The oatmeal chronicles -- Part 3

#IHI Just when you thought it was safe to have breakfast, the oatmeal chronicle offers another chapter.

In the post below, Joe Wright offered the following suggestion:

Two fixes that require no extra labor, and no new equipment:
1. don't serve oatmeal
2. do serve oatmeal, but use tapered soup bowls instead of those vertical-side breakfast bowls.

The problem as you laid it out previously was the bowls being too small for the ladle, right?--so you can change the ladle size or the bowl size. Easier to change the bowl size, because the hotel should have tapered-side bowls for soup or salad already without having to purchase, store, and maintain new bowls, new ladles or a new oatmeal dispensing system. In fact, if they can be washed quickly between breakfast and lunch services it means that the inventory is being used more efficiently as the bowls will be used 2x-3x/day rather than once, as with these breakfast bowls.

Given the low cost of oatmeal relative to other breakfast options, even if this might lead to guests taking a slightly larger quantity of oatmeal on average, it would still likely be worth it.

So imagine my surprise when, this morning, I see a waiter bringing a tray of larger bowls for use by the oatmeal servers. I say, "Those will be easier." He says, "Those are the backups, in case we run out of the smaller ones."

Snatching defeat from the jaws of victory. The solution was not only evident, but actually presenting itself.

Poster session @ IHI Annual Forum

#IHI The poster session at the IHI Annual Forum is a cornucopia of quality and process improvement projects from dozens of hospitals and physician groups. I filmed a few of the presenters and offer them here to give you a sense of the variety.

If you cannot see the video, click here.

Maureen sets the tone

#IHI Maureen Bisognano has just welcomed the 6000 delegates here and 15,000 watching around the world at the opening session of the IHI Annual Forum. The CEO's address establishes the theme for the Forum and for IHI's activities for the coming year and is a highlight of the conference.

Maureen's empathy and kindness come through in all she says and does, and so it was not surprising that her address focused on the patient experience. Some excerpts:

When [my nephew] Robbie was four months old, my sister took him back to his doctor for another routine check-up. During the visit, the doctor told my sister he would be giving Robbie his 4-month DPT shot. My sister asked, “Don’t you remember what happened last time?” The doctor paused. My sister described the hospitalization after the last shot, and the doctor told her that the illness was unrelated. He hesitated for a moment and then said, “I’ll give him half a dose,” and then administered the vaccination. Robbie died within 24 hours.

My sister asked me three questions that changed my life. She asked:

Why did the doctor not have the hospital records on hand?
How did he not know what the right care was?
Why didn’t he listen to me?

[Referring to some 220 patient and family histories for 34 different diseases and conditions taped by the New York Times' Karen Barrow:] I’ve been comparing the burden of illness, the voices of the patients in these videos, the experiences of patients and families I meet traveling around the country, to the clinical encounters I see. The conversations are really quite different, in many cases. I see empathy and technical excellence, but the conversation is medical, focused on the disease and often not on the total burden.

[Citing from Henry Ting and Victor Montori at the Mayo Clinic:] When we can’t lessen or ease the burden of illness, we can redesign to lessen the burden of treatment – they call this “minimally disruptive medicine.”

An ideal health system balances the contributions of science and the strengths and needs of the individual; and most important for achieving the specific outcomes with the patient, it has a robust learning system “for the patient”; “for the science” at all levels to modify plans when changes will help, and to leave things as they are when tampering is expensive and ineffective.

Then there is the personal part of caring and healing. How do we best teach new nurses and physicians, clinicians and leaders, how to care and how to improve?

Sometimes caring is minimally invasive technology that optimizes great advancements in the tools of care and minimizes pain and the length of time a patient has to stay in a hospital. Sometimes caring is minimally disruptive processes that are designed to care with and for the patient. Sometimes caring is just standing there. And sometimes, caring is partnering.

Rather than thinking about our work as caring for illness, Antonovsky offers a model of a continuous variable – a “health-ease” instead of a “dis-ease” continuum. A major factor in producing health is resilience – a sense of control and understanding. This will require new and deeper partnerships between patients and families and their provider teams. For years, we’ve had providers with empathy and a strong sense of caring. But what I’m adding today are processes and new designs to support and accelerate the conversations and to build resilience.

Together, our destination is the Triple Aim. It won’t be easy. It’ll take courage, new leadership skills, new care models, new business models, a commitment to equity, and new assumptions:

-- Health care systems can be sustained with modest annual cost increases; and
-- There is enough capacity in the systems to provide equitable, high-quality care to all; and
-- Solutions to national problems will be designed and implemented at the local level.

