done. It does not, by the way, guarantee full approval by either house of Congress, but without a small working group at some point in the legislative process, you never get close to a conclusion.
All that has really changed recently is that the sausage-making aspects of legislation are now more visible for the world to see.
What it will mean for the final bill, though, is that health care reform will not satisfy the President's three-part test of offering more access, lower costs, and consumer choice, but those in all segments of the industry have known since the start that this was not possible. In my view, the most important things that will be accomplished are eliminating nasty practices of insurance companies; establishing a national requirement for people to have health insurance; and subsidizing at least some of those who need it. The first will give security to those who have insurance but who fear losing it. The second will cause those healthy people who choose not to buy insurance to do so, helping to assure that they do not end up being a burden on all of us when they show up at the Emergency Room. The third will help some portion of the population get insurance and more access to preventative and diagnostic care.
We will find out months and years from now what our Congressional buddies horse-traded away to get this package. Some of it will not look pretty. Some of it will actually harm the underlying causes of more access, lower costs, and consumer choice. There will have been missed opportunities to rationalize the health care system, too. But all of that, I submit, is the nature of the legislative process, where the reality that "one person's costs are another person's income" gets transmogrified into a bill that gets enough votes to pass.
Here's one aspect of this, where certain Congressman are trying to protect medical device companies located in their states. And here's another summary, showing the interplay among several groups of constituents:
Doctors are expected to win a $240 billion boost in reimbursement rates that would shield them from a 21 percent pay cut next year for treating Medicare patients. Women who now pay higher insurance premiums for caesarean sections would be protected under antidiscrimination provisions. And although Congress is strongly considering a tax on high-cost “Cadillac’’ insurance plans, the charge is likely to be imposed on a smaller number of health plans, appeasing angry labor activists.
None of this should be a surprise. It is the legislative process in action, based on a republican form of government that was written into our Constitution by John Adams and his colleagues to assure that minority interests are considered.
In similar fashion, we should really ignore non-stories like this one in today's Washington Post. It contains complaints that the final negotiations are being held by a small group of people as opposed to the "big table" approach promised by the president during his campaign. This has been standard practice for decades, and it is necessary to actually get the final work done. It does not, by the way, guarantee full approval by either house of Congress, but without a small working group at some point in the legislative process, you never get close to a conclusion.
All that has really changed recently is that the sausage-making aspects of legislation are now more visible for the world to see.
What it will mean for the final bill, though, is that health care reform will not satisfy the President's three-part test of offering more access, lower costs, and consumer choice, but those in all segments of the industry have known since the start that this was not possible. In my view, the most important things that will be accomplished are eliminating nasty practices of insurance companies; establishing a national requirement for people to have health insurance; and subsidizing at least some of those who need it. The first will give security to those who have insurance but who fear losing it. The second will cause those healthy people who choose not to buy insurance to do so, helping to assure that they do not end up being a burden on all of us when they show up at the Emergency Room. The third will help some portion of the population get insurance and more access to preventative and diagnostic care.
We will find out months and years from now what our Congressional buddies horse-traded away to get this package. Some of it will not look pretty. Some of it will actually harm the underlying causes of more access, lower costs, and consumer choice. There will have been missed opportunities to rationalize the health care system, too. But all of that, I submit, is the nature of the legislative process, where the reality that "one person's costs are another person's income" gets transmogrified into a bill that gets enough votes to pass.
Saturday, October 17, 2009
Hey, that's our money!
An article by Todd Wallack and Andrea Estes in today's Boston Globe demonstrates the risks inherent in direct governmental participation in private corporations.
Here, the Commonwealth of Massachusetts decided to put money into a solar energy company:
The incentive package from the state included nearly $21 million in direct grants to the company, $22.6 million in tax incentives, $13 million in grants to build roads, upgrade electrical transmission lines, and upgrade other infrastructure to support the 450,000-square-foot Devens plant, a $1-per-year lease for 23 acres at Devens worth $2.3 million, and $17.5 million in loans.
There are two types of risk associated with this kind of investment. The first is that the firm might fail, taking with it millions of dollars in state assets. That is particularly likely in the energy field, where changes in world oil prices and advances in technology or unexpected competition can quickly make mincemeat of a firm's business plan.
In this case: A big problem is the price of solar panels, which keeps dropping, in part because of sinking demand and competition from China. The U.S. Synthetic Fuels Corporation, staked with billions of dollars in federal support, was another casualty of these kinds of market forces.
