Alan Lupo: Reporter

I had planned to take this day off, but I am moved to write this short note in memory of Alan Lupo, a beloved Boston reporter, who died today. I am lucky to be among those many who were blessed by friendship with this fine, kind, thoughtful, and genuine man. Over the past year, he was a patient at our hospital, and as much as it saddened me to see him there, I rather selfishly was pleased that I had a chance to spend time with him during my visits to his room. I loved his company. We had lots of good laughs and traded stories from the past 3+ decades of life in Boston.

When I say that Alan was a reporter, I choose the word carefully. I don't mean journalist, although that could apply, too. I mean that he was a down-in-the-streets reporter, who got news stories and columns the old fashioned way. He would talk to people and ask questions. And they were great questions, probing to the heart of the matter at hand. They could be tough questions, but they were never mean. (Actually, as I think about it, I don't ever recall Alan being mean.)

My first exposure to this guy was in the 1970s when I watched a show called The Reporters on WGBH, the local public TV station. Here's how it worked. Alan and his colleagues would walk around the streets of the city with a still camera and take black-and-white pictures and conduct interviews. The news would then be presented as a voice-over on TV, with the pictures of the interviewees and of the street scenes and other pertinent views. I think I recall that each segment lasted about 15 minutes, but I might be wrong about that. If you have watched Ken Burns' specials, you can get the idea, but this was not a history show. It was a current events news and feature show. It was engrossing, informative, entertaining, and gave as complete and fair a presentation on each story as you could imagine.

I was always sad that The Reporters went off the air. I assume it could not compete with the glitzier news programs that are based on television stations' belief that viewers have attention deficit disorder. But, I actually think there could be a place for such a show even today -- if it were done with the professionalism, depth, and empathy shown by Alan and his colleagues.

I have not met a person in Boston who knew Alan who did not love and admire him. Think of that. A person who conducted investigative journalism in one of the toughest political environments in the country, and he ends up beloved and admired. Over these last few months, as I have talked with other people who knew that he was terminally ill, none of us could mention him without choking up in sadness at the thought of losing him. Now we have lost him, and the tears can flow freely, as they do as I write this on the eve of a holiday that is otherwise wrapped in happiness and hope for the coming year.

Dirty Americans?

A guest post from Dr. Val Jones, a blogosphere friend. I was going to have a simple post today to wish my Jewish readers "l'shana tovah", but perhaps this will also get them thinking about those Rosh Hashanah apples in a different way! (BTW, I'll be off-line starting this evening and through tomorrow for the New Year's holiday.)

I took a beginning Spanish course at the University of Zaragoza, Spain, about ten years ago. One day I was at a local grocery store, picking through some apples and oranges when I noticed several women looking at me with utter disgust. I couldn’t imagine what was bothering them and returned their gaze with an innocent shrug.

“Sucio!” [dirty] uttered one under her breath. And the women shook their heads and pushed their shopping carts away from me in a huff.

My mind went into overdrive trying to figure out what I could possibly have done that was so utterly distasteful. I watched other women at the apple bin and slowly noticed that they had a systematic way of selecting their fruit. First they pulled a plastic bag off the roll, then they opened it and put their hand in it (as if it were an ill-fitting surgical glove), and then they began picking up the apples and oranges one by one to inspect them for defects. When they found one they liked, they simply inverted the bag and kept the item inside, without ever having skin-to-fruit contact.

“Ah hah,” I thought, “that’s why they thought I was ‘dirty.’ I was touching the fruit with my bare hands.” And from that day on, I have used the “surgical glove” approach to fruit selection. It’s a cleaner way to shop.

I was at a local farmer’s market today with my husband, and I noticed him rifling through an apple bin with a bunch of other eager shoppers. True to their “dirty” American upbringing, they were all inspecting the fruit with bare hands. I told my husband about my Spanish experience and asked him if he thought all the hands on the fruit might be spreading E.coli or other bacteria around.

He replied simply, “Well, I’d be more concerned about the foreign farmers fertilizing their plants with human manure than about the grocery store buyers touching the fruit. Besides, we wash our hands in America.”

Well, I’m not sure if the second statement is correct – Paul Levy will testify to just how difficult it is to get hospital employees to wash their hands! My bottom line is – please wash your fruit.

Another problematic ad

In a post below, I talk about a recent radio ad that I felt was inappropriate. Yesterday, I heard another one. In this ad, there is discussion of a recent research finding that presents the possibility of being able to detect cancer cells in the bloodstream of patients. This is truly great stuff, in that it might someday enable doctors to know if they were successful in removing or killing all of the cancer cells in a person or might enable them to obtain earlier detection of cancer than is currently possible. The people who did this research are outstanding scientists. We all are so fortunate that they devote lifetimes of time and energy to helping humanity.

