Will JAMA ever open up?

On the WIHI program today, I asked the following question of Catherine D. DeAngelis, MD, MPH, Editor-in-Chief of JAMA, the Journal of the American Medical Association:

NEJM and other journals allow public (non-subscriber) access to the full text of articles of general public interest. JAMA has steadfastly refused to do so. Why? As the others have shown, it results in no financial loss. And, it enhances the position of the journal among the public and decision-makers.

Examples are here and here. The second one was a 2010 article by Peter Pronovost, entitled, "Learning Accountability for Patient Outcomes," where only an excerpt was provided to the public. As I stated at the time, "Wouldn't you love to read the whole thing? Maybe, someday this influential journal will understand that it would be still more influential if it permitted free access to articles of public import like this."

Before being presented with this question, in response to another question, Dr. DeAngelis talked about how much JAMA wants to get accurate exposure for its articles:

We spend lots of money getting our articles out to the media. We give it to them early. We write up the ones that we think are important. Every week we put out a video news release. The one bug I have a about the media is when . . . a headline is absolutely wrong, opposite of what the article says.

So, you would think that the best way to get accurate, accountable exposure for articles of general interest would be to permit anyone to read them.

On my question, I am sorry to say she gave a misleading answer. Here are excerpts I was able to pick up:

This is discussed constantly. If it is an article of great public interest, we make it free immediately [for a short period of time]. We make all studies free after six months. I would love to make everything we do free. The problem is that it takes money to run a journal.

Actually, all those articles are not made freely available after six months. This is the message you get if you want to look at that Pronovost article from 2010:


To play back something Dr. DeAngelis said:

We are not a guild. We have an MD, not an MDeity. The patient is always the top priority.

So, let us allow patients to get access to these important articles.

Social media utility

It's time to revisit and evaluate the utility of our social networks. Let me take a personal look at the three main ones I use (in addition, of course, to this blog): Facebook; Twitter; and LinkedIn.

If it were only to keep up with people's birthdays, Facebook would remain a winner, even though I am willing to concede that I am not closely connected to all of my 4046 friends. But, it is fun to see what people are doing and thinking about; watching families grow; and getting links to interesting stuff. Also, there is no better way I know to reconnect with people from previous stages of your life -- schools, places you have visited or lived in, jobs. It is a great way to share my own photos from interesting places and to see those of my friends. Finally, this blog is republished there as a note. Please friend me here.

Twitter is my librarian. While about 5000 people follow me, I only choose to follow 167. For the most part, these are people or organizations who link to articles and websites that I am likely to find of interest. I no longer have to read any journals in fields that I care about. If something good has been published, someone on my list is bound to tweet it. Also, this blog is fed automatically to my Twitter feed. Please follow me here.

And then there is LinkedIn,who efficacy I have yet to figure out. Look at this summary page:


While this is a wonderful example of the power of exponential functions, what other value does it offer? I find Linkedin to be clunky to use and ugly to boot. But, I usually say yes to anyone who wants link to me, in the hope they find it useful.

What are your favorites? Have you dropped off of any sites? If so, why? If you choose to answer, please indicate your age, as I think patterns of use differ by generation.

Reaching out to patients in their homes

This is another in my occasional series about companies that are inventing new processes or leveraging expertise from other industries to enter the health care field.* This post is about outreach to patients and consumers in their homes. The key is offering this service in a cost-effective, standardized manner, keeping costs down, but ensuring that the value of information offered is high and leaving the customer more satisfied and loyal.

OnProcess Technology is a firm that provides reverse logistics management to other firms. This is a term I never heard until recently, but it is an important aspect of inventory control. The simplest example is that cable TV box in your house. When you discontinue service, how does the box get back to the manufacturer? Likewise, when a firm has placed some technological wizardry in someone's home or business, and the customer does not use it, how do you get information to the customer so the firm can optimize the value of the placement? Those two lines of business -- reverse logistics and remote customer service -- are OnProcess' specialties, and the company has been quite successful.

The folks there noticed that there are aspects of health care delivery that could use similar proactive outreach expertise, and they have created Reinforced Care to offer it. Their immediate market niche is to reduce hospital readmissions while improving the quality of patient care post-discharge.

Most people in the hospital world have come to accept the idea that contacting a patient shortly after discharge is likely to reduce the likelihood of readmission, but most hospitals are not set up to carry out that task. By outsourcing this function to Reinforced Care, the function is carried out systematically (in a multitude of languages) and in a manner designed to reduce variation, achieving a reduction in this important measure.

