How we spend our time

The New York Times posted this terrific interactive graphic on how Americans spend their day. Click on the different categories to explore groups within the population. I think the "computer use" category is probably understated, in that a lot of it is within other categories (like "work") or more and more simultaneous with others (like "TV" or "socializing"). Of course, there are those who also insist on texting while driving. I don't know how that is accounted for, but I wish they would stop.

Please call me next time

After years of being a somewhat public figure, I have gotten used to being misinterpreted and misquoted in the popular press, even when a reporter has interviewed me. But this is the first time someone in academia has done so, and it was compounded by a failure of a respected business magazine to conduct proper fact-checking.

Here's the story. I recently received a "teaser" saying,

"Recently, people have been asking us what they can do to respond to the current economic crisis and the major leadership challenges they face today. We have also received numerous requests for success stories of organizations investing in their capacity for adaptive change.

"Here are some new resources that we think you will find helpful:

"...Our article in the July-August issue of the Harvard Business Review, "Leadership in a (Permanent) Crisis," identifies three case studies that illuminate recommended practices, tools and tactics from the Adaptive Leadership framework. A quick taste:

"...Embrace disequilibrium – When Paul Levy became the CEO of Beth Israel Deaconess Medical Center, there was a high level of disequilibrium in the hospital. The organization had both financial challenges as well as difficult internal tensions. After working through the financial issues, Levy kept up the state of discomfort in order to induce change and resist the temptation for the organization to fall back on status quo."

There are two problems here. The first is that the authors misrepresent my management approach. The second is that neither they nor the publishers of the magazine contacted me in preparing their publication or the publicity surrounding the publication.

Beyond the break in protocol, this public characterization of how I manage an organization is troubling. The authors make it sound manipulative and disrespectful of the people in the organization, as opposed to a role more akin to coaching. They make no mention of how I frame issues in the context of the underlying values of the organization and the people working here, nor encourage a shared governance approach to problem-solving, both aided by being very transparent about the state of the institution. This draws strength and involvement from the staff: That, not embracing disequilibrium, is the key message.

Indeed, it feels like the authors squeezed what I actually did into their pre-existing analytic framework rather than fully exploring what it was.

Imagine how a nurse or doctor reading this would respond. I think they would feel that they had been used, versus how they really felt during that time -- engaged and energized. That is the ultimate problem with the materials presented by the authors and publisher.

I hesitated to write this, but I know of no other way to correct the record in a manner reasonably contemporaneous with publication of the teaser and the article.

Problem must be visible!

Well, back to work after some weekend diversions!

We recently hosted Mr. Hideshi Yokoi, president of the Toyota Production System Support Center in Erlanger, Kentucky, and Mark Reich, a general manager at TPSSC. This is part of our own orientation to Lean process improvement. Together, we visited gemba and observed several hospital processes in action, looking for ways to reduce waste and reorganize work. It was fascinating to have such experts here and see things through their eyes. Mr. Yokoi's thoughts and observations are very, very clear, notwithstanding a command of English that is still a work in progress.

The highlight? At one point, we pointed out a new information system that we were thinking of putting into place to monitor and control the flow of certain inventory. Mr. Yokoi's wise response, suggesting otherwise, was:

"When you put problem in computer, box hide answer. Problem must be visible!"

Too many zucchinis?

And, in case you missed this year's Zucchini Festival in West Stockbridge, MA, check out pictures here.

Art in the Park in Worcester

A great exhibit in Elm Park in Worcester, MA, through October 1. About 20 sculptures by various artists sprinkled throughout the park. Many are whimsical, like those shown here. It is worth a visit if you are in the area. See more pictures on my Facebook page here.

Beach umbrellas, from two sides

Nice sentiment

Great artwork on a Truro beach, composed in eel grass and sand.

Hey seals, look up and smile

Here's another view of those Cape Cod seals near Head of the Meadow Beach, this one from above, thanks to a friend who took us up for a scenic view in his Piper Cub.

Learning from success

A fascinating article about research being done by some folks at MIT. Apparently we learn better from success than failure.

When I asked Clif Saper, our Chief of Neurology to comment, he said the following. I think the last point has something to do with how I am supposed to treat Chiefs of Service!

