Bispebjerg Hospital -- A place in history

Here is a touristic Copenhagen interlude, although with a medical tilt, thanks to a tour given by Dr. Peter Skanning. The site we will discuss is Bispbjerg Hospital, built between 1907 and 1913, with a marvelous layout of buildings and gardens. I present more on the architect, Martin Nyrop (1849-1921), and the architectural features in the post below. Peter is an anesthesiologist who runs the hospital's poison center, but he has a strong interest in architecture and history, and he kindly gave me and others an extensive tour.

Let's start with the history lesson. After the Nazis took over Denmark, they tried to round up all the Jews to send them to concentration camps. The people at this hospital played a special role in foiling that attempt. Here's an excerpt from one presentation:

In September Hitler approved the deportation of the Danish Jews. Werner Best of the SS, Hitler's chief in Denmark, received the final order to proceed with deportation of Jews to death camps, on Sept.28, 1943. The Nazis were prepared to deport the 7,500 Jews, starting at 10 PM. on Oct. 1, 1943. Georg F. Duckwitz, a courageous German maritime attaché and Best's confidant, at great danger to himself leaked out the order to a leading Danish Social Democrat, Hans Hedtoft. Hedtoft later recalled:

"I was sitting in a meeting when Duckwitz asked to see me. 'The disaster is going to take place', he said. 'All details are planned. Your poor fellow citizens are going to be deported to an unknown destination'. Duckwitz's face was white from indignation and shame."

According to Duckwitz, 1 October was set as the zero hour and Hans Hedtoft immediately warned C.B. Henriques, the head the Jewish Community, and Dr. Marcus Melchior, the acting chief Rabbi of the Krystalgade Synagogue.

On September 29th, two days before the projected round up on Rosh HaShannah, the Jewish New Year, Dr. Marcus Melchior implored his stunned congregants and the whole Jewish community to go into hiding immediately.

Two German passenger ships, docked in Copenhagen’s port, were ready to ship approximately 5,000 Jews to Germany on their way to kz camp Theresienstadt. Buses were to take the remaining 2,500.

The word was passed and the Danes responded quickly, organizing a nationwide effort to smuggle the Jews by sea to neutral Sweden. The Danes dropped everything to help family members, neighbors, or friends and offered their support, conveying warnings and finding places for the Jews to hide. The Danes felt that persecution of minorities was a breach of Danish culture and they were not prepared to stand for it. From all strata of Danish society and in all parts of the country, clergymen, civil servants, doctors, store owners, farmers, fishermen and teachers protected the Jews.

Dr. Koster, who was in charge of Bispebjerg Hospital, was instrumental in arranging for hundreds of Jews to be hidden at the hospital before they made their escape to Sweden. The psychiatric building and the nurses' quarters were filled with refugees, who were all fed from the hospital kitchen. Virtually the entire medical staff at the hospital cooperated to save Jewish lives. Once it became known among Danes what the hospital was doing, money was donated from all over the country. The Danish police and coast guard also took sides with the oppressed by refusing to assist in the manhunt. To make their escape, many refugees were driven to the coast in ambulances belonging to the hospital.

One reason it was possible to hide all these people is the layout and architecture of the hospital. See the model in the photo at the top or the architectural drawing to the right. The hospital has thousands of rooms, almost impossible to count. It also has dozens of buildings connected by miles of underground tunnels. It is virtually impossible for anyone unfamiliar with the buildings and the tunnel system to find people who are hidden throughout the campus.


But, let us not understate the bravery of those involved in this rescue attempt. This was a spectacular humanitarian mission carried out by the populace of an occupied country. They truly risked their own lives for the sake of others. This was a mitzvah of the highest order.

Bispebjerg Hospital -- A place in architecture

As noted in the post above, Copenhagen's Bispebjerg Hospital is a marvelous architectural and landscape achievement. Here is a summary of that history from an article in Dan Medicinhist Arbog, interspersed with some photographs I took today. Thanks again to Dr. Peter Skanning for a marvelous tour. (More photos are posted on Facebook, here.)

The architect Martin Nyrop (1849-1921) who had just completed the monumental and beautiful Copenhagen City Hall along with the engineer AC Karsten (1857-1931) and landscape architect Edvard Glaesel (1858-1915) were entrusted with the task to develop the design of the hospital.... The 6 red 2-story brick pavilions are located around an axis along Bispebjerg hill with southeast facing bedrooms over viewing the lush patient gardens.

These sick rooms all had large double windows at the southeast providing excellent daylight. On the walls are washable frescoes with motifs from nature. Pavilion buildings are flanked by two avenues with linden trees on both sides and connected by crossroads between the buildings.