But there is a secondary advantage: The patients provide immediate feedback on service problems they experienced in the hospital, permitting hospital management to do "service recovery" before the patients receive their Press Ganey satisfaction survey. The result is a higher level of satisfaction, a metric that will be increasingly important with regard to reimbursement from Medicare and private insurers.

Eliza Corporation is also in the business of contacting patients, but in different way. The company uses speech recognition software that makes it possible for a computer to carry on a conversation with people over the phone (also in many languages). Employed by a health plan or a multi-specialty practice, for example, Eliza helps engage members in health and benefit topics and drive healthier behavior. The firm has a rules engine that allows the message to be tailored to the population.

The folks at Eliza understand that the choices available to consumers are overwhelming, especially with regard to benefit design and healthy living. The outreach function they offer helps people understand the options before them, in a manner more cost-effective that that traditionally available to insurance companies and physician practices.

These are but two examples of firms that have started to fill in the communications gap in this field. By enabling patients to be better consumers, the companies will help save money and improve the quality of care offered. As financial risk is reallocated in the health care world, services like these will be come more and more valuable to providers. Even before that shift occurs, though, providers with a broad view of patient quality and cost-effectiveness will take advantage of this new range of services.

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* As always, I will disclose any financial interest I have in companies I discuss. I have none in these cases.

JAMAing on WIHI

Integrity On and Off the Page: A Discussion with
JAMA’s (Departing) Editor–in-Chief
Thursday, June 9, 2011, 2:00 PM - 3:00 PM Eastern Time

Catherine D. DeAngelis, MD, MPH, Editor-in-Chief of JAMA, the Journal of the American Medical Association

It's hard to imagine the Journal of the American Medical Association – JAMA – without its editor-in-chief, Cathy DeAngelis, who will be stepping down this July. Since 2000 Dr. DeAngelis, JAMA’s first woman editor, has steered the peer-reviewed publication in important new directions and successfully brought about greater scientific integrity across the medical research and publishing industry. Because of her efforts, in concert with other prominent journal editors, virtually all clinical trials in the US are now listed in a public registry, as a condition of publication. JAMA won’t consider industry-funded research unless the data have been independently vetted.

Dr. DeAngelis’ principled stands, along with her interest in the narrative side of practicing medicine, as well as health policy and reforming the status quo, have all made JAMA more accessible and “required reading” for a broader audience. And her own story – which began in a coal-mining town in northeastern Pennsylvania, and has included nursing, pediatrics, and teaching – is far from over!

As Dr. DeAngelis prepares to return to the Johns Hopkins School of Medicine – this time around to start a Center for Professionalism in Medicine and the Related Professions – WIHI host Madge Kaplan is thrilled to welcome her to the program for what promises to be a lively hour of discussion. Dr. DeAngelis is as eager to share her thoughts about the challenges facing all research scientists today, including those engaged with improvement science, as she is passionate about maintaining the integrity of taking care of patients.

Bring your questions, your favorite article or art cover from JAMA, and your comments to this next WIHI!

To enroll, please click here.

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My note: Someone please ask her why they don't make the full text of public interest articles available at no cost to all readers.

Ron and Panera make a difference

When I first heard of this idea from Panera Bread's Ron Shaich, I was impressed with both its elegance and its humanity. In simplest terms, it is, "Eat what you need to. Pay what you can." It turns out that some people will pay more for their meals so that other members of the community who might be short of cash can afford theirs. You can read more about it at this AP story.

Here's an update Ron sent to some friends a few weeks ago:

This week marked a significant milestone for Panera. Our first Panera Cares cafe, which opened its doors to the community on May 16, 2010, in Clayton, MO, celebrated its first anniversary. After that came additional Panera Cares cafes in Dearborn, Michigan and Portland, Oregon. Today Panera Cares is serving 10,000 to 20,000 people a week and our cafes are now expected to serve 500,000 to 1 Million meals in the next year. Each café has been a success and each has become self-sustaining. As well we graduated our first class of at risk youth this past week and each “at risk” young person is now working and contributing to society.

One highlight of the week was when anchor Brian Williams announced on NBC Nightly News that an earlier piece on its “Making a Difference” series had inspired Panera to develop the idea for Panera Cares and that NBC would be airing a story on the Panera Cares concept.

Here's the clip. Click here if you cannot see the video.

Visit msnbc.com for breaking news, world news, and news about the economy

Now, let's graduate to Lean 404

I am borrowing some slides recently presented by James Womack, of the Lean Enterprise Institute, as a follow-up to my previous post about adoption of the Lean philosophy in an organization. If the description there was Lean 101, this is Lean 404.