The thing that is most salient in this work is the role of reward. Emilio Bizzi at MIT began studying prefrontal neurons and their role in directing eye movements in the 1960’s, and found that they had no real relationship to the eye movements when the monkeys randomly scanned the room. But later it was found that if you reward the monkeys for looking in a certain direction, they respond briskly. Primate prefrontal cortex is a machine for shaping behavior based on reward. There is a lesson in there...

Seeing through to quality

Jonathan Kruskal, our Chief of Radiology, points out out a useful website of the Radiology Society of North America, on which he has been working with the RSNA's Quality Committee. He notes:

This is a very useful site which includes resources for radiologists who want to get started with QI projects (very helpful for all of our residents now undertaking the QA elective); tools to help identify areas for improvement and tools for designing interventions, educational QA offerings (including the vertical daylong QI course at RSNA that Scott Gazelle from MGH and I am organizing this year); clinical guidelines and performance measures; and QA self assessment modules (SAM's).

I, too, note with some pride that the site links to four recent quality-related papers from Jonny's department (including those from Alex Bankier, Jacob Sosna and Bettina Siewert).

Edgar Schein helps out

Because of a gift from Twitter friend Ralf Lippold who I met (in person!) while he was attending a conference on Cape Cod, I just read a wonderful book by Edgar H. Schein entitled Helping, How to offer, give, and receive help. It is a great exposition of the importance of helping in a society. Beyond the general discussion, there are good lessons for people in business about the manner in which help is offered and received.

Here's is a short paragraph that I found compelling, headed, "Accepting help as a leadership function."

Many people in senior management positions have the power and the potential to be effective change managers through learning how to help, but their formal position and actual power often lead them into premature fixing. Those at the top of the ladder, in particular, are drawn to the expert and doctor role, whereas effective change management really requires the process consultant role. The dilemma of the organizational consultant is how to get across to clients that they need to learn how to be process consultants and accept the role as a legitimate and necessary part of being an effective leader.

You are so right, Joe!

A note from Joe Castro, manager in our trauma program:

I wanted to share several pictures with you that capture the beautiful gardens that surround the West Campus. The one above is of Michael Trzcinski and James Robblee – two of the many maintenance crew members responsible for keeping the medical center looking great! I see them often about the campus – always busy in the discharge of their duties. I told them what a great job they have consistently done to keep BIDMC looking good throughout the calendar year.

What you don’t see in these pictures are the MANY patients and visitors who take notice of the flowers. I walk between the Lowry building and the west campus buildings several times during the day. On countless occasions I see people react to colorful plantings either by taking pictures, stopping to smell the flowers, or simply sitting amongst them as a form of respite while taking a break from visiting a family member admitted to the ER or inpatient wards.

Michael and James spoke highly of the support given to them by their department heads, further mentioning the commitment of the medical center to maintain the quality and variety of the flower beds and their aesthetic value. Theirs is a job well done and I wanted to take this moment to ensure that these gentlemen, as well as others within their department, get the credit that they truly deserve!

Can you taste the difference?

If your place is like ours, you will find that lots of people purchase bottled water rather than using tap water. As someone who used to run the local water system, I can assure you that any municipal tap water delivered in America, and indeed throughout most of Europe, has to meet higher standards for purity and quality than water sold in bottles. Tap water also is delivered through pipes, often by gravity, with very little energy required, whereas bottled water uses petroleum for the bottles and for transport. (Indeed, some brands are transported thousands of miles.) Finally, bottled water is many, many times more expensive than tap water.

Here you see summer interns Joey Bazinet and Kimberly Chun offering taste tests to staff and visitors at BIDMC. Our facilities department is trying to persuade people to make the switch to tap water. Because inside pipes sometimes add their own flavors and particulates to the municipal water, our facilities folks will install and maintain a filter in anybody's lab or office area. Installation cost = $500-$600. Annual cost to maintain = $50 ($25 filter two times per year). Compare to the annual cost of Poland Spring water of over $700.

Another CEO enters the blogosphere

Welcome to Scott Kashman, CEO of St. Joseph Medical Center in Kansas City, who has started a blog. You can see it here.

Now that the numbers are growing, I have added a new category of links over there on the right side of the page, devoted to health care CEOs who have blogs. Please let me know if you know of others.

