A different approach to malpractice

A Facebook friend from New Zealand, Marie Bismark, writes:

I enjoy reading your blog and was greatly impressed with the honesty and openness of your response to the wrong site surgery incident. As always, my first thoughts are with the patient - and I trust that your hospital has found a way to meet the needs of patients who suffer such injuries without needing to engage in adversarial legal proceedings.

I've always felt very lucky to live, and practice medicine in New Zealand, where issues of compensation are dealt with quite separately from issues of professional and organisational accountability. All patients who suffer a treatment injury caused by medical care are eligible for no-fault, government funded, compensation (with no need to prove negligence). Claims are usually decided within a matter of days, and the package of care includes financial compensation as well as free treatment, rehabilitation, home help, childcare, and so on. As part of a separate process, a health ombudsman can inquire into the quality of care that was provided and make recommendations for systems improvement, further staff training etc.

Not likely to happen here, I'd guess, given the political influence of lawyers and a strong desire on the part of many to insist on financial or other punishment as a form of recompense. (A timely coincidence: See the sentence used in the noun example on Wiktionary to help define "recompense".)

Blogs are like muffins

Check out this recent conference, entitled, "The Health Blogosphere: What It Means for Policy Debates and Journalism," sponsored by the Kaiser Family Foundation on July 29. Lots of interesting stuff. But my favorite quote is at minute 54:35 from Tom Rosenstiel, Director of the the Project for Excellence in Journalism:

When I think of blogs, I think blogs are like muffins They range from everything from bran to chocolate cake. They are more of a shape than they are defining a particular kind of content.... They put you in the conversation, and tonally there is a similarity to blogs.... Similarities pretty much end there.

Pump TV

On June 30, I told you about our plans to solve the pump problem using the principles of BIDMC SPIRIT. We decided to document this problem-solving process with a home-made video. Here's the first of these videos, which presents a pretty good description of some of the problems and the perspectives of a lot of people working here. I am betting that those of you who work in other hospitals will watch this and think we filmed it at your place! Stay tuned as we work through this.

Waiting for Labor('s) Day?

Several months ago, I mentioned the large sum of money being spent by the SEIU on political races throughout the country. Now, an editorial in the Wall Street Journal questions the legality of the manner the SEIU is collecting these funds from its members. (By the way, the sum I mentioned was $75 million. The WSJ raises this to $150 million.)

I am not qualified to make a judgment on the legal issues raised by the Journal editorial writer, but I want to raise a related political issue. SEIU concludes one of its publications with the following depiction of the future: SEIU's health care profile -- and power -- will only continue to grow. After we help elect a pro-worker president and stronger pro-worker majorities in Congress, we will take all our energy, idea, organizing strength, grassroots lobbying and political muscle and make it happen. Next year, 2009, we -- all of us -- will make history. We will achieve quality affordable health care for every man, woman, and child in America.

Well written, for sure, but nowhere in the document does the SEIU mention a very specific and important part of its legislative strategy -- to change the federal law to eliminate the right of workers to vote on whether they want to have a union. The so-called Employee Free Choice Act would undo the long-standing practice under the National Labor Relations Act that provides for an election among the workers to decide if they want union representation.

Here is a story by Kevin Drawbaugh from the Washington Post last year, when the bill was considered by Congress. It appears that the two major Presidential candidates disagree about this bill, but thus far, this issue has not received much coverage or commentary. This is perhaps understandable at this stage in the campaign, but it will be very interesting to see the public's reaction if and when the question is raised in debates and elsewhere as the campaign heats up after, er, Labor Day.

BIDMC expansion plan

I can now divulge that there is substance to the rumors about BIDMC expanding its service territory to Alaska. Here's one of our recruits at a sled dog farm, arranging patient transport services that are appropriate in parts of that state.

Caring provides its own reward

A note from a relative of a patient who made special mention of the fact that he would like for this praise to get wide exposure. Here's the story:

This is a simple thank you for the wonderful job done by some pretty special people at your hospital. Forgive me if I don't get all the names right but I think that it is important that these people to be recognized.

My father was admitted Sunday thru the emergency room last in very serious condition. I won't go in to details of what was wrong, you have the records, but he was extremely critical. I was told about this while I was in Florida and called the hospital ER. I was gently told about his status by a nurse (I think Stacey) and reassured that while very serious, he was alive. We spoke at least 5 or 6 times that day, and each time she was patient with my questions and honest in her answers. Finally I spoke to Dr. Sonnerman who was again very truthful about the situation but in a way that really assured me that my father had a chance of surviving and would be transferred up to MICU as soon as possible.

