Thursday, January 31, 2008

Ready Resolve at NYU

Here is a really neat program at NYU's Tisch Hospital. Employee volunteers (each one serves for one hour per day for one week every other month) visit patient rooms and conduct a quick on-the-spot survey of patient needs and follow up to solve a series of common problems -- do the phone and TV work properly; are the room and bathroom clean; did you get the meal you ordered. The Ready Resolvers either fix or call in any problems imediately. The responding departments are responsible for resolving the problems within two hours. If they cannot fix the problem right away, they send a staff member to visit the patient to explain in person.

This began as a pilot in June on three units, with 27 volunteers. It was expanded in August to 4 additional units, with 63 volunteers.

Interesting, too, that the Ready Resolvers started to uncover problems that were systemic in nature, that require further hospital-wide work.

I like this idea. If you work in a hospital, here or elsewhere, do you?

Organizational wiki

This is a request for advice. As I have noted below, we are engaged in a major process improvement and staff engagement process we now call BIDMC SPIRIT. We are designing a system that will enable staff people throughout the hospital to call out problems that they see while doing their everyday work, and then have help teams focus in on those problems, do root-cause analyses, and construct sensible solutions and diffuse them throughout the organization. This process, in part, relies on experience from Toyota, but it also uses some newer work done by other organizations.

Our folks are excited and intrigued by this and are starting to get engaged. Among other things, we plan to conduct formal training in the approach for about 600 people -- roughly 10% of our staff -- to create a core group from whom the process will spread.

Because this is a really new approach to things for an academic medical center of our size, one of my goals is to make sure that people feel they can also participate in the actual design and implementation. For example, I'd like for the training and communication process to be modified from suggestions of people as it proceeds, so that we refine it and keep things clear and relevant as we implement the program.

In essence, I want to create the organizational equivalent of a wiki -- a process that is organic during its implementation as a result of multiple and transparent contributions by the participants themselves. Think about that as allowing the people in the hospital to enhance the process improvement process itself even as that process is being rolled out. Think about it further as an incredibly and intentionally democratic design approach that puts great faith in the staff to know what will be most effective in teaching themselves about the program, for the benefit of one another. Now, add on to that characterization the fact that this needs to occur in a real-time manner and in multiple languages (English, Spanish, Creole, and others) and across multiple job categories so that all people feel confident that their points of view are heard and respected in a culturally sensitive manner.

We have some ways we are employing to do this, but I would love to hear from others -- whether in the medical field or elsewhere -- who might have tried this and can provide stories or references to their work. Please don't focus solely on computer information systems: Remember that lots of our people do not regularly look at a computer.

Wednesday, January 30, 2008

Free transfers on the T. Not.

A complaint registered with me by one of our employees who takes a trolley line from Brookline and then connects with a bus at Newton Highlands to get to work at our Needham hospital.

According to the MBTA website:

Bus and Subway transfers are discounted when you use the CharlieCard. With a CharlieTicket, the full fare, plus the surcharge will be deducted from the stored-value on your CharlieTicket when you board the bus or subway.

With a CharlieCard, simply board the first vehicle of your trip and the corresponding fare is deducted. When you transfer, the faregate or farebox will automatically recognize you as a transferring customer, and deduct the additional transfer fee, if any. When transferring from a lower-priced service to a higher-priced service, like Local Bus-to-Subway, the price of your transfer is simply the difference between the two fares ($0.45). When transferring from a higher-priced service to a lower-priced service, like Subway-to-Local Bus, there is no cost to transfer.

Not quite so, remarks our friend. Apparently, your CharlieCard is time-stamped when you first get on the trolley line, and if the time you enter the bus is more than a certain number of minutes afterward, the discount doesn't work. Ditto on the return trip. A bus driver told this passenger that the second ride has to begin within 20 minutes of the first ride.

I don't know if the driver was correct, but -- as locals will tell you -- the trolley ride itself is likely to be more than 20 minutes, and if you have to wait for the bus connection, it might be 40 minutes or more before you actually get on the bus. Ditto on the return.

Apparently you can write to the T and ask for a refund if the transfer discount doesn't register. But that takes a couple of months to process. And, who wants to do that every day?

So, if this is all true, why would the people at the T be so concerned about a transfer having to occur within a certain number of minutes? Are they really worried about people "abusing" the system by, say, stopping for coffee en route to their destination? Do they think someone will hand off his or her card to another passenger at the junction of a rail and bus line and use it later in the day?

And, if it is not true that there is a specific allowable time interval, why doesn't the discount work?

Ads for the public schools?

While I know we have been talking about hospital advertising, I happened to notice an ad for the Boston Public Schools on the "T" while I was riding to work this morning. My first reaction was, why should the public schools spend time and money and effort advertising? Don't they have better things to spend their money on?

But then, I thought about it differently. The schools in Boston went through a very troubled period, and they have made a lot of progress over the last few years. Why not place some ads to remind people of this progress and give both students and the community a sense of confidence and pride? Perhaps it will enhance the atmosphere for hiring graduates of those schools, or give businesses a reason to get more engaged with them, or some other good thing.

So, image advertising for the public schools? Sure, why not!

Bill's donuts, and more

One of my favorite authors writes, in anticipation of Super Tuesday:

Amidst the endless debating, debacles, and the super duper dissing, it’s easy to forget that even politicians must eat.

I therefore urge you to read this fun little piece I’ve written for It probably won’t help you decide who to vote for, but you might learn something you never knew about our hungriest presidents. Bon app├ętit!

This reminds me, by the way, of an important and cogent piece of advice (please excuse the vernacular) all candidates should be given when running for office, "During a campaign, never miss an opportunity to eat or pee, because you never know when you will have your next chance and it can be a really, really long day."

Tuesday, January 29, 2008

e-patients online

Patient Dave, er e-Patient Dave, led me to the this website, entitled, because health professionals can't do it alone. This is a really fascinating blog about patient empowerment. Among other things, you will find there an "e-patients white paper" explaining their philosophy and approach. Emblematic of the site, you can either read the white paper as a PDF or participate in it as a wiki.

The site apparently began as a follow-on to the work of Dr. Tom Ferguson, who invented the term e-patients to describe individuals who are equipped, enabled, empowered and engaged in their health and health care decisions. He envisioned health care as an equal partnership between e-patients and health professionals and systems that support them.

There is a lot to read and absorb on this site. Please check it out.

Drug ads, men, and football

A bit more on advertising, this time about drug companies, with her usual dry humor, by Monique Doyle Spencer in today's Boston Globe.

Monday, January 28, 2008

Seeking hospital frequent fliers

This came in today's email. Say what you want about hospital advertising, this has to be the strangest thing yet -- a frequent flier program for hospital purchases! I quote it exactly: I couldn't make this up. Your thoughts?

Orlando, FL - January 28, 2008 - Paquin Healthcare Companies, Inc. today announced the launch of its new hospital-based customer loyalty program. The program, referred to as My Healthy Rewards, is a way of rewarding hospital's customers for using their products and services and engaging in wellness activities.

"We are pleased to announce the availability of My Healthy Rewards. This loyalty program will play a vital role in the success of any comprehensive healthcare retail strategy by increasing customer loyalty and repeat sales," said Tony Paquin, founder and CEO of Paquin Healthcare Companies, Inc.

My Healthy Rewards members can accumulate reward points based on their retail purchases, utilization of hospital or clinical services, or other healthcare related or wellness activities. As reward points accrue, members may receive award certificates, special offers, merchandise discounts and special sale notifications. There is no limit-the more consumers shop, the more they earn.

The loyalty program is just one part of a consumer healthcare strategy that enables hospitals to promote their brand and provide excellent service.

Proceeds from healthcare system retail outlets provide financial support for the development of high quality healthcare in their communities. This program enables members to contribute to the well-being of their communities by using their rewards card when shopping for healthcare products and services.

The company announced that the program will initially be deployed at 27 hospitals locations and is expected to generate at least 500,000 members in its first year.

The votes are in!

Lots of you seem interested in the inside story on managing change in the hospital, and I am happy to share what we are doing on the chance it might be informative to those in other organizations. For those who are interested, here is a follow-up to my Thanksgiving staff email on our process improvement program for BIDMC. We conducted an election to name the program, with unlimited nominations "from the floor" and a preliminary ballot to narrow the field to seven finalists. Asking the staff to name the program is just the most visible part of encouraging their participation in its design and implementation. Here's today's email announcing the winner:

Subject: The votes are in! BIDMC SPIRIT takes first place!


In an election that has set a national standard for voter turnout and lack of negative campaigning, and a full week before Super Tuesday, we have a winner in our naming contest for the new BIDMC process improvement program.

