Sunday, December 21, 2014

Your unrealistic assumptions and unmet expectations

I'm so grateful that many of you answered my question of last week:

"As a patient or family member in a hospital, what are your assumptions and expectations with regard to medical students and residents when it comes to patient safety?"

I promised to respond to your comments, and I will, but first, I'd like to reprint an excerpt from Gene Lindsey's weekly email message to his friends and colleagues, for I think it sets the scene nicely.

Although I graduated with honors and was fortunate to match with an excellent internship and residency program, I graduated as a physician in name only. In retrospect medical school for me was not much more than a big vocabulary lesson. By graduation I was well versed in the “what” of medicine and my clinical rotations had been an effective introduction to the “how” of hospital practice, but I was very short on the understanding of “why” and the complexity of effective practice especially in the ambulatory environment. I could talk like a doctor or at least pass for an intern.  I looked the part. I knew how to do a few things and was rapidly gaining the swagger associated with increased confidence in my ability to tap fluid off of the water soaked lungs of a patient who was short of breath, do a lumbar puncture as part of a fever work up, or rapidly and effectively respond to a code.

What took a lot longer to gain was confidence in my ability to meet a patient, understand them, appreciate the world they came from, really know their concerns, translate those concerns into a medical assessment, and finally help them understand what I had formulated and then help them choose a path forward. I think that my mentors or something in my development taught me to search for the equivalent of the IHI’s admonition to ask “What matters to you?” But putting that combined process of inquiry, empathy, discovery, diagnosis and treatment into practice is hard work.  Incorporating that mind set of patient centrality into all of the vocabulary, clinical skills, and social awareness is a long slow learning process that consumed many more than the 10,000 hours Gladwell says is the foundation of competence.

Wow, as a non-doctor, I am impressed with how hard it is to get good at this profession/craft/art/science.  And note that Gene's remembrances don't even cover the additional topic about which I asked, patient safety. Let's see what your expectations are.

Many of you raised the issue of training:  Andrew expects "that they have a high level of training for what they are asked to do and that safety [is an] important part of that."  From across the Pond, Anne Marie hopes "that they are working within their frame of competence." An anonymous person expects that "their training is a systematic, tested, and reviewed process, as evidenced by defined skills, knowledge, and abilities."

But you also recognize that these folks are trainees and therefore might not know the answers. Therefore you hope for self-awareness of their limitations and also expect that supervisors will be available to step in when help is needed.

On the first point, from Down Under, Kim hopes that they will "know their limits and seek help whenever needed." Kashif likewise says, "If there is any gray area, doubt or question, it is incumbent on the student - and should be part and parcel of the learning process - to ask for clarification and education from an attending or other superior."

Anonymous adds that the other part of the equation must also be present: "I would expect that there's someone around who is accessible that the trainees could turn to, with immediacy and in-person, when they're in over their head. And, I'd expect that that person would be around sufficiently to recognize when a resident or med student is in trouble with regard to understanding what's happening with a patient, even if he or she does not."

And, now, turning directly to the issue of safety, Bart assumes "that they're better oriented toward safety [than older doctors] since they're newly trained." E-patient Dave wants them "to follow documented safety procedures and welcome my questions (and my family's) and our attempts to help keep things safe." Nonlocal MD expects "exactly the same from them with regard to patient safety as I would expect from their attendings or, indeed, any doctor - awareness and attention to safety best practices."

Hilary then adds an important proviso, hoping "that residents, medical students -- and anyone in the hospital -- are empowered to speak up if they see a patient safety issue. More fundamentally, that they are supported by faculty and a hospital system which make patient safety a priority."

Paul expands on this:

"[T]here clearly needs to be a place to go (likely even anonymously) to report on patient safety issues that the student observes.

"Reporting is not with a punitive goal, but with a goal of protecting patients and supporting quality improvement. The organizational system where the student is placed ought to support this ability to report without fear of retribution or negative consequences for the reporting student."

OK, now let's turn to reality, which is nicely represented by a number of participants at the Telluride Patient Safety Camp, captured in submissions on the camp blog.  On the issue of training, it is not uncommon to hear from residents that their cumulative training in safety and quality issues during four years of medical school and two to three years of residency is in the vicinity of three hours.   AWilliams noted: "My school has a Patient Safety elective (of which I am on the waitlist for), but beyond that we are given no formal training in the Patient Safety Culture."

Thinking about cognitive, communication, and team behavior determinants of safety and quality, Giana O'Hara noted:  "I am struck by the lack of education in our institutions. Today’s lessons were profoundly important and informative, yet, our schools do not have room for things in their education such as human factor engineering and negotiations. They don’t even make time for true team building!"

JHollorman learned lessons at Telluride that had never been presented during formal training.  Among them: "Our own human fallibility causes us to deviate from safety protocols in the face of stress, make conclusions based on cognitive bias rather than real information, and underestimate our likelihood to cause an error."

Compare our small sample with the self-congratulatory comments of the Association of American Medical Colleges: "Most medical schools currently include patient safety and/or quality in their curricula."  That embedded link purports to indicate the number of medical schools with "patient safety" and/or "quality improvement" in their curriculum.  In truth, the vast majority of medical schools have no longitudinal curriculum through the undergraduate years that touches on this topic.  Here's a quote from a few years back that is still accurate:

The Lucian Leape Institute at the National Patient Safety Foundation released today a report that finds that U.S. “medical schools are not doing an adequate job of facilitating student understanding of basic knowledge and the development of skills required for the provision of safe patient care.

