Sunday, June 06, 2010

Progress, bit by bit

A hodgepodge of items, illustrative of things here at BIDMC and elsewhere:

Doctors working on Lean

First, excerpts of a note from Dr. Clif Saper, our Chief of Neurology, to his faculty and residents, about Lean training and going to gemba. We are getting a great response from the doctors as they learn to apply this approach to the work of the hospital:

I want to thank everyone for coming to the departmental meeting with the Lean group on Wednesday. I hope you enjoyed the introduction, and are as excited as I am about the potential for engaging all of our group in redesigning our work. The key take-home point I want to make is that this has to be a ground up effort, by the people actually doing the work. The goal is to empower you at the front line to redesign your workplace. This will not be easy, and it will not be quick. In fact, we do not expect to finish, ever, but to gradually refine our approach, on a continuing basis, over many years.

The homework for the first month is to “go to gemba” to see how our workplaces function, from the point of view of patients (who are our “customers”), our own docs, referring docs, and the staff who enable our work (front desk group on Shapiro 8, nurses and ward clerks on Farr 11).

I would like each of you to go to gemba (choose your site, but I expect that the residents will mainly concentrate on Farr 11 and the attendings mainly on Shapiro 8, but if you have a passion for the other site, please by all means indulge it). Take a pad of paper, and a watch with a second hand.

I would like you to decide to watch the process from the perspective of one individual (or type of individual, as you may end up watching more than one) in the gemba. For the clinic, you may choose a front desk worker, a physician, or a patient. For Farr 11, I would like you to watch morning rounds (some segment between 7am and noon) from the perspective of a ward nurse, resident, or patient (or patients if you choose more than one). Please write down on your paper a running list of what you observe, in the order you observe it, and try to time the different components of the process. Please plan to do this for at least one full hour, some time in the next three weeks.

The goal is to discover wastes (you will need the list of the 8 wastes that you received at the meeting). If you lack a copy of the list, please email Gregg Ramsey, our teacher on Wednesday, and he will send it to you by email.

Remember to announce yourself to the staff and doctors you observe. Just say that you are participating in the Neurology Lean project, and are there to observe today, to try to improve the patient experience. Please announce yourself also to patients (or have the doctor you are following do so), and ask their permission for you to observe.

I would then like to set aside some time before our next meeting on July 7, to review with groups of you what you found. My hope is that your own discoveries will allow us to divide up into working groups to tackle issues that we identify.

I look forward to seeing what you have found....

Surgical results

Next, a note from Dr. Charles Vollmer, who heads up our pancreatic surgery program with Dr. Mark Callery. The note is to the doctors in a number of departments who support this program:

This week Mark and I celebrated a significant milestone with the performance of our 600th major pancreatic resection over the last 8 years together here at BIDMC. This has come with an overall perioperative mortality rate of 1.3%, as well as other benchmark quality outcomes.

As you can tell from the size of the address string above, this has not come solely at our hands, but rather has been achieved by a collaborative effort among some of the world's finest doctors in the field of pancreas care. We are indebted to your skill, acumen, foresight and friendship. With continued dedication and hard work, we look forward to sharing further accomplishments with you.

Odds improving in Las Vegas

This quote from an article from Deloitte:

Las Vegas employers push hospital transparency, performance

Last week, the Health Services Coalition, a group of 24 self-funded insurance plans representing large employers in Las Vegas advised 13 area hospitals that they would direct their 260,000 enrollees to Intermountain Healthcare facilities in neighboring Utah if quality and transparency efforts did not improve. Specifically, the 20-year-old business coalition is seeking to change incentives from volume to quality and efficiency.

NHS puts it out there

And finally, this report from The Guardian about the British National Health Service's real-time clinical transparency.

The new government's information revolution rolled into hospital wards with the publication today of rates of hospital-acquired infections, such as MRSA, on a weekly basis.

Andrew Lansley, the secretary of state for health, confirmed that from today people will be able to check the weekly meticillin-resistant Staphylococcus aureus MRSA and Clostridium difficile (C diff) rates at their local hospital. He also published 12 weeks of data, giving the public their first view of the level of detail the department has been able to obtain.

From early next month, infection figures for all hospitals in England will be published every seven days on In March, there were about 20 outbreaks in English hospitals of MRSA, whereas by May this appeared to have dropped by half.

Previously, the infection rate for MRSA and C.Diff at NHS hospitals were released on a yearly basis and as an average for each NHS trust - which may comprise several hospitals.


e-Patient Dave said...

Great bunch of updates.

1. I'm still psyched about being one of the patients in Alice Lee's Lean workshop. I *loved* being able to work with the people on the front lines, helping figure out how to do their work better.

2. Re 1.3% mortality on pancreatic surgery: any idea what the national norm is, or what it was before the improvements started?

3. LOVE how the Vegas employer groups are willing to vote with their feet! Heck, there are a lot more of us citizens out there (and employees) than there are hospitals; it's crazy if we don't apply our leverage. (I note, btw, that this move is fueled by transparency: without published data, there's no basis for foot-voting. Right?)

