Wednesday, June 30, 2010

An astronaut speaks

Kathryn Schulz, author of Being Wrong, Adventures in the Margin of Error, sent along this link to a recent Slate interview with James Bagian, director of the VA's National Center for Patient Safety. Bagian, a former astronaut, had some great observations about improving quality and safety in the health care environment. Some excerpts that I like:

You can't change the culture by saying, ‘Let's change the culture.' It's not like we're telling people, "Oh, think in a systems way." That doesn't mean anything to them. You change the culture by giving people new tools that actually work. The old culture has tools, too, but they're foolish: "Be more careful," "Be more diligent," "Do a double-check," "Read all the medical literature." Those kinds of tools don't really work.
One thing we do that's unusual is we look at close calls. In the beginning, nobody did that in healthcare. Even today probably less than 10 percent of hospital facilities require that close calls be reported, and an even smaller percentage do root cause analyses on them. At the VA, 50 percent of all the root cause analyses we do are on close calls. We think that's hugely important. So does aviation. So does engineering. So does nuclear power. But you talk to most people in healthcare, they'll say, "Why bother? Nothing really happened. What's the big deal?"
In theory, punishment sounds like a good idea, but in practice, it's a terrible one. All it does is create a system where it's not in people's interest to report a problem.

Good motives and unintended consequences

Facts matter. Here is an example.

Based on comments by some, you would have thought that individual and small business insurance rates have gone up because of payments to hospitals and doctors or because insurers were somehow trying to take advantage of this group. It turns out that a well-intended provision in the Massachusetts universal access law created a moral hazard, a "situation in which one person makes the decision about how much risk to take, while someone else bears the cost if things go badly."

Kay Lazar reports in today's Boston Globe:

The number of people who appear to be gaming the state’s health insurance system by purchasing coverage only when they are sick quadrupled from 2006 to 2008, according to a long-awaited report released yesterday from the Massachusetts Division of Insurance.

The result is that insured residents of Massachusetts wind up paying more for health care, according to the report.

... [T]he gaming in the system . . . is adding as much as $300 million dollars to the health care system in Massachusetts’’ each year, said Tara Murray, spokeswoman for Blue Cross Blue Shield of Massachusetts, the state’s largest insurer.

...When state lawmakers overhauled the health care system in 2006, they combined into a single insurance pool consumers who buy coverage on their own with those who get insurance through their jobs at small businesses that employ 50 or fewer people. The aim was to make insurance more affordable for the individuals buying coverage on their own, who tended to be sicker and therefore had been paying very high premiums. And the hope was that having small businesses and their workers absorb some of the cost of covering this group would raise their premiums only modestly.

Is this the classified ad section?

I received this email on Sunday night. Perhaps it is just me, but it feels weird to get a solicitation like this, as though this were just a house or condominium building for sale. Note the postscript, too. Are hospitals now commodities?

80 Bed Hospital in a Southeast, Certificate of Need State For Sale

Dear Paul,

[Company name} has been retained to identify a buyer for an 80 bed, accredited, regional hospital in the Southeastern portion of the United States. The hospital is located within a community that is less than fifty miles from a major business hub with a population of over one million people.

Revenues are in the $20 million range and the business is profitable. The asking price is to be determined by using the lesser of the traditional formula of 100% of the trailing twelve months of revenues or simply $250,000 per bed.

The sellers are asking only qualified buyers to first submit their request for more information, after which they will be considered to privately participate in the owners' agenda to divest its facility and excess land. As this is not an auction, the sellers will convey title for the hospital and land to the first buyer who is able to close the transaction. Prior to the conclusion of the acquisition, they will preserve total discretion as to the confidential nature of the transaction.

Your request to be considered will be delivered to the Managing General Partners for their approval once you have signed a Non-Disclosure Agreement. Thereafter, a package will be available for immediate review with the intent to schedule a Conference call with one of the principals. We welcome all inquiries.


[name omitted]

Sr. Vice President
[company name]

PS: Are you curious about what hospitals are worth in today's market?

Call me at

Tuesday, June 29, 2010

Social media gaggle

Johnson and Johnson's Marc Monseau convened a group of health care social media addicts last night for a pleasant evening of dinner and conversation. Seen here are Chris Iafolla from Shift Communications, Laurie Edwards, Marc, Jack Barrette from WEGO Health, Shwen Gwee from Vertex Pharmaceuticals, yours truly, e-Patient Dave deBronkart, and Alicia Staley.

How weird to be in the physical presence of people!

As has been the case since I first started down this social media path, I learned more than I offered. The big topic was patient empowerment and creating true partnerships between patients and caregivers.

There was also some tech talk. For example, I never realized that the algorithms used by Google and other search engines actually make it hard for a person with an unusual physical problem or disease to find useful information. Since they are at the "tale end" of their disease, and since the search engines reward those sites that get the most traffic, a normal web search will often not pick up useful information for those patients. Thus, user groups -- self-created agglomerations of data-sharing colleagues from around the world -- can often provide people with advice that would otherwise be unknown. Patients can then take that information to their physicians and explore options. Powerful stuff!

But let me stop there and invite last night's participants to add their own comments, perhaps presenting something they learned last night or whatever perspective they would like.

Monday, June 28, 2010

In memoriam: Polly Arango

Polly Arango, a nationally known advocate for children, died on Saturday, June 26. In total, I only spent a few minutes with Polly at last year's IHI Annual Forum (picture here), but she made an immediate and wonderful impression.

After the conference, I was curious. Who was this person? It was then that I learned of her extensive accomplishments and her fine reputation. These are summarized in this obituary in the Albuquerque Journal. Among other things, she founded Family Voices, which aims to achieve family-centered care for all children and youth with special health care needs and/or disabilities.

Learning of her untimely death in a freak one-car accident in Alamosa, Colorado, I felt a blow-to-the-midsection loss. Others shared that view.

One of these people is Dale Ann Micalizzi, whom I have come to know via social media and in person. Her blog, here, describes her work in memory of her son, Justin, to improve medical quality and safety. Dale and Polly also connected right away at the IHI Forum, and Dale gave Polly a small pin in commemoration of that friendship. With Dale's permission, here is the text of Polly's thank-you note and the final poignant words in her own writing:

Dear Dale,

Thank you for the beautiful pin. I love angels and hearts. My brother Nick who died of a brain tumor in 2001 once gave me a beautiful angel pin to honor my work with Family Voices, an organization he loved. And the Family Voices logo is a heart -- so your pin is perfect. Thank you!

I thank you also for inviting me into your world of tragedy and compassion. Your work in safety and transparency, built upon your loss of Justin, is just incredibly inspiring -- to me and the audiences you touch, as you did in Orlando at the IHI forum. You've said such presentations are still hard for you -- even more reason for me to respect and honor you.

Sunday, June 27, 2010

Contradictions in Massachusetts

I have written before about the strange things going on in the Massachusetts health care insurance market. For those from out of state, here are some quotes that will give you a sense of the contradictions in the public policy arena.

