Sunday, September 30, 2007

On refereeing

Just finished a very busy weekend of refereeing youth games, from U10 all the way though high school. I have been refereeing kids soccer since 1994 and really enjoy being out with boys and girls while they are out enjoying themselves.

There have been many reports of parents and coaches abusing referees during youth games, and I don't want to spend much time on that. People who have grown up yelling at professional refs at baseball, football, and basketball games and view it as a privilege of the ticket price (my favorite: "Hey ref, you are missing a good game!") forget that those of us who officiate at youth games are not professionals and do it strictly as a community activity. Yes, we get paid a little bit (I donate my pay to charities) but that is just a symbolic recognition of the time and commitment that goes into doing the job.

I have noticed that some coaches and parents sometimes forget that a soccer game consists of a group of children kicking a piece of leather around a grass field. Does such a game ever have deeper meaning that that? Sure, it promotes teamwork and skill development and other good things, but it is fundamentally a group of kids who are PLAYING. We need to remember what playing is all about.

The other point is that it is hard to be a good referee. You are making a multitude of decisions and judgment calls (especially in soccer, where you are trained to keep the flow of the game going and not interrupt things for minor fouls), and you are doing this in real time with 12, 16, or 22 players on the field. You do it in good weather and bad, and when you are fresh or tired. You are on the run for over an hour (reportedly 5 or 6 miles in a 90-minute game), and you do not have a substitute (unlike the players.) Plus, you can only call what you see, and you cannot be looking at the entire field all the time, and sometimes players block your view. If you are parent or coach, try it sometime during a practice scrimmage.

There are times you need to remind the adults to behave to maintain a positive atmosphere for the children during a game. Here are some of the most effective things I have seen a referee say to a coach who has been not behaving properly during youth games.

John (adult ref) jogs off the field as the game progresses and stands right next to a coach who has been carping about his calls. The coach says, "What are you doing here? You need to be on the field." John says, "You know, you are right. You CAN see things better from here."

Art (adult ref) stops near a coach who has been complaining. "How do you have time to both coach and referee? I can only do one at a time."

And finally, Ally (age 14 referee) approaches an adult coach who has been persistently yelling about her calls. He is 6 feet tall and 200 pounds. She is just reaching 5 feet and may be 100 pounds. She stands in front of him and looks up and says very quietly, "Don’t you think you are taking things a bit too seriously?" He is silent for the remainder of the game.

Saturday, September 29, 2007

First (Class) Aid

Here's a picture of some of the BIDMC first aid team at Fenway Park last night, where they were recognized by the Red Sox in a pre-game ceremony for their great service to the patrons at the games. Nurse Cyndi Casey represented the group by throwing out the first pitch -- reportedly a strike over the inside corner.

Traffic Patterns

For years, my wife has claimed that the traffic gets worse every September in Boston. Not worse compared to the admittedly low-volume summer traffic, when many residents are on vacation and the 300,000 college kids are away. But worse compared to the previous September.

Each year, I disagree, saying that it just feels that way compared to the summer, and that you can't really remember what it was like a year previous. But this year, I am moving in her direction. Something is going terribly wrong this September. There are massive traffic tie-ups, randomly assorted throughout the metropolitan area. The "secret" routes the locals would usually take to avoid these are also congested.

If the Center for Short-Lived Phenomena were still around, I would send the query to them. But they seem to have disbanded. So, being a trained urban planner, I looked for the answer in the data.

If the number of miles of roads has stayed about the same, perhaps the number of vehicles on the roads has risen. Alas, it is really hard to get those numbers. Here is what I found on the web:

Total vehicles in operation in Massachusetts
2000 -- 4,933,209
2001 -- 5,198,221
2002 -- 5,406,846
2003 -- 5,479,394
2004 -- 5,456,267
2005 -- 5,420,206

Not good enough. I'm looking for a recent uptick and the data aren't there. Maybe I could dig up the number of new vehicles registered more recently. Here are those figures:

New Cars and Light Trucks Registered
2004 -- 329,941
2006 -- 291,556

But as new vehicles are registered, others are scrapped. The two charts seem to indicate that these may cancel out in any given year. For example, even though there were 300,000 new registrations in 2004, the 2005 total number of vehicles really didn't change very much.

But perhaps the use of vehicles has gone up even if the number has stayed about the same.

Maybe there is a hint from transit ridership. If that has gone down, more people would be driving their cars more often. We sometimes read articles about a decline in ridership. Did it happen this year?

Again, official current data are hard to find. Here are the latest published numbers I found.

Average weekday ridership on the MBTA
2000 -- 664,000
2001 -- 697,000
2002 -- 663,000
2003 -- 664,000

Not helpful at all.

Well, enough city planning for a Saturday morning. It is time for me to go referee some kids' soccer games. While I am away, perhaps someone out there can submit a good answer to this question. Or even just suggest some other theories.

Friday, September 28, 2007

October baseball

Back in March -- wanting to give my loyal blog readers ample opportunity to criticize or praise my managerial judgment -- I discussed our decision to be Official Hospital of the Boston Red Sox. The jury of my peers was split on that issue, but I want you to know that it is an intensely popular thing among our employees and physicians. Notwithstanding the (ahem!) high regard with which I am held by the staff, if I were to end this sponsorship arrangement, I would be dead meat. So I am happy to report that we were pleased to reach an agreement with the Red Sox to extend it for a second five-year term.

Here is a typical email from a staff member on the subject, when it looked like the team was imploding a couple of weeks ago, while our football franchise was doing really well:

Thank GOD! We have the Patriots to lessen the pain.
They won't break your heart like the SOX do 85 out 86 years!
A lifelong disgruntled SOX fan!

PS. By the way, do you have any SOX tickets

As you can imagine, when the playoffs arrive, there is a lot of interest in the allocation of our company seats at Fenway Park. We want to be really, really fair about this, while also using the opportunity to support a worthy cause. Here's how we solve the problem each year, as detailed in an excerpt from my email to the BIDMC community:


Now that a playoff berth for the Red Sox is assured, we can offer the long-awaited BIDMC Playoff Series Raffle. All are welcome to participate. As in the past, raffle tickets will be $5 each. You can buy as many as you like. As in the past, too, the proceeds of the raffle will be in recognition of a special group of people.

Who Benefits?
For the Divisional championship series, the proceeds will go to support the professional advancement programs of our Medical Technologists and other staff in the Pathology Department. These folks are among the unsung heroes of our hospital, performing millions of blood and tissue tests every year, running our blood bank, and carrying out other critically important tasks. Without them, the work of the hospital would grind to a halt. The proceeds of the raffle will give them scholarships to attend professional seminars. So, even if you don't win a game ticket, you can rest assured that your purchase will go to a worthy cause.

Which Tickets are These?
These are the two BIDMC corporate seats in Row 2 behind home plate. This is a view of the game that few get to experience, and here's your chance! We will pick three winners, one pair of tickets for each of the three potential home games. (Sorry, if you win the later game’s seats and there are fewer than three games, you will still get the tickets, but you will only get to use them by hanging them as decoration on your wall!)

We will do a separate raffle for the next playoff series, the ALCS, and the one after that, the World Series, if and when the Sox make it that far.

How Much, When and Where?
Raffle tickets cost $5 each. They will be on sale:

Friday, Sept. 28, and Monday, Oct. 1
11:30 a.m. – 1:30 p.m.
East campus Ullian dining area and west campus cafeteria

At off-site locations, the following staff members have graciously agreed to sell raffle tickets. Please be considerate and e-mail or call ahead before you visit:

** – Bowdoin St.
** – Lexington
** – Needham
** – 109 Brookline
** – Chelsea
** – Renaissance Center 5

The Rules
The raffle is for BIDMC, BID-Needham, BIDMC off-site, APG and CareGroup Corporate staff members and volunteers. You MUST HAVE A PHOTO ID FROM ONE OF THESE ORGANIZATIONS to purchase raffle tickets. There is no limit to the number of raffle tickets you may purchase.

