Kathryn Schulz, author of Being Wrong, Adventures in the Margin of Error, sent along this link to a recent Slate interview with James Bagian, director of the VA's National Center for Patient Safety. Bagian, a former astronaut, had some great observations about improving quality and safety in the health care environment. Some excerpts that I like:
You can't change the culture by saying, ‘Let's change the culture.' It's not like we're telling people, "Oh, think in a systems way." That doesn't mean anything to them. You change the culture by giving people new tools that actually work. The old culture has tools, too, but they're foolish: "Be more careful," "Be more diligent," "Do a double-check," "Read all the medical literature." Those kinds of tools don't really work.
---
One thing we do that's unusual is we look at close calls. In the beginning, nobody did that in healthcare. Even today probably less than 10 percent of hospital facilities require that close calls be reported, and an even smaller percentage do root cause analyses on them. At the VA, 50 percent of all the root cause analyses we do are on close calls. We think that's hugely important. So does aviation. So does engineering. So does nuclear power. But you talk to most people in healthcare, they'll say, "Why bother? Nothing really happened. What's the big deal?"
---
In theory, punishment sounds like a good idea, but in practice, it's a terrible one. All it does is create a system where it's not in people's interest to report a problem.
Wednesday, June 30, 2010
Good motives and unintended consequences
Facts matter. Here is an example.
Based on comments by some, you would have thought that individual and small business insurance rates have gone up because of payments to hospitals and doctors or because insurers were somehow trying to take advantage of this group. It turns out that a well-intended provision in the Massachusetts universal access law created a moral hazard, a "situation in which one person makes the decision about how much risk to take, while someone else bears the cost if things go badly."
Kay Lazar reports in today's Boston Globe:
The number of people who appear to be gaming the state’s health insurance system by purchasing coverage only when they are sick quadrupled from 2006 to 2008, according to a long-awaited report released yesterday from the Massachusetts Division of Insurance.
The result is that insured residents of Massachusetts wind up paying more for health care, according to the report.
... [T]he gaming in the system . . . is adding as much as $300 million dollars to the health care system in Massachusetts’’ each year, said Tara Murray, spokeswoman for Blue Cross Blue Shield of Massachusetts, the state’s largest insurer.
Based on comments by some, you would have thought that individual and small business insurance rates have gone up because of payments to hospitals and doctors or because insurers were somehow trying to take advantage of this group. It turns out that a well-intended provision in the Massachusetts universal access law created a moral hazard, a "situation in which one person makes the decision about how much risk to take, while someone else bears the cost if things go badly."
Kay Lazar reports in today's Boston Globe:
The number of people who appear to be gaming the state’s health insurance system by purchasing coverage only when they are sick quadrupled from 2006 to 2008, according to a long-awaited report released yesterday from the Massachusetts Division of Insurance.
The result is that insured residents of Massachusetts wind up paying more for health care, according to the report.
... [T]he gaming in the system . . . is adding as much as $300 million dollars to the health care system in Massachusetts’’ each year, said Tara Murray, spokeswoman for Blue Cross Blue Shield of Massachusetts, the state’s largest insurer.
...When state lawmakers overhauled the health care system in 2006, they combined into a single insurance pool consumers who buy coverage on their own with those who get insurance through their jobs at small businesses that employ 50 or fewer people. The aim was to make insurance more affordable for the individuals buying coverage on their own, who tended to be sicker and therefore had been paying very high premiums. And the hope was that having small businesses and their workers absorb some of the cost of covering this group would raise their premiums only modestly.
Is this the classified ad section?
I received this email on Sunday night. Perhaps it is just me, but it feels weird to get a solicitation like this, as though this were just a house or condominium building for sale. Note the postscript, too. Are hospitals now commodities?
80 Bed Hospital in a Southeast, Certificate of Need State For Sale
Dear Paul,
[Company name} has been retained to identify a buyer for an 80 bed, accredited, regional hospital in the Southeastern portion of the United States. The hospital is located within a community that is less than fifty miles from a major business hub with a population of over one million people.
Revenues are in the $20 million range and the business is profitable. The asking price is to be determined by using the lesser of the traditional formula of 100% of the trailing twelve months of revenues or simply $250,000 per bed.
The sellers are asking only qualified buyers to first submit their request for more information, after which they will be considered to privately participate in the owners' agenda to divest its facility and excess land. As this is not an auction, the sellers will convey title for the hospital and land to the first buyer who is able to close the transaction. Prior to the conclusion of the acquisition, they will preserve total discretion as to the confidential nature of the transaction.
Your request to be considered will be delivered to the Managing General Partners for their approval once you have signed a Non-Disclosure Agreement. Thereafter, a package will be available for immediate review with the intent to schedule a Conference call with one of the principals. We welcome all inquiries.
Sincerely,
[name omitted]
Dear Paul,
[Company name} has been retained to identify a buyer for an 80 bed, accredited, regional hospital in the Southeastern portion of the United States. The hospital is located within a community that is less than fifty miles from a major business hub with a population of over one million people.