The theme of this year’s Forum is Taking Care. With a focus on our health, we’ll be better able to take care of those who rely on us. We’ll be better partners with our patients and families. We’ll take care when we need to strengthen our capacity. We’ll take care of the precious resources of our time and our spirit. We’ll take care of our system. And with the new models we’ll build and share in 2011, I can call my sister and answer her questions about Robbie....

Welcome to the 22nd Annual National Forum. Take care, everyone.

The oatmeal chronicles -- Part 2

#IHI The oatmeal chronicles continue, with the folks at the Marriott displaying impressive responsiveness to the process problems noted yesterday. As you can imagine, revamping things overnight for a crowd of 6,000 people is not easy.

We arrived at the food area this morning to find friendly people serving the oatmeal. You can't expect a hotel to replace all the bowls and serving utensils at the drop of a hat, so this was a successful fix for the time being.

A member of the management nabbed me and graciously thanked me for pointing out the problem yesterday. "That's the best way for us to improve," she noted. "Thank you." A very good attitude!

So, for my readers, what would you do next on this issue? Is this the optimum solution? Is there a way to fix the underlying problem that is not so labor intensive? What else would you consider, and how would you do it?

Something tells me that this is going to be a case study at the next hospitality association annual meeting!

Dancing with the Safety Stars

#IHI Speaking of fun videos to promote safety, here's one produced by the folks at the Carondelet Health. Thanks to Scott Kashman, CEO of St. Joseph Medical Center, for reminding us that you don't need the resources of Universal Studios to produce an engaging, helpful guide for your staff. As he notes on his blog:

There was great participation in the making of the video, and while it's entertaining, it also carries serious reminders about the importance being safe in the care we provide to our patients. It is played to Men Without Hats' popular 80's song, Safety Dance.

If you cannot see the video, click here.

Universal safety

#IHI The transformation of health care from a cottage industry characterized by the artistic efforts of individual practitioners to a self-improving system of care delivery will be aided by lessons from other high performance industries. The IHI Annual Forum recognizes the potential for this learning opportunity. So, before the formal sessions start, the organizers arrange excursions to some local businesses in the Orlando area.

What does a theme park like Universal Orlando offer to clinicians and health care administrators? Well, it turns out that the resort has an exemplary safety record, both for the tens of thousands of daily visitors and for the actors and stunt people who perform every day. A group of us spent the better part of today in a conference room at the park, learning of the firm's principles and techniques. The lessons were a direct parallel to those I have discussed on this blog: Framing issues in the context of the purpose of the organization; standardization to avoid variability; encouraging front line staff to call out problems and near misses; prompt reporting of adverse events; and use of root cause analysis when failure occurs.

In the slide shown, note the parallel between the phrase, "No such thing as an accident," and Joe Gavin's comment from the Apollo space program, "There is no such thing as a random failure."

Each organization must adopt techniques that support these goals, techniques that are consistent with the culture of the organization. In the case of Universal, for example, "safety bucks" are handed out to staff members who report safety hazards. These coupons can be used to purchase food at the staff grill.

The company has also prepared an introductory safety video for its staff. It makes ample use of the movies and actors from the firm's cinema productions. It also has a good dose of humor thrown in, consistent with the desire for all activities to support an environment of fun in the park. Here is an excerpt from the Safety Man film.

If you cannot see the video, click here.

Oatmeal, the movie

#IHI Following up on the post below, here is a short video demonstrating one work-around that was invented to deal with the misdesigned breakfast serving system at the IHI Annual Forum. Notice that the inventor preferred to call it "innovation!"

My sources tell me that things will be different tomorrow morning. Stay tuned.

If you cannot see the video, click here.

Oatmeal work-arounds

#IHI Even at a process improvement conference, you encounter failed processes. Have you ever noticed, in a cafeteria or buffet line, that the serving ladle for oatmeal is often too large for the bowl into which it is being put? Such is the case at the Marriott in Orlando here at the IHI Annual Forum.

I captured this problem this morning at breakfast. What's interesting is to see the rapid development of work-arounds. One person abandoned the ladle and used a coffee cup to extract the oatmeal. In so doing, she put her fingers in very close vicinity to the food that would be taken by the following persons. And she then left a goopy, oatmeal covered coffee cup on the table -- in the way of the next person and too dirty to be reused. Other people tried different serving techniques, but they ran into problems because oatmeal just doesn't flow very well!