Almost 2000 votes were cast, and the run-away winner was:

BIDMC SPIRIT (Solutions Promoting Improvement Respect Integrity & Teamwork)

Please stay tuned over the coming weeks for more about this initiative -- further explanation, training, and experimenting. Remember, the goal of BIDMC SPIRIT is that we want every BIDMC staff member to be able to answer these questions with a resounding "Yes!" every day:

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?

I'll tell you right now that we are inventing something new here. Sometimes it will feel chaotic, inefficient, or downright dumb as we do this: You will probably question my judgment many times over for even trying it. But, let's give it a chance and see what we can do together with the right BIDMC SPIRIT!

(By the way, will the person who suggested this name please contact me?)




Wow, within minutes, I have already received the following comments back from the email:

Good morning, Excellent choice, that was my choice. Have a great day. Thank you.
Whoever named this did a great job....
Congratulations on running a great campaign
BRAVO!! Congratulations.....
wow.........I finally picked a if I could only make up my mind about the democratic primary..........
Junior Seau said this week over and over again the same thing you did -- "let's just give it a chance, everyone just needs a chance" -- and look where he is now!!!!! I voted for this one too!
I am very excited the BIDMC SPIRIT was selected! I had suggested it during the original polling process… but I am glad that so many people resonated with it!
I would love to have an active role in this campaign of BIDMC SPIRIT.
An abbreviation better than WMD.
Love the name.

And this really nice one later on:

Although I cannot take credit for the name or idea of this program, I think it is an important concept. I am happy to know that this is going to be implemented and feel as though everyone will benefit from it in the end (especially the patients). From my perspective, there is nothing more rewarding than taking care of individuals during a time of need. We will all experience this vulnerability at some point in our lives. The key (again in my opinion) is to deliver quality care in a supportive, nurturing environment. It is evident that happier employees ultimately equals a more positive work environment which in turn equals quality care.

Thank you for supporting this program and also for taking the time to recognize the individual who is responsible for creating the name. You send a powerful message and it sounds like you are getting a positive response.

Sunday, January 27, 2008

On advertising

Your comments have been a little tame and complimentary lately, so it is time to throw some meat to the lions and stir up some discussion. This is about hospital advertising.

I opened up my latest version of Newton Magazine, a very nice local monthly publication edited by Jonathan Brickman that is targeted to one particular suburb of Boston. The ad on the inside cover is about an orthopaedic service offered by Newton Wellesley Hospital in collaboration with Massachusetts General Hospital. Page four has a full-page ad about diabetes from the Joslin Diabetes center. Page seven has a full page ad about heartburn and other digestive disease treatments at BIDMC. Then, of course, there are the smaller ads sprinkled through the magazine from practitioners in cosmetic dentistry, ophthalmic services, varicose veins, plastic surgery, concierge primary care, in-vitro fertilization, acupuncture, psychology, home care, assisted living, and cord blood banking. But for this post, let me focus on the hospital ads.

Putting on my consumer hat for a moment, I briefly had the same reaction that I have when I watch those drugs ads on television: Do these ads work? Well, we certainly know that the drugs ads work in creating demand for those products -- often to the dismay of doctors who do not really want to prescribe them. That has been documented.

To answer the question for hospitals -- "Do these ads work?" -- you need to consider their purpose. One purpose might be to encourage consumers to seek elective treatment for a condition about which they might not have considered treatment (e.g., that arthroscopic surgery for a knee injury) and another is to try to have them consider your particular hospital for the treatment they have chosen. Effectiveness for the first is hard to measure. Although insurance companies will tell you that many more people are seeking those elective treatments than ever before, it is hard to know if that is tied to marketing. Effectiveness for the second is equally hard to measure, although sometimes a hospital will be able to track a patient's initial phone call to a given ad.

Another purpose is to respond from pressure from your doctors and show them that you support their programs. Before I took this job, I talked with the head of a major Boston hospital who gave that as the primary reason for ads. "There is no evidence that ads work in creating business," he said, "but we need to keep our doctors happy." I have certainly felt that pressure in my place, and so I understand the desire to send a signal to your doctors -- who, after all, are essentially free agents who can easily change hospital affiliation -- that you support their practices.

Another purpose might be to educate the public about certain diseases and treatments. I think academic medical centers like to rationalize that they are offering this general benefit to the public in their ads, but, really, who would consider these one-page blurbs an effective means for such education?

I think the ads are posted mainly as a component of creating a broader brand identity. In this regard, hospital ads are remarkably similar to many other corporate ads. But unlike other industries that use it to drive sales, brand identity in the medical field is probably minimally important in generating and maintaining a sufficient level of clinical business. Perhaps more important, it helps create a mindset that the hospital has standing and stature and permanence in the community. This is important in attracting employees, enhancing physician recruitment and affiliations with other hospitals and physician practices, and generating interest from lay members of the community to serve on the hospital's governing bodies and to offer philanthropic support. These three purposes are actually fundamental to commercial viability in the health care world, especially for academic medical centers.

I would love to receive comments from other hospital administrators and marketing firms on what I have just said. And, of course, from the rest of you, too, who are now drooling at the prospect of offering a heartfelt opinion.

Saturday, January 26, 2008

Amy at Newsweek

Please read this really well done story on by Amy Tenderich, the host of the Diabetes Mine blog (one of the best blogs out there.)

Friday, January 25, 2008

A quick trip to Cairo, and beyond

For those in Boston, I want to recommend a marvelous exhibition I saw last night at the Boston Architectural College on Newbury Street. But hurry, because it is only open until January 27. (I think it then travels to other cities.) As someone trained in urban planning, I found it particularly engaging, but I think it has general appeal, too.

The show is put on by the Aga Khan Historic Cities program of the Aga Khan Trust for Culture. This program was established in 1992 to carry out conservation and urban revitalization projects in culturally significant sites of the Islamic world, undertaking the restoration and rehabilitation of historic structures and public spaces in ways that spur social, economic, and cultural development. In addition to restoration of buildings and monuments, the program engages in activities related to adaptive re-use, urban planning and the improvement of housing, infrastructure and public spaces. It also carries out related socio-economic development initiatives directed at upgrading local living conditions.

Here's one example. The picture above shows the creation of a huge urban park in Cairo. This link gives you more information about this project, a 74-acre park in the city's historic district. The site was previously a rubbish dump and landfill, which had grown so much over the centuries that it actually buried the city's external wall. A beautiful park has been constructed, which is visited by over 1 million people per year, and the wall and surrounding buildings have likewise been rehabilitated. Local workers, previously unemployed or underemployed, have been trained in reconstruction and rehabilitation and were hired to do the work.

Here is an excerpt from the exhibition brochure:

The exhibit provides insight into how the preservation of historic cultural and religious monuments serves as a catalyst for socio-economic development and how the revitalization of architecture can build bridges, not only between the past and the present in the Muslim world, but also between the Muslim world and the West.

“From Afghanistan to Zanzibar, from India to Mali, the Aga Khan Trust for Culture’s support to historic communities demonstrates how conservation and revitalization of the cultural heritage – in many cases the only asset at the disposal of the community – can provide a springboard for social development. We have also seen how such projects can have a positive impact well beyond conservation, promoting good governance, the growth of civil society, a rise in incomes and economic opportunities, greater respect for human rights and better stewardship of the environment.”
-His Highness the Aga Khan

Interoperability on a grand scale

Our "Geekdoctor", John Halamka, has been hard at work with many colleagues from around the country by chairing a group to create national standards for electronic data interchanges in the health care world. Yesterday Secretary of HHS Mike Leavitt announced the first set of such standards. I am attaching the entire press release. I don't claim to understand all technical technical aspects of this, but I do know that this in an important step along the way to full interoperability of medical information systems in the United States.


Contact: Stacy Leistner
American National Standards Institute
(212) 642-4931

HHS Secretary Recognizes Products of HITSP Standards Work

Washington, DC, January 24, 2008: U.S. Department of Health and Human Services (HHS) Secretary Mike Leavitt recognized the first set of interoperability standards developed by the Healthcare Information Technology Standards Panel (HITSP). The HITSP advanced three of its “Interoperability Specifications” to help support the advancement of interoperable health records and a Nationwide Health Information Network in the United States aimed toward improved and more efficient care.

HHS Secretarial recognition of interoperability standards is referenced in an Executive Order (E.O. 13410) signed by President George W. Bush in August 2006 and promotes standards to be implemented in new and upgraded federal health systems. These standards will also become part of the certification process for electronic health records and networks.

