Well Mercy me! It's a podcast.

When I was CEO, a hobby of mine was trying out new forms of social media to communicate across the hospital's population.  My friends at Children's Mercy Hospital, who are engaged in an extensive and intensive transformation of their institution, understand that effective communication is a necessity.  They also get the idea that different folks get their information in different ways.  Some like email, some like blogs, and so on.  Your job as a leadership team is to employ a wide variety of modes so that folks can use the ones they like best.

So, I was interested to see the Kansas City hospital team start up a new podcast.  It will be posted weekly and is short and focused.  An excellent tool.

It was inaugurated by this email message:

As part of the new Children's Mercy Employee Discovery Series, Dr. Jason Newland is hosting a weekly 10-minute podcast for employees. His guests will include medical staff members and administrative leaders on important issues impacting the hospital. 

The first podcast, featuring Jason and Karen Cox, RN, PhD, is available by clicking here.

(http://www.childrensmercy.org/employeediscovery/)

Karen joins Jason to talk about how our staff responded to the recent snow storms. What worked? What could we do better next time? (Time: 10 minutes)

You can listen to the podcast directly from your computer or download it to your phone, tablet or iPad.

Got a question or a topic you’d like to hear about? Just email Jason.

Find a way to help Found in Translation

Last fall, I wrote about Found in Translation, an organization with a terrific dual purpose: "To help homeless and low-income multilingual women to achieve economic security through the use of their language skills; and to reduce ethnic, racial, and linguistic disparities in health care by unleashing bilingual talent into the workforce".  Now, CEO and founder Maria Vertkin sends an update of their activities and asks for some help:

I am happy to say that 12 of the 19 women who graduated from our pilot program in April 2012 have since found employment (6 of them as medical interpreters or in a similar position), compared with only 2 employed at the start of the program.  While this is great, we are hard at work to get closer to 100% of our grads getting employed within one year of graduation.  Cambridge Health Alliance has agreed to take in our graduated into their medical interpreting internship program, with the possibility of hiring them thereafter.  We've also recently entered into a partnership with a free clinic run by Tufts medical students, where 3 of our graduates are now employed part-time as medical interpreters. This clinic serves some of Boston's most vulnerable patients who have never able had professional interpreting before.  And, of course, we are thrilled to be building a direct pipeline from our program to jobs. Our second class will graduate this month, and two have already received job offers pending graduation.

When people hear about our successes, they are usually surprised to hear that we are, in a way, homeless.  We've accomplished all this working out of borrowed rooms and Paneras.  But the need for our program is overwhelming.  We received almost 200 applications for 30 spaces in our second training, and have gotten over a dozen requests to bring our program to other communities both locally and as far away as Kenya.  We are poised for growth, and our next step will be getting an office/classroom space of our own.  We've launched a campaign on IndieGoGo to accomplish this.  Here's the link.

Found in Translation is a cause that -- pun intended -- speaks to those in the multilingual professions. But we are a young start-up with a small audience, and that is why I want to ask for your help in reaching potential supporters.  To reach our goal, we need as many people as possible to visit our campaign page, watch our video, donate (in any amount -- there are perks at every level!), comment, and share the link on their social media.

Jha-ring conclusion: Use evidence!

@ashishkjha Ashish Jha is easy to distinguish from many health care policy people in that he is "an advocate for the notion that an ounce of data is worth a thousand pounds of opinion."  Unlike yours truly, he also has access to tons of data, so when he speaks, it is worth listening.

In a recent post on The Health Care Blog, Jha draws the following conclusion:

The debate around the readmissions measure has come to the forefront because of the CMS Hospital Readmission Reduction Program, which penalizes hospitals for “greater than expected” readmission rates. It has raised the question — does a hospital’s 30-day readmission rate measure the “quality of care” it provides? Over the last three years, the evidence has come in, and to my read, it is unequivocal. By most standards, the readmissions metric fails as a quality measure.

[I]f one measure of quality is external validity – being at least somewhat correlated with the gold standard (mortality rates) — how does the readmission measure do? In a paper published recently in JAMA, we see that readmission rates don’t do so well at all. Readmission rates are un-correlated with mortality rates. In fact, for one of the three conditions, the readmission rate seems to go the wrong way: the best hospitals for heart failure (i.e. those with the lowest mortality rates) have readmission rates that are actually higher. Not perfect. Readmissions seem to have little external validity as a quality measure. Readmissions are, however, correlated with two things: how sick your patients are, and how poor your patients are. We now have good data that the Hospital Readmission Reduction Program disproportionately penalizes big academic teaching hospitals (that care for the sickest patients) and safety-net hospitals (that care for the poorest).

