Who's waiting?

E-patient Dave referred me to this article in USA Today, entitled "Wait times to see doctor getting longer." The title says it all, but here's an excerpt:

The survey found that, on average, wait times have increased by 8.6 days per city. Boston had the longest wait, averaging 49.6 days.

But, now look at this marvelous contrast in our hospital, where we have made a concerted effort to reduce wait times. Over one year, the average wait time for all of our medicine clinics has dropped from 13 days to 4.4 days. (The figures are based on a sample of mystery shopping calls.)

Our goal is for all clinics to be under three days. Right now, 6 have been meeting that goal. Another six are in the 3-5 day range. Two are in the 5-10 day range, and one is greater than that. In these last three cases, the reason is that we have doctor vacancies that are being filled in July.

This kind of success takes coordination across multiple areas, constant review of our procedures, use of mystery shoppers to evaluate the patient experience, and transparency of the results both to ourselves and our patients. Speaking of mystery shoppers, our customer service ratings for these clinics had an average of 4.5, on a scale of 1 (poor) to 5 (excellent). We're still shooting for better -- a goal of 4.8.

The Overseers learn medicine

Our Board of Overseers comprises several dozen members of the community who have chosen to spend time learning about BIDMC, assisting in governance, and being ambassadors in the community. Today, over 200 of them and their friends joined us for an interactive experience in a number of our clinical and research areas. Several tours took place.

Here, you see one group visiting with Dr. Ram Chuttani in our advanced endoscopy suite. They are in the conference area that serves as the control room for the GI Division's educational offerings. The most famous is the Boston International Live Endoscopy Course, a cooperative venture of BIDMC, Rhode island Hospital, Boston Medical Center, Brigham and Women's hospital, and Massachusetts General Hospital. This is a three day course, with live endoscopies shared across the world, with commentary from Ram and other leading physicians.

With another group, Dr. Gary Horowitz from our Pathology Department explains the principles and techniques of clinical pathology to our Overseers, describing the millions of blood tests performed each year. He also pointed out the automatic testing equipment (like that below) that makes it possible to do these tests quickly and with a high degree of accuracy.

Red Sox Scholars Class of 2009

It was time yesterday to announce our new class of Red Sox Scholars. This a group of 25 academically talented fifth-graders from the neighborhoods of Boston who are promised a $10,000 college scholarship if they finish high school and enter college. It is the cornerstone program of our partnership with the Boston Red Sox, and we are designated as the Presenting Sponsor. Additional support comes from the Highland Street Foundation, Microsoft, the Peter and Carolyn Lynch Foundation, and Target.

At the pre-game ceremony, the children were accompanied by "Medical Champions" from BIDMC and are greeted by a member of the Red Sox team and presented to the park audience. I include pictures of some of the students with their Medical Champions.

During the pre-game ceremony, too, the Red Sox unveiled a new graphic on the left-field side of the Green Monster. The sign highlights the long-standing support provided to the Red Sox Scholars program by BIDMC. See the video below.

Steps towards universal health coverage

Finally, straight talk on health care reform. I mentioned earlier that the President's proposal to increase access, preserve consumer choice, and control costs -- while responsive to what people say they are concerned about in polls -- does not hang together.

Today the New York Times says the same thing:

For Congress and the administration to keep the promise of comprehensive health care reform, they will have to find the political will to pay for universal coverage and other investments that are needed right away but will not produce quick savings.

And see my comments below on the concept of "accountable care organizations." How is that compatible with consumer choice? Perhaps the Times can address that one in their next editorial. People in the Massachusetts State House and in DC are not yet doing so.

I say, focus on access first. Change the national insurance laws to do what MA did years ago, things that made it possible to achieve the expanded access provided by Chapter 58 of the Acts of 2006. Get rid of provisions that allow insurers to use pre-existing medical conditions and other such factors to turn down patients. Go beyond this, perhaps by using a model like that of the Netherlands:

All people are required to have insurance and can purchase it from any of a number of private insurance companies. Some of these companies are for-profit and some are non-profit. . . . No company can refuse to provide coverage to any person. . . . The government subsidizes the cost of insurance to people with low incomes. The insurance covers the full range of medical diagnostic and treatment services. You can also buy supplemental insurance to cover things like single rooms in the hospitals, cosmetic surgery, and the like.

