Monday, December 31, 2007

Windows of Hope

Windows of Hope is our oncology shop, located on the ninth floor of the Shapiro clinical center -- at the corner of Longwood and Brookline Avenues -- near the chemotherapy and other treatment areas. In addition to selling wigs, scarves, book, and other helpful items, it has become a place where cancer patients and families come and talk comfortably and share advice and stories about what they are going through. Linda and Terri, who run the shop, are warm and friendly people. You don't have to be a patient at our hospital to go there. All are welcome. Samples of their wares are in the pictures above.

If it sounds too good to be true

Technology Review has an excellent article by David Talbot entitled "The Fleecing of the Avatars", which deals with the difficulties of consumer protection and regulatory supervision of commerce on Second Life and other virtual worlds. Financial rip-offs are hard enough to avoid in-world, and this article gives a really good description of the issues when virtual currency is in play.

Thursday, December 20, 2007

Merry Christmas!

Just to take a break from this current addiction, I'm taking several days off from posting new items (although I will still moderate your comments), and so I wanted to leave you with this nice image at the top of my page. One of our nurse managers insisted that she did not want presents from her staff. They, being the usual strong-minded nurses at BIDMC, nonetheless insisted, but gave a gift in the form of this Christmas tree. Each "mitten" is a warm and kind personal message from a nurse to Sue.

An idea for US News and World Report

Here is an open suggestion for Avery Comarow, the editor of the annual US News and World Report ranking "America's Best Hospitals." Why not add to your algorithm extra points for those hospitals that voluntarily publish clinical indicators of the degree to which they harm patients? I am not talking about the usual hodgepodge of outdated CMS data, which are available anyway. I am talking about substantive clinical metrics, like central line infections, ventilator associated pneumonia, and the like. Or the ultimate, the hospital standardized mortality rate calculated by the Institute for Healthcare Improvement.

I can already hear the arguments against this. Who is going to validate the numbers? Which definition of central line infections should be used? How would you compare from hospital to hospital?

Please, put all that aside. Let's just accept as a premise that hospitals that choose to post these numbers do so not for comparative or competitive purposes, but rather to hold themselves accountable to the public for their efforts in quality and safety improvement. Shouldn't that be worth something in the US News listing?

A fallback, if you don't want to change your algorithm. Just create a special box listing the hospitals that post these kinds of results, along with their url, so people from hospitals around the world can check in and make their own judgments about the usefulness of this approach.

Avery, you have become a force in this field. As noted on your blog, your perspective uniquely qualifies you to observe and comment on the efforts by hospitals and other health care providers to improve care and patient safety. Why not use that influence to push the industry along to greater heights by giving space to those who risk holding themselves accountable in this manner?

Wednesday, December 19, 2007


I have linked at right to a blog I just learned about, Corazón Hispano. Here is a note from the author, Juan Jose Rivera, in response to a comment I left:

Saludos from Corazon Hispano blog. Thank you for your comment. It is very important for me that Hispanics have access to essential and practical prevention information. We represent the minority group in the US with the highest percentage of uninsured individuals. A significant number of Hispanics have access to the Internet, but not to a primary doctor.

He provides personal information on his profile:

Pertenezco al departamento de Cardiología de la Universidad de Johns Hopkins en Baltimore, Maryland. Además de mis obligaciones clínicas, me dedico a realizar investigación en el área de prevención cardiovascular. También escribo una columna mensual para el periódico médico nacional estadounidense Today in Cardiology.

This blog is very well written and quite informative. I hope you will pass it along to friends and associates.

Partial Credit

As a former state official, I understand the difficulties of running a state agency and therefore like to give credit where credit is due. This post is to award "partial credit" to the DCR, the state agency that runs the parks.

We had a big snowstorm on the weekend, but this is not unusual in New England. So you would think that the various agencies would be prepared to clear major walkways on public lands, particularly those walkways that lead to major mass transit stations. Not so. My particular T stop is Longwood, which serves thousands of people going to work at hospitals, school, and other institutions -- not to mention patients. A major passageway from the Longwood stop to the medical and academic area is a short walk through a park and across the Muddy River.

As late as yesterday, the walkway was a sheet of ice several inches thick. There had been no effort to clear it or to spread sand on it. It was treacherous.

So, today, I brought a camera to document this condition and send it along to the authorities and -- lo and behold -- the walkway has been plowed and sand laid down. The steps up the little bridge across the Muddy River likewise have been totally cleaned. The pictures above attest to this result.

So, that is the good news. The bad news is that it took so long. Partial credit awarded.

The new Commissioner of the DCR is Rick Sullivan, who used to be mayor of Westfield, MA. He is an honorable, hard-working, and competent person who understands the importance of proper and timely delivery of municipal services. Like his predecessors, though, he is hamstrung by inadequate budgets and, I am guessing, antiquated equipment. I think he is doing the best he can, but until and unless the public puts more pressure on their elected representatives for more adequate funding, the state park system will always be behind -- just as it was this week.

Tuesday, December 18, 2007

Physician Diversity -- Part 3

You know, if you know where to look, everything is available on the BIDMC website! Here is a report prepared by Rosemary Duda, Director of our Center for Faculty Development, as a guide to the faculty recruitment process, with a specific emphasis on trying to recruit under-represented minorities and women. Pages 40 to 42 of the book has charts showing the relative percentage of different levels of faculty at BIDMC in those categories and -- starting on page 43 -- compares our numbers to Harvard Medical School (including all the affiliated hospitals).

You can look at the numbers yourself, but it is clear that we are behind the rest of HMS in all faculty ranks.

Professor Duda's introduction to the book is very well written. Having served on search committees for department chiefs, I know that its recommendations are followed. Likewise, having talked to our chiefs, I believe that its recommendations are also carried out for division chiefs and other recruiting committees.

By the way, to answer comments on earlier posts, her language on page 6 concerning the value of diversity is very compelling: The advantages of a diverse faculty at BIDMC include optimizing our ability to provide high quality medical care for our underserved populations, addressing the issues of health and health care disparity in the underserved populations as these patients are more likely to seek physicians who are similar in ethnicity, culture, race and/or gender, and improving our cultural competency educational efforts and professionalism training. A diverse faculty also brings to the institution an expansion of the research focus that would encompass health issues related to women and underrepresented minorities.

But let us return to the question. If good intentions reign, and I believe they do, why are BIDMC's results less favorable than the rest of the HMS community? I know that a large part of the answer relates to the hospital's troubled period of 1996 through 2002, when many of the existing faculty left the hospital for greener pastures and when many potential young recruits were scared away by the uncertain future of the BIDMC. In fact, our moniker of "financially troubled BIDMC" did not leave the pages of journalism until sometime in 2004. I think this set us back many years, both in terms of new recruits and in creating a pipeline for later professorial advancement.

But let's open this up to those who want to comment, who know this place or know of it. Are there other factors at BIDMC that adversely affect our performance in this matter? Are those factors different from other Harvard hospitals? From other hospitals in Boston? Please dive in and offer your opinions and remedies.

Timely and important advice

Today's Boston Globe has timely and extremely important advice from Monique Doyle Spencer. You will not want to miss this.

Monday, December 17, 2007

Say it ain't so, Joe

I heard a great presentation this morning by Joe Newhouse, from the Department of Health Policy and Management at Harvard Medical School. There was one point that he made that really caught my attention. It was a cite to a 2004 article in the Journal of the American Medical Association (Dimick, et al, JAMA 2004; 292: 849) that presented the issue of how many cases you would need to collect of a certain clinical procedure to be able to make a determination that a given hospital's mortality for that procedure was twice the national average. It turns out that only for CABGs (coronary artery bypass grafts) are there enough cases performed to have statistical confidence that a hospital has that poor a record compared to the national average. For other procedures (hip replacements, abdominal aortic aneurysm repairs, pediatric heart surgery, and the like) there are just not enough cases done to make this assessment. (By the way, if you just want to know if a hospital is say, 20%, worse on relative mortality, you need even a bigger sample size.)

I have copied the basic chart above. Sorry, but I couldn't nab the whole slide. The vertical axis is "Observed 3 year hospital case loads", or the number of cases performed over three years. The horizontal access is "Operative mortality rates". The line curving down through the graph shows the frontier at which statistical significance can be determined. As you see, only CABGs are above the line.

And, as Joe pointed out, this chart is based on three years of data for each hospital. With only a year's worth from each hospital, you surely don't have enough cases to draw statistically interesting conclusions about relative mortality. And remember, too, that this is hospital-wide data. No one doctor does enough cases to cross the statistical threshold.

So, this would suggest that publication of hospital mortality rates for many procedures would not be helpful to consumers or to referring physicians.

Meanwhile, though, you might recall a post I wrote on surgical results as calculated by the American College of Surgeons in their NSQIP project. This program produces an accurate calculation of a hospital's actual versus expected outcomes for a variety of surgical procedures. Unfortunately, the ACS does not permit these data to be made public.

Where does this leave us? Well, as I noted in a Business Week article, the main value of transparency is not necessarily to enable easier consumer choice or to give a hospital a competitive edge. It 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, even if we can't compare hospital to hospital on several types of surgical procedures, we can still commend hospitals that publish their results as a sign that they are serious about self-improvement.

Sunday, December 16, 2007

IT Memory Lane

Another snowy day in Boston. Luckily it is Sunday, and this provided a perfect opportunity to go up and clean out the attic.

What should I find but my old class notes from the spring of 1969, a course entitled "Information Systems" -- "1.00," in MIT parlance -- taught by a wonderful professor named Dan Roos who, by coincidence, I happened to run into recently.

We used an IBM 360 computer in those days. It took up an entire room and probably had less memory than your cell phone does today. You would write your program in Fortran -- an example from my final project is shown in the bottom picture above. Then, you would punch Hollerith cards to encode the program on a medium that could be read by the computer. I show several above, along with a diagram they gave us to show what fields were punched by which key on the punch machine. The machine used a hexadecimal numbering system, so we were expected to be conversant in base 16 -- delineated as 0-9 and A-F.