But does the program help at all?  Here's where Ashish goes anecdotal on us (but at least he admits it!):

So, given its poor test characteristics, can we justify using the current hospital readmissions measure to grade hospitals on quality? I don’t think we can. However, here’s where my own ideas have evolved. ... [T]he 30-day readmission measure may be a good way to promote accountability in healthcare.

In conversations with colleagues and friends, the readmissions penalty program seems to have gotten some hospitals to think outside of their four walls. Hospital leadership has started to rethink the role of the hospital. Hospitals are building relationships with community-based organizations. Some are creating follow-up clinics while others are calling all the patients who are discharged to make sure they are doing OK at home.

And the personalized summary:

The readmissions program seems to be, for some hospitals, having a positive effect. Will it pay off? Will we see a real, sustained change in the way they provide care to patients after they are discharged? I hope so. But remember – some of the best hospitals in America have the highest readmission rates, almost surely because they care for sicker, poorer patients. In the current business model, they are doing things right – taking good care of the patient while the patient is in the hospital. It’s fine to ask these hospitals to change their business model and to become accountable for what happens to their patients after they are discharged. But, let’s not call them bad hospitals or suggest that they are providing poor quality care. There is no evidence that they are.

How refreshing to hear from an honest analyst, someone who distinguishes between conclusions based on evidence, hypotheses based on anecdotes, and hopes based on societal ethical standards!  The only thing missing from this article, in my view, is the "so what?" question.  What should we actually do?

I think the answer comes from transparency.  Just post, for the world to see, the readmission rates of all hospitals by clinical specialty and let admininstrators and doctors compare their performance to others.  Even without financial penalties, the inherent competitiveness of people in this field will cause them to evaluate their work and try to do better, consistent with underlying standards of quality.  Is CMS wants to provide a financial incentive, give a small bonus to hospitals that voluntarily post such results for each attending physician in real time, not months later.  Then, you'll see changes in practice patterns!

But this approach is not likely to be considered, much less adopted.  Federal and state policy is designed by other people.  Look at this comment by another health care policy person:

Stuart Altman, a professor of national health policy at Brandeis University [and chair of the Massachusetts Health Policy Commission Board], said he gets questions from hospital chief executives and chief financial officers asking "why are we getting penalized when we take care of the patient?"

"I tell them, 'you are big, rich and powerful, and you have the ability to resolve the problem and you will be part of the solution whether you like it or not.' "

"There are appropriate readmissions, such as related to different ailments or an unforeseen health event unrelated to the first admission," Altman said. "Hospitals are not penalized in those situations.

"However, there also are non-appropriate readmissions that can be benchmarked and compared with peers and the community."

Dirty hands and clean hands on WIHI

March 7, 2013: No Excuses, No Slack!
The Latest from the Front Lines on Hand Hygiene

(2:00 – 3:00 PM Eastern Time)

Featuring:
Gene H. Burke, MD, Vice President and Executive Medical Director for Clinical Effectiveness, Sentara Healthcare
Michael Howell, MD, Director of Healthcare Delivery Science, Director of Critical Care Quality, Beth Israel Deaconess Medical Center
Lisa L. Maragakis, MD, MPH, FSHEA, Director of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital
Scott A. Miller, MD, FACP, Vice President, Medical Affairs, Sentara Leigh Hospital
Tom Talbot, MD, MPH, Chief Hospital Epidemiologist, Vanderbilt University Medical Center

One of the cornerstones of infection prevention in any health care setting, including when someone is being cared for at home, is good hand hygiene. Much of the attention in recent years has focused on hospitals and their rates of hand hygiene compliance among staff. And rightly so. Among the biggest contributors to hospital-acquired infections are, inadvertently, health professionals themselves... and others who come in contact with patients.

The good news, as you’ll be reminded on the March 7 WIHI, entitled No Excuses, No Slack! The Latest from the Front Lines on Hand Hygiene, is that awareness of the necessity of strict hand hygiene compliance has never been greater… not just in the US, but in acute care settings globally. And this awareness has been coupled with practices that are being adhered to more reliably than ever before. But not everywhere, all the time; organizations that can tout rates as high as 95% are still the exception, not the rule, and good performers continue to face challenges closing the gap.

For the March 7 WIHI, host Madge Kaplan has rounded up infection prevention leaders and clinicians from four organizations whose recent innovations with hand hygiene at their facilities represent what could be the best bet yet that 100% compliance is achievable. Sentara, Johns Hopkins, Vanderbilt, and Beth Israel Deaconess Medical Center all have fresh approaches that rely on new kinds of auditing tools to discern what really works; better surveillance, monitoring, and measuring; reengineering; constant education; and a laser-like focus on behavior and culture change. 

What’s working in your organization? How are you getting your hand hygiene compliance rates to move upward? Compare and contrast your methods with those of our guests.

Please join us on the March 7 WIHI! Click here to enroll.

