OK, so not really that far west, but in Northampton, MA, at Cooley Dickinson Hospital. The press release follows. Congratulations to the entire group for a job well done!
NORTHAMPTON, Mass – It’s been one year and 28 days since a Cooley Dickinson Hospital ICU patient has become sick with ventilator-associated pneumonia, a serious infection that can occur in people who rely on ventilator machines to breathe.
“As of Nov. 29, that’s 393 days since the last ventilator-associated pneumonia infection,” Daniel J. Barrieau, director of respiratory care services says of an infection that in October topped a list of the most costly and common hospital-acquired infections.
According to the Centers for Disease Control’s National Healthcare Safety Network Report, Cooley Dickinson’s accomplishment of preventing Ventilator-Associated Pneumonia or VAP ranks the hospital’s performance in the top 10 percent of the nation’s medical/surgical intensive care units (ICUs).
VAP can occur in patients who, because of severity of illness or condition, require mechanical ventilation. When the ventilator tube that pumps life-saving air into vulnerable lungs becomes contaminated, the tube can act as a pathway for bacteria or secretions to enter the respiratory tract, paving the way for VAP. According to the Institute for Healthcare Improvement’s (IHI) website, VAP typically “afflicts up to 15 percent of those in ICUs so weakened by illness or trauma that they need mechanical help to breathe.”
Physicians and staff at Cooley Dickinson are working to eliminate VAP and have adopted a zero-VAP philosophy. Says Barrieau, “We are being aggressive about eliminating VAP, and our track record demonstrates our commitment to delivering the highest possible care to our patients.”
This aggressive approach is paying off. Barrieau says VAP infections in Cooley Dickinson’s intensive care unit have gone from 5 in 2007 to zero as of Nov. 29.
“Besides searching for clinical solutions to the VAP problem, we asked ourselves, ‘what could we change about our culture and our systems to improve our outcomes?’” says Barrieau.
This culture change began in 2005 when team of respiratory therapists, physicians, nurses, quality improvement staff and infection prevention specialists adopted a set of instructions from the Institute for Healthcare Improvement known as the IHI ventilator bundle. The IHI bundle offers a series of interventions determined to be the best evidence-based practices related to reducing the risk of VAP to patients.
Then, Barrieau explains, staff began to “push beyond the bundle of strategies to look for other ways to reduce the risk to patients and eliminate VAP altogether.”
They scrutinized the VAP cases to identify patterns and trends. For example, their analysis indicated that patients on ventilators for more than 19 days, those with difficult intubations and those who required transportation within the hospital were the most vulnerable.
Using an approach called clinical Microsystems, where front-line teams are empowered to make improvement decisions based on scientific data and best practices the team evaluated how each clinician relates their daily work and actions to VAP.
“Doing the minimum is not enough to achieve our zero-VAP philosophy,” states Barrieau. He says clinicians in a culture of zero VAP understand how their actions matter and that acting to reduce risk is part of the clinician’s standard practice.
In addition to preventing VAP infections in patients and providing best-practice care, there is a significant cost savings to the hospital. In 2007, based on Cooley Dickinson’s VAP prevention measures, the organization saved $200,000 by reducing or eliminating the occurrence of the infection and reducing the patient’s length of stay in the intensive care unit.
In 2006, the Institute for Healthcare Improvement named Cooley Dickinson a mentor hospital in three clinical areas including VAP. Since then, Barrieau and his colleagues have presented Cooley Dickinson’s VAP elimination strategies at professional conferences, and he has served on the Mass. Department of Public Health’s Healthcare Associated Infection Task Force.
In December 2007, Cooley Dickinson was one of three hospitals in Massachusetts to receive the Betsy Lehman Patient Safety Award for the organization’s work to eliminate hospital-associated infections including VAP.
In October 2008, Cooley Dickinson was featured in the Joint Commission Journal on Quality on Patient Safety and lauded for breaking new ground in quality improvement.
The five healthcare groups that contributed to the guide include the Healthcare Infection Control Practices Advisory Committee (HICPAC), the Society for Healthcare Epidemiology of American (SHEA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) and The Joint Commission.
Wednesday, December 03, 2008
Tuesday, December 02, 2008
Tipping point?
One of the nation's most thoughtful and foremost patient advocates, noticing that I had perfected the challenges of Twitter, wrote me and said,How about a challenge that's CEO sized...
Get all other health care execs in your region to be as transparent...
I found it hard to reply in meaningful way to this offer. I already feel a bit like the beaver that has been chewing the tree in this picture. It is hard to imagine what more we could do at BIDMC to push the transparency agenda. And it is so clear that it has tangible benefits for the quality and safety of patient care. So, I feel like we have been nibbling away at this issue for quite some time, but the tipping point remains an indeterminate distance away. And, with regard to this challenge, I think that the next steps have to take place elsewhere.
Perhaps the resistance comes from those who misconstrue that this is all about competition. As I have noted, it is not.
Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.
But I am starting to think that, within a short time, we might back into the competitive issues because a lack of transparency might hurt the reputation of some hospitals. Maybe that will show up as a result of a contrast with BIDMC when specific events occur. For example, if there is a wrong-side surgery in a hospital, and folks there try to downplay it instead of admitting it and learning from it, there will be an inevitable comparison made with the way we handled that kind of event.
I truly hope that things don't work that way. I hope instead that Boston becomes known as the place in which all major providers, supported and encouraged by the insurers and the state government, engage in the real-time public presentation of clinical results in those areas that are medically significant and reasonably good candidates for process improvement.
I found it hard to reply in meaningful way to this offer. I already feel a bit like the beaver that has been chewing the tree in this picture. It is hard to imagine what more we could do at BIDMC to push the transparency agenda. And it is so clear that it has tangible benefits for the quality and safety of patient care. So, I feel like we have been nibbling away at this issue for quite some time, but the tipping point remains an indeterminate distance away. And, with regard to this challenge, I think that the next steps have to take place elsewhere.
Perhaps the resistance comes from those who misconstrue that this is all about competition. As I have noted, it is not.
Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.
