Want to see a masterpiece theatre?

WGBH is offering tours of its studios in my online auction to benefit Bowdoin Street Health Center. Look under "Unique Experiences."

Interlocking circles and cycles

Still relatively new to the medical field, I am often struck by the interplay among generations of patients and doctors, and between doctors themselves. I have not seen it to this degree in other industries with which I have been associated. It makes the field intensely personal, with constantly interlocking circles and cycles of life.

Here's a microcosm. Dr. Harold Solomon learned about hypertension from one of the leaders in the field, Dr. Norman Kaplan, Clinical Professor of Internal Medicine, University of Texas Southwestern Medical Center at Dallas. Dr. Kaplan's book, Clinical Hypertension, is the standard in this area. Harold built a practice with an emphasis on this field, but also focused on delivering high quality primary care in general.

One of Harold's patients, Harvey ("Chet") Krentzman, died a few years ago. In recognition of the excellent care provided by Harold to her husband, Chet's wife Farla decided to lead an effort to fund a lecture series at our hospital in his name. One of the guest lecturers invited by Harold was Dr. Kaplan, in appreciation for his stature in the field and for his influence on Harold's own career.

Tonight, on the eve of tomorrow's lecture, a group of Harold's patients and physician colleagues joined to express their appreciation and affection for all three people. You see them above.

The gold standard

Our pathology labs receive accreditation from the College of American Pathology and the American Association of Blood Banking. Inspections are every two years and cover about 3000 separate standards. The reviewers are pathologists and technologists from other participant organizations.

We just completed an inspection conducted by a 15-member team, a group with very impressive qualifications.

I am proud to say that, not only did we pass with flying colors, but one surveyor said, "I have been doing inspections for 30 years and if any place has a gold standard, this place is It"!

As noted by Dr. Jeffrey Saffitz, our Chief of Pathology, "In more than 35 years in academic pathology, I have not witnessed such an extraordinary level of commendation and praise from a team of peer reviewers. Almost without exception, these seasoned, experienced inspectors indicated that they learned a great deal from us and they intend to implement many of our policies and practices in their own institutions. Many also expressed a desire to take some of our people back to their home institutions! The cooperation, trust, work-ethic, dedication and commitment to excellence by our lab personnel is absolutely unparalleled."

Congratulations to the entire team!

Hallelujah!

Craving culture? Check out Boston Baroque's Messiah and also their New Year's Eve concert at my auction to benefit Bowdoin Street Health Center.

And, why not combine it with a one night's stay at Boston's most romantic inn, the Charles Street Inn? Look for this newly arrived item under "unique experiences" on the auction site.

Urine my thoughts

I am always on the lookout for water saving techniques . It comes from having focused on this while running the metropolitan area's water system.

I, er, encountered this at MIT -- along with the handy sign that you can read while....

Back at the hospital, I inquired of our facilities folks whether we should have these in public restrooms at the hospital. A rather lengthy stream of information ensued from Mark Lutisch, our utility manager. I'll include most of it, for those of you who might be interested as you consider this in your own facilities.

Waterless urinals can save a lot of water and be fairly clean, with minimal odor. As waterless urinals don’t flush, there may be a reduction in bacteria or pathogens that are transported in aerosols to users. However, waterless urinals are not a set-and-forget plumbing fixture.

Prior to a waterless urinal retrofit project in older facilities, it is highly recommended that facilities 1) ensure that the slope of the drain line is ample, and 2) route drain lines to avoid problems such as sediment build up and 3) check drain heights are appropriate to the brand to be purchased. 4) Heavily corroded pipework should be replaced with PVC pipes. Facilities are far less likely to encounter problems with retrofit projects if these preparations are made.

A special and often-patented trap assembly that requires a special lighter-than-urine liquid must be added to the regular bathroom maintenance schedule. The trap assembly and the trap liquid must be added to the list of consumables that need to be purchased and resupplied for the life of the fixture. Maintenance staff require training in the proper care and feeding of all waterless urinals. Once the plumbers are gone, it’s up to the building staff to maintain the fixtures, and they still need daily cleaning and disinfecting, waterless or not. It may be necessary to clean urinal pipework before installing waterless urinals.

Toilets account for about 20% of BIDMC's water usage, urinals about 1%. A study by Water Management Inc. in 2007 recommended a focused fixture replacement program that zeros in on the fixtures with “the most bodies per potty”. They proposed to replace fixtures that have high per use flows and receive consistently high usage. These fixtures are generally located if common area and staff restroom facilities. Some plumbing fixtures would be excluded from the project scope based on low usage profiles. The cost was estimated at $380K with a 4.5 year payback. Because the energy budget did not have $380K for this measure, and the 4.5 year payback was not as good as other projects, toilet and urinal replacement was excluded from the water conservation project.