I guess it was Monday that he did get up to ICU and again the level of honesty and compassion from everyone that I spoke with, nurses and doctors was incredible. I think ICU nurses are a special group of people anyway, and the group that worked with my father was great. Nothing is scarier than being out of town, unable to get to the sick one and having to work THROUGH people. The team includes nurses Pat, Kerry, Dr. Adelman and Dr. Lippincott and Dr. Gillman. Each and everyone one of them was really terrific in communicating what was going on. But there are always people on a great team that seem to rise even above everyone else and should be recognized as the best of the best. Those two are Dr. Howell and one of the ICU Nurses -- Stephanie. I say they were the best not because they helped save him (in fact he passed away last night) but because they made the last days of his life incredibly easy for my father and those of us that loved him.

Dr Howell was straightforward and honest in the description of my father's illness and prognosis. It's not easy for anyone, doctor or not, to sit face to face and lay out the facts of the sickness and the possible choices for us to make on treatment (or, in fact, nontreatment). Dr Howell did this clearly and with compassion. And even if not able to take my call when I want in the hospital always returned the call. You can tell great companies by their great management. I guess the same is true in a hospital department. MICU is special.

Now to the one single person that made me feel compelled to write this note -- Stephanie! (Sorry that I don't know her last name but she was my father's ICU nurse the last two days of his life). First of all, she helped ME. I had my father's living will and definitely knew his wishes. Quality of life was the important thing and to be treated to be able to live a little while longer, or to be in bed for months etc. was not what he wanted. But even knowing that, I knew Saturday when I was going to meet Dr. Gillman and tell him what the plan was, it would be very hard for me to say that my father would rather die than to live an unknown time in machines or in pain. But when I spoke to Stephanie in the morning she had already had a conversation with my father, and he had told her in no uncertain terms his wishes. He was lucid and coherent and was able to speak. So when I got to the hospital, my father repeated his wishes of no treatment, no needles no surgery, but he wanted to be as pain-free as possible for the time he had left.

When I saw my father for the last time Sunday morning, he had deteriorated, and it was pretty certain he would pass in the next 24 hours. I left for the trip back to NY. Stephanie called me twice during the day to say he was resting comfortably and they were increasing the pain killers and keeping him off the ventilator longer. When she called me to tell me he had died at 6:12 pm (she called about 10 -15 minutes after that) she was so compassionate and caring that I felt as sorry for her as I felt for me. She only knew my father a couple of days yet seemed to know more about him and care about him dying peacefully than others that had known him for years.

One should never have to go to a hospital as either a patient or visitor. But if one has, to they should be lucky enough to be taken to BIDMC and meet the people that I met last week. I hope they are in some way rewarded and thanked for their work. Thanks.

I take the chance of saying that their reward comes from knowing they were helpful. They have truly felt your thanks. I add mine to you for sharing this story.

More gelato

My soccer buddy Eduardo, founder of Giovanna Gelato, has two more gelato and sorbet tastings this week. I heartily recommend the grapefruit sorbet, but also the orange and lemon sorbet. And, passion fruit and strawberry, too. All made from fresh ingedients. But then, too, there are the gelati themselves -- coffee, chocolate, pina colada. Ah, choices in life are very, very difficult.

Today between 4:00 pm and 7:00 pm at:
Kurkman's Market Company
227 Cypress Street
Brookline, MA 02445

Saturday, August 2 between noon to 2:00 pm at:
Volante Farms
1 Central Street
Needham Heights, MA 02494

Changes at Longwood

Two items that are emblematic of the constantly changing landscape in the Longwood area of Boston -- home to BIDMC, the Joslin Diabetes Center, Brigham and Women's Hospital, Dana Farber Cancer Institute, and Children's Hospital Boston -- not to mention several colleges, schools, museums, and religious institutions.

The 1873 brick building is at the corner of Longwood and Brookline Avenues, and I wanted to document its nice detail and placement before it is razed in the coming weeks to make way for a new research building for the Joslin and other tenants. People in the neighborhood knew it mainly as the home of a Rebecca's Cafe, but as its age suggests, it has been a fixture for well over 100 years.

The glass and steel structure is the new Center for Life Sciences, on Blackfan Circle, which will house several hundred thousand square feet of research space for BIDMC, Dana Farber, and Children's and perhaps others. It is built on land previously owned by the Judge Baker Children's Center and BIDMC. You can see in its windows reflections of the Harvard Institutes of Medicine and the HMS New Research Bulding, and just visible in the background is a small portion of Merck's Boston research laboratory. Actually, Blackfan Circle should be renamed, because it no longer ends in a cul-de-sac, but is actually a full-fledged street that nicely divides the superblock bounded by avenues Brookline, Longwood, Louis Pasteur, and the Fenway.

