Time for respect, not blame, at the NHS

In light of Don Berwick's recent advisory report for the National Health Service, this commentary by the Health Minister and his initiative send the wrong message. The Times of London reports:

Hospitals are to be forced to publish how much they pay for supplies under plans to end “scandalous” overpayments for basic goods. 

Dan Poulter, the Health Minister, said, "We must end the scandalous situation where one hospital spends hundreds of thousands more than another hospital just down the road on something as simple as rubber glove or syringes, simply because they haven't the right systems in place to ensure value for money.

Those of us who have studied procurement in hospitals know that there is nothing "simple" about this problem.

While the unit cost of goods purchased is always worthy of attention, it is actually the stocking of excess supplies that is likely to be more wasteful.  I'd wager that, if you visit the stores room in any NHS hospital (or for that matter, any US hospital), you would find an inventory that is far from the amount needed.  Why is that?

In most hospitals, there is a lonely person who has to decide when to purchase the next shipment of gauze pads, or bandages, or whatever.  He makes a personal judgment of this issue based on the speed with which those boxes leave his storeroom to head upstairs to the wards.  He has no formal training in inventory management and often has no data system to support him in his decision-making.  Accordingly, he employs informal rules of thumb for this ordering.  His incentive is to "never run out," and so he will always order more than the hospital actually needs.  He often works alone, and so when he goes on holiday, he orders still more extra supplies so that things will be all right in his absence.

But, it's worse than that, because the stockers on each ward and unit upstairs have exactly the same incentive.  Although there is a recommended par value of goods in each local supply closet and cabinet, his incentive, too, is to "never run out," and so he will always collect more supplies than are necessary from the central stores. His job is complicated by the fact that the local closets and cabinets are often crowded and poorly designed, so the actual inventory on each floor is unclear.

Those of use who teach Lean process improvement techniques know that one of the most likely places to find opportunities for savings is in this sector of a hospital's operations.  It is not uncommon to find that hospitals are over-purchasing by 10, 15, or even 20%. Then, because medical goods have expiration dates, a portion of the inventory is actually thrown out.

How does this all relate to Don's report?  While his report focused on safety, the conclusions actually are generalizable:

NHS staff are not to blame – in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to . . . problems.

Improvement requires a system of support: the NHS needs a considered, resourced and driven agenda of capability-building in order to deliver continuous improvement.

Recognise with clarity and courage the need for wide systemic change. 

Abandon blame as a tool and trust the goodwill and good intentions of the staff. 

Give the people of the NHS career-long help to learn, master and apply modern methods for quality control, quality improvement and quality planning.

Make sure pride and joy in work, not fear, infuse the NHS.

The language used by the minister and the one-size-fits-all type of solution proposed for this particular area exemplify an approach in opposition to the one advocated by Don and his advisory body. It does not consider the root causes of the problem or systemic solutions.  Equally important, the language used is not respectful nor supportive of the hard-working staff in the hospitals.

Walczak creates chances for change

Buried away in his campaign website is an extraordinarily thoughtful idea by Boston mayoral candidate Bill Walczak.  It represents the kind of thinking that can occur at the local level by people willing to think creatively and across disciplines.  This one is about education and health care.  Here's the quote:

Early education works best when parents are prepared and supported in their role as their child’s first teacher, and this needs to start with prenatal care. . . . The challenges that confront young people in many of our neighborhoods in Boston include violence, chronic poverty, poor housing, and unhealthy environments among others. These difficulties spill over into their social and educational experiences. The term applied to these phenomena is “toxic stress.” Strong evidence points to the physical and emotional toll that toxic stress places on children, including compromised brains and bodies.

