Session D11 at #IHI09

Yell Eureka if u c this!

That is a message to the attendees at the session I am now conducting at the IHI National Forum, entitled Using Social Media to Pursue Quality and Safety. I have asked them to keep their Twitter search open for the meeting hashtag, #IHI09, as an illustration of how quickly information can flow through the social media.

This post is timed to go up at 9:40am, just after the session starts. My blog posts automatically are fed to Twitter, and the hashtag will ensure that this post is collected by Twitter in the National Forum collection of tweets. The first person in my session to notice the tweet and yell "Eureka" will win a prize.

In the session, I will present our journey at BIDMC in the use of social media in encouraging our programs in patient safety and quality. This all started with some posts on this blog about central line infections, ventilator associated pneumonia, and hand hygiene. We discovered two things from those posts. First, the world would not come to an end if we disclosed clinical outcomes from our hospital. Second, the public presentation of these data acts as a stimulus to quality and safety improvement in the hospital. It serves to hold ourselves accountable to the standard of care we strive for.

Following publication on this blog, we moved to doing the same in a more expanded way on our corporate website. Here, you can see some of the same quality metrics, but you also see the full survey conducted by the Joint Commission when they came to accredit our hospital. Why? Well, the Joint Commission has important things to say about how well we run our place and where we should make improvements. How better for everyone in the hospital to see those things than to post them on the company website?

Each hospital has to decide for itself what degree of transparency is appropriate and comfortable, but as noted by John Toussaint here at the National Forum, it is an essential component of a culture of continuous process improvement. Social media can help spread the world.

Added later: The picture above is of the winner of the prize at this session, Dan Henderson, Health Justice Fellow, at UConn School of Medicine. Congratulations!

Poster Session at IHI

#IHI09 Sometimes you have to travel far to meet someone from home. Here are Faye Holder-Niles and Linda Haynes from Boston Children's Hospital offering a presentation at the IHI National Forum poster session, where dozens of teams offered stories about quality and safety improvements in their institutions.

Faye and Linda presented a summary of a primary care team approach to advising families and treating children with asthma. Using a combination of interventions (e.g., counseling about drug dosages, HEPA filters for vacuum cleaners, rodent control measures), they dramatically reduced the number of asthmatic incidents for the children in several of Boston's neighborhoods. A subsidiary benefit was a huge reduction in the number of emergency room visits. (Check out those charts behind their heads on the poster.)

Nice work by our neighbors across the street from BIDMC!

The Sekou Effect

#IHI09 This afternoon's keynote speaker at the IHI National Forum, at first blush, would appear to be as far removed from Don Berwick as you could imagine. While that was true about his mode of delivery, the message was remarkably consonant with Don's.

The performer was Sekou Andrews, who bills himself as a motivational poet/strategic presenter. You see him here with Forum Co-chair Polly Arango.

You really had to be there to get the full flavor of Sekou's presentations, but I attach this short video clip of his opening moments to give you a sense of his energy and creativity. This audience was ENGAGED!

Real time progress report on process improvement

#IHI90 "How am I doing?" used to say NY's Mayor Ed Koch, relying on the wisdom of the crowd in various settings to give him feedback. Well, here at the IHI National Forum, we have a real-time status report of how the attendees feel they are doing on a variety of process improvements. Using the IHI's Process Improvement Map as a guide, attendees were asked to place pins saying whether a particular topic was either "the most challenging" (Red) or "where you've had the most success" (Silver).

Mark Graban happened to come by and noted that this is a nice analog representation of the current status of things -- which now, ironically, I present here in digital format.

I photographed a few of the subject areas within the three process categories (leadership, support, patient care). You can see for yourself how this group of health care professionals feels things are going. There is definitely some "clumping" of red and silver stick pins. Maybe the "wisdom of this crowd" will be used by IHI to help set priorities and guide program enhancements over the coming months.

Berwick at the National Forum

#IHI09 Don Berwick's opening address is always a highlight of the IHI National Forum, and with good reason. He not only presents the latest and best about quality and safety improvements but also places those advances in the context of the broader health care environment.

Much of today's talk was about how to overcome the "tragedy of the commons", the natural inclination of people to ignore the externalities associated with their actions. The original formulation of this was set forth by Garret Hardin, using the example of overusing a common grazing area.

Don noted,

Like the villagers, rational health care stakeholders are eroding the common good simply by doing what makes sense to each of them – separately. In the short term, we each win. But, in the long term, we all lose. We lose the Triple Aim: better care for individuals, better health for populations, and lower per capita cost, all at once.

Name any stakeholder – hospital, physician, nurse, insurer, pharmaceutical manufacturer, supplier, even patients’ group – every single one of them says, “Oh, we need change! We need change!” But, when it comes to specifics, every single one of them demands to be kept whole or made better off. “Don’t stop my sheep; stop his.” So everybody draws on the Commons, the herds grow, and the Commons fails. If you don’t increase your herd, you’re a chump. And, who wants to be a chump?

Drawing on the work of Elinor Ostrom, Don stated the necessary conditions to offset those inclinations in a community of interest and pushed the attendees to action:

Here is my challenge. I challenge us to end the Tragedy of the Commons in health care. I challenge us to prove Garrett Hardin wrong.

It isn’t easy. Positive collective action, even in small communities, and especially in health care, is fragile. It could all just fall apart. But, it can work. I know it can work because, sometimes, some places, it does work.

But, I’m very mindful of who you all are. You are doctors and nurses tending patients, operating managers trying to keep 6 West going or clear the waiting lines. You’re QI directors coaxing the operating room into using a checklist, or executives getting ready to tell the Board some bad news. And, I think, you’re wondering, “What can I do from my limited perch to govern the Commons better? I’m already over my head.”

