Just a bit off, Dr. Gupta

As well intentioned and thoughtful as he is, Sanjay Gupta nonetheless misses the point in his recent New York Times op-ed "More treatment, more mistakes."  The theme of the chief medical correspondent for the Health, Medical & Wellness unit at CNN is:

Certainly many procedures, tests and prescriptions are based on legitimate need. But many are not.... This kind of treatment is a form of defensive medicine, meant less to protect the patient than to protect the doctor or hospital against potential lawsuits. 

Herein lies a stunning irony. Defensive medicine is rooted in the goal of avoiding mistakes. But each additional procedure or test, no matter how cautiously performed, injects a fresh possibility of error.

With a quick aside in admiration of Peter Pronovost's approach to harm reduction and some other process improvements, he then says:

What may be even more important is remembering the limits of our power. More — more procedures, more testing, more treatment — is not always better.

And then, remarkably, he presents M&M conferences as a remedy:

One place where I have seen these issues addressed is in Morbidity and Mortality, or M and M — a weekly gathering of doctors, off limits to the public, which serves in most hospitals as a forum for the discussion of mistakes, complications, deaths and unusual cases. It is a sort of quality-assurance conference where doctors hold one another accountable and learn from one another’s mistakes. They are some of the most candid and indelible meetings I have ever attended.

Having a consistent gathering to talk about the mistakes goes a long way toward that goal, and just about any institution, public or private, could benefit from a tradition like M and M. 

OMG.  Dr. Gupta has inadvertently given us a wonderful exposition about a lack of understanding of the nature of quality and safety process improvement in hospitals. Most harm is not caused by a doctor making an error of commission, i.e., an extra test or an unnecessarily executed procedure. The number of reported adverse events from such instances is dwarfed by other forms of harm -- hospital acquired infections, falls, failure to rescue, pre-39 week induced labor.  Many of these are not even reportable as harm.

Dr. Gupta's presentation reflects no knowledge about the science of process improvement.  Peter Pronovost's check list is not just a good idea.  Brent James' introduction of clinical protocols is not just a good idea.  These are approaches that introduce the use of the scientific method into the clinical setting.  In contrast, M&M conferences are essentially anecdotal reviews of an incredibly small number of adverse events.  I would not understate their importance as teaching tools (when they are conducted in a pedagogically appropriate manner), but they do not deal with systemic problems, with near misses, with the manner in which communication fails.

As Lucien Leape and others have stated, and as Dr. Gupta makes clear in a way he certainly did not intend, the medical profession needs to have dramatically improved training in the science of process improvement as part of the undergraduate and graduate medical education curricula.

CampaignZERO empowers patients with knowledge

As an adjunct to Martine's book, summarized below, check out the website from CampaignZERO.  It provides the actual check lists that should be employed in a number of clinical situations.  As an informed patient or family member, you can participate in a positive way to help reduce the likelihood of preventable medical errors.

There's a page, for example, about ventilator associated pneumonia, giving things a loved one can look for during the treatment of the patient, along with early warning signs of trouble.  That is just one of several conditions covered.

The organization lists its goals as follows: 

CampaignZERO delivers safety strategies to patients and their family-member advocates to prevent medical errors.

We know that family members especially can be empowered to help zero out those errors—and we’re here to help guide the way.

Our mission at campaignZERO is to foster collaboration among patients, their advocates and health care team. We believe this will result in better quality care and support for medical staff, especially nurses who serve on the front line in every hospital.

The Take-Charge Patient

In one of those ironies that sounds implausible, author Martine Ehrenclou found herself suffering from debilitating, chronic pain during the research for her book The Take-Charge Patient: How you can get the best medical care.  So she got to try out her own advice.  I am sure that helped strengthen the book and expand her already empathic view of the world.  She notes, "I never expected to live each chapter of this book, but it did prove to me just how invaluable this information is."

This is a very good book, loaded with helpful suggestions and advice for patients (and families) of all types. This is no excoriation of the medical profession.  Its premise is that a strong partnership works best.  The theme: "Taking charge of yourself as a patient is essential in order for your doctors and other medical professionals to serve you in the way they know best.  Your health care is a team sport."

I found the style to be approachable and readable.  The substantive content is excellent, as well.  Whether you are currently a patient or will be one, this is an excellent addition to your bedside table.

Well done, Partners!

John McArthur must be smiling.  But even the former Dean of Harvard Business School--the brains behind the concept of creating a provider network "too big to exclude" from any insurance company's product line-- could not have anticipated the degree to which the state's body politic would stand by and watch the aggrandizement of economic power that has occurred since the Partners Healthcare System was created in the early 1990s.  Indeed, beyond watching, the state is now poised to assist in a continuation of that trend.

The ability of Partners to demand and receive above-market payment rates from insurers has been well documented.  There is the apocryphal-sounding story of CEO Sam Thier saying to the head of Blue Cross Blue Shield, when the latter balked at a PHS rate request, "Bill, this is what good health care costs."  Bill paid it.  Then there was the attempt of Tufts Health Plan, a second tier insurer (in terms of size), to pay less.  Partners started a million-dollar marketing campaign to inform Tufts subscribers that they would no longer be able to go to Massachusetts General Hospital or Brigham and Women's Hospital.  Those subscribers threatened to leave the insurer in droves.  "Tufts surrendered in little more than a week."

But that is just a well-executed business strategy.  The real accomplishment of Partners has been its ability to persist in the exercise of such market power even after the disparity in payment rates was clearly documented--even after business leaders (i.e., subscribers) and government officials (i.e., protectors of the public interest) were led to understand that the Partners rates were, in effect, a tax on the state economy in the range of $200 million per year.  The body politic was told, in simple direct sentences:

Price increases, not increases in utilization, caused most of the increases in health care costs during the past few years in Massachusetts. Higher priced hospitals are gaining market share at the expense of lower priced hospitals, which are losing volume. The commercial health care marketplace has been distorted by contracting practices that reinforce and perpetuate disparities in pricing.

