Googling around

Please read John Halamka's latest posting about the personal health record service to be offered by Google. As he notes, BIDMC will be part of the roll-out of this service. An excerpt from John's blog explains how this will work:

To self populate the Google Health record, a patient who has a relationship to one of the Google interfaced providers, just clicks on the icon of their hospital. That icon offers up to 3 links. In the case of BIDMC, we'll offer

Upload your records
Make an Appointment
Securely Email your Clinicians

If a patient clicks on Upload your records, they will be asked to login to BIDMC's Personal Health Record, Patientsite, using the secure credentials that have been issued by their doctor, validating the patient's identity. Once they sign a consent, they will be given the option to initiate an upload of problems, medications, allergies and laboratories into Google Health. The patient initiates this transfer, with their consent, after understanding the risks and benefits of doing so. Once the data is in Google Health, the value to the consumer is expert decision support, disease information, and medication information based on the patient's data.

John further notes:

As part of the Google Advisory Council, I can tell you that many thoughtful people worked on the legal, technical, and policy issues around data use. Google will not advertise based on this data, resell it, data mine it , or repurpose it in an way. These consumer centric policies are similiar to the best practices adopted by Microsoft Health Vault.

It's important to me that in my role as chair of the national standards effort, HITSP, that I support all the major personal health record initiatives with interoperability. I've committed to Microsoft that BIDMC will work with Health Vault. I've committed to Dossia that we'll link with their Indivo Health platform. It's my hope that all of these efforts will converge to use one plug and play standard for clinical content and transport. Once they do, patients will be able to select the personal health record of their choice based on features, not just data.

I'd welcome comments on whether you, as a consumer, think you would find this kind of application useful.

Volunteers (and others) rule!

The outpatient oncology clinic is a busy place in our hospital. In addition to the trained medical staff, there are a large number of volunteers, many of them cancer survivors, who help make life a bit easier for those coming for chemotherapy treatments. Here is a note I received yesterday in appreciation of all of them (names have been changed):

Dear Paul:
Beth Israel continues to impress and inspire us. I never would have thought it possible to look forward to coming to a chemo clinic, but that is exactly what happens now, at Shapiro. Mark was diagnosed with cancer in the fall, and we have had the most amazing experience there. But that first visit to the ninth floor is made with trepidation, as you can imagine. Soon enough, however, an adorable volunteer (and cancer survivor) by the name of George gently introduces himself, as he offers juice and biscuits from a little trolley. Through the course of the day, one then meets the other volunteers -- all former chemo patients, which is brilliant inspiration for people facing a great unknown. These precious people -- the same group comes every Monday, as you probably know -- move around the clinic throughout the day, simply putting people like us at ease, offering lunch, treats, even warm blankets. From the very beginning, I felt that Mark and I were in a sort of cocoon of gentle caring. From those wonderfully inspiring photographs of cancer survivors at the elevators, to everyone on staff there -- MDs, nurses, and aides -- it is an amazing experience. I never thought that a cancer clinic could be such a cheery, optimistic place -- I know it isn't always, but it is, for us, often enough, and it is genuine. You're probably well aware of the incredible job that people do there, but I just wanted to let you know that it continues. Just one more reason to cherish our beloved hospital.
Very best,

Newsflash! NYU degrees devalued.

Boston-based parents of children graduating from NYU are reported to be asking for refunds in light of this news report.

Paintings in Lincoln

A break from hospitals and health care to turn to the finer things in life. One of my favorite local artists, Ilana Manolson, is having a show in March at the Clark Gallery in Lincoln, MA. In addition to the dates shown above, the gallery is opening for a preview on March 1st from 2-4 pm. If you are in the area, I think you will enjoy it.

Costs, costs, costs

As always, a thoughtful piece by Steve Bailey in today's Boston Globe, this one quoting Regina Herzlinger from Harvard Business School. An excerpt:

What consumers need, she says, is greater transparency. "The premise is that they are wonderful," she says of the hospitals. "Maybe they are. I would like to see some data that shows just how wonderful different hospitals are all across the United States. I would like to know how good is the Mass. General? How good is Brigham and Women's? How good is the Baptist? How many people get an infection? How long does it take to regain mobility after an operation? Dumb as I am, I could look at those data and understand them."

Well, as Reggie knows, you can check our website for this kind of information, in plain English, about BIDMC. Whether consumers use this information or not, we post it as a way to hold ourselves accountable to the public and ourselves to strive for ever greater clinical quality.

Mr. Bailey ends his column with this question: "Of course, we have to pay. The question is how much?" His question is also on the minds of John McDonough at Health Care for All and Charley on the MTA at Blue Mass Group. Previously, I have offered some of my ideas on this topic. And we are all looking forward to an expanded version of proposals from Senate President Terry Murray in the next several days.

Grand Rounds is up at Scienceroll

Grand Rounds is up at Berci Meskó's Scienceroll. The topic is the future of medicine. Please check it out.

Greetings!

Several months ago, we hired some new people and reassigned some other folks to become "greeters" at the various entries to our hospital. Their job, as the name implies, is to be available to help people find their way in the hospital, including escorting them as necessary to find the right place in our 2 million square feet of space. No, we do not get paid for this from the insurance companies or Medicare or Medicaid. It is simply designed to help people and make them feel more comfortable and welcomed.

I just received this nice note from one of our research staff folks after a meeting we held about improving the patient experience here:

Here is one small thing that I think we are doing extremely well. I’m often in the atrium of the Shapiro building, and every day I see the staffers in their maroon blazers helping patients with questions and giving directions. It’s the small things that make a big difference. Just yesterday I saw a woman entering in the Binney Street entrance on crutches who was immediately greeted and asked if she would like a wheelchair. She seemed very surprised at the offer, but seemed to be grateful for it. It stuck with me all day; she got not more than three steps into the hospital and she was already being cared for. I see things like that all the time now and I’m certain that patients, visitors, and other BIDMC staff do as well.

How things don't get fixed

So, as we start to implement BIDMC SPIRIT, here is a classic tale of a complaint and a solution that doesn't solve the root cause problem. Note that all people involved are very well intentioned, responsive, and caring of the patient , but how -- without a little prodding -- an underlying problem would have been left unsolved. By the end, we are headed in the right direction!

Note to me from a friend of a friend:

Amy S. suggested that I write to you about the difficulty that I have had registering on the BIDMC PatientSite. Quite simply, I tried to register as a patient and received a "Confirmation of Registration Request" by e-mail on February 11, 2008. I have still not received a username and temporary password. I currently correspond by e-mail with my primary care physician here in Worcester and find it quite helpful. The BIDMC patient site seemed to offer even more in terms of usefulness to a patient. It is frustrating and a little disquieting to discover that his piece of technology does not run as smoothly as I as a patient would hope the care at BIDMC runs.

My reply:

Hi. I am forwarding this to people here who can be helpful.

Reply to me from our CIO, with a copy to the right person in his place:

Happy to help. ABC, could you check on [this patient's] registration?

Note to the patient from ABC, with copy to me:

You are now registered for PatientSite. If you need further assistance, please do not hesitate to contact me.

Note to ABC from me:

Thanks. Now, I am curious as to why it didn't work for him. Can you explain? Is there anything we need to do to help others avoid this problem?

The IS person's reply to my query:

He sent two requests to register with Dr. X in the XYZ clinic. These requests typically go to office staff, and they did not respond to his requests.

My reply to administrative director in that clinic, with copies to others.

Well, let's pursue this and get to root cause and solve it, so it doesn't happen to future patients. (Pat and Jayne, also please note and offer BIDMC SPIRIT advice and assistance to [the AD] as needed.) Remember, no blame! Solve the problem.

Reply from AD, to me alone (!):

Thank you. Will follow-up with the admin staff.

Reply to the AD from me, again with copies to all others:

But, wait: There may be lessons for other clinics as well, so please do not do this in isolation. That is why I continue to copy others on this email thread....

Jayne, the VP who was copied, jumps in and says:

Dear All,

I will call a meeting to discuss the process for signing up for patient site. It would be good for everyone to understand the full process. Once we all know the full protocol and who is responsible for what portion of the process clearly without misunderstandings, then we can improve and re-document the process and roll this out to office assistants also as appropriate. Also, we need to ensure that the physicians also understand that they too need to approve their participation in patient site as I understand that has been a concern in the past.

