Tuesday, January 08, 2008
What about the other bugs? Every day . . .
Isn't is odd, as noted below, that a norovirus outbreak causes health care workers to wash their hands, while the pervasive existence of the normal strains of bugs in hospitals -- some far more dangerous -- doesn't seem to be as persuasive in convincing people to use proper hand hygiene?
Norovirus? Try "happy birthday to you"
A few months ago, we had a problem with the norovirus at our Needham hospital. It is a nasty bug that causes stomach flu-like symptoms. And, after you get over it, you can be reinfected. I note in today's Globe that it has appeared in some other health care facilities around town.
Hand-washing is the best solution, but you have to wash your hands for something like 20 seconds -- long enough to sing "happy birthday to you" while you are washing after using the toilet! But, then you have to be careful not to touch the handle of the faucet, the door handle in the rest room, and so on, because the bug persists on surfaces. Obviously, it is very important for food service workers to use extra precautions as well, in that the cafeteria can be a place where this virus is spread.
Hand-washing is the best solution, but you have to wash your hands for something like 20 seconds -- long enough to sing "happy birthday to you" while you are washing after using the toilet! But, then you have to be careful not to touch the handle of the faucet, the door handle in the rest room, and so on, because the bug persists on surfaces. Obviously, it is very important for food service workers to use extra precautions as well, in that the cafeteria can be a place where this virus is spread.
Monday, January 07, 2008
Nice work from the docs and geeks
A note from two of our doctors to share with you. This is nice work, reflecting the kind of interdisciplinary approach to research that is possible in academic medical centers.
Dear Paul,
We thought the attached study [here is the abstract] from our group in the BIDMC Department of Neonatology and the Division of Clinical Computing might be of interest given your focus on assessing health care system performance. This paper uses computer based simulation techniques to examine how change brought on by the availability of new technology affects clinical outcomes, system performance and costs in a regionally distributed system of health care. The specific care technology examined is the use of induced hypothermia for the treatment of asphyxiated infants.
Although these approaches have long been used in other industries to identify optimal strategies to improve costs, quality and efficiency they have only rarely been applied to health care. We believe this modeling paradigm has great promise in studying how health systems respond to change brought on by policy decisions, the availability of new technologies, or natural/man-made disasters.
We hope you find it of interest.
Regards
Jim Gray and John Zupancic
Dear Paul,
We thought the attached study [here is the abstract] from our group in the BIDMC Department of Neonatology and the Division of Clinical Computing might be of interest given your focus on assessing health care system performance. This paper uses computer based simulation techniques to examine how change brought on by the availability of new technology affects clinical outcomes, system performance and costs in a regionally distributed system of health care. The specific care technology examined is the use of induced hypothermia for the treatment of asphyxiated infants.
Although these approaches have long been used in other industries to identify optimal strategies to improve costs, quality and efficiency they have only rarely been applied to health care. We believe this modeling paradigm has great promise in studying how health systems respond to change brought on by policy decisions, the availability of new technologies, or natural/man-made disasters.
We hope you find it of interest.
Regards
Jim Gray and John Zupancic
Sunday, January 06, 2008
Glass 60% empty
Patient Dave sent me this quote from today's New York Times: "As of 2006, nearly 60 percent of doctors polled by the American College of Physician Executives said they had considered getting out of medicine because of low morale, and nearly 70 percent knew someone who already had." How do you feel about this?
Keeping up with Jones
Every now and then, a bright, young, energetic faculty member shows up with an outrageous idea, and we thoughtful, mature, seasoned clinical and administrative leaders say, knowingly, "Sure, go ahead, with our blessings." We know that his or her chances of success are minimal, but we don't have the heart to be discouraging. And then -- of course -- we are proven wrong when the young doctor produces a great success.
Such was the case with Dr. Dan Jones, a surgeon specializing in minimally invasive surgery (MIS). His idea was to create a center for skills training and assessment in MIS, with the thought that surgeons throughout the city would use it to learn and be assessed on a regular basis. His Chief and I, knowing the petty rivalries that exist in this town, knew it was impossible.
So, here we are just a few years later, and the center exists. It is called the Carl J. Shapiro Simulation and Skills Center and is supported by Mr. Shapiro's family foundation, by industry donations, other philanthropy, and the hospital and Harvard Medical School. And, as noted in this recent article by Liz Cooney, it is now an essential part of the surgical training at our hospital. And, people from all over town come to use it, as well. CRICO/RMF, the Harvard-affiliated hospitals’ liability insurer, gives surgeons a $500 voucher for a refresher course and another $500 rebate on their malpractice insurance from CRICO/RMF upon successful completion of the course.
Thanks, Dan, for proving us wrong!
Such was the case with Dr. Dan Jones, a surgeon specializing in minimally invasive surgery (MIS). His idea was to create a center for skills training and assessment in MIS, with the thought that surgeons throughout the city would use it to learn and be assessed on a regular basis. His Chief and I, knowing the petty rivalries that exist in this town, knew it was impossible.
So, here we are just a few years later, and the center exists. It is called the Carl J. Shapiro Simulation and Skills Center and is supported by Mr. Shapiro's family foundation, by industry donations, other philanthropy, and the hospital and Harvard Medical School. And, as noted in this recent article by Liz Cooney, it is now an essential part of the surgical training at our hospital. And, people from all over town come to use it, as well. CRICO/RMF, the Harvard-affiliated hospitals’ liability insurer, gives surgeons a $500 voucher for a refresher course and another $500 rebate on their malpractice insurance from CRICO/RMF upon successful completion of the course.
Thanks, Dan, for proving us wrong!
Saturday, January 05, 2008
Night Falls
Another in my occasional series of artists and performers. This painting is by Deborah Kravitz, who works at BIDMC. Here is her statement.Mystery and the poignance of change are themes of my “Night Falls” paintings. The light of day moving into night brings change to the look of the land and opens channels into my heart and mind.
The “Night Falls” paintings are imaginary, however, they were influenced by my trip to Mulranney, a remote West Irish village. Eerie extended twilights, a result of Mulranney’s geographic position, give the evenings a magical quality. Visually exciting, evocative contrasts abound, rapidly changing weather and light on fields that look both lush and oddly barren. These paintings are reflections of my inner world as well as Irish landscape.
The medium is acrylic paint on prepared masonite panel. I create a gestural, monochromatic underpainting by manipulating paint with both additive and subtractive techniques. The image is developed by additional layers of transparent color.
Deborah Kravitz 2007
Deborah Kravitz 2007
Thursday, January 03, 2008
Looking back after six years at BIDMC
A long post. I hope you enjoy it.
As I approach my sixth anniversary this week as CEO of BIDMC, I thought you would find it interesting to join me in reviewing two of my earliest communications with the staff of the hospital. When I arrived, the hospital was in dire financial straits, morale had plummeted, and there was an associated exodus of doctors, nurses, patients, and community support.
The Attorney General of Massachusetts, Tom Reilly, had watched the place deteriorate for many years and understandably had little confidence in its ability to survive as an academic medical center. Therefore, to ensure that the beds at the hospital would be available into the future for the good of the public, he was pressuring the Board of Trustees to sell the hospital to a for-profit hospital chain and end its life as an academic medical center. Tom and I had had a long-term mutually respectful and friendly relationship, and I had met with him the previous week and tried to persuade him to give me a short amount of time to turn things around. He agreed, saying, "Because you are personally willing to take this on, I am willing to give you a chance." (By the way, hearing that kind of sentiment from an AG is bit intimidating!) He placed strong and sensible demands on me and the Board to produce a plan, with strict financial milestones, and a commitment to regular reports on our progress.
The staff knew none of this last matter until I arrived and told them.
So the first email I sent was dated Monday, January 07, 2002 at 11:48 AM, roughly four hours after I started work, and was simply entitled "Message for BIDMC". Those of you who have been involved in business turn-arounds will find familiar elements from your own activities. For those of you who have not, this might provide an interesting vicarious experience.