If you work evenings or weekends, or cannot make the dates above, you can make a photocopy of your ID and ask a colleague to purchase raffle tickets for you, or you may contact Volunteer Services.

The winning raffle ticket will be drawn on Tuesday, Oct. 2, at 3:45 p.m. in my office. The winner will be informed via phone and e-mail, and the information will be posted on the BIDMC portal by 4 p.m.

Good luck!!

Thursday, September 27, 2007

More SEIU letters to doctors

I have discussed below the tactical use of letters from the SEIU to doctors at our hospital. Here is another type of letter. This one was an email sent to the doctor's business address.

This is clever approach to appeal to doctors' sense of concern about patients and to try ultimately to create a divide between physicians and hospital administration. Let's deconstruct this a bit -- first on elements of style (which, admittedly, are very well done!) First, the writer gives the impression that she has actually talked with other doctors in the hospital, who recommended that she contact this one. But, none of those doctors' names are provided. Second, while for privacy reasons I have deleted some personal items relative to the author's family, she made use of a familial connection to medicine to generate a sense of camaraderie and appearance of some technical knowledge of the field. Finally, there is an element of informality in the closing, i.e., use of first name and "Cheers", as a way to present a sense of intimacy, along with the offer to hold conversations confidential.

On the substantive side, notice the choice of topic, as though there is something special or unusual about the issue of patient bed delays at this hospital. Every hospital in Boston has delays in patients passing through the Emergency Departments. This has been well documented. Ultimately has to do with how much bed capacity you choose to build on the medical/surgical floors and in the ICUs. Each hospital tries its best to manage bed capacity and avoid the need for expensive new construction. (I wonder if the SEIU has written letters like this to all of the Boston hospitals.)

From: Sara Rothstein
To: Dr **
Subject: Patient Bed Delays @ BIDMC

Dr ** -

A number of physicians across BIDMC have suggested that I talk to you about the hospital’s challenges with patient bed delays.

By way of introduction, I am working with SEIU 1199/United Healthcare Workers East and leading its new physician outreach project in Boston. The outreach project is being done in conjunction with the union's efforts to organize healthcare workers at hospitals across Boston. . . .

SEIU 1199/United Healthcare Workers East has a strong history of partnership with healthcare providers and we would like to have similar partnerships in Boston, with the hospitals and with the physicians. As such, I am meeting with physicians to better understand the concerns and priorities in their departments. A number of people have expressed frustrations with delays in moving patients from the ED to inpatient units, moving patients between inpatient units and moving patients out of the hospital. Everyone I’ve spoken to has recommended that I speak with you for more information.

Would you have some time to talk more about this? The conversation would absolutely be confidential. I’d be happy to meet with you at the hospital or elsewhere if you prefer.

I look forward to hearing from you.


Sara Rothstein
Physician Relations

p.s. I want to apologize that you didn’t receive a letter we sent to BIDMC physicians last month. The letter to you was just returned to the union for being sent to the wrong address. I am attaching a copy of the letter and related attachments to this email. The letter was sent to physicians to explain our position on Free and Fair union elections. There has been a lot of back and forth on this topic between Paul Levy and the union and I’d be happy to answer any questions you may have.

Wednesday, September 26, 2007

Gotta love this one

In the continuing series on email solicitations to the CEO, here is one from a marketing company. If you are a marketing company, shouldn't you be better at marketing? Sorry if this embarrasses the sender, but I can't leave out certain items as I present the critique.

Hi Paul, [Use of "Hi" rather than "Dear". Use of first name rather than "Mr. Levy". This is overly familiar. May be appropriate among people of a certain generation, but definitely not so for people of my generation. BTW, in our hospital, we have a rule requiring patients to be addressed as Mr., or Mrs., or Ms. until and unless the patient permits the use of the first name.]

A friend of mine said we should be in touch. [An anonymous friend of his said we should be in touch. Is this supposed to be persuasive or meaningful?]

I am the Business Director for **, the leading medical marketing communications agency in Pittsburgh. [I love Pittsburgh as a city, but give me a reason to consider a firm that is not local when it comes to marketing.] We specialize in helping medical clients and laboratories build powerful brands and interactive experiences. [Why would I think that interactive marketing experiences would be of any value to or appropriate for a hospital?]

Can we be of any assistance to Beth Israel Deaconess Medical Center? [Hint: Never ask a question that has "yes" or "no" for an answer. The answer will always be "no".]

[Absence of "Yours truly" or other such closing.]

- Greg [Still overly informal.]

Greg **
Business Director
** Medical Marketing Communications The Marketing Agency to Medical Clients & Laboratories http://www.**.com/ [Poor formatting in that three lines of text are grouped together instead of starting each afresh. If I want a marketing company, I want one with good graphics and presentation skills.]

Tuesday, September 25, 2007

Yet another page from the playbook

Another in the continuing series about the tactics used by the Service Employees International Union during its union organizing efforts. In other jurisdictions, the SEIU has opposed hospitals who wanted to issue bonds to support clinical activities and projects. A key reason: To apply pressure on boards of trustees and management to agree to concessions that would tend to increase the chance of the union's success in organizing the workers.

Here in Massachusetts, the state agency charged with reviewing and ruling on such issues is Mass HEFA, the Health and Education Facilities Authority. This is a highly respected agency, one of the largest of its types in the country. It has diligently and professionally reviewed applications by non-profits to float bond issues for several decades.

Recently, Caregroup, the nonprofit corporation that owns BIDMC, Mt. Auburn Hospital, and New England Baptist Hospital, filed a notice with HEFA concerning a potential bond issue to fund capital improvements in the three hospitals. SEIU personnel have been monitoring this process and have most recently filed a Freedom of Information Request asking for documentation between CareGroup and HEFA on this proposal.

Of course, all information covered under the state's FOI law will provided, as it would be under any legitimate request. But this activity by the SEIU raises the question of whether the union intends to try to delay the issuance of such debt or to try to have unusual conditions applied to it, and if so, for what reasons and for what purpose.

[Disclosure: Many years ago, well before taking this job, I provided consulting services to MA HEFA in support of its effort to create an energy-purchasing cooperative for colleges, universities, hospitals and other non-profits across the state. The program, PowerOptions, remains in service to many non-profits in the state and continues to provides financial savings on their energy bills. I currently have no financial relationship with the agency and have not had any during any part of my tenure at BIDMC.]

The FTC rules

Check out this August 6 Federal Trade Commission ruling in Illinois, where a large hospital system resulting from a merger was ruled to have too much market power vis-a-vis its negotiations with managed care payers -- after the fact, in a retrospective review.

Three for the Road

1 - Eulogy for a Quality Measure

Dr. Thomas Lee writes in the New England Journal of Medicine:

On May 8, 2007, one of the best-known quality measures in health care was put to rest. The percentage of patients with acute myocardial infarction who receive a prescription for beta-blockers within 7 days of hospital discharge has been used to evaluate U.S. managed care plans since 1996. This measure will no longer be reported by the National Committee for Quality Assurance (NCQA) because it is simply no longer needed — a development that offers encouragement and important lessons.

The data in the graph show why the NCQA Committee on Performance Measurement voted unanimously to retire the beta-blocker measure. A . . .

Sorry, extract only without paying a fee -- but here are the next couple of sentences:

. . . decade ago, only two thirds of US patients who survived acute myocardial infarctions recieved beta-blockers; today, nearly all do. As the curve representing the 10th percentile crept above 90%, the NCQA found little variation among health plans. At least when it comes to this intervention, the U.S. health care system has become reliable.

2 - Mashup Request

Bob Coffield's excellent Health Care Law Blog had an interesting piece this past weekend citing NetDoc's mashup of HHS hospital data -- heart attacks, heart failure, pneumonia, surgical infection prevention -- with Google maps. Note the following thoughtful comment from Bonnie on this entry:

This is a very smart idea! Next, I want to see a mashup that shows hospitals within a certain region that exhibit the best infection control rates.

