Just finished a very busy weekend of refereeing youth games, from U10 all the way though high school. I have been refereeing kids soccer since 1994 and really enjoy being out with boys and girls while they are out enjoying themselves.
There have been many reports of parents and coaches abusing referees during youth games, and I don't want to spend much time on that. People who have grown up yelling at professional refs at baseball, football, and basketball games and view it as a privilege of the ticket price (my favorite: "Hey ref, you are missing a good game!") forget that those of us who officiate at youth games are not professionals and do it strictly as a community activity. Yes, we get paid a little bit (I donate my pay to charities) but that is just a symbolic recognition of the time and commitment that goes into doing the job.
I have noticed that some coaches and parents sometimes forget that a soccer game consists of a group of children kicking a piece of leather around a grass field. Does such a game ever have deeper meaning that that? Sure, it promotes teamwork and skill development and other good things, but it is fundamentally a group of kids who are PLAYING. We need to remember what playing is all about.
The other point is that it is hard to be a good referee. You are making a multitude of decisions and judgment calls (especially in soccer, where you are trained to keep the flow of the game going and not interrupt things for minor fouls), and you are doing this in real time with 12, 16, or 22 players on the field. You do it in good weather and bad, and when you are fresh or tired. You are on the run for over an hour (reportedly 5 or 6 miles in a 90-minute game), and you do not have a substitute (unlike the players.) Plus, you can only call what you see, and you cannot be looking at the entire field all the time, and sometimes players block your view. If you are parent or coach, try it sometime during a practice scrimmage.
There are times you need to remind the adults to behave to maintain a positive atmosphere for the children during a game. Here are some of the most effective things I have seen a referee say to a coach who has been not behaving properly during youth games.
John (adult ref) jogs off the field as the game progresses and stands right next to a coach who has been carping about his calls. The coach says, "What are you doing here? You need to be on the field." John says, "You know, you are right. You CAN see things better from here."
Art (adult ref) stops near a coach who has been complaining. "How do you have time to both coach and referee? I can only do one at a time."
And finally, Ally (age 14 referee) approaches an adult coach who has been persistently yelling about her calls. He is 6 feet tall and 200 pounds. She is just reaching 5 feet and may be 100 pounds. She stands in front of him and looks up and says very quietly, "Don’t you think you are taking things a bit too seriously?" He is silent for the remainder of the game.
Sunday, September 30, 2007
Saturday, September 29, 2007
First (Class) Aid
Here's a picture of some of the BIDMC first aid team at Fenway Park last night, where they were recognized by the Red Sox in a pre-game ceremony for their great service to the patrons at the games. Nurse Cyndi Casey represented the group by throwing out the first pitch -- reportedly a strike over the inside corner.
Traffic Patterns
For years, my wife has claimed that the traffic gets worse every September in Boston. Not worse compared to the admittedly low-volume summer traffic, when many residents are on vacation and the 300,000 college kids are away. But worse compared to the previous September.
Each year, I disagree, saying that it just feels that way compared to the summer, and that you can't really remember what it was like a year previous. But this year, I am moving in her direction. Something is going terribly wrong this September. There are massive traffic tie-ups, randomly assorted throughout the metropolitan area. The "secret" routes the locals would usually take to avoid these are also congested.
If the Center for Short-Lived Phenomena were still around, I would send the query to them. But they seem to have disbanded. So, being a trained urban planner, I looked for the answer in the data.
If the number of miles of roads has stayed about the same, perhaps the number of vehicles on the roads has risen. Alas, it is really hard to get those numbers. Here is what I found on the web:
Total vehicles in operation in Massachusetts
2000 -- 4,933,209
2001 -- 5,198,221
2002 -- 5,406,846
2003 -- 5,479,394
2004 -- 5,456,267
2005 -- 5,420,206
Not good enough. I'm looking for a recent uptick and the data aren't there. Maybe I could dig up the number of new vehicles registered more recently. Here are those figures:
New Cars and Light Trucks Registered
2004 -- 329,941
2006 -- 291,556
But as new vehicles are registered, others are scrapped. The two charts seem to indicate that these may cancel out in any given year. For example, even though there were 300,000 new registrations in 2004, the 2005 total number of vehicles really didn't change very much.
But perhaps the use of vehicles has gone up even if the number has stayed about the same.
Maybe there is a hint from transit ridership. If that has gone down, more people would be driving their cars more often. We sometimes read articles about a decline in ridership. Did it happen this year?
Again, official current data are hard to find. Here are the latest published numbers I found.
Average weekday ridership on the MBTA
2000 -- 664,000
2001 -- 697,000
2002 -- 663,000
2003 -- 664,000
Not helpful at all.
Well, enough city planning for a Saturday morning. It is time for me to go referee some kids' soccer games. While I am away, perhaps someone out there can submit a good answer to this question. Or even just suggest some other theories.
Each year, I disagree, saying that it just feels that way compared to the summer, and that you can't really remember what it was like a year previous. But this year, I am moving in her direction. Something is going terribly wrong this September. There are massive traffic tie-ups, randomly assorted throughout the metropolitan area. The "secret" routes the locals would usually take to avoid these are also congested.
If the Center for Short-Lived Phenomena were still around, I would send the query to them. But they seem to have disbanded. So, being a trained urban planner, I looked for the answer in the data.
If the number of miles of roads has stayed about the same, perhaps the number of vehicles on the roads has risen. Alas, it is really hard to get those numbers. Here is what I found on the web:
Total vehicles in operation in Massachusetts
2000 -- 4,933,209
2001 -- 5,198,221
2002 -- 5,406,846
2003 -- 5,479,394
2004 -- 5,456,267
2005 -- 5,420,206
Not good enough. I'm looking for a recent uptick and the data aren't there. Maybe I could dig up the number of new vehicles registered more recently. Here are those figures:
New Cars and Light Trucks Registered
2004 -- 329,941
2006 -- 291,556
But as new vehicles are registered, others are scrapped. The two charts seem to indicate that these may cancel out in any given year. For example, even though there were 300,000 new registrations in 2004, the 2005 total number of vehicles really didn't change very much.