The second risk is that political bodies have trouble with the concept of sunk costs. Private firms consider past investments as fiscally "gone" for purposes of evaluating future investments. But the government often behaves as if investments have a carry-forward risk of embarrassment, so it is more likely to throw good money after bad.
This part of the story demonstrates the latter point:
...After its efforts to borrow elsewhere failed, the company recently asked MassDevelopment for a new $5 million loan. ...MassDevelopment staff members warned last month that the company does not currently generate enough cash to pay it back, and gave it the highest score possible for risk, 6 out of 6. The $5 million request is also double the $2.5 million limit allowed under MassDevelopment’s own guidelines. Nevertheless, MassDevelopment’s board unanimously approved the loan at a board meeting Sept. 17.
Some Governors and Presidents like to believe that they are more able than the private markets to evaluate and support technologies and companies consistent with their policy agendas. The problem is that they use our money in support of their hunches, changing the private sector's risk-reward calculus that is essential for a proper evaluation of the investment's value.
Here, the Commonwealth of Massachusetts decided to put money into a solar energy company:
The incentive package from the state included nearly $21 million in direct grants to the company, $22.6 million in tax incentives, $13 million in grants to build roads, upgrade electrical transmission lines, and upgrade other infrastructure to support the 450,000-square-foot Devens plant, a $1-per-year lease for 23 acres at Devens worth $2.3 million, and $17.5 million in loans.
There are two types of risk associated with this kind of investment. The first is that the firm might fail, taking with it millions of dollars in state assets. That is particularly likely in the energy field, where changes in world oil prices and advances in technology or unexpected competition can quickly make mincemeat of a firm's business plan.
In this case: A big problem is the price of solar panels, which keeps dropping, in part because of sinking demand and competition from China. The U.S. Synthetic Fuels Corporation, staked with billions of dollars in federal support, was another casualty of these kinds of market forces.
The second risk is that political bodies have trouble with the concept of sunk costs. Private firms consider past investments as fiscally "gone" for purposes of evaluating future investments. But the government often behaves as if investments have a carry-forward risk of embarrassment, so it is more likely to throw good money after bad.
This part of the story demonstrates the latter point:
...After its efforts to borrow elsewhere failed, the company recently asked MassDevelopment for a new $5 million loan. ...MassDevelopment staff members warned last month that the company does not currently generate enough cash to pay it back, and gave it the highest score possible for risk, 6 out of 6. The $5 million request is also double the $2.5 million limit allowed under MassDevelopment’s own guidelines. Nevertheless, MassDevelopment’s board unanimously approved the loan at a board meeting Sept. 17.
Some Governors and Presidents like to believe that they are more able than the private markets to evaluate and support technologies and companies consistent with their policy agendas. The problem is that they use our money in support of their hunches, changing the private sector's risk-reward calculus that is essential for a proper evaluation of the investment's value.
Friday, October 16, 2009
Silver Lining
The American League playoff series is taking place between the Angels and the Yankees, with the Red Sox eliminated in the previous round. The last several days in Boston have been cold and wet. A BIDMC staff member, a true and loyal fan, said to me, "I'm sure glad the Red Sox don't have to play in this terrible weather."
Here's the beef
My friend Vamsi arrived in America many years ago from Chennai (formerly Madras), India, to attend college at the University of Iowa in Ames. Pretty soon, his favorite eating place was Perkins Restaurant, and his favorite dish was chicken fried steak. There was only one problem. Unknown to this Hindu, chicken fried steak was actually not chicken. It was beef, a forbidden food. He never could tell from the taste because he always smothered the dish with lots of gravy. Finally, after 4 1/2 years of college, he made the discovery. He now wonders how and when he will be punished for these multiple violations!Meanwhile, just this week, a friend reports that, in honor of Diwali, the company where she works is serving Tamarind Masala Meatloaf. Really. Picture included. Hopefully, the White House was a bit more culturally correct.
ICU = I (really) care for you and your family
Several months ago, I wrote about work being done in our ICUs to make them more patient- and family-friendly and responsive.
Each year, the Society of Critical Care Medicine (SCCM) selects one (and only one) hospital or ICU for its Family-Centered Care Award, the purpose of which is to "recognize innovation that improves the care provided to critically ill and injured patients and their families." If you’re not familiar with SCCM, it is the largest multiprofessional organization focused on critical care, with more than 14,000 members in 80 countries. This is an international competition.
