Where were you on Nov. 22, 1963?

When the announcement of President Kennedy's shooting was made public?

I was sitting in my eighth grade English class, left-hand row of seats in the classroom, the row nearest the windows, second seat back.  School was dismissed, and we went home to watch the other events of that week on television.

It is good to remember this admonition from him:  "My fellow Americans, ask not what your country can do for you, ask what you can do for your country."

But look at the context:

In the long history of the world, only a few generations have been granted the role of defending freedom in its hour of maximum danger. I do not shrink from this responsibility—I welcome it. I do not believe that any of us would exchange places with any other people or any other generation. The energy, the faith, the devotion which we bring to this endeavor will light our country and all who serve it—and the glow from that fire can truly light the world.

And so, my fellow Americans: ask not what your country can do for you—ask what you can do for your country.

My fellow citizens of the world: ask not what America will do for you, but what together we can do for the freedom of man.

We have strayed, but we can get it back!

Bungling toward bundling: Not so fast, please

If it were not such a serious distraction, the tendency of policy analysts to focus so greatly on “payment reform” -- capitation, global payments, and bundling -- as an answer to increasing health care costs would be all right.  But it is not all right.  It is not all right because the underlying premise behind payment reform is that over-treatment of patients is at the heart of rising health care costs.  While over-treatment exists, it is hard to conclude that it is the area for greatest possible progress in controlling costs.  Accordingly, if we focus on this “remedy,” we will fail to direct attention to other parts of the cost equation, parts that could be more important in bending the cost curve.

What are the determinants of high health care costs in America?

One part of the problem is demographic, a large increase in the number of elderly, who end up needing hospitalization or treatment for chronic illnesses; the arrival of the baby-boomer cohort at the age of hospitalization; and the pending arrival of a sedentary next generation who will suffer obesity and the sequelae of that malnourishment.

A second part of the problem is the lack of effective primary care.  Many people have not had access to primary care.  Those who do have discovered that primary care doctors are often forced into a triage role:  They spend the proverbial “18 minutes” with each patient, an inadequate amount of time, leading to excessive referrals to higher paid specialists.

A third part of the problem is application of “the rule of rescue” in American medicine, the tendency to spend larges amounts of money in high level tertiary and quaternary treatment, well beyond any rationale estimate of the value of a human life.

A fourth problem is that the unit costs of what we provide are high.  Starting with doctors, who need to recover the high cost of medical education in their salaries, to medical equipment and supplies and drugs, to the physical facilities in which care is offered.  Some of these high costs are simply the result of being a high-income country; some are structural in that they reflect regulatory requirements; and some are market-power driven.

A fifth problem is defensive medicine, the tendency by doctors to order unnecessary tests or conduct unnecessary procedures because they fear being sued for malpractice if things go awry.  (Note:  This, not the judgments awarded in courts, is the real cost of our malpractice system.)

A sixth problem is the degree of harm caused by doctors and hospitals.  The number of hospital-acquired infections, for example, is excessive, leading to further morbidity in the hospital setting, along with the associate costs of treating patients for secondary diseases that could have been avoided.

A seventh problem is likely the inefficiency of a multi-payer system, compared to the simpler administrative system that could exist with a single payer.  I say “likely” because there are other inefficiencies often associated with single payer systems, not the least of which is the rationing that results and the emergence of a parallel, private system of insurance and care for those who can afford it.

Finally, an eighth problem is the incentive given in a fee-for-service payment system to over-treat patients, in that a doctor’s income is based to some extent on the number of steps taken, not the results of treatment.

If we were being rational and rigorous about policy prescriptions, we would rank order these causes and determine the costs and benefits of policies that might offset them.  For example, we cannot change demographic patterns, but it could make sense to introduce public health programs to promote exercise and proper nourishment.  We could change the compensation system for primary care doctors so they could spend more time with patients.  We could subsidize physician education so they wouldn’t have to earn so much to pay off loans.  We could reform malpractice laws to reduce defensive medicine. And we could certainly engage in full-scale process improvement training of doctors and implementation of those techniques in hospitals to reduce the extra medical costs associated with harming patients.  (Those of us who have done the latter have demonstrated conclusively the cost savings, not to mention the mortality and morbidity benefits.)

But, our public policy leaders have not done this.  Instead, they assert that pricing-based over-treatment is the key problem, and they offer capitated rate plans and bundled payments as the solution.  If you look closely, you will find that most of those proposals come from payers, either insurance companies who have a corporate desire to shift risk to providers or government officials who are trying to reduce appropriations.  Or from economists, who have a tendency to simplify market behavior and blame everything on pricing regimes.  As I have said, when you have a hammer, everything looks like a nail.

We shouldn’t dismiss a change in the payment system just because it might benefit the insurers or the government, but we also shouldn’t adopt it just for that reason -- or because it fits into economists’ idealized models.  Instead, we should determine how big a portion of the over-treatment problem comes from the payment system versus other causes.  And then we should rigorously review the experience of such regimes and evaluate their costs and benefits.  We should also determine how practical it is to implement a new pricing regime.  For example, let’s look at the business and clinical relationships of the primary, secondary, and tertiary care doctors who will have to jointly share risk.  What would the internalized system of transfer payments look like, and how would it be decided?  It is often the case that these analyses are lacking.