Underground tunnels link the buildings. On both sides, the two lower pavilions on the same side of the central avenue staircase are linked together by a long covered bridge leading from the first floor of the first building to the ground flour in the next building because of the terrain slope.

My note: The tunnels are not only extensive, but they are beautifully constructed. The masonry is designed in a distinctive pattern, and there is a different mix of light and dark bricks as you proceed through the tunnels. So, if you are familiar with them, you can orient yourself in the hospital by the pattern in the tunnel wall.

This bridge connects the two pavilions with a building with operating theatres so that patients can be transferred indoors between operation theatre and sick room.

My note: The operating theatres face north so they can receive glare-free natural light through their glass ceilings and walls. Medical students viewed the surgeries from a raised gallery just inside the outside windows, seeing the operations through a plate glass separating wall.

Surrounding the sick pavilions administrative building, rheumatic outpatient department, laundry, kitchen and engine house are placed. Between the buildings, avenues and crossroads gardens designed with benches, beautiful flowerbeds and bouquets were established to the leisure of the patients.

The hospital offers a wealth of fine architectural designs and presents itself as a kind of garden village within the city.

Note, for example, this light fixture. The bulb holder and lens are in the shape of an acorn. On the right, designed into the ironwork just below the curved portion, is a portrayal of the three towers of the Copenhagen City Hall. Other designs, many with representations of plant life or symbols of the city, are found throughout the campus.


Finally, we should note how Nyrop borrowed classical architectural forms from earlier eras. He appears to have had a fascination with Roman architecture in particular. You can see one example here where he used Hadrian's villa as a model for one building. And below, you can see where he used the design of Roman baths as the model for the bathing building of his hospital. In one part of the bath building, he also used a specific room from Pompei as the pattern for a bathing room.

The Danes consider going public with medical errors

And now a final report from the Copenhagen conference. By the way, it was entitled, "Fremtidens Hospitalsledelse", or "Future Hospital Management." I was asked to present our experience at BIDMC with regard to quality and safety improvement and transparency of clinical outcomes. Regular readers will have seen much of that history here.

Part of the story was our decision to widely publicize a wrong side surgery throughout our hospital in July of 2008. The result was a concentrated effort by dozens of people to evaluate what had gone wrong and to implement changes in our pre-op procedures.

I explained that the decision by our Chiefs to go public with the event took less than five minutes of discussion -- and that five years earlier, it would likely also have taken five minutes, but with the opposite result. The point was that a change in organizational culture takes time. There is an old expression, "Culture eats strategy for lunch." I think there is a lot to that, and I explained that the comfort our people felt with transparency was key to many improvements that led to an enhanced level of quality and safety.

Then, for fun, I used the polling electronics at the conference to ask the attendees whether they thought that their hospital would broadly publicize and disclose the kind of medical error that I had described. Here are the results:


This is quite different from the results at the Risky Business conference in London last year, where only a handful of 300 attendees gave a positive reply. Why the difference? Passage of time? An audience, here, that comprised more senior level people? A cultural difference between Britons and Danes? You can suggest your own theory.

Johan reports from Belgium

I just heard an excellent presentation here in Copenhagen from Johan Kips, Director of the UZ Leuven, a large hospital in Belgium. (He is seen here before the talk making last minute translations in his PowerPoint slides, English being the lingua franca!) UZ Leuven is the first hospital to get accreditation by the Joint Commission International. Johan views that kind of accreditation as helpful in establishing a culture of continuous quality improvement in the hospital. But most of his talk was how to engage the MDs and other staff in disease specific quality improvements, building on the foundation of a general safety culture to structure the care within each disease. He described both parts working together as adding value, a strategic imperative.


He explained how the medical staff created modules (i.e., clinical pathways) for diagnosis, therapy, rehabilitation, and follow-up for various diseases and physical conditions. Then, using their health information systems, they can follow up on specific patients to see how well these pathways were being followed. In addition, they could link the costs of service lines to the income received for lines, looking for opportunities for cost savings, and then further designing the clinical pathways to be more cost-effective consistent with excellent patient experiences.

Similar approaches were applied to operational systems. Here, for example, is a chart showing the shift in waiting times for a certain set of eye conditions.


All in all, a superb presentation and a great story. In addition, it was presented modestly, with Johan making clear that he and his folks still had a lot to do. He was especially interested in hearing suggestions from the assembled audience.

Talking about transparency in Copenhagen

I am in Copenhagen to speak at a conference sponsored by Dagens Medicin, a newspaper for professionals and decisions makers in the medical and health care sector. According to my host, Kristian Lund, editor-in-chief, "The overall purpose of the conference is to inspire decision makers in Danish health care to improve leadership by using quality data. We are especially interested in hearing about your way of working with data and patient safety." As an outside guest, I am joined in a related topic by Johan Kips, Director of the UZ Leuven, the largest hospital in Belgium (2000 beds), who is here to address the attendees on the use of data to direct quality improvement. (Kristian -- another blogger! -- and Johan are in the accompanying photo.)