Revenues are in the $20 million range and the business is profitable. The asking price is to be determined by using the lesser of the traditional formula of 100% of the trailing twelve months of revenues or simply $250,000 per bed.
The sellers are asking only qualified buyers to first submit their request for more information, after which they will be considered to privately participate in the owners' agenda to divest its facility and excess land. As this is not an auction, the sellers will convey title for the hospital and land to the first buyer who is able to close the transaction. Prior to the conclusion of the acquisition, they will preserve total discretion as to the confidential nature of the transaction.
Your request to be considered will be delivered to the Managing General Partners for their approval once you have signed a Non-Disclosure Agreement. Thereafter, a package will be available for immediate review with the intent to schedule a Conference call with one of the principals. We welcome all inquiries.
Sincerely,
[name omitted]
Sr. Vice President
[company name]
PS: Are you curious about what hospitals are worth in today's market?
Call me at [number]
Tuesday, June 29, 2010
Social media gaggle
Johnson and Johnson's Marc Monseau convened a group of health care social media addicts last night for a pleasant evening of dinner and conversation. Seen here are Chris Iafolla from Shift Communications, Laurie Edwards, Marc, Jack Barrette from WEGO Health, Shwen Gwee from Vertex Pharmaceuticals, yours truly, e-Patient Dave deBronkart, and Alicia Staley.How weird to be in the physical presence of people!
As has been the case since I first started down this social media path, I learned more than I offered. The big topic was patient empowerment and creating true partnerships between patients and caregivers.
There was also some tech talk. For example, I never realized that the algorithms used by Google and other search engines actually make it hard for a person with an unusual physical problem or disease to find useful information. Since they are at the "tale end" of their disease, and since the search engines reward those sites that get the most traffic, a normal web search will often not pick up useful information for those patients. Thus, user groups -- self-created agglomerations of data-sharing colleagues from around the world -- can often provide people with advice that would otherwise be unknown. Patients can then take that information to their physicians and explore options. Powerful stuff!
But let me stop there and invite last night's participants to add their own comments, perhaps presenting something they learned last night or whatever perspective they would like.
Monday, June 28, 2010
In memoriam: Polly Arango
Polly Arango, a nationally known advocate for children, died on Saturday, June 26. In total, I only spent a few minutes with Polly at last year's IHI Annual Forum (picture here), but she made an immediate and wonderful impression.
After the conference, I was curious. Who was this person? It was then that I learned of her extensive accomplishments and her fine reputation. These are summarized in this obituary in the Albuquerque Journal. Among other things, she founded Family Voices, which aims to achieve family-centered care for all children and youth with special health care needs and/or disabilities.
Learning of her untimely death in a freak one-car accident in Alamosa, Colorado, I felt a blow-to-the-midsection loss. Others shared that view.
One of these people is Dale Ann Micalizzi, whom I have come to know via social media and in person. Her blog, here, describes her work in memory of her son, Justin, to improve medical quality and safety. Dale and Polly also connected right away at the IHI Forum, and Dale gave Polly a small pin in commemoration of that friendship. With Dale's permission, here is the text of Polly's thank-you note and the final poignant words in her own writing:
Dear Dale,
Thank you for the beautiful pin. I love angels and hearts. My brother Nick who died of a brain tumor in 2001 once gave me a beautiful angel pin to honor my work with Family Voices, an organization he loved. And the Family Voices logo is a heart -- so your pin is perfect. Thank you!
I thank you also for inviting me into your world of tragedy and compassion. Your work in safety and transparency, built upon your loss of Justin, is just incredibly inspiring -- to me and the audiences you touch, as you did in Orlando at the IHI forum. You've said such presentations are still hard for you -- even more reason for me to respect and honor you.
After the conference, I was curious. Who was this person? It was then that I learned of her extensive accomplishments and her fine reputation. These are summarized in this obituary in the Albuquerque Journal. Among other things, she founded Family Voices, which aims to achieve family-centered care for all children and youth with special health care needs and/or disabilities.
Learning of her untimely death in a freak one-car accident in Alamosa, Colorado, I felt a blow-to-the-midsection loss. Others shared that view.
One of these people is Dale Ann Micalizzi, whom I have come to know via social media and in person. Her blog, here, describes her work in memory of her son, Justin, to improve medical quality and safety. Dale and Polly also connected right away at the IHI Forum, and Dale gave Polly a small pin in commemoration of that friendship. With Dale's permission, here is the text of Polly's thank-you note and the final poignant words in her own writing:
Dear Dale,
Thank you for the beautiful pin. I love angels and hearts. My brother Nick who died of a brain tumor in 2001 once gave me a beautiful angel pin to honor my work with Family Voices, an organization he loved. And the Family Voices logo is a heart -- so your pin is perfect. Thank you!
I thank you also for inviting me into your world of tragedy and compassion. Your work in safety and transparency, built upon your loss of Justin, is just incredibly inspiring -- to me and the audiences you touch, as you did in Orlando at the IHI forum. You've said such presentations are still hard for you -- even more reason for me to respect and honor you.