A case in point is offered by Ezekiel Emanuel in the last of series of op-eds he has published in the New York Times.  This one is called, “Saving by the bundle.”  He offers bundled payments for chronic diseases as a partial solution to Medicare cost increases, and the article makes some good points.  But is there rigorous support for what he proposes?  He notes:

For two decades Medicare has been experimenting with bundled payments.  Since 2009, Medicare has been using the Acute Care Episode bundled payment program to cover 37 cardiovascular and orthopedic procedures.  While there has not been a definitive evaluation, preliminary data suggest savings of up to 10 percent and improved quality of care.  Unfortunately, the program does not cover rehabilitation and other post-discharge services.  Worse, it is voluntary and only a few hospitals are participating.

As a public policy recommendation, this would get a “D” in my classroom. Why?  In reverse order, we have a self-selection bias in our sample; an incomplete assessment of all treatment-related costs and benefits; preliminary data not yet subject to peer review; and 20 years of experiences that has not created momentum for change.

The Times editorial staff is also on the bandwagon in an editorial entitled, “Fixing Medicare.”  Endorsing full capitation, they say:

The solution, most experts agree, is to have Medicare pay doctors and other health care providers fixed sums to manage a patient’s care and then let doctors decide which services are truly necessary.

The editors recognize one possible downside of this strategy, but they brush it off in one sentence, offering no consideration of the regulatory and oversight costs involved:

Close monitoring would be needed to ensure that doctors don’t deny medically important services to improve their bottom lines.

(They fail to mention another impediment:  To manage care in this fashion, the patient must be seen by a closed network, whose providers share in the risk pool.  That is all right, but a major issue facing Congress will be whether it wants to take provider choice away from the general body of American elders.)

I think it can be demonstrated that capitation and bundling can work well in certain settings.  For example, treatment of “dual-eligible” people (those on both Medicare and Medicaid) seems to work better and be less expensive when care is managed under a capitated contract arrangement.  But, even there, we have to ask, “Better than what?”  Better than a completely disorganized system of care for poor elderly people who are shunted from provider to provider, often without a primary care doctor to advocate for them.  Still worth doing, for sure, but let’s not extrapolate from this extreme case to the general population.

Being one of those aforementioned economists, I have no aversion to an assumption that price patterns matter.  But when you make policy, you don’t just proceed on that basis.  After all, most of our economy runs on a fee-for-service basis, and we don’t suggest that government intervention is necessary to change that to create more efficiency and higher quality.  With some exceptions, buyers and sellers in those markets prefer a fee-for-service approach, Yes, health care is different.  But that is no excuse to ignore the full range of diseconomies in health care, figure out which ones matter the most, and go from there.  If we do this wrong, we will find out that “payment reform” is not reform at all.

Hey, UPMC! Head to New Zealand to learn

Regular readers will recall that my posts about a botched kidney transplant at UPMC were harsh with regard to the center's decision to punish a nurse and doctor when it was evident from the start, and now confirmed, that the problems there were systemic in nature.  Perhaps the folks at UPMC should take a leaf out of the book of Dr. Mary Seddon and CEO Geraint Martin of the Counties Manukau District Health Board in New Zealand.

In a post entitled "CMDHB's Attitude to Errors," the authors note:

[I]t’s vital to be clear about our organisation’s standpoint on this so that we can work towards a culture which supports staff to do their best.

Errors aren’t intentional, they don’t improve through punishment and they’re hard to predict. Usually they come about through a fault of the system. If somebody else could make the same mistake, it’s a systems error.

How we respond to errors is vitally important. The tendency can often be to place blame on the staff member involved. However the danger in this approach is that it discourages staff from reporting errors or communicating openly for fear they will be blamed and punished. Even if individuals are identified and removed, the cause of the error usually remains unidentified and the risk that the error will happen again remains.

What we need to do if something goes wrong is pull back from the instinct to place blame and instead think more deeply about the contributing factors. We need to think about how the system got us to where we are and where the faults in it lie. 

I was pleasantly surprised to learn that the experience at my own hospital helped contribute to this understanding:

At CMDHB, we have a ‘Just Culture’. This means an expectation of high quality individual performance but open disclosure should an error occur. In this case, we will acknowledge the error, apologise to the patient and their family, and commit to investigating the error and sharing learnings from it. All of this requires a culture in which people feel empowered to report errors and make suggestions on how to fix them. One of the motivations for doing this post was reading about a situation at Beth Israel Deaconess Medical Centre in Boston where, after a case of wrong site surgery, the chief surgeon went straight to the CEO to openly communicate about it. That ability to be open and to communicate well is critical to the kind of culture we need to foster at CMDHB.

Congratulations to the folks at CMDHB!

Dear colleagues at UPMC:

The flight from Pittsburgh to Auckland takes about 20 hours.  Well worth the trip, I'd say.

Sayings from the islands

[Note:  Updated on January 10, 2012, with corrections from Sonya of my original interpretations.]

I recently had a chance to visit a good friend, Sonya Nelthropp, in St. Thomas, US Virgin Islands.  We worked together years ago at the MA Water Resources Authority, and Sonya later had an instrumental role in creating the Virgin Islands Waste Management Authority.  We later learned that both of our families knew each other over the course of many decades in that they were among the "old" St. Thomas crowd.  (Here, for example, is one of mine, and here is one of hers.)

Anyway, Sonya related to me a number of old island sayings, and I share them here with you with some explanation:

He who does not hear will feel.  (If you don't obey the first time, expect corporal punishment the next time.)

When a fish comes out of water and tells you it's deep, it's deep.  (When someone of experience tells you something, pay attention.)

When your hand is in a tiger's mouth, take time to draw it out.  (When you are in a precarious situation or at a disadvantage, move cautiously or diplomatically.)

No so cat walk is so he mouse.  (Here, mouse is a verb, as in hunting mice.  Don't judge a book by its cover.)