In the manner of some surgeons who resist acknowledging systemic problems, one person said that he is able to overcome the design problem because he has "a steady hand."

Getting a hug

Our new Chief of Surgery, Elliot Chaikof, is featured in this short interview. He has lots of interesting things to say, but my favorite answer starts at 1:17, in response to the question, "What's your favorite part of the job?"

If you cannot see the video, click here.

Patient advocates band together

#IHI Back in July, I wrote about a new effort by IHI to help patient advocacy organizations. The summary:

Here's how it will get started. IHI wants to invite 35 to 50 patient advocates to its Annual Forum this December in Orlando, FL. The invitees will attend a special session at the beginning of the conference, and then they will attend the entire Forum as the week progresses. Their conference fee and travel expenses will be completely borne by IHI.

Our hope is to provide these folks with a terrific educational experience, but also use this first get-together as an organizational session for a "trade association" of patient advocacy groups. With planning and luck, we think we will be able to build an organization that will provide technical, educational, and marketing support to these small non-profits.

Well, thanks to the generosity of a number of hospitals and others, the group assembled today for the first time in a "Leadership Summit for Patient Activists and Partners in Quality and Safety." I have dropped by for part of the session. On the right, you see Dr. Steve Pratt, from BIDMC, who worked with Linda Kenney from MITSS, on the concept for this session. He is accompanied in this picture by Dale Ann Micalizzi.

The meeting started with a "tweet" from each attendee, telling their personal story that led to their current patient activities. Among them was Helen Haskell, Director of the Empowered Patient Coalition and Mothers Against Medical Error, seen here (right) with IHI's Madge Kaplan (left).

The person in the picture at the top of this post, Regina Holliday, is a medical advocate muralist. She is using paint and brushes to promote health reform and patient's rights. She was on hand to memorialize today's session.

No such thing as a random failure

#IHI Joseph Gavin, Jr., who died in November, was an aeronautic engineer who was intimately involved in the design of the first manned craft to land on the moon. He was also a key player in the rescue of the Apollo 13 astronauts. He was a remarkable fellow, and I had a chance to hear a tribute to him during this past week's meeting of the MIT Corporation. (He was in the class of 1941.)

One of the quotes ascribed to him during the presentation was, "There is no such thing as a random failure."

In this discussion board, a commenter says, with regard to that quote, "Amazing when you look at things now, that in the avionics industry of the time 'random' failures were acceptable! As he says, there is (almost) no such thing as a random failure... Everything has a cause, and in a safety critical system (or one-shot system like this), every failure cause has to be designed out..."

It strikes me that there is a parallel with medical care. I have discussed the problem of "These things happen" that often characterizes the delivery of care. I noted:

Several years ago, we had that attitude in our hospital with regard to certain types of medical outcomes. For example, we were content with our level of central line infections because we were below the national average. After all, these things happen. Then our chiefs of medicine and surgery said, "No, they don't have to happen. When they happen, people die. We are going to insist that we achieve zero central line infections." And then they got to work. As I have noted below, it is not an easy problem to solve, but it is worth the effort, and you can improve.

The science of process improvement can be applied to the delivery of care, as it has been to other high performance service and manufacturing industries. I hope my readers will excuse the degree to which I focus on this topic, but I cannot imagine a more important subject to cover.

This week, several thousand people will be attending the IHI Annual Forum to learn and trade information and stories along the theme of Taking Care. Maybe, if we learn well enough, we can say that "these things" no longer happen.

Here's Ethel Merman, to make the point in her own way. (If you cannot see the video, click here.)

BCBS of MA offers lower cost choices

In a comment on the post below, Barry Carol notes:

I keep hearing from numerous sources that tiered in-network insurance products have lots of potential to create countervailing power against hospitals that currently command high prices because of their market power and not their care quality.

Well, Blue Cross Blue Shield of MA has announced it will offer a product along those lines, but not based on an exclusive network, called Hospital Choice Cost Sharing. The description is here, with the following plain English introduction:

With Hospital Choice Cost Sharing, your choice of hospital and other related facilities determines what you pay for hospital care.

• Lower Cost Share ($) applies to hospitals and related facilities that have met our quality benchmarks and are lower cost. You pay less when you get care at these hospitals.
  
  
• Higher Cost Share ($$) applies to hospitals and related facilities that have met our quality benchmarks and are higher cost. You pay more when you get care at these hospitals.
  