I am really not sure. But, I have a strong feeling that it can – it has to – start with you. Command and control solutions seem weaker every day, and Elinor Ostrom’s brilliant explorations suggest that, in many contexts, higher authorities simply can’t do the job. Maybe someone smart enough and courageous enough in Washington can write a few rules that change the odds.... But, the odds of real reform, “re-form,” remain zero – the Commons is doomed – unless the action is closer to home – closer to you. So, drawing on Elinor Ostrom’s work, here’s are some ideas to start chewing on:

1. Understand your health care Commons. Understand its limits and boundaries. Understand who can and does draw upon the common pool of resource, and who it serves.
2. Adopt an aim. Here’s one: Over the next three years, reduce the total resource consumption of your health care system, no matter where you start, by 10%. Do this without a single instance of harm, rationing of effective care, or exclusion of needed services for the population you serve. Do it by focusing not on the habits of health care as it is now, but by focusing on what really, really matters....
3. Develop, fast, because there isn’t much time left, your own institutional structures – the ones you will need for local rule-making to better manage your Common Pool Resource. Do not wait for external rules to be made, or to change; do it yourself. One such structure might be, for example, a Community-wide board – the collection together of all the health care Boards with shared stewardship of the whole.
4. Develop, fast, because there isn’t much time left, monitors, so that you can track the use of the common resource, and find out who is sticking to the rules you write, and who is breaking them.
5. And, when people do break the rules – opportunists, free riders – create undesirable consequences for them, if you can, and ways to isolate them, if you cannot. Collective action is very fragile. You will need militia.
6. Identify and address conflicts early, often, and with confidence. Conflicts will be frequent and legitimate, and they will demand wisdom. The social capital – the commitment to protect the Commons – has got to trump these conflicts.
7. Expect and offer civility. This is the foundational transactional rule for effective, collaborative management of what we hold in trust.... Respect is a precondition.

He closed with this thought:

My friends, we can spend our days ahead fighting for our piece of the pie. We have plenty of role models for that. But, that’s for summer camp and the schoolyard; not for here. Not for this real and fragile world. Not for the Commons. Not when there is only one pie, and it is all we have and all we will ever have, and it is in our hands to preserve, not just for us but for our children and our grandchildren. We can wait for the rules to be written by others and for the laws on tablets chiseled by others to rescue us, but those rules will be less wise than the ones we can write, and those tablets will be, not our salvation, but weights upon our spirit. It is a very tough choice. Get everything we can? Or respect everything we have been given?

Spear talks about the right info

#IHI09 I ran into Steve Spear at the IHI National Forum. He was autographing copies of his book, Chasing the Rabbit. As always, he has something thoughtful to offer.

Here is a recent article he wrote about what kind of information is useful in process improvement. Here's the key line:

Some organizations undercut their ability to discover their way to greatness by confusing the information needed to see problems with the information needed to solve them. So, they overburden staff with establishing the former and then underarm them in tackling the latter.

I am sure this is the case in our hospital and others. We all have incident reporting systems that collect a ton of data but that might not be particularly useful in providing knowledge to the organization. Then, we might not have enough data to really drill down and solve a particular problem that we see.

Food for thought for your hospital?

Welcome reception at IHI

#IHI09 Shannon Mills, Community Manager for IHI, was on hand at the IHI National Forum to help people learn about the IHI Open School. Rebecca Vellejo and a colleague from the University of Kansas were explaining about the National Database of Nursing Quality Indicators. Lucille Skuteris joined a colleague to give information about Joint Commission Resources Consulting. Monda Shaver and Susan Lautner were marketing the Healthcare Facililties Accreditation Program, a competitor of the Joint Commission. And a new nanofiber product produced by a company called Vestagen Technical Textiles was on display, complete with a demo showing how it repels fluids.

Dr. Ship's Speech

If you -- as a health care provider or patient, or someone who knows one -- watch no other video about health care, watch this one of Dr. Amy Ship's acceptance speech when she was awarded this year's Compassionate Caregiver Award by the Kenneth B. Schwartz Center. It is an extraordinary summation of the meaning of compassionate care.

Auction for the Borum closes tonight

Our online auction to support the Sidney Borum Jr. Health Center closes tonight at 8pm. There are many wonderful items. Please bid generously here.

The Eliot School artistically helps The Borum

The Eliot School offers classes in crafts and fine arts to people of all ages – both at their schoolhouse in the heart of Boston and through the school partnership program, which sends teachers to classrooms throughout the city.

Founded in 1676 as a grammar school for colonial, African, and Native children, the school turned its focus to the manual arts in 1889. Since then, the school has taught craftsmanship and the pleasures of creativity. They are known for their excellent faculty, welcoming atmosphere, small class size, and the charm of their historic site in Jamaica Plain.

You can bid at our online auction to support the Sidney Borum, Jr. Health Center and join instructor Cecilia Galluccio for a new class, Burning Art & Design onto Wood. Here's the description:

With judicious use of wood-burning tools, drawings can elegantly decorate any wooden surface. In this workshop, learn from a compulsive doodler who creates stunning designs on bowls, spoons, tiles and furniture. Each student will complete a decorative tile just in time for Mothers Day. All materials will be supplied. (2 Sundays, 10 am–12:30 pm, Apr. 25–May 2)

What a great present to give to a member of your family or a friend!

Boston Baroque plays for The Borum

The Boston Baroque performance of Messiah is a Boston classic. The orchestra has generously donated a pair of tickets to the December 11 or 12 concert to support our online auction to benefit the Sidney Borum Jr. Health Center. Also included is a copy of Boston Baroque’s Grammy-nominated recording featuring highlights from Messiah.

The orchestra has also offered tickets to its wonderful New Year's Eve Gala Concert at Sanders Theatre.

Bid for both here.

An international quiz

#IHI09 I attended the international reception tonight at the IHI National Forum, which is representation from 42 countries. My tablemates (seen here) included people from Norway, Sweden, United Kingdom, India, and Canada.

