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))

Jobs, jobs, jobs

To provide more of a context for the theme below about the work environment in our hospital, I offer some statistics about jobs at BIDMC.

I recall seeing a chart somewhere that showed BIDMC to be the sixth largest private employer in the city of Boston. Indeed, many of the city's largest employers are academic medical centers, and they have all been growing. As has been noted on many occasions, the health care industry is the greatest engine driving Boston’s economy.

But the picture at BIDMC was not always so rosy. When I arrived in early 2002, BIDMC was in financial straits. The previous administration had already eliminated hundreds of positions, and I had to eliminate 600 more (over 10%) of the jobs (some filled, some unfilled) to enable the hospital to survive. That was truly an awful period -- not only for the staff who were laid off, but for those left behind.

Fortunately, in the months and years that followed, we engaged in a successful turnaround and have now been able to restore those jobs -- and more. Here is a summary of the average FTEs (full-time equivalents) on staff year by year.

FY2002 -- 4,562
FY2003 -- 4,694
FY2004 -- 5,013
FY2005 -- 5,353
FY2006 -- 5,635
FY2007 -- 5,792

But that increase of over 1200 jobs in five years doesn't tell the whole story. While employment at BIDMC has grown by 27% during this period, the actual payroll has grown by well more than that -- 63%. Why? Because the market for health care workers in Boston is extremely competitive. If we don't offer salaries and benefits comparable to other hospitals, we will not be able to attract enough of the best people to serve our patients. Remember, if people don't like it here, they can literally walk across the street and go to work at another great medical institution or college or biotech firm or pharmaceutical company.

For fiscal year 2008, we are budgeting another increase, this one in the range of 10%. Part of this is due to further expansion of staff -- almost 450 new positions. Most of these are related to increased patient activity on our floors, clinics, and in the ORs. A significant number, too, are being added to enhance customer service and to meet safety and regulatory requirements. The other part of the budget increase is for salary and wage increases. Like other places, we have a general pay increase about 3%, but we also add in significant amounts of funds for targeted market adjustments to keep up in highly competitive fields.

Saturday, November 24, 2007

More Thanksgiving thoughts

This post is prompted by the following note from one of our chiefs to his staff:

You can't fail to hear from most everyone that Thanksgiving is "my favorite holiday." No exceptions here. Among other things it is a stimulus for me to reach out, express awe and appreciation for the exemplary jobs you do in fulfilling our collective mission. This is not easy work, but the rewards are beyond measure. Thanks to you on behalf of our patients and this medical center.

I have the good fortune to work in a marvelous place like BIDMC, surrounded by well-meaning people who spend their time helping others deal with illness and disease and the real dramas faced by families as they go through difficult times. There are happy times here, too, when people are cured of their illnesses, and the happiest of all, when babies are born and new life arrives -- literally in rooms just a few floors above my office.

While there are daily challenges in the hospital environment, it is the underlying good will of people in these places that is the dominant characteristic. As teenagers in the 1960's, my classmates and I were inspired by John and Robert Kennedy and Martin Luther King, Jr., to enter careers of public service. In our self-centered way, we used to think of our generation as special in that way. But in this place, I see people in their 20's through their 90's who are devoting their lives to alleviating human suffering caused by disease. It is a marvelous commonality of purpose that binds us -- people of all ages, nationalities, religions, and races.

Before I worked here, I wondered (along with many of my friends) if people who worked in hospitals cared anymore. Much of what you hear about hospitals from the outside is related to complaints about insurance rules, difficult working conditions, burnt-out doctors, harried nurses, and rude front-desk staff. I have learned and want to assure my readers that the folks in hospitals do care and care deeply, but the health care environment is often not well suited to bring out the best in people. (By the way, I have learned through my travels that this is not just a US problem.)