“Safe and affordable healthcare depends upon the secure exchange of information among patients, providers, payers and government entities such as public health agencies,” explained Dr. John Halamka, HITSP chair and CIO of Harvard Medical School.

The HITSP “Interoperability Specifications” which pertain to three initial priority work areas (“Use Cases”) assigned to the Panel by the American Heath Information Community (AHIC), were accepted by Secretary Leavitt in December 2006 as interoperability standards in these areas:

§ Electronic Health Record (EHR) (e.g., the electronic delivery of lab results to providers of care),
§ Biosurveillance (e.g., data networks supporting the rapid alert to a disease outbreak), and
§ Consumer Empowerment (e.g., giving patients the ability to manage and control access to their registration and medication histories).

Each Interoperability Specification is an unambiguous “cookbook” that identifies the “named” standards and provides implementation guidance to all stakeholders exchanging the health care information specified in each Use Case.

The Secretary’s acceptance in December 2006 launched a year-long period of review and testing by healthcare providers, public health agencies, government agencies, standards developing organizations, consumers and other stakeholders. His recognition signifies the end of the testing period and the beginning of when federal agencies administering or sponsoring federal health programs will begin implementation.

“Recognition of the HITSP Interoperability Specifications is an important milestone” added Halamka. “Between the federal implications and the certification efforts of CCHIT, stakeholders will be motivated to adopt a standard way of sharing data throughout the Nationwide Health Information Network, leading to better healthcare for us all.”

During 2007, the HITSP continued its work by focusing on security and privacy constructs and a new set of Use Cases supplied by AHIC:

§ Security and Privacy constructs will help to keep patient health information secure in an electronic environment. The standards will also help to assure that this information will only be used by authorized personnel for official purposes, including electronic delivery of lab results to a clinician, medication workflow for providers and patients, quality, and consumer empowerment.

§ Emergency Responder-Electronic Health Record will track and provide on-site emergency care professionals, medical examiner/fatality managers, and public health practitioners with needed information regarding care, treatment, or investigation of emergency incident victims.

§ Consumer Access to Clinical Information will assist patients in making decisions regarding care and healthy lifestyles. Accessible information could include registration information, medication history, lab results, current and previous health conditions, allergies, summaries of healthcare encounters, and diagnoses.

§ Quality indicators will benefit providers by providing a collection of data for inpatient and ambulatory care, and will benefit clinicians by providing real-time or near-real-time feedback regarding quality indicators for specific patients.

At its meeting on January 22, 2008, AHIC unanimously recommended the 2007 work to Secretary Leavitt. If the Secretary accepts the recommendations as reported; the requisite one-year period of review and testing for the new Interoperability Specifications will begin.

Nearly 400 organizations representing consumers, health care providers, public health agencies, government agencies, standards developing organizations, and other stakeholders now participate in the HITSP and its committees. Members work together to define the necessary functional components and standards – as well as gaps in standards – which must be resolved to enable the interoperability of health care data. Public comments are considered as the Panel develops its recommendations.

About HITSP. Operating under contract to the U.S. Department of Health and Human Services (HHS), the HITSP is administered by the American National Standards Institute (ANSI) in cooperation with strategic partners including the Healthcare Information and Management Systems Society (HIMSS), the Advanced Technology Institute (ATI) and Booz Allen Hamilton.

About ANSI. ANSI is a private non-profit organization whose mission is to enhance U.S. global competitiveness and the American quality of life by promoting, facilitating, and safeguarding the integrity of the voluntary standardization and conformity assessment system. Its membership is comprised of businesses, professional societies and trade associations, standards developers, government agencies, and consumer and labor organizations. The Institute currently administers five standards panels in the areas of homeland security, nanotechnology, healthcare information technology, biofuels and identity theft prevention and identity management.

Thursday, January 24, 2008

How to get a good start to the day

As CEO, you never know how your day will start. This one started very well, with the following two emails waiting in my inbox. I share them with you because they made me happy. They show how a single person in a hospital can make a difference to patients and also affect the reputation of the institution.

#1 -- Yesterday morning I brought my mother to the BIDMC for a routine colonoscopy that took place in the Farr Building. As a self-appointed "secret shopper," I made an observation I'd like to share with you. When we arrived on the 8th floor, we were met by a nurse who introduced herself as Michelle. Michelle is truly a credit to your organization and her profession. She conveyed a caring and calming demeanor toward my mother and also exhibited the same professional courtesy with every patient in the waiting area. Clearly, patient-centered care is highly valued by Michelle. It is a team member like her who helps make BIDMC a first-class institution.

#2 -- I had meant to send this email back in November but got busy with the holidays. First met Ms. Morris, Rabb 3 Radiology, eight years ago when my husband was a patient at BIDMC for surgery. I now see her yearly when I visit that department for ultrasounds. She goes out of her way to be accommodating, efficient and most pleasant. Going to that department is a pleasure because of her being there at the registration desk. She is a great representation of BIDMC. Thanks for having Debra at that desk.

The votes are in -- Thank you!

Many, many thanks to all of you who voted for my blog in the Medgadget annual competition for best medical blog. I was very fortunate to win in two categories, Best Medical Blog and Best Health Policies/Ethics Blog. I am grateful to all who voted, but also want to express my deep appreciation for the others nominated in these categories, many of whom I read regularly. Special congratulations to all the other winners, but notably Dr. Val, and the Voice of Reason -- for Best New Medical Blog. If you haven't linked to Val's page, you really should check it out.

Wednesday, January 23, 2008

Red pills or black pills?

Sometimes you see a drug ad on TV, and when you think you hear something about its possible side effects, you are sure you heard it wrong. Such was the case when my wife saw an ad for a drug dealing with restless leg syndrome.

We thought we heard something like this: There have been reports of patients that have reported problems with gambling, compulsive eating, and increased sex drive. If you or your family members notice that you are developing unusual behaviors, talk to your doctor.

"Impossible," we said to one another. "They can't really market a drug that has these possible side effects, can they?"

Two days later, I am watching Jon Stewart and he is doing a comedy routine quoting from these ads.

Well, now that I had heard it from a reliable source, I did a little Google research and found an article on the subject from the journal Neurology, entitled, "Pathologic gambling in patients with restless legs syndrome treated with dopaminergic agonists."

Stewart wonders if we have this backward. He suggests that maybe we should develop a drug for compulsive gambling that has the occasional side effect of restless leg syndrome. Maybe he is more of a health care expert than I gave him credit for.

Tuesday, January 22, 2008

Chapter 93

As a non-MD, I don't often get to attend M&M (mortality and morbidity) conferences of our various departments. These are usually highly technical sessions where doctors discuss cases that have gone awry or otherwise have educational value for the residents and attendings.

I was invited to attend one today, though, where a special guest was present, the patient who arrived in the Emergency Department and went through an incredible medical process, leading very close to death. He and his mother were at the M&M to offer the capstone comments after the medical discussion. Back to that in a minute.

This was a very challenging case. A patient with many medical problems. A difficult diagnosis. A delay in the diagnosis that probably led to "coding" and a need to resuscitate the patient. For those of you who have not been through an M&M, you would be impressed by the candor of the discussion and the lack of blame and recrimination -- so that lessons from the case can be clearly identified and applied in the future.

The diagnosis was delayed because of "diagnostic anchoring," a topic discussed in Jerry Groopman's recent book, How Doctors Think. If you put blinders on the diagnostic path based on early indicators or predispositions, you will miss things that are important. That happened here. Luckily, though, the ultimate diagnosis was obtained in this case because the doctor in charge refused to close off other avenues of inquiry when the facts did not seem to support the initial presumption.

The successful resolution for this patient required incredible amounts of teamwork among emergency department doctors, internists, radiologists, pulmonologists, anaesthesiologists, respiratory therapists, transporters, and nurses. Here is a summary of the people and resources applied to this case.

•> 100 lab tests
•10 Electrocardiograms
•Continuous telemetry monitoring
•3 Chest X-Rays
•1 Echocardiogram
•2 Line placement procedures
•Seen by 9 physicians, 4 nurses
•Administered 12 medications

Back to the patient, a devout Muslim, who finished the case discussion by saying that he had woken up the next morning after dreaming about the number 93. He looked out the window to see the bright sun and blue sky and realized he was dreaming about Chapter 93 of the Holy Qur'an. I quote an excerpt:

The Brightness

In the name of Allah, the Beneficent, the Merciful.

I swear by the early hours of the day,
And the night when it covers with darkness.
Your Lord has not forsaken you, nor has He become displeased,
And surely what comes after is better for you than that which has gone before.

New payment plan?

Blue Cross Blue Shield of MA is proposing a new optional model for physician and hospital reimbursement. Alice Dembner at The Boston Globe explains, and Bob Oakes at WBUR offers a radio version of the issues involved.