But I am starting to think that, within a short time, we might back into the competitive issues because a lack of transparency might hurt the reputation of some hospitals. Maybe that will show up as a result of a contrast with BIDMC when specific events occur. For example, if there is a wrong-side surgery in a hospital, and folks there try to downplay it instead of admitting it and learning from it, there will be an inevitable comparison made with the way we handled that kind of event.
I truly hope that things don't work that way. I hope instead that Boston becomes known as the place in which all major providers, supported and encouraged by the insurers and the state government, engage in the real-time public presentation of clinical results in those areas that are medically significant and reasonably good candidates for process improvement.
Follow me @Paulflevy
When you have an addictive personality (any doubts, check my blogging record here), you have to be careful what you start.
I figured, though, that I could trust Scott Hensley, one of the guys who runs the Wall Street Journal Health Blog. He strongly suggested that I sign up for Twitter, noting that their blog appears there.
Oh, it was all too easy to slip into this. After all, I already had a Facebook account and was used to the idea of that kind of social media interaction.
Sure enough, after just two days of updates (42), attracting followers (60), following others (35), Hensley writes: "You're on fire! Good stuff."
But it was too late that I learned. As noted in an early update to me, Bob Coffield, who writes the Health Care Law blog, "Facebook was the gateway drug that led me to the crack that is twitter."
And, then to add insult to injury, Dr. Val, author of Getting Better with Dr. Val, reminded me that I had said, on a blog radio interview with Dr. Anonymous last April, that I would never sign up for Twitter.
And, since this "dialogue" is splayed out for all to see, Ramona Bates, author of Suture for A Living, wisely commented, "Things change. Times change. Circumstances change. Best to never say never."
Dr. A himself replied, "I admit I didn't get twitter at first as well. But, things change. We're glad you're here!"
Of course, he's glad I'm there. Addicts crave company of like-"minded" people.
So, now, like any self-respecting addict, I want my friends to join me, too.
Start here and follow the all-too-easy instructions. As an extra incentive, this blog is now automatically fed to Twitter.
Warning. One friend writes plaintively on her first update: "Trying to understand Twitter."
To which Yoda offers the eternal advice: "Do, or do not. There is no try."
I figured, though, that I could trust Scott Hensley, one of the guys who runs the Wall Street Journal Health Blog. He strongly suggested that I sign up for Twitter, noting that their blog appears there.
Oh, it was all too easy to slip into this. After all, I already had a Facebook account and was used to the idea of that kind of social media interaction.
Sure enough, after just two days of updates (42), attracting followers (60), following others (35), Hensley writes: "You're on fire! Good stuff."
But it was too late that I learned. As noted in an early update to me, Bob Coffield, who writes the Health Care Law blog, "Facebook was the gateway drug that led me to the crack that is twitter."
And, then to add insult to injury, Dr. Val, author of Getting Better with Dr. Val, reminded me that I had said, on a blog radio interview with Dr. Anonymous last April, that I would never sign up for Twitter.
And, since this "dialogue" is splayed out for all to see, Ramona Bates, author of Suture for A Living, wisely commented, "Things change. Times change. Circumstances change. Best to never say never."
Dr. A himself replied, "I admit I didn't get twitter at first as well. But, things change. We're glad you're here!"
Of course, he's glad I'm there. Addicts crave company of like-"minded" people.
So, now, like any self-respecting addict, I want my friends to join me, too.
Start here and follow the all-too-easy instructions. As an extra incentive, this blog is now automatically fed to Twitter.
Warning. One friend writes plaintively on her first update: "Trying to understand Twitter."
To which Yoda offers the eternal advice: "Do, or do not. There is no try."
Monday, December 01, 2008
"The most important part of my job"
I know I have overloaded you a bit with end-of-life issues, but I want to share two articles on the subject. The first is a very nice post by Bob Wachter, entitled My Patients Are Dying... And I've Never Been Prouder.
The second is an article written by BIDMC's Dr. Richard A. Parker. It is in the Annals of Internal Medicine, Volume 136, Number 1, 1 January 2002. I include excerpts from the introduction and the conclusions here, which are elegantly stated.
Introduction
Quality end of life care benefits patients, families, and physicians. Fear of abandonment, indignity, pain, discomfort, and the unknown trouble most of us when we contemplate dying and death. In my primary care practice at an urban teaching hospital, I have cared for 95 patients who have died over the past 12 years. I believe that relationships among the patient, doctor and family built over time usually allow a “good death,” and almost always prevent unwarranted resuscitation, futile interventions, and unnecessary suffering. I now view the end of life not as failure for either patient or doctor, but as a valuable opportunity for growth, insight, and closure.
Death is the bookend experience to birth, yet we are far from our agrarian roots, where the cycle of birth and death was a normal part of daily life. Our society celebrates and worships birth but flees death as if it were avoidable. And the only person empowered to directly assist in navigating life’s end, the physician, with skill and caring, must bring meaning and solace to patients and families as death looms.
Conclusions
Daily, physicians strive to comfort, diagnose, treat, cure, and extend life with quality. Yet we must recognize when to shift to palliative care. Patients expect, hope, and trust that their doctors are versed in dealing with end of life issues, but physicians need to learn and practice these skills. How ironic that doctors rarely, if ever, talk about dying amongst ourselves even though are patients expect to be experts in such care.
Keeping a record of all my patients who have died has helped me honor their memory and reminds me of the lessons they have taught me. Collecting such a history also sheds light on issues deserving improvement, such as instituting a home visit near the end of life. Regardless of the inexorable march of technology, birth and death will continue to bound our existence. Our society awards to physicians the authority and privilege of caring for people at the end of life. I have learned that caring for patients in the last chapter of their lives is the most important part of my job.
The second is an article written by BIDMC's Dr. Richard A. Parker. It is in the Annals of Internal Medicine, Volume 136, Number 1, 1 January 2002. I include excerpts from the introduction and the conclusions here, which are elegantly stated.
Introduction
Quality end of life care benefits patients, families, and physicians. Fear of abandonment, indignity, pain, discomfort, and the unknown trouble most of us when we contemplate dying and death. In my primary care practice at an urban teaching hospital, I have cared for 95 patients who have died over the past 12 years. I believe that relationships among the patient, doctor and family built over time usually allow a “good death,” and almost always prevent unwarranted resuscitation, futile interventions, and unnecessary suffering. I now view the end of life not as failure for either patient or doctor, but as a valuable opportunity for growth, insight, and closure.
