Wednesday, April 23, 2014

GRACE: It all started by asking why, five times

Back in 2010, I reported on a protocol developed by Dr. Melissa Mattison and others called GRACE (Global Risk Assessment and Careplan for Elders). As noted then, this program was designed to improve the care of all hospitalized elders, with the hope of reducing the risk of delirium, falls, pressure ulcers, functional decline, etc.

But let's go back to the genesis of GRACE, when the staff wondered what might be the cause of many of the falls experienced by older patients.  As I noted in 2009:

Our review process often indicated that the staff had done just the right things with regard to fall prevention and supervision of patients. Using the "5 Why" process of Lean, they kept digging into the cause of these falls. A hypothesis emerged: Perhaps we were contributing to the likelihood of falls by over-medicating geriatric patients or missing important parts of their supervision and therefore causing them or allowing them to be disoriented.

The GRACE protocol was the result of this root cause analysis.  I'm now happy to provide a progress report, in the form of an article in the Journal of the American Geriatric Society. The program has been shown to make a difference.  Here are some excerpts.

Recognizing that older adults have specific care needs that are distinct from the needs of younger adults, a group of geriatricians, hospitalists, and nurses designed a supplemental checklist to accompany the standard bedside monitoring form.

Specifically, the bundle provides staff with a bedside checklist for individuals aged 80 and older admitted to the hospital and decision support in the CPOE system. The bedside check-
list prompts staff to screen for delirium and to implement delirium prevention and management strategies. The CPOE system provides decision support for antipsychotic and opioid analgesic ordering.


There were four main components of the intervention that were critical to its success. First, the intervention was targeted to a population likely to benefit from the intervention and that staff and the CPOE system are likely to identify easily. Units where individuals were already receiving specialized care plans (e.g., intensive care units, inpatient psychiatry) were excluded. Second, the decision support required for success of the intervention was carefully designed for this target population. Third, outcomes focused on critical intervention components were predetermined and monitored. Finally, throughout the intervention, educational curricula were created and offered to staff across clinical disciplines—including nursing, physician staff, and residents.

The findings indicate that the intervention improved prescribing of sedating medications—participants were significantly less likely to be prescribed haloperidol in excess of 0.5 mg or intravenous morphine in excess of 2 mg. There were more triggers for acute change in mental status, but this was seen in individuals receiving the intervention and in the concurrent controls. Significantly more individuals receiving the intervention were discharged to home than to ECFs [extended care facilities] than would have been expected, suggesting less in-hospital functional decline.

Tensions and Tempers on WIHI

Madge Kaplan writes:

The next WIHI broadcast — Transforming Tensions and Tempers on Health Care Teams — will take place on Thursday, April 24, from 2 to 3 PM ET, and I hope you'll tune in.
Our guests will include:
  • Neil Baker, Principal, Neil Baker Consulting and Coaching
  • Nan Cochran, MD, President, American Academy on Communication in Health Care (AACH); Director, On Doctoring
  • Calvin Chou, MD, PhD, FAACH, Professor of Clinical Medicine, UCSF; Vice President for External Education, AACH
Enroll Now

The last thing a patient needs to experience at a hospital or a clinic is tensions between staff members. Yet, we've all been there and seen and heard things that make us wonder “who isn’t getting along with whom” or, worse, are we getting the best care when we can tell providers are just barely disguising their frustrations with one another? It's a fair question, especially since health care is being redesigned at all levels to be more of a team effort. Doesn't that mean that the team has to be cohesive and everyone needs to get along?

We're going to get into this important issue on the April 24 WIHI: Transforming Tensions and Tempers on Health Care Teams. The topic couldn’t be timelier, and we’ve brought together an expert group that spoke to a packed room about managing conflict on health care teams at IHI’s National Forum in December.

Neil Baker is familiar to many of you as an IHI faculty member who’s spent the past 30 years helping organizations and professionals better deal with the “people issues” that can not only stall improvement work but also jeopardize patient safety. Nan Cochran wears a lot of hats, including being President of the American Academy on Communication in Healthcare. Dr. Cochran does a lot of training in conflict management and negotiation, which we’ll tap into on the April 24 WIHI.

Calvin Chou at UCSF rounds out our panel. His work focuses on teaching medical students and residents humanistic clinical skills that are critical to communicating more effectively with patients. Some of these same skills can help health care teams better appreciate their differences and avoid overreacting to one another, to the detriment of the team and patients.

What are you and your colleagues learning about building rapport and resolving tensions? I hope you’ll tune into the April 24 WIHI to share your experiences, learn from our experts, and bring members of your health care team with you. And, if you sometimes wonder what’s behind some of the difficult behaviors on teams, here’s some interesting additional reading. See you on April 24!
I hope you'll join us! You can enroll for the broadcast here.

The slippery slope between academia and pharma

I want to be very careful about how I present the following information, as I mean to suggest no improper or illegal behavior on the part of any individual.  Instead, consistent with my previous columns on these matters, I mean to suggest that it is a slippery slope when people in academic medical centers join the boards of directors of pharmaceutical companies. The issue is not their honesty or expertise.  The issue is that we lose the expertise of key people in helping us resolve thorny public policy debates.  A further issue is that, in serving two masters, they contribute to the erosion of public confidence in the research and clinical activities of the health care sector.

We start with a story by Andrew Pollack in the New York Times.  The lede:

Record sales of a new hepatitis C drug pushed the first-quarter earnings of Gilead Sciences far beyond expectations, the company reported on Tuesday, but could also heighten concerns about the high cost of the drug, known as Sovaldi, and the ability of the health care system to pay for it.

He explains:

The rapid uptake of Sovaldi to some degree reflects pent-up demand, as many patients were holding off treatment until it was approved in December. The drug, a pill taken once a day, has a higher cure rate, a shorter duration of treatment and fewer side effects than previous treatments.

But Sovaldi, which has a list price of $1,000 per pill, or $84,000 for a typical course of treatment, has become a flash point in a debate over drug prices.