The latest evidence of the degree to which the company's political strategy has been effective is in the passage of legislation by the House and Senate this week.  The bill, now on the Governor's desk, has been erroneously described by one news report as "setting the stage for Massachusetts to become the first state to ­establish a target limiting how much providers and insurers spend on medical care."

Of course, it does no such thing because the horse has already left the barn.  Recall that just a few months ago, the state's largest insurer awarded Partners a rate increase larger than the statewide average, on a base that was already substantially above that of other provider networks. The goal was to ink this deal before legislation might pass that would limit such increases, as I noted several months before the contract was signed.

The figment of cost control in the new legislation has no effect on this result.  Why?  The bill, says the same news report:

would allow health spending to grow no faster than the state economy overall through 2017. For the five years after that, spending would slow further, to half a percentage point below the growth of the state’s economy, although leaders would have the power under certain circumstances to soften that target.

Providers and insurers that do not meet the spending targets would have to submit “performance improvement plans’’ to a new state commission. Failure to implement their plans could lead to a fine of up to $500,000.

The problem, of course, is that a provider network like Partners with costs well above the state average will find it easier to meet the governmental targets than those with lower costs.  Why?  Because each hospital or network will be judged on its percentage increases.  If you have a higher base, you can increase the absolute number of dollars being spent to a much greater extent than those with a lower base and still meet the percentage target.  Ironically, again, the state is acting to increase the disparity in costs between the have's and the have-not's.  It is enhancing Partners' market power.

Some will point to the fact that a new commission "would be required to conduct a 'cost and market impact review' of certain providers, including those that want to expand or do not meet the state’s spending benchmarks."  You can be sure that Partners will handle its accounts in such a way as to never be the target of such a review.  On the expansion front, in a strategy of burying the money, it has already invested heavily in new facilities.  This provides a twofer, avoiding future constraints on its ability to expand without state review while further increasing the cost basis against which future percentage increases will be measured.

The ability of Partners to succeed in the political domain has allowed it to get state authorization for mechanisms that will guarantee its market dominance for decades to come.  This all represents a superb execution of its business strategy.  Staying on message--persistent advertisements and press releases and speeches setting forth the assertions of a concern with cost control--wears people down.  In any event, such messages receive no rebuttal or rigorous analysis by the media.  Sprinkling money in support of worthy causes buys complacence or acquiescence by advocacy groups.

The overall context in the state makes this easier.  The local business community fails to be organized around these issues even though the current situation has a huge impact on their bottom line.  Indeed, one business group strongly opposed even the limited amount of government intervention contained in the bill.  Further, a one-party state offers no chance for loyal opposition in the halls of the legislature.

Well done, Partners.

Check out the FMLM blog

I just came across this blog from the Faculty of Medical Leadership and Management in London.  The purpose:

The Faculty of Medical Leadership and Management is a new UK-wide organisation that aims to promote the advancement of medical leadership, management and quality improvement at all stages of the medical career for the benefit of patients.

The idea of the blog:

The FMLM blog publishes original articles on a range of issues relating to medical leadership and management.

Our blog authors are FMLM members and invited guests from a variety of grades, specialties, backgrounds and geographical locations, each with a unique perspective on leadership and management issues.

I have paged through and found a number of thoughtful articles and am pleased to recommend it for your perusal.  I have also added it to my blog roll.

Attitudes are one thing, behavior is another

A recent article in Medical Education, "Changes in intern attitudes toward medical error and disclosure," compares the results of a survey conducted ten years apart:

Two cohorts of interns for the academic years 1999, 2000 and 2001 (n = 304) and 2008 and 2009 (n = 206) at a university hospital were presented with two hypothetical scenarios involving errors that resulted in, respectively, no permanent harm and an adverse outcome. The interns were questioned regarding their likely responses to error and disclosure.

Here are excerpts from the results:

For both scenarios, the percentage of interns who would be willing to fully disclose their mistakes increased substantially from 1999–2001 to 2008–2009.... 

About two thirds of fully disclosing interns in both scenarios believed ‘the patient’s right to full information’ to be the primary reason for their disclosure.

Prior training about medical mistakes increased more than four-fold between the cohorts.

The conclusion:

This comparison of intern responses to a survey administered at either end of the last decade reveals that there may have been some important changes in interns’ intended disclosure practices and attitudes toward medical error.

"Hold on," says my colleague David Mayer, who has been at the forefront of medical student and residency training programs in quality, safety, communications, and disclosure.  He warns us to be wary about believing attitude data:

We all say the right thing – we are not prejudiced about race or religion, we love mom and apple pie, etc. But what do we do when no one is watching is what makes the difference. Behaviors are much more important than attitudes.

An example is in reporting of adverse events, near misses, and unsafe conditions:

People say it is important for safety, but how many reports do people submit? AHRQ data say the vast majority of care givers submit none or a rare one that has to be submitted because of seriousness of harm.

He also reminds us to distinguish between real training and a lecture:

Medicine loves to give a 50 minute lecture on something and then call it training and part of a curriculum. We do this with ethics, professionalism, human factors, etc.