It is one thing to talk about reducing waste in a process and to learn techniques for doing so. It is another thing altogether to create the management competencies that permit this kind of process improvement to take place on a sustained basis. As Womack notes in the first slide above, most organizations do not have the competencies in place to do that.

In the slides below, he sets forth the difference in management approaches between the traditional view and the Lean environments. (Here is a similar oral description from a thoughtful doctor.)



How do you get there? The key is to have the nerve to experiment. Instead of thinking in traditional vertical silos and reporting relationships, you need to have enough confidence in people to let them think along the entire value stream of a given process. This empowers them to redesign the way work is done, extracting waste, improving worker satisfaction, and delivering more value to customers. In a hospital, where the customers are patients, "more value" can actually mean avoiding life-threatening errors and omissions. It can also "simply" mean a more pleasant experience; e.g., less time spent waiting to be seen in an ambulatory clinic.

Think about the organizational and leadership issue in soccer terms. Imagine that, as a coach, you try to improve your team by thinking separately about the forwards and how they will play and be evaluated; and then the midfielders; and then the defense; and then the goaltenders. Of course, that would be silly. The game is played horizontally -- not only across a field, but also across the various position players. As you reduce waste -- mishandled balls, poorly directed passes, and other miscues -- it is the interaction of the entire team, irrespective of vertical definitions, that leads to success. Your job as leader (coach) is to promote those interactions and engage all participants in process improvement. Yes, those goaltenders need their own specialized training, too; but your job as coach is the one Womack ends with below -- helping people figure out how to integrate the horizontal process improvement approach with the vertical organizational needs.

How do you get Lean?

Lean is not a program. It is a philosophy of management and of organization in a firm or institution. The LEAN approach to things is based on the concept of reducing waste in a process. In a typical clinical process in a typical hospital, over 90% of the steps taken to deliver care are wasteful, and it is not unusual to be able to reduce that by half. The results are better patient care and better financial results. (Regular readers have seen lots of examples of this from my former hospital.)

A leading figure in the spread of Lean to hospitals is John Toussaint. He was CEO of ThedaCare, in Wisconsin. After leaving that position, he founded the ThedaCare Center for Healthcare Value to spread the word about this approach. The Center has released its first DVD, a 44-minute video that highlights strategy deployment as a core part of the Lean management system at ThedaCare. Here's a summary:

The video takes you to multiple locations at ThedaCare and Appleton Medical Center, including the senior leadership "visual room" and two inpatient units. Toussaint, current CEO Dean Gruner MD, and COO Matt Furlan describe how strategy deployment helps align the entire organization and their improvement efforts around their "true north" objectives for measurably better care. You will also see front-line managers describe how they drive daily continuous improvement in alignment with ThedaCare's mission, vision, and strategy.

Several hospitals around the country have joined to create a Healthcare Value Leaders Network as they implement the Lean philosophy. Established in June 2009, the network now consists of 36 member organizations that have joined to collaborate and share their lean methods and experiences. The goal of the Network is to accelerate each organization's "Lean journey," allowing each member to progress more quickly and more effectively than they could on their own.

If I were on the board of trustees of a hospital facing a whole variety of financial and clinical issues, I would be asking the senior administrative and clinical leadership how they intend to reap the patient care and financial advantages that come from the Lean approach. If you are in that role, see what answer you get when you ask the question.

Unqualified Successes

This is a short retrospective about Massachusetts politics, but I present it for a purpose related to health care. In the 1970s and 1980's, there was a group of women who ended up in positions of great responsibility in public life. They were from the early generation of baby boomers who, in a different era, married and, instead of trying to balance raising children and holding a job, were stay-at-home moms. But they spent a good deal of their spare time involved with the League of Women Voters.

At the time, the LWV had a focus on citizen participation in local and state government. This was before public meetings were broadcast on cable television. LWV members would learn about current issues by attending governmental meetings and hearings in their city or town or at the State House. Then they would write up concise summaries for their members and others to read. It was a terrific way to get a civic education and also influence public policy.

As their children grew up, this same group of women entered the workforce and, because of their knowledge, often moved into positions of responsibility. Rita Baron, one of this group, created a word play by calling them "unqualified successes" because many of them, never having a chance to go to college, also accomplished a lot. It was the astute commissioner, understanding their capabilities, who would hire one of them to be the number two person in a state agency. (I put myself in that category when I asked Marcia Molay to be my deputy at the state Department of Public Utilities and the MA Water Resources Authority.) Others from this cadre of women would find their way to head up advocacy groups.