Death is the bookend experience to birth, yet we are far from our agrarian roots, where the cycle of birth and death was a normal part of daily life. Our society celebrates and worships birth but flees death as if it were avoidable. And the only person empowered to directly assist in navigating life’s end, the physician, with skill and caring, must bring meaning and solace to patients and families as death looms.
Conclusions
Daily, physicians strive to comfort, diagnose, treat, cure, and extend life with quality. Yet we must recognize when to shift to palliative care. Patients expect, hope, and trust that their doctors are versed in dealing with end of life issues, but physicians need to learn and practice these skills. How ironic that doctors rarely, if ever, talk about dying amongst ourselves even though are patients expect to be experts in such care.
Keeping a record of all my patients who have died has helped me honor their memory and reminds me of the lessons they have taught me. Collecting such a history also sheds light on issues deserving improvement, such as instituting a home visit near the end of life. Regardless of the inexorable march of technology, birth and death will continue to bound our existence. Our society awards to physicians the authority and privilege of caring for people at the end of life. I have learned that caring for patients in the last chapter of their lives is the most important part of my job.
Sunday, November 30, 2008
Thanks for engaging gracefully
I want to thank the many people out there who participated in our Thanksgiving weekend blog rally in support of Engage with Grace. When the day began last Wednesday, based on replies we had received, we thought we would have roughly 40 bloggers engaged in this. By Thanksgiving, there were over 80, rising to over 95 during the weekend. If you do Google or Twitter searches on "Engage with Grace", you'll get the idea.
I especially want to thank two of our local media blogs, White Coat Notes on Boston.com, and WBUR's Commonhealth. These blogs are generally outlets for news and commentary, not for causes, and it was exceptionally generous of them to devote their space to this community effort. And, of course, Kay Lazar's wonderful story on the front page of the Boston Globe got the day off to a spectacular start.
We had participation and/or coverage by the circulation giants in the health care blog world, the Wall Street Journal; Kevin, MD; Diabetes Mine (including, of course, our co-conspirator, The Health Care Blog) -- but also in several topically different blogs, like this one from the Caribbean, this one from a Florida sportsman, this one from the Outer Cape, and this one from a religious blogger. And it was great to "meet" these and other people with whom we probably never would have connected: MaryAnne, Cyndi, Xujun, Susie, and even someone from Australia. And special thanks, too, to a related winemaker.
Some people have already written in to ask, "What's next?" Well, I'm a firm believer in enjoying a good thing and letting it sink in for a while before thinking about what might be next. The Engage with Grace blog rally worked because it was a cause in which people of all persuasions could believe, it was translatable into a pretty simple message, and it was timely. Also, I think it gave people something easy to leave on their blogs over Thanksgiving, when they wanted to take a break anyway!
Whether the idea of a blog rally becomes a vehicle for other causes remains to be seen. Bloggers are pretty independent people, and getting them all to publish virtually identical posts at the same time and over the same interval will require a highly motivational cause and the right set of circumstances.
In the meantime, thanks to all who participated.
I especially want to thank two of our local media blogs, White Coat Notes on Boston.com, and WBUR's Commonhealth. These blogs are generally outlets for news and commentary, not for causes, and it was exceptionally generous of them to devote their space to this community effort. And, of course, Kay Lazar's wonderful story on the front page of the Boston Globe got the day off to a spectacular start.
We had participation and/or coverage by the circulation giants in the health care blog world, the Wall Street Journal; Kevin, MD; Diabetes Mine (including, of course, our co-conspirator, The Health Care Blog) -- but also in several topically different blogs, like this one from the Caribbean, this one from a Florida sportsman, this one from the Outer Cape, and this one from a religious blogger. And it was great to "meet" these and other people with whom we probably never would have connected: MaryAnne, Cyndi, Xujun, Susie, and even someone from Australia. And special thanks, too, to a related winemaker.
Some people have already written in to ask, "What's next?" Well, I'm a firm believer in enjoying a good thing and letting it sink in for a while before thinking about what might be next. The Engage with Grace blog rally worked because it was a cause in which people of all persuasions could believe, it was translatable into a pretty simple message, and it was timely. Also, I think it gave people something easy to leave on their blogs over Thanksgiving, when they wanted to take a break anyway!
Whether the idea of a blog rally becomes a vehicle for other causes remains to be seen. Bloggers are pretty independent people, and getting them all to publish virtually identical posts at the same time and over the same interval will require a highly motivational cause and the right set of circumstances.
In the meantime, thanks to all who participated.
First signs of ice
Photos from weekend wanderings at the MA Audubon Society's Broadmoor Sanctuary. Just the thinnest layer of ice.
Wednesday, November 26, 2008
Engage with Grace
Several dozen bloggers in the health care field and beyond are engaged today and through the Thanksgiving weekend in a blog rally*, simultaneously posting the item below to encourage conversation about a topic that's often avoided but needs to be addressed in every family: How we want to die. I've written about this before, with regard to my mother. Please try it, using the slide above as a discussion guide. It's not that hard to have the conversation with your loved ones once you get started.---
We make choices throughout our lives - where we want to live, what types of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we don't express our intent or tell our loved ones about it. This has real consequences. 73% of Americans would prefer to die at home, but up to 50% die in hospital. More than 80% of Californians say their loved ones “know exactly” or have a “good idea” of what their wishes would be if they were in a persistent coma, but only 50% say they've talked to them about their preferences.But our end of life experiences are about a lot more than statistics. They’re about all of us. So the first thing we need to do is start talking. Engage With Grace: The One Slide Project was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences. And we’re asking people to share this One Slide – wherever and whenever they can…at a presentation, at dinner, at their book club. Just One Slide, just five questions. Lets start a global discussion that, until now, most of us haven’t had.Here is what we are asking you: Download The One Slide (that's it above) and share it at any opportunity – with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started. Let's start a viral movement driven by the change we as individuals can effect...and the incredibly positive impact we could have collectively. Help ensure that all of us - and the people we care for - can end our lives in the same purposeful way we live them. Just One Slide, just one goal. Think of the enormous difference we can make together.