I am very proud to announce that BIDMC has received the award, which will be presented in January.
As Dr. Michael Howell, Director of Critical Care Quality, explained to our staff:
Why did Critical Care at BIDMC win this award? Because of your work. Literally hundreds of people have made small, incremental changes to help improve the experience of critical care for our patients and families. Anyone who has had a family member an ICU knows that it’s an extraordinarily trying time. From simulated family meetings for the medical residents, to family pagers in the SICU, to transition-out-of-the-ICU work in CVI, to pro-active rounding of chaplains, there have been a tremendous number of improvements over the past year and a half. Family satisfaction data (which we have meticulously collected) supports this as well. Today, families are more than twice as likely to report that they are completely satisfied with their decision-making role than they were when we started in April 2009, and we’ve seen improvements in other areas as well.
I also want to give special thanks to IHI's Maureen Bisognano, who had a special role in stimulating our activities in this arena. Maureen had a friend in our ICU for some time. Afterwards, she said that the medical care had been extraordinary, but that other aspects of our care were substandard and outdated. She was absolutely correct. Beyond that criticism, she has been a loyal guide in our work.
Here is the more detailed explanation from our award application:
DECIDING WHAT TO IMPROVE: MOVING THE LOCUS OF CONTROL TO PATIENTS AND FAMILIES
Strategically, we believed that how we chose what to improve was tremendously important. To be truly patient/family-centered, patients and families should set our improvement priorities. We therefore developed two initiatives to address this critical issue:
ICU Patient and Family Advisory Council
We believed that ongoing, longitudinal guidance from our patients and families was critical. We therefore assembled the ICU Patient and Family Advisory Council, a group of former ICU patients and family members (of both survivors and non-survivors). Each Council member serves for one to two years. The group meets bi-monthly.
As the first advisory council for our hospital, we consciously sought a model that could be emulated by others. After we identified potential Council members, we had a thoughtful selection process, including in-person interviews by a social worker and by a member of the Critical Care Quality staff. This selection process resulted in a group of patients and families who provides exceptional advice and guidance.
To elicit the best possible guidance, each Council meeting is facilitated using careful focus group methods. Each session focuses on a different aspect of the ICU experience. Examples of topics include (among others): emotional support in the ICU, family meeting curriculum design, waiting room revitalization, overall prioritization of improvement opportunities, and others.
FS-ICU: Family Satisfaction in the Intensive Care Unit
Traditional hospital-wide patient-satisfaction tools (e.g. Medicare’s HCAHPS; Press Ganey) have significant limitations in understanding the ICU experience. However, the FS-ICU is emerging as one of the potential gold standards in assessing families’ ICU experience.1 This rigorously developed survey instrument captures key domains of the ICU experience and has undergone multicenter validation. In addition, the survey has three open-ended questions designed to solicit opportunities for improvement. The FS-ICU is administered to families of ICU survivors within three days of transfer out of the ICU; it is mailed to families of non-survivors several weeks after the patient’s death.
We began administering the FS-ICU in April 2008 (i.e. just over one year after the multicenter FS-ICU’s publication) and have surveyed nearly 400 families to date. Quantitative analysis allows us to detect targets for improvement and to follow improvements over time. Qualitative assessment of the open-ended questions ensures that our Advisory Council’s advice resonates with a broader sample of patients. In addition, because we administer surveys in-person and in near-real-time, our team can perform real-time problem solving and address issues as they arise.
GETTING BETTER: A PORTFOLIO OF FAMILY-CENTERED CRITICAL CARE
Based on themes and specifics gathered from our ICU Patient and Family Advisory Council and the FS-ICU, we began the journey toward comprehensive, meaningful patient- and family-centered critical care. Below is a selection of activities, limited by space:
Communication
Simulated Family Meetings: Residents provide a great deal of direct patient care, but the optimal way to train them how to conduct family meetings is not known. We have implemented a program in which all medical house officers (>150 physicians) now rotate through our Simulation Center, receiving didactic and high-fidelity simulation sessions on conducting family meetings. The ICU Advisory Council provided major input into the curriculum for this educational program.
Transitioning out of the ICU: The move from an ICU to a regular floor can be very stressful. Now, when patients transition from the Cardiovascular ICU (CVICU) to the floor, RNs from both areas perform a hand-off with the patient in the room with a focus on pain management requirements. Patients have a direct say in their care and in how their pain is managed.
