How a blog held off the most powerful union in America

I've published a new book that might be of interest to those of you who care about the power of social media in preserving democratic values.  The story is about how I used this blog to fend off a corporate campaign by the Service Employees International Union between 2006 and 2010.  By denigrating our hospital, the SEIU was trying to put pressure on our Board and management to agree to process that would have shortchanged our employees' right to a free and open debate about the question of union organizing.  By using this blog to expose the corporate campaign playbook, the public and our staff were able to see through the union's tactics, and the effectiveness of the corporate campaign was nullified.

I was honored when David P. Boyd, Professor of Management at Northeastern University, agreed to write a foreword for the book.  Here are some excerpts:

In this book, Paul Levy offers a compelling historical narrative of labor-management relationships over a tumultuous five-year period. While the story itself is riveting and the stakes compelling, it is more than simple case narrative; rather it is a morality play about an attempt at power dominance which, if realized, would have foreclosed employee engagement. Through such tactics as “neutrality agreements” and “card checks,” a powerful union sought to become hostage-taker of a hospital’s financial and reputational halo. Levy knew such an approach would usurp the primary goal of the hospital to preserve and enhance patient care. It would also deny employees the right to debate and determine the environmental parameters within which they worked. Thus the principles in play were no less than institutional purpose and individual prerogative.

To safeguard the sanctity of these principles, a communications strategy became key; Quite novel as a weapon in 2006, this social medium offered several advantages. 

The result was victory for the hospital whose fundamental aspirations never fell victim to an external force.... The book remains more, though, than a treatise on unions and those they seek to organize. Rather it is a passionate plea that process be predicated on mutual respect. By shortcutting process, any group will nullify the ethical validity of its intended outcome.

The book is available on Amazon and in electronic form on all platforms.  While you are waiting for the book to arrive, you can go to this site if you would like to see a full compendium of my blog posts with regard to the SEIU corporate campaign.

An Epic voyage

Several months ago, I wrote a blog post comparing customers’ experience with Epic with the Stockholm Syndrome.

I reminded people of the syndrome:

Stockholm syndrome, or capture-bonding, is a psychological phenomenon in which hostages express empathy and have positive feelings towards their captors, sometimes to the point of defending them. These feelings are generally considered irrational in light of the danger or risk endured by the victims, who essentially mistake a lack of abuse from their captors for an act of kindness.

Then, I noted: 

What is striking about this company is the degree to which the CEO has made it clear that she is not interested in providing the capability for her system to be integrated into other medical record systems.  The company also "owns" its clients in that it determines when system upgrades are necessary and when changes in functionality will be introduced.  And yet, large hospitals sign up for the system, rationalizing that it is the best. 

I quoted an article by Kenneth Mandl and Zak Kohane in the New England Journal of Medicine:
 

We believe that EHR vendors propagate the myth that health IT is qualitatively different from industrial and consumer products in order to protect their prices and market share and block new entrants. In reality, diverse functionality needn't reside within single EHR systems, and there's a clear path toward better, safer, cheaper, and nimbler tools for managing health care's complex tasks.

A year ago, Forbes noted, "By next year 40% of the U.S. population--127 million patients--will have their medical information stored in an Epic digital record." 

It is this last point that we must now address, as I hear from my colleagues in the EHR world—no, not Epic’s competitors-- that Epic engages in practices that well help cement that market share for years to come.

They tell me, for example, there is the “good install credit.” If your enterprise chooses to have a significant portion of its IT staff trained and certified by Epic to conduct part of the system’s installation, you get a significant discount on the installation costs. On the one hand, training and using internal staff rather than outside consultants can be viewed as a good thing. On the other hand, what better way to assure future product loyalty than by indoctrinating a hospital’s internal IT force in the ways and means of this system?

Another technique they report to me is the limitation set on “certified consultants.” If you are a third-party consultant who would like to be certified as an Epic consultant, you have to promise not to work on other systems.

As a country we get nervous when any company in any sector has a market share in the range of 40% because we know that companies will use their market dominance to limit consumer options and hold back technological advancement.

In the 1980’s, we saw an antitrust case filed against the AT&T and its Bell System based on such concerns. AT&T, for example, engaged in an “installed base migration strategy,” a pricing policy that caused large business users to adopt its next generation of office-based telephone switching equipment, whether or not the users needed the new functionality. The pricing power was extraordinary. We also saw the company systematically prohibit the use of telephones and other premises-based terminal equipment provided by other manufacturers, claiming that it would damage the telephone network. You also had no choice of long distance carriers, and you paid for each call by the minute.

The situation was so pervasive that comedienne Lily Tomlin could easily generate laugh lines in her routine about Ernestine, the telephone operator, by saying, “We don't care, we don't have to...we're the phone company.”

Ultimately, the antitrust officials in the government stepped in, and the Bell System was broken up into its component parts. Competition was permitted in each segment. Anyone could install inside wire in their home or business. Anyone could manufacture and sell telephone sets. You had a choice of long distance carriers. Consumer choice expanded. Functionality increased to respond to market demand. Pricing plans changed. Value increased.

I see some analogies in the EHR environment. I hear that high-end specialty IT application companies—e.g., the best of breed emergency department system vendors—find it extremely difficult to make sales inroads in hospital systems that employ Epic, as compared to other enterprise systems. These are the folks that are developing the cutting edge applications to improve decision support, quality of documentation, and interoperability. They are the analogs to the terminal equipment, switching, and long distance companies that were squeezed out during the Bell System’s dominance.

Can we afford to delay the introduction of such systems in a health care system that is desperate for better quality and safety, greater efficiency, and higher value? While Epic does not have the market share once enjoyed by the Bell System, there is a special consideration here. We need to consider whether it is appropriate that an EHR company that is making its money in great measure on contracts paid directly or indirectly by federal funds should be able to engage in practices that support long-term market dominance.