I strongly believe that connecting our schools and health care providers will help to reshape some of these experiences. Our health care institutions need to become more proactive in integrating the realities of childhood poverty into their interventions. At the Codman Square Health Center, we replicated an approach developed by the Centering Healthcare Institute that includes group visits for expectant parents. This model connects parents to each other, their pediatrician/family physician, and the resources they need to support their children as they grow. One of the results was increased infant birth-weight, an important indicator of a child’s ability to develop, learn and thrive. Connecting this model to early childhood education and expanding the program to infants and toddlers will result in better care for children as they grow. This approach requires no major expense; just a reallocation of how already approved prenatal visits are used. As Mayor I will work with community health centers and other prenatal programs to expand group pre-natal and pediatric visits to include early childhood educators, supporting parents as first and primary teachers. This will build community capacity by linking families with each other and institutions at the early stages of parenthood.

This is good stuff.  Actually, very good stuff.  It's not surprising that Bill, who founded the Codman Square Health Center and served as its CEO for 32 years, would understand the interplay of education and health care.  But he takes that understanding and uses it to come up with a conceptual design for an initiative that would build a stronger sense of community and would not bust budgets.

I don't get to vote in Boston, but I find myself wishing I could. I know who would get my vote.

Cricket vs. Football (Soccer): The obesity wars

Under this headline:

Fitness and the beautiful game -- and football

A letter in The Times of London on August 5:

Sir, I do not agree that football is better than cricket in answering problems of inactivity and obesity (letter, Aug 3). Neither sport will cure obesity, but cricket demands far more physical and mental activity than football, at least where school and casual play are concerned. Indeed, the stamina required by cricketers far exceeds that of the footballer. The batsman's concentration, while defending the stumps and trying to score, is probably unequalled in any sport.  And each fielder must be ready to respond within a fraction of a second. As to the bowler, his every delivery will be watched and judged by one and all. Football is easier to stage and less expensive, but let us not forget the significance of the phrase, "That's not cricket," and despite misgivings about some umpiring, as a lesson for pupils in later life, there can be no better. And anyone who thinks cricket is the preserve of a certain class owing to a lack of equipment and facilities, ought to visit India where mile after mile of land plays host to the game, often with improvised implements, but never lacking in enthusiasm.
JACK LYNES
Pinner, Middx

Whaddayamean? This isn't hard exercise?

WWKS?

What would Dr. Koop say? According to Al Lewis and Vik Khanna, he would not be pleased that people have used his name for an award for a fraudulently described wellness program in Nebraska.

A lesson from Harvard

There are a lot of really bright folks at Harvard, including some of the world's experts in the health care field. How meaningful, then, when the university falls for the marketing plans of health insurance companies and finds itself under a rock.

The New York Times lays out the story:

It [Harvard] dropped its standard deal — a subsidy that rose in line with the price of the insurance policy — and switched some 10,000 workers on its payroll to a fixed subsidy that encouraged them to shop around for care. Families of workers who chose the Preferred Provider Organization offered by Blue Cross/Blue Shield — the most comprehensive plan, with lots of doctors and hospitals on its network — faced a $500-a-year jump in their out-of-pocket spending on health care.

Younger and healthier workers canceled their P.P.O. plans, enrolling in cheaper H.M.O. options or dropping Harvard insurance altogether. Left with a sicker patient base, the P.P.O. raised its premiums further, which prompted the next layer of relatively healthy customers to leave. 

Harvard has not been alone in facing this predicament.  I laid out the commercial logic of this pricing scheme a few months ago:

Notwithstanding public pronouncements to the contrary, it is evident that insurers have persuaded plan fiduciaries (i.e, companies who offer health insurance to their employees) to adopt plan designs that are priced to diverge from the rates that would be based on actuarial calculations.  Plan designs for high-cost subscribers are subsidized by plan designs for low-cost subscribers.  I believe the insurers do this for strategic reasons, to migrate customers to those plans that create the most income for the insurers.  The plans that create the most income for insurers are the ones that generate growth in claims:  Insurers want larger groups to insure and they want to insure unhealthy populations.  After all, claim adjudication is the major source of income for the insurance companies.