On a related note (the power of data), I'm psyched by the rapid progress in Open Government on HHS opening up its public health databases so innovators can make hay with it. The idea was conceived in March, and they're already live with the first wave of data. It's data that's always existed, but now it's opened up with access via Web services, so any programmer can get at it. They liken it to how the government's weather data appears freely in web sites and systems everywhere.

This "Community Health Data Initiative" was introduced in a full day conference Wednesday at the Institute of Medicine in Washington. Craig of Craigslist has a good description of it here, and video of the eye-popping two-hour introduction session is here.

Anonymous said...


I'm sure Dr.Vollmer could answer your #2 question in 5 seconds, but a quick search for pancreatic resections for cancer indicates operative mortality numbers like "0.7-3%", "less than 4%", and 1.5%. But note these were in the most experienced centers; with mortalities in the double digits in less experienced centers.

So his #'s seem to be well within the good to excellent range.

It may also vary with the exact type of resection.


Anonymous said...


Dr. Vollmer sent me this message:

Mortality rates in pancreatic resection have been studied using administrative databases at the national level. In a landmark paper in the New England Journal of Medicine (2003 Nov 27;349(22):2117-27) John Birkmeyer studied volume/outcome relationships in numerous major operations. In essence, for pancreatic resections the national mortality rates were 4% for high-volume centers (defined as > 11 resections a year), but increased to as high as 16% for low-volume centers. This 4-fold difference was the largest splay of all the operations studied, underscoring the value of specialization for this particular domain of surgery. As stated by one of the blog followers in response to your original post, the published rates in the literature - usually from centers of excellence in the field - hover around 1-4%. Nobody has a zero mortality rate in this field given the technical complexity combined with the generally high acuity level of the patients with these diseases (pancreas cancer, pancreatitis, etc..).

As for our own outcomes, recognizing there is variation on a yearly basis, our mortality rate for cases in our first year as a specialty center at BIDMC (2001-2002) was 2.9%, and for the current year it is 0%. We have previously published these and other perioperative outcomes in an paper in the Archives of Surgery (2007 Apr;142(4):371-80) entitled "Quality Assesssment in High-Acuity Surgery: Volume and Mortality are Not Enough".

And Dr. Callery adds:

Our paper argues that for such high-acuity surgery, once low benchmark mortality rates are achieved, deeper indicators of quality are necessary. More simply put "We've reached low mortality, but how do we know if we're reaching highest quality? How can we get even better?" To this end, we strive to improve, track and report many quality indicators such as operative blood loss, blood transfusion rates, ICU utilization and re-admission rates, to name a few.

e-Patient Dave said...

Thanks, doctors.

I think this is important for e-patients to understand. May I quote your words in a post on You can review before publication if you want - Paul has my email, just drop me a note.

I'm thrilled at the idea that some government data is finally starting to come out into the sunlight, to help people see which hospitals have experience in such things. The newly announced Community Health Data Initiative has great promise, I think - see the Palantir demo 31 minutes into the video at that link.

Information is power - power to the people! Especially the people who are being cut open for money.

Anonymous said...

Dave (and others),

This is all in the public domain, to be used as you like with customary crediting of source.

Anonymous said...

An important point made in the New England Journal article cited by the physicians above is that, at least for the 8 procedures studied, it is surgeon volume rather than hospital volume which counts:

"For all eight procedures we studied, the patients treated by high-volume surgeons had lower operative mortality rates than those treated by low-volume surgeons. Surgeon volume accounted for a relatively large proportion of the apparent effect of hospital volume, to a degree that varied according to the procedure. For some procedures, the association between hospital volume and outcome disappeared almost entirely after surgeon volume had been taken into account."

In other words, patients shouldn't just look at the hospital's volume of these procedures, but try to pick a surgeon who does a large number of them. Now granted, a high-volume surgeon tends to create a high-volume hospital, but the terms are not interchangeable.

And, once again, may I repeat my futile rant that such articles should be available to the public and not secreted away by subscription only. This research was partially funded by AHRQ, which we fund with our taxes.....

nonlocal MD

Anonymous said...

Rant away! I totally agree.

e-Patient Dave said...


The point about surgeon volume is completely consistent with the story of Diane Engelman and her daughter Hilary. The cardiologists in her health plan (one of the big integrateds) said the daughter needed mitral valve repair; the surgeons repeatedly disagreed, recommending replacement (carrying worse outcomes). Years of research led to the realization that the plan's surgeons simply don't do many of the repairs and they aren't very good at it. Long story short, after many denials by the surgeons (in the face of evidence), this nice person got up the gumption to go to the govt, and the plan got an immediate dope-slap. Her daughter promptly got the needed surgery - out of network - and just got the 18-month all-clear.

Anonymous said...


Not to go off topic from Paul's post, but, as I said on the e-patients' site, this is not excusable in my mind. Mitral valve repair is neither new nor experimental surgery; just because the plan's surgeons had insufficient experience was no reason at all to deny her treatment conforming to the current standard of care - especially at her young age and therefore vastly different life consequences for the two types of surgery. Speaking of rants, don't get me started.

nonlocal MD

Laura said...

I am SO pleased to see more conversation happening around LEAN! Thanks for clarifying some important points and I agree about open access to information....