(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team. )
---
* In case you are wondering, "blog rally" is a term we invented this past weekend. A blog rally is the simultaneous presentation of identical or similar material on numerous blogs, for the purpose of engaging large numbers of readers and/or persuading them to adopt a certain position or take a certain action. The simultaneous nature of a blog rally creates the ironic result of joining the efforts of otherwise independent bloggers for an agreed-upon purpose. As far as we can tell, this is the first recorded use of a blog rally -- occurring from November 26 through November 30, 2008, in support of a viral movement called 'Engage with Grace: The One Slide Project' -- organized to encourage families to discuss end-of-life care issues while gathered together for the Thanksgiving holiday weekend. This particular blog rally also has a parallel component on Facebook, where many people are donating their status to bring attention to Engage with Grace.
Monday, November 24, 2008
The ad I would buy
I was joking with a friend the other day that the Boston Globe Spotlight team (their investigative group) has managed to become a profit center for the newspaper, rather than a cost center. How so? Well, the main subject of two recent articles, Partners HealthCare, has been buying a series of editorial page ads in anticipation of the articles and today published a full page ad in response to them.
Relying on the placement of MGH and Brigham and Women's Hospital in the top ten of U.S News & World Report the ad notes that:
[T]here are real differences in quality between hospitals. Year after year Partners HealthCare hospitals rise to the top of this list because of investments in teaching, research, safety, and technology. Our patients continue to choose us time and again, especially for complex treatment. And the ultimate measure of quality is that physicians and other hospitals in the area frequently send their most challenging cases to our teaching hospitals.
We realize that there are costs associated with excellence. teaching hospitals, including MGH and Brigham and Women's, care for the sickest patients, the most complex diseases. We subsidize a broad range of service, some of which lose money, such as psychiatry and community health centers.
I can't afford these kind of ads, so I'll offer some thoughts here.
Can we please start by agreeing that these are two very impressive hospitals, staffed by superb physicians, nurses, and others, and deserving of substantial praise in many, many respects? We can also agree that they are destinations for very sick patients and that they subsidize many important services that receive insufficient reimbursement from private and public payers.
But, can we also agree that the differential in rates received by these two hospitals and the doctors working in them is not related to documented, quantifiable differences in quality between them and, say, BIDMC and Tufts Medical Center, two academic medical centers that are also acknowledged for their excellence and that are also destinations for very sick patients and that also subsidize many important services that receive insufficient reimbursement from private and public payers?
Can we also agree that, likewise, there is no documented, quantifiable difference in quality between Partners' community hospitals (like North Shore Hospital) and other community hospitals (like Beverly Hospital)? And yet, the rates received by those community hospitals and the doctors working therein are generally higher than the non-Partners community hospitals.
And finally, can we agree that the higher rates received by community primary care doctors and specialists in the Partners system are not related to documented, quantifiable differences in quality between them and non-Partners community doctors?
When you cut through it all, that is what the Globe stories were about. Everybody knows that Partners is able to achieve higher rates from private insurers because it has more market power than others in the Boston area. The Globe simply documented the figures that we have all heard about for years. Who can quarrel with this business model, envisioned at the creation of Partners years ago and executed superbly?
The issue for today, it seems to me, is whether in a region characterized essentially by nonprofit hospitals and nonprofit insurance companies, the government agencies that supervise those charitable institutions should care that this imbalance exists. This is more a question to be asked of the insurers than of the providers.
Now, here's the heart of the question. Is this a zero sum game? Is there some fixed pot of insurance premiums to be allocated, so that if rates for other hospitals were to rise, those for Partners hospitals would have to fall?
Regular readers of this blog know that my answer to this will be, "Wrong question." The correct question is how much money could be saved in the health care delivery system if we were all to invest in quality and safety and other process improvements. The answer is, "A lot." The first step, though, is to move towards basing rates on the quality of care delivered -- to give the proper incentives to make progress in this direction. Sorry, not quality as portrayed by a magazine, but as documented from actual clinical records, the kinds of records maintained by all of us, in real time, every day of the year.
Let's measure improvement in avoiding central line infections, ventilator associated pneumonia, "codes" on medical floors, and other preventable harm. I'm not saying that reimbursement rates should be mainly based on a comparison of hospital A's to hospital B's infection rate. Perhaps it would actually be more effective to emphasize the rate of safety and quality improvement within each hospital as an entity. And, please, let's get away from pay-for-performance reimbursement systems that use process measurements of the type collected (and two years late) by the government. (By the way, some of these have uncertain validity or perhaps harmful clinical results, e.g., 4-6 hour timing of the first dose of antibiotic for patients with pneumonia in the face of an uncertain diagnosis.)
In summary, I don't think Partners needs to defend itself for executing a thoughtful business plan. I think it is the public officials who supervise the nonprofits in the health care sector who should feel some time pressure. They need to figure out, and quickly, how to fix the disconnect between reimbursement rates and the degree to which hospitals achieve quality and safety improvements. It is the pursuit of those improvements that offers us the first and best hope to control the rise in health care spending in Massachusetts.
Relying on the placement of MGH and Brigham and Women's Hospital in the top ten of U.S News & World Report the ad notes that:
[T]here are real differences in quality between hospitals. Year after year Partners HealthCare hospitals rise to the top of this list because of investments in teaching, research, safety, and technology. Our patients continue to choose us time and again, especially for complex treatment. And the ultimate measure of quality is that physicians and other hospitals in the area frequently send their most challenging cases to our teaching hospitals.
We realize that there are costs associated with excellence. teaching hospitals, including MGH and Brigham and Women's, care for the sickest patients, the most complex diseases. We subsidize a broad range of service, some of which lose money, such as psychiatry and community health centers.
I can't afford these kind of ads, so I'll offer some thoughts here.
Can we please start by agreeing that these are two very impressive hospitals, staffed by superb physicians, nurses, and others, and deserving of substantial praise in many, many respects? We can also agree that they are destinations for very sick patients and that they subsidize many important services that receive insufficient reimbursement from private and public payers.
But, can we also agree that the differential in rates received by these two hospitals and the doctors working in them is not related to documented, quantifiable differences in quality between them and, say, BIDMC and Tufts Medical Center, two academic medical centers that are also acknowledged for their excellence and that are also destinations for very sick patients and that also subsidize many important services that receive insufficient reimbursement from private and public payers?