Paying for Sovaldi for all the patients who need it could put financial strain on insurers, state Medicaid programs, the Department of Veterans Affairs and prison systems. UnitedHealth Group, one of the largest insurers, said last week that its first-quarter earnings had declined in part because it had spent more than $100 million on hepatitis C treatments, including Sovaldi, far more than it expected.

Some doctors say there is a benefit to treating even early stages of the disease, to prevent scarring of the liver.

“If cost were not a factor, we would want to treat the entire population,” said Dr. Rena Fox, a professor of medicine at the University of California, San Francisco. She said it was frustrating that “we finally get this great treatment and then we withhold it.”

Now, let's look at the membership of the Gilead Board of Directors.  It is not atypical in including luminaries from many fields, and among the group is Professor Richard Whitley, from the University of Alabama at Birmingham. His compensation from Gilead has been reported as $425,000.  A truly impressive physician, Dr. Whitley is:

Distinguished Professor of Pediatrics, Professor of Microbiology, Medicine and Neurosurgery; Loeb Eminent Scholar Chair in Pediatrics; Co-Director, Division of Pediatric Infectious Diseases; Vice-Chair, Department of Pediatrics; Senior Scientist, Department of Gene Therapy; Scientist, Cancer Research and Training Center; Faculty, Gene Therapy Center; Associate Director for Drug Discovery and Development and Senior Leader, Pediatric Oncology Program, Comprehensive Cancer Center; Director, UAB Center for Emerging Drug Discovery; Co-Founder and Co-Director, Alabama Drug Discovery Alliance. 

He is also "responsible for the National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group whose role is to perform clinical trials of antiviral therapies directed against medically important viral diseases of children and adults including viruses considered as threats to human health." 

A more detailed description follows:

Through the NIAID-CASG we perform clinical trials of antiviral therapies directed against medically important viral diseases of children and adults. These include studies of neonatal herpes simplex virus infection, herpes simplex encephalitis, herpes zoster, enteroviral infections of the newborn, therapeutic interventions for congenital cytomegalovirus infections, hepatitis C, and respiratory virus diseases in the immunocompromised host. Work in these areas includes protocol design, assessment of efficacy and toxicity endpoints, application of contemporary clinical trial methodology and monitoring principals, and evaluation of biologic specimens obtained from volunteers in these studies.  [Emphasis added.]

According to this report, Dr. Whitley is an Editor of Antiviral Research, and is a member of the Editorial Boards of the Journal of Infectious Diseases, Sexually Transmitted Diseases, Reviews in Medical Virology, Antimicrobial Agents and Chemotherapy, Antiviral Chemistry and Chemotherapy, Infectious Diseases Watch for Pediatricians, Seminars in Pediatric Infectious Diseases, Gene Therapy, and Medscape Infectious Disease.

As we view all of this, we can only imagine the extent of Dr. Whitley's personal commitment to eradicating disease.  This is truly an outstanding record.  I'd bet, too, that he would strongly support expanded access to Sovaldi for humanitarian reasons.  But in all the searches I have done, I can find no public statements from him concerning the financial issue raised in Andrew Pollack's story.  Indeed, it would be very difficult for someone on the Gilead board to make a statement about such matters, as it would be viewed as inconsistent with the duty of loyalty and care required of corporate directors.

I note that Gilead has made the drug available at a dramatically lower cost in some other countries in the world.  As reported here,

The company’s reduced prices came after the World Health Organization worked with Gilead directly to help spread the drug's usage. So what determines who gets a discount and who doesn't? It's simple. Gilead admits their “global pricing model is based on a country’s ability to pay.”

As for the $1,000 a day American price for the extremely effective (and life-saving) medication, Gilead is holding firm that they “think the price is fair. It’s a one-time cost that is your lifetime cost.”

So, there we have the nub of the issue. An extremely respected scientist with Dr. Whitley's credentials could be among the most qualified in society to "referee" this kind of issue--to help us understand and balance the legitimate financial needs of the pharmaceutical industry with the equally important humanitarian concerns about a drug's availability and cost in America.  He cannot do so while on the board of the company producing the drug. The loss to society is that someone of Dr. Whitley's expertise and compassion is taken out of the public debate on these matters.

Beyond that, what does his silence on this issue say to the country about his duty to two masters, a federally subsidized drug research effort and a pharmaceutical company? What message does that send to the public about how they should view the relationships between academic medical centers and industry? I think it doesn't help either sector retain the public's confidence.
Distinguished Professor, Loeb Scholar Chair in Pediatrics, Professor of Pediatrics, Microbiology, Medicine, and Neurosurgery, University of Alabama at Birmingham - See more at: http://www.gilead.com/about/leadership/board-of-directors#sthash.f1uR5D5k.dpuf
Distinguished Professor, Loeb Scholar Chair in Pediatrics, Professor of Pediatrics, Microbiology, Medicine, and Neurosurgery, University of Alabama at Birmingham - See more at: http://www.gilead.com/about/leadership/board-of-directors#sthash.f1uR5D5k.dpuf
Distinguished Professor, Loeb Scholar Chair in Pediatrics, Professor of Pediatrics, Microbiology, Medicine, and Neurosurgery, University of Alabama at Birmingham - See more at: http://www.gilead.com/about/leadership/board-of-directors#sthash.f1uR5D5k.dpuf

Tuesday, April 22, 2014

Texting while "driving" in the OR

We all know we shouldn't text while driving, right? Because if you are going 30 miles per hour, your car has gone 44 feet for every second you are looking down at your iPhone. Bad things can happen even at that speed.  At 60mph, you go 88 feet per second.  Imagine how much damage you can do in that situation.  But remember the guy who said, "I only text on the highway"?

Well, now comes a new set of "drivers," doctors who text or otherwise use their electronic message devices while in the operating room. They are equally irresponsible.  Check out this article by Rebecca Buckwalter-Poza on Pacific*Standard. Excerpts:

In one ongoing malpractice case in Texas over the death of a 61-year-old woman following a low-risk cardiac procedure, attorneys for her family discovered that the anesthesiologist charged with administering anesthesia and monitoring the patient’s vital signs had been on his iPad throughout the operation. In his deposition, the surgeon testified that the anesthesiologist didn’t even notice the patient’s dangerously low blood-oxygen levels until “15 or 20 minutes” after she “turned blue.”