ABC, can you bring a process flow of how IS and offices handle requests and timelines of the process for approval. Also, how is it fully communicated to the patient, etc. Then we can discuss other components that contribute to a less than optimal response to the patient and solve to root cause, then roll out to all, the improved system so that everyone understands their roles.

Return visit with a surprise lesson

A note from a friend with a helpful story, which she said I could pass along here. She previously had radiation treatment for breast cancer, but had to return many months later for treatment in her spine.

I've been mulling over my experience with spinal radiation. I realized that the staff, when they are preparing me with information, has no way of knowing what I am anticipating about the experience. They don't know I am not taking them seriously -- because I do not know it will be very different from what I have experienced before. So I am thinking "5 treatments - ha! - the first 5 days of radiation were nothing! No side effects at all!" and of course a day later I'm lying in bed whining. I was very disappointed in myself.

You know that I loathe surgeons who say "You'll be fine in a day," when they know you won't, as if their words are divine power. That wasn't the case here -- I believe the staff told me the truth but I was not listening. I should have known, when they handed me anti-nausea medication, that they actually meant that you can feel nauseated.

I was an over-confident patient. I don't know what that means, but am mentally filing it away for the future.

The SPIRIT lives on

Here are several more comments from people being trained as part of BIDMC SPIRIT, our program to enhance the workplace for our staff. I hope you all are not getting tired of this, but I think it is important to continue to share these observations -- both internally and with those of you in other hospitals -- to give a sense of how a program like this gets rolled out and what issues are brought to the fore.

I love the observations – wish they were longer because you can learn so much by watching other people’s work.

Think that seeing other areas of the hospital creates huge benefits in understanding how pieces fit together and how remarkable the people of the organization are.

I like the idea of having SWAT teams who can bring fresh eyes from across the organization to observe and help improve work in each area.

I’m worried about the documentation that may be caused by the Spirit program – we can’t let documentation overshadow problem solving.

There are still some important elements of the program that haven’t been clearly enough defined so I don’t know what to do tomorrow when I get back to work.

We need to get physicians and mangers from the “supplier” areas into the orientation soon so that everyone who is working on problems together is doing it using the same method and eyes and people don’t get stalled on all their early problem call-outs.

I did not expect to be able to see problems since I didn’t know the work well, but I was easily able to see many problems. At one point I saw seven problems in six minutes!

It would be useful to have scripts for starting the investigations that help us get started on the skills that the Value Capture staff demonstrated today.

This experience was so important for helping “throw out what you think you know” and create a whole new way of thinking.

We have to think carefully about what the staff will hear about what is expected of them and of their managers.

I learned the importance of staying on point to fix problems one-by-one so that we don’t try to solve multiple problems at the same time and fail at all of them.

I’d like to know how this process will effect human resource evaluations and whether we will be changing our forms and processes to align them with Spirit.

We have to be careful not to confuse Incident Reporting and Spirit, but also to potentially use both processes on the same problem sometimes to incorporate appropriate (non-patient/worker identified) transparent learning and real time problem solving for some of our dangerous events.

We have to address the off shift, weekend, and holiday help chain or we will make many of our employees very frustrated.

The Spirit program and this orientation create a common ground and a common language for problem solving that will be useful to change our culture.

I would have preferred that the packet that was handed out could have been sent sooner. It was not the same information that came over the e-mail. The positive was getting into the field and seeing all the situations staff are dealing with. Also seeing leaders with experience helping us. Having the direction of people who will be trainers was very helpful.

I agree. During the debrief after the problem solving, hearing from what the other groups worked on in the other departments – their experience, their action plans, that was was helpful to me.

Coming in I dreaded that this would go on for 8.5 hours but it by very fast and it was very informative. I can see it happening. I was involved in the envelope saga. It was amazing to follow it through and see all that can come from one little envelope.

This was a good tool to organize problem solving. It forces focus, etc. Organizationally, it can’t hurt. For me it will definitely help in organizing problem solving and solutions. On the side of needing improvement, sometimes it seemed we were looking for problems. It would have been nicer if there would have been more actual call outs from the staff while we were there. Maybe preplanning to be there at busier times … so we’re there when people are ‘freaking out.’ 

The case examples we did, the role plays, were very good to prepare us and get us ready for the floors. It gave us tools. On the negative, going during lunch time inhibited follow-up. Folks can stagger their breaks on the floor but it’s still a hard time.

This is my second time out. I am less in awe (which means confused). The process seems more “backed up,” clearer. The staff are very open. On the concern side, we are still in the learning phase, and we are supposed to be starting very soon. Some things are still fuzzy … that’s going to be very hard.

The process of building the scientific method in the morning was very helpful but out on the floor in the afternoon it sometimes felt like a solution in search of a problem (when you’re a hammer everything looks like a nail). The staff may be so used to workarounds it was hard for them to get into it. It was great getting into the field … the dialogue with the chief tech was just great.

This was my third time. Its amazing to see it come together. To go from this being very uncomfortable for me today, as co-facilitator, to see the program really shaping up. It won’t be perfect but we need to be ready to say – as I will say to my division – we need to be ok with a little clunkiness. Our biggest challenge and the key will be to really use this to empower the staff.

The roleplays were really helpful and really important to do. I still feel like we need more tools to use to actually solve problems. Not instead of the training we are doing but as a “plus.” There are 10 or 20 key ideas out there that we would really find helpful. A few sessions on those would help.

The positive was to be on the unit and see what staff are dealing with, to see the opportunity to help. Within just one hour to get to the root cause of a problem like that … was great. A concern is the time involved from the help chain people. I also worry how this process will fit with others [internal queuing of work orders], that it won’t be used to move other things to the top of that queue.

This was my second time. It was definitely much clearer and more solid. The training was well organized. I have concerns about people’s time. The little problem in the mail room – the implementation plan is not going to be so fast to come together. It is important to try in real time though. I see that.

The role plays were helpful. Learning about other areas, being non-clinical myself. The tools were a good basis but make them easy to access and painless to use … if not people won’t use them.

I enjoyed the whole day. It gave me a knowledge base of root cause problem solving that I didn’t have. It opened up possibilities for me in my thinking. I want more tools to help promote this in my departments and not have this be seen as burdensome.

As we get to action planning it will reveal tensions in the organization. That’s how we’ve done things in the past, and people dig in. For example, the envelope problem. Some may say don’t do x because we care about y. These things will reveal tensions; it’s how we resolve them that will be key. I also want us to consider the benefit of outside eyes today. When this starts, if it’s just me and my staff working on these things there’s less value in breaking silos and seeing things fresh. I’d like to build in those outside eyes.

The observation was wonderful and helpful. I would have like to review the material, observe in the AM, then come back to process, then go back to the floor to problem solve. It’s easier to start this where we know. I would have liked to have started in our own departments, on problems that stay there. Not jump into things in the middle that cross over into other departments. Could we start this this way? Staying away from the interdisciplinary problems?

I enjoyed going out. I’m new to the hospital (3 months). Hearing other managers with their perspectives. One point I’d make is that we need to teach how to respect each other. It can be the most important thing. I spend a fair amount of time looking at things between the OR and other areas. So many problems stem from communication; we need to teach how to have respectful conversations. Another suggestion: have aggressive 6 month feedback on how this is going and what we can learn.

I liked going and observing; I saw a lot of things in my own area’s registration-it was very eye opening.

I enjoyed working with people in other people in other areas, the group setting was nice, it was nice to see the people behind the emails.

This will change the dynamics of what people see as problems; this can break down barriers.

It should remind us all that immediate need for me might not be immediate an immediate need for someone else and we need to show respect for each other.

I like the practical aspect; it builds ownership within and among departments.

Observing the blood bank lead me to understand what our department can do better.

It was interesting to see that something as simple as how we put a label on impacts someone else’s work- we are probably making other departments take extra steps and we don’t even know about it.

Communication is so important; rather than just getting used to it (the problem).

