Israel visit -- Part 1

I have been on a mission to Israel for several days with a number of Bostonian businesspeople, sponsored by the Combined Jewish Philanthropies. These kinds of programs are always engaging and informative, as an attempt is made to meet with people from a wide variety of political backgrounds, but also to meet with people living their everyday lives.

Whatever your view of the Israeli-Palestinian conflict, I am sure you would agree that schoolchildren are casualties. I hope you agree with me, too, that they are innocent victims. In addition to the chance of being killed, they suffer from other ravages of war.

We visited the Israeli town of Sderot, right outside of Gaza, a town that has experienced daily rocket attacks for many years, sometimes several times per day. As you can see, this school has been reinforced in many ways to deflect and withstand rocket attacks. Nonetheless, the children have grown up in an environment that leads many to suffer from post traumatic stress.

A program was introduced to help children cope with this emotional burden. It is called Havens of Calm, and it comprises pet therapy, pyschodrama, and yoga. The idea is to provide a school-based stress reduction and resilience building service accessible to all children when they need it. The program builds upon the mental health service provided by the education system (counselors and psychologists), as well as bringing in additional services and supplementary expressive therapies. It is funded by the Joint Distribution Committee with support, in part, from the people of Boston through the CJP.

We had a chance to watch the children and their therapists. By the way, note that the buildings built by the children as part of this session tend to have heavily reinforced roof structures, just like their school building. Compare this to what your own children would be likely to build: This is an unconscious result of their experience.

Healthy is . . . skating at Fenway

About 120 BIDMC staff members got a chance to take to the ice rink last week at Fenway Park. The rink was constructed for the New Year’s Day “Winter Classic” match-up between the Boston Bruins and the Philadelphia Flyers. As part of its special relationship as the Official Hospital of the Boston Red Sox and Red Sox Nation, the Sox invited BIDMC staff to have an exclusive one-hour free skate before the rink gets removed. Here's Joanne showing how to stay healthy.

Uncivil behavior within the SEIU?

A few weeks ago, I wrote of issues surrounding morality, power, and union organizing with respect to the SEIU. Now comes this fascinating article entitled SEIU's Civil War by Bill Fletcher, Jr. and Nelson Lichtenstein on a website called In These Times.

I know nothing about the authors or the website, although the site portrays itself as committed to social justice issues. One paragraph of the story struck home and seemed consistent with my post:

Although some SEIU locals have had histories of varying degrees of internal democracy and transformational politics, the SEIU has looked askance at such localist examples of democratic participation—not because the leadership of SEIU is hostile to mobilization or democracy in any formal ideological sense, but because it has had other agendas that all too often seemed to conflict with a decentralized and democratic structure. Efforts to democratize and transform the union controlled and led by rank and file members have been largely absent.

Honoring Dr. King

These are remarks delivered by our COO, Eric Buehrens, this past week at our annual Martin Luther King, Jr. memorial celebration:

It’s a pleasure to be here and to see this community come together in reverence for the memory of Dr. King, his work and legacy.

I hate talking about race in platitudes. It’s perhaps the most difficult, volatile and emotional topic in American social discourse, and so of course we do what we often do when faced with difficult and controversial topics, which is to either not talk about it at all, change the topic, or talk in platitudes.

I’m old enough to remember when Boston was a very different city and when a person of color risked life and limb if they walked on the wrong side of Dorchester Avenue, or got off at the wrong T stop, or as happened to Ted Landsmark, just happened to be walking across City Hall Plaza at the wrong time.

I’m also old enough to remember the heyday of the civil rights movement, the struggles and successes, and the murders of black and white civil rights activists, and then of course the assassination of Dr. King himself.

It would be easy to reflect on those days and then on the man who took office as President of the United States a year ago and deliver a homily on “see how much progress we have made”. And of course we have made progress. As maddening and backward as this great country can be in many, many ways, we change. Too slowly, and often at high cost, but we find a way to have the difficult conversations and we change.

But just last night in this hospital, we had an incident where a group of employees were sitting around at shift change in the locker room, and in the course of chatting and bantering, a white employee made a highly, highly offensive remark to an African American co-worker. Maybe innocently, maybe not with racist intent, but a stupid and thoughtless insult nonetheless.

