Googling around

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

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

Upload your records
Make an Appointment
Securely Email your Clinicians

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

John further notes:

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

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

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

Volunteers (and others) rule!

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

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

Newsflash! NYU degrees devalued.

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

Paintings in Lincoln

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

Costs, costs, costs

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

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

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

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

Grand Rounds is up at Scienceroll

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

Greetings!

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

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

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

How things don't get fixed

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

Note to me from a friend of a friend:

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

My reply:

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

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

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

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

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

Note to ABC from me:

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

The IS person's reply to my query:

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

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

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

Reply from AD, to me alone (!):

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

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

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

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

Dear All,

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

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

Return visit with a surprise lesson

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

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

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

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

The SPIRIT lives on

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The afternoon was really long.

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

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

Public? Private? Either? Both?

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

Private health? World Class Care.

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

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

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

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

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

The Mutating Playbook

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

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

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

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

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

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

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

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

London subway map

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

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

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

A natural!

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

The old and the new

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

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

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

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

An open letter across the sea

Dear friends,

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

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

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

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

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

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

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

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

Gratefully,

Paul

#3 in the world

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

Good morning, London!

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

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

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

Central MA nostalgia: Dubbleyokas

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

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

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

And thanks for listening to me.

Fundraising on Facebook

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

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

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

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