That was the path Rita chose, as she became director of the Charles River Watershed Association, an environmental advocacy group. She wanted to learn more about the activities of the Metropolitan District Commission, which ran the regional park system and controlled the watershed. Several years ago, she told me this story about using her LWV experience:

I went in one day. I ran into the secretary and said, "I would like to attend the commission meeting." She was absolutely aghast. The meetings were held in the commissioner's office, and the door was closed, and I said to her, "You know, Mrs. Silva, there is such a thing as an Open Meeting Law, and I'm a member of the public. I don't want to go in and disrupt anything. I don't want to partake in the meeting. I just want to sit there and listen and learn." So very timidly, she opened the door, and I slipped in and I sat in the chair right inside the door, and all the eyes looked at me. This is the first time anybody had had the nerve to pop in, and it wasn't too long after that that I would go in, and the door would be open.

Rita wrote a newsletter called The Streamer, which she sent to her members but also to an extensive list of public officials. Bill Geary, MDC Commissioner in the 1980s, used to say, "I learn more about the agency, what's going on, from reading the newsletter."

Rita explained her political philosophy:

The MDC felt that the agency owned the river. "This is our river," one of them said to me; and I said, "No, it isn't. It's my river. It belongs to the public. You simply have the management of it, but you don't own it. The people own it." That's when I came up with the phrase, "The People's River," and I pushed that idea for all it was worth. At the time, because the environmental movement was fairly new, there was great resistance to letting those people who don't know anything in on what we're doing. I could see it would just be a process of eroding that attitude.

Hmm, sounds a bit like health care, no? Who are the "unqualified successes" who will be the effective advocates for patient-driven health care? Who will break down the barriers to letting those people who don't know anything in on what we're doing? Who will demand the kind of meaningful transparency of clinical outcomes that will help drive process improvement?

Thus far, the patient advocacy movement is inchoate and not very effective. How will it develop into a barely restrained mob that demands and gets results from an often recalcitrant medical community?

Hint: The answer does not lie with a national movement, although information sharing will be helpful. It depends on local people who put pressure on community-based boards of trustees to hold local hospitals to a standard of care that will reduce harm to patients.

These Irish eyes are shining

A story from the Emerald Isle. The Irish Times reports that Dr. Rhona Mahony has just been elected the first female Master of a Dublin maternity hospital. The first one since 1894. I know this is a country steeped in tradition, but it is nice to see a change!

There is some speculation as to what her title will be. “Of course, I will be known as Mistress,” she says jokingly.

Confirming she will use the title Master, she says it has long been in use, is well understood and is, she says, an “affectionate” term. So Master Rhona it will be – in a positive, asexual, way.

The Mastership system is unique to the three Dublin maternity hospitals – the Rotunda, Coombe and Holles Street. Established in the 18th century by a royal charter given to the Rotunda, the system was well ahead of its time. It means the buck stops with one individual, both clinically and administratively.

Note this emphasis on good clinical practice, too: She believes the key to reducing the number of [Caesarian] sections is in how a woman’s first labour is managed – “we must make sure we don’t make her first delivery complicated” – as this leads to a much higher probability of an operative delivery.

And staff engagement: Mahony emphasises the extent to which every single staff member contributes to the success of NMH. “They go the extra distance every time and have a great esprit de corps."

Congratulations, Master Rhona!

Bittersweet memories of a soccer player

It was a wonderful spring day for soccer today, and it served to bring back memories for me of Melissa Leung. Melissa was an eighth grader when, in April 2001, she and three other classmates were killed during a bus accident while on a school trip. I realized today that it has been ten years, and I still remember her well and fondly.

Melissa had been a player on the Under-14 team I coached in the previous fall, and so it was extra shocking to hear of this terrible accident the following spring. She was a lovely girl, funny and outgoing. As a soccer player, she was about average for her age, but she had one very funny characteristic. When she played goalie and tried to punt the ball out of her area into the field, it would sometimes go back over her head. She actually had the potential of scoring against herself! We would all laugh when this happened, and she most of all.

So, the end of the season arrived, and many of the girls signed a thank-you card (above) to the coaches. How did Melissa sign it?

Meli Leung
Punter

Don't you already know if you are a drug user?

A friend saw this cocaine at-home drug test kit for sale at Duane Reade in New York City. I was stunned, but I guess I am naive. After all, why do you need a drug testing kit if you know you are taking the drug?