But the problem with the ad is that it gave the impression that because this discovery was made in one hospital, that hospital can offer superior cancer care to patients. As we know, even if this discovery were ready for clinical application, advances of this sort are made widely available to the world and are not held as proprietary by the discovering institution. (In this case, especially so, in that the discovery is actually part of a multi-institutional cancer research program in which results are widely shared among all participants.)

To be clear, the hospital buying the ad is a superb place to get diagnosis and treatment of cancer. What is objectionable in the ad was the decision to cite a promising research finding and to overstate its relevance to the current delivery of medical care in this hospital. This is particularly troubling in the cancer arena, where patients hunger for new treatments and cures and can easily leap to the conclusion that an experimental finding is already available to them. Perhaps some of you will view this as too fine a line of distinction, but I think we need to be careful here: All of this affects the entire medical community's credibility over time.

Caption contest

Just for fun, let's have a caption contest for the picture above. The caption should relate to the current US financial crisis. Please submit your entries!

Shoe on the other foot

A story by Mark Hollmer in today's Boston Business Journal summarizes a recent report by the Mass. Hospital Association, entitled Hospitals Rate Health Plans: A Critical Look at Performance Variation. I'm told that the full report will be on the MHA's website on Monday. Here's an excerpt of Mr. Hollmer's article:

Hospitals prefer to deal with local health plans over their national counterparts. But Bay State providers still want them to try harder to reduce inefficiency and extra costs, according to a new survey released Friday by an industry trade group.

"What we found is that no one plan is really performing at the top at every attribute," said Lynn Nicholas, president and CEO of the Massachusetts Hospital Association. "But all plans have strengths and weaknesses, which provides a great opportunity to learn from those who do it well in an effort to improve the field overall."

...[H]ospital executives said they want insurers to update and distribute more evidence-based clinical guidelines to help promote more cost-effective care. They also want health plans to better educate their members about their insurance and obligations so they can make more informed consumer decisions.

I am sure this report will be viewed as self-serving by the insurance companies, but the points made and the language used are remarkably similar to the comments those companies often make about hospitals. My conclusion: Both segments of the health care industry have a long way to go. Transparency in both sectors would go a long way towards self-improvement.

In that regard, let's do an experiment. Check out the websites of your favorite insurance companies and hospitals. See how many have adopted quantifiable audacious goals for quality improvement, patient satisfaction, or efficiency -- and how many post their actual operating results to hold themselves accountable? (If you find some that do, please submit their links as a comment.)

Double Talent

Former Boston anchorwoman Heather Kahn has joined forces with BIDMC's Rhonda Mann to create a series of broadcasts on two Boston media-affiliated websites. One partnership is with Channel 5's website, the BostonChannel.com and the other is with 105.7 WROR. You can watch here or here to see our latest segments on back pain.

Proverbial Wisdom

I am listening to a delightful interview by Tom Ashbrook on his show On Point on WBUR radio with David Crystal about his new book As They Say in Zanzibar, a compendium of proverbs from around the world. It is worth hearing right now or when it is repeated tonight or on the WBUR website.

Just yesterday, I heard a good one from China: "You can't cross a chasm in two small jumps."

If you would like to post your favorite proverb, please submit it as a comment. Let's see what people come up with.

Fan support

As part of our partnership with the Boston Red Sox, our staff provides first aid to the patrons at Fenway Park. As the regular season draws to a close (hopefully followed by a long post-season), the team kindly recognized the excellent work of this group in a pre-game ceremony. Here is a small subset of nurses and doctors hamming it up with Red Sox President Larry Lucchino while waiting to go on the field to be introduced to the fans before tonight's game.

Note to BIDMC folks: More pictures and more about this story will be posted tomorrow on our portal, and you can also find some more of my pictures now in Facebook on my profile page.

50 great years

At the Annual Meeting of our Boards last night, Board Chair Lois Silverman was honored for 50 years of affiliation with the hospital. Lois started that relationship as a student in the Beth Israel School of Nursing, on a $300 scholarship made possible by a gift from a philanthropic couple to the Jewish Orphans of Rhode Island in 1958. One thing led to another, and along with a very successful career in business and founding the Commonwealth Institute, Lois eventually was elected Chair of our Board of Directors three years ago.

In the picture above, Trustee Jonathan Lee presents Lois with a charm bracelet containing symbols of the various parts of her life related to BIDMC. A well deserved standing ovation followed.

State of the Blogosphere

Technorati is presenting an interesting series on the state of the blogosphere. Here is the introduction and the first two of five chapters. When I started this blog two years ago, there were about 80 million in the world. Now, Technorati counts over 130 million.