Sunday, June 27, 2010
Contradictions in Massachusetts
I have written before about the strange things going on in the Massachusetts health care insurance market. For those from out of state, here are some quotes that will give you a sense of the contradictions in the public policy arena.
They are, respectively, from two stories that appeared on the same day in the Boston Globe: "Rate cap for insurer overturned" and "Officials give up cutting health perks."
(1) An insurance appeals board yesterday overturned the state’s cap on health premium increases for small business and individual customers covered by Harvard Pilgrim Health Care . . . [finding] that rate increases Harvard Pilgrim initially sought in April are reasonable given what it must pay to hospitals and doctors. That ruling trumped the Insurance Division’s earlier finding that the requested increases were excessive.
(2) The state’s public employee unions won a major victory this week when the Legislature abandoned efforts to allow cities and towns to trim generous health care benefits enjoyed by thousands of municipal employees, retirees, and elected officials.
You can read the rest and related stories, but what is most disturbing is that the spirit of cooperation and compromise that existed when Massachusetts approved its health care reform law in 2006 has broken down. Part of the reason is that commitments made at that time have not be delivered upon. For example, the state had promised to lift Medicaid payment rates to something closer to the cost of delivering that service. Once the economy sank and state budgets were stressed, that was not possible. This left providers needing to collect more of their income from private insurers.
Meanwhile, the underlying determinants of health care cost increases continued apace -- wages and salaries of health care workers, supplies and equipment, drug prices, increased utilization, the medical arms race, and unhealthy life styles. Certain providers received disproportionate payment increases based on their market power and used those excess revenues to gain market share. Collectively, the industry did little to reduce harm and improve quality and garner the cost savings that would be possible from that. Access to primary care did not improve, forcing patients to go to emergency rooms. Those primary care practices that do exist often functioned as triage way stations for patients to go see higher priced specialists. For those who thought payment reform (i.e., capitation) was the answer, little progress was made, in part because insurers have yet to see a market for the restricted networks (i.e., reduced consumer choice) that would facilitate that kind of pricing regime.
So, now we are in a situation in which everyone is blaming everyone for the problem. Truthfully, everyone is the problem, and so this is an accurate representation, but it is not a helpful approach. Deadlock is the result.
At times like this, people often look for a global solution to sort things out. That is a mistake. There is not a politically possible global solution. There are too many legitimate vested interests to pass a bill or adopt a regulation that shifts hundreds of millions of dollars of costs from one group to another. As seen in the two stories above, it will either be legally unacceptable or politically infeasible.
Instead, it is a time for incremental changes that are directionally appropriate. There are things that can garner majority support that will move the system towards a more sustainable level.
But to agree on those, the rhetoric needs to be toned down, both within the field and from the government. The demonization of any particular sector destroys the kind of trust that enables people of good will to invent solutions that create value for all.
They are, respectively, from two stories that appeared on the same day in the Boston Globe: "Rate cap for insurer overturned" and "Officials give up cutting health perks."
(1) An insurance appeals board yesterday overturned the state’s cap on health premium increases for small business and individual customers covered by Harvard Pilgrim Health Care . . . [finding] that rate increases Harvard Pilgrim initially sought in April are reasonable given what it must pay to hospitals and doctors. That ruling trumped the Insurance Division’s earlier finding that the requested increases were excessive.
(2) The state’s public employee unions won a major victory this week when the Legislature abandoned efforts to allow cities and towns to trim generous health care benefits enjoyed by thousands of municipal employees, retirees, and elected officials.
You can read the rest and related stories, but what is most disturbing is that the spirit of cooperation and compromise that existed when Massachusetts approved its health care reform law in 2006 has broken down. Part of the reason is that commitments made at that time have not be delivered upon. For example, the state had promised to lift Medicaid payment rates to something closer to the cost of delivering that service. Once the economy sank and state budgets were stressed, that was not possible. This left providers needing to collect more of their income from private insurers.
Meanwhile, the underlying determinants of health care cost increases continued apace -- wages and salaries of health care workers, supplies and equipment, drug prices, increased utilization, the medical arms race, and unhealthy life styles. Certain providers received disproportionate payment increases based on their market power and used those excess revenues to gain market share. Collectively, the industry did little to reduce harm and improve quality and garner the cost savings that would be possible from that. Access to primary care did not improve, forcing patients to go to emergency rooms. Those primary care practices that do exist often functioned as triage way stations for patients to go see higher priced specialists. For those who thought payment reform (i.e., capitation) was the answer, little progress was made, in part because insurers have yet to see a market for the restricted networks (i.e., reduced consumer choice) that would facilitate that kind of pricing regime.
So, now we are in a situation in which everyone is blaming everyone for the problem. Truthfully, everyone is the problem, and so this is an accurate representation, but it is not a helpful approach. Deadlock is the result.
At times like this, people often look for a global solution to sort things out. That is a mistake. There is not a politically possible global solution. There are too many legitimate vested interests to pass a bill or adopt a regulation that shifts hundreds of millions of dollars of costs from one group to another. As seen in the two stories above, it will either be legally unacceptable or politically infeasible.