The joy of Division 4

Our regional youth soccer league places teams into one of four divisions, ranked from 1 to 4.  Division 1 contains the very best players, the ones who vie to be state champions, and it goes down from there.  By the time you get to Division 4, you find the kids who have the lowest level of individual skills, the least ability to execute plays requiring two or more members of the team acting in concert, and the poorest physical conditioning.

For a referee, officiating a Division 1 game is a physical and mental challenge.  The play is fast and furious; the teams are often evenly matched, so the official is required to move up and down the full length of the field many times; the kids exercise creative plays that are interesting to watch; and the players are likely to engage in intentional fouls of the other team, trying to do so when you have turned your attention to another part of the field.  Those of us who have refereed for many years view these high level games as fun, because they keep us on our toes and requires many judgment calls as the game progresses, all in real time.

In contrast, refereeing a Division 4 game can be as exciting as watching paint dry.  You seldom need to run to keep up with the play, whether or not one team dominates the game.  The fouls that occur are usually inadvertent, the result of clumsiness, not intent.  Goals seldom occur, as the kids have trouble making consecutive passes.

I was thinking of this today as I officiated a Division 4 boys game.  It was so boring that I was having trouble keeping my concentration, and then I realized I was not exercising a proper duty of care in my position as the lead official on the team.  I simply wasn't being fair to the 22 players on the field.  They were playing hard, but I was not.

So, I looked for things to notice about the boys and about the game, hoping to do a better job maintaining my interest.  The first thing I noticed was that the boys were nice to each other.  They all knew they were not terrific players, and so when someone made a good play, the others praised him.  When someone muffed a play, there was no criticism.  Quite the contrary.  You'd hear, "Good try, Joe," or "We'll get it next time, Sam."  Even when the error was egregious, one that would make me squirm in embarrassment for the child.

The next thing I noticed was that these were really intelligent kids.  The structure and vocabulary they used reflected the best students of their age level (13- and 14-year-olds).  They employed the sardonic--and often self-deprecating--humor that is characteristic of intelligent children who are good at science and math.  Perhaps you've heard it.  It is the humor that is displayed by people with enough confidence to realize that mistakes are to be learned from.  Interestingly, too, the boys were able to analyze the game situation and comment on it and know what should have been happening, even if they were unable to execute it.

Finally, the boys were having fun.  There were smiles.  There was laughter.

So, I finally realized that I was surrounded by the kids we would have affectionately called nerds.  I know the group well because I was one of them growing up and went to a college (MIT) that was full of them.  To stereotype, they are great at academics, not particularly great at athletics, and a bit socially inept, except when among themselves.  But, to recap, they were having fun.  They were thinking and learning the whole time.  They were behaving like good and supportive members of a team.

I felt abashed that I had allowed myself to become bored in their presence, that I wasn't giving their game the attention it deserved, that I had allowed my performance to wane.  I became revived and realized that their game was an important as any Division 1 game I had officiated.  I understood that it was filled with joy and that, if I did my job right, I could experience the joy myself.

This is where nurses and doctors differ

Tamara Schalken, chair of the hospital nursing advisory board at Jeroen Bosch Ziekenhuis, recently presented at TEDx in Nijmegen.  In eight cogent minutes, she explained the difference in skills and perspective between a great physician specialist and a super nurse.  Watch it here.  If you can't see the video, click here.

Health care is a service industry? Really!

Brian Powers, Amol S. Navathe, and Sachin H. Jain offer a thoughtful and interesting approach to the question of patient-centeredness in a recent blog post on the Harvard Business Review page, learning from service industries.  Here's the lede:

Current approaches to patient-centered care are based on aggregated preferences rather than individualized needs. Researchers and health systems deploy focus groups and surveys to assess general patient preferences in an effort to determine "what patients want." But patients are a diverse group with diverse needs. Characterizing general beliefs and preferences alienates those whose needs and preferences do not align with the majority. The result has been a monolithic view of patients and their needs — a framework that prevents the delivery of truly patient-centered care.

The authors call current efforts "well intentioned" but stemming from "a misguided focus on the needs of the average patient."  They point to other service industries that have gotten clever at segmenting their customer groups, learning about particular aspects of service that are relatively more important for those segments.

Customer segmentation is ubiquitous across service and consumer product industries, but its application to health care has lagged. As health-care-delivery systems expand and more data is stored in electronic databases, there exists the potential to prospectively segment patients according to their needs and preferences.

Why does the health care segment lag in this approach?

One reason is providers have been reluctant to see health care as a service industry. Only by accepting the reality that it is one can providers learn from the successes of others in the field. And there is plenty to learn.

One commenter notes with approval:

The patient sitting in front of a doctor is no longer "his" or "hers" patient. It is an individual with his own needs. Meaning the center of attention is no longer the doctor and his expertise but the patient.  More precise[ly] the demand[s] of the patient. Which [are] not the same as by the doctor perceived demand[s].
 
Or, as I would put it, "patient-driven care."

A true and great MD

Dr. Richard Wolfe, chief of emergency medicine at BIDMC, after attempting to revive the injured first Boston Marathon bombing suspect: "You have to put their interest first. It doesn’t matter if it’s a perpetrator or the president.’’

Smart Patients helps organize smart patients

In 1995, Gilles Frydman, founded the Association of Cancer Online Resources (ACOR), which evolved into the world’s largest collection of online cancer communities. These communities are remarkable, not only as support groups, but as repositories for the latest and best information about each disease.  Why? Because the participants care deeply about the topic. For them, knowing and sharing as much as possible can literally be a matter of life and death.

Now Gilles and Roni Zeiger, M.D., former Chief Health Strategist at Google, have created Smart Patients, an online community for cancer patients and caregivers.  Beyond patients helping patients, though, this will be patients helping corporations and organizations in the health care field. They note:  "Smart Patients’ business model is to conduct occasional voluntary surveys and share anonymous insights from patients with partners in the healthcare industry to help them provide better care and incorporate the patient perspective into the design of future clinical trials. The site has no advertising or marketing."