Well, maybe not Bonnie! After all, the site itself warns:

Important: This tool should not be used to make medical decisions - check the original data source (HHS Hospital Search) and discuss hospital options with your physician to select the best hospital for you. Neither hospital locations nor the accuracy of the rankings/data shown is guaranteed, and there may be errors and/or ommissions (sic).

3 - Does Disclosure Hurt Minorities?

Finally, a 2004 article in Circulation entitled "Racial Profiling,The Unintended Consequences of Coronary Artery Bypass Graft Report Cards," by Rachel M. Werner, MD, PhD; David A. Asch, MD, MBA; Daniel Polsky, PhD suggests:

Although public release of quality information through report cards is intended to improve health care, there may be unintended consequences of report cards, such as physicians avoiding high-risk patients to improve their ratings. If physicians believe that racial and ethnic minorities are at higher risk for poor outcomes, report cards could worsen existing racial and ethnic disparities in health care.

A similar conclusion was reiterated by a couple of the authors the next year:

Public reporting of quality information promotes a spirit of openness that may be valuable for enhancing trust of the health professions, but its ability to improve health remains undemonstrated, and public reporting may inadvertently reduce, rather than improve, quality. Given these limitations, it may be necessary to reassess the role of public quality reporting in quality improvement.

As arguments about disclosure start to be more vigorous here in Massachusetts, the first article is finding its way around the halls of government. Does anyone know if these same authors have updated their findings since 2005, or if there have been further articles by others on this subject?

Monday, September 24, 2007

Two ideas, one theirs, one mine

Here's theirs. Sir Brian Jarmin and Dr. Don Berwick today suggested that they would open a new page on the IHI website allowing hospitals that so desired to publicly report their hospital standardized mortality ratio, or HSMR. I have previously posted ours. I think this is a great idea. It would be voluntary, but I think it would also grow in popularity as hospitals get comfortable with more transparency.

Here's my idea. Why don't the insurers in Massachusetts require the hospitals here to report their HSMRs -- in private, with no publicity -- to them, the insurers, as a condition of being in the payers' networks? Why don't they also require the hospitals to submit their most recent Joint Commission survey? In both cases, if the results are out of whack with industry norms, or otherwise indicate quality or safety problems, the insurers could then require remediation plans to remain in good standing.

Event today in Boston -- Mortality Rates

Hospital Standardized Mortality Ratio:
A tool for consumer information and quality improvement?

Date: Monday, September 24, 2007, 9:30-11:30am
Location: Division of Health Care Finance and Policy, Daley Room
5th floor, China Trade Center, 2 Boylston Street, Boston, MA

Learn about the Hospital Standardized Mortality Ratio (HSMR).

Should hospital HSMR numbers be made public so that consumers can use this information in deciding where to get care?

Can the HSMR be used by hospitals to improve the care they provide?

Is the HSMR a reliable measure of mortality rates and one that can be used to compare hospitals' quality of care?

Speakers will address these questions and will provide perspectives on the use of HSMR for public reporting and for quality improvement within the hospital.

Professor Sir Brian Jarman, Senior Fellow at the Institute for Healthcare Improvement, Boston and Emeritus Professor at Imperial College, London, former President of the British Medical Association and developer of the HSMR.

Paul Levy, President and CEO, Beth Israel Deaconess Medical Center.

Gregg Meyer, MD, MSc, Senior Vice President for Quality and Patient Safety for the Massachusetts General Hospital and the Massachusetts General Physicians Organization.

John E. McDonough, PhD, Executive Director, Health Care for All.

Kenneth Sands, MD, Senior Vice President and Medical Director of Healthcare Quality, Beth Israel Deaconess Medical Center.

Moderator: Dana Safran, Sc. D., Vice President of Performance Measurement and Improvement, Blue Cross Blue Shield of Massachusetts and Associate Professor of Medicine, Tufts University School of Medicine.

Cosponsored by Health Care for All and the Massachusetts Coalition for the Prevention of Medical Errors.

To register, go to

For more information, contact Deb Wachenheim at 617-275-2902 or or Paula Griswold at 617-272-8000 x152 or

Sunday, September 23, 2007

Spas anyone?

One in a continuing series about emails you get when you are CEO of a hospital. Somehow these get through our spam filter. I'm still relatively new to health care, but I marvel to think that a consulting company has a "director of medical spa services." Look, America is a great country, and I love the entrepreneurial spirit demonstrated by these folks, but isn't it a better idea for hospitals just to get really good at what they are supposed to do rather than be distracted by people from the hospitality business to create health spas? If anything, let's use the experience these folks have from that sector to help us improve the quality of service for sick, nervous, and anxious people visiting our hospitals. There is plenty to do to make sure we are delivering our core business in a proper fashion before jumping off for the latest fad.

7 Secrets to Running a Successful Hospital Owned Medical Spa

Is your hospital contemplating a Medical Spa? Is this a million dollar opportunity or a million dollar boondoggle? Attend a free webinar on "Hospital Owned Medical Spas" to be held on Tuesday, October 9th at 12:00 pm EDT and see if a medical spa is right for your healthcare organization.

This webinar will share with you the 7 Secrets of Running a Successful Medical Spa.

Hospitals across the country are considering whether a Medical Spa is right for them. Join us and get the facts on this fast-growing industry. Some of the reasons hospitals are opening Medical Spas at a record pace are:

Physician partnerships
Drives additional business to core hospital services
New high-margin, non-reimbursed revenue stream
Enhanced focus on well-care instead of acute care
Benefit to employees, patients, and families
Brand building throughout your market
Competitive advantage

This short webinar will cover the specifics of how to properly analyze your market for a Medical Spa, how to avoid the most common mistakes, getting started, physician partnership opportunities, and financing options.

Starting a Medical Spa can be the best - or worst - action you can take this year. Spend 45 minutes with the experts.

Contact me via email or call me directly and I will send you the details on how to join us on this free webinar.

Best regards,
[name omitted]
Director of Medical Spa Services

Friday, September 21, 2007

Thursday, September 20, 2007

Teamwork wins against VAP

Back in March, I gave an update on our efforts to eliminate ventilator associated pneumonia in our ICUs. This requires implementing a five-part "bundle" of steps every day with every patient. You measure compliance in this program by the percentage of time you do all five steps. There is no partial credit.

An additional item is to perform dental hygiene on patients every four hours. The bugs that can cause pneumonia often originate in the mouth.

The goal is to reduce the number of cases of VAP, which statistically have a 30% mortality rate.

We report on this item on our company website, but I wanted to give you a secret advanced preview. The charts above show our improvement with the bundle and with dental hygiene.

I don't want to brag too much -- well, actually I do! -- because these results are spectacular. They are the result of terrific teamwork among several departments of nurses, doctors, and other health care professionals. Our best estimate is that the reduction in VAP from these efforts is amounting to about 320 cases per year at BIDMC. While it is risky to extrapolate to relatively small numbers by applying broad statistics, if the 30% mortality figure is applied to this number of cases, it means that our folks saved 96 lives per year.

For those interested in costs, a case of VAP is estimated to increase hospital costs by about $40,000 per patient. Once again, applying this broad average figure to our specific number of avoided cases (320) means cost savings to the hospital of about $12 million. Hmm, saving lives and saving money by teamwork and rigorous attention to detail. Any lessons here?

I knew it!

And it is also more interesting than just putting one foot in front of another.

Wednesday, September 19, 2007

Tie one on

Much has been made of a decision in the United Kingdom to forbid the wearing of neckties in hospitals, claiming that these are a source of infections. Here's one such article.

