Fan support

As part of our partnership with the Boston Red Sox, our staff provides first aid to the patrons at Fenway Park. As the regular season draws to a close (hopefully followed by a long post-season), the team kindly recognized the excellent work of this group in a pre-game ceremony. Here is a small subset of nurses and doctors hamming it up with Red Sox President Larry Lucchino while waiting to go on the field to be introduced to the fans before tonight's game.

Note to BIDMC folks: More pictures and more about this story will be posted tomorrow on our portal, and you can also find some more of my pictures now in Facebook on my profile page.

50 great years

At the Annual Meeting of our Boards last night, Board Chair Lois Silverman was honored for 50 years of affiliation with the hospital. Lois started that relationship as a student in the Beth Israel School of Nursing, on a $300 scholarship made possible by a gift from a philanthropic couple to the Jewish Orphans of Rhode Island in 1958. One thing led to another, and along with a very successful career in business and founding the Commonwealth Institute, Lois eventually was elected Chair of our Board of Directors three years ago.

In the picture above, Trustee Jonathan Lee presents Lois with a charm bracelet containing symbols of the various parts of her life related to BIDMC. A well deserved standing ovation followed.

State of the Blogosphere

Technorati is presenting an interesting series on the state of the blogosphere. Here is the introduction and the first two of five chapters. When I started this blog two years ago, there were about 80 million in the world. Now, Technorati counts over 130 million.

Follow-up to "never" event

Some of you have inquired what our follow-up has been to the wrong side surgery that took place in July. Here is an email that went out to the staff today on that topic, plus another case involving an impaired physician.

To: BIDMC Community
From: Kenneth Sands, MD, Senior Vice President of Health Care Quality
Subject: Updates after Summer Incidents

Over the summer, BIDMC experienced two troubling incidents that received considerable attention, and rightly so. The first was a “never event” (in this case, a wrong site surgery) and the second involved an impaired physician.

We have recently received the results of the investigations by the Massachusetts Department of Public Health into both cases. As always, we fully cooperated with DPH as they reviewed all our documentation and interviewed key staff on-site. We wanted to share with you a summary of what DPH said, and what improvements we have made in light of these cases:

1. In the case of the wrong site surgery, the DPH investigator concluded that BIDMC acted appropriately in reporting the event, discussing the error with the patient and apologizing to her.

The investigator also noted that BIDMC has initiated a corrective action plan that places ultimate responsibility for calling a “time-out” prior to surgery directly on the surgeon who will make the first incision. But the basic principle remains that while the surgeon always needs to initiate this step, it remains everyone’s responsibility to be sure that all safety protocols are being followed. Specifically, if for whatever reason it appears that the surgeon might neglect to call for the time-out, every other person in the OR is encouraged and empowered to mention that fact.

Additionally, a revision to the "Correct Site Universal Protocol Policy" (PSM 100-105) requires that “the scrub person will mount/arm the scalpel after the ‘time-out' has been completed.” This creates a “fail safe” that ensures that a surgery cannot go forward without following the proper procedure. Everyone working in the ORs has been informed of and trained in these changes to the policy.

2. In the second case, the DPH investigator determined “invalid” the allegation that BIDMC “failed to ensure quality care” in a surgical procedure performed by a physician who appeared to be impaired. The medical center was, however, cited for record keeping deficiencies in the case. The conclusions came after a thorough review of our documentation and interviews with clinicians associated with the case.

We are currently working together, with helpful advice from our Board of Trustees, on a new policy to strengthen the medical center’s procedures when a doctor or other caregiver is impaired or otherwise unable to perform his or her duties. This includes improvements in training for staff on what to do should they encounter such a situation. We will let you know what we come up with.

These recent events remind us that we need to remain ever vigilant about our everyday commitment to quality and safety. We continue to identify and tackle problems as soon as they arise and create a culture where talking about problems or necessary improvements is embraced.

All of us at BIDMC have been involved in efforts to make the medical center a safer and more welcoming place for patients and families. At the same time, we have set a new standard for transparency in our work – the good, the bad and the learning experiences have been laid out for all to see.

We know how much each of you cares about the medical center and the patients we serve. You have helped make BIDMC an exceptional place – for high quality and compassion. Always keep that in mind and be proud.

Why not to blog . . . or how to do it

On this post by B. L. Ochman, we find "10 Reasons Your Company Shouldn't Blog," mainly focused on her advice that CEOs shouldn't blog.