I am honored and pleased to join Beth Israel Deaconess Medical Center as President and Chief Executive Officer, and I look forward to getting to know many of you personally. This is a wonderful institution, representing the best in academic medicine: exemplary patient care, extraordinary research, and fine teaching. However, the place is in serious trouble, and we are going to have to work very hard during the next few months if we are to secure our future as a non-profit academic medical center.
I promise to have an open administration, sharing with you as much information as possible to help you be part of solving the problems of the medical center. Here is where things stand, as of today. Over the last several years, during one of the greatest economic booms in American history, hundreds of millions of dollars of the BIDMC's assets have gone toward paying the operating losses of the hospital. This was money that ordinarily would have been used as the source of funds for new facilities and equipment, for expansion of programs, and as a cushion for hard economic times. For whatever set of reasons, there was a failure to act to stop this financial outflow. We now face our last chance to reverse this problem.
The CareGroup and BIDMC Boards have a fiduciary responsibility to preserve the assets of this charitable organization to serve the public good. The Attorney General of the Commonwealth has the authority and responsibility to review the Boards’ progress in doing so. Because of the current state of the hospital's finances and because of its curious inability to make decisions during the past several years, some observers believe that the best way to preserve those assets is to sell the BIDMC to a for-profit hospital. This would ensure that the beds currently serving the public would continue to do so. In addition, the proceeds of such a sale, after paying off all of the hospital’s debt, would be placed in a community foundation to support healthcare services and programs in the region.
The good news is that my appointment by the BIDMC and CareGroup Boards means that any plans to sell the hospital are, for the time being, off the table. Frankly, I would not have taken the job unless I received that commitment -- because I know we can succeed. My assignment over the next few months is to take steps that will convince the Boards that saving the BIDMC as a non-profit academic medical center is a wise decision. I will be offering a specific plan for doing that, and we will be held accountable to extremely rigorous milestones. If we fall behind -- either because of a lack of will or a lack of ability to implement changes -- the result will be clear.
What specifics steps will we take? I will announce these over the coming days and weeks. As you know, The Hunter Group [note: a management consulting firm] is soon to submit their recommendations to us. Having seen earlier drafts of these recommendations, I can tell you that many of them are sensible and well thought out and way overdue. I am less certain that other recommendations are relevant to us, but all of them will get a thorough review by the administrative and medical leadership of the hospital. In addition, all of you will get a chance to review them and send comments to me, as they will be posted on our website.
Our review will result in detailed implementation plans and milestones for completion. One clear recommendation will be a reduction of staff throughout the hospital. While the exact number is not yet clear, several hundred positions will be eliminated to bring our level of staffing down to what can be supported by our clinical volumes. Layoffs are distasteful, uncomfortable, and scary, but we will carry them out as humanely as possible and treat people with respect and dignity. The many people who remain will be part of a more efficient medical center, and one that will be able to continue to carry out our important mission.
I have not taken this job to be part of a failure. I have taken it because I believe in you, your commitment, and your ability to succeed through this period of adversity. I am looking forward to showing the world what we can accomplish together.
Sincerely,
Paul Levy
A month later, after some very intense work, we put together the Recovery Plan. Here is the introduction to the document which was posted on the hospital's website.
Recovery Plan for the Beth Israel Deaconess Medical Center
February 1 , 2002
To: The Executive and Finance Committees of the Board of Trustees of the Beth Israel
Deaconess Medical Center
From: Paul F. Levy, President and Chief Executive Officer
Over the past several years, the BIDMC has run large, persistent deficits. The medical center has now reached the point where strong, effective, and immediate action is required to reverse this trend. The alternative to these steps will be a noticeable diminution in the quality of care offered by the hospital and a depletion of the assets that are held in the public’s trust. Neither of these results is acceptable.
This plan is a result of a concerted effort on the part of the medical and administrative staff over the past several weeks. It represents a level of teamwork and commitment that is extraordinary and unique in the history of this institution. It is designed to provide immediate financial relief, leading to long-term financial health. However, a financial plan for a hospital like the BIDMC must represent more than a simple reduction in expenses: The trademark of this hospital is its reputation for a warm, caring environment within which patients and their families receive the finest in medical care. Our record on patient satisfaction is extraordinary. If the BIDMC fails to maintain this mission, it will fail. Accordingly, where a decision to implement an activity with potential short-term financial gain conflicts with patient care, we have chosen to err on the side of maintaining patient care. Such choices do not undermine the financial recovery plan: They enhance it.
The healthcare market in Boston is highly competitive, and some have asked whether it is necessary for the BIDMC to exist as an academic medical center. These observers state that the key attribute of the BIDMC is the number of beds it has in service to the public, and that preservation of these beds should be the major goal facing the community. We reject this premise. While retention of beds is an important public health goal, the existence and enhancement of the BIDMC’s role as an academic medical center is also of vital importance to the Boston area medical community and beyond.
Academic medical centers, in general, are regional and national treasures that provide the public with more than high quality health care. They are the cauldrons of innovation in medicine, places in which research flows seamlessly from bench to bedside and back. Physician scientists observe symptoms and trends in patient care, carry hypotheses about the origin and treatment of disease to the laboratory for analysis and testing, and then transport laboratory results back to the clinic. The BIDMC is a national leader in biomedical research. That status is a result of peer reviews of BIDMC research proposals carried out by medical research scientists throughout the country. Scientists at the BIDMC conduct millions of dollars in research funded by the NIH and by foundations like the American Cancer Society, the American Heart Association, and the American Diabetes Association, reflecting the confidence of these organizations in the quality of science carried out here. In total, the BIDMC carried out $140 million in research last year, of which most supported the direct costs of the research and $34 million went to support indirect costs. Many of our scientists are the international leaders in their respective fields and play key roles in setting national research priorities through their roles in study sections and advisory boards. There are direct results from this research in place now throughout the world. Our research enterprise generates new intellectual property on a continuous basis, and this produces sponsored research programs funded by pharmaceutical companies, as well as start-up companies based on our technologies in which the medical center participates. Patients benefit from this research agenda directly when such research is applied but also by the fact that the existence of this effort encourages the very best doctors to practice at the BIDMC.
Academic medical centers are also the training ground for future physicians. As in the case of research, the interplay between education and patient care is extraordinarily important. The opportunity to work with and train an outstanding group of medical students and residents is a major attraction that draws the highest quality staff physicians to a world-class medical center such as BIDMC. Practicing physicians will also tell you that their involvement in training medical students and residents requires those physicians to maintain their professional edge, keeping current with the latest advances in clinical care. Trainees at all levels will report that their experience in the halls of the hospital is critical to their education as doctors. This phenomenon has been recognized by the federal government by its funding of medical residents through the Medicare program. At Beth Israel Deaconess, we receive approximately $53 million annually for graduate medical education (the training of residents and subspecialty fellows).
The BIDMC is a leader in medical education at all levels. Our physicians provide approximately one-third of the clinical instruction of Harvard Medical School students, offering training in the following fields: internal medicine, surgery, obstetrics and gynecology, neurology, psychiatry, orthopedics, radiology, pathology, anesthesiology, emergency medicine, dermatology, radiation oncology, and neonatology. At the residency level, the BIDMC offers training in all of the above fields to an annual incoming residency class of approximately 125 men and women (for a total complement of approximately 450 residents over their several years of training). An additional 160 physicians receive more advanced subspecialty training in a wide variety of disciplines.
Does the BIDMC need to exist and carry out these functions, or should it devolve into a community hospital, offering a range of medical specialties to the public? This is a plan that has been put forth by some observers. We think it is shortsighted. While it could be argued that the BIDMC’s scientists and teachers could go elsewhere, such an argument leads to a reductio ad absurdum result. The same could be said for every academic medical center. How are we to choose which organization should live or die?
We are realistic enough to know that, in today’s environment, the answer will be guided by the underlying finances of the institution. Unless the BIDMC is able to maintain its clinical programs in a manner consistent with fiscal responsibility, it will not be able to generate sufficient support to remain as an academic medical center. This plan is a blueprint that will support that result. The issue for the BIDMC is not so much whether it should remain an academic medical center: Rather, we will need to decide what mix of clinical care, research, and teaching can be supported. To date, the financial systems and institutional structures of the BIDMC have foreclosed making those decisions. As a result of changes we will make, those choices will be apparent, and decisions will be made about the programmatic priorities for the hospital.