After keypunching, you would hand your batch of cards to the system operator, who would feed them into the computer. Depending on your priority in the queue, you would wait five minutes or an hour for the program to be compiled by the computer, only to discover that you had made a programming error, a keypunch error, or had a hanging chad on one of your punch cards. The problem, of course, is that you didn't know which of the three problems had occurred!

Class 1.00 is still taught at MIT. Here is the description of the 2005 class from MIT OpenCourseWare. Every one of those desktop computers you see in the picture has a gazillion times (whether in base 10 or base 16!) more capacity than the old IBM 360. By the way, Fortran still exists, but these kids get to use Excel and Java instead. Seems a bit too easy to me . . .

Saturday, December 15, 2007

Welcome world!

It has been a while since I have taken the time to welcome readers from around the world. I am prompted to do so after glancing at my StatCounter statistics. Among the last 500 visitors I find viewers from Korea, Lithuania, Nigeria, Italy, Finland, Saudi Arabia, Kuwait, Ukraine, Germany, Thailand, Israel, Iran, Singapore, Indonesia, United Arab Emirates, Poland, Switzerland, Philippines, Sweden, South Africa, India, Pakistan, Denmark, Netherlands, Kyrgyzstan, United Kingdom, Turkey, and Canada (including Ontario, Alberta, British Columbia, and Quebec), and 26 states in the USA. (Don't worry. I don't know who you are personally, just the region where your ISP address resides.)

I am honored to have all of you as visitors. I think the issues we face in running hospitals here in the US are not very different from those in other countries, and I welcome your participation in our discussions. Both signed and anonymous comments are welcome, and we encourage perspectives from all over the globe.

Talking Turkish

We recently had a visitor from Turkey, who spent two weeks learning about our hospital. His hospital is about to go through a Joint Commission International survey. And, whaddayaknow, he posted our survey results on his new blog to give his folks an idea of what to expect.

Friday, December 14, 2007

White Christmas Pops

Lots of snowstorm stories from yesterday and last night. Here's one from my wife, who sings in the Tanglewood Festival Chorus and was on the roster to sing in two Boston Pops concerts yesterday. She was smart enough to take mass transit, rather than attempt the drive to Symphony Hall.

I got to Symphony just a little late, only to find something like eight people there ready to sing. It seems that the roads were gridlocked, and people were frozen there (pun intended). One person, for example, was on Boylston Street about two blocks above Symphony for about two hours. Stories were everywhere -- some people took four or five hours to go a few miles, others left their cars on the side of the road and walked or took the train. The record was a violinist who spent more than seven hours in his car. Keith Lockhart was being driven in and the car was stopped for hours in Kenmore Square. He just got out and walked the rest of the way.

They moved the concert up a half hour, and by that time there were about twenty-five singers (out of fifty) ready to do their thing. The orchestra, however, was very, very sparse. There were four first violins, four second violins, no oboes, one bass, no tubas, and no trumpets. It's hard to do a Pops concert without trumpets, and Keith moved around the music making the big trumpet pieces later on the program in hopes that some trumpet player would make it. Finally, we were doing Sleigh Ride (a piece by Leroy Anderson) that has a horse's "neigh" at the end which is done by the trumpet section. We were about half way through the piece when a lone trumpeter in street clothes made it to the stage door, came on stage, and played the neigh by himself!

Keith had the chorus and Santa go down into the seats with the audience to sing the audience sing-along. Needless to say, there weren't very many people there, so it was a cozy and friendly "sing." We were all wearing Santa hats, and one of the tenors gave his hat to a little boy. He kept it on the whole time, despite that fact that it kept falling down his face.

Less? More?

Retailers will hate this post by our CIO John Halamka, especially in these last days before Christmas, but his sentiments are very persuasive.

Community response

Kevin Cullen wrote this moving story in yesterday's Boston Globe. Yesterday afternoon, I received this note from our head of social work:

Even more moving than the story itself is the response that it has generated. We and the Globe have received dozens of calls from people who have seen the story and are offering either a room for this patient, or money to help him pay rent. This is a tribute to this patient, the staff who have worked tirelessly on his behalf and the generosity of strangers.

Thursday, December 13, 2007

Is this progress?

Is this progress? You get to vote with your comments.

Three of my friends ate at Legal Seafoods in the Prudential Center last night. At the conclusion of dinner, the server came over and, with great enthusiasm, told them that their restaurant was the first in Boston to have a new feature. (I gather from this article that it has been in use elsewhere.) It was a handheld device, running off a wi-fi system, that permitted the customers to pay their check at the table with their credit cards. (It is roughly equivalent to the one you use at a grocery store checkout.)

Yes, you can still split the bill among two or three credit cards, but you need to calculate the tip in advance from the paper bill so that you enter the right amount into the keyboard for each person.

One of my friends was very excited about this approach. Another could not see why it provided any advantage from the customer's point of view. Her view was reinforced when she mistyped a number, tried to clear and reset it, and received a message saying she should wait for the server.

This approach has been described as a way to minimize credit card fraud because you never hand off your card and have it leave your sight. It also has been described as a way to boost server productivity and speed up table turnover.

What's your take? Good, bad, indifferent? I'll send along your comments to Roger Berkowitz... or maybe he reads this blog.

By the way, this makes me wonder: Should we have a grocery-store type device for collecting co-pays at our clinics? Today, the desk attendant has to complete your transaction for you.

Salgirah Mubarak!

Today is the Aga Khan's 71st birthday, and this year marks his Golden Jubilee celebration of 50 years on the throne of Imamat. The Aga Khan is the spiritual leader of the Ismaili Muslims, and looks after both the spiritual and material/secular well-being of his followers.

It is quite remarkable that any leader fulfills 50 years of service, and this gentleman has made major contributions to world peace and economic development.

Here is a clip from a Canadian broadcast wishing the Aga Khan a happy birthday. There has been a close relationship between the Ismaili community and Canada since the time Canada served as a refuge for Ismailis who were expelled from Uganda by Idi Amin in 1972.

Wednesday, December 12, 2007


I was recently honored to give the Brunel Lecture at the engineering school at MIT. It was entitled "Process Improvement in the Rarified Environment of Academic Medicine." It is now available for viewing on MIT World. The lecture has similar themes to the one I gave at the National Academy of Engineering. Some of you had trouble downloading that one, and so you can try this one if you are interested.

Physician Diversity -- Part 2

A continuation of my new series about promoting diversity among our physicians at BIDMC. Please take a moment to read the thoughtful comments offered by readers after the last post. One commenter questioned the validity of my premise that we want greater diversity, but I am going to proceed on the assumption that we do. Feel free, though, to offer alternative points of view. And please be sure to read Jon's comments on the topic, which gives a helpful national perspective on the pool of applicants to medical school and the resulting difficulty that presents as we move along the pipeline to residency programs.

I promised I would give you some numbers, and here they are, as of November 2007. Thanks to Dr. Rosemary Duda, the Director of our Center for Faculty Development, for assembling these.

We have 744 clinical residents spread throughout our 13 academic departments. As I mentioned below, the gender mix is excellent, but the percentage of underrepresented minorities is small.

Male -- 370 (49.7%)
Female -- 374 (50.3%)

White -- 464 (62.4%)
Black -- 26 (3.5%)
Asian/Pacific Islands -- 193 (25.9%)
Hispanic -- 33 (4.4%)
American Indian -- 0 (0.0%)
Other -- 28 (3.8%)

Here is the pattern among the 487 BIDMC research fellows. Some of these are MDs, and some are not.

Male -- 280 (57.5%)
Female -- 207 (42.5%)

White -- 215 (44.1%)
Black -- 7 (1.4%)
Asian/Pacific Islands -- 234 (48.1%)
Hispanic -- 17 (3.5%)
American Indian -- 2 (0.4%)
Other -- 12 (2.5%)

Acknowledging these numbers, our graduate medical education (GME) office has encouraged the creation and support of a BIDMC Diversity Committee, which is primarily a resident committee, but also has some faculty membership and mentoring. One of our fine young doctors, Sean Kelly, currently serves as faculty advisor and one of our BIDMC residents, Alden Landry, is serving as Chairman of the committee. They collaborate with the Office for Diversity and Community Partnership at Harvard Medical School and the minority affairs and diversity offices at the other HMS hospitals.

Rather than summarizing all their activities, I'll invite Sean and Alden and any other committee members and any of our other residents and fellows to post their own comments. I also invite people at other hospitals here in Boston or elsewhere to post their thoughts on the matter. What works? What doesn't? Are there success stories from elsewhere that can help inform our programs?

Tuesday, December 11, 2007

Drugs in the workplace

There was a piece in the New York Times Magazine in November entitled "Dr. Drug Rep" by Doctor Daniel Carlat who discussed the interplay of drug companies and physicians, and his own evolution concerning the appropriateness of aspects of that relationship. I thought it was a fascinating article.

Then, this past week, the Magazine published a letter to the editor from Dr. Amy N. Ship, a superb internist in our hospital's primary care practice. Here it is, in case you missed it. Strongly held beliefs, clearly presented.

Even without Dr. Carlat's delayed recognition of the positive spin Wyeth clearly expected him to put on its product, why did it take a year for him to realize that he was being paid and pampered to sell a product? How could he seemingly miss the obvious: that his M.D. and credentials provided for Wyeth a patina of legitimacy that its drug reps couldn't muster independently? Why did it take him so long (while he amassed $30,000) to see that his position was morally corrupt?

The "lessons" that he reputedly learned are not new or unique. I'm proud to work in a medical practice where pharmaceutical representatives are not permitted.