Here's more from their press release issued today:

Smart Patients is launching with several partners who will help seed the community. One of the company’s early partners is The Bonnie J. Addario Lung Cancer Foundation, based in San Carlos, California. “We are honored to be partnering with Smart Patients. It is a perfect fit with our philosophy that educated and empowered patients live longer,” said Bonnie Addario, Founder and Chair of the Foundation.

Cancer Commons, a nonprofit, open science initiative linking cancer patients, physicians, and scientists in Rapid Learning Communities, is also partnering with Smart Patients. “It's critical to bring patient data as well as patient wisdom to our research teams, to accelerate the development of personalized cancer therapies. We're excited to work with Smart Patients to close that loop,” said Sarah Greene, Executive Director of Cancer Commons. Smart Patients will tap into the knowledge of networked patients to help speed the development of needed cancer treatments.

Smart Patients is working with Oncosec Medical to incorporate patient input into the design of upcoming clinical trials of Oncosec’s skin cancer treatments. “We’re excited to learn from the Smart Patients community. We believe that by incorporating patient feedback into the design process of our clinical programs, we will improve the speed and efficiency of our trials,” said Punit Dhillon, CEO of OncoSec.

Another partner, WorldOne Interactive, has assembled the leading engagement platform for physicians, including Sermo, the largest online physician community in the United States. “Partnering with Smart Patients aligns with our mission to support the physician decision journey and improve patient outcomes. Oncologists, in particular, are interested in patient experiences and clinical outcomes. Providing physicians the opportunity to hear and learn from a robust network of patients having educated discussions on clinical trials and the latest science is a powerful educational tool," said Jake Coniglio, SVP Global Strategy & Corporate Development.

WIHI - -Live from London

April 18, 2013: Patients See What We Don’t – Engaging Patients in Safety – Live from London and the International Forum on Quality and Safety

(Special Time: 1:15 – 2:15 PM ET / 6:15 – 7:15 PM BST)

Featuring:
Susan Hrisos, Senior Research Associate, Institute of Health & Society, Newcastle University (UK)
Jane O’Hara, MSc, PhD, Senior Research Fellow, Yorkshire Quality & Safety Research Group, Bradford Institute for Health Research
Martin Hatlie, JD, CEO, Project Patient Care; President, Partnership for Patient Safety; Co-founder, Consumers Advancing Patient Safety

It’s easy enough to say patients need to be engaged in all levels of their care, including being aware of best practices and anything that could inadvertently result in harm. But what does this actually look like day-to-day, especially in the high-stakes, busy environment of today’s highly complex hospitals? And what good does it do for patients and families to notice and speak up about things if there’s no one on the receiving end trained to respect and act upon the information?

With at least a decade’s worth of ideas and initiatives on patient engagement with patient safety as a backdrop, new research on what is and isn’t working in the UK — with broad application to the US and elsewhere — will be in the spotlight on the April 18 WIHI entitled Patients See What We Don’t – Engaging Patients in Safety – Live from London and the International Forum on Quality and Safety. The new analysis is being presented at the IHI-BMJ International Forum on Quality and Safety in Healthcare by leading researchers at Newcastle University and the Bradford Institute for Health Research in England. WIHI listeners will get the first peek at the findings, thanks to Susan Hrisos and Dr. Jane O’Hara, whose work headlines a workshop session in London the very next day. They’ll be joined by Martin Hatlie, one of the leading voices and experts on patient engagement in the US, who is eager to comment on the research and describe new models for effective patient/provider collaboration around safety that are emerging in the states.

Patient engagement in patient safety is here to stay. The only question is how this vital part of improvement can be more effective, and what skills patients and providers alike need to work together for the same goal.

We’re live from London on April 18 at a special time — don’t miss this upcoming WIHI! Click here to enroll.

National Stop Snoring Week

@britishsnoring. The British Snoring & Sleep Apnoea Association has an excellent website.  Check it out here, in anticipation of National Stop Snoring Week (April 22-26).

Flexibility in Engineering Design -- Free Webinar

MIT SDM Systems Thinking Webinar Series

Richard de Neufville, Ph.D., Dr. h.c.
Professor of Engineering Systems and of Civil and Environmental Engineering
Date: April 22, 2013
Time: Noon - 1 p.m. EDT
Free and open to all
Register

About the Presentation

Designed for those concerned with acquiring and implementing new products and systems, such as owners, managers, developers and engineers, this webinar will explain the concept of flexibility in engineering design, using non-technical language and many practical examples.
Professor de Neufville will cover:

• the problems with predetermined forecasts and requirement sets;
• the benefits of flexibility in engineering design and its role in developing products that can adapt to a wide range of uncertainties;
• how flexibility in engineering design delivers value by reducing or eliminating downside risks, increasing access to upside opportunities, and ultimately producing overall win-win solutions and developmental strategies;
• specific ways successful companies apply flexibility in engineering design, and;
• a framework and next steps for applying flexibility in engineering design in your organization.

We invite you to join us!

About the Speaker

Richard de Neufville, Ph.D. and Dr. h.c., is a leader in the field of systems planning and design and author of "Flexibility in Engineering Design," the first book in the new engineering systems series published by MIT Press. He has also published six other texts and currently teaches several MIT courses in this field that are directed generally to engineering systems, with a focus on product design, real estate, urban development, and airport systems design. Prof. de Neufville is currently involved in developing a wide range of flexibility analysis applications, including design of offshore oil platforms, civil engineering infrastructure, automobile plants and parts, and electrical power systems.

Halsey Burgund brings us Patient Translations

I introduced Halsey Burgund to many of you back in January, when he was working on a new piece of public art called ROUND: Cambridge.  This was an "exhibit" that comprised recordings made by people as they wandered around the city, tied to particular locations.  I thought it was very creative and said,

Now, imagine a hospital that allowed people to do the same thing.  Think about what we would hear from patients about the quality and safety of care being delivered, or physical features of our buildings, or whatever.  But we have to want to listen.