They are, respectively, from two stories that appeared on the same day in the Boston Globe: "Rate cap for insurer overturned" and "Officials give up cutting health perks."

(1) An insurance appeals board yesterday overturned the state’s cap on health premium increases for small business and individual customers covered by Harvard Pilgrim Health Care . . . [finding] that rate increases Harvard Pilgrim initially sought in April are reasonable given what it must pay to hospitals and doctors. That ruling trumped the Insurance Division’s earlier finding that the requested increases were excessive.

(2) The state’s public employee unions won a major victory this week when the Legislature abandoned efforts to allow cities and towns to trim generous health care benefits enjoyed by thousands of municipal employees, retirees, and elected officials.

You can read the rest and related stories, but what is most disturbing is that the spirit of cooperation and compromise that existed when Massachusetts approved its health care reform law in 2006 has broken down. Part of the reason is that commitments made at that time have not be delivered upon. For example, the state had promised to lift Medicaid payment rates to something closer to the cost of delivering that service. Once the economy sank and state budgets were stressed, that was not possible. This left providers needing to collect more of their income from private insurers.

Meanwhile, the underlying determinants of health care cost increases continued apace -- wages and salaries of health care workers, supplies and equipment, drug prices, increased utilization, the medical arms race, and unhealthy life styles. Certain providers received disproportionate payment increases based on their market power and used those excess revenues to gain market share. Collectively, the industry did little to reduce harm and improve quality and garner the cost savings that would be possible from that. Access to primary care did not improve, forcing patients to go to emergency rooms. Those primary care practices that do exist often functioned as triage way stations for patients to go see higher priced specialists. For those who thought payment reform (i.e., capitation) was the answer, little progress was made, in part because insurers have yet to see a market for the restricted networks (i.e., reduced consumer choice) that would facilitate that kind of pricing regime.

So, now we are in a situation in which everyone is blaming everyone for the problem. Truthfully, everyone is the problem, and so this is an accurate representation, but it is not a helpful approach. Deadlock is the result.

At times like this, people often look for a global solution to sort things out. That is a mistake. There is not a politically possible global solution. There are too many legitimate vested interests to pass a bill or adopt a regulation that shifts hundreds of millions of dollars of costs from one group to another. As seen in the two stories above, it will either be legally unacceptable or politically infeasible.

Instead, it is a time for incremental changes that are directionally appropriate. There are things that can garner majority support that will move the system towards a more sustainable level.

But to agree on those, the rhetoric needs to be toned down, both within the field and from the government. The demonization of any particular sector destroys the kind of trust that enables people of good will to invent solutions that create value for all.

Tour de Shuls

I just finished riding in the Tour de Shuls, a cleverly named bike ride that benefits a special program to meet the social and religious needs of developmentally challenged Jewish adolescents who attend Camp Ramah. As noted on the web site:

The Tikvah ("hope") Program provides these youth with the full Ramah experience - swimming, boating, sports, the arts, dance, dramatics, and more - under the supervision of specially trained staff.

The ride comprises several legs connecting synagogues in the Boston suburbs. It goes through some beautiful areas, and you receive friendly welcomes and refreshments at each host site. The only reported problem -- and I don't mean this in any stereotypical way! -- is that some people complain there is too much food and that they therefore gain weight from their 10-, 25-, 50-, or 75-mile ride . . .

Donations are still welcome, here.

Saturday, June 26, 2010

Vuvuzelas app

After writing the post below, I learned about the free vuvezela app for your IPhone or IPad when a friend demonstrated it. Imagine, you can make that noise anywhere now. I have some ideas....

First, though, make sure you pick your team's color.

If you cannot see the video, click here.

Friday, June 25, 2010

About vuvuzelas, and balls that work strangely

The Washington Post recently published this article by Anne Applebaum about vuvuzelas, the loud horns that you hear in the World Cup matches.

For those who haven't been following, the vuvuzela is a longish plastic trumpet that produces a buzzing noise, something like an overgrown penny whistle. When thousands of people blow these whistles at once, they make a very loud buzzing noise, something like a massive swarm of bees. When played in a World Cup soccer stadium, they create an irritating background hum -- one that is capable of ruining the sound on a billion television sets around the world.

She then talks about the different reactions to these horns by folks from around the world. I did my own survey of fellow soccer players and parents of the girls I coach. Typical responses:

I hate that noise. It must go. It's enough to embrace curling as a favorite sport.

I am enjoying watching the games at home with the sound turned off.

Meanwhile, there is this article by Devin Powell at Inside Science that suggests that the ball (the Jabulani) being used in the World Cup doesn't behave right, especially at low speeds when it is not spinning. It appears that there is an unexpected knuckle ball effect.

[Tests showed] that as the ball slows, its behavior becomes more like that of a smooth sphere than previous World Cup balls. At just under 45 mph, turbulent flow becomes laminar and the ball suddenly feels heavy drag forces that put on the brakes.

[Also, the] sideways force on the Jabulani fluctuates more than the forces on the 2006 World Cup ball, which could cause it to bend in unpredictable ways and help to explain the reactions from goalkeepers.

But, before you think that those guys from France have an excuse, look at this final point:

Considering all of the other variables involved in the World Cup -- from pitches at high altitudes to inconsistent player performances -- it's unclear whether these differences in the ball in this are extreme enough to affect the final scores.

Thursday, June 24, 2010

The primary care experience in MA

Massachusetts Health Quality Partners presents a recent survey of patient experiences with primary care. There are both positive and negative findings, compared with a survey conducted before the implementation of universal health care access in the state.

About 78,000 commercially insured patients responded to the statewide survey. There was reported overall improvement in several dimensions of the doctor-patient relationship, such as communication and knowledge of their patients, but there are aspects of doctor-patient communications that need work. A summary:

There is broad agreement that there are important dimensions of care that patients and their families should expect to receive from their primary care practice. Key findings in MHQP's latest patient experience survey highlight where there continues to be room for improvement in these aspects of care, including:

Knowledge of the patient: When asked if their primary care physician seemed to know their medical history and to know them as a person, both adults and the parents of pediatric patients reported improvements compared with 2007; but 30 percent of adult patients and 25 percent of parents say their primary care physicians do not always know important medical history information.

Informed of test results: The survey found that about 30 percent of adult and pediatric patients did not always receive follow-up reports on test results from their doctor's office, unchanged from 2007.

Coordination between primary care doctors and specialists: About 40 percent of adult patients and 35 percent of parents of pediatric patients reported that their physician did not always seem well-informed about the care they received from specialists to whom they had been referred. Pediatric results were slightly better than two years ago, while adult ratings were unchanged.

Wednesday, June 23, 2010

Pride and Ownership

Seen above are members of our environmental service (EVS) group. Left to right are Jean Simeon, Operating Room Lead Housekeeper (22 years at BIDMC), Christopher Valentine (5 Years), Pedro Hernandez (25 years), and Hugo Barros (2 Years). I received the following report from John Dzialo, project director in Perioperative Services, which includes the Central Processing Division. CPD is the group of people who clean surgical instruments.