He elaborates:

The question I would have liked to see studied is (1) how many had serious training and (2) saw a disclosure role modeled in the real world by an MD/organization, and (3) then went to work in a place that made disclosure part of their culture (e.g. Michigan, UIC). That would be interesting because I believe most students would say the education and TRAINING (heard real patients describe how bad they were treated when lied to, got to do a simulated disclosure with an SP, appreciated how difficult a conversation it is to do, got feedback through debriefing, etc) helped them prepare for the time they had to do the disclosure communication. That is how we train students to give other bad news (e.g., telling patients they have cancer) and there is lots of data that shows the educational model is beneficial to them later when they have to have that conversation. I believe that is how you change culture…and behavior (not attitude).

Bravo, Ipswich! (And I don't mean the Tractor Boys.)

John Watson, director of operations at Ipswich Hospital NHS Trust in the UK, included the following message in this week's staff newsletter.  Going to gemba is at the heart of Lean.  This is a great start!

Many hospital managers find their time tied to countless meetings, reviews of performance targets and other duties that take them away from the ‘front line’. We lose contact and understanding. However, what we know is once we spend more time out where the work is being done watching what is going on we will be surprised what we learn. We learn that the jobs we are asking our staff to do every day are often not do-able because there are not stable and reliable processes to support them. It helps managers to know what the problems are every day that are preventing our staff delivering waste-free care because we can then prioritise our work.

Therefore we have started a weekly process where a group of 20 senior Trust managers block every Tuesday morning to just go out to the front line and respectfully watch what’s happening. Each week we plan to place these managers, myself included, into 20 different areas. This is not checking up on colleagues. This is watching to learn and see where we can better help.

Last week I observed Sarah Willingham undertaking the receptioning of the Ophthalmology Outpatient clinic. I was struck by her calmness and professionalism despite the relentless pace of how her job needed to be done. I noticed small things that we simply haven’t designed properly to help such staff. Her phone was on another desk and she had to get up repeatedly to answer it or use it to chase notes. My hope is that gradually we find ways to learn from such observations and correct the countless little things that our dedicated staff have to find a way through.

If you have an area you would like us to come and watch or if you would like to be involved please let me know. If you have to deal with a work process that you think could be made better and have an idea please let me know or ask us to come along and observe how you try to work with it. This is a simple but small yet crucial step into how we think and act differently.

Will the NHS medal?

I am guessing that many Americans who watched the opening ceremonies of the Olympics were, at best, confused by the presence of National Health Service nurses during the choreography.  Here's a video of a portion of the show:



Indeed, Los Angeles Times sports writer Diane Pucin tweeted, "For the life of me, though, am still baffled by NHS tribute at opening ceremonies. Like a tribute to United Health Care or something in US."

This prompted a response by @swaldman: "Well, maybe, if United Health Care were government-run and a source of national pride."

And another by @MaxwellLeslie: "The NHS is one Britains greatest & most loved Institutions, reinforcing the ignorant American stereotype very well with that tweet."

Remember when Don Berwick was nominated to head up CMS, the US Medicare agency?  One of the strikes against him by conservative opponents was that he had expressed admiration for the British health system.

This is what Don actually said on the occasion of the NHS' 60th birthday:

The National Health Service is one of the truly astounding human endeavors of modern times.  Just look at what you are trying to be: comprehensive, equitable, available to all, free at the point of care, and – more and more – aiming for excellence by world-class standards.  And, because you have chosen to use a nation as the scale and taxation as the funding, the NHS isn’t just technical – it’s political.  It is an arena where the tectonic plates of a society meet: technology, professionalism, macroeconomics, social diversity, and political ambition.  It is a stage on which the polarizing debates of modern social theory play out: between market theorists and social planning, between enlightenment science and post-modern skeptics of science, between utilitarianism and individualism, between the premise that we are all responsible for each other and the premise that we are each responsible for ourselves, between those for whom government is a source of hope and those for whom government is hopeless.  But, even in these debates, you have agreed hold in trust a commons. You are unified, movingly and most nobly, by your nation’s promise to make good on an idea: the idea that health care is a human right.  The NHS is a bridge – a towering bridge – between the rhetoric of justice and the fact of justice.

And then he moved on to say:

Is the NHS perfect?  Far, far from it.

[I]n improving its quality, two facts are true: the NHS is en route, and the NHS has a lot more work ahead. 

How can you do even better?  I have ten suggestions:

And then he went on to outline those, summarized by columnist Ezra Klein, as follows:

Conservatives have convinced themselves that the NHS is a terrible system, which I guess is their right. But insofar as Berwick is actually offering recommendations to government-run health-care systems -- and that's what he's doing here, and what he'll be doing at CMS -- his guiding principles seem fairly inoffensive.

What were those radical suggestions?  Well, as I read them, they would apply just as well to the health system of the United States and every other developed country I have visited:

1.  First, put the patient at the center – at the absolute center of your system of care.

2.  Second, stop restructuring. 

3.  Third, strengthen the local health care systems – community care systems – as a whole.

4. Fourth, to help do that, reinvest in general practice and primary care.

5.  Fifth, please don’t put your faith in market forces. 

6.  Sixth, avoid supply-driven care like the plague. 

7.  Seventh, develop an integrated approach to the assessment, assurance, and improvement of quality. 

8.  Eighth, heal the divide among the professions, the managers, and the government. 

9.  Ninth, train your health care workforce for the future, not the past.

10.  Tenth, and finally, aim for health.

So, my take is like Don's.  Both beloved and berated by the British citizenry, the NHS is a marvelous social experiment that is nowhere near the finish line.  With a most dedicated and caring staff and bureaucratic beyond belief, both, it carries the torch forward.  In the former colonies (the US), we take on the task in a different way, but we face the same issues.  Indeed, as I have noted, "After all, the countries are dealing with the same organisms, both biologically and politically."   The two types of systems have a tendency to converge in many ways, "Suggesting that -- in all systems -- a concerted focus on quality, safety, transparency, and process improvement would be well worthwhile."