Tchaikovsky arrives at Haddasah

"Forty students from the Jerusalem Academy of Music and Dance took a classical approach to the flashmob as they flashwaltzed Tchaikovsky's Waltz of the Flowers at the new Sarah Wetsman Davidson Hospital Tower in Jerusalem. Doctors, patients and passers-by joined in the fun.

"The surprise concert was part of Good Deeds Day, an annual event that originated in Israel in 2007 and now takes place in over 50 countries worldwide. On this day volunteers reach out to the less fortunate and the vulnerable.

"The Academy students enjoyed the day so much that they have decided to schedule regular concerts at the hospital. Hadassah Medical Organization treats over one million patients annually, without regard to race, religion or national origin."

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

 

The prisoner's dilemma in ACOs

Now comes the Society for General Internal Medicine, jumping on the global payment bandwagon. John Commins at HealthLeaders Media reports that the SGIM has concluded, "Fee-for-service medicine is a financially unsustainable payment model that should be phased out by the end of the decade."

What is this really about? SGIM has finally concluded that the existing rate structure, which favors proceduralists over cognitive specialists, will never be changed under the fee-for-service rubric.  But, if we adopt capititation, will the reallocation will somehow mysteriously occur?  Not likely. 

There remains remarkably little discussion about how capitated, or global, budgets should be allocated among the various types of doctors and facilities engaged in providing care.  As Bruce Landon noted last year, this is a key issue:

The fundamental questions become how ACOs will choose to divide their global budgets and how their physicians and other service providers will be reimbursed. Thus, this system for determining who has earned what portion of payments — keeping score — is likely to be crucially important to the success of these new models of care.

Under ACOs and many commercial global payment products, providers will continue to receive traditional fee-for-service payments, and hospitals will receive their usual contracted payments, through either the diagnosis-related-group (DRG) system or per diem payments. All spending for each patient that is attributed to the ACO will then be tracked and compared with the calculated budget retrospectively at the end of the performance year in order to calculate savings or losses. Thus, standard fee-for-service payments remain the de facto method for keeping score.

Let's go further, though, and posit a potential adverse impact of global payments that has not been discussed to date.  It derives from a phenomenon known as the prisoner's dilemma,which "shows why two individuals might not cooperate, even if it appears that it is in their best interests to do so."

Let's say that you are a surgeon in an ACO being paid per procedure.  You have been advised that, if there is a surplus for the ACO at the end of the year, you will get a small percentage of that.  You do a calculation of the likelihood of a surplus occurring and of your likely share.  You conclude that doing one or two more surgeries per month will give you more income that your likely share of the surplus.  You also figure out that the same will be true for your colleagues.  How do you act?  If you are economically rational, you do the extra procedures.  Ironically, if all the proceduralists do the same, the ACO might run a deficit rather than a surplus and might cause a clawback of all physicians' payments--including those internal medicine doctors represented by SGIM who so strongly advocated for global payments.

This quality stuff isn't easy

Jim Conway, from whom I have learned more than just about anybody, has done it again in a blog post entitled "Leadership and Pre-occupation with Failure" on the site run by the Paediatric International Patient Safety and Quality Community.

A short version might be, "Just when you think you are making progress, you don't understand how you are undercutting your own efforts.  Keep trying and learning.  This quality stuff isn't easy."

Read it and let Jim know what you think. Excerpts:

The CMO of a rural community healthcare system was pleased after kicking off a patient safety meeting with more than 100 front-line clinical, administrative and support staff.  The organization had shown a dramatic decline in serious adverse events and now the numbers for most months were very small.  The chart showing the downward trend was striking.  He was therefore stunned with the first comment from staff: “If that’s what you think then it is clear you don’t have any idea of what goes on in my unit every day.”
 
This story is real.  It occurred in an excellent organization, and I was there as it unfolded.  The organization’s leaders knew that if you try to do everything, you will accomplish nothing, so they set strategic quality and safety targets and the organization was on an active journey forward.  However, they became too focused on these few events, forgetting that their targets were a small piece of the universe of harm and failure, maybe just 5% of it.  No mention was made at the meeting of the larger context of failure.  No mention was made as to how this data linked to all the incident reports that get filed every day.  For the front-line staff, what leadership was saying bore no resemblance to the failure they, patients and family members deal with every day.

On one occasion during my own career, a physician leader was presenting some strong work from a team on a new clinical information system.  At the end of the presentation I congratulated the team and asked “What new categories of error are we implementing with this system?”  With a very frustrated and abrupt tone the leader replied, “Aren’t you ever satisfied?”  I thought and then said “No, I can’t be.” 

Every time you change a system, what is your approach to critical risk assessment, to failure detection?