Beyond this program of "cure" insurance, there is a separate government program for "care". This covers long-term care and other parts of the medical care spectrum that are essentially uninsurable.

Further, I would hold off creating a new public insurance plan for basic care until we see how this system works. Public policy works best when changes are made incrementally. There are always unintended consequences. Best to take it a step at a time and build in opportunities for mid-course corrections.

You cannot quickly revise the structure of an industry that has evolved over half a century. Perturb it in the direction you want to go. The first step is to get people covered by insurance.

How do you make an ACO accountable?

A letter to the editor in the New York times from Timothy Ford follows up on a point I made the other day about the President's proposals for "accountable care organizations," an idea that is also getting a lot of talk in Massachusetts in the deliberations of the payment reform commission.

Here's the pertinent part:

What our system needs are more Kaiser, Geisinger, Mayo and Intermountain health systems. These are the integrated delivery systems that are already delivering higher quality and lower costs. But the Medicare and Medicaid programs have been no more successful than private insurers in supporting the growth of these organizations. If you want to see real health reform, we need to have incentives to encourage more of these entities to emerge.

Here in Massachusetts, there is only one such entity that approaches the definition of an ACO, Partners Healthcare System. But there is no sign that it has used its size and scale to deliver care at a lower cost. Indeed, there is evidence that it has used its market power to extract higher rates from insurance companies. Likewise, there are no data to show that quality, safety, and efficacy in the delivery of care throughout the Partners system is better than other community hospitals or academic medical centers.

It seems to be time to ask the question explicitly. Is it the desire of MA state officials that the rest of the hospitals become integrated systems? (As a side question, how many such systems do you want in the state?) If so, how would you hold them accountable? So far, there is little evidence of governmental ability or political will to do so. Who is creating the policy framework that considers this issue in a manner that goes beyond the structure of reimbursements?

While we are at it, who is looking at the issue of plan design? If you create ACOs, you probably intend to limit consumer choice of physicians and doctors as part of their insurance plans. Do you mean to put the primary care doctors in the middle of that issue, restoring them to the hated "gatekeeper" role we saw during the era of managed care?

Focusing solely on reimbursement models is a recipe for failure. Let's think more broadly.

Manhattanhenge

Courtesy of NPR's Science Friday, produced by Flora Lichtman:

Twice a year, the sunset lines up with New York City's street grid -- making for spectacular views. Neil deGrasse Tyson, director of the Hayden Planetarium in New York, identified the cosmic event over a decade ago and coined it Manhattanhenge. Last weekend was the first Manhattanhenge of 2009 -- we watched the sun from 42nd street, along with about 50 other astronomical enthusiasts.

The WIHI chat room

A picture of Madge Kaplan from the set of the WIHI webcast below, along with some comments from the chat room. The topic was mainly this blog. While some comments were directed to me, others were going back and forth among the listeners. There was not time to reply to all questions, but to hear my answers and the whole thing, check the podcast available here sometime on Friday.

Moulay Alaoui: In this era of transparency in health care and trend of patient demand, it is very relevant. However, it is very courageous of you to use this medium.

Denise Vincent: Oh gosh yes, the EPA makes water treatment plants send an annual report to all customers.

Cristina Wilhelm: The blog makes me think of the Wizard of OZ...the curtain has opened and everyone can look in. Kudos to you for opening the curtain yourself.

Pamela Ressler: Communication is essential in healthcare, but often we are afraid of it -- and it does take courage and vulnerability to put yourself out there, as Paul has done so well through his blog.

Mary Ann Bone: Has your legal department responded to your blog?

Sandra Snider: I've been afraid to blog too much about work for fear of getting in trouble.

Brian Yanofchick: Apart from a legal department's predictable issues, how have other staff, such as physician, nurses, others responded?