Primary Causes

The following sentence from the report of the Massachusetts Payment Reform Commission caught my eye: "It is widely recognized that the current fee-for-service health care payment system is a primary contributor to the problem of escalating costs and pervasive problems of uneven quality." As mentioned below, I admire the work of this Commission, and I have no quarrel with the principles adopted by it, but I believe this particular conclusion is overstated. The characterization is risky in that it gives no relative weighting to other causes and may serve to take those other causes of the hook in terms of policy development. Some reading the report may think that if you change payment methodologies, it will make a sufficiently significant dent in the rate of health care cost inflation. I'm not so sure.

I recently had a chance to view the average annual medical cost inflation rate of a health system's capitated patient group over the last five years. It was ten percent. This was ever so slightly below the health system's fee-for-service patient group, and I am willing to concede that the payment system made a difference. But the point is that is was not a major difference. What might be the other "primary contributors" to the problems we are trying to solve?

Here's my list, produced with the benefit of no data, but just observation of what actually goes on in the four walls of our hospital:

1) Demographics. The huge cohort of baby boomers have now entered the age at which they are seeking hospital care. Meanwhile, their parents are living longer than ever and are coming to the hospital for both acute and chronic care.

2) Entitlement. The first cohort named above expects and demands everything for themselves, and of the insurance products they expect their employer to purchase. For their parents, they often expect extraordinary end-of-life care interventions, paid for by Medicare.

3) New stuff. See #2 above. A knee that previously would have remained sore in the past or be treated by physical therapy becomes a target for arthroscopic surgery.

4) The medical arms race. Physicians and hospitals feel compelled to buy the latest technology, even without proof of enhanced clinical efficacy.

5) Defensive medicine. Yes, the threat of malpractice law suits leads to over-testing and other extra costs.

6) Regional medical mythology. Thanks to Brent James for this insight. Local practice patterns often are just that, with no evidentiary basis.

7) Preventable harm in clinical settings leading to extended hospitalization and bodily injuries.

8) Lack of access itself. If people don't have health insurance and can't get proper early diagnostic and preventative care, they are a more expensive burden on society when they get sick.

9) The cottage industry problem. The medical profession, both in physician practices and hospitals, has failed to adopt process improvement approaches that are common in other industries, that result in redesign of work flow and systems to derive efficiency, quality, and standardization.

10) A sedentary and malnourished lifestyle for all age groups, leading to obesity and other associated physiological problems that are the precursors to major health issues.

In a post below, I outlined the things I would like to see in federal health care reform legislation. Those don't address all of the causes mentioned above, but we should not expect a new law to do so. We can fix some of our inadequacies through legislation, but many components of our problems lie deeper in society.

P.S. While there are pro's and con's of each country's health care systems, similar cost pressures have become evident in much of the rest of the world. Perhaps this suggests that a common organism underlies our problems, homo sapiens and its curious ability to live longer and expect more.

Grateful Nation coming events

A number of grateful patients and families (some seen above) have organized fund-raising events for our hospital. Biking, walking, golf, or tennis: You can find them here. Please join us.

And for those who eschew exercise and just like to shop, here's another one on August 11 at 6pm in Copley Place: David Yurman, America’s renowned fine jewelry and timepiece designer, will host an exclusive shopping event previewing the latest David Yurman collections. A portion of the evening’s proceeds will benefit the Sarcoma Tumor Bank at BIDMC, under the direction of Mark Gebhart, MD.

Presidential swap shop

A pet peeve of mine is how the inventory of office supplies continues to grow in an organization. I have seen this everywhere I have worked and in many places I have visited. I'm talking basic stuff -- paper clips, alligator clips, three-ring binders, pads of paper, pens, and pencils.

And, even though there is a ton of stuff in the building, office managers continue to order more of it.

In a previous place I worked, I put out an order saying that we would no longer permit purchases of paper clips. Guess what? We never ran out. They just kept getting recycled when documents would be sent from one office to the next.

We plan to have a general office supply swap for the hospital soon, but I thought I'd run an experiment in the meantime. It is based on my community experience running a soccer cleat exchange. I created the "Presidential swap shop" in the corridor near my office, which is within eyesight of a highly trafficked thoroughfare. The sign says, "Take what you need, leave what you don't." Already, within a couple of days, there has been a dramatic amount of trading activity.

Those neat red boxes are the containers in which pipette tips arrive at the labs. We use thousands per year. They are perfect storage boxes for all kinds of stuff here and at home. They are flying off the shelf of the swap shop.