Can we also agree that, likewise, there is no documented, quantifiable difference in quality between Partners' community hospitals (like North Shore Hospital) and other community hospitals (like Beverly Hospital)? And yet, the rates received by those community hospitals and the doctors working therein are generally higher than the non-Partners community hospitals.
And finally, can we agree that the higher rates received by community primary care doctors and specialists in the Partners system are not related to documented, quantifiable differences in quality between them and non-Partners community doctors?
When you cut through it all, that is what the Globe stories were about. Everybody knows that Partners is able to achieve higher rates from private insurers because it has more market power than others in the Boston area. The Globe simply documented the figures that we have all heard about for years. Who can quarrel with this business model, envisioned at the creation of Partners years ago and executed superbly?
The issue for today, it seems to me, is whether in a region characterized essentially by nonprofit hospitals and nonprofit insurance companies, the government agencies that supervise those charitable institutions should care that this imbalance exists. This is more a question to be asked of the insurers than of the providers.
Now, here's the heart of the question. Is this a zero sum game? Is there some fixed pot of insurance premiums to be allocated, so that if rates for other hospitals were to rise, those for Partners hospitals would have to fall?
Regular readers of this blog know that my answer to this will be, "Wrong question." The correct question is how much money could be saved in the health care delivery system if we were all to invest in quality and safety and other process improvements. The answer is, "A lot." The first step, though, is to move towards basing rates on the quality of care delivered -- to give the proper incentives to make progress in this direction. Sorry, not quality as portrayed by a magazine, but as documented from actual clinical records, the kinds of records maintained by all of us, in real time, every day of the year.
Let's measure improvement in avoiding central line infections, ventilator associated pneumonia, "codes" on medical floors, and other preventable harm. I'm not saying that reimbursement rates should be mainly based on a comparison of hospital A's to hospital B's infection rate. Perhaps it would actually be more effective to emphasize the rate of safety and quality improvement within each hospital as an entity. And, please, let's get away from pay-for-performance reimbursement systems that use process measurements of the type collected (and two years late) by the government. (By the way, some of these have uncertain validity or perhaps harmful clinical results, e.g., 4-6 hour timing of the first dose of antibiotic for patients with pneumonia in the face of an uncertain diagnosis.)
In summary, I don't think Partners needs to defend itself for executing a thoughtful business plan. I think it is the public officials who supervise the nonprofits in the health care sector who should feel some time pressure. They need to figure out, and quickly, how to fix the disconnect between reimbursement rates and the degree to which hospitals achieve quality and safety improvements. It is the pursuit of those improvements that offers us the first and best hope to control the rise in health care spending in Massachusetts.
Sunday, November 23, 2008
Laboring in Washington
(1) The Obama team continues to pull in very able people for the new Administration. One announced last week is Patrick Gaspard, executive vice president of SEIU Local 1199, who will be the President's Political Director. One of Mr. Gaspard's tasks now will be to remember to work for the interests of his new boss, rather than his old organization -- especially given the difficulty of persuading the public that eliminating secret ballots (through the so-called "Employee Free Choice Act") as part of union certification drives is consistent with core American values.
See the items below to get a sense of how this issue is likely to be portrayed. If you were the new President, would you make this a legislative priority? The new chief of staff, Rahm Emanuel, is going to have thread this needle very, very carefully or he will jeopardize lots of other priority measures. Don't you think it is interesting that no one in the Administration seems to want to talk about this bill? Do a web search and try to find someone on the inside saying anything about it. If you do, please post the link as a comment.
(2) A friend writes:
I came across a news item whose irony I needed to pass along. Yesterday, the House Congressional caucus voted to replace the powerful chairman of the Energy and Commerce Committee, John Dingell. Since I've known Dingell for over 20 years, I decided to inquire as to the vote to see how close the election was. I was told that that information was not available, since the Democratic caucus members not only vote by secret ballot but also refuse to make public the final tally. Aren't those the same folks favoring the denial of secret balloting in union elections?
(3) A post on a blog on an anti-labor blog called LaborPains.org.
See the items below to get a sense of how this issue is likely to be portrayed. If you were the new President, would you make this a legislative priority? The new chief of staff, Rahm Emanuel, is going to have thread this needle very, very carefully or he will jeopardize lots of other priority measures. Don't you think it is interesting that no one in the Administration seems to want to talk about this bill? Do a web search and try to find someone on the inside saying anything about it. If you do, please post the link as a comment.
(2) A friend writes:
I came across a news item whose irony I needed to pass along. Yesterday, the House Congressional caucus voted to replace the powerful chairman of the Energy and Commerce Committee, John Dingell. Since I've known Dingell for over 20 years, I decided to inquire as to the vote to see how close the election was. I was told that that information was not available, since the Democratic caucus members not only vote by secret ballot but also refuse to make public the final tally. Aren't those the same folks favoring the denial of secret balloting in union elections?
(3) A post on a blog on an anti-labor blog called LaborPains.org.
The Employee Freedom Action Committee (EFAC) called on Senate Democrats to replace today’s secret ballot vote over Sen. Joseph Lieberman’s (D-CT) committee chairman status with the public open vote method they would like to implement in union organizing elections.
Democrats are slated to cast a secret ballot vote today to decide whether Lieberman will maintain the chairmanship of the Homeland Security and Governmental Affairs Committee. That stands in stark contrast with their support for the misnamed Employee Free Choice Act (EFCA) which will effectively eliminate the secret ballot vote in union organizing elections. EFCA is expected to be one of the first items on the legislative agenda in 2009.
One of the benefits offered by a secret ballot vote is that Democratic Senators who support their colleague won’t have to fear retribution from left wing activists and bloggers who strongly dislike Lieberman. Similarly colleagues who oppose Lieberman won’t have to fear retribution from the Senator if he maintains his Chairmanship. That same protection from retribution will be denied American workers who will be forced to make a decision on the union in public.