Maureen Watchmaker: I am a nurse case manager who has been at BIDMC before and after Mr. Levy's arrival (since 1999). To answer Mr. Yanofchick's question, from listening to colleagues, the overall response (including my own) started as suspicion, moved to incredulousness tinged with hope and now has become an attitude of "of course this is should how a CEO should behave." Now, as times become tough, most of us feel hopeful with Mr. Levy at the helm. With the SEIU circling our hospital, I think that his transparency has been one of the factors that have kept them out.

Brian Yanofchick: Thanks for that response. Very helpful. I'm not surprised by the initial worry, but heartened that staff have begun to see it as a plus.

Shawna Willcox: Maureen, what is the SEIU?

Maureen Watchmaker: Shawna-It is a very aggressive union that has targeted BIDMC.

Lawrence Van Rossum: Question: Do you think Hospitals need to take a serious look at the Process of Patient Care and Clinician work flow in order to achieve a better level of service and harm less patients?

Charles Lee: You mentioned medicine is a "cottage industry". Is this changing with government, hospital corps, PPOs, HMOs, etc. becoming more and more the norm?

Aline Gonsalves: Unless you learn to blog and be more open in all communications (whether clinical or other), as long as privacy laws are not violated, it is crucial this type of blogging become part of organizations' daily running or our teenagers will make it so in the near future. It's crucial CEO's learn how to do this as soon as possible before they are forced to. Blogging and internet network are tools for enabling, not destroying.

Moulay Alaoui: Great point! Healthcare provision quality is central and it is mainly about processes not persons. Standardization is an ultimate goal of this industry, especially within a system (a conglomerate of providers).

Ann Bailey: How have patients/community responded to the blog and outcomes data? Are you getting any feedback? Some organizations report that patients/potential patients may not understand what the data says or how they might use.

Dave Weinstock: Do physicians need to be salaried and work for the hospital to help standardize (as an organization versus a collaboration of individual contractors)?

Doug Bonacum: Have you had any malpractice allegations brought against BID where Blog / Website information was used against you?

Brian Yanofchick: Communication methods like this are a great opportunity to positively change a culture from one of paternalism to one of true accountability.

Sandra Snider: I'd rather post our outcomes data than have Healthgrades post data that is years old.

Daniel Grigg: I'm wondering how much time it takes to do the blog each day. Once you begin, it's a pretty serious commitment to keep up with it.

Madeleine Girard: If an organization is truly transparent, the "need to know" attitude disappears. And all the fears and worries that come along with it.

Daniel Roy: In dealing with healthcare professionals, the mentality has always been that they are behind the times...presumably because of the fear of change and risk of increasing liability. I applaud you for taking a leap to change that perception.

Madeleine Girard: I agree with you Daniel. A huge culture change is happening in my workplace with a new CEO at the helm. His style reflects Mr. Levy's though he is not yet blogging... Something to suggest at our next meeting.

Sandra Snider: If the public knows you use mistakes in a positive way to improve care and prevent future events, they will be more likely to forgive us our mistakes.

Nick Dawson: Is there something unique about healthcare that lends itself to "social media" - its a topic that is much hotter than social media in other industries from John Lockhart to All Participants:I am a hospital board member studying the new IRS form 990. Will you discuss executive compensation issues on your blog ?

J Zuercher: Healthcare impacts everyone!

Aline Gonsalves: It's about connecting as people.

Pamela Ressler: And communication allows for more effective collaboration -- provider/patient, leadership/staff.

Maureen Bisognano: In this day and age, leaders need to use all methods of communication to reach the many audiences they need to connect with...we are in a time of "continuous partial attention" (Tom Friedman), and we know that people learn and contribute in many ways. You reach them all!

Aline Gonsalves: As a business consultant in healthcare, it's important to realize it's crucial impact on accountability frameworks within healthcare. It helps surface assumptions that exist in healthcare. With the "accuracy" of internet medical information, assumptions are made that can result in wrong decisions. Blogging and internet networking can clarify misconceptions.

Ron Ferrand: Is there a recording of this webex available?

Jesse McCall: Recording available at: http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/WIHI.htm?TabId=14 by tomorrow.