Bills, laws, and consequences

Here are two news items that reflect the inclination of public officials to play fast and loose with the issues when it comes to health care legislation:

(1)  The New York Times reports that a result of the new federal health care law is that hospitals serving uninsured immigrants are likely to face budget stresses since those people are not eligible to participate in the health care insurance exchanges envisioned by the law, nor are they eligible for Medicaid.  This comes as no surprise to students of the new law, but the response from the President's folks is off-point and misleading:

The Obama administration said the Affordable Care Act supported safety-net hospitals in other ways, pointing to measures that raise payments for primary care and give bonuses for improvements in quality. 

Raising rates for primary care doctors does nothing for this population and also does nothing for hospital finances.  As for bonuses for quality improvements, they are accompanied by penalties for such things as relatively higher readmission rates.  Recall this conclusion from a study conducted at Brigham and Women's Hospital:

Among 905 764 discharges in our sample, patients discharged from public hospitals (27.9%) had higher readmission rates than nonprofit hospitals (25.7%, P<0.001), as did patients discharged from hospitals in counties with low median income (29.4%) compared with counties with high median income (25.7%, P<0.001).

Conclusions—Given that many poor-performing hospitals also have fewer resources, they may suffer disproportionately from financial penalties for high readmission rates.  As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care.  (Circ Cardiovasc Qual Outcomes. 2011;4:53-59.)

(2) Meanwhile, at the state level, the Governor shows up as a late arrival on the issue of the disproportionate rates paid to certain health care systems, a pattern regularly documented by the Attorney General.  Under the misleading headline, "Patrick offers a plan to control care costs," a story reports:

The governor’s plan requires the administration to conduct a “cost and market impact review’’ of any medical provider it suspects is engaging in or plans to engage in anticompetitive behavior.

The reporter lets the administration off the hook by never addressing why it needs legislative authorization to do what it already has the authority to do.  Until now, the Governor has carefully ducked the issue whenever it has been brought up.  His administration has been MIA, notwithstanding the AG's presentation of her annual findings to one of his line state agencies under previously approved legislation.

By the way, even with no teeth, the proposal has opposition:

[The] president of the Massachusetts Taxpayers Foundation, said the plan is “an open invitation for unaccountable bureaucrats to go on a witch hunt.’’

As if those bureaucrats would be any more unaccountable than the people involved in secret negotiations between the dominant provider and the dominant insurer.

Lucia's Kitchen: Not your beachside clam shack

Several years ago, Lucia Velasco-Evans started business in a small roadside stand.  Her vision was to offer foods from or inspired by her home land of Mexico.  Things went well, and she expanded into this larger quarters.

If you are traveling on Route 1 through York, Maine, and are looking for a change from fried clams and other beach food, this is the place to go.  Our favorite was the budín azteca: layers of corn tortillas, pulled chicken, mole sauce and cheddar cheese.

In addition to sit-down and takeout service, Lucia offers catering.  Here is the website.

I asked when the cookbook would be published.  She claims not to have time to do that.  The world is less for that, and I am hoping she writes one some day.  I suggested she start with Tastebook to make it easy.

Canada stories

I have just returned from a very pleasant camping and touring trip to New Brunswick and Nova Scotia, two beautiful provinces with lovely and interesting people.  As much as I try to put health care and process improvement behind me during vacations, they somehow manage to impinge, often for unexpected reasons.  Here are three anecdotes and observations that arose.  I offer them for what they are worth.  Again, please understand that the context was always one of warm and caring people, but people who face systemic and societal issues--just like south of the border.

Low tide in Alma, on the Bay of Fundy

The first story is a humorous one that comes from a seafood restaurant in Alma, NB, on the Bay of Fundy.  They were serving a linguini and sea food dish (with scallops, shrimp, and haddock), and I asked the waitress if I could please add a lobster tail to the dish.

"No," she answered, "all of our ordering is by computer, and there is no button to push to add lobster."

"What if you were to talk to the chef and ask him to add it?" I inquired.

"It is easy for me to talk to the chef.  We talk all the time," she said, "but he can't do it either because there is no button he could use."

Hmm, not a very customer-centric or Lean process!  While I was tempted to try a Five Easy Pieces approach to the problem, it seemed simpler to just order something else.

Scallop fleet in Digby, NS

The second story comes from a community hospital in Nova Scotia.  A member of our party had taken a dive into the surf and had been thrashed into the sand by a crashing wave.  He bumped his head badly and jarred his neck, and he needed emergency care.  Beyond the possible concussion, there was a clear danger of spinal cord injury or broken neck bones.

The Canadian health care system is quite good, and we knew we could expect good treatment.  What we did not understand is that a person from another country has to personally register and prove his or her ability to pay before going through the ED triage nurse.  So, this injured patient was sent to walk to another part of the hospital and spend a good amount of time filling out paperwork--including a promise to be bound by the legal system of the province in the event of a malpractice claim--before being evaluated.  Once this was over and the patient could be seen, the doctor immediately fitted the person with a neck brace, just in case there was serious spinal injury.

In the US, for all of its health care system problems, no such patient would have been sent to another part of the hospital and required to fill out such forms before being immediately seen in the ED.  Also, a family member would have been permitted to fill out the required forms.

Also, the patient needed a CT scan, which was not offered in the local hospital.  The staff at the local hospital called ahead to the regional hospital and said someone would be waiting for us.  We drove to that hospital, about 20 minutes away.  Not only was no one waiting, but the person at the front desk wanted the patient to go through all the paperwork again.  After persuading that person that the forms were already filled out, the patient was sent to radiology, where the door was locked and no one was visible.  Rousing a custodian, the patient finally found the way to the CAT scanning area and found a technician.