Over the last 2 weeks we have been installing a new washer and decontamination unit in the West OR/CPD. The installation required some renovations to the existing space, including replacing a portion of the existing flooring. All in all the required renovations came out as planned. In looking at the ceiling tiles, many were discolored from years of exposure to the elements created within the room. It was thought best to replace them at this time. The existing walls also showed the same discoloration, which we felt took away from the overall appearance of the newly renovated area.

At one point two of the 3-11 shift EVS employees who are assigned to the OR came into the area to check up on our progress. They looked at the older section of flooring that in certain areas had become stained. They assessed the stained flooring and reassured me that they could get it cleaned to match the newer flooring. I asked them if they thought they could do something with the walls as well which they once again replied that they would make them look new.

When I returned the next day to do my assessment of how the installation was going, I immediately observed the "stain free" floor and the beautifully cleaned walls and cabinets. Later in the day, at the change of shift I met up with the EVS staff to thank them for a job well done. When we were looking at their work, we talked about the ceiling tiles and how much cleaner the new ones make the area look. When we decided to change all the ceiling tiles we did not take into consideration to replace the supporting grids. When EVS staff noticed how much the discoloration of the grids took away from the new ceiling tiles, they took it upon themselves to hand clean all of the grids (not a quick and easy task to complete).

The "Pride and Ownership" exhibited by the 3-11 OR EVS staff was over whelming . They certainly could have limited their work to the few areas that we identified as needing attention. They took it upon themselves to not only complete the additional work requested but to broaden the overall scope to what they felt should also be done.

What we see often is the end results of a new piece of equipment being installed. What often does not get recognized is the pride and commitment of others that played a significant supporting role in the completion of a project. The pride and commitment exhibited by the EVS staff in their supportive role in the completion of this project is a value that can only be described as "Priceless".

Pretty data. Useful?

This is an interesting portrayal, provided by GE, of hospital quality metrics. It compiles data from the Joint Commission's 2009 Annual Report on Quality and Safety and presents it in a visually attractive manner that permits a qualitative comparison among hospitals in each state. I provide a partial view above.

So, this is pretty, but is it useful? I don't think so. As I have said before:

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

So, I think a better presentation would be one in which I could compare my own hospital's data year by year using the same kind of side-by-side visual imagery. Then, we could get a quick view of how we have progressed over time -- in essence, competing against ourselves, rather than against our colleagues in the state.

Tuesday, June 22, 2010

Why I love BIDMC

This is why I love my hospital. Everyone feels the right to complain and to suggest. And generally, the complaints and suggestions are received nondefensively, evaluated, and acted upon. Here's an example.

First, Research Administrator Diane writes to Carol, who runs the food service in the staff/visitor cafeteria, and she also copies me on the email.

Hi Carol,

I went to the Ullian Café today after my workout to get some lunch. I usually avoid the grill section due to the unhealthy choices that it has to offer, but today I saw folks with what appeared to be a simple burger made with a tortilla, so I checked it out.

I saw that this special came as a duo, i.e., 2 tortilla’s for the $4.75 price. Both parties before me asked if they could get only one, and were told no.

I bought the special and then came back to my desk to check out the nutrition info.
If this is correct, from the website, I just had 1480 calories in just the “special”. I also would have preferred to have gotten only one.

What really got my attention though was the fat %. In just one meal, a lunch, I consumed 210% of my daily fat allowance!

For a health institution, I find that absurd! Isn’t there some other way to get good tasting healthy food from our café?

Why can’t people by only 1? Why wasn’t this info posted on the sign for the special? And if you can’t buy one then you should show the real numbers for the total meal.

Normally, I don’t get upset about some of the choices you offer as I can tell visually that they are high fat, calories or sodium, but this item had me fooled and I’m sure it has fooled others.


I write back to Carol, with a copy to Terry Maratos-Flier, a faculty member with a strong interest in obesity:

Good points, Diane. Carol, what do you think?


Carol responds:

Good Morning Diane,

Thank you for your feedback! The Quesadilla Burger which is the special for the week was brought back because of popular demand. We do offer many Wellness Items on the menu daily and hopefully you have seen some of the items such as grapes,fresh fruit cups, strawberry yogurt parfait (utilizing local strawberries), celery with ranch or peanut butter, hummus with pita, Chobani Greek yogurt as well as entrees and specialty sandwiches. The entrees and sandwiches are marked with a Wellness logo and we also feature vegetarian options daily. We have lowered the sodium in our soups, sandwiches and entrees.

Regarding the Quesadilla Burger and only being able to buy two, I spoken to staff and going forward they will offer the option for 1. I apologize for this inconvenience.

Thank you again for your feedback, we are always looking to add new items and improve our performance. I can be reached at [phone] or email if you have any further questions or suggestions.


Terry also pitches in with a suggestion and copies Nora, who also works in food services:

I'd like to make the following suggestion which is to differentially price the single and double quesadilla's. There is emerging evidence that pricing to a degree drives "healthy" food choices. Consumers are more likely to buy a diet drink if the sweetened drink costs more. I also think the calories ought to be posted as they are for the soup, salads and other items.

Since we are a healthcare institution I think "nudging" people towards better health choices is and at the same time educating them should be part of our mission. 1400 calories is close to the daily requirement for some people and $4.95 is a price that encourages this consumption. I would guess that if you priced a single at $3.75 a significant number would opt for the single, even though it costs more than half. This would be an easy experiment to do, data obtained from the cash register.

Nora responds:

That is a wonderful suggestion, we priced the double at $4.75 and the single at $3.50. We can take a look at data to see the effect.


(Meanwhile, Elisabeth Moore, one of our nutritionists, is on national television talking about serving sizes. We might not always practice what we preach, but we keep trying!)

It is not just teenagers

In a post below, I relate Dr. Amy Ship's recommendation to her patients and to her colleagues that they focus seriously on the dangers of cell phone use while driving. Now comes this study by the Pew Research Center that blows apart the myth that it is mainly teenagers who are texting while driving:

One in four (27%) American adults say they have texted while driving, the same proportion as the number of driving age teens (26%) who say they have texted while driving.

In addition, 49% of adults say they have been passengers in a car when the driver was sending or reading text messages on their cell phone.

OMG. What a silly and terrible way to hurt someone or be hurt.

Monday, June 21, 2010

Schwartz Center Rounds work

One of the great legacies in recent medical history was provided by Kenneth Schwartz, a relatively young man who died of cancer, whose story of compassionate care noted, among other things:

I realize that in a high-volume setting, the high-pressure atmosphere tends to stifle a caregiver's inherent compassion and humanity. But the briefest pause in the frenetic pace can bring out the best in a caregiver and do much for a terrified patient. . . .

If I have learned anything, it is that we never know when, how, or whom a serious illness will strike. If and when it does, each one of us wants not simply the best possible care for our body but for our whole being.

This image was the impetus for the creation of a center to conduct programs to educate, train and support caregivers in the art of compassionate health care.