(4) A comment about an SEIU presentation on another blog:
I am a progressive, supported Obama, BNF, DSSC, Al Franken and others with $$ this season - but I cannot support the EFCA. It just seems to be so anti-democratic. Why are we afraid of a secret ballot? Let people decide in private whether they want representation or not. The goal should not be more union members, the goal should be fair treatment for workers. While I admire much of Robert's work - his statement that the EFCA will "effectively restore the middle class..." is just over the top. Support the right to an election, support penalties for anti-union activities but do not support the EFCA.
(5) But then there are those who are ready to take to the streets if Mr. Obama backs off.
Saturday, November 22, 2008
"Araña" means "spider"
Small world category: While refereeing a boys soccer game recently, I started to talk with the coach and inquired where he was from, and he was of Romanian descent but grew up in Lima, Peru. I said, well, as an exchange student in high school over 40 years ago, I stayed with a Romanian family in Lima, and asked if he knew them.
Of course, it turned out that he was a good friend of one of the boys in the family, and we laughingly talked about the mischief they would do together. The family I lived with owned a textile factory next to their house, and the boys would take used spindles, fill the hollow core with gunpowder, and shoot them over the neighborhood from the roof of the house.
The daughter of the family, aged 4 or 5 at the time, adopted me and would escort me through the garden behind the house. She was the one who taught me the most Spanish, because she would jabber on and on. Total immersion for me! For her part, I think she was surprised that I knew so few "important" words, words that describe things at the eye level of a little girl.
So, to Lisa, I owe the credit for teaching me that "araña" means "spider".
Of course, it turned out that he was a good friend of one of the boys in the family, and we laughingly talked about the mischief they would do together. The family I lived with owned a textile factory next to their house, and the boys would take used spindles, fill the hollow core with gunpowder, and shoot them over the neighborhood from the roof of the house.
The daughter of the family, aged 4 or 5 at the time, adopted me and would escort me through the garden behind the house. She was the one who taught me the most Spanish, because she would jabber on and on. Total immersion for me! For her part, I think she was surprised that I knew so few "important" words, words that describe things at the eye level of a little girl.
So, to Lisa, I owe the credit for teaching me that "araña" means "spider".
Friday, November 21, 2008
Uncle!
Many months ago, I wrote about the da Vinci Robot Surgical System and expressed doubts about whether there was evidence to support the clinical efficacy of this equipment, as opposed to the marketing efficacy of the company selling it. Well, the time has come to graciously say, "Uncle!"
Without making any representations about the relative clinical value of this robotic system versus manual laparoscopic surgery, I am writing to let you know we have decided to buy one for our hospital. Why? Well, in simple terms, because virtually all the academic medical centers and many community hospitals in the Boston area have bought one. Patients who are otherwise loyal to our hospital and our doctors are transferring their surgical treatments to other places. Prospective residents who are trying to decide where to have their surgical training look upon our lack of the robot as a deficit in our education program. Prospective physician recruits feel likewise. And, these factors are now spreading beyond urology into the field of gynecological surgery. So as a matter of good business planning, concern for the quality of our training program, and to continue to attract and retain the best possible doctors, the decision was made for us.
So there you have it. It is an illustrative story of the health care system in which we operate.
Without making any representations about the relative clinical value of this robotic system versus manual laparoscopic surgery, I am writing to let you know we have decided to buy one for our hospital. Why? Well, in simple terms, because virtually all the academic medical centers and many community hospitals in the Boston area have bought one. Patients who are otherwise loyal to our hospital and our doctors are transferring their surgical treatments to other places. Prospective residents who are trying to decide where to have their surgical training look upon our lack of the robot as a deficit in our education program. Prospective physician recruits feel likewise. And, these factors are now spreading beyond urology into the field of gynecological surgery. So as a matter of good business planning, concern for the quality of our training program, and to continue to attract and retain the best possible doctors, the decision was made for us.
So there you have it. It is an illustrative story of the health care system in which we operate.
Thursday, November 20, 2008
Farr better
Another wonderful application of Lean process improvements on one of our floors, done in conjunction with our BIDMC SPIRIT program. A seemingly simple reorganization of the supply closet. It always seems to prompt the question, why didn't we do this before? Well, the answer is that people are so busy doing work-arounds and getting by that they don't have time to get better. (By the way, the title of this post is a play on words: The work was done on the 5th floor of our Farr building.)A note from our Lean guru, Alice Lee:
I know there was a comment in your blog asking if RNs should be organizing a supply room. Well, they are among the primary users of the supply room and know best what items need to be co-located, what items can be retired, what additional items need to be added, what the correct par level is (after analyzing usage trends). There is a true sense of ownership with full participation at all levels so the work is sustained.
The RNs and PCTs as well as MDs go in the supply room many times a day and waste many, many minutes a day searching for things, not finding them even if they are, there due to the disorganization and overstock of so many items.
We have a place for everything now that makes sense and locates the most frequently used items at eye level. As we transform each unit, the nurse manager and medical director marvels at how much of a crowd pleaser this is with the staff. Morale boost!
I know there have been comments also about whether the rapid improvement approach is the right one. Most of the work is actually parsed and distributed throughout a month in preparation for the 2 day concentrated effort to make the physical changes needed. It is hard work that is fun and builds a closer team. It brings people together that may have had an adversarial relationship previously (Unit staff & distribution staff). This is not unlike the ED and Lab working together to solve the hemolysis problem.
Even the meal tray
As far as I'm concerned, you can take all those posted quality metrics and throw them out the window when you get a letter like this one that I received from a patient:
BIDMC is a special place. The nursing care deflates your stress about being in the hospital. The doctor's talent makes you believe you have the best possible care. The atmosphere makes you feel that people like their jobs and feel invested in them, so you feel that everybody is paying attention, whether they are cleaners, food service, transport, department heads, trustees.
I especially noticed the employees' investment in their jobs. (NURSE: "Doctor, I noticed you are testing Ms. X for TB. If we believe she might have TB, should we institute those protocols now?" TRANSPORT: "The nurses are really busy. I'll reconnect your oxygen so you can go back to bed and I'll tell them that I did." NURSE: Let's not wait for the bed to be changed. I want it to be dry for you when you have these fevers." She changed the bed and me three times that night.)
Symbol of cooperation regardless of rank or function: Nobody left my room without taking my meal tray with them.
