Just pecking

These guys were seen near our front entrance. At least they are not smoking!

(Thanks to pathologist Jonathan Hecht.)

AARP confirms value of mystery shoppers

I have written here once or twice about our mystery shoppers. Here's a new article in the AARP Bulletin on this topic.

As noted in this story, we continue to find this a very important way of meeting our patients' expectations:

Sherry Calderon, manager of ambulatory services at Beth Israel, says: “I really feel like this kind of regular checking has driven change here that nothing else has.”

Globe covers The Real Life Body Book

Here's a nice article in the Boston Globe by Liz Cooney about The Real Life Body Book, written by Hope Ricciotti and Monique Doyle Spencer. The opening:

Dr. Hope Ricciotti has noticed something different about her young patients. A gynecologist-obstetrician in practice for 16 years, she takes time during pelvic exams to explain what she is doing so the patient is informed and at ease during an uncomfortable part of the visit.

But younger women don’t necessarily want to hear what she’s saying. Lying back on the exam table, they might be texting or listening to their iPods.

My readers got early word of this book here.

Hope be not proud

I started to write this post to offer my appreciation to Kevin, MD, for posting a chapter of ePatient Dave's Laugh, Sing, and Eat Like a Pig, and for Dave and his publisher for graciously allowing anybody to read the entire chapter without having to buy the book. The story is compelling, and this particular chapter is especially so.

But that was before I read the exchange of comments on Kevin's blog. At least one commenter took offense at her perception that Dave was glorifying the role of hope in the treatment of cancer, and in so doing might be disparaging people who do not experience that hope, suggesting that they are somehow weak and inadequate. As you read through Dave's response and that of other observers, it becomes clear that he certainly did not intend to suggest such a conclusion. Indeed, by comment #15 or so, the exchange had gone on sufficiently long that the participants had come to a rapprochement on the issue, in part because of the respect they showed for each other's opinion.

During this last 8+ years that I have been CEO of a hospital, I have had occasion to talk to lots of people with cancer. Truthfully, I had never done so before because I was too uncomfortable to do it. To this day, for example, I regret not spending time with my good friend Leah as she was dying from breast cancer about 20 years ago. As I suspect is the case for many of us, I just found it too scary and uncomfortable. I now have started to appreciate what I lost as a result, and I also have learned how helpful I could have been.

Each person faces cancer in his or her own way. There is nothing right or wrong about the different approaches people take. Denial or acceptance is not a statement about someone's character. Having hope or not does not always come from an explicit decision to be hopeful; it often just happens one way or the other. Likewise, the spectrum from stoicism and strength to dependence and, yes, even weakness, are reactions that are unpredictable until you are actually faced with the disease. Too, how one feels can change over time -- whether minute to minute, day to day, or year to year. So, one thing I have learned is not to be judgmental about how a person responds to cancer.

The other thing I have learned, I think, is how to be helpful. I'm not talking about bringing over dinner or giving someone a ride to chemotherapy or other such logistical support -- although that is helpful. No, I have learned how to have a conversation with a cancer patient and hear what he or she needs to tell me. I have learned how to answer and, equally important, when not to answer. I have learned that a lot of the protective layers that we include in our day-to-day conversations fall away when someone knows that he or she might be dying.

I always wondered how people could choose to be oncologists. I used to imagine that it would be the most depressing field of medicine, in that a fairly high percentage of the patients die of their disease. I have come to understand the happiness that a doctor feels when he or she helps a patient beat the disease outright or gain several more years of life. But, I have also come to understand the deep connection that can occur between an oncologist and a patient, especially when the disease is terminal.

Several years ago, one of our beloved hospital employees lay dying with cancer. I went to visit her at the bedside and hold her hand. We talked quietly. She said she was concerned about how her children and grandchildren would do without her. Deeply religious, she was really wondering how they would choose to live their lives. I listened and then I said, "You have to trust that you have given them an upbringing that will lead them the right way. Now, it's time for you to stop worrying about them and just think about yourself." She sighed and smiled and said, "I suppose you are right," and I could see her body relax right then and there. What a gift we had given each other in that moment.

So, now I want to express my appreciation to Kevin, Dave, and Dave's publisher for giving us a chance to eavesdrop on one of those conversations. I want to thank them for giving us a chance just to witness first hand the bared souls of people who have faced this disease in whatever way is best suited to them.

