To provide more of a context for the theme below about the work environment in our hospital, I offer some statistics about jobs at BIDMC.
I recall seeing a chart somewhere that showed BIDMC to be the sixth largest private employer in the city of Boston. Indeed, many of the city's largest employers are academic medical centers, and they have all been growing. As has been noted on many occasions, the health care industry is the greatest engine driving Boston’s economy.
But the picture at BIDMC was not always so rosy. When I arrived in early 2002, BIDMC was in financial straits. The previous administration had already eliminated hundreds of positions, and I had to eliminate 600 more (over 10%) of the jobs (some filled, some unfilled) to enable the hospital to survive. That was truly an awful period -- not only for the staff who were laid off, but for those left behind.
Fortunately, in the months and years that followed, we engaged in a successful turnaround and have now been able to restore those jobs -- and more. Here is a summary of the average FTEs (full-time equivalents) on staff year by year.
FY2002 -- 4,562
FY2003 -- 4,694
FY2004 -- 5,013
FY2005 -- 5,353
FY2006 -- 5,635
FY2007 -- 5,792
But that increase of over 1200 jobs in five years doesn't tell the whole story. While employment at BIDMC has grown by 27% during this period, the actual payroll has grown by well more than that -- 63%. Why? Because the market for health care workers in Boston is extremely competitive. If we don't offer salaries and benefits comparable to other hospitals, we will not be able to attract enough of the best people to serve our patients. Remember, if people don't like it here, they can literally walk across the street and go to work at another great medical institution or college or biotech firm or pharmaceutical company.
For fiscal year 2008, we are budgeting another increase, this one in the range of 10%. Part of this is due to further expansion of staff -- almost 450 new positions. Most of these are related to increased patient activity on our floors, clinics, and in the ORs. A significant number, too, are being added to enhance customer service and to meet safety and regulatory requirements. The other part of the budget increase is for salary and wage increases. Like other places, we have a general pay increase about 3%, but we also add in significant amounts of funds for targeted market adjustments to keep up in highly competitive fields.
Monday, November 26, 2007
Saturday, November 24, 2007
More Thanksgiving thoughts
This post is prompted by the following note from one of our chiefs to his staff:
You can't fail to hear from most everyone that Thanksgiving is "my favorite holiday." No exceptions here. Among other things it is a stimulus for me to reach out, express awe and appreciation for the exemplary jobs you do in fulfilling our collective mission. This is not easy work, but the rewards are beyond measure. Thanks to you on behalf of our patients and this medical center.
I have the good fortune to work in a marvelous place like BIDMC, surrounded by well-meaning people who spend their time helping others deal with illness and disease and the real dramas faced by families as they go through difficult times. There are happy times here, too, when people are cured of their illnesses, and the happiest of all, when babies are born and new life arrives -- literally in rooms just a few floors above my office.
While there are daily challenges in the hospital environment, it is the underlying good will of people in these places that is the dominant characteristic. As teenagers in the 1960's, my classmates and I were inspired by John and Robert Kennedy and Martin Luther King, Jr., to enter careers of public service. In our self-centered way, we used to think of our generation as special in that way. But in this place, I see people in their 20's through their 90's who are devoting their lives to alleviating human suffering caused by disease. It is a marvelous commonality of purpose that binds us -- people of all ages, nationalities, religions, and races.
Before I worked here, I wondered (along with many of my friends) if people who worked in hospitals cared anymore. Much of what you hear about hospitals from the outside is related to complaints about insurance rules, difficult working conditions, burnt-out doctors, harried nurses, and rude front-desk staff. I have learned and want to assure my readers that the folks in hospitals do care and care deeply, but the health care environment is often not well suited to bring out the best in people. (By the way, I have learned through my travels that this is not just a US problem.)
Beth Israel Deaconess is characterized by a kind of warmth, compassion, and respect that is legendary, but even it can be a tough and tiring place to work. I view my job as CEO as trying to create a workplace that reflects the deep underlying values of our staff, working to minimize those aspects that inhibit or impair their ability to carry out their heartfelt mission. In this, I am warmly and strongly supported by our lay leaders, members of the community who volunteer to serve on our boards and have the ultimate governance and fiduciary responsibility for this institution. Not many of us are given the privilege of heading up an organization like BIDMC, so I am trying to use my tenure here to make a positive difference for the people who work here.
Last week, I sent the following email to our staff along these lines. Like other things I have shared with you about BIDMC, I am sharing this one. Those of you who are new to this blog might find it surprising that I do so. Regular readers will not be surprised. A hallmark of this administration is transparency -- even when such openness is awkward or embarrassing -- because holding ourselves publicly accountable is the best way for us to improve.
I will also keep you informed of our progress as we move through implementing the program outlined in email. I do so because I think we will learn a lot about ourselves and about the path towards process improvement. I am very confident we will flub up aspects of this as we move along. There may well be those out there who will be quick to judge when we do. But as an academic medical center, one of our jobs is to share what we learn so that it might be helpful to others here in Boston and throughout the world.
----
Dear BIDMC,
What's the most important activity at our hospital? Providing patient-centered care?
Right!
But what do we spend most of our time doing? Patient care??
Wrong. It is fetching. As in spending time trying to find a piece of equipment, a certain paper form, or some other supply. Or it’s re-doing work. As in writing the same piece of information in 3 different places.
