Congratulations to Peter Pronovost

Peter Pronovost has been elected to the Institute of Medicine.  Bravo!  This is so well deserved.  Here's a summary of his work from Newswise.

A professor of anesthesiology and critical care medicine and surgery at the Johns Hopkins University School of Medicine, Peter J. Pronovost directs the Armstrong Institute for Patient Safety and Quality at Hopkins and is senior vice president for patient safety and quality for Johns Hopkins Medicine, where he has transformed the way hospitals around the world think about bloodstream infections.

Peter Pronovost has brought a scientifically rigorous yet common-sense approach to eliminating medical errors and unnecessary harm, shaping the national conversation about patient safety in the process. His biggest success so far: the much-heralded, cockpit-style, five-step checklist for doctors and nurses designed to prevent central-line associated bloodstream infections (CLABSIs). The simple checklist, coupled with a program that promotes a culture of safety, has transformed the way hospitals think about bloodstream infections, which kill more than 30,000 patients a year and sicken many thousands more. Thanks to Pronovost, these infections are no longer seen as a cost of doing business. They are preventable.

Pronovost and his team have dramatically reduced ICU bloodstream infections throughout the state of Michigan and exported that success to hospitals across the nation and the world. His program is now in place in 47 states, Puerto Rico, the District of Columbia and in many countries throughout the world. As he spreads the message that CLABSIs can be virtually eliminated, he is also using these strategies to prevent other harm, such as surgical-site infections and pneumonias contracted through the use of ventilators.

In 2008, Pronovost was awarded a MacArthur Fellowship, or “genius grant,” from the John D. and Catherine T. MacArthur Foundation for exhibiting exceptional creativity and showing the promise to make important future advances based on a track record of significant accomplishment. That same year, he was also named one of Time magazine’s “100 Most Influential People.”

He is the author of the book, “Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out,” published in 2010. He is also author of more than 200 research articles.

Thought for the day

Clouded visions of purity and virtue

In an op-ed entitled, "The Thing Itself," New York Times columnist David Brooks decries the fact that, in this polarized political environment, "many issues that were once concrete and practical are distorted because they have become symbolic and spiritual."  "Nearly every practical question becomes a values question," he notes, and "to compromise on any front is to court disaster."  "There are rewards for those who fight over symbols, few who see the thing itself."  And, then, with regard to one specific program that had become a policy disaster, he explained that "its champions ignored basic practical considerations.  They were befogged by their own visions of purity and virtue."

I think this is a good appraisal of the current state of the body politic, and I am struck by how often it applies in the health care arena.  Let's face it, the issues are pretty straightforward -- providing access to health care; shifting our focus from a system based on the high-end "rule of rescue" to one based on a thorough system of primary care, prevention, and early detection; paying special attention to the management of care of the 15% of the population who account for 85% of the costs; reducing the amount of preventable harm in clinical settings; and introducing techniques of process improvement that have been proven to work in so many other sectors.  Those, to use Brooks' terms, are "the thing itself."  But then we surround them with ideology and a lack of analytical rigor in policy-making, and we end up with a stalemate, lack of progress, or, maybe worse, unintended consequences.  Let me give three examples:

Class-less

The Community Living Assistance Services (CLASS) Act, inserted into the health care reform legislation, was intended to be a voluntary program open to all working Americans. It would have provided a basic lifetime benefit of a least $50 a day in the event of illness or disability, to be used to pay for even non-medical needs, such as making a house wheelchair-accessible or hiring a home caregiver to assist with basic tasks.

As noted in the Washington Post, "The program was to be entirely self-financed with the premiums participants paid. Obama officials said that presented them with a problem: If they designed a benefits package generous enough to meet the law’s requirements, they would have had to set premiums so high that few healthy people would enroll. And without a large share of healthy people in the pool, the CLASS plan would have become even more expensive, forcing the government to raise premiums even higher, to the point of the program’s collapse."

All of this was obvious to many observers when the bill was being considered, and so it is no surprise that the administration had to conclude that the program was infeasible.  But look at this response:

“I’m very disappointed,” said Connie Garner, who helped draft the CLASS Act while on the staff of the late senator Edward M. Kennedy (D-Mass.).  “CLASS is a critical backstop, giving working families a tool to protect themselves from being one illness or injury away from poverty,” said Garner, who directs a group called Advance CLASS Inc. “The president promised to implement this program. We expect him to keep that promise.”

De-capitated

As discussed here many times, the concept of capitated, or global, payments as a replacement for fee-for-service pricing has interesting pro's and con's.  As to the key question of whether it will produce better outcomes at lower costs, though, it does not have much empirical support.

Where this is empirical support, I have found two categories of interest.  The first is those companies, like Commonwealth Care Alliance, who have taken on the care of small populations of dual eligible patients, those on both Medicare and Medicaid.  They have figured out how to manage those patients on a budget much more efficiently compared to those patients who, in essence, navigate their own way through the health care system.  This is good, although the situation with which they are compared is scarcely a paragon of anything.

The second is those systems, like Geisinger, that own both an insurance company and a provider network and are therefore able to optimize costs and transfer prices internal to their financial bottom line, and who are dominant providers in their market area.

But these kinds of example are few and far between and are not representative of the health care system.  Accordingly, there seem to be two main groups who support capitation.   One group does it for business purposes related to a corporate goal of shifting risk.  The other group adopts the rhetoric that all doctors want to do is order expensive tests and procedures to make more money.  Here's one summary from an advocacy group:

Under the global payment structure, docs are paid a set amount of money for each patient they care for, rather than for each procedure or test they provide. So, the providers have incentive to increase efficiency and better coordinate care between nurses, primary care physicians (PCPs) and specialists. 