Then I figured that cocaine users who might face employer drug tests use this to make sure they have been off the drug long enough not to get fired. Or, if not already employed, to make sure they can get hired by a company that does a pre-employment drug test.

Or maybe women who are about to start a family and who know of the drug's impact use the test to find out if the drug is out of their system before they get pregnant.

Or maybe parents use it to check out their kids.

That appears to be how the whole idea got started, according to this story in the New York Times from November 17, 1998:

Ms. Cloud, still suspicious of her son, decided to do her own drug tests, sending him into the family bathroom in boxer shorts with instructions to come out with a cup full of urine that she could ship to a local laboratory for analysis.

That is how Ms. Cloud began a cottage industry: the home drug testing business. ...Last month, the Food and Drug Administration approved the latest of these kits, the QuickScreen at Home Drug Test made by Phamatech, a San Diego manufacturer of diagnostic tests. The company bills its product as the first to give parents a result at home. Phamatech says that when the kit hits drug stores in December, screening for marijuana, cocaine, LSD or heroin will be as simple as taking a home pregnancy test.

Whatever the reason, it is a sad statement that there is sufficient demand for this product to make it profitable and to have it sold by New York City's largest drugstore chain.

Some of my best friends are in private equity

Like moths to a flame, private equity investors are quick to pounce on those sectors of the economy that have the potential for higher than average returns. Such investors also have an appetite for the higher risk that accompanies those sectors. In this manner, private equity can serve a useful role in capital formation for the economy. It also helps money managers who want a portion of their portfolio to be in that part of the risk-reward spectrum.

Health care is a fertile field for private equity. You might not think so because of concern about rising costs, but as someone once said, "One person's costs are another person's income." Let's look at it this way. First, more people will have access to insurance to pay for diagnosis and treatment because they will be newly eligible for private insurance under the national health care reform law. Second, demographic changes in society are producing an ever-increasing demand for health care services. Longer lifespans and the aging population offer a growing number of people with cancer and the other diseases that are more likely to occur with age. The number of Medicare beneficiaries is projected to rise from 46.6 million today to 78 million in 2030. (It was 40 million in the year 2000.)

It is with this background that we should consider the growing interest by private equity in proton beam facilities. You have heard before about my real concern about the cost impact of rapid expansion of the number of such facilities.

I want to expand on that today and give you a sense of how the dollars work in this kind of investment. I have pointed out how the Medicare rate-setting process contributes to its profitability. Let's look at this in very rough form.

First, the revenues. Let's assume we have a facility that can serve about 1500 patients per year, with an average reimbursement of $50,000. We generate annual revenue of $75 million.

On the cost side, let's say a new facility costs $125 million and is financed with 60% debt; is depreciated over 20 years; is in leased space; and has personnel and other expenses. Total expenses will be in the range of $30 million.

Net profit (pre-tax) is about $45 million per year. The private equity investors have put in about $50 million in cash. This starts to look pretty good.

That's just one projection, and I am not privy to real pro forma's so I might be a bit off track. This article has a more conservative view of the numbers. For now, ignore the variability in the assumptions. Instead, note this all-important introductory line from the article:

Proton beam therapy gets a 9% reimbursement increase for 2011. . . .With the new CMS payment level, reimbursement for simple treatments is now $1,031 (APC 664), up from $942 in 2010. More complex treatments are reimbursed at a rate of $1,349 (APC 667), up from $1,232 in 2010. Depending on the cancer, a protocol of 10 to 15 treatments may be required per patient.

You can understand why the moths are flocking! In an era of flat Medicare payments to hospitals and doctors, these payments are going up at three times the rate of inflation.

But now, compare these actions by CMS and the resultant private equity gold rush with important scientific and public policy concerns, set forth in a 2008 US News and World Report article:

But certain doctors—not to mention the occasional patient who has experienced side effects from proton therapy—wonder whether the high-tech allure of protons hasn't outpaced the science. "Because of Internet buzz, the morbidity associated with proton beam therapy is underappreciated," says Anthony Zietman, a radiation oncologist at Mass General who specializes in prostate cancer. Many of his patients, he says, are surprised to learn that proton beam therapy exposes the bladder and rectum to high doses of radiation and does, in fact, carry a significant risk of causing impotence. Although preliminary research has suggested protons may be superior to conventional radiation for prostate cancer, there's a lack of randomized studies (the type doctors consider most rigorous) comparing the two—and standard radiation techniques are improving all the time.