These costs apply to services such as:

• Inpatient Care
• Outpatient Day Surgery
• Outpatient Diagnostic High-tech radiology
• Outpatient Diagnostic Lab Tests
• Outpatient Diagnostic X-rays, and other imaging tests
• Outpatient Short Term Rehabilitation therapy

These cost levels don't apply to emergency care. If you get care at a hospital during an emergency you will pay the lower cost share, no matter where you go. This also applies if you're admitted to the hospital from the emergency room.

How much of a higher cost? Here are some examples:

And then a list of the hospitals is provided, indicating whether they are in the higher costs or lower cost category. Here is part of the list:

Lower cost non-hospital imaging providers and laboratories are also provided.

Customers are offered a simple worksheet to help them make choices, and a toll-free number to call with questions:

It will be revealing to see the degree of acceptance of this new plan over the coming months. According to the article cited above, "Businesses who join the Hospital Choice plan would see an average premium increase of 4.5 percent on Jan. 1, compared with nearly 10 percent if they continued without any change."

In the past, such plans might not have received favor, but times have changed. Congratulations to BCBS for testing the market and for offering consumer information that is clearly presented and understandable.

Wrong sites, wrong costs

I heard an excellent presentation by David Morales, Commissioner of the Massachusetts Division of Health Care Finance and Policy, a few weeks ago. He presented these two charts, one (above) showing the spread in payments to hospitals for childbirth, and the other (below) showing the sites of service, differentiated by those same payments.

The perverse nature of the current utilization and reimbursement system is evident. Higher priced facilities have a larger market share than lower priced facilities.

Over the coming months, in accordance with an act passed last summer, the Division will be constructing an all-payer claims database (APCD). It will comprise medical claims, dental claims, pharmacy claims, and information from member eligibility files, provider files, and product files. It will include fully-insured, self-insured, Medicare, and Medicaid data. It will also include clear definitions of insurance coverage (covered services, group size, premiums, co-pays, deductibles) and carrier-supplied provider directories.

The Commissioner noted that the result will be "a dataset that allows a broad understanding of health care spending and utilization across organizations, population demographics, and geography." In my view, it will be a moving force in rationalizing payments to providers across the state, allowing policymakers and businesses to address the market-power driven system of reimbursements that has evolved over the years.

Glad we could help!

No further comment needed.

Enthusiastic transparency

The State of Washington posts a variety of information about hospital infection rates. The latest addition to this is the publication of surgical infection rates. The website provides data on infections following three important types of surgeries: cardiac, orthopaedic, and hysterectomies. The Washington State Legislature required the data to be collected and made public in House Bill 1106 in 2007 and House Bill 2828 in 2010. Here is a section of the press release from the Washington State Hospital Association:

“Washington’s hospitals are enthusiastic participants in providing this new information about surgical infection rates,” said Carol Wagner, vice president for patient safety at the Washington State Hospital Association. “We believe that public reporting helps hospitals improve, assists consumers in making good decisions about hospital care, and creates collaboration between hospitals and quality experts.”

“Hospitals are dedicated to the care and comfort of our patients. In most cases, the data show good results, though there are also areas for improvement. Our member hospitals are working hard to implement changes to stop surgical infections, and we expect the results to get better and better,” concluded Wagner.

Washington State’s infection reporting program is considered a national leader. The National Conference of State Legislatures highlighted Washington, along with nine other states, in its recent report, "Lessons from the Pioneers: Reporting Healthcare-Associated Infections."

Note, too, the publication of central line infection rates and ventilator pneumonia infections.

I like the sound of that: enthusiastic participants. Congratulations to the WSHA for their part in helping bring this about and to the Washington legislature for their leadership.

New site: Care and Cost

I'm passing along this announcement.

Today, David Kibbe and Brian Klepper are launching a new forum for health care professionals, Care & Cost (C&C), that we hope you’ll consider adding to your regular diet of health care information and thought.

We’ve tried hard to design C&C to appeal to health care practitioners from every part of the industry, from imaging, benefits and medical management to law, physicians and palliative care. Every day we’ll run one or two think pieces, as well as interesting charts and images. Our goal is to provide a marketplace of practical ideas that provokes questions and comments. Under the heading “Urgent Science,” we’ll publish refereed review articles that lay out the scientific arguments, with citations, for implementing new approaches into clinical practice. And, from time to time, we may also re-publish articles run elsewhere in the past, simply because they are still relevant.