The recovery plan is guided in great measure by the recommendations of The Hunter Group ("THG"). The report prepared by THG has been made available to every employee in the medical center, and we have received hundreds of suggestions and comments regarding the implementation of the measures contained therein. Every one of these suggestions has been considered by senior management. There is much that is good in THG report. It sharpens the focus of our efforts, offering a range of specific financial targets we must achieve. Many of the recommendations of THG are correct, and in fact reinforce those of previous consulting firms. We embrace those recommendations wholeheartedly and have already started implementing many of them. Other THG recommendations are correct insofar as their purpose and goal, but need modification with regard to implementation. In this proposed recovery plan, we commit to achieving the financial results of such measures set forth by THG, but we promulgate a more realistic plan for achieving them. A small number of THG recommendations are unsupported and impractical and have been dismissed. Finally, we offer a set of our own recommendations that were not proposed by THG.
Our recovery plan has a clear financial target. Progress towards that target will be presented to the Board, and it is measurable at every step along the way. We have considered THG’s recommendation that our approach should be to reach a goal of a 3% margin on clinical care within the next two-and-a-half years. This is not realistic given our plan to maintain high quality patient care and, if achieved, would place the BIDMC in a range of performance seldom achieved by academic medical centers. It also would place an undue strain on an institution that will already face massive organizational challenges.
Inherent in our target is a need to stem the "run rate", the degree to which hospital operations are depleting the unrestricted assets of the corporation. We must and will demonstrate a dramatic reduction in the run rate throughout the remaining months of fiscal year 2002. Clear targets for fiscal year 2003 and 2004 are also presented, leading to a break-even result in fiscal year 2004. In the interim, we believe it is appropriate to budget a certain level of operational support from the endowment for three purposes: to compensate for the institution’s past lethargy in making operational improvements; to support the level of research and teaching that are critical to the overall success of this academic medical center; and to serve as a venture fund to finance strategic initiatives that will bring longer term revenue enhancement and quality improvement in this hospital.
On the revenue side of the ledger, we project no increase in patient volumes for fiscal year 2002, but we do commit to a modest increase in such volumes in 2003 and 2004. This contrasts with THG report, which has no expectations of such revenue growth. This commitment is offered by the chiefs and the medical staff directly. It reflects the substantial financial investment being made to recruit a number of the excellent surgeons to this hospital. It relies, too, on increasing physician productivity, particularly with regard to ambulatory care. Finally, it rests in great measure on enhancing relationships with referring physicians throughout the Boston area. The physicians are directly accountable for the success of this recovery plan, and they are willing and ready to stand by that commitment.
Also, on the revenue side, we show income from the rental of real estate. This measure reflects the surfeit of space in the medical center, relative to the size of its clinical and academic functions. That the amount included in our rental projections is achievable reflects inquiries and commitments made during the last several weeks, as well as our own estimate of future tenancies. In choosing to rent space, we will limit ourselves to tenants which have a strategic synergy with the medical center -- organizations which conduct medical research and clinical care that is consistent with our mission and with which we are likely to want to maintain a close relationship over the coming years.
How can the Board best measure our progress in carrying out this plan? Of course, we will provide month-to-month figures on patient volume and financial performance. The advantage of such real-time data is that it offers the potential to track early indicators, but the disadvantage is that any given month’s figures can also cause misleading hope or discouragement. Obviously, it is only the trend over several months that is meaningful.
The difficulty of measuring the success of our program is inherent in the nature of this medical center. The preponderance of our costs are fixed, but the preponderance of our revenues are variable. Even a small shift in patient volumes can cause large swings in the month-to-month bottom line. This problem is aggravated by the fact that the hospital has and will invest large sums of money in the potential for future growth. We have large commitments to recruitments in surgery and anesthesia, for example. Likewise, our physical plant and equipment is sized for a larger patient volume than currently exits.
If we were in the manufacturing business, we would shed workers, close down divisions, and sell assets in the face of a downturn in volume – in essence, adjusting the fixed cost base to be commensurate with a reduction in revenue. Here, our investment commitments are not so variable or fungible. Our staff is our key resource. We cannot increase and decrease the numbers of doctors, nurses, and technical staff every quarter in response to volume changes. Neither can we buy and sell property and reconfigure operating rooms and other patients facilities every several months.
If we were financially healthy, we could deal with these variations by drawing on our "bank account" of unrestricted reserves, knowing that those reserves would be replenished in good times. Here, we have done this for a number of years but without replacing those funds, thus severely restricting the amount available for future use. As THG notes, time is running out if we intend to use those reserves in that manner for much longer. We are proposing a dramatic reduction in this practice, but, as noted above, some continued drawdown of these funds should be expected over the next two-and-a-half years as we pay off the investment costs needed to bring about a longer term level of sustainable patient volumes.
The major portion of this submission is our plan. In that section, we present our major initiatives in Quality of Patient Care; Revenue and Volume Growth; Expense Management; and Strategic Direction. We also provide a narrative comparison with THG’s recommendations in each area.
Our report also contains a series of charts presenting the financial summary for BIDMC that is our target for fiscal years 2002, 2003, 2004. We show projected overall financial results for each year, along with a month-by-month projection of the run rate during this period. These figures are presented alongside those offered by THG. Accompanying these figures is a summary of the performance monitoring tools and metrics that will be in place to measure our success in meeting these financial targets.
Finally, for ease of review, we present a chart in which we present each of the 200-plus THG recommendations and its projected effect in each of the three fiscal years. In the same chart, there is a narrative indicating the degree to which we accept the recommendation along with the financial target associated with our plan for each of the three fiscal years.
Before closing, I must address the concern that has been raised by THG and by other observers: Does the medical center have the ability and the will to carry out these recommendations? Many of the THG recommendations have been offered by previous consultants and yet were not carried out. Why is the situation different now?
Let us briefly review the reasons for the institution’s past failure. Recall that BIDMC had previously engaged Ernst and Young, Deloitte and Touche Consulting, and CSC as consultants to offer advice on achieving financial improvements. These firms independently developed many good ideas which significantly overlapped each other; so the turnaround plans did not fail because of a lack of ideas. While certain aspects of each plan may not have been totally achievable, the majority of the initiatives could have been accomplished.
One of the problems encountered was that the financial target that was established was too small. For example, the 1999 Genesis project stated the budget problem as $52 million per year. In the course of that effort, opportunities were identified totaling $95 million, of which management agreed to implement $75 million, of which about $59 million was actually achieved. However, the projected budget problem increased from $52 million to approximately $100 million during that period.
Another problem was that of unrealistic expectations. The 2000-2001 turnaround plan placed significant reliance on the establishment of a profitable partnership with a pharmaceutical or bio-tech company. The confidence expressed by senior management in this highly uncertain venture was not supported by evidence from outside the organization. In addition, knowledgeable people within the medical center who doubted its efficacy were treated as nay-sayers, and their voices were stilled or discounted.
A third problem was a failure to mesh broad views of how things would improve with the process of change within the organization. The plan developed in 2000 was announced before determining if certain key elements of its design could be accomplished. This conceptual "model" emerged as a "plan" before details could be developed, and the plan was immediately challenged at the detail level in a confrontational manner. Rather than a rational evaluation of the concepts, details were challenged: Decisions were then made in response to the confrontations. Senior management underestimated the reaction to the plan and was distracted by internal and external politics and publicity. As a result, it was difficult to address the very complex implementation and management issues inherent in the change process.
Significantly, a sense of urgency in the medical center had not been established prior to the announcement of this or any previous plan. While BIDMC senior leaders understood the urgency, they overestimated how successful they had been in communicating that sense and establishing it more broadly in the hospital. In part, too, many physicians did not accept the urgency because of a belief that a merger with Partners Healthcare system could occur; that a break-up of CareGroup would solve the problems of the BIDMC; or that Harvard Medical School and Harvard University would act as saviors.
