The blue glove medical record

From a close friend, about an experience in another hospital:

So, Mom is taken to the ED over the weekend for treatment of an infection. On one side of the room is the computer terminal for EMR access, with ever-changing screen savers touting the benefits of using the electronic record: safer, faster, more accurate, easier for the provider, better for the patient, etc. On the other side of the room, connected to Mom, is the electronic vital sign monitor: heart rate, blood pressure, oxygen, etc.

Half a dozen times, the tech came in to record her vitals. The procedure is: Put on one blue latex glove, take a Sharpie, write down the vital signs on the back of the gloved hand, leave the room, repeat a few hours later.

Does the blue glove go into the paper record? I dunno, but I guess the fancy EMR and the fancy electronic monitor don't talk to each other, because we have to rely on double manual transcription to record vital signs.

By the way, they use the same procedure up on the floor. Plenty of opportunity for improvement in health care.

TFC @ BIDMC

In addition to the Marshfield High School performers, we were fortunate also to have a visit this week from members of the Tanglewood Festival Chorus, who performed some holiday songs in one of our public spaces. Here is an excerpt of an unusual version of the The Twelve Days of Christmas. While listening, try to catch a glimpse of my wife Barbara, a veteran chorus member, who arranged for the performance to be held for the benefit of our patients and staff. (If you cannot view the embedded video here, follow this link to see it on YouTube.)

Listening to the staff

Many people around the country followed the dramatic story last March when our employees generously gave up salary increases and benefits to help save hundreds of jobs of their fellow workers. A key part of that process was that staff members had multiple paths to contact me with suggestions and reactions to various proposals. Thousands of people did that, and it was very helpful as I made decisions on these matters.

Several months have passed, and our financial situation has improved. We hope to be close to the time when we might restore salary increases and/or benefits. I needed to know which of those items would be most important to our workers, to help set the priorities for restoring them. It was time to check in again.

Two emails follow. I sent out the first just before Thanksgiving and the second one yesterday.

As I have talked about all this with people around the country, many have expressed surprise that, as CEO, I would "take the risk" of consulting our staff on these matters. For some, this is considered an odd ceding of executive authority. My view is just the contrary. If a CEO cannot rely on the judgment and opinions of those doing the work in an organization to help him/her make the final decisions on matters affecting those very people, what does it say about the level of mutual respect in that institution?

Here's the first email:

Dear BIDMC,

As Thanksgiving approaches, it is good to remember that we are blessed to work in a place devoted to healing and characterized by mutual support. Our collective decision in March to adopt a different approach to balance our budget to avoid what might have been hundreds of layoffs is consistent with our deeply held values. It brought national and regional acclaim to our hospital and to those of you who work here. I am proud of your participation in making those decisions during that difficult time.

But that does not mean everything is easy. Here is a representative note from Carol:

I am writing you to express my concerns after reading the Annual Operating Plan where it says that we want to "Create and implement programs to recruit and retain an outstanding and diverse workforce including competitive benefits and compensation programs, career development programs to prepare employees for jobs in areas facing skills shortages, and leadership development programs to enhance the strength and capabilities of our managers."

My concern is that it may become harder to recruit and retain “outstanding people” with the loss of benefits. Everyday we all go to the grocery store, the gas station and pharmacy and pay more for the things that we need, not want but need. I would appreciate any feedback in regards to the time frame of reinstituting some our lost benefits.

In talking to my colleagues I find that I am not alone in these concerns. At this point it seems that the surrounding hospitals are better compensated then we are. The difference between them and us is that we have a dedicated and loyal staff.

Here was my short answer, but I am writing to give you a longer one and, once again, to ask your advice:

Thank you, Carol. We are working to restore the benefits as soon as possible. More to come on that front. I do not believe our compensation is out of line with other hospitals, but I do know that we laid off many fewer people than those hospitals because of the sacrifices that everyone here participated in. That was the choice before us, for which we and the staff here received tremendous credit. If I were to make the choice again, I would do the same thing.

So, what's going on and what are our plans?

What's going on is that we ended the fiscal year on September 30 with a $10 million operating margin for the year, much better than the $20+ million loss we were projecting in March. Frankly, through the spring and summer we were just on a pace to break even, but then we had a few lucky one-time events in September (like a commercial dispute that went our way) that were pleasant surprises.