Beth Israel Deaconess is characterized by a kind of warmth, compassion, and respect that is legendary, but even it can be a tough and tiring place to work. I view my job as CEO as trying to create a workplace that reflects the deep underlying values of our staff, working to minimize those aspects that inhibit or impair their ability to carry out their heartfelt mission. In this, I am warmly and strongly supported by our lay leaders, members of the community who volunteer to serve on our boards and have the ultimate governance and fiduciary responsibility for this institution. Not many of us are given the privilege of heading up an organization like BIDMC, so I am trying to use my tenure here to make a positive difference for the people who work here.

Last week, I sent the following email to our staff along these lines. Like other things I have shared with you about BIDMC, I am sharing this one. Those of you who are new to this blog might find it surprising that I do so. Regular readers will not be surprised. A hallmark of this administration is transparency -- even when such openness is awkward or embarrassing -- because holding ourselves publicly accountable is the best way for us to improve.

I will also keep you informed of our progress as we move through implementing the program outlined in email. I do so because I think we will learn a lot about ourselves and about the path towards process improvement. I am very confident we will flub up aspects of this as we move along. There may well be those out there who will be quick to judge when we do. But as an academic medical center, one of our jobs is to share what we learn so that it might be helpful to others here in Boston and throughout the world.



What's the most important activity at our hospital? Providing patient-centered care?


But what do we spend most of our time doing? Patient care??

Wrong. It is fetching. As in spending time trying to find a piece of equipment, a certain paper form, or some other supply. Or it’s re-doing work. As in writing the same piece of information in 3 different places.

Admit it. If you are a nurse on the floor or the OR or the PACU, a respiratory therapist in the ICU, a person cleaning surgical instruments in CPD, or a practice assistant in a clinic, think of how much time you spend fetching instead of actually taking care of a patient or doing the job you’ve been hired to do to support patient care – whether that’s running lab tests, preparing food in our kitchen, or repairing a broken piece of equipment. How much of your day is spent in these ways versus face-to-face time with patients or in doing something tied directly to patient care and the support of that care? If you are a typical person here, it is way over 50% and more like 80%.

But I don't have to tell you that, do I?

We might have the latest in cutting edge technology to take care of our patients and the finest doctors, but in a big institution like BIDMC -- like in most hospitals -- the organization of our work is based on patterns and systems that might as well be 100 years old.

The practice of medicine in academic medical centers like ours is a cottage industry. While other fields and industries have progressed in terms of process improvement, ours remains woefully behind.

Every day, thousands of you undertake "work-arounds" to solve the problems you face in delivering care. And you do solve those problems -- by dint of personal commitment, hard work, and good will. As a result, our patients get extraordinary care.

But, because we all invent work-arounds, we often don’t solve the underlying work process problems that pervade every aspect of what we do. And you go home feeling really tired and wondering how you really spent your day.

Over the next several months, we are going to start a program to work on these problems. Our goal is simple. We want to improve the quality of the time you spend here at BIDMC so you can focus on the things that matter instead of working around problems you encounter.

While the goal is simple, the solution is not. We want a solution that will identify and start to solve problems on the floors as they occur. We want a solution that will uncover and fix underlying problems, not result in yet another set of work-arounds.

We have been studying other efforts around the country and have come up with an approach that we think makes sense for BIDMC.

Recently, we had a chance to spend some time with people from a group called Value Capture. They relayed the content of speech by former Secretary of the Treasury Paul O'Neill at the Harvard Business School. He outlined the three questions every employee should be able to answer with a resounding "Yes!" every day in order for an organization to have the potential for greatness:

Am I treated with dignity and respect by everyone I encounter, regardless of role or rank in the organization?

Am I given the knowledge, tools and support that I need in order to make a contribution to my organization and that adds meaning to my life?

Did somebody notice I did it, i.e., am I recognized for my contribution?

Does that sound right to you? It feels right to me. The Value Capture folks, who have done this in some other places, are going to help us design the program for BIDMC.

Let’s be honest. We can’t all answer "Yes!" to these questions today, and, in fact, in many instances we don’t even come close. But our goal is to get there. If this works, we will set a new standard for staff satisfaction and participation in the operation of an academic medical center.