Instead of installing waterless urinals, Water Management Inc. recommended simply modifying the flush valves on 50 high use urinals to reduce the volume used per flush to 0.8 gallons per flush, saving about 282,000 gallons and $4K per year. Replacing the flushometers (possibly with infrared no touch sensors) is a cost effective way of reducing urinal wastewater.

In FY12 the energy plan will request funding for toilet and urinal replacement, along with a study on rainwater harvesting, greywater harvesting, and irrigation scheduling. However, we may pilot low flow toilet fixtures sooner in several high use bathrooms.

Thanks for your support,
Mark Lukitsch
Utility Manager, BIDMC

Sleepy? Amorous?

Which side (of the river) do you prefer? Win a hotel room in Boston or Cambridge for a visiting friend or relative . . . or for that romantic night out. Courtesy of the Four Seasons and the Courtyard by Marriott. Bid at my auction for Bowdoin Street Health Center.

Tom Sellers --->> DC

My friend Tom Sellers has fled Boston and taken a new position as President & CEO of the National Coalition for Cancer Survivorship. (Locals here will know that Tom led the fundraising, community relations, and development activities for a $30 million American Cancer Society project to build a 50,000 square foot Hope Lodge in Boston to provide free lodging to over 1,000 cancer patients annually. Before that, he worked at the United Way and in the MA state government.)

He is very excited about this and tells me that there are nearly 12 million cancer survivors living in the United States and that NCCS is the oldest survivor-led cancer advocacy group in the country. This group advocates for quality cancer care for all Americans and provides tools that empower people affected by cancer to advocate for themselves. It was founded by and for cancer survivors more than 20 years ago. Its governance requires at least half of the Board members to have had a cancer diagnosis some time in their lives, and many staff members are cancer survivors, so they speak from experience.

Tom says, "One of our newest initiatives is the Journey Forward program, which is targeted to health care professionals and patients. Upon completing treatment, many cancer survivors find themselves wondering, “What’s next?” The Journey Forward program, is a collaboration of the NCCS, Wellpoint, UCLA Cancer Survivorship Center, and Genentech. It helps survivors with the transition from uncertainty to the next stage of survivorship through the use of treatment summaries and follow-up care plans that summarize cancer treatment and give clear steps for follow-up care and monitoring.

"Cancer care plans put survivors in a better position to advocate for themselves, monitor their health, and participate in decisions about their future care. Journey Forward’s custom-made Survivorship Care Plan Builder is available to any oncologist, and the electronic Medical History Builder allows patients to easily record their own health history. Journey Forward’s survivorship toolkit currently offers templates that include information specific to survivors of breast and colon cancer, and a generic model that is applicable to survivors of many cancer types will soon be available.

"The program is completely free, and more information about how you can develop a plan is available here."

Hungry?

Head downtown for a great lunch or dinner at the Chinatown Cafe on Harrison Street, courtesy of proprietor Hing Soo Hoo. First, though, bid on a gift certificate at my online auction to benefit Bowdoin Street Health Center.

Who cares if it is off-season?

Take 10 friends for a tour of Fenway Park, courtesy of our Red Sox partners. Or have lunch with Executive Vice President Sam Kennedy. Bid at my auction to benefit Bowdoin Street Health Center.

If you visited yesterday, check out some new items today.

GRACE: Will it be amazing?

Our folks are working on an important new project. It derives from a number of adverse events, cases in which elderly patients fell and were injured. Our review process often indicated that the staff had done just the right things with regard to fall prevention and supervision of patients. Using the "5 Why" process of Lean, they kept digging into the cause of these falls. A hypothesis emerged: Perhaps we were contributing to the likelihood of falls by over-medicating geriatric patients or missing important parts of their supervision and therefore causing them or allowing them to be disoriented.

Our group began to construct a new "geriatric bundle" of care. (You have seen this be tremendously effective in other arenas, like avoiding Ventilator Associated Pneumonia.) But what should it look like, and what should it include? Well, we have just started rolling it out on an experimental basis, and we will report the results as things progress. Here's a summary from the staff:

The Geriatric Bundle now has a new name - GRACE (Global Risk Assessment and Careplan for Elders). This program is designed to improve the care of all hospitalized elders admitted to the BIDMC, with the hope that we will reduce the risk of delirium, falls, pressure ulcers, functional decline, etc.