There is a lot of work that will come out of this and some will be hit more than others.

The afternoon was really long.

It is awkward observing someone and I am sure they feel the same way.

How will people stay motivated when we are unable to solve everything, how will we feel about this workload, how can this become part of our intelligence versus hunting through a log.

Public? Private? Either? Both?

A concluding chapter about health issues in the UK. Arriving at Heathrow Airport on Sunday, I saw the following advert whilst waiting in the immigration queue:

Private health? World Class Care.

It was a billboard for HCA Hospitals, a private company offering a variety of specialties side-by-side with the public National Health Service. The poster noted in small letters at the bottom, "GP referral may be required."

Not understanding the relationship of this parallel private system to the public system, I was further enlightened by this story by Sarah Lyall in the New York Times, which was sent by a friend upon my return. Here's a teaser quote:

Created 60 years ago as a cornerstone of the British welfare state, the National Health Service is devoted to the principle of free medical care for everyone. But recently it has been wrestling with a problem its founders never anticipated: how to handle patients with complex illnesses who want to pay for parts of their treatment while receiving the rest free from the health service.

As I have mentioned elsewhere, there seems to be a convergence between the health care systems in Europe and that in the United States:

I predict . . . that the systems will start to look more and more alike over time. Pressure in the US for a more nationally-determined approach. Pressure in Europe for more of a private market approach. It shouldn't surprise us to see this convergence. After all, the countries are dealing with the same organisms, both biologically and politically.

The Mutating Playbook

Several recent events reminded me of a subtle change in the tactics being used by the SEIU in its corporate campaign against BIDMC. You may recall that I have described this kind of campaign as an attempt to denigrate the reputation of the hospital and its trustees in order to put pressure on the institution to agree to concessions in the organizing process that would eliminate many of the protections contained in the National Labor Relations Act. This is a long-standing pattern used by the SEIU in several jurisdictions.

Here's the mutation to the playbook. The SEIU has apparently decided that it does not want to look like it is trying too hard to hurt the reputation of the hospital. Why? Well, I am guessing that there are two reasons. The first is a legal one. Unions are being sued by companies who are alleging that the union's corporate campaign against the employer constitutes illegal racketeering. Here is an excerpt from the December 10, 2007, Wall Street Journal Online:

Employers are using laws originally aimed at organized crime to combat aggressive union organizing efforts that they claim amount to extortion. Two lawsuits filed by employers in the past two months invoked the federal Racketeer Influenced and Corrupt Organizations Act, or RICO, to claim unions have tried to damage their reputations and businesses through public-relations campaigns and other tactics. In both suits, the companies claim the unions are spreading false and damaging information through flyers and the Internet and at demonstrations.

Perhaps the SEIU is particularly worried that a motion to dismiss one of these case was denied by a Federal court.

The second reason might be that, in a town like Boston, which is so dependent on the health care sector, there is not much taste among public officials and others for destroying the reputation of one or more highly respected academic centers.

So, does this mean an end to the corporate campaign? No way. It just means that the attacks are more subtle and are always put in the context of improving the health care delivery system. And they will tend to be directed personally at trustees and other individuals, rather than at the hospital, per se. Indeed, first, there will often carefully be a statement along the lines that the hospital does many good things for patients and the community. This way, no one at the SEIU can be accused of wanting to hurt the hospital.

Nice work guys. This is clever and thoughtful and is designed to switch attention away from the union's unabated desire to put pressure on the employer to concede to changes in the federal organizing rules. Instead, the union has arrogated to itself the role of public defender -- citing alleged accounting errors, alleged failures of trustees to carried out their fiduciary role, and alleged failures of licensing, regulatory, and other bodies and public accounting firms to do their jobs properly. In today's post-Enron, post-subprime-loan corporate environment, such allegations are meant to leave the public thinking, "Well, there must be something wrong." Because the rules surrounding hospital finances and other matters are so complicated, no simple answer -- no matter how accurate -- can be given by the institution in a way that effectively rebuts each accusation in the public eye. And then, of course, it gets picked up and repeated every time the union files a new allegation.

Stay tuned for more mutations in forthcoming chapters of this saga. But, rest assured, the playbook is still in use.

London subway map

From several speeches given by Lord Darzi, demonstrating inequalities in the effectiveness of the public health system within London. I think this is a particularly effective graphic showing the decreased life expectency between the wealthier districts of the city compared to the less wealthy.

In case you can't read the numbers, male/female life expectancy drops from 77.7/85.2 years in Westminster to 70.7/78.4 in Canning Town. (The source of data is London Health Observatory using Office for National Statistics data. The diagram was produced by the Department of Health.)

Again, I present this not be create a debate about the merits of the British and US health care systems. After all, a similar map could be presented along the Red Line or Orange Line routes in Boston. I offer it mainly to express my appreciation of the willingness to be open and present numbers like this so the public can fully engage in the improvement process at the NHS.

A natural!

The letter above is from the daughter of one of our fundraising folks to her mom. I don't know if you agree, but it appears to me than there has been some genetic transfer of persuasive ability to this young lady!

The old and the new

What I really love about the United Kingdom is how it holds on to the past while also pursuing the latest trends. An illustration of the former is to the left, the plumbing facility in the bathroom of my South Kensington hotel room. An example of the latter is this website.

Part of the current NHS plan is to introduce the concept of polyclinics, which I believe to be roughly analogous to our multi-specialty groups. Here, primary care physicians would join with specialists in one location to offer a range of primary and secondary care outside of hospital settings. One reason to do this is to reduce the number of stand-alone GPs, who, because they are working alone, really cannot provide good access to their patients or a very full range of care.

The idea of linking to Second Life is very clever. Any person can enter the virtual world of Second Life and take a tour through a polyclinic to get a feeling of what it would be like. In addition, the program includes a survey to allow members of the public to comment on what they have learned and to make suggestions as to how the concept might be improved.

I had not seen this done anywhere else before, and so I was impressed. Then, this morning, I learned that there are several other examples of medical facilities on Second Life. Bertalan Meskó provides a top ten list here. I haven't had a chance to look through them carefully, but I think the NHS usage of this application remains an unusual example of a way to both educate the public about a governmental proposal and also to seek public comments.

An open letter across the sea

Dear friends,

As many of you know, I am a relative neophyte in the health care world, taking this CEO position just six years ago. Since then, it has been OJT (on-the-job-training) to learn this business while also using experience from other fields to enhance the working environment for our staff, upgrade the quality of the patient experience for those visiting our hospital, and also try to participate in a helpful way in the public policy debates of our time.

On this latter point, I have seen persistent comments from many observers about the flaws of the US health care system. Those flaws are indeed evident, and it is very healthy for society to focus on them to improve the situation. However, you often hear comparisons of the system in the US with the health care environments in other countries; and those countries are often described as being "ahead of us" on this or that aspect. Such comments, for example, point to greater levels of insured coverage for the population or stronger delivery of primary care.

I used to think that the main reason the US has not moved towards some of the European models of care had mainly mainly to do with the power of interest groups here that causes gridlock at both the state and federal level. And, indeed, I still would not deny the strength of those opposing forces. Yet, I often wondered, if our system is so flawed and "theirs" is so much better, wouldn't political leadership arise to break the logjam and move us in that direction? But, now, having had a chance to view several of those systems more closely, I see that the grass is not nearly so green as one might have thought. Each country has designed variations of insurance and coverage and access for its population, but each country is also going through the same kind of debates as are we -- in the hope of improving the equitable distribution of care, enhancing quality and safety, and increasing efficiency.

My purpose in mentioning this -- which to many of my more experienced and knowledgeable readers may not be news at all -- is not to get into a debate about the relative merits of each country's health care system. It is to make the point that there is a cadre of people around the globe with a strong commonality of interest in learning from one another for the sake of improvement.

When I was first invited to Iceland to meet with health officials from the Nordic countries, I was bemused that they thought I might have anything to offer in their environment of state managed systems. Yet I was told after my meetings there that several of our initiatives at BIDMC were of great interest and potential value in their hospitals. Ditto in the Netherlands. And, just this week, ditto in the UK.