The higher a monkey climbs, the more his nakedness shows.  (A statement about the growth in arrogance as a person moves up the chain of command, especially when he starts out a bit full of himself.)

He gave her a basket to carry water.  (Said when someone malevolently offers advice or assistance that is not useful, intending to make your task more difficult.)

[New one:] Sit on a crooked sick and cut a straight one.   (If you can't change your situation, bide your time and look around for a better opportunity.)

Choice: Eat or throw tomatoes

While the Congressional "supercommittee" falls into a black hole on the issue of federal government spending, the entire body is hard at work and demonstrates tremendous political spine in declaring that pizza is a vegetable.  As noted by Kristin Wartman in the Huffington Post:

If there were any lingering doubts as to whom our elected representatives really work for, they were put to rest Tuesday when Congress announced that frozen pizza was a vegetable. The United States Congress voted to rebuke new USDA guidelines for school lunches that would have increased the amount of fresh fruit and vegetables in school cafeterias and instead declared that the tomato paste on frozen pizza qualified it as a vegetable.

But maybe that is a good use of their time because, in truth, the supercommittee's ability to reach consensus or not is irrelevant.  If they do not reach an agreement, as noted in the New York Times:

[W]ithout an immediate threat of fiscal calamity . . . the cuts to federal spending triggered by a committee failure would not take place until 2013, leaving Congress an opportunity to find other escape hatches.

Likewise, if there is an agreement, it will be so conditional on other measures that need to be approved, that it, too, will be meaningless.

I don't know about you, but I am tired of hearing about how "hard" the Congresspeople are working on all this is.  It is mainly political theater.  But unlike regular theater, these actors never even bother to learn new lines.

Please review this course about radiation

A fellow alumnus from my high school, George Polak, asks us for some help in reviewing a new on-line radiation curriculum:

We would greatly appreciate if your followers would view and comment on an online course about radiation and radiation safety that we are about to put up on our website.

We are especially interested in knowing:

1. If you found the language “plain” – unscientific and easy to understand for a lay person.
2. Did it answer any questions you might have had about radiation and radiation safety?
3. Any other comments

To access the course, go to:

http://pmos.cciinteractive.com/radiationsafety/

The password is: sievert24

Click "SME Review" (left hand menu on bottom), and then click "Understanding Radiation, under Lesson (i.e. the second link, farther to the right).

Please take a few minutes to view. Then send your comments to gpolak [at] radiationsafety [dot] ca.

Many thanks.

Fall in Brookline

A photograph from this morning, with the morning light coming through this pretty tree on Clark Road in Brookline.  My cheesy little old cellphone camera makes it slightly impressionistic.

With Brown medical students

I was invited to address a class at Alpert Medical School at Brown University this week. Entitled "Healthcare in America," this is a student-run preclinical elective on health policy and advocacy.  I include pictures of some of the students who made particularly thoughtful observations or who asked really good questions.

Beyond the expected issues of comparing the United State health care system with those of European countries, we spent some time on issues of process improvement in hospitals.  I had stressed the lessons of Lean, i.e., the idea of empowering and relying on front-line staff to call out problems and work-arounds and to work on solutions to reduce harm waste in the hospital setting.  I pointed out that the people who work in hospitals, including and especially the transporters, food-service workers, and housekeepers, are extremely well-intentioned and driven by a desire to improve patient care.

I later received a note from Peter Kaminski, Class of 2015, who confirmed some of these thoughts:

I spent several years working in the kitchen and volunteering in the transport department at Emerson Hospital in Concord, MA. Just as you described, my coworkers, especially those in transport, were some of the kindest people I've ever met. Many are retired members of the community and are still the same dedicated humanitarians they were over 8 years ago when they first taught me what healthcare was truly about. While visiting some of them this past summer, I quickly realized that I wouldn't be going into medicine were it not for their influence. 

With those thoughts in mind, it was fantastic to hear someone with your experience and influence affirming the vital importance of consulting support staff in crucial decisions to improve patient safety and satisfaction alongside organizational efficiency. I have no idea what the future will bring but it is greatly comforting to know that healthcare at its core is still people serving people, whether that means performing bypass surgery, wheeling a patient down to radiology, or bringing a patient their lunch.

Thanks for the invitation!

Health Literacy on WIHI

Health Literacy: New Skills for Health Professionals 
November 17, 2011, 2:00 PM – 3:00 PM Eastern Time

 
Guests:

Helen Osborne, MEd, OTR/L, President, Health Literacy Consulting; Author, Health Literacy from A to Z (Second Edition 2011)

Gail A. Nielsen, BSHCA, Director, Learning and Innovation, Center for Clinical Transformation, Iowa Health System; Faculty, Institute for Healthcare Improvement

Lisa M. Stevens, MSHSA, Director of Clinical Quality, Crusader Community Health

In its 2004 report, "Health Literacy: A Prescription to End Confusion," the Institute of Medicine defined health literacy as “the degree to which individuals have the capacity to obtain, process, communicate, and understand basic health information and services needed to make appropriate health decisions.” Seven years later, the field of health literacy has exploded into something far beyond this most basic description. There are legions of health literacy advocates and initiatives; innovative, creative, and culturally attuned resources; a much greater emphasis on empowerment and engagement rather than mere compliance; and a far greater understanding – helped along by research – of the health consequences of low health literacy.

We wouldn’t be able to recount such progress without the hard work of champions like Helen Osborne, who has just released the second edition of Health Literacy from A to Z: Practical Ways to Communicate Your Health Message. Helen joins WIHI on November 17 to discuss how this latest edition can serve as the backbone for any health care organization’s efforts to communicate and engage more effectively with patients of diverse backgrounds and health care fluency.