There are three main components of the initiative:
- Provider Order Entry (POE) enhancements
- Improved Pharmacy/Medication safety
- Bedside care protocol

The bedside care component is a major piece and through the diligent work of many is well on its way to implementation. A tool is a GRACE bedside flow sheet that will be used for all patients 80 and older each day. You can see it and the other elements at this link to Slideshare, where you can read the entire presentation that was shared with our clinical staff on several floors.

Online Auction to Benefit Bowdoin Street Health Center

I am starting a new feature on this blog. I hope you enjoy it and participate.

Some friends of mine are involved in a new company called BiddingforGood. What EBay brings to the world of auctions in general, B4G brings to the world of charity auctions. It is a consolidator, facilitator, and operator of on-line auctions for charitable causes and organizations.

With the help of B4G and some of the BIDMC staff, I will be holding an on-line auction each month to benefit one of the BIDMC's affiliated community health centers or another worthwhile health care-related cause.

This week's auction will benefit BIDMC's owned Bowdoin Street Health Center, a wonderful place providing primary care, specialty care, and many support functions to a section of Dorchester in Boston. I am trying to raise money for an ultrasound machine, so pregnant women can have ultrasounds in their neighborhood setting rather than having to spend time and money to travel to BIDMC for this service.

Just click here to enter the auction site. There are some great items -- travel, food, concerts, sport events, art, and memorabilia. Also, some very special people are offering to provide inspirational and informative presentations at your civic organization or company. Finally, there are a couple of special items from our partners, the Boston Red Sox.

Bid early, bid often, and bid high! You have until 8pm on Monday, November 9, to submit bids.

Also, if you would like to offer items or services for this or future auctions, please click here or on the "Donate" button on the right side of this blog.

In the interest of total disclosure, I want you to know that bidding in this auction will place you on a mailing list for future auctions, both mine and others around the country. You can have yourself taken off that list at any time.

Please let me know what you think about this idea and the B4G site.

And, good luck!

Out of line

Depending on your point of view, competition is either the strong point or the underside of Boston's spectacular collection of hospitals and physicians. It does produce an exceptional desire to succeed, to deliver the highest levels of clinical care. But it also has the potential to be rather juvenile and wasteful of resources. But here is an unusual case where it got downright ugly and out of line.

The story is documented yesterday in a Boston Globe article written by Liz Kowalczyk. The case involves a request for a restraining order against their former hospital physician organization by two doctors who chose to join another hospital's network. Why would they need a restraining order? I have seen the court complaint. Here is a representative part:

Defendant Caritas Christi Physician Network, Inc. ... has failed and refused to send a timely notice to patients presently under the Plaintiffs’ care with respect to the change in affiliation and Plaintiffs’ new contact information. Notwithstanding this failure, Defendants have further refused to agree to remedy the situation by permitting the Plaintiffs to maintain temporary custody of their active patient files until such time as patients have been fully informed of the change and given the opportunity to continue care with Plaintiffs. Without regard to the needs of Plaintiffs’ aged and chronically ill patient population, Defendants propose to remove forthwith ... all active patient files, with the exception of those patients who have a scheduled appointment with Plaintiffs in the next two weeks. Defendants also have failed and refused to agree to ensure that Plaintiffs’ new contact information will be provided to everyone who calls that number, notwithstanding that Defendant is keeping the phone number Plaintiffs have had for over thirty years.

The judge granted the restraining order. The legal standard for a restraining order is that the moving party has "a likelihood of success on the merits of its claim and, without the requested injunction, risks suffering irreparable harm." I'll leave you to read the story, but I want to respectfully disagree with Liz's characterization in one part of it.

She notes, "The disagreement highlights the intense competition among hospitals in the Boston area to hire and retain established physicians, especially primary care physicians." Not so! This is something altogether different.

This is out and out cruelty to patients by attempting to restrict their doctors' access to them and their medical records. I can't recall any other hospital system behaving in this manner when a doctor chooses to join another network, no matter how competitive the environment.

Newton and the Countefeiter

I'd like to suggest a book to you, entitled Newton and the Counterfeiter, by Thomas Levenson (Houghton Mifflin Harcourt). Levenson is a professor in Writing and Humanistic Studies at MIT.

We are all familiar with Isaac Newton's outstanding contributions to science and mathematics, but how many know about his career after 1695? In that year, tired of university life at Cambridge, he moved to London to become Warden of the Royal Mint.