As a young leader I loved being a firefighter, coming in on a great big problem, and leading the team that fixed it. Then a colleague suggested that maybe those problems shouldn’t have risen to that stage if I and we had been doing a better job in the first place.  If a strong system had been built, and we were listening to the signals suggesting problems, we could have fixed them earlier.  Many clinical colleagues say they’ve seen a similar scenario, often at morbidity and mortality conferences.  The focus is on the save and not on the fact that the harm shouldn’t have happened in the first place.

Organizations and their leaders must develop this pre-occupation with failure and then do something with the data.  

Dr. Seuss has taught us “the more that your learn, the more places you will go.” John Kelsch of Xerox noted “To do things differently, we must see things differently.  When we see things we haven’t noticed before, we can ask questions we didn’t know to ask before.”  Each of us has seen and been part of exceptional care and caring.  A pre-occupation with failure will help us move closer to that being the experience of EVERY patient, family member, and staff member, EVERY time.     

I'm only thinking of him

In the musical Man of La Mancha, the hero's niece Antonia piously, but insincerely, sings the song "I'm only thinking of him."

I'm only thinking of him,
I'm only thinking of him,
Whatever I may do or say;
I'm only thinking of him!
In my body; it's well known,
There is not one selfish bone...
I'm only thinking end worrying about him!

A reprise is being sung in Albuquerque, New Mexico.  For years, the University of New Mexico Hospital has served as the safety net hospital for the region's poor and uninsured, supported in part by $90 million per year from a dedicated tax levy.  Now comes the Lovelace Health System, owned by Tennessee's Ardent Health Services, offering to share beds with UNMH as an alternative to UNMH building a new $146 million hospital.

I am moved by the generosity of this for-profit chain.  I'm sure they are only thinking of the needs of the public and the burden facing UNMH.

Oh wait, a story in Albuquerque Business First eventually mentions something of interest:

[Lovelace CEO Ron] Stern’s letter also said the Lovelace Medical Center in the Downtown area has an occupancy rate of 61 percent and could easily take overflow patients from UNMH.

Oh, 61 percent.

By the way, was Lovelace proposing to take all kinds of patients, or only ones with insurance?

Let's turn back to the song.  (Click here if you can't see the video).

Residency work hours revisited

What do residency program directors and residents think about the restricted work hours that were put into effect in 2011?  They don't like them.  Should we care what they think?

The New England Journal of Medicine reports on a survey of residency program directors.  Main conclusions:

Program directors reported that many aspects of training and patient care have been unchanged by the 2011 regulations, including resident supervision (62.0%), patient safety (57.0%), balance of service and education (60.9%), scores on in-service exams (73.6%), and fatigue (54.4%). Perceived quality of life for residents was the sole area identified by a plurality of respondents (49.5%) as having improved. Meanwhile, a negative effect was reported for resident education (64.8%), preparedness for senior roles (73.2%), and “ownership” of patients (78.6%); respondents also noted diminished continuity of care (82.0%) and increased frequency of handoffs (88.0%). Most program directors reported an increase in their own workload (73.8%), as well as increased utilization of physician extenders, such as nurse practitioners and physician assistants (61.4%). Finally, less than half the program directors (42.7%) reported that their residents are “always” compliant with duty-hour regulations.

In a previous survey of residents themselves, notes Kaiser Health News,

The residents themselves also [had] negative views of the changes.  A similar survey of 6,201 residents published in NEJM in June found that while 62 percent felt that quality of life had improved for interns, half reported that quality of life had gotten worse for senior residents, who were picking up the slack. Meanwhile, 41 percent reported that the quality of their education had gotten worse, and 48 percent disapproved of the rule changes.

What are we to make of this?  One observer on the National Patient Safety Foundation listserv said:

I was dismayed by this when I saw it. Then I remembered that this was an opinion survey. It is interesting, though, that residents and interns have so little regard for (and insight into) their own human limitations due to fatigue. They have already been socialized into the wonderful world of medicine, where everyone thinks she or he is superman, able to leap tall shifts in a single bound. Of course, nurses feel that way too. Most would rather work fewer longer shifts rather than more shorter shifts, even when confronted with evidence that the latter is safer.

Before we reach conclusions, it might be good to look at the science.  I recall a talk years ago by Charles Czeisler, the chief of the division of sleep medicine at Brigham and Women's Hospital.  He certainly made the point that an extended periods without sleep are dangerous (for patients, the residents themselves, and traffic accident victims as residents drove home).  But here's the thing:  I may remember this wrong, but I thought part of conclusion was that the pattern of sleep-and-awake mattered a lot--in terms of attentiveness--not so much the total number of hours of sleep that one got during a week.  If so, the prohibitions set forth by the ACGME may be mis-designed.

But, there is one thing for sure, as noted by the observer above:  Residents will never believe that any set of rules is good for them or their patients.  They are tricked by their own cognitive errors and imbued with a deep cultural prejudice into believing that they can "handle" anything that comes before them. In that regard, the medical education system has failed them.