But perhaps the use of vehicles has gone up even if the number has stayed about the same.
Maybe there is a hint from transit ridership. If that has gone down, more people would be driving their cars more often. We sometimes read articles about a decline in ridership. Did it happen this year?
Again, official current data are hard to find. Here are the latest published numbers I found.
Average weekday ridership on the MBTA
2000 -- 664,000
2001 -- 697,000
2002 -- 663,000
2003 -- 664,000
Not helpful at all.
Well, enough city planning for a Saturday morning. It is time for me to go referee some kids' soccer games. While I am away, perhaps someone out there can submit a good answer to this question. Or even just suggest some other theories.
Friday, September 28, 2007
October baseball
Back in March -- wanting to give my loyal blog readers ample opportunity to criticize or praise my managerial judgment -- I discussed our decision to be Official Hospital of the Boston Red Sox. The jury of my peers was split on that issue, but I want you to know that it is an intensely popular thing among our employees and physicians. Notwithstanding the (ahem!) high regard with which I am held by the staff, if I were to end this sponsorship arrangement, I would be dead meat. So I am happy to report that we were pleased to reach an agreement with the Red Sox to extend it for a second five-year term.
Here is a typical email from a staff member on the subject, when it looked like the team was imploding a couple of weeks ago, while our football franchise was doing really well:
Thank GOD! We have the Patriots to lessen the pain.
They won't break your heart like the SOX do 85 out 86 years!
Sincerely,
A lifelong disgruntled SOX fan!
PS. By the way, do you have any SOX tickets?
As you can imagine, when the playoffs arrive, there is a lot of interest in the allocation of our company seats at Fenway Park. We want to be really, really fair about this, while also using the opportunity to support a worthy cause. Here's how we solve the problem each year, as detailed in an excerpt from my email to the BIDMC community:
Dear BIDMC,
Now that a playoff berth for the Red Sox is assured, we can offer the long-awaited BIDMC Playoff Series Raffle. All are welcome to participate. As in the past, raffle tickets will be $5 each. You can buy as many as you like. As in the past, too, the proceeds of the raffle will be in recognition of a special group of people.
Who Benefits?
For the Divisional championship series, the proceeds will go to support the professional advancement programs of our Medical Technologists and other staff in the Pathology Department. These folks are among the unsung heroes of our hospital, performing millions of blood and tissue tests every year, running our blood bank, and carrying out other critically important tasks. Without them, the work of the hospital would grind to a halt. The proceeds of the raffle will give them scholarships to attend professional seminars. So, even if you don't win a game ticket, you can rest assured that your purchase will go to a worthy cause.
Which Tickets are These?
These are the two BIDMC corporate seats in Row 2 behind home plate. This is a view of the game that few get to experience, and here's your chance! We will pick three winners, one pair of tickets for each of the three potential home games. (Sorry, if you win the later game’s seats and there are fewer than three games, you will still get the tickets, but you will only get to use them by hanging them as decoration on your wall!)
We will do a separate raffle for the next playoff series, the ALCS, and the one after that, the World Series, if and when the Sox make it that far.
How Much, When and Where?
Raffle tickets cost $5 each. They will be on sale:
Friday, Sept. 28, and Monday, Oct. 1
11:30 a.m. – 1:30 p.m.
East campus Ullian dining area and west campus cafeteria
At off-site locations, the following staff members have graciously agreed to sell raffle tickets. Please be considerate and e-mail or call ahead before you visit:
** – Bowdoin St.
** – Lexington
** – Needham
** – 109 Brookline
** – Chelsea
** – Renaissance Center 5
The Rules
The raffle is for BIDMC, BID-Needham, BIDMC off-site, APG and CareGroup Corporate staff members and volunteers. You MUST HAVE A PHOTO ID FROM ONE OF THESE ORGANIZATIONS to purchase raffle tickets. There is no limit to the number of raffle tickets you may purchase.
If you work evenings or weekends, or cannot make the dates above, you can make a photocopy of your ID and ask a colleague to purchase raffle tickets for you, or you may contact Volunteer Services.
The winning raffle ticket will be drawn on Tuesday, Oct. 2, at 3:45 p.m. in my office. The winner will be informed via phone and e-mail, and the information will be posted on the BIDMC portal by 4 p.m.
Good luck!!
Here is a typical email from a staff member on the subject, when it looked like the team was imploding a couple of weeks ago, while our football franchise was doing really well:
Thank GOD! We have the Patriots to lessen the pain.
They won't break your heart like the SOX do 85 out 86 years!
Sincerely,
A lifelong disgruntled SOX fan!
PS. By the way, do you have any SOX tickets?
As you can imagine, when the playoffs arrive, there is a lot of interest in the allocation of our company seats at Fenway Park. We want to be really, really fair about this, while also using the opportunity to support a worthy cause. Here's how we solve the problem each year, as detailed in an excerpt from my email to the BIDMC community:
Dear BIDMC,
Now that a playoff berth for the Red Sox is assured, we can offer the long-awaited BIDMC Playoff Series Raffle. All are welcome to participate. As in the past, raffle tickets will be $5 each. You can buy as many as you like. As in the past, too, the proceeds of the raffle will be in recognition of a special group of people.
Who Benefits?
For the Divisional championship series, the proceeds will go to support the professional advancement programs of our Medical Technologists and other staff in the Pathology Department. These folks are among the unsung heroes of our hospital, performing millions of blood and tissue tests every year, running our blood bank, and carrying out other critically important tasks. Without them, the work of the hospital would grind to a halt. The proceeds of the raffle will give them scholarships to attend professional seminars. So, even if you don't win a game ticket, you can rest assured that your purchase will go to a worthy cause.