The anesthesiologist admitted to texting, accessing websites, and reading ebooks during procedures. He claimed, though, that “even when I’m doing so, I’m always listening to the pulse ox, always checking the blood pressure, always—you know, at least every five minutes.” It seemed lost on him that five minutes is an eternity in medicine: The brain begins to die after just a few minutes without oxygen.

While throughout the 1980s, most programs banned residents from so much as studying in operating rooms or on the ward, doctors now routinely do far more distracting things in these same settings, with no possible medical justification—from tweeting to texting to posting on Facebook.  

The term “distracted doctoring” doesn’t seem adequate to describe the phenomenon of health care providers who habitually use electronic devices for non-medical purposes during appointments and procedures. These doctors, nurses, and technicians aren’t momentarily distracted: They’re deciding to interact with Facebook friends or Twitter followers instead of the patient in front of them.

Perhaps hospitals should do what our local transit system does:  They prohibit even possession of cell phones by transit drivers while in buses and rapid transit vehicles.  Because if you have it, you will use it.

Monday, April 21, 2014

How to come to terms with wanton cruelty

A friend whose mother was murdered in Kabul, Afghanistan last month teaches us a lesson in how to come to terms with wanton cruelty.   If you feel inclined to support her family's non-profit organization in support of education and service opportunities for Afghan boys and girls, click here.

A small thank you to everyone who has made this month one surrounded with beauty and love. It is a quiet time, but there are miracles at every glance. I am ever more convinced that we need to embrace opportunities to be humbled – humbled by nature, by love, by those around us who understand the world differently. Perhaps in that humility we can find a way to all get along. Though I have refrained, for the most part, from reading the news reports, I do know that the attack in Kabul last month was carried out by boys who were not yet men. Had they met my mother in any other circumstance, they would have been met with kindness, and perhaps seen another way through this world. In light of this, and in gratitude to my loved ones who continue to share the beauty of this world with me, I make my peace today:

Oh, boys. You can’t have known
The silent mystery of the wind,
Tousling the hair of the childish grass
As if it had just made
A cheeky joke.
Or the laughter of the birds
Who were eavesdropping
The. Whole. Time.
But I will continue watching.

You can’t have heard
The endless waves of secrets
Held in every shell
Or the delighted squeals
Of a child bearing
Witness
To it all.
But I will continue to press my ear close
So I don’t miss a single heartbeat
This world has to offer.

You probably never knew
The grace of the sun
Caressing the caterpillar
Assuring it that
There will be light
When it is reborn.

You can’t have known
The giddy feeling of a first picnic
Or the electricity of holding hands
For the very first time
With one who will see you
Through everything.

You can’t have known
The hilarious struggle
Of a very pregnant woman
Trying to put on
Socks.

Oh boys.
You can’t have felt
The undeniable mercy
Of kneeling,
Touching your forehead
To Earth’s Lips
That the universe may tell you
Over and over and over again that
It loves you.
Yes, I am completely enthralled by
The Irresistible Beauty
Of this world.

And I will stay forever in that embrace
And love it back with all I have
And quietly pray that
Though you never knew it here
The peace is with you now.


Look, you can watch this happen in real time!

Those of you who had any doubt at all about the points I raised in my recent post about how the daVinci robot system has extracted funds from the health care system, check out this story by Jaimy Lee and Harris Meyer on Modern Healthcare, "Surgical Robot Costs put Small Hospitals in a Bind."  Excerpts:

Memorial Hospital of Converse County last year purchased a $2 million da Vinci Surgical System, the second hospital in Wyoming to do so. Memorial executives said they expect their facility to perform about 100 robotic surgeries a year. That's far below the estimated volume experts say is needed to produce a viable financial return within six years on the robotic system, whose average cost ranges from $1.5 million to $2 million.

Memorial, which reported an operating loss of $2.2 million in the first half of fiscal 2014, used cash reserves to buy the da Vinci system, manufactured by Sunnyvale, Calif.-based Intuitive Surgical. Memorial said 40% of its cost will be reimbursed by Medicare as a capital expense because it is a critical-access hospital.

Ryan Smith, the hospital's CEO, said he doesn't mind if it takes awhile for the pricey new piece of equipment to pay off because it's already attracting patients who previously would have traveled to other hospitals in Colorado or Utah to get robotic surgery. Also, it helps his hospital recruit and retain surgeons, and is expected to reduce surgical complications and lengths of stay. “We did not buy the da Vinci system to get a very high return on investment,” Smith said. “It was the right thing to do for our patients.”


While overall sales of da Vinci systems are on the decline, a number of small and rural hospitals are considering following in Memorial Hospital's footsteps, believing it will help them attract and retain surgeons and appeal to patients. The government system for financing critical-access hospitals helps underwrite some of the costs.

But small hospitals going down that path will face the same issues now confronting major systems that have installed surgical robots. Some studies have raised doubts about whether robotic surgery offers better outcomes than standard laparoscopic procedures. And Intuitive Surgical faces dozens of product liability lawsuits across the country filed by patients who claim injuries from the device. 


[By the way, notice how the hospital's website above, promises: "reducing outpatient recovery times, blood loss, and pain."  See my earlier post for documentation of how these claims are unsupported by the evidence.] 

For critical-access hospitals, Medicare helps subsidize the purchase as a capital expenditure on a depreciated basis, calculated by what percentage of patients are Medicare beneficiaries. But “it's a big question in terms of priorities and where your scarce resources are best used,” said Brock Slabach, senior vice president of the National Rural Health Association. “Patients perceive it to be better. But is the cost worth the benefit?”  

More small hospitals view the da Vinci system “as a tool they need to recruit and retain surgeons and to stay viable,” said Liz Tiernan, a consultant in the Advisory Board Co.'s research and insights groups. “It is considered a standard of care .… but it's rarely financially viable for them.”

[W]hen surgeons at a smaller hospital don't reach the estimated proficiency threshold, that raises questions about the adequacy of their experience. “It becomes even more difficult to justify this decision,” Tiernan said. 