For FY2010, we are budgeting for a 2% operating margin, or about $30 million, but that is based on retaining the same sacrifices in salary and benefits that we discussed back in March. That margin is less than we would like, in terms of our investment needs in physical plant and equipment, but we can get by.

Here's the issue we face right now. The economy still stinks, with a 10% unemployment rate, reduced consumer spending, and the like. It is really hard to know how we will fare in that kind of environment. Is there really an economic recovery about to happen, or will the region slide further down? Will the governor be forced to cut Medicaid payments again? What will Congress do with Medicare as part of health care reform?

So, how do we answer Carol's question? When should we go back to business as usual and restore salary and benefit cuts?

We have an agreement with our Board that we can start to restore those cuts if our operating results for the year show a consistent pattern that is better than our budget. A consistent pattern is something we would see in mid-January, based on our operating results through December.

Let's assume the best! In preparation for what might be, I'd like your help to plan our actions.

The question is this. If and when we are able to start to phase in the things we took away, which would you like to get back first?

Restoration of ET time
Restoration of the 401(k) match
Restoration of the annual merit salary increases

...You can write me directly, but also please respond on this survey instrument so we can get the overall view from lots of people. Click here between now and Monday at 5pm: [link omitted]. I'll post the results on our portal. Your opinions will be one input into my decision on the matter.

I will let you know that decision, and I will also provide you with the specific financial metrics that would trigger the decided-upon restoration of benefits and/or salary increases. I will keep you informed as the weeks go by of our progress towards those metrics, and you will know -- as soon as I do -- when things will be restored. That seems most fair to me: You have a right to know as much as I do on this matter, and you have my commitment that everything will be presented to you in a clear and open way.

Best wishes for a happy holiday for you and your family.

Sincerely,

Paul

Here's the follow-up email:

Dear BIDMC,

I hope you and your family had a happy and safe Thanksgiving holiday. Back before the holiday, I asked you to help me decide which of the salary and benefits you would like to have restored if and when the hospital's financial picture rebounds. Remember that back in March, I told you not to expect any restoration through all of FY 2010, so the fact that I am even bringing this up now should be viewed as a relatively positive sign.

Almost 2000 of you responded (a third of those working here), and results were overwhelming:
Restore annual salary increase: 65%
Restore 401(k) match: 21%
Restore full ET accruals: 14%

Thanks for your help in setting our priorities: So that will be our goal, to restart annual salary increases. Here's how I would like it to work. We will look at our financial results late in January and if we are at or better than budget, we will start up raises again. We would do that effective April 1, the date raises stopped last year. That way, it would be much easier to keep track of everything, and everybody would have faced exactly the same period (one year) without an increase. The amount of increase would be 3% if everything goes according to plan, and you would receive it on your regular anniversary date, thereby keeping everyone on par with those who received a 3% increase in the October through March period last year. Managers and supervisors who had their raises revoked as of April 1, 2009 would have them restored effective April 1, 2010.

Regardless of what happens for the larger group of staff, employees in grades 1-4, who received their 3% raise throughout last year, will continue to receive the additional 2% raise announced earlier this year, consistent with our desire to protect those staff members from any gap in salary increases over this time period.

Where are we right now, relative to budget? Well, October was a strong month, and November was a slow month, and December thus far seems about on target. I am cautiously optimistic, but we live in uncertain times, and I am not guaranteeing that we will be able to do this. I will keep you informed over the coming weeks about whether we are able to meet our goal of restoring increases as of April 1st. This does not mean we are giving up on restoring other benefits, but my hope is to start with the salary increases.

I wish everyone an enjoyable holiday season and prosperous New Year.

Sincerely,

Paul

Marshfield High School @ BIDMC

Students from Marshfield High School visited BIDMC yesterday for brief holiday concerts in several of our public spaces. Thanks to them for taking the time and gracing our halls! (If you cannot view the embedded video here, follow this link to YouTube.)

Harnessing the wisdom of the crowd

This follows up on the post below about using networked intelligence to solve complex problems. Our Chief Academic Officer, Vikas Sukhatme, told me about two websites based on this concept.

One is called Innocentive and the other is called Topcoder, the first for inventions of a general nature, the second for software solutions. The idea of formally using the wisdom of the crowd, stimulated by prize money, to solve problems is fascinating and powerful.