This is a fascinating topic to discuss in this venue, as the Danish health care system is quite good, but it does face interesting challenges. Here is a part of a summary from the WHO European Observatory on Health Systems and Policies.

Like the other Scandinavian countries, Denmark is characterized by a strong welfare state tradition, with universal coverage including diagnostic and treatment services, is free for all citizens except for certain services such as dental care, physiotherapy and medicine requiring patient co-payment. Equity and solidarity are important underlying values in the system, and surveys show a persistently high level of patient satisfaction. The system has a relatively good track record in terms of controlling expenditure and introducing organizational and management changes, such as transition to ambulatory care, and introduction of activity-based payment.

. . . More generally, the Danish system, like many other European health systems, faces challenges of guaranteeing access and quality while at the same time keeping costs under control. An ageing population and rising expectations regarding service are contributing factors in challenging the sustainability of the public health system.

This gives part of the context for a point Kristian wrote in my letter of invitation, "You will have a unique opportunity to influence Danish health care management in a rare situation since the government is ready to invest more than 5 billion Euro in new hospitals. Denmark is also about to reform the allocation of specialities and we are in the process of re-evaluating the education of specialists."

Here is a bit more background. Denmark currently spends about 8% of its GDP on health care (not counting the educational subsidy to those studying to be doctors and nurses.) There is an expectation that this will be quickly rising, to over 10%, within just a few years. There is pressure on the government to spend more to enhance and expand services. For example, while treatment of heart disease is excellent, cancer care is considered less than adequate by US standards, with less use of imaging and chemotherapy; and there is a desire to upgrade it. There is also a huge building program going on -- eight new hospitals are under construction. Too many hospitals are engaged in high-level procedures, and there is a need to consolidate those, but there is reluctance from those currently engaged in those arenas. I had heard previously that the primary care system was very good, with quick care and integrated electronic medical records. The former is true. It is easy to get an appointment quickly, and the care is excellent. The latter is not. Integrated EMRs are not present at the primary care level, although they are at the hospitals. Finally, there is budget pressure: When the end of the fiscal year arrives and a hospital is behind on its budget, it "manages by congestion," delaying procedures until the next year. A colleague here jokingly said, "I don't know why people from abroad come to visit, thinking our system is wonderful. We think it is awful."

I have talked on several occasions about the convergence of issues and health care design between the US and the nationalized systems of other developed countries. Denmark seems to provide another example of this. As my hosts indicated, we face the same demographic challenges and the same desire on the part of the public for the latest and best in health care technology. It is always helpful to share stories and ideas in pursuit of improved care for all.

The Jubilee Project helps on Hep B

Here's the latest video from the Jubilee Project. As always, when you view it, a donation will be made to a charity. Co-founder Eric Lu sent me a message and press release:

We are happy to announce that The Jubilee Project has released its first music video, "Why I Sing," by Rooftop Pursuit. This video is used to help raise awareness and funds for Hep B Free, an organization dedicated to tackling the problems of hepatitis B. Every view raises 2 cents for Hep B Free, and anyone can choose to become a sponsor by pledging to donate a penny per view. Sponsors may also set a cap if they'd like.

Over half of those infected with chronic hepatitis B in the US are Asian Americans and Pacific Islanders, and one in ten Asian Americans and Pacific Islanders have the disease. It is the only disease where you will find such a huge racial disparity.

"We wanted to be involved in raising awareness for hepatitis B because of the prominence of the disease in the API community and among our own friends and families," said Eddie Lee, co-founder of The Jubilee Project. "We have to end hepatitis B transmission today, and the first step is awareness."

Also known as the "Silent Killer," Hep B currently affects 1 in 10 Asian Pacific Islanders, compared to 1 in 1,000 of the general public, and is the primary cause of liver cancer. Despite this, Hep B can be prevented with by vaccine, and treatments prevent liver cancer.

The Jubilee Project is also seeking sponsors to support this effort. Sponsors offer one penny per view, but can cap how much they ultimately choose to donate, as low as $50.

Funds will be used for national Hep B Free efforts to end Hep B and liver cancer including public awareness, clinician education, screening, vaccination and linkage to care.

"Hep B Free has a multi platform approach to outreach," says Hep B Free co-founder Ted Fang, director of the AsianWeek Foundation. "Not only are we on the ground with person to person connections, but we are also spreading the word and raising money using social media, events, partnerships, foundations and business partners."