Monday, December 10, 2007

Downstream impacts

One of the great joys of teaching is to stimulate a student's interest in a topic and then hear, years later, how that might have contributed to career choices and positive impact on the world. Here's one such story. I am not sure there is a direct connection, but I like to think that I planted a seed.

Several years ago, I was asked to teach a group of seventh grade girls about sewage. Yes, I know what you are going to say, but I had just been running the local water and sewer agency, and their teacher wanted to cover an environmental topic, and so there I was. After making sewage in the classroom (details another time if you want them!), we took a tour of a local headworks. This is a facility in which lots of sewer pipes converge into long, open, deep, fast-flowing channels of wastewater en route to the local sewage treatment plant. While viewing this flow, one girl noticed some life preservers hanging nearby, and asked what they were for. I gave the obvious answer.

The next day, I received a note from her father, saying how much the girls learned on the field trip and relating an age-appropriate comment from his daughter, Amy: "Life preservers, Dad! I'd rather die!"

Well, that same Amy has just finished three years working for Environmental Justice for California Water Rights, where she lobbied all over the state for better drinking water for underserved communities. She helped get new water systems for some small Salinas valley communities, and she was instrumental in preserving water rights for the Winnemum Indian tribe in Shasta County. Here is an article describing some of her activities.

Thanks to Peter for the update, and best wishes to Amy and her colleagues in their pursuits.

Sunday, December 09, 2007

"It happened the way I called it"

I just returned from my annual soccer (football) referee recertification clinic. I have been reffing since 1994 and many years ago upgraded from the entry Grade 8 to Grade 7. As best I can tell, the main difference between the two grades is that I now have to take an annual physical exam and also pass an annual written test. The passing grade for the latter is 85%, which I think means that it is acceptable to be wrong 15% of the time. (Hey, that's not bad. There was a period of time where the passing grade for nuclear power plant operators on the NRC's test was 65%. Let's not think about what that meant! That preceded Three Mile Island.)

One of the things I love about fútbol is that the rules we use are the same throughout the world. Theoretically, that means I could officiate a game in Brasil or Italia or Cameroon or Korea as well as a game here in Massachusetts. I say theoretically because there is no way I could keep up with the players there.

There is a joke among experienced referees that you go through three stages of self-confidence as you get more and more experience officiating matches. The first is when you are starting out and are insecure. A coach complains about a call, and you reply, "I'm doing the best I can."

After a couple of years, you gain self-esteem, and you reply, "I called it the way I saw it."

Finally, when you have the full degree of self-assurance, you reply, "It happened the way I called it."

Actually, though, what was clear among my teachers and colleagues today is that the more experienced referees reach a level of comfort at which they no longer respond so defensively to complaints about their officiating. There is more of an understanding that your job as referee is to make yourself as invisible as possible and let the game flow. In what other sport, for example, is there the equivalent of the "advantage" rule, where you intentionally do not stop play to call a penalty if the aggrieved team's possession of the ball is not harmed by the foul? Soccer is a passionate game for players, coaches, and fans, and it is the referee's job to let many of those passions roll of your back and enjoy the overall experience while ensuring an appropriate level of fair play on the pitch.

Friday, December 07, 2007

Benefit Dance concert in SoHo

LA-based Lineage Dance Company, which holds dance concerts to benefit non-profit organizations, is offering performances tonight and tomorrow in the Joyce SoHo in New York City to raise awareness about Brotherhood/Sister Sol. They will be performing the New York premier of "Dancing Through The Ages," which uses community members of all ages.

Thursday, December 06, 2007

Physician diversity -- Part I

As my loyal readers know, I don't hesitate to brag about BIDMC when I think we are deserving, but I also write about areas where we need to improve. This is one of those latter topics. I can't cover it all in one post, so I will follow up with more in coming days and weeks.

Here's the issue. If you were to look at the mix of patients here, it would feel like a mini-United Nations in terms of the racial mix. But, if you look at the medical staff -- full-fledged physicians, fellows, and residents -- it looks different, with under-represented minorities being a very small percentage of our trainees and attending physicians. (By the way, on the proportion of men and women, the story is better.)

This is a general problem in medicine nationally (with little progress notwithstanding well intentioned efforts). It is a bigger problem in Boston than other places, and I believe it may be a bigger problem at BIDMC compared to some other places in Boston. "Why here?" is the question I'd like to explore with you, and I'll give you real numbers and other facts in future posts, along with how we are trying to do better.

For today, let's start with the beginning of the physician pipeline. Harvard Medical School does quite a good job in recruiting a diverse entering class. Here is an article from a few years ago documenting this, showing about 19% minority admissions. Those students spend a lot of their time in the Harvard hospitals (BIDMC, MGH, Brigham & Women's, etc) doing their clinical rotations. I think it is fair to say that they love the time spent at BIDMC because we have great teachers and give them a great educational experience.

Then the students apply for residency programs. The minority students are in great demand, and they do very well in terms of the "match" process that characterizes the residency selection program. Many HMS graduates want to stay in Boston, but there has always been a tendency among them to seek the residency programs that have greater prestige. MGH in particular has always been viewed that way. But the other thing that happened here from 1996 on was the financial disaster following the merger of the BI and the Deaconess. For years, the local pool of HMS applicants that might have been interested in BIDMC, including the minority applicants, essentially dried up. Simply put, they feared that this hospital would not be around much longer. So the primary source of minority medical students that were most familiar with our hospital and comfortable with our faculty basically disappeared. And since residents serve as a major source of faculty recruits going forward, if this pipeline dries up, you start behind in terms of expanding the number of young minority faculty members.

With the financial recovery of the BIDMC and the reinvigoration of our clinical and education programs, we are back to being seriously considered by HMS graduates as they apply for the residency training. That should help. But it does not address the full range of concerns.

In the next postings, I will cover more of this topic and also will move up the pipeline and successively cover junior faculty, senior faculty, and chief-of-service issues.

Wednesday, December 05, 2007

PFL at the NAE

Well, in case you are not sick of reading my stuff about process improvement in hospitals, you can get a real aural overdose in this speech I gave at a recent symposium at the National Academy of Engineering. It was the first chance I had to publicly consolidate my thoughts on the matter.

Sorry about some nerdy jokes at the beginning, but, hey, it was a talk to a group of engineers! (For ease of reference, the blog post on preventing ventilator associated pneumonia to which I refer in the speech is here. The BIDMC transparency website to which I refer is here.)

Running time is just over twenty minutes. Excellent listening as you catch up on emails . . .

Tuesday, December 04, 2007

Pursuing Perfect Care in Ohio

Several weeks ago, I mentioned the retreat we held with the BIDMC and BID~Needham hospital boards to review the role and scope of the governing bodies of our organizations, as a precursor to establishing audacious quality, safety, and patient satisfaction goals for the two hospitals. In just a few weeks, the two boards will meet again, and I will be able to report to you on the overall direction voted by them. In the following months you will be able track our progress towards exacting, quantified goals.

Several days ago, I had a chance to visit with a board member from Cincinnati Children's Hospital about their self-improvement process, entitled Pursuing Perfect Care. This has been an extraordinary program, pervading the entire institution, and achieving great results. A key aspect of the process has been utter transparency about the organization's progress towards its goals. Check this page for a summary of the operational definitions of the items that are measured and reported upon publicly. As I have noted elsewhere, transparency is not a matter of trying to create a competitive advantage for one hospital versus another. It is a way of holding one's own organization accountable to itself and to the public.

In the last several days, executives from several of the state's insurance companies have made suggestions regarding cost control of medical expenses in Massachusetts. As reported by our friends at Health Care for All, they suggested legislation that would include the following items:

1. Public Reporting of Preventable Errors and Prohibiting Billing for Avoidable Mistakes
2. Strengthening the Determination of Need Process
3. A Special Commission to Study State-Funded Stop-Loss Coverage
4. Allow for the Operation of Limited Service Clinics
5. Medical Malpractice Reform
6. Require Electronic Transmission of Health Care Transactions
7. Repeal Mandated Benefits that are no Longer Effective
8. Comparative Effectiveness Studies of Medical Services
9. Extend the Moratorium on Mandated Benefits
10. Permit Mandate-Lite and Mandate-Free Products
11. Hospital Reporting on Measures to Reduce Duplicative Diagnostic Services
12. Hospitals Reporting on Measures to Eliminate ER Diversions and Overcrowding
13. Make Greater Use of Managed Medicaid
14. Eliminate Duplicative Regulatory Requirements
15. Standardized Reporting Requirements
16. Streamline Administrative Processes
17. Standardize Physician Credentialing

Perhaps some of these might be good ideas in their own right, but they do not get at the underlying structural problem in the delivery of care in hospitals. This is not to say that hospital costs are the sole or main determinant of cost increases in health care, but they are admittedly an important part of the trend. We do not need to wait for legislation to make improvements.

The clear message from my colleague in Ohio was this: THE most significant step hospitals can take to improve cost-effectiveness is to reduce harm to patients in their institutions by adopting aggressive quality and safety goals, measuring their success towards them, and reporting on their progress to the public. Not that we should need an economic argument to do a better job for patients, but it is good to know that two go hand in hand. We intend to pursue this agenda with all due energy at BIDMC and BID~Needham.

Piling On

Someone at the health insurance plan associated with Boston Medical Center did something wrong. As reported by Alice Dembner in today's Boston Globe, BMC gave the impression in a letter to 2600 people that they would lose their ability to be treated at BMC if they didn't sign up with the hospital's insurance plan.

Now, let's all agree that this was a wrong and bad thing to do. (I think most of us would believe that it was the result of some lower level staff person writing a letter poorly rather than some dastardly plot to force 2600 people to use the hospital.) But what is the right response and the right remedy?

BMC immediately apologized and said they would take steps to make sure this doesn't happen again. Seems like enough to me.

