Tuesday, March 31, 2009

Grand Rounds -- When things go awry

Welcome to this week's edition of Grand Rounds, the weekly rotating carnival of the best of the medical blogosphere. (The host next week is Leslie at Getting Closer to Myself.) Our theme draws on my desire to encourage greater transparency in the delivery of clinical care. In the spirit of Dr. Ernest Codman, I asked doctors, nurses, and other providers to write about incidents in which they made or were present for a medical error. What were the circumstances, and what did you do in response to the situation? How did you feel about the event, and how did it change your practice of medicine afterward.

Likewise, I asked patients who have been the victim of, or loved-ones who have seen, clinical harm to tell their stories. How did your provider(s) respond, how has the event has changed your view of the practice of medicine, and what advice you would give to the profession?

I had lots of responses -- with great appreciation for focusing on this topic. Some people who do not write blogs submitted essays. While this may violate the rules of Grand Rounds, I include some excellent examples.

To set the stage, I start with a lovely essay by Cherie Abbanat, an instructor at MIT. It illustrates the long-lasting fear that comes from an adverse medical experience, but it also shows how the kind ministrations of the next nurse or doctor can make up for that experience and leave the patient healed in several ways.

General Grief
I'm 17 years old and I just found out that I have to have my wisdom teeth out. “It's no big deal” says the dentist, “but all 4 of your wisdom teeth are impacted so you have to go to the hospital to have the procedure done.” “Oh, also,” he adds, “that's the only way that insurance will pay for it.”

My mom's an RN and assures me that the general anesthesia I have to have is really not a problem. I think of it as a kind of adventure. After all I've never been “put under” before. I'm hoping I won't be “put down” in the process.

Off to our local hospital I go for the procedure – that was the hospital where the dentist practiced and I didn't question the choice. After all, I was born there.

The needle went in fine, the mask was placed over my face, and I remember trying to count backwards and not making it very far. Why count backwards when I couldn't even probably count forward? My mom was smiling the whole time.

The next thing I know I am waking up and I want my mother. I mean, I really want my mother. I am crying and calling for her. Of course, no one can hear me because my mouth is packed with gauze.

She is not coming and I'm getting more anxious.

The next thing I know the anesthesiologist comes to my bedside and asks me “Do you remember anything about the procedure”. I look at him incredibly and it all comes flooding back....

I'm on the table, they yank and then they yank again. The pain is so strong, I can hardly take it. Left side, top tooth is being ripped out of my jaw. My jaw resists. It doesn't want to let go. The dentists don't care, they are going to get it out of there one way or another.... I groan, I try to move... everything goes blank.

After I finish telling my story, the anesthesiologist politely gets up and walks away. I never see him again, never!

My mom finally comes to get me and tells me that I slept much longer than I should have and she can't figure out why. I was there an extra two or three hours. I know why and I tell her. She seems concerned. I just want to go home and take some pain drugs. Turns out I'm allergic to codeine, and I break out in hives as a result. Also, I lose feeling in my chin because a nerve was damaged when they ripped the tooth out of my head. I can never feel my chin normally again. I'm a mess of bruises, hives and I take longer than it seems necessary to heal.

It's 2008 and January and cold. I'm on my way to have my gall bladder out at Mass General. I'm nervous. This will be my second experience with general anesthesia, and I'm not looking forward to it. I think I'm better prepared, though. I tell them I'm allergic to codeine. I tell them about my experience and no one seems that concerned, but I am. I really am. Then I meet an elderly RN. She explains that she will not use the computer when she talks to me because she thinks its rude. She listens to me tell her about my experience. She touches my hand and says, “That was not a good experience for you. That shouldn't have happened. How are you feeling about this next surgery?” I start crying and tell her my fears. She listens, she really listens. I feel heard, finally.

I'm on the table and I'm about to be wheeled in for the operation. My feet are cold and I wonder if they will make sure my feet stay warm. The nurse gives me warmed blankets and I feel more relaxed. I can't believe they are pre-warmed. It makes such a difference and helps to calm me down.

The man I've been waiting for shows up – the anesthesiologist. Actually, there's a team. I tell one of the doctors, Mark, my story, but I'm calmer. Mark shows me a device and says, “We have this new device that I will put on your forehead to monitor your progress under general anesthesia. It's okay,” he says “I'll be careful.” Then he asks me where I teach and I tell him MIT. I also tell him that I know that what he is doing is not an exact science. He laughs and acknowledges that this is true, but then tells me, “I was in Course 7 (biology) at MIT.” This relaxes me because I'm laughing and we talk about the MIT undergrad experience. The moment arrives. The needle goes in and the mask goes on. Mark says, “Okay, Cherie. Time to sing the MIT fight song with me, ready?” I laugh and start to sing, “E to the U du dx....”

I'm at home recovering. I'm sore, but okay. I never felt a thing. The phone rings and it is Mark. He wants to know how I am. He apologizes for not coming to see me after the procedure and tells me he just wanted to make sure I'm okay. I smile and we talk awhile. I tell him how glad I was to have him with me through it all. I thank him for his work and for the call. It means so much.

Next we turn to another story from Dr. Val Jones. It presents the sequence of error, disclosure, apology, and change in process that dramatically lowered the probability of a similar error in the future. It is entitled, "What to do when mistakes happen." A key component of the apology, noted by Dr. Val, is the sincerity displayed by the provider. "The rehabilitation medicine attending notified the family of the error, explained exactly what happened and apologized with tears."

Laurie Edwards builds on this theme, ending her post on A Chronic Dose, with this thoughtful summary: Every profession, every interaction between people presents an opportunity for errors. Obviously the stakes are usually much greater when it comes to medical errors, but the basic rules apply nonetheless: Treat people with dignity and respect. Focus on fixing the problem appropriately and moving forward. Be forthright. Sometimes the hardest thing to do is simply say “I’m sorry.” Yet for (non life-threatening) errors, those two words can mean the difference between a blip on the proverbial radar screen and an event that damages trust and fosters resentment.

The Samurai Radiologist agrees, at "Getting the finger from a patient." Telling the story of a diagnostic imaging error and apology, he concludes, "Admitting mistakes to patients is not yet a universal practice, but it sure felt good this time, to me and my patient."

White Coat uses his experience from another part of life to illustrate that sometimes patients get it wrong. What appears to be an error is not always an error: I encourage you not to just create the label "error" but rather to explore whether an "error" is really an error at all. It's good that you are exploring the issue, but I think we have to define the issue before we can get a handle on it.

Expanding on this, he offers advice to patients:

When there is a bad medical outcome, or even when there is the perception of a bad medical outcome, the natural tendency is for patients to assume the worst. The patient with the bad outcome then discusses his experience with others, and may be provided with misinformation. Enough misinformation and pretty soon the patient is all worked up - maybe for no reason.

Not saying that bad outcomes never occur from someone doing something wrong.... Just saying to make sure you’re well informed before making that decision.

But Barbara Kivowitz submits another post that reminds us that there is another type of harm, "The Harm of Omission". An excerpt:

The harm of omission I experienced was grievous and insidious. It took a long time to recognize its existence and impact. And there is no one to blame.

The harm of omission lives at the core of the structure of our health care system. It is that there is really no organizing structure. There are separate disciplines each with its own language, expertise, methods, values, and staff.

Maybe this is what Bongi has in mind in his post, "Surgical principle number 2: Fear nothing but fear itself." But I have a feeling that this is not what Barbara meant exactly!