Of course, I immediately asked our infection control people about this, seeing a potential opportunity to improve patient care and make life more comfortable for male doctors. Excerpts from their response:

The focus should remain on good hand hygiene and cleaning of equipment (especially stethoscopes) – all of which actually touch the patient. If health care workers cleaned their hands well immediately before touching a patient, it wouldn’t matter if their ties, white coats, palm pilots or pagers were colonized, since these things presumably have minimal contact with the patient, if any. Although all of these fomites have been shown in studies to become colonized, there has never been data proving transmission of infection to a patient. This topic comes up every year – it is a big distraction from the real issues. The CDC and SHEA (Society of Healthcare Epidemiology of America) agree with this stance.

Here is a quote I found about the CDC's view on the matter that supports this view, but I note that the 2004 article in which it is cited seems to head the other direction:

The Centers for Disease Control and Prevention (CDC)’s Guidelines for Environmental Infection Control in Health-Care Facilities state that, “although microbiologically contaminated surfaces can serve as reservoirs of potential pathogens, these surfaces generally are not directly associated with transmission of infections either to staff or patients. The transferal of microorganisms from environmental surfaces to patients is largely via hand contact with the surface.”

Sounds like some disagreement among the experts. Well, who knows? We started one revolution. Maybe the British will start another.

Leapfrog recognition, too

And, another recognition, this one from Leapfrog. Suzanne Delbanco, who has been heading this group for many years, is stepping down. Congratulations to her for her thoughtful approach to the issues and leadership of this important organization. I remember when they first came to Boston to explain their program: It was considered so cutting edge and controversial!

A lot has changed during her seven year tenure in health care, in part because of Leapfrog. The question now is whether Leapfrog has lost importance by actions and programs and disclosure efforts that have hopped over its own approach. That needs to be resolved by its Board as it conducts a search for a replacement to Suzanne.

More kudos to Ben and the team

Congratulations again for another award to Dr. Ben Sachs and his team in our OB/GYN Department. This one is national is scope, jointly from the National Quality Forum (NQF) and the Joint Commission. It is called the John M. Eisenberg Patient Safety and Quality Awards. Here's a summary from StreetInsider:

This organization is being recognized for the adaptation and application of the military and commercial aviation Crew Resource Management (CRM) principles to the field of obstetrics. After the CRM curriculum was modified for clinical application, 220 staff received training to incorporate the CRM principles and concepts into their daily work processes. The result was a dramatic reduction in major adverse obstetric events, which reduced malpractice liability exposure and improved overall patient safety and the quality of obstetric care. Specifically, a 25.4 percent reduction in the Adverse Outcomes Index (a measure developed for the project) was realized, and the severity of adverse events was reduced by 13.4 percent. The success of this work has been broadly recognized and has driven or influenced similar initiatives, including those of the Harvard Risk Management Foundation, the Commonwealth of Massachusetts, the State of Maryland, and the District of Columbia, among others.

"Ethically and medically, we felt justified in keeping him"

Please check out this story by Joseph Kahn in today's Boston Globe. Here's a case where the rewards to the caregivers were as meaningful as to the patient.

Monday, September 17, 2007

Simple questions? Simple answers?

"Simple questions" looking for answers:

If medical costs experienced by insurance carriers in Massachusetts are rising at a pretty constant 12 percent per year, driving premium increases of similar magnitude, but economic activity is rising at a rate of 3-4%, at what point does the situation become untenable for the businesses in the state?

If the medical cost increases are caused about 50% by unit cost increases for providers and 50% from increases in utilization (especially utilization of tertiary care) by residents of the state, what countervailing forces might come into play to help alleviate the situation?

If the unit cost increases for providers are driven in great measure by salary pressures from health care workers, what might offset those increases?

Some possible "simple answers":

Self-driven and/or payer-stimulated structural changes by providers to increase efficiency and productivity, i.e., reduce dollars per episode of care delivered.

Decoupling of insurance payments from volume to reduce providers' incentives to increase volume.

Support by insurers to enhance the primary care portion of the system, to enable better preventative care and early diagnoses and intervention (aka, attempt to shift the delivery of services away from high end tertiary care back towards the primary end).

Enforced rationalization of care by insurers based on actual outcomes data (including financial incentives to patients) to encourage patients to go to higher quality providers.

Exclusion by insurers of providers who do not offer sufficiently high quality service, either overall or in particular specialties.

Creation of a strong consumer movement to demand disclosure of outcomes data to help drive process improvement.

Creation of a strong employer movement to demand disclosure of outcomes data to help drive process improvement and to create demand for insurers to offer new networks of high performance providers.

What are your questions and answers? If we narrow these down, maybe we can help set the agenda.

Disclosure in Chicago

Won't it be a pleasure when stories like this one cease to be newsworthy?

Thanks to Business Week

Many thanks to Business Week for inviting me to submit an article to the online edition. Here it is. The topic will be no surprise to readers of this blog.

Sunday, September 16, 2007

Do we need Storrow Drive?

Apologies to those from other cities or who are just reading this blog for health care items, but every now and then I like to dive back into the infrastructure arena. It is actually the field I am trained in, worked in for many years, and taught at MIT. So sometimes I can't resist. One of my colleagues in this field is Fred Salvucci, former MA secretary of transportation. We worked together in state government and also at MIT. We were gabbing about a bunch of topics, and both of us had been thinking about this one, and it just bubbled up. I don't know if he wanted me to make it public, but if you like the idea, give him credit. If you don't, give me the blame.

The topic is Storrow Drive, a road that began in the days of "parkways", pleasure roads that were off-limits to trucks. From the beginning, this one was controversial, in that it was built on state parkland bordering the Charles River. The Charles River basin was itself an early, successful example of regional planning, envisioned by Charles Eliot in the 1890's as a unique combination of urban parkland, flood control, and improved sanitation.

Today, Storrow Drive is a main arterial road, leading traffic to various points of downtown Boston. Most of the time, you are too busy driving around odd curves and on ramps and off ramps and avoiding aggressive Boston drivers to remember that you are on a pleasure vehicle parkway. The physical components of the road have deteriorated over the last 70 years and require major rebuilding. The current controversy is how to carry out the construction and maintain the traffic flow. A plan floated by the state is to take existing parkland -- the Esplanade -- as a temporary route during this construction period. This has raised objections from a variety of quarters. Here is an example published yesterday by two former highly respected parks commissioners, John Sears and Bill Geary.

Opportunities like this come along but rarely, and I think we should ask the question: Do we need Storrow Drive? Please understand that I have not done a detailed technical analysis -- and this idea might be all wet -- but would the City of Boston and the region be better off without a commuters' highway alongside one of the most beautiful portions of the city?

Imagine Boston without Storrow Drive, say from the BU Bridge to the Longfellow Bridge. The horrible gash isolating the Back Bay from the Charles River would be gone. There could be a walk to the river from every street between Charles and St. Mary's.

Impossible, you say? Look at San Francisco, where the Central Freeway was taken down after it was damaged in an earthquake -- or the West Side Highway in New York, which was likewise eliminated when a portion collapsed.

How to do it here? Let's say that a new BU Bridge -- and yes, the BU Bridge will have to be replaced soon because it is in terrible shape -- were connected directly to exit and on ramps from the Mass. Turnpike and then repositioned on the Cambridge side to align with Vassar Street instead of bumping into the Reid Overpass on Memorial Drive so that Turnpike drivers could go directly to their destinations at MIT and Kendall Square. Let's say the Grand Junction railroad bridge were reconfigured as an express bus and pedestrian route from Cambridge to Boston to enhance mass transit, walking, and biking between Cambridge and BU and the Longwood Area. Let's say the Longfellow Bridge -- and yes, this bridge will be rebuilt also -- had revised approaches on the Boston side. You get the idea.

The lesson from San Francisco and New York is that highways like this generate their own traffic. When they are eliminated, the traffic can be directed more rationally, and urban amenities like access to the water, walking, biking, and parklands can be enhanced. Maybe Storrow Drive is really needed. But maybe it isn't. Before we spend millions of dollars duplicating its design flaws, let's ask the question with an open mind and consider the alternatives.