But, no, first they get accused of "losing sight" of the purposes of the MA health reform legislation. Someone else asserts that BMC's actions are "all about money and not about health." Then, they have an investigation by the Attorney General to see if they violated the state's consumer protection law? What's next: Financial damages?

Folks, they made a mistake. This is the hospital that has stood tall for care of the indigent for years. If we make (perhaps literally) a federal case about every glitch and error that occurs in implementing a highly complex state law, we only succeed in generating cynicism and ill will that will ultimately undermine this noble experiment.

Monday, December 03, 2007

A note from the interns

For those of you who wonder whether young people who choose medicine still care, please read this note from three of our interns to the nurses on the oncology (including bone marrow transplant) units with whom they worked during their month-long rotation on those floors. (And, of course, it says something really nice about the nurses, too!)

As we're finishing up our last few hours on BMT/OMED, we want to thank you for all your help in the past month. We started with three consecutive code blues in our first week, and it has been a tough five-week block for us interns. But we have learned a lot from the patients and you guys. Thank you for showing us the ropes, for always being the most fervent advocates for the patients, for being so responsible, responsive, and prompt to remind us when we forgot to order labs or TPN. Thanks for your patience, your smiles, and, many times, your food!

We wish we knew more medicine, more ways to relieve pain, more treatment strategies so that our patients could have a few more months with their loved ones. We wish we could have done something differently so that the patients didn't have to spend Thanksgiving evening with us. We wish that we didn't have to tell so many twenty-two-years-old the new diagnosis of lymphoma, that we didn't have to announce so many deaths. We wish we could have helped you guys more in your care for the sick.

Thank you for everything.

Endowment Policies

Here is a thoughtful article on the issue of endowments written in response to suggestions by some in Congress that universities and other large non-profits should be required to spend 5% of their endowment each year. As noted by the authors, this would be bad policy. (Note: I serve on the MIT Corporation, along with Mr. Mead.)

Don't Require Colleges to Spend More of Their Endowments
Chronicle of Higher Education
November 9, 2007

The demand for higher education and academic research ­and the costs of providing them has risen in recent years, and the search is on for easy answers to limit the financial burdens on families and the government. The most recent suggestion has been to require colleges and universities, especially large and prestigious ones, to spend more of their endowments. Congress, for example, is considering a proposal to require institutions with big endowments to spend at least 5 percent of that money each year, the same percentage that nonprofit foundations are required to spend.

So why don't universities spend as much as they can of their endowments to stop tuitions from rising, or to allow more low-income students to attend college, or to reduce the need for federal investment in scientific research?

The short answer is, they already do.

We serve as chairmen of the boards at two of our nation's most-important research universities. As taxpayers, business people, parents, and citizens, we strongly support the goals of making college affordable, aiding low-income students, and conducting research. And as board chairs, we know that endowments are used for precisely those purposes and more. Last year alone, America's colleges and universities spent more than $15-billion from their endowments to subsidize tuition, make college inexpensive or free to millions of students, raise the quality of education, conduct research, and otherwise improve the services that they provide to students and society. On average higher-education institutions spent 4.6 percent of their endowments last year.

Why don't we spend more? In part, it is because we can't. We have a legal and moral responsibility to honor our donors' wishes and ensure that our institutions' endowments are at least as strong 10, 20, and 50 years from now as they are today, so that they can serve the needs of students and society then as they do now. We take few of our responsibilities more seriously than the stewardship and strengthening of our institutions' endowments.

Indeed, for more than three centuries, endowments have helped colleges and universities assist students, conduct research, construct new facilities, hire faculty members, and carry out a host of other activities that would not have been possible had they relied solely on tuition and government support.

An endowment is typically made up of numerous different funds contributed by separate donors. Individuals, businesses, foundations, and others are exceedingly generous to colleges and universities; in the 2006 fiscal year alone, they provided $28-billion in contributions. People contribute for a variety of reasons: out of loyalty, because institutions are an important part of their community or state, or simply because they believe in the missions that the colleges are supporting.

Most of those donors are, in fact, fairly specific about their objectives. They might direct the money to research on a specific disease, to the establishment of a faculty position in a particular area of studies, or to financial aid for students. Institutions appreciate their generosity, and they are legally and ethically bound to honor a donor's intent.

Moreover, donors also usually specify that they want their generosity to produce benefits for many years to come. They want their contribution managed so that some of the earnings are spent, while the rest are reinvested to ensure that the endowment rises enough to let the annual payout keep pace with rising costs ­ in good economic times and in bad.

For example, a donor contributes $1-million to create a permanent fund for cancer-related research. She wants the fund to produce research support that keeps up with inflation, regardless of the markets' performance. To do that, the fund must grow larger, even as it is paying out a steady stream of research dollars. Recall Joseph's advice to the Egyptian pharaoh to store grain during the coming seven years of abundance to feed his people during the drought that would follow. Endowment managers reinvest revenues earned during years of abundance to ensure that spending can keep up with inflation during the lean years, when markets are not so friendly.

The issue is not only one of donor intent, however. Between us, we have served on dozens of corporate, university, foundation, and other boards. In each of those positions, we have shared with our colleagues management and fiduciary responsibilities for multimillion-dollar or even multibillion-dollar corporations and other institutions. An essential part of our stewardship of those institutions has been to ensure that they are at least as strong in the future as they are today. Robust endowments are crucial to sustaining colleges' high-quality education and research.

Endowments are, in fact, providing increasing support for current activities. Among the colleges with large endowments, about one-third of annual operating revenue comes from endowment spending ­ and at Harvard, for example, that figure has grown from 21 percent just 10 years ago, while at Yale it has almost doubled.

For many higher-education institutions, endowment spending is the single largest source of revenue ­ more than tuition, research grants, and clinical income from medical schools. Some institutions with large endowments have undertaken bold initiatives on student aid; Princeton University, the University of Pennsylvania, and the University of Virginia, for example, have made a college education virtually free for students from low-income families, as well as those from many middle-income ones. Endowment revenue is also indispensable for investments in academic programs that make American universities the envy of the world.

Endowments have grown significantly in recent years, despite what they spend, and that is a good thing. It helps ensure that colleges and universities have the resources to continue to improve and contribute to the well-being of our society. Much of the growth has been a result not only of increased donations but also of sound financial management. But to update Joseph, and paraphrase the warning investors have heard many times, recent growth of investments is no guarantee of future performance. Indeed, average endowments declined nearly 10 percent between 2000 and 2002. Institutions would be irresponsible if they assumed that investment returns will always grow rapidly. And endowment managers are under no illusion that they will.

Strengthening higher education and research in both the short term and the long term is important to our nation's well-being. Forcing endowments to spend more quickly might help in the short run, but it's a recipe for long-term weakening of a major national asset. Too often we see the government ignore long-term needs to address short-term goals. It shouldn't force us to do the same.

Dana G. Mead is chairman of the Corporation of the Massachusetts Institute of Technology, of which he has been a member since 1996. He was chairman and chief executive officer of Tenneco Inc. from 1994 to 1999. Jeremy M. Jacobs is chairman of the Council of the University at Buffalo, State University of New York, and chairman and chief executive officer of Delaware North Companies.

Sunday, December 02, 2007

Revisiting the Stark Laws

David Whelan, at Forbes, has posted a very interesting interview with Congressman Pete Stark about the "Stark laws" passed in 1989 and 1995. These laws control many relationships between and among doctors and hospitals. The interview is worth reading. I think it is really hard to write legislation in the health care arena that does not have some unintended consequences. The field is so complex that it is unlikely that even a well written bill won't have unforeseen effects in one or another sector.

French Toast Alert

The French Toast Alert graphic on the right is a gift to the blogging world from AdamG at It is spreading to websites throughout the region, as we all make our contribution to the health and security of the Greater Boston area in the face of the dastardly threat of (ohmygosh!) snow in New England. Please click and read so you and your loved ones will be prepared.

Darn, too late to vote for Pier Paolo!

Our own Dr. Pier Paolo Pandolfi, a world expert in cancer research, was nominated for the Italian periodical Home Men's Health Man of 2008 competition. His rivals included model David Gandy, "surfista" Ryan Heavyside, basketball player Danillo Gallinari, Olympian Andrew Howe Besozzi (shown here) -- and other hulks. As well as assorted folks from other fields.

Unfortunately, I received word of this too late to vote -- and, more importantly, too late to ask all of you to vote also and create a landslide.

Please note that the periodical's subtitle is "il piacere di essere uomo", which Alta Vista translates as "the pleasure of being a man." I have not asked Pier Paolo if that is his personal motto, but we have nonetheless inscribed it over the door of his laboratory, as our belated tribute to his being nominated. Congratulazioni!

Saturday, December 01, 2007

Hook, line, and sinker

Restaurateur Ana Sortun led a small group of us on a shopping tour today of several of Watertown's Armenian groceries. (She generously donated her time as a prize in a charity auction we had attended for one of Boston's great music ensembles.) While we were keeping warm in the back of Sevan Bakery, Ana led us through her shopping list and explained the variety of spices, vegetable, dried goods, canned goods, frozen foods, dairy, and deli that we were about to see, feel, smell and taste.

First, though, she offered us a prosaic* depiction of spices, explaining that each particular mix of spices in the world's cooking provides an arrow in the atlas in terms of the food's location and culture. She also depicts each particular mix as the "source of craving" that we might have for different types of food -- Middle Eastern, Greek, Mexican, and so on.

Then, to prove the point, we were told about and got to experience za'atar, the wonderful blend of herbs -- with distinctive varieties from Jordan, Syria, Israel, Turkey, Lebanon and elsewhere. Za'atar also refers to one of the herbs itself, a hyssop related to thyme, but with a flavor that is a cross between thyme and oregano. It is dried and blended with sesame seeds and sumac, which itself is cured with salt. The resulting flavor, notes Ana, catches you "hook, line and sinker" and is one of those things that creates cravings ever after. There was total agreement in our group after our taste test!