I was pretty gratified to learn that the supervisor, an old white guy like me, heard about it at home and got in his car and drove in to talk to the employee who was offended as well as the one who made the remark. This supervisor had the presence of mind to know that this was important, and to understand that the only way we change and grow as a community and as a society is to face our history and the legacy of racial division with honesty and a commitment to change. That is this hospital’s commitment to our community and to every one of our employees.

Saying sorry

Natasha Singer writes this interesting article about apology in the health care world in today's New York Times. I'm quoted briefly at the end. Would love your comments.

Transparency? Not here, please.

Our friends at The Health Care Blog have posted a letter from the founder of C-SPAN to Speaker Pelosi asking for televised proceedings of the health care bill conference committee. This has generated lots of comments.

I think this is a bad idea. Maybe this will surprise those of you who know me for pushing transparency. But the world of negotiation requires some privacy.

The C-SPAN fellow confuses transparency of result with transparency of process. Sometimes, the process needs to be held in confidence to build the kind of trust you need to reach an agreement.

Negotiations like this need to be held in private for effective compromises to be reached. For example, part of a negotiation is for each party to discuss how they are going to help the other party persuade his/her colleagues to go along with the negotiated agreement. You can't really talk about such things in public.

If this set of meetings is broadcast, the real negotiations will take place in a quiet room somewhere else on Capitol Hill.

Breast cancer meme on Facebook

I was wandering through my Facebook friends and started to see status bars with colors -- "black", "white," "red." I had no idea what it was about so I posted a query on Twitter and within 20 minutes had tons of replies. A sample: "Women are naming the color of their bras to heighten awareness of breast cancer. Interesting idea.."

Well, it turns out to be somewhat controversial. Here are two articles with lots of comments pro and con. Feel free to post your opinions here or there.

Lean Resolutions

Pat Wardwell, COO of the Greater Boston Manufacturing Partnership suggests ten New Year's resolutions for Lean leaders. The summary:

1. Set aside time each week to actively and openly nurture the Lean journey in your organization;
2. Get out of your office and walk the value stream at least once per week;
3. Resolve to use your eyes and ears more than your vocal chords when on the shop floor;
4. Ask 5 different people who work for you "what can be improved" at least once a week;
5. Participate in an improvement project team meeting, training session or kaizen event at least once per month;
6. Ask to be shown an implemented improvement idea from all areas reporting to you at least once per month;
7. Read at least one new Lean article or book a month;
8. Attend a conference, plant tour or participate in a webinar or podcast on Lean topics once per quarter;
9. Vow to visit at least one external customer or supplier each quarter;
10. Develop your own "Manager's Standardized Work."

Ten top celebrity health stories

I have written before about a site called Celebrity Diagnosis. Devoted to "teachable moments in medicine," it is well written and informative. Dr. Mark Boguski, in our Department of Pathology, is one of the founders and writers. Here's their list of the 10 most important stories from 2009.

J. Smith auction closes tonight

The online auction to benefit the Joseph Smith Community Health Center closes at 8pm tonight. Get your bids in!

Having trouble reading this? Bid on an eye exam and glasses!

Wanna hamburger with your Celtics tickets? Check this!

How about a hot air balloon adventure?

Maybe you are just hungry.

Or, get ready for the Red Sox spring training with this accessory.

Bean Counters -- Part 1

I guess it is time to start a new series, on bean counters. I am fully aware of the need for fiscal responsibility on the part of health care providers and insurance companies, so please don't take what comes as an invitation for profligate spending. But there are times when, in the name of saving money, places lose their moral compass and engage in behavior that is cruel to patients and families and is often wasteful, to boot.

Here's one, with names left off. A long-term patient was sent to us from a rehab hospital belonging to another health care system. After an appropriate stay in our ICU, we sought to send this ventilator-dependent patient back to the facility from which s/he had come. The facility refused, saying that they would not accept the patient because s/he had used up the annual Medicare allotment for in-patient stays. When we inquired further, we learned that they were trying to put pressure on the family to come up with a cash payment to offset this reduction in government payments.

Eventually, we were able to shame the rehab hospital into taking back this patient, but we were required to board the patient in our ICU for an extra six days.