By the way, I have been wondering. Why is it called "reimbursement" in the hospital and physician world? In every other sector, we call it "payment". Can you imagine going to a grocery store and saying to the check-out clerk, "I'd like to reimburse you for this head of lettuce"?

Monday, January 21, 2008

Responses to our new goals

As promised below, I am sharing some of the responses I received from members of the staff and also outside observers after we announced our new goals for patient satisfaction and quality and safety. As you will see, there is a variety of opinion on the issue. This is not expected. I am going to divide them up by doctors, nurses and other staff, and outside folks who read the story or editorial in the newspaper or heard a radio interview.

I am not including my replies to these emails. You can offer your own replies in the comments!


#1 -- How does BIDMC plan to determine if harm prevention measures are actually causing unintended harm? This isn't an idle question - we have bypassed much of the usual science of medicine when invoking quality improvement. We assume that if we force providers to don gloves and gowns before examining patients in an ICU that they will still go into the rooms just as much. We assume that the pass-off errors caused by resident work-hour changes won't exceed the benefits from reduced fatigue errors. We assume that the benefit of infections prevented by forms and checklists with central venous catheters makes up for the occasional delay in acute resuscitation. We assume that the benefits of medication reconciliation in the outpatient world will exceed the harm done by the loss of precious minutes spent actually talking with patients (my department can't even provide projected numbers on how long it should take the average MD to type in an average med list for our patients.) These are all measurable questions. Perhaps we assume too much? Auerbach's editorial on the question in the NEJM should have been a clarion call for us to redouble our efforts to evaluate change before declaring it beneficial.

#2 -- I am delighted to hear from your email of the Hospitals' re-affirmation to emphasizing patient satisfaction.

#3 -- (A) Makes me proud. I think that this is in part an ethics issue: there are few moral responsibilities we have as serious and widely acknowledged as the Hipprocratic admonition to “Do No Harm.”

(B) At our monthly Ethics Rounds (held in every ICU and 15-20 units total) we should consider moving from asking about “any cases of adverse events in the past month that you think weren’t disclosed/reported properly?” to “any cases in the past month where a patient was harmed by something we did that was preventable?”

(C) We could also encourage our individual Ethics Liaisons (designated by the chiefs of more than 50 clinical and administrative units) to think about ways they can help foster a culture in which we take moral responsibility for not harming patients, and constructive “preventive ethics” efforts not to do so in the future.

We have found our many Ethics Rounds a useful tool in the past for exploring in a BIDMC-wide way the views or experiences of front-line clinical staff about ethical aspects of issues such as a possible VIP unit. Our Ethics Liaisons Program is already proving it has great potential for engaging a large group of individuals across multiple departments.

#4 -- (Reply comment from another doctor:) RE "C", I would emphasize even more strongly that the moral responsibility is to learn as much as possible from every episode of harm in order to prevent that harm from recurring. We need to remain clear that competent and well intentioned providers may find themselves part of an event in which there is harm, and foster the culture where people see these as learning opportunities to prevent future harm.

#5 -- This is good, and it is clear that goal number one can be published because it only provides a measuring stick (new for BIDMC) for something we have already been doing. But goal number two: How does the hospital elegantly air this goal without the fear of being criticized for not having been doing this all along? Perhaps a better wording would be to emulate the wording of the first goal and say that we will establish new measures to ensure that our preventive measures work, so that we can fix them if they don't.

#6 -- I really liked your very thoughtful and important words on public radio this morning.

# 7 -- I am concerned about the wording of the second goal- there is a problem when you set an unobtainable goal, only to publicly show that you couldn't achieve it. Here is the unobtainable goal:

"BIDMC will eliminate all preventable harm by January 1, 2012."

This cannot be done, because it is stated in absolute terms. Eliminating "all preventable harm" is a noble ideal, but it is unrealistic given the complexity of delivering health care by multiple layers of teams and individuals. The best that any hospital can do is to develop mechanisms to reduce preventable harm, not to guarantee that all harm will be prevented. Any preventable harm, even if it was humanly impossible to foresee it, and even if no other hospital could prevent it, will be held against us as a failure to achieve what we promised.

I suggest that this second goal be revised as follows:

BIDMC will continue to create an environment that reduces preventable harm to the fullest extent possible. To this end, by January 1, 2012 we will be recognized as a national leader in the field of patient safety. We will accomplish this by continually monitoring all preventable and non-preventable occurrences of harm, and continuously improving our systems to allow the greatest opportunity to reduce harm.

This is also a noble goal, but it has the merit of being achievable....

#8 -- This is great, and the report in yesterday’s Globe has a lot of people elsewhere talking about it, and very favorably. May I suggest that the next step, given your interest and ability to be well ahead of the curve, would be – where the specific data permits such granularity – to know and report whether results were similar or different segmented by race, ethnicity, age group and gender. It would be fabulous to be able to say, with respect to various indices of care, that there was no difference at BIDMC when examined by race, ethnicity, gender and age group.

Nurses and other staff

#1 -- I treasure my place here and I imagine it will be a very long time before I will look elsewhere. I love this safety and quality initiative and I even love the naming exercise for the "thing"!!! Thanks for being who you are- it makes it possible for us to be who we are as well.

#2 -- Thank you for taking the lead in making and returning BIDMC a wonderful place for patients. I hope to contribute to the attainment of this goal as a clinical nurse.

#3 -- I am a nurse working at [a specified floor], and was just wondering if this meeting was in response to latest news that medical insurance will not be reimbursing hospitals for preventable occurrences (aside from the obvious that we care and value patient safety and prove that we are one if not the BEST hospital in Boston)?

#4 -- Take the leaps...set the goals...Count Me In!

#5 -- These are goals we can certainly reach. Over the last two years, we've made great strides creating performance measures in the Department of Medicine's divisions. After many meetings with our colleagues and data collection, it feels good to see the improvements based on our results.

#6 -- You have my support...please let me know what I can do to attain the goals you have set.
This is an awesome hospital....and I'd like to help make the patient experience even better.

#7 -- Although the initiatives you are describing relate to patient care, I believe that all subjects in research studies are patients as well. Please do not hesitate to contact me if I can lend my support and experience to any committees under development or in any way you see fit.

#8 -- WOW!

#9 -- These initiatives are terrific. I appreciate them both as an employee but more importantly, I appreciate it as a patient. Should I, or my family, be so sick that we need to be hospitalized, I want to feel confident, when we are most vulnerable, that we will be cared for safely. While we have not ever been hospitalized, we have utilized the outpatient services and have run up against some significant gaps in quality care. I've raised those issues with the appropriate managers and in both cases they responded quickly and appropriately. We have a way to go at all levels. You can count on me to help work toward these goals.

#10 -- I appreciate your and the Board's "raising the bar" at BIDMC and BID-Needham. I am looking forward to doing my part.

I want to make sure you're aware of something I saw at the FDA website. I imagine you are aware of it but since it appears to be right in line with the announced aspirations and "The Thing" I felt I should take a chance at being redundant. The title of the FDA program is "AHRQ Releases Toolkits to Help Providers and Patients Implement Safer HealthCare Practices" and here is the link.

#11 -- A thought about patient feedback: The several times I have been hospitalized, the efforts of staff to go beyond courtesy to make me feel taken care of and cared about have always stayed with me more than anything else about a hospital stay. And of course, apathy, lassitude or grumpiness has made an equally strong impression on me. There were times when I felt mistreated by “bad apples” (not at BIDMC). At the time, I wished I had had the opportunity to give feedback to the hospital. However, in the weakened state of illness, patients do not have the physical or mental energy to seek recourse on their own. If patients were given feedback cards (as often happens in restaurants) when they are admitted (not on leaving, when the memory is less accurate), this would help in more ways than one: the patient would feel he/she had recourse, and would thus leave feeling the hospital cared, even if the “bad apple” didn’t appear to, and 2) if they know patients have this forum, bad apples are likely to take more care how they treat patients.

Question regarding the phrase in your email: “We will measure ourselves based on national benchmarks”: I was just wondering if national benchmarks include a measure of staff satisfaction, since patient satisfaction depends daily on the way they are treated.

Outside folks

#1 -- I can say that after my experiences @ BI & my husband's experiences at an unnamed hospital, you are well ahead in the process & examples.

#2 -- Bravo!

#3 -- Bravo! I will follow with great interest.

#4 -- Reading today's Globe, I was once again struck by how very proud I am to be associated with Beth Israel Deaconess Medical Center. Not only do I appreciate your forward thinking but am amazed at your goal to not only be first, but to do right.