I especially enjoyed this comment by Mark Brooks:

CEOs time is extremely precious. The best way to extract a blog out of a CEO, and keep it colloquial is to interview them twice a week, then transcribe, then edit to something interesting. The time impact to the CEO should be 10 minutes per interview. Transcription and editing and posting time an additional ~60 minutes per interview.

Whew, fortunately, I never had this advice when I started this whole thing two years ago. I might never have started. But at least if I followed Mr. Brooks' approach, someone on my staff would know what is going to be posted before they read it here.

But, poor misled Mr. Brooks, thinking CEO time is precious. In fact, it is the least valuable time in an organization if things are working right. And, if things are not working right, it is even less valuable.

Heartfelt feelings

(Printed with the patient's permission.) My friend Bob Kavanagh recently visited our hospital for heart surgery. Upon arriving home, he gleefully sent an excerpt from his medical record (contained on this memory stick) to his colleagues at work and his family:

FROM THE SURGEON:
Later that day he was weaned from sedation and awoke neurologically intact...

You can see Bob here holding his cough pillow. When asked if he wanted his picture on this blog, he replied, "That is certainly all right with me. That is a NY Yankees jacket I have on...."

Wheeling through the Hub

Several thousand people joined together yesterday for Hub on Wheels, a bike ride through the neighborhoods of the City of Boston. The ride is a fundraiser for the Boston Digital Bridge Foundation, a which provides technology training and computer equipment to underserved communities.

We had about 80 people from BIDMC on the ride, and several more of our folks also joined with the people at Cataldo Ambulance Company to provide first aid along the 10 mile, 30 mile, and 50 mile routes. Some of the riders and first aid crew are shown in the pictures above.

We were greeted by Steve Miller, originator of the Hub on Wheels event, and Nicole Freedman, Mayor Tom Menino's bicycle "czarina," both of whom are pictured here as well. I think Nicole was giving me some kind of hint with the sign she is carrying.

Sunshine in Worcester

Douglas Brown writes an important op-ed in today's Boston Globe about the experience of his hospital with public reporting of clinical outcomes. His conclusions are below. Please note again: Transparency is not about competition. Is about each institution making itself better and safer, and sharing what is learned across the health care system.

What have I learned?

First, public reporting works. It created a strong incentive to improving our quality. Second, responding to the crisis transparently, while more risky, was the right thing to do. At times, even lawyers must lean into the discomfort of transparency. It was the best course for our patients, our staff, and our community. Finally, humility saves lives. There is nothing more humbling than having to suspend a program. But it taught us to never accept the status quo, to know we can always get better, and to highly value a culture of learning and continuous improvement.

Breathe

From Kevin, MD, you HAVE TO listen to and watch this.

In memoriam: Susanna Burgett

Please read this obituary.

Time for another apology

Well, it turns out, in the post below, that I unwittingly engaged in a bit of revisionist history. As you may recall, I said this:

"But then I noticed two problematic items in the document that was about to be approved. Here's the first: It is the responsibility of the physician initiating the procedure to initiate the time-out.... I said, don't we want to expand on this and make it clear that each staff person in the room is encouraged and empowered to question whether the time-out has taken place and/or to remind the physician that it should be."

But then I wrote this:
"Why did I have to suggest these modifications? ... And if not, why wouldn't any other member of the MEC have thought to raise them."

One of the doctors at the MEC meeting later reminded me that he, not I, actually first brought up this point. Shows you how tricky memory is. My only explanation is that I remembered it as being my idea because I did indeed comment on it in the way mentioned, and that I was the one who brought up the second point about patient involvement in the time out. But he is exactly right, and I apologize for presenting it wrong.

So I think the record is now accurate, and I am pleased that this current revision helps make my original purpose even more complete. The thrust of my first post was meant to present part of the story of our evolution as an organization and of me personally as CEO. As this same doctor later reminded me, "There are many people in our medical center who are thinking and acting in support of patient safety in multiple ways every day. Although we are not yet where we ultimately want to be, our progress should be acknowledged along with our challenges." To put a more finely focused light on this, this whole MEC episode reinforces Göran Henriks' point: "There needs to be trust from the support system that tells the people at the front that we respect what they are trying to do."

A lucky number?