Admit it. If you are a nurse on the floor or the OR or the PACU, a respiratory therapist in the ICU, a person cleaning surgical instruments in CPD, or a practice assistant in a clinic, think of how much time you spend fetching instead of actually taking care of a patient or doing the job you’ve been hired to do to support patient care – whether that’s running lab tests, preparing food in our kitchen, or repairing a broken piece of equipment. How much of your day is spent in these ways versus face-to-face time with patients or in doing something tied directly to patient care and the support of that care? If you are a typical person here, it is way over 50% and more like 80%.
But I don't have to tell you that, do I?
We might have the latest in cutting edge technology to take care of our patients and the finest doctors, but in a big institution like BIDMC -- like in most hospitals -- the organization of our work is based on patterns and systems that might as well be 100 years old.
The practice of medicine in academic medical centers like ours is a cottage industry. While other fields and industries have progressed in terms of process improvement, ours remains woefully behind.
Every day, thousands of you undertake "work-arounds" to solve the problems you face in delivering care. And you do solve those problems -- by dint of personal commitment, hard work, and good will. As a result, our patients get extraordinary care.
But, because we all invent work-arounds, we often don’t solve the underlying work process problems that pervade every aspect of what we do. And you go home feeling really tired and wondering how you really spent your day.
Over the next several months, we are going to start a program to work on these problems. Our goal is simple. We want to improve the quality of the time you spend here at BIDMC so you can focus on the things that matter instead of working around problems you encounter.
While the goal is simple, the solution is not. We want a solution that will identify and start to solve problems on the floors as they occur. We want a solution that will uncover and fix underlying problems, not result in yet another set of work-arounds.
We have been studying other efforts around the country and have come up with an approach that we think makes sense for BIDMC.
Recently, we had a chance to spend some time with people from a group called Value Capture. They relayed the content of speech by former Secretary of the Treasury Paul O'Neill at the Harvard Business School. He outlined the three questions every employee should be able to answer with a resounding "Yes!" every day in order for an organization to have the potential for greatness:
Am I treated with dignity and respect by everyone I encounter, regardless of role or rank in the organization?
Am I given the knowledge, tools and support that I need in order to make a contribution to my organization and that adds meaning to my life?
Did somebody notice I did it, i.e., am I recognized for my contribution?
Does that sound right to you? It feels right to me. The Value Capture folks, who have done this in some other places, are going to help us design the program for BIDMC.
Let’s be honest. We can’t all answer "Yes!" to these questions today, and, in fact, in many instances we don’t even come close. But our goal is to get there. If this works, we will set a new standard for staff satisfaction and participation in the operation of an academic medical center.
The program will involve some training and new approaches to our work. Most of all, it will involve you. Don't worry. It will not be painful. It may actually -- dare I say this? -- be fun! And in the long run, we won’t see this as a "program", but rather just as the way we constantly improve work and care at BIDMC.
Have I got you curious? I hope so. Stay tuned for more details this winter.
In the meantime, though, I need help. Every program has to have a name. What should we call this one? I am hoping for something decidedly unbureaucratic -- and maybe even with a sense of humor. Please write back with your ideas.
Best wishes to you and your family for a lovely holiday!
Paul
You can't fail to hear from most everyone that Thanksgiving is "my favorite holiday." No exceptions here. Among other things it is a stimulus for me to reach out, express awe and appreciation for the exemplary jobs you do in fulfilling our collective mission. This is not easy work, but the rewards are beyond measure. Thanks to you on behalf of our patients and this medical center.
I have the good fortune to work in a marvelous place like BIDMC, surrounded by well-meaning people who spend their time helping others deal with illness and disease and the real dramas faced by families as they go through difficult times. There are happy times here, too, when people are cured of their illnesses, and the happiest of all, when babies are born and new life arrives -- literally in rooms just a few floors above my office.
While there are daily challenges in the hospital environment, it is the underlying good will of people in these places that is the dominant characteristic. As teenagers in the 1960's, my classmates and I were inspired by John and Robert Kennedy and Martin Luther King, Jr., to enter careers of public service. In our self-centered way, we used to think of our generation as special in that way. But in this place, I see people in their 20's through their 90's who are devoting their lives to alleviating human suffering caused by disease. It is a marvelous commonality of purpose that binds us -- people of all ages, nationalities, religions, and races.
Before I worked here, I wondered (along with many of my friends) if people who worked in hospitals cared anymore. Much of what you hear about hospitals from the outside is related to complaints about insurance rules, difficult working conditions, burnt-out doctors, harried nurses, and rude front-desk staff. I have learned and want to assure my readers that the folks in hospitals do care and care deeply, but the health care environment is often not well suited to bring out the best in people. (By the way, I have learned through my travels that this is not just a US problem.)
Beth Israel Deaconess is characterized by a kind of warmth, compassion, and respect that is legendary, but even it can be a tough and tiring place to work. I view my job as CEO as trying to create a workplace that reflects the deep underlying values of our staff, working to minimize those aspects that inhibit or impair their ability to carry out their heartfelt mission. In this, I am warmly and strongly supported by our lay leaders, members of the community who volunteer to serve on our boards and have the ultimate governance and fiduciary responsibility for this institution. Not many of us are given the privilege of heading up an organization like BIDMC, so I am trying to use my tenure here to make a positive difference for the people who work here.