The first order of business was a quiz, to be answered as a team. This was a good ice-breaker and also somewhat informative. Here are some questions. See how you do:

1. The smallest General Practice in the UK is in one of the 70 Orkney Islands off the coast of Scotland. How many patients are registered with this practice?
A. 300 B. 220 C. 120 D.40

2. What is the maximum number of patients an Italian General Practitioner can enroll?
A. 1000 B. 1300 C. 1500 D. 2000

3. What proportion of the financial compensation of an average English General Practitioner is "pay for performance" for achieving quality goals?
A. 0% B. 5% C. 10% D. 30%

4. In low income economies, which of the following interventions has the largest ability to reduce infant mortality?
A. Oral rehydration solutions B. Strong primary care C. Antibiotic availability
D. Clean running water E. Breast feeding

5. In a recent international survey of GPs, which country had the highest percentage of doctors using electronic medical records in their practice?
A. New Zealand B. Netherlands C. Germany D. USA

6. The Swedish government has announced a national fund to support the achievement of equality goals in healthcare, including gender and race equality in the health services. What is the fund worth?
A. $25 million B. $80 million C. $100 million D. $120 million

7. A woman in the West Midlands region of the English NHS recently became the oldest person in the world to have a hip replacement. How old is she?
A. 99 B. 101 C. 103 D. 108

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Answers: D, C, D, E, B, B, C

Steps to change a culture

#IHI09 John Toussaint, CEO of the Thedacare Center for Healthcare Value, presented a session called Leading a Continuous Improvement Transformation at the IHI National Forum.

What does it really take to change a culture? He outlines several steps, requiring a focus on purpose, process and people, based on the Toyota Production System, or Lean, philosophy. Examples of success are Group Health of Puget Sound, University of Michigan, Thedacare Collaborative, and Gunderson Lutheran. All have made significant reductions in the cost of delivering care while improving quality. Bolton, in the UK, likewise showed dramatic improvements in clinical quality indicators.

Here are the steps.

Purpose: This comprises a general statement of mission -- e.g., to improve the health of the citizens of the communities we serve -- but it also must be translated into a more detailed strategy, and still more detailed goals.

Strategy: Deliver measurably better value to customers. For example, we want to achieve reliable quality, measured as 3-4 defects per million opportunities.

Understandable goals: Focus on only three! For example, Quality: Decrease defects and waiting time by 50% each year; Business: Increase productivity by 10% each year; Engagement: Number of suggestions implemented (number/employee). Set the bar high but pick clearly understandable measures.

Process:

Transparency of data drives change. (By the way, in terms of reducing harm, he notes, "Zero is possible, and from a leadership perspective, we should ask for nothing less.")

Metholodogy for achieving results: It is the leader's responsibility to create the system that allows people to solve problems. Use of A3's creates a rigorous approach to problem solving. This formalizes PDSA ("plan, do, study, act"). (There are 5400 active A3s going on in Thedacare!) This approach makes it easier to persuade others and understand others, to foster dialogue, to develop thinking problem solvers, and to do all this on the front lines.

Other TPS activities include: value stream analysis; rapid improvement events; continuous daily improvement; visual tracking. Improvement results in less staff "hunting and gathering." New standard work improves both logistics and care.

People:

White coat leadership <-- versus --> improvement leadership.
All knowing, in charge, autocratic, buck stops here, impatient, blaming, controlling <-- versus --> patient, knowledgeable, facilitator, teacher, student, helper, communicator, guide.

Continuous improvement is based on respect for people. The leader's job is to develop people.

Can you say yes to these three Paul O'Neill questions every day:

--Are my staff treat with dignity and respect by everyone, regardless of role or rank in the organization?
--Are they given the knowledge, tools and support they need in order to make a contribution to our organization and that adds meaning to their life?
--Are they recognized for their contribution?

New habits are needed by managers and leaders: Help define the problem; ask questions instead of providing answers; think of problems as golden nuggets instead of opportunities to blame; teach subordinates how to solve problems; mentor subordinates to replace you; be humble.

Participatory Action Research

#IHI09 Roger Resar (speaking) and John Whittington (with some audience participants), of IHI's R&D team, recently were involved in developing and testing an innovative approach to actively engaging physicians to provide evidence-based and effective care through "clinician-friendly standardization." The two engaged the Faculty Mindwalk attendees in a hands-on exercise.

Beyond the National Forum, Roger and John hope to try out "participatory action research" with the attendees to test novel solutions to tough problems. They want to create a network of the attendees to be involved with IHI as innovators who will "create new approaches to seemingly intractable health care delivery issues."

Katharine Luther, RN, from Texas Medical Center, gave an example. A local team did on-site work on the area of fall prevention while communicating with Roger at IHI to test out concepts, engaging in an iterative collaboration approach between the "field" and the resources back in Cambridge. The idea was to ask clinicians to discern between "usual" and "special" patients, 80% and 20%, respectively. About 50% of the falls occurred in each category, which, interestingly did not correlate with the usual Morse score for fall susceptibility. This led the team to a create a bundle of three items (more easily reached call buttons, lower bed height, better placement of IV stand) that could be used to reduce falls across the broad population of patients, notwithstanding the Morse score.

The lesson of this example, Roger concluded, was about co-learning between the field and the IHI R&D group, with the immediate benefits accruing to the local partner, but eventually offering advances that might also go beyond the particular local partner to a broader audience.

Mindwalk at the National Forum

#IHI09 -- The IHI National Forum just started with a session called Faculty Mindwalk for those involved in teaching sessions over the next three days. This is a nice opportunity to reconnect with others involved in the patient quality and safety movement and also make new friends.

