Scenes from the English countryside

Two sets of road signs I saw recently in the UK. They are so much more expressive than the ones we see here, but when you start putting two or three on top of one another, it can lead to some confusion. Do I go over the bridge before the road narrows? Does the road curve before I turn left?

Then, again, since I was driving on the left, I barely noticed the signs anyway!

The electrical pole warning sign, however, left no doubts.

The downside of competition

A funny moment the other day.

The CEOs of the larger Harvard hospitals founds ourselves in several meetings over the course of consecutive days, working together on areas of common concern -- clinical research, supporting greater diversity on our staff and faculty, and stimulating enhancements between engineering and medical care. These were great sessions, with a clear commonality of interest and purpose, characterized by healthy give-and-take in friendly and helpful discussions, and good progress. After the last of these sessions, one of my colleagues turned to the rest and said, "Okay, enough collaboration for today. Let's go back to competing."

He was joking, of course, and we had a good laugh; but, as I have noted before, this is in fact the nature of the relationship. It has its advantages and disadvantages.

I think the major disadvantage is that the competition in the clinical arena is so intense that we end up duplicating services that could be consolidated or otherwise rationalized. (In saying this, by the way, I also mean to reference the duplication that also occurs when we include the non-Harvard hospitals in Boston.) I have talked about this before, focusing on the area of solid organ transplants. If there are fewer than say, 400, adult liver, kidney, and pancreas transplants in all of Eastern Massachusetts per year, does it make sense to spread them out among six or seven hospitals located within 15 miles of one another?

Each hospital has to make major investments in staff and equipment to carry out a proper transplant program, and the current organization makes economies of scale impossible. It also means that each program is unlikely to be highly profitable -- or perhaps profitable at all -- because it lacks sufficient volume to spread the fixed costs across a large enough patient base.

And yet we persist in this fashion, responsive to the demands and wishes of our physicians and because we have a mindset that we cannot be a "real" hospital unless we offer this service to the public.

As I have said in recent forums and elsewhere, we need to be protected from ourselves in this regard, either by the insurance companies or the state government. Thus far, though, they have been too timid to act. The public ends up paying the price for this inefficiency.

The story of Mike, the gentleman

I received the following story from a friend. It is hard to post it without appearing to take a position in the current Presidential election, but I am really not doing so with that purpose in mind. I have been very careful on this blog not to discuss my personal political preferences, as I think those are not relevant to the topics I discuss on this website. You should not assume anything about my vote (which I took this morning) from this story. Regardless of your preference in this election, or how you think it is going to turn out, I hope you will agree that is a wonderful story about elections in America, one that gives a warm feeling about the possibility of comity and good will during even hard-fought campaigns:

Upon arriving at the Hamilton County Board of Elections in Cincinnati to vote early today I happened upon some friends of my mothers - three small, elderly Jewish women. They were quite upset as they were being refused admittance to the polling location due to their Obama T-Shirts, hats and buttons. Apparently you cannot wear Obama/McCain gear into polling locations here in Ohio.

They were practically on the verge of tears. After a minute or two of this a huge man (6'5", 300 lbs easy) wearing a Dale Earnhardt jacket and Bengal's baseball cap left the voting line, came up to us and introduced himself as Mike. He told us he had overheard our conversation and asked if the ladies would like to borrow his jacket to put over their t-shirts so they could go in and vote.

The ladies quickly agreed. As long as I live I will never forget the image of these eighty-plus year old Jewish ladies walking into the polling location wearing a huge Dale Earnhardt racing jacket that came over their hands and down to their knees!

Mike, patiently waited for each woman to cast their vote, accepted their many thanks and then got back in line (I saved him a place while he was helping out the ladies). When Mike got back in line I asked him if he was an Obama supporter. He said that he was not, but that he couldn't stand to see those ladies so upset. I thanked him for being a gentleman in a time of bitter partisanship and wished him well.

After I voted I walked out to the street to find my mother's friends surrounding our new friend Mike - they were laughing and having a great time. I joined them and soon learned that Mike had changed his mind in the polling booth and ended up voting for Obama. When I asked him why he changed his mind at the last minute, he explained that while he was waiting for his jacket he got into a conversation with one of the ladies who had explained how the Jewish community, and she, had worked side by side with the black community during the civil rights movements of the 60's, and that this vote was the culmination of those personal and community efforts so many years ago. That this election for her was more than just a vote...but a chance at history.

Mike looked at me and said, "Obama's going to win and I didn't want to tell my grandchildren some day that I had an opportunity to vote for the first black president, but I missed my chance at history and voted for the other guy."

Global Triggers

My regular readers know that, at BIDMC, we keep track of lots of clinical outcomes and post our progress towards our goal of eliminating preventable harm for all to see. But there is a problem. Even with the best of reporting systems and even with a strong no-blame environment that encourages people to report errors and bad outcomes, things go on every day that are undetected or unreported.

So, even though we think we are doing a pretty good job in monitoring our progress, it would be great to triangulate our current methods of reporting and collecting adverse events (aka "harm") with other analytically rigorous approaches. One that we have started to use was developed by the Institute for Healthcare Improvement and is called Global Triggers.

This is a thoughtful and interesting method that is based on reviewing a sample of clinical records each other week to look for "triggers", which are basically clues that a patient may have experienced an adverse impact during his or her treatment. The harm that has occurred to the patient is not necessarily in the category of preventable harm. Rather, it is simply an indication of something going wrong from the patient's point of view.

In a way, the method is similar to the kind of sampling that a manufacturing company uses by taking a small number of widgets out of its assembly line and measuring how many are defective. It turns out that you don't have to take very many to get a statistically valid result. And, if you do it every week in a consistent way, you can see through the week-to-week variation and watch trends over time.