For more information about the collaboration, or to pledge as a sponsor, contact Eric Lu at (469) 688-0988 or email to Eric_Lu [at] hms [dot] harvard [dot] edu.

Click here if you cannot see the video.

WIHI on Crisis Management

Reports from the Frontlines of Effective Crisis Management
Thursday, April 7, 2011, 2:00 PM – 3:00 PM Eastern Time

Jim Conway, MS, FACHE, Senior Fellow, Institute for Healthcare Improvement

Anthony A. Armada, FACHE, President, Advocate Lutheran General Hospital, Advocate Lutheran General Children’s Hospital

Michael A. Fisher, President and CEO, Cincinnati Children’s Hospital Medical Center (CCHMC)

Uma R. Kotagal, MD, MBBS, MSc, Senior Vice President, Quality, Safety and Transformation, CCHMC; Executive Director, James M. Anderson Center for Health Systems Excellence

Michelle Hoppes, RN, MS, President, American Society for Healthcare Risk Management; Senior Vice President and National Director for Healthcare Risk Management and Patient Safety, Sedgwick Claims Management Services

It’s every hospital executive’s worst nightmare – a phone call carrying the news that a patient at the facility has died or been seriously injured due to an adverse event. Action is now called for on multiple fronts. Do you have a plan for what to do?

Jim Conway and three co-authors developed the IHI white paper, Respectful Management of Serious Clinical Adverse Events, to guide senior leaders on a comprehensive set of “best practices” not just to handle and respond to unforeseen incidents, but to learn from each incident so that future medical tragedies are less likely. One key is that everyone in the organization has a role to play and no one in the organization is ignored. Transparency with and attention to the needs of patients and families are foundational.

Since the IHI white paper was published in the fall of 2010, thousands of senior and frontline staff have benefited from its clarity of purpose and advice. Not only that, some organizations have turned to its guidance when faced with serious situations. We’re going to hear from two of those organizations – Cincinnati Children’s Hospital Medical Center and Advocate Lutheran – on the next WIHI. Their leaders – Michael Fisher, Uma Kotagal, and Tony Armada – are eager to share what they learned and continue to learn about crisis management. Jim Conway and Michelle Hoppes, a risk management expert, will offer the context in which all of health care delivery must consider its obligations to patients, staff, and the larger community when it comes to safety and principled actions if and when things go wrong.

WIHI host Madge Kaplan hopes you’ll join this important and timely discussion. To enroll, please click here.

Partners in Health of Maine

We have all heard about the good work being done by Partners in Health, but there is another PIH, lesser known, but equally well-intentioned. It is called Partners in Health of Maine. It is a nonprofit, nondenominational organization whose mission is to provide health services, training, education and volunteer opportunities for health care providers in third world countries. Its activities have been limited to Central America, with a focus on Nicaragua and Guatemala. The organization grew around the volunteer work of Dr. Robert Bach, a general surgeon from Maine, and other health care workers who had been volunteering in Central America since 1975. The two PIHs started at about the same time, and I guess both want to keep the name!

Most of the work of PIH of Maine has centered on the Autonomous Atlantic Region (RAAN), Nicaragua’s largest province, which occupies approximately a fifth of the land area and is located on the Northeastern Caribbean coast. This area is inhabited by indigenous Miskito Indians and people of Afro-Caribe and Spanish descent.

A friend of a friend provides some of the color of the Maine organization in a recent email, written after attending a briefing in the US, complete with a story of low-cost innovation by a clever team:

I am going to Nicaragua because I was invited by old friends from Waterville. John and Mary got involved five or six years ago. The work was originally focused on providing medical care to a town on the Atlantic side of Nicaragua. John is a pathologist, and he has been instrumental in writing grants and training Nicaraguan doctors to prepare and read slides in an effort to catch some of the rampant cases of cervical cancer early enough to provide treatment.

In the States, slides are prepared with the aid of a $30,000.00 tissue processor. The machine is massive and the reagents are unavailable in Nicaragua. So the ever-resourceful John invented a way to process slides using a $69.00 microwave oven! He enlisted the aid of his brother-in-law, a retired computer chip engineer, and the two of them figured out a way to program the oven to cycle and hold the kind of temperatures required to "fix" the slides.

And, then some more!

John’s wife Mary is an artist. She was featured on one of the slides shown during the PIHOM presentation...her smiling face lit up the screen and the caption underneath read “I’m an artist...is there anything I can do to help?”