A tale of two Blues

An MIT professor colleague, an expert in computers, writes:

The last couple of months have been very heavy duty bad medical stuff for me.  Horrendous. So, I've been able to see the dysfunctional medical insurance system in action.   Do you understand how Blue Cross/Blue Shield actually works?  Out of, oh, maybe 80 transactions over 2 months -- they managed to get one, as in the number 1, correct.  The rest are mistakes, mis-billings, computer errors, everything one can imagine.  And the only reason I can ever figure it out is because I am dogged and know something.  I can't even begin to imagine the bone-head database that lurks behind all of it, along with inept programming, but whatever it is, the people running the place (sorry if I tread on toes) -- up to and including all the executives, are simply, sorry to say, totally bonkers.  And they are just middlemen. They aren't providing services, just managing to extract rents. Badly.

P.S. BTW, my running statistics on them, is that out of 540 transactions with them over the past 1.8 years, they have gotten two, as in the number 2, correct.   Not a good batting average. Why are they so inept?

Let's see if we can correlate this description with this recent earnings report in the Boston Globe:

The state’s largest health insurer boosted its earnings in 2012, while three other Massachusetts health plans reported net income declines from the previous year as they absorbed a new state assessment to fund initiatives under a cost containment law.

Blue Cross Blue Shield of Massachusetts recorded net income of $163.9 million for the 12 months ending Dec. 31, a gain of 20.4 percent from the $136.1 million it earned in 2011. The better showing was powered by a sharp increase in fourth-quarter earnings and higher operating income in 2012, offsetting a modest drop in investment income for the year and a $65 million accounting charge taken to cover the cost of the new state assessment.

After a $149 million net loss in 2009, financial results at Boston-based Blue Cross have climbed steadily over the past three years as the insurer has focused on strengthening its business and introducing products aimed at slowing the growth in premiums.

“We’ve made a concerted effort to grab hold of our company and get costs in line with revenues,” Blue Cross chief financial officer Allen Maltz said.

Help break open The Wall of Silence

When @PatientAdvocacy, @hhask, @MLMillenson, @dmayer33, and @medstarsafety get together, its like Joshua and the battle of Jericho:  The walls will start tumbling down.

In this case, though, they need a little financial help.  Check out this request on Kickstarter to help document the most comprehensive safety, quality, and transparency cultural shift in a US hospital system:

As the new Vice President of Quality and Safety for MedStar Health, Dr. David Mayer is leading a group of hospitals in the Baltimore/Washington area to change the way healthcare responds to patient harm.

Few have attempted to change the safety culture of an entire hospital system on this scale. This is an historic moment in healthcare to track in real-time the implementation of a new safety framework – and to do it in the backyard of our nation’s capital – with the hopes that the advances made at MedStar will lead to positive change across the nation.

Will you join us in documenting this important effort? 

If you cannot see the video, click here.

Was that a Nikon or a Canon?

If we put aside issues of criminality, the most interesting part of the story of the soldier who divulged secret files to Wikileaks is how unsophisticated and commonplace his actual actions were.  As noted by the New York Times:

Private Manning said he put the files on a digital storage card for his camera and took it home with him on a leave in early 2010.

Private Manning eventually decided to release the information by uploading it to WikiLeaks. To do it, he said, he used a broadband connection at a Barnes & Noble store because his aunt’s house in a Maryland suburb, where he was staying, had lost its Internet connection in a snowstorm.

New York Times Photo

Goal Play! is now an audiobook

By popular request, I have now issued an audiobook version of my book Goal Play! Leadership Lessons from the Soccer Field.  The book  has sold thousands of copies in paperback and on Kindle, but many of you have asked for a version to which you can listen.

I hope you enjoy it.  I did most of the narration myself (see above for an actual outtake!), but other people have taken on some of the roles in the book--including the foreword written by Edgar Schein--and I think you will like the production quality and sound effects.  (You can listen to that section of the book here, at my other blog on Wordpress, which permits inclusion of audiofiles in blog posts.)

I had to make a choice about distribution of the audiobook.  Some suggested using Audible.com, but their terms and conditions are a bit unfriendly for a self-produced audiobook.  Instead, I decided to disintermediate them and use a service called PayLoadz.  This is a simple front-end that connects to fulfillment through Paypal.  You click on the purchase link on this home page and immediately are given a PayPal screen, where you can use your PayPal account or a credit card.  Then, you are provided with a link that contains the audiobook, and you download it.

I've set it up so that the entire book is in one compressed file that you can unzip (on PCs) or unstuff (on Macs).  After you download, you can save it to your hard drive or copy it to a CD or a thumb drive or whatever you like.