Seen here are: Eugene Litvak, President and CEO of the Institute for Healthcare Optimization, with Vin Sahney of Blue Cross Blue Shield of MA; Mark Splaine, the newly appointed Director of the Center for Leadership and Improvement at the Dartmouth Institute for Health Policy and Clinical Practice, with Paul Batalden, his predecessor; and June Wylie, Jackie Ley, and Jane Murkin, from the NHS Quality Improvement program in Scotland.

Out with the bad air, in with the good

As the cold weather arrives, we all know how to button up our home to reduce energy loss, but sometimes we end up not allowing enough fresh air to enter the house. How to do it without losing lots of heat is the question. An answer is provided by an item in our online auction to benefit the Sidney Borum Jr. Health Center.

Company owner Mark Bernfeld has donated the Tamarack DreamAire 5000 home or office air purification system as an auction item. Here's his description of how it works:

This machine will kill viruses, mold spores and bacteria before entering the home. Every 30 seconds fresh outside air is brought into the home, filtered through an electrostatic precipitation process (ESP) heated (if so desired) and then reverses direction to pull stale inside air out of the home. Using only 15 watts of electricity the air replacement/filtering and cycling operates constantly. Extremely quiet, the DreamAire 5000 uses one 4" duct for bringing air in and exhausting it out of the home. Rated for 1,200 square feet, the DreamAire 5000 will clean the air in an entire home, office or classroom. Attractive LED control panel makes operation simple. Filter cleaning indicator will illuminate when necessary.

See more and bid here.

As good as cash, for The Borum

You can spend this weekend fighting traffic and shopping for holiday gifts, or you can bid from the comfort of your home for gift cards that support the Sidney Borum Jr. Health Center.

Cards include the following: $150 for Saks; $50 for L'Occitane; $110 for City Sports; $50 for John Dewar; and $500 to spend at any of 40 locations.

Need stocking stuffers? How about free admission coupons for National Amusements cinemas.

Here is the auction site.

Helping Our Bodies, ourselves

A note from Judy Norsigian, Executive Director of Our Bodies Ourselves.

Like other valuable "social benefit" organizations, Our Bodies Ourselves is facing a very difficult financial period and needs your support more than ever. As we are approaching our 40th anniversary of the first publication of Our Bodies, Ourselves, we hope that you will visit our website, consider all that we do now, and contribute to our longstanding, non-commercial, public interest work that has benefited millions across the globe. I also hope that you will forward this message to others who might value and support what we do.

All contributions large and small greatly appreciated:

http://www.firstgiving.com/judynorsigian

Thanks so much for your consideration.

Best- Judy

Noah's Ark arrives in Needham

I am so impressed by the generosity of our patients and their family members. Here is a tapestry from South Africa, entitled "Noah's Ark", that was given to our community hospital in Needham from a grateful family. Here's the story behind it:

The artist, Alexa Kirsten, was born in South Africa to a British mother and a South African father. She grew up in the Hogsback in the eastern cape, a rugged mountainous area. Alexa's cloths have found homes all over the world. She notes:

"All the years at Hogsback and the years in the bush and now living near the sea and the mountains, all these things have influenced me. I love color and find great solace in it. A friend and I started a little screen printing business 30 years ago. We printed lengths of cloth. I found it too tedious and eventually branched out on my own and started painting tablecloths. I have lost count of all the cloths that I have made, I would estimate close on 1000 by now after all these years."

You can see more on this website. Dan Siagal from Capetown Trader tells me: "In 2005 Alexa was assaulted, stabbed repeatedly in the back and left for dead on the floor of her neighbor’s house. She had a near-death experience and feels that she touched the face of God. After having to learn to walk again she has continued with her fabric art; however, it has changed and become more vibrant and meaningful. The colors are brighter and the pictures clearer and stronger. She draws solace from her work. It has been a huge part of her recovering and therapy. She would like to share her work as an encouragement to the struggling, depressed and sad people of the world.

"Cloth Art images are hand-drawn, hand painted, original artworks of African images caught on cloth. Decorated with enchanting scenes drawn from African life, each one is individually hand painted. Inspiration is drawn from the accumulated cultural diversity of today and of a time altogether more ancient. Scenes may include a combination of animals, villages, the breathtaking African night sky, or whatever the artist chooses; no two are exactly alike, but each is a brightly-painted delight. The colors are bold and cheerful. They evoke a childlike perspective, full of wonder and smiles, celebrating life under the South African sky. Some tell a story such as Noah’s Ark."

When a great big zero is A+

On several occasions, I presented data here on this blog about the efforts of BIDMC to eliminate central line infections. You can now view those data on our hospital website.

Our community hospital, BID~Needham, operates under its own license and has a staff and Board highly committed to quality and safety improvements. It also chose to engage in a program to eliminate central line infections. The Needham effort had several components:

-- Develope guidelines for the prevention of blood stream infections;
-- Work with procurement to create a standardized supply kit;
-- Use a standardized protocol for maximum sterile barrier precautions;
-- Use Chlorhexidine-based antiseptic for skin preparation;
-- Use a standardized protocol for catheter hub and port disinfection; and
-- Educate both health care worker and patients.

Well, the results for this small hospital are pretty spectacular and are presented above. They have demonstrated that a sustained rate of zero is possible. I say that this is one case where zero warrants a grade of A+!

Leapfrogging ahead

Nice recognition for BIDMC, Brigham & Women's, Baystate, and Children's Hospital here.

A grand show by Dave and Danny

Medical grand rounds at BIDMC today consisted of a presentation by Dave deBronkart (aka e-Patient Dave) and his primary care doctor, Danny Sands (seen here with Chief of Medicine Mark Zeidel.)

Back in January 2007, Dave went in for a routine radiology study. As he noted a few days later on his CaringBridge site:

On January 2, 2007 a routine shoulder x-ray showed a mass in a nearby part of my lung. Four weeks later, it appears to be kidney cancer that’s spread to both lungs. This site will chronicle the learning and emotional processes we’re going through as we learn and do everything we can to maximize my chances. Top of the list: a strong mental attitude and a clear mind!