Saturday, September 15, 2007

(B)ring those cowbells again

Back in April, I related the story of the cowbells on Boston's river roads that are used to signal truckers that their rigs are too high for the underpasses. The theme is revived in a story by Michael Levenson in today's Boston Globe.

But note this contrary view:

But some specialists said the use of cowbells could be dangerous.

"I don't like it at all," said Thomas Hicks, director of the office of traffic and safety at the Maryland Department of Transportation who serves on a national panel of highway engineers. "It might fly off and run into somebody's windshield and a cowbell is usually pretty substantial steel."

There is not an iota of evidence from the past 20+ years that the cowbells are dangerous. Instead, there are 20+ years of experience that the bells and signs together reduced the danger of trucks crashing into overpasses. You want "substantial steel"? Try a multi-ton steel truck smashing into a steel overpass. That's substantial steel.

Dear Commissioner of DCR, please just put back and maintain what is proven to work.

Congratulations, Jerry!

Bravo to Doctor Jerome Groopman (Chief of Experimental Medicine at BIDMC) for being awarded a Quill Award in the Health/Self-Improvement category for his book How Doctors Think.

(The picture has nothing to do with the book, but I really like it. It was sent to me by my sister, Sita Likuski, after she took it along the Alameda shoreline in California.)

Thursday, September 13, 2007

Something in their water?

Should I install a new filter in the water supply system serving our IS department? Notwithstanding the picture below of our CIO, John Halamka, I had been able to push back any worries of unorthodox or risky behavior on behalf of our IS staff. Now, John reports the following news and sends the pictures above: "One of my IS Managers, Bill Gillis, just set the new world record for the land speed record on a motorcycle (250cc class) of 214.775 miles per hour at Bonneville Salt Flats!" Here's more information.

Wednesday, September 12, 2007

Notes from Gaza and Boston

From a physician friend in Gaza:

This week Jews are celebrating the New Year -- Rosh Hashana -- and Muslems are celebrating Ramadan.

On this occasion of Rosh Hashana, I wish you a peaceful and happy days and have our world become a better place to live in peace and harmony. I wish you and your family health , happiness and gratification.

May this year be a better than the previous one, a year of peace, safety, health and freedom from oppression and fear, and I pray that our dreams and aspirations come true.

And similar thoughts from a colleague here in Boston:

As you prepare your minds, bodies and spirits for a time of celebration and reflection, I wanted to send you warm greetings. In solidarity, I will be praying for peace in Israel and throughout the world. In solidarity, I will reflect on ways that I may treat fellow beings with greater love and respect, not turning a blind eye to the suffering of others. In solidarity I will give thanks for all my blessings, most notably that each of you is part of my life.

And warm wishes to all of my loyal readers as well.

Patient generosity of spirit

It is a well recognized phenomenon, but it still brings me up short when I see it. The issue is that when life support is removed or a patient dies for other reasons, family members often want to make sure that the attending physician does not feel too upset by the event. Perhaps this is some kind of transference reaction, but I think it is more a case of generosity of spirit emerging from the particularly close relationship that develops during these end-of-life cases.

I recently received a note from a colleague whose relative had died after a difficult hospital procedure. He wrote to tell me about the case and said about the physician: "He seemed very upset. He is a good and conscientious man. Please check in on him and make sure he is OK."

Can you believe this one?

Another in my occasional series on email solicitations that really make you wonder. I've left the link so you can get all the details. Does anyone really sign up for this one?

Dear Paul Levy,
If you'd like to learn strategies to effectively handle dreaded conversations with your most stubborn doctors, this is your last chance to register for a live, 60-minute Audio Conference:

"Dealing with Difficult Doctors: Eliminate Power Struggles & Bad Behavior"
Wednesday, September 19, 2007 1:00-2:00 p.m. ET

Getting into a power struggle with a difficult doctor is a bad idea.
Listen to proven strategies to conduct difficult conversations and improve your department’s culture. Save your hospital valuable time and money by nipping potential problems in the bud. During this 60-minute conference, you and your staff can clear the air, deal with problems quickly and build a culture of excellence.


Hosted by Progressive Business Publications, a leader in fast-read actionable advice on workplace issues, the audio conference gives you the opportunity to add immediate, impact to your marketing efforts in a manner that is:

FAST - No wasted time here. Get right to the heart of the matter in a 1-hour block designed to easily fit into your busy schedule.

CONVENIENT - No airlines. No travel. No time out of the office.
Listen from the comfort and convenience of your desk.

EASY - A telephone is all the equipment you need. Just dial in, punch in your access code, and you're in. That's it. Follow along with the audio conference handouts provided in advance.

ACTIONABLE - Our audio conferences provide money-saving tactics you can start using right when you hang up the phone.

IDEAL FOR MULTIPLE LISTENERS - Use a speakerphone and as many people as you want can listen in - at no extra cost to you. Many professionals use these sessions as a cost-efficient, time-efficient means of training supervisors, managers, and staff and reinforcing key issues in a fresh new manner that they will remember and act on.

AFFORDABLE - Priced at $199, it is a fraction of the cost of travel and attendance fees for other high-priced conferences or seminars.

Tuesday, September 11, 2007

HBS on the IT Case

For those of you with a detailed interest in our information systems, Richard Bohmer, F. Warren Mcfarlan, and Julia Adler-Milstein have just published a case study entitled "Information Technology and Clinical Operations at Beth Israel Deaconess Medical Center". It is available from Harvard Business Online for purchase. Here is the link.

Meanwhile, please see the picture above of our intrepid CIO, John Halamka, who recently climbed the Eaglet in Franconia Notch -- the tallest rock pillar east of the Mississippi. The Eaglet is located in Franconia Notch, just across Highway 93 from the former Old Man of the Mountain. Look closely and note John's body position and posture. He explains:

We were doing a data center electrical cutover, so I was checking in via Blackberry.

Monday, September 10, 2007

SEIU response

The Boston Globe's White Coat Notes contains the following, after citing my post below:

The union responded this afternoon, saying Levy "continues to parrot the Bush Administration's talking points in the way he mischaracterizes Senator Kennedy's ... bill, which was not the subject of our letter."

"Despite Mr. Levy's attempts to obfuscate what many hospital workers throughout Boston are actually asking for, our message is clear," SEIU executive vice president Mike Fadel said in an e-mail. "Hospital workers across the city are calling for free and fair union secret ballot elections, which include a code of conduct agreed to by employers to ensure their right to vote is not interfered with by hospital management."

This is really something. It appears that the nastiest thing you can say about someone in Massachusetts is that (1) they they may have said something similar to what a Republican administration has said and (2) that they might disagree with our senior Senator. In our overwhelmingly single party state, this is a way of trying to isolate (and watch for this next -- demonize) someone who disagrees with you.

For the record, I have tremendous regard and affection for Senator Kennedy and what he has done for this state, this country, and the world and -- how shall I say this politely? -- much less regard and affection for the Bush administration.

But that is not really the point, is it? These issues ultimately rise or fall on their own merit. As I mentioned below, I have seen no public reports that any person in authority at any of the hospitals in Boston has agreed with the SEIU's proposed code of conduct. Are all the hospital CEOs pseudo-Democrat anti-incumbent apologists for the Republican party? Or are there substantive and legitimate reasons for the lack of traction for the union's proposal in this city? Or perhaps someone has agreed to the code of conduct but has not made it public. If so, now would be a good time to speak up and explain the reasons for your agreement.

Friday, September 07, 2007

Another page from the playbook

Several weeks ago, I gave an update on the tactics that have been used by the Service Employees International Union in its attempt to organize unions at hospitals. Here is another page from the playbook.

Recently, many of our doctors received a letter from the union in which the following points were made: (1) that the BIDMC's administration has mischaracterized its position; and (2) that the SEIU has asked that the management of Boston's not-yet-union hospitals agree to a "free and fair election code of conduct", "free for workers to make up their own minds under fair secret ballot voting conditions." This code would include "a commitment by hospital executives to neither devote patient care funds toward disruptive anti-union campaigns, nor divert health care workers' time from their patient care duties to attend mandatory anti-union meetings." The code of conduct would "call on all parties to allow workers to make their own decisions in an environment free of coercion and to honor the outcome of a secret ballot election." The union says, "The secret ballot point is noteworthy, given that one CEO has been publicly arguing against a code of conduct by asserting that he supports secret ballot elections."