Follow-up to "never" event

Some of you have inquired what our follow-up has been to the wrong side surgery that took place in July. Here is an email that went out to the staff today on that topic, plus another case involving an impaired physician.

To: BIDMC Community
From: Kenneth Sands, MD, Senior Vice President of Health Care Quality
Subject: Updates after Summer Incidents

Over the summer, BIDMC experienced two troubling incidents that received considerable attention, and rightly so. The first was a “never event” (in this case, a wrong site surgery) and the second involved an impaired physician.

We have recently received the results of the investigations by the Massachusetts Department of Public Health into both cases. As always, we fully cooperated with DPH as they reviewed all our documentation and interviewed key staff on-site. We wanted to share with you a summary of what DPH said, and what improvements we have made in light of these cases:

1. In the case of the wrong site surgery, the DPH investigator concluded that BIDMC acted appropriately in reporting the event, discussing the error with the patient and apologizing to her.

The investigator also noted that BIDMC has initiated a corrective action plan that places ultimate responsibility for calling a “time-out” prior to surgery directly on the surgeon who will make the first incision. But the basic principle remains that while the surgeon always needs to initiate this step, it remains everyone’s responsibility to be sure that all safety protocols are being followed. Specifically, if for whatever reason it appears that the surgeon might neglect to call for the time-out, every other person in the OR is encouraged and empowered to mention that fact.

Additionally, a revision to the "Correct Site Universal Protocol Policy" (PSM 100-105) requires that “the scrub person will mount/arm the scalpel after the ‘time-out' has been completed.” This creates a “fail safe” that ensures that a surgery cannot go forward without following the proper procedure. Everyone working in the ORs has been informed of and trained in these changes to the policy.

2. In the second case, the DPH investigator determined “invalid” the allegation that BIDMC “failed to ensure quality care” in a surgical procedure performed by a physician who appeared to be impaired. The medical center was, however, cited for record keeping deficiencies in the case. The conclusions came after a thorough review of our documentation and interviews with clinicians associated with the case.

We are currently working together, with helpful advice from our Board of Trustees, on a new policy to strengthen the medical center’s procedures when a doctor or other caregiver is impaired or otherwise unable to perform his or her duties. This includes improvements in training for staff on what to do should they encounter such a situation. We will let you know what we come up with.

These recent events remind us that we need to remain ever vigilant about our everyday commitment to quality and safety. We continue to identify and tackle problems as soon as they arise and create a culture where talking about problems or necessary improvements is embraced.

All of us at BIDMC have been involved in efforts to make the medical center a safer and more welcoming place for patients and families. At the same time, we have set a new standard for transparency in our work – the good, the bad and the learning experiences have been laid out for all to see.

We know how much each of you cares about the medical center and the patients we serve. You have helped make BIDMC an exceptional place – for high quality and compassion. Always keep that in mind and be proud.

Why not to blog . . . or how to do it

On this post by B. L. Ochman, we find "10 Reasons Your Company Shouldn't Blog," mainly focused on her advice that CEOs shouldn't blog.

I especially enjoyed this comment by Mark Brooks:

CEOs time is extremely precious. The best way to extract a blog out of a CEO, and keep it colloquial is to interview them twice a week, then transcribe, then edit to something interesting. The time impact to the CEO should be 10 minutes per interview. Transcription and editing and posting time an additional ~60 minutes per interview.

Whew, fortunately, I never had this advice when I started this whole thing two years ago. I might never have started. But at least if I followed Mr. Brooks' approach, someone on my staff would know what is going to be posted before they read it here.

But, poor misled Mr. Brooks, thinking CEO time is precious. In fact, it is the least valuable time in an organization if things are working right. And, if things are not working right, it is even less valuable.

Heartfelt feelings

(Printed with the patient's permission.) My friend Bob Kavanagh recently visited our hospital for heart surgery. Upon arriving home, he gleefully sent an excerpt from his medical record (contained on this memory stick) to his colleagues at work and his family:

FROM THE SURGEON:
Later that day he was weaned from sedation and awoke neurologically intact...

You can see Bob here holding his cough pillow. When asked if he wanted his picture on this blog, he replied, "That is certainly all right with me. That is a NY Yankees jacket I have on...."

Wheeling through the Hub

Several thousand people joined together yesterday for Hub on Wheels, a bike ride through the neighborhoods of the City of Boston. The ride is a fundraiser for the Boston Digital Bridge Foundation, a which provides technology training and computer equipment to underserved communities.

We had about 80 people from BIDMC on the ride, and several more of our folks also joined with the people at Cataldo Ambulance Company to provide first aid along the 10 mile, 30 mile, and 50 mile routes. Some of the riders and first aid crew are shown in the pictures above.