Started in 1997 at MGH, the Schwartz Center Rounds are now held in more than 186 sites across the United States. They are designed to enhance relationships and communication among members of multidisciplinary health care teams and to create supportive environments in which all can learn from each other.

So, how well does all this work? A recent article suggests it works very well. Beth Lown and Colleen Manning have published a study in Academic Medicine based on surveys of program participants in a number of institutions over the years. They found that the Rounds improved a sense of teamwork:

In particular, respondents had a heightened appreciation of the roles and contributions of colleagues from other disciplines and improved communication about both psychosocial issues and clinical issues.

The Rounds have also reduced caregivers' feeling of isolation in treating patients with complex and difficult conditions:

Rounds attendance improved their sense of support and decreased their stress and sense of isolation.

These findings are consistent with anecdotal reports I often receive from members of our staff. It is heartening that the good-willed people who work at the Schwartz Center have produced such lovely results for members of the health care professions and for the patient and families they serve. Lots of credit also goes to the members of the community who have supported them financially. Hint: Donate here.

Sunday, June 20, 2010

Trek Across Maine 2010

I'm just back from riding in this year's Trek Across Maine, where I joined about 2500 other people in biking over three days from Bethel to Farmington to Waterville to Belfast (about 170 miles) in a fund-raiser for the American Lung Association of New England. The money raised supports education, research, and advocacy. In addition to the riders, there are also hundreds of volunteers who make the ride possible -- directing traffic, preparing snacks at the rest stops, handling logistics, and like this person below, loading luggage for transfer to the next stop.

Many people join the ride in teams, and some produce their own riding jerseys. I thought this was one of the more creative designs.

Families often participate, and there are special things organized for the kids, like face-painting.

This year's ride was a special one for my cousin-in-law Tom, corresponding to an unmentionable birthday. You see him here with his wife, my cousin Suzie, who joined in as a volunteer.

Friday, June 18, 2010

Mike's versus Modern

This is a very serious clinical trial and one worth repeating by anybody who happens to be in Boston's North End. IRB approval is not required.

With thanks to Adam at Universal Hub for the link.

A pipeline that leads upstream

What do the following names have in common? Beauvais, Brandao, Chanlatte, Gaines, Gebregziabher, Moorman, Ramos, Vicent, Viller, Weller.

Certainly not ethnic or national background. (But it is from that very diversity that comes the strength of our hospital and, indeed, our country.)

In this case, these are the last names of the recent graduates of our Patient Care Technician Pipeline Program.

Patient Care Technicians work with nurses and other healthcare professionals to provide direct patient care. They play a vital role in the delivery of care on the many floors that comprise a hospital. PCTs probably spend more time with patients than almost any other profession, and it takes special training to be good at it.

At BIDMC, we decided to create a program that would enable some of our dedicated employees in other jobs to learn to be PCTs and move up the health care career ladder. Our Human Resources and Patient Care Services departments designed a nine week in-house program to train people for this role. During the first six weeks, employees attend class two nights a week and participate in four skill practice sessions. After successfully completing the classroom training, participants enter a three week, full-time hands-on training run by a nursing educator on a patient care unit. Trainees continue to receive their salary and benefits during this time. At the end of the three week hands-on training, program graduates move to jobs as PCTs on different units at BIDMC.

This is a picture of our current graduating class. Many have worked here for four or five years. Some were Patient Observers ("sitters"). Other worked as food service workers, rad tech assistants, or material handlers. Here's more of their story and a video on the BIDMC website.

Now, all of them have been promoted to their new jobs. Some are already thinking about the next step. Today a PCT, tomorrow a nurse?

Wednesday, June 16, 2010

Who's playing whom when in the World Cup?

An innovative and great World Cup calendar, here.

Moving lots of babies

An important aspect of hospital operations is to prepare for the unexpected, a catastrophe that can cause a major disruption to patient care. All hospitals plan for such things, and then we do drills.

Today's drill took place in our Neonatal Intensive Care Unit (NICU). The scenario required an evacuation of two dozen newborns to another floor. The elevators worked at the start but were then simulated to go out of service, so some babies had to be put in baskets and carried down three or four flights of stairs to another nursery. Their life support systems and medications had to be in place the entire time.

I present a short video of some of these scenes. It felt very real. You quickly forget that the "babies" are dolls (as shown in the early frames, complete with simulated medical histories). A more comprehensive video was made of the entire exercise, observers were keeping notes, and there will be a full debrief for the entire staff. My inexpert opinion, though, was that people did a really good job. Especially when you consider (last frame in video) that the real babies still needed to be cared for during the whole exercise.

I later learned, too, that there is a dearth of literature on NICU evacuations. Given hurricanes and tornadoes, you might think that there would be generally accepted standards for dealing with this particularly vulnerable population. A member of our faculty plans to write up this experience and contribute to the literature on the topic.

If you cannot see the video, click here.

Fresh fruit and vegetables

Our staff members show endless creativity and generosity in supporting the people who live in the Bowdoin/Geneva neighborhood of our affiliated Bowdoin Street Health Center. A note from Cathy Wirth, Healthy Food Access Coordinator:

The BSHC farmers’ market will be running from July 8th to October 28th this year. In order to attract new farmers to the market and to support our efforts to make produce available to more low-income families in the neighborhood, we are piloting a Community Supported Market program. We will be selling Community Supported Market Shares to BIDMC staff in [two of our buildings]. For $250 ($25/week for 10 weeks), we will deliver a box of produce from one of our farmers’ market growers to staff in those buildings every Friday. Included in the share price is a donation to help cover the cost of subsidized shares to be offered to low-income families near the health center. We are keeping the program very small this year and just targeting [those two sites] for logistical reasons, but if the program is successful we are interested in opening it up to a larger segment of BIDMC staff in coming years.

MITSS Hope Award nominations

I am pleased to post this announcement from MITSS (Medically Induced Trauma Support Services, Inc.)

Nominations are now being accepted for the Third Annual MITSS HOPE Award. The MITSS HOPE Award was established in 2008 to recognize people -- patients, families, health care providers, hospitals (or teams or departments therein), academic institutions, community health centers, grass roots organizations, EAP programs, etc. -- who exemplify the mission of MITSS: Supporting healing and restoring hope to patients, families, and clinicians impacted by adverse medical events, medical errors, or unexpected outcomes.

This year’s award is being sponsored by rL Solutions, and the winner will receive a $5000 cash prize to continue their work. The award will be presented at the MITSS 9th Annual Dinner to be held at The Westin Copley Place on Thursday, November 4, 2010. Visit here for eligibility criteria, submission requirements, deadlines, and more. Nominate someone who is doing great work (including yourself!)

Contact: Winnie Tobin, Communications Director
830 Boylston Street, Suite 206
Chestnut Hill, MA 02467
(617) 232-0090

Schulz is correct about being wrong

Author Kathryn Schulz recently provided a newspaper exposition of some of the themes of her new book, Being Wrong, Adventures in the Margin of Error. As noted on her website, Kathryn has "a credible (if not necessarily enviable) claim to being the world's leading wrongologist."