I remember a conversation with the dean of a well known Boston medical school three years ago when I suggested that these items be added to the curriculum."Our faculty aren't interested in that," he said dismissively.  His students are now the ones taking care of you, the ones you expect will be trained in quality and safety matters.

And, finally, let's turn to Hilary's and Paul's hope, that students and residents will find an open and welcoming environment within which to report areas of concern, or specific instances of patient harm.  Again, as we all know from experience, this is observed more in the breach than in the reality.  The ACGME's CLER Program mandates that these features be included at hospitals that sponsor residency programs.

"How's it going?" you might ask.

Well, we can't find out because the ACGME will not release the results of its assessments.  If the medium is the message, the lack of transparency evidenced by the residency supervisory body is a clear indication of its poor understanding of the importance of meeting these educational criteria.

I offer all of these comments not to get you overly discouraged but to suggest that the patient safety movement and its advocates are missing a big topic.  In their focus on process improvement, patient engagement, and the like, they are missing the fact that much hope lies with the coming generation of doctors.  In our zeal, for example, to require reporting of hospital acquired infections and never events, or to pursue changes in the payment system to supposedly prompt better management of care, we neglect the coming generation's need for education and support.

Saturday, December 20, 2014

Ebola watch

Here are some random thoughts about Ebola.  Remember when it used to be in the headlines?

A friend wrote:

I recently read Jose Saramago’s fictional 1997 novel, Blindness, in which mass hysteria ensues as an inexplicable epidemic of white blindness sweeps through a town. Widespread panic marches through the community. The government, in an attempt to control the contagion, reacts by enacting increasingly repressive and ineffective measures. Victims are quarantined in a derelict asylum under armed guard, and left largely to fend for themselves. Social order breaks down rapidly both inside the crowded, filthy asylum and outside of it, in the community, as people begin to treat one another with fear and suspicion. The breakdown of social infrastructure and basic decencies leads to even worse afflictions. It is a remarkably prescient account of how humans react to something that scares us. 

Another friend who has been working on the front lines of Ebola planning and response humorously noted that the most significant advance in rational American preparedness for the disease occurred on November 5.  Why? This was the day after election day. My friend noted that the bad behavior of several governors, most notably Chris Christie and Andrew Cuomo, had simultaneously made outcasts of the extremely dedicated health care workers who had volunteered in Africa and unnecessarily raised undue concern among the American public as to the actual danger to the US population.  It remains unreported whether the governors had read Saramago's book.

Meanwhile, recall that the federal government originally designated under two dozen hospitals nationwide to accept Ebola patients.  Here's the map from October.  But many places felt left out--both for reasons of ego and finance (i.e, looking for a share of the multi-billion emergency appropriation, including $166 million for hospital preparedness and support).  So by December, there were 35 designated hospitals (with more to come--at least one in each state suggests the President, counting votes in the Congress.)  I'm sure the list, though, is based solely on a logistical and scientific determination of need.

Wait, did I mention the amount of requested funding, over $6 billion?  Here's the page with the CDC case counts, both for the US and abroad.  Fewer than 20,000 cases worldwide, and 4 in the US.

Let's compare this to another, ongoing public health hazard. This site notes:

In American hospitals alone, the Centers for Disease Control (CDC) estimates that hospital acquired infections (HAIs) account for an estimated 1.7 million infections and 99,000 associated deaths each year. 

How does the US government respond to the need for training and process improvement in this arena? By penalizing hospitals, especially those with the sickest and poorest patients:

An analysis of the penalties that Dr. Ashish Jha, a professor at the Harvard School of Public Health, conducted for KHN found that penalties were assessed against 32 percent of the hospitals with the sickest patients. Only 12 percent of hospitals with the least complex cases were punished. Hospitals with the poorest patients were also more likely to be penalized, Jha found. A fourth of the nation’s publicly owned hospitals, which often are the safety net for poor, sick people, are being punished.


Priorities? Even Saramago would be unable to write a fictional account that is more strange than reality.

Friday, December 19, 2014

When a company is run by droids

This column was originally to be focused on Uber, which allowed its shortage algorithm to increase the prices of taxis out of the Sydney central business district by four times during the recent hostage episode--and who, at first, responded to complaints by saying, "Well, we need to increase prices to encourage more drivers to enter that sector of the city."

This tin ear to public opinion got them in a heap of trouble, even though they later changed their tune and offered people free taxi service during the crisis.

But even that pales compared to Heartland Regional Medical Center in St. Joseph, Missouri.  Listen to this report from NPR and Pro Publica.  Excerpts:

Heartland, which is in the process of changing its name to Mosaic Life Care, seizes more money from patients than any other hospital in Missouri. From 2009 through 2013, the hospital's debt collection arm garnished the wages of about 6,000 people, according to a ProPublica analysis of state court data.

After the hospital wins a judgment against a former patient in court, it's entitled to take a hefty portion of the patient's paychecks going forward: 25 percent of after-tax pay. For patients who are the head of household, if they tell the hospital or court that information, the hospital can seize only 10 percent of each paycheck.

But Heartland, through the debt collection company Northwest Financial Services, often sues both adults in a household — garnishing one at the 10 percent rate and the other at the full 25 percent of their pay. The hospital also charges patients 9 percent interest, the maximum allowed under state law.