And Alvaro Fernandez expands the scope of today's topic a bit more, in a post entitled "Therapy vs. Medication, Conflicts of Interest, and Intimidation." He notes that harm can result when researchers mispresent and misreport studies' results, when medical journals don't disclose the obvious conflicts of interests by those researchers, and when, in his view, JAMA tries to stifle appropriate criticism of those two points with intimidating tactics.

And, likewise, Amy Tenderich expands our scope with a discussion of the harm that is caused by a company's mismanagement of a useful product.

Before returning to more serious matters, let's take a short interval with a slightly mystical story from Chris Nickson (aka precordialthump) entitled, "The Mark of the Beast." I'm sure it has something to do with today's topic . . . .

Now, back to traditional care delivery, Lisa Lindell wrote a book entitled 108 Days about the following experience. She passionately draws some strongly held conclusions:

My husband was hospitalized for 108 days with severe (35% tbsa) burn injuries on March 5, 2003. I'm an accountant with no medical background, humbled and grateful that he's going to be cared for in such a prestigious institution, renowned for their burn unit. I was there to keep him company, distract him from his pain, and stay out of the way of the medical staff and bend myself to their will and guidance regarding his recovery. I was genuinely and sincerely grateful and humbled. Comforted just in knowing he was in "the best" place he could be.

108 days later I miraculously got my husband out of that hellhole, documented the ordeal in a book, and embarked on a patient-safety crusade that has cost my family dearly. Emotionally, financially and physically we have sacrificed to get this much-needed focus on quality care in a crusade that is still going strong 6 years later. A battle that has become a war with an army of medical-error victims just like me, connected by the Internet and spread across the country. We're all terrified of the day we ever have to encounter a hospital stay again. We're driven by fear, pain and shame for our medical community. We're not driven by rage at some doctor as many of you define us.

What did I learn? Physicians have very little notion of what's actually happening at the bedside. That's not a criticism, just a fact. I learned any person ever admitted to a hospital needs an advocate at their bedside 24/7, an advocate in a friend or loved one. I learned my role and job as his wife wasn't to "keep him company" or stay out of anybody's way, but to save his life, with or without the co-operation of the professionals. I learned, in hindsight, my husband nor myself were never viewed (by staff at the hospital) as fellow American citizens, people with lives and jobs and children and a home and a life.

My advice? Advocate for your patients. Abolish "visiting" hours. Put your patient first. From the CEO to the housekeeping staff, everyone can be, and should be, a healer. Give the medical profession back their dignity, respect and trust that the public used to have for you. You have to earn it back. By being honest and forthright, by telling your lawyers and insurance companies how YOU practice medicine, not the other way around. Join or become a PSO (Patient Safety Organization), demand that PSO's be mandatory, not voluntary, and demand patient feedback be part of the process. Listen to your patient, don't ask them how they liked the food, ask them how many times they saw their physician today. How many times they saw a nurse during the night shift. Listen to your nurses. Staff your hospitals with a safe nurse-to-patient ratio, stop overloading nurses with chores and duties that have nothing to do with patient care, but have been given priority status over actual patient care (paperwork, inventory, secretary...the list never ends). Fund a patient safety organization. Include patients on boards, medical boards, oversight committee's. Stop hiding from and lying to us.

Duncan Cross provides similar examples based on his own care in, "When Errors Attack," and then also provides plainspoken advice to doctors and patients. He concludes:

My advice to providers: listen to your patients. I think the inability to listen is symptomatic of a bigger problem in health care, that patients are taught to think of themselves as subordinates in the physician-patient relationship. I’ve written a lot of posts against that attitude, and usually my point is that it’s bad for patients. What should be obvious from this post is that this attitude is also bad for physicians; a patient who isn’t allowed to help his doctor can’t help that doctor avoid serious mistakes. How physicians might cultivate more equitable relationships with their patients is a different post, but learning to listen - and listening to learn - is a good start.

And Robin, who has a chronic condition, adds her own story about a doctor who was unfriendly and antagonistic and unhelpful, and another who apologized for him. After she complained about the first one, she "asked my good friends if I was over-reacting. I asked my parents the same thing. They assured me I wasn't, but that's what chronic illness does. It beats us down to the point we are almost apologizing for being ill, and then when we do react...well, we second-guess our reactions."

Rocky Samuel is a student at Harvard Medical School, finishing his third year. He sent a reflection piece that he wrote in response to an adverse event that he witnessed. While a later review showed no indication of medical error, his insights could apply in a variety of circumstances. Here's an excerpt:

The mood on labor and deliver was unwaveringly joyful, until the unthinkable happened; a mother died in labor. Just writing the words “a mother died in labor” brings back a flood of emotions. On labor and delivery, there is almost always a happy ending, and if there is a bad outcome, it is never a surprise. This was the unthinkable. Many senior attending had delivered more than 50,000 babies without seeing what I saw on my fifth day on obstetrics.

It was a bright autumn morning, and the floor was as busy as ever. The flow of patients fluctuated greatly on labor and delivery, and the staff knew that babies never respected anyone’s work schedule. The residents were busily caring for patients and teaching students, and the nurses quickly completed their tasks for the day. This was no change from the baseline hustle and bustle I had become accustomed to while on the floor. I exited a room after talking with a patient to discover a nightmare. The normally loud central station was now deafeningly silent, and everyone stood like statues looking into one of the rooms with a closed door. The motionless environment would be occasionally interrupted by residents and nurses running in and out of the room, their faces denatured by a horror I will never forget. We were all holding our breath, hoping that the worst would not happen. Then, one of the residents swung the door wide open, walked out of the room, and began to weep. She was followed by a long line of staff who cried tears that I am sure have not dried completely even now. We all knew what had happened at that point. Saying the words was unnecessary. What was never ever supposed to happen, somehow, happened.

Throughout my life I have come to embrace death as a natural part of life, but this time it just didn’t seem right. As a medical student, I was greatly affected by the events of that day, but I cannot even begin to imagine the torment experienced by the staff. In the end, I learned many lessons that I know I will take with me for the rest of my career, but, most of all, I realized that the worst outcomes, the things that are never supposed to happen, are sometimes inevitable, and we must never forget that even as highly skilled physicians, death and disease will continually humble us.

Nurse Ausmed tells the story of Jane, a registered nurse of twenty years experience. "She is thorough, careful and deliberate. And on a Tuesday morning she makes a multiply-by-ten error." The post is called "That Sinking Feeling." Things eventually work out fine for the baby in question, but Jane is seared by the experience, notwithstanding strong support from her colleagues.

She is horrified at even the slightest possibility that she might have caused harm to a patient, particularly one so vulnerable. The ward has hit a bit of a slow patch for the first time that morning and her colleagues gather, reassuring her that she is in good company. They tell stories of their own, mistakes they have made and how stupid they felt.

Ryan DuBosar, Senior Editor at ACP Internist, gives us a teaser about this article: What happens when an internist orders test results, and then never sees the results? From an actual case file, a 61-year-old asymptomatic man sees his internist of 10 years for a check-up. When reviewing the medical record, the internist sees PSA test results of 11.8 ng/mL. Surprised by this finding, the internist digs further. A year ago, the PSA was 8.2 ng/mL and three years ago it was normal. The patient was never told; the internist is certain she never saw it. She wonders what to do next.