There, he ran into another very bright person, in the form of William Chaloner, an accomplished counterfeiter, who was rising through the ranks of the underworld. As he had in other fields, Newton invented methods of investigation and proof, but these were designed to catch criminals.

Mr. Levenson's writing style is engaging, and you find yourself turning pages quickly. The book reads more like a novel than non-fiction, and the factual basis for the story makes it even more intriguing.

Pumpkins @ BIDMC

Here are some of the winning entries from the BIDMC annual pumpkin carving contest.

Lead cases studies will be available

We just finished our presentations at the BCBS conference. The full case studies will be available on the BCBS of MA sites mentioned below, but also on the IHI website.

Berwick jumps in, too

Following up on the post below, Don Berwick, CEO of the Institute for Healthcare Improvement is offering the keynote address at the BCBSMA conference. I'll try to pick up his major themes as he goes along.

Don offered stage-setting remarks for the CEO presentations to follow. He noted that the MA universal coverage law is being used as an example by people in Washington, DC, even though there remains lots to do with its implementation. He termed that law a "moral commitment," but one that requires lots of attention to the offshoots and results of that kind of commitment.

Don said that the work of the Lead group is also path-finding in its own way.

Regarding the current debate in DC, Don suggests that most of what seems to be playing out is an oscillation between two kinds of alternatives: Spend more or do less. The political process has the means to get through this kind of dialectic. But what the CEOs here know is that there is actually a third option: Redesign the care. The quality movement is formed by a kind of optimism. It always can be better; therefore we should stive. "Better is the option: Redesign is the plan."

Until now, it has not been necessary to do this in the health care system, and many parts of the system are still delivering care based on old models. Congress and the Administration don't get this because they don't deliver care. They don't know what the potential is and how to achieve it.

Don suggests that there are other elements in achieving this potential. The first domain of care is inherent in the Institute of Medicine list: Safe, effective, patient centered, timely, efficient, and equitable. He notes that we have gotten better in this domain, and he presented lots of examples across hospitals. "We know a lot, and it can be done."

The second part of the story has to be based on value, a system that we can afford. "I do not regard it as ethical that health care takes up 16% or more of the national economy." This steals wealth from other important causes like education, culture, and infrastructure. The health care system is way overbuilt. "Health care is not entitled to the growth in GDP that it demands." This will not be solved by focus on the IOM domains. We have to use scientific knowledge about process improvements and knowledge of systems to achieve the IHI triple aim: Better care, better health, and lower per capita costs.

There are some high value areas of the US. We brought together 10 of those regions and did a debrief. These places have broken the back of supply-driven demand. They also evidence high degrees of cooperation between medical groups and hospitals, among hospitals, and with payers. In every one of those communities, people in positions of responsibility both inside and outside of the health care system have chosen to exercise that responsibility. The attributes of the executives in the successful markets include: Confidence in possibility; appeal to the heart of the work force; constancy of purpose; alignment of resources for achievement of the long-term aims (money and time -- use a low discount rate in evaluating investment choices); review and reflection; translation into finance (bridge between the world of improvement and the world of money -- the CFO is at the table); management of spread (take pockets of excellence and help them be be pervasive); formats for cooperation ("not love, not even peace, but some way to get together") -- move good news from one place to another; celebration at the community level.

Jumping In

I'm currently attending a conference organized by Blue Cross Blue Shield of MA entitled, "Jumping In: Learning from CEOs about driving health care quality improvement." This conference represents the summation of a BCBS program called Lead, in which five MA health care institutions created a community of practice to learn about ideas, concepts, and implementation of meaures to improve the safety and quality of care.

My colleagues in crime in the Lead program are (seated): Vinod Sahney, SVP at BCBSMA; Jeanette Clough, CEO of Mount Auburn Hospital; Helen Streider, CEO New England Baptist Hospital and Maureen Broms, VP of Health Care Quality and Patient Safety at NEBH; and (standing) Eugene Lindsey, CEO of Atrius Health; Craig Melin, CEO of Cooley Dickinson Hospital. Yup, that's Don Berwick standing to Gene's right: More on him in a second.

All of the program materials are, or will be, available online here for providers and here for employers. There are some impressive stories, including how Mount Auburn virtually eliminated medical errors over a period of several months.

The keynote presentation will be given by Don Berwick in a few minutes. I'll try to pick up highlights and get back to you.

Auction item reminder

Please don't forget to donate to my collection of auction items to benefit Bowdoin Street Health Center. Thanks!