Sunday, April 20, 2014

I, Robot has nothing on the truth

Here's the IMDb summary of the 2004 movie I, Robot:

In the year 2035 a techno-phobic cop investigates a crime that may have been perpetrated by a robot, which leads to a larger threat to humanity.

But we don't have to wait until 2035.  We've seen a different kind of "crime" perpetuated by a robot during the last decade or so.

If we could start all over again, would we want the medical community to spend billions of dollars in capital and operating costs on a medical device that had no proven relative efficacy compared to conventional, lower cost techniques?  I think most of us would say, "No."

But the medical community has been complicit in carrying out exactly this scenario with regard to the daVinci surgical robot.  The federal government has likewise stood by and watched, as have insurers.  At best, the establishment media has let the story go on for years, and, at worst, has been quick to jump on the bandwagon.  All to benefit the managers and shareholders of a private company.

What kind of money are we talking about?  How about 2,585 installations at a purchase price of about $1.5 million, or $3.9 billion?  And a required annual maintenance contract of about $150,000, for $387 million per year.  And disposable supplies used per surgery of about $2000, with about 100,000 cases per year, for a cost of $200 million.  (Or calculating another way, Intuitive Surgical, Inc. reported revenue of $2.3 billion in 2013, $2.2 billion in 2012, $1.8 billion in 2011.  Net income for those three years, by the way, totaled $1.8 billion.)

This has been a breathtaking saga.  We could hope that it would present lessons for the future, but there is no indication that it has done so, whether for the expanded use of this technology to other areas, or the introduction of other devices and procedures that comprise the medical arms race.

The most recent bit of evidence of the degree to which the country has been taken in is summarized in this article from Medpage Today:

Robot-assisted radical prostatectomy (RARP) led to complication rates, readmission rates, and rates of additional cancer therapy similar to those of conventional surgical prostatectomy, a review of almost 6,000 cases showed.

Patients who underwent RARP had significantly higher complications rates at 30 and 90 days, but blood loss and transfusion rates were lower, as was the risk of a prolonged hospital stay. After adjustment, the overall complication rates did not differ.

"RARP and open radical prostatectomy have comparable rates of complications and additional cancer therapies, even in the post-dissemination era," Quoc-Dien Trinh, MD, of Dana-Farber Cancer Institute in Boston, and co-authors concluded. "Although RARP was associated with lower risk of blood transfusions and a slightly shorter length of stay, these benefits do not translate to a decrease in expenditures."

But how about those supposed advantages with regard to urinary function and sexual function, i.e., quality of life issues?  Here was the result in a 2013 study in Urology:

Introduction of RALP (robot-assisted radical prostatectomy) did not result in improvement of functional outcome. There was no difference regarding urologic function/bother score or sexual function/bother score at 36-month follow-up in patients treated with LRP or RALP.

But this is not a new story. Look at this article from Urology in 2008:

Radical prostatectomy is an effective form of therapy for patients with clinically significant prostate cancer; however, outcomes are highly sensitive to variations in surgical technique. Because of the risks of perioperative complications and urinary and sexual dysfunction, which appear to be as great with robotic-assisted prostatectomy as with any other technique, patients with low-risk cancer, especially those >60 years, might be attracted to more conservative alternatives, including active surveillance, radiotherapy, and focal ablation.

Another article in Urology in 2011 talked about the learning curve associated with this "intuitive" system.  It suggests that a man might want to ask just how many procedures his surgeon has, er, under his belt:

Despite the intuitive nature of the daVinci system a definite learning curve with RALP (robotic-assisted laparoscopic prostatectomy) exists in relation to console time and LOS. Over 50 cases need to be completed to effect an appreciable improvement in learning curve. Positive surgical margin rates did not improve, suggesting that this may have a longer learning curve.

Had people been alert to this 2007 article in Urology, they could have seen that, in addition to the patient perspective, there is an institutional one, too, associated with the cost of learning curve for this equipment:

The literature search involved 8 series, with a range of learning curves from 13 to 200 cases. The least expensive learning curve was $49,613 and the most expensive learning curve was $554,694. The average learning curve was 77 cases and cost $217,034.

Conclusion

Costs associated with operative time while learning RAP (robotic-assisted prostatectomy) are substantial, and should be considered when deciding whether to implement RAP at an individual institution.

A 2008 article presented the business case as follows:

Purchase of a robot reduces income by at least $415,000 per year, due to the cost of the device and the service contract. Donation of a robot lessens the financial impact by $300,000 per year. If an institution maintains an identical caseload when switching from LRP to RAP, then it cannot maintain equivalent profits.. This holds true even if the robot is donated.

To maintain profits, an increase in caseload is needed to cover the added costs of the robot. At all levels of baseline productivity, purchase of a robot requires a greater case volume to maintain profits, relative to donation of a robot. Centers that perform a high volume of LRP at baseline need to only make small increases in total case volume to maintain profit, while centers with low volumes at baseline need to make very large changes in operative volume to cover the additional costs of robotics.

Like an airline making money with an airplane, the robot will only pay for itself if it is used at a high volume.

Imagine what kind of financial pressure that puts on doctors and hospitals to recommend prostate surgery rather than more conservative treatment approaches. How many men have had surgery who did not need to because of those pressures? How many of those have suffered irreparable harm?

Friday, April 18, 2014

Congratulations to Willy Spaan

I met Willy Spaan many years ago, during a visit to my former hospital. Later, he invited me to his hospital, Jeroen Bosch Ziekenhuis in the Netherlands, to conduct a number of seminars and workshops on quality and safety and other process improvement.  I'm very pleased to pass along, now, this announcement:

Prof. dr. W. Spaan, Chairman of the Management Board of the Jeroen Bosch Hospital, has been elected Care Manager of the year 2014. The jury awarded the title to Spaan because he is the most innovative and inspiring, and implemented patient safety into every layer of the organization. W. Spaan is someone who doesn’t have to be in the spotlights. He encourages the employees and medical specialists and provides them with the freedom to successfully do their work.