Instead, it is a time for incremental changes that are directionally appropriate. There are things that can garner majority support that will move the system towards a more sustainable level.
But to agree on those, the rhetoric needs to be toned down, both within the field and from the government. The demonization of any particular sector destroys the kind of trust that enables people of good will to invent solutions that create value for all.
Tour de Shuls
I just finished riding in the Tour de Shuls, a cleverly named bike ride that benefits a special program to meet the social and religious needs of developmentally challenged Jewish adolescents who attend Camp Ramah. As noted on the web site:The Tikvah ("hope") Program provides these youth with the full Ramah experience - swimming, boating, sports, the arts, dance, dramatics, and more - under the supervision of specially trained staff.
The ride comprises several legs connecting synagogues in the Boston suburbs. It goes through some beautiful areas, and you receive friendly welcomes and refreshments at each host site. The only reported problem -- and I don't mean this in any stereotypical way! -- is that some people complain there is too much food and that they therefore gain weight from their 10-, 25-, 50-, or 75-mile ride . . .
Donations are still welcome, here.
Saturday, June 26, 2010
Vuvuzelas app
After writing the post below, I learned about the free vuvezela app for your IPhone or IPad when a friend demonstrated it. Imagine, you can make that noise anywhere now. I have some ideas....
First, though, make sure you pick your team's color.
If you cannot see the video, click here.
First, though, make sure you pick your team's color.
If you cannot see the video, click here.
Friday, June 25, 2010
About vuvuzelas, and balls that work strangely
The Washington Post recently published this article by Anne Applebaum about vuvuzelas, the loud horns that you hear in the World Cup matches.
For those who haven't been following, the vuvuzela is a longish plastic trumpet that produces a buzzing noise, something like an overgrown penny whistle. When thousands of people blow these whistles at once, they make a very loud buzzing noise, something like a massive swarm of bees. When played in a World Cup soccer stadium, they create an irritating background hum -- one that is capable of ruining the sound on a billion television sets around the world.
She then talks about the different reactions to these horns by folks from around the world. I did my own survey of fellow soccer players and parents of the girls I coach. Typical responses:
I hate that noise. It must go. It's enough to embrace curling as a favorite sport.
I am enjoying watching the games at home with the sound turned off.
Meanwhile, there is this article by Devin Powell at Inside Science that suggests that the ball (the Jabulani) being used in the World Cup doesn't behave right, especially at low speeds when it is not spinning. It appears that there is an unexpected knuckle ball effect.
[Tests showed] that as the ball slows, its behavior becomes more like that of a smooth sphere than previous World Cup balls. At just under 45 mph, turbulent flow becomes laminar and the ball suddenly feels heavy drag forces that put on the brakes.
[Also, the] sideways force on the Jabulani fluctuates more than the forces on the 2006 World Cup ball, which could cause it to bend in unpredictable ways and help to explain the reactions from goalkeepers.
But, before you think that those guys from France have an excuse, look at this final point:
Considering all of the other variables involved in the World Cup -- from pitches at high altitudes to inconsistent player performances -- it's unclear whether these differences in the ball in this are extreme enough to affect the final scores.
For those who haven't been following, the vuvuzela is a longish plastic trumpet that produces a buzzing noise, something like an overgrown penny whistle. When thousands of people blow these whistles at once, they make a very loud buzzing noise, something like a massive swarm of bees. When played in a World Cup soccer stadium, they create an irritating background hum -- one that is capable of ruining the sound on a billion television sets around the world.
She then talks about the different reactions to these horns by folks from around the world. I did my own survey of fellow soccer players and parents of the girls I coach. Typical responses:
I hate that noise. It must go. It's enough to embrace curling as a favorite sport.
I am enjoying watching the games at home with the sound turned off.
Meanwhile, there is this article by Devin Powell at Inside Science that suggests that the ball (the Jabulani) being used in the World Cup doesn't behave right, especially at low speeds when it is not spinning. It appears that there is an unexpected knuckle ball effect.
[Tests showed] that as the ball slows, its behavior becomes more like that of a smooth sphere than previous World Cup balls. At just under 45 mph, turbulent flow becomes laminar and the ball suddenly feels heavy drag forces that put on the brakes.
[Also, the] sideways force on the Jabulani fluctuates more than the forces on the 2006 World Cup ball, which could cause it to bend in unpredictable ways and help to explain the reactions from goalkeepers.
But, before you think that those guys from France have an excuse, look at this final point:
Considering all of the other variables involved in the World Cup -- from pitches at high altitudes to inconsistent player performances -- it's unclear whether these differences in the ball in this are extreme enough to affect the final scores.
Thursday, June 24, 2010
The primary care experience in MA
Massachusetts Health Quality Partners presents a recent survey of patient experiences with primary care. There are both positive and negative findings, compared with a survey conducted before the implementation of universal health care access in the state.