The program will involve some training and new approaches to our work. Most of all, it will involve you. Don't worry. It will not be painful. It may actually -- dare I say this? -- be fun! And in the long run, we won’t see this as a "program", but rather just as the way we constantly improve work and care at BIDMC.

Have I got you curious? I hope so. Stay tuned for more details this winter.

In the meantime, though, I need help. Every program has to have a name. What should we call this one? I am hoping for something decidedly unbureaucratic -- and maybe even with a sense of humor. Please write back with your ideas.

Best wishes to you and your family for a lovely holiday!


Thursday, November 22, 2007

Tuesday, November 20, 2007

I can't hold a Kindle to this one

OK, time for a consumer survey. What do you think of the Kindle, the wireless electronic book that will be available from Amazon on November 29?

Here's the quickie description: This is an ebook that is connected wirelessly directly to Amazon. No computer needed. $399 purchase price. You purchase the books you want electronically and they arrive in your hand-held device. Newspaper subscriptions are also available. It does not need wifi so you can buy a book wherever you are.

Reaction from a close friend: I'm drooling to get one.

My Luddite response: Sorry. Why is this good? Can't I just read a book?

Her reply: So you're sitting on a plane. You brought a book with you but you don't feel like that book anymore. You open your Kindle and download a new one from Amazon for $10. Or you subscribe to the newspaper, which is delivered to your Kindle every morning. Or you want to read that new War & Peace translation but it's too heavy to take on vacation. Or you're traveling with children and can get a new book for them to read in one minute. Or you want to read a novel you are embarrassed to be seen reading in public. No more having to fit that "Plato's Republic" dust jacket around Danielle Steele.

Now it's your turn . . . .

Grand Rounds from Mexico

Grand Rounds is up at Mexico Medical Student this week. ¡Muy bien hecho, Enrico!

Monday, November 19, 2007

"Don't worry about it"

I have written before about hand hygiene and the inexplicable difficulty of getting people who are trained in medicine to be attentive to this most basic infection control method. (For BIDMC's latest compliance with this and other clinical safety and quality metrics, you can check our website.)

I am still not pleased with our progress, but this is not just our problem. It appears to pervade medical centers. Here's a true story about a recent example at another place in town.

A friend of mine (let's call her "Mary") was accompanying a friend of hers (let's call him "Sam") to a visit with his doctor's office. Sam has Parkinson's disease and needs help getting around. Sam also needs to be accompanied through his office visit because he takes lots of medications, and the doses and frequency of them are changed from time to time, and he gets confused unless there is someone to help him keep track.

At this visit, several dosages and frequencies were changed, and it became Mary's job to unload and reload Sam's medication dispenser box so he would have the right pills for the right days of the week. As she was moving pills around, and breaking some of them in half, she suddenly realized that she had spent the whole day opening doors for her friend and touching all kinds of surfaces in the hospital and had neglected to wash her hands before handling his medications. Mary blurted out, "Gee, I forgot to wash my hands."

The nurse responded, "Don't worry about it." Now, because of all the medications he already takes, Sam is prohibited from taking any other medications if he catches a cold or gets a sore throat or any such problem. So, for him, a cold is a particularly uncomfortable event. Mary, who therefore was worried about it, temporarily put aside the nurse's comment and looked for a disinfectant dispenser somewhere in the exam room. There was none.

Mary, not being the shy type, made clear to the nurse that she was not pleased with either her comment or this situation. But how many of us would have the nerve to do that? Probably not many. I fear, though, that unless we as patients take it upon ourselves to remind our providers, progress in this arena will be all too slow.

P.S. When Mary told me about this story a few days later, she had a cold . . . .

Sunday, November 18, 2007

Great Scott! Deep blogging!

I shared a panel last week with David Meerman Scott, who has written a wonderful book (best seller) called The New Rules of Marketing and PR: How to Use News Releases, Blogs, Podcasting, Viral Marketing and Online Media to Reach Buyers Directly. The title tells it all, and I recommend it highly to anyone trying to figure out how to sell or publicize a product, a service, or a cause.