In coming weeks, I may also offer a CD version of the book.  I have deferred this for now because it involves a different kind of fulfillment.  Please let me know if that would be more helpful to you.

In the meantime, please click here and enjoy the show!

When the doors of the mind open

I’ve often wondered why the psychiatric wards are the most drab and depressing parts of hospitals.  After all, you’d think that the architects and interior designers would be instructed by the facilities administrators to brighten things up for those patients suffering from mental illness and for the clinical staff who take care of them.  But no.  You know, even from the outside of the ward, that this is an unpleasant environment.  The door to a locked ward, with at best a small window looking in and out, is placed at the end of a dark corridor, surrounded by a wall colored in institutional gray or green, and often with no sign indicating what is inside.  Hope is quashed.

That despair is precisely what Teresa Pasquini, the mother of a young man with mental disease, noticed at Contra Costa Medical Center in Martinez, CA.  She notes: “The doors of the psychiatric units were seen as the hospital’s property and a way to control access.  Visitors were also controlled, and the mysterious world of the psychiatric units were misunderstood and often feared.  The entry into this emergency service was bare and unwelcoming.”

But change was possible, through a broadly inclusive Lean behavioral health rapid improvement event.  She explains:  “The Lean process takes you away from the meeting room and puts you on the front line of care observing each process.  This allows you to recognize what is waste and what has value.  Lean lets you see across the silos of the system and recognize the delays, the redundancies and harm.”

Indeed, while much of the focus of Lean is often on waste attributed to classical manufacturing concepts like excess transport, inventory, and waiting, those of us engaged in Lean often point out that one of the key wastes is “the waste of human potential.”  Unfortunately, if there is ever a part of a hospital that is likely to feature the waste of human potential--both of staff and patients--it is in the mental health areas.

Look at this simple result.  Teresa explains:  “With the help of a community partnership and three mental health consumers, who designed and painted the entrance to the psychiatric emergency area, this door now symbolizes the commitment to patient and family partnership and to co-producing a more welcoming and accessible experience for all who come here for care.”

Hold the presses: Clinicians jointly decide and act!

I did a double-take after glancing at this chart posted on the wall in the obstetrics department at Contra Costa Regional Medical Center in Martinez, CA.  What were those terrible peaks in the record of pre-39 week elective induced deliveries?  Then I looked more closely and realized what the scale was on the vertical axis.  Each of the two peaks represented only one such delivery! The rate during those two months remained below 1%.  And one of the two deliveries was only one day short of 39 weeks.  For the rest of the three years shown, the statistic stayed resolutely at zero.

I immediately spun around to the chief nurse on the floor, "How'd you do that?"  I had in mind the experience of so many other hospitals, including those in Massachusetts, which have had much higher rates and only recently have focused attention on this issue.  (The problem being that pre-39 week babies suffer distress and problems much more often than full term babies.  This puts them at risk and sometimes requires visits to the intensive care unit.)

Her response was way too simple:  "We collectively agreed that this was a serious issue and that we would religiously follow the criteria for early induction laid out by ACOG (the American College of Obstetricians and Gynecologists.) If a doctor shows up wanting to induce an earlier delivery, any person on the staff is empowered to question the decision. In case of conflicting opinion, we jointly discuss it."

For those who want to follow the lead of this public hospital in California, check out the ACOG Practice Bulletin, "Clinical Management Guidelines for Obstetrician-Gynecologists:  Induction of Labor," Number 107, August 2009.

Oh, by the way, did you notice that I said that the chart above was on the wall for all to see?  That's the kind of transparency that helps an organization hold itself accountable to the high standards it has set for itself.  Notice, too, that the goal is zero, not some national benchmark.  As I have said before, there is no virtue in benchmarking yourself to a substandard norm.  Bravo on all fronts to CCRMC.

Rabble rousers say, "We are the expert system navigators"

Teresa Pasquini (above, left) is a self-styled rabble rouser, "the queen of the letter writers," who used to spend hours trying to get her local hospital to do a better job caring for patients.  Who better then for CEO Anna Roth (above, right) to recruit as one of the first Family Member Partners for the Contra Costa County Regional Medical Center & Health Centers.

Patient-family advisory councils have been described as "the next blockbuster drug," the single most important advance in the delivery of medical care that is likely to show up in hospitals.  I had the pleasure today as Teresa and Anna participated in a webinar offered by the National Association of Public Hospitals on the topic of patient an family engagement.  Appropriately, most of the time in the webinar was taken by Teresa describing her motivation and involvement in the PFE process.  Her first statement got my attention, and the rest of her talk kept it.  Here are some excerpts:

I need to start my comments by sharing what drives my passion and commitment to this work.  I am the proud mom of a 30-year-old son with schizoaffective disorder who has spent the majority of the past 14 years in psychiatric facilities behind locked doors.