Also on board for the November 17 WIHI is former IHI Fellow and Iowa patient safety leader, Gail Nielsen, who has been working hard on health literacy for years, with a special emphasis on improving patient/provider partnerships, shared decision making, and care coordination. Together with Lisa Stevens, a quality expert from Illinois focused on cultural competency, Helen and Gail promise to discuss where and how health literacy efforts stand to benefit from health care reform and what it’s going to take to close communication gaps that still remain for millions of Americans.

This is a both an exciting and challenging time to take stock of what’s now possible to ensure and navigate health literacy. WIHI host Madge Kaplan invites you to tune in on November 17 and to share health literacy tools and initiatives from your own organizations. We welcome your interest and participation!  

To enroll, please click here.

Tell us the lessons, UPMC

Way back in May, I suggested that a botched kidney transplant at UPMC, for which a nurse and doctor were blamed, was "not totally a person problem," but more likely reflected systemic issues in that hospital.  After more information came out, I suggested that UPMC should "attack the problem, not the people." 

Well, the Pittsburgh Post-Dispatch now reports:

[A] federal agency on Tuesday put UPMC's transplant program on probation, a rarely used form of discipline handed down for some of the most serious transplant errors.

The federal Organ Procurement Transplant Network (OPTN) said it meted out the discipline not only because of the kidney transplant error, but because UPMC's transplant program was found to have problems in its communication and documentation procedures before.

And look at this,

OPTN's president John Lake said in a statement Tuesday after an OPTN board meeting in Atlanta, where the decision to discipline UPMC was reached. "The University of Pittsburgh Medical Center has identified a need for process improvement in communicating key clinical information among transplant staff members."

 

Hmm, so what happens to that doctor who was demoted and the nurse who was suspended?  Do they remain scapegoats for an institutional failure? If this was an institutional failure, shouldn't the Chief of Service, the Chief Medical Officer, or the CEO of the hospital suffer some form of sanctions?

 

The answer, obviously, is that none of them should have been or should be punished:  This should be viewed as a learning opportunity for all, both inside UPMC and more widely.  Early on, I said, "It will . . . be revealing to see if UPMC shares the results of what they learn more broadly with the transplantation community."

 

The question remains as to whether UPMC will broadly and helpfully explain to other transplant programs around the country what they learned from all of this. Perhaps OPTN should make that a requirement of getting off probation.

Helping Lauren help others

From time to time, I like to use this blog to help individuals who are helping others around the world.  I often find that it is the busiest and hardest working people who manage to give of themselves in this way.  Here's one such case.  Lauren Picarde, a registered nurse at Beth Israel Deaconess Medical Center, sent me this note. I hope this moves you to help out.

One of the reasons I decided to become a nurse was to care for less fortunate people around the world without access to exceptional healthcare. After almost five years of experience on an acute surgical trauma unit, I have decided it is time to share my knowledge and provide care and education to underprivileged populations.

On January 20th 2012, I will travel to Namibia, Africa to volunteer for two weeks at the Bushman Medical Lifeline Clinic. There I will work alongside a physician and head nurse to care for patients across the lifespan. The Bushman people are a deprived indigenous people inhabiting the desert areas of Namibia as well as Botswana and Angola. The people have often been neglected, if not discriminated against, when it comes to medical care. The project was set up in 2003 with the aid of overseas investment and is now run as a charitable extension of the Clinic in Windhoek. The clinic has literally become a lifeline for the local people and an established part of the community. Volunteers provide hands on support at the clinic, participating in observations, running reception and helping in the pharmacy. Dealing closely with patients from the local San community, volunteers learn more about their way of life and give care to patients living in extreme poverty.

The total cost of the trip is close to $3,200. I have already covered the cost of my flights; however the cost of volunteering goes directly back into the projects themselves for items such as building materials, medical equipment, and medical supplies. If you can support this project in any financial way, your donation will be much appreciated. 

Please contact Lauren at Laurn718 [at] gmail [dot] com if you are interested in helping out. Thank you.

Blinked last time, but hammering this time

CommonHealth reports that contract renewal talks between Tufts Medical Center and Blue Cross Blue Shield of Massachusetts have broken down.  This "could leave at least 88,000 patients in search of a new primary care doctor, reports WBUR’s Martha Bebinger. Blue Cross is alerting employers (whose employees have Blue Cross health plans) in letters today that they may no longer be able to go to Tufts."

This contract negotiation tactic by BCBS with the relatively small Tufts system practically demands a contrast with the give-away the company agreed to with the region's dominant provider group just a few weeks ago.  What a warm set of press releases were issued back then, as both sides presented their deal as reducing health care costs, when it actually augmented the excessive differential in rates that had been awarded to that provider group for years.

This time, the press releases are a lot less friendly, and the parties seem far apart.  Maybe the explanation is that there was just no money left after that other contract was signed.

Buena suerte, hospitales de Madrid. Lean es mejor.

Speaking of Lean process improvement, it appears that the folks running hospitals in Madrid could use some help.  Check out this article on smartplanet, entitled, "Madrid hospitals look to free beds."  The lede:

Spanish hospitals are looking to speed up check in and check out processes, without cutting patient care.

So, officials from sixteen hospitals in the city are getting together to share ideas.  The article notes that most hospitals do have programs and objectives geared towards greater efficiency, but that they are “siloed” from department to department and problems often feel a “domino effect.”