David's website also led me on to As he notes: Michael Schaefer's Deep Blog is a useful tool and worth checking out. It is a quick and simple portal to top blogs in many different categories -- a place where blogs are easily found and accessed.

You may have noticed some new buttons on the right side of this page. Those are some of the aggregator websites included on Deep Blog. Do some exploring!

You may also have noticed that I have reorganized my recommended links on this blog. The new categories seem to be evolving organically as I proceed with this blogging adventure. Now that my readership has grown, I am particularly happy to publicize artists, performers and authors who work I have enjoyed. Feel free to forward those or other suggestions.

Saturday, November 17, 2007

Babson scores big! Welcome back, Len!

Babson College has scored a major coup in securing Len Schlesinger to be its new president. Len has superb business credentials, but he is also a top-notch educator and also has experience in university administration. He has been working in Columbus, Ohio, with Limited Brands for several years, and it will be great to have him back in Boston. Babson already has a strong reputation, but I am predicting that Len's tenure will bring the school to a new level.

Babson joins another local business school, Bentley College, which named Gloria Larson to be its president earlier this year, in inviting a person of great energy and savvy to be its next leader. While places like Harvard Business School and MIT's Sloan School often grab the prestige of being major academic business centers, these smaller, focused colleges do a great job in training business leaders. They also play an important role in local community economic development and civic roles, a role the bigger schools sometimes forget in their zest to be world leaders.

Friday, November 16, 2007

Spam I am

Please read this post by John Halamka about fighting spam in the hospital. Here's a tidbit to get you to read more:

At BIDMC, we receive an average of 886,674 emails every day from the internet. We deliver 57,103 of these, meaning that 829,751 of these are spam.

Thursday, November 15, 2007

Reply from one of our doctors

People often ask me how our doctors feel about the things I post on this blog. The answer, of course, is as varied as our faculty, and -- trust me -- our faculty is not the least bit shy about letting me know how they feel. After I wrote a post on safety and quality a couple of weeks ago, one of our doctors wrote me the following note. I'd like to share it with you to get your reactions. Please understand that this is a world class clinician who is beloved by his patients and who has an exemplary record in safety and quality. So he is not saying we shouldn't be good at that, but he is saying something about how he thinks the hospital marketplace really works and what I should be emphasizing in public statements.

No one in their right mind could want anything but the safest possible hospital. But complex human organizations are inherently frail in the infallibility department. So while we have to work on this continually, we should not confuse that with "quality".

In the marketplace, people want the "best doctor". You will never hear anyone saying that they picked their doctor because the hospital he practiced at had a better safety record.

While we have to be excellent at safety, quality in the minds of the public is related to whether they think that the care they are getting from their doctor is the best. By this they mean, is the doctor practicing at the very highest level, making the right diagnosis, giving them access to the cutting edge and best therapies. Quality is not how many falls we have, because even though you and I know that the falls are dangerous and kill people, no one comes into the hospital thinking that they are going to fall.

If you make patient safety your acid test, you are not going to attract the kind of patients you need to stay in business. The difference, in the mind of the public, between quality and safety is huge. Quality means the medical care expectations. Safety is merely expected…until something goes wrong.

So, from my point of view, the emphasis at BIDMC has to be on quality, as in finding things that we are simply the best in the world at, and riding that wave.

A letter of appreciation

This is one of those really heartwarming letters I receive. I know some of you might think it is just self-congratulatory pap when I post these kind of notes, but please recognize that part of my audience on this blog is our own staff, as well as our board members and other local supporters of our hospital, and I think it is it important for those beyond the particular people mentioned to see this kind of appreciation. As noted by the writer, when I asked him if I could publish it here: "Absolutely . . . on both accounts! As a teacher and healthcare provider, I know how exciting and rewarding it is when I get notes from patients and students!"