Which Tickets are These?
These are the two BIDMC corporate seats in Row 2 behind home plate. This is a view of the game that few get to experience, and here's your chance! We will pick three winners, one pair of tickets for each of the three potential home games. (Sorry, if you win the later game’s seats and there are fewer than three games, you will still get the tickets, but you will only get to use them by hanging them as decoration on your wall!)
We will do a separate raffle for the next playoff series, the ALCS, and the one after that, the World Series, if and when the Sox make it that far.
How Much, When and Where?
Raffle tickets cost $5 each. They will be on sale:
Friday, Sept. 28, and Monday, Oct. 1
11:30 a.m. – 1:30 p.m.
East campus Ullian dining area and west campus cafeteria
At off-site locations, the following staff members have graciously agreed to sell raffle tickets. Please be considerate and e-mail or call ahead before you visit:
** – Bowdoin St.
** – Lexington
** – Needham
** – 109 Brookline
** – Chelsea
** – Renaissance Center 5
The Rules
The raffle is for BIDMC, BID-Needham, BIDMC off-site, APG and CareGroup Corporate staff members and volunteers. You MUST HAVE A PHOTO ID FROM ONE OF THESE ORGANIZATIONS to purchase raffle tickets. There is no limit to the number of raffle tickets you may purchase.
If you work evenings or weekends, or cannot make the dates above, you can make a photocopy of your ID and ask a colleague to purchase raffle tickets for you, or you may contact Volunteer Services.
The winning raffle ticket will be drawn on Tuesday, Oct. 2, at 3:45 p.m. in my office. The winner will be informed via phone and e-mail, and the information will be posted on the BIDMC portal by 4 p.m.
Good luck!!
Thursday, September 27, 2007
More SEIU letters to doctors
I have discussed below the tactical use of letters from the SEIU to doctors at our hospital. Here is another type of letter. This one was an email sent to the doctor's business address.
This is clever approach to appeal to doctors' sense of concern about patients and to try ultimately to create a divide between physicians and hospital administration. Let's deconstruct this a bit -- first on elements of style (which, admittedly, are very well done!) First, the writer gives the impression that she has actually talked with other doctors in the hospital, who recommended that she contact this one. But, none of those doctors' names are provided. Second, while for privacy reasons I have deleted some personal items relative to the author's family, she made use of a familial connection to medicine to generate a sense of camaraderie and appearance of some technical knowledge of the field. Finally, there is an element of informality in the closing, i.e., use of first name and "Cheers", as a way to present a sense of intimacy, along with the offer to hold conversations confidential.
On the substantive side, notice the choice of topic, as though there is something special or unusual about the issue of patient bed delays at this hospital. Every hospital in Boston has delays in patients passing through the Emergency Departments. This has been well documented. Ultimately has to do with how much bed capacity you choose to build on the medical/surgical floors and in the ICUs. Each hospital tries its best to manage bed capacity and avoid the need for expensive new construction. (I wonder if the SEIU has written letters like this to all of the Boston hospitals.)
From: Sara Rothstein
To: Dr **
Subject: Patient Bed Delays @ BIDMC
Dr ** -
A number of physicians across BIDMC have suggested that I talk to you about the hospital’s challenges with patient bed delays.
By way of introduction, I am working with SEIU 1199/United Healthcare Workers East and leading its new physician outreach project in Boston. The outreach project is being done in conjunction with the union's efforts to organize healthcare workers at hospitals across Boston. . . .
SEIU 1199/United Healthcare Workers East has a strong history of partnership with healthcare providers and we would like to have similar partnerships in Boston, with the hospitals and with the physicians. As such, I am meeting with physicians to better understand the concerns and priorities in their departments. A number of people have expressed frustrations with delays in moving patients from the ED to inpatient units, moving patients between inpatient units and moving patients out of the hospital. Everyone I’ve spoken to has recommended that I speak with you for more information.
Would you have some time to talk more about this? The conversation would absolutely be confidential. I’d be happy to meet with you at the hospital or elsewhere if you prefer.
I look forward to hearing from you.
Cheers,
Sara
Sara Rothstein
Physician Relations
SEIU
p.s. I want to apologize that you didn’t receive a letter we sent to BIDMC physicians last month. The letter to you was just returned to the union for being sent to the wrong address. I am attaching a copy of the letter and related attachments to this email. The letter was sent to physicians to explain our position on Free and Fair union elections. There has been a lot of back and forth on this topic between Paul Levy and the union and I’d be happy to answer any questions you may have.
This is clever approach to appeal to doctors' sense of concern about patients and to try ultimately to create a divide between physicians and hospital administration. Let's deconstruct this a bit -- first on elements of style (which, admittedly, are very well done!) First, the writer gives the impression that she has actually talked with other doctors in the hospital, who recommended that she contact this one. But, none of those doctors' names are provided. Second, while for privacy reasons I have deleted some personal items relative to the author's family, she made use of a familial connection to medicine to generate a sense of camaraderie and appearance of some technical knowledge of the field. Finally, there is an element of informality in the closing, i.e., use of first name and "Cheers", as a way to present a sense of intimacy, along with the offer to hold conversations confidential.
On the substantive side, notice the choice of topic, as though there is something special or unusual about the issue of patient bed delays at this hospital. Every hospital in Boston has delays in patients passing through the Emergency Departments. This has been well documented. Ultimately has to do with how much bed capacity you choose to build on the medical/surgical floors and in the ICUs. Each hospital tries its best to manage bed capacity and avoid the need for expensive new construction. (I wonder if the SEIU has written letters like this to all of the Boston hospitals.)
From: Sara Rothstein
To: Dr **
Subject: Patient Bed Delays @ BIDMC
Dr ** -
A number of physicians across BIDMC have suggested that I talk to you about the hospital’s challenges with patient bed delays.