Again, the actual medical care at each step of this process was excellent, and the clinical staff were attentive, friendly, and professional.  And we were through the whole diagnosis in under four hours.  I found myself, though, comparing the process with that in the US, where EMTALA rules the day when a patient shows up in an ED, requiring immediate care without regard to legal status or ability to pay.

Hodo Cookies at the St. John (NB) City Market

The third story relates to obesity.  I have come to understand that this a worldwide problem in developed countries, and the US is a prime example.  I did not expect, though, to see it in the Maritimes.  More frightening than in the adults, the rate of teenage and young adult obesity was clearly visible.  This made me think that Canada, which has done so well in controlling its health care costs, is in for an inevitable uptick over the coming decades.

Triples on WIHI

July 26, 2012: Triple Perspectives on Triple Aim in a Region
2:00 – 3:00 PM Eastern Time

Guests:
Craig Brammer, Director, Beacon Communities, Office of the National Coordinator for Health Information Technology, US Department of Health and Human Services

Shelley B. Hirshberg, MHSA, Executive Director, P2 Collaboration of Western New York; Project Director, Western New York Aligning Forces for Quality(AF4Q), Robert Wood Johnson Foundation

Carol Beasley, MPPM, Executive Director of Strategic Projects, Institute for Healthcare Improvement

Katherine Browne, MBA, MHA, Chief Operating Officer, National Program Director, Aligning Forces for Quality, Robert Wood Johnson Foundation
 
There’s a lot of interest in the Triple Aim in the US, Canada, and several European countries. And it’s no wonder. Ever since IHI conceived of the framework of the simultaneous pursuit of better health, better health care, and lower per capita costs, a whole array of strategies have opened up for health care improvers. Some of the most interesting and groundbreaking strategies have built as much on insights from outside health care as within. And, just imagine if the various communities making headway with the Triple Aim started to think regionally? Well, many are and that’s the evolution we’re going to learn about on the July 26 WIHI, tapping into three related but unique endeavors: IHI’s Triple Aim Initiative (with special focus on recent regional work), the Beacon Community Program (a project of the Office of the National Coordinator for Health Information Technology), and the Robert Wood Johnson Foundation’s Aligning Forces for Quality (AF4Q).

These three efforts combined have already impacted nearly 200 communities, to the point where many now realize that thinking regionally is the logical next step. Among other things, a regional focus forces an examination of cross-cutting social issues that affect more than a single community – issues such as unemployment, education, transportation, and crime. One community’s solutions to the needs of an aging population, people with chronic conditions, and individuals with complex social problems might benefit the community next door. Further, a regional outlook necessitates building even broader coalitions, drawing on the expertise of health systems operating in multiple locations, state and municipal leaders, public health experts, urban planners, economic developers, and more.  

Our guides for the July 26 WIHI are Craig Brammer, Katherine Browne, Carol Beasley, and Shelley Hirschberg from AF4Q’S initiative in western New York. This effort alone has some 270 partners and a portfolio of projects, including health information technology, that point to what’s possible when one starts to act regionally as well as locally. We’ll be identifying other emerging regional “movers and shakers” as well. We look forward to your interest and your ideas on this next WIHI. See you then!

To enroll, please click here.

Time off

I'm taking a blogging break for a few days.  See you later in the week.

No hype on Lean

I sometimes hear skepticism from hospital CEOs who are presented with the idea of adopting the Lean philosophy for their institution.  "Why does this feel like a religious sect?"  "I have no interest in learning Japanese."

Putting aside the ethnocentric context for the latter statement, in that the philosophy was actually introduced to the Japanese by W. Edwards Deming, let's admit that Lean is not for everybody.  But let's also acknowledge that it can make a huge difference for hospital staff and patients when it is undertaken carefully and in good spirit, with commitment from senior leaders.

Here is a short and thoughtful summary of some experience to date, an article in Hospitals and Health Neworks by Steven Garfinkel based on research conducted for the Agency for Healthcare Research and Quality.  The bottom line:

At every institution, staff at all levels reported improved employee satisfaction. They cited opportunities for front-line involvement in problem solving, employee collaboration across ranks and units, efficiency improvements, opportunities to spend more time with patients, and improved patient experience. 

Not surprisingly, cost-benefit ratios and return on investment were never explicitly considered when the organizations we studied adopted Lean. Instead, senior executives were committed to improving quality and efficiency. They adopted Lean because it was tractable — particularly when reliable estimates of cost and benefit were difficult to make. Once leaders adopted Lean, none paid much attention to implementation costs. Top managers saw Lean as part of an array of available quality-improvement tools. All said they were pleased with Lean's results. They viewed Lean as yielding long-term process and quality improvements that enhanced their institution's efficiency and financial viability.

We cannot be sure that Lean is more effective than other process improvement techniques. But we did find that Lean can be successfully adapted from manufacturing to fit the complexities of health care.

Cost structures in search of revenue

A colleague recently quoted a Harvard Business School professor (I forget which one), who said “Businesses are cost structures in search of revenue streams.”  I don’t know this professor or what he had in mind exactly, but I want to offer my interpretation.  I believe that what he was suggesting that, no matter how innovative or entrepreneurial a firm might have been at its start, once it is has been in existence for some time and has an established place in the social economy, its goal in life is to persist.  It leaves the world of innovation, often loses its purpose, and exists solely to exist, i.e., to cover its costs.  Often this is a reflection of the corporate hierarchy, where, sadly, leaders lose their sense of providing true value to their customers, intent instead on aggrandizing their own position and preserving their status.  The firm no longer reflects the creativity of risk-taking, becoming a bureaucratic shell of its former glory.