Mr. Levy,
You don't know me, but my wife recently spent 5 days in BIDMC to have a total mastectomy and breast reconstruction, and I wanted to take a moment to thank you for her excellent and passionate care, and to recognize the outstanding operations and culture evident in BIDMC.

All of our experiences at BIDMC, from our consults and surgery with Drs. Adam Tobias and Susan Troyan (and their staffs), to the nursing care provided in pre and post op recovery, to the nursing care provided to my wife during her recovery time (most notably from a young nurse from Tennessee named Rita W. -- we can't recall her last name, but she was on the 6th floor) were courteous, competent and caring . . . all of which made my wife's experience much more relaxing & assuring. With particular reference to Drs. Tobias and Troyan, our appointments were all on time, and we never felt rushed or "numbered" during the actual office visits . . . at all times, I felt like my wife was the only patient they had scheduled for those particular times, and the patient interactions were soothing and congenial. Obviously, we are also very pleased with the quality and expertise of the actual healthcare delivered too, as my wife is recovering well and her prognosis is excellent!

Incidentally, I just finished reading Jerome Groopman's book, How Doctors Think, in order to use it for one of my classes, and it was exciting and refreshing to see the measure that you have taken (and he mentions in depth) to reduce nosocomial infections in your hospital -- great to see literature in action!

Thanks again & best wishes for continued success.

Wednesday, November 14, 2007

In memoriam: Sarah Wernick

I was saddened to read an obituary this morning about Sarah Wernick, a wonderful, intelligent, and funny person who was best known for writing books about women's health. In our family, though, Sarah was best known for leading my wife to a source of Valrhona chocolate. In fact, she found the place where you could buy the 5 kilogram size of this chocolate. Do you have any idea of how big an 11 pound piece of chocolate seems when it is being stored in your refrigerator? Or, how about 22 pounds, so we could have two varieties?

For this and so many other lovely reasons, we will miss Sarah and offer our condolences to her husband Willie and their sons.

Tuesday, November 13, 2007

Dutch Treat

I just returned from a quick trip to Amsterdam where I was invited to speak at a session called "Health Care Innovation Event", a conference of the CEOs and other top administrators of many of the Dutch hospitals, along with the Dr. Ab Klink, Minister of Health, Welfare, and Sport. I am a little amazed by this -- and no, I am not being falsely modest -- but people are very interested in the quality and safety process improvement steps we have taken at BIDMC and also in our efforts at transparency on this blog and on our hospital's website. I am surprised because I think we are just beginning to tap the potential improvements we can make in this arena, and we consider ourselves as just learning how to do it well. Other hospitals, like those in the Ascension Health system and Cincinnati Children's Hospital, have been at it for a longer time and with greater results. Nonetheless, it is very nice to have a chance to explain our programs to others around the world and to meet really interesting and thoughtful people. Inevitably, I bring back more ideas than I impart.

After the formal presentations in Amsterdam (at the amazing ING building!), we had break-out sessions during dinner. (They were very accommodating and made my table the sole English-speaking one.) During the sessions, the facilitator at each table was posting the table's comments in real time on video discussion boards spread around the room. It was like having a dozen simultaneous twitter sites going on! Later, the combined discussion board was used by the MC as a tool for reporting the major conclusions from each table.

By the way, the Netherlands has a very interesting and recently enacted insurance program for the country. This replaced the former system of government insurance. All people are required to have insurance and can purchase it from any of a number of private insurance companies. Some of these companies are for-profit and some are non-profit. There are about four large ones and over a dozen small ones. No company can refuse to provide coverage to any person. The annual cost of insurance is about 1000 to 1200 Euros. The government subsidizes the cost of insurance to people with low incomes. The insurance covers the full range of medical diagnostic and treatment services. You can also buy supplemental insurance to cover things like single rooms in the hospitals, cosmetic surgery, and the like.

Beyond this program of "cure" insurance, there is a separate government program for "care". This covers long-term care and other parts of the medical care spectrum that are essentially uninsurable.