Including Families on Multidisciplinary Rounds: For several years, families have routinely been invited to stay in the patient’s room during the exam and discussion in many of our ICUs. However, we believe this involvement should be expanded. In October of this year, we will begin a pilot to actively invite and include families on multidisciplinary work rounds. In order to help in moving the field forward, we are planning a meticulous effectiveness evaluation of this strategy, using time/motion analyses and the FS-ICU as outcome measures.
Standardized Communication at ICU Admission: Our Advisory Council provided guidance on what kinds of information was most helpful in the first day of a patient’s stay. This new introductory brochure covers information on staff roles in the ICU as well as the day-to-day logistics of visiting (such as parking). It also provides pointers to additional information and information about how family members should take care of themselves during this trying time.
Spiritual Care: Chaplaincy staff now actively solicit patient/family needs by pro-actively rounding in the ICUs. Spiritual care satisfaction scores have more than doubled (p =0.005). Our chaplaincy was recently covered in a major metropolitan newspaper.
Improving the Critical Care Experience
Waiting Room Revitalization: Our Advisory Council and FS-ICU results identified the waiting room as an important factor in satisfaction and a major opportunity for improvement. In spite of the economic challenges of the past year, our hospital dedicated capital to renovating a waiting room serving three of our ICUs. The renovation was designed with active input from our Patient/Family Advisory Council. Thus, the waiting room (now “Family Room”) included functions that are meaningful to our family. Opened in July 2009, we have seen marked improvement in the FS-ICU scores for the waiting room (p = 0.04).
Family Sleep Room: Providing the ability to stay close to loved ones is important. In tandem with our waiting room revitalization, we created two rooms to provide overnight accommodations for our families.
Eliminating Visiting Hours: Our Critical Care Executive Committee voted unanimously to support open access for families, eliminating formal visiting hours. This helps accommodate family members who work late and allows loved ones to visit at their convenience, rather than at ours.
Untethering Families from the ICU
Family Pagers: Our Advisory Council pointed out the feeling that they had to stay in or near the ICU at all times, in case anything happened. We now provide pagers (think Olive Garden) to families that allow them to go to the coffee shop, cafeteria, and nearby shops with the confidence that we can page them if they are needed. These have received rave reviews from families, nurses, and doctors alike.
Computers for ICU Families: Many families use email and social networking to update extended families and friends. Access to the web and email also allows some family members to keep up with some work/employment duties while being close to loved ones. In addition to ubiquitous wireless internet, we now provide public computers in our revitalized family room. These computers open a customized ICU website which includes links to online medical resources such as SCCM’s Official Patient and Family website.
CarePages: Our hospital contracted with Carepages to provide an infrastructure to support patient- and family-created blogs about their health challenge. These private and personalized web pages allow families to share the latest news with friends and family and receive messages of support, without the time and effort required to call large numbers of people.
EVALUATING EFFECTIVENESS
This comprehensive, family-guided program focused on improving the family-centeredness of critical care in our nine adult ICUs. We believe there are two measures of evaluating its effectiveness:
Organizational commitment: In this challenging environment, hospitals cannot commit resources to ineffective programs. Besides being featured on our CEO’s blog, our medical center has supported this key effort in several ways. First, a half-time critical care nurse helps lead this work. Without this, our program would not have been successful. In addition, the Division of Critical Care Quality focuses the resources of the Director of Critical Care Quality (an MD) and a Masters-trained Critical Care Project Manager. Finally, we were fortunate to receive the capital support required for our waiting room revitalization.
Improvement in Outcomes: The FS-ICU provides an opportunity to rigorously measure family-centered outcomes of our work. In addition to statistically significant improvements in spiritual care and waiting room scores, we have seen consistent improvements in families’ rating of overall satisfaction with decision-making, which we believe represents a true outcome measure of our improvement work. In the baseline period (n=45 surveys), 40% of families reported complete satisfaction with their decision-making role. In the past six months, 66% of families report complete satisfaction with decision-making (n=95); in the past three months, 82% of families report this highest level of satisfaction (n=34). Mean decision-making satisfaction scores have correspondingly increased from 3.7 to 4.85 (p=0.005 for Spearman correlation between month and mean decision-making score).
1. Wall RJ, Engelberg RA, Downey L, Heyland DK, Curtis JR. Refinement, scoring, and validation of the Family Satisfaction in the Intensive Care Unit (FS-ICU) survey. Crit Care Med. Jan 2007;35(1):271-279.