And more of their "analysis:" 

The current fee-for-service system rewards the quantity of care over quality. You have to go to a doctor’s office or a hospital to be seen and to be tested. Each one of those visits is charged separately. There’s no incentive to do it any other way because the visits and the tests are how the doctor and the hospital make their money.

Global payments support more nurses, community health workers and cost-effective help, like online consultations or home visits. Public health must be integral to this structure as well.

When wishful thinking and rhetoric take over in a policy debate, unintended consequences arise.  This same group, for example, expressed surprised concerns "about narrowing patients’ choices for medical care," something that is inherent in the limited networks you need to make capitated payment regimes work.  Should we be relieved to know that this group "will watch to make sure residents get the care they need?

Re-admitting -- "Never" again

In the absence of a analytical support that might diagnose a particular problem in a rigorous fashion, regulatory agencies will do what regulatory agencies do:  Accept the rhetoric of their political leaders and use the hammer in their hand and see everything as a nail.

I have addressed this problem with regard to so-called never events:

In the face of slow progress, there is little doubt why the regulatory hammer is employed. But it is a crude tool. Its effectiveness as a deterrent is minimal because it does not address the structural issues underlying the problem. It emphasizes a particular outcome rather than a process that will achieve it. It penalizes people when it is too late to make a difference. Finally, it serves mainly to create resentment among those who are targets for improvement. Such is often the nature of regulation, no matter how well intended.

The target de jour is readmissions.  The Boston Globe notes:  "President Obama and members of Congress have cited high numbers of hospital readmissions as a main driver of soaring health care costs, as well as being bad for patients."  The Wall Street Journal explains that at a town-hall meeting the President  compared readmitting a patient to the hospital to bringing a car back to the mechanic -- as inapt a comparison as one could imagine.  He asserts, "And too often we’re not seeing the best practices in some of these hospitals to prevent people from being readmitted. That costs a lot of money."

This leads to the following policy prescriptions:

Starting in 2013, those with the highest rates could be docked Medicare payments. The health and human services department has pledged $500 million to help hospitals partner with community-based organizations that help patients make the transition from a hospital bed to their home.

Wow, this feels like foreign policy.  There, we pound the table and assertively define the enemy to show that we are manly and powerful leaders -- before we are accused of weakness by the other party.  We impose sanctions and supply armaments to the opposing forces, and we find ourselves in a quagmire.  In health care, we grab on to one of many interrelated clinical issues and define it to be a "main driver" and both penalize providers and throw money at the problem.  As in foreign policy decisions, I predict many unintended consequences.

The Jubilee Project explores diabetes

Here is a video by the Jubilee Project's Eric Lu highlighting the voices of diabetic patients and their struggles and dreams.  As always, every view generates a contribution for a worthy charity.

If you cannot see the video, click here.

Don't wake up late if you plan to shower

A Perfect Stay.  I can't think of another thing to say.

How bare should the bare essentials be?

An article by Jessica Zigmund in Modern Healthcare (October 10), entitled “The Bare Essentials,” presents an interesting conundrum for the federal government as it defines what should be covered by the health insurance programs that will be offered by state exchanges under the Patient Protection and Affordable Care Act.

The short version of the controversy is that an advisory panel from the Institute of Medicine has made recommendations concerning what clinical conditions should be covered.  But the National Association of Public Hospitals and Health Systems would like to see “critical enabling services,” such as language interpretation, transportation, and case-management included as well.

The balancing job for the Department of Health and Human Services is to create insurance plans that are reasonably expansive in terms of coverage, but not so much so that they cannot be offered at affordable prices.  The law requires insurance plans to cover at least ten general categories of health services: ambulatory services, emergency care, hospitalization, laboratory services, maternity and newborn care, mental health and substance abuse programs, pediatric services, including oral and vision, prescription drugs, preventive and wellness services and chronic disease management, and rehabilitative and habilitative services and devices. The coverage must also be similar to those provided by typical employers.  Over 68 million people will be likely to procure insurance under these standards.

The IOM committee viewed its role as reviewing evidence-supported medical conditions.  NAPH took a broader view.  Of course, there are cost implications here, with interest groups on both sides.  As noted in the article, “If the rule is very robust, it could make plans too expensive and not meet the law’s goal of coverage and access for all.  But if it’s too bare-boned . . . then the package could be viewed as depriving millions of people of the coverage they need.”

I have great sympathy for the points raised by NAPH.  For language interpretation, for example, it is not appropriate to rely on a family member or friend to be the go-between in a discussion between a patient and a doctor.  Indeed, it can raise grave cultural difficulties:  Imagine an English-speaking teenage son translating for a Southeast Asian woman and her gynecologist.  Neither can you expect family members to maintain clinical dispassion in an emergency room setting.  Good communications is not just a convenience:  It can be a matter of life and death.

The issue is whether the insurance plans should cover such expenses when they are essential to the treatment of the categories of illness envisioned by the law.  They are not always covered by private insurance plans now.  The hospitals absorb those expenses when they are not covered.  Perhaps it is a good time to make them an accepted and expected portion of the insurance products.

It looks like we might have to wait a while for the answer, though.  The article notes that, in typical Washington fashion, “There has been talk that a final rule might be pushed back until after the 2012 elections because of the political implications attached to it.”

What happens in Atlantic City . . . gets reported here

I just returned from giving a keynote address at the Annual Institute of the New Jersey and Metropolitan Philadelphia Chapters of the Healthcare Financial Management Association.  Regular readers of this blog will not be surprised at the themes I covered (transparency, front-line driven process improvement, the virtuous cycle between reducing harm and financial efficiency), and I need not elaborate on them here.