Well, Halsey has done that one step better.  He writes:

Just wanted to let you know that since we last spoke, I have had a flurry of activity on a project that I have long been interested in pursuing on health.  Obviously, I thought you might find it interesting.  I am collecting voices of people talking about their experiences as a patient and with health issues in general and creating an evolving musical piece using those voices.

The project, called Patient Translations, was commissioned originally for the Healthcare Experience Design conference in Boston (http://healthcareexperiencedesign.com/) late last month and will be traveling to TEDMED in DC (tedmed.com) next week.  It's a collaboration with a visual artist, Kelly Sherman, who is using the same raw material of spoken voices to create a visual component to the artwork.

In any case, if you are curious, more info is at patienttranslations.com and you can get the free app on your iPhone if you want to listen or contribute.

 

Here's a screen shot of part of the website:

 

$2.2 billion in revenue, but training is not our job

I don't really want to write so much about the problems of robotic surgery, but when I hear a quote like this from the main manufacturer of the equipment, I can't let it go without commentary:

Intuitive has no duty to train doctors on the da Vinci system under Washington law, the company has said in its court filings.

Here's the context, in this latest story from Bloomberg:

Intuitive Surgical Inc. (ISRG), a maker of surgical robots used in more than 300,000 U.S. operations last year, faces its first trial over claims it marketed the devices to doctors without providing adequate training. 

A state court jury in Port Orchard, Washington, is scheduled to hear opening arguments tomorrow afternoon about whether Intuitive properly trained a physician who, in his first unassisted surgery using the company’s da Vinci surgical system, removed the prostate gland of a patient who later died. 

The lawsuit is one of at least a dozen filed against Intuitive since 2011 alleging injuries tied to the robot-surgery systems. Intuitive’s robots, which cost about $1.5 million each, are used in 1,371 U.S. hospitals, the company has said. The robots and related products generated most of the company’s $2.2 billion revenue in 2012.  

Kitsap County Superior Court Judge Jay Roof last month rejected Intuitive’s bid to throw out the suit and scheduled the trial to conclude in May. The judge found the state’s product- liability laws require medical-device makers to properly train physicians who buy their products. 

Now look how the company and the doctor end up on opposite sides of the case.

According to court filings, [Doctor] Bildsten said Intuitive’s training didn’t inform him of the need to create the watertight seal or warn of the risk of abdomen inflation. After reading Food and Drug Administration documents about the “learning curve to obtain basic competency” with the da Vinci system, Bildsten said, “I believe I likely would not have agreed to begin training on the robot had I been given this information,” according to the filing. 

Bildsten said Intuitive told him he could achieve “basic competency” after two assisted surgeries, and that the company did not tell him that consultants paid by Intuitive reported that such proficiency couldn’t be reached “until twenty or more operations were complete,” according to the filing.

Intuitive has argued in court documents that lawyers for Taylor’s family are attempting to create a “totally new cause of action” against medical device manufacturers -- the “duty to train” -- under the Washington Product Liability Law. 

Under the state law, Intuitive had no duty to train Bildsten or warn him of the risk of the surgery, according to the filing. 

“Dr. Bildsten, a board-certified, licensed surgeon was responsible for making sure he could perform the surgery he chose to perform and to do so safely,” Intuitive argues in the filing.

If you are a surgeon using this equipment, I bet the interplay gives you a warm and fuzzy feeling.

I wonder which medical malpractice insurance company is watching this, wondering why they didn't engage in risk mitigation procedures as part of their underwriting process.

Meanwhile, back on Wall Street:

Investors are so far unconcerned with what the trial result might mean for Intuitive, said Andrew S. Zamfotis, an analyst at evaDimensions in New York. The company is “practically printing money with these robots,” and for shareholders the trial “hasn’t moved the needle yet,” he said in a phone interview.

Sadness in Boston

Thanks to so many friends and colleagues who have inquired about our well-being.  All is fine in our household except for a sense of overwhelming sadness for those killed and hurt by a mean and crazy person or persons, and for the loss of innocence and joy for what the Boston Marathon has been to this community.  We will never be able to stand along the race route in the future with the same sense of happiness. We will still go, of course, in solidarity and purpose--and to show that life goes on--but it will be different.

Robotic surgery: New medical malpractice underwriting risk

If I am a medical malpractice insurance company, should I be concerned about a new underwriting risk?

The question is prompted by a recent story in the Denver Post.  The lede:

The Colorado medical board has charged Dr. Warren Kortz with 14 counts of unprofessional conduct after a series of failed procedures with Porter Adventist Hospital's robotic surgery arm, as federal officials launch a wider review of the highly touted procedures. 

The state alleges that from 2008 to 2010, Kortz cut and tore blood vessels, left sponges and other instruments inside patients after closing, injured patients through improper padding and positioning, subjected some to overly long surgeries, and had to abort kidney donations because of mistakes.

Now, one surgeon does not an actuarial trend make.  The article notes:

The U.S. Food and Drug Administration said it is stepping up interviews of surgeons about the devices after a new series of mishap reports, although the agency said it has not yet identified a trend. Hospitals spend more than $1 million on each of the da Vinci-brand surgery units and are under pressure to keep them busy.

The lack of a trend, however, does not protect doctors and hospitals from malpractice cases.  If I were a plaintiff's attorney, here's the way I would frame the medical malpractice argument to a judge and jury:

A hospital and its doctors decide to purchase and employ a surgical robot, notwithstanding a lack of peer-reviewed evidence as to its clinical efficacy vis-à-vis other forms of laparoscopic or open surgery.

There is evidence that the hospital has spent significant sums of money in marketing the availability of the robotic surgery in its service territory.  There is evidence, too, that ties the marketing campaign to a change in that hospital's market share for the particular procedures advertised.  The profit-and-loss statements of doctors in the hospital show the income gained from this change in market share.

The doctors in that hospital present poor documentation as to why they chose to employ the robot on particular patients, failing to show in the medical records--or in the patient consent forms--a clear demonstration of relative risks and benefits vis-à-vis other forms of laparoscopic or open surgery.  At the hospital governance level, the medical executive committee of the hospital has failed to adopt specific rules and regulations concerning such documentation in the medical records or patient consent forms.