We've just been doing this for a few months now, and IHI says you need at least a year's worth of data to have sufficient observations to have a useful tool. Even though the Global Triggers approach captures all kinds of harm and not just preventable harm, there should be some correlation between the direction of the two categories. We are looking forward to getting those results and monitoring them over time as a way of validating our other reporting tools and feeling more confident about measuring our progress.

Are there others of you out there who have used this IHI methodology and would like to share what you have learned or how it has helped you in your quality improvement programs? If so, please comment.

Getting ready for the holidays

Time for a major change of pace. My cousin Roger sends this note, which I post now so that people who are interested have time to bake this by the holidays:

I just came across an interesting article in the Milwaukee Journal Sentinel on a Caribbean traditional Christmas fruitcake. See it here. It has a resemblance to the Panama wedding cake in many of its ingredients and preparation.

The Panamanian wedding cake to which he refers has been described, with some elaboration, in my daughter's article in Salon here.

Role model

A letter like the following is a wonderful affirmation of what people here at BIDMC try to do. I reprint it with permission of the patient. I embed the link to the Globe article for those of you who haven't seen it.

This morning, I read the Boston Globe article about transparency, errors and surgery at BI and was compelled to write to you about the remarkable experience I had 4 weeks ago when I had a radical nephrectomy (based on a Dx of a 9 cm renal cell carcinoma) at BI performed by Andrew Wagner. I’ve been in healthcare for over 30 years and before I met Dr. Wagner my opinion of surgeons was probably stereotypical although reinforced with actual experience. That is, if I talked to a med student who said they were interested in becoming a surgeon I had one of two reactions. The first was “Good, he/she should definitely have limited contact with conscious people,” and the second was “What a waste…he/she would be great with people.”

Dr. Wagner caused me to re-think those assumptions as he is as extraordinary in his people skills as he is technically. His technical skills were evidenced by my recovery. Upon leaving the hospital I didn’t take as much as a single Advil. To me, that means that he moved my organs so minimally they didn’t even know he was there!

It was his humanity, though, that left a profound impression on me and caused me to trust him absolutely. Some examples…..

His first sentence to me was “I am so sorry this happened to you;” and he meant it! After a few minutes of conversation, he asked if anyone accompanied me to the appointment. I responded that my husband and closest friend did and he asked for their names. He then left the room and went to get them. He didn’t ask a nurse or a secretary to do it…he brought them in himself. He gave me his email address and responded when I had questions. Finally, he called me the night before the surgery (a Sunday evening) to ask if I had any last minute questions or any anxiety that he could help with. I have never heard of a surgeon doing that and neither have my doc friends.

If you were responsible for bringing him to BI, congratulations…you hired a brilliant mensch!

My total experience at BI was a good one although as with any patient-hospital interaction, there could be improvement. I responded to the BI ambulatory care survey with some observations and recommendations. I hope to hear if there are any changes in process. Specifically, using your clinical decision support technology as a partial proxy for patient advocacy would be a great strategy. I’m attaching that survey response in case you’re interested…

Anyway, thought you might want to hear about an extraordinary physician…what a role model for the rest of the clinical staff!

Sincerely,

Eye on SEI

The picture above is of the mobile billboard hired by the SEIU to publicize its "Eye on BI" campaign. The union sent it to be visible at a fund-raising event held Friday night for our affiliated community hospital, BID~Needham.

Let's think about this. The attendees at this event are loyal supporters of this community hospital. They serve as voluntary members of its governing bodies, and they donate their hard-earned money to the hospital because they believe in its mission and have confidence in the management and staff. They know that SEIU opposed the issuance of bonds to finance the expansion of the hospital's emergency room and other services. They come out for a pleasant evening together to support the hospital, and they see the SEIU spending money on a mobile billboard to denigrate the reputation of the academic medical center that has also provided millions of dollars in support of their community hospital.

(In case you are wondering, a mobile billboard like this can be purchased for stints of 220 hours of travel time. The rental cost is $12,100 per 220 hours. There is also a $3,500 production fee for the panels.)

Is this effective? Well, you can be sure that attendees at this gathering were not impressed and remain very loyal to the institution. Well, how about the workers at BIDMC itself?

To answer that, in the post immediately below this one, I am sharing the responses I have received from staff members about SEIU's advertising campaign -- beyond those comments on my blog posting a few days back. The short summary: Even staff members who are sympathetic to unions are put off and insulted by the campaign.

So, is this a strategic error on the part of SEIU? After all, why would you want to alienate the very work force you are ultimately trying to recruit or from who you are trying to obtain support?

The answer, as I have explained in earlier posts, is in the nature of a corporate campaign. The object at this point is not to organize the workers: It is to organize the company by attempting to degrade its reputation in the community, in the hope of getting concessions in the certification process. In this case, too, there may be an interest in showing other hospitals in Boston what the union can do if it wants to spend money trying to hurt your reputation.

Once upon a time, unions would try to organize workers. Their organizers would actually spend time getting to know the workers, trying to build trust, and thereby enhance the likelihood of winning a certification election. SEIU, though, does not start by trying to organize the workers. It tries to organize the company using the methods we are now seeing. Beyond the mobile billboard, SEIU has spent tens of thousands of dollars in just one month on misleading advertising at bus stops, on radio, and on television about topics that have little or nothing to do with workers' concerns.

So, maybe we need a new slogan: Boston needs to keep an eye on SEI. After all, a union that spends this kind of money to undermine the reputation of a respected part of the health care system, that leads dedicated people working in that hospital to feel insulted and attacked, and that denigrates its volunteer community leadership needs to be watched very, very closely.