Congratulations. This is a great day.

#5 -- Congratulations to both of you and your Boards for this outstanding initiative.

#6 -- Hearty congratulations and a bold and positive step!

#7 -- First rate and I am sure will be supported by all of us.

One issue to think about over time. You can make the hospital experience great and are doing that. However, with the advent of out patient care and day surgery, much of the experience takes place in the doctor's office. Some are not so great at continuing the great feeling one gets at the hospital.

As a lawyer I represent many banks. I am acutely aware that how I treat the bank's customer in documenting the transaction reflects back at the bank.

I hope you can (or can continue to) foster that feeling in your doctors.

Regards and with continuing admiration for what you are doing.

#8 -- Congratulations on your quality goals. Nice to see someone put a stake in the ground and focus on what this business is really about.

#9 -- Impressive move by you and your board. That's the way to push the envelope. Let's hope others take up the challenge as well.

#10 -- Great Globe Editorial today! I’m so proud to now be a BI patient!

#11 -- Good luck with the initiative. It’s a big undertaking.

#12 -- I am really delighted that you have chosen to meet this head on. Obtaining accurate data and putting the CARE back into healthcare will continue to keep us in the forefront both in Boston and nationally.

#13 -- I can’t tell you how excited I am by your commitment to avoid all preventable harm to patients. It is simply the right thing to do. In a similar vein, I first learned of Ascension Health’s commitment to “no preventable deaths by 2008” in the fall of 2004. I have known Dr. Sandy Tolchin for many years and have had the opportunity to learn of his efforts, initially at Borgess Health Alliance in Kalamazoo and now as VP Clinical Excellence in collaboration with David Prior and others at Ascension Health. When I last spoke with him in the late fall, he said, “We have now demonstrated that flawless care is achievable.”

Saturday, January 19, 2008

What's in a PCAC?

Following on our theme below, I am presenting a bit more on our governance of hospital safety and quality to provide background to others in the field who might be interested. A friend asked me how our Patient Care Assessment and Quality Committee (PCAC) is constituted and what its charter is. Here it is in its entirety. The key points are that its job is related to the overall institutional goals established by the Board of Directors (the ones mentioned below), as well as statutory responsibilities. Also, that membership by the lay leadership (entitled "Medical Center Governance" below) always exceeds that of internal management and clinical leadership. Note, too, the inclusion of the Vice President of Education to ensure that quality and safety programs are integrated into the educational programs for both medical students and residents -- very important in an academic medical center.

This is a hard-working committee for the volunteer leadership, meeting monthly and dealing with difficult and challenging issues. We have great appreciation for those people, who devote hours well beyond the committee meetings in staying informed and thinking about the most important topics on the Board's agenda.

BIDMC Committee Charter
Patient Care Assessment and Quality Committee (PCAC)

Reports To: BIDMC Board of Directors

The mission of the Patient Care Assessment and Quality Committee (PCAC) is to support the aspirations for clinical quality and safety for BIDMC as set forth by the Board of Directors, and make appropriate recommendations for improvement. The PCAC shall also serve the role of Medical Peer Review Committee as defined under the statutes of the Commonwealth of Massachusetts.

Charge and Scope:
Monitor the occurrence of harm to BIDMC patients, with a focus on response and corrective action when harm occurs.
Select and monitor priority metrics that evaluate clinical quality and safety processes and outcomes achieved within BIDMC.
Recommend to the Board of Directors, at least annually, priority initiatives for improving quality and safety of care at BIDMC, and monitor the extent to which approved priority initiatives are satisfactorily executed.
Ensure that BIDMC remains alert to current best practices for quality and safety, at BIDMC and other entities (in health care as well as other settings), and recommends appropriate adoption. This shall include ensuring that best practices within BIDMC itself are spread and implemented throughout the organization.
Approve annually the Qualified Patient Care Assessment Program.
Ensure that all regulatory reporting mandates for clinical performance, including the filing of major incident reports to the Commonwealth, are met.
Ensure that members of the Committee have the appropriate knowledge and training necessary to carry out the mission of the committee.

Committee Chair:
Member of BIDMC Governance, Appointed by Chair of Board of Directors

Chair (Member of Medical Center Governance)
Vice Chair (Member of Medical Center Governance)
Chair, Board of Directors, ex officio
CEO, ex officio
President, faculty practice, ex officio
Chair, Medical Executive Committee, ex officio
Chair, Deptartment of Surgery, ex officio
Chair, Department of Medicine, ex officio
Chair, Academic Department (Rotating 1 year appointment, appointed by the Chair of the Medical Executive Committee)
Vice President, Education, ex officio
11-24 Members (Members of Medical Center Governance)

Chief Operating Officer
Senior Vice President, Clinical Operations
Senior Vice President, Health Care Quality
Patient Care Assessment Coordinator

Meeting Schedule:
Monthly (except no August meeting)

Thursday, January 17, 2008

Source material on quality, safety, and patient satisfaction

As a follow-up to the post below on the quality, safety, and patient satisfaction goals established by the BIDMC and BID~Needham Boards, I thought some of you might be interested in reading the material that led to the votes. It is a bit long, but descriptive of the issues that were considered. For some of you, this might be more than you want to know. For others, it might provide primary source information that could be valuable for your own institutions. My hope is that more hospitals will find themselves moving in this direction, and if the accompanying memo helps in your own consideration, please feel free to use it. (In the memo below, the LEAD program refers to a partnership between our hospitals and Blue Cross Blue Shield of MA, under which auspices the Board training program was held.)

In my next posting, I plan to give you a sense of the internal feedback that I have received since making this announcement.

To: BIDMC Board of Directors and PCAC Members
BID-Needham Board of Trustees and PCAC Members

From: Lois E. Silverman, Chair, BIDMC Board of Directors
Seth Medalie, Chair, BID-Needham Board of Trustees
Robert Melzer, Chair, BIDMC PCAC
Paula Ivey Henry, Vice Chair, BIDMC PCAC
Christoph Hoffmann, Chair, BID-Needham PCAC
Paul F. Levy, CEO, BIDMC
Jeffrey H. Liebman, CEO, BID-Needham
Ken Sands, MD, Senior Vice President, Healthcare Quality
Stan Lewis, MD, Senior Vice President, Network Development
Dianne Anderson, Senior Vice President, Clinical Operations

Re: LEAD Board Program Follow-up

Date: November 30, 2007

Dear Board Members,

Following our immensely engaging LEAD retreat last month, a group of us got together to draft a proposal on quality and safety goals for both hospitals for your formal consideration.

It was clear from the retreat discussions that there should be two ambitious overarching goals for both institutions: One for the quality and safety of care and another for patient satisfaction.

The group agreed that the Board’s role is to set an expectation for organizational performance for these two areas. Management is then expected to devise programs for achieving these goals, and to determine the metrics against which performance will be measured. We anticipate that the structure of the Board meetings will change to include systematic reviews of the programs related to these goals on a quarterly basis.

On the patient satisfaction front, we propose the following goal:

BIDMC and BID-Needham will create a consistently excellent patient experience. We will measure ourselves based on national benchmarks and, by January 1, 2012, be in the top 2% of hospitals in the country, based on national survey responses to “willingness to recommend.” For this goal, BID-Needham will measure itself against national peer group hospitals and BIDMC against a national dataset of all hospitals.

A top 2% goal means that effectively nine out of every ten patients rate the hospital in the top tier category on national surveys for willingness to recommend. BIDMC is presently performing in the top 10-15% range, on average. BID-Needham is in the top 30%. This goal represents a steep climb in performance for both institutions.

Formulating a goal for quality and safety proved more challenging, as there is a broad spectrum of definitions for harm and error, and consequently a broad range of implications for goal setting. First, there is a distinction between preventable and non-preventable harm. The latter type occurs when a patient is harmed as a result of a cause that could not have been predicted or prevented, such as the administration of a drug resulting in an adverse reaction that a patient’s history would not have indicated. Preventable harm, on the other hand, occurs when there is a failure on the part of either an individual or a system to render ideal care, such as when the administration of an incorrect dose or medication results in an adverse outcome causing actual injury to the patient.

It should further be noted that there is a distinction between harm and error, and that not all errors result in harm to the patient. For example, an incorrect dose of a particular drug administered to a patient might not affect the patient. The Institute for Healthcare Improvement (IHI) reports that only 10 to 20% of errors are ever reported, and of those, 90 to 95% cause no harm to patients. While much can be learned from all errors, many (including IHI) recommend that institutional governance focus on those causing actual harm. The theory is that by discussing openly those events actually experienced by patients, a hospital begins to foster a culture of safety that shifts from individual blame for errors to comprehensive system design and therefore lasting improvement in safety.