A good friend of mine, a retired doctor, has been pestering me for years on this topic, saying that this is what has happened to many of the formerly great hospitals in America, particularly the academic medical centers.  She views this as a relatively recent phenomenon.  She does not assert that the doctors and nurses are any less caring or dedicated, but rather that the leaders of these centers have become calcified with regard to their social mission.  They focus instead on expanding market share, growing margins, and attracting philanthropists to contribute to unnecessary and flamboyant edifices.  They have no real interest in reducing costs, but rather in obtaining and securing revenue streams to cover ever-increasing costs.  Most importantly, they neglect the harm they cause to patients in their facilities, preferring to assert that they deliver high quality care without being willing to be transparent with regard to actual clinical outcomes.  When they are shown data that indicate that their levels of care are no better than others, or perhaps worse, they answer that “the data are wrong” or “our patients are sicker.”

I have been agnostic with regard to my friend’s assertions.  For one thing, my experience in the medical field is of more limited duration, so I could not ascertain whether the change she suggests has occurred.  For another, I am more optimistic in nature than she, and so I tend to see half-full glasses rather than half-empty ones.  Also, I have been lucky to spend lots of time with hospital leaders like Paul Wiles, John Toussaint, Gary Kaplan, Jeff Thompson, and Ora Pescovitz who represent the vanguard of those focused on the things of most value to the communities they serve.

But this week, I was informed of an event that has shifted me more into my friend’s camp.  In response to a top ranking by US News--a ranking that, as I have discussed, has virtually no probative value--a local hospital actually organized a celebratory parade of an amphibious tour boat (Duck Boat).  In the past, such parades (admittedly more extensive) have been used to promote the championship seasons of local sporting teams (like the 2007 Red Sox, above), thereby giving fans a chance to yell and scream and applaud their athletic heroes.

Now, I am all for celebrating accomplishments.  At my hospital, we, too, used to be happy about favorable media ratings, even if we knew they were fundamentally meaningless.  But to spend thousands of dollars on a self-aggrandizing circuit (as well as on the right to use the US News logo in publicity) seems to me to reflect exactly the kind of behavior suggested by my friend.  How does this kind of activity promote anything good or useful about the provision of high quality and safe health care in the community?  It appears to be mainly a commercial activity designed to garner market share and otherwise stimulate revenue growth for an entity that, as I have noted, could do so much more to demonstrate a commitment to the kind of care that some of its own faculty and that of other institutions has been shown to save lives, reduce morbidity, and lower costs.

This Duck Boat rally is especially noteworthy when you read the actual words of the editor at US News who notes that the rankings are "to help those who need an unusual degree of skilled inpatient care decide where to get it, especially when there's time to make a choice."  Indeed, the parade is essentially celebrating a nullity when it comes to the day-to-day needs of the community in which this hospital is located.

I yearn for the day when the hospitals in Boston get together and jointly demonstrate progress in eliminating preventable harm, adopting a consistent approach to front-line driven process improvement, and engaging in truly patient-driven care.  Now, that would be something worth celebrating (although I would still omit the Duck Boats.)  For models of that kind of behavior, look west to Ohio, Wisconsin, Washington, and Michigan.  The hospitals there have been hard at work on that approach--with modesty, dignity, and class--literally leaving many "top" Boston institutions in their wake.

Quality without science and research is absurd

If there were something called a Nobel Prize in Medicine, it would be awarded to Peter Pronovost for the number of lives he has saved by his applied research in quality improvement.  Oh wait, there is a Nobel Prize in Medicine, but they will never award it to Peter because the way he saves lives is based on the scientific method.  Oh, wait the Nobel Prize in Medicine is based on applying the scientific method to questions of broad human health import and is awarded "to the person who shall have made the most important discovery within the domain of physiology or medicine." So, they will never award it to Peter because he applies the scientific method in clinical settings and saves lives today as opposed to engaging in reductionist research in laboratories that may never save any lives.

Who knows?  Maybe someday the Nobel Prize committee will review the evidence and decide that scientifically conceived experiments and programs in clinical process improvement are worthy of their attention.  When that day comes, they need only read Peter’s book Safe Patients, Smart Hospitals to find the source material for the award presentation.

But in the meantime, every person involved in the delivery of care in hospitals should read this book.  I am not so keen on the subtitle--”How one doctor’s checklist can help us change health care from the inside out”--because that is a highly simplified shorthand for the many lessons contained in the book.  Sure, there is the checklist story, first applied to eliminating preventable central line infections.  But, as Sullenberger notes, "A checklist alone is not sufficient. What makes it effective are the attitude, behavior and teamwork that go along with the use of it."  A checklist applied to an organization that has not engaged in a cultural change that promotes respectful relationships among the clinical staff--described by Peter as a comprehensive unit-based safety program--will fail.  Peter’s contribution is explaining how to create such an environment and in telling the story of his successes and failures along the way.

My favorite story is about the CEOs of the Michigan hospitals and how they learned they could help in the statewide effort to eliminate central line infections.   One CEO said, “You do not get to be CEO without having answers to questions.  Yet I do not have a clue what to do to improve safety. I am not comfortable admitting that.”

Peter admitted that he did not have all the answers either, but that a show of commitment from the CEOs was essential to programmatic success.  “What if I made this easy for you?  What if we were to send you one simple task for you to do each month, would that help?”

They liked the idea.  Our first trial run came when we learned most of the hospitals used an antiseptic solution called Betadine to clean the skin prior to placing a central line . . . [but] chlorhexadine had been proven to be 50 percent more effective at reducing infections.  Even though the two cost about the same, only 20% of the hospitals in Michigan stocked chlorhexidine....