As satisfying as that might be, these visits are even more valuable for me in providing a fresh perspective on issues at my own hospital and in suggesting particular ideas that we might want to borrow to improve how we deliver health care, how we make a better workplace, and how we relate to the community. Equally satisfying, there is a warmth and camaraderie among people engaged in the delivery of care that offers even a newcomer like me entry into the "club" of extremely well-intentioned people who devote their lives to alleviating human suffering caused by disease.

The point of all this rambling? Well, in a somewhat wordy manner, I write this as an open thank-you note to Lord Darzi, David, Ruth, Steven, Rachel, Tom and all their colleagues in the UK for allowing me the opportunity to be in their company, to share ideas, observations, perspectives, and, yes, even some poorly delivered across-the-pond jokes. Although it may not alway be emphasized in some of the press reports about your strategies and plans, your overwhelming sense of public service and desire to build the best possible health care delivery system for your citizenry is ringingly clear.

In our clumsy way here in the US, we pursue the same goal. Whether in a single hospital or for the country as a whole, we do not seek to design, a piori, the best complex system. Like you, we seek to discover it by honestly viewing and admitting our faults and errors in an open, blame-free environment in which respectful engagement leads to constant improvement. Thank you for letting me participate with you to learn from your experience.

Gratefully,

Paul

#3 in the world

More to come on my visit to the UK later, but for now the following observation: With about 1.4 million employees, the National Health Service is reportedly the world's third organization, after the Chinese army and the Indian national railway system. Imagine trying to manage process improvement for this group! Nonetheless, I learned of some remarkable innovations being employed and considered. Stayed tuned.

Good morning, London!

Actually, it is still Sunday night, but I am writing this to ensure an early morning greeting to my friends and colleagues in London in anticipation of a lecture I am giving at Imperial College London at 18:00 on Monday at the Sir Alexander Fleming Building. I look forward to being with my UK colleagues to share information on approaches to lead change in institutions undergoing large-scale transformation. I have been asked to discuss ways of improving engagement with staff and patients, and making changes that increase patient satisfaction. Also, I am to explore ways of -- and benchmarks for -- measuring success in an academic medical center/academic health science center. The session is hosted by Lord Darzi of Denham, KBE, who has taken on a major role in the efforts to enhance the National Health Service.

My audience has already been very tolerant of me. I had previously asked them to read postings on this blog in anticipation of this lecture, and I now notice a loyal readership from the UK every morning as I check my blog statistics. I am looking forward to many questions and comments from the audience, in the hope we can use this occasion to draw on ideas from one another. Speaking of metrics, I suppose a measure of my success will be how many people in the UK continue to read the blog after the lecture!

Meanwhile, inspired by my friend in the posting below, I had a marvelous lunch of fish and chips today at the Sea Shell Restaurant on Lisson Grove.

Central MA nostalgia: Dubbleyokas

A note from a very good friend in Worcester. You will either identify with it or not. Sorry if you don't.

Do you remember when we were kids occasionally getting a dubbleyoka? Not really having enough to do I have been in search for them for quite a while. I have even been buying farm fresh eggs from Suney's Pub on Chandler Street. They have great fish and chips on Fridays. Well, I had heard a rumor that Fairway beef (this is the Siegel family that used to run Boston Beef) had them -- so yesterday instead of buying eggs at Suney's, though I did have the f&c for lunch, I scooted over to Fairway and bought a 20 egg flat of Super Jumbos (that's right, Super Jumbos!) from Johnson's Egg Farm in Westminster -- ($3.49) -- I also bought some for one of my carpenters -- he is paying me back in coffee all next week -- good deal, huh? Well, these suckas are hug -- big as your fist -- I can't even imagine what they felt like coming out of the chicken. Oh my god! Anyway, I got up early, 5am this morning, to have a couple before work, and, lo and behold, as god is my witness, standing on the graves of our ancestors, two eggs -- two dubbleyokas!

Life is good! There is hope -- Obama can win -- a new day is dawning -- the icecaps are coming back -- peace is possible -- George Bush is history -- and I saw all that in a Circulon 9 incher right here on my stove top in little old Worcester, Mass.

And thanks for listening to me.

Fundraising on Facebook

The chart above is from an article on CrunchBase about Facebook, showing the growth in subscribers since the service was opened up to the world beyond students. Amazing quote: "Facebook users’ passion, or addiction, to the site is unparalleled: more than half use the product every single day and users spend an average of 19 minutes a day on Facebook. Facebook is 6th most trafficked site in the US and top photo sharing site with 4.1 billion photos uploaded."

I became intrigued with the idea of using the Facebook cause feature as a possible fundraising tool for our hospital after I saw that a neighboring hospital had raised over $50,000 for one of its cancer programs in this manner. So last weekend I set up a cause, called Healing Music, to raise funds for our harp player and other musicians and sent a notice to some friends. It is has been fun to literally watch the viral marketing that results. I don't know if it will raise much money -- although it is a good cause and you should feel free to donate! -- but it is also an excellent way to inform people about a worthwhile feature of our hospital and to share a nice idea with other medical centers as well. (By the way, the fee taken by the people who run the fundraising application, less than 5%, is very reasonable, especially since it costs nothing at all to set up a cause.)

But, beyond this, the wall-to-wall conversations on Facebook can be really entertaining and illustrative of important cultural differences throughout the world. Here, for example, is a post-Super Bowl note from a Boston-bred relative to her good friend in New York:

You know what?! Fine. You won. Good playing. Catch a ball on your head and all that crap. But sending me an invite to join the "Giants fan club"? Not cool.

Learning to get the SPIRIT

More in our continuing series on BIDMC SPIRIT, our effort to enhance the work environment for staff throughout the hospital. Here are additional comments from people who have just gone through the train-the trainers training program. You can get a feel for both the excitement and the nervousness.

I really liked seeing how other areas of the hospital worked. It was nice having a hands on view of the hospital. It was a long day. The information was great, and you have to go over the material before you go out to try it but it is a long day and a lot to digest.

The process [for problem solving] is a plus. Being able to step back from the daily rush and think through an effective process. What’s needed is even more disciplines in this group.

What was great was learning how one problem can have implications in many other areas, something I never would have imagined. An issue is that a think we will need a little bit of handholding in our own areas, once this starts … help working through some problems until we are used to it.

Loved the trainers. They knew their subject. They were knowledgeable. I am not clinical and it was so interesting to see the work on the floors.

My worry is about the areas that are the suppliers to many areas. They are very gung ho right now but even in training they are getting lots of calls and I worry about them being overwhelmed. We need to develop supports for them from Day 1. Even now they are joking that “It’s 2:00 – SPIRIT training time – so my pager is about to go off.” We don’t want them to burn out … [Later in conversation same participant offered the following idea …] It would be helpful if some of the observation visits could take place in those supply departments. I think it would send two messages. The first is that it would help them be prepared to respond more effectively to calls re: real time root cause problem solving. Second, it would send the message that this is about you, too. And that’s important.

The positive was that we went out and did real problem solving on the floor. It was insightful. It was nice to see challenges that other areas face. It was a long day.

Getting out was great. We have never done that in our other trainings. Great. I need the bibliography that was mentioned – this is just a total shift for us – plus that list of tools / helpful hints for working with staff on real time problems. My barrier or worry is that problems that need to go to other areas [for investigation / solution development ] may take time, and may hit barriers. We may need to get back together once we start and look at how well that is working and revisit our efforts there.

I’m coming away from this today with real good tools to attack problems. The trainers were great. It’s good subject matter. It’s a long day but you probably have to do it in one day. Actually using the tools was great.

It was great. The best for me was being on my own floor and getting to use the tools from the AM in the afternoon. It helped me see things I was seeing differently, in a way the staff could see and feel as well … very helpful. It did help me to think about the roots of things, about why the problems I am seeing are occurring. To improve it, I would send ahead more background on change management coming in, and make sure we had more tools going out.

I liked having no choice about where I observed. Given my experience here, I wouldn’t have picked to go back to peri-op because I assumed I knew how everything worked. When I got back there of course I realized I didn’t know how it really worked.

