Thursday, October 02, 2014

There's many a slip 'twixt the cup and the lip

"How could it happen?" is the question everyone's asking.

No, not the guy who walked into the White House past the Secret Service.

The nurse who asked the question.  CNN reports:

The first person to be diagnosed with Ebola on American soil went to the emergency room last week, but was released from the hospital even though he told staff he had traveled from Liberia.

Hospital officials have acknowledged that the patient's travel history wasn't "fully communicated" to doctors, but also said in a statement Wednesday that based on his symptoms, there was no reason to admit him when he first came to the emergency room last Thursday night.

A nurse asked the patient about his recent travels while he was in the emergency room, and the patient said he had been in Africa, said Dr. Mark Lester, executive vice president of Texas Health Resources. But that information was not "fully communicated" to the medical team, Lester said.

The man underwent basic blood tests, but not an Ebola screening, and was sent home with antibiotics, said Dr. Edward Goodman with Texas Health Presbyterian Hospital.

Three days later, the man returned to the facility, where it was determined that he probably had Ebola. He was then isolated.

There are probably several reasons. The simplest one, "the nurse messed," up might be correct, but it is also likely to be incomplete.  If a full-scale root cause analysis were conducted, we'd probably learn about any of the following: a lack of training of front-line clinical staff with regard to this disease, a series of protocols that are not attuned to this new and rare disease, and/or habitual poor communication between the triage staff and others.

Let's hope the country learns from this experience.  That's a most important task for the CDC to focus on right now.

Think how powerful a teaching tool this would be: If the nurse and MDs at Texas Health produced a 7-minute YouTube video of what went wrong and how they've changed their protocols.  That would go, er, viral within hours.

Walid offers a summary

Continuing our series on the CMS Open Payments database, I offer this chart prepared by Walid Gellad, and posted on Twitter at @walidgellad, summarizing the payments made from Intuitive Surgical to doctors and hospitals for five months in 2103.  Gellad describes himself as "Primary care physician. Health services research. Co-direct Pitt Center for Pharmaceutical Policy & Prescribing. Opinions my own."  Here's his bio.

Striking to me, as I noted below, is the number of payments and amount (over $2 million) made for "education," i.e., paying doctors to attend training sessions on the use of the daVinci robotic surgery equipment.

Wednesday, October 01, 2014

Money and trust

In my post below, I offer some information about payments made nationally by Intuitive Surgery to hospitals and doctors to support the extended use of the daVinci surgical robot.  Here, I take a look at some local examples.  As I searched through the Massachusetts listings, two names popped out as repeated recipients of cash or in-kind payments and services in amounts exceeding $2500:

Jeffrey Spillane,  Southeastern Surgical Associates, in Hyannis, who operates at Cape Cod Hospital; and James Hermenegildo, Truesdale Surgical Associates, in Fall River, who operates at Charleton Memorial and St. Anne's Hospital.

Dr. Spillane is credited as "the first thoracic surgeon to bring Robotic Assisted Thoracic surgery to Cape Cod." His practice website lists the following promotional article in the local newspaper: "A da Vinci for the modern age," Cape Cod Times.  Further, his page at SSA leads patients to this Southeastern Robotic Surgery Web Site and also to watch this Intuitive Surgical-produced video.

For the five months of 2013 data so far reported by CMS, Dr. Spillane is listed as receiving five payments of $3000 or $3500 from Intuitive for "education" along with payments $150 or $300 for food and beverage on the same dates.

Dr. Hermenegildo is credited by Southcoast Health System with introducing robotic single site surgery for gall bladder removal to the geographical area south of Boston.  (I have written about doubts that are raised by Intuitive's hope to expand the daVinci's reach into cholecystectomies.)

This surgeon's reported payments for the five months include three of $2500 each for education, six payments of $500 each for education, and two payments of $150 for food and beverage.

I don't know much about the Intuitive Surgical training program, but I am surmising that personal attendance at educational events provides doctors with the $2500-$3500 fee (along with meals), and perhaps the online modules offer a $500 fee.  Whatever those details, I don't see why it is appropriate for doctors to be paid for education programs by equipment manufacturers.

But, at this point, the issue is not about my opinion.  Neither does this post have anything to do with the technical competence of these doctors, which I assume is at the highest levels.  Instead, the CMS report raises a different type of issue, one at the heart of the doctor-patient relationship. Trust.