Even if there is a record of simulation or other training by the doctor using the machine, the evaluation of his or her performance in that training session is not carried out by an objective observer.  Maybe the extent and type of training are not even documented.  Perhaps, too, the general pedagogical efficacy of the training has not been subjected to peer review by experts in clinical process education.  At the hospital governance level, the medical executive committee of the hospital has failed to address the issue of granting privileges for use of the robot that sufficiently address these pedagogical and documentation concerns.

(In some cases,) the doctor has employed the robot in novel settings, beyond those used by the preponderance of physicians.  At the hospital governance level, the medical executive committee of the hospital has failed to systematically address the issue of granting privileges for use of the robot for these purposes.

Each of these opportunities to enhance the plaintiff's case can be offset by an appropriate risk management approach.  But how many medical malpractice insurance companies have recognized this new vulnerability and taken steps among their insured entities to ameliorate the risks?

Apparently not many, if these ads from a simple Google search on "medical malpratice robotic surgery" are any indication.

#QIIQ: @CIRSEIU asks, "What's your QI IQ?"

I have made note before of the excellent work being done by CIR, the SEIU Committee of Interns and Residents, in promoting a better patient quality and safety environment in the hospitals in which its members work.  Now, comes a new effort worth watching--and you can watch on Twitter if you follow the hashtag #QIIQ.  Here's a description sent by a friend at CIR:

This year, the CIR Policy and Education Initiative, partnering with the Healthcare Transformation Project of Cornell University, is organizing a series of conferences in the New York metropolitan area to focus  on the topic of physician leadership in quality improvement and patient safety.

The first conference is on April 13 (9:45am-4:00pm) in Manhattan and is entitled: 

"What's your QI IQ?: Resident Physicians as Quality Improvement Leaders."

The conference will feature: 

• interactive didactic sessions led by James Pelegano, MD, MS, Program Director for the Jefferson School's Master's Program for Healthcare Quality and Safety, and an innovator in the field of Patient Safety and Quality;
• Small-group breakout sessions that will allow participants to practice and refine the methods they have learned;
• Panel discussion with resident physicians who are currently working on Quality Improvement and Patient Safety;
• Hands-on workshop on the formulation and writing of QI/Patient Safety project proposals. 

We are interested in hearing from others and sharing our experience in engaging housestaff around Quality and Safety. We would appreciate any feedback on how to meet the needs of current and future physicians who face the prospect of practice in a rapidly changing healthcare system. 

Good people helping people in need

Every community has them.  People who need help.  Every community has them.  People who offer help. But, expecting nothing in return, these are unsung contributors to the heart and soul of the region.

It's time to mention one such group here in the Boston area.  It's a small nonprofit called Hospitality Homes.  The mission is simple:

Hospitality Homes was the first program of its kind in the nation.  The organization has about 150 host families.  The services are free of charge and are made possible by the generosity of the volunteer hosts and supporters.

Anyone is eligible to be a guest who:

• Lives more than 50 miles from the hospital. 
• Has a permanent home to return to after his/her stay.
• Is an important support person for the patient.
• Is not likely to put the host family at risk.

Unfortunately, the need for convenient, caring, and cost-free accommodations for patients’ family members increases every year.  The place needs volunteers and financial support.

Dr. Louis Caplan, a neurologist at BIDMC, is quoted on the HH website about the pleasure of being a host:

My wife and I have been enriched by our experiences with the many families we have hosted. In one instance, we met a woman from India with a condition that left her effectively blind.  At the end of her stay we shared in the sheer joy of her regained sight.
 

Hospitality Homes is a 501(c)(3) nonprofit organization, governed by an able and diverse board of directors and operated by an excellent staff. Donations are fully tax-deductible.

Teaching Girls Soccer

One day left to contribute to this Kickstarter project to create a great video for coaching girls soccer.  It's close.  Please help, now.  Watch the video.

Validating communication

This video was produced some time ago, but I had not seen it.  Please take a few minutes and watch the interaction between Naomi Feil and Gladys Wilson. Stick with it to the end.


Many thanks to Janice Lynch Schuster for bringing this to my attention.  Janice recently wrote an article about steps you can take to communicate with people with dementia.  The article made mention of the "validation method" pioneered by Feil in the 1980's.  That is what is at work in the video.

While there have been questions raised about the method in the scientific community, I dare you to watch this video and not feel that it has some power.

If you cannot see the video, click here.

Learning from the un-checked checklist

As long as we are on the issue of cognitive errors, it is instructive to review the crash of an MQ-9 Reaper in an unpopulated area in Nevada on Dec. 5, 2012.  The U. S. Air Force Air Combat Command recently published a full report of the incident, noting, "The aircraft, one inert Guided Bomb Unit, a Hellfire training missile, a Mission Kit, and one M299 missile rail were destroyed. The loss is valued at approximately $9.6 million.  There were no injuries or damage to other government or private property."

A summary:

The Accident Investigation Board President therefore found by clear and convincing evidence that the causes of the mishap were:

1) prior to the flight, the throttle-quadrant settings were improperly configured during the reconfiguration of the GCS from MQ-1 to MQ-9 operations

2) this throttle change went unrecognized because the mishap pilot did not personally execute the checklists on his control rack prior to gaining control of the aircraft, and

3) the pilot stalled the aircraft due to an unrecognized, commanded reverse-thrust condition that existed whenever the pilot's throttle was at any position except fully forward.

Additionally, the AAIB found by a preponderance of evidence that the mishap pilot failed to execute his GCS preflight in accordance with technical order procedures, substantially contributing to the mishap.

How many hospitals would publish such a report for the world to see?

Applying resilience engineering to health care

A very special conference is coming up in June 13-14, entitled "Ideas to Innovation: Simulating Collaborations in the Application of Resilience Engineering to Healthcare."  It is a joint production MedStar Health and the University-Industry Demonstration Partnership (UIDP) as the first conference in UIDP’s Ideas to Innovation series.