What was great was that it was experiential. It fundamentally changes training. Great. Giving everyone one way to think about problem solving would be huge. As awesome a task as it sounds, it is totally worth undertaking. The negative was the eight hours is not enough to equip a manager to do it effectively. We need a log for the process of implementation itself. A place that issues and struggles can be called out and learning shared. A kind of help chain support for how to be better at it.

The diversity of this group was a huge plus. We need more prerequisites coming in. It’s a little loose at the end. Coming out of these trainings the managers are saying “Oh my G-d.” If we think about it, we could come out of the trainings with a clear sense of next steps that may help everyone come out feeling more positively.

This is really exciting. I didn’t know what to expect on the floor. It was easy to identify problems. If we do it, it will be incredible. If we can make it a way of life. The question is how to do this. One key thing we identified today was the issue of when managers are called [in the help chain] and they haven’t been trained yet, it can be worrisome. They might say they know “who” may have messed up and you want to rush to say “ no, no we’re looking for a system issue” … so that’s an issue and it’s hard to create safety in the moment.

The basic tenet of safety is key. Once established they (participants in problem solving) were much more forthcoming.

I was struck that doing this on a busy unit at a busy time, seemed overwhelming. But the more we circled back to staff as they were able to give us a minute the more things did move along. Seemed more possible.

At the start, so many things will be identified. For the first month, how should we prioritize? I am worried we are about to open Pandora’s box here.

One idea I had today that you may hear about is to once a year have a BIDMC Spirit Award. Something really meaningful. And done in a way that doesn’t convey the message that only this SPIRIT achievement counts and yours doesn’t matter …

It’s the issue of training that keeps me up at night. I don’t want to do this [act as trainer] until we are ready for prime time. We may need more support for a longer period from the people who’ve done this during their whole career.

This is my second time [training to be a trainer]. Last Thursday, my worry was the sense our staff have of handing over problems to you to be solved. Today, we scared several people. It was definitely not our intent. It’s just that people who have not yet been to orientation respond in the old way, as if “I did something wrong.” We are really going to have to work on that.

I am worried about tomorrow on my unit. I will talk to them about this experience today. I am not sure they are going to wait until March 1 to call out. It’s a good thing, I know. As they become more used to identifying problems, it will be a real burden to try to keep up and make this work.

There are tremendous tensions building up in the system about how we are going to be able to do this. Stating the obvious to people about these things is really, really important for leaders to do.

I was struck by how important it is to get the managers involved to work the staff, to not “jump the help chain” straight to the staff level. It’s what’s going to make sustainable solutions possible.

True safety comes in the moment, through the work itself. But can we prepare the culture? Can we have the managers understanding that they are important, they are vital, to work toward sustainable solutions?

To write or not to write

So, here's the moral dilemma. Three of your favorite bloggers -- Jessica Lipnack, John Halamka, and I -- were invited to attend tonight's performance of Julius Caeser at the American Repertory Theatre in Cambridge, MA, and then blog about it. This is part of an experiment by ART to link into social media and other outlets to expand the experience of the actual stage performance. We were given free tickets and were told we could write anything we want.

Even before the performance, I felt a bit awkward. Truthfully, I have not gone to the ART in years because I gave up several years ago after attending many shows that I thought were pretty awful. But, I figured this would be fun and, hey, maybe it was time to give the company another chance. Nonetheless, I expressed concern: What if I didn't like the show? Was I somehow obliged to say nice things because I had been given a free ticket?

We were assured otherwise. No obligations. No conditions.

Well, let's just say that I was disappointed. The show had poor pacing. And, as we would say in music, it had no dynamic variation.

But the writing was really spectacular. This fellow Shakespeare deserves a lot of credit.

There was one segment in particular that made me and the person behind me gasp as we heard it. It is Act III, Scene 1, right after Caesar is murdered. After Brutus suggests that they bathe their hands in Caesar's blood, Cassius says:

Stoop then, and wash. How many ages hence

Shall this lofty scene be acted over,

In state unborn and accents yet unknown.

I think we gasped because we were reminded of how many times political aggression and murder are undertaken by people couching their actions in terms of bringing liberty to the population, but who really are driven by the same desire for power as their predecessors. Shakespeare's theme from hundreds of years ago has been replayed over and over again through the centuries, even to our own time. Thanks to the ART for the vivid reminder.

You can take your $15 fee and ... !

In the past, I have sometimes used this blog to refer to articles from medical journals when I felt they had broad public interest. Sometimes, those articles have not been available to the general public because they were only available by subscription. From time to time, commentors to this blog have complained about this. I have let those comments go by without reply.

But, finally, I have had enough. I want to state this clearly and directly: When a respected medical journal issues a press release about a given article that has important public policy ramifications but does not make available the full text of the article, it is a bad thing. It inhibits full public understanding of the issue and makes us beholden to other people's interpretation of the article. It is inconsistent with the general principle of academic discourse and also is counterproductive in facilitating an informed debate on issues.

Here is today's example, from the Journal of the American Medical Association ("JAMA"). Last week, I received the following email from the AAMC (Association of American Medical Colleges):

The Feb. 13 issue of JAMA will include an article on a new study examining the status of institutional conflicts of interest policies at U.S. medical schools. The study was undertaken by the AAMC and Massachusetts General Hospital, and provides the first national data on medical school policies and practices for dealing with institutional financial conflicts of interest. Susan Ehringhaus, associate general counsel for regulatory affairs in AAMC's division of biomedical and health sciences research, is the lead author on the article.

This topic is clearly of great public interest and import, and so I asked the question of whether the full article would be available for reading upon publication. The answer I received today was, "No." Checking the JAMA website, I confirmed this. I can read the titles, the authors, and a short abstract. But I can't read the article and reach my own conclusions about the methodology employed, the assumptions made, and the results.

I can even read a press release issued by the AAMC about the article. But I can't read the article and reach my own conclusions about the methodology employed, the assumptions made, and the results.

Tomorrow, I may be able to read newspaper reports about the article. But I can't read the article and reach my own conclusions about the methodology employed, the assumptions made, and the results.

Oh wait, I can, if I pay $15 (plus tax) for the privilege of having 24 hours of access to the article, and only from the computer I am currently using.

Please understand that I do not begrudge journals that need to charge subscriptions to stay in business. But I find it upsetting when a respected journal issues an occasional article about an important public policy issue and does not allow wide and unhampered circulation. Surely, allowing open access on such a matter can only enhance the reputation of the journal. Restricting it is totally unnecessary and, beyond the mercenary aspects, feels elitist and condescending, a reputation the medical profession does not need to reinforce.

Another type of poll: Is it accurate?

I am not taking sides. I am just wondering.

While we are talking below about social media, does it mean anything that Barack Obama has over 500,000 members in his Facebook group and Hillary Clinton has just over 110,000?

John McCain, by the way, has 58,000.

Grand Rounds is up

David Harlow provides a Valentine's theme this week on Grand Rounds. Nicely done!

What's your social media score?

Well over a year ago, John Bell published a blog entry that gave people a chance to measure their company's social media score. As I re-read the checklist this week, I realized how much progress BIDMC and our staff and I had made in this regard. I also noted how little progress many of my colleagues in the health care industry had made. Meanwhile, other industries (and politicians) are zooming along and incorporating social media into their advertising, marketing, communications, and internal operations.

Just for fun, I compare the answers I would have given for BIDMC in late 2006 with what we would answer today.

Does anyone within the company already blog? (including personal blogs). Yes/yes. (2006/2008)

Do any of these existing bloggers post on business related issues (vs. personal blogs)? Yes/yes.

Has senior management stopped making jokes whenever a junior staffer mentions the word "wiki" in a meeting? No/yes.

Have you ever invited customers or stakeholders to a company meeting just to hear their perspective? No/yes.

Have you ever published public information - done an interview, released some news, said something publicly - without prior written approval from the legal department? Yes/yes.

Is Web publishing decentralized in your organization. No/yes.

Do you have RSS feeds on your corporate Web site? No/no.

Does your communications team value more than big media clips? No/yes.

Does your company reward entrepreneurial behavior from within the organization? Yes/yes.

Does your C-level leadership (CEO, CMO, COO, etc...) understand the difference between Robert Scoble and Bob Lutz? No/yes.