During this last effort, a clear vision for the BIDMC was not accepted. The result was a failure to develop a guiding coalition of key physicians, managers, and Board members, resulting in an inability to remove obstacles to a new vision. This led to a failure to put the needs of the organization ahead of the individual needs and desires of its many internal constituencies. Suggestions that really could have made a difference were not accepted.
Finally, the last turnaround plan had a strong dependence on increasing clinical volumes, especially of high level tertiary and quaternary care. However, the lack of confidence on the part of specialty physicians in the future of the hospital led to faculty turnover that increased the volume gap. Meanwhile, remaining physicians did not fundamentally alter their practice to spend more time on clinical activities.
How is the current situation different? First and foremost, there is now a clear understanding on the part of the medical and managerial staff that the "platform is burning." The decision by the CareGroup Board of Directors to consider seriously the sale of the hospital is now widely known and has provided strong motivation to all parties to work on solving the institution’s financial problems. The involvement of the Attorney General of the Commonwealth, given his statutory responsibility with regard to public charities, underscores the fact that the Board of Directors will be held accountable for its fiduciary responsibilities, lending even greater credibility to that potential threat.
Second, we have shared with the entire hospital the contents of the Hunter report. This independent analysis offers a sobering conclusion about the future of the medical center, absent effective action. It offers detailed proposals for action within every department. It provides us with the tools to establish a realistic financial target, based on appropriate estimates of inflation in personnel and supply costs. It also provides objective criteria by which corrective actions can be judged. Broad-based knowledge of these aspects is key to success, and the report has received over 100,000 hits on the company intranet, and there have been thousands downloads of all or a portion of it. This is an unprecedented distribution of a management consulting report in an academic medical center. (We will follow up with a similar distribution of this plan.)
Third, we have created an environment in which suggestions and contributions from the broad base of physicians and employees are welcomed, solicited, and evaluated. Even if all of these ideas are not adopted, the fact that we have asked is an important aspect of building a constituency for the final decisions. We have created a culture that will avoid failure because the needs of the organization are clearly considered along with the needs and desires of individuals. Suggestions that really can make a difference will be accepted.
This is not to say that the path is easy or straightforward. While the physician leadership and individual physicians care deeply about the future of the BIDMC and are actively engaged in this effort, the day-to-day decisions of those physicians will depend on the creation of institutional incentives (both between the hospital and HMFP and within HMFP) that clearly align the financial and operational incentives of individual faculty practices and the hospital. Likewise, nurses and technical workers on whom we rely so much for the care of patients will need to make adjustments in the way they carry out their work, while maintaining the overall quality of care. Administrative staff will have to focus on the fact that they are part of the overhead cost in an organization the core mission of which is to serve patients and families, and so they will need to be engaged in continuous improvement and searches for greater efficiency.
The foundation for these efforts, though, has been poured. The spirit of the hospital is strong, and the commitment of those working here is as intense as ever. In summary, we offer a financial plan that is real and achievable, but we recognize the tremendous effort that will be required to achieve it. The plan satisfies the fiduciary responsibilities of this Board of Trustees. First and foremost, it promises our patients and their families that the quality of care they receive at this hospital will meet the high standards they expect. Equally important, it ensures that the public’s trust with regard to the preservation and use of the institution’s charitable assets will be sustained, providing a prudent financial plan for the maintenance of those funds. I am pleased to present you with this plan on behalf of the physicians and nurses, and the technical, administrative, and support staff of this organization. We have confidence in this medical center, and we ask for your support in voting to approve this plan.
Sincerely,
Paul F. Levy
President and Chief Executive Officer
As I approach my sixth anniversary this week as CEO of BIDMC, I thought you would find it interesting to join me in reviewing two of my earliest communications with the staff of the hospital. When I arrived, the hospital was in dire financial straits, morale had plummeted, and there was an associated exodus of doctors, nurses, patients, and community support.
The Attorney General of Massachusetts, Tom Reilly, had watched the place deteriorate for many years and understandably had little confidence in its ability to survive as an academic medical center. Therefore, to ensure that the beds at the hospital would be available into the future for the good of the public, he was pressuring the Board of Trustees to sell the hospital to a for-profit hospital chain and end its life as an academic medical center. Tom and I had had a long-term mutually respectful and friendly relationship, and I had met with him the previous week and tried to persuade him to give me a short amount of time to turn things around. He agreed, saying, "Because you are personally willing to take this on, I am willing to give you a chance." (By the way, hearing that kind of sentiment from an AG is bit intimidating!) He placed strong and sensible demands on me and the Board to produce a plan, with strict financial milestones, and a commitment to regular reports on our progress.
The staff knew none of this last matter until I arrived and told them.
So the first email I sent was dated Monday, January 07, 2002 at 11:48 AM, roughly four hours after I started work, and was simply entitled "Message for BIDMC". Those of you who have been involved in business turn-arounds will find familiar elements from your own activities. For those of you who have not, this might provide an interesting vicarious experience.
I am honored and pleased to join Beth Israel Deaconess Medical Center as President and Chief Executive Officer, and I look forward to getting to know many of you personally. This is a wonderful institution, representing the best in academic medicine: exemplary patient care, extraordinary research, and fine teaching. However, the place is in serious trouble, and we are going to have to work very hard during the next few months if we are to secure our future as a non-profit academic medical center.
I promise to have an open administration, sharing with you as much information as possible to help you be part of solving the problems of the medical center. Here is where things stand, as of today. Over the last several years, during one of the greatest economic booms in American history, hundreds of millions of dollars of the BIDMC's assets have gone toward paying the operating losses of the hospital. This was money that ordinarily would have been used as the source of funds for new facilities and equipment, for expansion of programs, and as a cushion for hard economic times. For whatever set of reasons, there was a failure to act to stop this financial outflow. We now face our last chance to reverse this problem.
The CareGroup and BIDMC Boards have a fiduciary responsibility to preserve the assets of this charitable organization to serve the public good. The Attorney General of the Commonwealth has the authority and responsibility to review the Boards’ progress in doing so. Because of the current state of the hospital's finances and because of its curious inability to make decisions during the past several years, some observers believe that the best way to preserve those assets is to sell the BIDMC to a for-profit hospital. This would ensure that the beds currently serving the public would continue to do so. In addition, the proceeds of such a sale, after paying off all of the hospital’s debt, would be placed in a community foundation to support healthcare services and programs in the region.
The good news is that my appointment by the BIDMC and CareGroup Boards means that any plans to sell the hospital are, for the time being, off the table. Frankly, I would not have taken the job unless I received that commitment -- because I know we can succeed. My assignment over the next few months is to take steps that will convince the Boards that saving the BIDMC as a non-profit academic medical center is a wise decision. I will be offering a specific plan for doing that, and we will be held accountable to extremely rigorous milestones. If we fall behind -- either because of a lack of will or a lack of ability to implement changes -- the result will be clear.
What specifics steps will we take? I will announce these over the coming days and weeks. As you know, The Hunter Group [note: a management consulting firm] is soon to submit their recommendations to us. Having seen earlier drafts of these recommendations, I can tell you that many of them are sensible and well thought out and way overdue. I am less certain that other recommendations are relevant to us, but all of them will get a thorough review by the administrative and medical leadership of the hospital. In addition, all of you will get a chance to review them and send comments to me, as they will be posted on our website.
Our review will result in detailed implementation plans and milestones for completion. One clear recommendation will be a reduction of staff throughout the hospital. While the exact number is not yet clear, several hundred positions will be eliminated to bring our level of staffing down to what can be supported by our clinical volumes. Layoffs are distasteful, uncomfortable, and scary, but we will carry them out as humanely as possible and treat people with respect and dignity. The many people who remain will be part of a more efficient medical center, and one that will be able to continue to carry out our important mission.
I have not taken this job to be part of a failure. I have taken it because I believe in you, your commitment, and your ability to succeed through this period of adversity. I am looking forward to showing the world what we can accomplish together.