In sum, the most important questions can only be answered by patients being served by these two doctors and the thousands of others listed in the Open Payments database:  "Have you been informed that the manufacturer of equipment that is used in one of three possible approaches to your surgery has made payments to your doctor? Do you have any concerns as to whether your doctor's clinical approach to your care might be influenced by the (now reported) financial relationship with this manufacturer?"

Walking around money

It's been a long time since I wrote about the extremely close relationship between the University of Illinois Chicago, its surgical faculty, and Intuitive Surgical, the manufacturer of the daVinci robot.  I am drawn to do so again by the publication yesterday by CMS of the Open Payments database, showing payments from manufacturers to doctors and hospitals.  The presentation demonstrates the remarkable number of payments ISRG has made throughout the country in support of its robotic surgery devices. UIC is just one of many beneficiaries.

As noted by Charles Ornstein at Pro Publica, though, this database is by no means complete. He points out:

* The data doesn’t cover all payments.
The Physician Payment Sunshine Act, part of the 2010 Affordable Care Act, called for the first public release of this data 18 months ago. But because of delays writing detailed rules implementing the law, the first release of data will happen today and it will only cover payments for a few months, from August to December 2013.

* By design, some data on research payments won't be included.
The Sunshine Act allows drug and device companies to delay the publication of data related to research of new products or, in some cases, new uses for existing products. The payments won't be made public until the product is approved by the Food and Drug Administration, or four calendar years after the payment was made, whichever comes first. It is unclear how much money is involved, but, again, just because a doctor doesn't show up as receiving a research payment doesn't mean he or she hasn't received one.

* Because of errors, additional data isn't being released.
CMS has acknowledged that one third of the payment records submitted by companies for last year had data problems that could lead to cases of mistaken identity. The names associated with those payments won't be released today. Federal officials are asking companies to recheck the data, which should be released publicly next year.

With these limitations is mind, I went to the database and filtered the entries by name of company--Intuitive Surgical--and there are thousands of entries.  I then ranked them in descending order.  Most recipients were hospitals, but some were individuals.

Many doctors and hospital received payments for "education"  or "services other than consulting, including serving as faculty or speaker at venues other than a continuing education program."  One of the top recipients in these categories is the University of California, with a total exceeding $600,000.  There were some large items, $175,000 and $100,000; but most of the 79 entries were in the range of $3000 to $6000 payments.

No doubt it is coincidental that the surgery department at UC Davis presents this website parroting unsupported assertions about robotic surgery's benefits to patients.


Another is Houston's Methodist Hospital, which received over $200,000 in the "education" category.

Again from their website, we see the misleading comparison of robotic surgery to open surgery, but no mention of the relative value of manual laparoscopic surgery.


In all, there are almost 17,000 payments from ISRG from this five-month period.  Some are pennies for reimbursements, but almost 1600 are in the range of $2000 to $10,000.  Where are the recipients?  Baltimore, Philadelphia, Tampa, Atlanta, Phoenix, Miami, New York, Loveland, Reno, Newark, Kissimmee, Lansing, Austin, Orlando, Basking Ridge, Greenville, Owensboro, Detroit, Brooklyn, Ypsilanti, Kirland, Menomee Falls, Mt. Clemens, Hialeah, Bemidji, Tulsa, Blue Ash, Sarasota, Patchogue, Jackson, Plains, Cincinnati, Columbus, Jonesboro, Oklahoma City, Novi, Minneapolis, Shelby Township, Pittsburgh, Eau Claire, Green Bay, Denver, Appleton, Jupiter, Kansas City, Las Vegas, Gainesville, Wausau, Rochester, North Little Rock, Milwaukee, and dozens more.

In the old days of politics, we would have called this "walking around money," sprinkling beneficence to engender widespread support and loyalty.

Let's get back to Illinois.  Right near the top of the CMS list was the UIC's Pier Giulianotti.  According to CMS, he received two payments of $50,000 each in cash or cash equivalents as "grants" for the Clinical Robotic Surgery Association.  What's that?  According to its website, it is a "new society devoted to the minimally invasive robotic surgery." It is registered as a not-for-profit corporation.

I couldn't find any mention of Intuitive Surgical financial support on the website, even in Dr. Giulianotti's welcoming letter, but I did find a number of testimonials for the organization from UIC faculty members.  You might remember some of these people from the full page New York Times Magazine advertisement in which the University allowed its name and reputation to be used in support of Intuitive Surgical.