She finds fault in the way we find fault in ourselves. "Misunderstanding our mistakes . . . — seeing them as evidence of flaws and an indictment of our overall worth — exacts a steep toll on us. . . . [I]t impedes our efforts to prevent errors in domains, such as medicine and aviation, where we truly cannot afford to get things wrong."

The book is engaging and thought-provoking.

Kathryn uses our wrong-side surgery experience at BIDMC as an uncommon example of using error to improve things, particularly when an aggressive target for error reduction has been established and when a commitment to transparency has been adopted.

She notes, "If you really want to be right (or at least improve the odds of being right) you have to start by acknowledging your fallibility, deliberately seeking out your mistakes, and figuring out what caused you to make them."

(Bostonians can hear Kathryn in a reading this Friday evening at the Harvard Book Store.)

Tuesday, June 15, 2010

Boguski talks genes

Dr. Mark Boguski, a member of our Pathology Department, gave a short talk today to our Trustees about the evolution of the use of human genomics in the diagnosis and treatment of disease. I found it to be a great layperson's guide to the topic and include some video excerpts below.

If you cannot see the video click here.

WIHI on imaging practices

Here's a notice about an upcoming WIHI program.

The Image of Better (Radiation) Imaging Practices
Thursday, June 17, 2010, 2:00 PM – 3:00 PM Eastern Time

James R. Duncan, MD, PhD,
Associate Professor of Radiology and Surgery, Washington University School of Medicine, St. Louis, Missouri
Richard T. Griffey, MD, MPH,
Associate Chief for Quality and Safety, Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri

Imagine an electronic card that has all your vital medical information on it. Not too farfetched. Now, imagine that this same “smart card” also contains your radiation exposure history. Who needs to know, you ask? Well, a growing number of global patient safety experts believe this is precisely the type of information patients and medical providers should be tracking to help prevent unnecessary CT scans and the like, especially as evidence mounts that all these tests begin to add up in ways that that can endanger people’s health. Cancer is being studied the most, which is of course ironic since powerful and advanced radiation imaging is what also helps diagnose cancerous tumors at their earliest and most treatable stages.

It’s precisely because of this good news/bad news story about radiation imaging that WIHI welcomes Dr. James Duncan and Dr. Richard Griffey to the program on June 17 to help explain new thinking to improve decision making and reduce overuse of CT scans especially. With at least two CT scans performed in the US every two seconds, getting out in front of this skyrocketing practice couldn’t be more timely and challenging. But there’s promising work to discuss, much of it emanating from the pediatric community where evidence suggests children are undergoing record numbers of radiation tests, leading to an early and excessive lifetime exposure. It’s essential, for starters, say Drs. Duncan and Griffey, to know the facts and to understand the benefits of diagnostic alternatives. Should there be an “ultrasound first” policy?

WIHI host Madge Kaplan welcomes your knowledge, opinions, and questions about an area of medicine that’s ripe for review and improvement. Please join WIHI on June 17. To enroll, please click here.

Monday, June 14, 2010

Red Sox Scholars arrive . . . and graduate

The newest class of Red Sox Scholars were inducted yesterday, and the oldest class had a graduation ceremony. To recall, a key component of our partnership with the Boston Red Sox is to be Presenting Sponsor of the Red Sox Scholars. Each year we select 25 fifth grade boys and girls to participate in the program. They receiving mentoring, exposure to people and programs here at BIDMC, and a scholarship when they graduate high school and go to college.

The first class we chose, from 2003, has now finished high school, and many were on hand yesterday to be recognized for their achievement. Meanwhile, the cycle continued with the induction of the class of 2010.

In the video, you see Meg Vaillancourt, Executive Director of the Red Sox Foundation, introducing these two classes at a gathering before the on-field ceremony. Then you see them entering the field before yesterday's Sox-Phillies baseball game. Red Sox President Larry Lucchino was on hand to personally congratulate the seniors, who were later introduced one by one to the entire stadium. Among others, Boston Public Schools Superintendent Carol R. Johnson was there to shake hands.

Then, the fifth graders, escorted by a baseball player and a BIDMC medical champion, were introduced to the crowd. Finally, BIDMC Board Chair Steve Kay joined a member of each class for a ceremonial first pitch.

If you cannot see the video, click here.

Marketplace misconception

There is much to be said for the proposed acquisition of the Caritas Christi system by Cerberus, a private equity firm. The potential for capital infusion into the hospital system, funding of the employees' pension plan, and payment of state and local taxes are among the attributes of the deal. The proposal will be under state review for a number of months but has already stimulated a lot of news coverage.

Of course I am not privy to internal business plans, but I believe that the most recent press reports have created a misconception about the likely future role of the Cerberus system in the Massachusetts marketplace. The Boston Globe recently reported that the company is seeking to acquire other community hospitals. The story cited sources who said that Cerberus would want "to create a chain large enough to compete in markets outside Boston with nonprofit Partners HealthCare, the state’s largest medical provider and owner of Massachusetts General Hospital and Brigham and Women’s Hospital."

In the Boston Herald, too, an article asserts that Cerberus "could threaten Partners’ role as the dominant player in the Greater Boston medical market."

This is a useful misconception if you are the Partners system and are facing regulatory review and criticism for having used your dominant market power to secure higher payments from the state's insurance companies for your doctors and hospitals.

But there is little reason to believe that Partners will be hurt by a strengthened and expanded Cerberus network. The hospitals that have been mentioned as potential acquisitions are not in areas that compete with the outlying Partners hospitals. Several actually are current competitors of Caritas Christi hospitals.

It is thus more likely that the acquisitions would help bolster the presence of the Caritas hospitals in those geographic areas it already serves and permit it to branch out into areas not covered by Partners' community hospitals. This makes good business sense in that insurance rates in Massachusetts are higher for hospitals that enjoy a geographic advantage. Even if the insurance rate system is changed to eliminate that kind of pricing advantage, the Cerberus strategy would be helpful in the creation of Accountable Care Organizations that are likely to accompany payment reform (See here, on page 11.)

Finally, the Cerberus community hospitals will need access to tertiary care for those patients who cannot be treated locally. The idea that Cerberus would engage in a commercial battle with Partners seems inconsistent with its likely consideration of MGH and Brigham and Women's as potential tertiary destinations.

Friday, June 11, 2010

FINALLY, a computer message that I understand

Sent by a friend. Timely, as the weekend arrives.

Correlation or cause and effect?

Scientists and economists are trained to distinguish between correlation and cause and effect. The Boston Globe's Rob Weisman has written a series of stories that might lead us to wonder, "Which is it here?" Here's the sequence.

The MA health insurance companies (mainly non-profits) propose increases in the rates for small business and individual health insurance policies. The Division of Insurance disallows those increases and sets an arbitrary cap.

The new rates do not meet actuarial standards, which are important to maintain capitalization ratios for the insurance companies. An internal email emerges that indicates the Division's own staff has major concerns about this potential "train wreck."