We live in dangerous times, and there have to be security provisions that we didn't need a few years ago, but you wonder how some of them are decided upon. Take this sign on my local mailbox. It has been there for many months, but this is the first time I really paid attention to it. How did they decide on 13 ounces? Is there something about explosives that makes 13 ounces a threshold for danger? According to this, it used to be 16 ounces. Maybe there is a security expert reading this who can explain.

Ad out

We have all become accustomed to ads by pharmaceutical companies in which they try to convince us that we are at risk for one or another disease and therefore should ask our doctors about their medications. I think a lot of us find those ads distasteful, and many of us believe that they result in unnecessary expenditures on health care.

Well, today, for the first time, I heard a radio ad for a hospital that seemed to me to fit in the same category. It was an ad for a certain vascular center, and it suggested that leg cramps, among other things, could be a sign of peripheral arterial disease. The purpose, pretty clearly, was to get listeners to wonder if this and the other symptoms mentioned might be serious enough to warrant a diagnostic visit to this particular vascular center.

As you know, I am not a doctor, much less a vascular specialist of any sort, but I am guessing that the incidence of peripheral arterial disease among the general population with muscle cramps has to be very, very small. It would be one thing to explicitly target the ad to those at greater-than-average risk of vascular disease (e.g., those with diabetes, smokers, high blood pressure, heart disease, or high cholesterol), but this was a general audience ad. I certainly believe that some percentage of people with PAD who should be getting treatment are not getting treatment, but this ad felt to me (and my accompanying car passenger) to be designed to produce fear and/or anxiety beyond a legitimately targeted audience.

As I have mentioned below, many of us in the hospital world advertise our services. Those ads usually talk about our capabilities, our doctors, access or the like. This is the first time I can remember an ad that seems intent on actually stimulating the demand for specific disease-related medical services among the general population. I don't think this is good for us to do. Insurance companies, government, and employers are beseeching us to control health care costs, especially through a reduction in unnecessary utilization of services. They say that we are insensitive to those cost factors, and we give them support for this position if we advertise our services in the manner I heard today on the radio.

Hearing this ad has made me more sensitive to this issue, and I plan to ask our marketing folks to review all of our ads to make sure we have not gone down a similar path. I do not think we have, but I'll let you know in a later post if we find some.

Corporate Campaign in Upstate NY, too

Tom Quinn, President and CEO of Community General Hospital in Syracuse, NY, tells what it is like to watch an SEIU corporate campaign in action. Bravo to him for exposing this attempt at intimidation.

Tom's type of honesty is virtually the only way to splay out for the public this kind of nasty practice. Why? Because these stories are often not considered newsworthy enough by the media, or because they are presented in a manner that spouts unsupported assertions that are impossible to rebut.

New BIDMC website

We have a new website for our hospital here. A lot of people worked really hard to design this and to make the transition from the old one to this one. Please check it out and let me know what you think.

Mea culpa

We are really, really trying to get better at this quality and safety stuff, but there are so many aspects to it that sometimes things slip by. Here's an example. Today our Medical Executive Committee was preparing to vote on a universal protocol policy related to taking "time-outs" before invasive procedures. We already had done this for surgical time-outs; but we recognized that a slightly different approach would be more suitable for procedures outside of the ORs (e.g., in endoscopy or interventional radiology suites).

Part of the policy includes some unambiguous guidelines, like this: The team will stop, pause, and verbally verify their agreement on the identity of the patient, the procedure to be performed, all patient allergies, the site of the procedure, including laterality, the correct position of the patient and radiological exams, if applicable. There was unanimous support among the MEC members about the need for this policy, and it started to move quickly to adoption.

But then I noticed two problematic items in the document that was about to be approved. Here's the first: It is the responsibility of the physician initiating the procedure to initiate the time-out. On its face, there is nothing wrong with this, as it is, indeed, the physician who has final responsibility for what happens to the patient. But, I said, don't we want to expand on this and make it clear that each staff person in the room is encouraged and empowered to question whether the time-out has taken place and/or to remind the physician that it should be. After all, when we had our recent wrong-side surgery case, only part of the problem was that the surgeon was distracted and forget to initiate the time-out. An equal contributing factor was that no one else in the OR thought to remind the doctor or question whether the time-out had occurred.

The second problematic sentence was this: It is not necessary to include the patient's participation in the time-out process as this may not be applicable. Hold on, I said, don't we want to reverse the emphasis and establish a presumption that the patient should be invited to participate, unless it is somehow inappropriate or not possible. Why not involve the person with the most direct interest in the procedure to help out?