Pay your fare! Or else! Unless you can't.

Back on October 29, I told you the story of the uninformative signage on the MBTA's Green Line and also mentioned the stern warnings about fare evasion presented to the public on those signs. Well, now I have my new Flip videocam and have documented that warning. But stay tuned till after the warning. Then you get a view of the fare box in my train. The dollar bill payment slot is not functioning, so the driver has inserted a dollar bill into the slot to prevent people from using it.

And who says MTBA riders are not honest? Even as the train pulls away several stops later, you can catch a glimpse of the dollar bill hanging out of the machine, having been left in place by dozens of ethical riders. (If you cannot view the embedded video here, you can follow this link to see it on YouTube.)

Ganz, Hillel, and the SEIU

As a child of the '60s, I grew up with heroes like Bobby Kennedy and Martin Luther King, Jr. Then in college, we all learned about and were inspired by their precursors, ranging from Thoreau to Gandhi. We studied, too, recent practitioners of the art of community organizing from Saul Alinksy to Cesar Chavez.

I hadn't met Marshall Ganz until I was preparing to introduce him at the IHI National Forum. It was marvelous to meet someone who had been through a parallel journey. While our paths have been different -- his in community organizing and mine in public service -- we have employed many of the same strategies and techniques. More important, I found that we have been motivated by a similar set of values.

Marshall ended his presentation with the famous quote from Hillel, also one of my favorites:

If I am not for myself, who will be for me?
If I am only for myself, what am I?
And if not now, when?

This followed his impressive speech about the nature of community organizing and, in particular, the importance of having an underlying set of values to serve as the moral basis for a movement.

Having now watched the SEIU for several years, I was struck by the contrast between Marshall's prescriptions and this union's mode of operation. As I listened to his talk, I realized that the union has, in many ways, lost its soul as it has gained power and influence. It has become part of the "they" that is the target of community organizing. Instead of drawing on the resources available to it -- the courage, passion, creativity, and commitment of workers -- it relies on money and power to gain more money and power.

What do I mean, and who, after all, am I to say anything about this? First the latter. I am just someone who cares deeply about the personal and professional development of workers, as well as their economic well-being. I am particularly interested in providing an environment in which those at the lower end of the economic spectrum can succeed in American life. I like to think that my actions and those of our hospital reflect this desire. We have tried to demonstrate it through process improvement approaches that empower all workers, through job training and development programs that give people a step up, and by adopting personnel policies that especially support lower wage workers. We are not perfect at doing all of this, but we do try.

SEIU materials indicate that the union believes in similar things. But the execution of its strategy does not reflect an underlying respect for its constituents that Marshall Ganz makes clear is at the heart of community organizing.

When I watch the SEIU at work, I see an approach more akin to that used by large, powerful corporations. I see union organizing based on trying to stifle debate. I see large amounts of dues-derived dollars being spent on corporate campaigns that denigrate the very work being carried out by the workers. When I talk with SEIU workers from other hospitals, they tell me that they do not feel a close personal connection with the union or the local stewards. When I talk with politicians, they tell me that they feel they have to publicly support the SEIU because of dollars and election-day logistical help; but they say that their support is only skin-deep because they fundamentally do not trust the union. They fear that it will quickly and viciously turn against them if there is a policy disagreement.

Marshall used the story of David and Goliath as an example of how the underdog in a social battle volunteered when no one else would take the charge and used courage and ingenuity to win -- throwing off the constraints and approaches of the old way (Saul's armor) and using the resources available to him (the sling) to surprise a ponderous and overly confident enemy with a small but deadly stone to the forehead. Compare that to the SEIU, which has diverged from those methods and become reliant on the trappings of power to acquire still more trappings of power. The union may or may not be successful in following this path, but in the meantime it will not be able to answer Hillel's three questions in a manner consistent with an underlying set of values that will motivate workers and that is respectful of them.

Happy Chanukah, Katya Apekina style

When ceramic artist Katya Apekina arrived in the US from Russia, she was virtually unknown here. We purchased one of her works, this pretty Chanukah menorah, in 1992. At the time, most of her pieces were quite small. One of her friends, Francis Putnoi, was introducing her to the art world and advised her to produce larger pieces. She made many of those, some of which are on display as the decor in Newton's Cafe St. Petersburg. Since then she has become very popular. Katya also makes pieces for table tops and other settings, often with a Jewish theme. Here is her website.