Toussaint and Gerard tell us how to get on the mend

John Toussaint and Roger Gerard have published a book entitled On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry. Ordinarily, you would be well advised to be skeptical of anyone promising revolution and transformation, but not here.

Here's an excerpt from the introduction:

With few exceptions, [government policy] debaters assume that healthcare costs are fixed, that America's proud history of medical care and innovation comes with a staggering bill.

We know different.

Governments can tweak payment systems and probably get some temporary fiscal relief. But until we focus reform efforts on where most of the money goes, which is healthcare delivery, we will remain stuck in a revolving door of near disaster and narrow escapes. To get to the point where all people have access to high-quality healthcare, affordably, we must focus our attention on how the healthcare delivery system determines costs and quality. Then we need to change that delivery model entirely.

In fact, hospitals, physicians, and nurses -- all of healthcare -- must change. First, we must emphasize the science of medicine over the art. This means turning to evidence-based medicine, which is already underway in some sectors. But we are also talking about evidence-based delivery, work that has barely begun.

And then, they go on and explain how to do this.

You can get a sense of the message in this video produced by the Lean Enterprise Institute, which also published the book. If you can't see the video, click here.

$20 billion may not be the whole story

In case you missed this, preventable medical errors costed the country $19.5 billion in 2008 — or roughly $13,000 for each avoidable case, according to a report published Monday by the Society of Actuaries (SOA).

Maybe I missed them in the document, but I didn't find central line infections, ventilator associated pneumonia, spread of MRSA, failure in timely recognition of patient deterioration, failure to diagnose, and other conditions that can result from systemic flaws in the delivery of care. If so, the number is understated.

For example, we found remarkable cost savings resulted from avoiding ventilator associated pneumonia in our hospital alone. As discussed below:

Preventing 744 cases over three years -- at a treatment cost of about $20,000 per case -- translates into a societal savings of $14.9 million during this period.

Whether $20 billion or more, the report presents yet another compelling reason to eliminate preventable harm in our hospitals.

Reducing Risks During Hand-offs

The hand-off of a patient from one doctor to another is an episode ripe for potential problems. Important data about the patient's condition might not be transferred, and there is also the potential for miscommunication between the caregivers. In academic medical centers, the responsibility for the hand-off is often in the hands of the interns, i.e., the first year residents. As duty hours for residents have become more restricted to avoid overtired doctors, the number of hand-offs that occur has necessarily increased -- by something like 40%.

(The trade-offs between the dangers associated with tired doctors and those associated with increased hand-offs has been well discussed elsewhere, and it is not my purpose here to argue the case. For the former, you find serious medical errors, medication errors, diagnostic errors, car crashes, depression, and burn-out. For the latter, you find longer lengths of stay, medication errors, and more adverse events, especially those associated with communication failures.)

Three years ago, the Risk Management Foundation published an edition of its Forum entirely devoted to the subject of how to reduce risks during hand-offs. It remains a good summary of the issues, and you can view it here.

Last year, one of our Senior Residents, Kelly Graham, decided to use the research phase of her residency to test out some interventions to see if they could reduce the likelihood of hand-off related errors. She compiled the following baseline assessment for BIDMC (which, as noted, was similar to a previous assessment at Brigham and Women's Hospital):


Kelly decided to focus on three aspects of hand-offs: The systems in place, the written communications, and the oral communications. Her hypothesis was that by taking a systematic approach to intervening in each component of the patient hand-off, we could improve the quality of sign-outs, patient safety, and intern satisfaction.

The "prior" that Kelly was trying to change is the age-old system: Interns learn how to do hand-offs on the floors by watching their senior residents. Process improvement folks reading this know that is a recipe for a high degree of variation in practice and for a systematic transmittal through time of bad habits and approaches that increase the likelihood of harm.

So, Kelly's aims were to provide resident physicians and patients with safe hand-off practices; to promote a “standard operating procedure” for hand-off; and to take hand-offs out of the hidden curriculum of medical training and make it part of our formal education process.

On the system side of the equation, she noted that many hand-offs actually did not occur between the doctor leaving the service and the doctor arriving. Instead, an intermediary person often took the information from the departing doctor and later relayed it to the arriving doctor. Like the old game of telephone, this increased the likelihood of flawed information transfer. (In fact, prior studies indicated a loss of 22% of the desirable information that should be passed along at the time of transfer.)