By way of introduction, I am working with SEIU 1199/United Healthcare Workers East and leading its new physician outreach project in Boston. The outreach project is being done in conjunction with the union's efforts to organize healthcare workers at hospitals across Boston. . . .
SEIU 1199/United Healthcare Workers East has a strong history of partnership with healthcare providers and we would like to have similar partnerships in Boston, with the hospitals and with the physicians. As such, I am meeting with physicians to better understand the concerns and priorities in their departments. A number of people have expressed frustrations with delays in moving patients from the ED to inpatient units, moving patients between inpatient units and moving patients out of the hospital. Everyone I’ve spoken to has recommended that I speak with you for more information.
Would you have some time to talk more about this? The conversation would absolutely be confidential. I’d be happy to meet with you at the hospital or elsewhere if you prefer.
I look forward to hearing from you.
Cheers,
Sara
Sara Rothstein
Physician Relations
SEIU
p.s. I want to apologize that you didn’t receive a letter we sent to BIDMC physicians last month. The letter to you was just returned to the union for being sent to the wrong address. I am attaching a copy of the letter and related attachments to this email. The letter was sent to physicians to explain our position on Free and Fair union elections. There has been a lot of back and forth on this topic between Paul Levy and the union and I’d be happy to answer any questions you may have.
Wednesday, September 26, 2007
Gotta love this one
In the continuing series on email solicitations to the CEO, here is one from a marketing company. If you are a marketing company, shouldn't you be better at marketing? Sorry if this embarrasses the sender, but I can't leave out certain items as I present the critique.
Hi Paul, [Use of "Hi" rather than "Dear". Use of first name rather than "Mr. Levy". This is overly familiar. May be appropriate among people of a certain generation, but definitely not so for people of my generation. BTW, in our hospital, we have a rule requiring patients to be addressed as Mr., or Mrs., or Ms. until and unless the patient permits the use of the first name.]
A friend of mine said we should be in touch. [An anonymous friend of his said we should be in touch. Is this supposed to be persuasive or meaningful?]
I am the Business Director for **, the leading medical marketing communications agency in Pittsburgh. [I love Pittsburgh as a city, but give me a reason to consider a firm that is not local when it comes to marketing.] We specialize in helping medical clients and laboratories build powerful brands and interactive experiences. [Why would I think that interactive marketing experiences would be of any value to or appropriate for a hospital?]
Can we be of any assistance to Beth Israel Deaconess Medical Center? [Hint: Never ask a question that has "yes" or "no" for an answer. The answer will always be "no".]
[Absence of "Yours truly" or other such closing.]
- Greg [Still overly informal.]
Greg **
Business Director
** Medical Marketing Communications The Marketing Agency to Medical Clients & Laboratories http://www.**.com/ [Poor formatting in that three lines of text are grouped together instead of starting each afresh. If I want a marketing company, I want one with good graphics and presentation skills.]
800.***.****
Hi Paul, [Use of "Hi" rather than "Dear". Use of first name rather than "Mr. Levy". This is overly familiar. May be appropriate among people of a certain generation, but definitely not so for people of my generation. BTW, in our hospital, we have a rule requiring patients to be addressed as Mr., or Mrs., or Ms. until and unless the patient permits the use of the first name.]
A friend of mine said we should be in touch. [An anonymous friend of his said we should be in touch. Is this supposed to be persuasive or meaningful?]
I am the Business Director for **, the leading medical marketing communications agency in Pittsburgh. [I love Pittsburgh as a city, but give me a reason to consider a firm that is not local when it comes to marketing.] We specialize in helping medical clients and laboratories build powerful brands and interactive experiences. [Why would I think that interactive marketing experiences would be of any value to or appropriate for a hospital?]
Can we be of any assistance to Beth Israel Deaconess Medical Center? [Hint: Never ask a question that has "yes" or "no" for an answer. The answer will always be "no".]
[Absence of "Yours truly" or other such closing.]
- Greg [Still overly informal.]
Greg **
Business Director
** Medical Marketing Communications The Marketing Agency to Medical Clients & Laboratories http://www.**.com/ [Poor formatting in that three lines of text are grouped together instead of starting each afresh. If I want a marketing company, I want one with good graphics and presentation skills.]
800.***.****
Tuesday, September 25, 2007
Yet another page from the playbook
Another in the continuing series about the tactics used by the Service Employees International Union during its union organizing efforts. In other jurisdictions, the SEIU has opposed hospitals who wanted to issue bonds to support clinical activities and projects. A key reason: To apply pressure on boards of trustees and management to agree to concessions that would tend to increase the chance of the union's success in organizing the workers.
Here in Massachusetts, the state agency charged with reviewing and ruling on such issues is Mass HEFA, the Health and Education Facilities Authority. This is a highly respected agency, one of the largest of its types in the country. It has diligently and professionally reviewed applications by non-profits to float bond issues for several decades.
Recently, Caregroup, the nonprofit corporation that owns BIDMC, Mt. Auburn Hospital, and New England Baptist Hospital, filed a notice with HEFA concerning a potential bond issue to fund capital improvements in the three hospitals. SEIU personnel have been monitoring this process and have most recently filed a Freedom of Information Request asking for documentation between CareGroup and HEFA on this proposal.
Of course, all information covered under the state's FOI law will provided, as it would be under any legitimate request. But this activity by the SEIU raises the question of whether the union intends to try to delay the issuance of such debt or to try to have unusual conditions applied to it, and if so, for what reasons and for what purpose.
[Disclosure: Many years ago, well before taking this job, I provided consulting services to MA HEFA in support of its effort to create an energy-purchasing cooperative for colleges, universities, hospitals and other non-profits across the state. The program, PowerOptions, remains in service to many non-profits in the state and continues to provides financial savings on their energy bills. I currently have no financial relationship with the agency and have not had any during any part of my tenure at BIDMC.]
Here in Massachusetts, the state agency charged with reviewing and ruling on such issues is Mass HEFA, the Health and Education Facilities Authority. This is a highly respected agency, one of the largest of its types in the country. It has diligently and professionally reviewed applications by non-profits to float bond issues for several decades.