The first step in identifying harm is to develop a clear definition. Our small group reviewed several definitions of harm, ranging from IHI’s very comprehensive definition of all harm, including preventable and non-preventable harm, to the Ascension Healthcare System’s quality goal of no preventable harm. We felt that we needed to focus our resources where we can have the greatest impact, on eliminating preventable harm. At the same time, we wanted to maintain an organizational awareness of all harm, including non-preventable adverse events, and to seek to reduce our overall incidence of harm. The goal that we propose for quality and safety, therefore, is:

BIDMC and BID-Needham will eliminate all preventable harm by January 1, 2012. We will accomplish this by continually monitoring all preventable and non-preventable occurrences of harm, and continuously improving our systems to allow the greatest opportunity to reduce harm.

To determine and clarify how we would actually measure harm, we propose a modification of the categorization developed by the National Coordinating Council for Medication Error and Reporting and Prevention, known as the “NCC-MERP” Framework, to consist of the following categories of evidence of harm:

- Required hospitalization or extended hospitalization
- Permanent harm or disease progression
- Patient death

We feel that focusing on these categories will give us the greatest opportunity to achieve a meaningful and sustainable reduction in harm, while making the best use of our resources. The occurrence of harm that falls into any one of these categories would qualify for individual case review. In addition, while the boards of our institutions will focus on “preventable harm,” we also expect our respective PCAC committees to develop systems for periodic assessment and reporting on the occurrences of harm that are not within the categories listed above.

It is important for the Boards and the respective organizations to understand that these goals represent a far-reaching aspiration for our hospitals and for the level of care that we seek to provide. We must acknowledge that getting there will be a three to four year journey that will require further strengthening of our culture of safety and transparency. It will mean further bolstering our efforts to create an environment where caregivers feel safe discussing the occurrence of harm.

We discussed and propose the following timeline: At the December Board meetings, each Board will discuss and vote on these proposed goals and the attached resolution. Management would then be charged with outlining specific programs with measurable milestones to achieve these goals. In January, staff will be asked to present to their respective PCAC committee a timetable for these programs for the following year, along with a trajectory of performance towards the end goals. Upon review and approval by the respective PCAC committee, the action plans and milestones will be brought to the Board at its first subsequent meeting. A quarterly review of progress towards these goals would then become a regular element of each institution’s Board and PCAC meetings. In addition, the Compensation Committee of each hospital will be charged with building these quality and safety goals into the annual incentive plans for senior management.

We welcome your feedback and questions on these proposed goals, and look forward to our discussions at the December Board meetings.

Aspirations for BIDMC and BID~Needham

Here is an email I sent last night to the staff of BIDMC and our community hospital, BID~Needham. Thanks to CEO Cleve Killingsworth and others at Blue Cross Blue Shield of MA for being our partners in the Board training and providing other assistance and encouragement that helped lead to this step: Please see Jeff Krasner's story and an editorial in today's Boston Globe. Special thanks to Jim Conway at the Institute for Healthcare Improvement for his wise counsel and for conducting a significant segment of our Boards' training, and to three unnamed patients who addressed the Boards and powerfully made these issues tangible. Finally, after the text of this email, please read the statement we received on this matter from State Senator Richard T. Moore (Senate Chair of the Joint Committee on Health Care Financing).

There are some things that we do that are meant to transform our hospital, to set us on a path to very high standards that, at first blush, appear so audacious as to be unachievable. But if you never take the leap and set out the goals, you never know what you really can achieve.

Today, we announce such goals, in the hope that they will set the stage for such a transformation.

Several weeks ago, the Board of Directors of BIDMC and the Board of Trustees of BID~Needham met and had serious discussions about what their hopes were for our two hospitals. As the representatives of the community who have fiduciary responsibility for our two non-profit organizations, they decided on a pair of goals that represent their aspirations for us. Of course, the clinical and administrative leadership of the hospital were deeply involved in these discussions as well and provided the technical support for the decisions that were made.

The Boards decided that two overarching types of goals were important. The first relates to patient satisfaction. The second relates to safety and quality of care. Here is the vote that was taken by the BIDMC Board (and a virtually identical one was taken by the BID~Needham Board):

WHEREAS, the Board of Directors, Patient Care Assessment and Quality Committee ("PCAC"), and Patient Care Services Committee ("PCS Committee") of Beth Israel Deaconess Medical Center ("BIDMC") have determined that it is in the best interest of BIDMC to set ambitious and overarching goals related to healthcare quality and patient safety, and patient satisfaction.

To approve the following goals for BIDMC related to healthcare quality and patient safety, and patient satisfaction:

BIDMC will create a consistently excellent patient experience. We will measure ourselves based on national benchmarks and, by January 1, 2012, be in the top 2% of hospitals in the country, based on national survey responses to "willingness to recommend." For this goal, BIDMC will measure itself against a national dataset of all hospitals.

BIDMC will eliminate all preventable harm by January 1, 2012. We will accomplish this by continually monitoring all preventable and non-preventable occurrences of harm, and continuously improving our systems to allow the greatest opportunity to reduce harm.

That Management will develop and implement action plans and programs to achieve these goals, to be reviewed and approved by the PCAC Committee, PCS Committee, and the Board, and will report to the Board, PCAC, and PCS Committee on at least a quarterly basis using defined metrics against which performance will be measured.

Daunting, eh? You bet. Here's more. We will be publicizing our progress towards these goals on our external website for the world to see. In other words, we will be holding ourselves accountable to the public for our actions and deeds. Our steps towards transparency have just been notched up a level.

These Board votes certainly do not mean that we are not already doing a good job now. Our Boards have immense respect and affection for all of the staff who work in our hospitals. They know you take really good care of patients and provide a warm and caring environment for patients and families. But the votes mean that our Board members who represent the community want us to do even better, out of a sense of public service and also out of a sense of pride that we can do better.

Over the last several months, we have seen a hint of what is possible. Our efforts at infection control on the floors and in the ICUs are but a few examples. Meanwhile, too, we have made process and customer service improvements in a number of clinics. We have saved lives, reduced adverse events, improved customer satisfaction, and made life a bit less hectic for some of our staff. (You know from previous emails that I am working hard to make even more improvements on that latter point.)

We have come a long way. Six years ago, both of our hospitals were close to being sold or shuttered. Four years ago, we had passed through a turn-around and proved our ability to survive. These past two years, we have shown that we are vibrant members of the Boston and Harvard medical communities. Now, we rise to the largest challenge yet -- setting standards for patient satisfaction and reduction of harm that are truly world class.

Stay tuned as we roll this out and decide on the yearly priorities and work plans that will eventually lead to reaching these audacious goals. In the meantime, as always, please keep in touch with your ideas, suggestions, and criticisms.


Here is Senator Moore's statement:

“BI-Deaconess deserves to be strongly commended for taking this challenging, bold step to improve health quality and transparency. By including a small community hospital (BID-Needham) as well as a major academic medical center, BI-Deaconess becomes a true champion of health care quality and patient safety. Their leadership in promoting transparency is unprecedented in the Commonwealth, and is fully consistent with the principles behind legislative initiatives such as Senate Bill No. 1277/House Bill No. 2226, An Act Improving Consumer Healthcare Quality. They obviously understand the meaning of 'First, Do No Harm.' They get it right!”

Thank you, Senator!

Tuesday, January 15, 2008

In Memoriam: Dr. Judah Folkman

Scott Allen at the Boston Globe and White Coat Notes reports on the death of Dr. Judah Folkman, a legendary researcher at Boston Children's Hospital. The fact that, as of this writing, 63 comments from the public were submitted to the online version of this report gives a sense of how this gentleman was regarded in Boston and beyond. Please read them for a sense of his widespread impact.

Our condolences go to Paula and her family and all of Judah's many friends.

Monday, January 14, 2008

How to vote on

No, this is not about hanging chads. I've talked to friends who say they have voted on for their choice of best blogs, but they have often done it wrong. If you just click on the name of the blog on the homepage or above the "ballot" on the voting pop-up page, it does not record as a vote. (In fact, all it does is to send you over to that website.)

To record a vote, you actually have find the page with the green ballot by clicking on the Medical Blog Awards trophy on the homepage and then clicking on the Please vote here link. Then put your cursor on the "hole" next to the blog of choice, click to leave a dot, and then click again on the bigger "vote" button, for your vote to be recorded.

So, regardless of your choice of candidates, if you did it wrong, you might want to return and vote again.

As I mentioned below, I would be honored to have your vote, in either or both categories: Best medical weblog or Best health policies/ethics weblog.