Sincerely,
Paul Levy
A month later, after some very intense work, we put together the Recovery Plan. Here is the introduction to the document which was posted on the hospital's website.
Recovery Plan for the Beth Israel Deaconess Medical Center
February 1 , 2002
To: The Executive and Finance Committees of the Board of Trustees of the Beth Israel
Deaconess Medical Center
From: Paul F. Levy, President and Chief Executive Officer
Over the past several years, the BIDMC has run large, persistent deficits. The medical center has now reached the point where strong, effective, and immediate action is required to reverse this trend. The alternative to these steps will be a noticeable diminution in the quality of care offered by the hospital and a depletion of the assets that are held in the public’s trust. Neither of these results is acceptable.
This plan is a result of a concerted effort on the part of the medical and administrative staff over the past several weeks. It represents a level of teamwork and commitment that is extraordinary and unique in the history of this institution. It is designed to provide immediate financial relief, leading to long-term financial health. However, a financial plan for a hospital like the BIDMC must represent more than a simple reduction in expenses: The trademark of this hospital is its reputation for a warm, caring environment within which patients and their families receive the finest in medical care. Our record on patient satisfaction is extraordinary. If the BIDMC fails to maintain this mission, it will fail. Accordingly, where a decision to implement an activity with potential short-term financial gain conflicts with patient care, we have chosen to err on the side of maintaining patient care. Such choices do not undermine the financial recovery plan: They enhance it.
The healthcare market in Boston is highly competitive, and some have asked whether it is necessary for the BIDMC to exist as an academic medical center. These observers state that the key attribute of the BIDMC is the number of beds it has in service to the public, and that preservation of these beds should be the major goal facing the community. We reject this premise. While retention of beds is an important public health goal, the existence and enhancement of the BIDMC’s role as an academic medical center is also of vital importance to the Boston area medical community and beyond.
Academic medical centers, in general, are regional and national treasures that provide the public with more than high quality health care. They are the cauldrons of innovation in medicine, places in which research flows seamlessly from bench to bedside and back. Physician scientists observe symptoms and trends in patient care, carry hypotheses about the origin and treatment of disease to the laboratory for analysis and testing, and then transport laboratory results back to the clinic. The BIDMC is a national leader in biomedical research. That status is a result of peer reviews of BIDMC research proposals carried out by medical research scientists throughout the country. Scientists at the BIDMC conduct millions of dollars in research funded by the NIH and by foundations like the American Cancer Society, the American Heart Association, and the American Diabetes Association, reflecting the confidence of these organizations in the quality of science carried out here. In total, the BIDMC carried out $140 million in research last year, of which most supported the direct costs of the research and $34 million went to support indirect costs. Many of our scientists are the international leaders in their respective fields and play key roles in setting national research priorities through their roles in study sections and advisory boards. There are direct results from this research in place now throughout the world. Our research enterprise generates new intellectual property on a continuous basis, and this produces sponsored research programs funded by pharmaceutical companies, as well as start-up companies based on our technologies in which the medical center participates. Patients benefit from this research agenda directly when such research is applied but also by the fact that the existence of this effort encourages the very best doctors to practice at the BIDMC.
Academic medical centers are also the training ground for future physicians. As in the case of research, the interplay between education and patient care is extraordinarily important. The opportunity to work with and train an outstanding group of medical students and residents is a major attraction that draws the highest quality staff physicians to a world-class medical center such as BIDMC. Practicing physicians will also tell you that their involvement in training medical students and residents requires those physicians to maintain their professional edge, keeping current with the latest advances in clinical care. Trainees at all levels will report that their experience in the halls of the hospital is critical to their education as doctors. This phenomenon has been recognized by the federal government by its funding of medical residents through the Medicare program. At Beth Israel Deaconess, we receive approximately $53 million annually for graduate medical education (the training of residents and subspecialty fellows).
The BIDMC is a leader in medical education at all levels. Our physicians provide approximately one-third of the clinical instruction of Harvard Medical School students, offering training in the following fields: internal medicine, surgery, obstetrics and gynecology, neurology, psychiatry, orthopedics, radiology, pathology, anesthesiology, emergency medicine, dermatology, radiation oncology, and neonatology. At the residency level, the BIDMC offers training in all of the above fields to an annual incoming residency class of approximately 125 men and women (for a total complement of approximately 450 residents over their several years of training). An additional 160 physicians receive more advanced subspecialty training in a wide variety of disciplines.
Does the BIDMC need to exist and carry out these functions, or should it devolve into a community hospital, offering a range of medical specialties to the public? This is a plan that has been put forth by some observers. We think it is shortsighted. While it could be argued that the BIDMC’s scientists and teachers could go elsewhere, such an argument leads to a reductio ad absurdum result. The same could be said for every academic medical center. How are we to choose which organization should live or die?
We are realistic enough to know that, in today’s environment, the answer will be guided by the underlying finances of the institution. Unless the BIDMC is able to maintain its clinical programs in a manner consistent with fiscal responsibility, it will not be able to generate sufficient support to remain as an academic medical center. This plan is a blueprint that will support that result. The issue for the BIDMC is not so much whether it should remain an academic medical center: Rather, we will need to decide what mix of clinical care, research, and teaching can be supported. To date, the financial systems and institutional structures of the BIDMC have foreclosed making those decisions. As a result of changes we will make, those choices will be apparent, and decisions will be made about the programmatic priorities for the hospital.
The recovery plan is guided in great measure by the recommendations of The Hunter Group ("THG"). The report prepared by THG has been made available to every employee in the medical center, and we have received hundreds of suggestions and comments regarding the implementation of the measures contained therein. Every one of these suggestions has been considered by senior management. There is much that is good in THG report. It sharpens the focus of our efforts, offering a range of specific financial targets we must achieve. Many of the recommendations of THG are correct, and in fact reinforce those of previous consulting firms. We embrace those recommendations wholeheartedly and have already started implementing many of them. Other THG recommendations are correct insofar as their purpose and goal, but need modification with regard to implementation. In this proposed recovery plan, we commit to achieving the financial results of such measures set forth by THG, but we promulgate a more realistic plan for achieving them. A small number of THG recommendations are unsupported and impractical and have been dismissed. Finally, we offer a set of our own recommendations that were not proposed by THG.
Our recovery plan has a clear financial target. Progress towards that target will be presented to the Board, and it is measurable at every step along the way. We have considered THG’s recommendation that our approach should be to reach a goal of a 3% margin on clinical care within the next two-and-a-half years. This is not realistic given our plan to maintain high quality patient care and, if achieved, would place the BIDMC in a range of performance seldom achieved by academic medical centers. It also would place an undue strain on an institution that will already face massive organizational challenges.
Inherent in our target is a need to stem the "run rate", the degree to which hospital operations are depleting the unrestricted assets of the corporation. We must and will demonstrate a dramatic reduction in the run rate throughout the remaining months of fiscal year 2002. Clear targets for fiscal year 2003 and 2004 are also presented, leading to a break-even result in fiscal year 2004. In the interim, we believe it is appropriate to budget a certain level of operational support from the endowment for three purposes: to compensate for the institution’s past lethargy in making operational improvements; to support the level of research and teaching that are critical to the overall success of this academic medical center; and to serve as a venture fund to finance strategic initiatives that will bring longer term revenue enhancement and quality improvement in this hospital.
On the revenue side of the ledger, we project no increase in patient volumes for fiscal year 2002, but we do commit to a modest increase in such volumes in 2003 and 2004. This contrasts with THG report, which has no expectations of such revenue growth. This commitment is offered by the chiefs and the medical staff directly. It reflects the substantial financial investment being made to recruit a number of the excellent surgeons to this hospital. It relies, too, on increasing physician productivity, particularly with regard to ambulatory care. Finally, it rests in great measure on enhancing relationships with referring physicians throughout the Boston area. The physicians are directly accountable for the success of this recovery plan, and they are willing and ready to stand by that commitment.