It was actually stage 4 renal cancer, spread to multiple sites in his body. Thus began an intense learning adventure for both Dave and Danny. Dave first learned that his expected lifespan was measured in weeks, given the stage of his disease. He then helped guide his own treatment by connecting with many resources to learn about his disease and therapeutic approaches to it. Danny, who was already pretty astute about such things, learned more deeply than he could have imagined that the kind of deep patient involvement exemplified by Dave can change the course of a relationship with a physician, and the course of a disease.

Dave successfully received treatment of Interleukin-2 at BIDMC and his tumors shrunk. He decided to spend his new life telling the lessons he learned about patient involvement. Here's a summary from Health Leaders Media.

The Partnership of Physician and Patient
When Dave deBronkart was diagnosed with stage four kidney cancer in January 2007, he turned to the Internet. "I've always been an online guy, so of course I Googled my butt off," he says. What he found: "Outlook is grim. Prognosis is bleak." But then his doctor told him about an online chat room for kidney cancer patients on the cancer-support site Acor.org, where the patient community provided vital validation about Interleukin, a treatment he already had researched. The potentially toxic cancer treatment is decidedly not for everyone. But deBronkart's doctor said he was qualified for the treatment and he followed his doctor's advice, which he says shrunk his tumors—and saved his life.

Since then, he's become an online advocate for patient engagement and empowerment, and is known to many as e-Patient Dave.

The "e" in e-patient represents a number of descriptors: equipped, enabled, empowered, engaged.

Effective e-patients are involved in their own health in a number of ways, deBronkart says:

• They look at their medical records online
• They may share medical records with family and friends who know medicine
• They use e-mail to correspond with their doctors
• They are active partners with the various physicians involved in their care
• They're often active in patient communities
• They may become active researchers

deBronkart works late into the night—long after knocking off work at his day job as a software marketer—spreading his patient empowerment message in chat rooms, on blogs, via Twitter, and in other forums. "My message has simplified. I just believe that patients have every right to know what their options are and they have a fundamental right to pursue those options," he says. "My point here is not that doctors can't do the job—it's that patients can help. We actually have the ability to contribute and help in this economically difficult industry.

Danny and Dave are now both active in the Society for Participatory Medicine, spreading the word and publishing research in support of "a cooperative model of health care that encourages and expects active involvement by all connected parties (patients, caregivers, healthcare professionals, etc.) as integral to the full continuum of care."

After grand rounds, I ran into the two in the hallway and reminded Dave of my response when he told me about his disease in January of 2007 and explained that it was likely that he only had several weeks to live. We are both officers in our MIT class, and we were planning our 35th reunion. I said, "Dave, that doesn't work. You need to attend our reunion in June."

Well, Dave not only attended that reunion -- to the enthusiastic welcome of his classmates -- but we are starting to look forward to attending the 40th together.

On the ebb and flow of public policy

Part of the legacy of the Bush administration, with its mistaken tendency to rely on unfettered capitalism as the engine of economic growth and capital formation, is the Obama administration, with a mistaken tendency to believe that legitimate functions of the private sector should instead be directed and controlled by, or subsumed into, the government. (Each administration has been supported in its views by a majority in the Congress.) The old administration could not understand why there was a call for government intervention in failed markets. The new administration does not understand why there is a call for less government intervention before markets fail in a different way.

Examples about the Bush administration are rampant, and I need not repeat them here. Those folks are gone, anyway.

But the new administration is here, and some commentary is called for. With a 9-10% official unemployment rate and another 7-8% of the population no longer looking for work or underemployed, the top priority should be to adopt policies that will stimulate job creation. Economic recovery of the sort that creates jobs will depend on private sector innovation and risk-taking. Signals from the administration suggest that this will be discouraged.

Let me give two examples from the health care field. These will be controversial, because the sectors I discuss have serious detractors and have not always provided the best examples of citizenship; but they are important as major employers in the country.

I'll start with insurance companies. Commentors on this blog and elsewhere wonder why there should be private insurance companies in the business of providing health care coverage. The answer is that there are actuarial risks associated with the payment of health care costs. Private insurance companies make or lose money depending on their ability to manage that risk and to be innovative in design of new insurance products. (Yes, I know they sometimes do other things that are nasty -- like pre-existing condition exclusions -- but those practices can be statutorily eliminated or regulated.)

When the government provides health insurance, the actuarial risk does not disappear. Instead, it is built into the cost of government. The proposed Obama public insurance organization is one that will attract customers who are actuarially higher risks. Because there will be an expectation of "affordable" premiums for this group of people, the organization will be given authority to use public funds or the public balance sheet to cover those actuarial risks. To the extent such subsidies are implicit in the premiums of the public insurance organization, it will have a competitive advantage vis-a-vis the private insurers. It will grow, and they will shrink. So, of course the private companies lobby against the public option.

Let's now turn to the pharmaceutical companies, who had promised the administration several billions in savings over the coming decade. There was shock recently when those companies raised their prices for drugs. What did they have in mind? Well, they were already looking at flat profit margins because of patent terminations and long cycles in drug development. They are concerned that growth in the industry will move from the US to countries like India and China, which are encouraging its development. Then, they watched how the health care legislation was evolving and saw nothing that would help them in the American market, and feared things that might harm them, and so they took a pre-emptive step.

Here is the ironic political dynamic: Every time an industry responds to a potential government intervention with an unpopular move, it provides fodder to the Obama folks that more such intervention is necessary. "See how selfish they are," is the refrain.

To which I say, yes, they are selfish because that is the nature of capitalism. People will not risk their money to invest in enterprises unless there is a reasonable possibility for return consistent with the underlying risk of the business. I have talked to many people in the venture capital world and the private equity world who have decided to hold back on new investments in the health care field because they do not see a dynamic that will reward risk-taking. They look at the treatment of the insurance and pharmaceutical sectors and assume that a similar scenario will come to play in other segments of the industry. Their anxiety is compounded by their belief that the cost of the health care legislation will be much greater than estimated. Therefore, they believe that more and more of the industry will find itself subject to governmental constraints over time.