Bad enough?  Wait:
 
In 2006, the hospital sued the Heries and got a court judgment against them for the full bill plus legal fees — more than $18,000 in total. Ever since, the hospital has been taking 10 percent out of Keith Herie's paychecks.

To make some more money, Kathleen Herie got a low-wage retail job at Sam's Club. But then Heartland hospital began seizing 25 percent of her paychecks after taxes — meaning both she and her husband were now getting their pay docked at the maximum level allowed under state and federal law. On top of that, the hospital placed a lien against their home — which also prevents them from refinancing. According to a Heartland operations memo, this is done in all cases in which the company has won a judgment exceeding $1,000.

Enough? Look:

In 2010, Heartland sued Keith and Kathleen Herie again. Keith was experiencing chest pains, had tests done and ended up with new bills totaling upwards of $10,000. But this time, based on his income on his tax returns, the couple could have qualified to get their entire bill forgiven under the hospital's financial aid policy.

But they say nobody told them that. They didn't formally apply for aid. So the hospital charged them the full bill and garnished their wages again. Altogether, over the years, the couple has paid $19,779 through garnishments, according to court records. They still owe $25,739.

Want more?

The Heries' case highlights a key point: When a hospital garnishes patients' wages, it learns how much they make. But even if the patient is very low-income, Heartland doesn't consider that. Once you get sued, you no longer qualify for assistance. "The time to do that would have been back when you got the bill or when the bill initially went to collections," Wagner says. Hospital spokesperson Tracey Clark says charity care is reserved for patients who "seek it and legitimately work with us." Meanwhile, the hospital is seizing the wages of many patients who could qualify for free or reduced-cost care.

Last point:

Heartland is a non-profit hospital. It made $605 million in gross revenues last year, and $45 million of that was profit, an 8% margin in a business where 2-3% margins are the norm.

Thursday, December 18, 2014

Please answer the question.

If you haven't answered the question I pose below, would you please do so as a comment on that article?  It requires no technical knowledge, and I'd value your opinion.  Thanks.

Enforcing AG's agreements with hospital systems

Bruce Mohl at Commonwealth Magazine reports that the state of Massachusetts has started "to assess $1,000-a-week fines on Steward Health Care for failing to turn over to regulators the company’s audited financial statements, with the current tab standing at $12,000"  This story is the latest chapter dating back to August.  Back then I made a suggestion:

Back in October 2010, when the Attorney General recommended approval of Steward's takeover of the Caritas Christi hospital system, she was able to get the following agreement: 

"Steward, and any successor-in-interest to Steward, will, notwithstanding its for-profit status, fully cooperate with any investigation, inquiry, study, report, or evaluation conducted by the Attorney General under her oversight authority of the non-profit charitable hospital industry to the same extent and subject to the same protections and privileges as if Steward were a public charity." 

So all it takes is for the Attorney General to announce to Steward that she wants this information as part of a joint study with CHIA.  Perhaps she will make that offer to CHIA.

The Attorney General is the lawyer for state agencies.  Why her office is not mentioned in the current story as supporting CHIA in this regard is problematic. This seems to be part of pattern of inability to enforce, in that Steward has also acted to close one of its acquired hospitals (Quincy Medical Center) before the allowed period stated in the agreement.

If this simple set of commitments can't be enforced by the AG, imagine how difficult it will be to enforce the much more complicated proposed settlement with Partners Healthcare System.  I hope the AG-elect is watching closely and is learning the lesson, and chooses to withdraw the PHS agreement from the Court.

Wednesday, December 17, 2014

Please answer this question

At a meeting this week of the MedStar Health patient and family advisory council, Rosemary Gibson and Anne Gunderson asked,

"As a patient or family member in a hospital, what are your assumptions and expectations with regard to medical students and residents when it comes to patient safety?"

Please think about that for a moment, and post your answer as a comment here.  (I'll respond afterwards.)

Everyday innovators show the way at U. Mass.

I hear through the grapevine that my July post about U. Mass Memorial Health Care in Worcester was not well received by some colleagues in Central Massachusetts.  I can certainly understand that, as I did not portray an optimistic prognosis.  I certainly hope to be proven wrong, and recent numbers from that quarter look better, as reported in this story by Lisa Eckelbecker at the Worcester Telegram.

But regardless of how things progress, I want to expand on a passing comment in that blog post, which I meant with all sincerity:

Dr. Dickson, by all accounts, is a thoughtful, honest, and effective leader, with a terrific sense of what it takes to improve hospital work and clinical processes.

Eric writes a marvelous blog--Everyday Innovators--that is documenting many aspects of the process improvement journey occurring at U. Mass.  He celebrates the small and the large, giving special attention to the ideas created by front line staff.  Here's an excerpt from one recent example:

Our first Idea of the Week comes from a team who has taken these principles to heart, the Anti-Coagulation Center staff. After reading an article about how patient perception of quality of care begins in the reception area, team member Pam Burgwinkle, a nurse practitioner and manager of the center, brought the subject up at her team’s idea huddle and collectively they examined some of the topics discussed in the article.

Pam was looking for ideas about how they could demonstrate to patients UMass Memorial’s commitment to patient centered care. As always our care givers had lots of great ideas including ensuring the reading materials are current, adding plants to the reception area and making sure the patient education material is fully stocked.

Finally the team came up with their best idea adding a USB port charging station so our patients can keep their phones charged and provide updates to their family and friends. 

Well done! 