Mastering the Senate

As a student of politics and government, I love the US Senate. Really. Sure it can be incredibly frustrating, but to watch it in action is fascinating. The best description I have found is in Robert Caro's biography of Lyndon Johnson, Master of the Senate. The tradition of unlimited debate and the associated two-thirds vote requirement for cloture gives each senator a chance to include something for his or her favorite constituency, until the magic number of votes is reached.

For a small picture of how it works, check out this article by Robert Pear in the January 3 New York Times about the health care bill. A summary:

Republicans complained of “sweetheart deals,” payoffs and kickbacks. But the Senate majority leader, Harry Reid, Democrat of Nevada, brushed aside the criticism.

“There’s a hundred senators here, and I don’t know if there is a senator that doesn’t have something in this bill that was important to them,” Mr. Reid said. “If they don’t have something in it important to them, then it doesn’t speak well of them. That’s what this legislation is all about. It’s the art of compromise.”

Here's what it has for Nebraska, and here's the new Lousiana Purchase. And here's a more general description. Mr. Reid probably overstates things when he says that all 100 senators have something in the bill. I think it is more like 60.

Snow angels in the outfield

Several of our folks provided first aid services at Fenway Park on New Year's Day for the NHL's Winter Classic hockey match between the Boston Bruins and Philadelphia Flyers. You see them here on the right.

After the game, when medical responsibilities were over, a game of "Truth or Dare" ensued, and Dan and Cyndi ended up making snow angels in center field.

The next day, at the Bruins Legends Classic charity game, BIDMC staff members again showed up at the park, this time to donate their services for the benefit of the Boston Bruins Foundation, Red Sox Foundation and Hockey Fights Cancer.

A new team assembles

This is the first week for staff members from Atrius Health and BIDMC to work side by side in taking care of patients on our medical/surgical floors. Key players in this collaboration are the case managers who help patients and families with transition of care issues and other matters.

Seen here are Marianne Lille, BIDMC RN; Sue Farrell and Karen MacDonald, case managers from Harvard Vanguard Medical Associates; and Ellen Miller, BIDMC case manager.

Meanwhile, the information systems folks from BIDMC and Atrius have done a marvelous job in integrating our electronic medical records systems. Read more about that here on John Halamka's blog.

$340 million = Old School

This article by Haya El Nasser in yesterday's USA Today presents a remarkable view of the old way of marketing and publicity. The Bureau of the Census is going to spend $340 million on a promotional blitz to "promote the benefits of responding to the 10-question Census."

Beyond a 46-foot trailer and 12 13-foot trailers traveling 150,000 miles, $140 million will be spent on TV, radio, print, and outdoor advertising; and there is another $80 million on ads for racial, ethnic, and non-English speakers in 28 languages.

Promoting the census is very important. After all, it is the basis for representation in Congress and other governmental functions. We certainly want full participation.

But this is so old school.

There is not a single mention in this story about using social media for this purpose. So I looked further. I found this e-newsletter for Census partners and also this toolkit, one of several available to organizations that might want to promote the Census. Each toolkit has common elements, like letters, announcements, brochures, calendars, posters, certificates.

Still pretty old school.

Contrast this with the power of the networked intelligence approach discussed below in two posts. Imagine if the Census Bureau engaged in this kind of crowdsourcing to invent ways to reach out to lots of difference segments of the population. And used the reach of Facebook and Twitter and other sites to carry the message. For a lot less money.

The Obama administration virtually invented social-media-based campaigning during the last election. The company that did a lot of that work has since branched out into lots of other exposure and advocacy functions. Maybe they would offer pro bono service to the government to help get people counted. Or even if they charged for it, I bet they could do it for a lot less than $340 million.

“Somebody screwed up big time.’’

The blame game is ubiquitous in Washington, DC. This quote and others floating around exemplify exactly the wrong approach to improving our country's anti-terrorist system.

Let's think through the problem. Tens of thousands of patriotic Americans work in federal agencies trying to protect our shores. They face a threat of unknown dimensions, involving ten of thousands of possible bad guys who want to hurt us.

Statistically, even if our system worked very, very well, one or two terrorists could slip through and do something dastardly. However, we have to admit that the system may not work so well.

When I go through airport security, I am prompted to mix historical metaphors. Our TSA Red Coats employ a Maginot Line against a group of guerrilla fighters who change venues, clothing, and weapons to penetrate our static defense system.