Has your marcom team read 30 blog posts from at least 10 blogs over the last two weeks? No/yes.

Has your marcom team downloaded and watched/listened to audio or video podcasts? No/yes.

Yes to 0-4 questions: Your organization is not ready.
Yes to 5-8 questions: Your organization is ready to listen.
Yes to 8-12 questions: you are probably more ready than most.


Summary for BIDMC: 2006 -- 4 yes; 2008 -- 11 yes.

But let's ask some more questions that were not included in Mr. Bell's original survey:

Do you regularly survey employees and rely on majority rule for matters of corporate significance? No/yes. (2006/2008)

Do you regularly post clinical information (e.g., on infection rates) on your corporate website for the world to see? No/yes.

Do you post results of Joint Commission accreditation surveys on your corporate website for the world to see? No/yes.

Do you post the results of patient satisfaction surveys on your corporate website for the world to see? No/yes.

Do any senior managers in the company post their profile on Facebook and communicate with staff through this medium? No/yes.

Have you pretty much given up on purchasing newspaper ads and rely instead on social media for marketing and communication. No/yes.

Life Disrupted, a preview

Fellow blogger Laurie Edwards from A Chronic Dose is working on a book, to be published by Walker and Company in July, entitled Life Disrupted, Getting Real About Chronic Illness in your Twenties and Thirties. I was asked to review it and, without giving away lots of it, I want to tell you that is it beautifully written and will be extremely helpful both to young people with chronic illness and their friends, families, and associates.

Here is one excerpt that I found particularly moving, from a chapter entitled "Salient Suffering":

Suffering doesn't make you a better person, in the sense that a person with these challenges is somehow more noble or "good" in a moral way. But I think there's another dimension to this notion of being a better sufferer, one stripped of greeting-card-inspired platitudes and skewed interpretations of what it means to live with illness. The more you suffer, the more you are able to recognize suffering in others. The fact that our experiences make us privy to this knowledge is a privilege I think gets lost in the "suffering saint" attributes of illness, but what we do with that knowledge is what really counts. We're not better people because we can empathize with someone's struggle with infertility or migraines or because we can nod our heads in understanding when someone is frustrated about a diagnosis or a side effect. However, if we are able to channel accumulated patient experiences in a way that somehow makes a positive impact on someone else in a similar situation, then there is something redemptive about our suffering.

Life in Balad, aka Mortarritaville

Excerpts of a note, reprinted with her permission, from Major Kristin Messer, one of our nurses on duty providing medical care to the wounded in Iraq:

Hi Everyone,

Well, we've been here for about three weeks now and I think I'm finally "settled" in and trying to get used to things. For those of you who don't know where I am, it's at Balad Air Base/LSA Anaconda. It's about 20 miles northeast of Baghdad, right in the middle of the Sunni Triangle. Its nickname is "Mortarritaville" because it's mortared on daily basis. Luckily for us, the bad guys have lousy aim!!

When we first arrived, I didn't think I'd make it. There were four of us in about a 10 x 10 room, all working different shifts, so not much sleep. Then there was the noise of the constant Black Hawks, Chinook helicopters (those are the huge Marine helicopters), F16s, C17s, etc. that literally rattle your room as they go overhead. I'm sort of used to that now and I can sleep through some of it. The bathrooms and shower (called "Cadillacs") are about a 300 yard walk from the room. So there you are in the middle of the night, having to go to the bathroom, up on a top bunk, with no ladder. Not wanting to slither quietly out of the top bunk and then have to don your PT (physical training) gear for the 300 yard walk out in the cold, you lie there debating with yourself, "Should I get up, can I hold it until I get up?" Ultimately, the bladder always wins. After a couple of those nights, I've decided to cut myself back to just three-four liters of water a day and to stop drinking liquids by 7 pm...no debates with myself since!! When the two other people in our room finally left (about a week later) and we were able to unpack and have a little more space it was much better.

Since the moment we arrived, we were put to work, 12 hours/day for about a week and a half without a day off. We're now able to take some time off. We work four 12 hour days, have a day off, work four 12 hour days and then on call for a day...and then the schedule repeats itself. When we walk back and forth to work, we have to wear our kevlar gear or IBA (individual body armor) that weighs 43 pounds, along with my trusty 9mm weapon at my side. At first it felt as though it weighed a ton, but you sort of get used to it...now it feels like about 10 pounds. My goal when I got here was to do at least one push up by the time I leave here with the IBA on...I'll take pictures to prove it!! This place is probably a bit like a minimal security prison...you're only allowed to wear two outfits: either your regular uniform or your PT gear and that's it! And you get three lousy square meals/day...actually I bet real prisoners get better food! Our housing units (there like the worst trailers you've ever seen), are lined with sand bags on the outside and then surrounded with 20 foot concrete barriers around the different sections of trailers. Surrounding the entire housing area is a security fence with razor wire on top. We get in and out of the complex through a security gate with a combination...so we let ourselves out and then we let ourselves back into the 'prison' after our shifts. The base itself is quite large. It's Air Force, Army, Marines, civilians and third country nationalists. There are about 35,000 of us here.

Our water supply here is fed by the Tigris River and apparently all the pumps/filter systems that feed the base are ancient and in desperate need of major repairs. So in part of letting the Iraqi's take their country back, they are fixing all the equipment. The down side of this is that they didn't warn us when they were going to start and they work slowly. The result?? Four straight days without water for 35,000 people. That means NO SHOWERS! It's now back in small amounts so we are allowed to shower on "even" days. However, those showers are "3 minute combat showers." In other words, get wet, shut the water off, lather up, rinse off...that's it. The shower stalls themselves are probably about a foot square in diameter. Now there is truth behind "don't drop the soap." If you do and then try to bend over and pick it up, you knock your against the wall and your butt hits the faucets. You can't even put your arms up to wash your hair without your elbows hitting the walls! From what were told, this repair could take 3-4 weeks! I can't wait to be able to take a shower without shutting the water off, being able to move, not wear flip flops, stay in there for more than 3 minutes and not have to walk a quarter of a mile to get there! But that's not going to happen until I get back.

It's especially picturesque around here when it rains. This time of year is considered their rainy season, but honestly, it really hasn't been that bad. When it does rain, even drizzle, it is miserable. The terrain here is just dirt and rocks and since there's no drainage/sewer system, the dirt turns to thick, sticky mud. When you step in it, it's like quick sand with suction cups, it sucks your foot right in. Then when you try to walk on the rocks to get rid of the mud, the mud then becomes super glue-like and all the rocks stick to your shoes. So you're walking around with all kind of rocks on the bottom of your shoes trying to balance yourself...not too safe. I've already twisted both ankles by snapping them on rocks I never saw. One resulted in a fall...I went from an upright position to flat on my face in an instant...thank God the ground was dry and no one witnessed it. My first thought? Dear God, I hope I can get up with this flak vest that weighs 43 pounds!! I think it was the thought that someone might see me and I popped right back up!

The hospital here is fairly new, with out 360 people working here. The majority of our patients are Iraqi's...both good and bad. It's tough taking care of the insurgents! The hospital has a helipad right outside where I work (it's actually 4 pads in one area) and we have Black Hawks and Chinooks landing all day long. From the helipad, you can see the perimeter wall about 200 yds. away. I am still wondering what genius in the military thought to build a hospital that close to the perimeter!! Now that it's been here for two years and they're realizing its close proximity to the "wire," they're building a double, reinforced, steel & concrete roof over the hospital!

I began this e-mail yesterday, but was unable to finish, so hopefully I can finish today...yesterday was a bad day. We've had some good days and some bad days and I'm praying that yesterday was the worst. Unfortunately, we had three American troops come in, who were killed in action. When they were entering a home, it was booby trapped with IED's and three of the eight men were instantly killed. I will never be able to erase those images. When a fallen troop is bought in, they have a beautiful ceremony here in the ER that is called "Fallen Angel." The first time I witnessed it was on our second day here and I was praying that I'd never have to see it again. Unfortunately, that has not been the case. In the middle of the Super Bowl, we had 3 KIA's come in and instantly, it puts everything into perspective, the game didn't matter, the water shortage didn't matter and neither did the lack of communication that we've become some reliable on. None of it mattered. What mattered was the reason we're all here. When we lose a troop or a KIA comes in, everyone gets in a big circle around the body in the ER, the Chaplain says a prayer and then a huge American flag is unfurled by an honor guard. The flag is then tucked around the body, then everyone stands at attention and salutes as the body is taken out. No matter how many times you see this, it doesn't get any easier and there's never a dry eye in the place. When it's three at once, it's even more difficult. I pray that we don't have any more of these.