The purpose of the Times article is to explore whether a similar phenomenon might occur under Obamacare or whether there will be enough competition among insurers to keep a lid on "the death spiral of adverse selection" and rate increases. Of course, that national issue is more complicated than the one facing a single employer.  The problem, as I have noted, is the growing lack of competition on the supplier side, a trend that is encouraged by the administration's desire for Accountable Care Organizations that will be large enough to bear a larger portion of the actuarial risk of population groups.  Indeed, that consolidation can more than offset the hoped-for competition in the insurance market.  From the Times:

“The more health plans compete for insured in a local health market, the more fragmented the payment side of the market will be vis-à-vis the ever more consolidated supply side,” Uwe Reinhardt of Princeton, a contributor to The Times’s Economix blog, wrote me in an e-mail. “And the higher prices for health care will be.”

We need to accept the fact that there is really very little in the national health care legislation that is likely to control the ascent of costs. We have the country's underlying demographic trends and other factors like the medical arm's race; requirements on insurers for guaranteed issue and expanded coverage; and greater concentration in the provider market.  The drafters of the legislation knew this to be the case and assumed that the higher costs would be met by new taxes during future administrations.  The logic and need for universal coverage of the population is incontrovertible, and it needs to proceed. But as I said many, many months ago, when the President promised the nation access, choice, and lower costs, he was misleading us.  You get two out of three, not all three.

Quick, arrest that senior intelligence official!

In a post below, I make note the point that the boundaries of security clearances are extremely elastic and will be used by any administration to suit its purposes.

I also decry the media, saying:

The story-hungry press lets them get away with this with impunity, often citing "Administration sources who could not be identified because of the sensitivity of the information" or some such silly moniker. 

Little did I know that a few hours later the New York Times would publish this story, with a full explanation of NSA data-collecting algorithms and other information.  It contains the following words:

To conduct the surveillance, the N.S.A. is temporarily copying and then sifting through the contents of what is apparently most e-mails and other text-based communications that cross the border. The senior intelligence official, who, like other former and current government officials, spoke on condition of anonymity because of the sensitivity of the topic, said the N.S.A. makes a “clone of selected communication links” to gather the communications, but declined to specify details, like the volume of the data that passes through them. 

Who has the higher ethical lapse here, the administration or the newspaper?

In any event, if Edward Snowden deserves arrest for what he disclosed, what about this person, who provided detailed information on the same topic?

The teachable moment

Tweets are flowing about George W. Bush's annual stress test and the resulting angioplasty and stent insertion.  Why? Because the care provided to our last President is inconsistent with current evidence-based medicine recommendations. Indeed, hospitals would risk non-payment from the government and private insurers for the type of treatment received by Mr. Bush.

Here's a full description from Burt Cohen's Stent Blog.  He links to a number of tweets from people, including Eric Topol, who says:

Relative to Pres Bush, here are the @ACCinTouch recommendations against stress testing http://www.cardiosource.org/News-Media/Publications/Cardiology-Magazine/choosing-wisely.aspx

Burt Cohen notes:

Was a CT angiogram necessary?

This test is not currently covered by Medicare or most insurance providers for this indication, mainly because it’s considered one of those “over-used unnecessary tests.”

He follows:

Was a stent necessary?

Or could Bush’s coronary artery disease have been managed with optimal medical therapy. 

Noting the absence of public comments about this from many prominent health care experts and commentators (Dr. Oz, Sanjay Gupta, Atul Gawande, Don Berwick, ex-Surgeons General, AARP, Brian Williams, the American College of Cardiologists), a friend summarizes:

You and me, and everyone who gives a hoot about the health care system talks of the adult conversation and the teachable moment.  Look in the mirror.  I would call what we have in front of us a whopper.  

If W did indeed have a screening stress test, mind you--in an incredibly fit, teetotaling, non-smoking Texan, then who will be a immune from over testing and misuse of resources?

We have a root cause of system ills right in front of us, but the A in RCA, i.e, the analysis caboose, has seemed to decoupled from the engine.

 

Indeed, where are the mainstream media and the advocates?  Are you afraid to challenge this type of care because it involves a member of the country's ruling class?  In doing so, do you implicitly advocate a two-tiered system of care for the country? One where the rest of us pay for "royalty" to receive a more costly level of care than the rest of us?