That being said, my favorite was muhammara, a mixture of crushed red pepper, ground walnuts, pomegranate molasses, and olive oil. Put that on your pita bread and taste it.

Did I mention that Ana has a cookbook, appropriately entitled Spice: Flavors of the Eastern Mediterranean? If you are really lucky, you live in a city like Los Angeles or Boston, where there are large Armenian communities where you can readily find the ingredients.

*Eek! See comment below and offer substitutes for this word, please!!!

Supporting the Troops

One of our staff members had a great idea, which we immediately put in place. Here's the description below in my email to the entire hospital. I post it here (without the actual link) as a suggestion to other organizations, hospital or not, as to something that you might want to consider. (I am also posting some of the first comments back from staff so you can see reactions.)

Subject: Holiday Letter Campaign to Support the Troops

The holidays are a time when families come together. But for active military personnel deployed overseas the holidays can be especially lonely and difficult.

Many of you support the troops on your own, but here’s a chance for BIDMC to help brighten the season for our colleagues and family members serving overseas. Let’s gather the names and addresses of all BIDMC employees and staff, as well as any of our family members, who are deployed on active military duty. We can then make that list available on the portal for anyone interested in sending out a holiday greeting.

We need to act fast to make this happen.

If you know the name and mailing address of a colleague or family member serving in the military, please click this link to fill out a form that includes the full name and mailing address of the service person being honored, as well as what department you work in and your relationship to this person.

This form will also be available in the BIDMC Today news section on the BIDMC Portal where we will post the names, addresses and information (we will start the postings early next week.) The rest is up to you.

Thanks to John Donaher, RN, Deac-4, for suggesting such a great idea.

Here are three replies:

Although I don’t have a loved one serving in the military I think this is a wonderful gesture and I hope many will rise to the occasion. I recently heard a piece on NPR about the recent push to email military holiday greetings and the press officer being interviewed stated that many personnel will never see those emails and the old fashioned letter is warmly received by those on active duty. For me, I will get names from the BIDMC Today next week to ask my 4th grade Girl Scout Troop to write letters at our meeting next Tuesday.
Ideas like this make BIDMC all the more human.
Thank you Paul, this is a wonderful idea. As a former military member this will really mean a lot to anyone who receives a greeting. Thanks!
What a wonderful idea. I am blessed to not be personally impacted with family there but will happily send some cards & get my kids to do some art work. Thanks for the avenue to make it happen.

Friday, November 30, 2007

Message from (or for) every Mom

Jessica Lipnack features Anita Renfroe's "What Mom says" on Endless Knots. "What a mom says in 24 hours, condensed into 2 minutes and 55 seconds!" It is great. Forward this to everyone you know!

Scary spam

I received the following comment on this blog:

Ephedra Diet Pills Still Available

I take the ephedra diet pill in the morning and again at noon. I make sure I take the pills at least a half hour before the big turkey meal mom cooks. This system works good for keeping the weight off around Christmas, too.

For more Info visit: [omitted].

The linked site then has all kinds of articles about how epedhra should not have been taken off the market and is good for you. But I don't think there is much to controvert the decision of the US government to ban this substance in 2004.

Shortly before the ban, I went to the funeral of a 31-year-old man who had decided he was not thin enough and started taking ephedra. He went to sleep one night and did not wake up the next morning.

I know we cannot control what is out there, but this one is kind of scary.

Thursday, November 29, 2007

Lactards unite

My daughter uses the term "lactard" for those of us in her family and friends who are lactose intolerant. I thought she invented it, but I have since discovered that is not the case. I'm not sure how I feel about the term, in that it feels vaguely politically incorrect, but it has now become a regular part of our family's language.

Anyway, she sent me and others the ad above, with the following note: "To my favorite lactards, I think this is supposed to be about the treatment of cows, but it's funnier if you read from a lactose-intolerant point of view."

Wednesday, November 28, 2007

The Orb has arrived

A couple of weeks ago, our CIO John Halamka started a new feature on his blog about new devices and gizmos. The first one was about the Orb. He writes, "The Orb is a handblown etched glass sphere containing LEDs for every color of the rainbow plus a text pager interface with an XML parser. . . . Metrics are turned into a web service call that results in a page to the Orb every 5 minutes, updating the color."

John noted that you could "place Orbs at the nursing stations, in waiting rooms, or on the CEO's desk etc."

Being an MIT grad (and apparently sharing one of John's geekiness genes), I couldn't resist, and he was kind enough to get one for me and install it. You see it on my desk above. It gives me a signal of how many people are actually in the waiting room in our Emergency Department. The Orb supports 35 different colors and glows blue if no patients are waiting, greens for 1 to 5, yellows for 6 to 10, reds for 11 to 20 and flashing red for over 20.

I know this might seem a little silly to some of you, but I actually like the idea and wanted to see it in action. For people who want to keep track of important metrics but don't want to have to check their computer over and over again, it is a handy tool with lots of applications.

Safety in the NICU

Mark Graban at Lean Blog asked the following question as a comment to a posting below. It is interesting and important enough to repeat here for a larger audience -- and particularly for people at other hospitals who might find the answers of value. I am sure the BIDMC people mentioned would be very happy to provide further information to people from other hospitals. (Also, I have to admit to a little pride in that our folks, who already thought they had a very good plan on this matter, went further to adopt additional safeguards for these very tiny babies.)

"Do you have thoughts to share on the preventable heparin error involving Dennis Quaid's twins in L.A.? What steps is BIDMC taking to proactively prevent that same error from occurring in your hospital?"

After consulting with our people, I posted this initial response, with the help of Greg Dumas, one of our pharmacists:

I asked our folks about the heparin question you raised. Here is part of the response from one of our pharmacists. As you can see, the staff is still working on other ideas.

"Please see the steps below that we put in place prior to the tragic September 2006 incident at Methodist Hospital in Indianapolis.

"1) Heparin Flush Syringes 10 unit/mL are stocked in the NICU Automated Dispensing Machine(ADM). These syringes are stored separately from adult heparin products in an area designated for "Neonate Use Only".

"2) All medications that are filled in the NICU ADM are checked by a pharmacist prior to delivery.

"3) All heparin containing intravenous fluids are prepared by the pharmacy.

"Additionally, the pharmacy does not stock the Baxter heparin products , which were involved in both the Indianapolis and the LA incidents.

"After the most recent heparin incident at Cedar Sinai, our Clinical Pharmacy Coordinator Medication Safety, we decided to evaluate utilizing the bar code technology as an added safety measure. The NICU/Pharmacy Committee will review this at this Tuesday's meeting.

"Providing medications safely and effectively for our NICU population is of utmost importance to our pharmacy."

And, a bit more explanation:

"The Methodist Hospital NICU stocked heparin flush 10 unit/mL in 1 mL vial. The pharmacy technician mistakenly delivered heparin 10,000 unit/mL vials which are used for SC injections for DVT prophylaxis(there are also 20,000 unit/ml vials). This is what caused the 1000 x overdose. The news stories do not say that a pharmacist checked the vials before they before they were delivered. We require all medications be checked by a pharmacist.

"I am comfortable that this could not happen here. We purchase pre-made 3 mL heparin flush 10 unit/mL in 12 mL syringes. These syringes are blue and stored in a special section of the pharmacy designated for NICU only. The adult heparin flush syringes are 100 unit/mL and in a yellow syringe. These are stored with the main inventory far away from NICU stock."In July, we began stocking the NICU with premix heparin IV solutions. This enabled us to remove the heparin 1000 unit/mL 10 mL vial that had been stocked for nurses to prepare initial IV bags for UAC and UVC lines. The RN would add 500 units to the 1 liter bag of fluid.

"We removed the heparin 1000 unit/mL vial in July and the only heparin in Omnicell now is the heparin flush syringe. This was a safety quality initiative that the NICU/Pharmacy committee had started a couple of years ago and finally implemented it this July."

I just received a followup from Susan Young, clinical nurse specialist, in our NICU:

"The NICU/Pharmacy committee met today; pharmacists Karen Smethers and Steve Maynard joined us to look at other safety measures we could use in the NICU to prevent mis-dosing heparin. The NICU has only one concentration of heparin stored in Omnicell - the 10 unit/mL syringe. This syringe has a blue label. There is another syringe available through Pharmacy that is 100 units/mL. It has a yellow label.

"Omnicell has the ability to read barcodes. We decided to use this feature for heparin to provide a double check for the system. Pharmacy technicians load the heparin syringes into Omnicell. When they do this, they will barcode the heparin syringes. This will provide some safety, but will not ensure that all syringes are of the correct concentration because only one syringe can be scanned when filling the Omnicell bin. (To scan each syringe would require the technician to close the draw after each individually scanned syringe and re-enter Omnicell.)

"The second part of the safety will require the NICU nurse to scan the syringe when removing it. This will ensure that she has removed a syringe with the correct heparin concentration, in the chance that a syringe was incorrectly loaded in a batch. These added steps provide some added layers of safety.

"The NICU is moving ahead with implementation of POE. This will also help to prevent errors and overrides when we have a quicker way of sending order sets for medications to the Pharmacy. Admission of infants to the NICU is one time when we remove medications prior to them being overseen by Pharmacy. Umbilical lines require heparin, vitamin K and erythromycin are administered quickly. POE will help with this process. One system issue that interferes with a more rapid process is that infant medical record numbers are generated after an infant is born. The committee will be examining whether it is possible to start that process earlier so that medications that are needed immediately after birth would be ordered and authorized by Pharmacy, in some cases even prior to the birth of the infant. Working with Admitting is key to this part of the plan, and one that is recommended by Karen Smethers as a way to provide more Pharmacy oversight."