...The lingering questions about prostate cancer are helping to fuel a debate over the location of new proton beam centers and the pace of expansion. Experts who believe prostate cancer should be widely treated estimate there could be a need for scores of new centers. Others contend that five to 10 evenly distributed academic research centers could better serve the rare patients who most need protons—and help determine whether the therapy should be extensively used to treat prostate and other common tumors.

We never learn when it comes to health care. Old patterns repeat. A new technology is invented. Sure, it has some good therapeutic effects for some patients; but it really takes off when marketeers or investors prey on people's fear of disease to suggest that it should be available to everybody in their backyard. A new bolus of costs is then added to the system without proper evaluation.

It feels like the last line from The Great Gatsby:

So we beat on, boats against the current, borne back ceaselessly into the past.

Here's the deal, though. If you believe that there is some overall, sustainable level of health care expenditures for a country, every dollar that goes into expanding the number of facilities like these proton beam machines is one less dollar for primary care, cognitive specialists, palliative care, and the like. If we permit the "rule of rescue" to drive our health care expenditures, we will never focus on the most cost-effective and compassionate aspects of the care delivery system.

Some of my best friends work in private equity. But I don't trust them to make the right decisions for our health care system. I would like to think I could trust CMS, but it appears to have become complicit in the medical arms race. Other parts of government remain silent as this occurs.

In 1961, President Eisenhower said:

This conjunction of an immense military establishment and a large arms industry is new in the American experience. The total influence — economic, political, even spiritual — is felt in every city, every statehouse, every office of the federal government. We recognize the imperative need for this development. Yet we must not fail to comprehend its grave implications. Our toil, resources and livelihood are all involved; so is the very structure of our society. In the councils of government, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military-industrial complex.

Change a few words and see if this doesn't describe many aspects of our health care system, fifty years later.

The experts agree on transparency

It can feel lonely out here when you are beating the drum for transparency as a necessary supportive adjunct to process improvement. So it is really nice when some of the world's experts on the topic are singing the same tune.

I just saw this article, entitled "Truth Telling: Can Your Hospital Handle It?" by Bill Santamour at H&HN Daily today. I promise that I read it after writing yesterday's post. Excerpts:

Former U.S. Treasury Secretary Paul O'Neill . . . said hospitals ought to post rates of nosocomial infections, patient falls, medication errors and employee injuries on the Internet for all to see, and he thinks they ought to do it every day. "Let's bring some energy to this," he said.

Gary S. Kaplan, M.D., CEO of Virginia Mason Medical Center in Seattle, agrees that transparency is key. Improving safety "is really about change management, making our organizations better. How can we do this unless we have an environment of transparency?"

[The government] information reported needs to be a lot more up to date, said Carolyn Clancy, director of the Agency for Healthcare Research and Quality. "We're not so good at timely transparency," she said. "We must get to a place where we get data in something like real time."

My quotes from yesterday:

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

[T]ransparency of data alone is not sufficient. What makes it powerful in establishing creative tension in an organization are: The currency of the data; the fact that the metrics being made transparent have been chosen by those involved in the process improvement efforts; and the fact that the transparent outcomes are supported by a structure of ongoing process improvement.

A hat trick for Jillian

Regular readers know the pleasure I get in coaching soccer, watching the kids learn and excel, and then staying in touch with them as they move on. You also know about my fixation on infrastructure and the enjoyment I had running the region's water and sewer system. Well, now, the two arenas have melded.

When I ran the MWRA, we introduced a school education program to teach kids about the water and sewer system. Part of the program was an annual poster and writing contest. This year, with over 1,100 posters entered, one of my soccer alumnae, 8th grader Jillian Lu, won first place in the grade 6-8 category. But, she also won first place in this age group last year, and also the year before! (At the awards ceremony last week, there was some word that her competitors are pleased than she is moving on to a new age group.)

A full picture of Jillian's entry is above, and I also provide some closeups of details. I don't recall Jillian ever achieving a hat trick in a soccer match (although she had a great shot), but she deserves congratulations for accomplishing it in this venue.

Getting transparency right

This is about transparency, when it is useful and when it is not. The term is now an established part of the health care lexicon, but there is little substantive discussion about how it is being used.

As I said in an article in Business Week over three years ago:

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

Now, there rises an additional misconception. The perversion of the transparency concept that has evolved rides on the desire of CMS and private insurance companies to use publicly published outcome data to financially reward or penalize hospitals. As expected, this is raising hackles. The complaints often heard from hospitals are ones we have discussed before: "The data are wrong." "Our patients are sicker."

I am not going to accept those complaints, but I am going to suggest that the usual government mandates for transparency of data provide little basis for the kind of process improvement we need in hospitals. What's wrong with these mandates?