I was told that the country as a whole spends 45 billion Euros on health care for these two types of coverage, for 16 million people -- or about 2800 Euros per year per person. With the "cure" portion amounting to 1000 to 1200 Euros per person, that leaves 1600 to 1800 Euros per year for the "care" portion.

The hospitals are non-profit, like most in the US. Interestingly, payment for services rendered is not generally based on the kind of diagnosis specific ("DRG") system we have in the US, although there is a movement in that direction. There is actually very little documentation -- for billing purposes -- of the services rendered. Either doctors are on salary or the billing is based on a simple count of those patients coming through. That's one way to reduce administrative costs. On the other hand, as was pointed out at our meeting, this means that there is very little accountability for the choice and efficacy of the clinical procedures actually undertaken. A person at our table suggested that Holland should move more to the US reimbursement system to hold providers more accountable. This was met with mixed reactions, as people understood that this would add administrative costs to the system.

Grand Rounds is up.

Grand Rounds is up on Dr. Anonymous this week. Please check it out.

Monday, November 12, 2007

Patient in my own hospital

Two stories about being a patient in my own hospital.

(1) I am really lucky to have a primary care doctor who knows how to protect me, as president of our hospital, from our well meaning doctors. Why do I need protection? Well, because the specialists are really proud of their work and want to use any malady that I have to show me their stuff. My doctor knows how dangerous this can be!

A few years ago, I signed up for an ocean kayaking trip in Patagonia. This was to entail pretty strenuous outdoor living and paddling all day long for two weeks. The program therefore required a physical exam and recommended a stress test for those over a "certain age." So I asked my PCP to order one.

She says, "No. I refuse to order a stress test for you."

"Huh?", I reply intelligently.

"Here's the deal," she says. "If I order the stress test, our especially attentive (knowing who you are) cardiologist will note some odd peculiarity about your heartbeat. He will then feel the need, because you are president of the hospital, to do a diagnostic catheterization. Then, there will be some kind of complication during the catheterization, and you will end up being harmed by the experience."

"But the reality is that whatever peculiarity he might find in your heartbeat has probably existed for decades, or your whole life. There is no history of heart disease in your family. You ride 100 miles per week on your bike and play and referee soccer for hours every week, and you have never had a symptom that would indicate a circulatory problem. Therefore, I will not authorize a stress test."

"Yes'm," I dutifully reply.

(2) A few years ago, I had a routine colonoscopy, and the GI doctor clipped off a couple of polyps and sent them to the lab for analysis. Standard practice to see if they are pre-cancerous.

Three days later, I am walking to work next to one of our pathologists down a very busy Longwood Avenue. I say, "Good morning. How are you?"

He quietly replies, "Fine, and so are you. I did your histology yesterday. No problems. Have a pleasant day."

Diagnostic skills

A friend who is a primary care doctor once told me that 85% of the symptoms that he sees in patients don't matter. They will simply go away over time. Jerry Groopman notes the same in his book How Doctors Think (on page 100): "Nearly all of the complaints patients describe to their primary care physician, such as headache, indigestion, and muscle pain, are of no serious consequence."

This makes it all the more impressive when a PCP has the diagnostic skill to notice the symptoms that do matter. This is especially the case for pediatricians, who often have to rely on noncommunicative patients and parents' descriptions of their child's symptoms. Two stories of this ilk follow.

A baby and mom go to visit the pediatrician for a "well child visit" several weeks after the child's birth. Everything seems normal, and the visit is about to end. The doctor closes with one last question: "Is there anything you have noticed about Sally that has you curious or concerned?" Mom replies, "Well, I notice that she sweats a lot while nursing." Alarms go off for the doctor, who suspects a problem and orders tests. It is found that the child has a rare heart defect that prevents proper blood flow, particularly during the somewhat strenuous nursing activity. Cardiac surgery is undertaken, and the baby is fine, avoiding major complications that might not have showed up till years later.