Where you stand depends on where you sit

Pro Publica (@ProPublica ) has published a wonderful article entitled, "The Surveillance Reforms Obama Supported Before He Was President". It is worth reading.

By the way, have you noticed that this and previous Administrations feel quite free to disclose their chosen tidbits of secret information when it is politically expedient to do so.  The story-hungry press lets them get away with this with impunity, often citing "Administration sources who could not be identified because of the sensitivity of the information" or some such silly moniker.  Like the one this week about Al Qaeda threats discovered in secret ways:

It is unusual for the United States to come across discussions among senior Qaeda operatives about operational planning — through informants, intercepted e-mails or eavesdropping on cellphone calls. So when the high-level intercepts were collected and analyzed this week, senior officials at the C.I.A., State Department and White House immediately seized on their significance.

“This was a lot more than the usual chatter,” said one senior American official who had been briefed on the information but would not provide details.

And then look at the complicity of the media:

At the request of intelligence officials, The New York Times withheld some details about the intercepted communications.  

Note how the Administration discloses certain details to select newspapers on the condition the information is not released. It extends special privileges to some reporters to make them feel like they are on the "inside." These favors are returned over time.

Just saying, the boundaries of security clearances are extremely elastic and will be used by any administration to suit its purposes. But these guys will never be prosecuted for doing so.

Goodbye, Mr. Snowden

Last month I wrote a piece about Edward Snowden in which I suggested that his decision to flee the scene and not face punishment after disclosing secret US intelligence information was inconsistent with the country's long history of dissent and civil disobedience. I further suggested that such actions would tend to undermine his moral standing on the issue. Many of you offered comments agreeing or disagreeing.

Now, Mr. Snowden has gone a step further along this path by accepting asylum from Russia. As the New York Times notes in an editorial:

Asylum is for people who are afraid to return to their own country because they fear persecution, unlawful imprisonment or even death because of their race, their ethnicity, their religion, their membership in particular social or political groups, or their political beliefs.

Mr. Snowden undoubtedly fears returning home because he would be arrested and prosecuted. But those fears do not qualify him for asylum. 

Mr. Snowden has unfortunately made a mockery of his principles.  The Times further notes:

And does he really feel safer in a country where Mr. Putin, an increasingly authoritarian leader, has jailed and persecuted his critics?

I'm not saying it would be easy for him back in America.  The Administration will surely throw the book at him to deter others who might consider similar acts.  But we do have a vigorous and independent judiciary, with multiple levels of appeal, as well freedom of speech and press that could be harnessed to build a political coalition in support.  But, by accepting the help of a despotic regime without those structures, Mr. Snowden has forfeited any chance of using the resiliency of the American judicial and political system to help him and his cause.

Berwick advice to the NHS is universal

Several months ago, Don Berwick was asked by the government of the UK and the senior leaders of the NHS to assemble an advisory board to review problems within that organization and make recommendation for the future.  The report has been issued and contains the following broad conclusions.  While some may appear especially applicable to the national health care delivery system that is under the jurisdiction of the NHS, they are actually equally applicable to health care institutions and delivery systems in the US and much of the rest of the developed world.

From the Executive summary:

The following are some of the problems we have identified:

Patient safety problems exist throughout the NHS as with every other health care system in the world.

NHS staff are not to blame – in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.

Incorrect priorities do damage: other goals are important, but the central focus must always be on patients.

In some instances, including Mid Staffordshire, clear warning signals abounded and were not heeded, especially the voices of patients and carers.

When responsibility is diffused, it is not clearly owned: with too many in charge, no-one is.

Improvement requires a system of support: the NHS needs a considered, resourced and driven agenda of capability-building in order to deliver continuous improvement.

Fear is toxic to both safety and improvement.

To address these issues the system must:

Recognise with clarity and courage the need for wide systemic change.

Abandon blame as a tool and trust the goodwill and good intentions of the staff.