The alternative was to require direct communication between the departing intern and the arriving intern, in a standard location (the house officer lounge). Doctor-to-doctor interaction increased from 25% to 100%.

The next intervention was designed to present a common template of information to be transferred. Pull-down menus on the computer helped to ensure that standard categories would be discussed, and standard language would be used as much as possible to reduce variation in the transmittal of patient data.

And the final intervention, the one that is likely to raise eyebrows among my lay readers, is the idea of teaching how to do a sign-out in the classroom before arriving on the medical floors. Huh?

Well, the baseline assessment was that interns are not prepared for hand-offs during medical school. 91.3% of interns at BIDMC reported no hand-off training prior to residency; and 92% interns nationally report no hand-off training prior to residency. So Kelly designed and implemented a case-based, interactive, sign-out workshop during the interns' orientation.

As the year went along, she surveyed the residents and also kept track of patient data. She reached the following conclusions:

Interns are ill-prepared for transitions of care; “double hand-offs” may reduce work hours slightly, however the trade-off is that they may be unsafe for patients; involving the primary team in the hand-off process has a powerful effect of patient safety and physician satisfaction; electronic templates are reliable tools to ensure sign-outs are complete; and interns respond well to incorporating hand-off training into their education.

And, now look at the clinical efficacy of the experiment. There was a dramatic reduction in adverse events, near misses, and data omissions. In fact, the first two interventions were so powerful that it was not possible to fully evaluate the strength of the last one -- but the training did help to improve interns' job satisfaction.

The interventions are now embedded in our Department of Medicine's system of training and care. The interns who just arrived don't know enough to know that they are doing something different from the past because they never experienced the ad hoc system that was in place before. Congratulations to Kelly and her colleagues for demonstrating how an academic medical center can contribute to the improvement of clinical processes, something just as important as our contributions to basic and translational research about disease.

CPOE adds to GRACE

Many of you have expressed an interest in GRACE (Global Risk Assessment and Careplan for Elders). This is an experimental protocol designed to improve the care of all hospitalized elders admitted to BIDMC, with the hope that we will reduce the risk of delirium, falls, pressure ulcers, and functional decline.

A key component of GRACE is its integration with our computerized provider order entry system. Here is a recent article on that from Scientific American, which in turn is based on an (unfortunately subscription-required) article in the Archives of Internal Medicine. Here's an excerpt, quoting Doctor Melissa Mattison on our staff:

"Our study found that when doctors were alerted that the drugs they were ordering could pose a danger to older hospital patients, the orders dropped almost immediately," said Mattison, who was the first author on the study.

After the new CPOE function was installed at BIDMC in 2005, the orders for potentially inappropriate medication (PIM) for older adults dropped—and stayed—some 20 percent lower than what they had been (down from an average of 11.6 a day to 9.9 a day).

"Many drugs commonly used today have not been tested in seniors or elderly patients," Mattison said. "As a result, a dose that is appropriate for a younger adult may lead to potentially harmful side effects in older individuals, who tend to metabolize medications more slowly."

Massachusetts update

Here is one of my occasional updates on the Massachusetts scene, for people looking for hints as to the kind of issues that might arise nationally as health care reform is implemented.

I have written several times about the ongoing saga between the state administration and the health care insurers in the state concerning premiums for small businesses and individuals. Over the last several weeks, several insurers have reached settlements with the Division of Insurance. At least one has not and has prevailed at the appeals board because the rates forced upon it by the state were not actuarially sound. Where settlements have been was reached, they were not based on actuarial principles: They was based on a desire to get past this impasse and provide some stability to customers.

Here's a quote from one company official:

Blue Cross spokesman Jay McQuaide said the organization agreed to accept “less-than-adequate rates’’ — which he said are too low to cover its costs — to resolve the uncertainty for customers.

The disturbing aspect that remains is a lack of understanding by some state officials of the issue. There appears to be a presumption that hospitals and doctors are somehow taking advantage of the situation to raise their costs. But that is at variance with what hospitals are actually doing and facing.

Here, for example, we see one hospital facing huge losses and another one laying off staff in the face of financial pressures.

There are sophisticated observers of the scene, however, who continue to offer thoughtful views. Here is an op-ed in today's Boston Globe by Robert Pozen entitled "A bitter health care pill." An excerpt:

[T]he perfect is often the enemy of the good in health care. Instead of taking a decade to move from fee-for-service to a capitation system, the state should implement two relatively significant cost-saving measures: Reduce the number of mandatory coverage items and charge higher copayments for using the highest-cost providers.