Another child, a two year old girl, returns to the PCP with the second urinary tract infection ("UTI") in as many months. Alarms go off for the doctor. After assuring herself that the parents are using proper sanitary practices during diaper changes, she orders a test of urinary function that indicates reflux of urine from the bladder back to the kidneys. The little girl's ureters are not properly implanted in the bladder, permitting backflow. The pediatrician notes, "I've seen too many teenage girls with kidneys damaged from years of undetected reflux and persistent UTIs." After several months of prophylactic antibiotics to see if the girl will outgrow the problem, she undergoes surgery in which the ureters are re-implanted, and the UTIs stop.

Saturday, November 10, 2007

Where does that money go, anyway?

Several months ago, I related the sad story that resulted from the merger of the New England Deaconess and Beth Israel Hospitals in the mid-1990s. Fortunately, the troubled times are behind us, and BIDMC has been quite successful in providing clinical care, conducting research, and offering training to the medical professions. Along with that success has been financial progress. The millions of dollars in operating losses have been turned around to show operating surpluses. This trend is seen in Chart 3 above. (The numbers for fiscal year 2007 will be available in several weeks, after the annual audit is well under way.)

Since we are non-profit, these gains do not go to stockholders. They are plowed back into the hospital in the form of investment in buildings, facilities, and equipment to provide patient care and carry out research. Every year, we have to replace aged plant and equipment and also investment in new technology to provide the highest levels of care.

During the period of financial turn-around, we intentionally underinvested in the hospital because we needed money to meet the payroll and other operating expenses, and we knew we would not generate enough margin to cover all the capital needs. So we fell behind each year. One way of measuring this is shown in Chart 1, where I compare the amount spent on capital each year compared to annual depreciation. If you look at the bars below the line, you can see the cumulative amount we fell behind in the early years. Later, when earnings improved, we were able to increase capital investment and begin to catch up. By this year (fiscal year '07) we had caught up on the previous years' deficiencies, based on this metric.

But, as anybody in health care will tell you, if you just invest an amount equal to depreciation, you are falling behind. This is because depreciation is based on the original cost of plant and equipment, not replacement cost. If you consider the current costs of buildings and equipment, you need to invest much more than depreciation to stay even, much less get ahead. In Chart 2, I show how our cumulative capital spending during this period has compared to 130% of depreciation -- a number that is at the low end of desired investment for major facilities like ours. On this chart, you can see that we are still catching up for those bad years. It will take several more years of very good earnings to get current.

Our hope is to continue to make a healthy operating margin to renew and refresh old buildings and equipment and also invest in needed expansion both at BIDMC and our Needham affiliate. The demand for our clinical services continues to grow, and we need have adequate facilities to meet our obligations to the public. To answer the question posed in the title, that is where that money will go. But we are also very cognizant of the importance of balancing capital requirements against the very real needs of our staff -- in terms of salaries and benefits and career advancement opportunities and appropriate staffing ratios. It doesn't do you much good to invest in capital if you don't also invest in people. So, we do the operating budget first, based on staff needs and quality and safety requirements. It is the margin available after that which is available for capital investments.

Friday, November 09, 2007

Equal time

I don't want the post below to be the cause of sibling rivalry, so here is the Boston Globe announcement of my other daughter's dance concert in Cambridge, MA this weekend.

Thursday, November 08, 2007

The birth of a winemaker

To share the adventures of a young winemaker, please visit this site by my daughter Syrah or Petite S'ra (formerly known as Sarah). I recommend the movie, as well as earlier postings. She sent the following message to me after I asked if it was all right to post a story on this health care blog and was granted permission:

You might even preface with a note that wine has always been tied to health and medicine. Researchers may change their minds every day about whether red wine will lower cholesterol, prevent heart disease, increase longevity, raise IQ scores or do the reverse, but the simple truth is that wine makes people happy, which is a key part of being healthy. You might further tell your readers that a case of my Zebra Wines (to be released in 2008) will make them exceedingly happy, and therefore at peak health.