The Division of Insurance puts several insurance companies under administrative oversight because of perceived financial weakness and expects to add more to the list soon.

How long will it take before some insurance company publicly posts financial results that are below state standards? What happens then? A loss in subscribers, as businesses lose confidence in that company. Then, do we see a forced merger or takeover, reducing the level of competition among the health plans?

The Division's answer: Insurers should stiff those hospitals who rates are up for renewal this year. The leaders of the state's hospital association note:

Cuts in insurance reimbursements for many of our state’s hospitals will further destabilize these institutions and are likely to lead to significant job loss at hospitals, some of which already are operating in the red.

Two train wrecks.

I vote for cause and effect.

Before we undermine two of the most important sectors of the state economy, it is time to change the rules and move away from an arbitrary system of health care finance to one that has legal accountability and transparency, one that enhances competition rather than diminishing it.

Thursday, June 10, 2010

Social media interlude

Two items about social media.

1) I often get the question in interviews, "How much time do you spend on your blog and other social media?" I often answer, "You wouldn't think of asking me how much time I spend on the telephone, and it is a lot less efficient than social media."

Think about it this way. A major advantage of social media is its asynchronicity. The person or people with whom I am communicating do not have to be doing it at the same time as I do. Another advantage, of course, is the broader reach of social media, being able to be in touch with dozens, hundreds, or thousands of people.

But, for those who still want to know. I usually write one blog post per day. I'm a pretty fast writer, so that takes 10 to 15 minutes, usually at home at night or first thing in the morning. (This one is being composed during the Celtics-Lakers game!) When readers submit comments, I get email notifications so I can monitor those comments. As you can note from looking at the blog, there are unlikely to be more than two dozen comments per day. Each one takes just a few seconds to review and post.

Keeping up with Facebook and Twitter are "fill-in" activities during the day. I leave them open and check when I have a minute or two. (I send birthday greetings from home before going to work.)

Regarding email, I try to check accumulated messages at least once per half hour, depending on my meeting schedule. I do that because I do not want to be a bottleneck while people wait for my assent or opinion on matters related to hospital business. One trick of time management I learned years ago is to read each message only once and act on it immediately. That is usually possible, although some messages take extra thought and therefore require a return visit later in the day.

2) Regarding social media access in the work place, I received the following email message this morning:

I've noticed significant Facebook usage among employees at work on hospital computers.
I believe this distraction has a significant effect on productivity.
I have friends in private practice who have fired employees for using social media sites at work while they are supposed to be attending to patients.
It may be time to add Facebook to the list of blocked sites; a list that includes sections of Craigslist, the lottery, and pornography.

To which I replied:

Sorry, but absolutely not. Facebook is a useful communications tool, just like email and telephones. The latter can be misused, too.
Besides, if you ban Facebook on computers, people will just use it on their iphones..

See more on this here.

Wednesday, June 09, 2010

Driving and distraction

My BIDMC doctor, Amy Ship, offers a Perspective article in the New England Journal of Medicine entitled, "The Most Primary of Care — Talking about Driving and Distraction." (The free full text is available here.)

Amy notes:

At the medical school and academic practice where I teach, students and residents routinely query patients about habits associated with harm, asking about the use of helmets, seat belts, condoms,cigarettes, alcohol, and drugs. There is little solid evidence that asking these screening questions has any benefit. But we continue to ask them — as I believe we should. And as technology evolves, our questions must be updated in keeping with the risks: it's time for us to ask patients about driving and distraction.

... Recently, I have added a question about driving and distraction to my annual patient review of health and safety. I begin with the customary seat-belt question. Then I ask, "Do you text while you drive?" Although I'm concerned about both texting and talking, most people are aware of the risks associated with texting, and many judge it more harshly. If a patient admits to texting while driving, I share my knowledge and concerns. Many patients who do not text while driving voice opinions about its dangers, giving me an opening to note that talking on the phone while driving actually causes more accidents than texting. Although I can share published data . . . , I find it more powerful simply to say that driving while distracted is roughly equivalent to driving drunk — a statement that captures both the inherent risks and the implied immorality.

Amy did this with me during my most recent physical exam, ending the discussion with, "How will you feel if you injure someone because you were answering a phone call?" That was pretty powerful.

Now, the truth. Even though I know this to be the case and have written about it before, I find that it is all to easy to be a recidivist, to rationalize answering that phone because "it is something important" or "it will just take a few seconds." Well, at 30 miles per hour, you go 44 feet per second. That's more than enough distance to destroy someone's life before you focus back on the road.

My new approach is to turn off the phone when I am on the road. That's the only sure way to comply with my doctor's orders.

Please leave a message . . . .

Web course at Tufts

Lisa Gualtieri (Adjunct Clinical Professor in the Health Communication Program) asks me to publicize this course:

Tufts University School of Medicine

Sunday July 18-Friday July 23, 2010

Most healthcare and public health organizations who are trying to communication with healthcare consumers share these problems: “our website hasn’t been touched in three years”; “we set up a Facebook page but don’t know what to do with it”; and “what exactly is Twitter and how do we use it?” With 61% of American adults looking online for health information, healthcare organizations need a Web strategy and healthcare professionals need to understand the latest technologies to plan and execute health communication initiatives. There can be a risk in not embracing the Web if other health organizations are and if healthcare consumers expect it. Yet it is difficult to decide which of the rapidly evolving Web technologies to select and how to use them to provide effective health communication, especially as part of a coherent Web strategy.

This course covers how to develop and implement a Web strategy to drive a health organization’s online presence, specifically the processes for selecting, using, managing, and evaluating the effectiveness of Web technologies for health communication. The course will use case studies from organizations to illustrate initiatives with a discussion of what worked and the recommended improvements and will work in small teams on a Web strategy redesign for Harvard Health Publications. Guest lecturers will provide insights on their experiences with the use of Web technologies for healthcare organizations and on topics that will lead to better use of Web technologies for health communication including on how healthcare consumers search and how to reach them, health reporting, and graphic design for health Web sites. Guest lecturers include: Bill Tancer, author of Click: What Millions of People Are Doing Online and Why it Matters, Gary Schwitzer, Tara Montgomery, Ed Coburn, Tania Schlatter, and Kent Bottles, MD.

Boston fans

Brandeis University's Stuart Altman and Harvard's Bob Blendon joined our Board of Overseers last night for a panel discussion on the recently passed national health care bill. The moderator was former TV anchorwoman Liz Walker.

At the end of the session, the group showed their true colors!

Tuesday, June 08, 2010

Thoughts about Gaza

Warning. This is not about health care. It is about Israel. If you don't think I should be writing on the subject, please skip to another post.

Several months ago, I had a chance to visit Israel and wrote about it here, ending with this thought:

The creation of a Palestinian state is an existential requirement for the future of Israel as a Jewish state. But, the creation of a Palestinian state which has a credo of denying Israel’s right to be a Jewish state is an existential threat to the future of Israel. Resolution of that contradiction is the job facing this country and the world community.