It is out of such engagement and creativity that progress occurs.  There is a leadership and team building example here that has value to hospitals everywhere.

Best of luck to Eric and his team at U. Mass.  I hope and trust you will prove my earlier post to be totally off base!

Not really a victory

Quincy city officials and the Attorney General are likely to claim victory in getting Steward Healthcare System to agree to open a "satellite" emergency room at the otherwise shuttered Quincy Medical Center (in addition to an already operating urgent care facility elsewhere). Patrick Ronan at the Patriot Ledger reports:

Amid calls from state and local officials to retain an ER in a city with more than 93,000 residents, Steward announced Tuesday that it has filed a letter of intent with the state’s Department of Public Health to open a satellite ER in the hospital’s existing emergency department at 114 Whitwell St. The for-profit company said it still plans to close the rest of the 124-year-old hospital by Dec. 31.

Steward said the satellite ER will be open 24 hours per day, seven days per week, and it will be staffed with physicians and nurses. There will also be on-site diagnostic radiology and laboratory services. Patients with serious emergencies or who need inpatient services will be taken to other acute-care hospitals.

A word of caution comes from a knowledgeable person:

Deborah Socolar, a North Quincy resident and former co-director of the health reform program at Boston University’s School of Public Health, said she is concerned about how the satellite ER will be staffed. She said some of Quincy’s ER workers were under the impression it would close Dec. 31, so they got new jobs.

Socolar said news of the ER staying open, although welcomed, doesn’t change the fact that Quincy is about to lose its hospital. “It’s obviously still a loss for the city to not have a full-fledged ER that would have operating rooms upstairs and as a result would be able to handle a wider, more diverse array of patients,” Socolar said. 

But it really goes beyond that, doesn't it? Do you really want to give the impression to the public that an ER exists when there is no connection in the building to the kind of services that might be needed for emergent patients? What are the clinical ramifications of the delay associated with accepting a patient for triage and initial treatment in Quincy and then bundling him/her up for transport to another hospital? Some percentage of patients will be better off going directly to a real hospital's ER directly.  Who is going to make that judgement?  If you were an EMT with a patient in your ambulance, what choice would you make?  If you have concerns and you call ahead to the Quincy ER, you are likely to hear, "Best to take the patient directly to a full service ER."


Look at these two maps.  If you need emergent care and live in the north or west part of Quincy, you may well be better off going to BID-Milton from the start (above).  If you live in the south or east part of the city, you may well be better off going directly to South Shore Hospital (below).  In short, a good portion of those 93,000 Quincy residents will not need or want a satellite ER.


Here's my prediction:  After the six-month trial period, this facility will be quietly closed, citing a lack of business.  The ambulance drivers and the public will vote with their feet.

Tuesday, December 16, 2014

CLER as mud

Back in April, I raised the question of why the ACGME was not publishing the results of its surveys with regard to CLER, Clinical Learning Environmental Review.  The program description states:

CLER emphasizes the responsibility of the sponsoring institution for the quality and safety of the environment for learning and patient care, a key dimension of the 2011 ACGME Common Program Requirements. The intent of CLER is “to generate national data on program and institutional attributes that have a salutary effect on quality and safety in settings where residents learn and on the quality of care rendered after graduation.”

CLER provides frequent on-site sampling of the learning environment that will:
  • increase the educational emphasis on patient safety demanded by the public; and,
  • provide opportunity for sponsoring institutions to demonstrate leadership in patient safety, quality improvement, and reduction in health care disparities.
The question remains, months later:  Where is the data that the ACGME collects about this important GME quality and safety curriculum? Why can't medical students who are interested in joining hospitals with vibrant patient safety and quality programs see it during their residency match process?

And fundamentally, why won't the ACGME model the kind of transparency that is needed to bring about clinical process improvement?

How bad is it? It's so bad that . . .

It struck me that this old Dilbert cartoon characterizes many hospitals.  The situation described may present a problem as they try to run ACOs to manage patient care under a risk-sharing model of reimbursement, especially when they must do so across many institutions and physician practices--each of which has the same problem of cost accounting.

Monday, December 15, 2014

All That's White Isn’t Necessarily Propofol

With thanks to Saskatchewan's Health Quality Council Chairperson Susan Shaw for the reference, please check out this short article on a near miss in a large community hospital.

I have only one quibble with the author's choice of language.  She says:

As with any near miss or drug error, there were a series of unusual circumstances that led to this product being placed on an anesthesia table top. 

Actually, many such errors do not require a series of unusual circumstances.  It is the pattern of everyday work that often leads to preventable harm.

Meanwhile, with thanks to Jan M. Davies, Professor of Anesthesia & Adjunct Professor of Psychology, University of Calgary, I add this short video from George Carlin about "near misses."  Enjoy!

Getting the skinny on skin conditions

I usually get nervous when something seems too good to be true, but every now and then the spark of human goodness comes through. Unless I am missing something, here's an example, sent to me on Twitter by Dr. Howard Green, @DermHag, a dermatologist in West Palm Beach.

He wrote:

Here's a first look at Skinstamatic a ground breaking mobile collective sourced medical search app.








Curious, I followed up with Howard:

Very interesting. So the consult is free? Do users get some kind of priority for appts? Often hard to get one.

He replied:

Free. No priority just recognition of Skinstamatic user at this time although identified photobook is available to be viewed by Dr.

All in all, this looks like a generous use of social media capabilities from members of the profession.  What do you think?