While it is awkward to impute another's motivation, it appears that the letter has three purposes. First, to obfuscate the statements made by management of hospitals about this issue. Second, to present a revisionist view of what the union itself has said in other forums -- like in the US Congress, where it has strenuously argued for an elimination of elections. Third, to attempt to drive a wedge between the management and a hospital's physicians by using these mischaracterizations and appealing to the doctors' underlying sense of fairness and fondness for the workers in the hospital.

I am not sure to which CEO the SEIU is referring. On the off chance it refers to me, you can judge for yourself in that the statements I have made are clear and available here for you to see in many of these blog postings. At BIDMC, we surely support a free and fair election, and our Board of Directors has adopted and published a code of conduct on this matter that properly reflects the federal rules and regulations governing such matters. Here it is:

Beth Israel Deaconess Medical Center
General Code of Conduct Regarding Organizing Activities

BIDMC has a strong commitment to its mission of community service in providing excellent clinical care, conducting medical research, and training future generations of medical professionals. As an academic medical center and prominent member of the corporate and civic communities, BIDMC is committed to an environment of respectful and open discourse and debate among its management, employees and physicians. It is of the utmost concern to the Board of Directors that this fair and unhindered exchange of points of view is maintained and supported during all times, including any attempt by unions to organize staff at BIDMC. Therefore the Board of Directors adopts this General Code of Conduct.

Conduct Standards

BIDMC has long believed that managers, supervisors and employees best serve the interests of patients by working together. Further, it is imperative that everyone in the work environment remain focused on patient care while continuing to have open communication and professional interaction respecting everyone's freedom of belief.

Managerial and Supervisory Employees of BIDMC

When communicating with employees, including regarding union activities, managers and supervisors are encouraged to promote an open and robust dialogue and share with employees factual information. Managers and supervisors also should feel free to express their opinions and encourage employees to ask questions. On the other hand, in any discussions with employees, respect is paramount. Specifically in the union activities context, managers and supervisors must not threaten or interrogate employees about their union activities, nor may managers or supervisors make promises to employees to induce them to be against the union. Finally, managers and supervisors must not conduct surveillance of union activities.

Non-Managerial/Supervisory Employees of BIDMC

Non-managerial and non-supervisory employees may engage in union organizing activities only on non-working time and only in non-patient care areas. BIDMC’s “No Solicitation and No Distribution” policy, “Use of Public Space Policy” and the Human Resources Department are available as resources to answer questions in this regard.


Finally, individuals not employed by BIDMC may not engage in union organizing activities on BIDMC property.

Additional Information

Anyone with questions or concerns regarding this General Code of Conduct is urged to contact the Beth Israel Deaconess Human Resources Department or the Beth Israel Deaconess Office of Business Conduct.

Now, I know this may not be what the SEIU has in mind. But what it has in mind is not consistent with the balanced approach adopted by the Congress and the courts under the National Labor Relations Act.

Let me give just one example that is problematic in the approach suggested by the SEIU, its point of not using patient care funds for anti-union activities. The term "patient care funds" is highly ambiguous. All hospitals have multiple sources of revenues -- Medicare, Medicaid, private insurance companies, philanthropy, interest, dividends, intellectual property, sales of real estate -- and these dollars are indistinguishable once they are received. Some of these sources contribute to the hospital's margin, i.e, excess of revenues over costs. But in other cases, like Medicaid, the state underpays hospitals relative to patient care costs, and so those services are subsidized by a number of other sources. To prove that "patient care funds" were not being used, say, for legal counsel during a unionization drive would be a CPA's dream, in terms of billable hours, because there is no methodology for an auditable resolution to this matter.

I don't know if the SEIU has indeed asked any hospitals in Boston to adopt its proposed code of conduct, but I do know that there are no public reports of a hospital having agreed to do so. If one of them has, please submit a comment on this blog so we will all know that you have. The union's attempt to suggest that there is only one CEO in this city who believes along these lines has not been supported in any way whatsoever. If there is a CEO out there who agrees with the SEIU's proposal, please publish the code you have adopted and speak up so we can all understand why you have agreed to such a code.

Thursday, September 06, 2007

Lesson from Missoula

One of the most moving speeches I have read is one given by Don Berwick, the head of the Institute for Healthcare Improvement, at his 1999 annual symposium. It was entitled Escape Fire, and it drew lessons from a tragic fire at Mann Gulch in Montana.

Here is a summary from the link above: "When fire surrounded more than a dozen firefighters on the hillside, their leader had an unusual idea for survival. He burned an area of pasture around him and lay down in the dead grass in hopes the fire would pass over him (an escape fire). His team found the method too risky and refused to join him. Most of them perished in the inferno, while their leader survived. Dr. Berwick's message to health care professionals is that rejecting innovative ideas will have grave consequences on the industry."

I had occasion recently to visit the smokejumpers headquarters in Missoula, Montana. You would be hard-pressed to imagine a more dedicated group of people, who risk their lives by parachuting into remote areas to snuff out forest fires. As you can imagine, too, this is a group that pays a lot of attention to safety and that has a terrific record on that front. By any measure, we in health care have a lot to learn from them.

Imagine my surprise then, when I conversed with one of the crew and asked a simple question based a picture in the wall of the HQ. It showed a jumper leaving a plane in a "sitting" position, legs out front. I simply asked, "Is that the expected body position?" The man I asked said that it was a generally good position in that the aerodynamics tended to twist the person's body in the right direction to avoid tangling up in the airplane or other problems.

But then he said that for a tall person, the position could be problematic in that some percentage of the time, the aerodynamics would actually twist you in the wrong way, leaving the jumper a bit disoriented and his parachute apparatus in an uncomfortable position. So, he said, he learned to bend his legs up under his butt and take a more cannonball position leaving the plane. This would avoid the unexpected twist after leaving the airplane. Later, in talking with other jumpers, he learned that some of them did the same thing. So, there was an informal "rule of thumb" that was in play for some of the jumpers for many years.

Here was the interesting punch line: Notwithstanding the long-standing existence of this helpful informal knowledge, it has only been recently that this alternate form of jumping position was formally included in the smokejumpers' training curriculum.

The lesson for the rest of us: If an absolutely superb, tight-knit, highly focused, and disciplined organization like the smokejumpers occasionally experiences informal work-arounds to safety and quality issues -- with inherent delays in systemic education and improvement -- imagine the degree to which this occurs in complicated places like hospitals.

Wednesday, September 05, 2007

Why do policemen like doughnuts?

A very much lighter note from the New York Daily News of September 4. In a special kids section, the question is asked, "Why do policemen like doughnuts?" The answer given by John F. Timoney, chief of the Miami Police Department:

It's because doughnut stores, especially in New York City, are everywhere. The ethnic foods can change from neighborhood to neighborhood, but the one staple is coffee and donuts. It's quick and easy; if while you are eating in the car you happen to get an emergency call, you can discard them easily . . . you throw them out of the window and you are gone.

Call to my readers. Does this ring true? And, how would a NYC cop answer the question? And is the answer different for Boston, home to Dunkin' Donuts? How about other cities?

Come on folks. Take a break from health care and give us your answer, but don't spill the coffee on your keyboard.

Tuesday, September 04, 2007

Poetry from nurses and doctors -- Part II

Here are some pieces of prose and some more poems written by doctors and nurses here that were presented at one of our Schwartz Center Rounds several weeks ago. Warning: Some of these will hurt to read.


A Job
By Grace Campbell-Dupont

A job is a job, but it is what you bring to it which makes the difference
your job should bring out the best in you, no matter the situation or circumstance.