The election was organized by the magazine Zorgvisie, and is annually awarded to the most successful care manager of the year. The other two nominees were Jan Kimpen, CEO of University Medical Centre Utrecht, and Jeroen van den Oever of Fundis, formerly Vierstroom, in Gouda.

Quality

As chairman, Spaan has made quality into the guiding principle of care. He has tirelessly worked to create an active and open patient safety culture at the Jeroen Bosch Hospital (JHA). The existing internal and external openness about mortality rates, the quality indicators and disasters have greatly contributed to the internal awareness that it is important to keep improving, and that patients have confidence in organizations that are built on a strong culture of improvement.

 A personal encounter in 2008 with Donald Berwick, the former CEO of the Institute of Health Improvement, the leading institute in the field of quality and safety in health care, inspired him to implement the six dimensions of quality (Safety, Patient-centered, Effectiveness, Efficiency, Timely and Equality) as a corporate strategy in our hospital. From that moment, Spaan started to focus on quality in the care we provide to our patients. This has also led to JHA belonging to the five best hospitals in the Netherlands with regards to care indicators. 

The Jeroen Bosch Hospital is very proud that Spaan is elected as care manager of the year. His nomination is a great opportunity to further promote his mission for quality and safety, and to continue inspiring others. 

All candidates are assessed on the sustainable and innovative results they have achieved in the health care organization they lead. Their ideas about the organization of care inspire others inside and outside their institution, and they are an example for care managers in the Netherlands. The three candidates were nominated by a selection committee consisting of Professor Pauline Meurs and organization consultant Hanke Lange.  The winners were announced at the end of the congress  Focus on proper care in Haarlem.  Jury President André Rouvoet, also chairman of Insurers Netherlands, announced the winners.

Shelter in Place

One year later:  A few days after last year's Boston Marathon bombing, while the police and others were searching for the remaining suspect, the Governor asked people to "shelter in place," to stay at home and avoid being on the streets.

A sign of the cooperation received is this traffic map of the Boston metropolitan area on that day.  All routes are shown as green, i.e., no traffic at all!

But some people found it difficult to stay inside on a beautiful spring day.  These two young folks escaped for an exercise routine in the field behind my house!



Thursday, April 17, 2014

Berwick DID like the UK system after all

In a remarkable show of disinterest by the mainstream media in Massachusetts, it appears that only the Associated Press cared enough about Don Berwick's proposal for a single payer plan to give it the attention of a reporter. Here's the story:

BOSTON (AP) — Democratic candidate for governor Don Berwick on Wednesday called for a ‘‘single health care payment system’’ for Massachusetts.

Berwick, who headed the federal Centers for Medicare and Medicaid Services for 17 months, is one of five Democrats, two Republicans and three independent candidates seeking the state’s chief executive post.

Speaking at Boston University School of Medicine, he praised President Barack Obama’s health care law and the 2006 Massachusetts law that inspired it, adding that Massachusetts can again lead the nation.

But, he said, the state and country can do better by essentially expanding Medicare, which covers the elderly, to include all residents regardless of age.

‘‘We can create and manage a simplified, transparent, efficient, and fully accountable single health care payment system in Massachusetts and we can make it work for the people,’’ Berwick said in a prepared copy of the speech.

That ‘‘single-payer’’ option has long been a dream of liberal Democrats, but has also been considered a political impossibility in a divided Congress.

It was Berwick’s praise for aspects of the British single-payer health care system that marked him for criticism from congressional Republicans, who said it showed his affinity for big government programs. They blocked his confirmation as Obama’s permanent head of the Centers for Medicare and Medicaid Services after his temporary appointment.

Berwick on Wednesday brushed off the criticism of those he called ‘‘naysayers’’ and said a single-payer system would have less ‘‘waste, confusion, complexity, and opacity’’ than the current system, which he said forces patients and doctors to spend time and money sorting out varying coding systems and billing rules.

By contrast, he said, Medicare spends just 1 percent on overhead.

It is ironic that the case made by lots of Republicans against Don for the CMS job was, in fact, based in part on his position on this issue.  Back then, recall, "Republicans . . . seized on remarks he made praising Britain’s National Health Service as an 'example' for the United States to follow." Of course, the Republicans dramatically overstated the issue and would have found any reason to be against him, but time has shown it to be the case that Don actually does support an NHS-like single payer system.

Now, the question is whether this issue will resonate in Massachusetts.

Acts of leadership and courage can be powerful forces for social change

Two lovely articles crossed my desk, and I'd like to share them with you.

The first is by Peter Pronovost, called "The ripple effect." Excerpts:

Cornell University sociologists Milena Tsvetkova and Michael Macy explained how we are much more likely to perform a kind act when we experience or witness one. Experiencing a small kindness is more potent than observing on.

There is a large segment of health care workers who want to do the right thing, to do things differently, but are held back for a variety of reasons. Sometimes they just want to know that there are others who are willing to move forward with them. Someone needs to takes that first step, to set off the chain reaction. Others want to know that if they lead, others will follow.

Take, as a great example, Janet Wall, a support associate on the Weinberg ICU at The Johns Hopkins Hospital. Wall has worked on the unit for 14 years and often jokes that she is “protecting her house” when she sees a behavior that is not consistent with the values that the unit is built around. If she sees anyone neglect to perform hand hygiene before entering a patient room—be it a world-renowned surgeon or a clerical worker—she will immediately remind them to do so. She’s on the unit to save lives, she proudly announces.

Anyone who has worked in health care or been a patient knows how uncomfortable it can be to ask someone else to wash their hands. But Wall took the risk to do something different and hold others accountable. And once she did, other support associates and staff began to follow. Many staff who had never before taken those kinds of risks began to speak up. This social movement has spread around the unit, and even nurses who before did not feel empowered to speak up are doing just that.

Acts of leadership and courage can be powerful forces for social change when they are aligned towards a goal. And as Wall demonstrates, you don’t need a C-suite title to set these in motion. So start a social movement in your unit or clinic. Take that first step—an uncommon act of kindness, generosity or courage. Witness or experience these acts, and then pay it forward, and watch as the world around you begins to change.