Barbara Olson, a nurse from Georgia, writes, "I've been waiting to share this story, and it just seemed to pour out after I read your invitation the other day. I don't know if my story fits, as I am both a family member and a health care professional. But my ability to see 'the big picture' (details of which I share in the post, "A Belief Born of Despair") helped me to heal personal wounds and leverage my position as a health care professional in hopes of finding effective solutions."

What could go more awry than a surgeon having a heart attack while performing surgery? InsureBlog's Henry Stern tells the true story of the Italian doc whose dedication to his patient overrode his own immediate health crisis.

David Williams at the Health Business Blog writes about "(Un)acceptable quality levels in health care." His bottom line: "It’s pretty shocking that people struggling with cancer end up as the victim of so many errors in their treatment. McDonald’s would be out of business if they screwed up so many orders. So would Fedex. American consumers don’t typically accept this level of error in other service industries and shouldn’t accept it in health care either."

Speaking of messing up, can we accept that giving the wrong price for a procedure is a kind of harm? Jay Norris says so here. A summary: "The initial visit was billed at $165. The surgery came to $1,639, ouch! I expected it to be a little higher than what I was quoted, maybe even $600, $700? But it was over 5x higher than the ballpark estimate I was given on the phone. “It’s hard to tell?” I guess so!"

Roane Weisman tells us "my story of how the medical system gave up on me after my stroke." She concludes: "Doctors must understand what illness means in the lives of their patients. They must use their positions, their authority and their words wisely. They have the power to heal, but they also have the potential to destroy hope and, along with it, the chance to recover."

Cindy Pittman sends the following story:

Last year my father-in-law was in the grips of advancing oral cancer. Utilizing the medical contacts at my disposal I dragged him away from the "we only do surgery, will never send him for radiation" rural practice to the best tertiary treatment center and where I had recently received my MHA.

Sadly, as the cancer advanced faster than imaginable, stealing his ability to communicate, this very institution stole his health and last bit of dignity. Increasingly over medicated, he was first sent to the psych ward, followed by a sitter who seized the opportunity of a 'difficult patient,' claiming he hit her [because she stole his wedding ring, which she later returned.] In the interim, our 'difficult patient' had another sitter who was nowhere to be found until long after he stopped breathing and suffered brain damage.

I quickly learned that patient health and safety should extend beyond the physicians and nurses to a culture of accountability. I’ve also learned how quickly one negative event/perception can have far-reaching outcomes for our patients.

Ann Folsom tells a story about her local hospital that does not involve a medical error per se. In so doing, she reminds us that medical care involves administrative and other people in addition to health care providers.

My husband was at the hospital because his doctor wanted him to get three days of monitoring as he changed meds for arrhythmia. He was really cold because the room could not be warmed.

Nurses entering the room remarked on it, and left the door open into the hallway to try to bring in a little heat, but that wasn't enough. They tried warming hospital blankets and bringing them in, but of course after a few minutes, the blankets cooled off again. He kept shivering, so I asked if it would be okay if I brought in a comforter from home.

The nurses said that was a good idea, and they recommended it, so I brought a big comforter, and spread it double over on his bed on top of the hospital blankets, and tucked it in. This helped him to sleep better at night.

On the last morning, when he was released, a maintenance man came in to fix the heater, and told us that the dust in the radiator kept clogging it, that this was an ongoing problem, and that he had to keep doing repairs, as the problem wasn't prevented.

Linda Kenney's personal story is well known to many of us, and it is a tribute to her that it led to the founding of Medically Induced Trauma Support Services (MITSS). Here's an abridged version:

November 18, 1999, marks a day that changed my life forever. I was scheduled for a total ankle replacement. As this was my 20th surgery, it didn’t seem a big deal to my family, friends, or me. The reason for most of the surgeries was the fact that I was born with bilateral club feet.

I met with the anesthesiologist, Dr. Rick van Pelt, and we formulated a plan for general anesthetic with a block which would numb from my knee down. This would help with post operative pain management. I said goodbye to my husband and went to the pre-operative area where the block was performed. The block had been delivered, and within minutes I had a grand mal seizure followed by full cardiac arrest. They called a code but were unsuccessful in restoring my cardiovascular function. Fortunately for me, there was a cardiac suite ready for another patient, and they were able to bring me across the hall and open my chest to hook me up to a cardio pulmonary bypass machine. This all happened with thirty five minutes of the onset, and after an hour or so on bypass I was slowly weaned off. I was then taken up to the cardiac intensive care unit.

When I awoke days later and realized what had happened, I was so grateful to be alive and felt extremely fortunate.... I had one conversation with someone who said I had an allergic reaction to medication, but this didn’t make any sense to me. During my entire hospital stay, not one staff member referred to the incident. It was like the giant elephant in the room – lurking in the corner with no one daring to mention it. I remember thinking…well, if no one is talking about it, maybe it isn’t such a big deal.

When I was discharged, I was given instructions on how to care for my chest and information regarding a visiting nurse. But, no one informed me of the emotional impact an event like this would have on me or my family.

Since physically I looked like I had prior to the surgery, family and friends assumed I should be over it by now. At this time I felt so alone and isolated. In hindsight, I realize that they didn’t understand (nor did I) that I hadn’t dealt emotionally with the event up until now. I felt as though I was falling apart. I felt abandoned by the hospital. I met with my orthopedic surgeon a few months after the incident, and we started to discuss what had happened. He began to share with me what that day was like for him but was unable to continue because he became too emotional. It was then that I realized this event didn’t just affect my family and me but the healthcare providers as well. (Go
here for more information on Dr. van Pelt’s experience.)

I began to realize that this was bigger than me. More than likely, other patients and families as well as clinicians were not being emotionally supported following unexpected outcomes and medical errors. It became clearer that there were many reasons for this (fear of litigation, the healthcare culture, no infrastructure for emotional support, etc.). I felt compelled to change the system which had failed me. I experienced an incredible sense of responsibility because I was one of the lucky ones to have survived. I came to know firsthand that there was a large hole in the healthcare system which needed to be filled. In 2002, I founded a non-profit organization, MITSS, to bridge the gap.

It has been an incredible journey. I have come to know many others whose experiences mirror my own. I understand their pain and frustration with the system which does not yet adequately support them. Their stories serve to inspire me and reaffirm the fact that there is still much work to be done. The fact remains -- even in the safest of healthcare systems, things can and do go wrong. I don’t believe there are bad people in healthcare. Sometimes, they just don’t know what they don’t know.

Finally (almost), Westby Fisher sends this note: "About a year and a half ago, I wrote a piece about the importance of medical errors to doctors' and nurses' training; about the importance of morbidity and mortality conferences and touched on the loss of the autopsy as a teaching aide. Obviously, it struck a cord with folks and remains one of my favorite pieces, in part, because it takes a contrarian stance on the subject: that medical errors are good for you. Although it's not a particular case study, as it seems you want, I thought it might be relevant to your grand rounds."

And, one more from Ramona Bates, not because it is quite on topic, but because it has really good advice that might help someone. She says, "Be a potential hero -- Learn CPR." Actually, I guess it is on topic. All health care workers should know this basic set of skills.

Now, finally, a last minute submission from Tanya. She thought it would be too late for this edition of Grand Rounds, but I added it as a tragic bookend to the lovely essay provided by Cherie at the beginning. You will see why.