For one thing, the data are old. While you cannot manage what you do not measure, trying to manage with data that are a year or two or more older is like trying to drive viewing the road through a rearview mirror. The principles of Lean process improvement and other such systems suggest that real time "visual cues" of how the organization is doing are essential. Why? Because that kind of data is indicative of the state of the organization right now, not what existed months or years ago. Such data are collected in hospitals on a current basis. If their main purpose is to support process improvement, they do not need external validation or auditing to be made transparent in real time.

For another thing, the choice of data in the government's approach to transparency is externally imposed. Process improvement occurs when the people who do the work jointly decide what areas of change are important. We need to trust that the clinicians and administrators in hospitals, working with their patients and boards of trustees, are better able to decide on quality and safety priorities than the government or its agents. We want the hospitals to be transparent about the metrics they choose, knowing that their doctors, nurses, other staff will value the results highly and act on them.

Finally, the payers' approach to transparency creates attention on meeting certain outcomes, rather than stimulating a desire to design and implement a comprehensive structure to achieve better outcomes. A wise colleague said recently, "Obsession with outcome without obsession with structure will fail."

Captain Sullenberger talked about this in another respect: "A checklist alone is not sufficient. What makes it effective are the attitude, behavior, and teamwork that goes along with the use of it."

In summary, transparency of data alone is not sufficient. What makes it powerful in establishing creative tension in an organization are: The currency of the data; the fact that the metrics being made transparent have been chosen by those involved in the process improvement efforts; and the fact that the transparent outcomes are supported by a structure of ongoing process improvement.

As we have seen by examples on this blog, those hospitals that have been most effective in the challenge of process improvement have not done so because a government agency is making their clinical outcomes transparent. They have done so because the administrative and clinical leadership, strongly supported and encouraged by boards of trustees, have made it clear that this kind of effort is a top priority. More and more places each month have discovered the importance of transparency in supporting their efforts. How this takes place will be specific to each hospital, but it is clear that, to be effective and sustainable, change must come from within.

Kudos to Glen Cove Hospital

The folks at Glen Cove Hospital are on a roll. Last October, they were listed by the New York State Department of Health as having the lowest central-line associated blood stream infection rate in medical-surgical intensive care units among 113 non-major teaching hospitals in the state. At the time, they had gone over two years without an infection of this sort.

A few week ago, I met Maureen White, RN, from North Shore-LIJ Health System, who told me that the record was now over 2.5 years. This morning, I confirmed that with Jeanine Woltmann, RN, in the Infection Control department.

As of April 30, Glen Cove had gone 1223 ICU patient-days without a central line infection. An outstanding accomplishment by any measure.

How did they do it? Was it some government regulation? Was it incentive payments from the insurance companies or Medicare?

No. They did it because they wanted to do it. Here's the magic solution:

"The superior results at Glen Cove are the result of a collaborative effort between nursing, infection control and physician staff," said Brian Pinard, MD, chief of surgery. "These clinicians have consistently put their motivation and caring into action to reduce the risk of infection while caring for patients."

The culture of patient safety in hospitals has changed dramatically in the last several years, according to Dr. Pinard. He explained that, prior to 2005, there was a common misconception in healthcare that some hospital infections were unavoidable and beyond anyone's control. He said the path to the perfect record began with the hospital's embracing the Institute for Healthcare Improvement's 100,000 Lives Campaign and its emphasis on preventing medical errors and infections.

The hospital's initiatives included communication through daily inter-professional rounds, education, and monitoring of various programs, among them hand hygiene, sterile practices and the use of universal safety protocols. This led to excellent outcomes, improved patient safety, decreased length of stay, a decrease in mortality and cost avoidance, according to Dr. Pinard.

In other words, the people at Glen Cove Hospital do not accept or believe the premise that "these things happen." I again repeat the wise words of Ethel Merman, and also present the original scene from It's a Mad, Mad, Mad, Mad World:

Now what kind of an attitude is that, 'these things happen?' They only happen because this whole country is just full of people who, when these things happen, they just say 'these things happen,' and that's why they happen! We gotta have control of what happens to us.



If you cannot see the video, click here.

Bach and Kocher: Good try. Wrong plan.

Peter Bach and Robert Kocher offer an intriguing but wrong-headed approach to expanding the roster of primary care doctors in America. In a New York Times op-ed entitled, "Why medical school should be free," the authors note:

Fixing our health care system will be impossible without a larger pool of competent primary care doctors. . . . [T]he American Academy of Family Physicians has estimated a shortfall of 40,000 primary care doctors by 2020.