In both cases, the doctors and nurses on the MEC immediately agreed and even suggested helpful language that would accomplish these objectives. But I was left thinking, "Why did I have to suggest these modifications? Why wouldn't they be self-evident to the subcommittee that had written the policy? And if not, why wouldn't any other member of the MEC have thought to raise them." In fact, later I was a bit critical of our SVP for Health Care Quality on these points in a private conversation with him.

One of our trustees was observing the meeting, and I also raised these questions with him. "Too much to do, too busy to read," was his commentary about the medical staff members of the MEC. While that is true, it is not a satisfactory answer. After all, it has just been a few weeks since the wrong-side surgery case, and everyone is attuned to this type of error.

My friends in the patient advocacy world will probably say, at this point, that's why you need patients on every committee and working group in the hospital. Patients will see things that the medical staff overlook and bring in a useful perspective. This can be true, but it actually takes a lot of thoughtful planning and time to create a productive environment for that kind of patient advisory input -- and, even then, there will always be some decisions made without patient consultation.

I have a different answer. After the Blue Cross Blue Shield conference yesterday, I asked a question of Sweden's Göran Henriks, who has worked for two decades on improving safety and quality to make Jönköping County's health system one of the best in the world. "Knowing what you now know," I said, "how long would it take your doctors, nurses, administrators and staff to get to your current level of performance if you were starting afresh?" His reply: "Five years."

Old habits and viewpoints, in other words, are deeply embedded. While every sentinel event presents an opportunity for learning and improvement, it is in the everyday tasks that the possibility for continuous and lasting improvement exists. I happened to be the one to call out two examples today. But, it is the marvelous diversity of experience and perspectives of the people in an organization that provides a reservoir of such possibilities. Our goal is to create an environment in which everyone in the hospital will feel empowered and excited to do the same, whenever they see opportunities for improvement. Training people to do that is what takes time, as we each have a unique way of learning.

And so I realized that I was wrong to have criticized the SVP. It's my job to help people to engage in this learning adventure by setting the appropriate example of humility and encouragement, and I blew the chance today with one very well intentioned individual. But tomorrow will certainly provide other chances to do better.

Some ads I get

Notwithstanding our excellent spam control program, I get tons of broadcast emails sent to me as CEO of a hospital, selling all kinds of services -- but especially services related to coding patient treatments to get the highest payment from insurers and Medicare. I suppose this is just a sign of the times and indicative of the structure of the health care industry.

I confess that I do not understand many of these ads. I'm not saying that I don't understand why I get them. I am saying that I literally don't understand most of the terminology. Here are some excerpts from a small sample of those I received yesterday. I guess the one I really need is the last one listed . . .

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Billing Success Secrets -- Live audio conference

In Dec. 2007, UnitedHealthcare adopted the Centers for Medicare & Medicaid Services' Correct Coding Initiative (CCI) edits -- but not all of them. And for you pediatric coders out there who aren't familiar with CCI edits, that's not all. The insurer has also interpreted CCI bundles and extrapolated CMS' rationale to apply to additional codes. And as anyone knows who's dealt with CCI edits before, the system it is vital for proper payment and anti-fraud protection.
Get up to speed on how UHC is bundling your services during this can't-miss audioconference with expert speaker Jennifer Godreau, BA, CPC. In one hour, she'll uncover which common pediatric services UHC bundles, when the payer allows a modifier to override the edits, and other reimbursement policies.

---
Red Flags That Could Lead the Feds Right to Your Door

Physicians and Practice Managers: Do you live in fear of the day the Feds march through your front door, ask your staff to step away from their desks, and seize all your computers and practice records? If an indictment follows, you could be in for the fight of your life.
Fraud accusations don't just happen to criminals. They can, and DO happen to honest, upstanding physicians ... just take it from speaker and expert witness Barbara Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC. In this one-hour audioconference, Barbara will share shocking real-life scenarios that took unsuspecting physicians by surprise. Find out why they were accused, how they defended themselves, and what they could have done differently so that you can prevent this from happening, or if it does happen, optimize YOUR practice's defenses.

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Esophogeal Dilation CPT Code Surprises

Error-proof esophageal coding requires a solid understanding of dilation procedures and the nuances of medical necessity. In just one hour, certified gastroenterology coder Carol Pohlig will teach you everything you need to know about esophageal dilation coding: from the reasons for the dilations to the techniques and their CPT codes.