Each year, the Society of Critical Care Medicine (SCCM) selects one (and only one) hospital or ICU for its Family-Centered Care Award, the purpose of which is to "recognize innovation that improves the care provided to critically ill and injured patients and their families." If you’re not familiar with SCCM, it is the largest multiprofessional organization focused on critical care, with more than 14,000 members in 80 countries. This is an international competition.
I am very proud to announce that BIDMC has received the award, which will be presented in January.
As Dr. Michael Howell, Director of Critical Care Quality, explained to our staff:
Why did Critical Care at BIDMC win this award? Because of your work. Literally hundreds of people have made small, incremental changes to help improve the experience of critical care for our patients and families. Anyone who has had a family member an ICU knows that it’s an extraordinarily trying time. From simulated family meetings for the medical residents, to family pagers in the SICU, to transition-out-of-the-ICU work in CVI, to pro-active rounding of chaplains, there have been a tremendous number of improvements over the past year and a half. Family satisfaction data (which we have meticulously collected) supports this as well. Today, families are more than twice as likely to report that they are completely satisfied with their decision-making role than they were when we started in April 2009, and we’ve seen improvements in other areas as well.
I also want to give special thanks to IHI's Maureen Bisognano, who had a special role in stimulating our activities in this arena. Maureen had a friend in our ICU for some time. Afterwards, she said that the medical care had been extraordinary, but that other aspects of our care were substandard and outdated. She was absolutely correct. Beyond that criticism, she has been a loyal guide in our work.
Here is the more detailed explanation from our award application:
DECIDING WHAT TO IMPROVE: MOVING THE LOCUS OF CONTROL TO PATIENTS AND FAMILIES
Strategically, we believed that how we chose what to improve was tremendously important. To be truly patient/family-centered, patients and families should set our improvement priorities. We therefore developed two initiatives to address this critical issue:
ICU Patient and Family Advisory Council
We believed that ongoing, longitudinal guidance from our patients and families was critical. We therefore assembled the ICU Patient and Family Advisory Council, a group of former ICU patients and family members (of both survivors and non-survivors). Each Council member serves for one to two years. The group meets bi-monthly.
As the first advisory council for our hospital, we consciously sought a model that could be emulated by others. After we identified potential Council members, we had a thoughtful selection process, including in-person interviews by a social worker and by a member of the Critical Care Quality staff. This selection process resulted in a group of patients and families who provides exceptional advice and guidance.
To elicit the best possible guidance, each Council meeting is facilitated using careful focus group methods. Each session focuses on a different aspect of the ICU experience. Examples of topics include (among others): emotional support in the ICU, family meeting curriculum design, waiting room revitalization, overall prioritization of improvement opportunities, and others.
FS-ICU: Family Satisfaction in the Intensive Care Unit
Traditional hospital-wide patient-satisfaction tools (e.g. Medicare’s HCAHPS; Press Ganey) have significant limitations in understanding the ICU experience. However, the FS-ICU is emerging as one of the potential gold standards in assessing families’ ICU experience.1 This rigorously developed survey instrument captures key domains of the ICU experience and has undergone multicenter validation. In addition, the survey has three open-ended questions designed to solicit opportunities for improvement. The FS-ICU is administered to families of ICU survivors within three days of transfer out of the ICU; it is mailed to families of non-survivors several weeks after the patient’s death.
We began administering the FS-ICU in April 2008 (i.e. just over one year after the multicenter FS-ICU’s publication) and have surveyed nearly 400 families to date. Quantitative analysis allows us to detect targets for improvement and to follow improvements over time. Qualitative assessment of the open-ended questions ensures that our Advisory Council’s advice resonates with a broader sample of patients. In addition, because we administer surveys in-person and in near-real-time, our team can perform real-time problem solving and address issues as they arise.
GETTING BETTER: A PORTFOLIO OF FAMILY-CENTERED CRITICAL CARE
Based on themes and specifics gathered from our ICU Patient and Family Advisory Council and the FS-ICU, we began the journey toward comprehensive, meaningful patient- and family-centered critical care. Below is a selection of activities, limited by space:
Communication
Simulated Family Meetings: Residents provide a great deal of direct patient care, but the optimal way to train them how to conduct family meetings is not known. We have implemented a program in which all medical house officers (>150 physicians) now rotate through our Simulation Center, receiving didactic and high-fidelity simulation sessions on conducting family meetings. The ICU Advisory Council provided major input into the curriculum for this educational program.