Reassert the primacy of working with patients and carers to achieve health care goals.

Use quantitative targets with caution. Such goals do have an important role to progress, but should never displace the primary goal of better care.

Recognise that transparency is essential and expect and insist on it.

Ensure that responsibility for functions related to safety and improvement are vested clearly and simply.

Give the people of the NHS career-long help to learn, master and apply modern methods for quality control, quality improvement and quality planning.

Make sure pride and joy in work, not fear, infuse the NHS.

The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.

We have made specific recommendations around this point, including the need for improve training and education, and for NHS England to support a network of safety improvement collaboratives to identify and spread safety improvement approaches across the NHS.

Our ten recommendations are as follows:

1. The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning.

2. All leaders concerned with NHS healthcare – political, regulatory, governance, executive, clinical and advocacy – should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement and support.

3. Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts.

4. Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS’s needs now and in the future. Healthcare organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well-supported.

5. Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals, including managers and executives.

6. The NHS should become a learning organisation. Its leaders should create and support the capability for learning, and therefore change, at scale, within the NHS.

7. Transparency should be complete, timely and unequivocal. All data on quality and safety, whether assembled by government, organisations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.

8. All organisations should seek out the patient and carer voice as an essential asset in monitoring the safety and quality of care.

9. Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction.

10. We support responsive regulation of organisations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to willful or reckless neglect or mistreatment.

Less than two years

#TPSER9 It would take less than two years to fill Arlington National Cemetery with the victims of medical harm. Less than two years to fill a cemetery that holds over 100 years' worth of US Military casualties and their family members.

This is an excerpt from a lovely post by Tracy Granzyk relating part of last week's "Telluride East" training program for residents, medical students, nurses, and others at Georgetown University.  In a break from the classroom activities:

As we made our way across Washington DC, organic conversations between students and faculty grew throughout the largest Telluride gathering in nine years. I was fortunate to get to know a number of students on the walk to and from this national landmark, many of those conversations each deserving a blog post all their own. Like Rose Ngishu for example–a nurse and mother of four from Kenya now in Galveston, TX, and in her third year of medical school. Rose shared how she knew at 7 years old, living in a country where any healthcare was a luxury, that she wanted to become a doctor and change the conditions in her country of origin. A woman, who despite many personal obligations, continues to push stubbornly toward her goal of improving the lives of those less fortunate and become a physician.

Saturday’s hike culminated on the hill beneath Robert E. Lee’s house with Dave Mayer and Rosemary Gibson centering the group around the fact that it would take less than two years to fill Arlington National Cemetery with the victims of medical harm. Less than two years to fill a cemetery that holds over 100 years worth of US Military casualties and their family members. Rosemary then encouraged us to break up into groups of 3-4 and remember by name, if possible, patients or family members that we personally knew affected by medical harm. The group then came back together and honored those we had discussed in our smaller groups. A new Telluride tradition began this week–one that connected the head with the heart, patient with provider.

I was pleased to be part of the faculty again for this event, conducting a session on negotiation.  Here's a nice summary by Ben Fisher at the Washington Business Journal.

Monkeys and Bananas

Did you ever wonder how things develop to the point of, "We don't do it that way here?"  This phrase often works as the stop sign that impedes process improvement.

Well, here's one cogent explanation, in the form of a video entitled "Monkeys and Bananas."


Thanks for this lead go to Australia's Sarah Dalton, a Fullbright Scholar studying the development of clinical leadership programs at Anne Arundel Medical Centre and throughout the US.

A misguided initiative petition

One of the problems when you criticize a union proposal is that you are at risk of being tarred as "anti-union."  I'm not.  But I'll take the risk of that response in criticizing one union's plans for a referendum here in Massachusetts.

The Massachusetts Nurses Association, which represents about 20% of the state's nurses, is preparing a petition that would impose nurse staffing ratios on the state's hospitals. This kind of proposal, akin to one in place in California, has been rejected many times by the state Legislature, which realizes that such matters are best determined by the clinical and administrative folks in hospitals rather than by regulation.  California is the only state that has these kind of rules, based on a 1999 law, and there have been many unintended consequences.