Instead, I want to talk about the huge variety of vendors and other companies exhibiting at the meeting.  If one were cynical, one could walk away understanding how health care and related expenses constitute 16 percent of the nation’s GDP.  But, if you look beyond that, you will see many firms that are involved in offering services designed to reduce the cost of health care and make it more effective.  Let me mention two I happened to visit.  (I have no financial interest in either.)

The first was a company called Avery Telehealth, based in Scottsdale, Arizona.   This firm is offering a readmissions avoidance program for it clients, promising a 30% reduction in readmission rates for congestive heart failure, acute myocardial infarction, and the like.  I was impressed with the no-nonsense approach employed.  It is heavy on personal involvement from care transition social workers, daily contacts from call center nurses, and using telecommunications to connect residence-based equipment to monitor patients' daily status and vital signs.

In a different category, JBH Advisory Group from New York City offers hospitals help in refining their food and nutrition services programs.  The company views these services from a retail/restaurant operations perspective rather than an institutional health care framework.  JBH consultants have assisted in over 1000 hospitals in the last 18 months, realizing a reduction in total food and nutrition services costs from 13 to 30 percent, averaging 26%.

This is just a very small sample, but I was pleased by a lot of what I saw.  On a humorous note, I include a picture of the give-aways of one bank at the trade show.  They clearly did not expect many doctors to attend this meeting, as the use of fat-and-happy-MD stress balls in the hands of finance folks might be misconstrued!

Going along to get along

The relative quiet since the state's largest insurer gave away a huge rate increase to the state's dominant health care system  --  a 2-3% increase on a base that is, what, 15 to 20% higher than the rest of the market -- is indicative of something here in Massachusetts.  After all, if there was ever a time for that insurer to challenge the market power of the provider group, this was it, with other hospitals and physicians waiting in the wings to serve the public at a lower cost and employers looking for lower priced products.

Year's ago, the CEO of this provider group said to a then-balking CEO of this insurance company, "This is what good health care costs."  The latter conceded, and the pattern was established.  The current team seems to feel the same way, even in the face of evidence from other parts of the region that such costs are not necessary to deliver high quality care.

Or maybe this was a case of going along to get along, slipping a story by a body politic and media that has lost the will or interest to focus on another large, implicit tax increase on the people and businesses of the state.

How I made the call

Here's my ruling on the soccer play described in the post below.  Thanks to all for your opinions.  This business of refereeing a football game is very challenging.  Things happen quickly and unpredictably.  I often find it useful to replay the tough calls and share them with others, as here, as part of learning to be better at this.  After 17 years or so of being a licensed referee, it still bothers me when a child is hurt, even if I think my call was correct.

Going back to the match, I allowed the goal, as a clean charge with the goalie not in possession.  The red coach differed, saying I had an obligation to protect the goalie.  The white coach saw it the way I did.  No surprises on either side there!

Here's what my referee colleagues said when I presented the case to them:

John:  Agree with your call. No real obligation to protect the keeper in the Laws of the Game. Sounds like a 50-50 ball misjudged by the keeper.

Jeff:  It might depend, for me, on the extent of the 'collision, goalie knocked down'. Part of playing fairly in going up to head a ball is to be able to come down and not knock over an opponent - a player is responsible for his momentum - body, cleats, whatever. When that opponent is the keeper, refs might apply even stricter judgement to what is a fair jump. That said, at U12 D1 a level of physical play is of course expected and needs to be accepted. So I guess for me it would depend on the extent of the contact against the keeper after the header (which I of course can't judge).

Bill:  Agree with John, assuming that white player was jumping more or less straight up. D-1 (division 1) almost requires you to allow it.

Tom: Seems like another classic case of “you had to be there to see it.”  You were the one there, so I would tend to go with your call.  Some things I might’ve considered:  I think we do have to consider that the keeper can be more vulnerable than the average player.  However, sometimes  keepers endanger themselves as “part of the job.”  What was the angle and speed of the white player when he went up to head the ball?  Did he launch himself at it and perhaps into the keeper? Or did he go up fairly vertically, in which case perhaps the keeper’s momentum carried him underneath the descending white attacker?  Sometimes, attacking players might say after a foul “but, ref, I got the ball.”  In which case the answer is that “yes, but you had to go through the other guy and foul him to get to it.”

From your description, the keeper does not have possession, therefore I would be influenced by the speed, trajectory, and control of the white attacker’s leap to head the ball and win a 50-50 situation.

BTW, players are sometimes “hurt” in games when their pride takes a hit. Maybe that was part of the play in your game? 

My reply:  Thanks, Tom. Yes, I was close and had a good angle, and I saw it as a fairly vertical jump, with the keeper going forward under him.  In fact, I remember, in that split second, being impressed with the fact that it was a remarkably clean approach to the header. (There was a big height differential between the two players.)

You make the call

It was Columbus Day weekend here, creating a holiday opportunity for many youth soccer (football) tournaments.  I was referee of a half dozen games on Sunday and Monday in Natick, a neighboring town.

Even though these are children's games, the level of play is excellent, and the games often present challenging calls for the referee.  Here's the situation I faced in one of the games.  You decide the call, and later today, I will post my decision, along with commentary from some of my colleagues.

It is a Under-12, top division, boys match, hard driving and physical but quite clean.

A high bouncing ball approaches red's goal.  The red goalkeeper comes out to get it, but it starts to bounce over him.  As it is in the air over his head, a white player, having jumped up, cleanly heads it into the goal.  The two collide and both are knocked down.  The goalie is hurt by the collision and has to leave the field.