Transitioning out of the ICU: The move from an ICU to a regular floor can be very stressful. Now, when patients transition from the Cardiovascular ICU (CVICU) to the floor, RNs from both areas perform a hand-off with the patient in the room with a focus on pain management requirements. Patients have a direct say in their care and in how their pain is managed.
Including Families on Multidisciplinary Rounds: For several years, families have routinely been invited to stay in the patient’s room during the exam and discussion in many of our ICUs. However, we believe this involvement should be expanded. In October of this year, we will begin a pilot to actively invite and include families on multidisciplinary work rounds. In order to help in moving the field forward, we are planning a meticulous effectiveness evaluation of this strategy, using time/motion analyses and the FS-ICU as outcome measures.
Standardized Communication at ICU Admission: Our Advisory Council provided guidance on what kinds of information was most helpful in the first day of a patient’s stay. This new introductory brochure covers information on staff roles in the ICU as well as the day-to-day logistics of visiting (such as parking). It also provides pointers to additional information and information about how family members should take care of themselves during this trying time.
Spiritual Care: Chaplaincy staff now actively solicit patient/family needs by pro-actively rounding in the ICUs. Spiritual care satisfaction scores have more than doubled (p =0.005). Our chaplaincy was recently covered in a major metropolitan newspaper.
Improving the Critical Care Experience
Waiting Room Revitalization: Our Advisory Council and FS-ICU results identified the waiting room as an important factor in satisfaction and a major opportunity for improvement. In spite of the economic challenges of the past year, our hospital dedicated capital to renovating a waiting room serving three of our ICUs. The renovation was designed with active input from our Patient/Family Advisory Council. Thus, the waiting room (now “Family Room”) included functions that are meaningful to our family. Opened in July 2009, we have seen marked improvement in the FS-ICU scores for the waiting room (p = 0.04).
Family Sleep Room: Providing the ability to stay close to loved ones is important. In tandem with our waiting room revitalization, we created two rooms to provide overnight accommodations for our families.
Eliminating Visiting Hours: Our Critical Care Executive Committee voted unanimously to support open access for families, eliminating formal visiting hours. This helps accommodate family members who work late and allows loved ones to visit at their convenience, rather than at ours.
Untethering Families from the ICU
Family Pagers: Our Advisory Council pointed out the feeling that they had to stay in or near the ICU at all times, in case anything happened. We now provide pagers (think Olive Garden) to families that allow them to go to the coffee shop, cafeteria, and nearby shops with the confidence that we can page them if they are needed. These have received rave reviews from families, nurses, and doctors alike.
Computers for ICU Families: Many families use email and social networking to update extended families and friends. Access to the web and email also allows some family members to keep up with some work/employment duties while being close to loved ones. In addition to ubiquitous wireless internet, we now provide public computers in our revitalized family room. These computers open a customized ICU website which includes links to online medical resources such as SCCM’s Official Patient and Family website.
CarePages: Our hospital contracted with Carepages to provide an infrastructure to support patient- and family-created blogs about their health challenge. These private and personalized web pages allow families to share the latest news with friends and family and receive messages of support, without the time and effort required to call large numbers of people.
EVALUATING EFFECTIVENESS
This comprehensive, family-guided program focused on improving the family-centeredness of critical care in our nine adult ICUs. We believe there are two measures of evaluating its effectiveness:
Organizational commitment: In this challenging environment, hospitals cannot commit resources to ineffective programs. Besides being featured on our CEO’s blog, our medical center has supported this key effort in several ways. First, a half-time critical care nurse helps lead this work. Without this, our program would not have been successful. In addition, the Division of Critical Care Quality focuses the resources of the Director of Critical Care Quality (an MD) and a Masters-trained Critical Care Project Manager. Finally, we were fortunate to receive the capital support required for our waiting room revitalization.
Improvement in Outcomes: The FS-ICU provides an opportunity to rigorously measure family-centered outcomes of our work. In addition to statistically significant improvements in spiritual care and waiting room scores, we have seen consistent improvements in families’ rating of overall satisfaction with decision-making, which we believe represents a true outcome measure of our improvement work. In the baseline period (n=45 surveys), 40% of families reported complete satisfaction with their decision-making role. In the past six months, 66% of families report complete satisfaction with decision-making (n=95); in the past three months, 82% of families report this highest level of satisfaction (n=34). Mean decision-making satisfaction scores have correspondingly increased from 3.7 to 4.85 (p=0.005 for Spearman correlation between month and mean decision-making score).