Ten years ago my son, Noah, died 3 days following a tonsillectomy. It was a day procedure and we were sent home. He was not able or was not willing to drink or eat and he was vomiting often. This continued through the first and second nights at home. I called the doctors on call all weekend, a total of 7 times, for advice. He continued to not drink or eat, and finally on Sunday morning they told me to take him to the emergency room. There they treated him for dehydration, kept him for 23 hours and released him, still not taking anything by mouth. A home nurse was scheduled to give him IV fluids at home 12 hours at night.

No one evaluated the surgical site or the persistent cough he had or really anything. The physician literally popped his head in and told us that he was going home, that he was suffering from dehydration and nothing more. He never once physically examined him. The surgeon consulted by phone and never saw him either. We were tired and confused and took him home. He hemorrhaged 5 hours after being home. Not a trickle: It was loads of blood coming from his mouth and nose. He stopped breathing three times. The first two times I was able to clear his airway and revive him. The third time I could not clear the blood clot, and he died before the ambulance arrived.

I was contacted by the surgeon. For a period of time he answered my questions. He did not ever explain to me what had happened. When I pushed him, he told me that I would never be able to understand what had happened. No one from the hospital contacted me. I requested a meeting to better understand what had happened, but that was refused. When I finally had asked one too many questions of the surgeon he said, "There is nothing I can do for you. Your only choice is to sue me." Sadly that is what I did.

Apart from my son's death, the lawsuit was the second worse experience in my life. It kept the wounds fresh for years following his death. I was humiliated and belittled during the depositions. The outcome was in my favor...technically we won...but nothing ever has felt so empty as that "victory".

I had been a special ed teacher before Noah was born. I was a happy stay-at-home mom. After his death I read everything I could find regarding tonsillectomies and complications. It led me to learn more about medical errors. At first I was angry at the physicians that had ignored my son's needs. Later I realized that it was a system deeply flawed that had caused his death. Since then I went on to get a MPH and am now a PhD student focusing my research on patient safety interventions.

What advice would I give clinicians? There is so much but here are a couple:
-- Take the time to listen when a patient or family are telling you that there is something wrong. I knew he was not well and kept saying so.
-- Don't treat only the obvious symptoms. Take the time to go one level deeper.
-- Tell patients/families important symptoms to look for -- especially things that are not intuitive. For example, blood that has been swallowed and vomited might look like coffee grounds not blood.

Monday, March 30, 2009

Don't ever forget it

A lovely evening event Saturday night -- a fundraising gala for the Jewish Family and Children's Service of Greater Boston. They took the occasion to give their Community Leadership Award to Irving Rabb (shown here) and Melinda and James Rabb. Jim is Irving's son and is a GI doctor affiliated with BIDMC.

The family has been known for decades for their personal involvement in and financial support of charities in the Boston area and beyond. In his thank-you remarks, Irving (now 96) related the story of his father saying to him as he entered college, "This community has been good to you. Don't ever forget it." He never did, and neither has his family. (Here's a longer version of the story, written a few years ago.)

An example and a lesson for all of us.

Sunday, March 29, 2009

And yet more birds

Special for all the Twitter users out there. Great work, as always, by Walt Handelsman at Newsday.

More birds of a feather

Erin Ailworth at the Boston Globe writes a sweet story about several companies in which executives and staff, including our good friends at Cambridge Health Alliance, gave up pay or benefits to avoid layoffs of their fellow workers. I wonder if the day will come when this kind of story is not newsworthy because such behavior becomes the norm.

Saturday, March 28, 2009

Birds of a feather

Birders are trained to be alert for out-of-range birds passing through. Some of our neighbors noticed this Eurasian Teal in a nearby pond. As the name implies, this duck is way out of his territory. In addition, he was trying to court a female mallard, so I guess he was confused about lots of things.

This other unusual duck also had beautiful plumage on her head. She was seen with her parents at a nearby restaurant. Her father was a bit embarrassed by the headgear, but I thought she wore it well and, unlike the Teal, quickly attracted an admirer of the opposite sex.

Friday, March 27, 2009

Really, it didn't smell!

A blast from the past this week from my good friend Steven C. Davis, President of Rackemann Strategic Consulting, Inc. Steve was head of the MA Environmental Policy Act office when I was running the regional water and sewer system. We were both committed to figuring out how to stop sewage sludge discharges into Boston Harbor. The answer was to collect the sludge, dry and bake it, and make it into fertilizer. It is still going on, and 70 tons per day of sludge are now recycled and used beneficially.


I was just looking at the ficus benjamina tree in my office and remembered with great clarity when I was MEPA Director. You came to visit around the sludge processing plant for MWRA and brought a small bag of the processed sludge, which was to be used as a soil amendment and fertilizer. I put it around the roots of the ficus and told you that if the tree flourished, it would be a good thing. The tree flourished and, lo, these 23 or 24 years later, it still thrives and it still is in my office.

What a pleasant memory. I hope all is well with you.


Thursday, March 26, 2009

Inviting Grand Rounds submissions

I have been asked to host medical Grand Rounds -- the weekly rotating carnival of the best of the medical blogosphere -- on Tuesday, March 31. I hope that I will stimulate a large number of submissions on the following topic: When things go awry.

This is a topic that draws on my desire to encourage greater transparency in the delivery of clinical care. In the spirit of Dr. Ernest Codman, I ask doctors, nurses, and other providers to write about actual incidents in which they made or were present for a medical error. Please explain the circumstances and what you did in response to the situation. But, equally important, please tell us how you felt about the event and how it changed your practice of medicine afterward. Of course, please conform to the requirements of HIPAA in your submission.

I also ask patients who have been the victim of, or loved-ones who have seen, clinical harm to relate their personal stories. Tell us how your provider(s) responded, and how the event has changed your view of the practice of medicine and what advice you would give to the profession.

And, to get the most prominence for this edition of Grand Rounds, a posting that includes commentary from both a provider and his/her patient will get the highest rating.

I will not be publishing submissions on other topics. Sorry, but I want to have a specific focus this week.

Please submit your entries by Sunday evening, March 29 to plevy [at] bidmc [dot] harvard [dot] edu, and include "Grand Rounds" in the subject line. Many thanks.

Tony was tops!

I was invited to UMass-Dartmouth's Charleton College of Business today to spend time with faculty and students to discuss hospital-related management issues. This is part of an occasional "Executive on Campus Program" run by the school to give MBA and other students a chance to interact with people in the business community.

My hosts were Dean Eileen Peacock and Hershel Alpert, Executive-in-Residence (in photo). Hershel, a very successful businessperson, has offered this time in his retirement to help in an educational role at the college. Eileen, by the way, is soon leaving her post to be vice president for Asia of the AACBS, the organization that accredits business schools worldwide. We wish her well as she travels to her new assignment in Singapore.

As always, I enjoyed the time with the students (some shown here), who came from three classes: strategy, services marketing, and quantitative methods. They were attentive and friendly, and asked great questions. First prize goes to Tony, though, seen in the top picture in the grey sweatshirt and between two more reticent friends. He had the quickest and best answers to several questions I posed to the students.

Judy's hoping you will come

Judy Kaufman is a former cancer patient who organizes occasional events to benefit the hematology/oncology patient care unit at BIDMC. This year, Judy's Hope is based at the F1 go-cart racing center in Braintree, MA, and will be held this weekend on Sunday, March 29, from 1pm to 5pm. There will be entertainment for all ages and indoor adult racing, plus a silent auction as well as a quickie board. Note: This is all indoors. Perfect for a rainy Sunday!