Let's hear it from the staff

To continue the theme from the posting directly above, here are those comments I received from staff members about the recent SEIU ad campaign after I sent an email explaining what it was all about:

Frankly, I thought the content of the ad, as well as the manner of delivery was despicable. I was disgusted that the union attempting to court the nursing staff was responsible for such a caustic advertisement.

The information you sent to us regarding the union, (how and why managers need to be open and positive, giving facts, when possible), was noteworthy.

I also work as a public school teacher, as an active association (union) member, and find this also related to our administrators and how we, as an association, interact with them so that our students can have the best education, like patient care, possible. Thanks and great remarks.

My employees are very disturbed by this particular campaign. It is hostile, relentless, and they are harassed at home, at work and on the street, not to mention embarrassed by the negativity.

Thank you so much for this E-mail. It made me feel better. I am disturbed that there is a bill right now before Congress, to remove the right to a 'secret ballot'. I'm proud to work at BIDeac.

I worked at several union hospitals (including the Brigham) until I came here to BIDMC as a traveler. I was concerned, initially, about it not being a union hospital because I didn't know the difference. Unions were all I knew. However, I am pleased to say that I've never been happier as nurse here at BIDMC. I spent a year as a traveler and now I have been here for another 5 years (the longest I've stayed at any hospital). I travel an hour and fifteen minutes to get here and it's worth it. I could have gone back to the Brigham for increased wages but chose to stay here because of the environment and the close relationships and openness we have with our physicians and nurse managers. It angers me that the SEIU is trying to ruin a good thing here and I pray they go away!

Thank you for all the important information. Your words helped me and hopefully will help others who do not want BIDMC to unionized, but to continue to provide high quality care that we are proud of.

I agree, it is a free country. All the more reason why I am in full support of your actions. I have worked at hospitals with 1199, it is unbearable and could make a provider want to leave the hospital out of frustration.

You have just reminded me once again why I am so incredibly proud to be part of this hospital...thank you!

I am a long term BIDMC employee. I became aware of "Eye on BI" by reading your blog. I looked at that web site and found it so foolish I could only laugh! I think it is a good thing that you are open about this issue and I thank you for bringing it to our attention.

Thank you! I understand more clearly and I feel MUCH better.

I was actually just thinking about writing you. We've seen the truck go by out the window of our staff room, and there was a flyer in there one day which listed the SEIU allegations against BI... and all it did was make me mad that they were attacking not just our labor policy, but the quality of our hospital as a whole. And you're absolutely right - it IS a personal attack. I'm very proud to be working for this hospital, and the short time I've spent here has only demonstrated how caring and committed we are to patient care. I personally believe that labor unions have a place and should be an option for employees to consider, and the unions have historically done great things for workers (like the 5 day work week) but the smear tactics SEIU is employing now just makes me view them poorly.

We often times discuss the union in our dept and I constantly remind my co-workers of the lack of honesty these folks employ. Why would I want someone dishonest representing me?

Thank you for your leadership. I love taking care of patients in our patient centered environment.

Thank you for confirming what I quickly identified as a union "smear" campaign. I love my job and am happy to work at a hospital that supports open dialogue among it's employees. I have the utmost confidence in the leadership of the hospital.

Thanks for this information. I always get very upset when people attack the Beth Israel. I feel that I work in the best hospital in the City of Boston.

Another thoughtful and articulate presentation. I have great faith in our management team. I am not anti union in any respect, but I do share your belief that the union is not advocating for a fair process.

I've heard some of the advertising, and it is insidiously vicious. I'm glad that you are addressing this directly.

Thanks for sending this. It's a privilege to work here.

Like others, I was handed Union propaganda. I read what they gave me. Their effort increased my respect for and loyalty to BIDMC.

I think the union's activities are despicable and I am proud that you and BIDMC have called them on their activities.

I heard one of these adds yesterday driving home from work and I was shocked until I heard who paid for the advertising. Then it all made sense. Sure hope others see through it too.

I was quite upset by the ad I heard, since I've worked here many years plus the occasional ER visit myself. My experience was nothing but positive for me and my husband.

As a medical student at Columbia Presbyterian, this union went on strike, attempting to block everyone from entering the hospital, including students attempting to get an education. Racial comments were also made. As a resident at Columbia, I came to expect that the phlebotomist would either not come or state blood was not drawn because the patient refused, only to find the patient said no such thing. I learned to be a phlebotomist, transporter, I even ran my own blood samples, whatever it took to ensure decent patient care. Room turnover was so bad, most rooms were unavailable to patients until eight at night, forcing residents to perform histories and physicals in the lobby waiting area so they could get home at a decent hour. I dare not venture into physical plant cleanliness. When I came to the BI as a resident, I was absolutely shocked that people gave a crap , went above an beyond and thereby allowing me to focus on being a physician. Obviously, I never went back and hope we as an institution don't take this step backwards. There is nothing but power and ego involved here with patient care at the bottom of the list. Keep it up.

I have read your letter very carefully, and it takes away some of the anger that grew in me at the bold efforts of that union to degrade the establishment that I've felt right at home in my almost 30 years working here. Last Friday there was heavy campaigning around Joslin Park, crossing over to Brookline Ave. I was approached by a member offering me a "mouse pad and a flyer" I gave him a few choice words in a polite manner, smiles and all. When the other group across the street saw that I did not accept the "gift offered" they started walking toward me when I got across the street. They were looking at me in an angry way, I had to warn them to keep away from me or I will go to the cop that was standing at the construction work site at Dana Farber. This just goes go to show that they have a potential to intimidate employees in any way possible if their media tactic does not work, of which I hope it does not. I know the freedom of speech and the right to make a choice is law, but it will not take away the DEDICATION and COMMITMENT That we all have here at the Medical Center.