Thanks for nothing

I was excited to see that our Boston transit system, the MBTA, had installed these LED signs on the line I take to and from work. I eagerly anticipated messages saying, "Next train in 8 minutes" or "Green Line delay because of track repair."

But, no. The sign remained dark for the half-hour I waited for a train tonight.

Well, not totally dark. There was the message, simulcast on the public address system and the LED sign, warning us that fare evasion was a crime and that we could be punished mightily for it.

But not a word about the actual train service.

I have to give the MBTA something for truth in advertising. It describes this capital improvement project (or one like it) as follows: This project will install new LED information signs on the platforms and lobbies of busy subway stations. These signs will provide visual equivalent of audio information on train arrival times and destination information.

In that sense, the signs are the visual equivalent of the public address system on this line, which for years has also failed to give audio information about delays or train arrivals.

Brava, Helen!

I don't usually post emails from other hospital CEOs to their staffs, but this one is so kind and thoughtful that it presents a model for others to emulate. Helen Streider stepped in from a lay Board position to be Interim CEO of New England Baptist Hospital when there was an unexpected vacancy in the job. This, in itself, was generous act. Now, as her term ends with the arrival of a new CEO, she bids farewell to the staff in an incredibly gracious manner.

This will be my final Reflections as Interim President and CEO. It has been a remarkable year (actually 14 months). To this day, I am proud that the Trustees asked me to take on this responsibility and humbled by the honor. It has been a great privilege to work at the helm of this extraordinary institution where the values of respect, ownership, superior service and excellence result in legendary service being a prominent part of the culture.

These values are some of the reasons that my father, a thoracic surgeon, loved the Baptist, and the reason why I have enjoyed working at this institution, from the time I had a summer job during college, through my service on the Board of Trustees.

I knew as I started to work last August that I would be supported by a talented Executive Team and helped along the way by all who work here, and this proved true. I am proud that we were able to go beyond just holding the fort and accomplish so much together this year.

First and foremost, we continued our journey toward keeping our patients safe by reducing complications such as infections, skin breakdowns and medication errors. All of nursing, health care quality, infection control, environmental services and everyone who washes their hands regularly contributes to this progress. The pharmacy, nursing units, and the PASU learned to solve problems to root cause, reducing medication errors that reached the patient by 33%. To be successful with this process means that we must not blame each other for mistakes, but instead figure out how to change systems to avoid errors. We have learned to be transparent and now know it is safe to call out issues as they arise.

When the economy failed, and we, like so many, lost value in our investments and our pension assets, and our volume declined, the entire staff pulled together and made sacrifices to enable us to make, and even exceed, our budget. Special kudos go to the patient care teams who cooperated in continuous, precise flexing of staff and closing units when volume levels required.

And then there was the horrible winter, when Security roared into action getting folk up the hill for their shifts, and the wonderful patient care team spent overnights here and did everything in their power to make sure that they were here to care for their patients (including one nurse who walked up the icy hill in her socks).

We have renewed our alliance with our medical staff by coordinating negotiations with insurers and, in the process, aligned our quality goals with the medical staff metrics.

We reached a milestone in our Master Facility Plan in September as we opened the beautiful new Central Sterile Processing Department and a leading edge OR. The remarkable thing about the construction and facilities team was not only that they accomplished these goals, but met them while keeping disruption to operations to a minimum, and Environmental Services kept us clean and shiny throughout. What a great team!

By the end of the fiscal year our surgical admissions, outpatient visits and radiology volume actually exceeded that of 2008, despite the economic downturn and various other challenges. The increase in volume is due in large part to the efforts of our medical staff to increase their work, and to the incredible efficiency in the OR and perioperative teams. We also were fortunate to have several Harvard Vanguard orthopedists join our ranks in a testimony to their belief in our quality and that this is a place where their patients will have better outcomes. And now, as we are blessed with greater volume, all departments are rising to the challenge of caring for more patients while holding to our high standard of care.

And through all of this, our Food & Nutrition team fed us, catered events with panache, and comforted out patients with room service. They sustained us with that vital coffee and snacks as we dragged into early morning or evening meetings ready to put our heads on the conference table. How would we survive without them?

And what a beautiful tea party they orchestrated for us yesterday. Thanks to all for a lovely afternoon of smiles and to everyone who came to wish me well. And special thanks for my beautiful new chair.

So now Trish arrives on November 2^nd . . . and I will be sleeping in! We all are excited about her leadership and look forward to helping her help us be the very best we can be.

Thank you all for a wonderful, exciting and challenging experience and for all that you do for this Hospital.

Helen