Tuesday, November 27, 2007


A friend invited me to opening night at the annual Auto Show in Boston, and I thought it would be a nice break from health care, so I went. With much of my background in the energy field, I was of course attentive to the degree to which the auto industry is making efforts to be more efficient. I am sorry to say I had to look really hard tonight at the auto show to find much evidence of those concerns. I guess the manufacturers and dealers figure that the public really is not going to focus on energy efficiency, even with gasoline at over $3 per gallon.*

My favorite vehicle in that regard was a Yukon. When you are driving around, you really don't get a sense of how BIG this truck is. City mileage was given at 16mpg, and highway mileage was 19mpg. But, in an attempt to offset this, there was a sign pasted across the windshield bragging that it uses ethanol 85.

With no offense meant to the farmers in the Midwest, this is not a solution to our energy problems. According to this report and others I have seen, ethanol production from corn apparently is slightly better, in terms of total energy use, that using petroleum directly; but we would really be better off if the ethanol were made from the cellulose is woody, fibrous plants.

And, of course, whether gasoline or ethanol, we would be still better off if the vehicles we used achieved more miles per gallon. On this front, Congress (yes, both under Republican and Democratic majorities), has been noticeably deficient in nudging the auto industry to higher mileage standards. Instead, they have pushed the country toward creating subsidies to corn farmers in the cause of encouraging ethanol use. Maybe those Iowa presidential caucuses are scheduled so early to ensure that neither party forgets the farmers! In any event, I see little or nothing in the national public debate on energy issues that improves on what we knew or were trying to do 30 years ago, when the first bump-up in prices occurred. Perhaps the real leadership in this arena will come at the state level and from corporations that are forward-looking in their own operations and in anticipating and satisfying consumer demand. As an example, check out today's announcement by Google and see what you think.

*My European readers will laugh at this when we say this is a high price, as they pay about that amount per liter.

Grand Rounds is up

Grand Rounds is up at Prudence, MD. Please check it out.

Monday, November 26, 2007

Responses to Thanksgiving email

As promised, I want to keep you up to date on responses to the staff email included in the post below. The email certainly struck a chord, and the replies give you a sense of the range of feelings within our hospital. This is the one that sticks with me the most and gets to the heart of what I would like to change: This facility provides great pay and benefits. Fulfillment, though, is something that I seek elsewhere. What a shame that we cause anyone to feel that way!

Remember, these were not anonymous replies, and I am fortunate that people here are so forthright with me. These are mostly unexpurgated and presented in the order I received them, so you get the vicarious pleasure of reading both the good and the bad. And yes, you can laugh (or groan) with me at the humor!

I am guessing that people in other hospitals will see common themes -- or would, if they asked the questions.
Hi Paul,

You're SO right about the fetching!!!

Three things come to mind:

1. On rounds, I spend at least twice as much time looking for patient charts as I do with the patients. This is due to simple lack of consideration by my colleagues who feel they are too important to spend their time putting the chart back when they're done with it---some consciousness-raising here would be great!

2. We had a semi-similar program here in the 80's called "Prepare 21" as in "prepare for the 21st century." (But I'm sure you already knew that. . .) People were very skeptical about the program until they received their first "incentive" check which distributed the cost savings the hospital realized during that quarter from implementing the suggestions made, then suddenly the whole staff was on board and knocking themselves out for new ideas. (It would have warmed your heart if you had been here then.)

3. In the movie "Mean Girls" (a classic) the girls tried to introduce a "cool new word" into the vernacular; that word was "fetch" (as in, "your new sweater looks really fetch.") Maybe the inspiration for the new program's name could come from there???

All the best for a great Thanksgiving (the best holiday of the year, since it is the all-American, non-sectarian, no-gift-giving-pressure holiday devoted to family, eating, and football.)
What a wonderful email Paul !!

I am proud to be a part of BID.
I think it should be named The 3rd Hand...since every nurse wishes she/he had an extra hand and also, tends to multi-task beyond the call of duty.
Hello Paul,
It might be a "fun" idea to have a contest on picking the program name.
My program name would be "let’s have fun getting it done".
I loved this communication. I’m ready to get involved!
Hope your Thanksgiving is also wonderful…
Hello Mr. Levy,
Hospitals typically make use of an antiquated hierarchical form of management. This is true for the BIDMC, and we keep using a playbook which relies on scolding and belittling the staff. And yet we continue to call upon outside consultants to speak with the staff, while year after year the existing management teams treat input from the front lines with contempt.

Why can’t our current management staff learn from their own teams? Is it a feather in our cap to point out that we are hiring—paying for—outside consultants to find out how we can improve? Can we not "capture value" and get "lean" with our current leaders? Whenever I have an opportunity to answer survey questions, I always respond, "Please talk to your staff."
I’m convinced that this could work.

I don’t mean to have a disrespectful tone. This facility provides great pay and benefits. Fulfillment, though, is something that I seek elsewhere. How many former managers in our midst want nothing to do with leadership positions? Your concern and good wishes for Thanksgiving—and for the general improvement of the professional development of the staff are genuine and appreciated. Thank you.
Truth is, we also spend tragic amounts of time documenting instead of being in contact with patients. Even more than fetching.
I love this idea.

When I am rounding, I spend a lot of wasted time looking for and "fetching" charts that were not put back on the rack after someone used them. This shows lack of respect for whomever they think will put them away (reminds me of my teenager…)
Thank you. Happy Holiday to you and to your loved ones as well. My suggestion for the title is "Let us make it work, TOGETHER".
Dear Mr. Levy,
What a wonderful way to start my day. My motto has always been in my 30+ (ahem) years that "This is not just a paycheck". I truly believe if this program is successful, that employees will take pride in their work and feel "valued" and that they are not here to simply put in their time and then go to the bank for survival. The increased self esteem will also be such an added perk.
I hope you have a safe and happy holiday as well.
Mr. Levy,
I normally don't write back on these sorts of things, but this one has caught my attention. I personally can answer no to two of your questions. Many employees in my position feel like the extra's we do go unnoticed but if we make an error it is immediately noticed. Each day I come to work and think about the person on the other side of my counter (the patient). I treat each patient as if he/she was my mother or father. I try to instill in others that patients come here because they are usually sick. This is especially true in my division (thoracic surgery). The last thing any patient or family member needs to hear is "I don't know" or feel as though they are bothering us. I love what I do for work and I would relish the thought they our supervisors would notice a job well done. Telling someone they have done a good job goes a long way and brings a smile to the employee. Feeling good about your job is an important part of doing a good job. Thank you for taking on a project to make each employee feel as thought he/she is a valued employee. My suggestions for a name for your upcoming program are: Feel good at work and I matter.

Happy Thanksgiving.
Hi Paul,
This is very, very exciting news. Your idea is wonderful. I have one suggestion that you might find of value. It may be helpful to create a hotline, either a phone or email based response venue that allows employees to report stuck ideas.

The one thing that is very discouraging is when people work hard on finding solutions only to have them get "lost" in the system. One of the major stumbling blocks in a large institution like this is that what one person does can and often does affect others in different departments. So when a change is proposed, it has to go through a committee. It is important that feedback be given to those who worked on a solution, especially if it is discovered that one aspect of the problem is made worse by the proposed solution. They should be encouraged to work with the department to find an acceptable solution.

In order for employees to feel empowered, they need to have a voice in finding out what is happening to their proposal.

I really appreciate your leadership. We are truly lucky to have you as our team captain.
Dear Paul,

Happy Thanksgiving to you and your family also. I want to compliment you on the wonderful vision you have at just about everything you do and say and plan, I truly appreciate all your efforts.

Yes, you caught my attention and in my opinion you are right on target. I think BIDMC does a superb job generally but I believe there is always room for improvement. The thought that keeps coming to my mind about what to call the 'program' is to look at it from the perspective of why these "work-arounds" can be so prevalent. I think it is because of how we all choose at times to 'overlook' things. Such as "oh well that was the last 'whatever', I don't have time to tell somebody my patient needs me now, I am sure someone else will order more", etc. I think a good name for the program might be DO. Which I believe would stand for Don't Overlook. If just a few more people chose to not overlook something we could be even better than we already are to our patients and fellow staff.

Thanks for caring so much.
Good day Mr Levy,

You should name the programs (DRKN) it identify the three questions. D is for dignity, R is for respect, K is for knowledge, and finally N is for notice.
Hi Paul
I find this idea intriguing, I have a suggestion with a little humor attached:
S uggestions
M aking "SMILE"
I nstitutional
L ife
E asy

Enjoy the Holiday
Good Morning Mr. Levy,
This message may be one of hundreds that you receive this morning alone; I just wanted to drop a quick note to thank you for your timely message. This is an issue that I have been bringing in to work recently. It's nice to know that it is being discussed and that more is to come.
I wish you and your family a wonderful Thanksgiving.
What comes to mind-
Smart Care
Working Smart
HOW ABOUT "FETCHING R-E-S-P-E-C-T"------I think ARETHA FRANKLIN would respect this choice!!!!!!!
A suggested name for this program: RESPECT = Representing Evaluating Specialties Provides Excellent Consistency Throughout

Happy Holiday!
Hi Paul,
This is VERY exciting! I work in the OD group. I've spent a lot of time with the Nursing groups for the survey of their big complaints is this "fetching" you describe. They're tired and frustrated.

I look forward to learning more about this critical initiative!

Happy Thanksgiving to you and your family. Drive safely.
Good Morning,
Happy Thanksgiving to you and your family!
One suggestion for a program name – "Streamline to Success"
What a great idea….When I worked as an Operations Coordinator for Nursing it was a daily challenge.

Maybe we could call it "finding Nemo".
I love my job....always might make it more fun?...bring it on
Good morning Mr. Levy
I know you are very busy and I appreciate your time.

I have been wanting to email you for a bit now.............I came to BIDMC in September as a new Med-Surg CNS for the East Campus. When you spoke to my orientation group you said "if you find something wrong or can't figure out why we do something, tell me soon........for in a very short time you will get used to this way and you won't be of any use to me."