Thank you for clarification of this issue. I am sure you anticipated that BIDMC's leadership in transparency would be used against us. As Kent Keith wrote in his poem "The Paradoxical Commandments", "... Honesty and frankness make you vulnerable. Be honest and frank anyway...".

It is frustrating to live with the fact that a reputation is much easier to smear than to build, and to hold yourself to a standard of conduct not shared by those who are better at breaking things than building them. In the face of vandals demanding tribute, the high road is hard, but necessary.

Thank you for your time and support, I worked at the company who had union I will never want it again...

As someone who has worked in a union environment in the past, (Seattle, WA) I too am completely AGAINST the union as it offers nothing but negativity, pulls staff and management in separate directions and this negativity is as well shown by this recent exposure, As an employee of BIDMC for over 4 years, I couldn't be more proud to work here. I too am a believer in free speech, but, is there anything we can do as employees to HELP in the fight to end the "UNION" coming into BI?? If there is anything we can do, please let me know, I think its a disgrace and very unprofessional what the union does and represents for their own best interest.

Thank you so much for sending this email. I've been at the BI for over 6 years and started off as a traveler. I had enough confidence in the establishment to sign on as staff and would never think of moving to another hospital because I believe in our practice and our mission and values. I understand the concept of free speech, but it is very hurtful when people purposely set out to hurt others with smear campaigns. I appreciate you giving some feedback on it and this just solidifies my faith in this establishment.

With everything else going on in people's lives: the economy, the pressing decision of the presidential election, and just the day to day stresses, we surely don't need this. I appreciate your time in informing the staff as to the why BIDMC is being targeted and providing your support to all.

Thank you Paul -- I have never written you an email until today. It was important for you to respond to this to us. I know it is difficult to "refute" this type of campaign. You can't win that battle - You will be painted as the powerful executive squashing the "rights" of the "little" people when in fact your trying to protect them from "bullying" tactics the union themselves so frown upon us. What I'm afraid of is, in this society it seems the more outlandish the claim the more believable it is. If you say it long enough and loud enough, people start to believe it.

I work in a hospital -- that says a lot about me and what I believe in -- I'm proud to work here -- I could go somewhere else and make more money but this is my choice. I don't appreciate their misleading, false and denigrating statements. It all such garbage - I had hope we could refute these "claims" but I understand your position.

I am sorry to see you and the hospital suffering negatively due to this smear campaign. As an employee I am glad to see you take a principled stand on this unionization issue. I am also a little worried on a personal level whereby if a union did establish itself here at BIDMC I may be forced to become a member of a closed shop union or else suffer the consequences. I wish you good luck in your handling of this problematic issue.

Thank you for this letter. We all know it is just propaganda, but feel good that you have addressed the issue.

Thank you for sending this and for being willing to put yourself on the line publicly about the SEIU's activities. Many staff have been upset over what's happening out there and I think it's important to acknowledge that. I also think it's important to stand up to the SEIU as you have and let them know that we won't be bullied. I fear that many of the staff they will be targeting don't understand the full implications of being unionized and are at greatest risk of being hurt by it. We can do a far better job of protecting our staff, especially the most vulnerable ones, than any union can.

I just wanted to take a moment to relay my time as a member of SEIU to you. Before I worked at BIDMC I worked in hospital represented by SEIU. In my experience their main function was to protect the employees which were not living up to the expectations of their job. This, in turn, led to a confrontational relationship with the management of the hospital. Since working at BIDMC I have never once looked back and wished I had stayed in my union position. I have never felt that my manager has ever asked anything of me that she would not do herself, I earn a fair wage, and I am treated very well here. In addition I would rather keep the percentage of my paycheck that would be taken by law for union dues if BIDMC were to unionize. I just wanted to share my experience with you and for you to know that I for one am proud to be a non-union employee of BIDMC.

Thank you for taking time to address this issue. For some time, I've wanted to speak to you about this matter.

I have been contacted, via unsolicited mailings, from this union and read the terrible things they've chosen to print in various publications. I know that these half-truths are meant to harm the medical center's reputation. I understand that to them, BI represents a lot of money in member dues and that these tactics are meant to be divisive and hurt morale of our staff so they can swell their ranks and coffers. Staffs are often enticed by the "grass is greener" argument to join a union. I know from personal experience that this simply isn't true and that unions today do not improve quality, efficiency, or employee relations. I have no respect for their underhanded tactics.
I am very proud of our non-union hospital. My leadership is supportive and fair and I know that I don't need a union official to act a middleman when I have an issue to discuss with them.
I've spoken with others here who feel the same way. We are all proud to call ourselves employees of the Beth Israel Deaconess Medical Center.
When I get something from the union, I put it where it belongs -- in the trash bin.
I've had my eye on BI for over 5 years and like what I see. That's why I work here.
Please continue to fight the underhanded tactics and lies of this self-serving, power-hungry group. You have our support.

Thank you for this informative update of the current activities of SEIU. I too heard a radio announcement unflattering to BIDMC regarding rates in the ER and how expensive we were compared to other institutions. However, the tone of the ad was decidedly vindictive so I dismissed it as propaganda.

I know you are busy and your mailbox is probably full but wanted to get back to you to let you know that It is always so good to hear from you on these upsetting matters. I am very proud of the work I do here at BIDMC and I am thrilled to be employed in a hospital that doesn't incorporate the SEIU. If they were in this hospital it would be less of a place in my opinion. You so well put it into perspective and that is always comforting. BIDMC is a wonderful institution and does not deserve the untruthful maligning that is the product of the SEIU, they absolutely disgust me in their conduct. The media should be vetting their business practices and unethical tactics. You are supported in your efforts to set the record straight Paul, keep up the good work.