BIDMC is a special place. The nursing care deflates your stress about being in the hospital. The doctor's talent makes you believe you have the best possible care. The atmosphere makes you feel that people like their jobs and feel invested in them, so you feel that everybody is paying attention, whether they are cleaners, food service, transport, department heads, trustees.
I especially noticed the employees' investment in their jobs. (NURSE: "Doctor, I noticed you are testing Ms. X for TB. If we believe she might have TB, should we institute those protocols now?" TRANSPORT: "The nurses are really busy. I'll reconnect your oxygen so you can go back to bed and I'll tell them that I did." NURSE: Let's not wait for the bed to be changed. I want it to be dry for you when you have these fevers." She changed the bed and me three times that night.)
Symbol of cooperation regardless of rank or function: Nobody left my room without taking my meal tray with them.
Follow-up from Sunday
Once again, for my out-of-town readers, a link to today's Boston Globe story following up on the one published on Sunday.
Wednesday, November 19, 2008
More from Chicago
Here are some pictures of attendees at the Joint Commission event mentioned below. I think these folks are from Indiana, Wisconsin, New York, New Jersey, and Florida. Over 400 people attended. You should next year!
At the Joint Commission
I'm currently in Chicago, having been invited to speak at the Joint Commission's annual conference on quality and safety, "Safety and Quality Solutions: Driving Sustained Improvements." My talk is about to follow that given by Mark Chassin, President of the Joint Commission (shown in picture). As I sit here waiting, I am summarizing what he is saying for those of you not in attendance. (Apologies in advance if I do not do a completely thorough or accurate job. Please excuse typographical errors, too, as it is tricky to listen, synthesize, and type at the same time.)Mark described the environment within which the Joint Commission finds itself in the quality field and what kind of improvements are needed. "Despite our best efforts, we still have serious quality and safety problems in all of the domains we try to work in." In addition to the usual areas, there is a particular new focus on overuse, an essential problem to solve if the issue of affordability in the health care system is to be addressed.
But there are models of success, which serve as learning opportunities. Core measures have improved since their introduction in 2002. For example, the average for compliance with acute MI metrics (e.g., aspirin on arrival) is over 70%, with about 95 percent of hospitals having performance over 90% in two key metrics. So it is possible to have success in carrying out important metrics that lead to improved outcomes.
But the value of other metrics is problematic, in terms of achieving actual clinical results. For some, the measure we use doesn't really assess the process that we want to assess (e.g., smoking cessation counseling advice.) For some, the process that is assessed is far removed from the outcome we want to achieve (e.g., oxygenation of left ventricular function assessment). For some, the measure is susceptible to workarounds, more than encouraging the process we want have happen (e.g., heart failure discharge instructions). For some, measures lead to adverse effects (e.g., 4-6 hour timing of the first dose of antibiotic for patients with pneumonia in the face of an uncertain diagnosis).
"We should start withdrawing measures like this that are not excellent," that have these problems. But Medicare needs to do the same thing. It can't just be the Joint Commission's decision.
But let's look beyond the particular measures and find out "where's the beef" in real improvement so we can focus on the most important things. Unfortunately, there is a scarcity of evidence as to what those are, both in the hospital setting and other settings. As health care assimilates new drugs, devices, procedures, and equipment, "the goal posts keep moving" because of the increased complexity of the care system. And, in a time of scarce resources, we need to be cognizant that the Joint Commission itself influences how those resources of used. If we don't have the highest confidence that a measure is excellent, we shouldn't ask you do to it. "We have an obligation to maximize the health benefits of our measures and standards."
There has been a balance between the roles of the government and the private sector in overseeing quality in health care. Two related forces are affecting that balance: (1) bad things are happening even in Joint Commission accredited hospitals, and (2) routine safety process break down routinely and visibly. "Our public stakeholders are losing patient with us." Unless we get better at things, this will lead to a change in the balance between the government and private sector roles.
The expectation of our public stakeholders is that major adverse events, like wrong side surgeries, should diminish in frequency and be eliminated. If that does not happen, we should expect legislators to pass new laws. The nature of the legislative process is that new laws can often be heavy handed and not recognize the subtleties of these issues. Unfortunately, laws are not the best way to achieve the right results, but it is easy to see why they are passed.
So, how do we got a lot better quickly and document that improvement, to help maintain the appropriate balance between governmental supervision and private sector responsibilities? The first major barrier to this is lack of capacity in the health care system to execute robust process improvement. Secondly, we have not truly adopted a true safety culture.
We need to learn from other industries -- high reliability organizations -- and apply those lessons in the health care system. Those organizations have a commonality in their methods of achieving their excellent results. (My comment: See similar points by Steven Spear.) Mark quoted Karl Weick: "Safety is a dynamic non-event." Mark then went into details on this point, which I will not summarize, as regular readers have seen lots of this topic on this blog.
The Joint Commission wants to work with health care institutions to help them adopt these methods. But, he is also doing this to achieve internal improvements within the Joint Commission. He wants to improve its own customer service, to reduce costs, and to be more effective in carrying out its mission.
On the issue of safety culture, Mark noted that there are three imperatives of a safety culture: trust, improve, and report. On the trust point, the aim is not a blame-free culture, in that there is a difference between small errors (for learning) and egregious errors (for discipline, equitably applied). My note, please review this post for more on this topic.
Learning begins with reporting, especially near misses. "They are free lessons", an opportunity to fix a system before it breaks. A bureaucratic culture celebrates near misses rather than learning from them. High performance organizations react to near misses exactly the same way you would react to an adverse event.
Finally, on the Joint Commission itself, Mark cited improvements over the past five years, but firmly said, "We need to continue the aggressive improvement of our own processes." "We must increase confidence by pruning the measures that don't help, by focusing on and enhancing the ones that do," and by helping to provide useful process improvement tools to the the industry.
Seasonal trauma
News to me. Our chief of surgery notes an interesting "blip" in a certain kind of accidents during this fall season: Broken feet from people falling off a ladder while cleaning out the leaves from their clogged roof gutters. He recently moved to Boston from the Midwest and said it was common there, too.Have others noticed this?