This will be a great family event. Beyond the go-cart racing, activities of the day include:
-making stuffed animals
-answering trivia questions
-sandy candy
-decorating cupcakes
-design your own toy race car
-spray painting t-shirts.

Auction items include:
-2 VIP passes to Ellen Degeneres along with a gift basket
-4 Back stage passes to a live taping of Two and A Half Men with a signed autograph and offical shirt.
-Signed DVD of The Office
-Signed Red Sox baseball
-Girls teen basket
-Childrens activity basket
-gift certificates to many restuarants including $200 to Davios
-Healthworks monthly gift certificates with bag, yoga mat...
-Swanboats gift certificates with bag and souvenirs
-Silver piece of jewelry from Dorfman collection
-CBS-behind the scene tour for 12
-200 bulbs planted for you
-10lbs of Stavis shrimp
-Dario Preger Photographer-2 gift certificates for family sitting and one 8x10
and many other items.
And many more wonderful items.

Read more about it on Facebook. You don't have to be affiliated with BIDMC to attend. This is a fun-for-the-whole family event that raises money for a good cause.

Wednesday, March 25, 2009

Er, thanks, we won't be needing that

In today's email:

I wanted to follow up on the information I sent regarding our private jet program. As you may know, Blue Star Jets has access to over 4,000 different jets that can be accessed in as little as 5 hours anywhere in the world. We were also quoted in the Wall Street Journal as one of the most cost effective ways to fly private. Please let me know if you have any questions or if you would like to discuss an upcoming trip in more detail.
I look forward to earning your business and becoming your private aviation provider.
Best regards,
David Parrillo Jr.
Blue Star Jets
Any Jet. Any Time. Any Place.
Blue Star Jets Rated #1 Most Prestigious Jet Service, Luxury Institute, 2008

Tuesday, March 24, 2009

At the ACHE

Jim Conway, Senior Vice President of the Institute for Healthcare Improvement, invited me to join him at the annual meeting of the American College of Healthcare Executives in Chicago. ACHE is an international professional society of more than 30,000 people who lead hospitals, health care systems, and other health care organizations. About 1300 showed up for our 7am session this morning, entitled "Transparency and Leadership in Quality and Safety Measures."

The pictures show some of the attendees, looking remarkably chipper given the early hour, from Tennessee, Texas, Florida, and elsewhere. Also, there's Howard Horwitz, ACHE's education vice president. Finally, there are the labeled water glasses to prove that Jim and I were actually there: These guys are serious about infection control! (But it gave me a chance to joke that I did not see if the man who put on the labels had washed his hands.)

I always learn something when I hear Jim talk. The takeaway moment for me was when he displayed a chart showing survey results about the "top issues confronting hospital CEOs." In 2008, 43% percent of those surveyed indicated that patient safety and quality were among their top three concerns. This is an improvement from 2003, when the figure was only 26%. That's the glass-half-full interpretation.

Jim's interpretation, in contrast, is that 57% of the hospital CEOs surveyed did not have safety and quality in their top list of concerns. This is a major indictment of the health care system and demonstrates a lack of understanding of the concerns of a broad group of stakeholders -- patients, families, public interest advocacy groups, business leaders, governors, and legislators. I do not know if we were preaching to the choir today, or if we were able to make some converts.

Final budget decisions

To give you the next chapter in our budget issues, here's the email that was sent out yesterday to the BIDMC community:


Many thanks for your participation, suggestions, ideas, and criticisms during the last couple of weeks. And special thanks for the generosity shown by hundreds of you throughout the hospital, including the Chiefs and Dr. Rosenberg. It is time to let you know my decisions about the budgetary matters we have all been discussing.

First, though, permit me to offer some observations. At stressful times like this, there is a natural tendency to feel fear. Most of us have families to support or other obligations that go beyond the basics of food, clothing, and shelter. We try our best to plan our lives and live carefully and frugally, saving for future contingencies. Then, an earthquake-like phenomenon occurs, a massive disruption in our economic system that shakes the very foundations of decisions about consumption, savings, and personal security. Add to this a follow-on tremor by telling you that the hospital has been affected by the broad economic issues and that we will have to make tough decisions that will affect you personally.

I know that this is very distressing. In my view, we have two ways to respond. We can retreat into isolation from one another. That path leads to resentment, distrust, and a slow degradation of the work environment and of the sense of mission of our hospital. Or, we can look within and find that the values which have guided our care of patients and families are also the same values that apply to our care for one another. In the words of Lois, a manager our Department of Medicine, I think we will learn much from the process. I even dare to believe that we will become a community of healing for one another, just as we are for our patients.

I choose to believe that we want to do the latter, that we work in this particular hospital because we have come to trust the BIDMC family to care for one another. My decisions below are guided by this premise. Some of you will disagree with aspects of what I have decided, or the rationale for them. I have read and heard those views in your comments on the chat room and in personal emails. I promise you that I have seriously considered those views, and that I respect them, but there comes a time when I need to balance competing concerns and make a decision that will not be popular with all. Please trust and understand that I don't take on this role with a belief that my views matter more than any of yours, but because it is sometimes my job to try to consolidate and reflect back the underlying ethical and moral judgments that you have expressed to me. I believe that this is one of those times, and that we as a hospital will be judged by the broader community for how we handle these issues.

So, my decisions below are guided by some social principles as well as business principles. As noted from the outset, I will do what I can to protect the lowest wage earners among us. Even above that income level, I will tend to ask proportionally greater sacrifices from those higher up in the income stream than those below. I do not do this because I believe people earning in the mid-range or even the high range have fewer financial obligations than the others. I know there are people earning $70,000 or even over $100,000 with very tight budgets and lots of financial commitments. But, as a general matter, people who have been earning more for years do have more options and assets than those who have earned less. I feel an obligation, therefore, to skew our budget relief plan in a manner that asks more of those higher up the wage scale.

What does this mean specifically? It means that the people in Grade 4 and below will be exempt from any salary cutbacks and will receive their expected 3% raise this year. People in these grades will be subject to the same reduction in earned time and in 401(k) contributions as everyone else. They will be subject to layoffs for poor performance like anyone else, but they will not be subject to current layoffs as a result of reconfiguring the work organization.

The Decisions

Earned Time Accruals
Many of you objected to the manner in which we proposed to trim earned time accruals during the next several weeks. You said, “Can we please reduce the amount of accruals more gradually, over several months, rather than all at once.” We will do this. The rate of earned time accruals will be reduced so that this is spread out between April and the end of September. The amount of reduction will be about the same: Weekly accruals will be reduced by approximately 19% during this six-month period, which will result in three to four days less accrual of ET for full-time employees, depending on years of service, and prorated amounts for part-time employees. I think you should expect a similar reduction in the total number of days accrued in FY2010, although it will be spread out over more months.

Earned Time Cash-out
Before I address this specifically, let me provide a context and summarize how earned time currently works here. Your comments often indicated some misconceptions of the rules.

BIDMC’s Earned Time (ET) program combines paid time off benefits into one bank of accrued benefit hours and allows employees to draw from this bank. The amount of ET you accrue depends on how long you have worked here. The minimum is 28 days per year for full-time employees, rising to a maximum of 39 days per year. (The ET program does not cover absences covered by Worker’s Compensation, military reserve duty, jury duty or death in the family. These are covered by separate rules.)