WIHI show today at 3pm EDT

Please join me and Madge Kaplan today for an IHI audiocast at 3pm EDT. It's free, but enroll in advance. Best to listen in front of your computer with the browser on, as we may make reference to blog postings.

Is [G]overnment [M]edicine next?

From today's Boston Globe:

In a detailed two-page letter to key senators released yesterday, the president wrote that he wants to "fully offset the cost of healthcare reform" by cutting an additional $200 billion to $300 billion from Medicare and Medicaid over the next decade, on top of the $309 billion reduction he has already proposed in the government's two main healthcare programs for the poor, elderly, and disabled. (I have provided the embedded link to the actual letter.)

I'm trying to give this a fair shake and not jump to conclusions, because the motivation is noble. The question is whether this is real cost-cutting, or appropriation cutting. If you just cut appropriations, you just dumb down health care. You get to cost-saving by reducing medical errors and harm to patients and by engaging in the kind of continuous process improvement that has been found in the most successful firms in other industries. See Steve Spear's comments on this. The items mentioned in the letter sound rather more like administrative efforts to avoid government payments than a recognition that the medical field remains a cottage industry at the actual level of care delivery. Creation of "accountable care organizations" could result in an agglomeration of inefficient hospitals and other providers, a step that could also cement in the benefits to those institutions that are already part of large systems with more market power. You do not want to create the medical equivalent of "Government Motors." Careful, here, folks.

Meanwhile, hospitals, do you see the hand-writing on the wall? Academic medical centers have the most to lose here: There is no natural constituency in Congress to provide high levels of support for graduate medical education to these high-cost hospitals. While there is a community hospital in every Congressional district, academic medical centers are much fewer in number and concentrated in just a few districts. Count the votes.

Easily making it easier at Gemba

A repetitive theme of our Lean training is that many of the best ideas are easy to implement, but they would never get management's attention absent a clear commitment to listen to the front-line staff. Here's one example that some of our senior management team learned during our visit to gemba, this time at the Hematology laboratory.

The manager of the lab took the initiative a few months ago to set up a very easy system for getting staff suggestions. It took the form of a single card on which any person could make a suggestion, give the reasons for it, and offer his or her opinion as to why it would be helpful. OK, that's just like a suggestion box, right? But the difference here was a daily staff huddle at which the crew would discuss each idea and vote on it. If it was approved, it would be implemented. (As a reward, the suggester's picture would be added to the card and it would be posted on the wall.)

When we asked Nicole Burston (shown here) what was the best idea to come along so far, she said it was an extra label printer (also shown here). Huh? Well, it turns out that some blood separation "spins" need to be "double-tubed." Each tube needs an identifying label. The old way: Walk across the lab to the area where the original tube was labeled; bother the team whose people are busy putting on the original labels by asking them to do extra work, disturbing their sequence; and then walk back across the lab. Do this dozens of times per day.

The alternative, print out a new label on the printer located at the place it is needed.

Manager Gina McCormack (shown here) was asked, "Was this a new idea that had never been raised before?" Nope, but it always got put off for other priorities and reasons. "Did you have to come up with money for this and therefore postpone another project?" Nope, I just called the IS department and told them it was part of a Lean improvement event, and they ordered it and paid for it out of their budget.

Noted SVP Walter Armstrong, "Organizations often suffer from a sense of resignation. You don't ask because you assume you will not get what you need." The Lean process helps break through that bottleneck.

New line of business

At BIDMC, we pride ourselves on excellence in strategic planning and implementation. With the proposed changes in reimbursement methodologies in Massachusetts, we have decided that veterinary services are likely to be more profitable. We recently put out the word to the community, and these folks arrived for the opening day sale.

But we are worried about their ability to understand our signage. So we have been working to recruit the right kind of interpreters.

(Thanks to Elizabeth Hur for the photo.)

Boston's Future Leaders

Boston's Future Leaders are a group of young professionals sponsored by their employers for a year of engagement, mentorship and training, organized by the Greater Boston Chamber of Commerce. One part of the program is called "Leaders Connect: A Conversation with the Leaders of Today and Tomorrow." At this luncheon, Boston's Future leaders hear from a prominent member of the Greater Boston business community while connecting with the program's alumni and members of the Chamber's Board of Directors.