McAfee and his new enterprise

I just attended a book party for Andrew McAfee, who has written a great book called Enterprise 2.0 (Harvard Business Press). Here's my blurb for the book:

"Andrew McAfee coined the term Enterprise 2.0 to describe a phenomenon that has changed the way the world does business. Now he takes it a step further. Whether your firm is already deeply embedded in Enterprise 2.0 or you are trying to communicate its value to your staff and your customers, you will soon wear out this book by repeatedly referring to its thoughtful descriptions, advice, and insights."

Here's a view of Andy at the party, courtesy of my new Flip video camera. Uh oh, another addiction!

Two cheers for Dave

This post is in honor of e-Patient Dave, on two fronts:

Point 1: Old prejudices die hard, even among well intentioned people.

There's a site called The Web Nurse with lots of useful information about online training to be a nurse. They recently published a list of "Top Blogs to Learn About Medicine." I was flattered to be included, but then I started looking at the list. Do you see what's missing? There is a not a single blog written from the point of view of patients, by patients, or for patients.

If you look to the right, I have a list of almost 20 excellent ones, especially this one, without trying very hard. Can't a nursing site do better?

I don't think I would have noticed this a year ago, but I have had the message pounded into me by Dave's blog (compounded by a bit of training from IHI's Maureen Bisognano).

Point 2: Symptoms give rise to differing possible diagnoses.

Dave himself was recently invited to speak to the regional San Francisco Healthcare Information and Management Systems Society meeting. He reported to me:

20 minutes into the talk, the lights in the left side of the room went out. Somebody suggested "Motion detector?" Well, there were 50 people on that side of the room, so I didn't think it likely, but I went over and waved my arms, and the lights came on. Since that didn't happen any other time that day, it appears that side was motionless long enough that the sensors thought everyone had gone home. :)

I replied that this indicated one of two things. Either he put everyone to sleep, or they were in rapt attention and therefore not moving. Based on our recent Grand Rounds, I surmised the latter, because I saw the same effect with our doctors. But you never know. Maybe he had a bad day.

Fortunately for Dave's future speaking career, the riddle was solved by a report from Jan Oldenburg of Kaiser, board member of Northern California HIMSS, who organized the event. She said that a board member described the talk as "mesmerizing."

Red Sox Scholars @ BIDMC

Part of the Red Sox Scholars program is to give the kids exposure to a variety of career opportunities and fields of endeavor as they go through middle school and high school and think about college and beyond. Today, the Class of 2009 came for a view of our medical and surgical Simulation and Skills Center and our NICU. They asked lots of great questions and took notes. (But that was after the pizza.)

Ppl hv 2 pass niceness tst 2 wk here, rt?

Ppl hv 2 pass niceness tst 2 wk here, rt?

This was a text message I received this morning from a grateful patient.

My reply, "Right!"

Here's an example, a note from a person in human resources to the head of our food services:

Good morning Nora,

I would like to applaud two of your wonderful employees, Odalis Lajara and Janaliz Figueroa from the Farr Cafeteria. This morning I went to the café and when I got to the bottom stairwell, I found an elderly woman who looked like she was about to pass out. I asked if she was okay. She stated, "No, I feel like I am going to get sick and I am diabetic." I called over to Odalis and Janaliz and told them in Spanish (the little I know) that she needed something to eat and orange juice to drink. We then had a team rescue going on. Odalis and Janaliz sat her down, I made her an english muffin and retrieved some orange juice for her. Odalis and Janaliz never left her side. We also gave her a banana and some peanut butter crackers.

We had a conversation with her and found out that she flew in from California, She is a patient of Dr. Chu at Joslin. We decided that Janaliz would escort the patient over to Joslin and I would return to work and contact Dr. Chu's office. I left my contact info for Dr. Chu to contact me with Shaka and she in turn would explain this situation to Dr. Chu. It was so wonderful of Odalis and Janaliz to come to the rescue of a grateful patient who in our conversation loves coming here to Boston for all her health care.

Please offer my sincere gratitude to both these employees for knowing that the patient comes first!