Sunday, December 14, 2014

Randi Redmond Oster questions protocol

Back in April, Randi Redmond Oster sent me a copy of her book Questioning Protocol with the following inscription:

My mission is to help make this book obsolete in 10 years!  In the meantime, I hope it helps others navigate the system.

Well, I've finally had a chance to read the book, and it is excellent. The story told is much more than her son's experience with Crohn's disease.  It is a narrative about the the types of things that regularly happen in hospitals.  I'm not so much talking about medical errors, although those occur. No, this is more about a pervasive tendency of participants in the health care system, as noted by Helen Haskell:

“This was a system that was operating for its own benefit.” 

What she meant was that each person in the hospital was unthinkingly engaged in a series of tasks that had become disconnected from the underlying purpose of the hospital. They were driven by their inclinations and imperatives rather than by the patient’s needs. 

Doctors and nurses face an abundance of tasks every day, and they apply their energy, creativity, and experience to those tasks. But, they often neglect to connect with the patients and families whom they are treating. This is a not a case of bad intentions. Indeed, these folks are among the most well-intentioned people in the world.

Randi relates the story of a doctor's failure to contact her before giving the boy a drug, even though there was no emergent reason for doing so and even though the mother had clearly requested to be consulted on such matters:

"No, I did not contact you. I'm sorry. I did what we always do. Dr. Simmon told me you had an issue with steroids but he saw the pros and cons of administering them. Dr. Hughes and I agreed it was the best course of action."

A follow-up with Dr. Simmon occurs a few hours later:

"I spoke with Dr. Stark today and I understand your concern about steroids. I know you never met her before but she is my partner and I support her medical decision." He blurts this out, stating his position so clearly, that even with a bad [telephone] connection I hear him sharp. The tone in his voice seems like he is concerned about keeping a unified medical front, not about my son.

 "Doctor, Gary is not to have steroids until I understand the justification for taking them. Stop them immediately." I say it strong and clear.

The next day, Dr. Stark says:

"I spoke with Dr. Hughes and Dr. Simmon and since Gary is going to have surgery in three days and he can withstand the pain, he doesn't need steroids. We will not be giving them to him.

I don't think we can expect this kind of scenario to change.  Many in the profession are not ready to change, and they've not been trained to do so. Also, they face innumerable new pressures and obstacles to providing patient-driven care.

Randi learned this during her son's experiences in hospitals.  She therefore developed a series of approaches and techniques to help insert herself into the care regime.  She calls the book Questioning Protocol, and by trial and error, she learned how to do so in a manner that was less likely to cause clinicians to be defensive and upset.  She taught them how to become partners with the patient and his family.

After the episode above, she reports:

Things seem to change in the hospital from this point.  Clearly, they must have written in Gary's records that we are to be made aware of everything and given the opportunity to ask questions.

Now these strangers understand how we operate as a family. I understand they have a well-oiled machine they work in every day.  They move through the machine gears ducking and turning in synchronization with each other, sometimes forgetting that a newcomer might be terrified.  I think they believe that trust in the machine is essential. After all, they know they are the experts.

I feel as if the machine slows down for them when I try to get up to speed.  I see their frustration creep up.  They have other people to process.

The doctors are the first to say they do not have all the answers.  I realize maybe that's why they don't like the questions. But this experience reinforces my resolve: Unless it's life-threatening, I must STOP the machine and understand exactly what is happening.  I'm incorporating these new people into OUR team.

Each chapter of the book contains a portion of her family's narrative, but then ends with two or three or four concrete pieces of advice for people who finds themselves in the clutches of the health care system.  The advice is cogent and clear and helpful.

I highly recommend this book.  I don't think it will be obsolete, as Randi hopes, in ten years.  Buy it now for when you'll need it.  You will.

Pedestrian injuries from cell phones

You will recall the excellent advice of my primary care doctor, Amy Ship, when it comes to using a cell phone while driving.  Don't!

Now comes this story from Governing, about the dangers to pedestrians who are walking and using their cell phones, both talking and texting.  It was brought to my attention by the folks at Commonwealth Magazine.  Excerpts:

Pedestrian injuries due to cell phone use are up 35 percent since 2010, according to federal emergency room data reviewed by Stateline, and some researchers blame at least 10 percent of the 78,000 pedestrian injuries in the U.S. in 2012 on mobile device distraction. The federal Fatality Analysis Reporting system attributes about a half-dozen pedestrians deaths a year to “portable electronic devices,” including phones and music players.

Emergency room visit data analyzed by Stateline are published by the Consumer Product Safety Commission, and incidents caused by distracted walking are likely to be underreported, since the injured party would have to confess to texting or phoning while walking.

A Stony Brook University study in 2011 documented the effect of texting on navigation while walking, finding it significantly more dangerous than talking on a cell phone, leading to a rate of 61 percent navigation errors in simulated situations.

“While talking on the phone is a distraction, texting is much more dangerous because you can’t see the path in front of you,” Jehle said.

Saturday, December 13, 2014

I'll take generic cancer treatment, please


Speaking of insipid hospital advertising in Jacksonville Airport, what's the story about this one from Mayo Clinic?  Who on earth doesn't offer personalized cancer treatment?

And, why does it say "most" insurance plans accepted?  Why wouldn't they accept all insurance plans?

As below, does any of this kind of advertising contribute to the public good?

Friday, December 12, 2014

NowIknowmemorial. Do you really?