Also, on the revenue side, we show income from the rental of real estate. This measure reflects the surfeit of space in the medical center, relative to the size of its clinical and academic functions. That the amount included in our rental projections is achievable reflects inquiries and commitments made during the last several weeks, as well as our own estimate of future tenancies. In choosing to rent space, we will limit ourselves to tenants which have a strategic synergy with the medical center -- organizations which conduct medical research and clinical care that is consistent with our mission and with which we are likely to want to maintain a close relationship over the coming years.
How can the Board best measure our progress in carrying out this plan? Of course, we will provide month-to-month figures on patient volume and financial performance. The advantage of such real-time data is that it offers the potential to track early indicators, but the disadvantage is that any given month’s figures can also cause misleading hope or discouragement. Obviously, it is only the trend over several months that is meaningful.
The difficulty of measuring the success of our program is inherent in the nature of this medical center. The preponderance of our costs are fixed, but the preponderance of our revenues are variable. Even a small shift in patient volumes can cause large swings in the month-to-month bottom line. This problem is aggravated by the fact that the hospital has and will invest large sums of money in the potential for future growth. We have large commitments to recruitments in surgery and anesthesia, for example. Likewise, our physical plant and equipment is sized for a larger patient volume than currently exits.
If we were in the manufacturing business, we would shed workers, close down divisions, and sell assets in the face of a downturn in volume – in essence, adjusting the fixed cost base to be commensurate with a reduction in revenue. Here, our investment commitments are not so variable or fungible. Our staff is our key resource. We cannot increase and decrease the numbers of doctors, nurses, and technical staff every quarter in response to volume changes. Neither can we buy and sell property and reconfigure operating rooms and other patients facilities every several months.
If we were financially healthy, we could deal with these variations by drawing on our "bank account" of unrestricted reserves, knowing that those reserves would be replenished in good times. Here, we have done this for a number of years but without replacing those funds, thus severely restricting the amount available for future use. As THG notes, time is running out if we intend to use those reserves in that manner for much longer. We are proposing a dramatic reduction in this practice, but, as noted above, some continued drawdown of these funds should be expected over the next two-and-a-half years as we pay off the investment costs needed to bring about a longer term level of sustainable patient volumes.
The major portion of this submission is our plan. In that section, we present our major initiatives in Quality of Patient Care; Revenue and Volume Growth; Expense Management; and Strategic Direction. We also provide a narrative comparison with THG’s recommendations in each area.
Our report also contains a series of charts presenting the financial summary for BIDMC that is our target for fiscal years 2002, 2003, 2004. We show projected overall financial results for each year, along with a month-by-month projection of the run rate during this period. These figures are presented alongside those offered by THG. Accompanying these figures is a summary of the performance monitoring tools and metrics that will be in place to measure our success in meeting these financial targets.
Finally, for ease of review, we present a chart in which we present each of the 200-plus THG recommendations and its projected effect in each of the three fiscal years. In the same chart, there is a narrative indicating the degree to which we accept the recommendation along with the financial target associated with our plan for each of the three fiscal years.
Before closing, I must address the concern that has been raised by THG and by other observers: Does the medical center have the ability and the will to carry out these recommendations? Many of the THG recommendations have been offered by previous consultants and yet were not carried out. Why is the situation different now?
Let us briefly review the reasons for the institution’s past failure. Recall that BIDMC had previously engaged Ernst and Young, Deloitte and Touche Consulting, and CSC as consultants to offer advice on achieving financial improvements. These firms independently developed many good ideas which significantly overlapped each other; so the turnaround plans did not fail because of a lack of ideas. While certain aspects of each plan may not have been totally achievable, the majority of the initiatives could have been accomplished.
One of the problems encountered was that the financial target that was established was too small. For example, the 1999 Genesis project stated the budget problem as $52 million per year. In the course of that effort, opportunities were identified totaling $95 million, of which management agreed to implement $75 million, of which about $59 million was actually achieved. However, the projected budget problem increased from $52 million to approximately $100 million during that period.
Another problem was that of unrealistic expectations. The 2000-2001 turnaround plan placed significant reliance on the establishment of a profitable partnership with a pharmaceutical or bio-tech company. The confidence expressed by senior management in this highly uncertain venture was not supported by evidence from outside the organization. In addition, knowledgeable people within the medical center who doubted its efficacy were treated as nay-sayers, and their voices were stilled or discounted.
A third problem was a failure to mesh broad views of how things would improve with the process of change within the organization. The plan developed in 2000 was announced before determining if certain key elements of its design could be accomplished. This conceptual "model" emerged as a "plan" before details could be developed, and the plan was immediately challenged at the detail level in a confrontational manner. Rather than a rational evaluation of the concepts, details were challenged: Decisions were then made in response to the confrontations. Senior management underestimated the reaction to the plan and was distracted by internal and external politics and publicity. As a result, it was difficult to address the very complex implementation and management issues inherent in the change process.
Significantly, a sense of urgency in the medical center had not been established prior to the announcement of this or any previous plan. While BIDMC senior leaders understood the urgency, they overestimated how successful they had been in communicating that sense and establishing it more broadly in the hospital. In part, too, many physicians did not accept the urgency because of a belief that a merger with Partners Healthcare system could occur; that a break-up of CareGroup would solve the problems of the BIDMC; or that Harvard Medical School and Harvard University would act as saviors.
During this last effort, a clear vision for the BIDMC was not accepted. The result was a failure to develop a guiding coalition of key physicians, managers, and Board members, resulting in an inability to remove obstacles to a new vision. This led to a failure to put the needs of the organization ahead of the individual needs and desires of its many internal constituencies. Suggestions that really could have made a difference were not accepted.
Finally, the last turnaround plan had a strong dependence on increasing clinical volumes, especially of high level tertiary and quaternary care. However, the lack of confidence on the part of specialty physicians in the future of the hospital led to faculty turnover that increased the volume gap. Meanwhile, remaining physicians did not fundamentally alter their practice to spend more time on clinical activities.
How is the current situation different? First and foremost, there is now a clear understanding on the part of the medical and managerial staff that the "platform is burning." The decision by the CareGroup Board of Directors to consider seriously the sale of the hospital is now widely known and has provided strong motivation to all parties to work on solving the institution’s financial problems. The involvement of the Attorney General of the Commonwealth, given his statutory responsibility with regard to public charities, underscores the fact that the Board of Directors will be held accountable for its fiduciary responsibilities, lending even greater credibility to that potential threat.
Second, we have shared with the entire hospital the contents of the Hunter report. This independent analysis offers a sobering conclusion about the future of the medical center, absent effective action. It offers detailed proposals for action within every department. It provides us with the tools to establish a realistic financial target, based on appropriate estimates of inflation in personnel and supply costs. It also provides objective criteria by which corrective actions can be judged. Broad-based knowledge of these aspects is key to success, and the report has received over 100,000 hits on the company intranet, and there have been thousands downloads of all or a portion of it. This is an unprecedented distribution of a management consulting report in an academic medical center. (We will follow up with a similar distribution of this plan.)
Third, we have created an environment in which suggestions and contributions from the broad base of physicians and employees are welcomed, solicited, and evaluated. Even if all of these ideas are not adopted, the fact that we have asked is an important aspect of building a constituency for the final decisions. We have created a culture that will avoid failure because the needs of the organization are clearly considered along with the needs and desires of individuals. Suggestions that really can make a difference will be accepted.
This is not to say that the path is easy or straightforward. While the physician leadership and individual physicians care deeply about the future of the BIDMC and are actively engaged in this effort, the day-to-day decisions of those physicians will depend on the creation of institutional incentives (both between the hospital and HMFP and within HMFP) that clearly align the financial and operational incentives of individual faculty practices and the hospital. Likewise, nurses and technical workers on whom we rely so much for the care of patients will need to make adjustments in the way they carry out their work, while maintaining the overall quality of care. Administrative staff will have to focus on the fact that they are part of the overhead cost in an organization the core mission of which is to serve patients and families, and so they will need to be engaged in continuous improvement and searches for greater efficiency.