And then the next is from Tracy Granzyk at MedStar Health, called "Teamwork and Thinking Differently: Can Healthcare Leaders Do This?" Viewing a terrific instrumental quartet, she observes:

A piano has 88 keys, yet new music is created every day. How can we take what we have to work with in healthcare and see what has yet to be discovered or apply what has yet to be tried — especially when it comes to teamwork.

Wednesday, April 16, 2014

Meanwhile, south of the Massachusetts border

Just when I thought that Massachusetts health care environment was complicated, along comes this story from ConvergenceRI.  Richard Asinof is a tireless reporter who documents the health care comings and goings in the state.  We could use someone of his energy and depth in Massachusetts, someone who connects current events with what has happened in the past--with a healthy dose of similes and an appreciation for irony.

Look at these excerpts, for example:

Like new spring growth in the briar patch, thorny consequences of Prime Healthcare’s takeover of Landmark Medical Center have begun to emerge, less than four months after the deal was finalized that allowed the California-based, for-profit hospital system to purchase the financially troubled nonprofit community hospital.

UnitedHealthcare Insurance Company and UnitedHealthcare of New England have asked the R.I. Department of Health to remove Landmark from its network of hospitals, along with 52 physicians, 32 of which are primary care providers, who have “admitting privileges exclusively” at the hospital. 


The only commercial insurer with an ongoing participating agreement with Landmark is Blue Cross & Blue Shield of Rhode Island – a legal arrangement that was part of the final purchase deal.   

There is a certain amount of irony in the current situation, given the events of two years ago, when in the summer of 2012, it was Blue Cross & Blue Shield of Rhode Island that had requested to remove Landmark from its network of hospitals during its contract negotiations with Steward and Landmark, leading to an aggressive advertising campaign attacking Blue Cross by Steward and Landmark and a lawsuit against Blue Cross by the special master that was later withdrawn.

Failed mediation efforts with Blue Cross involving Rhode Island Attorney General Peter Kilmartin [and leaked confidential letters between Kilmartin and Steward Health Care CEO Dr. Ralph de la Torre] led in part to the breakdown of the proposed purchase of Landmark by Steward, a for-profit hospital system based in Boston and owned by a private equity firm, Cerberus, in New York City.

Amazing. Miraculous. Groundbreaking. Incredible.

Gary Schwitzer from HealthNewsReview.org makes this point on Twitter:

A journalist must work hard to fit “amazing, miraculous, groundbreaking, incredible” into 1 robotic surgery story.

He is referring to this piece on TheSpec.com. Although the entire story is worth reading, I especially like this approach to the scientific method:

The new donation will support the funding of surgeries but also launch a more complete program where patients' results can be tracked. It's hoped those results can be used to promote broader use of robotic surgery and secure more funding, said Dr. Waël Hanna.

It's clear we don't have to wait for the results of those studies!

Three days to help Alex go back in time

Our buddy Alex Green has made good progress on his IndieGoGo project to step back in time and engage in old-fashioned typesetting.  Three days are left, and he's 91% percent of the way there.  Please help bring back a bit of the past. Contribute here.

Tuesday, April 15, 2014

Berwick proposes Medicare for all in Massachusetts

Massachusetts gubernatorial candidate Don Berwick is holding a press conference on Wednesday, April 16, at 7pm at Bakst Auditorium at Boston University's School of Medicine to present his plan called "Medicare for All," a single payer system for the state.  Many will be curious to see what he proposes.

As one of Don's supporters in the Democratic primary race, I don't necessarily agree with all he says, but I love that he stretches the limits in his public policy proposals.  It keeps the race vibrant and gets people engaged.

There is a delicious irony to Don's single payer approach in this state, in that a large argument for it has been provided by the state's largest insurer, Blue Cross Blue Shield--which would be put out of business by the proposal.  Why?  Well, BCBS has been so intent on expanding the use of global payments that it has effectively shifted actuarial risk from itself to the providers who have adopted that payment regime.  One can logically ask the question: "If insurance companies don't bear risk, why do we need insurance companies?"  If all they do is handle transactions and claims, who needs them as plan administrators?  What core competencies do they bring to bear that any well-run financial services organization does not?

I'm being slightly facetious but not a lot.  The state's insurers continue to collect a similar percentage of the premium dollar each year for administrative functions.  They seem unable to realize economies and improvements in that part of their business.  Thus, as premiums have risen, their share has risen proportionately. Indeed, one can argue that they have an incentive for higher premiums and more claims processing.  Hmm, it sounds like they operate under their own fee-for-service reimbursement approach, something they decry as inappropriate for the rest of the industry!

Poke that sleeping lion, Don, and we'll see whether it responds with a roar or a meow!

What happened to the Massachusetts exchange?

In the "people's republic of Massachusetts," the Pioneer Institute often gets a bad rap as a conservative think tank.  The Democratic establishment does its best to ignore it, but I have found the Institute to do good work and raise issues in a thoughtful and rigorous manner.

One recent topic followed by the Institute concerns the failure of the Massachusetts health exchange.  Recall that this exchange worked quite well for years before the Accountable Care Act, but then it went into a tailspin during the compliance process for the new law.  Analyst Josh Archambault notes:

As a result of the failed Connector website, 160,000 Massachusetts residents are on temporary public Medicaid coverage even though they don't qualify for MassHealth. Failure at the Connector will cost Massachusetts taxpayers over $100 million dollars this year.  So, Pioneer has questions about how Massachusetts went from having a well-functioning Exchange to one of the worst performances of any state in the Union.

This week legislators on Beacon Hill are finally convening a second hearing in the seventh month since open enrollment started under the ACA, on the failures at the Connector.

This follows a recent Congressional hearing featuring the executive director of the Connector, and a February hearing in Boston where legislators simply vented at officials from the Commonwealth.

Yet, even with these two hearings, little information has been released to the public on how the state got into this mess in the first place.