Your call.  Allow the goal?  Or, call a dangerous play against the white attacker and not allow the goal?

Do you need any other facts to help decide the matter?

Dear NY Times, let us interpret the news

It used to be that you could count on the New York Times to separate clearly news stories from analysis or commentary, but the newspaper now regularly blurs the distinction.  Let me give an example from today's paper, in a front right story entitled (in the paper edition), "Median Incomes Shrank Further After Recession". 

By the way, that I might agree with the opinions put forth is not the point.  The point is that a news story is supposed to be news, not opinion.  Let the readers draw their own conclusions.

Here's the lede:

In a grim sign of the enduring nature of the economic slump, household income declined more in the two years after the recession ended than it did during the recession itself, new research has found. 

The use of the term "grim" is problematic, as it is the writer's characterization.  The sentence would have be accurate and properly sparse without it.  But that is minor compared to this conclusion, two paragraphs further along:

The finding helps explain why Americans’ attitudes toward the economy, the country’s direction and its political leaders have continued to sour even as the economy has been growing. Unhappiness and anger have come to dominate the political scene, including the early stages of the 2012 presidential campaign.

Where does this come from?  There is no evidence presented in the story that there is a connection between the two.  Maybe, for example, people's attitudes towards their political leaders result from those leaders behaving like incompetent boobs (my opinion).  But there is not even support included in the story for the proposition that these are "Americans’ attitudes" or that they have "continued to sour," i.e., grown in scale.  Again, I am not saying the conclusion is wrong:  I am saying that, in a news story, the reporter is supposed to provide factual support for the statements.

The rest of the story, after the page turn, is an excellent summary of economic research on the income issue, by this reporter who presents this kind of material well.

In previous decades, the Times would have separated the news story -- "median incomes shrank" -- from an accompanying news analysis story  -- "grim figures explain public malaise."  By combining the two aspects into one story, the newspaper falls into the entertainment trap of certain television networks.  Maybe that is its intent.

Two Degrees continues to warm up the world

I was pleased to hear this story about Two Degrees on APM's Marketplace, which focused on  the role of social entrepreneurs in helping with world hunger problems. 



Regular readers may recall my earlier stories about this company, which purchases and donates a nutrition food pack to a malnourished child in Africa for each one of their nutrition bars sold here.  To make it even better, the food pack is also produced in Africa, helping to support the local economy.

Here is a picture of a distribution at Shining Hope in Kibera, Nairobi, Kenya.  My friend Lauren Walters, co-founder, says the company is on track to donate 150,000 more packets by the end of the year.

A Yom Kippur commentary on the Jonah story

Rabbi Robert Goldstein, of Temple Emanuel in Andover, MA, invited me to deliver a Yom Kippur commentary today on the Jonah story.  I'm not used to combining religion with health care, but thought I'd give it a shot.  Here it is, a bit longer than my usual posts.

            We all know the first part of the Jonah story, where he avoids a divinely mandated mission and eventually finds his way back to it, after a three-day visit inside of a whale.  After all, who wouldn’t change his mind while sitting in the dark in a roiling mess of bile and dead fish?

            This first part of the story has a clear message about taking on responsibility, even when you fear the consequences.  But let’s also remember the follow-on part of the story.  Jonah has gone to Ninevah, telling them it is time to get their moral and ethical act together.  The population repents, and the king of Ninevah dons sack cloth and sits in ashes.  Even the animals fast.  The Lord spares the city.

            Now, Jonah is really upset.  He sits around stewing.  In essence, he says, since God is merciful, he would have forgiven the city anyway, so why make Jonah go through all this pain and suffering and fish gut routine.   “Take my life,” he says.  The Lord says, “Art thou greatly angry?”  No reply from Jonah is noted.

Jonah stomps out of the city and sits waiting to see what will happen to Nineveh.  God makes a plant grow over him to shade him, but then he sends a worm to bite the plant’s root, and it withers.  Now, Jonah is exposed to the full force of the sun, becomes faint, and asks again to be taken out of this world.  It is time for God to crystallize the message. 

And God said to Jonah: 'Art thou greatly angry for the gourd?' And he said: 'I am greatly angry, even unto death.'
And the LORD said: 'Thou hast had pity on the gourd, for which thou hast not laboured, neither madest it grow, which came up in a night, and perished in a night;
and should not I have pity on Nineveh, that great city, wherein are more than six score thousand persons that cannot discern between their right hand and their left hand?'

            The book ends there, after four short chapters.  With God as our role model, what guidance are we given about the general approach we should take with regard to forgiving others?

            This is an important question in the health care world.  Let me frame the issue.  I hope you will agree with me that people who choose to be doctors are among the most well-intentioned people in the world.  They devote their lives to alleviating human suffering caused by disease.  They study for years in school, do biomedical research to discover the causes of and cures for illness, and spend time generously teaching the next generation of physicians.

            There is a paradox, though, in that this same group of extremely well-intentioned people, when working together in the nation’s hospitals, constitutes the fourth ranked public health hazard in the country – in terms of the likelihood that you or I as a patient will be killed or injured while in their care.  I am not talking about dying from disease:  I am talking about the 100,000 people per year who are victims of preventable death.  That’s twice as many as US soldiers who died in the entire Vietnam War.

            The reasons for this are mainly systemic, embedded in the nature of how work is organized in hospitals.  The solutions, though, are clear and have been implemented in many other complex industrial and service environments.  And yet, the people running most of the nation’s hospitals – administrators, physicians, and their Boards of Trustees – have failed to devote sufficient leadership, energy, and commitment to solving the problem.  Indeed, when harm occurs, most people in the hospital world say, like Milton Berle to Ethel Merman in It’s A Mad, Mad, Mad, Mad World, “These things happen.”