The folks at the MA Hospital Association have correctly noted:

The arcane concept of applying ratios is especially disturbing in the rapidly evolving Massachusetts reform environment that is centered on rewarding hospitals and other providers based on quality of care delivered and patient satisfaction. Integrating care across the care continuum depends on continually changing patient care and assessment decisions arrived at by a full care-giving team, and not by inflexible, government regulation.

Here's a copy of the instruction sheet being handed out to the MNA members.  It is interesting to note that nurses are instructed not to collect signatures from other bargaining units (i.e., other unions) in their hospitals.  Might that be because a rigid nurse staff ratio could cause other unionized clinical assistants--who are valued members of the care delivery teams--to have fewer jobs?

Two gun stories

I live in Massachusetts, so there are some things I just don't understand.  Here are two examples from elsewhere in America:

A friend who does lobbying in Texas explained to me that people entering the Capitol building have to go through metal detectors.  Except people who have a CHL--concealed handgun license--who can bypass the metal detector by showing the license to the security guard.

The New York Times confirmed this in a story this past spring, noting:

Texas lawmakers . . . described carrying weapons in the Capitol as a personal security habit, doing what they did elsewhere in the state, whether shopping, dining, praying or driving. They also wear their weapons, they said, for the same reason they keep jacks in their vehicles and fresh batteries in their smoke detectors at home. They said there was a difference between being paranoid and being prepared.

So only the people who don't have guns have to go through the metal detectors.

In California:

A KGO-TV news crew was robbed at gunpoint of camera equipment while accompanied by a security guard in West Oakland in broad daylight.

A station official did not respond to a request for comment.

 I'm kind of a loss for words myself.

May you never see the difference

A lovely Facebook post from Jack Sullivan, Senior Investigative Reporter at Commonwealth Magazine:

We were at the Y pool the other day and Gwyni was pointing out the goggles on one of the kids in the pool.
 

"Which one?" I said.
 

"The kid with the brown hair," she said.
 

"Where?" I asked.
 

"Right there, the boy with the brown hair and blue bathing suit," she said exasperated.
 

The fact that the kid she was pointing out was the only black kid in a pool of about 10 other kids never occurred to her. I love my color-blind grandchildren.
 

Happy 9th Birthday, Gwyni. May you never see the difference.

Seven years of blogging!

I'd like to take this opportunity to acknowledge the seventh anniversary of this blog. On August 2, 2006, I took the leap with this short post, noting:

The other day, I was reading a NY Times article that menitoned that only 1 CEO of a Fortune 500 company had a blog. I don't run a Fortune 500 company, but I do run Beth Israel Deaconess Medical Center, a large academic medical center in Boston. I thought it would be fun to share thoughts with people about my experience here and their experiences in the hospital world. 

Truly, I had no idea where this would lead.  Would anyone be interested in what I said? Would there be enough topics to write about?

As you might expect, thing started slowly.  After a couple of weeks, I did a Google search for my blog, and it didn't show up! Why? Not enough traffic to stimulate the search algorithm.  So I sent an email to my 500 (!) closest friends telling them about the blog, asking them to read it, and asking them to tell their friends about it.  I also started linking my blog to others in the health care field and creating relationships with other bloggers by commenting on their posts.  Shortly thereafter, I showed up in the search engine.

Things really broke open, though, when the Boston Globe's Chris Rowland wrote an article about it on October 6. Privately, too, Chris suggested that my writing style was a bit boring and proposed that I make my articles a bit more edgy and controversial.  As regular readers know, I took that to heart.

Cross-linking to other social media over time was also an important way to gain readership.  When Facebook opened up to nonstudents, Nick Jacobs--the first hospital CEO blogger--suggested I join.  He said, "I think you'll have fun with it."