Dr. Bach admitted he groaned a bit inside when she showed up with her offer! And today she has grown into the heart and soul of the tiny grassroots group. Mary has painted colorful and uplifting murals on the hospital walls, she has taken over the newsletter, she writes grants, she teaches English classes. Yes, there was/is a lot she can do to help and her example was a great inspiration to the non-medical folks in the room. "Health" directly translates to "hope" in Arabic and medical care is only one leg of the stool.

This is a lovely example of people helping people. They are looking for volunteers, supplies, and cash. Go to this website for more information on how to help out.

They have heard. Are they ready?

Cheryl Clark at Health Leaders Media offered this summary from a recent conference of the American College of Healthcare Executives (ACHE).

They have heard, and hopefully understand, how important it now is. They are going to have to change their organizations in major, cataclysmic ways especially if they haven't started to do so already.

Tom Dolan, president and chief executive officer of ACHE, says leadership in general is now "much more knowledgeable" about the steps they have to take. "They know they need to reduce costs. They understand they have to adopt Toyota and Lean manufacturing strategies. They know they have to reduce errors, medication mistakes, reduce readmissions and improve quality measures for specific diseases. "They know they have to dramatically re-engineer the way we provide care and can't tinker the way they have in the past."

Here is what I am not sure of, and I mean this with affection and respect. I am not sure that the current generation of leadership in academic medical centers knows how to do what is summarized above. I actually think that leaders of some community hospitals might be better trained in such matters. Why?

Well, the career path of people chosen to be leaders of academic medical centers tends to be based on success in the things valued in the academic medical environment. As is often the case in universities, people work their way up through the ranks of the faculty based on prowess in research and specialized clinical areas. Sure, as they become division and department chairs, they take some courses in business and management, but their promotions tend to be based more on academic achievement than on managerial and leadership skills. And the continuing education courses often do not include strong training in the kind of process improvement techniques and philosophies mentioned by Mr. Dolan.

There are, of course exceptions. I can think of a handful of people who have made the transition and have demonstrated great leadership in instituting these kinds of approaches in an academic medical center. Gary Kaplan at Virginia Mason in Seattle is the prime example.

But maybe I am wrong. Let's give my readers an invitation to offer the names of others they know in this category. This is your chance to brag! Which people in academic medicine are in the vanguard of the kind of change mentioned by Mr. Dolan?

ACO rules: Where's the beef?

I'm sorry, but I just don't get it. Last week, CMS announced proposed regulations about setting up Accountable Care Organizations. Here's the statutory background and the theory of the case, as set forth in the March 31 Medicare Fact Sheet:

Section 3022 of the Affordable Care Act, added a new section 1899 to the Social Security Act (the Act) that requires the Secretary to establish the Shared Savings Program by January 1, 2012. This program is intended to encourage providers of services and suppliers (e.g., physicians, hospitals and others involved in patient care) to create a new type of health care entity, which the statute calls an “Accountable Care Organization (ACO)” that agrees to be held accountable for improving the health and experience of care for individuals and improving the health of populations while reducing the rate of growth in health care spending. Studies have shown that better care often costs less, because coordinated care helps to ensure that the patient receives the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors.

Here's the introductory paragraph from the CMS summary:

ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities. The Medicare Shared Savings Program will reward ACOs that lower growth in health care costs while meeting performance standards on quality of care and putting patients first. Patient and provider participation in an ACO is purely voluntary.

How will this work? And, will it work?

Let's dig in.

The proposed rule would require providers participating in an ACO to notify the beneficiary that they are participating in an ACO, and that the provider will be eligible for additional Medicare payments for improving the quality of care the beneficiary receives while reducing overall costs or may be financially responsible to Medicare for failing to provide efficient, cost-effective care. The beneficiary may then choose to receive services from the provider or seek care from another provider that is not part of the ACO.

. . . Medicare would continue to pay individual providers and suppliers for specific items and services as it currently does under the fee-for-service payment systems. The proposed rule would require CMS to develop a benchmark for savings to be achieved by each ACO if the ACO is to receive shared savings, or be held liable for losses. Additionally, an ACO would be accountable for meeting or exceeding the quality performance standards to be eligible to receive any shared savings.

So, the PPO character of Medicare would not change: "The provider may not require a beneficiary to obtain services from another provider or supplier in the same ACO."

How can you be held accountable, as a provider group, if you cannot control the management of care of your patients? I'm not blaming CMS for this contradiction. The agency is simply implementing what Congress and the President ordered it to do. There is no way Congress will limit choices among the Medicare population.

Real cost savings will not result from ill-conceived government laws and regulations: They will occur when physicians and other health professionals redesign the work that takes place in their offices and hospitals. Attempts to generate that redesign by government regulations, especially self-contradictory ones like this, will fail.