On checklists

Lots of you have been asking me to comment on the story by Atul Gawande in the New York Times, in which he discusses a hospital that had to stop a quality improvement checklist program because of an adverse ruling by the federal agency that reviews human subject experiments. I really didn't know what more to say on this, in that Atul wrote the story in his usual brilliant manner, made the case clearly, and certainly got as much publicity for the cause as possible by its placement.

Meanwhile, though, a movement has started to make sure the government does not overreach in this area. Charlie Baker, for one, has written very well on the subject, and so, especially, has Bob Wachter. And I just received, through Bob, a copy of a letter from the American Hospital Association to Secretary Leavitt on the matter. I haven't heard anything about a reply from the Secretary. I know he has a blog, and this might be a good time to use it and reassure all of us.

Here is the AHA letter, in whole:

January 3, 2008

The Honorable Michael Leavitt
The U.S. Department of Health and Human Services
200 Independence Avenue, S.W., Room 615F
Washington, D.C. 20201

Dear Mr. Secretary:

In a December 30 New York Times op-ed piece, Dr. Atul Gawande raises important questions about a misguided and potentially dangerous policy of the Office for Human Research Protections that would impose an unprecedented deterrent to quality improvement efforts across the country. I am writing to ask you to immediately retract any statements from the Office of Human Research Protections that imply that quality improvement efforts should undergo review by Institutional Review Boards, and that consent should be obtained from all patients before changes could be incorporated.

As you know, hospitals across the nation are engaged in a variety of activities aimed at redesigning health care delivery systems to ensure that our patients get the best possible care we can deliver. Some of these activities are organized by hospitals, such as the Michigan Health and Hospital Association’s Keystone project that Dr. Gawande cites. Others include projects initiated by the Institute for Healthcare Improvement, the Quality Improvement Organizations funded by the Centers for Medicare & Medicaid Services, and the work of several professional societies and organizations such as the American College of Surgeons and the American College of Cardiology.

As Dr. Gawande points out, research to determine which drugs or procedures will benefit patients requires appropriate oversight by an Institutional Review Board (IRB) and informed consent by the patients. However, those efforts are far different from the quality improvement efforts exploring the use of checklists, computerized reminders, teamwork training, and other steps to ensure that the care we intend to deliver is actually delivered.

It is worth noting that hospitals and health care professionals are not the only ones engaged in such projects. The quality transparency efforts in which the AHA, the Department of Health and Human Services (HHS), and several other organizations have partnered, the local value exchanges your department has fostered, and the value-based purchasing initiatives you have championed are other examples. Yet, HHS has, quite reasonably, sought no IRB review or informed consent for these changes, because they, too, are intended simply to improve the delivery of care.

As quality improvement efforts become more standardized and rigorous, and as the data collection efforts that support this work become more extensive, it would be right and appropriate to contemplate how we can collaborate to ensure that the welfare of patients remains the central concern and that patient privacy is protected. It also would be appropriate to consider effective ways for hospitals and other providers to communicate with the public about their quality improvement efforts. However, it would be wholly inappropriate and detrimental to the patients and communities we serve if the measures apparently championed by the Office for Human Research Protections were to force hospitals and others to discontinue their quality improvement efforts.

On behalf of America’s hospitals, I urge you to ensure that the essential quality improvement efforts underway across the nation continue unabated.


Rich Umbdenstock
President and CEO

Pack up your troubles

From my friend John:

"I hope you are like this 109 year old Australian woman and are still blogging at 109 years old."

As you dig down into the site, check this link to hear and watch Olive sing "Smile, Smile, Smile". It is marvelous, especially the repeat halfway through the clip.

Exit interview

I am realistic enough to know that not everybody loves their job here and that people sometimes leave with hard feelings, but when you get a note like this months later from a medical technologist who spent two years with us, you have to feel good:

Hello Mr. Levy,

I had the most incredible experiences working at BIDMC and miss it so much! There is a palpable sense of community within the hospital that is almost impossible to find anywhere, especially in an urban setting. Trust me, I have had a few rotations around Boston and constantly yearn for the comfort and kindness of BIDMC employees. If it had not been for my wonderful position at the hospital and the strong support of my colleagues, I would have not gone back to graduate school to obtain my nurse/nurse practitioner degree.

I hope after my studies I may just find a path back to BIDMC. All the best to you and your hospital.

Sunday, January 13, 2008

Who's on first

A true story about cultural competence related by my friend Ed, who spent some time on a low budget trek through northern Africa after graduating from college in the 1970's.

While in Algeria, he met a young man who asked, "What is your name?"

Ed replied, "I am Ed."

"Really?" said the young man, "Ahmed is my name, too!"

"No," said Ed, "I AM Ed!"

"Yes, Ahmed!" replied the other.

For Inspector Gadget

Have secrets? This is just for you. A biometric memory stick for your computer. You drag your finger twice over the little sensor (the orange strip at the bottom end), and that encodes your fingerprint. Then, only you can get access to the data in your memory stick when you plug it into a computer, by again passing your finger over the sensor. (There is a sliding door to protect the sensor.)

Am I a Luddite (don't answer that!), or is this a technology in search of a purpose? Maybe I don't have many secrets, but I think there will be limited demand for this. On the other hand, maybe I should add more intrigue to my life and find some secret data that I want to carry around with me.

Do you have secret data that you would want to protect this way? Hmm, is it HIPAA compliant to carry patient data in this manner? Perhaps our CIO, John Halamka, or others will comment on that.

(The company that makes this is call TwinMOS.)

Saturday, January 12, 2008

Whither thou goist I shall go

Back to our more interesting and important week's topic of helping others and giving back. Please read this lovely story by Irene Sage in today's Boston Globe about Ruth Adomunes, a BIDMC staff member who is helping to build a school in Haiti by making and selling bracelets.

I like the final paragraph: Wherever Adomunes goes, she carries a large tote bag filled with bracelets. "This is my portable store," she says. "If someone says, 'Do you have any bracelets?' 'Yes, I do.' "

Friday, January 11, 2008

>500 letters in the mailroom

Our mail room staff called today to say that over 500 letters had arrived from the SEIU to doctors in the hospital. One of the doctors was kind enough to share his with me, a letter from Mike Fadel, Executive Vice President. I'll spare you most of the details, but I will give you a small quote:

"BIDMC's CEO recently has complained that he has been singled out for public criticism on the 'question' of whether hospital workers should be promised that they will not be threatened by executives on the decision of unionizing. Be he has singled out his own institution by essentially promising to fight against BIDMC's own caregivers as if they were adversaries."

Those of you who are regular readers of this blog know that all of the above is not true. You know the high regard and respect I have for our employees, and you know of my personal efforts to improve the work environment at this hospital -- both for their sake and in support of providing better care to our patients. You can also see exactly what I have said about union organizing in general and the tactics of this union in particular.

The union's use of language is carefully chosen. It is meant, first, to isolate me by giving the impression that I am the only hospital CEO in Boston who feels this way. Not so. The others may not say so publicly, but they readily say so privately. (Who knows, perhaps they are wise to do it that way!)

Second, it is meant to try to create divisions between the doctors and the administration of the hospital. Not likely to be effective, either, in that the doctors see quite clearly what tactics are at play here.

A third subtle aspect of the package sent to the doctors is the inclusion of an op-ed from a Jewish newspaper that makes similar accusations and states that I am acting in a manner inconsistent with the "Jewish tradition of social justice." Months ago, I raised a hint as to this tactic as well. Perhaps the SEIU thinks that doctors at a hospital, one of whose antecedents was established by the Jewish community, would be receptive to this argument. Perhaps they don't understand that many people are likely to find it an offensive and mistaken use of religion in support of a political or organizational cause.

Meanwhile, I hear from friends on Beacon Hill that the union persists in complaining about this blog and what I say in it. What I say in it, as all of you know, is out there for the world to see and evaluate. If any of you catch me in a misleading comment or a mistake you can say so immediately and for the rest of the world to see.

Sunshine is the best disinfectant.

Dr. Codman was right then, and he is right now

Please check out this article by Doctors Swensen and Cortese from the Mayo Clinic. An excerpt:

Transparency was an issue for the American medical profession a century ago, and transparency is an issue for the American medical profession today. In 1905, Ernest Codman, MD, first described the "end result idea." The end result idea is simply that doctors should follow up with all patients to assess the results of their treatment and that the outcomes actively be made public. The end result idea was considered heretical at the time, but in retrospect Codman was sagacious and prescient. He was an advocate for transparency, which he believed would promote quality improvement, patient choice, and physician learning. Transparency is best viewed as an opportunity, one that we should fully and enthusiastically embrace. It offers a substantive boost as organizations step up to the moral imperative of improving patient care to the best it can be.