Outer Cape Frogs

More lessons learned from switching sides

On May 16, I posted a letter from one of our staff people that generated many comments. Today, the original author of that letter offered a follow-on comment on that entry, and I re-post it here for you to see.

I am the BIDMC employee that wrote the original email to Paul about "switching sides". My mother died a few weeks ago, and today I went to see my mother's favorite nurses to give her a bracelet that I had given to my mother during one of her hospital stays to "brighten up her hospital jonnie." It was a very emotional moment for me, but she was the person that I thought of every time I looked at that bracelet. This is the nurse had been with us since her diagnosis and had made a poster for my mother to "fight hard" while she was on vacation. She was the nurse who helped move my mother off of her bed sore when her nurse that day said she needed to finish her lunch (truly the minority at BIDMC). This is who I think of when I recollect the people who took care of my mother.

All I can say, is that after a two month stay in a long term care facility, BIDMC is doing a phenomenal job, and their dedication to caring for patients and trying to get better every day at it cannot be challenged. The same issues exist throughout our health care system, but the difference is that BIDMC leadership cares. My mother's long term care facility was for-profit, and although the individual nurses and aides tried very hard to care for her, the resources just did not exist. I compared her nurses to flight attendants as they walked up and down with their medication carts distributing drugs. They had no time to be nurses. In addition, we did not receive any hospice assistance until three days prior to my mother's passing and this was because a family friend knew a hospice nurse; had I requested hospice care, my mother would have been transferred from covered under Medicare to not being covered at all, other than a hospice consultation to the family. What is right about that?

My mother died in peace. I know she is in a better place. This experience had been extremely eye opening for me. I continue (from my first day at BIDMC) to be proud to work here, but will always strive for communication, communication, communication.

A tale of one city

Two illustrative stories about health care in today's Boston Globe, with stories by Kay Lazar and Jeff Krasner. While various interest groups squabble about the perceived zero-sum game of who is going to pay for the costs of the health care in Massachusetts, new entrants to the region find a way to gain market share in a small segment of the sector by delivering services at a lower cost.

The problem with the health care "marketplace" is that it is not a real market. There are so many intermediaries that the usual connection between buyer and seller that we see in other fields does not exist. Thus, the incentives for suppliers (doctors and hospitals) to engage in efficiency improvements and value enhancement are extremely slow to emerge. Also, the incentives for consumers to seek greater quality and lower costs likewise are very weak in this field. (This is aggravated, of course, by the lack of transparency about relative quality of providers.)

Then, we overlay on that the fact that government sponsored programs, Medicare and Medicaid and other state subsidized insurance plans, are ruled by administrative fiat and competing political agendas, and we see that over 40% of the delivery of health care is not subject to market influences at all. One result there is the focus on quick fixes that have headline value (not allowing payment for "never" events, for example) that only cover an infinitesimally small portion of the problem but do not address underlying structural problems. Another result is political battles focused on splitting the pie differently but not making the pie the right size or more tasty.

For those of us in academic medical centers, the result will be a gradual whittling away of financial support for the type of clinical care, research, and education for which we were created. We have already seen it on the research side, with cuts at NIH. I predict the next focus in Congress will be on Medicare funding for graduate medical education (residency training).

I have tried to make the point here and in my public appearances that unless academic medical centers prove their value to society as centers for quality and safety improvement and enhancement of operating efficiency in hospitals, the inevitable political response to our pleas will be, "What have you done for me lately? You are the highest cost portion of the health care system, and yet you display no leadership in modeling the kinds of changes we need for it to be sustainable over time."

Ditto, by the way, for the medical schools. When will the thoughtful deans of our medical schools take on the concept of introducing the science of care delivery as a major focus of the curriculum, so that their faculty and new generations of doctors come to believe that field to be as interesting as the study of disease, diagnosis, and therapies? The opportunity exists for leadership opportunities for those universities that pave the way in this arena.

Then, imagine hospitals and medical schools doing this together! As Arlo Guthrie suggests, "Friends, they may thinks it's a movement."

Absent that commitment, the health care agenda will be set by interest groups who will self-interestedly squabble over the distribution of the pie and/or seek commercial advantage by cream-skimming profitable sectors of the health delivery system. Political officials, meanwhile, will follow the votes in setting legislative and administrative agendas. The major institutions that are the crown jewels of the American medical system and were created solely to serve the public good will be, at best, participants in the squabble, and, at worst, passive observers whose assets and programs and influence are slowly but inevitably diminished.