1. Wall RJ, Engelberg RA, Downey L, Heyland DK, Curtis JR. Refinement, scoring, and validation of the Family Satisfaction in the Intensive Care Unit (FS-ICU) survey. Crit Care Med. Jan 2007;35(1):271-279.
The 5S projects are spreading
Remember the 5S component of Lean process improvement? Well, it applies in all kinds of settings, not just clinical areas. Here are some examples from our Human Resources staff. Laurie reported: "A small group of us in Staffing took this Columbus Day to discover not a new land, but to reclaim our offices through 5S!"
Thursday, October 15, 2009
Going virtual @ BlogWorld
I just finished participating in a panel discussion at BlogWorld & New Media Expo at the Las Vegas Convention Center. Except I was in Boston. We had hoped to have a video link, but that didn't work out, so I joined by telephone.Here's a picture of our panel, provided by Dr. Val Jones, entitled, "The value of blogs to hospitals, news organizations, and industry." Shown are moderator Gary Schwitzer (Health News Review), Marc Monseau (Johnson & Johnson's JNJ BTW Blog), Bob Stern (MedPage Today), and me. I offer the closeup of me in case it is unclear in the top picture.
Update on October 20: Here's a video clip from Dr. Anonymous. October 22: An another on You Tube.
A rock star!
It isn't often that one of our young investigators hits the top ten, but check out this feature from Popular Science about BIDMC pathologist John Rinn.
Not all that long ago
Passing through London earlier this week, I visited a friend who had met Paul Robeson during one of the latter's trips to England several decades ago. Robeson told my friend of a reception at the White House, where he had been invited by First Lady Eleanor Roosevelt. As noted here, "At the height of his popularity, Robeson was a national symbol and a cultural leader in the war against fascism abroad and racism at home."A certain US Senator approached Robeson and addressed him as "Professor." Robeson, confused, said, "Senator, I am not a professor. Why do you call me that?"
The reply, "Well, normally, I would call you nigger, but I can't use that term in this White House, so I'll just call you Professor."
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Note: Picture courtesy of Wikipedia.
Wednesday, October 14, 2009
For Thyroid Cancer Survivors
I wasn't aware of the Thyroid Cancer Survivors' Association, Inc. before receiving a note recently. I am happy to pass along information about a conference this weekend:
Thyroid cancer survivors and families from around the United States, as well as Canada, Brazil, and United Kingdom, will gather in Danvers, Massachusetts, on October 16-18, 2009, to learn from expert physician specialists about the latest research in thyroid cancer, during the 12th International Thyroid Cancer Survivors' Conference.
Speakers at the more than 100 sessions at the Sheraton Ferncroft Hotel at 50 Ferncroft Road, Danvers, Massachusetts, include more than 30 medical professionals, mental health professionals, an attorney, other specialists in well-being, and thyroid cancer survivors and caregivers. There are speakers about each type of thyroid cancer (papillary, follicular, medullary, anaplastic, and variants), for people of all ages at all phases of testing, treatment, and follow-up.
This educational and supportive event is FREE to anyone who requests a scholarship to cover the $50 registration fee (or $30 for one day). Walk-in attendees are welcome.
For the complete program schedule and further conference details, click here, call 1-877-588-7904, or e-mail to thyca [at] thyca [dot] org.
Thyroid cancer survivors and families from around the United States, as well as Canada, Brazil, and United Kingdom, will gather in Danvers, Massachusetts, on October 16-18, 2009, to learn from expert physician specialists about the latest research in thyroid cancer, during the 12th International Thyroid Cancer Survivors' Conference.
Speakers at the more than 100 sessions at the Sheraton Ferncroft Hotel at 50 Ferncroft Road, Danvers, Massachusetts, include more than 30 medical professionals, mental health professionals, an attorney, other specialists in well-being, and thyroid cancer survivors and caregivers. There are speakers about each type of thyroid cancer (papillary, follicular, medullary, anaplastic, and variants), for people of all ages at all phases of testing, treatment, and follow-up.
This educational and supportive event is FREE to anyone who requests a scholarship to cover the $50 registration fee (or $30 for one day). Walk-in attendees are welcome.
For the complete program schedule and further conference details, click here, call 1-877-588-7904, or e-mail to thyca [at] thyca [dot] org.