We went to the doctors and nurses and encouraged them to change the antiseptic solutions . . . but the staff didn’t know how to make this happen. . . .  So we sent all the CEOs a memo asking them to make sure that, within on e month, every hospital stocked chlorhexidine in their central line kits. . . .  In one month it was done.

Every hospital can accomplish the kinds of changes described by Peter in this book.  But they have to want to.  To quote Jim Womack, "Whether you think you can or you think you can't -- you're right."

But accomplishing change is not the same as wishing it were so.  Process improvement is a discipline.  At one point in the book, Peter expresses frustration at the lack of data collected by several hospitals participating in the improvement program.  A colleague says, “This is not how quality is done in this country.  Quality is a concept that has never been viewed as research or science.  As long as hospitals are doing projects they think will make patients safer, they believe patients are safer.”

Peter makes the case strongly:  This is unacceptable.  “Quality without science and research is absurd.”

Right.  Now let’s get back to that Nobel Prize committee. 

How complex systems fail

Many thanks to Tim O'Reilly @timoreilly for sending me this thoughtful piece by Richard I. Cook, MD, from the Cognitive Technologies Laboratory at the University of Chicago.  It is a pithy article with a long title:  "How Complex Systems Fail (Being a Short Treatise on the Nature of Failure; How Failure is Evaluated; How Failure is Attributed to Proximate Cause; and the Resulting New Understanding of Patient Safety)."

Some excerpts follow.  If you are not careful, you can quickly fall into a terribly pessimistic view of the potential to improve quality and safety in clinical settings.  But if you think about it a bit more, you can see that having a "learning organization," one that constantly strives to be very good at getting better, is the best answer we have.

Complex systems contain changing mixtures of failures latent within them.
The complexity of these systems makes it impossible for them to run without multiple flaws being present. Because these are individually insufficient to cause failure they are regarded as minor factors during operations. Eradication of all latent failures is limited primarily by economic cost but also because it is difficult before the fact to see how such failures might contribute to an accident. The failures change constantly because of changing technology, work organization, and efforts to eradicate failures.

Complex systems run in degraded mode.
A corollary to the preceding point is that complex systems run as broken systems. The system continues to function because it contains so many redundancies and because people can make it function, despite the presence of many flaws. After accident reviews nearly always note that the system has a history of prior ‘proto-accidents’ that nearly generated catastrophe. Arguments that these degraded conditions should have been recognized before the overt accident are usually predicated on naïve notions of system performance. System operations are dynamic, with components (organizational, human, technical) failing and being replaced continuously.

Post-accident attribution accident to a ‘root cause’ is fundamentally wrong.
Because overt failure requires multiple faults, there is no isolated ‘cause’ of an accident. There are multiple contributors to accidents. Each of these is necessary insufficient in itself to create an accident. Only jointly are these causes sufficient to create an accident. Indeed, it is the linking of these causes together that creates the circumstances required for the accident. Thus, no isolation of the ‘root cause’ of an accident is possible. The
evaluations based on such reasoning as ‘root cause’ do not reflect a technical understanding of the nature of failure but rather the social, cultural need to blame specific, localized forces or events for outcomes.

Hindsight biases post-accident assessments of human performance.
Knowledge of the outcome makes it seem that events leading to the outcome should have appeared more salient to practitioners at the time than was actually the case. This means that ex post facto accident analysis of human performance is inaccurate. The outcome knowledge poisons the ability of after-accident observers to recreate the view of practitioners before the accident of those same factors. It seems that practitioners “should have known” that the factors would “inevitably” lead to an accident. Hindsight bias remains the primary obstacle to accident investigation, especially when expert human performance is involved.

Failure free operations require experience with failure.
Recognizing hazard and successfully manipulating system operations to remain inside the tolerable performance boundaries requires intimate contact with failure. More robust system performance is likely to arise in systems where operators can discern the “edge of the envelope”. This is where system performance begins to deteriorate, becomes difficult to predict, or cannot be readily recovered. In intrinsically hazardous systems, operators are expected to encounter and appreciate hazards in ways that lead to overall performance that is desirable. Improved safety depends on providing operators with calibrated views of the hazards. It also depends on providing calibration about how their actions move system performance towards or away from the edge of the envelope.

WWAD? (A=Atul)

The sad story of Rory Staunton, the young boy who died of sepsis infection, has been prompting a lot of commentary.  I have noticed that is the nature of press coverage that it often takes a sympathetic figure to get attention to a long-term, systemic problem in the health care system.  I have written here of the efforts of Dr. Jim O'Brien and others at the Sepsis Alliance to help doctors and nurses learn of the early warning signs of a sepsis infection.  Let's hope that the recent story will give a greater impetus to the expansion of training about this important clinical problem.

But it is not of that topic that I write today.  Instead, I would like to explore the obligation of the dominant health care provider in the region to become a force in reducing harm and improving quality and safety in its own institutions and beyond.  I am prompted to do so by a banner advertisement that accompanied Maureen Dowd's story today about Rory Staunton.  Here's the ad:

When you see an ad like this accompanying such a sad story, you are tempted to click through to actually see how "Partners is changing health care for the better" with regard to the types of issues elicited in the story.  What do we find?

Well, not much about the topic at hand.  While some other stories are included, a pervasive theme seems to be about cost.  Also, part of the messaging is meant to undermine reports done by the state's Attorney General about the disproportionate level of rates received by this provider group:

I don't mean any of this to suggest that this provider group is not trying to provide excellent care.  I know many of its doctors and nurses and have found them to be impressive and well intentioned people.  It just seems that this provider system is so intent on messaging for political purposes that we don't get to learn what they have done about the kind of misdiagnosis and mistreatment seen in the Staunton case, or for that matter what they have done to eliminate harm in other settings.  After all, there are many impressive and well intentioned clinicians throughout the United States who still collectively represent the fourth or fifth ranked public health hazard in the country.