Career advice sought

A friend writes below. She is in the municipal bond world, working as an associate in public finance at an investment bank. As indicated below, she is currently contemplating where she wants to go in her career. She seems to want more from life than being an investment banker. Perhaps you would like to offer advice in your comments?

I'm thinking I'd like my next job move to be health care focused. Given my interest in policy and my desire to work in a field that I feel is socially important"and yet also challenging, health care seems to fit my needs.

I am curious. Do you have any recommendations for the types of roles that are interesting in health care finance today? Since I'm getting my CFA [Chartered Financial Analyst, a designation for investment professionals] it needn't necessarily be public finance. I am wondering what type of job I could pursue now that could transition into working for a policy think tank or a not-for-profit advocacy group down the line. I just wanted to do some exploring. Recommended reading for keeping up on health care would also be great!

More signs in the Athens of America

Back to our occasional review of signage seen in public places. The infrastructure geek in me likes to evaluate them for efficacy. The one above is from the Kennedy School at Harvard. Really terrible jokes and scenarios come to mind.

And here is part of a very clever ad for a restaurant search engine, seen on the Boston transit system.

This is no eggsageration!

In a previous post, I made the point that meal components and serving sizes are contributing to a huge increase in obesity in the US. With no offense meant to my friends in the South, this especially seems to be the case in that part of the country.

While waiting for an airplane at the Tampa airport last week, I decided to order the vegetable omelette for breakfast, figuring it would be the healthiest thing on the menu at the Sam Snead Tavern near my departure gate. What showed up was this behemoth!

Sam could never have done so well if he ate this way!

Learn the MIT physics curriculum in one hour

I am an unabashed MIT fan. Here's why. It is hard to imagine this happening elsewhere, and with such good humor.

From:
Date: Fri, Apr 1, 2011 at 8:04 AM
Subject: 5-Minute Physics Lectures, 8 pm tonight
To:

Want to learn 144 units of physics in 1 hour? Neither do we, but at least there'll be free cookies/cocoa/tea!

If you're curious to sample the entire Course 8 curriculum from 8.022 to Quantum Field Theory II at ultrarelativistic speeds, come to 8-329 tonight at 8 pm to experience each class losslessly compressed into 5 minutes or less by your friendly neighborhood Physics majors. To quote Chancellor Grimson's recent email, "This is not some dry 8.01 lecture."

Also featuring Prof. John Belcher TEACHING HIS OWN CLASS (8.07).

Part of Physics Exploration Week, hosted by Undergrad Women in Physics.

---
Explanatory notes: A "unit" for an MIT class is equivalent to an hour per week of class time or expected homework. A 12-unit class at MIT is roughly equivalent to 4 credit-hours elsewhere. "Course 8" means the Department of Physics. At MIT, a course is a department. A class is a course. Classes are designated with the course number first, and then the class number after that. They roughly rise in degree of difficultly based on the digits. 8.01 is thus a lower level course than 8.07. Buildings and rooms at MIT are designated by numbers, too. Room 8-329 is on the third floor of building 8. The building numbers tell you where you need to go on campus. Building 8 would be between Vassar Street and the Charles River, relatively close to the river, to the right of the large dome in the middle of the MIT campus (as you face that dome from the river.) Clear?

Crowdsourcing for his book

Mark Graban, an expert on the use of Lean process improvement in hospitals, has opened up his own process as he prepares revisions of the "Visions of a Lean Hospital" ideal state chapter in his book, Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction.

He notes on his blog:

I’ve shared the first chapter of the book for those who signed up on my book’s site. Now as I’m making revisions, I’d like to get your input and ideas around the final chapter – “A Vision for a Lean Hospital.” I think the chapter has some good ideas, but given my audience here, I’m not going to pretend I have all the answers for hospitals. So I’d like to hear what you think in the comments for this post, or email me. What’s missing? What’s confusing? What’s wrong?

Here's your chance to be a ghost writer!

How the veterans are winning the war

At a seminar last night at the Center for Public Leadership at Harvard's Kennedy School, one of the students asked a question along the lines of, "How do you know when you have done too much with regard to transparency?" My answer was that the question presupposed the wrong approach to transparency, that it was being driven by the CEO without proper attention to the efficacy and appropriateness of what was being measured and disclosed. Instead, I suggested that it should be driven by the leadership of the organization, but based on metrics that were viewed as useful and appropriate by the clinical staff. In such an instance, transparency serves the function laid out by IHI's Jim Conway, as summarized here in an article discussing the BIDMC experience:

[P]ublic reporting created what management guru Peter Senge calls creative tension, a key in getting an organization to change. Announcing a daring vision — the elimination of patient harm — combined with honestly publicizing the problems, fuels improvement, he said.