Last week, I sent the following email to our staff along these lines. Like other things I have shared with you about BIDMC, I am sharing this one. Those of you who are new to this blog might find it surprising that I do so. Regular readers will not be surprised. A hallmark of this administration is transparency -- even when such openness is awkward or embarrassing -- because holding ourselves publicly accountable is the best way for us to improve.
I will also keep you informed of our progress as we move through implementing the program outlined in email. I do so because I think we will learn a lot about ourselves and about the path towards process improvement. I am very confident we will flub up aspects of this as we move along. There may well be those out there who will be quick to judge when we do. But as an academic medical center, one of our jobs is to share what we learn so that it might be helpful to others here in Boston and throughout the world.
----
Dear BIDMC,
What's the most important activity at our hospital? Providing patient-centered care?
Right!
But what do we spend most of our time doing? Patient care??
Wrong. It is fetching. As in spending time trying to find a piece of equipment, a certain paper form, or some other supply. Or it’s re-doing work. As in writing the same piece of information in 3 different places.
Admit it. If you are a nurse on the floor or the OR or the PACU, a respiratory therapist in the ICU, a person cleaning surgical instruments in CPD, or a practice assistant in a clinic, think of how much time you spend fetching instead of actually taking care of a patient or doing the job you’ve been hired to do to support patient care – whether that’s running lab tests, preparing food in our kitchen, or repairing a broken piece of equipment. How much of your day is spent in these ways versus face-to-face time with patients or in doing something tied directly to patient care and the support of that care? If you are a typical person here, it is way over 50% and more like 80%.
But I don't have to tell you that, do I?
We might have the latest in cutting edge technology to take care of our patients and the finest doctors, but in a big institution like BIDMC -- like in most hospitals -- the organization of our work is based on patterns and systems that might as well be 100 years old.
The practice of medicine in academic medical centers like ours is a cottage industry. While other fields and industries have progressed in terms of process improvement, ours remains woefully behind.
Every day, thousands of you undertake "work-arounds" to solve the problems you face in delivering care. And you do solve those problems -- by dint of personal commitment, hard work, and good will. As a result, our patients get extraordinary care.
But, because we all invent work-arounds, we often don’t solve the underlying work process problems that pervade every aspect of what we do. And you go home feeling really tired and wondering how you really spent your day.
Over the next several months, we are going to start a program to work on these problems. Our goal is simple. We want to improve the quality of the time you spend here at BIDMC so you can focus on the things that matter instead of working around problems you encounter.
While the goal is simple, the solution is not. We want a solution that will identify and start to solve problems on the floors as they occur. We want a solution that will uncover and fix underlying problems, not result in yet another set of work-arounds.
We have been studying other efforts around the country and have come up with an approach that we think makes sense for BIDMC.
Recently, we had a chance to spend some time with people from a group called Value Capture. They relayed the content of speech by former Secretary of the Treasury Paul O'Neill at the Harvard Business School. He outlined the three questions every employee should be able to answer with a resounding "Yes!" every day in order for an organization to have the potential for greatness:
Am I treated with dignity and respect by everyone I encounter, regardless of role or rank in the organization?
Am I given the knowledge, tools and support that I need in order to make a contribution to my organization and that adds meaning to my life?
Did somebody notice I did it, i.e., am I recognized for my contribution?
Does that sound right to you? It feels right to me. The Value Capture folks, who have done this in some other places, are going to help us design the program for BIDMC.
Let’s be honest. We can’t all answer "Yes!" to these questions today, and, in fact, in many instances we don’t even come close. But our goal is to get there. If this works, we will set a new standard for staff satisfaction and participation in the operation of an academic medical center.
The program will involve some training and new approaches to our work. Most of all, it will involve you. Don't worry. It will not be painful. It may actually -- dare I say this? -- be fun! And in the long run, we won’t see this as a "program", but rather just as the way we constantly improve work and care at BIDMC.
Have I got you curious? I hope so. Stay tuned for more details this winter.
In the meantime, though, I need help. Every program has to have a name. What should we call this one? I am hoping for something decidedly unbureaucratic -- and maybe even with a sense of humor. Please write back with your ideas.
Best wishes to you and your family for a lovely holiday!
Paul
Thursday, November 22, 2007
Tuesday, November 20, 2007
I can't hold a Kindle to this one
OK, time for a consumer survey. What do you think of the Kindle, the wireless electronic book that will be available from Amazon on November 29?Here's the quickie description: This is an ebook that is connected wirelessly directly to Amazon. No computer needed. $399 purchase price. You purchase the books you want electronically and they arrive in your hand-held device. Newspaper subscriptions are also available. It does not need wifi so you can buy a book wherever you are.
Reaction from a close friend: I'm drooling to get one.
My Luddite response: Sorry. Why is this good? Can't I just read a book?
Her reply: So you're sitting on a plane. You brought a book with you but you don't feel like that book anymore. You open your Kindle and download a new one from Amazon for $10. Or you subscribe to the newspaper, which is delivered to your Kindle every morning. Or you want to read that new War & Peace translation but it's too heavy to take on vacation. Or you're traveling with children and can get a new book for them to read in one minute. Or you want to read a novel you are embarrassed to be seen reading in public. No more having to fit that "Plato's Republic" dust jacket around Danielle Steele.