I hope and pray that this note finds you all well and please keep praying for our troops.

Talk to you all soon.

Kristin

No gossip! That's an order!

No need for me to comment on this one.

Trainees report back and train trainers

As promised, I want to keep you up to date on our experiences as we implement BIDMC SPIRIT, our process improvement program of the sort described by Steve Spear. We are now at the stage of orienting people and training the trainers, the people on our staff who will train over 600 staff members in the techniques of calling out problems and pulling together help teams to solve them. We are assisted by some folks from a firm called Value Capture, which was founded by Paul O'Neill based on his experience at Alcoa.

After the first session, as part of an effort to improve the orientation and training sessions themselves, the group leader asked:

“Tell me one thing that was great or positive about today/SPIRIT so far … and one thing that was negative or is worrying you.”

Here are the replies:

Great: The observations, the real time problem solving and action plan development. The wonderful openness of Donna (director) and her team. Some of the role plays. Today was an incredibly useful exercise. The train the trainer approach is the right one. Scary to think about doing the training, but workable. As valuable as the Value Capture people are it’s important that we show we really own this in as many ways as we can. What was bad or am I worried about? It’s a long day! The chairs were bad. The room. We are training several hundred people, but only a small portion by March 1st. I am worried we will not have enough people ready with the language and the tools. But somehow I think it will work out. We need to manage expectations and the anxiety. We need to tell people we will not be great at this at first … but it will be a start.

Ditto to everything above. Great was the observation and work on the areas we went to – that was the highlight. We called out that the PACU role play should be further simplified (told as a simple story, holding discussion until end). I also agree about changing the room.

I came in with skepticism … a lot of skepticism … and I am leaving feeling a lot better, less skeptical. Going through this was transformative. My worry is that there are still 1,000 things to learn … will we be ready? Should we cut our teeth by piloting this in a few units first?

Great: The observation and the hands on problem solving. The willingness of the staff to participate! They were really ready. They knew about SPIRIT from Paul’s messages. My worry is the same. Do we really have the readiness to train? Will management be ready. Should we ramp up from a pilot?

Great: I was pleased to see the staff’s wariness melt and the problem solving process become fun! I worry that we have to get it deep enough down to the front line staff level. Use the code team example – have an outsider who wears the lanyard who can come and help – objective eyes in an observer – together with maintaining the transparency. Those are the keys to make it safe.

I see that this could be so incredible. But I worry there on the same count. Will we be able to be fully engaged and work staff through the barriers … to really get this rolling. I am somewhat overwhelmed by the number of problems. I don’t want to let staff down. We want it to work for them.

I see the positive culture change here. I loved the value of outside eyes for problem solving. We need to add the additional helpful hints, watch outs, useful phrases to help managers approach this w/employees in real time.

This is transformative. In the middle of doing the work on the floor today it hit me. Earlier in the day, I was hung up on the connection between the log and problem solving, and then it hit me – Is this a tool or is it about a new process and way of thinking about problems. It’s the latter.

Great: It’s simple steps … we laid it out easily and we followed it. Not easy to do but still good. It’s easy to understand (the method). What worries me? We have different skill levels in the organization. I worry about will it be used at a level that it will be used well? I’m worried about time. I worried that we’ll be able to take time away from other things, especially when it’s patient care. I need more tools as a trainer. I’d like more exposure to the help chain; we didn’t have to use it in our problem.

The observation opportunity was fantastic. We struck gold with our group and problem and the staff we worked with. What’s positive is we are pushing decision-making closer to the people who do the work. I worry about training. I need more problem solving exercises to feel comfortable as a potential trainer. Also, I think this is OK/great in departments with a participatory culture, but in departments with different norms if not implemented and supported well it could be quite harmful to the people. We need to think about the involvement of coaches/outside eyes.

I went from being skeptical on the (problem solving) log to feeling it could be very useful … and applied to all kinds of problems. The last module on the log was very useful.

In terms of worries: We have not been good enough messaging that this process is for hunting and fetching problems. We’ve got to be clear about what this is for. And also for the other systems that we are preserving.

Keep in mind, it’s hard when a few things are still blurry. But consider how this is being designed as a process to improve as improvements are suggested. It’s already been improved and will continue to do so.

Have Paul continue to message directly to the staff on this. They hear him. He is such a popular figure. He is clear. They also listen because he doesn’t fill up our e-mail with too many things.

I’d like another review session, to help prepare as a trainer (in addition to the planned development sequence – just a couple hours to go over the design, etc).

Karma on line

Almost a year ago, I wrote about Daja Wangchuk Meston and his marvelous book called Comes the Peace, My Journey to Forgiveness (Free Press, 2007). Now, he and his wife Phuni are featured on Boldfacers. Watch the video.

$75 million? Thanks, but I'd rather not donate.

A recent article about an election-year campaign by the SEIU prompted me to go through my notes from a meeting almost two years ago. The scene was at Boston's Parker House Hotel, on May 23, 2006, where Senator Kennedy had invited all of the Boston area hospital CEOs to meet with Dennis Rivera and several other members of the SEIU leadership. I haven't written about this before because I wasn't sure of whether the contents of the meeting were supposed to be public, but now that the SEIU has said the same things publicly, I am comfortable reporting them.

At the meeting, Mr. Rivera said that the SEIU needed $100 million to educate the American public and run a national campaign on the patient access and universal coverage issue. He explained that the union did not have that large sum of money and therefore needed it from the hospitals. He also said quite clearly that there would be an effort to elect Democratic candidates and defeat Republican candidates.

The announcement this week reiterates and confirms his remarks. The dollar amount is $75 million instead of $100 million, but perhaps it was just a rounding error two years ago -- or maybe they have already spent a portion of the difference between the two numbers. And sure enough, during the Presidential campaign and in other local and gubernatorial races, the SEIU has likewise supported Democratic candidates who agree with its point of view.

All this is legal and above-board, so I am not raising that issue. Indeed, you and I may personally agree with some or all of these political aims. However, at a time when Massachusetts -- with the closest thing to a universal access law -- is trying to control the growth of health care expenses, I am hard-pressed to see why hospitals, insurers, and consumers in Massachusetts should support a union effort to add an additional tax on our health care system and its workers to provide dollars to support a national political agenda and support for particular candidates. I am not as familiar with other states, and I wonder if the same concerns might arise there.

Of course, if you happened to disagree with the SEIU's political goals, you might have an additional reason to be concerned about this use of funds from the health care delivery system. But, even if you agree completely with the union's objectives, do you support this means of raising revenue?

More on fetching and work-arounds

Some colleagues and I had a chance today to spend some time with Steven Spear, from MIT and the Institute for Healthcare Improvement, who is an expert on the kind of process improvement program we are trying to carry out at BIDMC. That he had terrific and useful insights was no surprise to those of us who have read some of his work.

Steve also made mention of research carried out by Anita Tucker, from Harvard Business School, in which she spent many hours observing nurses in hospitals. (I did not find this particular study, but here is one that summarizes it.) Her conclusions were consistent with my own observations and the points I made in my staff email back in November -- and many comments I received from our staff after that email. Professor Tucker found that nurses who encounter problems or impediments on the hospital floors generally will invent a quick work-around to solve those problems. This makes sense. First of all, they are really busy and just need to get the problem solved. Secondly, most organizations do not provide a way to call out problems and have them solved in a timely or effective fashion. Unfortunately, this pragmatic approach to problem-solving leaves systemic problems untreated and, indeed, aggravated by an additional layer of work-arounds.