While waiting for the LMA shuttle this morning, which is also a bus stop, I came face to face with one of those adds. I was repulsed by the add and didn't understand why this was being said about the place I have worked at for 28 years. If this is the type of union that can only get it members by these types of ploys, then they must truly be desperate. It also saids something about the character of those in charge.

Your message is extremely timely, as I just saw my first "anti-BIDMC" bus stop ad in front of Vanguard Medical Associates about half an hour ago, and it disturbed me greatly. I work (and have worked for the past 20+ years) in hem/onc research at 21-27 Burlington, and activities/advertising at the main hospital campus often escape me....but here this was right under my nose when I went to take a little walk. In fact, I was mentally preparing an e-mail to you to voice my distress when your message was broadcast, so, thank you. I consider myself generally pro-union and am descended from a long line of pro-union teachers, etc. Yet the tactics of SEIU have been bothering me from the very first phone call that I got at home months ago. I tried rational conversation at first, but have since given up! The idea that SEIU can improve my research funding, while funding sources everywhere are drying up, is laughable. Laughable and sad at the same time. It's sad to me to see BIDMC (and you personally, in the ad I saw) portrayed in this negative light.

I saw the ad at my bus stop at Landmark this morning and then someone pointed it out in the free newspaper floating around. I am writing because I do not understand how this slander is legal. I can't imagine any other institution of our size without issues but I for one am very proud to work at BIDMC.

When pumpkins drink too much

As we approach Halloween, I couldn't resist posting this utterly silly picture. I don't know who set it up. (Some people have a lot of time on their hands!) Sorry if you don't like it or expect more serious things on these pages, but I thought it was very well done.

Note, especially, the subtle warning about underage drinking in the form of that little guy in the middle!

Share the savings

I was invited to be a panelist today at the MA Medical Society's annual leadership forum, entitled "Cost, Quality and Access, The Challenging Journey Continues." Secretary of Human Services Judy Ann Bigby provided an overview of the state's health care environment. This was followed by a national perspective from Susan Dentzer (picture above), Editor-in-Chief of Health Affairs, having joined that journal in May after ten years as the on-air health correspondent on PBS' NewsHour with Jim Lehrer. And then we heard from Elliott Fisher (also shown above), Director of the Dartmouth Institute for Health Care Policy and Clinical Practice.

There were a number of common themes between Susan and Elliott which were reminiscent of points I have heard before from other observers like Brent James. Much of this, though, is based on the actual work done by Elliott and colleagues at Dartmouth. Key points: Unnecessary variation in the delivery of health care and an inverse correlation between spending and clinical results. The "paradox of plenty", explained Elliott, suggests that those regions with more medical resources not only have higher costs, but worse technical quality; worse access to primary care; lower satisfaction with hospital care; worse communication among physicians; greater difficulty ensuring continuity; great perception of scarcity; and lower satisfaction by providers with their career.

Brent James had talked about "local medical mythology" as an explanation for the unexplained variation in medical treatment across regions. Elliott reinforced that but also tied it into the payment system by suggesting that the payment system ensures that existing capacity in a region will be fully utilized because physicians adapt to available resources with more referrals, more admissions, and more ICU stays. He advocated a reformulation of the current fee-for-service approach that would establish a target growth rate in overall health care spending and then share the savings between the insurers and the providers if the provider group achieved lower-than-expected growth in spending.

I'm sure I am not giving this all justice in this short summary, but I think you get the idea. Lots of food for thought. In particular, this shared savings approach offers an interesting alternative to the fully capitated type of plans that have recently been proposed in some forums.

Addendum: I found out they made a podcast of the panel discussion. Here it is.

National forum scholarship opportunity

A notice I received that may be of interest to those of you involved in pediatric care:

Justin's HOPE Project and the Institute for Healthcare Improvement are extremely proud to announce the Justin Micalizzi Memorial IHI Scholarship in loving memory of Justin A. Micalizzi who died at the age of 11 due to a medical error following the incision and drainage of a septic ankle. Learning from this devastating loss, and making a difference that will improve pediatric health care is Justin's family's quest. Justin's HOPE project will award scholarships to health caregivers who are committed to serving vulnerable underprivileged and underserved pediatric populations globally.

The Justin Micalizzi Memorial IHI Scholarship will cover the cost of the General Conference fees for IHI's 20th National Forum on Quality Improvement in Health Care in Nashville, Tennessee, on December 10-11, 2008. In addition, the scholarship will provide a $1,000 stipend to be used toward travel, lodging, or other Forum expenditures (including fees for Learning Labs or Minicourses held on December 8-9).

Requirements: To apply, please complete a 500 word essay explaining your dedication to and passion for serving vulnerable pediatric populations, and your desire to improve children's health care. Please submit your essay to info@ihi.org no later than Oct. 31, 2008. Those awarded with this scholarship will be notified by Nov. 14, 2008.

For more information about Justin's HOPE at the Task Force for Child Survival and Development, please visit here.

A good time for a heart-to-heart talk

I think this might be a very important piece of research. I quote portions of the abstract from a recent article in JAMA. Comments and observations, as always, are welcome.

Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment

Alexi A. Wright, MD; Baohui Zhang, MS; Alaka Ray, MD; Jennifer W. Mack, MD, MPH; Elizabeth Trice, MD, PhD; Tracy Balboni, MD, MPH; Susan L. Mitchell, MD; Vicki A. Jackson, MD, MPH; Susan D. Block, MD; Paul K. Maciejewski, PhD; Holly G. Prigerson, PhD
JAMA. 2008;300(14):1665-1673.