Now it's your turn . . . .
Grand Rounds from Mexico
Grand Rounds is up at Mexico Medical Student this week. ¡Muy bien hecho, Enrico!
Monday, November 19, 2007
"Don't worry about it"
I have written before about hand hygiene and the inexplicable difficulty of getting people who are trained in medicine to be attentive to this most basic infection control method. (For BIDMC's latest compliance with this and other clinical safety and quality metrics, you can check our website.)
I am still not pleased with our progress, but this is not just our problem. It appears to pervade medical centers. Here's a true story about a recent example at another place in town.
A friend of mine (let's call her "Mary") was accompanying a friend of hers (let's call him "Sam") to a visit with his doctor's office. Sam has Parkinson's disease and needs help getting around. Sam also needs to be accompanied through his office visit because he takes lots of medications, and the doses and frequency of them are changed from time to time, and he gets confused unless there is someone to help him keep track.
At this visit, several dosages and frequencies were changed, and it became Mary's job to unload and reload Sam's medication dispenser box so he would have the right pills for the right days of the week. As she was moving pills around, and breaking some of them in half, she suddenly realized that she had spent the whole day opening doors for her friend and touching all kinds of surfaces in the hospital and had neglected to wash her hands before handling his medications. Mary blurted out, "Gee, I forgot to wash my hands."
The nurse responded, "Don't worry about it." Now, because of all the medications he already takes, Sam is prohibited from taking any other medications if he catches a cold or gets a sore throat or any such problem. So, for him, a cold is a particularly uncomfortable event. Mary, who therefore was worried about it, temporarily put aside the nurse's comment and looked for a disinfectant dispenser somewhere in the exam room. There was none.
Mary, not being the shy type, made clear to the nurse that she was not pleased with either her comment or this situation. But how many of us would have the nerve to do that? Probably not many. I fear, though, that unless we as patients take it upon ourselves to remind our providers, progress in this arena will be all too slow.
P.S. When Mary told me about this story a few days later, she had a cold . . . .
I am still not pleased with our progress, but this is not just our problem. It appears to pervade medical centers. Here's a true story about a recent example at another place in town.
A friend of mine (let's call her "Mary") was accompanying a friend of hers (let's call him "Sam") to a visit with his doctor's office. Sam has Parkinson's disease and needs help getting around. Sam also needs to be accompanied through his office visit because he takes lots of medications, and the doses and frequency of them are changed from time to time, and he gets confused unless there is someone to help him keep track.
At this visit, several dosages and frequencies were changed, and it became Mary's job to unload and reload Sam's medication dispenser box so he would have the right pills for the right days of the week. As she was moving pills around, and breaking some of them in half, she suddenly realized that she had spent the whole day opening doors for her friend and touching all kinds of surfaces in the hospital and had neglected to wash her hands before handling his medications. Mary blurted out, "Gee, I forgot to wash my hands."
The nurse responded, "Don't worry about it." Now, because of all the medications he already takes, Sam is prohibited from taking any other medications if he catches a cold or gets a sore throat or any such problem. So, for him, a cold is a particularly uncomfortable event. Mary, who therefore was worried about it, temporarily put aside the nurse's comment and looked for a disinfectant dispenser somewhere in the exam room. There was none.
Mary, not being the shy type, made clear to the nurse that she was not pleased with either her comment or this situation. But how many of us would have the nerve to do that? Probably not many. I fear, though, that unless we as patients take it upon ourselves to remind our providers, progress in this arena will be all too slow.
P.S. When Mary told me about this story a few days later, she had a cold . . . .
Sunday, November 18, 2007
Great Scott! Deep blogging!
I shared a panel last week with David Meerman Scott, who has written a wonderful book (best seller) called The New Rules of Marketing and PR: How to Use News Releases, Blogs, Podcasting, Viral Marketing and Online Media to Reach Buyers Directly. The title tells it all, and I recommend it highly to anyone trying to figure out how to sell or publicize a product, a service, or a cause.
David's website also led me on to DeepBlog.com. As he notes: Michael Schaefer's Deep Blog is a useful tool and worth checking out. It is a quick and simple portal to top blogs in many different categories -- a place where blogs are easily found and accessed.
You may have noticed some new buttons on the right side of this page. Those are some of the aggregator websites included on Deep Blog. Do some exploring!
You may also have noticed that I have reorganized my recommended links on this blog. The new categories seem to be evolving organically as I proceed with this blogging adventure. Now that my readership has grown, I am particularly happy to publicize artists, performers and authors who work I have enjoyed. Feel free to forward those or other suggestions.
David's website also led me on to DeepBlog.com. As he notes: Michael Schaefer's Deep Blog is a useful tool and worth checking out. It is a quick and simple portal to top blogs in many different categories -- a place where blogs are easily found and accessed.
You may have noticed some new buttons on the right side of this page. Those are some of the aggregator websites included on Deep Blog. Do some exploring!
You may also have noticed that I have reorganized my recommended links on this blog. The new categories seem to be evolving organically as I proceed with this blogging adventure. Now that my readership has grown, I am particularly happy to publicize artists, performers and authors who work I have enjoyed. Feel free to forward those or other suggestions.