Passing through Jacksonville Airport, we saw the advertisement above for a local hospital.  I guess I should be used to ads that suggest that robotic surgery has "quicker recoveries," but this ad made me wonder what other assertions this hospital might make.  What I found is all too typical of the generic, meaningless, and unsupported advertisements hawked by marketing firms and favored by hospital PR departments, CEOs, and Boards of Trustees.

I went to the website to review other aspects of the "NowIknowmemorial" campaign.  Here are the other three images presented.


What does "some of the shortest" mean? Compared to what? Over what time period?  I searched the website and couldn't find those answers.


Of course, OB hospitalists are a valuable service offering, but does it matter that Memorial was the first, if others now have this service?  Obstetrics competition is apprently rife in Jacksonville.  This article notes:

Maternity care is a major marketing tool for hospitals. A nice facility and positive birth experience can mean that the mother, who overwhelmingly makes the health care decisions for the family, will return for pediatric and other care.


And, the ultimate meaningless metric.  But let's say the US News ranking has some validity.  Is this hospital in the Honor Roll of Best Hospitals, one of just 17 out of over 5000 nationwide.  No.  So it's one of the hundreds of so-called "best hospitals."

Here's the actual page from the rankings.  First, let's see how many services were ranked by US News.  Well, none:


Now, let's see how the hospital compares to its peers with regard to patient satisfaction:


Oh dear, below both the state and national average with regard to likelihood to recommend, and above average with regard to unlikelihood to recommend.

Look, I don't mean to pick on this hospital.  Its campaign is emblematic of so many others being run around the country.  I think it's reasonable to ask: Does any of this kind of advertising contribute to the public good?

Thursday, December 11, 2014

When they lose their way

This story by at Bloomburg News shows what often happens in "make your numbers to make your bonus" organizations.  Summary:

Cracks in the foundation of Wal-Mart’s retail business in China have been developing for years, hidden by questionable accounting and unauthorized sales practices.

Let this be a lesson to boards of trustees of health care systems who focus too much on CEOs' achieving corporate financial objectives.

Two leaky lifeboats strapped together?

Priyanka Dayal McCluskey and Robert Weisman at the Boston Globe report that Boston Medical Cemter and Tufts Medical Center are considering a merger, "a deal that, if approved, would be the biggest union of Boston teaching hospitals in nearly two decades."

They note:

A merger would link two nonprofit hospitals that both treat many low-income patients and have endured financial struggles.

While such conversations are worth pursuing, the issue facing the institutions is whether they would be stronger together than they are separately.  If not, this could be a case of strapping two leaky lifeboats together, leading to a faster demise than if they remained apart.

What are the obstacles to success?  First, one of the consequences of the Affordable Care Act has been a diminution in public support for safety net hospitals, like BMC.  There's no indication that government policy will change on that front.

Second, TMC has the weakest referral base of all the teaching hospitals in Boston and, despite best efforts on that front, it remains behind the other big hospitals on that front.

Third, BMC has a large number of unions (is it 14?) that, in the words of a prior CEO, "make it impossible to manage."

For a merger to succeed financially, we need to look for accretive value.  Would it be possible to eliminate layers of overhead, achieve economies of scale in purchasing and other functions, and negotiate better contracts with insurers?

Is it possible to rationalize areas of clinical care?  For example, both hospitals have kidney transplant programs that are, frankly, too small to justify in the own right.  By combining them, costs could be reduced and outcomes likely improved.  Might there be other examples?

But it is often  difficult to accomplish such rationalizations, in that the doctors in each hospital might feel a proprietary interest in their programs.  Someone would have to negotiate a new clinical leadership agreement.

Which brings up the biggest issue of all:  Most mergers are not mergers.  They are takeovers by one party.  The BIDMC example is apt.  A so-called merger of New England Deaconess Hospital and Beth Israel Hospital in the mid-1990's was actually a takeover of the former by the latter.  This led to resentment, alienation, and near bankruptcy.  (In contrast, the successful "merger" of MGH and Brigham and Women's Hospital to create Partners Healthcare System was not a clinical merger at all.)  The cultural issues associated with mergers reign supreme, and I trust that the parties at BMC and TMC are thinking through those aspects as well as the clinical and business aspects.

Interestingly, the Globe story notes that while Tufts is connected with Tufts University School of Medicine and BMC is affiliated with Boston University School of Medicine, "the medical schools . . . would not be part of the deal."

A question to ask is, why not?  We don't need to consider a merger of the two medical schools to rationalize their undergraduate medical education and graduate medical education programs.  There might be efficiencies to be garnered there.  And with the weakness of its other education affiliate, Steward Healthcare, perhaps Tufts Medical School should be considering more of a strategic alliance with its colleagues at BU to ensure the strength of its medical education program.

Wednesday, December 10, 2014

HealthNewsReview lives on!

Many of us are extremely pleased to hear that Gary Schwitzer and his colleagues at HealthNewsReview have received a major grant from the the Laura and John Arnold Foundation:

Stuart Buck, JD, PhD, the Vice President of Research Integrity for the Arnold Foundation, said:
“With a ‘publish or perish’ mentality, researchers are incentivized to produce findings that are striking enough to grab headlines and citations, even though such findings may be exaggerated. News organizations often pass along such findings uncritically, without carefully considering how a study was conducted and whether the results are based on accurate science. We are pleased to provide funding so that Gary Schwitzer and his team can help the media to evaluate medical studies and press releases with a skeptical eye.”
Among other things, the grant will permit Gary and friends to:

Add new systematic reviews of health care news releases (from sources including medical journals, drug/device manufacturers, academic medical centers). This is the most important new feature made possible by the new grant, allowing us to critique news releases that are often the faucets that turn on health news. 