Tuesday, November 18, 2008
Time to brag a little
Excerpts from BIDMC and Blue Cross Blue Shield of MA press releases today. (More available here.)BIDMC TOPS BLUE CROSS BLUE SHIELD MASSACHUSETTS RANKINGS
FOR HEALTH CARE QUALITY AND COST EFFICIENCY
BOSTON – Beth Israel Deaconess Medical Center (BIDMC) topped the list among Massachusetts hospitals in Blue Cross Blue Shield of Massachusetts’ (BCBSMA) Blue Distinction® designation of hospitals making a difference in health care outcomes and value.
BIDMC won the designation for its efforts in Bariatric Surgery, Cardiac Care, Complex and Rare Cancers, and Bone Marrow, Stem Cell and/or Allogeneiac Transplants. The medical center was among 16 Massachusetts hospitals designated by the state’s largest health insurer in a process that involved collaborating with employer groups, providers, and specialty medical societies.
“BIDMC has focused intensively on providing high quality, well coordinated care in these specialized service lines, and it is gratifying to see these efforts manifesting as better outcomes for our patients,” said Kenneth Sands, MD, senior vice president of health care quality.
Blue Distinction is a nationwide program that recognizes medical facilities that meet a national set of objective, evidence-based thresholds for clinical quality developed in collaboration with expert clinicians and leading medical organizations. This designation provides consumers with a credible, easily identifiable means of selecting facilities that best meet their individual specialty care needs.
“BCBSMA is committed to delivering on our promise of high quality, more affordable health care by working to eliminate the overuse, under use, and misuse of health care services. Blue Distinction is another way we demonstrate this commitment,” said BCBSMA Chief Physician Executive John Fallon, MD.
“Based on clinical data from hospitals and registries, research indicates that Blue Distinction Centers demonstrate better, more consistent overall outcome with fewer post-procedure complications and lower mortality rates,” Fallon said.
The analysis includes 41,333 patients treated within a facility setting, 22,322 of which were treated at BDC-designated facilities and 19,011 at other facilities. The analysis is based on cardiac events and procedures occurring during calendar year 2006, with follow-up in 2007.
BCBSMA launched Blue Distinction in 2007 with the Blue Distinction Centers for Cardiac Care. In 2008, the health insurer launched three Blue Distinction programs: Transplants, Complex and Rare Cancers and Bariatric Surgery. Due to the high level of success that BDCs have seen with regard to quality outcomes and value, Blue Cross and Blue Shield companies are in the process of expanding the program to additional specialty areas.
NAME | | | | CITY | | | | DESIGNATED FOR |
| Bay State Medical Center | | | | Springfield | | | | Bariatric Surgery, Cardiac Care |
| Beth Israel Deaconess Medical Center | | | | Boston | | | | Bariatric Surgery, Cardiac Care, Complex and Rare Cancers, Transplants-Bone Marrow, Stem Cell and/or Allogeneiac |
| Boston Medical Center | | | | Boston | | | | Bariatric Surgery, Cardiac Care |
| Brigham & Women’s Hospital | | | | Boston | | | | Bariatric Surgery, Cardiac Care |
| Cape Cod Hospital | | | | Hyannis | | | | Cardiac Care |
| Caritas St. Elizabeth’s Hospital | | | | Boston | | | | Cardiac Care |
| Dana Farber-Brigham & Women’s Cancer Center | | | | Boston | | | | Complex and Rare Cancers |
| Faulkner Hospital | | | | Jamaica Plain | | | | Bariatric Surgery |
| Lahey Clinic | | | | Burlington | | | | Bariatric Surgery, Cardiac Care, Complex and Rare Cancers |
| Lawrence Memorial Hospital | | | | Medford | | | | Bariatric Surgery |
| Massachusetts General Hospital | | | | Boston | | | | Bariatric Surgery, Cardiac Care |
| Massachusetts General Hospital Cancer Center | | | | Boston | | | | Complex and Rare Cancers |
| Mount Auburn Hospital | | | | Cambridge | | | | Cardiac Care |
| Newton –Wellesley Hospital | | | | Newton | | | | Bariatric Surgery |
| North Shore Medical Center | | | | Salem | | | | Cardiac Care |
| Tufts Medical Center | | | | Boston | | | | Cardiac Care, Transplants-Liver |
| Winchester Hospital | | | | Winchester | | | | Bariatric Surgery |
And some more union spending
Speaking of union spending, there apparently will be a TV campaign for the so-called "Employee Free Choice Act" (the one that would eliminate secret ballot elections.) An ad from this campaign, which reportedly will be on CNN and other sources, can be seen here and is explained in more detail here.
Question for Washington insiders and political reporters: Did the Obama team ask the unions to try to generate more support for this bill, or is the campaign an attempt to keep pressure on a new administration that is busy with many important issues to make the bill a legislative priority?
Question for Washington insiders and political reporters: Did the Obama team ask the unions to try to generate more support for this bill, or is the campaign an attempt to keep pressure on a new administration that is busy with many important issues to make the bill a legislative priority?
SEIU goes Googling
It is impressive and instructive to note the many ways the SEIU has chosen to spend money on advertising about BIDMC. I mentioned before the hundreds of thousands of dollars spent on radio, television, mobile billboards, and bus stop ads. The latest purchase, apparently to reach the social media audience, is an ad that appears when you do a Google search on BIDMC, Beth Israel Deaconess, and who knows how many other topics related to BIDMC.
Try it. In the upper right hand corner of the search results page, you will see this ad:
For those of you who own stock in Google, I hope you see an easy way to enhance your company's revenues. Just do a search for BIDMC and click through on the SEIU ad!
For the record, if you really want to know the many things that BIDMC does NOT hide, including one the most open presentation of clinical outcomes in the country, follow the Google search link to our website instead and click through to Quality and Safety.
Try it. In the upper right hand corner of the search results page, you will see this ad:
Eye On BIDMC
High costs, patient problems
What does Beth Israel have to hide?
www.eyeonbi.org
High costs, patient problems
What does Beth Israel have to hide?
www.eyeonbi.org
For those of you who own stock in Google, I hope you see an easy way to enhance your company's revenues. Just do a search for BIDMC and click through on the SEIU ad!
For the record, if you really want to know the many things that BIDMC does NOT hide, including one the most open presentation of clinical outcomes in the country, follow the Google search link to our website instead and click through to Quality and Safety.
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