As we saw all too clearly during the Bush years, a lack of government regulation can be exceptionally dangerous for the economy. I worry that the swing of the pendulum has now gone too far and that there is too great a reliance on government intervention that will be dangerous in its own way.

Please recall, as I say this, that I am strong supporter of expanding access to health insurance and other necessary reforms. I believe some expanded government role is needed to achieve those goals. This is a question of degree.

Basketball fans can help The Borum

There are some great tickets for upcoming Cetics games at our auction to benefit the Sidney Borum, Jr., Health Center. One game even includes $20 in Fuddruckers Gift Certificates. Click here to check them out.

Stephanie will help you to help The Borum

Stephanie Lee has offered 5 hours of virtual assistance to benefit our online auction for the Sidney Borum, Jr. Health Center.

Here is the description:

Scratchpad Secretaries is a Virtual Assistant practice catering to small business owners and the savvy solopreneur! We provide a wide-array of administrative, creative and technical services. Overwhelmed this holiday season? We've got you covered!

Cats and dogs open their home for The Borum

This is available only through our online auction to support the Sidney Borum, Jr. Health Center.

Are you an animal lover? Get a behind the scenes look at the MSPCA-Angell in Boston. Learn the history of one of the first humane organizations in America and how it has shaped vast changes in society, the environment, and the roles of animals in our lives. The MSPCA-Angell has impacted our sense of kindness and care for animals – and for one another. Visit The Angell Animal Medical Center and see the Emergency Treatment Area, the Critical Care Unit, the MRI Unit and the Internal Medicine Service Area. Tour the Boston Animal Care and Adoption Center and learn how animals are evaluated and cared for in preparation for adoption. This certificate entitles a group of up to five people to participate in a private tour/information session to learn how the MSPCA-Angell is “A voice for those who cannot speak for themselves.”

Hockey @ Fenway supports The Borum

Will this ever happen again? The last two NCAA championship college hockey teams -- Boston University and Boston College -- play hockey at Fenway Park on Friday night, January 8.

The game is sold out. Sure you can go to ebay, but you can also get tickets here, at our online auction to support the Sidney Borum Jr. Health Center.

Prefer professional teams? Then, bid on the New Year's Day NHL Winter Classic game between the Boston Bruins and the Philadelphia Flyers.

Thanks to the Boston Red Sox for donating both items.

Tom Brady breathes for The Borum

The Boston Globe has donated this collector's item for our online auction to support the Sidney Borum, Jr. Health Center. Framed and signed, it is the perfect gift for that Patriots fan in your midst.

Ramona stitches for The Borum

Dr. Ramona Bates, from Little Rock, offers her sewing skills to support our online auction for the Sidney Borum Jr. Health Center. Here is a detail of the lovely child's quilt she has made for the occasion. It is called Chalkboard Daydreams and measures 38 inches by 42 inches. You can see more details on her website here.

Then go to this site to bid.

Geri Denterlein helps The Borum

Geri Denterlein is one of the Boston luminaries who has offered to help our online auction to support the Sidney Borum Jr. Health Center. Here's the description of her auction item:

Geri Denterlein, founder and president of Denterlein Worldwide Public Affairs, one of Boston’s premier public relations firms, will host a one hour consultation and lunch for the winning bidder. The lunch will be held at one of Geri’s favorite restaurants, Asana, at Mandarin Oriental, Boston. Well known and highly respected in the industry, Geri has advised some of the most recognizable names in the region, including Century Bank, BIDMC, Thermo Fischer Scientific, and Boston Society of Architects. Drawing on her more than 25 years of experience in media, government and business, Geri will be the perfect catalyst to spark lively discussion and will create an excellent networking opportunity for the winner.

Please check the auction site, too, for inspirational presenters for your company or civic club.

It's time to bid for Sidney Borum

My online auction to benefit the Sidney Borum, Jr. Health Center is now open! There are truly spectacular items this month, perfect for holiday gifts. But also please remember that this is a worthy cause. These doctors and nurses walk the streets of Boston at night to help homeless teenagers and young adults get access to medical care. Let's show how much we appreciate them by bidding often and high!

To tempt you, I'll summarize just some of the items included. Some are local to Boston, but many can be used anywhere:

Two tickets to the sold out Boston College-Boston University hockey game at Fenway Park on January 8.

Two tickets to the January 1 Winter Classic hockey game at Fenway park.

A beautiful, handmade child's quilt by Dr. Ramona Bates. (See a closeup here.)

Tickets to Boston Baroque's Messiah on December 11 or 12.

Tickets to Boston Baroque's New Year's Gala.

A class in wood-burning art and design at the Eliot School in Jamaica Plain.

A baseball signed by 12 Red Sox rookies from the class of 2008 (including Clay Buchholz, Jed Lowrie, and Justin Masterson.)

A framed photo of Tom Brady, signed by him.

Gift cards galore: $150 for Saks; $50 for L'Occitane; $110 for City Sports; $50 for John Dewar; and $500 to spend at any of 40 locations.

The world's best brownies from Emily's Brownies.

Membership at Equinox to work off the brownies.

A Tamarack DreamAire 5000 home or office air purifier.

A Puma golf bag.

Travel offers in Cambridge, Provincetown, and New Hampshire.

A free consultation on immigration law.

Hours of virtual office assistance from Scratchpad Secretaries.

Inspirational lectures and consultations with amazing people.

Plus jewelry, a leather briefcase, and other gift ideas.

Check here for more.

Why wait four years?

I was struck during President Obama's health care speech before Congress several months ago that the reforms he advocates would not go into effect for four years, until 2014. This timetable, too, is written into both the House and Senate versions.