Here's one person from the ad:

Robotic surgery is a constantly evolving field, CRSA website is an invaluable tool to stay up to date.  The platform is easily navigable and is very practical. Information shared on the website includes basic procedures and more complex ones making the site of unique interest for beginners and for expert robotic surgeons. The possibility to assist to entire procedures during the live events is a formidable educational  opportunity to learn from the masters without the need to travel. It's amazing to see how such a large group of surgeons from all over the world is open to share their experiences and work as a group to improve the quality of care and the quality of Surgery.
Francesco Bianco, MD, Assistant professor of Surgery
Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago.


Here's another:

The CRSA represents a common ground where pioneers of robotic surgery coming from various subspecialties work side by side with young, ambitious and promising robotic surgeons. This synergism has created a dynamic and exciting surgical community where masters of robotic surgery share on a daily basis their terrific experience in the operative theater with innovative ideas brought in by young, brilliant individuals that have the potential to be the next generation of robotic surgery innovators.

The website of the association is clearly in line with these traits as it offers a tremendous amount (835 and the number increases each month) of advanced robotic surgery videos presented in a modern looking and easy to navigate internet frame.

CRSA represents for me the ideal place to cultivate and share my passion for robotic surgery and innovation and to provide my contribution for the advancement of the field and therefore I strongly and unconditionally support this association.
Antonio Gangemi, MD, FACS, Assistant Professor of Surgery
Division of General, Minimally Invasive and Robotic Surgery University of Illinois at Chicago, IL, USA.


And another:

Having the opportunity to share the experience from international surgeons has an incredible value for our clinical and research practices. The CRSA website allows surgeons to be connected and integrated allowing to share experiences in difficlut cases.

CRSA has more than 800 videos about diverse robotic procedures, I dont know of any other portal so complete and diverse. Direct communication with other robotic surgeons dealing with similar problems is a powerful advantage of the portal as well.

For any robotic surgeon , experienced or begginer CRSA portal gives extensive material , comments and opinions that improve their clinical experience. CRSA website is also an important communication channel to be informed about upcoming meetings, trainig courses and news of the robotic world. I highly recommend the CRSA website to any surgeon around the world who wants to start a robotic practice.
Enrique Elli, MD, Assistant Professor of Surgery, Associate Director of Bariatric Surgery
Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago.

Tuesday, September 30, 2014

And now, robotic hernia surgery

First it was prostate removals, then it was hysterectomies, then it was gall bladder removals, and now (tah dah!), Intutive Surgical offers robotic hernia surgery.  Again, another procedure that is already offered at low cost and with excellent results.

Please watch over the coming days as people start to correlate the names of surgeons who have endorsed these "advances" with payments from this company.

Walking down the aisle

I've often admired the people who work in physical medicine and rehabilitation.  Beyond the technical skills involved, there are often strong relationships built among patients, families, and caregivers.

Here's one example from Alegent Health Immanuel Rehabilitation Center, where a young woman fulfills her dream of walking down the aisle on her wedding day.

Here's more about Gina Giaffoglione, who has a pretty remarkable story.

Monday, September 29, 2014

Look what happens when the facts are presented

A reader writes:

I thought you would appreciate this overview of a study from the University of Utah on patient decision making when health care costs and outcomes are transparent. 
 
The authors studied the decisions made with regards to laparoscopic versus open appendectomy on pediatric patients when both cost (obviously higher w/ lap) and outcomes (similar w/ peds) were discussed upfront with the parents prior to surgery. Families chose open procedures almost twice as much as compared to the lap approach. 

This would become an even more interesting study to also include a third arm and similar transparent cost/outcomes discussions with da Vinci…that is, if only some hospital would be willing to participate. 

Indeed!  Here are excerpts from the article.

Consumer price comparison is almost nonexistent in the U.S. health care system, but a new study shows that when given the choice between a less costly “open” operation or a pricier laparoscopy for their children’s appendicitis, parents were almost twice as likely to choose the less expensive procedure – when they were aware of the cost difference. The study, published in the September issue of Annals of Surgery online, shows that providing pricing information upfront can influence patient choice of surgical procedures and potentially lead to cost savings in health care, a sector of the economy that accounts for more than 17 percent of the U.S. Gross Domestic Product, says Eric R. Scaife, M.D., senior author, associate professor of surgery and chief of pediatric surgery at the University of Utah (U of U) School of Medicine.