Here's the description:

Resilience Engineering is a paradigm for safety in complex socio-technical systems, yet its application to healthcare is still very limited. Resilience engineering focuses on the fundamental systemic characteristics that enable safe and efficient performance in both expected and unexpected conditions. 

How can resilience engineering be applied to make our healthcare systems safer? During this two day gathering at the National Academies’ Keck Building in Washington D.C., world experts in resilience engineering and resilient health care will present a set of principles and practices that practitioners can leverage in their efforts to improve safety. The workshop will share knowledge, spark innovative ideas, and inspire new collaborations and partnerships to apply resilience engineering in healthcare. Representatives from sectors of academia, industry, and government will work together to explore the ways in which resilience engineering can be applied in healthcare.

Registration information is available at this site.

Raj teaches us human factors

A subtle advantage enjoyed by MedStar as it engages in its quality and safety transformation is the existence of its close affiliate, the National Center for Human Factors Engineering in Healthcare.  Another presenter at today's Quality and Safety Risk Management Retreat was Raj Ratwani, senior human factors scientist at NCHFEH.  Raj is a behavioral scientist with extensive experience in the airline industry and in the defense field.  I found--as did the attendees--much to learn from him.

Raj's presentation was an excellent primer on the types of errors that present themselves in complex systems.  Rather than knowledge-based errors (where people perform the wrong step as a result of a lack of knowledge) or rule-based errors (where people perform the wrong step because of misapplication of a rule), the predominant form of error in hospitals and other types of organizations is skill-based.  In this category, people perform the wrong step because of a slip or a lapse.

Raj stated, "No matter how capable we are, there is variability in our performance."  He noted that we all come to work with intentions to work at our highest level, but our work environment is full of interruptions, the workload is generally high, and fatigue and stress are real issues.

The task then is to design mechanisms that make it more difficult for people to make these kind of errors.  Instead of a "person approach" that focuses on the errors of individuals and blames them for failures of memory and attention, adopt a "systems approach" that focuses on the conditions under which individuals work and that builds defenses to avert errors or mitigate their effects.

Seeing clearly at MedStar

I was pleased to be invited to the quarterly Quality and Safety/Risk Management Retreat at MedStar, a hospital system that has adopted audacious goals for improvement in these arenas.   My topic was on the power of transparency in helping to bring about the kind of organizational change needed to deliver consistently high quality care to patients.  I found an attentive and engaged audience of people from all of the MedStar hospitals, hosted by David Mayer.  David (below, left) was brought into the system in the last year to lead its quality and saftey transformation.

My theme, as regular readers of this blog will expect, is that transparency's major value is in providing creative tension within hospitals so that they hold themselves accountable to the standard of care in which they believe.  This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

For me, a measure of how well a hospital system is doing is the degree of modesty displayed by the leaders and staff when you ask, "How are you doing?"  Here, David asked the question of the attendees:  "On a scale of 1-10 (10 being the most transparent), how transparent is MedSatr compared to other hospitals and health systems?"  Also, "Provide one example of how MedStar can become more transparent with its patients and with its associates."  The discussion groups met for a while and returned with the following verdict:

I actually think the participants were a bit hard on themselves.  I think their assumption about the level of transparency at other hospitals was too high.  From my view, MedStar is already above average.  Of course, as I noted today, there is no virtue in benchmarking yourself to a substandard norm!  MedStar has a ways to go on the transparency front, but it is off to a good start.

I left with a terrific impression of the energy and good intentions of those in the room.  The level of participation and engagement was exemplary.  This is a system worth watching over the coming months and years!

Beautiful: Teaching girls soccer

By now, anyone reading this blog knows of my passion for coaching soccer and especially for coaching girls soccer--going on now for over 20 years.  This has been an exceptionally rewarding part of my life, with extensions to my professional life as well.  I have also been incredibly lucky to have created friendships with hundreds of girls and their families over the years.  Many of my alumnae are still in touch, and I find myself writing recommendations for them for college and graduate school and for jobs (and hiring several of them!)

Now comes a fantastic Kickstarter project entitled, Beautiful: Teaching girls soccer the Boston Breakers way.  This professional women's team has joined up with producer Ralph Ranalli to produce two videos--one for coaches and one for parents--chock full of ideas for effective coaching of girls.  These are products that will become the standard for years to come, but only if we fund it.

There is only a short time left.  Please help with a generous contribution.

I dare you to watch the video on the site and then not contribute!  Here's a sample:

(Click here if you cannot see the video.)

 

John Toussaint provides a roadmap to Lean success

This should be an excellent (and free) webinar, given by John Toussaint, one of the true experts in hospital process improvement.  Here's a description from Joshua Rapoza at the Lean Enterprise Institute.

I'd like to invite you to join us April 16, 2013, at 2:00 pm (Eastern) for the 60-minute, free webinar "A Roadmap to Lean Healthcare Success" with John Toussaint, MD, CEO of the ThedaCare Center for Healthcare Value, author of On the Mend, and a national leader in improving healthcare through lean principles.

As CEO of ThedaCare, Dr. Toussaint introduced the successful ThedaCare Improvement System, a lean healthcare system.

In this webinar and Q&A, he'll describe a roadmap to lean healthcare success, based on his visits to 120 healthcare organizations as well as many visits to leading lean manufacturing companies.

Learn what Dr. Toussaint will cover and how to register.

It's time to vote!

Ok, I need some serious Boston-style (early and often) voting to help a worthy website win first prize.  Maybe you remember my post back in November about a great website to help kids get ready for hospitalization?  Kinderwebsite was produced by a couple of people at Jeroen Bosch hospital in the Netherlands.

Well, now the site is in a competition to be named one of the top five websites for children in the Netherlands.  You can vote from anywhere in the world.  Go to this site.  Find the category that lists the Kinderwebsite --> Halloziekenhuis.nl.  Click on the box that says stem.  It will take you to the voting page.  Then vote for our candidate.  It will then make you do one more step where you enter your email address and agree to some privacy clause.