Why the delay?

It is hard for me to imagine, even given the federal rulemaking process, that it should take four years to establish an insurance exchange from which people can buy coverage. This is the exchange that would eliminate the nasty practices of insurance companies: Denying coverage because of pre-existing conditions; limiting annual or lifetime payments; and rescission of policies. It is hard for me to imagine, too, why it should take four years to fully deliver targeted subsidies to lower income people so they can afford insurance.

As noted by Princeton Professor Paul Starr in yesterday's New York Times: "By comparison, when Medicare was enacted in 1965, it went into effect the next year."

This leaves me with a bad feeling. It looks like the Obama team does not want implementation of the health care bill to take place during their first term. Why? Perhaps they know that the cost of the plan is higher than they are saying. Or maybe they know that the options available to consumers will be less attractive than currently portrayed.

Maybe they are worried that if all this happens on their watch, re-election in 2012 will be in jeopardy.

I have yet to find a knowledgeable observer who does not agree that the cost of universal coverage will be high and that consumer choice will become more limited to the degree that federal policy tries to control costs.

I personally think the cost of universal access is worth it and an important public policy imperative; but the administration puts itself into a box when it downplays the consequences of the legislation. It is forced to postpone the effective date until after the 2012 election, so it will not suffer political backlash from a public that has been misled.

Let's hope that Congress sees this otherwise and implements these important measures more quickly. (Wouldn't it be ironic if the Republicans offered a floor amendment accelerating the effective date? How could the majority party oppose that?)

Leftovers on the run

Dan Nadworny sends out the weekly email update to our Emergency Department staff. Above is an excerpt from his latest edition. The photo was taken at the entrance to our ED.

On guard. Whew!

One in an occasional series about email solicitations from total strangers for products and services that just make you wonder. In many cases, as here, they feel comfortable with the familiarity of using a first name even though we have never been introduced, they use the wrong name of our organization, and they have bad grammar or punctuation. In this instance, too, the surveillance product offered here is provided for no charge by Google and other web servers.

I wonder whether their monitoring skills will pick up this post about themselves.

Hi Paul, would you have time in the next week to discuss better ways to monitor what's being said about CareGroup, on the Internet and learn how to use social media in your marketing strategy?

PRWatchdog provides healthcare facilities with alerts on high-level negative and positive mentions of your brand online (blogs, news, social media, and community sites), we ferret out the ones that could damage you and send you real-time notification with suggested action items. We help you maintain a top reputation score with minimal demand on your already busy day. In addition, we can help you capitalize on websites like Facebook and show you how to use them to better communicate your message to your patients.

Let me know a time that you're available, thanks Paul.

Regards,
[name deleted]
President, PR WatchDog
600 Northpark Building, #1700
Atlanta, GA 3O328
[email and telephone deleted]
www.PRWatchDog.net

Thanks to Gourmet Caterers

As the Thanksgiving holiday weekend draws to a close, I want to give a "shout-out" to Robert Wiggins, President, and his staff at Gourmet Caterers in Roslindale, MA. Each year Mr. Wiggins donates dozens of gift certificates for Thanksgiving and Christmas "turkey dinners for 10 with all the trimmings" to charities who then auction them off to support their causes. (I purchased mine at The Boston Harbor Association annual gala, which supports environmental education programs.)

When I went to pick up my food on Wednesday morning, I was told that I was one of 58 holders of such gift certificates that day. You go around the back to the white tent to pick up your food. There I met Glenn, an employee of 14 years, who helped load the dinner into my car.

This is no small meal: 22 pound turkey, stuffing, gravy, mashed potatoes, fresh green beans, candied yams, butternut squash, cranberry orange relish, cheese and crackers, Parker House rolls, and choice of two pies (apple, pumpkin, or pecan). When they say this is dinner for 10, they must be thinking of 10 hungry lumberjacks!

Thanks to the folks at Gourmet Caterers for their generosity to so many organizations in the Boston area.

Engage with Grace Blog Rally

The Engage with Grace blog rally has spread far and wide, for the second year. Here is a list of participants that I have seen so far. I'll keep adding. If I missed you, please submit a comment with the name and url, and I will update this posting.

In case you wonder why we do this, see this post on my blog below:

Last year I had a discussion with my loved one because of the blog rally and unfortunately it actually came into play in Sept. when she was diagnosed with end stage pancreatic cancer. Something that we did not anticipate but really must be brought to light, especially with elderly couples; often the primary advocate is so distraught at the probability of losing their 47+ year partner, emotions cloud key judgement. We experienced battles with my uncle over increasing pain meds., etc. and hospice walked such a fine line because he, as her health proxy could have asked them to leave at any time (as we were told). So in addition to having a discussion regarding these end of life questions -- elderly couples really need to think about whether their spouse will truly be able to carry out their wishes when the time comes.

Matthew Holt's The Health Care Blog
ElizaBlog
NetAge Endless Knots
Boston Globe White Coat Notes
NPR Health Blog
Kim Painter on USA Today
Pallimed
Health Care Law Blog
33 Charts
The Tsunami Mommy
NickDawson.net
EMed concepts
e-patients.net
Diva Marketing Blog
Health Populi
David Fisher, MD, MPH
A Traveler from the World of Work
Roni Zieger on the Huffington Post
Melissa Cooks Gourmet
The Medical Quack
David Harlow's HealthBlawg
Kevin, MD
Massachusetts Liberal
Michael Miller's Health Policy and Communication Blog
Beating Social Anxiety
Pam Ressler's Blog
Ted Eytan, MD
Suture for A Living
Project Health Design
Bouncing Baby Boomers
Muck Rack
Justin's Hope
Osteopathic Injustice
NHPCO
Trusted MD
Grief, Loss, and Transitions
Reflections in a Head Mirror
Fresh Widow
Public Healthcare Promotion
Just So you Know
Precious Bodily Fluids
Operation Marathon
Networks, Complexity, and Relatedness
Dr. Shock, MD
The Orthopedic Posterus
Compliance Building
Laika's MedLibLog

(from here down -- added after initial posting)
The New Life of e-Patient Dave
Cathy Arnst at Business Week
Justen
PharmaGossip
Musings of a Distractible Mind
Palliative Care Grand Rounds
MITSS -- Medically Induced Trauma Support Services
Health IT and Healthcare Reform
Jazz Ramblings
Grief Healing
Anatomy on the Beach
Medicalcenterinfo.com
McDoc
Ignite09
E-Learning
Brass and Ivory
Colorectal Cancer Coalition
Suzi's Musings
Chronic Healing
Perfect Memorials
Hefidi
Esse Diem

(In case you are wondering, that's 70, so far . . .)