“Unlike other areas of the U.S. economy where it’s typical for people to compare prices before purchasing, health care consumers seldom know what they’ll pay for a procedure, meaning they have no basis for comparing costs,” Scaife says. “But our research found that when they have the information, consumers want to be in on health care decisions and that cost can influence what they choose when procedures are equally effective and have similar outcomes.”

Reasons for choosing the open operation varied among patients who received pricing information, including incision size, number of incisions, past experience and influence from a medical provider outside the surgical team. The most common reason, however, was cost: 31 percent of respondents said price was the primary influence on their choice of procedure.

“Cost-saving measures are important to me when it doesn’t impact the safety of the patient,” one respondent said.

The vast majority of respondents, 90 percent, said they liked having a choice in their health care, while only 3 percent would have preferred not to be given a choice. Lower median-income families were more likely to choose the open procedure than those of higher median incomes, but after accounting for the income difference, patients and parents exposed to the cost information still were 1.7 times more likely to choose the open procedure. Health insurance status appeared to play no role in the procedure choice.

Sunday, September 28, 2014

You can only shake your head and wonder

The Attorney General's 73-page filing with the Court about her (now slightly revised) deal with Partners Healthcare System deserves at least 73 pages of rebuttal, but that isn't going to happen. You see, as noted in Commonwealth Magazine:

The timing of Coakley's response seemed designed to maximize her aggressive response to her critics and minimize pushback. Her aides released the amended deal, the comments on the original deal, and her responses to them at 5 p.m. on Thursday, too late for her critics to respond. If they do respond on Friday, the news will air over the weekend, when fewer people will be paying attention. On Monday, Coakley's agreement with Partners goes to Suffolk Superior Court Judge Janet Saunders for review.

Then, when it gets to Court, there are only three other parties who have a right to be heard:

~Partners Healthcare System;
~South Shore Health and Educational Corporation, which is seeking to be acquired by PHS; and
~Hallmark Health Corporation, which is seeking to be acquired by PHS.

That's right. This is part of a process that has been termed "transparent" by the Attorney General's office:

Step 1: Negotiate and sign a deal with PHS in secret;
Step 2: Present it to the Court;
Step 3: Suggest to the Court that comments should be allowed--but only after the Greater Boston Interfaith Organization put pressure on her to allow those public comments;
Step 4: Revise the deal in a few minor ways, respond to the public comments, and present them to the Court without allowing a chance for rebuttal from other interested parties;
Step 5: Oppose intervention by other parties in the court case.

But it gets worse still.  Just read this paragraph from page 46 of the AG's filing [emphasis added]:

Several comments suggest that the comprehensive price caps do not do enough to reduce the gap between Partners current reimbursement rates and the prices of other health care providers, that is, to combat the “provider price disparity” that has been well documented in Massachusetts (initially by the Attorney General’s Office). This is not an appropriate lens through which to evaluate this remedy. These comments appear to suggest that the UPGC [unit price growth cap, which limits PHS price increase to the lower of general or medical inflation] should cut back on the pricing advantage that they attribute to Partners’ current market position. But the remedies in the proposed Consent Judgment cannot be evaluated compared to claims that the Attorney General did not bring. Rather, the measure of the UPGC is whether it addresses the harms identified in the Complaint. 

This paragraph boggles the mind.  The AG spent several years documenting the fact that Partners' market power is responsible for the substantially higher rates it receives from insurers for the same work done by other academic medical centers, community hospitals, and physicians.  Indeed, she concluded that this disparity has been one of key drivers of health care cost increases in Massachusetts.  She does not suggest in her filing that the UPGC will reduce the disparity--and indeed it will not.* Instead, she argues that this topic is irrelevant to the complaint she initially filed against PHS.

The obvious question is why she never included this aspect of Partners' market power in her complaint and why she did not seek a remedy to it. 

Oh, here's the answer she offers (on page 30 and elsewhere):

If we don't like this deal she has signed, others are free to file an anti-trust lawsuit against PHS.

I thought that was her job.

--
* Remember this summary on Commonhealth [emphasis added]:

But will the deal close the gap between what Brigham and Women’s is paid for that MRI as compared to Beverly Hospital? Only if the low-cost hospitals get some significant rate increases.

If Partners prices rise 2 percent a year, and prices for similar Boston hospitals go up 3.6 percent, the gaps narrow, Boros says.