Experience comes in many ways and comes in handy when applied to every day situations. It does not matter what you do, as long as it is done with pride deriving satisfaction at the end of the day.

High values and great expectations come with the job sometimes
that expectation fall short when there is no connection between self and job.

To listen is to learn and to learn is to give your very best, to observe is to be diligent
To see and to do without being asked, Give your best as is expected.
Never short change your giving because you will compromise what you believe in. There is Satisfaction to be gained in knowing that you give not only of what is expected, but of your very best.

My work is very important to the smooth running of the UNIT
I may not have all the answers to many question asked but there is resource
just a phone call away, and just knowing that you have tried makes a difference. Smile while you can, no matter the outcome let your eyes brings hope, your voice sooth the caller, the one who is grieving and hope to those who need to see that the person at the desk gives respect and understand their anxiety.

Finding a job that you like is not easy or one that brings satisfaction
but when you do, it brings out the best in you, even though it is not about you
but what you can do and how well you can do it.
Working in the UNIT gives a clear and sober understanding of how important
and precious life is. Each day brings new experience and new appreciation for the smallest things in life, nothing is taken for granted as it can be taken away in just one breath...

Behind each drawn curtain excellent care is given to which I may not be a part but when that curtain is drawn with urgency and there is no time to waste it is time For action you must ready.

With humility I take my chair and give the best of my self performing
Just like the day before. As you look and see, listen and learn a whole new world unfolds of endurance, strength and dedication of those on whose shoulders rest the responsibility of making health and Safety their priority and the true spirit of TEAM coming together for the purpose of caring.


By Matthew Hitron, MD

During my third year of medical school one of my patients died. It was a medical error that killed her, and I have been told to feel that the responsibility for it is shared, as a system and as a team. I didn’t feel that way then, and I don’t feel that way now. She died not only because of a screw up, but because no one really cared. I live with the fact that I could have stopped it. She needed someone to care, and I failed her in that. She was an elderly woman with many problems and a dementia that made her difficult to interview and examine. She was uncooperative and at times combative. She had no family, with a court appointed legal guardian and HCP. She arrived from her nursing home with mucus stains on her face and two necrotic toes. She swore at you, and even spat at you when you tried to speak with her. There are ways to break down the story into its components, and analyze the systems that failed; the cracks that she fell through. But it is smoke clouding the picture of a patient who was going to challenge all her care givers by requiring of them a true and exhausting commitment to her humanity; a humanity that was easily forgotten after a few seconds in the room. She was passed off from person to person, service to service, consult to consult; and I was complicit in this.

It was two weeks into my third year medicine clerkship. At times it felt like a show and I was painfully aware of the need to impress. I was not about to back down from any task, and was constantly negotiating the third year paradox of needing to learn everything while hiding the fact that you know nothing. My resident warned me she would be tough, but I had to prove I was good. She was admitted that night uneventfully, numerous consults were called, and the day was over.

The next day she was the last patient on rounds, kept NPO and on maintenance fluids while she sat in her room like that was the curative measure. Nothing happened. The team would wait for the consults to do something and the consults would wait for the team to tell them what to do. The removal of her dead toes was at least some sort of plan, but her strangely elevated INR, her ominous acidosis, and her altered mental status were just glossed over before lunch, with vitamin K, bicarb, and olanzapine given to make everybody feel better.

I came in the next morning, and as I flubbed my way through the note jotting down a K+ value of 2.0, it never occurred to me to be sure someone else knew about it. I remember thinking “wow; that sure is low…” if it were a test question I would have gotten it right. With all the nurses, consultants, and residents milling around her, someone must have seen it too and acted with purpose. No one did that morning. Instead of taking ownership, I was just another in a long line who passed the responsibility off, with no one left after me to pick it up.

Late that afternoon potassium was finally hung on her IV. The patient was alive, and I had dodged a bullet. I walked to the stairwell, stopped on a landing and leaned against the wall, “Take ownership” I said to myself, “you may be the only one left.” I remember feeling like I learned a huge lesson without a patient having to pay with her life.

I also remember moments later, and will never forget; the panic, the disbelief, and the grim realization that a patient had fallen through the cracks to her death, while I ran up the stairs to the sounds of the code alarm.


Sharing My Body
By Janet Greene, RN

Before I knew it,
I was sharing my body with a stranger.
No love binds us, but my whispers go unheard.
I cannot get away.

A cancer has crept in.
Motionless, I dance with this intruder.
My feet are numb.
I struggle for balance.

I am sharing my flesh with a partner
Who touches private parts in me
And leaves me nothing.


A Smile
By Sally Dennett RN

Why do we do what we do?
Long days, tired legs,
Families stressed,
100 things in our heads,
Trying to mend,
Trying to heal,
Mind, body and spirit thrown into one day,
Hoping our efforts pay,
Sometimes feeling helpless,
What else can we do?

A beautiful young woman in her prime,
Came to us just hanging to life,
Mother distraught wanting answers and hope,
Time would tell, is all we could say,
Head injuries have their own game play.

A daughter lying dormant in a hospital bed,
Mom and family while they are there,
Helping paint nails and wash hair,
Small gestures make strong bonds grow,
In a situation where nobody knows,
Will she wake up?
Talk again?
Walk again?
Be my beautiful daughter again?

Three months pass,
A phone call received,
You’ll ever guess the voice said,
She jogged today,
Speechless, Wow, what could I say?

Weeks pass and a visitor arrives,
The beautiful young woman, is before my eyes,
Walking and talking, incredible to see.
Mom has a grin that could light up the sky,
Her beautiful daughter looking strangely at me,
My eyes filling with tears of delight,
Why is she crying Mom?
Who is she?

I was your nurse,
Seemed all I could say,
Still in awe of what I saw,
Hours and hours of multiple tasks,
Hoping to make it all good at last,
Rollercoaster emotions for all concerned.
Then months of not knowing just what happened,
(often the norm in hospital land)

The emotion I felt at the sight that I saw,
Makes every long day mean so much more.
Every day struggles are put into place,
And all I see is a smiling face.
So, why do we do what we do?
Long days, tired legs?
Families stressed,
100 things in our heads?????????????????

Life is special………………


JM’s God.
By Glenn Bubley, MD

Entering JM’s room I find him where I always do,
Pouring over his large print Bible as if its all brand new.
Before I can ask him how is today,
He looks me in the eye and asks if I’m ok. I marvel at how important my answer is to him
As he lies on his hospital bed, tubes in every limb.
If there is an ultimate justice of genuine worth,
Surely JM and his kind will inherit the earth.

In JM’s time he was a victim of segregation,
With no chance to rise above his station.
He working loading boxes with his back and hands,
Acceding for years to his bosses demands.
And now even with cancer he’s neither bitter nor angry,
His struggle comported with the utmost dignity.
This man of sorrow, acquainted with grief,
Only by his release will he find ultimate relief.

Although there may be a balm in Gilead,
On this ward, IV morphine is the best we have.
Although the pain of cancer gnaws at his bones
He’s apt to laugh more often than groan.
His smiles leave lines etched on his old black face
Reflecting an inner peace that cancer can’t erase.
His strength seems to be emanate from a glimpse of God,
A glance that may be as close as men are ever allowed.
Now hobbling through the valley of the shadow without moorings,
Will he soon “mount up on the wings of eagles” up soaring?

As for me, I have much more than my daily bread.
So I wonder what it is about the future I dread.
If I could embrace the mystery of his faith might I break free,
If I could quash my doubts could JM’s God touch me?
If I could genuinely consider the lilies of the field,
Might I find a faith that feels strong and real?
Then would vain-glory and self promotion,
Fall away in favor of more genuine emotions?
Would everything change if I could begin to ponder
If it really possible that He walked on water?
Did Moses really hear the Lord from the bush?
Does JM’s bible verses contain seeds of truth? Can a book learning cynic be taught by an unschooled man,
That some things are controlled by an unseen hand?