The Extended Illness (EI) program accrues paid time off for employees to use for a personal illness, or to take care of a family member during a leave of absence that has been designated and approved as an FMLA leave. Employees must use 24 hours of ET before the EI bank can be tapped. Eligible full-time employees accrue Extended Illness hours at a rate of 16 hours per year. This amount is prorated for part time employees.

Employees may not carry over more than one year’s Earned Time accrual into the following calendar year. Earned Time hours in excess of one times the annual accrual as of the end of the calendar year are rolled into the employee’s Extended Illness bank.

But, we have also had a rule that a person can cash out a portion of their surplus Earned Time days each year, rather than have it flow into the EI bank. The rule now is that employees must have at least 120 hours in their ET bank and must leave a minimum of 80 hours after cash-outs. This is prorated for part-time employees. The hours allowed for cash-out are based on years of service.

It is this rule that I have proposed to cancel going forward, and I have decided that we will go forward with that proposal. I understand that some people have come to expect to have these funds available each year, but this is a very unusual benefit. When we are reviewing how competitive our overall salary and benefits are in the region, we frankly do not consider the idea that someone can get an extra week or two of pay in return for not using Earned Time.

The change is effective immediately. However, I am sympathetic to the fact that the cancellation of the ET cash-out benefit will leave some employees with personal emergencies that they had planned to meet through the cash-out provision. Employees who have an immediate situation that compromises their ability to meet an important obligation that threatens their home, their family or their ability to continue working should send an appeal during the first week of April to Judi Bieber in the Human Resources Department. A committee will carefully consider these requests and will grant exceptions to the cash-out provision on a one-time basis.

Here are examples of the circumstances we will consider for exceptions:

    • Impending college tuition payment
    • Medical/Dental bill for scheduled procedures
    • Contracts signed for immediately necessary home/car repairs
    • Summer family care arrangements that allow an employee to come to work

We will not consider payments for vacation homes, cruises, weddings or new vehicles, general cost-of-living items like gas, food or clothing or contributions to savings accounts of any sort.

Employer Match to Retirement Funds
In my earlier message, I proposed to temporarily discontinue BIDMC’s 2% match to the 401(k) plan and the contribution to the executives' 403(b) plan. I said that we would expect to reinstitute these payments in FY2011. This proposal drew a number of comments pro and con. I have decided to adopt it. I am sympathetic to the fact that people who are closer to retirement will feel the effect of this step more than people who do not have plans to retire in the near future. However, it is one of the largest single items we can use to save money -- $3.5 million for the remainder of FY2009 -- and it has the least impact on current family budgets.

Annual Merit Increase for Directors and Managers

I will be reducing the salaries of directors and managers who received their 3% raise in January to the level they had before that date. As a general matter, directors and managers have higher pay that non-managers, and this decision is consistent with the principles I set forth above. Directors and managers will, of course, keep the increment in pay received from January 1 through March 30, but the base will be lowered as of April 1 to the previous level.

Annual Merit Increase for Non-managers
After earned time, perhaps the largest number of comments came in on the issue of how to handle this year’s 3% annual merit increase. I had proposed to suspend it going forward, i.e., for those people who would have received it on April 1 or thereafter. But I also said that people who had already received their increases would get to keep them.

Since this is the item with the biggest current hit to spendable income, people quite properly raised the issue of equity. Why shouldn’t people give back their increase and therefore be treated equally with those who have not yet gotten it? I have to admit that this is a tough call when the fairness issue is raised, but it is an easier call when you consider that people who have already received their raise have come to expect that amount in their paycheck each week and have budgeted for it. This is a bit different from people who have not yet received it. Perhaps I am trying to make too fine a point here, and you will still disagree, but it feels more right to me to do it this way.

To clarify, though, it also means that the people whose anniversaries are April 1 and after will be the first to receive merit increases when we reinstate the program. In essence, we will re-set the merit increase calendar to that date, instead of the usual October 1.

When will merit increases start again? I think we should plan on two years without increases – although we will start them up again sooner if the FY2010 results are better than we currently anticipate. So, if you were to have received an increase in April through September 2009, your next one will instead be during the same month in 2011. If you already received an increase in October through December 2008, your next one will be in the same month in 2011. If you already received an increase in January through March 2009, your next one will be in the same month in 2012.

(For those managers who received a raise on January 1 but whose raise will be rescinded, you will next be eligible for a raise on April 1, 2011. In essence, the managerial anniversary date will be re-set to April 1.)

The Residents
A few of you asked why residents should be exempt from the merit increase cancellation. The main reason is that we make a promise to prospective residents, when they apply, about the level and trajectory of wages. They, in turn, make a multi-year contractual commitment to our hospital. If we were to renege on that commitment, it would severely affect our future recruitment efforts in the highly competitive market that characterizes the Boston academic medical centers. Furthermore, to change the salary structure after the residents have submitted their selections for residency (called “the Match”) would place us in violation of national rules created to govern the selection process.

Beyond that, please rest assured, based on the fairness criteria, that the wages paid to residents – whether on an annual or hourly basis – are certainly not in any way overly generous, especially when one considers the average indebtedness of medical students when they graduate and enter our program.

Other Items
All the other items I proposed in my earlier email – meals at meetings; Blackberry and cell phone reimbursement; employee events; and attrition -- will go into effect. These received virtually unanimous support in your comments. And the salary cuts voluntarily offered by the vice presidents and Chief Operating Officer Eric Buehrens and me will go into effect. Finally, let's all continue to seek out other cost-savings measures in the floors, units, and offices.

Early Retirement/Donations/Layoffs

Early Retirement
As I mentioned, all these steps will save $16 million in FY2009 and reduce the number of required layoffs from 600 to about 150. It is possible that we will be able to further reduce that number during the next couple of weeks. Many of you suggested that early retirements are a key step that could avoid some layoffs, and I am going to adopt your idea. We will institute an early retirement program that will permit people 62 and older who have completed 3 or more years of service to leave with a severance payment. Plus, employees in this group who are currently enrolled in health and/or dental insurance could elect to continue their participation at employee rates until the age of 65, when they are eligible for Medicare. In addition, employees volunteering for this program may be eligible for retirement benefits through the Pension Plan.

This is only a brief summary of the plan, and more information will be published soon. For those who are interested in considering early retirement, informational meetings will be held on Wednesday, March 25 at 8:00 AM and on Thursday, March 26 at noon in Shapiro 1A.

Donations to the hospital

Donations to the hospital can also help avoid layoffs. For example, the $350,000 in funds already committed by the Chiefs has already saved about ten jobs during this fiscal year. Charitable donations from the doctors as part of the fundraising being conducted by HMFP can also help, although we do not yet know by how much, in that the donations have not yet arrived.

I also want to encourage other staff members who feel so inclined to make donations. You can make donations on our website at www.bidmc.org and designate the gift for the BIDMC Staff Support Fund, or you can deliver them to the Development Office at 109 Brookline Avenue. To give you an extra incentive, my wife and I will personally match gifts through April 10 at the rate of $1 for every $10 donated.


Given these measures, I hope that the new layoff figure of 140 people will go down over the next couple of weeks. I’d like to see it drop considerably, but we’ll just have to see. We will wait until the last possible moment to issue notices of termination so that we can evaluate the effect of the early retirement and philanthropic initiatives.