“Specifically, our 2012 data shows that Brigham and Women’s prices are 24 to 33 percent higher than Beth Israel Deaconess Medical Center and 26 to 59 percent higher than Tufts Medical Center. After six years, these gaps close to 13 to 21 percent higher for BIDMC and 15 to 45 percent higher for Tufts,” Boros said.

Of course that assumes insurers in Massachusetts would offer lower-cost hospitals rate increases that are almost twice as high as Partners, something they have never done before.

And they shouldn’t, says Nancy Kane, who’s been studying hospital financing in Massachusetts for more than 30 years and teaches at the Harvard School of Public Health.

“It doesn’t make the whole more affordable if everybody’s trying to grow their rates,” Kane said. “[The AG's deal] doesn’t address the larger issue of affordability. It’s sort of a Band-Aid at this point.”

Kane says if the state wants real competition among hospitals, it would have to either set rates or force Partners to sell off some of its hospitals.

Saturday, September 27, 2014

Please, no lawyers in youth soccer!

A parent writes to the president of a youth soccer program (names changed):

Thank you again for offering to advocate on behalf of my daughter, Mary, who wishes to comply with her pediatrician's advice not to remove the very small studs with which her ears were pierced this morning.  I've taken the liberty of drafting a legal document that would eliminate any liability that NGS might possibly have in connection with Mary's compliance with her pediatrician's advice. I've been a practicing attorney for over fifteen years; I cut-and-pasted the key language in this document from boilerplate I've used countless times on behalf of a wide variety of clients.  I've attached a signed jpeg version, along with a Word version in case you or anybody else would like to make any revisions.

This is, of course, quite time sensitive.  If at all possible, I'd like to close the loop before Mary's team's next soccer practice, which is scheduled for Friday afternoon.  If you think it would be helpful for me to reach out to anyone else, please let me know. 

Again, thank you very much for trying to help Mary.  She loves playing soccer with her team, and the idea of not being able to play for the rest of the season is causing her the kind of distress that only seven year olds are capable of feeling.  Because we failed to anticipate and prevent this problem, my wife and I feel awful, as well.  If you can help solve this problem, it would mean an enormous amount to my family.

Sorry, but no. My advice to the league president:

Absolutely, absolutely not.  This is a well established rule throughout the state and the league and we should not make exceptions for one girl. We have drilled referees for years to make no exceptions. It puts the referee in a terrible position, and then others will say, "What about me?"  I don't care what kind of legal release the parent is willing to sign.  This is the referee's responsibility, and I wouldn't want any referee, much less a youth referee, forced to make the decision.

The mistake is easily rectified:  New earrings can be removed for and hour and reinserted.  Kids and parents have done it over and over again.  A little ice applied to the ear solves the problem of reinserting, perhaps with some Vaseline if needed or antibiotic if desired.

This stuff about a pediatrician's advice is really silly.

If the family doesn't want to go through the removal and reinsertion, they can simply take the earrings out and have a new hole made in a few weeks.

BTW, this is a time for parents to explain to the seven year old that sometimes, rules are rules, and to say it in a positive manner and not "blame" anyone.  She'll do what they tell her and she'll be happy about it if they handle it the right way.

In summary, this has happened dozens of times in the past, and we all get through it quite easily.

The coach should also enforce the rule during practice, by the way, so it does not even arise at game time.  The referee should not be the first person to mention the problem to the coach at game time.  It should also be solved well before that.

A colleague added, in agreement:

There is a reason for that—athletic, medical, legal, and insurance entities have advised and mandated that we, as referees, are first and foremost responsible for maintaining safety in soccer matches. Soccer leagues, tournaments, and the companies that provide them with liability insurance specify in their rules that no jewelry will be allowed on players—especially children players. Every time a player uses her head to play, or is bumped in the head by another player, or falls to the ground, or has a ball ricochet off her head, she is potentially inches from having the impact point involve her ears.

Anyone interested in safety—a referee, a coach, an administrator, or a parent—should be completely committed to the enforcement of the no jewelry rule.  And even if the latter three groups are not committed, we as referees must, with no exceptions, protect our young players.  I have officiated nearly 2,800 games in 18 years; I have never allowed earrings on girls or boys—taped or otherwise.  Dozens and dozens of times, I have counseled players, coaches, and parents that they can follow the remedies suggested in Paul's note, or they can choose not to play.  I say it gently, politely, and empathetically, but I am always firm.  It is the right thing and the only thing to do with young players, including all high school games.