            To which Mrs. Marcus replies: 

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. 

At the most fundamental level, we might look upon this complacency as a betrayal of the doctors’ oath to “do no harm.”  How, though, could we reconcile such a judgment with the profession’s clear devotion to good intentions?

            Well, I hate to put it this way; but good intentions are not enough.  I used to sing with the BSO’s Tanglewood Festival Chorus.  One day, a famous conductor was rehearsing the chorus, and one singer rather energetically and persistently kept making a noticeable mistake.  After several takes, the conductor put down his baton, looked into the chorus, and said, “You know, enthusiasm isn’t worth a darn if you are singing the wrong notes.”

            How much more so in the medical setting, when a mistake can result in the removal of the wrong organ, can cause a preventable terminal infection, or where there is a huge variation in practice among residents and attending physicians, giving lie to the concept of evidence-based medicine.  Dr. Brent James from Intermountain Health in Utah describes this as, "well-documented massive variation in practice based on local medical myths."  He notes: 

We continue to rely on the "craft of medicine," in which each physician practices as an independent expert -- in the face of huge clinical uncertainty (lack of clinical knowledge; rapidly increasing amount of medical knowledge; continued reliance on subjective judgment; and limitations of the expert mind when making complex decisions.) 

As Brent notes, physicians, unfortunately, have been trained to often sing the wrong notes.  The question, then, is how to persuade and re-train physicians to learn to apply a scientific approach to the delivery of care to the same degree that they have learned the scientific method in conducting medical research.  Well, oddly enough, the last portion of Jonah gives us a hint:  It is to be gracious enough in the presence of failure to forgive the offence.

Here is a representative story from my former hospital, something that happens in hospitals hundreds of times per year throughout the country:

In July of 2008, a patient woke up after orthopaedic surgery and asked her doctor, “Why is the bandage on my right ankle instead of my left ankle?”  It was at that moment that the surgeon realized he had operated on the wrong limb.  It would be hard to know who was more distraught at this moment, the patient or the doctor, who realized that he had violated a life-long oath to “do no harm.”

The surgeon immediately notified his Chief of Service and me, as CEO.  All of our department chiefs and quality assurance people met to review the underlying causes of the error.  It was quite clear that the “time-out” protocol that was our hospital’s policy, which was designed to avoid precisely this kind of error, had not been properly carried out.  In the weeks following this disclosure, a number of people asked me if we intended to punish the surgeon in charge of the case, as well as other people in the OR who did not carry out that protocol.

Some people were surprised by my answer, which was: "No, this person has been punished enough by this searing experience. He promptly reported the error to his Chief and to me.  He also took all appropriate actions to disclose and apologize to the patient, as well as participate openly and honestly in the case review."

This reaction was supported by one of our trustees, who likewise pointed out that it would be hard to imagine a punishment greater than the self-imposed distress already being felt by the surgeon.  But another trustee said that it just didn't feel right that this highly trained physician, "who should have known better," would not be punished. "Wouldn't someone in another field be disciplined for an equivalent error?" this trustee asked.

This was a healthy debate for us to have, but a wise comment by a colleague made me realize that I was over-emphasizing the wrong point (i.e., the doctor's sense of regret) and not clearly enunciating the full reason for my conclusion. He said, "If our goal is to reduce the likelihood of this kind of error in the future, the probability of doing that is much greater if this doctor is not punished than if he is."

I think he was exactly right. Punishment in this situation was more likely to contribute to a culture of people hiding their errors rather than admitting them. And it is only by having a culture in which people freely disclose errors that the hospital as a whole can focus on the human and systemic determinants of those errors.

We are left with a follow-on question, though: Under what circumstances does the need to punish someone trump the other concerns about institutional learning and a no-blame environment? Beyond the obvious case in which a doctor intentionally harms a patient -- where no one would doubt the application of punishment -- I am afraid that the answer is, "It depends."

How do you offset the predisposition of most people to want to assign blame, especially when those people are trained professionals, like doctors, whose education supported such an insidious cultural imperative?  Or putting it another way, how do you help people in an organization enjoy learning from mistakes? 

Hospitals are hotbeds of errors, so they offer us excellent laboratories within which to try and study different approaches to create a learning environment.  But, as a scientist might say, the substrate must be appropriate and welcoming.

If you are going to treat people justly when errors are made, you need a standard of justice.  In the medical world, we have a guide for just decisions about behavior.  It is a scale based on the nature of the event and the error.  In our hospital, it was formally voted upon by the medical leadership as a standard of review. 

The idea is that there are certain events that are always blame-free and others that are certain to require disciplinary action.  In the former category, we have mistakes that are made when there is no policy or process in place, when the person incorrectly interpreted an ambiguous policy or process, or when he or she was actually following the official policy.  In contrast, people can expect disciplinary action when they intentionally cause harm or tamper with the error reporting process (i.e., a cover-up); when they recklessly or intentionally disregard patient safety; or when they repeatedly violate hospital processes, policies, or standards.

But no formula can cover all events.  It is appropriate to acknowledge that judgment will be used in the “gray areas.”  This kind of formal template provides comfort to doctors and nurses that there is a standard by which their actions will be judged.  Here is an example of the virtuous response it can provoke, from a young nurse who wrote me just hours after I sent out an email to the staff explaining our view of this just culture: 

I feel inclined to respond to your email with an experience I had today on the floor. At work today I made a mistake, a medication error. My stomach turned, I felt faint . . . however I recalled my focus earlier in the day: on the integrity of the hospital and the type of light that it shined on my paradigm as I entered my day. I felt an immediate sense of freedom and put my attention on what I needed to do to correct the error. Although embarrassment and fear visited me, I wasn't overwhelmed by the emotions. I contacted the right people, and helped maintain the safety of my patient. It was a very challenging day . . . and I grew. I will go to sleep with integrity; knowing I was honest, feeling I had done all I could.