Bike Fridays in Boston, plus Hub on Wheels

A note I am passing along from the City of Boston's biking czarina, Nicole Freedman:

RIDE INTO WORK WITH A POLICE ESCORT.
July 25 and August 22

WHAT: SAFE, GUIDED CONVOYS WITH POLICE ESCORT Lead by experienced cyclists and escorted by Boston Police, convoys follow a fixed schedule and route and originate at locations throughout metro-Boston. All convoys finish at City Hall Plaza Boston.

FREE BREAKFAST, BIKE EXPO AND MUSIC Whether you ride in with a convoy or ride along, join us at Boston City Hall for free food and fun, courtesy of 100.7 WZLX, Mass Commute, Mass Bike, and all our sponsors.

More information here.

And get ready for this year's Hub on Wheels on September 21. A great day to explore Boston neighborhoods on your bicycle. We are pleased to be sponsors of the event and provide first aid at stations along the route.

Management 101, 201, 301, and 401

I've seen and read lots of business books that ostensibly have significant insights into the role of management, but here in one sentence is the best summary I can think of. It comes from Dr. Stuart Rosenberg, who is CEO of our faculty practice, Harvard Medical Faculty Physicians at BIDMC:

"The only role of management is to create an environment where people left to their own devices and unsupervised are most likely to engage in behavior that advances the goals of the organization."

He elaborates in a second sentence:

"That means that people have the training, equipment, space, motivation, pay, understanding of expectations, sense of fulfillment and joy, and all the other things that will ensure that their behavior, the only thing that counts, is what we desire for the organization."

(Just as a reminder for those unfamiliar with makeup of many academic medical centers, HMFP is a separate corporation from BIDMC (the hospital), and it serves as the employer for the physicians on our faculty. Stuart therefore is a peer to me, the hospital CEO, and the two of us and our organizations must work with a great sense of interdependence and collaboration to create joint success. I feel very lucky to have a partner of his caliber as we carry out our public service mission together.)

A picture is worth . . .

With the ubiquity of picture-taking cellular phones and digital cameras, patients and visitors to our hospital have a new -- and very effective -- tool with which to report problems in the hospital. Here is an email note I received from one of our regular guests and its accompanying photos.

Here are a couple of photos from the radiology changing area suggesting that upkeep could be more professional. The first is locker instructions that have long since seen better days (as a result of which two other patients I overheard were having trouble making the locks work). The second suggests that when somebody mounted a new mirror on the changing room wall, they forgot to wipe its birthmarks off it. :)

BTW, all three radiology people I dealt with today were great.

Please note that it is a violation of our rules to take photos of any people. Actually, strictly speaking, it is against our rules to take photos at all in public and patient care places, unless someone has permission and is accompanied by an appropriate member of our staff. HIPAA makes us very sensitive to the possibility that someone will inadvertently or intentionally take a photograph of a patient and in so doing violate his or her privacy by distributing the picture publicly or privately. But as these photographs indicate, technology has made it virtually impossible to enforce that kind of rule. We therefore depend on people to be very careful with how they use what is easily available to them. In this case, I have to admit that I kind of like what happened. The photographs made the nature of the problem very clear and enabled me to seamlessly pass along the suggestion to our staff.

(Blogger formatting note: I post these columns on the Firefox internet browser, as the formatting of text and pictures seems to work best there. When you view the same post on certain versions of Internet Explorer, there is often a problem with the display of the text nearby the photograph. Sorry about that. I haven't figured out a solution to that problem. And now that Bill Gates has left Microsoft, I have no personal (hah!) connection there to resolve the issue.

Wrong math

I have great respect for Jim Stergios and the Pioneer Institute he heads. The Institute has been an important force in Massachusetts public policy debates for many years. But I think Jim has the wrong policy prescription in an op-ed published in today's Boston Globe.

Citing the higher than expected costs of the Massachusetts Healthcare Reform Act of 2006, Jim proposes that there should be a reduction in payment to Boston Medical Center and Cambridge Health Alliance, the two largest hospital providers of care to the poor in the Boston metropolitan region. To be fair, Jim is not the first to propose this. Over the years, there have been periodic attacks on BMC and CHA for their special payments. Several years ago, for example, many of the community hospitals complained that they were subsidizing these urban safety net facilities.

Beyond ignoring the history of these hospitals in our city and the special role they play in the health care system, Jim's proposal puts the focus of the financial problem in the wrong place.

The reason for the higher than expected costs of Chapter 58 is pretty simple. The costs were underestimated at the start. More people than expected signed up for state-subsidized health insurance. And, lo and behold, once people had insurance, they actually used it for medical care. The actuarial estimates of the dollars per person covered were wrong.