The foundation for these efforts, though, has been poured. The spirit of the hospital is strong, and the commitment of those working here is as intense as ever. In summary, we offer a financial plan that is real and achievable, but we recognize the tremendous effort that will be required to achieve it. The plan satisfies the fiduciary responsibilities of this Board of Trustees. First and foremost, it promises our patients and their families that the quality of care they receive at this hospital will meet the high standards they expect. Equally important, it ensures that the public’s trust with regard to the preservation and use of the institution’s charitable assets will be sustained, providing a prudent financial plan for the maintenance of those funds. I am pleased to present you with this plan on behalf of the physicians and nurses, and the technical, administrative, and support staff of this organization. We have confidence in this medical center, and we ask for your support in voting to approve this plan.
Sincerely,
Paul F. Levy
President and Chief Executive Officer
So that's how it all started. So far, so good, as a result of thousands of people both within the hospital and from the community with a shared set of values working together to support an incredibly worthwhile mission. Let's see what the coming years bring.
Wednesday, January 02, 2008
PatientSite comes through again
I know I have written about PatientSite before, but I wanted to share this recent note from a patient. I am sorry if it seems too self-congratulatory for me to do this, but when you get a reaction like this, it is very satisfying. You can check out the demo here.
Just wanted to let you know that the patientsite.org program is FANTASTIC!! I recently had an Echo and Stress test (due to chest pains and shortness of breath) which came out normal, but I could get the results when it was convenient for me, without bothering my very busy physician -- especially since the results were normal. Of course, had they been abnormal he would have been available to discuss the results, but to be able to access my information and get the details I needed so quickly and simply is just amazing (and efficient). Congratulations to you and the whole IT team for a very patient-centered program.
Just wanted to let you know that the patientsite.org program is FANTASTIC!! I recently had an Echo and Stress test (due to chest pains and shortness of breath) which came out normal, but I could get the results when it was convenient for me, without bothering my very busy physician -- especially since the results were normal. Of course, had they been abnormal he would have been available to discuss the results, but to be able to access my information and get the details I needed so quickly and simply is just amazing (and efficient). Congratulations to you and the whole IT team for a very patient-centered program.
Bravo Brigham!
Liz Kowalczyk writes in the Boston Globe today about plans by Brigham and Women's Hospital to improve access to families of patients in its intensive care units. The Brigham is just completing a new building, and they have designed the ICU rooms to have sufficient space and amenities to permit family members to stay overnight. Here is the significant excerpt:
The rooms will be as big as 350 square feet - about double the size of the hospital's current rooms - and patients will be able to designate a relative or friend to stay with them each night, basically living alongside them in the room.
Doctors and nurses will encourage family members to help provide basic care, such as bathing and changing bandages, and allow designated individuals to remain in the room for most procedures, including removal of chest tubes, insertion of intravenous lines, and even resuscitations.
This is really an excellent step, and the Brigham deserves credit for including the possibility in the design of the new space -- but mainly for adopting medical rules and regulations that encourage this type of care.
In this regard, we are behind at BIDMC. As noted by a recent patient in a letter to me: "The ICU staff generally still sees family as outside of the direct care system.... The first night in the ICU was really awful, in that the visiting hours were strictly imposed, and we were allowed 2 people to visit her for five minutes every other hour. The nurse would look up at the clock when we entered, a kind of visual cue that she was counting. I’d strongly encourage (maybe, beg) for you to reconsider this policy in the ICU and throughout. I was told that the policy was in place for several reasons, but that the staff would never keep a family and a dying patient apart. I agree but think you are missing some wonderful energy and resources by placing limits in non-terminal situations."
So thanks to the Brigham for setting a great example. We are currently reviewing our own regulations to figure out what changes we should make. Likewise, in designing new ICUs and other rooms, we will be sure to make this a physical possibility. (By the way, the decision by the Brigham to expand the normal size of a room clearly adds costs. I think many would agree that this is money well spent, but I wonder if any of the insurers out there reading this would want to comment on how they feel about paying for this.)
The rooms will be as big as 350 square feet - about double the size of the hospital's current rooms - and patients will be able to designate a relative or friend to stay with them each night, basically living alongside them in the room.
Doctors and nurses will encourage family members to help provide basic care, such as bathing and changing bandages, and allow designated individuals to remain in the room for most procedures, including removal of chest tubes, insertion of intravenous lines, and even resuscitations.
This is really an excellent step, and the Brigham deserves credit for including the possibility in the design of the new space -- but mainly for adopting medical rules and regulations that encourage this type of care.
In this regard, we are behind at BIDMC. As noted by a recent patient in a letter to me: "The ICU staff generally still sees family as outside of the direct care system.... The first night in the ICU was really awful, in that the visiting hours were strictly imposed, and we were allowed 2 people to visit her for five minutes every other hour. The nurse would look up at the clock when we entered, a kind of visual cue that she was counting. I’d strongly encourage (maybe, beg) for you to reconsider this policy in the ICU and throughout. I was told that the policy was in place for several reasons, but that the staff would never keep a family and a dying patient apart. I agree but think you are missing some wonderful energy and resources by placing limits in non-terminal situations."
So thanks to the Brigham for setting a great example. We are currently reviewing our own regulations to figure out what changes we should make. Likewise, in designing new ICUs and other rooms, we will be sure to make this a physical possibility. (By the way, the decision by the Brigham to expand the normal size of a room clearly adds costs. I think many would agree that this is money well spent, but I wonder if any of the insurers out there reading this would want to comment on how they feel about paying for this.)
First 2008 baby in Boston
A friendly competition among hospitals each year. Let's do our best to make it a good year for all the new arrivals!
Tuesday, January 01, 2008
Dear PHC, Please vote yes on mini clinics
Way back in May, I wrote in support of storefront clinics of the type proposed at that time by the company that owns CVS pharmacies. Since then, there has been a lot of back-and-forth on the issue. Significantly, the state Department of Public Health looked into the issue and received lots of comments as to how best to proceed.
Monday, December 31, 2007
Windows of Hope
Windows of Hope is our oncology shop, located on the ninth floor of the Shapiro clinical center -- at the corner of Longwood and Brookline Avenues -- near the chemotherapy and other treatment areas. In addition to selling wigs, scarves, book, and other helpful items, it has become a place where cancer patients and families come and talk comfortably and share advice and stories about what they are going through. Linda and Terri, who run the shop, are warm and friendly people. You don't have to be a patient at our hospital to go there. All are welcome. Samples of their wares are in the pictures above.If it sounds too good to be true
Technology Review has an excellent article by David Talbot entitled "The Fleecing of the Avatars", which deals with the difficulties of consumer protection and regulatory supervision of commerce on Second Life and other virtual worlds. Financial rip-offs are hard enough to avoid in-world, and this article gives a really good description of the issues when virtual currency is in play.
Thursday, December 20, 2007
Merry Christmas!
Just to take a break from this current addiction, I'm taking several days off from posting new items (although I will still moderate your comments), and so I wanted to leave you with this nice image at the top of my page. One of our nurse managers insisted that she did not want presents from her staff. They, being the usual strong-minded nurses at BIDMC, nonetheless insisted, but gave a gift in the form of this Christmas tree. Each "mitten" is a warm and kind personal message from a nurse to Sue.
An idea for US News and World Report
Here is an open suggestion for Avery Comarow, the editor of the annual US News and World Report ranking "America's Best Hospitals." Why not add to your algorithm extra points for those hospitals that voluntarily publish clinical indicators of the degree to which they harm patients? I am not talking about the usual hodgepodge of outdated CMS data, which are available anyway. I am talking about substantive clinical metrics, like central line infections, ventilator associated pneumonia, and the like. Or the ultimate, the hospital standardized mortality rate calculated by the Institute for Healthcare Improvement.
I can already hear the arguments against this. Who is going to validate the numbers? Which definition of central line infections should be used? How would you compare from hospital to hospital?
Please, put all that aside. Let's just accept as a premise that hospitals that choose to post these numbers do so not for comparative or competitive purposes, but rather to hold themselves accountable to the public for their efforts in quality and safety improvement. Shouldn't that be worth something in the US News listing?