Saturday, November 17, 2007
Babson scores big! Welcome back, Len!
Babson College has scored a major coup in securing Len Schlesinger to be its new president. Len has superb business credentials, but he is also a top-notch educator and also has experience in university administration. He has been working in Columbus, Ohio, with Limited Brands for several years, and it will be great to have him back in Boston. Babson already has a strong reputation, but I am predicting that Len's tenure will bring the school to a new level.
Babson joins another local business school, Bentley College, which named Gloria Larson to be its president earlier this year, in inviting a person of great energy and savvy to be its next leader. While places like Harvard Business School and MIT's Sloan School often grab the prestige of being major academic business centers, these smaller, focused colleges do a great job in training business leaders. They also play an important role in local community economic development and civic roles, a role the bigger schools sometimes forget in their zest to be world leaders.
Babson joins another local business school, Bentley College, which named Gloria Larson to be its president earlier this year, in inviting a person of great energy and savvy to be its next leader. While places like Harvard Business School and MIT's Sloan School often grab the prestige of being major academic business centers, these smaller, focused colleges do a great job in training business leaders. They also play an important role in local community economic development and civic roles, a role the bigger schools sometimes forget in their zest to be world leaders.
Friday, November 16, 2007
Thursday, November 15, 2007
Reply from one of our doctors
People often ask me how our doctors feel about the things I post on this blog. The answer, of course, is as varied as our faculty, and -- trust me -- our faculty is not the least bit shy about letting me know how they feel. After I wrote a post on safety and quality a couple of weeks ago, one of our doctors wrote me the following note. I'd like to share it with you to get your reactions. Please understand that this is a world class clinician who is beloved by his patients and who has an exemplary record in safety and quality. So he is not saying we shouldn't be good at that, but he is saying something about how he thinks the hospital marketplace really works and what I should be emphasizing in public statements.
No one in their right mind could want anything but the safest possible hospital. But complex human organizations are inherently frail in the infallibility department. So while we have to work on this continually, we should not confuse that with "quality".
In the marketplace, people want the "best doctor". You will never hear anyone saying that they picked their doctor because the hospital he practiced at had a better safety record.
While we have to be excellent at safety, quality in the minds of the public is related to whether they think that the care they are getting from their doctor is the best. By this they mean, is the doctor practicing at the very highest level, making the right diagnosis, giving them access to the cutting edge and best therapies. Quality is not how many falls we have, because even though you and I know that the falls are dangerous and kill people, no one comes into the hospital thinking that they are going to fall.
If you make patient safety your acid test, you are not going to attract the kind of patients you need to stay in business. The difference, in the mind of the public, between quality and safety is huge. Quality means the medical care expectations. Safety is merely expected…until something goes wrong.
So, from my point of view, the emphasis at BIDMC has to be on quality, as in finding things that we are simply the best in the world at, and riding that wave.
No one in their right mind could want anything but the safest possible hospital. But complex human organizations are inherently frail in the infallibility department. So while we have to work on this continually, we should not confuse that with "quality".
In the marketplace, people want the "best doctor". You will never hear anyone saying that they picked their doctor because the hospital he practiced at had a better safety record.
While we have to be excellent at safety, quality in the minds of the public is related to whether they think that the care they are getting from their doctor is the best. By this they mean, is the doctor practicing at the very highest level, making the right diagnosis, giving them access to the cutting edge and best therapies. Quality is not how many falls we have, because even though you and I know that the falls are dangerous and kill people, no one comes into the hospital thinking that they are going to fall.
If you make patient safety your acid test, you are not going to attract the kind of patients you need to stay in business. The difference, in the mind of the public, between quality and safety is huge. Quality means the medical care expectations. Safety is merely expected…until something goes wrong.
So, from my point of view, the emphasis at BIDMC has to be on quality, as in finding things that we are simply the best in the world at, and riding that wave.
A letter of appreciation
This is one of those really heartwarming letters I receive. I know some of you might think it is just self-congratulatory pap when I post these kind of notes, but please recognize that part of my audience on this blog is our own staff, as well as our board members and other local supporters of our hospital, and I think it is it important for those beyond the particular people mentioned to see this kind of appreciation. As noted by the writer, when I asked him if I could publish it here: "Absolutely . . . on both accounts! As a teacher and healthcare provider, I know how exciting and rewarding it is when I get notes from patients and students!"
Mr. Levy,
You don't know me, but my wife recently spent 5 days in BIDMC to have a total mastectomy and breast reconstruction, and I wanted to take a moment to thank you for her excellent and passionate care, and to recognize the outstanding operations and culture evident in BIDMC.
All of our experiences at BIDMC, from our consults and surgery with Drs. Adam Tobias and Susan Troyan (and their staffs), to the nursing care provided in pre and post op recovery, to the nursing care provided to my wife during her recovery time (most notably from a young nurse from Tennessee named Rita W. -- we can't recall her last name, but she was on the 6th floor) were courteous, competent and caring . . . all of which made my wife's experience much more relaxing & assuring. With particular reference to Drs. Tobias and Troyan, our appointments were all on time, and we never felt rushed or "numbered" during the actual office visits . . . at all times, I felt like my wife was the only patient they had scheduled for those particular times, and the patient interactions were soothing and congenial. Obviously, we are also very pleased with the quality and expertise of the actual healthcare delivered too, as my wife is recovering well and her prognosis is excellent!