Pioneer asks 100 questions that it asserts, "need to be answered regarding just what happened during implementation"  I include the first 43 here for your perusal.The kinds of questions raised by Josh are essential to conducting a root cause analysis to understand what went wrong, in the hope of doing better on this kind of project in the future.
  1. Why did the Commonwealth decide to completely rebuild its website exchange? Why did it not work off the foundation of its old website?
  2. Why did the University of Massachusetts Medical School hold the contract for the exchange development? Did the Connector and MA HHS shape the Early Innovator Grant application?
  3. Why were the University of Massachusetts Medical School principal leads on the contract both policy experts, not technical experts?
  4. What was the bidding process that led to the selection of CGI? What factors were considered?
  5. What other companies bid on the contract?
  6. What state employees provided technical expertise to design the website contract?
  7. Were any of the website contracts granted on a sole-source basis?
  8. Why did the state's IT department (ITD) play a limited role in implementation and contracting?
  9. It is clear to outside auditors that the original deal with CGI was too ambitious. Did state employees or CGI include the level of bells and whistles in the original contract? 
    (Background: The promise was a Rolls Royce exchange.)
  10. Problems arose early with conversations about scaling back the original contract starting as early as January 2013, when did serious problems first start to emerge? 
  11. How quickly were issues escalated and to whom? What exactly was the escalation process? 
  12.  When did senior staff at UMass Medical School first know about the problems? 
  13. When did Connector senior staff first know about the problems?  
  14. When did Mass HHS senior staff first know about the problems?
  15. When did the Governor first know about the problems?
  16. When did the CMS state officer assigned to Massachusetts know about the problems?
  17. How frequently were these groups updated about the depth of the problems with the website?
  18. Is there a precedent for reworking IT contracts multiple times in the Commonwealth during such a short engagement?
  19. What are the guidelines for reworking state contracts? Were they followed?
  20. Technical staff under contract with UMass Medical were removed from quality review committees because of their critical assessment of CGI's work, why?
  21. Independent reviewers criticized the Commonwealth for being understaffed in multiple areas of this project, and for high staff turnover, why was this the case?
  22. Best practices for project management were not followed. Which were not, and how will things be different going forward?
  23. Why was no firm pull the plug date set for the project?
  24. When was the decision made to go live, even with the well-known lack of basic functionality?
  25. What percentage of the website was expected to be functional on October 1st?
  26. What percentage was functional on October 1st?
  27. Why did the Connector spend significant advertising money in mid-October to increase traffic to the website with all of the known issues?
  28. Why were the Governor and other senior Connector staff denying that the website had major problems until early November 2013?
  29. Was it ever discussed to simplify MassHealth (Medicaid) eligibility rules during the design process? 
    (Background: Massachusetts has over 250 eligibility rules, and has added enormous complexity to the site design.)  
  30. Did state officials mislead the Federal government on the progress of the project at any point? 
    (Background: Independent reports have noted that code was often submitted with limited to no testing, and the Committee on Oversight has raised questions about security protocols being followed during the entire project.)
  31. Were security agreements signed by state officials truthful for the level of security provided by the website to users?
  32. (Background: As one example, a Minimum Acceptable Risk Standards for Exchanges agreement was signed by the executive director of the Connector and the HHS Secretary in September 2013. Yet independent auditors in September listed the lack of a testing schedule to determine the basic security of the system as a major concern. The Chairman of the U.S. House of Representatives Committee on Oversight has raised security concerns about the state connecting to the federal data hub.)  
  33. What was the standard of proof required by the federal government for the state to pass each "gate review" for the readiness of the site?
  34. Why was the Commonwealth habitually slow in turning around the review of CGI code?  
  35. How many citizens have paid for their plan and still lack an insurance card? 
    (Background: At one point the number was over 2,200)
  36. Why were there no basedlined deliverable and baseline dates updates as the project progressed? (Background: Independent auditors document a lack of baseline in August 2013, with the last being submitted in February.)
  37. How many staff who worked on the UMass Medical School contract have been moved over to other departments or contractors still working on the project?
  38. Why was CGI allowed to change delivery dates without consulting state officials? (Background: This has been a criticism by independent auditors.)
  39. Why were changes to the project allowed "without formal approval and assessment of downstream impacts.."? (Background: This has been a criticism by independent auditors.)
  40. Once the severity of the technical problems became overwhelming, why was contingency planning understaffed by both the Commonwealth and CGI? (Background: This has been a criticism by independent auditors.)
  41. Why was the site allowed to go live without any UAT (user acceptance testing), a standard for any IT project?
  42. When did CMS grant the Commonwealth a delay for testing under the CCIIO Blueprint Test Scenarios? (Background: Independent auditors have noted the state missed the 8/23/2014 delayed deadline.)
  43. Why was there no "formal method for holding individuals and organizations accountable for achieving agreed-to deadlines for project tasks"? (Background: This has been a criticism by independent auditors.)
  44. Why was it announced to the public that CGI was being "fired" before the state had developed the terms of that separation? 

Monday, April 14, 2014

Elton John praises hospitalists!

I never knew that I knew Elton John, but then he showed up in this video to sing a song in honor of hospitalists.  I suspect--and I mean this without criticism--that this rendition is highly unlikely to top the charts.  As I post it right now, it has had 689 views.  With your help, maybe we can get it up into the four digit range!

Sunday, April 13, 2014

7,100,000 is less than 7,000,000

Excellent Saturday Night Live spoof of Fox TV coverage of health insurance sign-ups by the statutory deadline.  Here's the video.

Invitation: Patient and family engagement virtual meeting

Linda Kenney from MITSS says, in asking me and you to pass along this notice:

"I thought you might be interested, or you can pass along to PFAC members or other patient and family members you think might be interested."

Virtual PFE Network Meeting:  Please Join Us on Wednesday, April 16 at 4:00 p.m. EDT.

Patient and family engagement (PFE) is a critical element in improving patient safety and reducing harm.  Consumers, patients, families and patient advisors, as well as providers of care, have a role to play. They must be supported to ensure integration of PFE into all patient care. Please join us on Wednesday, April 16, from 4:00 – 5:00 p.m. EDT for the Patient and Family Engagement (PFE) Network Meeting.