Blocking Facebook won't stop stupidity

A couple of people have asked me to address the recent story in California about some hospital employees who took pictures of a dying patient and posted them on Facebook. Some of these people have been fired, and others have been disciplined. "Aha," some have said, "this shows that Facebook and other social media should be banned from hospital servers."

Here's what it really shows. It shows that some people are really insensitive and don't understand the privacy laws.

Is Facebook the cause of this? No. Does it facilitate the publication of pictures of all kinds? Yes.

As noted here, breaches of patient confidentiality can happen in many ways. Apparently, a common problem is when patient data is faxed to the wrong telephone number. And then there are the occasional cases where a portable computer with patient records is lost.

I know the counter-argument. These other examples are minor lapses and don't cause patient data to be spread to thousands of people instantaneously.

But here is the point. If you block Facebook on the hospital server, will it nonetheless be used in the wrong way by misguided people? Yes. They will use their iPhones or some other such handheld devices.

I know this sounds like the pro-gun argument, "Guns don't kill people. People do." However you might feel about that issue, this one is different. By blocking this medium on your hospital server, you will remove a highly effective communications tool, all because you are fearful that a few misguided people will misuse it. You trade the illusion of security for a loss of community.

Feral tomato rescued and brought back into society

Here's a follow-up to my Saturday post about our opportunistic tomato.

Our head of operations writes:

Hi Paul,

This picture shows how Brendan's team showed this plant a little TLC. His team will continue to give it special treatment!

Rick

We fail when we don't forgive

For my soccer friends, but also for observers of the hospital world, here is a lesson in unforgiving behavior, from a blog subtitled, The Cultural Politics of Soccer. I am reminded by a statement from one of our doctors: "We are told that we are not permitted to make mistakes." This is, of course, an impossible standard of performance for anybody. The great leaders throughout history have tried to teach us that learning and redemption -- not only for the protagonist but also for his or her community -- only occur when mistakes are accepted as part of the human condition and are acknowledged with a generosity of spirit.

The summary:

Rättskiparen (The Referee) is short documentary about Martin Hansson, the referee who missed Thierry Henry's handball. A Swedish television program had already committed to this project before the infamous incident which kept Ireland from going to South Africa. The station's plan had been to track the country's top ranked referee in the months leading up to the 2010 World Cup - as fate would have it, the story of course got more complex with that one game. It's an incredible portrait - part of a wave of films looking at referees. This one has an unusually personal quality to it.

If you cannot see the video, click here.

Rättskiparen | The Referee [2010] from Freedom From Choice AB on Vimeo.

A tree grows in, er, well not quite!

Many thanks to Justin for chatting with me on Facebook about this new life form in a highly trafficked area just outside our ambulatory center in the Longwood Medical Area:

Heads up, a rogue tomato plant is growing outside Shapiro, sidewalk side of the soup or salad patio. It's amazing it survived as long as it has, but it has flowers, and likely will soon have tomatoes, well if it is not kicked, pulled, or weeded.

I surmise that someone dropped a tomato while eating a salad for lunch.

Lean is for bakeries, too

There is a problem once you learn the Lean philosophy and techniques: Every setting prompts you to imagine how much better it could be if these principles were adopted.

Earlier this week, a friend gave me a sample of some marvelous cranberry bread from a new bakery in Wellfleet, PB Boulangerie. She warned, though, that the place has long lines and that I should be prepared to wait, unless I arrived at the 7am opening time. I arrived at 7:05 and found a line of 20 people. Here is a picture of the ones behind me after I had been there ten minutes.

Now, it is summer on Cape Cod, and who really cares if you have to wait? You meet people from all over and compare notes about beaches, restaurants, and the like. But, then we noticed that the line was scarcely moving. Earlier customers set up their coffee and pastries at a nearby table, and they were practically finished eating by the time I approached the front door.

Once inside, the problem was made evident. There were plenty of serving people (four), but the bakery was rife with batch processes. Two people were in charge of taking orders for bread and pastries; one person was in charge of coffee orders; and one person was the cashier. After the bread person took your order and put it carefully in bags, s/he would place the order on a low shelf, under the counter near the cashier. Meanwhile, the coffee person would hand you your coffee directly.