Well, there were a few things here and there but nothing dramatic that you probably weren't already aware of. I have been involved with the LEAN project and that certainly has had an impact on changing work habits, etc.

So why am I writing? Well, two reasons...............
First, I want you to know how genuinely privileged I feel to work here at BIDMC. I have never felt so welcomed or respected. I chose to come here (yes, I had several other offers) and have never regretted that decision. My days are long and challenging but I couldn't work for or with better people.

This Thanksgiving, I have much to be grateful for.

Second, I'd like to be part of the Value Capture project in any way you deem appropriate. I have been trying to find a way to bring the FISH philosophy here to BIDMC It is a simple concept really and incorporates much of what is part of the Value Capture culture....... It is based on the way business is conducted at the Seattle Fish Market.......honestly, I couldn't make this up!

A. Make their day...............what can you do to make your positive energy contagious?
B. Be there..........being fully present in the moment to all of our customers, internal and external. How are you"being" on the job?
C. there a way to bring fun into an otherwise serious situation?
D. Choose your can wake up everyday and 'select' your attitude. Hey, everyday you wake up is a good day as it sure beats the alternative!
....all of this may seem simplistic and obvious, however it has true value and is worth considering.

Thank you for your time and attention. I wish you and your family the very best this holiday season.
Here is my idea.
BID Real MC Time! Or just BIDMC Real Time!
I've been an employee at BIDMC since 1981 and I've seen quite a few changes. We used to have a program called "Prepare 21" where employees submitted ideas and were rewarded with ones that worked and made a positive difference. Art School, perhaps teaching was my first career choice, but soon after marriage and a child, I came to then named "Beth Israel Hospital" and it was one of the best decisions I've made. I continue to enjoy my work today.
I now working in Ambulatory Education & Systems supporting our Ambulatory clinics and working hard to make things work for the practices (and I do teach)! I love taking a creative/out of the box approach to things! Here is my "creative" suggestion:
The BID-HIGH Plan or The BIDMC-HIGH Plan or simply
"Bidding to Better, Caring to Win"
Thank you for your hard work to better this Institution.
A suggestion below:
"Revolutionize Your Job!"
Free your work flow from cumbersome processes and unnecessary paperwork to get to the heart of patient care and support.
For the new program's title:
"Because it's right" or It's only right""We're only human" or "Do the Right Thing" or"WHat I learned in kindergarten""It doesn't take much"or"It never hurts to be kind".
Corny, I know, but, I look forward to the program.
Mr. Levy- Happy Thanksgiving to you and your family. Name for the new program--- "Our Work is Fun!!!"--
Dear Paul,
What a refreshing email! It really hits home. There are countless work-arounds every day that we take care of patients. As a nursing supervisor on the evening shift, I get paged for many most basic, mundane things all the time. Interestingly enough, items that should already be at the point of care are prime contenders! Well, the other night I had this dream: I was paged to bring, get this, a bag of composted manure. Yes, you read that right. I woke up and laughed out loud! So, my "fetching" went from the ridiculous to the sublime! At least they didn't want a bag of lime, which is VERY heavy and could have resulted in a work related injury. I applaud your new idea and I hope it can be very successful.

Happy Thanksgiving to you and yours.
Thank you! Happy thanksgiving to you and your family as well- This project/training tool sounds like exactly what BI needs! I would call it ‘project moral’ for employee moral because that is the underlying heart of BI.
Sounds like a great idea to me and I'd love to be involved.
Love your blog - have never posted, but always read!
Happy Thanksgiving!
I wanted to write back with a thought. It is clear that like most - or more realistically all - medical center employees, I do a lot of fetching & rework. Certainly some of this is related to inefficient processes, and I agree it's a terrific idea to try to improve these processes.
But another problem is that there is not enough support to enable me to do as much physician work as I'd like to do. I spend a lot of time doing work that a non-physician could do. As you well know, lots of support positions were cut during the hospital's very difficult financial times, and many have never been added back. We manage with fewer personnel, but it means many of us are doing work that really would be more appropriately done by others, and all of us are working significantly harder than we have been in the past.

I had brought this point up at a forum you attended a year or so ago, and you had replied that these concerns were valid, but that medical center's operating surplus was not such that adding staff was realistic.

Working smarter is a good thing, but having enough people to do the job is just as important.
Good day Mr. Levy,

I am writing back as you suggested with my idea. My Suggestion for a Name:

(I would have done the text using text art, but I did not have the option on my workstation).

Happy holidays to you and your loved ones.
Good morning,
The program sounds looong overdue. How about:
"SAS" -SaveAStep (ie get "sassy" about saving time)
Have a great Thanksgiving,
Suggested program name "If I had my way, we would ……..".
Hi Mr Levy,
This maybe a start to a name- (driven) program & it stands for d-dignity, r-respect, I- I did it, v- value, e-encounter, n-noticed.
Happy Thanksgiving
Hello Mr. Levy,
How about the program name of "Innovations"!
Just a thought….This will be a great collaboration and I look forward to it.
Submitted for your consideration are a few names for the new program BIDMC will begin working on over the next several months:

The Quality Time Initiative
The Get There Program
The Work Around Initiative
The Gotta Go Initiative
The Short Visit Initiative
The Short Stay Initiative
The Focus Program
The Focus Factor
The Prime Directive
The Prime Time Directive
The Can Do Initiative
The Ready for Prime Time Directive

Thank you for taking time to read this communication. I hope the Holiday is a safe and pleasant one for you and your family.
I don't have an idea for a name - it all sounds exciting - just wanted to wish you and your
family a Happy Thanksgiving.
Healing the healers.
Hello Paul,
I am very happy to see that you’ve decided to take on this monumentous challenge. I can’t think of a better way for all of us to focus on improving the quality of service to our patients.

My suggestion is to name this the "Mirror Image" Program because every time that I have a chance to improve patient care or go out of my way to help anyone, I always consider it a chance to treat that person as if it were myself or a family member. My mirror image encounter. At least this works for me and I am always happy to regard myself as the kind of employee that I would want my Mother to meet, for example, if she had to visit BI as a patient.

Thanks for listening!


One of my college professors once told our class that "Efficiency" is "doing things right" and "Effectiveness" is "doing the right things". This sounds like what this program is trying to achieve so maybe a good name could be "Achieving Efficiency and Effectiveness at BIDMC" or something like that? I’m not crazy about that exact name though… I think it’d be better if the name told people straight out that we’re trying to improve our ability to "do things right" and "do the right things".


Dear Paul,
Sounds fantastic….I look forward to implementing some of the strategies for home too!
For a title how about "BIDMC - Working from the Inside Out" or "BIDMC - Turning it Inside Out!"
That was the first thing that came to mind. I’m sure it will be very clever! Thanks.


Putting air in the Cadillacs tires


A few ideas for names:
Operation Short cut
Operation direct access
Operation Direct path
Operation Straight line
Happy thanksgiving!


"Slam Dunk"
I’m not aware if there is a more efficient process in sports; among leaders, the objective is achieved more than 98% of the time. It can be done with a flourish, but in most cases it is direct and decisive (and has the same value).

Dear Paul,
Here is a suggestion for a name: Project Butterfly Effect.
It is not that funny, but it is both, inspirational and scientific.
From Wikipedia: …" The flapping wing [of the butterfly] represents a small change in the initial condition of the system, which causes a chain of events leading to large-scale phenomena. Had the butterfly not flapped its wings, the trajectory of the system might have been vastly different."
Happy holidays!


I'm glad to hear that we are working on this area that we are in desperate need of repairing. I have often found that we get so caught up in the bureaucracy that we often miss the goal, the patient. I work in the Ultrasound department and I have often heard people say that they were hired to do ultrasounds not office work, which translates into less time for quality patient care. I'm not saying that my co-workers do not strive to offer the best care possible, however, it is exhausting sometimes keeping up with everything else that is required of us.
Thank you, for your constant care and supervision of our facility.

Operation Recovery
Group Care
Caring Group
Fetching Care

How about "STRAIGHT LINE' .....A more direct way to deliver care without all the obstacles!


Good morning Paul,
This popped into my head as I popped the turkey in the oven and myself into the shower:
"Heart Work." It speaks to the staff's work ethic, dedication, compassion, commitment to quality, and, of course, and caring.
BTW, I've been a patient rep here for five years and elsewhere for another five.
I would very much like to team up with you when this program launches. You could use someone who can accurately portray the patients' points of view as you make this place even safer and smarter.
Let's talk (turkey?)!


Dear Paul, The overall idea is excellent, to treat everybody with respect regardless of rank and appreciate others work, but I am not sure how that will cut down all the bureaucratic rules and double work which is forced upon us today. However, in view of the time of launch of this program and its content I think it should be called: "Don’t be a turkey"-program or for short: "No – turkey" program. With best wishes for a happy Thanksgiving


I want to propose the following as a possible name for the new program.
Over time
Lead to

The solution.


Mr. Levy,
Thank-you for the opportunity to contribute to this very important effort. As a new employee here at BIDMC, I am very impressed with the collegiality of the staff and the openness to new ideas. My suggestion for naming this program is: The Patient FIRST Initiative.
The letters in FIRST each represent a characteristic needed to accomplish the goals outlined in your commentary.
This name also emphasizes and reinforces our commitment to the patient. Every minute of every day should be spent with the patient in mind even when we are not directly involved in patient care. This requires each of us to re-evaluate how we go about our daily work, how we interact with and treat each other as individuals, and what changes we can make to provide the best possible care to our patients.
Thanks again for the opportunity to share my thoughts. It is very refreshing to be asked by the President and CEO of a major teaching hospital for your contributions. I am quite sure that I made the correct choice in coming to BIDMC.



what a lovely email!
I look forward to the fruits of this labor.