HNR is one of those examples of social media that validate the medium, offering unvarnished reviews of claims in a field where unverified claims are commonplace.  This grant is a terrific contribution to the public good.  

Tuesday, December 09, 2014

Commoditizing patients

This report on BetaBoston made me uneasy.  I'm almost reluctant to comment because my colleagues in the industry may see it as a part of a pattern to criticize a certain health system, but I would say the same thing regardless of what company might be involved in this venture.  See what you think.  Here are key excerpts from the article:

The Center for Connected Health at Partners HealthCare has created a secure survey tool to help medical product makers and investors get feedback from patients and customers. The new mobile app and Web-based survey tool called cHealth Compass will charge companies for the service and pay survey takers for their time.

New enrollees get a flat $50 when they register and $110 per year to take monthly surveys. Other opportunities from individual vendors could pull in between $20 to $50 per survey.

“We currently have several hundred people, and are actively enrolling more,” said Jethwani. The goal is to enroll 2,000 patients from Massachusetts by summer 2015, and then expand to include residents from other parts of the United States.

Client companies will pay a fee for the service, depending on how many questions are included in their surveys and how many patients they intend to reach.

My first reaction is that the health system has just found a new way to commoditize patients.

My second reaction is that this effort is designed only to help companies. It is not designed at all to help patients.  The press release doesn't even pretend that it is otherwise.

My third reaction concerns the potential for bias that is created when responders are paid.

If there were a way for patients to find value by participating in surveys, outside of money--like in this case--that approach might lead me to a different set of conclusions.

Only at IHI!

The Annual Forum run by the IHI always has some surprises.  The best one for me this year:  Only here could you be in the ballroom watching a keynote address by Atul Gawande while exercising on a treadmill!

A just culture at work

The health care world is abuzz with a report from Oregon about a woman who died from a drug administration error.  There are many details about what went wrong and why, but I was extremely pleased to see this statement from the hospital:

"While human mistakes were made in this case, we as a health system are responsible for ensuring the safety of our patients," the health system said in a statement. "No single caregiver is responsible for Loretta Macpherson's death. All of us in the St. Charles family feel a sense of responsibility and deep remorse."

Saddened, they also went right to work to fix underlying problems:

The health system said in a statement that it has put several measures in place to make sure the mistakes aren't repeated. It's enforcing a "safety zone" in its pharmacies so workers can complete medication verifications with fewer distractions, and it's bringing in an external pharmacy expert to provide recommendations.

The hospital system is also looking at changes in how patients are monitored after medication is administered.

Although newsworthy, this event is not unusual. There are many such errors that occur in hospitals, all too frequently.  Also, there are many times more that number of near misses that go unreported, each one of which offers the potential to uncover and remediate systemic problems.

Monday, December 08, 2014

Behind the scenes at the World Center Marriott

Starting with the end of the day first, you see here Melissa Hayes, Regional Director of New York's HELP/PSI Inc. summarizing observations from day-long excursion at the IHI National Forum in which a group of us had a chance to go behind the scenes of the Orlando World Center Marriott.  The purpose was to learn how the resort handles the flow of large volumes of visitors and delivers high levels of customer service in the front office, adheres to schedule in the banquet kitchen, manages daily housekeeping operations, runs a golf club, and tends to a multitude of details in events and convention services.  Our goal was to see if there were lessons from this kind of business that might be applied in health care settings.  Participants on the tour came from a variety of organizations in the US, Singapore, New Zealand, Scotland, Norway, Canada, Iceland, and the UK.

It was figuratively and literally a "soup to nuts" tour, with presentations on site from a variety of program managers.  Here you see New Zealand's Helen Mason with James Rothier, the senior banquet chef.  He gave a detailed view of the food preparation process for the thousands of meals served every day, whether for large conventions of the size represented by the IHI Forum (over 5000) or for smaller business and personal events that take place during the year.  We focused on food safety issues, but also worker safety in a busy work environment characterized by sharp knives, hot water and oil, cooking fires, and large movable containers.

On another front, a visit to the lost and found provided a reunion for Scotland's Michael Kellet with Sydia Dawkins, who, on the previous day, had returned to him a Blackberry he had lost in the seat cushions of one of the hotel's restaurants.  Sydia's boss, Mike Cord, explained the procedures followed when items were lost in the hotel (a common problem in hospitals, too!)  In a place the size of the Marriott, this amounts to thousands of objects per year, and they are kept in storage for up to six months on the chance that travelers will be delayed in claiming and retrieving them.

And so on, through many back corridors of the hotel, as we heard of the logistical challenges in a place of this size, many of which paralleled the service issues facing hospitals. At the debrief, my colleagues Marie Schall and Deborah Bamel (left) and I asked the participants to meet in small groups to compile and categorize their observations of key aspects of the hotel's procedure and to try to draw lessons for their home environments.  The categories shown on Melissa's group's sheet were echoed by the others in the room:  A strong focus on customer satisfaction; intensive and extensive training of staff in standardized approaches to the work environment; strong communication within and across operational divisions; an unending pursuit of high quality; a culture of collaboration, respect, and caring; and, above all, a commitment to associates' recognition and empowerment.