About 78,000 commercially insured patients responded to the statewide survey. There was reported overall improvement in several dimensions of the doctor-patient relationship, such as communication and knowledge of their patients, but there are aspects of doctor-patient communications that need work. A summary:
There is broad agreement that there are important dimensions of care that patients and their families should expect to receive from their primary care practice. Key findings in MHQP's latest patient experience survey highlight where there continues to be room for improvement in these aspects of care, including:
Knowledge of the patient: When asked if their primary care physician seemed to know their medical history and to know them as a person, both adults and the parents of pediatric patients reported improvements compared with 2007; but 30 percent of adult patients and 25 percent of parents say their primary care physicians do not always know important medical history information.
Informed of test results: The survey found that about 30 percent of adult and pediatric patients did not always receive follow-up reports on test results from their doctor's office, unchanged from 2007.
Coordination between primary care doctors and specialists: About 40 percent of adult patients and 35 percent of parents of pediatric patients reported that their physician did not always seem well-informed about the care they received from specialists to whom they had been referred. Pediatric results were slightly better than two years ago, while adult ratings were unchanged.
About 78,000 commercially insured patients responded to the statewide survey. There was reported overall improvement in several dimensions of the doctor-patient relationship, such as communication and knowledge of their patients, but there are aspects of doctor-patient communications that need work. A summary:
There is broad agreement that there are important dimensions of care that patients and their families should expect to receive from their primary care practice. Key findings in MHQP's latest patient experience survey highlight where there continues to be room for improvement in these aspects of care, including:
Knowledge of the patient: When asked if their primary care physician seemed to know their medical history and to know them as a person, both adults and the parents of pediatric patients reported improvements compared with 2007; but 30 percent of adult patients and 25 percent of parents say their primary care physicians do not always know important medical history information.
Informed of test results: The survey found that about 30 percent of adult and pediatric patients did not always receive follow-up reports on test results from their doctor's office, unchanged from 2007.
Coordination between primary care doctors and specialists: About 40 percent of adult patients and 35 percent of parents of pediatric patients reported that their physician did not always seem well-informed about the care they received from specialists to whom they had been referred. Pediatric results were slightly better than two years ago, while adult ratings were unchanged.
Wednesday, June 23, 2010
Pride and Ownership
Seen above are members of our environmental service (EVS) group. Left to right are Jean Simeon, Operating Room Lead Housekeeper (22 years at BIDMC), Christopher Valentine (5 Years), Pedro Hernandez (25 years), and Hugo Barros (2 Years). I received the following report from John Dzialo, project director in Perioperative Services, which includes the Central Processing Division. CPD is the group of people who clean surgical instruments.Over the last 2 weeks we have been installing a new washer and decontamination unit in the West OR/CPD. The installation required some renovations to the existing space, including replacing a portion of the existing flooring. All in all the required renovations came out as planned. In looking at the ceiling tiles, many were discolored from years of exposure to the elements created within the room. It was thought best to replace them at this time. The existing walls also showed the same discoloration, which we felt took away from the overall appearance of the newly renovated area.
At one point two of the 3-11 shift EVS employees who are assigned to the OR came into the area to check up on our progress. They looked at the older section of flooring that in certain areas had become stained. They assessed the stained flooring and reassured me that they could get it cleaned to match the newer flooring. I asked them if they thought they could do something with the walls as well which they once again replied that they would make them look new.
When I returned the next day to do my assessment of how the installation was going, I immediately observed the "stain free" floor and the beautifully cleaned walls and cabinets. Later in the day, at the change of shift I met up with the EVS staff to thank them for a job well done. When we were looking at their work, we talked about the ceiling tiles and how much cleaner the new ones make the area look. When we decided to change all the ceiling tiles we did not take into consideration to replace the supporting grids. When EVS staff noticed how much the discoloration of the grids took away from the new ceiling tiles, they took it upon themselves to hand clean all of the grids (not a quick and easy task to complete).
The "Pride and Ownership" exhibited by the 3-11 OR EVS staff was over whelming . They certainly could have limited their work to the few areas that we identified as needing attention. They took it upon themselves to not only complete the additional work requested but to broaden the overall scope to what they felt should also be done.
What we see often is the end results of a new piece of equipment being installed. What often does not get recognized is the pride and commitment of others that played a significant supporting role in the completion of a project. The pride and commitment exhibited by the EVS staff in their supportive role in the completion of this project is a value that can only be described as "Priceless".
Pretty data. Useful?
This is an interesting portrayal, provided by GE, of hospital quality metrics. It compiles data from the Joint Commission's 2009 Annual Report on Quality and Safety and presents it in a visually attractive manner that permits a qualitative comparison among hospitals in each state. I provide a partial view above.So, this is pretty, but is it useful? I don't think so. As I have said before:
There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-Ã -vis other hospitals in the same city or region. Both these impressions are misguided.
Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.
So, I think a better presentation would be one in which I could compare my own hospital's data year by year using the same kind of side-by-side visual imagery. Then, we could get a quick view of how we have progressed over time -- in essence, competing against ourselves, rather than against our colleagues in the state.
Tuesday, June 22, 2010
Why I love BIDMC
This is why I love my hospital. Everyone feels the right to complain and to suggest. And generally, the complaints and suggestions are received nondefensively, evaluated, and acted upon. Here's an example.