Here are the instructions that have been given to the vice presidents. The order of layoffs will be based on the following four criteria, in this order, and apply to all BIDMC facilities (including Bowdoin Street, Lexington, and Chelsea, but not BID~Needham):

Performance: Poor performance will be the first factor in selecting individuals to be laid off. In fairness to those thousands of you who work hard and well, we will be moving more quickly that we would have in normal times when it comes to removing people for poor performance. Although we always expect the highest level of performance from our managers and employees, exceptional performance becomes even more critical when we must continue our work with fewer resources. Many departments will be affected by the layoffs we will implement. Our ability and willingness to retain managers and employees who are not meeting performance expectations will significantly decrease. The Medical Center stands by its personnel policies, including PM-04 (our Corrective Action Policy). That said, when staff levels are reduced we expect that terminations based on performance or behavioral problems will occur more quickly (in some cases immediately) and the corrective action described in PM-04 may be truncated or bypassed entirely, even in the most routine circumstances. I say this not to sound threatening, but to encourage every manager and employee to redouble your efforts to maintain the highest level of performance so we can keep the Medical Center running smoothly with reduced resources. Your consistently excellent performance is key to our success.

Volume: Where volume, hours of care or other demand metrics have not met budget and are unlikely to grow in the near future, we need to reduce salary expense so we do not carry over future structural problems.

Structural Reorganization: Some areas have the opportunity to restructure operations, streamline workflow, improve productivity and save personnel expense.

All Other: If these measures which are tied to performance and productivity can’t get us to the needed goal, then the least desirable alternative will become part of the solution.

I expect and hope we will not get to the last category. Indeed, I think that the first category will comprise the bulk of our termination notices. But I wanted you to have exactly the same information as the vice presidents so you know what their task is during the next few days.

Also, as I said to you earlier, all of this will likely close the gap for FY2009, but we have to understand that there is some uncertainty about that for FY2009, and there is still more uncertainty for FY2010. I want to defer action beyond this and see how things work out for us and the national and state economies. Only if still needed after these steps would we return to the idea of other layoffs. I expect we would review that early in the summer, and of course, will keep you all informed as we go along.

Thank you for your patience and understanding during this period.


Monday, March 23, 2009

Observations on value-driven behavior

The recent extensive publicity about my approach to addressing budgetary problems at BIDMC is a bit discomfiting to me personally. While it is always nice to get good reviews and favorable press, I view what we are doing as so consistent with the values of the people at BIDMC that I think that the praise that is being applied to me individually seriously misses the point. Yes, leadership really matters. But after all, it is our staff who are choosing to make sacrifices to help avoid layoffs and to help the lower wage workers in our hospital. They are the true heroes, whom people need to be focusing on most. If they didn't have the core values they are showing these days, nothing I or any other leader could do would matter.

Clearly, there is something bigger going on, something I had not fully understood or anticipated. I have come to conclude that the credit being given to me is reflective of something that people seek and need during these rough times. Thomas Friedman writes about it in yesterday's New York Times, citing a lack of leadership at the national level that would draw people to think more deeply about their values and to act on them.

“There is nothing more powerful than inspirational leadership that unleashes principled behavior for a great cause,” said Dov Seidman, the C.E.O. of LRN, which helps companies build ethical cultures, and the author of the book “How.” What makes a company or a government “sustainable,” he added, is not when it adds more coercive rules and regulations to control behaviors. “It is when its employees or citizens are propelled by values and principles to do the right things, no matter how difficult the situation,” said Seidman. “Laws tell you what you can do. Values inspire in you what you should do. It’s a leader’s job to inspire in us those values.”

Dr. Lachlan Forrow, an ethicist at BIDMC, thinks that Mr. Friedman has it just slightly wrong. In a note to me, he says, "I do not think it's true that what the most effective leaders do is "inspire in us those values" (though yes, that's part of the story), as much as embody them, honor them in the rest of us, encourage and facilitate their expression/release, and then celebrate that release so there's a positive feedback loop."

I really like Lachlan's formulation of the case. In an earlier post, I referred to Lois, a manager in our Department of Medicine, who taught me that our community's approach had contributed to her ability to deal with the fear of the moment, enabling her to be able to be generous to others. This was extremely touching and meaningful to me and supports Lachlan's statement.

Last week, I heard about a priest in Duxbury, MA who was using our hospital's experience to make the same points. I thought this was an isolated case, but then a friend sent me this link to a pastor in Concord, MA. I remain a bit abashed by the personal nature of the post, but I need to share with you the lesson that this preacher set forth and to commend his leadership in doing so for his congregation. And I am grateful, too, for how he empowers our own staff at BIDMC -- regardless of their religious beliefs -- to further greatness by specifically citing their good deeds.

The employees at Beth Israel Hospital may or may not be Christians, but they certainly give us Christians a sign of the kind of giving our faith requires of us.

It’s always easy to give from our surplus,
from what we don’t really need. But the love of Jesus asks us to give from our want: to give even when we don’t have enough to give or when it seems we have nothing left to give.

The more this economy pinches and squeezes and drains us,
the more real will become the options faith sets before us.

May the sacrament we share here nourish in us
the love that gives freely of itself for the sake of others.

Saturday, March 21, 2009

A mitzvah, don’t you think?

A note I print in its entirety from Ediss Gandelman, our director of community benefits.

Hi Paul,

Our BIDMC staff gave so much this week, and today they continued to keep on giving.

Several months ago we were approached by the American GI Association, the Department of Public Health and the American Cancer Society to join with them in replicating a free colonoscopy screening event that was so successful in Texas. Tom Lamont (PL note: our chief of GI) quickly put out an email to the GI physicians and got an overwhelming response from docs willing to donate their time to do procedures on a Saturday in March (today). But as I learned in trying to organize the event, the docs account for probably 25% of the effort—when I called together all the departments who would be need to be involved, I learned that we had a cast of thousands—okay, not thousands but at least 30! AND EVERYONE MADE THE GENEROUS DONATION OF TIME AND TALENT!

Pictured in this photo are many of my treasured colleagues who participated today including:

Our GI specialists—Drs. Douglas Horst and Alan Moss.

Nurse Manager: Janet Lewis.

The nurses: Laureen Smith, Judy Oakes, Robin Dunn, Cheryl Smith, MaryAnne Hickey, Kerri Grief, Chris Hunt, Marie Paul (actually left early to take her sign language course so she can better serve our patients).

Nurse/Med Tech: Sokha Hou.

The receptionist: Tinea Simpson.

Interpreters: Grace Peters and Winmolwan Reed.

Corporate communications: Zineb Marchoudi (who is not in the photo as she took the photo).

Administrators: Eileen Joyce, Sara O’Connor and Ediss Gandelman.

Our 9 patients who benefited from the free colonoscopy procedures were all uninsured or underinsured patients from our affiliated partner, the Joseph M. Smith Community Health Center. So, in the picture are the JMSCHC staff who were responsible for recruiting the patients, making sure they were educated and prepped properly for the procedure, and ensuring that any and all barriers were removed: Nancy Gilday, RN and Alejandro Alvarez, case manager.

Behind all these smiling faces also are many others from BIDMC, without whom this effort would not have been successful including:

Judy Jensen and Gina McCormick from Pathology and the “slicers and dicers” who will prepare the specimens from today’s procedures.

Dan Bazinet from Security.

Mark Leonard from Housekeeping.

Beth O’Toole, Mary Feeley, Martina Comisky, and Kristin McKenney from our fiscal department.

And last but not least, our senior managers who supported the effort—Jayne Sheehan, Alice Lee and Diana Richardson.