Thank you,
Michele

I've been Uncluttered!

Speaking of networks (like below), the largest single source of referrals I have received for this blog is this one, unclutter.com. It appears that lots of people in the world seek help to unclutter their lives! Those that do loyally follow the links on the pages referred to. Above is the listing of the top pages viewed on my blog over the last day or so. Beyond my last two posts, the most popular pages are exactly the ones embedded in the post to which unclutter.com linked.

Red balloons and social networking

A great story, here, about the use of social media to solve a difficult computational problem.

The U.S. Defense Department’s Defense Advanced Research Projects Agency (DARPA) was holding a competition that weekend: on Saturday morning, 10 large red weather balloons would be raised at undisclosed locations across the United States; the first team to use social media — like online social networks and communication systems — to determine the correct latitude and longitude of all 10 would receive $40,000.

They MIT team relied on incentives akin to Tupperware parties:

The crux of the MIT team’s approach was the incentive structure it designed — a way of splitting up the prize money among people who helped find a balloon. Whoever provided the balloon’s correct coordinates got $2,000; but whoever invited that person to join the network got $1,000; whoever invited that person got $500; and so on. No matter how long the chain got, the total payment would never quite reach $4,000; whatever was left over went to charity.

The result:

On Saturday morning the balloons went up, and by the end of the day the MIT team — which consisted of postdocs Riley Crane and Manuel Cebrian and grad students Galen Pickard, Anmol Madan, and Wei Pan — had won the competition.

Getting ready for Christmas

Forwarded by a friend. I'm not sure of the origin.

“The good news is that I truly outdid myself this year with my Christmas decorations. The bad news is that I had to take him down after two days. I had more people come screaming up to my house than ever. Great stories. But two things made me take it down.

First, the cops advised me that it would cause traffic accidents, as they almost wrecked when they drove by.

Second, a 55-year-old lady grabbed the 75 pound ladder and almost killed herself putting it against my house and didn’t realize that it was fake until she climbed to the top. (She was not happy.) By the way, she was one of the many people who attempted to do that. My yard couldn’t take it either. I have more than a few tire tracks where people literally drove up my yard.”

Not an early adopter

#IHI09 Following a wrong side surgery a year-and-a-half ago, an interdisciplinary team of our staff revamped our pre-surgical protocol and developed training materials for all OR staff. Here is a sequence of excerpts of recent emails on the topic.

Please rest assured that this doctor is in a distinct minority, at least in our hospital. Unfortunately, I heard reports at the IHI National Forum from people in other hospitals that his view remains all too common elsewhere.

---
Surgeons and residents,
Dr. Hurst (Acting Chair of Surgery) and I wanted to let you know you must complete this training module. All OR users must do this. . . .

Please click on the link below to go through the module and do the few questions required. Your completion will be recorded in performance manager, but if necessary send your verification e-mail to your supervisor so they can make sure you have been credited with completion. It is required of all attendings and residents using the operating rooms.

This is an important issue for the institution, as it was one of the corrective actions created when we had the wrong site surgery a while back. . . .

I am sending this out today, as there is a proposal being forwarded to the OR Executive Committee to block OR scheduling and resident access to the ORs until the module is completed. In so doing it is hoped we will have significant compliance. . . .

Thanks in advance for your help with this. If at all possible do it today.
Don Moorman, Vice Chair

---
Reply from one surgeon, sent (probably in error) to the entire mailing list!

Don,
I realize you are only the messenger, but in my humble opinion, this is the classic example of “the tail waging the dog”. Because some goofball operated on the wrong side, we now must all engage in this annoying practice every time we operate. It’s that kind of world, I guess. Too bad!

---
Response from Doug Hanto, Chief of the Transplantation Division, also sent to the entire mailing list:

I can guarantee you that every surgeon who has operated on the wrong side or left a lap or instrument in a patient never thought it could ever happen to them. These procedures are designed to protect patients from errors that even with the best intentions can happen to the best of us unless we are extra vigilant and have policies and procedures like this in place. . . .

Sincerely,
Doug

Good work and good works

Some noteworthy recognition and developments. Congratulations to all.

Paul Solman and team won an Emmy this week for outstanding coverage of a current business news story for "Faces Behind the Numbers," a duo of pieces on U.S. unemployment. This series included the story about the “share economy” with interviews of people at of the Beth Israel Deaconess Medical Center staff.