Context
Talking about death can be difficult. Without evidence that end-of-life discussions improve patient outcomes, physicians must balance their desire to honor patient autonomy against a concern of inflicting psychological harm.

Objective
To determine whether end-of-life discussions with physicians are associated with fewer aggressive interventions.

Design, Setting, and Participants
A US multisite, prospective, longitudinal cohort study of patients with advanced cancer and their informal caregivers (n = 332dyads), September 2002-February 2008. Patients were followed up from enrollment to death, a median of 4.4 months later. Bereaved caregivers' psychiatric illness and quality of life was assessed a median of 6.5 months later.

Main Outcome Measures
Aggressive medical care (eg, ventilation, resuscitation) and hospice in the final week of life. Secondary outcomes included patients' mental health and caregivers' bereavement adjustment.

Results
One hundred twenty-three of 332 (37.0%) patients reported having end-of-life discussions before baseline.... After propensity-score weighted adjustment, end-of-life discussions were associated with lower rates of ventilation... resuscitation ... ICU admission ... and earlier hospice enrollment. In adjusted analyses, more aggressive medical care was associated with worse patient quality of life ... and higher risk of major depressive disorder in bereaved caregivers ... whereas longer hospice stays were associated with better patient quality of life .... Better patient quality of life was associated with better caregiver quality of life at follow-up....

Conclusions
End-of-life discussions are associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care is associated with worse patient quality of life and worse bereavement adjustment.

Breathing helpers

This is National Respiratory Care Week, an opportunity to acknowledge and thank respiratory therapists throughout the country for their important contributions to patient care. Here at BIDMC, we have two broad groups of therapists, the adult RTs and the ones who take care of the new babies in our neonatal intensive care unit.

I have written before about the wonderful work that goes on in the NICU and also about the spectacular teamwork that has dramatically reduced the rate of ventilator associated pneumonia in our hospital. The respiratory therapists are at the center of those programs, and so much else. We appreciate what they do, and their kindness and expertise in taking care of patients and in helping patient families understand what is happening during what can often be distressing clinical episodes.

Fostering collaboration

Here's a really neat website. It is the portal for the Harvard Clinical and Translational Science Center, one of several federally-funded centers designed to promote the acceleration of medical scientific advances to clinical application -- or to put it more simply, improving human health.

Harvard Catalyst, as we have nicknamed it, is "a shared enterprise of Harvard University, its ten schools and its eighteen Academic Healthcare Centers, as well as the Boston College School of Nursing, MIT, the Cambridge Health Alliance, Harvard Pilgrim Health Care and numerous community partners." It is funded by a five year, $117.5 million grant from the National Institutes of Health (Clinical and Translational Science Center, CTSC) and $75 million dollars from the Harvard University Science and Engineering Committee, Harvard Medical School, Harvard School of Public Health, BIDMC, Brigham and Women’s Hospital, Children’s Hospital Boston, Dana-Farber Cancer Institute and Massachusetts General Hospital.

The major job of Harvard Catalyst is to connect thousands of investigators in the Boston area, to encourage the growth of the clinical and translation investigative community, and to enable success through access to resources and by reducing barriers. That is where the website comes in.

Play with it and try out some of its features. After you get through (or click past) the opening scenes, click through to "Profiles" under "People". How would you like to search?

Let's say you want to see who is working in the area of say, sleep. Put that in as a key word, and you will see the 360 people in the Harvard system who have any record in their CV about research related to sleep. Click on any one of them to see his or her complete CV, other research interests, co-authors, other researchers who have similar interests, and even people who have offices near the one you chose. If you see an article of interest, click on it, and go right to the abstract.

Need to locate a core facility to help with an experiment you are planning? Click through to "Core Facilities" under "Resources." Then pick the category you want on the left to get a full description of services offered by each individual facility.

Now, you want to drive to that spot: Go to the "Atlas" under "Resources" and get driving (and parking!) directions to the place you are seeking.

And so on.

Good stuff, I think, and well presented and easy to use.

Welcome, Amy!

Health Care For All has a new Executive Director, Amy Whitcomb Slemmer. Here's her bio. She arrives at a critical time in the implementation of Massachusetts health care reform, and we all wish her well in this important advocacy role.

MITSS auction on line

If you cannot attend the fund-raising gala for MITSS (Medically Induced Trauma Support Services) on November 6, you can still participate in the auction. Go to this website and start bidding! This is an excellent cause, and now might be just the right moment to get a good deal on some Red Sox tickets.

More about Monique's book

Please check out this article by Liz Cooney in the Worcester Telegram about Monique Doyle Spencer's new book.

SPIRITed Transport

It has been some time since I gave you an update on BIDMC SPIRIT, our employee-driven process improvement effort. In addition to a variety of small projects, we have focused on several large hospital-wide attempts to improve the work environment. One of them is the issue of transporting patients to testing. As I noted back in June,

There have been several SPIRIT call-outs by transporters and other staff related to miscommunication about the mode of patient transport. A request is made for one means of transport (for example, wheelchair), yet another means of transport is what is brought (for example, a stretcher).

At the time, we found the following underlying symptoms:

There is a communication disconnect between Service Response, the testing location, and the unit to which the patient is assigned.
There are no clear cut guidelines as to who decides the mode of patient transport, or when, or how.
Nursing’s way of determining how to send a patient differs from how the testing location might want to receive the patient. Each use different criteria. An unfortunate side-effect is that the transporters are caught in the middle of communications between senders and receivers.
When Service Response gets a call for a patient transport request, the level of detail varies depending on who took the call.
(Interestingly, Radiology has its own system, in which they call the unit to confirm “we’re coming to pick up Patient X in a wheelchair,” but still they end up with the same problem. When they arrive, it turns out that the nurse requested a different mode of transport.)