As everywhere, there are some cultural problems that can complicate the situation:

[B]esides emergencies, Spanish hospitals shut down Friday afternoon until the busiest time of Monday morning, often keeping patients there two days longer than necessary. After congestive heart failure, the most popular cause of a longer length of hospital stay is simply the fact they were admitted on a Friday.

The medical director of the private Madrid Hospital Moncloa, Carlos Zarco described some services of hospitals functioning on the weekends as a great idea, but essentially “imposible” and very expensive in Spain. He said that profitability would go down, but he does think departments like radiology should be open on weekends.

Claro, imposible.  I think this is an example of focusing on the hardest solution, rather than redesigning every day work flows to eliminate waste and inefficiency.  Instead of bringing administrators together to analyze the problems from on high, it is time for them to go to gemba and watch the obstacles and work-arounds that the front line staff face every day.

Uncool and unLean taxi batching at Logan Airport

One of the things you learn from Lean is that batch processing is often inefficient and wasteful compared to continuous flow processes.  I have sometimes used this blog to illustrate this phenomenon, like at this bakery and, ironically, even at the food service line of a Lean conference.

I saw another example when I arrived at Logan Airport late at night this past week and was waiting for a taxi.  Here's the scene behind me.  Counting those in front of me, at least 50 people were in line at Terminal B, with more showing up every minute.

Taxis were arriving in groups of three to five as they were sent over from the parking lot at which they are required to wait.  In between, the dispatcher required all passengers to wait behind a chain.  (By the way, note the signage!)

Then the taxis arrived and parked at the curb. 

Only then would the dispatcher allow the batch of three to five passengers groups past the chain.  It would take them about a minute to reach their cabs, load their luggage, and sit inside.  Since the cab at the front of the line was furthest from the chain, its passenger would have the longest distance to walk and take the most time to load. 

Only after that first cab was filled and ready to leave could any of the ones behind it proceed to leave.

In between batches, the dispatcher had nothing to do. He even had time to visit a passing MassPort supervisor driving by in his SUV.

I was about number 40 in line when I arrived at the scene.  It took me over a half hour to get into a cab using this approach.  Each batch had three to five cabs, arriving every three to five minutes.  Loading took a minute for each batch.  I had to wait for eight to ten batches. 

Imagine a simple improvement to this system.  Assuming the taxis have to come over in batches from their parking lot, why not have the dispatcher get people ready to load by standing at pre-marked spots along the sidewalk, ready to load luggage and hop in as soon as a car pulled up.

But imagine a further enhancement.  I asked my cab driver, "Did you have to wait a long time at the remote parking lot before being freed up?"  "No," he said, "only about 15 minutes."  I was stunned that this could be the case on a very busy night, with unmet demand at each terminal.

Apparently the overall dispatcher at the parking lot sends a clump of cabs to each terminal, in sequence, when it is a busy night.  With five terminal locations, every fifth group will show up at any given terminal, always in a batch.  That batch takes time to exit the parking lot, and then the next group moves up the line from their parking places.  What if, instead, the dispatcher at the parking lot sent each single cab, on a continuous basis, to the next terminal in sequence?  A steady flow of individual cabs would arrive at each terminal, separated by less than a minute, to be entered by a waiting passenger at the curb.

I'll let our process flow engineers do the math, but I guarantee this approach would have reduced waiting times considerably, both for cab drivers trying to make a living by getting as many trips as possible and for passengers trying to get home as quickly as possible.

Mr. Ness, everybody knows where the booze is.

A quality-driven MD colleague writes with frustration about two problems in his academic medical center.  I often hear similar comments from nurses and doctors, and so I present the examples for your consideration.

This hospital has a poor record with regard to hand hygiene (in the 30% range), and my colleague suggested at an infection control meeting suggested that the rates be publicly posted in the hospital to provide an impetus for improvement.  "I suggested that instead of being embarrassed, maybe we should OWN the data." This, of course, is a standard and accepted approach in quality improvement.  S/he was told that the "the lawyers will not let us do this."  S/he wonders, "Who, exactly, is our primary concern?"

At another meeting, the chief nursing officer asked why there had not been more progress made with regard to central line infections in the ICUs.  It turned out that there had been meetings with  the bedside staff which identified a number of problematic workarounds they had created. However, the team was limited in what they could do because decisions about equipment and kits are made based on cost, away from the bedside. The CNO was upset because the local folks had not shared with her what they had already done and wanted to know why they hadn't told her about these problems – while acknowledging she couldn't do anything about them.

My friend summarized: 

I explained that if she wanted to find out what was going on – she need only walk onto the unit and ask.

This all reminds me of the scene in The Untouchables. Elliot Ness talks about busting Al Capone if only he knew where he was making his booze. Sean Connery's character (Jimmy Malone) takes him to a post office across from the police station.  Ness can't believe the booze is there. Malone says, "Mr. Ness, everybody knows where the booze is. The problem isn't finding it, the problem is who wants to cross Capone."

The problem isn't knowing HOW to fix this problem. It's doing what it takes to accomplish that -- over-ruling the lawyers and accountants and doing the hard-work to change the culture. This can't happen if the C-suite leads from meeting rooms.

These stories exemplify the huge cultural schism in the country between the minority, those institutions that have taken on the quality and safety agenda and internalized it into their decision-making and process improvement efforts, and the majority, the ones that have not.  Each year at the IHI Annual Forum, I hear from nurse managers and young doctors asking, "What can I do to get my CEO/CFO/CNO/Board of Trustees to support us in what we know must be done?"