E-Patient Dave deBronkart and BIDMC's Dr. Danny Sands were were included in this year's list of "20 People Who Make Healthcare Better" in Health Leaders magazine. Dave writes about it here on his blog.

The Journal of Clinical Oncology (JCO) announced that BIDMC's Stephen A. Cannistra, MD, will become Editor-in-Chief of JCO effective May 2011. This was the result of an international search by American Society of Clinical Oncology. The JCO is the most highly regarded oncology specialty journal in the world.

Academic Medicine, the Journal of the Association of American Medical Colleges, published an insightful article about the development of the Center for Quality and Safety at Massachusetts General Hospital.

Facebook now has almost the same number of unique visitors as Google and Yahoo.

Joanne and Emily at your service

#IHI09 Many thanks to Joanne Healy and Emily Crites for organizing the logistics at the IHI National Forum. Everything went incredibly smoothly as the IHI "blue shirt" team took good care of 5000 people on site over four days in Orlando.

College drop-out does good (and well)

#IHI09 Marshall Ganz was the keynote speaker at this morning's plenary session at the IHI National Forum. As co-chair of the event, I had the privilege of introducing him. See biographical details here. An excerpt: "Marshall entered Harvard College in the fall of 1960. In 1964, a year before graduating, he left to volunteer as a civil rights organizer in Mississippi." And thus began a lifelong career in movement building. (He eventually, 28 years later, went back to conclude his degree.) Before getting into lessons learned, Marshall explained what it was like to be involved in the early days of the civil right movement in the South.

Marshall summarized five practices that constitute leadership for change, which I summarize very briefly here:
1) Using storytelling to enable people to act together for change. "Narrative is how we learn to make choices, to understand the world affectively. Stories teach us how to act under uncertainty. We need to learn how to tell stories purposefully."
2) Building relationships. "Create a mutual commitment to a common purpose. Association makes the whole greater than the sum of its parts."
3) Creating an organizational structure based on team leadership rather than individual leadership. "Establish clear norms of behavior for the teams."
4) Translating shared values into action requires a focus on a few strategic objectives. "How to turn what we have into what we need to get what we want. Good strategy flows from commitment. Commitment puts us into a place where we have to figure it out. Use the resources we have, not the ones we don't. Don't buy in to conventional notions.
5) Actions to be real have to be real, concrete, and specific, with measurable results. "It matters what we count. There has to be a connection between metrics and strategy. Does the strategy move us towards the goal and increase our capacity to work together, and are people learning and growing as a result of the effort?"

Session E11 at #IHI09

Yell Eureka if u c this!

That is a message to the attendees at the session (a repeat of the one below) I am now conducting at the IHI National Forum, entitled Using Social Media to Pursue Quality and Safety. I have asked them to keep their Twitter search open for the meeting hashtag, #IHI09, as an illustration of how quickly information can flow through the social media.

This post is timed to go up at 11:25 am, just after the session starts. My blog posts automatically are fed to Twitter, and the hashtag will ensure that this post is collected by Twitter in the National Forum collection of tweets. The first person in my session to notice the tweet and yell "Eureka" will win a prize.

In the session, I will present our journey at BIDMC in the use of social media in encouraging our programs in patient safety and quality. This all started with some posts on this blog about central line infections, ventilator associated pneumonia, and hand hygiene. We discovered two things from those posts. First, the world would not come to an end if we disclosed clinical outcomes from our hospital. Second, the public presentation of these data acts as a stimulus to quality and safety improvement in the hospital. It serves to hold ourselves accountable to the standard of care we strive for.

Following publication on this blog, we moved to doing the same in a more expanded way on our corporate website. Here, you can see some of the same quality metrics, but you also see the full survey conducted by the Joint Commission when they came to accredit our hospital. Why? Well, the Joint Commission has important things to say about how well we run our place and where we should make improvements. How better for everyone in the hospital to see those things than to post them on the company website?

Each hospital has to decide for itself what degree of transparency is appropriate and comfortable, but as noted by John Toussaint here at the National Forum, it is an essential component of a culture of continuous process improvement. Social media can help spread the world.

Added later: The picture above is of the winner of the prize at this session, Mark Trahant. Congratulations!