By the time you got to the cashier, she had become a bottleneck. She would reach under the counter and grab the closest order, and lift it up and place it on the counter and say, "Did you have two baguettes?" and you would say, "No, I had the brioches," and she would bend down and replace the first order with your order. Meanwhile, some independent process would be going on for the coffee.

The person next to me was a process engineer, and so you can imagine the conversation we started to have. What if there had been a continuous process, with visual cues, all focused on the needs of the customers? The possibilities were endless.

In this case, though, the elapsed service time, start to finish, was 55 minutes.

But, here are the almond paste and raspberry brioches, along with the cheese bread and cranberry bread. Worth the wait!

Gazpacho without tomatoes

As we approach the ripe tomato season here in New England, gazpacho shows up more and more in restaurants and home dinner parties. That led me to wonder what the Europeans used before tomatoes were introduced from the New World.

Well, it turns out that there is a tomato-free form of gazpacho in Spain, called ajo blanco, based on almonds, bread, and garlic. It appears to be of Arab origin. Here's the recipe.

Now, while we are at it, what did the Italians use on their pasta before tomatoes arrived? And reaching back, what did they use for a starch before pasta arrived? (No, Marco Polo did not bring noodles to Italy. It appears that the Arabs had something to do with this, too.)

Waving goodbye to Wave

Google recently announced that it was abandoning Wave, a multimedia social media collaboration tool. I'm sorry about this, as I thought it had great potential. That being said, I never used it, so perhaps I was typical. Pete Cashmere writes on CNN Tech:

Wave was perhaps the prototypical Google product: Technically advanced, incredibly ambitious and near-impossible to use.

Its demise is the canary in the coal mine for Google's social networking plans: Facebook is destined to build the Web's next wave, as Google continues to tread water.

Meanwhile, let's take a look at what is going on at Facebook and elsewhere, courtesy of EduDemic. I offer #6 (regarding Facebook) and #10 (regarding Twitter) especially for those hospitals and other companies who choose to block these media on their servers, in the hope they will consider how fruitless that is.

1. The average Facebook user has 130 friends.
2. More than 25 billion pieces of content (web links, news stories, blog posts, notes, photo albums, etc.) is shared each month.
3. Over 300,000 users helped translate the site through the translations application.
4. More than 150 million people engage with Facebook on external websites every month.
5. Two-thirds of comScore’s U.S. Top 100 websites and half of comScore’s Global Top 100 websites have integrated with Facebook.
6. There are more than 100 million active users currently accessing Facebook through their mobile devices.

Over at Twitter:

1. Twitter’s web platform only accounts for a quarter of its users – 75% use third-party apps.
2. Twitter gets more than 300,000 new users every day.
3. There are currently 110 million users of Twitter’s services.
4. Twitter receives 180 million unique visits each month.
5. There are more than 600 million searches on Twitter every day.
6. Twitter started as a simple SMS-text service.
7. Over 60% of Twitter use is outside the U.S.
8. There are more than 50,000 third-party apps for Twitter.
9. Twitter has donated access to all of its tweets to the Library of Congress for research and preservation.
10. More than a third of users access Twitter via their mobile phone.

No gamble on this front

Given the continuing front page coverage of a failed gambling bill, Massachusetts voters have reason to be forgiven if they have no knowledge of the recently passed health care bill. There has been virtually no coverage of the legislation which passed both houses unanimously last week.

As I noted below, the bill's provisions about transparency of rates, costs, and clinical outcomes are noteworthy. But there are other important features, too.

If you do a web search, you find some mention of the bill. Here's a piece from an insurance web site. The head of the retailers association, a person who was not timid in past months about the need for a bill, is quoted:

Jon Hurst, president of the Retailer's Association of Massachusetts, said the bill will enable small businesses to obtain premium prices that large employers use their market clout to secure.

"This is the most important reform small businesses have seen in 20 years designed to give them and their employees' health insurance premium relief and equal rights under the law and in the marketplace," Hurst said.

I offer no opinion here on the gambling bill, but I am confident that whatever its economic impact might or might not have been, the economic impact of the health care bill will be more pervasive for years to come.

Staff talk about purpose

Here are some responses I received to the staff email presented below. I never know how my messages will be received or what reactions they will provoke. I can always count, though, on thoughtful engagement and a reaffirmation of the underlying values of our hospital.