Recently, Caregroup, the nonprofit corporation that owns BIDMC, Mt. Auburn Hospital, and New England Baptist Hospital, filed a notice with HEFA concerning a potential bond issue to fund capital improvements in the three hospitals. SEIU personnel have been monitoring this process and have most recently filed a Freedom of Information Request asking for documentation between CareGroup and HEFA on this proposal.
Of course, all information covered under the state's FOI law will provided, as it would be under any legitimate request. But this activity by the SEIU raises the question of whether the union intends to try to delay the issuance of such debt or to try to have unusual conditions applied to it, and if so, for what reasons and for what purpose.
[Disclosure: Many years ago, well before taking this job, I provided consulting services to MA HEFA in support of its effort to create an energy-purchasing cooperative for colleges, universities, hospitals and other non-profits across the state. The program, PowerOptions, remains in service to many non-profits in the state and continues to provides financial savings on their energy bills. I currently have no financial relationship with the agency and have not had any during any part of my tenure at BIDMC.]
The FTC rules
Check out this August 6 Federal Trade Commission ruling in Illinois, where a large hospital system resulting from a merger was ruled to have too much market power vis-a-vis its negotiations with managed care payers -- after the fact, in a retrospective review.
Three for the Road
1 - Eulogy for a Quality Measure
Dr. Thomas Lee writes in the New England Journal of Medicine:
On May 8, 2007, one of the best-known quality measures in health care was put to rest. The percentage of patients with acute myocardial infarction who receive a prescription for beta-blockers within 7 days of hospital discharge has been used to evaluate U.S. managed care plans since 1996. This measure will no longer be reported by the National Committee for Quality Assurance (NCQA) because it is simply no longer needed — a development that offers encouragement and important lessons.
The data in the graph show why the NCQA Committee on Performance Measurement voted unanimously to retire the beta-blocker measure. A . . .
Sorry, extract only without paying a fee -- but here are the next couple of sentences:
. . . decade ago, only two thirds of US patients who survived acute myocardial infarctions recieved beta-blockers; today, nearly all do. As the curve representing the 10th percentile crept above 90%, the NCQA found little variation among health plans. At least when it comes to this intervention, the U.S. health care system has become reliable.
2 - Mashup Request
Bob Coffield's excellent Health Care Law Blog had an interesting piece this past weekend citing NetDoc's mashup of HHS hospital data -- heart attacks, heart failure, pneumonia, surgical infection prevention -- with Google maps. Note the following thoughtful comment from Bonnie on this entry:
This is a very smart idea! Next, I want to see a mashup that shows hospitals within a certain region that exhibit the best infection control rates.
Well, maybe not Bonnie! After all, the site itself warns:
Important: This tool should not be used to make medical decisions - check the original data source (HHS Hospital Search) and discuss hospital options with your physician to select the best hospital for you. Neither hospital locations nor the accuracy of the rankings/data shown is guaranteed, and there may be errors and/or ommissions (sic).
3 - Does Disclosure Hurt Minorities?
Finally, a 2004 article in Circulation entitled "Racial Profiling,The Unintended Consequences of Coronary Artery Bypass Graft Report Cards," by Rachel M. Werner, MD, PhD; David A. Asch, MD, MBA; Daniel Polsky, PhD suggests:
Although public release of quality information through report cards is intended to improve health care, there may be unintended consequences of report cards, such as physicians avoiding high-risk patients to improve their ratings. If physicians believe that racial and ethnic minorities are at higher risk for poor outcomes, report cards could worsen existing racial and ethnic disparities in health care.
A similar conclusion was reiterated by a couple of the authors the next year:
Public reporting of quality information promotes a spirit of openness that may be valuable for enhancing trust of the health professions, but its ability to improve health remains undemonstrated, and public reporting may inadvertently reduce, rather than improve, quality. Given these limitations, it may be necessary to reassess the role of public quality reporting in quality improvement.
As arguments about disclosure start to be more vigorous here in Massachusetts, the first article is finding its way around the halls of government. Does anyone know if these same authors have updated their findings since 2005, or if there have been further articles by others on this subject?
Dr. Thomas Lee writes in the New England Journal of Medicine:
On May 8, 2007, one of the best-known quality measures in health care was put to rest. The percentage of patients with acute myocardial infarction who receive a prescription for beta-blockers within 7 days of hospital discharge has been used to evaluate U.S. managed care plans since 1996. This measure will no longer be reported by the National Committee for Quality Assurance (NCQA) because it is simply no longer needed — a development that offers encouragement and important lessons.
The data in the graph show why the NCQA Committee on Performance Measurement voted unanimously to retire the beta-blocker measure. A . . .
Sorry, extract only without paying a fee -- but here are the next couple of sentences:
. . . decade ago, only two thirds of US patients who survived acute myocardial infarctions recieved beta-blockers; today, nearly all do. As the curve representing the 10th percentile crept above 90%, the NCQA found little variation among health plans. At least when it comes to this intervention, the U.S. health care system has become reliable.
2 - Mashup Request
Bob Coffield's excellent Health Care Law Blog had an interesting piece this past weekend citing NetDoc's mashup of HHS hospital data -- heart attacks, heart failure, pneumonia, surgical infection prevention -- with Google maps. Note the following thoughtful comment from Bonnie on this entry:
This is a very smart idea! Next, I want to see a mashup that shows hospitals within a certain region that exhibit the best infection control rates.
Well, maybe not Bonnie! After all, the site itself warns:
Important: This tool should not be used to make medical decisions - check the original data source (HHS Hospital Search) and discuss hospital options with your physician to select the best hospital for you. Neither hospital locations nor the accuracy of the rankings/data shown is guaranteed, and there may be errors and/or ommissions (sic).
3 - Does Disclosure Hurt Minorities?