Thanks!

Please nominate for Compassionate Caregiver Award

It's time to think about possible nominees for the Schwartz Center Compassionate Caregiver Award.  Petra Langer writes:

We’re accepting nominations for the 2013 award from all six New England states until May 3^rd.  Both individual caregivers and caregiver teams are eligible.  The award recipient or team receives a cash prize of $5,000, and the four finalists receive $1,000 each.  All five are honored at our annual dinner on November 21^st at the Boston Convention Center before an audience of more than 2,000 people.  More details are at http://www.theschwartzcenter.org/ourprograms/cca.aspx. You should know that this is the 15^th anniversary of the award. Since its inception, more than 1,200 caregivers have been nominated and 70 honored.  Here’s a link to a video about last year’s honorees: http://bcove.me/3mwhwotk.

What was said, and what wasn't

The existence of an organization called the Association of Health Care Journalists is an indication of the resources being allocated across America and other countries to the coverage of this field.  I think it is a great thing that the group exists and is able to come together--virtually and physically--to build skills, compare notes, and bring in expert speakers, as they did recently in Boston.

Members of the association, though, may not have realized the danger of drawing stories from panel discussions.  Comments made by panelists are often designed to further promote the story lines of their organizations, lines carefully crafted over the years to support corporate objectives. There can be inadequate time to check the assertions made by panelists before writing summations of such sessions.

Here's one such story, about efforts by Massachusetts to contain health care costs.  Read it and see how the two dominant health care organizations in the state--an insurer and a provider network--coordinate the story lines on which they have joined hands.

First, the insurer expounds on its favorite capitated, or global, payment methodology, the one that ostensibly controls costs.  The "new payment method has not lowered overall spending, but it has controlled the rate of cost increases – below 2 percent annually," according to the story.

Taken at face value, this sounds good, until we remember two things.  First, the insurer padded first-year global payment budgets a few years ago to entice a number of hospitals and doctors to sign on.  It sure is easier to show a lower annual increase when you have an inflated base.  In addition, we need to remember what this insurer gave away to the dominant provider group.  As noted here:

Recall that the state's largest insurer gave away a huge rate increase to the state's dominant health care system  --  a 2-3% increase on a base that is, what, 15 to 20% higher than the rest of the market.

Think about the arithmetic.  The only way to give achieve an overall rate of cost increase below 2 percent while giving away a rate increase above that level to the largest provider is to give smaller increases to the subordinate providers in the state, thereby enhancing the market power of the dominant provider.

Oh, but what did the dominant provider agree to in return?  According to the AHCJ story, the dominant provider has "has changed its payment structure."

Really?  Let's go back to the deal that was signed, as reported by Robert Weisman in the Boston Globe:

Under the agreement, Partners agreed to participate in Blue Cross’s alternative quality contract, a so-called global payment that gives health care providers a budget for patient care and incentives for healthy outcomes rather than billing for each visit and procedure.
 
Th[at] new contract . . . covers only about 25 percent of the Partners patients insured by HMO Blue.

As noted, we can't blame the reporter in this case for reporting what was said in a panel discussion.  Perhaps, though, we can blame the conference organizers for creating a panel that was so likely to produce unsupported--and unrebutted--public relations story lines.

"All change begins with one small test."

Anna Roth, CEO of Contra Costa Regional Medical Center, wrote me the other day with a summary that is revealing about what we are all trying to do.  It is all the more powerful because CCRMC is a safety net hospital, short on resources but strong on mission.  The context was her description of a “Change Agent Fellowship" program, modeled after her own IHI fellowship, which couples mentoring and experiential learning with traditional learning such as didactic sessions.

The fellows were chosen by an executive leader who assumed the role of their sponsor and general support throughout the fellowship year.  Fellows were also assigned mentors. These were strong leaders from within and outside our system who could work with fellows and comfortably provide feedback to executive sponsors. I recruited an accomplished executive who had recently retired to run the program.

Each executive makes a promise to the fellow that they will look for learning opportunities and experiences. We have weekly seminars where fellows and their sponsors meet and have speakers join. They discuss projects individually and in a group setting. Though the fellows work on extremely diverse things such as; getting patients and families engaged on all improvement teams; eliminating infections in the hospital;  creating a social impact bond to bring diverse stakeholders together to eliminate suffering in Richmond neighborhoods near the refineries; embedding primary care and respite services within our homeless shelters…it goes on. These discussions often lead to identification of barriers.

Often even though the projects are quite different, the barriers are common across projects. Frequently one barrier is lack of leadership engagement or support to overcome local conflicts of interest or simple things that an executive sponsor can do to help such as authorize a purchase or extra staffing to conduct a test to learn.

What happens?  What is learned?

In terms of the leaders, they will tell you the experience of taking the journey with the frontline staff is both humbling and transformational. Most of us leaders don’t know about improvement or how to lead change. We are promoted because we are masters of the current system. It isn’t easy to stop, listen and let others guide/lead us. This can also be seen by some as weakness. Health care is notorious for charismatic heroes. Faster and more is often seen as better.

The truth is the most important decision made in my organization is not made by me in a board or conference room, but by one staff member at a time, one patient at a time, far away from the board room and far from me. My job is to help create circumstances that will allow our team to easily do what is right. Our mission is what guides us and that is why people come to work. They don’t come to work to cause harm which we hear so much about and is happening far too frequently. They come to help people.  I’m not trying to boast or ring our bell. We have a great deal of work to do. We have only scratched the surface. There isn’t a day that goes by I don’t think about how much more we need to do.  

All change begins with one small test. For us, the fellowship is one strategy designed to systematically deliver an experience that enables leaders and the front line to offer and accept help and to begin doing this on a regular basis with one person. We have seen leaders begin connecting with employees, patients and family members in a very different way after sponsoring a fellow and the fellows go deep into the operation or to the front-line and influence and amplify the voice and ideas of those around them. 

Janice pleases through poetry

Janice Lynch Schuster, @medicaring, who writes very well about health issues (especially aging and end-of-life issues), has another skill.  Check out her haiku here.