First, Research Administrator Diane writes to Carol, who runs the food service in the staff/visitor cafeteria, and she also copies me on the email.
Hi Carol,
I went to the Ullian Café today after my workout to get some lunch. I usually avoid the grill section due to the unhealthy choices that it has to offer, but today I saw folks with what appeared to be a simple burger made with a tortilla, so I checked it out.
I saw that this special came as a duo, i.e., 2 tortilla’s for the $4.75 price. Both parties before me asked if they could get only one, and were told no.
I bought the special and then came back to my desk to check out the nutrition info.
If this is correct, from the website, I just had 1480 calories in just the “special”. I also would have preferred to have gotten only one.
What really got my attention though was the fat %. In just one meal, a lunch, I consumed 210% of my daily fat allowance!
For a health institution, I find that absurd! Isn’t there some other way to get good tasting healthy food from our café?
Why can’t people by only 1? Why wasn’t this info posted on the sign for the special? And if you can’t buy one then you should show the real numbers for the total meal.
Normally, I don’t get upset about some of the choices you offer as I can tell visually that they are high fat, calories or sodium, but this item had me fooled and I’m sure it has fooled others.
Dianne
I write back to Carol, with a copy to Terry Maratos-Flier, a faculty member with a strong interest in obesity:
Good points, Diane. Carol, what do you think?
Paul
Carol responds:
Good Morning Diane,
Thank you for your feedback! The Quesadilla Burger which is the special for the week was brought back because of popular demand. We do offer many Wellness Items on the menu daily and hopefully you have seen some of the items such as grapes,fresh fruit cups, strawberry yogurt parfait (utilizing local strawberries), celery with ranch or peanut butter, hummus with pita, Chobani Greek yogurt as well as entrees and specialty sandwiches. The entrees and sandwiches are marked with a Wellness logo and we also feature vegetarian options daily. We have lowered the sodium in our soups, sandwiches and entrees.
Regarding the Quesadilla Burger and only being able to buy two, I spoken to staff and going forward they will offer the option for 1. I apologize for this inconvenience.
Thank you again for your feedback, we are always looking to add new items and improve our performance. I can be reached at [phone] or email if you have any further questions or suggestions.
Thanks!
Carol
Terry also pitches in with a suggestion and copies Nora, who also works in food services:
I'd like to make the following suggestion which is to differentially price the single and double quesadilla's. There is emerging evidence that pricing to a degree drives "healthy" food choices. Consumers are more likely to buy a diet drink if the sweetened drink costs more. I also think the calories ought to be posted as they are for the soup, salads and other items.
Since we are a healthcare institution I think "nudging" people towards better health choices is and at the same time educating them should be part of our mission. 1400 calories is close to the daily requirement for some people and $4.95 is a price that encourages this consumption. I would guess that if you priced a single at $3.75 a significant number would opt for the single, even though it costs more than half. This would be an easy experiment to do, data obtained from the cash register.
Nora responds:
That is a wonderful suggestion, we priced the double at $4.75 and the single at $3.50. We can take a look at data to see the effect.
tks
Nora
(Meanwhile, Elisabeth Moore, one of our nutritionists, is on national television talking about serving sizes. We might not always practice what we preach, but we keep trying!)
First, Research Administrator Diane writes to Carol, who runs the food service in the staff/visitor cafeteria, and she also copies me on the email.
Hi Carol,
I went to the Ullian Café today after my workout to get some lunch. I usually avoid the grill section due to the unhealthy choices that it has to offer, but today I saw folks with what appeared to be a simple burger made with a tortilla, so I checked it out.
I saw that this special came as a duo, i.e., 2 tortilla’s for the $4.75 price. Both parties before me asked if they could get only one, and were told no.
I bought the special and then came back to my desk to check out the nutrition info.
If this is correct, from the website, I just had 1480 calories in just the “special”. I also would have preferred to have gotten only one.What really got my attention though was the fat %. In just one meal, a lunch, I consumed 210% of my daily fat allowance!
For a health institution, I find that absurd! Isn’t there some other way to get good tasting healthy food from our café?
Why can’t people by only 1? Why wasn’t this info posted on the sign for the special? And if you can’t buy one then you should show the real numbers for the total meal.
Normally, I don’t get upset about some of the choices you offer as I can tell visually that they are high fat, calories or sodium, but this item had me fooled and I’m sure it has fooled others.
Dianne
I write back to Carol, with a copy to Terry Maratos-Flier, a faculty member with a strong interest in obesity:
Good points, Diane. Carol, what do you think?
Paul
Carol responds:
Good Morning Diane,
Thank you for your feedback! The Quesadilla Burger which is the special for the week was brought back because of popular demand. We do offer many Wellness Items on the menu daily and hopefully you have seen some of the items such as grapes,fresh fruit cups, strawberry yogurt parfait (utilizing local strawberries), celery with ranch or peanut butter, hummus with pita, Chobani Greek yogurt as well as entrees and specialty sandwiches. The entrees and sandwiches are marked with a Wellness logo and we also feature vegetarian options daily. We have lowered the sodium in our soups, sandwiches and entrees.