The articles on C&C will broadly explore two overarching themes. One is the health care cost crisis, which remains very much with us and threatens the stability of both the industry and the US economy. The other is the countervailing trend, the explosion in innovative solutions - tools, programs and designs - aimed at making health care better, cheaper and more available.

We’ve already recruited a couple dozen well established health care writers. At the same time, we’d be delighted to entertain articles from anyone with an insight or something to say to the health care community.

In the interest of keeping the discussion most engaging, we’ve decided to do three things.

· First, we’ll require commenters to use their names. If it’s worth saying, it’s worth owning up to saying it.

· Next, we’ll demand courtesy and professionalism. Insulting or abusive language won’t be published.

· Third, comments should be on point. Entries that simply show up to, say, make a political diatribe, won’t make it either.

We hope you’ll visit early and often and join in the fray.

Please pass this announcement along to colleagues you think might also be interested.

Best regards.

David C. Kibbe and Brian Klepper

Two stories about transparency

Here are a couple of stories about transparency of clinical outcomes. I present them for your review and comment.

The first is one from the Los Angeles Times, entitled "'Error-free' hospitals scrutinized." Here are some excerpts:

California public health officials are scrutinizing hospitals that claim to be error-free, questioning whether nearly 90 facilities have gone more than three years without any significant mistakes in care.

Eighty-seven hospitals — more than 20% of the 418 hospitals covered under a law that took effect in 2007 — have made no reports of medical errors, according to the California Department of Public Health.

The high percentage has raised concerns that errors have gone unreported. Some patient advocates say it is an indication that hospitals are unwilling to police themselves. State officials have given hospitals until Tuesday to verify their records as error-free or to report errors, as required by law.

Next, a report from The Health Foundation in the United Kingdom. Martin Marshall, Clinical Director and Director of Research and Development, and the late Vin McLoughlin, Director of Quality Performance and Analysis, have published a paper called, "How might patients use information comparing the performance of health service providers?" It is on the BMJ website. They note:

There is a growing body of evidence . . . describing what happens when comparative information about the quality of care and the performance of health services is placed in the public domain. The findings from research conducted over the last 20 years in a number of different countries are reasonably consistent and provide little support for the belief that most patients behave in a consumerist fashion as far as their health is concerned. Whilst patients are clear that they want information to be made publicly available, they rarely search for it, often do not understand or trust it, and the vast majority of people are unlikely to use it in a rational way to choose ‘the best provider’. The evidence suggests that the public reporting of comparative data does seem to play a limited role in improving quality but the underlying mechanism is reputational concern on the part of providers, rather than direct market-based competition driven by service users.

. . . How should policy makers, managers and clinicians respond to these findings? Some might be tempted to suggest that we should focus only on those who work in the health service and discount patients as important stakeholders. We believe that this would be wrong. The public has a clear right to know how well their health system is working, irrespective of whether they want to use the information in an instrumentalist way. Improving the relevance and accessibility of the data should be seen as a good thing in its own right and may start to engage a large number of people in the future.

. . . That patients might want to view health as something other than a commodity presents a conceptual as well as a practical challenge to those responsible for designing and producing comparative performance information. We suggest that for the foreseeable future presenting high quality information to patients should be seen as having the softer and longer term benefit of creating a new dynamic between patients and providers, rather than one with the concrete and more immediate outcome of directly driving improvements in quality of care.

Sign congestion

Sometimes, with "new eyes," you see things you walk by every day. As I went to visit a sick friend yesterday, not as the hospital CEO but just a visitor, here was the scene I found at the elevator in one of our main lobbies.

Each one of these signs was likely added for good reason. But, in combination, they are problematic -- too cluttered.

Also, they are not culturally competent. The blue sign on the left has several languages. None of the others do.

Perhaps it is time for a Lean rapid improvement event about our signs.

Is this normal?

This is a story about consumer choice using publicly available information. Unfortunately, it is also about the power of suggestion as used by an incumbent provider organization.

The friend who sent me this note is a research fellow at one of the Boston teaching hospitals, so I guess he is more likely than most to do the kind of research he summarizes. Most people would have taken the referral advice offered without question. If they ever did ask to see a different doctor, most would never get past the "need" for asking for "special permission."

Hi Paul,

I had a strange encounter, and I was wondering if you could tell me if this is normal.

A few months ago my primary care physician recommended I see dermatology for my eczema. His clinic recommended the names of two dermatologists within the same health care system. I looked up both dermatologist on healthgrades.com and found that their patients had given them luke-warm reviews. (There were many reviews, so this wasn't a sampling problem). Also, I have been reading the medical literature about eczema, and knew there were a lot of recent advances, so I wanted somebody who had published and was familiar with the research.