And another person added:

It really needs to be enforced at all levels. I would occasionally ask folks if they wanted to be sent links to pictures and articles of girls suffering major injuries from playing with earrings, but never got any takers. 

Friday, September 26, 2014

MED QIPS takes off at Georgetown Medical School

Self-styled as "the first-ever club for patient safety at Georgetown Medical School," MED QIPS is up and running!  Medical Students for Quality Improvement and Patient Safety have set a goal of raising awareness and fostering advocacy for patient safety at the medical school level.  This is an exciting step forward, partially coming out of the students' participation at the Telluride Patient Safety Summer Camp this past year--but really derived from the students' own sense of purpose on these matters.

Some of the organizers are seen in the picture above, from left: Sam McAleese, Elissa Falconer, Natalie Medvedeva, and Brian Daily. Absent are Daliha Aqbal and Jameson Hollomon.

They have three sets of goals:

Learning:  Organize activities to improve medical student understanding of QIPS issues;
Medical Education: Incorporate patient saftey concepts into the medical curriculum; and
Change: Create a patient safety culture of accountability, transparency and mindfulness among medical students.

They are planning film screenings, speakers, research opportunities, and social events.  Get in touch with them by email at MedQIPS [at] gmail [dot] com or visit the Facebook page at GUSOM MedQIPS.

Wachter and Gibson on overuse

Here's a superb conversation between two of the world's experts, Robert Wachter and Rosemary Gibson, on the following issue: What is the magnitude of overuse in medicine?  And what to do about it.  The depth of their knowledge and understanding is something to behold. This should be required reading for all in the health care world.

The opening [but keep reading!]:

Dr. Robert Wachter, Editor, AHRQ WebM&M: What is the magnitude of overuse in medicine? 
 
Rosemary Gibson: We don't measure the extent of overuse so we don't know its magnitude. I believe it is pervasive.
 
RW: As you look at the pathophysiology of it, are you convinced that financial drivers—which I guess I interpret as being the more you do the more you get paid—are the dominant reason for overuse? What evidence supports that?
 
RG: Yes, financial incentives are the dominant cause of overuse. But other factors contribute to overuse. Uncertainty in medicine drives overuse. A natural proclivity may be to do something in a context of uncertainty. Fear of malpractice suits drives overuse. Beliefs are a factor. Physicians and patients have their beliefs about medicine and its possibilities and limitations.

Thursday, September 25, 2014

Can health care help hire our heroes?

I know we all feel gratitude to the men and women of our armed forces and do our best in helping them re-enter civilian society after their tours of duty.  One leading program along those lines, run by the US Chamber of Commerce Foundation, is called "Hiring Our Heroes."  The program was launched in March 2011 as a nationwide initiative "to help veterans, transitioning service members, and military spouses find meaningful employment opportunities."

It occurs to me that the health care world can offer jobs that might take advantage of the special skills and training of many in the military.  Those of us who have been advocating for an improvement in the team processes and communication in health care often take note of lessons to be learned from military settings.  Crew Resource Management, for example, was invented by the military to deal with high-pressure, cockpit environments where a strict hierarchy of authority is required, but where every member of the team has a responsibility to help ensure the safety of the entire team.  There is a direct parallel with the environment of operating rooms and intensive care units and other settings in hospitals, where a senior physician might be in charge of the "cockpit," but where every member of the team has a responsibility to help avoid harm to patients.

I note that the Chamber's program has a number of corporate sponsors, but I don't see much involvement yet from many health care systems (HCA being the notable exception.)  Perhaps this is an area worthy of attention from hospital leaders, who might thereby help a willing and able workforce of worthy veterans supplement their usual hiring patterns--and in so doing, help infuse systems of team management and communication that can bring benefit to the clinical staff, patients, and families.

Wednesday, September 24, 2014

When leaders don't lead

I made note last week of the strange silence from our state's largest insurance company, Blue Cross Blue Shield, with regard to the pending antitrust settlement between the Attorney General and Partners Healthcare System.  The impetus for my column was a strong statement by the state's other insurers that the proposed deal would be bad for the state's health care system and consumers.

But I didn't make it personal.  The Boston Globe's Thomas Farragher has now done so in a column in which he asks the CEO of BCBS why the company has been silent on the issue:

Apparently cured of laryngitis, he got on the phone to explain.