South Cove welcomes Dr. Yeh
South Cove Community Health Center is one of the health centers affiliated with BIDMC. It has locations in the Chinatown section of Boston and also in Quincy.Last night, the folks at South Cove kindly sponsored a welcoming celebration for our new chief of Obstetrics and Gynecology, John Yeh. Here's a picture of some of those attending. From left to right, they are: Dr. Hee Man Chie, OB SCCHC; John; Helen Chin Schlichte, BIDMC Board of Directors; Dr. Steven Tang, SCCHC Founder and Board Member; April Tang, SCCHC Founder and Board Member and BIDMC Overseer; and Cindy Chen, SCCHC Board Member.
Judith Kurland, Mayor Menino's Chief of Staff, offered greetings on behalf of the Mayor. John presented his plans for the OB/GYN department and for continued close collaboration between BIDMC and South Cove. And, of course, the food was delicious!
MITSS Annual Dinner
Medically Induced Trauma Support Services (MITSS) is a non-profit organization whose mission is “To Support Healing and Restore Hope” to those patients, family members, and clinicians who have been affected by a medical error or an adverse medical event.
MITSS holds one major fund-raising event each year, and it will be held on November 12 at the Boston Marriott Copley Place. Proceeds from the event will be used to fund support groups for patients, families, and clinicians; individual counseling; phone support and referral assistance. MITSS also work with health care organizations to assist them in setting up an internal process for supporting their clinicians.
The keynote speaker for the event is Susan E. Sheridan, Co-founder and President of CAPS, Consumers Advancing Patient Safety, which focuses on creating a partnership between consumers and providers of care.
MITSS is an organization worthy of support. For more information, click here.
MITSS holds one major fund-raising event each year, and it will be held on November 12 at the Boston Marriott Copley Place. Proceeds from the event will be used to fund support groups for patients, families, and clinicians; individual counseling; phone support and referral assistance. MITSS also work with health care organizations to assist them in setting up an internal process for supporting their clinicians.
The keynote speaker for the event is Susan E. Sheridan, Co-founder and President of CAPS, Consumers Advancing Patient Safety, which focuses on creating a partnership between consumers and providers of care.
MITSS is an organization worthy of support. For more information, click here.
Back to the insurance tax issue
Watch the House-Senate reconciliation process closely after the Senate acts and the health care bills move to conference committee. As I mentioned weeks ago, the scope of the so-called "Cadillac" tax on insurance premiums will be a key issue.
Why? Because many insurance plans adopted as part of collective bargaining agreements would be covered by the Senate-proposed tax. There will be no such provision in the House bill.
As reported by the Commonwealth Fund, members of the House are already gearing up on this issue.
It would be a odd policy choice, indeed, if the Democratic majority gives a special exemption to union health plans while taxing non-union benefits.
A more democratic approach and one that takes advantage of the existing progressivity of the US tax system would be to eliminate or scale back the current tax exemption for all employer sponsored insurance plans. Higher income taxpayers (whether union members or not) with higher marginal tax rates would pay proportionately more under that kind of proposal.
But I predict that you will not see a real public debate on this issue. It will be decided in the closed door sessions of the conference committee and placed before both houses as an understated component of the final bill. It will be a bargaining chip that the House uses in returning for giving up the public option insurance plan. The Obama administration, which feels it owes its existence to major financial and organizational support from the SEIU and other unions but has been unable to deliver on explicit pro-labor bills, will be quietly lobbying in this manner.
Why? Because many insurance plans adopted as part of collective bargaining agreements would be covered by the Senate-proposed tax. There will be no such provision in the House bill.
As reported by the Commonwealth Fund, members of the House are already gearing up on this issue.
It would be a odd policy choice, indeed, if the Democratic majority gives a special exemption to union health plans while taxing non-union benefits.
A more democratic approach and one that takes advantage of the existing progressivity of the US tax system would be to eliminate or scale back the current tax exemption for all employer sponsored insurance plans. Higher income taxpayers (whether union members or not) with higher marginal tax rates would pay proportionately more under that kind of proposal.
But I predict that you will not see a real public debate on this issue. It will be decided in the closed door sessions of the conference committee and placed before both houses as an understated component of the final bill. It will be a bargaining chip that the House uses in returning for giving up the public option insurance plan. The Obama administration, which feels it owes its existence to major financial and organizational support from the SEIU and other unions but has been unable to deliver on explicit pro-labor bills, will be quietly lobbying in this manner.
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