That does not suggest that the Act was ill conceived. Not at all. It was a law designed to provide greater insured access to health care. The theory, which will play out over time, is that people with insurance will make better use of primary care and will have better health over time than when they would wait until they were really sick and show up at emergency rooms. But in the meantime, for example, those poor women who had not had mammograms in 20 years will now have them, and some percentage will be diagnosed with breast cancer and will begin treatment. In short, it is entirely reasonable to expect a bulge in health care costs among the population that previously did not have insurance.

If we want to keep this new system in place, there are only three sources of revenue for these costs: The taxpayers, the insurance companies and through them their subscribers, and the hospitals. None of these have tremendous political support, and there will be interesting political debates and compromises on Beacon Hill as this is figured out. I am afraid, though, that Jim has mistakenly chosen to avoid the first two and then focused his solution on a subset of the last one.

Guide to Just Decisions About Behavior

To follow up on our conversations below about punishment and discipline following medical errors, we have been experimenting with the scale above as a guide. Let me know what you think about it, particularly the gray area in the middle in which case-by-case discretion is employed. (If you click on the image above, your computer will make it larger and you wil be able to read the categories more clearly.)

Did you do this on purpose?

My post below and a similar one of the Wall Street Journal Health Blog have engendered a lot of comments about punishment after medical errors. The discussion is important and is not yet complete. Let's expand on the topic here.

Thanks to Don Berwick from IHI who referred me to a recent article by Dr. Charles Denham, entitled "May I have the envelope please." (Journal of Patient Safety. 2008 Jun;4(2):119-123.) Chuck relates the marvelous approach to error used by Jeannette Ives-Erickson at the Massachusetts General Hospital. When there is a screw-up in nursing, she calls the involved nurse into her office and asks one question: “Did you do this on purpose?” If the nurse answers, “No,” then Jeannette says, “Well then it is my fault.... Errors stem from systems flaws.... I am responsible for creating safe systems."

As Tom Botts mentions below and as Chuck reinforces in his article, "When we push the envelope in health care, senior leaders and many clinician often never know about the adverse events because these events are often hidden and masked by the complexity and fragmentation of care.... We automatically fall in a name-blame-shame cycle citing violated policies and ignore the laws of human performance and our responsibility as leaders."

Turning back to Ives-Erickson, Chuck notes, "In a few short moments with a caregiver after an accident, the leader declares ownership of the systems envelope, and the performance envelope of her caregivers, and creates a healing constructive opportunity to prevent a repeat occurrence."

Recognizing that the comments made on this blog and the WSJ blog may or may not be representative of the general public, I was nonetheless impressed by the degree to which people felt that punishment was an essential part of process improvement. It also occurred to me that the easy path for a hospital administrator in this kind of environment would be to punish the wrong-doer, bolt on a new process, protocol, procedure, or requirement, and declare the problem solved. After all, that shows decisive and timely leadership.

There's only one problem. That doesn't work. Or if does, only for a short time or until a new glitch is uncovered.

Many of the comments show to me the level of dissatisfaction with and anger about the health care system in general, and perhaps also individuals' experience with certain "god-like" physicians. But, if those admittedly understandable emotional reactions guide our approach to process improvement, we will not make the kind of progress we need.

Lee Carter, chairman of the board at Cincinnati Children's Hospital -- a national leader in the quality and safety movement -- put it in elegant, all-American Midwest terms: Transparency depends on TRUST....trust that one can report an error without getting whacked. I absolutely agree with your blog in both the lack of punishment for this event and reserving the right to punish for events in the future. If punishment were to be meted out, it should be spread to everyone in the OR who didn't call for a time-out. The point is that it wasn't only the surgeon's responsibility. This is what we are working very hard to spread throughout Cincinnati Children's and we are making slow progress.

Think about it. One of the national leaders says that his place is making slow progress. Let's learn from that. Let's not let our own impatience with the errors that occur cause us to leap to a type of solution that appears easy and direct but that is fundamentally flawed.

Wellfleet Bay birds

My wife just returned from a digital nature photography course at the MA Audubon Society Wellfleet Bay Wildlife Sanctuary. Included in her now much larger portfolio are the red-winged blackbird and kingfisher seen above.

How did they do that?

The Pharm Animals, a softball team representing the BIDMC pharmacy department, pose in front of "their" team sign on the Green Monster after a softball game at Fenway Park yesterday.

Behind the Green Monster

Ever wondered what it looks like in the space behind the Green Monster at Fenway Park, where the scorekeepers sit? Here's a view through a crack in the wall. Each number weighs about five pounds, so those guys are tired by the end of the game from changing all the scores, not only for the Red Sox game being played, but for every other American League and National League game going on, too.