Here are are some of the attendees at today's event, along with a "trio of Paul's" -- Paul Connolly from the Federal Reserve Bank of Boston; Paul Guzzi, from the Chamber; and Paul LaCamera from WBUR public radio. A fourth Paul, yours truly, was invited to be the luncheon speaker. Regular readers of this blog can guess what I talked about. (Somehow, coaching girls soccer was part of the speech.)

Local Photography Show

Facebook in Reality

For my social media friends: Check this out.

The infrastructure chronicles -- Volume 1

A recent Boston Globe story by Stephanie Ebbert about squabbling between two state agencies involved in the rehabilitation of a local bridge has prompted me to start a new occasional series on this blog. People who don't know about my lives before health care may not know that I am an infrastructure junkie. For reasons my daughters consider very odd, I love roads, bridges, sewage treatment plants, electricity cables, and the like. If you are not interested in this topic, stop reading, but from time to time, I'm going to relate stories to you about this field, but mainly positive ones, where creative public officials and others have made the fabric of urban life better for the public -- in ways that never, ever make the newspapers.

Here's the first. Back in 1999 or so, I was Administrative Dean at Harvard Medical School. Connie Cepko, one of our faculty members, called one day. Her complaint: Riding to work on her bicycle every day, she noticed that the Longwood Avenue bridge over the Muddy River and the MBTA tracks was full of dangerous potholes. What could I do about this, she wondered.

Actually, I knew that I could do nothing, at least within a normal human lifespan. That bridge is a jurisdictional nightmare. It is at the border of two municipalities (Boston and Brookline), spans a transit line (MBTA), and also goes over a state park (owned at that time by the Metropolitan District Commission). Just figuring out who would be responsible for the road paving would take decades, much less getting the right person to order a repair.

So, I called Rick Shea, who was the President of MASCO, our non-profit planning and service entity for the schools and hospitals in the Longwood Area. The next day, Connie called to thank me for getting the potholes filled and a new, smooth surface on the bridge. "My pleasure," I replied, wondering what happened.

I called Rick and he said, "I knew it would be impossible to find someone of authority to make this repair, so I just hired an asphalt firm and had the work done. Each jurisdiction -- if they noticed -- probably thought it was the responsibility of another. Therefore, no complaints. Job accomplished. Happy to help."

A celebration for those who have been touched by cancer

Sunday, June 7 -- 8am to 3pm
Harvard Medical School Quadrangle
200 Longwood Avenue
Boston, MA
(Note: See Hester's comment below about pre-registering!)

Celebration of Life is a full day of celebration, education, and kinship for the cancer community. The event raises awareness of the battle against cancer, and welcomes all men and women who have been touched by this class of diseases. We've been doing this for sixteen years.

Celebration of Life brings together patients and their friends and family members, along with physicians, nurses, social workers, and other cancer care providers at BIDMC. It is designed to give people living with cancer an opportunity to share personal experiences, information about new treatments and support systems, and to learn from Harvard Medical School physicians and community experts—and, of course, each other.

The event is the brainchild of Hester Hill Schnipper, LICSW, BCD, Chief of Oncology Social Work at BIDMC, and a breast cancer survivor. She notes, "Celebration of Life puts a face on cancer, while providing hope to all that fight it."

Celebration of Life is held on National Cancer Survivors Day—an annual, worldwide day of symbolic unity for cancer survivors, their loved ones, and cancer care providers. This year, there will be more than two dozen symposia and workshops led by BIDMC faculty and staff and other community experts. There will be an extended lunchtime discussion with cancer survivors hosted by Kelley Tuthill, WCVB-TV reporter and breast cancer survivor, lively music, art, and opportunities for participants to share their personal stories.

Finally, there are fundraising events, with auction items including a basketball signed by all of the Boston Celtics (!), plus also items from the Bruins and the Red Sox.