When they break through, we bolt on a new technical solution. Will full body scanners make a difference? Yes, they can see the outlines of people's bodies, but they cannot see what might have been put in body orifices or what is hidden by flaps of fat, or what might have been swallowed. Do we think that a terrorist will worry about being being physically uncomfortable for a few hours as s/he heads to a suicide mission?

I admit that such systems have some deterrent effect, but they can be bypassed. And usually with low-tech approaches.

The problem facing our security services is how to encourage and enable all their loyal employees to act in a cooperative and creative fashion. Fast moving targets like terrorists change their stripes often, but they will leave traces -- digital traces, physical traces, relationship traces (think of that Nigerian father). Our security folks need to feel the freedom to follow those traces and to report them within and among the national agencies. They need a culture that thanks them for following gut instincts and calling out problems and near misses.

I admittedly don't know much about the culture of these agencies, but I can guess that a predominant motivation is CYA. I say this because I know how large organizations work, and it is the very unusual one that rewards people for calling out problems. We see the opposite in hospitals, financial services, and manufacturing. And we see it big time in the government, where the body politic, with quotes like the one above, tends to encourage that kind of motivation.

I have spent a lot of time in these blog pages exploring how to achieve continuous process improvement in a complex organization. I gave the example of Tom Botts at Royal Dutch Shell, who realized that the fault behind two fatalities lay with the leaders of the company, not with the workers who strayed to the wrong part of an oil rig. I summarized, too, the approach of John Toussaint and others in the hospital arena and Paul O'Neill at Alcoa, and forwarded advice from Steven Spear.

Contrast those lessons with what you are hearing in Washington, DC.

I'd like to see Mr. Obama help the agencies get past the blame game that is going on right now and focus on organizational, along with technological, strategies that enhance their ability to ameliorate terrorist threats. He clearly has the leadership ability to do that.

But here's the rub, and it is both a political one and a personal one. The political one is this. He has to persuade our citizens that he is strong-willed enough and competent enough to fight the terrorism that heads our way, but he would also need to persuasively reframe the manner in which he intends to carry this out.

The personal one is this. Our President has never run a complex organization. Does he know how to do it? Does he have advisors who do? I hope so, or we will just see a replay of this blog's headline sometime in a year or two.

Online auction for J. Smith Community Health Center

There's a new online auction to benefit the Joseph M. Smith Community Health Center.

JMSCHC provides high-quality, comprehensive, culturally-competent and affordable primary health care and selected specialty services to families and individuals in Allston, Brighton, Waltham and surrounding communities. All are welcome – children and adults, the insured and uninsured, the employed and unemployed, long- and short-term residents and recently arrived immigrants.

Bids will be accepted until 8pm on January 7. As always, there are great items for yourself or for gifts. Here is a sampling:

Eye exam and glasses from the Joseph Smith Center.
Celtic tickets, along with a Fuddruckers gift certificate (Jan 18).
A trip for two to Washington, DC.
Custom made box by a woodworking instructor from the Eliot School.
A hot air balloon ride for two (almost anywhere in the country!)
Membership at the Equinox Fitness Club.
Caviar.
One dozen brownies from Emily's Brownies.
Private cooking instruction from TaylorMade Meals.
Red Sox memorabilia.
Overnight stay at the Courtyard by Marriott in Cambridge, MA.
Concert tickets for Luciana Souza Trio (Jan 22) and Carolina Chocolate Drops (Jan 23).
Tours of the MSPCA and WGBH.
An interior design consult from Brenda Be.

Please bid often and pass this along to your friends.

Medical wisdom

A note from a friend:

I asked my doctor today, during my annual physical, if I look fat.

His response: "I’ve been married a very long time, and you’ve got another think coming if you think I’m going to tell any woman she looks fat. That includes you."

Auction sneak preview

A new online auction begins tomorrow to benefit the Joseph M. Smith Community Health Center. The auction will run from January 1 to January 7. You can sneak a preview here, but you can't bid until 6am on New Year's Day.

Engage with Grace hits the Top 10

Health Leaders Media lists Engage with Grace as one of 10 phrases that became part of the health care lexicon in 2009. I'm sure our blog rally propelled it up there. It is a lot more useful than most of the other expressions, I say.