I owe Scott Hensley, one of the authors of the Wall Street Journal Health Blog, "thanks" for leading me to the addiction that is known as Twitter. Shortly after, I confessed my dependence, quoting Bob Coffield, who writes the Health Care Law blog: "Facebook was the gateway drug that led me to the crack that is Twitter."

Over time, the blog evolved into something that I never predicted. The kinds of stories I wrote morphed into a wide variety of commentary on things happening in my hospital to issues of wide social import.  Along the way, I "invented" transparency as a management tool by posting actual infection rates and other clinical outcomes from our hospital, in real time, for the world to see. I did not understand that doing so would help result in a transformation of care in our hospital, as we adopted a goal of eliminating preventable harm and holding ourselves publicly accountable for the standard of care we delivered.  Little did I realize, too, the pervasive impact that doing so would have on the health care profession as a whole, indeed beyond the borders of the US.

I documented, too, our learning experience with Lean process improvement, offering stories of success from the front-line staff.

Meanwhile, I helped expose the inequities in the hospital pricing environment in Massachusetts, where market power--rather than quality--rules the roost.  Over time, this issue got the attention of newspaper columnists and eventually the body politic.  It clearly riled some politically powerful people, who were used to getting their way and who took the matter very personally.

I also must mention the very important series of about 50 posts over a five-year period in which I exposed the corporate campaign being run against our hospital by an aggressive union that sought to infringe the rights of our workers. This led to my book, How A Blog Held Off the Most Powerful Union in America.

I also tried to take on the medical arms race, pointing out how marketing by suppliers and mispricing by Medicare results in the expansion of the use high cost equipment, with no regard to medical efficacy.

For a while, I devoted my Wednesday columns to answering questions posed by students. Among the most-read posts, to this day, is the one from 2007 entitled, "For Students: Don't collect degrees." In it, I answered this question: As someone who is in on the business/medical/policy of today's health care system, what do you think about the career prospects of those pursuing a joint JD/MPH? Is it worth it?

And, of course, there were the occasional columns about my passion, coaching girls soccer and refereeing youth games.  These led to my book, Goal Play! Leadership Lessons from the Soccer Field.

Along the way, I would often get the question of how much time I spent on the blog and other social media.  As noted here, I suggested that this was the wrong question: That's like asking how much time you spend talking with people. 

When I left the hospital in early 2011, I briefly considered ending the blog, but persisted out of habit and upon the suggestions of some loyal readers.  The name changed.  A highlight was being introduced to a doctor in California a few months later who said, "Oh, you're Not Running a Hospital!"

As I noted two years ago:

I have been pleasantly surprised to see that viewership has continued to grow.  My topics have become less Boston-centric (except where Massachusetts offers broader lessons).  Also, of course, I no longer present inside stories about my former hospital.  I now consider myself an unabashed advocate for those causes mentioned in the masthead.  In that capacity, I am more free to be even more direct than before (if that is possible!) about things that matter to patients and families, and also to doctors, nurses, and other people involved in the delivery of care.

I have found, too, that many of you are eager to join in by sending me story ideas from your regions -- events and concepts that you know are important to your constituencies and more broadly.  I welcome those suggestions and promise to maintain your confidentiality as I rewrite them for the general audience.

The blog has also turned into a bit of a magazine over the years, with other topics of interest to me and, I hope, to you.  You don’t have to stick with me very long to know of my passion for soccer, infrastructure, civil rights, effective government, good food, and nature.  I hope that the articles on those topics provide a nice break for you, as they do for me.  After all, you can’t talk about health care all the time!

I repeat my thanks to you -- regular readers, occasional readers, newly arrived readers -- for allowing me the privilege to let this site provide useful, informative, or entertaining content in your lives.

Do you know this man?

I was flipping through the Washington Post today and noticed this advertisement on the back page of the first section, probably the most expensive location in the newspaper.  It is an ad for Eliquis, a blood thinning agent for people with atrial fibrillation that is presented as an alternative to warfarin.  I make no judgment about the relative efficacy of the drug compared to others, but I was drawn to the question of why Bristol-Myers Squibb chose this particular male model to represent its product.