And here's what we said we'd do:

We are in the midst of collecting a baseline for Radiology and Central Transport on the West Campus. This includes the number of transports per day, and the number of “wrong” modes for each day. This also includes overall transport time. The anticipated time to implementation of a solution is about 4 weeks.

Well, it turns out that this took a lot longer than 4 weeks, but it is because we expanded the scope of the project so it became a design from scratch of the process used by all parties involved in transporting a patient between an inpatient unit and a testing area (e.g., radiology). Go-live for the new approach is this Tuesday. What follows is an outlined summary sent to me by one of our Senior Vice Presidents. She was keen to note that the effort involved participation, suggestions, and energy from people at all stages of this process, exemplifying the whole idea of BIDMC SPIRIT, lots of well intentioned people working together for the good of patients and each other.

We'll see how it goes on Tuesday! As the summary below anticipates, no doubt there will be some glitches, for -- as anyone in any hospital can tell you -- this is a complicated environment. But I hope that you get the point that even solving the glitches together is part of the idea.

---
Where did we start?

Multiple SPIRIT callouts re: mode of patient transport (e..g., transporter arrived on unit with stretcher, nurse thought patient should go in wheelchair.)
Resulted in:
Transporter hunting and fetching;
Delays (impacts our patients, our nursing unit staff, our testing areas, our transporters and transport times, etc);
Sometimes patient went to testing unit on mode that couldn’t be used in that test; test had to be rescheduled;
Confusion among transporter, nursing unit, SRC and testing area staff.

After discussion among representatives of all staff involved, the group determined that entire process of transport (not just choice of mode of transport) from inpatient unit to testing area was:
Not defined/standardized;
Created re-work and delays;
Included less than optimally safe practices;
Created frustration/tension among departments (RNs, UCOs, SRC, transport, testing areas);
Would provide opportunity for many BIDMC staff to apply Lean/SPIRIT principles.

Decision to broaden scope of project to entire process: Starting with request for transport and ending with patient return to unit following test.

What process did we use to design new process?
Front line staff from each area described to each other current practice and problems and found that:
Process differed by unit and testing area;
Some groups are doing extra work that they thought helped other group, but didn’t;
Identified lots of rework and potential for confusion;
Terminology is not defined consistently, leading to confusion;
It was very valuable to learn how all parts fit (or don’t fit) together.

We drew process flow for entire current process, listing all problems/potential for errors, then described “ideal” state and draw a new process flow (making sure we used “Lean” principles” described below) to reach that.

3. Entire group developed specific steps for each activity in pathway, understanding each others’ roles.
Tweaked process flow as specifics required.
Challenged any step that was inconsistent with “design principles” to get closer to “ideal”.

4. Developed approach and materials for staff education, roll out and continued improvement of new process.

“Lean” principles used to shape “Ideal” new process
“Activity” Principle: Specify all steps in process.

“Connection” Principle: Ensure communication and hand-offs can be carried out appropriately.

“Pathway” Principle: Include no (or minimum) “forks” or “loops”, i.e., each member of the team should have one clear path to follow.

“Improvement” Principle: Use scientific method (data driven, evidence based), involve front line staff, keep improving -- “call out” when unable to perform step as specified.

Major Elements of New Transport Process
Scheduling:
Testing area determines mode of transport (exceptions only permitted based on patient clinical condition and only after resource nurse discussed with testing unit to ensure that test could still be carried out).
Only one call made to Unit to schedule patient test, with standard set of info using standard nomenclature. (Currently, many testing areas call several times to give “heads up” of when test probably will be. Nursing staff noted this does not help them.)
Time communicated is the scheduled pick-up time (not test time). That’s what matters to the nursing unit and transporter.
All testing locations to schedule tests/transport via phone (some were using fax, causing staff to look for info in different places)

Patient Preparation:
Clear assignment to and definition of role of UCO in chart preparation and notification of RN re: transport.
Increased communication and established time frame (5 minutes) for nursing assistance with patient departure or arrival.
Involvement of the Resource RN to assist transporter if delay of 10 min. occurs
15 minute maximum time for transporter to wait before going to next job.

Handoffs:
Face-to-face handoff must ALWAYS occur between patient’s nurse/designee and transporter upon patient’s departure AND return to unit. (Important safety improvement and will ensure that patients are receiving appropriate information).
Nursing unit staff ALWAYS to assist transporter in transferring patient to/from stretcher or wheelchair (important safety issue).

Continuous improvement:
Members of design group shadowing transporters first 2 weeks;
Managers assigned to serve as extra “help chain” for first 2 weeks so as much “real time” review of calls outs can be done;
Encouraging call outs for whenever process doesn’t work as designed (and underscoring it’s nobody’s fault);
Meeting 2 weeks post go-live to review all call outs and tweak process (and/or education) as needed.

Bottom Line
Reduction in time-wasted hunting & fetching
+
Alleviation of frustration and confusion (for both staff and patients)
+
Clarity in role responsibilities re: transport
+
Consistent and standard communication throughout patient transport process

= Improved Patient Care + Improved Employee Satisfaction and Collaboration + Better Use of Resources (through minimizing delays)

Fall scene

Early fall colors from the Mass. Audubon Broadmoor Sanctuary. By the way, this was taken with my cell phone, if you can believe it. The relatively poor lens and fewer pixels seems to help give it a softer feel.