I found another dermatologist, Dr. Caroline Kim. Her patients loved her (according to healthgrades.com), she had published articles in dermatology research (from scholar.google.com), and she trained at top institutions: Harvard Medical School and MGH. I made an appointment with her.

I called my PCP and asked for a referral. The receptionist told me Dr. Kim was "out of network" and they would have to ask my PCP for special permission. I thought this was odd because I had Blue Cross PPO insurance (not HMO), so as far as I knew, there was no "out of network".

A month later, my referral had not been sent. I called my PCP again, and asked for them to send it. After I gave her the name and phone number of the dermatologist, this was the conversation.

Receptionist: I am sorry, that is out of network. We will have to check with Dr. X.

Me: What does "out of network" mean? I thought I had PPO insurance.

Receptionist: You won't get the best care if you go out of network.

Me: Is this a [health care system] policy?

Receptionist: We might not know what medications you are prescribed if you go out of network. Your medical records might not get transferred back to our office.

Me: Is this a [heath care system] policy?

Receptionist: Yes.

A week later I had my referral.

It seems like this health care system is using an insurance term -- "out of network" -- to trick patients into going to specialists that work for the same company. Am I wrong?

En route to True North

"True North" is a key concept in Lean process improvement. It might be viewed as a mission statement, a reflection of the purpose of the organization, and the foundation of a strategic plan.

Here are illustrative thoughts from two observers:

The "ideal vision" or "True North" is not metrics so much as a sense of an ideal process to strive for. It sets a direction, and provides a way to focus discussion on how to solve the problems vs. whether to try.

If we don't know where we're going, we will never get there. "True North" expresses business needs that must be achieved and exerts a magnetic pull. True North is a contract, a bond, and not merely a wish list.

Lean is inherently the most democratic of work place philosophies, relying on empowerment of front-line staff to call out problems. The definition of True North, however, does not rely on that same democratic approach. Instead, it is established by the leadership of the organization.

At BIDMC, we have been engaged in a slow and steady approach to adoption of Lean. Our actions have been intentionally characterized by "Tortoise not Hare," as we methodically train one another, carry out rapid improvement events, and integrate the Lean philosophy into our design of work. As you have seen on this blog, staff members have come to embrace Lean and have used it in a variety of clinical and administrative settings.

(For more examples, enter "Lean" in the search box above. I have been presenting them here for some time in the hope that they would be useful to those in other hospitals who are thinking of adopting this approach.)

We have intentionally not, until now, tried to define True North, but things have now progressed sufficiently in terms of our application of the Lean philosophy that the organization is crying out for it. This is just as we had hoped. Establishment of True North before this time, i.e., without an understanding of its role, would not have been as useful in our hospital.

So, the clinical and administrative leaders recently met to try to nail this down. The process is not over. Indeed, our Board of Directors has yet to pitch in and offer their thoughts. But, we are far enough along that I thought you would enjoy seeing the draft.

Here it is:

BIDMC will care for patients the way we want members of our own families to be treated, while advancing humanity's ability to alleviate human suffering caused by disease. We will provide the right care in the right environment and at the right time, eliminating waste and maximizing value.

Here is some commentary to help you interpret and deconstruct this. The first sentence is based on the long-standing tradition of our two antecedent institutions, the New England Deaconess Hospital and the Beth Israel Deaconess hospital. The late doctor Richard Gaintner used to refer to the Deaconess as, "A place where science and kindliness unite in combating disease." That could just as well have been applied to the BI. As an academic medical center, our public service mission of clinical care is enhanced by -- and enhances -- our research and education programs. Our mission is to help humanity, not just the people who live in our catchment area.

The second sentence is offered in realization that the Ptolemaic view of tertiary hospitals as the center of the universe is no longer apt (if it ever was!) We need to view ourselves as being in service to primary care doctors, community hospitals, and other community-based parts of the health care delivery system.

On another level, it is also reflective of the fact that society expects us to be more efficient both within our own walls and in cooperation with our clinical partners, adopting approaches to work that do not waste societal resources.

In contradistinction to what I just said about this not being a democratically established statement, I offer our draft to you -- both those within BIDMC and worldwide -- for your criticism and suggestions. I don't know of other places that engage in this form of crowd-sourcing with regard to True North, but readers of this blog are unusually informed about health care matters, and I welcome your observations.