I want to state this as clearly as possible:  The leaders of academic medical centers and medical schools are failing to be the leaders the country needs at this time. In their failure, they sow the seeds of burdensome governmental and regulatory requirements, for those in policy positions will see the vacuum and will fill it. In their failure, they persist in accepting the view that "these things happen," and are personally -- yes, personally -- responsible for thousands of preventable deaths and injuries each year.  This is the most significant ethical issue facing the profession, and they simply fail to accept responsibility.

In memoriam: David Staelin

On November 7, MIT's David Staelin wrote to several of us who participate with him in a seminar:

We [with Carl Staelin] have finally finished our book on neural spike processing and its relation to perception and cognition....  The copyright enables redistribution of parts or all of it without permission, either electronically or in print.
 

The website will be updated periodically.  I hope you and your colleagues find both the quantitative and the more qualitative and speculative parts useful.

On November 10, David died.  The dedication to the book reads:  "We dedicate this monograph to our wives and families who helped make this work possible and life worthwhile."

The introduction reads: 

This monograph addresses in a new way how brains may use signal spikes to compute, perceive, and support cognition. It presents and simulates simple novel numerical models of neurons and discusses the relationship between their performance and known neural behavior. Modest math skills combined with the included brief review of neural signaling should enable most readers to understand the basic issues while skimming over the more specialized portions.

What simple and elegant statements from a man who exemplified the open exchange of academic thought in the pursuit of knowledge.  He will be greatly missed.

First Ohio, now California

In the footsteps of Ohio Hospital Association, the California Hospital Association seems poised to take a great leap backward in the realm of transparency.  Payers and Providers reports:

The California Hospital Association has withdrawn its support for the CHART healthcare quality program, a dramatic move that raises questions about the future of the landmark initiative.

The California Hospitals and Assessment Reporting Task Force was launched in 2004,and is one of the first coordinated efforts to report on the quality of care in a state’s hospitals. More than 240 facilities representing nearly 90% of the inpatient beds statewide report on various facets of the quality of care they deliver, including infection rates, treating heart attack victims and maternity care. The data and analysis is posted for consumers on the Calhospitalcompare.org website.

As in the case of Ohio, the decision seems to be based on thoughts that the CMS Hospital Compare website and other such national sites create duplication and undue burdens on hospitals.  What a shame.  The California site is well constructed and among the easiest to use that I have seen.  That is especially the case if you are a Californian and want to view local hospitals quickly and easily.  También hay una versión en español que funciona con un simple clic.  Why would you want to discontinue the one that is done well in favor of the one that is cumbersome and out of date?

Remembering our veterans: Not just a Monday holiday

A health care blogging break in honor of our veterans.  For a history of Veterans Day, see here.  I always liked that it is one holiday that does not get moved to the closest Monday:

Veterans Day continues to be observed on November 11, regardless of what day of the week on which it falls. The restoration of the observance of Veterans Day to November 11 not only preserves the historical significance of the date, but helps focus attention on the important purpose of Veterans Day: A celebration to honor America's veterans for their patriotism, love of country, and willingness to serve and sacrifice for the common good.

A murmuration of starlings

This is an absolutely astounding video, filmed in Ireland.

If you cannot see the video, click here.

Murmuration from Sophie Windsor Clive on Vimeo.

Coletta at MITSS

Carey Goldberg over at CommonHealth reported on a speech by Sandra Coletta, head of Rhode Island's Kent Hospital at this year's annual dinner of MITSS.  I won't steal her thunder, but will simply say that this is about the values demonstrated by a leader of a hospital when she acknowledged its systemic errors in the death of a patient.

Back in September, 2008, I related some stories of this type, where other leaders likewise took responsibility.  I am sorry that it remains newsworthy that a hospital leader would act in this way, but it is still unusual enough to warrant attention.

The SCAD ladies set an example

John Novack, from Inspire.com, a place that organizes online patient communities around various diseases and conditions, sent me this link to a great online report entitled, "The SCAD Ladies Stand Up: Stories of Patient Empowerment."

From the introduction: 

The “SCAD Ladies” story is an extraordinary one: women with a rare heart disease self-organized online and began studying their disorder. This patient initiated effort led to physicians at the Mayo Clinic launching new research to learn more about spontaneous coronary artery dissection (SCAD).

The first essay is by Sharonne Hayes, a Mayo doctor, who notes:

Enter “patient-initiated” research. Still in its infancy, this may prove to be the new “gold standard” for the study of uncommon medical conditions.

It stands to reason that the people most highly motivated to support or to even initiate investigations of a rare condition are those personally affected and their close relatives. Our experience with the “SCAD ladies”, Katherine Leon and Laura Haywood-Cory and their online “heart sisters”, provides an example of successful patient-driven, social networking–enabled research. Our pilot and ongoing studies demonstrate that if a large organized group of patients self-identify and present themselves to researchers as study participants, a major barrier to rare disease research can be eliminated.

Delivering a patient-prioritized research agenda to potential investigators, as was done by the SCAD group, also may serve as an incentive for busy clinician-investigators and help convince them to commit to a new line of research or to this unfamiliar study methodology. Many organized patient advocacy groups have developed research agendas. However, the highly engaged and committed women who prompted the SCAD study, linked only via the Internet, demonstrated levels of sophistication and specificity in their patient-initiated research questions that were on par with those developed by formally organized groups. They had clearly done their research, and as a result, allowed this researcher to more clearly visualize the potential of success.

Check out the other essays from patients, which follow in the report.  They are well worth reading.

We will spend many years dying

Here is an excellent post by Janice Lynch Schuster on Disruptive Women in Health Care.  The occasion was Steve Jobs' death, but she draws broader lessons.