This meeting of the PFE Network will provide an opportunity to convene the group in conversation about patient and family engagement. We will recap the PFE work that is under way as a part of the Partnership for Patients, and discuss priorities to move forward. We will also seek input from you about needed training sessions and other resources that would be useful. More information can be found in the PFE Network Meeting Flyer by visiting this link. We hope you will join us, and please invite friends and colleagues who may be interested.To register, please visit: Virtual PFE Network Meeting.

Saturday, April 12, 2014

The feet that won the game

My team of 12-year-old soccer players asked me to take this picture in honor of a well-played 2-1 victory today.

Thursday, April 10, 2014

It took 400 years to sell the movie rights

A throw-back, seen in the used book section of a book store. The movie probably could have helped Shakespeare to become well known, but it only got a rating of 7.9 out of 10.  No doubt the dialogue needed rewriting.

Wednesday, April 09, 2014

Empathy on WIHI

Madge Kaplan writes:

The next WIHI broadcast — Reclaiming Empathy: Best Practices for Engaging with Patients — will take place on Thursday, April 10, from 2 to 3 PM ET, and I hope you'll tune in.
Our guests will include:
  • Helen Riess, MD, Director, Empathy and Relational Science Program, Department of Psychiatry, Massachusetts General Hospital
  • Stacie Pallotta, MPH, Senior Director, Office of Patient Experience, Cleveland Clinic
  • Martha Hayward, Lead for Public and Patient Engagement, Institute for Healthcare Improvement
Enroll Now

Empathy is not the same thing as sympathy. In the first instance, we feel seen and truly heard; sympathy tends to maintain a distance between two people, often deliberately so. One of the best explanations of the distinction, and why empathy can be so much more powerful, is an online video narrated by human vulnerability expert Dr. Brené Brown. And then there’s the Cleveland Clinic’s video about empathy, directed at health professionals. This moving reminder of the stories behind the faces of patients that pass through health care every day has been viewed on YouTube over a million times.


Why the seemingly sudden need to draw the attention of doctors and nurses to the humanness of the patients before them? Is it because, as some fear, empathy is becoming harder and harder for health professionals to feel or express in the course their jobs? Could be, but there’s nothing inexorable about the loss of empathy in health care today. And, as we’ll learn on the April 10 WIHI: Reclaiming Empathy: Best Practices for Engaging with Patients, there are effective ways to help today’s busy and often overwhelmed caregivers reconnect with their own feelings and the feelings of others, namely their patients.

At the Cleveland Clinic, Stacie Pallotta is part of a team that’s looking at empathy as one important part of an overall strategy to improve patient experience. Dr. Helen Riess, who specializes in the neuroscience of emotions, is turning her findings into “empathy education” for health professionals. She’s also found that if students’ empathy towards patients tends to erode over the course of their medical training, as evidence suggests, new research shows that additional training can either disrupt or reverse this process.

Is there something that patients and families can do if the doctors and nurses and staff they encounter are having a bad day or are so stressed by being pulled in million different directions that they can’t seem to register much more than a weak smile? We’ll ask IHI’s lead for public and patient engagement, Martha Hayward, that question. And we want to know what you think, too. Please join us for this discussion about the value of empathy and human connection to improving health and health care, on the April 10 WIHI.
I hope you'll join us! You can enroll for the broadcast here.

Time for Compassionate Caregiver Award nominations

The Schwartz Center Compassionate Caregiver Award is an opportunity to recognize extraordinary caregivers in our midst. The award is one of the region’s most prestigious honors in healthcare.  Nominations for this year's award are now open and are due by May 9, 2014.  The details are here.

For an example of an extraordinary caregiver, click back to this award ceremony in 2009.

The quarterbacks of the health care system

Here's a great article in Commonwealth Magazine about the buying and selling of physician practices in Massachusetts.  Author Bruce Mohl notes:

In many respects, primary care doctors are the quarterbacks of the new health care system, the marquee players that every team is scrambling to sign. Some work under contract, others under lease arrangements, and more and more are becoming employees of the teams. The financial details of these employment arrangements are tightly held secrets, but rumors abound of signing bonuses, lavish incentives, and big paydays. The health networks—the teams—scoff at such reports, but many of them quietly whisper that their competitors are offering physicians outlandish deals.

As the state’s health care industry consolidates, regulators and the media have focused most of their attention on high-profile hospital mergers and acquisitions. But the pursuit of primary care physicians may eventually have a more profound impact on health care. Those networks that control the most doctors will control the most patients, and with them will come more revenue, more referrals, and more leverage in negotiating reimbursement rates with insurers. 

Tuesday, April 08, 2014

"Good" news: It's not just people

Source: Sunday Telegraph
The UK Sunday Telegraph reported this week:

The waistlines of Britain’s pets have expanded to ever greater dimensions, with a new report revealing that almost half of cats and dogs are now regarded by vets as obese. The new study suggests the numbers of overweight animals has soared in the last five years, and claims that the cost of treating pets for obesity-related conditions is now around £215 million a year.

The problem is worst in dogs, with vets reporting that 45 per cent of those they treat are obese or overweight. The situation is little better in cats (40 per cent), while it was also noted in almost a third of small animals, like rabbits, hamsters and guinea pigs (28 per cent). Even pet birds now suffer with their weight, with problems observed in 15 per cent.

Is this about exercise? Mainly not:

One in three owners admitted feeding their animals “human” food, while the numbers giving them leftovers had risen by 28 per cent in the last five years. Vets believe this is the leading cause of pet weight gain – responsible for eight out of ten cases in dogs. 

Is that all?  No:

[S]ome experts have started to blame pet food manufacturers themselves for making obesity problems worse. David Jackson, a former pet industry nutritionist, has set up a website – whichdogfood.co.uk – where he analyses the contents of various brands. 

It discovered salt, sugar, oils and fats in a number of leading brands and found chicken dinners containing just four per cent chicken. Some pet nutritionists and behaviourists argue that, just as with children’s junk food, pet food today is at least partly responsible for an epidemic of animal obesity, as well as some behavioural issues. 

I don't know even how to begin thinking about this. How does all this make you feel? Should we care? If so, what's to be done?