Regarding the Quesadilla Burger and only being able to buy two, I spoken to staff and going forward they will offer the option for 1. I apologize for this inconvenience.
Thank you again for your feedback, we are always looking to add new items and improve our performance. I can be reached at [phone] or email if you have any further questions or suggestions.
Thanks!
Carol
Terry also pitches in with a suggestion and copies Nora, who also works in food services:
I'd like to make the following suggestion which is to differentially price the single and double quesadilla's. There is emerging evidence that pricing to a degree drives "healthy" food choices. Consumers are more likely to buy a diet drink if the sweetened drink costs more. I also think the calories ought to be posted as they are for the soup, salads and other items.
Since we are a healthcare institution I think "nudging" people towards better health choices is and at the same time educating them should be part of our mission. 1400 calories is close to the daily requirement for some people and $4.95 is a price that encourages this consumption. I would guess that if you priced a single at $3.75 a significant number would opt for the single, even though it costs more than half. This would be an easy experiment to do, data obtained from the cash register.
Nora responds:
That is a wonderful suggestion, we priced the double at $4.75 and the single at $3.50. We can take a look at data to see the effect.
tks
Nora
(Meanwhile, Elisabeth Moore, one of our nutritionists, is on national television talking about serving sizes. We might not always practice what we preach, but we keep trying!)
It is not just teenagers
In a post below, I relate Dr. Amy Ship's recommendation to her patients and to her colleagues that they focus seriously on the dangers of cell phone use while driving. Now comes this study by the Pew Research Center that blows apart the myth that it is mainly teenagers who are texting while driving:
One in four (27%) American adults say they have texted while driving, the same proportion as the number of driving age teens (26%) who say they have texted while driving.
In addition, 49% of adults say they have been passengers in a car when the driver was sending or reading text messages on their cell phone.
OMG. What a silly and terrible way to hurt someone or be hurt.
One in four (27%) American adults say they have texted while driving, the same proportion as the number of driving age teens (26%) who say they have texted while driving.
In addition, 49% of adults say they have been passengers in a car when the driver was sending or reading text messages on their cell phone.
OMG. What a silly and terrible way to hurt someone or be hurt.
Monday, June 21, 2010
Schwartz Center Rounds work
One of the great legacies in recent medical history was provided by Kenneth Schwartz, a relatively young man who died of cancer, whose story of compassionate care noted, among other things:
I realize that in a high-volume setting, the high-pressure atmosphere tends to stifle a caregiver's inherent compassion and humanity. But the briefest pause in the frenetic pace can bring out the best in a caregiver and do much for a terrified patient. . . .
If I have learned anything, it is that we never know when, how, or whom a serious illness will strike. If and when it does, each one of us wants not simply the best possible care for our body but for our whole being.
This image was the impetus for the creation of a center to conduct programs to educate, train and support caregivers in the art of compassionate health care.
Started in 1997 at MGH, the Schwartz Center Rounds are now held in more than 186 sites across the United States. They are designed to enhance relationships and communication among members of multidisciplinary health care teams and to create supportive environments in which all can learn from each other.
So, how well does all this work? A recent article suggests it works very well. Beth Lown and Colleen Manning have published a study in Academic Medicine based on surveys of program participants in a number of institutions over the years. They found that the Rounds improved a sense of teamwork:
In particular, respondents had a heightened appreciation of the roles and contributions of colleagues from other disciplines and improved communication about both psychosocial issues and clinical issues.
The Rounds have also reduced caregivers' feeling of isolation in treating patients with complex and difficult conditions:
Rounds attendance improved their sense of support and decreased their stress and sense of isolation.
These findings are consistent with anecdotal reports I often receive from members of our staff. It is heartening that the good-willed people who work at the Schwartz Center have produced such lovely results for members of the health care professions and for the patient and families they serve. Lots of credit also goes to the members of the community who have supported them financially. Hint: Donate here.
I realize that in a high-volume setting, the high-pressure atmosphere tends to stifle a caregiver's inherent compassion and humanity. But the briefest pause in the frenetic pace can bring out the best in a caregiver and do much for a terrified patient. . . .
If I have learned anything, it is that we never know when, how, or whom a serious illness will strike. If and when it does, each one of us wants not simply the best possible care for our body but for our whole being.
This image was the impetus for the creation of a center to conduct programs to educate, train and support caregivers in the art of compassionate health care.
Started in 1997 at MGH, the Schwartz Center Rounds are now held in more than 186 sites across the United States. They are designed to enhance relationships and communication among members of multidisciplinary health care teams and to create supportive environments in which all can learn from each other.
So, how well does all this work? A recent article suggests it works very well. Beth Lown and Colleen Manning have published a study in Academic Medicine based on surveys of program participants in a number of institutions over the years. They found that the Rounds improved a sense of teamwork:
In particular, respondents had a heightened appreciation of the roles and contributions of colleagues from other disciplines and improved communication about both psychosocial issues and clinical issues.
The Rounds have also reduced caregivers' feeling of isolation in treating patients with complex and difficult conditions:
Rounds attendance improved their sense of support and decreased their stress and sense of isolation.