We were greeted by Steve Miller, originator of the Hub on Wheels event, and Nicole Freedman, Mayor Tom Menino's bicycle "czarina," both of whom are pictured here as well. I think Nicole was giving me some kind of hint with the sign she is carrying.

Sunshine in Worcester

Douglas Brown writes an important op-ed in today's Boston Globe about the experience of his hospital with public reporting of clinical outcomes. His conclusions are below. Please note again: Transparency is not about competition. Is about each institution making itself better and safer, and sharing what is learned across the health care system.

What have I learned?

First, public reporting works. It created a strong incentive to improving our quality. Second, responding to the crisis transparently, while more risky, was the right thing to do. At times, even lawyers must lean into the discomfort of transparency. It was the best course for our patients, our staff, and our community. Finally, humility saves lives. There is nothing more humbling than having to suspend a program. But it taught us to never accept the status quo, to know we can always get better, and to highly value a culture of learning and continuous improvement.

Breathe

From Kevin, MD, you HAVE TO listen to and watch this.

In memoriam: Susanna Burgett

Please read this obituary.

Time for another apology

Well, it turns out, in the post below, that I unwittingly engaged in a bit of revisionist history. As you may recall, I said this:

"But then I noticed two problematic items in the document that was about to be approved. Here's the first: It is the responsibility of the physician initiating the procedure to initiate the time-out.... I said, don't we want to expand on this and make it clear that each staff person in the room is encouraged and empowered to question whether the time-out has taken place and/or to remind the physician that it should be."

But then I wrote this:
"Why did I have to suggest these modifications? ... And if not, why wouldn't any other member of the MEC have thought to raise them."

One of the doctors at the MEC meeting later reminded me that he, not I, actually first brought up this point. Shows you how tricky memory is. My only explanation is that I remembered it as being my idea because I did indeed comment on it in the way mentioned, and that I was the one who brought up the second point about patient involvement in the time out. But he is exactly right, and I apologize for presenting it wrong.

So I think the record is now accurate, and I am pleased that this current revision helps make my original purpose even more complete. The thrust of my first post was meant to present part of the story of our evolution as an organization and of me personally as CEO. As this same doctor later reminded me, "There are many people in our medical center who are thinking and acting in support of patient safety in multiple ways every day. Although we are not yet where we ultimately want to be, our progress should be acknowledged along with our challenges." To put a more finely focused light on this, this whole MEC episode reinforces Göran Henriks' point: "There needs to be trust from the support system that tells the people at the front that we respect what they are trying to do."

A lucky number?

We live in dangerous times, and there have to be security provisions that we didn't need a few years ago, but you wonder how some of them are decided upon. Take this sign on my local mailbox. It has been there for many months, but this is the first time I really paid attention to it. How did they decide on 13 ounces? Is there something about explosives that makes 13 ounces a threshold for danger? According to this, it used to be 16 ounces. Maybe there is a security expert reading this who can explain.

Ad out

We have all become accustomed to ads by pharmaceutical companies in which they try to convince us that we are at risk for one or another disease and therefore should ask our doctors about their medications. I think a lot of us find those ads distasteful, and many of us believe that they result in unnecessary expenditures on health care.

Well, today, for the first time, I heard a radio ad for a hospital that seemed to me to fit in the same category. It was an ad for a certain vascular center, and it suggested that leg cramps, among other things, could be a sign of peripheral arterial disease. The purpose, pretty clearly, was to get listeners to wonder if this and the other symptoms mentioned might be serious enough to warrant a diagnostic visit to this particular vascular center.

As you know, I am not a doctor, much less a vascular specialist of any sort, but I am guessing that the incidence of peripheral arterial disease among the general population with muscle cramps has to be very, very small. It would be one thing to explicitly target the ad to those at greater-than-average risk of vascular disease (e.g., those with diabetes, smokers, high blood pressure, heart disease, or high cholesterol), but this was a general audience ad. I certainly believe that some percentage of people with PAD who should be getting treatment are not getting treatment, but this ad felt to me (and my accompanying car passenger) to be designed to produce fear and/or anxiety beyond a legitimately targeted audience.

As I have mentioned below, many of us in the hospital world advertise our services. Those ads usually talk about our capabilities, our doctors, access or the like. This is the first time I can remember an ad that seems intent on actually stimulating the demand for specific disease-related medical services among the general population. I don't think this is good for us to do. Insurance companies, government, and employers are beseeching us to control health care costs, especially through a reduction in unnecessary utilization of services. They say that we are insensitive to those cost factors, and we give them support for this position if we advertise our services in the manner I heard today on the radio.

Hearing this ad has made me more sensitive to this issue, and I plan to ask our marketing folks to review all of our ads to make sure we have not gone down a similar path. I do not think we have, but I'll let you know in a later post if we find some.