Partnership for Healthcare Excellence

Speaking of consumer health care information (see below), the Partnership for Healthcare Excellence has started an ad campaign and a website designed to help create more effective and informed patients. As a new organization, they are very interested in getting feedback, so please take a look and see if their approach and information is helpful to you.

Curious about long-term drug use

A colleague of mine recently reported that, in talking with patients just after they have been prescribed a drug by their primary care doctor or specialist for a chronic condition, he found that they often do not understand the purpose of the drug and, in particular, how long they should take it. The result can be non-compliance with the regime they have been given, leading to a tapering off or discontinuation of a drug that is supposed to be taken for an extended period of time.

This perked my interest in that clearly one aspect of quality of care has to do with people's understanding of drug regimes they have been given. If a drug is really important to someone's health and poor understanding leads to non-compliance, then the result will not be good.

I am curious and would like to hear from those of you knowledgeable on this topic. Is this a common problem? Is the problem indeed a lack of effective communication between the doctor and the patient? If so, have any efforts been made by anybody to test out alternative ways of communicating this information to patients? I would guess that the drug companies out there might have studied this problem, but have doctors or insurers or Medicare?

Tuesday, November 06, 2007

Moral guide

Everyone I run into at the hospital wants to talk about Rose. I guess if you have been around a hospital as a nurse and volunteer for 50 years and live to be 101 years old, you have an impact on lots of people!

Today, Dr. Lachlan Forrow and I were at the front door waiting to share a cab downtown and we started talking about Rose. Lachlan has been head of our ethics program for years and also runs our palliative care service.

(More importantly, his daughter is a very good player in our town's soccer program, and I referee her games from time to time. In fact, Lachlan and I first met when I ordered him away from the goal area during a game. He was busy photographing his daughter's team from behind the goal line, and I told him he was distracting the girls and asked him to move over to the sidelines with the other parents. He complied. He had to. In contrast, as a faculty member in our hospital, he has much more freedom in choosing to comply or not with my requests. But I diverge from today's point!)

Today, Lachlan said something about Rose along the lines of her being the kind of person who, when you do something in a patient setting that you feel really good about, you think that she would have been pleased. From there we went to the broader topic of how many of us have a person like that in our lives: When we are in a tense, pressured, or difficult situation and have to make the right moral choice, our actions are often influenced by how someone we admire would have hoped that we would behave.

The concept goes beyond having a mentor. It is having someone who serves as a standard against whom we judge our own behavior during a moral test. The person can be alive or long gone. But at that moment of truth, he or she is standing over your shoulder watching and judging. (This is distinct, although perhaps additive to, the kind of conscience pricking that comes from religious beliefs.)

What do you think? Do you have a private moral guide in the person of someone alive or dead whose opinion you value during those tough moments?

Congratulations, Rich!

I am proud to announce that our Dr. Richard Schwartzstein has received the prestigious Alpha Omega Alpha Robert J. Glaser Distinguished Teaching Award from the AAMC.

Rich has received an unprecedented 13 teaching awards voted by his students at Harvard Medical School (HMS). He is vice president for education at BIDMC and serves as clinical director of our Division of Pulmonary Medicine. Also, he is executive director of the Carl J. Shapiro Institute for Education and Research at HMS and BIDMC.

Rich's quote puts this in a great context, symbolizing a major attribute of academic medicine -- the integration of clinical care, research, and teaching: "For me, active work as a clinical investigator has been critical to enhancing my capabilities as a teacher, and has allowed me to provide a model for students to consider as they contemplate their own career choices."

The AAMC explains: As a medical educator, Richard Schwartzstein skillfully integrates his extensive knowledge of basic and clinical sciences to teach students about respiratory pathology. As a clinician and researcher, he carefully weighs what patients say about their breathing difficulties to better understand dyspnea. And by successfully using each experience to enrich the other, he shows students how to balance a multifaceted and rewarding career in academic medicine.