Finally, a 2004 article in Circulation entitled "Racial Profiling,The Unintended Consequences of Coronary Artery Bypass Graft Report Cards," by Rachel M. Werner, MD, PhD; David A. Asch, MD, MBA; Daniel Polsky, PhD suggests:
Although public release of quality information through report cards is intended to improve health care, there may be unintended consequences of report cards, such as physicians avoiding high-risk patients to improve their ratings. If physicians believe that racial and ethnic minorities are at higher risk for poor outcomes, report cards could worsen existing racial and ethnic disparities in health care.
A similar conclusion was reiterated by a couple of the authors the next year:
Public reporting of quality information promotes a spirit of openness that may be valuable for enhancing trust of the health professions, but its ability to improve health remains undemonstrated, and public reporting may inadvertently reduce, rather than improve, quality. Given these limitations, it may be necessary to reassess the role of public quality reporting in quality improvement.
As arguments about disclosure start to be more vigorous here in Massachusetts, the first article is finding its way around the halls of government. Does anyone know if these same authors have updated their findings since 2005, or if there have been further articles by others on this subject?
Monday, September 24, 2007
Two ideas, one theirs, one mine
Here's theirs. Sir Brian Jarmin and Dr. Don Berwick today suggested that they would open a new page on the IHI website allowing hospitals that so desired to publicly report their hospital standardized mortality ratio, or HSMR. I have previously posted ours. I think this is a great idea. It would be voluntary, but I think it would also grow in popularity as hospitals get comfortable with more transparency.
Here's my idea. Why don't the insurers in Massachusetts require the hospitals here to report their HSMRs -- in private, with no publicity -- to them, the insurers, as a condition of being in the payers' networks? Why don't they also require the hospitals to submit their most recent Joint Commission survey? In both cases, if the results are out of whack with industry norms, or otherwise indicate quality or safety problems, the insurers could then require remediation plans to remain in good standing.
Here's my idea. Why don't the insurers in Massachusetts require the hospitals here to report their HSMRs -- in private, with no publicity -- to them, the insurers, as a condition of being in the payers' networks? Why don't they also require the hospitals to submit their most recent Joint Commission survey? In both cases, if the results are out of whack with industry norms, or otherwise indicate quality or safety problems, the insurers could then require remediation plans to remain in good standing.
Event today in Boston -- Mortality Rates
Hospital Standardized Mortality Ratio:
A tool for consumer information and quality improvement?
Date: Monday, September 24, 2007, 9:30-11:30am
Location: Division of Health Care Finance and Policy, Daley Room
5th floor, China Trade Center, 2 Boylston Street, Boston, MA
A tool for consumer information and quality improvement?
Date: Monday, September 24, 2007, 9:30-11:30am
Location: Division of Health Care Finance and Policy, Daley Room
5th floor, China Trade Center, 2 Boylston Street, Boston, MA
Learn about the Hospital Standardized Mortality Ratio (HSMR).
Should hospital HSMR numbers be made public so that consumers can use this information in deciding where to get care?
Can the HSMR be used by hospitals to improve the care they provide?
Is the HSMR a reliable measure of mortality rates and one that can be used to compare hospitals' quality of care?
Speakers will address these questions and will provide perspectives on the use of HSMR for public reporting and for quality improvement within the hospital.
Professor Sir Brian Jarman, Senior Fellow at the Institute for Healthcare Improvement, Boston and Emeritus Professor at Imperial College, London, former President of the British Medical Association and developer of the HSMR.
Paul Levy, President and CEO, Beth Israel Deaconess Medical Center.
Gregg Meyer, MD, MSc, Senior Vice President for Quality and Patient Safety for the Massachusetts General Hospital and the Massachusetts General Physicians Organization.
John E. McDonough, PhD, Executive Director, Health Care for All.
Kenneth Sands, MD, Senior Vice President and Medical Director of Healthcare Quality, Beth Israel Deaconess Medical Center.
Moderator: Dana Safran, Sc. D., Vice President of Performance Measurement and Improvement, Blue Cross Blue Shield of Massachusetts and Associate Professor of Medicine, Tufts University School of Medicine.
Cosponsored by Health Care for All and the Massachusetts Coalition for the Prevention of Medical Errors.
To register, go to http://www.hcfama.org/index.cfm?fuseaction=page.viewPage&pageID=615
For more information, contact Deb Wachenheim at 617-275-2902 or dwachenheim@hcfama.org or Paula Griswold at 617-272-8000 x152 or pgriswold@macoalition.org.
Sunday, September 23, 2007
Spas anyone?
One in a continuing series about emails you get when you are CEO of a hospital. Somehow these get through our spam filter. I'm still relatively new to health care, but I marvel to think that a consulting company has a "director of medical spa services." Look, America is a great country, and I love the entrepreneurial spirit demonstrated by these folks, but isn't it a better idea for hospitals just to get really good at what they are supposed to do rather than be distracted by people from the hospitality business to create health spas? If anything, let's use the experience these folks have from that sector to help us improve the quality of service for sick, nervous, and anxious people visiting our hospitals. There is plenty to do to make sure we are delivering our core business in a proper fashion before jumping off for the latest fad.
7 Secrets to Running a Successful Hospital Owned Medical Spa
Is your hospital contemplating a Medical Spa? Is this a million dollar opportunity or a million dollar boondoggle? Attend a free webinar on "Hospital Owned Medical Spas" to be held on Tuesday, October 9th at 12:00 pm EDT and see if a medical spa is right for your healthcare organization.
This webinar will share with you the 7 Secrets of Running a Successful Medical Spa.
Hospitals across the country are considering whether a Medical Spa is right for them. Join us and get the facts on this fast-growing industry. Some of the reasons hospitals are opening Medical Spas at a record pace are:
Physician partnerships
Drives additional business to core hospital services
New high-margin, non-reimbursed revenue stream
Enhanced focus on well-care instead of acute care
Benefit to employees, patients, and families
Brand building throughout your market
Competitive advantage
This short webinar will cover the specifics of how to properly analyze your market for a Medical Spa, how to avoid the most common mistakes, getting started, physician partnership opportunities, and financing options.