Incidentally, I just finished reading Jerome Groopman's book, How Doctors Think, in order to use it for one of my classes, and it was exciting and refreshing to see the measure that you have taken (and he mentions in depth) to reduce nosocomial infections in your hospital -- great to see literature in action!
Thanks again & best wishes for continued success.
Mr. Levy,
You don't know me, but my wife recently spent 5 days in BIDMC to have a total mastectomy and breast reconstruction, and I wanted to take a moment to thank you for her excellent and passionate care, and to recognize the outstanding operations and culture evident in BIDMC.
All of our experiences at BIDMC, from our consults and surgery with Drs. Adam Tobias and Susan Troyan (and their staffs), to the nursing care provided in pre and post op recovery, to the nursing care provided to my wife during her recovery time (most notably from a young nurse from Tennessee named Rita W. -- we can't recall her last name, but she was on the 6th floor) were courteous, competent and caring . . . all of which made my wife's experience much more relaxing & assuring. With particular reference to Drs. Tobias and Troyan, our appointments were all on time, and we never felt rushed or "numbered" during the actual office visits . . . at all times, I felt like my wife was the only patient they had scheduled for those particular times, and the patient interactions were soothing and congenial. Obviously, we are also very pleased with the quality and expertise of the actual healthcare delivered too, as my wife is recovering well and her prognosis is excellent!
Incidentally, I just finished reading Jerome Groopman's book, How Doctors Think, in order to use it for one of my classes, and it was exciting and refreshing to see the measure that you have taken (and he mentions in depth) to reduce nosocomial infections in your hospital -- great to see literature in action!
Thanks again & best wishes for continued success.
Wednesday, November 14, 2007
In memoriam: Sarah Wernick
I was saddened to read an obituary this morning about Sarah Wernick, a wonderful, intelligent, and funny person who was best known for writing books about women's health. In our family, though, Sarah was best known for leading my wife to a source of Valrhona chocolate. In fact, she found the place where you could buy the 5 kilogram size of this chocolate. Do you have any idea of how big an 11 pound piece of chocolate seems when it is being stored in your refrigerator? Or, how about 22 pounds, so we could have two varieties?
For this and so many other lovely reasons, we will miss Sarah and offer our condolences to her husband Willie and their sons.
For this and so many other lovely reasons, we will miss Sarah and offer our condolences to her husband Willie and their sons.
Tuesday, November 13, 2007
Dutch Treat
I just returned from a quick trip to Amsterdam where I was invited to speak at a session called "Health Care Innovation Event", a conference of the CEOs and other top administrators of many of the Dutch hospitals, along with the Dr. Ab Klink, Minister of Health, Welfare, and Sport. I am a little amazed by this -- and no, I am not being falsely modest -- but people are very interested in the quality and safety process improvement steps we have taken at BIDMC and also in our efforts at transparency on this blog and on our hospital's website. I am surprised because I think we are just beginning to tap the potential improvements we can make in this arena, and we consider ourselves as just learning how to do it well. Other hospitals, like those in the Ascension Health system and Cincinnati Children's Hospital, have been at it for a longer time and with greater results. Nonetheless, it is very nice to have a chance to explain our programs to others around the world and to meet really interesting and thoughtful people. Inevitably, I bring back more ideas than I impart.After the formal presentations in Amsterdam (at the amazing ING building!), we had break-out sessions during dinner. (They were very accommodating and made my table the sole English-speaking one.) During the sessions, the facilitator at each table was posting the table's comments in real time on video discussion boards spread around the room. It was like having a dozen simultaneous twitter sites going on! Later, the combined discussion board was used by the MC as a tool for reporting the major conclusions from each table.
By the way, the Netherlands has a very interesting and recently enacted insurance program for the country. This replaced the former system of government insurance. All people are required to have insurance and can purchase it from any of a number of private insurance companies. Some of these companies are for-profit and some are non-profit. There are about four large ones and over a dozen small ones. No company can refuse to provide coverage to any person. The annual cost of insurance is about 1000 to 1200 Euros. The government subsidizes the cost of insurance to people with low incomes. The insurance covers the full range of medical diagnostic and treatment services. You can also buy supplemental insurance to cover things like single rooms in the hospitals, cosmetic surgery, and the like.
Beyond this program of "cure" insurance, there is a separate government program for "care". This covers long-term care and other parts of the medical care spectrum that are essentially uninsurable.
I was told that the country as a whole spends 45 billion Euros on health care for these two types of coverage, for 16 million people -- or about 2800 Euros per year per person. With the "cure" portion amounting to 1000 to 1200 Euros per person, that leaves 1600 to 1800 Euros per year for the "care" portion.
The hospitals are non-profit, like most in the US. Interestingly, payment for services rendered is not generally based on the kind of diagnosis specific ("DRG") system we have in the US, although there is a movement in that direction. There is actually very little documentation -- for billing purposes -- of the services rendered. Either doctors are on salary or the billing is based on a simple count of those patients coming through. That's one way to reduce administrative costs. On the other hand, as was pointed out at our meeting, this means that there is very little accountability for the choice and efficacy of the clinical procedures actually undertaken. A person at our table suggested that Holland should move more to the US reimbursement system to hold providers more accountable. This was met with mixed reactions, as people understood that this would add administrative costs to the system.