The recent events with regard to the blockade of Gaza are part of this whole scene. It is all too easy for those of us removed from those events to make judgments as to who was right and who was wrong. But I found this article by Bret Stephens to be indicative of many issues raised when people make judgments about motivations and actions. It is so clear that there is a double standard with regard to actions by Israel compared to actions by countries set on destroying it.

A few excerpts:

Questions for liberals: What does it mean to be a friend of Israel? What does it mean to be a friend of the Palestinians? And should the same standards of friendship apply to Israelis and Palestinians alike, or is there a double standard here as well?

... [C]onsider what it means for liberals to be friends of the Palestinians.

Here, the criticism becomes oddly muted. So Egypt, a country that also once occupied Gaza, enforces precisely the same blockade on the Strip as Israel: Do liberal friends of Palestine urge the Obama administration to get tough on Egyptian President Hosni Mubarak as they urge him to do with Israeli Prime Minister Benjamin Netanyahu? So a bunch of "peace" activists teams up with a Turkish group of virulently anti-Semitic bent and with links both to Hamas and al Qaeda: Does this prompt liberal soul-searching about the moral drift of the pro-Palestinian movement? So Hamas trashes a U.N.-run school, as it did the other week, because it educates girls: Do liberals wag stern fingers at Palestinians for giving up on the dream of a secular, progressive state?

Well, no. And no. And no. Instead, liberal support for Palestinians is now mainly of the no-hard-questions-asked variety. But that is precisely the kind of support that liberals decry as toxic when it comes to Western support for Israel.

... [T]he task of defending Israel is hard. It's hard because defenders must eschew cliches about "the powerful" and "the powerless." It is hard because it goes against prevailing ideological fashions. And it's hard because it requires an appreciation that the choice of evils that endlessly confronts Israeli policy makers is not something they can simply wash their hands of by "ending the occupation." They tried that before—in Gaza.

Choose: Choice is good or bad

Boston Globe columnist Steven Syre offers a thoughtful political view of health care issues in Massachusetts today. An excerpt:

The latest edition of an annual health care poll conducted by Mass Insight suggests most people don’t find the price they pay for health coverage to be a serious problem. The poll, which will be officially released next week, also shows a large majority of people don’t want to give up anything when it comes to health coverage or the freedom to choose whom they see for medical help.

... A majority of people polled said they disapproved of limiting coverage for high-cost and experimental treatments as well as policies that limit coverage for prescription drugs. A whopping 80 percent were against limiting consumer choice of doctors and hospitals.

I found this to be interesting because it is consistent with polls I have seen over the years. It suggests a disconnect between the policymakers and the general public, particularly on the issue of choice. But, perhaps there is an understandable reason for this disconnect: People have no sense of what it costs to get medical services at different hospitals; and they have no sense of the relative efficacy and safety of treatment in those hospitals. Maybe if they knew, they would be more amenable to paying less and getting equal or better care.

Last year, when the MA Payment Reform Commission issued its report promoting a move to global payments, many people who were enthusiastic about the report skimmed over the issue of patient choice. Limiting patient choice is a sine qua non if the state is serious about changing the mode of payment to a capitated system. But we do not have to have a repeat performance of the disaster of managed care from the past. Transparency of payment rates and clinical results is a necessary condition for success.

Three ways to set payment rates

My suggestion last year that Massachusetts move away from the "free market" approach it uses to set hospital reimbursement* rates was not well received by the hospital world. But, this year, as people notice that their rates are being set by insurance companies in an unaccountable and unreviewable fashion (see this letter to the editor), more and more are saying, "Well, maybe. What would it look like?"

There is a range of options. Let me lay out some of them in summary fashion here, recognizing that a presentation in this forum is inherently simplistic. I would love to see a public forum in which these are debated.

One approach is that used by Maryland, with full determination of rates for each hospital by a rate-setting commission. Like public utility rate-setting, this involves lots of reviews and administrative procedures.

A variant of this is that we could have a state agency produce default rates (both fee-for-service and capitated) that serve as a state-wide rebuttal presumption. There could be prescribed (i.e., formulistic) add-on's for geographic cost-of-living differences, teaching obligations, other government requirements, and the like. In this scenario, unless either the insurer or the provider made an evidentiary case for different rates in front of an administrative body, the agency's presumed rates would apply.

Another approach that does not require a rate-setting calculation is to permit either the provider or the insurance company to request the presence of an observer from the state to sit in and witness the give-and-take during the rate-setting discussions. He or she would be permitted to ask questions of either party, have access to all proprietary information, and to make suggestions to the parties. The theory here is that the presence of an objective facilitator or mediator would help level the playing field when either the provider or the insurer has more market power.

The final requirement, which must be added to any of three concepts above, is absolute, complete transparency of payment rates. That, more than any rate-setting formula, is likely to drive all rates to the mean, eliminating the huge disparity that exists today. There is no reason not to put it in place immediately while we debate the rate-setting process.

* I remain bemused by the term "reimbursement," when "payment" is used in every other sector of society. This is a strange carry-over from a different era. I suggest we get rid of it.

Monday, June 07, 2010

The Aging LGBT Community

We held our annual Lesbian, Gay, Bisexual, Transgender achievement awards ceremony today and presented awards to Dr. Michael Wong from BIDMC's Division of Infectious Disease and Sue O'Connell and Jeff Coakley from Bay Windows. Dr. Wong has been involved in the laboratory, the clinic, and the community in the HIV-AIDS arena. New England's largest LGBT newspaper, Bay Windows has brought award-winning articles and editorials for more than two decades to the region.

The theme of today's session was, "Our future: The aging LGBT community." The featured speaker was Lisa Krinsky, Director of the LGBT Aging Project. You can see excerpts of her talk below. In her talk, she refers to a Stud Maddox documentary entitled Gen Silent. Here's the clip we showed to the audience.

I, for one, was surprised and saddened to learn of gay people going back "into the closet" because of their fear of how they will be treated in long-term health care settings. The movie is moving and well worth watching. As Lisa notes in this excerpt, it will be available for viewing here in the Boston area in the near future.

If you cannot see the video of Lisa's talk, click here.

Sunday, June 06, 2010

Update on GRACE

This is an update on an experimental protocol I mentioned last fall, called GRACE (Global Risk Assessment and Careplan for Elders). As noted then, this program is designed to improve the care of all hospitalized elders admitted to BIDMC, with the hope that we will reduce the risk of delirium, falls, pressure ulcers, functional decline, etc.

When I have mentioned this program in my various speeches, there has been tremendous interest from doctors and nurses across the country. I recently asked Dr. Melissa Mattison, who is part of the working group that has designed and is implementing the program, for an update. I provide it here for the benefit of those hospitals who are following the experiment.