Now that I am in a non-patient-care role, I do spend a fair amount of time fetching, but more than that I spend time wondering--wondering what my role is, wondering if the person tasked w/ initiating a meeting will get around to it, wondering what the deadline is--basically, wondering how we are going to work together in a team.

In a front-line clinical situation, roles are clearer, more similar to a sports situation, or an industrial process.

The murkiness is draining.

So, I would be infavor of a slogan that captured the clarity of how teams work together.

Since I don't know a lot about sports, I don't have anything clever to offer, but basically something that captures
1. leadership recognizes that it is tasked w/ helping everyone know their role/position and play their best in that position
2. everyone has their own honor at stake for playing their best in their assigned role.

What do coaches say to people to propel them forward in these ways?

I would love to hear more of that coming from my colleagues' lips!


Dear Paul F. Levy,
I loved your email. Dare I hope that things might turn around for the caregivers here? You have turned this place around on so many levels but here in the OR on the west campus we continue to suffer and struggle to provide high quality care. Not a day goes by that I don’t consider leaving because of system inadequacies. I won’t waste this email detailing our woes but instead look forward.
Based on your description of us fetching…. I think you might call it the Fido Project. It’s fun, it’s light, it’s non- bureaucratic. Your project can be used to transform "fetching" from a verb to an adjective. I have more ideas but right now I have to run to get something.
Thanks for reading,

One less step


Hello Paul,

Well you hit the nail on the head about antiquated systems, etc and also with the 3 questions which allow greatness to be possible. Value Capture is good. It can work here.
I returned to the Deaconess (BIDMC) after working here 25 years ago. I have been caught crying in the bathroom (which shouldn't happen at age 49) both frustrated and disappointed. I thought I was coming back to major league, and I have, except that systems you mentioned are far worse than I had expected for a hospital of such caliber. Even my superiors admit to the chaos. One said to me, "You will learn to function in this dysfunctional environment" - How sad and telling is that!! I want to like my job.

Fetch is a verb which should only apply to a dogs actions, so I will propose your program to be called "No Fetch"
I doubt it'll go over but it is unbureaucratic! How 'fetching' is that!!


how about Absolute Fabulosity? :)


Paul Levy,
Thanks for daring to take the steps that have led this institution to firm footing.

Of the past you underscore:
1. Big institutions, like most hospitals, are based on old patterns and systems.
2. Other fields have progressed in terms of process improvement, but medicine is woefully behind.
3. Personal commitment, hard work, and good will, have allowed patients to get extraordinary care, due to "work-arounds" (despite the suboptimal effectiveness of systems).

Goal: Engage the whole medical center in strategic planning.
We seek, the next steps, to advance the process. How to begin to solve the "underlying work process problems."
It's time for us to get "HIP" to the improvements which will drive this organization to superior continued growth. This name ("HIP") is a mix of bureaucracy and modernism, with a flair that grabs attention. In fact that is also the point of the whole new "not-a-program"--to as much as reasonable advance old bureaucratic positions/patterns to more adaptive ones, but accomplish it with a vigor and flair that is exciting, even trend-setting.

It's time to get "HIP" to the New Directions at BIDMC--You tell us how!! You show the way!!

How to improve HEALTH at BIDMC?
Get HIP--(Join BIDMCs' H.E.A.L.T.H. Improvement Program)

Hospital Efficiency And Long Term Healthcare Improvement Program. H.E.A.L.T.H. Improvement Program

Nice because it ties in older concept of Hospital Efficiency Index (HEI), but emphasizes push towards new directions in medicine towards "health," not more classical/currently accepted "management of illness." Such "management" is institutionally embodied in rigid adherence to "work-arounds" that ought to have long been supplanted by systems adjustments. "Management" has its accepted share of the activity at any time, but dramatic advances in treatment (and institutional effectiveness and patient care) will multiply, when a thoughtful process has been engaged about how we can all get "HIP."

Help us get "HIP." Join BIDMCs' HEALTH Improvement Program.
"Setting the trends (viz. synonym for 'hip') for a Healthy Future." Beth Israel Deaconess Medical Center.

Issue 1: Working together to be a trendsetter. (Regardless of role or rank, I have real knowledge to share with and about My BIDMC--and WE care, listen and respond to every concern).
Visual 1: You or someone else who embodies the institution (like the Apple vs. PC commercials) could dress in a stuffy way (clearly not your usual style), and act as if they are trying to learn a new dance step.

In the distance an employee who had been cleaning the floor or some other work (holding a mop, or a pipette, or a phlebotomy tray, RN pausing as they put something into the tube system, MD looking over while typing a note into computer) could be shaking their head and laughing, while rubbing their head in amusement.

Another shot could have them sitting next to you working through an issue they identified (showing you/us how to be/do "HIP.")

Help us get "HIP." Join BIDMCs' HEALTH Improvement Program.
"Setting the trends for a Healthy Future." Beth Israel Deaconess Medical Center.

Issue 2: "Pain" of doing the "training and (learning) new approaches to our work." "Learning!--When's the test?"
Despite the "it will be fun" argument--I'm sure it strikes fear into seasoned staff, nurse and physician alike, and probably even some administrators. "Once again another new procedure, process, system, and an additional layer of paperwork, I have to learn!?" "Fun!--yeah, hearing you loud and clear boss."
(Learning this set of knowledge, tools and support will enhance my ability to contribute to and enjoy My BIDMC and my private/personal endeavors).

Visual 2: Grouchy caricature of employee reading the "Get HIP" announcement, reads the line, "It will be fun." Retorts, "Fun!--yeah, hearing you loud and clear boss. Another set of papers to fill out." (The really jovial medicine attending who works on IT integration, though not so grouchy, could swing this well also.)

In the background or in another frame, the room where the training is going on, can have Club lights and music and people doing the electric slide, while a few are off on the side learning how to do it.

[Learning the electric slide. It's a 'fun' experience, that most people found at least a little difficult--to have to tolerate the learning process. But after doing so, most have enjoyed years of real fun after just a little time adjusting and learning. To bring this right home, the picture could be 'staged' in the cafeteria, as if the cafeteria were going to be the room used to do the "training." All the chairs tables could be stacked to the side, DJ in place and employees (or actors dressed as such), could dance around for the shot and others act the part of learning the new steps. You've got to be in the shot--nice if a few department heads (RN, SW, Cafeteria, Medicine, Surgery, Psychiatry, etc), could swing over for some of the shots also].

Tag line-- Can you do the Macarena?

Get "HIP." Join BIDMCs' HEALTH Improvement Program.
"Setting the trends for a Healthy Future." Beth Israel Deaconess Medical Center.

Visual 2A Another Visual or another part of Visual 2, could have people doing limbo dancing, where each person's effort is recognized or "Soul Train" Line Dancing where the whole line watches one person do improvised/interpretative dance. (This could emphasize the notion that many people are pausing to recognize and appreciate each person's contribution).

Issue 3: The Fetch-It/Re-Write Paradox
Visual 3: Harried RN/staff/MD, can be seen in a blurred shot running back and forth for papers/medicines/labs/supplies etc. Or frustratingly copying information from one format to another--yet another time, for billing purposes/or whatever reason.

First screen is all that's needed. With tag- "Don't you think it's time to get HIP?" Join BIDMCs' Health Imp . . .

A second screen, could show person with a light bulb coming on above/in their head.

Third screen, Slick (well-groomed, etc) follow-up shot of same person, with- Are you HIP? button, clipped on to their white coat--no longer harried, but now dancing fluidly (or contentedly proceeding) through their work, in half the time with improved accuracy (improved patient care).

Get "HIP." Join BIDMCs' HEALTH Improvement Program.
"Setting the trends for a Healthy Future." Beth Israel Deaconess Medical Center.

Question: Do patient's also have the opportunity to get "HIP?" Could be a way to enhance participation in patient survey's of Quality of Care/Treatment Experience.

Bless you for finally doing something about this!!!! I became an x-ray tech because I never wanted a desk job, but's just as you said.

Any chance the project could start in the west campus O.R.? There is so much $$$ waste in staff turnover (requiring expensive temporary staff, overtime shifts, etc). Have you ever seen the list of experienced OR staff who have left here (because of frustrations with the systems)? It’s as long as your arm. Most staff didn’t WANT to leave, they just felt they couldn’t tolerate the dysfunction any more. I know that because I have worked here for 20 years and watched my friends leave one by one.
It CAN be fixed. But it requires that someone important care.
Thanks for reading.


As institutions like ours are particularly enamored with acronyms, my suggestion is:
Redefining Efficiency - Valuing and Managing Proficiency (RE-VAMP)


Hello Mr. Levy,
Despite having a militant connotation, I suggest "Mission Ready Program". The program has the concept of what occurs in the military before personnel are allowed to go into the field of combat; that is to have all elements of the process by which we deliver our services functioning at the highest level prior to execution. If we think holistically about the challenges we face, it is much like a battle that we must overcome, or better yet a war. We win our little battles with our workarounds, but the war deals with the underlying problem that seeks and needs resolution. Second, the concept of the hospital’s mission statement is evoked. Again in the military it is known by all what the organization stands for and what guides the organization based on the mission statement. Illuminating the idea of the mission statement brings focus of values and pride to the people of the organization. For us to face the challenges that you have laid out, it is a fitting concept.
Thank you for your consideration.


Dear Paul,
Hope your holidays were wonderful. This new initiative sounds just wonderful and so much in the BIDMC philosophy and spirit. So, in my spare time between patients here are some names. Don’t know if there is a deadline for naming the program and others may come to me if you want more!

Old Problems: New Solutions
Old Problems/Fresh Ideas
Show Us The Way!
Try It, You’ll Like It!
Solution Central
Staff Strategies
2008: In with the New
Not the same old, same old
Anatomy of the Workplace
Better Idea Design Makes Cents
Better Ideas Deliver More Care


Service Improvement or P.I.G (Process Improvement Group(s))