Janet Reeder from Kaiser Sunnyside Medical Center offered a visual summary of the latter point by capturing this hall of honor of associates who had been recognized for extraordinary work by their peers and supervisors.


I'm hoping other participants in the excursion will offer comments about the experience and expand on my brief summary.  Stay tuned over the next day or two as they arrive below.

Sunday, December 07, 2014

Shrink to grow

I want to make an outrageous proposal to the board of trustees of Partners Healthcare System (PHS) as they go about deciding on their next CEO:  Hire someone to split up your health care system so that it can productively grow.

This is a matter of good management and good public policy.  Let me explain.

From the beginning, the creation of PHS was never intended to result in a clinical integration of the flagship hospitals, Massachusetts General Hospital (MGH) and Brigham and Women’s Hospital (BWH).  The two organizations have disparate cultures and have always suffered from mutual jealousies, sometimes rising to the level of disdain.  The senior leadership of PHS recognized early on the futility of clinical integration and instead focused on back-office functions—purchasing, information systems, and negotiations with insurers.  On those fronts, they were relatively successful, achieving some economies of scale and other financial gains.

As the system grew, with acquisition of physician groups and incorporation of outlying community hospitals, the clinical split between the flagship hospitals was reinforced.  To this day, physicians and community hospitals refer their patients primarily either to MGH or BWH.  Researchers in each flagship hospital have no special interaction with those in the others, compared to interaction with the other non-PHS Harvard hospitals.  Education programs—undergraduate medical education and residency programs both—likewise are physically and culturally separate in most respects.  Quality improvement programs, to the extent they exist, are hospital-centric.  Development of new clinical initiatives occurs in one place or the other, but seldom in both.

Beyond that, each hospital has used its influence at the PHS headquarters to impair some of the creative energies in the other.  There are plenty of stories, for example, of times an initiative at BWH might have the potential to be truly competitive with an established program at MGH, and only to find itself quashed at the corporate level.  These were not cases of rationalizing care delivery: They were simply opportunities for ego-flexing.

Likewise with regard to philanthropy.  Donors are identified early and separately as MGH targets of opportunity or “BWH people.”  Never the twain shall meet, and their identities are carefully guarded until the gifts are secured.

So this is not truly an integrated health care system, and it will never be.

On the business side, too, the existence of economies of scale has clearly reached a point of diminishing returns.  Look, for example, at the recent $1 billion information systems contract with Epic.  I am willing to bet that disparities in the models of care and administrative requirements between the two segment of PHS are causing that IT system to have higher costs than would occur if it were being constructed for two separate and more culturally distinct organizations.

Likewise, there is little or no advantage in purchasing contracts for this large system that would not be available for two somewhat smaller, but still very large systems.

Further, the centralized PHS corporate office with high salaried people in the high-rent Prudential Center is quite properly viewed with resentment as mere overhead by those both on Fruit Street and Francis Street.

The one thing that might be argued is that PHS has had effective and extreme power in its negotiations with insurance companies, leveraging its network spread to demand higher rates than almost all in the region.  But, even there, a case can be made that the leverage was based on geographic dominance in each subregion—a dominance based either on the presence of the MGH-affiliated branch or the BWH-affiliated branch—as much as the system as a whole.

Meanwhile, though, the size of Partners makes it a target for opponents when it seeks to grow.  Witness the recent objections to the acquisition of community hospitals to the north and south of Boston.  What might make sense from a public policy point of view, with regard to suburban-to-urban secondary-to-tertiary clinical integration, gets squashed or subject to burdensome regulatory requirements.

Everybody interested in health care in Eastern Massachusetts—government officials, business customers, and consumers—seeks to bring about cost savings, service improvements, and a drive to higher quality care.  Notwithstanding lots of recent state legislation, there is a growing recognition that the only way to achieve this is a greater level of competition in this marketplace.  As things stand, Lahey, BIDMC, Tufts and the others can only nibble at the edges, and they scarcely make a difference in the overall results in terms of those desired areas of improvement.  Meanwhile, Steward Healthcare System is showing signs of rapid decline and irrelevance.  Boston Medical Center, too, remains in its safety-net niche, scraping by with diminished state and federal resources.

The best way to generate real competition is to split PHS so that MGH and its network and BWH and its network have separate corporate identities and bottom lines.  This would acknowledge the de facto clinical separation of the two components of the PHS system and give each organization a real incentive to grow—but this time through excellence in care delivery rather than corporate heft.  Each, too, might seek new clinical alliances with the aforementioned Lahey, BIDMC, Tufts, Steward, and BMC, offering the potential for rationalization of care and better use of financial resources.

Would the Partners board have the nerve to dismantle a system they assume is working well?  Frankly, not likely.   But this is not a case of having to worry about accretive value for shareholders or private equity investors.  There are no shareholders here.  The only audience of concern should be the public.  The board owes it to that public to review the twenty-year history of the corporation and objectively determine whether the region is better off for the creation of Partners Healthcare System, and whether the future is better served by one entity or two. Indeed, any potential CEO worth his or her salt should be asking the question before taking the job.

(Note to Attorney General-elect Maura Healey:  Might they be more likely consider a breakup if you tossed out the wrong-headed proposed agreement negotiated by your predecessor and threatened a true antitrust lawsuit jointly with the US Department of Justice?  This is a moment for a great negotiator, and you have the power to set up the situation for an agreement that is truly in the public interest.)