Starting a Medical Spa can be the best - or worst - action you can take this year. Spend 45 minutes with the experts.
Contact me via email or call me directly and I will send you the details on how to join us on this free webinar.
Best regards,
[name omitted]
Director of Medical Spa Services
7 Secrets to Running a Successful Hospital Owned Medical Spa
Is your hospital contemplating a Medical Spa? Is this a million dollar opportunity or a million dollar boondoggle? Attend a free webinar on "Hospital Owned Medical Spas" to be held on Tuesday, October 9th at 12:00 pm EDT and see if a medical spa is right for your healthcare organization.
This webinar will share with you the 7 Secrets of Running a Successful Medical Spa.
Hospitals across the country are considering whether a Medical Spa is right for them. Join us and get the facts on this fast-growing industry. Some of the reasons hospitals are opening Medical Spas at a record pace are:
Physician partnerships
Drives additional business to core hospital services
New high-margin, non-reimbursed revenue stream
Enhanced focus on well-care instead of acute care
Benefit to employees, patients, and families
Brand building throughout your market
Competitive advantage
This short webinar will cover the specifics of how to properly analyze your market for a Medical Spa, how to avoid the most common mistakes, getting started, physician partnership opportunities, and financing options.
Starting a Medical Spa can be the best - or worst - action you can take this year. Spend 45 minutes with the experts.
Contact me via email or call me directly and I will send you the details on how to join us on this free webinar.
Best regards,
[name omitted]
Director of Medical Spa Services
Friday, September 21, 2007
Thursday, September 20, 2007
Teamwork wins against VAP
Back in March, I gave an update on our efforts to eliminate ventilator associated pneumonia in our ICUs. This requires implementing a five-part "bundle" of steps every day with every patient. You measure compliance in this program by the percentage of time you do all five steps. There is no partial credit.An additional item is to perform dental hygiene on patients every four hours. The bugs that can cause pneumonia often originate in the mouth.
The goal is to reduce the number of cases of VAP, which statistically have a 30% mortality rate.
The goal is to reduce the number of cases of VAP, which statistically have a 30% mortality rate.
We report on this item on our company website, but I wanted to give you a secret advanced preview. The charts above show our improvement with the bundle and with dental hygiene.
I don't want to brag too much -- well, actually I do! -- because these results are spectacular. They are the result of terrific teamwork among several departments of nurses, doctors, and other health care professionals. Our best estimate is that the reduction in VAP from these efforts is amounting to about 320 cases per year at BIDMC. While it is risky to extrapolate to relatively small numbers by applying broad statistics, if the 30% mortality figure is applied to this number of cases, it means that our folks saved 96 lives per year.
For those interested in costs, a case of VAP is estimated to increase hospital costs by about $40,000 per patient. Once again, applying this broad average figure to our specific number of avoided cases (320) means cost savings to the hospital of about $12 million. Hmm, saving lives and saving money by teamwork and rigorous attention to detail. Any lessons here?
Wednesday, September 19, 2007
Tie one on
Much has been made of a decision in the United Kingdom to forbid the wearing of neckties in hospitals, claiming that these are a source of infections. Here's one such article.
Of course, I immediately asked our infection control people about this, seeing a potential opportunity to improve patient care and make life more comfortable for male doctors. Excerpts from their response:
The focus should remain on good hand hygiene and cleaning of equipment (especially stethoscopes) – all of which actually touch the patient. If health care workers cleaned their hands well immediately before touching a patient, it wouldn’t matter if their ties, white coats, palm pilots or pagers were colonized, since these things presumably have minimal contact with the patient, if any. Although all of these fomites have been shown in studies to become colonized, there has never been data proving transmission of infection to a patient. This topic comes up every year – it is a big distraction from the real issues. The CDC and SHEA (Society of Healthcare Epidemiology of America) agree with this stance.
Here is a quote I found about the CDC's view on the matter that supports this view, but I note that the 2004 article in which it is cited seems to head the other direction:
The Centers for Disease Control and Prevention (CDC)’s Guidelines for Environmental Infection Control in Health-Care Facilities state that, “although microbiologically contaminated surfaces can serve as reservoirs of potential pathogens, these surfaces generally are not directly associated with transmission of infections either to staff or patients. The transferal of microorganisms from environmental surfaces to patients is largely via hand contact with the surface.”
Sounds like some disagreement among the experts. Well, who knows? We started one revolution. Maybe the British will start another.
Of course, I immediately asked our infection control people about this, seeing a potential opportunity to improve patient care and make life more comfortable for male doctors. Excerpts from their response:
The focus should remain on good hand hygiene and cleaning of equipment (especially stethoscopes) – all of which actually touch the patient. If health care workers cleaned their hands well immediately before touching a patient, it wouldn’t matter if their ties, white coats, palm pilots or pagers were colonized, since these things presumably have minimal contact with the patient, if any. Although all of these fomites have been shown in studies to become colonized, there has never been data proving transmission of infection to a patient. This topic comes up every year – it is a big distraction from the real issues. The CDC and SHEA (Society of Healthcare Epidemiology of America) agree with this stance.
Here is a quote I found about the CDC's view on the matter that supports this view, but I note that the 2004 article in which it is cited seems to head the other direction:
The Centers for Disease Control and Prevention (CDC)’s Guidelines for Environmental Infection Control in Health-Care Facilities state that, “although microbiologically contaminated surfaces can serve as reservoirs of potential pathogens, these surfaces generally are not directly associated with transmission of infections either to staff or patients. The transferal of microorganisms from environmental surfaces to patients is largely via hand contact with the surface.”
Sounds like some disagreement among the experts. Well, who knows? We started one revolution. Maybe the British will start another.