Codman "walked the walk" as well as "talked the talk." He openly admitted his errors in public and in print. In fact, he paid to publish reports so that patients could judge for themselves the quality of his care. He sent copies of his annual reports to major hospitals throughout the country, challenging them to do the same. From 1911 to 1916, he described 337 patients who were dismissed from his hospital. He reported 123 errors. He measured the end results for all. Codman passionately promoted transparency in order to raise standards. Codman said, "Let us remember that the object of having standards is to raise them."

...A century later, the medical profession is still struggling with the same issues as though they were new. Dr. Codman was right then, and he is right now. Fundamental to the quality movement and American medicine in the 21st century are the same peer review, standardization, systems engineering, and outcome measurement issues. Publishing results for public scrutiny remains a controversial topic. We should embrace transparency as a component of our tipping point strategy to ignite the change we all need to transform our organizations and our profession.

Thursday, January 10, 2008

Inspiring and powerful

The theme this week seems to be "giving back" or "paying it forward." Here is another chapter.

Every Monday morning, I have the pleasure of welcoming new employees of BIDMC at an orientation session we hold for them. Later, there is a section in the program when we ask the new employees to think about a time they may have gone to a hospital for themselves or accompanied a loved one. In thinking about the experience, we then ask them to evaluate whether it was positive (and what made it so) or did not go well and what could have improved it.

Here's a note from the group leader, Lynda, about what happened this week:

Depending on the audience, some weeks we get all kinds of responses and then sometimes people are more reticent. This week, the audience was a bit quiet so I piped in with my own experience of having just gone through significant experiences of my own and how the kindness that I received from staff made a difference in my healing. I asked the group if anyone could “top that”.

A woman in the audience raised her hand and proceeded to tell all of us about the time, 4 years ago, when her father who was a patient here, was dying. She choked back tears as she told about her family all being there and the staff making sure everyone had a place to sleep and food to eat around the clock and whatever else they needed. They were apparently there for a number of days but went through the experience together as a family, with their father, being totally supported by the staff.

Then she added that she decided she wanted to come and work here in order to be able to give others the kind of experience she had here and to work with these remarkable people.

All in all, tearful and inspiring and powerful for all of us present.

Thank you, PHC

Stephen Smith at the Boston Globe reports that the state Public Health Council voted to allow storefront clinics in Massachusetts. (I had written in support of this vote last week.) CVS, the original proponent, apparently plans to open more than two dozen. Now, having gotten permission, CVS needs to carry this concept in a manner that will set a high standard and prove the wisdom of the PHC vote. I wish them well in introducing this innovation into the MA health care delivery system.

Wednesday, January 09, 2008

Don't let others define who you are

Each year, in cooperation with the Boston YMCA and in conjunction with the Martin Luther King, Jr. holiday, we present Black Achiever awards to members of our staff who have made significant contributions to the workplace and their community. We also invite a guest to offer a keynote address, and this year it was Rev. Dr. Michael E. Haynes, Senior Pastor Emeritus, at Roxbury's Twelfth Baptist Church. Rev. Haynes was a personal friend of Dr. King's, having met during the latter's training at Boston University. It was inspiring and enlightening to hear stories from that period.

Equalling inspiring, though, was the acceptance speech delivered by Dr. Yvonne Gomez-Carrion, an obstetrician in our hospital. I asked her for permission to post it here, and I include it in its totality.


Good afternoon! I am truly honored and humbled to be here today with all of you to celebrate the life of Dr. Martin Luther King, Jr. and to accept this Black Achiever award. I thank Dr. Ronald Marcus, my mentor and friend, for nominating me and for the committee for choosing me.

I have worked hard all of my life, and I have received so many, many blessings.

Yes, I have always loved being challenged. I love giving orders, and I love helping others work through difficult situations.

At age 8, I realized my calling: I wanted to be a doctor. So many individuals went out of their way to impress upon me how hard this path would be, and many told me that I would never make it as a physician, a healer.

I encountered so many negative people along my journey. The naysayers seemed to be everywhere, BUT those folks were trumped by my parents, many incredible mentors and dreamers like myself who inspired, promoted and assisted me at every opportunity .

I have been blessed to have friends who ARE encouraging, positive and like me, want to make a significant contribution to this world, to our community.

When I was told that I wasn't smart enough or that I couldn't go to the schools that I attended because my parents would not be able to pay, well I studied, received academic scholarships, and I sought out jobs that would give me insight into the medical world.

Growing up, I would get angry about the condition of my community in Brooklyn, NY, the lack stores with fresh and nutritious foods, the abundance of fast food and liquor stores, the lack of good medical and dental care and the many challenges to obtaining a good education.

The more angry I became, the harder I worked.

I never gave up: WITH HELP, I figured it out!

I appreciate that everyone needs to chart their own path. You need to figure out what you have passion for, what will bring you joy and satisfaction while giving back to your community.

I received countless valuable messages. These messages were pounded into my head by those who nurtured me.

They would say:

*Stick to your values.
*Don't let others define who you are.
*Surround yourself with positive people... My dad would always tell me, "Show me your friends and I will tell you who you are."
*Don't give up because things get rough.
*Have faith in yourself.

Life is full of disappointments and tragedies -- these provide the lessons that we must receive in order to grow.

I thank God for my family, friends, my amazing church community, my medical colleagues and my patients.

It is because of YOU that I stand here this afternoon!

Like Dr. Martin Luther King, Jr., I, too, dream and I challenge. Today, I challenge each and every one of you to:

*Seek out a child who is suffering from the ills of poverty, dangerous communities and substandard education.
*Seek out a child of color.
*Seek out a child with a learning difference.
*Seek out a child who feels that violence is the way.

REMEMBER, compassionate mentoring has the power to change and enrich another's life.

I will leave you with one of my favorite prayers, an "old healing prayer" from Central America:

Do all the good that you can
In all the ways that you can
By all the means that you can
To all the people that you can
In all the places that you can
For as long as ever YOU can

Thank you very much!!!

Elections everywhere!

Many thanks to the folks at Medgadget for including me as a finalist in two categories of their 2007 Medical Weblogs Awards. I am ambivalent about the voting, as I am blogosphere "friends" with some of the competitors in both categories, and I have great respect for all of them.

That being said, I would be honored to have your vote in this election, if you think this blog is worthy.

Federal campaign laws apply to this contest. No cash contributions above the legal limits, please. And, I do not accept contributions from tobacco companies . . . .

Tuesday, January 08, 2008

Pay it forward

Of all the great things that happen at BIDMC, the most satisfying to me is when we are able to help people realize their dreams and rise through the ranks of the health care and research fields.

Tonight, we held a graduation dinner for the first group of surgery tech's, ED tech's, and others who have completed their nursing degrees and will now be working in the hospital as RNs. Over two years ago, we chose employees to be sponsored in this program through a competitive process that took into account educational attainment to date, college placement test scores, and job performance. We paid for the tuition and books and fees at Mass Bay Community College, but these young folks put in the sweat equity, working after hours and on weekends. They were joined at the congratulatory dinner tonight by their friends and families, college officials, as well as their supervisors and mentors at the hospital. The special guest speaker was the Chair of our Board of Directors, Lois Silverman, who herself was the beneficiary of a similar program decades ago, when she received a $300 scholarship to attend the Beth Israel School of Nursing.

This is but one of several program that we have in place to provide career and professional advancement to people in the hospital, especially lower wage workers. These are funded out of our regular operating budget, from philanthropic donations, by a grant from The Boston Foundation, and by a grant from the Commonwealth of Massachusetts.

Another program is one that enables people to become surg tech's. Here, we partnered with Mass Bay to offer modified academic programs in a format that allows employees to continue to work full-time while pursuing their career-advancing education. Courses are offered at the hospital in the evenings or online, with labs taking place on weekends at college and clinical rotations on site. We provide funds to cover students' tuition and also a stipend to help them meet living expenses during the second half of the program, when their 24 hours of weekly clinical practicum require that they reduce their regular work hours.

Still another program is training people to be research administrators, a growing area in the world of academic medicine. Another we are kicking off will train people to be medical lab tech's, a tremendous growth field, as well. Yet another provides more elementary training in math and English to help people get to the level that they can participate in more advanced training.

It is, of course, greatly satisfying that people will earn more money as they move up the career ladder and have more opportunities. But what means more to me is that we are continuing in a tradition that reinforces the American Dream. Through hard work, persistence, dedication -- and a helping hand -- men and women can gain greater personal and professional satisfaction in their work and and, in turn, look back to help the next group coming through.