I like a recent one, entitled "Grandmom," which subtly ties her various interests together:

I see my Grandmom
Settled in her favorite chair
Comfort in what’s passed

Community needs on WIHI

April 4, 2013: 

Community Health Needs Assessments Part 2:
Lessons from North Carolina

(2:00 – 3:00 PM Eastern Time)

Featuring:
Dorothy Cilenti, DrPH, MPH, MSW, Senior Investigator, North Carolina Institute for Public Health; Clinical Assistant Professor, UNC Gillings School of Global Public Health
John Morrow, MD, MPH, Pitt County Health Director; Incoming President, North Carolina Association of Local Health Directors
Craig James, MPH, President and CEO, Highlands-Cashiers Hospital

One of the reasons it’s so hard to transform US health care into something that’s safe, value-driven, and patient-centered, but also focused on improving the health of the local community, is that the responsibilities and the responsible parties have grown up completely separately. For example, it is not a naturally occurring event for the local public health department to coordinate its efforts with local hospitals… except in cases of disease outbreaks or disaster. So, imagine how rare it is to sit down together to craft overlapping goals for population health or to hatch new initiatives to keep residents from needing expensive acute care. It helps to have a convener to bring parties together… which is why we’re going to be examining one such coalition that has formed in North Carolina… on the April 4, 2013, WIHI, Community Health Needs Assessments Part 2: Lessons from North Carolina.

WIHI host Madge Kaplan invites you to hear what’s been going on under the auspices of the North Carolina Institute of Public Health (NCIPH), and the leadership of Dr. Dorothy Cilenti and her team. They’ve brought together local health directors like Dr. John Morrow, who now leads the statewide health directors association; and hospital leaders like Craig James who sees the mission of one small, critical access facility as part of something larger. They’re all laying the groundwork for the future of health and health care in the state. The effort has become especially relevant and pressing because of new federal requirements for nonprofit hospitals to engage in robust community health needs assessments, with help and input from other groups and agencies. These new IRS rules, and how to make them meaningful, were the focus of the March 21 WIHI, which we invite everyone to listen to as background and context for the April 4 discussion.

One of the more intriguing dimensions to the work in North Carolina is its explicit mission to create multiple “community health systems” throughout the state to build and model best practices for population health. The collaborative driven by NCIPH is also working on analyzing return on investment and economic impact to “create the business case for working collectively on improving community/population health.” We’ve got a great case study to learn more about on April 4. Please join us, and make your own work on population health and community health needs assessments all the richer. See you then!

Please join us on the April 4 WIHI! Click here to enroll.

Spike out Sepsis

Dr. Jim O'Brien sends this announcement about a 6-on-6 sand volleyball tournament to support the Sepsis Alliance, to be held at The Bogey Inn in Powell, Ohio, on June 22.

There will be lots of news about SOS 2013 to come.  To get on the mailing list click here.

Two intriguing summer courses at Tufts Medical School

Lisa Gualtieri, @LisaGualtieri, with the Department of Public Health and Community Medicine at Tufts Medical School, is again running two great summer courses.  One is online and the other is on campus.  I had a chance to sit it on one of Lisa's classes a couple of years ago.   She is an engaging teacher, and the courses attract a diversity of students.

Here's a description of the two summer courses, with a link leading to more details.

Mobile Health Design examines the impact and potential of mobile devices for consumer health at a national and global level. The focus of the course is on how to design evidence-based health apps that incorporate mobile user experience, predictive analytics, and big data to help people achieve their health goals. The online course runs May 22—June 26, 2013

5th Tufts Summer Institute on Digital Strategies for Health Communication covers how healthcare and public health organizations develop and implement digital strategies to drive the success of their online presence, with a focus on how to use web, social media, and mobile technologies to reach a target audience. The case study is Massachusetts Medical Society. The course is offered July 14-19, 2013 on Tufts' Boston campus.

e-Patient Dave does it again

Dave deBronkart, @ePatientDave, and his doctor, Danny Sands, have published a new book, Let Patients Help.  Well, almost.  It is still in its pre-broad distribution mode.  Version 0.91, Dave calls it.

You can (should) order it directly from Createspace, here.  It is very good.

The dangers of risk-taking

Several weeks ago, I suggested that the MA Division of Insurance was not doing its job properly in implementing a provision of recent state legislation.

There is a provision of the law ("Chapter 176T, Risk-bearing Provider Organizations") that was written to provide some assurance that provider organizations--physician organizations, physician-hospital organizations, independent practice associations, provider networks, accountable care organizations and any other organization that contracts with carriers for payment for health care services--would be financially capable of bearing the risk of alternative payment contracts.

A recent post on Disease Management Care Blog, reprinted later on The Doctor Weighs In, shows that this is not an academic concern.

"Wellspan" is a highly regarded and well-run hospital system that is local to the DMCB. This recent news report is telling because Wellspan's success and challenges probably apply to other emerging integrated institutions that have an appetite for risk contracting. 

According to the press report, Wellspan garnered an excellent credit rating because... 

"766 physicians — more than 75 percent of those in the hospital's market — are affiliated with WellSpan, which [was] counted as a key credit strength."

 But the bad news is that the rating also.... 

.....noted that WellSpan's physician group, which employs 411 of those doctors, generated losses of $19.6 million in 2011 and $21.4 million in 2012 (bolding DMCB). 

The DMCB has heard similar statements from seasoned health system administrators both locally and nationally.  If "physician integration" is supposed to be the bedrock of ACOs, how is it that the docs are responsible for millions of dollars in losses?  What is the likelihood that these organizations will finish December 31, 2013 in the black?

A few Massachusetts hospitals and physicians have long experience with risk. Others are new to the concept and, according to the word on the street, do not have in place the kind of care management regime and data sophistication needed to avoid a deficit in these plans.  That is especially the case because Blue Cross padded first-year global payment budgets to entice hospitals and doctors to sign on.  Now that those plans are starting to bite, look for losses to emerge.