Clicking through Lean

An aspect of the Lean process improvement that is reinforced often in our training sessions is to learn to identify and eliminate "the 7 wastes" that are found in production and service organizations. Here is a handy pen that clicks through the forms of waste to help you remember them: defects, waiting, motion, inventory, processing, transportation, and overproduction. Thanks to Greater Boston Manufacturing Partnership for the memory tool.

What's an ex-President worth?

Did this bother you, or is it just me? A Jim Rutenberg article in yesterday's New York Times presented the story of former Presidents Clinton and Bush addressing an audience in Toronto about their presidential experiences. I'm sure that was a fascinating and worthwhile session.

Here's the part that was troubling to me: "Each earned more than an estimated $150,000 for the appearance."

As far as I can tell, an ex-President gets the following from taxpayers: A $191,300 salary, full coverage for himself and his spouse in the federal health care system, staff for his office, office rental expenses, coverage of all telephone and postage expenses, and certain travel expenses.

I don't begrudge any of that. After all, this is one of the hardest jobs in the world, and ex-Presidents continue to have public obligations even after their term of office ends. And I am pleased if they can make lots of money, too.

But shouldn't we require some kind of offset if an ex-President is able to bring in money by selling stories about his time in public service? For example, Mr. Clinton's speaking fees and book royalties have reportedly amounted to over $50 million since leaving office. What if the first dollars that came in were used to reimburse the taxpayers' contribution to the president's ability to go on the speaking circuit?

The idea of a salary offset is common in business. If a person has a severance agreement, the annual payment is often subject to this kind of offset if he or she receives income from another source during the severance period. Why shouldn't we apply that in this case?

SEIU surveys the residents

This week, residents at our hospital received an email survey request from the SEIU. Does this mean the union is thinking about organizing the residents, or does it hope to obtain responses that would be helpful in a corporate campaign? Some residents wondered how SEIU has the resources to obtain their email addresses and also how it can afford to conduct this kind of survey. The answer, as I have noted before, is because it can.

Dear Residents of Beth Israel Deaconess Medical Center,

As part of its effort to organize hospital workers in Boston, 1199SEIU has been reaching out to residents and attendings to better understand the joys and challenges of working at academic medical centers in Boston. As the end of your residency is near, we would like to give you the opportunity to tell us about your own residency experience. We would appreciate your thoughts on compensation for your residency and a few current healthcare policy issues.

Please consider filling out the following survey; it is brief and shouldn’t take more than 5 minutes. Your name and personal information will be kept confidential. Responses will be compiled in the aggregate.

One resident wrote me the following note:

Should I respond to this survey and tell them the truth how enjoyable it truly is to work at BIDMC, how the salaries are fair for the market, and other generally positive things or would they simply use this to twist any words I said to the negative?

I feel that you have done a better than outstanding job at defending the management of this hospital through the budget crisis across the country and at being in touch with all employees about the day-to-day challenges of running a hospital; very much in the spirit of transparency, I think.

My gut tells me to toss the below e-mail in the garbage with an unsubscribe order, but my heart tells me to tell the positive truth. What should I do?

Of course, I made clear that this is a matter of personal preference. Here's the survey. Anyone can fill it out. I'll help you with the answers I would give:

Q. During your residency at BIDMC did you have the opportunity to negotiate you (sic) salary and/or benefits?
A. I believe that, under the national rules of residency selection, this is not permitted.

Q. Were you required to take a pay cut as part of the [BIDMC] budget cutbacks?
A. No, residents were exempt from any cuts. See here, paragraph 24.

Q. Should residents have been asked to take a pay cut as part of the budget cutbacks?
A. No, but is SEIU advocating a reduction in residents' pay? Ditto, paragraph 25.

Q. Do you think that BIDMC would respect employees' desire to form a union?
A. What do you mean by desire? Do you mean by a secret ballot election? Or do you mean under the SEIU's proposal to eliminate secret ballot elections or limit debate during elections? If the latter, how would you know what the employees' desire actually is?

Happy birthday to the OR staff

Every month, nurse Tere McCarthy makes a cake in honor of OR staff members who are celebrating their birthday that month. Here is this month's version -- Fenway Park. I was lucky to catch this photo before too much was eaten!