You can't see the paper clips and alligator clips, but they are also moving well, as are the three-ring binders. Meanwhile books are coming and going like a lending library.

I hear reports that other swap shops are popping up around the hospital. Maybe it's a movement.

You call this a photo-op, Mr. President?

Hello? Who is doing PR for President Obama? Why would you put this picture -- the President trying out a surgical robot -- on the White House web site?

Look at this post on medGadget for commentary.

So, Mr. Obama provides free nationwide marketing for this device, a machine that is totally counter to what he is trying to accomplish with health reform.

The people at Intuitive Surgical must be gloating today. You can't buy this kind of publicity.

Maybe, next he should be seen piloting an F-22 (photo credit embedded).

Taking care of one of our own

A note from an administrative staff member who became a patient, reprinted with permission:

I wanted to personally send you an email, not send in the BIDMC Patient Survey, regarding my medical care at BIDMC over the last year. (This is my first week back from my one year medical LOA).

July 9th, 2008, after my PCP received blood work results back on me, it was suggested that I go to “a Boston hospital” to have my blood work rechecked. My numbers looked funny. Where else would I go but to BIDMC, where I worked. I drove in myself, went to the ED, where before you know it I was in an isolation room. Little did I know just how sick I really was. I wished I had a family member or friend with me. I never expected the news I was about to hear. A nurse came in (I wish I knew her name but I don’t) and sat with me. I said “I’m really sick aren’t I?” She said “Yes, you are”. I asked if I had leukemia and she said she really didn’t know but oncology doctors would be in to see me soon. The personal treatment that I received from the ED was exceptional. The staff was wonderful and truly caring.

That evening I was shipped up to 7 Feldberg where I spent the next 5 weeks, diagnosed with APML, leukemia. I believe it takes a special person, doctor or nurse, to be a caregiver to a very ill person. There were days that I wasn’t sure I was ever going home, but the staff never let that thought stay in mind for very long. I can’t say enough about “my family” on 7 Feldberg. They made it a point to get to know me and my family personally. Although everyday I hoped and prayed that I would be going home, I couldn’t have been in a better place. The folks on 7 Feldberg have my praise!

I started my outpatient treatment right away. Off to Shapiro 7 I went 5 days a week for 5 weeks. I had a 2 week break and then back in for another round. My good days were really good; my bad days were really bad. But I always went home comfortable physically and psychologically. I really don’t want to point out anyone, any department over another, but I have to in my case. The staff (medical and administrative) on the Hematology/BMT floor is great. It’s scary knowing that you have cancer, but when you walk into the front desk area you are greeted with such compassion, almost forgetting the reason why you are there in the first place. Once again, very special people.

My BMT nurse has been with me through thick and thin. My Oncologist is phenomenal. I have a great NP who was actually one of my nurses on 7 Feldberg. I sent them an email last week on my anniversary date and thanked them for all they do for me. I told them that I appreciate them allowing me to consider them my extended family. I had a standing weekly blood draw at 8am every Monday and saw my NP and doctor shortly after. Since coming back to work, that does not fit into my schedule, so I had to ask them what they could do to help me out. Again they have gone above and beyond. I take the shuttle from my office on my lunch hour once a week. My nurse will fit me in whether I’m 15 minutes early or 15 minutes late, basically making her schedule around mine. The next day I see my NP and doctor after their last appointment. I still can’t believe that they have done everything possible to make my transition back to work a smooth one. I’m here for my staff when I need to be, and they are going out of their way to see me, working around my schedule. Where else would I find that level of service?

In closing, during my inpatient stays and my outpatient appointments, there wasn’t a day that I thought I was in the wrong place. From Food Services, Housekeeping, Social Work, Patient Transport, Patient Accounts, CTscan, MRI . . . I could go on and on but I'd be afraid I would forget someone. What was a tough experience for me was made much easier by all the staff we have here. I’m in remission now, and I’m sure that with the exceptional treatment I receive I will remain that way for a very long time.

Thank you from a very satisfied patient!

BID~Needham construction progress

Speaking of videos, click here to watch an update of the construction project at BID~Needham hospital. This video shows you the outside of the new emergency department and walks you through the new inpatient unit. The grand opening is planned for this fall.