Monday, November 12, 2007
Patient in my own hospital
Two stories about being a patient in my own hospital.
(1) I am really lucky to have a primary care doctor who knows how to protect me, as president of our hospital, from our well meaning doctors. Why do I need protection? Well, because the specialists are really proud of their work and want to use any malady that I have to show me their stuff. My doctor knows how dangerous this can be!
A few years ago, I signed up for an ocean kayaking trip in Patagonia. This was to entail pretty strenuous outdoor living and paddling all day long for two weeks. The program therefore required a physical exam and recommended a stress test for those over a "certain age." So I asked my PCP to order one.
She says, "No. I refuse to order a stress test for you."
"Huh?", I reply intelligently.
"Here's the deal," she says. "If I order the stress test, our especially attentive (knowing who you are) cardiologist will note some odd peculiarity about your heartbeat. He will then feel the need, because you are president of the hospital, to do a diagnostic catheterization. Then, there will be some kind of complication during the catheterization, and you will end up being harmed by the experience."
"But the reality is that whatever peculiarity he might find in your heartbeat has probably existed for decades, or your whole life. There is no history of heart disease in your family. You ride 100 miles per week on your bike and play and referee soccer for hours every week, and you have never had a symptom that would indicate a circulatory problem. Therefore, I will not authorize a stress test."
"Yes'm," I dutifully reply.
(2) A few years ago, I had a routine colonoscopy, and the GI doctor clipped off a couple of polyps and sent them to the lab for analysis. Standard practice to see if they are pre-cancerous.
Three days later, I am walking to work next to one of our pathologists down a very busy Longwood Avenue. I say, "Good morning. How are you?"
He quietly replies, "Fine, and so are you. I did your histology yesterday. No problems. Have a pleasant day."
(1) I am really lucky to have a primary care doctor who knows how to protect me, as president of our hospital, from our well meaning doctors. Why do I need protection? Well, because the specialists are really proud of their work and want to use any malady that I have to show me their stuff. My doctor knows how dangerous this can be!
A few years ago, I signed up for an ocean kayaking trip in Patagonia. This was to entail pretty strenuous outdoor living and paddling all day long for two weeks. The program therefore required a physical exam and recommended a stress test for those over a "certain age." So I asked my PCP to order one.
She says, "No. I refuse to order a stress test for you."
"Huh?", I reply intelligently.
"Here's the deal," she says. "If I order the stress test, our especially attentive (knowing who you are) cardiologist will note some odd peculiarity about your heartbeat. He will then feel the need, because you are president of the hospital, to do a diagnostic catheterization. Then, there will be some kind of complication during the catheterization, and you will end up being harmed by the experience."
"But the reality is that whatever peculiarity he might find in your heartbeat has probably existed for decades, or your whole life. There is no history of heart disease in your family. You ride 100 miles per week on your bike and play and referee soccer for hours every week, and you have never had a symptom that would indicate a circulatory problem. Therefore, I will not authorize a stress test."
"Yes'm," I dutifully reply.
(2) A few years ago, I had a routine colonoscopy, and the GI doctor clipped off a couple of polyps and sent them to the lab for analysis. Standard practice to see if they are pre-cancerous.
Three days later, I am walking to work next to one of our pathologists down a very busy Longwood Avenue. I say, "Good morning. How are you?"
He quietly replies, "Fine, and so are you. I did your histology yesterday. No problems. Have a pleasant day."
Diagnostic skills
A friend who is a primary care doctor once told me that 85% of the symptoms that he sees in patients don't matter. They will simply go away over time. Jerry Groopman notes the same in his book How Doctors Think (on page 100): "Nearly all of the complaints patients describe to their primary care physician, such as headache, indigestion, and muscle pain, are of no serious consequence."
This makes it all the more impressive when a PCP has the diagnostic skill to notice the symptoms that do matter. This is especially the case for pediatricians, who often have to rely on noncommunicative patients and parents' descriptions of their child's symptoms. Two stories of this ilk follow.
A baby and mom go to visit the pediatrician for a "well child visit" several weeks after the child's birth. Everything seems normal, and the visit is about to end. The doctor closes with one last question: "Is there anything you have noticed about Sally that has you curious or concerned?" Mom replies, "Well, I notice that she sweats a lot while nursing." Alarms go off for the doctor, who suspects a problem and orders tests. It is found that the child has a rare heart defect that prevents proper blood flow, particularly during the somewhat strenuous nursing activity. Cardiac surgery is undertaken, and the baby is fine, avoiding major complications that might not have showed up till years later.
Another child, a two year old girl, returns to the PCP with the second urinary tract infection ("UTI") in as many months. Alarms go off for the doctor. After assuring herself that the parents are using proper sanitary practices during diaper changes, she orders a test of urinary function that indicates reflux of urine from the bladder back to the kidneys. The little girl's ureters are not properly implanted in the bladder, permitting backflow. The pediatrician notes, "I've seen too many teenage girls with kidneys damaged from years of undetected reflux and persistent UTIs." After several months of prophylactic antibiotics to see if the girl will outgrow the problem, she undergoes surgery in which the ureters are re-implanted, and the UTIs stop.