Excellent example of actualization of purpose versus a mission statement not so well actualized. (Radiology)
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I love it, thanks. I have always tried to live by, "Treat others as you would have them treat you" and have raised my children as my parents raised me. My daughter now works as fitness trainer working with the elderly (many of whom remind her of her now deceased grandparents) and my son found his passion working to integrate those with special needs. To know that I work for such a special organization makes coming to work even more enjoyable.

Working with women in OB/GYN, I try to treat each on as I would want my mother, sister, or daughter treated. It makes no difference to me when I am informed that a patient is a doctor or wife of one. No one gets special treatment, because I feel everyone that comes here gets SPECIAL treatment!
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I have always believed by giving some control back to the patient, it helps eliminate high anxiety and make the patient feel respect. Thank you for your thoughts. (Med/Surg)
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As a nurse on labor and delivery I just wanted to say that was a wonderfully put statement. As you know we on L&D form very strong emotional bonds with our patients and their families sometimes repeatedly with additional children . We form a certain kind of interdependence relying on each other in a way that is truly unique. Thanks for the "heads up." We appreciate it, and it made total sense. Also made me smile.
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Hi Paul...this is a great message from you, and I look forward to hearing more, as time goes on. You may remember several years ago when you hosted small groups for dinner, we spoke about treating patients as we would want our own families and loved ones to be treated. As part of my interviewing process, since I began in this position, I have always referenced that message. What I tell applicants (and anyone else who will listen to me!!) is, "I need people who treat everyone, but I will concentrate on patients now, as they would want to be treated or how they would want their families or loved ones to be treated." If we don't do this, then when our time or their time rolls around, and it does roll around for all of us sooner or later, we have no right to expect more than we've given. And even if it feels like it isn't happening, that's okay, do it anyway because it's the right thing to do!

Your statement, "It is very different from the training received by doctors, and even that received by many nurses. Beyond being respectful, empathetic, and compassionate, it requires us to be ever modest about our knowledge and in our demeanor."

This is key! Until and unless we all recognize and appreciate that we all need the next person in order to be successful, to make the clock tick, we will never rise to the level we otherwise might. The surgeon needs the housekeeper to clean the OR, the housekeeper needs the equipment to accomplish the work, the manager needs a strong staff, and on it goes. I have always believed that no one is more important than the next, and that, in medicine, patients must be listened to with great attention; if not, we've lost a great deal in the process and will never reach the heights that we are capable of reaching - together. The crush is on in health care, all around! (Gastroenterology)
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Thank you very much for sharing with us the airline industry story. it is so true that we can never forget what we are working at BIDMC for. We are here to carry a big mission in delivery -- the best and safe care for our patients and their families.

We should never forget how lucky we all are that we are not standing the other side in needing that care but using our skill and knowledge in helping the others. (Peri-Operative Services)
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I was thinking precisely the same things about airlines and customer service as I flew back to Boston on a crowded flight on Saturday. I always check Southwest first, not because they're necessarily cheaper, but because I like their ethic, and the tension on other airplanes due to carry-on baggage simply doesn't exist there.

Not too long ago, I asked a flight attendant at another airline how they coped with the increased carry-ons. She surprised me by saying that their cabin crew were not actually logged in as "at work" until the flight took off. Any arranging of bags and assisting of passengers before take-off was quite literally done on their own time. So, apparently, it's the customers and the staff who are suffering from the checked-bags policy.

Compare that with our ethic here at BIDMC - treating patients "as we would like ourselves and our families to be treated". This is so often the way to make the patient experience simpler, more efficient, and crucially - more welcoming. A motivated staff understand and agree with the reasons for doing what they do. That's a large part of what we Mystery Shoppers encourage among our terrific front-line BIDMC staff.

Thanks for a thought-provoking message. (Ambulatory Services)

On purpose

An email I sent to our staff last night:

Dear BIDMC,

Stick with me through some background that might seem irrelevant. Then, I hope you like where it leads!

A few weeks ago, I heard a talk by Roy Spence, the author of It's Not What You Sell, It's What You Stand For: Why Every Extraordinary Business Is Driven by Purpose. As suggested by the book's title, his proposition is that truly excellent organizations are those characterized by a common sense of purpose. This is different from having a mission statement or corporate objective, which state a business direction. It is more about having a desire to change the world for the better.