As Steve has written in his studies of Toyota and reviews of other high performance organizations, the common characteristic of these organizations is not in their ability to design perfect and complex production or service delivery systems. Rather, it is their ability to discover great systems. They do this by managing their work flow to encourage people at all levels to call out problems; to "swarm" together to solve those problems; to share this process of discovery with others in the organization so that the solutions are diffused widely; and to cultivate the skills of people throughout the organization to be involved in this kind of constant improvement.

It was heartening to hear this reinforcement for the kind of program we are beginning at our hospital, which was named BIDMC Spirit in our own election campaign. I feel like we are on the right track. Now comes the simple (hah!) part -- doing it. Our first training session was held today. Stay tuned for further developments.

The ethics of CEO blogging

Last week, the Harvard Medical School Division of Medical Ethics held a session on the ethical issues surrounding blogging by a CEO, particularly the CEO of a health care institution. Local examples were this blog and the one published by Charlie Baker, CEO of Harvard Pilgrim Health Care. Unfortunately, I could not attend, but I received a note from one of the attendees who told me about some issues that had been raised. I'll report on that and add the comments I would likely have made if I had been present.

One of the discussants identified four domains that he thought of as important in thinking about the ethics of a CEO blog, and about which he posed some questions:

1. Voice: Is the CEO blogger blogging as an individual or as the voice of the organization? Charlie's blog is hosted in the HPHC website and linked to HPHC marketing materials. Yours is on Blogger and not linked to the BIDMC site. But when the CEO speaks, what he or she says can't be separated from the organization.

My reply: Whenever I give a speech, or testify before a legislative or regulatory body, or give a media interview, or write an article (for this blog or a journal) people assume that I am speaking from a position of authority and responsibility for the organization. That is just something that cannot be avoided. I do my best to be aware of the institutional consequences of what I say, regardless of the forum.

2. Authenticity: Who is speaking? Is it a real human being speaking, or an avatar created by a ghost writer? Are comments posted as received or are there schills setting up softballs and deletion of tough questions? In other words, is it a real voice and a real discussion?

Reply: I think my readers know that the posts are mine alone. Certainly, the media relations people and lawyers at BIDMC know that! Likewise, the comments are yours alone. I post them all, unless they contain bad language or personal medical information or private personnel information. I keep looking for those softballs, but they are few and far between.

3. Reliance: From a legal perspective, to what extent does CEO blogging create obligations for the organization or claims that outsiders can make?

Reply: See #1 above. Concerning claims, there is little I say on the blog that does not exist in some other form in the hospital (or in my speeches, articles, or elsewhere) and therefore could be used by attorneys as discoverable information in a legal proceeding.

4. Privacy: When Charlie or you draw on communications from patients/members, even if these are de-identified, should consent be asked for from the person(s) involved?

Reply: I ask for consent from patients or their loved ones who write to me. I also de-identify the stories, unless the person involved prefers otherwise. I do not generally ask for consent to use material a staff member sends me about an issue or a process (for example, this one), but I would of course ask permission to print anything related to the personal life of a staff member.

Quality and bond ratings

As non-profit corporations enter the tax-exempt bond market to sell debt (i.e., borrow money) in support of their clinical, research, and teaching missions, they receive credit ratings from Moody's, Standard and Poor's, and Fitch. The people at these rating agencies conduct a thorough review of the many business aspects of each hospital or hospital system that is issuing debt and give a grade as to its credit-worthiness. This grade has a direct and real impact on your cost of borrowing and thereby on your ultimate cost of providing service to the public.

Recently, Moody's issued a report entitled "Clinical Quality Initiatives Have Positive Long-Term Impact on Not-for-Profit Hospital Bond Ratings". Here is a publicly available excerpt:

From a credit perspective, a not-for-profit hospital's focus on a quality agenda can translate into improved ratings through increased volume and market share, operational efficiencies, better rates from commercial payers, and improved financial performance. Like many strategies, we recognize that realizing financial returns from a quality strategy may require large capital costs and incurred operating losses in the short term. However, over the long-term, a hospital's focus on quality will be viewed as a credit positive if greater patient demand and financial improvements materialize. Many not-for-profit hospitals are launching strategies to improve evidence-based clinical outcomes and patient safety, which we view as the two key facets of a strategy aimed at improving quality. The effort to improve quality is a major component of most hospitals mission to provide the best patient care possible.

And another:

Moody’s anticipates that in the short-term, strategies to improve quality and patient safety will likely reduce operating results for many hospitals as the tools and steps to implement the strategy may require adding costs faster than benefits are realized. However, hospitals that eventually demonstrate a sustainable link between quality investments and better clinical outcomes will likely gain competitive advantage, thereby improving financial performance and possibly their bond ratings.

This is an interesting point of view and one worth watching over time, to see if these financial results materialize. I have to admit that our decisions to adopt audacious quality improvement targets actually were not driven by this kind of business strategy. They were driven, plain and simple, by a desire to do a better job taking care of patients, a fundamental goal of the organization. Further, as I have noted:

The main value of transparency is not necessarily to enable easier consumer choice or to give a hospital a competitive edge. It is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

That being said, I certainly would not mind if the trends projected by Moody's turn out to be true -- and their analysts surely are more knowledgeable than I because of their broad industry experience. In the meantime, over the next few months, CareGroup -- the holding company that owns BIDMC, New England Baptist Hospital, and Mount Auburn Hospital -- plans to issue bonds to finance important patient improvements at the hospitals (like a new Emergency Department at BID~Needham) and to take advantage of low interest rates to refund older outstanding debt. We were pleased to note that a January 30, 2008, bond rating by Moody's for the forthcoming bond issue had the following paragraph:

CareGroup's hospitals have set high standards to meet quality initiatives in their pursuit of transformational change. CareGroup's three major hospitals have been included in a pilot program established by Blue Cross and Blue Shield of Massachusetts to reduce unnecessary procedures and transform the delivery and quality of care provided. To that end for example, BIDMC is holding itself publicly accountable to certain standards and scorecard measures that providers nationwide have historically never before publicly disseminated. We applaud all these efforts and believe it could be a differentiating factor for CareGroup in its market.

A simple idea for hand hygiene

From one of our Emergency Department doctors comes this very sensible and simple approach that could be used by doctors in almost every setting -- both to remind themselves to practice correct hand hygiene and to reassure patients that they have done so:

After much personal trial and error, I finally came up with a successful solution to the hand-washing issue. The key for me is incorporating a preset routine into my introduction whenever I walk into a room to meet a patient, much like the pre-shot routine of a golfer or a basketball player shooting a free throw. My routine is...”Hello, I am Dr. Jones. I am going to wash my hands as we get to know each other. What brings you to the ER today?” I teach this type of routine to my residents as well.

Voices of Slaves

A friend forwarded this link from PBS to me. She notes: If you haven't seen this, it's worth exploring. It's the WPA recordings of former slaves. Beautiful and heartbreaking and uplifting.

Social media in the military

This is a really fascinating post on Jessica Lipnack's blog about Lt. Gen. Bill Caldwell's proposal to allow, nay encourage, military personnel to use blogs and You Tube and other social media to tell their stories.

Helping Immigrants

I once heard a great interview with historian Arthur Schlesinger, Jr. by Chris Lydon, a former WBUR public radio broadcaster. It was on the occasion of the publication of his last book, and Chris asked him what was the most important lesson he had learned from studying American history. It was something like this: "Never underestimate the tendency of the American public to become xenophobic."

I thought this was a striking statement. It came without pause or hesitation and so was clearly "top of mind" for Schlesinger. And, as we have watched political debates about immigration and immigrants during the past Congressional session and now during the Presidential primaries, we see it raised over and over.

There is a group in this state called the Massachusetts Immigration and Refugee Advocacy Coalition (MIRA) that provides information, support to immigrants, and political advocacy in support of the desire of people from around the world to have a chance to live the American Dream. A few weeks ago, a number of us joined to hear from Senator Kennedy and thank him for his efforts on behalf of this cause. We also heard from a young mother who described events that took place during an immigant raid in New Bedford last year. As Senator Kennedy remarked, there were things that happened in that raid that one could not have believed possible in this country.

I don't often use this blog to ask your support for political causes, but I do so now and hope you join many of us to help this organization.