This makes it all the more impressive when a PCP has the diagnostic skill to notice the symptoms that do matter. This is especially the case for pediatricians, who often have to rely on noncommunicative patients and parents' descriptions of their child's symptoms. Two stories of this ilk follow.
A baby and mom go to visit the pediatrician for a "well child visit" several weeks after the child's birth. Everything seems normal, and the visit is about to end. The doctor closes with one last question: "Is there anything you have noticed about Sally that has you curious or concerned?" Mom replies, "Well, I notice that she sweats a lot while nursing." Alarms go off for the doctor, who suspects a problem and orders tests. It is found that the child has a rare heart defect that prevents proper blood flow, particularly during the somewhat strenuous nursing activity. Cardiac surgery is undertaken, and the baby is fine, avoiding major complications that might not have showed up till years later.
Another child, a two year old girl, returns to the PCP with the second urinary tract infection ("UTI") in as many months. Alarms go off for the doctor. After assuring herself that the parents are using proper sanitary practices during diaper changes, she orders a test of urinary function that indicates reflux of urine from the bladder back to the kidneys. The little girl's ureters are not properly implanted in the bladder, permitting backflow. The pediatrician notes, "I've seen too many teenage girls with kidneys damaged from years of undetected reflux and persistent UTIs." After several months of prophylactic antibiotics to see if the girl will outgrow the problem, she undergoes surgery in which the ureters are re-implanted, and the UTIs stop.
Saturday, November 10, 2007
Where does that money go, anyway?
Several months ago, I related the sad story that resulted from the merger of the New England Deaconess and Beth Israel Hospitals in the mid-1990s. Fortunately, the troubled times are behind us, and BIDMC has been quite successful in providing clinical care, conducting research, and offering training to the medical professions. Along with that success has been financial progress. The millions of dollars in operating losses have been turned around to show operating surpluses. This trend is seen in Chart 3 above. (The numbers for fiscal year 2007 will be available in several weeks, after the annual audit is well under way.)Since we are non-profit, these gains do not go to stockholders. They are plowed back into the hospital in the form of investment in buildings, facilities, and equipment to provide patient care and carry out research. Every year, we have to replace aged plant and equipment and also investment in new technology to provide the highest levels of care.
During the period of financial turn-around, we intentionally underinvested in the hospital because we needed money to meet the payroll and other operating expenses, and we knew we would not generate enough margin to cover all the capital needs. So we fell behind each year. One way of measuring this is shown in Chart 1, where I compare the amount spent on capital each year compared to annual depreciation. If you look at the bars below the line, you can see the cumulative amount we fell behind in the early years. Later, when earnings improved, we were able to increase capital investment and begin to catch up. By this year (fiscal year '07) we had caught up on the previous years' deficiencies, based on this metric.
But, as anybody in health care will tell you, if you just invest an amount equal to depreciation, you are falling behind. This is because depreciation is based on the original cost of plant and equipment, not replacement cost. If you consider the current costs of buildings and equipment, you need to invest much more than depreciation to stay even, much less get ahead. In Chart 2, I show how our cumulative capital spending during this period has compared to 130% of depreciation -- a number that is at the low end of desired investment for major facilities like ours. On this chart, you can see that we are still catching up for those bad years. It will take several more years of very good earnings to get current.
Our hope is to continue to make a healthy operating margin to renew and refresh old buildings and equipment and also invest in needed expansion both at BIDMC and our Needham affiliate. The demand for our clinical services continues to grow, and we need have adequate facilities to meet our obligations to the public. To answer the question posed in the title, that is where that money will go. But we are also very cognizant of the importance of balancing capital requirements against the very real needs of our staff -- in terms of salaries and benefits and career advancement opportunities and appropriate staffing ratios. It doesn't do you much good to invest in capital if you don't also invest in people. So, we do the operating budget first, based on staff needs and quality and safety requirements. It is the margin available after that which is available for capital investments.
Friday, November 09, 2007
Equal time
I don't want the post below to be the cause of sibling rivalry, so here is the Boston Globe announcement of my other daughter's dance concert in Cambridge, MA this weekend.
Thursday, November 08, 2007
The birth of a winemaker
To share the adventures of a young winemaker, please visit this site by my daughter Syrah or Petite S'ra (formerly known as Sarah). I recommend the movie, as well as earlier postings. She sent the following message to me after I asked if it was all right to post a story on this health care blog and was granted permission:You might even preface with a note that wine has always been tied to health and medicine. Researchers may change their minds every day about whether red wine will lower cholesterol, prevent heart disease, increase longevity, raise IQ scores or do the reverse, but the simple truth is that wine makes people happy, which is a key part of being healthy. You might further tell your readers that a case of my Zebra Wines (to be released in 2008) will make them exceedingly happy, and therefore at peak health.
Partnership for Healthcare Excellence
Speaking of consumer health care information (see below), the Partnership for Healthcare Excellence has started an ad campaign and a website designed to help create more effective and informed patients. As a new organization, they are very interested in getting feedback, so please take a look and see if their approach and information is helpful to you.
Subscribe to:
Posts (Atom)