Doors, hope and harm have been a running theme in our life since our son was diagnosed.

My son has been hospitalized over 30 times in several locked facilities.  The past 14 years have been a blur of suicide attempts, over 40 involuntary holds, revolving hospitalizations, and a permanent conservatorship.  With a diagnosis at age 16, we began to navigate a maze of services in one of the most integrated health care systems.  It was a nightmare.

I was an angry mom when I was invited to my first Lean event at CCRMC.

Prior to this event, there was concern about me whispered around the tables and behind closed doors.  Cautious warnings were shared about my outspoken, even radical, direct action approach.  Fortunately, the Administration of CCRMC took a risk and opened their doors and minds and even encouraged me to push them forward.  The first event was the beginning of a special human connection that ignited our shared vision of hope.

Our partnership started off without clear direction.  There were underlying control issues.  We moved cautiously building trust and respect.  By staying at the table we began to overcome our fears and find our way to the "field beyond right and wrong."

We were teaching and learning together and laying down the tools that had been failing.  We were challenging the system and embracing the tension that comes from change.  And there was tension.

The tension was often whispered offline or subtly felt in meetings.  The staff was not trained to be open with "outsiders" in the room.  The patients and families were not familiar with "medicine speak." But through determination, courage, and leadership, the comfort level increased and transformation began.

Contra Costa County Health Services has shown bold courage by offering our community a trusting, authentic, shared learning experience and partnership that goes beyond the traditional advisory role.  We are not token advisors but rather equal and respected partners.  We have learned to speak the truth, hear the truth, and go and see the truth.  With constancy of purpose and focused direct action, we are co-creating a system where the consumers, families, community organizations, clinicians and staff work in a true partnership.  No politics, no discrimination, no special interest, no egos, just pure ethical health care based on the needs of the patient.  I have seen it happen.  It is possible.

Nothing is scarier that the health system when your child is sick.  Please, don't be afraid of an an angry mom or patient.  Invite family members like mine to tell you our experiences and let us help you create solutions.  Nobody comes to work to harm others.  We are the expert system navigators and we will help you design a better system for all.

Dreamlining about quality and safety

Richard Corder says, "I Wish My Hospital Was A Dreamliner."  As a team training and patient safety and quality specialist at CRICO, the captive malpractice insurance company of the Harvard-affiliated hospitals, he knows of what he speaks.  Listen to excerpts:

The stories have now been relegated to the back pages. “… Smoldering batteries forced safety regulators to ground Boeing’s new 787 Dreamliner jets.” This is a glimpse into the challenges that this aircraft and company seem to have been besieged by. The recent grounding of the fleet comes on the heels of other safety related incidents that while “typical” with a new plane have caused some concern given the rapid sequencing of events.

By the estimates made by the Institute of Medicine in early 2000, deaths from mistakes in healthcare are associated with the equivalent of one of these planes falling out of the sky every single day. The high estimate was of 98,000 people a year dying as a result of preventable harm and error.

What has been remarkable to me about the Boeing story, is not so much the incidents, not so much that the fuel leaked, or that the cockpit alarm went off or that it took forty minutes for a fire to be extinguished, what’s remarkable to me is that these are the stories, these are the headlines that we are reading and that the TV networks are carrying.

These “incidents,” for those of us who work in healthcare, are what we refer to as “near misses” and “good catches.” No one has died, no one has been injured, and no one has suffered anything more I suspect than a delay in getting to his or her destination. Oh, and some bruised pride and quarterly earnings impact for Boeing I expect.

In our hospitals, these “incidents”, these “near misses” rarely get reported internally; the associated press and the national evening news certainly don’t pick them up as front page stories.

If we are obsessed with safety, like the human factors focused airline industry, our near misses and our good catches would be enough for us to stop the line, stand back and work to develop safer systems.
 
So what can leaders do?

Lead a culture where you model that it is safe to speak up and encourage people to call out near misses, report good catches and model the mindset and actions of being personally accountable.

Make it known that while clear roles and clarity around authority are important, everyone is personally empowered to speak up or call an unsafe or potentially unsafe behavior to the attention of their colleagues.

Use all meetings, from the board to the bedside, to tell stories of how a mistake was avoided and how, when things go wrong, you recovered.

When things do go wrong because they will, we are human beings caring for human beings, don’t point fingers and blame people. Own the outcome, work to learn from the failure, apologize, atone and remain open to feedback.

Adopt some of the human error mitigation systems that the airlines have embraced. First names only and the sterile cockpit rule require that people only address each other by their first names in the cockpit and that during specific times only conversations pertinent to flying the plane are permitted. We have a choice to hold ourselves to these relatively simple agreements in our operating rooms and exam rooms.