What is it about this image that someone has concluded will draw people to ask their doctor to prescribe this medication? I have to guess that BMS's ad agency conducted focus group sessions, testing out this photo against others.  I wonder what other faces were offered?

Can we parse this fellow's visage?  It is a male with gray hair showing.  Is this meant to send the message that he understands the problems of older men?  Perhaps people would view him as ruggedly handsome, so is the company playing to the fear of men that their virility would be at risk with AF?  And that this problem would be solved by Eliquis?  (I thought that product was sildenafil citrate, produced by a competing firm, Pfizer.)  How do any of these factors relate to the other target audience, women?

So I decided to call the 855-ELIQUIS number and ask.  A friendly and helpful person answered.  I wondered who the person in the ad was, saying that I assumed it was someone notable who was endorsing the product.  The person on the phone said she would research that question.  She returned shortly thereafter and said that she was sorry, but they "didn't have any information on that question at this time."

I went to our favorite source, Google.  On January 24, 2013, Medical Marketing and Media noted the FDA's late-2012 approval of the drug and reported:

The company sees advertising and promotion spending “increasing in the high single-digit range” for 2013....

“Higher spending is strategically prudent to assure a successful Eliquis launch,” said CreditSuisse's Catherine Arnold in an analyst note.

But no hint of a rationale for this photo.

But not to worry.  The FDA is on the case.  MMM reports:

According to OPDP (Office of Prescription Drug Promotion), “Our objective as an agency is to increase the quality of DTC (Direct to Consumer) ads so they do not contain any misleading information and instead provide patients with good information about prescription drugs and medical conditions.”

So whatever the rationale for this photo, we can be confident that it contributes appropriately to consumer understanding of this drug and does not attempt to use any subliminal messaging to encourage people to use it.

A warm farewell and welcome to full time in education

Check out this lovely column about Robin Dibner, who is leaving medical practice to devote full-time to residency education.  One quote:

When you are in an ambulatory practice as an attending, whether solo, group, specialty, or faculty practice – you and your patients choose each other.  Over time the ones who are not a good fit drift away.  The ones who remain loyal are wonderful!  And you learn to work with each one in a collaborative relationship to promote their health, adherence to treatments, and prevention.  They learn to trust you, and you them.

Goal Play! at NE Mobile Book Fair

Thanks to New England Mobile Book Fair at 82 Needham Street in Newton for inviting me to present a reading and signing of Goal Play!  It will be held Wednesday, August 14 at 7pm.  Here are the details.  Please come by!

Infrastructure heroes

I used to run the regional water and sewer system for the Boston metropolitan area, and I found that the people on the front line who operate these systems are among the unsung heroes in our communities.  (In that regard they are similar to many of the front-line staff people in hospitals.)  Here's a wonderful story from the Washington Post about a group of folks at the Washington Suburban Sanitary Commission who, by dint of dedication, persistence, and hard work, helped avoid a difficult situation in their community.  The lede:

Brad Destelhorst stood in the dimly lit, musty vault — a small concrete room 20 feet underground near the Capital Beltway — and tried not to think about his soaked feet, or the muddy water he stood in, or the fact that more than 100,000 people in southern Prince George’s County needed him to fix the unfixable.

For almost 12 hours Tuesday, Destelhorst and fellow mechanics for the Washington Suburban Sanitary Commission chiseled years of thick rust off gears that corrosion had frozen in place and then fashioned new gears out of the gunked-up pieces of metal. 

Other crews had spent three days trying to fix the valve.... But with new parts for the 48-year-old valve unavailable, the other crews had said they found it impossible to repair. 

Destelhorst, an admittedly stubborn former auto mechanic from Crownsville, wouldn’t have it. He said Thursday that he was prepared to break every tool he had to get the gears turning and the valve closed.

“No one should have to go without water,” he said.

We often take underground infrastructure for granted. Let's not forget the need to maintain it properly or the dedicated folks who keep it operating.