Global Risk Assessment and Careplan for Elders (GRACE) is a multidisciplinary approach to standardize and improve care for hospitalized elder patients. GRACE Includes:

* Computerized Provider Order Entry modifications to assist MDs, NPs, and PAs by encouraging care that helps patients maintain their physical and mental capabilities including early and frequent ambulation, limiting the use of potentially inappropriate medications, and limiting the use of indwelling urinary catheters;

* A bedside checklist that prompts bedside staff to screen patients daily for the presence of delirium and to use proven strategies to prevent delirium;

* Pharmacy modifications to ensure that MDs and pharmacists are aware of geriatric warnings when ordering potentially inappropriate medications;

* Nursing Initial Patient Assessment (IPA) customizations so that nursing staff are prompted at admission that the patient is a “GRACE patient” and provide a customized Nursing care plan addressing the patient's needs.

Phase 1 - Successfully deployed on November 10, 2009 -Bedside checklist for delirium assessment and prevention has been used on the three main Medicine units.
Phase 2 - Successfully deployed on April 6, 2010 - POE Rollout to Medical units for patients 80 and older.
Phase 3 - Successfully deployed on April 26, 2010 - Bedside Flow sheet and POE rollout to all units except Deac-4, ICUs, Oncology for patients 80 years and older.
Phase 4 - Scheduled to be deployed in Fall 2010 - Bedside checklist and POE rollout for 65-79 year old vulnerable elders to all Units (automatically classified as GRACE patients based upon certain comorbidities).

Ongoing - Educational campaign to help house staff and Nursing understand the components of the GRACE intervention and how to recognize and treat delirium.

Since November 2009, we have improved the program in several ways. We have worked with Nursing to modify the Nursing Initial Patient Assessment (IPA). This prompts the bedside team to recognize when a patient is a “GRACE patient.” It also provides a standard Nursing care plan for these patients. When the floor nurse completes the IPA, s/he is prompted to print the bedside checklist and place it in the vital signs book at the patient's bedside. This went live on 3 pilot units in early April and hospital-wide with the rest of the CPOE modifications on April 26.

Because the BIDMC Pharmacy is overhauling and standardizing their warning systems within CPOE, we are working with them to ensure there will be geriatric-specific medication warnings available to both ordering providers and pharmacists. Deployment of this is expected in 2011 due to the programming requirements of this project. We are also collaborating with IS for a CPOE GRACE opt-in for patients who are not otherwise identified as GRACE patients.

Nearly 80% of Medicine house staff said the GRACE bedside checklist has increased their awareness of the presence of delirium in their elderly patients.

Numerous providers (MDs, and RNs) have asked if they could use the GRACE bedside checklist in patients who are not currently “GRACE patients” (80 and older). MDs have asked to be allowed access to the CPOE modifications (an opt-in) for non-GRACE patients. We expect to have additional data later in June.

Seven minutes on patient empowerment

Watch this or below, please.

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

Progress, bit by bit

A hodgepodge of items, illustrative of things here at BIDMC and elsewhere:

Doctors working on Lean

First, excerpts of a note from Dr. Clif Saper, our Chief of Neurology, to his faculty and residents, about Lean training and going to gemba. We are getting a great response from the doctors as they learn to apply this approach to the work of the hospital:

I want to thank everyone for coming to the departmental meeting with the Lean group on Wednesday. I hope you enjoyed the introduction, and are as excited as I am about the potential for engaging all of our group in redesigning our work. The key take-home point I want to make is that this has to be a ground up effort, by the people actually doing the work. The goal is to empower you at the front line to redesign your workplace. This will not be easy, and it will not be quick. In fact, we do not expect to finish, ever, but to gradually refine our approach, on a continuing basis, over many years.

The homework for the first month is to “go to gemba” to see how our workplaces function, from the point of view of patients (who are our “customers”), our own docs, referring docs, and the staff who enable our work (front desk group on Shapiro 8, nurses and ward clerks on Farr 11).

I would like each of you to go to gemba (choose your site, but I expect that the residents will mainly concentrate on Farr 11 and the attendings mainly on Shapiro 8, but if you have a passion for the other site, please by all means indulge it). Take a pad of paper, and a watch with a second hand.

I would like you to decide to watch the process from the perspective of one individual (or type of individual, as you may end up watching more than one) in the gemba. For the clinic, you may choose a front desk worker, a physician, or a patient. For Farr 11, I would like you to watch morning rounds (some segment between 7am and noon) from the perspective of a ward nurse, resident, or patient (or patients if you choose more than one). Please write down on your paper a running list of what you observe, in the order you observe it, and try to time the different components of the process. Please plan to do this for at least one full hour, some time in the next three weeks.

The goal is to discover wastes (you will need the list of the 8 wastes that you received at the meeting). If you lack a copy of the list, please email Gregg Ramsey, our teacher on Wednesday, and he will send it to you by email.

Remember to announce yourself to the staff and doctors you observe. Just say that you are participating in the Neurology Lean project, and are there to observe today, to try to improve the patient experience. Please announce yourself also to patients (or have the doctor you are following do so), and ask their permission for you to observe.

I would then like to set aside some time before our next meeting on July 7, to review with groups of you what you found. My hope is that your own discoveries will allow us to divide up into working groups to tackle issues that we identify.

I look forward to seeing what you have found....

Surgical results

Next, a note from Dr. Charles Vollmer, who heads up our pancreatic surgery program with Dr. Mark Callery. The note is to the doctors in a number of departments who support this program:

This week Mark and I celebrated a significant milestone with the performance of our 600th major pancreatic resection over the last 8 years together here at BIDMC. This has come with an overall perioperative mortality rate of 1.3%, as well as other benchmark quality outcomes.

As you can tell from the size of the address string above, this has not come solely at our hands, but rather has been achieved by a collaborative effort among some of the world's finest doctors in the field of pancreas care. We are indebted to your skill, acumen, foresight and friendship. With continued dedication and hard work, we look forward to sharing further accomplishments with you.

Odds improving in Las Vegas

This quote from an article from Deloitte:

Las Vegas employers push hospital transparency, performance

Last week, the Health Services Coalition, a group of 24 self-funded insurance plans representing large employers in Las Vegas advised 13 area hospitals that they would direct their 260,000 enrollees to Intermountain Healthcare facilities in neighboring Utah if quality and transparency efforts did not improve. Specifically, the 20-year-old business coalition is seeking to change incentives from volume to quality and efficiency.

NHS puts it out there

And finally, this report from The Guardian about the British National Health Service's real-time clinical transparency.

The new government's information revolution rolled into hospital wards with the publication today of rates of hospital-acquired infections, such as MRSA, on a weekly basis.

Andrew Lansley, the secretary of state for health, confirmed that from today people will be able to check the weekly meticillin-resistant Staphylococcus aureus MRSA and Clostridium difficile (C diff) rates at their local hospital. He also published 12 weeks of data, giving the public their first view of the level of detail the department has been able to obtain.

From early next month, infection figures for all hospitals in England will be published every seven days on In March, there were about 20 outbreaks in English hospitals of MRSA, whereas by May this appeared to have dropped by half.

Previously, the infection rate for MRSA and C.Diff at NHS hospitals were released on a yearly basis and as an average for each NHS trust - which may comprise several hospitals.