So yes, I wish my hospital was a Dreamliner. Because Dreamliners are not falling out of the sky; they are being stopped, checked, called back and inspected.

Accountability in medical education

Medstar's David Mayer, who has been one of the nation's leaders in medical education, sets forth an interesting proposition:

With CMS, HRSA and others investing close to $9 billion dollars annually in graduate medical education, the day has now come for greater accountability in graduate medical education around safety and quality. Imagine what would happen if academic medical centers were ”reimbursed” for their graduate medical education the same way hospitals are now being reimbursed for patient care with penalties for lapses in safety and quality education, similar to readmission or infection rates. A reimbursement model based on Value-Based Education and HCAHPS for graduate medical education…where organizations like Consumer’s Union, Healthgrades and Leapfrog would publish annual ”grades” for GME quality and safety programs across the country. That would surely raise the stakes, get institutional leadership’s attention, and change the graduate medical education landscape. Is that type of educational “transparency” heading our way in the not-too-distant future?

What do you think about this idea?

Leadership for Learning Organizations at MIT SDM

I'm very pleased to have been invited to present a webinar with the MIT System Design and Management program this coming Monday.  I hope you'll join in.  Here's the announcement:

Leadership for Learning Organizations: Lessons from healthcare, sports, and more to help you obtain better results
 
Paul F. Levy, author
Date: February 25, 2013
Time: Noon - 1 p.m. EDT
Free and open to all
Register

About the Presentation

The world is rife with process improvement methods designed to deal with systemic issues facing manufacturing and services firms. Although proven tools, such as Six Sigma, Re-engineering, and Lean, exist to build learning organizations with enhanced efficiency and deliver higher quality products to customers, most organizations never achieve these goals. Why do so many work redesign efforts fail?

Paul Levy offers answers in a story-laden presentation based on his experience in several important leadership roles. These include serving as CEO of Beth Israel Deaconess Medical Center in Boston and executive director of the Massachusetts Water Resources Authority. Levy's presentation will also draw from his work in coaching girls' soccer over two decades. His recently published book, Goal Play! Leadership Lessons from the Soccer Field, draws on experiences gleaned from both parts of his life. Whether you are a CEO, department head, division manager, a professional who wants to work with others to improve the systems in your organization, or a volunteer in your community, this presentation offers insights to help you provide value wherever you are.

About the Speaker

Paul F. Levy served most recently as CEO of Beth Israel Deaconess Medical Center in Boston, where he saved this Harvard-affiliated academic medical center from financial turmoil that was leading to bankruptcy. Later, he introduced unprecedented levels of transparency into the health care field, resulting in substantial improvements in patient quality and safety, while enhancing financial results and market share. Previously, as executive director of the Massachusetts Water Resources Authority, he led the program to clean up Boston Harbor, executing a massive environmental remediation project ahead of schedule and under budget. He is the author of the recently published book, Goal Play! Leadership Lessons from the Soccer Field.

About the Series

The MIT System Design and Management Program Systems Thinking Webinar Series features research conducted by SDM faculty, alumni, students, and industry partners. The series is designed to disseminate information on how to employ systems thinking to address engineering, management, and socio-political components of complex challenges.

At the Sloan School with Professor Berndt

It was a pleasure to join MIT Professor Ernst Berndt for his class "Economics of the Health Care Industries" at the Sloan School of Management.  Tonight's topic was "Managing Health Care Costs and Quality." This class has an unusually diverse group of students--undergraduates from MIT, Wellesley, and Tufts; MBA students; executive MBA students; and several people with MD and Ph.D. degrees.  Students who offered particularly thoughtful comments are pictured here.  Please hire them.  (The fellow in the bottom picture wanted to make it clear how to find him!)


Ernie started off with a marvelous exposition of many factors relating to health care costs.  This chart above on the concentration of health care expenses in the US was striking, showing that 5% of the population accounts for about 48% of the nation's costs.

My job was to provoke a bit of discomfort and debate, and I explored several topics with the students.  I started with the question of whether the fact that health care accounts for 17.9% of GDP was a problem.  If so, why?  Was it too high or too low?  If one looks at some of the OECD countries with lower percentages, is it an indication that they are more efficient or that they are spending too little?  If the US number was too high, which participants in the health care system should receive less?  How much less?

We then entered discussions about using payment rates as incentives for efficiency improvements.  Is the failure of many pay-for-performance programs to produce meaningful results a function of poor design or a disconnect with what motivates doctors and nurses and how they make decisions?

We discussed further whether accountable care organizations would be likely to succeed, a variant on Elliot Fisher's joking comment of whether they would be accountable, caring, and organized.

I left the group with descriptions of two approaches that have been demonstrated to be successful in offering higher quality, lower cost care:  Managed care programs for dual-eligible (Medicare and Medicaid) patients; and front-line driven process improvement in hospitals.