PHEW…I hope I didn’t leave anyone out and apologize if I did! But it certainly takes a village to do a free colonoscopy! AND the bonus was getting to see Doug Horst tango with Judy Oakes!!!

A mitzvah, don’t you think?

The waste patrol at work, all 6000+ of them!

I love that people throughout the hospital are now involved in ferreting out waste. And I like it even better that they are calling out problems they see. And I like it even better when our managers treat these comments politely and respectfully, even when they sometimes have to explain why suggestions might not always be the best possible idea. Here's an email chain from today between one of our nurses, me, one of the vice presidents, and then another who had been copied. (I have changed the nurse's name for privacy purposes.)

Saturday, 9:14am
Hi Paul,

I was frustrated this morning when I came into the West Campus front entrance to find a new dispenser of complimentary umbrella bags for visitors. Why would we be purchasing something so unnecessary as this when we are being forced to give up [other things]? I really felt this was inappropriate.


Saturday, 9:23am
News to me, Mary, although I could imagine that we do it to keep wet umbrellas from dripping all over our floors, which would then have to be cleaned up. I'll inquire around. Diana?

Saturday, 10:37am

Thanks for your note-I know it is frustrating in these times to see something that looks like waste!

As you probably know, we've been doing a lot of work on employee safety through the Spirit initiatives. There have been literally hundreds of employee slips and falls in the last several months. Besides the pain of these incidents for the employee, slips and falls result in a major cost to the medical center in claims and lost productivity.

When the slips and falls committee, chaired by Jayne Sheehan and Michael Kennedy, investigated the root cause of these events, they discovered a significant number occur in lobbies when employees (and patients) slip on water that has dripped off of umbrellas. The umbrella bags are an inexpensive solution to help keep our employees and patients safe. (And eliminating just one claim from a bad fall will more than cover the cost of the bags!)

Please feel free to contact me if you would like more information. Thank you again for your note!


Saturday, 10:47am
Thanks, Diana and Mary,
Yes, Michael and I spent a lot of time investigating real time slips during inclement weather. It was clear the dripping umbrellas caused a wake of slips for not only our employees but our patients, particularly on the slick terrazzo floors and vct floors. We immediately looked into solutions to allow folks to keep their umbrellas, but leave a safe path behind them. Michael found a great solution, used in many other environments, and thought bringing it to the health care environment would serve the same purpose.

Important to note, is that the expense of all umbrella trees and the bags came to 1/10th of the cost of one employee injury where an employee may be then out for one or two days of leave. I felt it is well worth the minimal dollars to keep our staff who hurry a lot from campus to campus and our patients and their families safe.

Thank you, as always, for your thoughts and concerns during this fiscally challenging environment.
Jayne Sheehan

Saturday, 12:20pm
OK, thank you all for your responses. That certainly sounds reasonable and well thought out.


Friday, March 20, 2009

Coming to terms with things as they are

I have been struck by the outpouring of interest in and support for BIDMC's approach to solving our budgetary shortfall this year. Starting with Kevin Cullen's story in the Boston Globe, which was spread throughout the country and picked up on dozens of blogs and elsewhere, people seem to be looking for good news in these hard times. Here, within the hospital, we have learned a lot about our colleagues when we face adversity and band together to solve problems.

But, it is not always an easy lesson. Sometimes it is downright painful to get there. Here is one incredibly honest and insightful email I received from Lois, a manager in our Department of Medicine.

Dear Paul,

Thank you for the opportunity to have an open air debate. I'm discouraged by the cuts that are necessary, but recognize that given this severe economic downturn that cuts are necessary. Lately, when I am with people who are complaining, or have a lack of understanding of the issues, I've been asking them what they would do differently. Usually they don't have an answer. As a manager, I applaud you for taking a thoughtful, difficult way, by choosing transparency in the process. I know that none of these decisions are easy.

Last evening, I went to a lecture by Jon Kabat-Zinn, founder of the Mindfulness Stress Reduction Clinic at U Mass Med School. I had to look at my own feelings. Yes, I want to support the lower wage earners. But, I found myself resisting when it means personal sacrifice. I was surprised at how much my fear was blunting my usually generous heart.

Jon Kabat-Zinn defined healing as "coming to terms with things as they are, allowing things to unfold, and recognizing our interconnectedness." You are choosing a different way of handling this challenge, I think we will learn much from the process. I even dare to believe that we will become a community of healing for one another, just as we are for our patients.


The doctors pitch in, too!

Jeff Krasner at the Boston Globe writes about the generosity of our doctors. Here's the note from Dr. Stuart Rosenberg, head of our 800-doctor faculty practice (HMFP), sent to the BIDMC community last evening:

By now, we all know about the enormous stresses on the world economy and the inevitable negative impact on the healthcare system including BIDMC. In the past week it has been announced that economies and cost savings will be necessary in order to continue the critical responsibilities BIDMC has to our community.

Yesterday evening, the BIDMC Department Chiefs of Service and HMFP took steps to demonstrate our support of the outstanding and loyal staff of the medical center. We created the "Physicians Support BIDMC Fund" to complement job preservation and budget efforts at the hospital. As a start, each of the 12 Chiefs and I have agreed to make a significant voluntary contribution to BIDMC for this purpose, the total of which is over $350,000.

We are also sending a letter to the entire BIDMC physician community, inviting them to make as generous a contribution as possible to this same effort. Although physicians are not employed by the hospital, our commitment to patients, teaching, and research are inextricably linked to BIDMC. Thus, just as medical center staff and colleagues are asked to make sacrifices, so shall we.

It is a privilege to be associated with so many fine individuals whose daily hard work and commitment add so much value to our community. Together we will come through this challenge stronger and better positioned to continue our important work.

Thursday, March 19, 2009

Young adjunct staff members

A belated St. Patrick's Day gift sent to me, which I share with you, too. The note is from one of our nurses, whose daughter, the mother of these kids, also works for us:

I know you are extremely busy, but your smile for the day is in the pictures. My grandchildren, born here at BIDMC, are the pride and joy of the Oncology Shapiro 9, where their mom is a patient and on the West campus where she shows them off with me. As you can see, they are also Fenway fans.

They are part of BIDMC.

Wednesday, March 18, 2009

Caller-Outer of the Month Award #3

Today was the monthly meeting of our Board of Directors, along with another chance to present our Caller-Outer of the Month Award. It was given to Deborah Kravitz, seen here, who works in our Central Processing Division (CPD).

The purpose of the award is not to recognize someone who has solved a problem, but rather to recognize someone on the staff who has noticed a problem and called it out. The idea is that call-outs lead to root cause analyses that enable us to fix problems systematically rather than engaging in work-arounds. Our Board of Directors created the award as part of our BIDMC SPIRIT program to encourage people to call out problems to make our hospital a better place to work. (Beyond the recognition, the award is accompanied by two really good tickets to a Red Sox game.)

You may recall reading about the LEAN rapid improvement event we ran in the CPD recently. Well, Deborah got the whole thing started many months ago when she invited me for a tour of CPD, and I was able to see the terrible working conditions facing her and her colleagues as they try to carry out their job of sterilizing all of the surgical instruments used in the hospital's ORs. After some delay, Deborah nudged me again a few months later and pointed out that nothing had improved. So, we got to work on the problem and with the help of the CPD staff, are now on the path to a much healthier, safer, and efficient work environment.

By the way, Deborah is also a talented artist. Check out a sample of her work here.