These findings are consistent with anecdotal reports I often receive from members of our staff. It is heartening that the good-willed people who work at the Schwartz Center have produced such lovely results for members of the health care professions and for the patient and families they serve. Lots of credit also goes to the members of the community who have supported them financially. Hint: Donate here.
Sunday, June 20, 2010
Trek Across Maine 2010
I'm just back from riding in this year's Trek Across Maine, where I joined about 2500 other people in biking over three days from Bethel to Farmington to Waterville to Belfast (about 170 miles) in a fund-raiser for the American Lung Association of New England. The money raised supports education, research, and advocacy. In addition to the riders, there are also hundreds of volunteers who make the ride possible -- directing traffic, preparing snacks at the rest stops, handling logistics, and like this person below, loading luggage for transfer to the next stop.
Many people join the ride in teams, and some produce their own riding jerseys. I thought this was one of the more creative designs.
Families often participate, and there are special things organized for the kids, like face-painting.
This year's ride was a special one for my cousin-in-law Tom, corresponding to an unmentionable birthday. You see him here with his wife, my cousin Suzie, who joined in as a volunteer.
Friday, June 18, 2010
Mike's versus Modern
This is a very serious clinical trial and one worth repeating by anybody who happens to be in Boston's North End. IRB approval is not required.With thanks to Adam at Universal Hub for the link.
A pipeline that leads upstream
What do the following names have in common? Beauvais, Brandao, Chanlatte, Gaines, Gebregziabher, Moorman, Ramos, Vicent, Viller, Weller.Certainly not ethnic or national background. (But it is from that very diversity that comes the strength of our hospital and, indeed, our country.)
In this case, these are the last names of the recent graduates of our Patient Care Technician Pipeline Program.
Patient Care Technicians work with nurses and other healthcare professionals to provide direct patient care. They play a vital role in the delivery of care on the many floors that comprise a hospital. PCTs probably spend more time with patients than almost any other profession, and it takes special training to be good at it.
At BIDMC, we decided to create a program that would enable some of our dedicated employees in other jobs to learn to be PCTs and move up the health care career ladder. Our Human Resources and Patient Care Services departments designed a nine week in-house program to train people for this role. During the first six weeks, employees attend class two nights a week and participate in four skill practice sessions. After successfully completing the classroom training, participants enter a three week, full-time hands-on training run by a nursing educator on a patient care unit. Trainees continue to receive their salary and benefits during this time. At the end of the three week hands-on training, program graduates move to jobs as PCTs on different units at BIDMC.
This is a picture of our current graduating class. Many have worked here for four or five years. Some were Patient Observers ("sitters"). Other worked as food service workers, rad tech assistants, or material handlers. Here's more of their story and a video on the BIDMC website.
Now, all of them have been promoted to their new jobs. Some are already thinking about the next step. Today a PCT, tomorrow a nurse?
Wednesday, June 16, 2010
Moving lots of babies
An important aspect of hospital operations is to prepare for the unexpected, a catastrophe that can cause a major disruption to patient care. All hospitals plan for such things, and then we do drills.
Today's drill took place in our Neonatal Intensive Care Unit (NICU). The scenario required an evacuation of two dozen newborns to another floor. The elevators worked at the start but were then simulated to go out of service, so some babies had to be put in baskets and carried down three or four flights of stairs to another nursery. Their life support systems and medications had to be in place the entire time.
I present a short video of some of these scenes. It felt very real. You quickly forget that the "babies" are dolls (as shown in the early frames, complete with simulated medical histories). A more comprehensive video was made of the entire exercise, observers were keeping notes, and there will be a full debrief for the entire staff. My inexpert opinion, though, was that people did a really good job. Especially when you consider (last frame in video) that the real babies still needed to be cared for during the whole exercise.
I later learned, too, that there is a dearth of literature on NICU evacuations. Given hurricanes and tornadoes, you might think that there would be generally accepted standards for dealing with this particularly vulnerable population. A member of our faculty plans to write up this experience and contribute to the literature on the topic.
If you cannot see the video, click here.
Today's drill took place in our Neonatal Intensive Care Unit (NICU). The scenario required an evacuation of two dozen newborns to another floor. The elevators worked at the start but were then simulated to go out of service, so some babies had to be put in baskets and carried down three or four flights of stairs to another nursery. Their life support systems and medications had to be in place the entire time.
I present a short video of some of these scenes. It felt very real. You quickly forget that the "babies" are dolls (as shown in the early frames, complete with simulated medical histories). A more comprehensive video was made of the entire exercise, observers were keeping notes, and there will be a full debrief for the entire staff. My inexpert opinion, though, was that people did a really good job. Especially when you consider (last frame in video) that the real babies still needed to be cared for during the whole exercise.
I later learned, too, that there is a dearth of literature on NICU evacuations. Given hurricanes and tornadoes, you might think that there would be generally accepted standards for dealing with this particularly vulnerable population. A member of our faculty plans to write up this experience and contribute to the literature on the topic.
If you cannot see the video, click here.
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