MITSS (again, their other blog)
Emerging Medical Concepts
Street Prophets
Grief, Loss, and Bereavement Edublog
BIDMC
Adam Bosworth's Welblog
Healthcare Ruminatio
Epidemiology Cafe
Marty Bonick

An Evening of Thanks

This is a short break from Engage with Grace to consider the other end of the spectrum of life. Each year on the night before Thanksgiving, our Neonatal Intensive Care Unit (NICU) holds a small party called "An Evening of Thanks". It is a chance for parents and their now-larger babies to return and visit with the nurses and doctors with whom they spent time while those premature or seriously ill babies developed or got well enough to go home.

Here are some visitors who came tonight. Many came with siblings. In the bottom picture, you see nurse Melissa Adams holding one of her alumnae.

Engage with Grace -- Reprise

Last Thanksgiving weekend, many of us bloggers participated in the first documented “blog rally” to promote Engage With Grace – a movement aimed at having all of us understand and communicate our end-of-life wishes.

It was a great success, with over 100 bloggers in the healthcare space and beyond participating and spreading the word. Plus, it was timed to coincide with a weekend when most of us are with the very people with whom we should be having these tough conversations – our closest friends and family.

Our original mission – to get more and more people talking about their end of life wishes – hasn’t changed. But it’s been quite a year – so we thought this holiday, we’d try something different.

A bit of levity.

At the heart of Engage With Grace are five questions designed to get the conversation started. We’ve included them at the end of this post. They’re not easy questions, but they are important.

To help ease us into these tough questions, and in the spirit of the season, we thought we’d start with five parallel questions that ARE pretty easy to answer:

Silly? Maybe. But it underscores how having a template like this – just five questions in plain, simple language – can deflate some of the complexity, formality and even misnomers that have sometimes surrounded the end-of-life discussion.

So with that, we’ve included the five questions from Engage With Grace below. Think about them, document them, share them.

Over the past year there’s been a lot of discussion around end of life. And we’ve been fortunate to hear a lot of the more uplifting stories, as folks have used these five questions to initiate the conversation.

One man shared how surprised he was to learn that his wife’s preferences were not what he expected. Befitting this holiday, The One Slide now stands sentry on their fridge.

Wishing you and yours a holiday that’s fulfilling in all the right ways.

To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team. If you want to reproduce this post on your blog (or anywhere) you can download a ready-made html version here

The NICU goes Lean

Our Lean process improvement efforts proceed. The most dramatic evidence comes in the form of 5S process improvement events, but please recall that this is all part of a "tortoise-like" engagement throughout the whole hospital.

But check out the BEFORE and AFTER of the NICU supply room. This improvement took 6 weeks of prework and 2 days of physical transformation. $15,600 overstock was removed from the carts. More importantly, as this improvement is sustained, it will make life easier for all of the nurses and doctors working on this floor taking care of really little babies.

Click here to see Pink Gloves

I usually avoid posts with a commercial tilt, but this is a worthy exception. A note from a friend:

Emily Somers created, directed and choreographed this video in Portland last week for her Medline glove division as a fundraiser for breast cancer awareness. This was all her idea to help promote their new pink gloves. I don't know how she got so many employees, doctors and patients to participate, but it started to really catch on and they all had a lot of fun doing it.

When the video gets 1 million hits, Medline will be making a huge contribution to the hospital, as well as offering free mammograms for the community. Please check it out. It's an easy and great way to donate to a wonderful cause, and who hasn't been touched by breast cancer?

Sidney Borum auction reminder

As you start thinking about holiday shopping after Thanksgiving, please give some thought to shopping at my online auction to benefit the Sidney Borum, Jr. Health Center.

There are already a lot of good items. Look here for a preview.

Several cash gift cards: You could use those as presents or to buy presents. Travel, books, golf equipment, and more. Inspirational speakers, too, for your business meetings or civic events.

More to come. Check back.

This auction runs from Dec. 1 at 6am to Dec. 7 at 8pm. Please tell your friends, and feel free to donate items if you would like, too.

In memoriam: Arnold Rosoff

Arnold Rosoff, known to the world as an exceptional advertising executive, died this week at age 93. Arnold was a trustee and volunteer in our hospital.

Here's the most fitting tribute I have heard, from one of our nurses, Jane Wandel:

I wanted to share my memory of Arnold as an ED volunteer. He volunteered as an orderly and worked alongside the paid orderlies in the department - indistinguishable from them in terms of his role. In fact, it was many months before most of us on the staff realized that he was a hospital trustee. He was kind and quiet, gentle and humble. He ran specimens and pushed stretchers; he readily helped with the most menial and, at times, unpleasant jobs in the unit. He treated everyone - from housekeeper to attending physician - with enormous respect and kindness. We adored him.

US Healthcare Reform Photoshop Contest

Dr. Wes announces the first (and perhaps only) US Healthcare Reform Photoshop Contest. Photographs in support or against the current efforts will be equally considered. The winner receives an iPod Touch. Get more details here.