“I’m not trying to be cute, but we’ve been neutral,’’ said Dreyfus, whose company accounts for about half of Partners’ commercial business. “It was our judgment that [Coakley’s office] got the best deal they could. We weren’t going to substitute our judgment for theirs.’’

What Farragher makes clear is that silence is not neutrality.  Silence is assent.  This CEO is sophisticated and thoughtful and understands that point as well as anybody in the state.

Dreyfus is better than the sum of that quote. A group of antitrust experts called flatly for rejection of the settlement. The state’s Health Policy Commission estimates the expansion could smother competition and hike health care spending by $49 million a year. Dreyfus’s competitors, a group of other insurers, have raised red flags, and a coalition of Partners hospital competitors have said the deal will drive up costs.

Andrew Dreyfus is a smart national voice in America’s raging healthcare debate. He’s a sought-after speaker across the country, for good reason. He has held down costs. He’s been a proven leader. But not this time.

We cannot always know what incents people to act in certain ways.  We can, however, judge the import of their decisions. Last week, I put it this way:

[BCBS'] actions over the years and its silence now join it irrevocably with Partners as an advocate for higher health care costs in Massachusetts.

Tuesday, September 23, 2014

Encouragement: Please keep sending forth a tiny ripple of hope

Being a patient advocate--trying to change the world or at least your corner of it to make health care safer, higher quality, more transparent, and more patient driven--is hard work.  It can also be lonely work.  It can also be discouraging because the pace of change in this field sometimes feels like watching a race between a snail and a flow of molasses on a cold day.  If you've been through medical errors yourself, or if you have a loved one who was, this can leave you pretty upset and discouraged.

So it has been recently for a gentleman from Sweden.  A mutual friend, Marije Elderenbosch, wrote to ask for help for him:

Torbjörn Hammar has been trying to improve Swedish healthcare for the past four years, as his wife died as a consequence of several medical errors. He wants to eliminate such errors and create more openness in healthcare to help others. Sadly, he now wants to quit, because he feels he is getting nowhere. He got one of Sweden's biggest newspapers to write about his wife and what went wrong, he has one of the biggest trade unions supporting him, Swedish radio interviewed him, but right now he just feels sad and alone.

What he needs is hope, a tiny spark of inspiration, maybe a few pointers, and I was hoping you could help me here. I know you are very busy and I am not even sure what I am asking you exactly, but I refuse to let this wonderful man quit. Can you help me in any way? Tips, ideas, people, whatever.


I shared this call for help with several friends who have been active in the field.  Their comments were eloquent, and with permission from all, I share them with you to share with others who might be feeling the same way as Torbjörn.

E-Patient Dave deBronkart offered this perspective:

Marjie, I'm sorry to hear about his terrible loss, which all of us know about, too well. 

Your email didn't give any idea why he feels sad and alone.  Is he in another understandable wave of grieving?  Did he want some specific change, and it got voted down? 

Or perhaps he's going through something we all know about: the stage of disillusionment people often feel after their first big wave of intense energy is completely spent, and the whole universe has not changed yet.  Then, after a while, you learn that the road it long and that complex systems generally don't change fast. 

This is especially hard to tolerate when you know clearly that there's real human harm from the delays. 

I first learned about this effect around 1982, through a co-worker who was involved in The Hunger Project.  After you see a few children starve to death, and you feel powerless about it, and you bust your ass giving everything you have to stop the problem, it takes some work - and some spiritual transformation - to recommit yourself to the "long haul," the difficult work of learning what it will take to create real change that lasts. 

In the case of the hunger issue, I attended a weekend workshop "Beginner's Guide to Ending Hunger." One of their tips: "Take vacations." (That is, prepare for the long haul.) 

In the case of The Hunger Project, decades of efforts at all kinds of things, from massive UN relief projects to national-leader summits and everything else, ultimately led to learning that what works is very different from top-down:  As this page says (on the right), the "three pillars" are
 *   Gender Equality
 *   Mobilization at a Grassroots Level
 *   Partnership with Local Government

Who would ever have thought that, back in 1980?  President Kennedy had said in 1963 that we have the capacity to end hunger, and all we lacked was the political will.  Well, it turns out complex system problems need to be resolved by discovering what micro changes produce profound effects.
 

I mean, who would have thought that gender equality is a key enabler of resolving hunger? 