I had thought that JM’s God was only a useful superstition,
But his life bears witness that the Holy Ghost’s not just an apparition.
If he’s found a lasting faith and true hope that abides,
Then nothing else matters on this mortal side.
His pain and the cancer is just a brief bother,
Before he finally stands before his Father.
And on that last journey that we all take alone,
Will a redeemed JM stand before the throne?
And will he hear these words now that his race is run,
“My good and faithful servant, well done, well done.
Walk up right into this new Jerusalem, it’s not a dream
Here justice pours down like water, righteous a never-failing stream”


By Christina Ho

As a medical interpreter in the hospital, the target group I encounter daily is mainly Chinese. They are mostly from China, Southeast Asia or even other parts of the world. Their education and cultural backgrounds are so diverse that I sometimes have difficulties to interpret the way to make them understand thoroughly. Moreover, there are even some miscommunications or misinterpretations in between that I am

totally unaware of due to my insensitivity until they speak up to let me know. One day, I was told by a doctor to call a patient at home for an immediate blood work which was very important for the adjustment of the dosage of the medication that he had been taking. At the time I called, I got the patient's mother (an elderly) on the phone. She told me that his son was at work and wouldn't be home until midnight and she didn't have his work phone number. The best way that I could think of to contact him was to leave my phone number for him to call me back. So, I tried to have her to take down my phone number. Without hesitation, she refused. No matter how hard I explained and stressed on the importance of getting this message across, she refused. It sounded weird to me. I got so frustrated and talked to myself, “That’s your son! What is the reason that you are not willing to help at all? How difficult is it for you to take down numbers?"

As I calmed down a little bit, I asked," What is your difficulties? Is there anything that I can help you with? She hesitated and stuttered, “To be honest, I am totally illiterate. I couldn't write, not even numbers." I was awakened and apologized, “I’m sorry for being insensitive. How do you usually do if you want to write numbers?" She answered, “Using strokes.” ”Great! What a good idea! Let us try." I then gave out my number slowly. During the process, we had a lot of fun though. When she finally got the number and repeated to me, I was so happy that she got it all right.

Before I hanged up, I praised her for doing a great job and thank her for the help. She was so happy for what she did and promised me that she would definitely pass the message to her son.

In my job, I learn something new everyday. Not just I can be sharpened on the skill of the language but the sensitivity to people which is the most rewarding part. The more I asked myself this question -- How often do I put my feet in someone's shoes to try to understand them better? -- the more I understand Jesus's love for being a mankind on earth.


What it Means to Care (Vol IV/2007)
By P.T.S.

It can make an impression
not so many years after you are born
the calming influence
in the midst of a storm
Your first one more often
is a mom or a dad
as they share the good
along with the dad
It might be a mom
a cousin or a friend
who inspires you also
to follow the trend
It may be a noun
It can be a verb
There can be negatives
well deserved
It can be one who is there
during your years in school
a friend and a teacher
who helps you with the tools
It might be something
better than any other
because the person cares
and helps another
It is something that
will probably never be given its due
but in its ideal is an example
for more than just a few
It should command respect not only from others but from those who perform its tasks as it recipients often
do not have the words to ask
It can have horizons that know no bounds It may stumble
and have its ups and downs
It may cause all of us to pause and remember what makes a job a profession with rewards that can't be measured. It is not always about the money or the red that is often seen
that can make it held
with well deserved esteem
It might be an extra moment
to listen to one's concern
or studying a little harder
to help and to learn
by anticipating a need
or giving a med'
or just by helping one
to get out of bed
It may be speaking up
when no one else will
I am worried
This person is ill
It is the giving of one's time
a most valuble gift
which makes it so unique
with each continuous shift
It may be actions performed today
that are remembered long after tomorrow
which help others overcome
their fear, their pain, their sorrow
This is Nursing
if you don't know by now
a job, a profession? that asks
the why, the when, the how
This is Nursing
if you want to know more
knowledge, organization, respect
enthusiam and more
This is Nursing
as observed through the years
or a synonym
for what it means to care


The Destruction of Urban-Day Market
Dagan Coppock, MD

The market was open, the market of sand,
Of dust blowing down with harmattan wind
Over pulp of a mango, pulp of a hand.

Fingers of smoke and ashes had fanned
Over bodies of people, burnt and pinned
By the market when opened, the market of sand.

Two tribes of Yoruba, claiming the same land
Of dry season fruit, desiccated and thinned.
The pulp of a mango. The pulp of a hand.

The soldiers had guarded, the Ife had manned
The gates of Urban-Day, its corrugated tin,
And opened the market, the market of sand.

Armed Modakekes with a list of demands
Entered the tension, an explosion of limbs,
The pulp of a mango, the pulp of a hand.

It must have been stirring, it must have been damned,
That obsession with volume, the splitting of skin
As markets when opened and salted with sand,
The pulp of a mango, the pulp of a hand.


Remembering Walter
By Janet Fantasia

I approach your portal, weathered wood of snakeskin amber and brown.
Through the film of gray lace, a shaft of light and you emerged,
a short, hunched figure scuffing towards me down the hall, your
withered hands, one melded to the other, straining to heave
open the door so I could give you the weekly shot to oil your joints.

I trailed behind, the nurse’s bag digging in my shoulder.
“How are you doing?” I asked.
“SOS” you said and smiled that mischievous smirk unless you were worried about your health or money
which I could tell by your downturned mouth and monotone.

In the spare room stood columns of boxes, a stockpile of saline, gauze pads, sterile gloves and ointment.
“Walter, this medicine is expired.
You cannot use it to treat your wound,” I cautioned.

Worn oilcloth covered the large kitchen table hidden by medication inserts, papers, coins, novelties
a coffee mug, napkin holder and an outdated Pill Bible.
I sat in the dinette chair, but yours was the office swivel with a cushion of five inch yellowed foam.

You filled tiny paper cups with your daily pills. Using both hands
to lift the Princess phone,
a recorder attached for fading memory,
you called the pharmacy and doctors’ offices.

Clever contraptions you devised made it easier to get through the day-from the window-shade puller-upper to
the angled piece of tin on the air-conditioner to deliver the coolest blast on a scorching day.

The stove and fridge were on borrowed time.A dented saucepan sat tilted on the burner, steam escaping from the crinkled tin foil cover.
Boiling water crackled for instant coffee to have with your soft-boiled egg, hemorrhaging yellow on the plate.

I examined you and peered at your feet,
two squishy water balloons, dusky and cool, your toes, gnarled and overlapping, then a foray into your ancient icebox for the Tin Man’s injection.

Sometimes, I asked you to lie in your bed for a dressing.. In slow motion, you removed the tattered blue terry robe.
Hiking up each hip, knobby fists with shriveled claws
pressing downward into the mattress, you reached the precipice and I vaulted your legs to supine.

We commiserated about your latest doctor’s visit, the news or something on your mind like the time your coronary artery was blocked and the doctor said “That was almost it.”
“He shouldn’t have said that. I was scared.”

A hard binder on the shelf bulged with files kept of so many admissions, dubbing you a “frequent flier.”
Grinning, you showed me an image of your coronary arteries before and after the stent. On the left, a hazy cluster of
branches and the right, a blossoming tree of blood flow.

You trusted me with your life, my pager screeching when your heart pounded double-time and for the pain in your neck, a cervical fracture.

You returned home, an erector set from the shoulders up and handed me a
camera to capture a miniature astronaut.

You had my number on Caller ID and called the night your bag broke and you were alone and frightened.
My phone rang at 3 a.m. I heard the anxiety and embarrassment in your voice. Dressing quickly,
I splashed cold water on my face for the long drive.

I gave you the “bad” news I was
promoted and moving to another office.
Later, I learned you had died
in the hospital where the nurses knew you by name. I took this hard, having been your nurse so long.

Since you left, I slow my car while passing your home half expecting to see your oversized Buick tipped
into the tiny driveway. There is a BMW there now. I wonder how much has changed inside and how much of you remains.