Here's the one that struck home most to me:

For many years now, I’ve written on this subject with Dr. Joanne Lynn, a geriatrician and hospice physician. In our book, Handbook for Mortals: Guidance for People Facing Serious Illness, we talk about the living with/dying of conundrum. Americans like to talk about “the dying” as if they were a different sort of person, in contrast to the rest of us, whom Joanne characterizes as the “temporarily immortal.” Once someone has been labeled as dying, we expect him or her to go about the business of doing just that: taking to bed, saying farewells, making peace with God, signing up for hospice, giving up daily routines and purpose. We think of the dying as a distinct group, with different interests, and an entirely different role to play in this life.

The fact is, for Boomers like Jobs, we will spend many years dying of something. Nearly 80 million of us are aging together, and along the way, we will accumulate illnesses of old age: heart disease, cancer, and Alzheimer’s. Thanks to modern medicine and public health, we will live for a long time with what have become chronic conditions. Where these diseases once killed swiftly and uniformly, they are now chronic conditions with which we live—and from which we die.

Bravo to Brent James

Dr. Brent James last week was awarded Columbia Business School’s W. Edwards Deming Center for Quality, Productivity and Competitiveness. As described in the press release:

The Deming Cup grew from the center’s drive to highlight the achievements of business practitioners who adhere to and promote excellence in operations – the Deming Center’s area of focus. This award is given annually to an individual who has made outstanding contributions in the area of operations and has established a culture of continuous improvement within their respective organization.

Dr. James was recognized for his pioneering work in applying quality improvement techniques that were originally developed by W. Edwards Deming and others, in order to help create and implement a “system” model at Intermountain, in which physicians study process and outcomes data to determine the types of care that are most effective.

Imagine that, improving clinical care is consistent with efficiency in the health care system.  This has to be another lie, just like that stuff about Pronovost saving lives and reducing costs by reducing the rate of central line associated bloodstream infections.  Or assertions by that trio of fraud, Spear, Toussaint, and Kaplan.

This stuff can't be true.  If it were everybody would be doing it.  Right?

Back on January 15, 2009, I published a post entitled "What does it take?", in which I expressed frustration with the slow pace of process improvement in hospitals.  What followed in the comments was a virtual seminar by some of the country's leaders in the field.  They are still worth checking out.  Brent offered his point of view:

Paul, you have put your finger on what I regard as THE core task of the present generation of the healing professions. It is very clear that we are in the midst of a transition. The term of art that is usually used to describe the present state – and which Don Berwick so eloquently explained (at least, at the level that an individual physician would experience it) – is “the craft of medicine.” It’s the idea that every physician (or nurse, or technician, or administrator, etc.) is a personal expert, relying primarily on their personal commitment to excellence. In a very real sense, every physician occupies his/her own universe, with its own reality, truths, physical constants. As a physician I might say to a colleague, “What works for you, works for you. What works for me, works for me. Let’s both stay focused on the patient – our core fiduciary commitment to put the patient first in all things – and that will guarantee the best possible results.”

David Eddy said it most eloquently: This core assumption of the craft of medicine is scientifically untenable.

As a direct result of some solid research around this fact, the healing professions are in the midst of a major sea-change, a once-in-a-century shift: We’re moving from “medicine practiced as individual heroism” to “medicine as a team sport.” The kinds of tools you’re talking about make perfect sense in a team setting, but almost no sense within the craft of medicine.

Don is right in calling it culture change. However, we are well past the tipping point. There is strong evidence that the professions have committed to a new course and are actively moving. It’s the difference between 5% of the profession “getting it” (where we are now), and moving to a point where it is standard, accepted, background business essentially all of the time.

The key change concept was perhaps best expressed by Winston Churchill: “People like to change; they just don’t like to be changed.”

I am also deeply impressed by Roger’s classic text on change: Diffusion of Innovation. He describes bottom-up change, by sharing results (both data and word of mouth) from initial thought leaders (his “early adopters”). That has worked very well for us, and makes the change fun – rather than something that a bunch of external “know nothings” are trying to do to you. 

You only have three seconds

In my continuing occasional series about entrepreneurs, I present this gentleman, a shoeshine guy at the corner of Sixth Avenue and 47th Street in New York City.  Street vendors often engage in hawking to attract business, but this fellow is a master.  As people walk by, he turns from the current customer's job, makes eye contract, and offers a pithy phrase that is meant to draw business.

"When are you going to do something about those shoes?

"Don't you love her?  What about those shoes?"

"Are you selfish?  Think of those shoes."

When I remarked on how effectively he segmented the market, (i.e., how well he seemed to understand what would work with different folks) he said, "You only have three seconds to make a connection."

It worked on me.  As I walked by, all he did was to shake his head from side to side and say, mournfully, "Those shoes . . . ."

Entitlement or naïveté?

I make it a practice of saying, "Yes," to any student or young professional person who wants career advice.  This serves two purposes.  One is to provide (hopefully) helpful assistance to someone starting his or her career.  The other is for me to be rejuvenated by the energy and idealism of the next generation of community leaders.

This week, a person who is involved in health care consulting at one of the big firms sought advice about how to move from that environment to a job "somewhere in the provider-payer space."  (By the way, I hate the term "space" when it is used in this manner, but I have learned to expect it from consultants and venture capitalists.)

The person thought that the ideal job would be to join the internal strategic planning group in a large academic medical center.

I advised against this.  I pointed out that such groups are often marginalized in AMCs.  They tend not to be respected by the doctors and nurses, because they are viewed as not understanding the obligations, work flows, and other issues associated with delivering clinical care.