Hey, we're a case study!

I received a lovely note recently from Paul Batalden, one of the true gurus of patient safety and quality, who teaches at Dartmouth:

Dear Paul,
I write to tell you of one application of your transparency about the wrong site surgery event this past summer.

In starting my class this fall on the intellectual underpinnings of the improvement of health care, I decided to take your blog and its responses, the Globe blog and responses and the WSJ blog and responses and give them to my Master's class ahead of our first session. I assigned a "role" of patient, family member, surgeon, anesthesiologist, nurse, payer, CEO, board member to each student and asked them to prepare a two page description of the actions they would recommend and the worries that they might have about what they were recommending.

At the start of class, I divided them into tables of mixed roles and asked them to come up with a plan, why they thought it might work and how they might know it was.

We had a very good conversation and I'm including some of the outputs of the discussions for your interest.

Here are the reports from two of the groups. Good work, I say. Whatever you think of their conclusions, it is terrific that these students have real-life examples to work from, to hone their analytic skills and think through the types of problems they will certainly face in their careers. And they are really lucky to have Paul as an instructor to help them think through these matters.

Group 1

1. What concrete actions are needed? Why?
a. Overall, our group felt that there were safety mechanisms in place to prevent such incidents from occurring (i.e the time out) but for some reason they did not work in this case. The focus of our groups actions were understand why the safety mechanisms did not work and “fix the process” as needed.
b. A quick thorough investigation of the actual event, report this to Chair of Surgery, CEO, Governing Board.
c. Direct observation of the process of patients coming in and out of surgery. There will be multiple processes going on, so it will be important to observe how these different processes work with and against each other.
d. The Chair of Surgery would review and be responsible for approving the overall workflow and process of how patients are brought in and out of the surgical suites.

2. What monitoring process should be used to know that you have effectively prevented the recurrences of the problem?
a. It is often the case that adverse events such as performing surgery on the wrong site are due to multiple small errors occurring and building on each other. They may also occur at transition points. While serious events are rare, there are probably many near misses that need to be defined and measured.
b. Need to measure severe adverse events as well.
c. Simulation of the process, to have the different surgical teams practice during high patient volume scenarios. Tapes of these simulations need to be reviewed to understand team functioning and strengthen teamwork/communication.

3. How will you monitor the costs of what you have put in place?
a. There will need to be someone who observes the process and maps the process out-this is a cost incurred.
b. There may need to be fewer procedures per day-this is a cost incurred.
c. The cost of one adverse event will need to be balanced with the cost of monitoring the process.

4. When might you review the actions taken.
a. The Governing Board and CEO would get monthly reports of near misses as well as the change in the process that occur because of observations.
b. The Chair of Surgery will get weekly reports of near misses and the change process that occur because of the observation.
c. The surgical teams will have real time feedback of near misses and will be expected to implement change processes immediately and measure the effect of a change.
d. Graphical displays (dashboards) will be available throughout the hospital and will show the real time performance of the surgical teams in terms of successes and near misses.

5. How might you help others learn from the actions you’ve taken?
a. Team performance can be improved and the lessons learned about how to improve the functioning of teams can give insight to other teams within the hospital.
b. Adapted M&M conferences for all staff.
c. Implement simulations for all teams.

6. Why haven’t these actions already been taken?
a. Competing demands
b. Busy surgical schedule
c. There may be a culture of just checking the box that a safety check has been done, without reflection on what it means.
d. Observation and process improvement require additional training and money (at least initially).

---
Group 2

Below is a summary of our group presentation regarding the "wrong side surgery" case. In order to prevent future wrong side surgeries (and other medical errors), we have devised a 3-part approach involving:
-Pay for performance
-Better pre-op procedures
-Better time-out procedures

Pay for Performance
From a financial perspective, nobody wants to pay for the cost of a medical error. Our position is that payers should reimburse based on performance. In order to measure this performance, it is beneficial to assign a quality score to each organization. This way, insurance companies and payers can choose to only contract with high quality providers.

Better Pre-Op Procedures
We recognize that miscommunications and errors happen, and so it is important to devise a standard protocol for making those errors less likely. Before surgery, the surgical site is usually marked. However, those markings can be ambiguous. By color coding a "yes" on the correct side and a "no" on the wrong side, there is less likelihood of error due to misinterpretation. We also suggest allowing the patient to be involved in the marking. The patient (if able), pre-op nurse, and the surgeon should all sign the surgical site in an effort to further reduce error.

Better Time-Out Procedure
Time-outs are already "implemented," but the key is making sure that they are actually being carried out. In an operating room, there is often a superiority issue that may cause a nurse or assistant not to speak up if the surgeon goes through the time-out incorrectly or skips it altogether. To remedy this, we suggest assigning a "time out captain" who will always initiate the time out. This may be the surgical nurse, or a tech in the OR who is prepping the tools. By assigning a role, it is more likely to be done. We also recommend having some sort of written time-out. By forcing the people in the OR to write out the right person, right place, and correct site rather than just quickly checking it off, it ensures that this step will not get skipped. Finally, a visual projection on the wall of the operating room may be a good tool to reinforce the time out. By projecting a picture of the patient (or outline of a patient) and highlighting the correct area to be operated on, surgeons will have a visual check before they begin.

Review
In order to track the efficacy of our approach, we recommend tracking the time-outs missed and also tracking quality scores of the hospital itself. It is also important to conduct random safety checks in order to confirm the quality scores.
Wrong-side surgeries are not regular occurrences, but other medical errors happen more frequently. We believe that our three steps will help to correct the underlying issues, leading to less overall medical errors.