A fallback, if you don't want to change your algorithm. Just create a special box listing the hospitals that post these kinds of results, along with their url, so people from hospitals around the world can check in and make their own judgments about the usefulness of this approach.
Avery, you have become a force in this field. As noted on your blog, your perspective uniquely qualifies you to observe and comment on the efforts by hospitals and other health care providers to improve care and patient safety. Why not use that influence to push the industry along to greater heights by giving space to those who risk holding themselves accountable in this manner?
I can already hear the arguments against this. Who is going to validate the numbers? Which definition of central line infections should be used? How would you compare from hospital to hospital?
Please, put all that aside. Let's just accept as a premise that hospitals that choose to post these numbers do so not for comparative or competitive purposes, but rather to hold themselves accountable to the public for their efforts in quality and safety improvement. Shouldn't that be worth something in the US News listing?
A fallback, if you don't want to change your algorithm. Just create a special box listing the hospitals that post these kinds of results, along with their url, so people from hospitals around the world can check in and make their own judgments about the usefulness of this approach.
Avery, you have become a force in this field. As noted on your blog, your perspective uniquely qualifies you to observe and comment on the efforts by hospitals and other health care providers to improve care and patient safety. Why not use that influence to push the industry along to greater heights by giving space to those who risk holding themselves accountable in this manner?
Wednesday, December 19, 2007
Heartsaver
I have linked at right to a blog I just learned about, Corazón Hispano. Here is a note from the author, Juan Jose Rivera, in response to a comment I left:
Saludos from Corazon Hispano blog. Thank you for your comment. It is very important for me that Hispanics have access to essential and practical prevention information. We represent the minority group in the US with the highest percentage of uninsured individuals. A significant number of Hispanics have access to the Internet, but not to a primary doctor.
He provides personal information on his profile:
Pertenezco al departamento de CardiologÃa de la Universidad de Johns Hopkins en Baltimore, Maryland. Además de mis obligaciones clÃnicas, me dedico a realizar investigación en el área de prevención cardiovascular. También escribo una columna mensual para el periódico médico nacional estadounidense Today in Cardiology.
This blog is very well written and quite informative. I hope you will pass it along to friends and associates.
Saludos from Corazon Hispano blog. Thank you for your comment. It is very important for me that Hispanics have access to essential and practical prevention information. We represent the minority group in the US with the highest percentage of uninsured individuals. A significant number of Hispanics have access to the Internet, but not to a primary doctor.
He provides personal information on his profile:
Pertenezco al departamento de CardiologÃa de la Universidad de Johns Hopkins en Baltimore, Maryland. Además de mis obligaciones clÃnicas, me dedico a realizar investigación en el área de prevención cardiovascular. También escribo una columna mensual para el periódico médico nacional estadounidense Today in Cardiology.
This blog is very well written and quite informative. I hope you will pass it along to friends and associates.
Partial Credit
As a former state official, I understand the difficulties of running a state agency and therefore like to give credit where credit is due. This post is to award "partial credit" to the DCR, the state agency that runs the parks.We had a big snowstorm on the weekend, but this is not unusual in New England. So you would think that the various agencies would be prepared to clear major walkways on public lands, particularly those walkways that lead to major mass transit stations. Not so. My particular T stop is Longwood, which serves thousands of people going to work at hospitals, school, and other institutions -- not to mention patients. A major passageway from the Longwood stop to the medical and academic area is a short walk through a park and across the Muddy River.
As late as yesterday, the walkway was a sheet of ice several inches thick. There had been no effort to clear it or to spread sand on it. It was treacherous.
So, today, I brought a camera to document this condition and send it along to the authorities and -- lo and behold -- the walkway has been plowed and sand laid down. The steps up the little bridge across the Muddy River likewise have been totally cleaned. The pictures above attest to this result.
So, that is the good news. The bad news is that it took so long. Partial credit awarded.
The new Commissioner of the DCR is Rick Sullivan, who used to be mayor of Westfield, MA. He is an honorable, hard-working, and competent person who understands the importance of proper and timely delivery of municipal services. Like his predecessors, though, he is hamstrung by inadequate budgets and, I am guessing, antiquated equipment. I think he is doing the best he can, but until and unless the public puts more pressure on their elected representatives for more adequate funding, the state park system will always be behind -- just as it was this week.
Tuesday, December 18, 2007
Physician Diversity -- Part 3
You know, if you know where to look, everything is available on the BIDMC website! Here is a report prepared by Rosemary Duda, Director of our Center for Faculty Development, as a guide to the faculty recruitment process, with a specific emphasis on trying to recruit under-represented minorities and women. Pages 40 to 42 of the book has charts showing the relative percentage of different levels of faculty at BIDMC in those categories and -- starting on page 43 -- compares our numbers to Harvard Medical School (including all the affiliated hospitals).
You can look at the numbers yourself, but it is clear that we are behind the rest of HMS in all faculty ranks.
Professor Duda's introduction to the book is very well written. Having served on search committees for department chiefs, I know that its recommendations are followed. Likewise, having talked to our chiefs, I believe that its recommendations are also carried out for division chiefs and other recruiting committees.
By the way, to answer comments on earlier posts, her language on page 6 concerning the value of diversity is very compelling: The advantages of a diverse faculty at BIDMC include optimizing our ability to provide high quality medical care for our underserved populations, addressing the issues of health and health care disparity in the underserved populations as these patients are more likely to seek physicians who are similar in ethnicity, culture, race and/or gender, and improving our cultural competency educational efforts and professionalism training. A diverse faculty also brings to the institution an expansion of the research focus that would encompass health issues related to women and underrepresented minorities.
But let us return to the question. If good intentions reign, and I believe they do, why are BIDMC's results less favorable than the rest of the HMS community? I know that a large part of the answer relates to the hospital's troubled period of 1996 through 2002, when many of the existing faculty left the hospital for greener pastures and when many potential young recruits were scared away by the uncertain future of the BIDMC. In fact, our moniker of "financially troubled BIDMC" did not leave the pages of journalism until sometime in 2004. I think this set us back many years, both in terms of new recruits and in creating a pipeline for later professorial advancement.
But let's open this up to those who want to comment, who know this place or know of it. Are there other factors at BIDMC that adversely affect our performance in this matter? Are those factors different from other Harvard hospitals? From other hospitals in Boston? Please dive in and offer your opinions and remedies.
You can look at the numbers yourself, but it is clear that we are behind the rest of HMS in all faculty ranks.
Professor Duda's introduction to the book is very well written. Having served on search committees for department chiefs, I know that its recommendations are followed. Likewise, having talked to our chiefs, I believe that its recommendations are also carried out for division chiefs and other recruiting committees.
By the way, to answer comments on earlier posts, her language on page 6 concerning the value of diversity is very compelling: The advantages of a diverse faculty at BIDMC include optimizing our ability to provide high quality medical care for our underserved populations, addressing the issues of health and health care disparity in the underserved populations as these patients are more likely to seek physicians who are similar in ethnicity, culture, race and/or gender, and improving our cultural competency educational efforts and professionalism training. A diverse faculty also brings to the institution an expansion of the research focus that would encompass health issues related to women and underrepresented minorities.
But let us return to the question. If good intentions reign, and I believe they do, why are BIDMC's results less favorable than the rest of the HMS community? I know that a large part of the answer relates to the hospital's troubled period of 1996 through 2002, when many of the existing faculty left the hospital for greener pastures and when many potential young recruits were scared away by the uncertain future of the BIDMC. In fact, our moniker of "financially troubled BIDMC" did not leave the pages of journalism until sometime in 2004. I think this set us back many years, both in terms of new recruits and in creating a pipeline for later professorial advancement.
But let's open this up to those who want to comment, who know this place or know of it. Are there other factors at BIDMC that adversely affect our performance in this matter? Are those factors different from other Harvard hospitals? From other hospitals in Boston? Please dive in and offer your opinions and remedies.
Timely and important advice
Today's Boston Globe has timely and extremely important advice from Monique Doyle Spencer. You will not want to miss this.
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