I suggested, instead, that this person seek a "line" job in a hospital, helping to run an ambulatory clinic or some other operational role.  "Learn what it is like," I said, "to organize how care is delivered, dealing with nervous patients, stressed out nurses, and doctors with strongly held views.  Over time, you will demonstrate good work and initiative and how make changes.  Based on that, you may be asked to participate in task forces that help set the strategic direction for the hospital.  By then, too, you will be known and respected by clinicians and therefore less likely to be marginalized."

The response was firm and immediate: "No, I don't want to do that.  My salary would take a cut, plus I want to be involved at a higher level in the institution."

I was struck by this.  Just a short time out of MBA school, followed by a stint as a consultant, this person was confident s/he would provide value in the corporate planning function of the most complicated type of business in the world.  Whatever happened to the idea of starting low, learning what life is like on the front lines, demonstrating ability, and working one's way up the ladder?

Instead of being rejuvenated by the energy and idealism of someone in the next generation, I felt like I was facing an overabundance of entitlement.  Perhaps, though, I took it the wrong way.  Maybe it was just naïveté.

Texas-sized shoot-out

It has been some time since I reported on the Parkland Memorial Hospital saga.  A new article about things in Dallas draws us back to events in Texas.

Here's the title: "Ask the Editor: DMN Managing Editor George Rodrigue responds to accusations from UT Southwestern's Dr. Daniel K. Podolsky".  Here's the link.  Here's the lede:

Our Sunday story on patient safety indicators among Texas’ larger hospitals drew a rather heated response from Dr. Daniel K. Podolsky, president of UT Southwestern Medical Center. His University Hospital-St. Paul finished rather badly in the standings, and Dr. Podolsky accused us of cooking the books. His theories are incorrect – we played it straight, and we included all the necessary caveats about the limitations of our data – but maybe, if you care about journalism or health care, you’ll find our dialogue to be an interesting debate. As usual in these cases, we’ve printed Dr. Podolsky’s full comments below, along with our response.

I am sure that public relations consultants across the country are viewing this as a case study in media relations.

South Carolina on WIHI

Organizing for Health: A Story from South Carolina
November 3, 2011, 2:00 PM – 3:00 PM Eastern Time

Guests:
Rick Foster, MD, Senior Vice President of Quality and Patient Safety, South Carolina Hospital Association

Kate B. Hilton, Director, Organizing for Health; Principal in Practice for Leading Change at the Hauser Center for Nonprofit Organizations at Harvard University

Landis Landon, President, Immaculate Merchant Services; Resident, Columbia, South Carolina

In August of this year, a very different sort of town hall meeting was held in Columbia, South Carolina. About 90 people who shared the zip code 29203 sat down to talk about the health issues they faced. The list was long: lack of dental care, colon cancer, breast cancer, diabetes, heart disease, stroke, mental illness, low birth weight babies, and more. Any one of these issues is worthy of attention; indeed, in most parts of the US, you can find initiatives trying to either prevent or reduce the burden of specific diseases that affect specific individuals. But what if the approach was more comprehensive and more widespread – and, most importantly, engineered by the community itself? What if hundreds of people from across the community –representing neighborhoods and businesses and insurance companies and local hospitals and municipal offices and professional schools – all decided to band together to turn things around?

That’s what the people decided in Columbia, South Carolina, and WIHI is pleased to welcome to the program some of the key leaders behind the effort – Rick Foster, Kate Hilton, and Landis Landon – to describe their groundbreaking mobilization.

Some of the concepts and goals underpinning the Healthy South Carolina campaign are quite familiar, such as expanding the role of primary care and helping everyone become more physically active. What sets this initiative apart is the strategy. It starts with training some 300 leaders by the end of this year (2011). They’ll play several roles, but will focus in part on fanning out across Columbia, SC, to work directly with residents on creating pathways and programs to better health. There will also be a major emphasis on improving everyone’s health literacy and communication skills. And every part of the community’s health care delivery system is pledging, along with insurers, to engage in serious discussions about how to improve access to primary care, reduce reliance on emergency departments for non-urgent problems, and reduce costs.

Yes, it’s just the beginning stages and yes, it’s just one community. And no one knows whether this multi-year effort will succeed. Still, at a time when new models of better health, better health care, at reduced per capita costs, are badly needed, Healthy South Carolina is an initiative to root for, learn from, and watch. WIHI Host Madge Kaplan hopes you’ll join her and her guests on Nov 3. Invite someone from your community to tune in with you!  

To enroll, please click here.

l'equip petit

Of all the football (i.e., soccer) videos I have seen, this is the most inspiring.  It captures the beauty of the game through the eyes of the young players from a team in Spain.  It provides intense validation for those of us who coach youth teams.

If you can't see the video, click here.


l'equip petit from el cangrejo on Vimeo.

Blog roll revisions and invitation

Attentive readers will note two changes in my list of blog links (to the right.)  First, I have moved blogs related to Lean process improvement into the "Transparency" category.  The two are so interrelated that it made sense to combine them.  If you write a blog about Lean, I would be happy to consider it for inclusion.  Just offer it in a comment below.  Also, if you are part of a hospital association, hospital, or other organization that is strongly committed to transparency and have a website or a blog about that, please let me know in a comment below.

Second, I have updated several other blogs to indicate a "dormant" status.  These are blogs that have been officially closed by their writer or are otherwise inactive but have a wealth of information and interesting points of view that still deserve reading.  An example is Mike Sevilla's Dr. Anonymous.  (Mike is now over at Family Medicine Rocks, where he offers a slightly different perspective on things.)  Another is Lester Leung's Apollo, MD, which gave us a travelogue in his journey from pre-med to the beginning of residency.