Making medical school free would relieve doctors of the burden of student debt and gradually shift the work force away from specialties and toward primary care.

We estimate that we can make medical school free for roughly $2.5 billion per year — about one-thousandth of what we spend on health care in the United States each year. What’s more, we can offset most if not all of the cost of medical school without the government’s help by charging doctors for specialty training.

[U]nder our plan, medical school tuition, which averages $38,000 per year, would be waived. Doctors choosing training in primary care, whether they plan to go on later to specialize or not, would continue to receive the stipends they receive today. But those who want to get specialty training would have to forgo much or all of their stipends, $50,000 on average.

This is such a convoluted plan that it is unlikely to get much traction, but its proposal is indicative of a more fundamental problem, a huge gap in what primary care doctors and other cognitive specialists get paid under Medicare (and therefore by private insurers) compared to what procedural specialists get paid:

Our plan would not directly address the chronic wage gap between primary care providers and specialists. But efforts to equalize incomes have been stymied for decades by specialists, who have kept payment rates for procedures higher than those for primary care services.

I have discussed this problem here, and it has been documented by others. The rate-setting process used by CMS is deeply flawed. By inaction and secrecy, the agency has chosen to let specialists have the influence cited above. It is indicative of this deeply ingrained pattern at CMS that these two respected folks, high-level participants in the Washington arena,* were unable to use their positions in federal administrations to get the job done in a much simpler fashion.

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*Bach was a senior adviser at CMS from 2005 to 2006. Kocher was a special assistant to President Obama on health care and economic policy from 2009 to 2010.

The Infrastructure Chronicles -- Volume 8

In December of 2005, there was a breach of the dam holding back the 50-acre Tom Saulk reservoir in Missouri. This created what was called a mini-tsunami, with 17 foot waves.

The proximate cause of the problem was that a simple water level gauge failed, and so the power company overfilled the dam. There were redundant systems in place to measure the water levels, but they had been bypassed, leaving a single failure mode in place.

The state public service commission investigated the accident and found that the utility's "decision to continue operating Taum Sauk after the discovery of the failure of the gauge piping anchoring system and the consequent unreliability of the piezometers upon which [its] control system was based is frankly beyond imprudent – it is reckless."

The design of safety systems for infrastructure is a science, as it is in hospitals. There is one thing common to both: If you rely on a single point of control to avoid disaster, you are likely to fail. Sometimes catastrophically.

The Infrastructure Chronicles -- Volume 7

Fred Salvucci, transportation engineer extraordinaire in Boston, has often told this humorous story about his grandfather:

When my grandfather was preparing to immigrate from Italy to the US, he was told the streets were paved with gold. He learned three things upon arriving. He learned that the streets were not paved with gold. He learned that the streets were not paved. And he learned that he was going to pave them.

There was a generation of Italian stone and brick workers who constructed many of the buildings and infrastructure projects in this region. Some of them worked on the sewer system. Not much craftsmanship there, you might think, until you remember that the early sewer pipes were made with brick, not pre-cast concrete like today.

I have been inside some of those large old sewer pipes and I have seen the interior construction. The pattern of the brickwork is pure artistry. Many have lasted over 100 years in a environment that is extremely corrosive. Unfortunately (well, maybe you think it is fortunate), you cannot go and tour them. But here are some pictures from the 1902 First Annual Report of the Metropolitan Area Water and Sewerage Board that will give you an idea of what you are missing. The one above is entitled, "Construction of circular tunnel with air compressor and metallic shield, in Centre Street, Jamaica Plain." The one below in Milton required an open cut through the granite that characterizes that region and was then lined with bricks.

Person or system problem, or both?

I am going to do something really wrong, commenting without knowing all the facts. But guessing from a press report, I am betting that this story is not totally a person problem:

A Pennsylvania medical center demoted a surgeon and suspended a nurse who were involved in the transplant of a kidney from a donor who had hepatitis C, a spokeswoman said on Thursday. The University of Pittsburgh Medical Center has also suspended its live-donor liver program as a precaution, though no problems were found with that program, UPMC spokeswoman Jennifer Yates said in a statement. The medical center voluntarily suspended its live-donor kidney transplant program earlier this month after discovering the infected kidney and notified the United Network for Organ Sharing, a national transplant agency. The agency plans to conduct a review.

It will be interesting to follow this story as it develops. It will also be revealing to see if UPMC shares the results of what they learn more broadly with the transplantation community.

In the meantime, will this have an impact on the hospital's ad campaigns?