I expressed the concern last night that the general recalcitrance of the medical profession about engaging transparency will inevitably lead to fiats about disclosure from government regulatory agencies. The problem with those fiats is that they will be grossly constructed and force hospitals and doctors to focus on the wrong things, in a manner not consistent with widely established principles of process improvement. (See, for example, this approach in Maryland.)

Now comes the Veterans Administration, proving the case with panache! You may recall my complimentary post on the VA back in January. Thomas Burton's article this week in the Wall Street Journal -- "Data Spur Changes in VA Care" -- documents this in more detail. Some excerpts:

Hospitals serving U.S. military veterans are moving fast to improve care after the government opened a trove of performance data—including surgical death rates—to the public.

The information was released at the urging of VA Secretary Eric K. Shinseki. Among other things, it presents hospitals' rates of infection from the use of ventilators and intravenous lines, and of readmissions due to medical complications. The details have been adjusted to account for patients' ages and relative frailty.

"Why would we not want our performance to be public? It's good for VA's leaders and managers, good for our work force, and most importantly, it is good for the veterans we serve," Mr. Shinseki said in an emailed statement.

At VA hospitals in Oklahoma City and Salem, Va., the rate of pneumonia acquired by patients on ventilators was shown last fall to be significantly higher than the national VA average. The Salem hospital says a relatively low number of patients on ventilators skewed its infection rate higher, but staff members at both facilities say the numbers prompted action.

Seeing the data helped, says the Salem hospital's chief of surgery, Gary Collin, because "you can become kind of complacent."

In contrast, notes the article:

This unusually comprehensive sort of consumer information on medical outcomes remains largely hidden from the tens of millions of Americans outside the VA system, including many of those in the federal Medicare system.

And, as I reported last month,

A November 2010 report from the Health and Human Services inspector general concluded that one in seven Medicare patients is harmed by medical care, nearly half of those avoidably.

Conway is right. Senge is right. The veterans have figured out how to start winning the war for patient safety and quality and process improvement. The rest of the profession is in retreat and is letting the wrong people design the battle plan.

Conversation at the Center for Public Leadership

Many thanks to the Center for Public Leadership at Harvard's Kennedy School for inviting me to meet with the Zukerman and Dubin Fellows tonight. The Zuckerman Fellows are graduate students or professionals from the fields of law, business, or medicine who are pursuing a second degree in health, education, or public policy in order to broaden and deepen their understanding of public sector issues. The Dubin Fellows are master's degree students at the JFK School who have demonstrated strong character, academic excellence, the ability to thrive and lead in the face of adversity, and a commitment to making a transformative impact on the communities they serve.

My topic was about lessons from leadership positions, with a particular focus on engaging front-line staff in process improvement, building constituencies in the complex environment of academic medical centers, and the importance of transparency in both clinical and administrative matters.

I promised to post the pictures of those who asked especially good questions, but everyone did! I don't have room here for all, but I include a few. Special thanks to Laura Burke (bottom right), a resident in Emergency Medicine at BIDMC, for her role in organizing tonight's event.

It's not "nothing" -- Accepting gratitude

A friend and I were discussing the point that effective communication is most likely to occur when the other person feels that you understand his or her situation. This is an underlying premise of negotiation theory: You are more likely to be successful at a negotiation when you understand the other person's underlying interests and when you make it clear to that person that you do. To do otherwise, whether in negotiations or other settings, is likely to lead to speaking at a person, rather than to the person. Not because you mean to, but because the other person will not value what you say, compared to when they think you really "get it."

One of the things I learned in my hospital days was how to accept gratitude. A hospital can be an uncomfortable place for patients and family members. It is a strange physical environment, where people are anxious because of feared or actual medical conditions or forthcoming procedures or tests. In that situation, when you do something kind for someone, the person is truly grateful. It can be as simple as offering directions, or picking up a fallen object, or something much more serious.

When I started working in the hospital, when someone would say "Thank you" to me, I would often answer, "It's nothing," or "No problem." Wrong! I was taught that such an answer devalues the gratitude that the other person is feeling. A more appropriate response is, "It is my pleasure," or "I am so pleased I was able to help." That indicates that you understand their feelings.

Over the years, I trained myself to do this. Lo and behold, once I got rid of the "It's nothing" conversation stopper, people would jump in and continue the conversation even further. I was able to learn so much more about people's fears, expectations, experiences, and hopes and then help translate those into improvements in the clinical environment.

Try it. It's not "nothing."

A mentor hospital

The Institute for Healthcare Improvement gives the following update. How impressive! And how generous of Columbia Regional to offer to share what they have learned. What a shame that The Joint Commission has not followed this lead by making its best practice library available to all.