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Career Step

Become a leader in the coding industry by being certified as a Professional Coder. Let our AAPC certified instructors help you get prepared to pass the American Academy of Professional Coders' CPC® Exam with flying colors. It is as simple as it sounds! CPC® Training Camps are small intensive preparation courses. You will get one-one instruction from our AAPC certified presenters. There are only 10 limited spots available. It is first come, first serve so reserve your spot today.

Dr. Berwick's vision

The closing keynote address at the conference was given by Don Berwick, President and CEO of the Institute for Healthcare Improvement. It was entitled Health Care Leaders and the “Triple Aim”. It’s risky to summarize a Berwick talk because it is always well constructed and elegant. I’ll take a chance with a few highlights.

His focus was on what’s left to do, rather than what’s already been done. There’s a lot to be done. There is a big gap between what we have and what we could have. Looking at what is spent in the US on health care, we see that we spend a lot, and we do not get our money’s worth -- either in terms of access or results. We need to grapple with the fact that we have a low value system.

It is also a system characterized by extreme variation in spending, over $3000 per capita in Medicare spending between the lowest quintile and highest quintile parts of the country. There is no positive correlation between spending and results. In fact, it is a negative correlation. In other words, this is $3000 of negative return.

We don’t have one big problem here. We have two, and this requires a sophisticated and parsed solution with two separate paths.

One path is about getting better care when you are sick. This is based on achieving the following dimensions of excellence when you are sick and need care: Safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. This is done by designing better processes and deploying them.

The second problem has to do with the drivers of the low value system. On the high cost side, this derives from the constant entry of new technology, drugs, and the like without documented relationships to outcomes; no mechanism to control costs; and supply-driven demand. On the low-quality side, it comes from over-reliance on doctors for things that non-doctors can do; no foreign competition; and undervaluing system knowledge.

Berwick’s approach to this is defined as the “Triple Aim”: Improve the experience of care + raise the level of the health status of the population + control the per capita cost. He states that the root of the problem is that the business models of almost all health care organizations depend on keeping these aims separate. Berwick proposes a system that will focus on individuals and families; offers strong primary care services; provides population health management; imposes a cost control platform (i.e., a strict population budget); and enforces system integration to make this all happen.

Q & A

I'll not include all the questions and answers for the panel from this part of the conference. But here are two.

First, an exchange with Göran:

Q. What are the top three tactics to get past inertia (among the medical staff)?

A. People in medicine like to be the best. You have to talk about people about what they love to be best in, not about something unrelated to their own desires.

You cannot win everybody. You have to be patient. In the meantime, they need to feel that there is a context that believes in them, so that when they come around, they will feel supported.

Support systems (HR, Finance, etc) are all services for the front, i.e., where the actual value is delivered to the patient. There needs to be trust from the support system that tells the people at the front that we respect what they are trying to do.

And, another answer from Uma, to a related question:

We instituted a daily failure reporting system. We conduct a same day investigation of daily events, followed by implementation of improvements on a continuous basis. This makes it part of the culture to report problems on a current and regular basis.

The panel digs deeper

Next at the conference was a panel discussion led by Larry Tye, a former Boston Globe reporter. It included Louise Liand, SVP for Quality and Clinical Systems Support at the Kaiser Foundation Health Plan and Hospitals; Göran Henriks, Chief Executive of Learning and Innovation, The Qulturum in the County Council of Jönköping; and Uma Kotagal, SVP for Quality and Transformation at Cincinnati Children’s Hospital Medical Center.

Louise explained the implementation of the electronic medical record system at Kaiser. Göran talked about the learning environment in Sweden in general, gaining knowledge from the success of others. He also discussed the use of physician extenders and real-time monitoring to create better access and results in the orthopaedic arena. Uma explained her hospital’s success in treating children with bronchialitis, focusing on the lack of evidentiary support for what had been the standard practice for treating patients, and modifying it to institute more efficacious approaches to the management of this disease -- which included a much closer relationship with community physicians to keep children out of the hospital in the first place.

What works, asked Larry, that could inform this conference audience? This is a continuing learning process, even for us, said all three. Göran said it well: “We need to meet systems that have energy in this field, so we can be refueled in our own efforts.” "If you hear about something good, get on a plane and find out!", said Uma.