I know healthcare presents these types of moral dilemmas to all of us who choose this challenging field to work in. Beth Israel is a safe place to honestly confront these dilemmas and strive to achieve the excellence that I know can exist. 

But I need to lead you deeper into the wrong-site surgery case by suggesting that the discussion about disciplining the doctor was off point.  The question should have been:  Should we discipline the hospital’s leaders?  Let me explain.

There is a kind of team training, called Crew Resource Management (or CRM), developed by the military to enhance the functioning of crews in an airplane cockpit.  If the surgical team had gone through that training, it would have helped avoid the wrong-site surgery.

This advance in team training was not unknown at Beth Israel Deaconess Medical Center.  Just three years before the wrong-side surgery case, the doctors, nurses, and other OR personnel in the Obstetrics department in our hospital spent months learning CRM after an incident that left a baby dead and a mother near-dead for weeks.  The case was shocking to our staff, who had always viewed themselves as one of the best obstetrics departments in the nation.  Those reviewing the case quickly diagnosed that poor communications among the care team, not a lack of technical ability, was the cause of this tragedy.  Ben Sachs, the chief of the department, brought in trainers from the Department of Defense to teach his clinicians how to work together in the high-stress “cockpits” of the labor and delivery rooms.  The CRM training took many months and was mandatory for all personnel.  The result was a substantial improvement in patient outcomes, later documented in peer-reviewed journals.

We received awards for this program, as it was quite innovative in the health care community.  In the citation for one such award, it was noted: 

The success of this work has been broadly recognized and has driven or influenced similar initiatives, including those of the Harvard Risk Management Foundation, the Commonwealth of Massachusetts, the State of Maryland, and the District of Columbia, among others. 

You would have thought that, based on that experience, we in leadership positions would have encouraged and supported – if not mandated -- an expansion of that training program to everybody involved in any kind of surgical or interventional procedures.  But we failed to do so -- even though the work was “broadly recognized and influenced similar initiatives” elsewhere.  In so doing, we let a ticking time-bomb keep ticking.  It was only a matter of time before a process failure would occur in one operating room or another.  When it happened, it was more our fault than the surgeon’s.  If there was anyone to blame, it was I, the CEO, who had failed to assert our obligation to spread the learnings of the Obstetrics department to all of other medical specialties, to every appropriate team of clinicians in the hospital.

Ours was not the only organization to have learned that the leadership role in such matters is determinative of process improvement in an organization, but equally important, the personal and professional growth of people working there. Let me bring in an example from another field, oil exploration, one of the most dangerous occupations in the world.  A number of years ago, after being involved in an oil rig tragedy in which he personally had to call off the search for men left missing at sea, Tom Botts at Royal Dutch Shell decided that he would implement the most comprehensive program possible to protect workers’ safety at these remote outposts in the ocean.  Notwithstanding that program – the best in the industry – two men lost their lives on a North Sea oil rig when they mistakenly went into a portion of the facility that should have been off-limits.  It would have been easy to blame the two men who, after all, went where they should not have.  Instead, Tom launched a thorough, top-to-bottom review of the organization. He explained: 

We decided to be as open and transparent about the incident as possible and went through a Deep Learning journey involving hundreds of people that examined in detail all the root causes that contributed to the accident to get a clear picture of the system that produced the fatalities. Even though the two men who were killed could have made better decisions, my senior leadership team and I could find places where we “owned” the system that led to the tragedy. 

It was a defining moment for us when we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. That gave license to others deeper in the organization to go through the same reflection and find their own part in the system, even though they weren’t directly involved in the incident.

 Back to the second part of the Jonah story.  I hope you won’t think this sacrilegious, but maybe God decided not to punish the people of Ninevah because he realized that he was complicit in their bad behavior.  I guess this depends on your concept of God, but if there is an all-powerful being, shouldn’t he be pretty good at teaching us how to behave?  If he is going to intervene, why wait until we have gone so far down the wrong path?

There is an old joke about a guy who dies and goes to heaven, where he patiently waits in line to get through the admission process.  A fellow wearing a white jacket and stethoscope rather rudely pushes his way through the crowd to get in the entrance.  The new arrival says to his neighbor in line, “Who’s that?”  The reply, “Oh, that’s just God.  He thinks he’s a doctor.”

Perhaps the story of Jonah suggests that God is more modest than this joke implies, but only if there is a substrate upon which we can learn.  Perhaps it is our own attitude toward forgiveness that suggests whether we can be forgiven.

By the time I left my job at BIDMC, we could document that the steps we had made in process improvement and avoiding preventable harm meant that hundreds of people whom we otherwise would have killed and maimed were instead walking out of our hospital.  I had mixed feelings about that.  Of course, I was pleased; but I kept wondering whose mothers, fathers, sisters, and brothers we had caused to die in previous years – the years before we stopped saying “these things happen.”  The fact that other hospitals in the region and beyond had not gone as far as we had was no solace.  It was our mission to avoid harm, not cause it.

If it were possible, I would ask forgiveness of those families whose loved ones we hurt for so many years.  I would say, “It was I, as leader of this place, who should have worked harder, smarter, and faster to avoid the tragedy that befell your family.”  It would be my hope that such an acknowledgment would lead those people to forgive me, as God forgave Ninevah and as he ultimately forgave Jonah.