Mentor Hospital Goes 5 Years Without a VAP

Staff at Columbus Regional Hospital in Columbus, IN, recently celebrated an amazing accomplishment. They have gone five years without a single incidence of a ventilator-associated pneumonia (VAP). These deadly pneumonias used to be considered an unfortunate reality in ICUs. As a participant in IHI's 100,000 Lives and 5 Million Lives Campaigns, the hospital took aim at reducing VAP by implementing the IHI Ventilator Bundle, evidence-based care guidelines that, when reliably applied, can drastically reduce and even eliminate these infections. One of the enduring legacies of the Campaigns is a robust registry of mentor hospitals, facilities that have outstanding track records in improvement in Campaign-related topic areas that have generously agreed to provide support and clinical expertise to hospitals seeking help with their implementation efforts. Columbus Regional has been a mentor hospital since 2006 for the topics of VAP, Rapid Response Systems, the Central Line Bundle, and Heart Failure Core Processes. IHI congratulates Columbus Regional on their tremendous achievements.

Please nominate for Schwartz Center Award

I am pleased to post this at the request of the Schwartz Center. Please see below and consider people or groups of people who might be worthy recipients of this award:

Nominations Open for Schwartz Center Compassionate Caregiver Award®
New England Caregivers Sought Who Demonstrate Extraordinary Compassion for Patients

Boston, MA (March 22, 2011) – The Schwartz Center for Compassionate Healthcare, a nonprofit organization dedicated to strengthening the patient-caregiver relationship, is seeking nominations for its 2011 Schwartz Center Compassionate Caregiver Award®. For the first time since the program began in 1999, caregivers from all six New England states are eligible.

The winner will receive $5,000 and be honored at the Kenneth B. Schwartz Compassionate Healthcare Dinner on November 17^th at the Boston Convention Center. Last year’s event attracted more than 2,000 attendees. Four finalists will also be recognized and receive $1,000 each. Nominations are due April 22, 2011. Information on how to nominate a caregiver for this prestigious award is available on the Schwartz Center’s website.

The center and award are named after Ken Schwartz, a Boston healthcare attorney who died of lung cancer in 1995 and came to believe that medicine is about more than performing tests and surgeries, or administering drugs. As he wrote in an article published in the Boston Globe Magazine, “These functions, as important as they are, are just the beginning. For as skilled and knowledgeable as my caregivers are, what matters most is that they have empathized with me in a way that gives me hope and makes me feel like a human being, not just an illness.”

Nominees must work in a health-related organization or practice, such as a hospital, physician office, outpatient clinic, community health center, visiting nurse or home health agency, nursing home, or hospice organization. Any paid caregiver or team of caregivers with direct patient contact in Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island or Vermont is eligible. Nominees may include physicians, nurses, physical and occupational therapists, social workers, psychologists, nurse practitioners, physician assistants, certified nursing assistants, home health aides, and chaplains – as well as interdisciplinary teams. Nominations may be made by patients or healthcare professionals.

In 2010, the Schwartz Center Compassionate Caregiver Award® was given to the Haitian Mental Health Team at Cambridge Health Alliance in Massachusetts. In 2009, the award went to Dr. Amy Ship, an internist in the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center in Boston. [My note: Listen to her speech here.]

The winner and finalists will be selected by a regional review committee based on how well the individual or team embodies the characteristics of compassionate healthcare, which are defined by the Schwartz Center as follows:

• Showing respect for the patient, the patient’s family, and those important to the patient
• Conveying information in a way that is understandable
• Treating the patient as a person, not just a disease
• Listening attentively to the patient
• Striving to gain the patient’s trust
• Always involving the patient in treatment decisions
• Apologizing to a patient if a caregiver makes a mistake
• Communicating test results in a timely and sensitive manner
• Comfortably discussing sensitive, emotional or psychological issues
• Considering the effect of an illness on the patient, the patient’s family, and those important to the patient
• Expressing sensitivity, caring and compassion for the patient’s situation
• Spending enough time with the patient
• Striving to understand the patient’s emotional needs
• Giving the patient hope, even when the news is bad
• Showing understanding of the patient’s cultural and religious beliefs

The Schwartz Center for Compassionate Healthcare was founded in 1995 by Ken Schwartz, a prominent Boston healthcare attorney who died of lung cancer at the age of 40. Based at Massachusetts General Hospital in Boston, the center sponsors programs to educate, train and support caregivers to provide compassionate, patient-centered care. Its signature program, Schwartz Center Rounds, has been adopted by 215 hospitals, outpatient centers and nursing homes in 32 states and reaches more than 60,000 clinicians a year.

The Schwartz Center Compassionate Caregiver Award is made possible in part by the generosity of AstraZeneca, a leading pharmaceutical company.