Leapfrog recognition, too
And, another recognition, this one from Leapfrog. Suzanne Delbanco, who has been heading this group for many years, is stepping down. Congratulations to her for her thoughtful approach to the issues and leadership of this important organization. I remember when they first came to Boston to explain their program: It was considered so cutting edge and controversial!
A lot has changed during her seven year tenure in health care, in part because of Leapfrog. The question now is whether Leapfrog has lost importance by actions and programs and disclosure efforts that have hopped over its own approach. That needs to be resolved by its Board as it conducts a search for a replacement to Suzanne.
A lot has changed during her seven year tenure in health care, in part because of Leapfrog. The question now is whether Leapfrog has lost importance by actions and programs and disclosure efforts that have hopped over its own approach. That needs to be resolved by its Board as it conducts a search for a replacement to Suzanne.
More kudos to Ben and the team
Congratulations again for another award to Dr. Ben Sachs and his team in our OB/GYN Department. This one is national is scope, jointly from the National Quality Forum (NQF) and the Joint Commission. It is called the John M. Eisenberg Patient Safety and Quality Awards. Here's a summary from StreetInsider:
This organization is being recognized for the adaptation and application of the military and commercial aviation Crew Resource Management (CRM) principles to the field of obstetrics. After the CRM curriculum was modified for clinical application, 220 staff received training to incorporate the CRM principles and concepts into their daily work processes. The result was a dramatic reduction in major adverse obstetric events, which reduced malpractice liability exposure and improved overall patient safety and the quality of obstetric care. Specifically, a 25.4 percent reduction in the Adverse Outcomes Index (a measure developed for the project) was realized, and the severity of adverse events was reduced by 13.4 percent. The success of this work has been broadly recognized and has driven or influenced similar initiatives, including those of the Harvard Risk Management Foundation, the Commonwealth of Massachusetts, the State of Maryland, and the District of Columbia, among others.
This organization is being recognized for the adaptation and application of the military and commercial aviation Crew Resource Management (CRM) principles to the field of obstetrics. After the CRM curriculum was modified for clinical application, 220 staff received training to incorporate the CRM principles and concepts into their daily work processes. The result was a dramatic reduction in major adverse obstetric events, which reduced malpractice liability exposure and improved overall patient safety and the quality of obstetric care. Specifically, a 25.4 percent reduction in the Adverse Outcomes Index (a measure developed for the project) was realized, and the severity of adverse events was reduced by 13.4 percent. The success of this work has been broadly recognized and has driven or influenced similar initiatives, including those of the Harvard Risk Management Foundation, the Commonwealth of Massachusetts, the State of Maryland, and the District of Columbia, among others.
"Ethically and medically, we felt justified in keeping him"
Please check out this story by Joseph Kahn in today's Boston Globe. Here's a case where the rewards to the caregivers were as meaningful as to the patient.
Monday, September 17, 2007
Simple questions? Simple answers?
"Simple questions" looking for answers:
If medical costs experienced by insurance carriers in Massachusetts are rising at a pretty constant 12 percent per year, driving premium increases of similar magnitude, but economic activity is rising at a rate of 3-4%, at what point does the situation become untenable for the businesses in the state?
If the medical cost increases are caused about 50% by unit cost increases for providers and 50% from increases in utilization (especially utilization of tertiary care) by residents of the state, what countervailing forces might come into play to help alleviate the situation?
If the unit cost increases for providers are driven in great measure by salary pressures from health care workers, what might offset those increases?
Some possible "simple answers":
Self-driven and/or payer-stimulated structural changes by providers to increase efficiency and productivity, i.e., reduce dollars per episode of care delivered.
Decoupling of insurance payments from volume to reduce providers' incentives to increase volume.
Support by insurers to enhance the primary care portion of the system, to enable better preventative care and early diagnoses and intervention (aka, attempt to shift the delivery of services away from high end tertiary care back towards the primary end).
Enforced rationalization of care by insurers based on actual outcomes data (including financial incentives to patients) to encourage patients to go to higher quality providers.
Exclusion by insurers of providers who do not offer sufficiently high quality service, either overall or in particular specialties.
Creation of a strong consumer movement to demand disclosure of outcomes data to help drive process improvement.
Creation of a strong employer movement to demand disclosure of outcomes data to help drive process improvement and to create demand for insurers to offer new networks of high performance providers.
What are your questions and answers? If we narrow these down, maybe we can help set the agenda.
If medical costs experienced by insurance carriers in Massachusetts are rising at a pretty constant 12 percent per year, driving premium increases of similar magnitude, but economic activity is rising at a rate of 3-4%, at what point does the situation become untenable for the businesses in the state?
If the medical cost increases are caused about 50% by unit cost increases for providers and 50% from increases in utilization (especially utilization of tertiary care) by residents of the state, what countervailing forces might come into play to help alleviate the situation?
If the unit cost increases for providers are driven in great measure by salary pressures from health care workers, what might offset those increases?
Some possible "simple answers":
Self-driven and/or payer-stimulated structural changes by providers to increase efficiency and productivity, i.e., reduce dollars per episode of care delivered.
Decoupling of insurance payments from volume to reduce providers' incentives to increase volume.
Support by insurers to enhance the primary care portion of the system, to enable better preventative care and early diagnoses and intervention (aka, attempt to shift the delivery of services away from high end tertiary care back towards the primary end).
Enforced rationalization of care by insurers based on actual outcomes data (including financial incentives to patients) to encourage patients to go to higher quality providers.
Exclusion by insurers of providers who do not offer sufficiently high quality service, either overall or in particular specialties.
Creation of a strong consumer movement to demand disclosure of outcomes data to help drive process improvement.
Creation of a strong employer movement to demand disclosure of outcomes data to help drive process improvement and to create demand for insurers to offer new networks of high performance providers.
What are your questions and answers? If we narrow these down, maybe we can help set the agenda.
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