Let me end with a story of the transformative power of forgiveness.  Those who know me know of my passion for soccer, and especially for coaching girls in our community league.  I recently had lunch with one of my alumnae, now aged 28. Tovah said to me, "Do you remember that play I made in the tournament we went to in Connecticut?"

Even though 14 years had passed, I remembered her gusty play with clarity, "Of course, you made a great save in front of the goal.”  The goalie had run out to clear a ball, but an opponent had taken possession and fired at point-blank range at our net.  Tovah stood there in front of the goal and used her chest to knock down the shot.

"I don't remember that," she said, "I mean when I mistakenly headed the ball into our own goal and caused us to lose the game."

"I forget that one," I replied.

"Well, I was devastated and was sitting on the grass after the game, sobbing my heart out. You came over and said, 'Don't worry, Tovah, great defenders sometimes score against themselves. Only the best defenders go out aggressively after every open ball. Every now and then, it deflects and goes into the net. You did a wonderful job.'

"I stopped crying, stood up, brushed myself off, and walked off smiling, saying to myself, ‘I'm a great defender!’ That season was very meaningful to me.”

She remembered this 14 years later.

The lesson is so clear.  You never know when a kind or supportive word from you will make a lasting difference.  When you offer solace or encouragement to a person who has made a mistake, it matters.  To do so, though, you must truly believe that it is not the mistake that matters:  It is the lesson that can be drawn from it.

L’shanah tovah to Tovah and to all of you.

The Rabbi and the KKK

A Yom Kippur-appropriate story from SnapJudgment.

The Rabbi and The KKK by SnapJudgment

Only if state officials step up

Apropos of the story below, see this comment from a piece by Paul Ginsburg in the New England Journal of Medicine.

The unchecked market power of some providers promises to become increasingly problematic for private payers. And if market approaches prove insufficient to solve a problem of this magnitude, regulatory intervention becomes more likely.

As predicted

Big deal.

Here's what I predicted last April, with regard to the negotiation between the state's largest insurer and the state's largest provider group:

Look for the following "victory" announcement in the coming months:

The parties agree to experiment with bundled payments for certain diseases and procedures, staying far away, though, from a full system of capitation. The parties agree to a general rate increase of just a few percent. Together, they will say, this will "bend the cost curve" for this large group of doctors and hospitals. There won't be much talk about the fact that the base upon which the bundled payments and other fee-for-service payments is set remains far above market.

End result: Continued use of market power as the prime determinant in setting reimbursement rates.

So, here it is, as reported by Robert Weisman in the Boston Globe.  Excerpts:

A new pact between the state’s largest health insurer and its biggest hospital and doctors network could boost efforts to contain health care costs, both sides said yesterday.

Under the deal, annual rate increases that were projected at 5 to 6 percent for the next three years will be lowered to between 2 and 3 percent. 

The new contract won’t end payment disparities between top-paid providers and struggling community hospitals, which also are being asked to accept smaller pay increases.

Under the agreement, Partners agreed to participate in Blue Cross’s alternative quality contract, a so-called global payment that gives health care providers a budget for patient care and incentives for healthy outcomes rather than billing for each visit and procedure.

Th[at] new contract . . . covers only about 25 percent of the Partners patients insured by HMO Blue.

Big deal.

Beam me out of here, Scotty!

Johns Hopkins radiation oncology resident Kendra Harris informs us that the most common reason radiation oncologists give for not reporting medical errors is fear of getting colleagues into trouble, liability and embarrassment in front of colleagues.  This was the result of a survey of 274 people from Johns Hopkins, North Shore-Long Island Jewish Health System in New York, Washington University in St. Louis, Missouri, and the University of Miami.

Whoa!  Doctors who are sending the wrong amounts of radioactivity into us, or into the wrong parts of our bodies, or making other errors, are more worried about "trouble, liability and embarrassment" than about making process improvements?

Sorry, but this is just inexcusable.  As you know, I'm all for working on cultural changes to create no-blame environments and just cultures, but there has to be a place for individual responsibility.

Interestingly, the physicists, dosimetrists and radiation therapists who work in the radiation oncology centers are more likely to report errors.  This suggests that there is something in the system of medical education -- or in the self-selection of people who become radiation oncologists -- or both, that causes this result.

The title of Dr. Harris' paper is "Learning From Our Mistakes: A Multi-Institutional Survey of Attitudes and Practices Related to Voluntary Error and Near-Miss Reporting".

The good news, Harris says, is that few respondents reported being too busy to report or that the online tool was too complicated. "Respondents recognized that error events should be reported and that they should claim responsibility for them. The barriers we identified are not insurmountable," she added.

Good news.  Right.

Barriers.  Right.

Lead (as in Pb) between the ears -- instead of other grey matter -- it seems to me, is the main barrier.

Meryl Runion speaks with clarity

The next speaker I am hearing at the "Made Lean in America" conference is Meryl Runion, author of Speak Strong, on the topic "Phrases for Continuous Communication Excellence."

Here are excerpts of some phrases I picked up:

The way we say things really does matter.

The words we say send a signal as to our commitment to continuous improvement.

What if every conversation you had had a bit more clarity?

How to get continuous improvement in communications.  This involves several journeys and learning to use phrases that help traverse them.

The journey from perfectionistic to aspiratory:

Don't let people think of perfection as a measurement of how they are not making progress.

Imagine a world where you create an aspirational vision and don't get mixed up with perfectionism. 

The journey from performing to experimenting:

Every single conversation is a experiment, where we learn and find out what works and doesn't work.