I have noticed that the media in this city gives this provider group a bye on these issues.  Perhaps the reporters are so busy covering legislative debates on cost issues that they don't have time or inclination to see what's being done--or not being done--to stop killing and maiming patients.

So, here's my suggestion to enterprising reporters.  Let's consider who in Boston is most associated by the public at large with ideas for improving the quality of care.  Among that group is clearly Dr. Atul Gawande, a physician in this very provider organization, who has done superb work in this field.   A reporter might compile a list of  the major conclusions in Atul's books and articles. Then, the reporter could take Atul's recommendations for improving the quality of care delivery and see the extent to which they have been adopted by his hospital and by the entire health care provider network in which he works.

Several years ago, I noted:

The Partners hospitals are full of well intentioned, dedicated people. But there has not been a corporate public commitment to reduction of harm and to transparency of clinical outcomes that could help build broad public confidence in the quality and safety of patient care.... Ironically, some of the world experts in these matters are faculty members in his hospitals. The Partners system should be a world leader in the science of health care delivery, along with the fields in which it already holds prominence.

I'm not saying all of Atul's ideas are necessarily the right ones for all organizations, but should not the major provider group be held accountable to show how they have implemented his ideas, or if not, why they have not?  Who knows?  There might be some good news on this front worthy of publicity.  If so, perhaps future banner ads will click through to more relevant success stories.

Klepper makes the payment case clear

This is a very important article by Brian Klepper on Medscape.  It is entitled: "Will Anyone Listen When Former CMS Chiefs Call For More Objective Physician Payment?"  Pay particular attention to the parts about the committee that establishes the relative rates paid by Medicare to different kinds of specialists, a formula that affects virtually all private insurance companies as well.

There was a general sense that the RBRVS system was built on a series of errors, and that CMS' relationship with the RUC started off, to use Dr. Wilensky's term, "innocently enough," but has become increasingly problematic over time.

Tom Scully, CMS' Administrator under George W. Bush, took responsibility for helping facilitate the AMA's involvement and was perhaps the most passionate that it had been an error.

One of the biggest mistakes we made ... is that we took the RUC...back in 1992 and gave it to the AMA. ...It's very, very politicized. I think that was a big mistake...When you go back to restructuring this, you should try to make it less political and more independent.

I've watched the RUC for years. It's incredibly political, and it's just human nature...the specialists that spend more money and have more time have a bigger impact...So it's really, it's all about political representation, and the AMA does a good job, given what they are, but they're a political body of specialty groups, and they're just not, in my opinion, objective enough. So when you look at the history of it, CMS is starting to push back more, which is a good thing, I think it would be much better to have an arms-length transaction where the physician groups have a little more of an objective approach to it. And, look, that is the infrastructure of $80 billion of spending. It's not a small matter. It's huge.

But perhaps the most striking statement was made by Bruce Vladeck, HCFA Administrator during the Clinton Administration. In speaking about the problems generated by RBRVS (and by inference, the broader issues of SGR and the RUC as well) in the face of severe economic stresses, he called for the leadership and will required to simply do the necessary course correction.

I'm hopeful that some combination of the need to address overall deficit reduction strategies more generally and a different kind of political climate in the relatively near future will create the opportunity for people to say, "We made a mistake in 1997. We created a formula that produces irrational and counterintuitive results, and we're just going to abolish it and start all over again in terms of some kind of cap on Part B payments. It's the only way we're going to get out of this morass."

In a policy environment less susceptible to influence and more responsive to real world problems, the gravity of consensus on display at this roundtable would justify a call to action. As it was, it validated what many know: that we are rushing headlong down a catastrophic path, steered by forces other than reason and responsibility. The best we can hope for is that someone with authority and courage is listening.

Kate Spencer's new friends in India

My friend Katherine Spencer, Notre Dame class of 2014 (sociology and pre-health studies), is spending several weeks volunteering in and around Kancheepuram, India this summer.  She writes, "These two women wanted their picture taken so they can be famous in the United States. I promised to show it to as many people as possible."  I asked her for more of the story in return for spreading the images far and wide!  Here it is:

These women are part of the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA). It is an act that aimed to eradicate rural poverty by providing eligible people (below the poverty line) with manual labor for minimum wage. The project we visited was in a village that was renewing a Kai Rassi clinic with this NGO, Hand in Hand.

A Kai Raasi clinic takes place once a week or once every two weeks and provides basic healthcare and medicines to the people. They are required to pay 20 India Rupees (less than a dollar!) and they see a qualified doctor. The doctor often gives them referrals to go to government hospitals if needed and Hand in Hand workers ensure that they get there. Hand in Hand supplies the clinics with medicines like soft pain killers and anti-diarrheals.

The workers were very excited--as was the local government leader--to be renewing the clinic. Here is the link to the Wikipedia page on the government scheme. I'll point your attention to the criticisms section, as it is very interesting. During this particular visit, one of the Hand in Hand Workers, Ms. Rajeswari, was counseling the women on causes, symptoms and consequences of anemia. Anemia is a huge problem here. She educated them about iron tablets they should be taking and foods they can be eating to raise their iron levels.

Here's a picture from another work site we visited.  There are a lot of awareness programs going on through Hand in Hand, and they aim to educate villagers on their health rights and major health issues. In this particular one, we talked about loans they can be given to construct toilets and renovating local Anganwadi centers that act as day care for village children. They are given a nutritional lunch while attending, aiming to eradicate malnutrition.