An example Roy gave was Southwest Airlines, who purpose is to give people the freedom to fly. You could probably quote the tag line: “You are now free to move about the country.” I listened as he talked about the airline’s actualization of this sense of purpose. One example occurred when the entire airline industry decided to start charging for baggage. Southwest was advised by its financial people that doing the same would save millions of dollars and make millions of dollars. The company decided, though, that charging people for luggage would conflict with its purpose and so -- contrary to all advice -- not only decided not to charge for luggage but to begin a now famous Bags Fly Free advertising campaign. “We love bags!” proclaimed actual baggage handlers on the tarmac.

Sure enough, the company did not save or make millions of dollars from this decision. It made billions of dollars, as the public responded by shifting gobs of business from other carriers.

I hadn’t thought about this much until today, when I got on an American Airlines flight and noticed virtually every passenger board a full flight with a “rollerboard” style suitcase to put in the overhead bins. They were all trying to avoid the $25 fee for checking their bags.

The tension was palpable among the passengers and the flight attendants. Passenger who boarded later peered ahead in the aisle wondering when the next open spot would be for their bags. Flight attendants were alternating between repacking each overhead bin to maximize its carrying capacity and hurrying passengers along so we could have an “on-time departure.”

The result: Airline employees were devoting all of their emotional energy to the baggage. If you had questions about anything else, they could not make eye contact because they were scanning the bins for empty spaces.

Another result: Passengers’ relative comfort with the flight had already been diminished, and we hadn’t even taken off yet. Categories were created between the “have’s” and “have not’s”. Those of us who arrived earlier (because of “priority access”) felt the calm superiority of secure overhead bag placement, while those who arrived after felt like they had missed something. One person actually asked me how I had managed to get on board before her.

To think, this all started with a different sense of purpose. For Southwest’s staff, everything is about wanting to give us the freedom to fly, and because of that, the airline’s customers never have a doubt.

I realized that I’d be hard-pressed to know American Airlines’ purpose. I opened up the magazine in the seat pocket to see if I could find it. There is a letter from the CEO which says something about “all my AA colleagues all over the world who put their hearts and souls into taking you wheresoever you want to go in the world.” At first blush, you might say that is the same thing Southwest says, but it is not quite the same. The AA line is about their doing something for you, not your doing something for yourself. It is not liberating: It is creating a dependence.

Let’s switch to medicine and hospitals now. As you all know, at BIDMC, we have a long-standing purpose. It is not a business objective in our strategic plan or mission statement, but it is deeply held: “To treat patients and their families as we would want members of our own family treated.” Achieving this purpose is a full time endeavor for all of us who work here -- including those involved in research and teaching as well as clinical care.

In the last eight years, we have accomplished a financial turn-around, successfully implemented a strategic plan and gained market share, dramatically enhanced patient quality and safety, come together as a community during economic hard times to save jobs and to protect our most vulnerable staff members, and begun an approach to process improvement (Lean) that is highly respectful of one another.

And, through it all, we took great care of patients and their families.

Notwithstanding these great successes, we have begun to learn that we cannot satisfy our purpose if we make all the decisions for patients and their families. In the ICUs and elsewhere we have established patient and family advisory councils that bring in the wisdom of our clients in logistics, space planning, and even clinical protocols. Several months ago, I wrote about one such effort in our ICUs that actually received international recognition.

Of all the lessons we have learned here at BIDMC, this may be the hardest. It is very different from the training received by doctors, and even that received by many nurses. Beyond being respectful, empathetic, and compassionate, it requires us to be ever modest about our knowledge and in our demeanor.

This kind of approach is most successful when it is a partnership, where dependence in one direction is transformed into bidirectional interdependence. I'm not writing today to provide lots of details, but to give you a heads up: Over the coming months, look for an expansion in our engagement with these advisory councils and other outreach to our patients and their families. We also plan to work with the Institute for Healthcare Improvement to encourage and enhance the activities of patient-run organizations in Boston and beyond.

If we can learn to be full partners with our patients in carrying out our purpose, the sky’s the limit.

Thanks, as always, for your involvement, support, ideas, passion, and encouragement.

Sincerely,

Paul

In memoriam: Daja Wangchuk Meston

There is a beautiful obituary in today's Boston Globe about Daja Wangchuk Meston, about whose book Comes the Peace I wrote over three years ago. I am hard-pressed to add anything to Bryan Marquad's summation except to agree with one person quoted:

"Laughter and giggling and levity are the spirit of life. It’s what we need and what we all crave. Wangchuk had it and it was natural and graceful.’’