Ask, "What would happen if . . ."

The journey from Disney to reality:

Disney created unrealistic expectations.  We have been conditioned to think that's the way it should be.

It is OK to be flawed.  Problems are opportunities.

The more I show I don't know, the more quickly I learn.

Offer, "Would you like to hear the mistakes we made along the way?" 

The journey from the problem to the process.

Say, "I notice the improvement."

The journey from "looking good and being right" to humility and learning to learn.

Say, "I won't pretend to know all the answers."

The journey from workarounds to trust.

People need to know that they can count on your word.

Protect the power of your words by saying what you will do and do it.  By saying what you mean, and mean what you say.

The journey from power to influence.

Ask, "Will you please open your fist?"

The journey from single dimensions to multi. 

The old linear thinking doesn't work.

Between these two worlds requires balance.

The journey from static to dynamic.

The words are changing.  The old words don't work anymore.  New words emerge.

IMO becomes IMCO -- "in my (current) opinion."

The Lean dentist

The next speaker I am hearing at the "Made Lean in America" conference is Sami Bahri, DDS, author of Follow the Learner: The Role of a Leader in Creating a Lean Culture.  The book describes how this organization, the Bahri Dental Group, transformed its work and thinking from a traditional batch-and-queue approach to one focused directly on the needs of the patient, not on the needs of the practitioners.

Sami related how his practice in Jacksonville, Florida was growing unsustainably.  His solution to complexity was to "hire more people," but he soon realized this was not the answer.  "I wanted to get rid of the problem.  I needed to find a theory.   With a theory, you can make quick decisions."  He then became aware of the Lean philosophy and the work of Jim Womack and others.  Reading a number of books, he figured out how to apply Lean manufacturing ideas to his practice.

Sami summarized that Lean was an evolution over time of our collective thinking.  We started as craftsmen; then moved to the division of labor; but then, with more complex processes, we had quality problems; then time and motion studies of people led to improvement of functions; and then we learned to follow the product to improve efficiency and improving quality.

Sami said, "I went back and started learning how Toyota did it.  How did Ohno start?  'The TPS started when I challenged the system.' "

Sami noted, "It took him five years to produce a high quality car.  It took me nine years in our practice."

His conclusion after all this time:  "The most important ingredient is people.  Are they learning every day?  If you want them to learn and sustain the system, you need your people."

Speaking of his practice, he noted, "Set-ups stand in the way of one piece flow.  We eliminated these."

Sami defining "leveling" as balancing load and capacity.  The idea was to distribute procedures, according to TAKT time, evenly throughout the schedule.

He had to define "flow" in dentistry.  This resulted in a system of one appointment to see all providers.  The end was continuous treatment, with no delay between providers (just-in-time treatment).

His goal was that the patient's stay time would be equal to the treatment time, eliminating waits, optimizing use of the patient's time but also the providers' time.

The treatment the patient receives changes during the appointment, but the patient location stays the same.  Providers move to where they are needed.  Crossing the functional barriers was key.  The hygienists, whose lives improved dramatically under this approach, ultimately said, "Please don't give me my own room.  I'll go to whichever room the patient is located."

Sami reported on patient satisfaction surveys, showing a remarkable uptick in their views about his office and his staff.

All in all, this was a marvelous presentation by a thoughtful entrepreneur applying the theories of Lean to a new setting.

John Shook on "The big lie about outsourcing"

The keynote speaker at today's "Made Lean in America" conference, is John Shook, CEO of the Lean Enterprise Institute.  He is seen here with Lesa Nichols, whom John describes as a true TPS (Toyota Production System) expert with GBMP (Greater Boston Manufacturing Partnership).  His speech is entitled "The Big Lie About Outsourcing."  I'll try to pick up main points as he talks and relay them to you.

John related two recent conversations with CEOs of two American businesses, one medium sized and one large.  The CEOs at both had outsourced parts of their manufacturing processes, but had concluded, when thinking about the current recession, that they could do better by bringing things back from overseas.  Making things where you sell them seemed to make more sense, if you could do so in accordance with Lean principles.  Indeed, says Shook, outsourcing takes us far from the concept of effective value stream management.  It is not a matter of just the lowest piece price.  But even with a low piece price, it is not always cheaper to go abroad.  The lowest labor cost is not always indicative of total value.  The rush to outsource to garner economies often meant that we lost the core capabilities of our companies.

Value stream dynamics is a way to think about this. 

The ideal supply chain is one with the effectiveness and efficiency of vertical integration, but with the flexibility of looser networks of suppliers.  But that is very difficult to accomplish, and describing it that way can be interpreted as a "a solution to copy," without understanding the real purpose of the relationships.

The key is trust among all the participants in the value stream.  Within a company, TPS/Lean does this is a very specific way.  It is both a social system and a technical system.  When a person sees a problem, s/he calls it out; the manager responds in real time; a root-cause analysis is performed; and solutions are developed and implemented.  The philosophy is, "I'm going to trust the front-line worker to initiate this."

If this is true within a company, it also has to be true between the company and its suppliers.  We should not think of the supply chain (outsourcing) as series of discrete transactions.  Instead, it should be viewed as an opportunity for deep learning.  This creates deep adaptability as things change.  Instead of optimizing discrete transaction points, we want to create an adaptive learning system.

We need to work towards the concept of total system efficiency, not just low piece costs.  How can we synchronize things through this system?  The same kind of trust needed within a company must exist across the corporate relationship, too.  This is very different from what we have seen over the last several years.

We have a great opportunity: To reconfigure value streams, both with and between companies, and make them as rational as possible.