Personally I believe that something similar will happen in medical safety: empowering patients, in full partnerships with the medical industry, will prove to be a vital component. And that will take time.

In closing: this is a big task he's taken on, it sounds like he's being effective, and he's going to need lots of help.  It may be that he's found a purpose for the rest of his life.

Tracy Granzyk, who works on process improvement at Medstar Health and is a key player in our resident and student education programs at Telluride, said:

I'm so sorry to hear of your friend's loss. Please invite him to connect with all of us and others, fighting the same fight all over the globe. I personally am re-energized each year by "educating the young" at the Telluride Patient Safety Summer Camps, or attending Patient Safety meetings with colleagues, such as the Lucian Leape yearly Forum or IHI and NPSF Conferences and more. There is strength in numbers--and your friend is not alone. Ask him to reach out--via email, Skype or our blog just to have a virtual cup of coffee, if nothing else. 

As Dave mentions so eloquently, this is a long, often frustrating, journey with far more complexities than any one story can tell. We all feel at times we're climbing Everest without oxygen or a sherpa, but then we have a conversation with a friend or colleague equally as passionate, or a resident or medical student who takes on the cause, and we re-commit to press on to support them and other friends/colleagues, so that the terrible loss your friend experienced, as well as others so dear to all of us, will only be due to terrible accidents--not something that could have been prevented. 

I love the reminder and insight that Dave also shared, that it turns out complex system problems need to be resolved by discovering what micro changes produce profound effects. This, in many ways, reiterates what Atul Gawande talks about in a New Yorker article, "Slow Ideas".

What will be the next "micro change" we as a group can create that will have the greatest impact on patient & healthcare professional safety, as well as engagement in new ways by both parties in any healthcare encounter?

I'm still in! And you're right--we can't afford to lose those who also "get it". We need to continue to grow our "square root" of everyone, so that the real change we're talking about can continue to move forward.

Please reassure him that he's not alone -- share this email -- and tell him to reach out!

And finally, Richard Corder, who works at CRICO, the Harvard system's captive medical malpractice insurance and risk management company:

I am so sorry to hear of your friend's loss, and of his feeling of sadness and loneliness. Please let him know that he is not alone, far from it. 

The work of change (especially in patient safety and health care) often feels lonely, because it is the brave who stand up, and speak up with a quivering voice and shaking hands against that that we have held as "normal" for so long. 

That act, in and of itself, is nerve-wracking and scary. The reality is that the kind of cultural change that we are working toward for will only come about when we remember that we are not alone, that we do this in memory and honor of those who have died too soon, and that we are making a difference by changing the conversation and telling our stories. 

I am inspired by much of what Tracy and Dave have referenced and by remembering that others have grappled with similar realities in the past. I love this quote from Robert Kennedy from a speech made in South Africa in 1996: 

"It is from numberless diverse acts of courage and belief that human history is shaped. Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current that can sweep down the mightiest walls of oppression and resistance." 

When I first started working in this space, Don Berwick MD, then at the IHI, reminded me that to be successful in this space of change, we must find and make friends. They get us through the toughest of times, remind us why we do what we do, are ready to laugh, cry, commiserate and celebrate with us. Please know that you and Torbjörn have a friend in each of us and many more. Please encourage him to connect and to keep making ripples.

CLER on WIHI

Madge Kaplan writes:

The next WIHI broadcast — September 24, 2014: From Here to CLER: Graduate Medical Education and the Clinical Learning Environment Review (CLER)  — will take place on Wednesday, September 24, from 2 to 3 PM ET, and I hope you'll tune in.
Our guests will include:
  • Kevin B. Weiss, MD, MPH, Senior Vice President, Institutional Accreditation, Accreditation Council for Graduate Medical Education (ACGME)
  • Robin Wagner, RN, MHSA, Vice President, Clinical Learning Environment Review, ACGME
  • Maren Batalden, MD, Medical Director of Hospital Quality, Associate Director of Graduate Medical Education for Quality and Safety, Cambridge Health Alliance (CHA)
  • James Moses, MD, MPH, Medical Director of Quality Improvement, Boston Medical Center; Academic Advisor, IHI Open School for Health Professions
Enroll Now
A new IOM report released over the summer has reignited debate and discussion about the financing and goals of graduate medical education (GME) in the US. Given that Medicare is the primary funder, to the tune of $15 billion per year, the report’s authors call for greater accountability for all the government support, along with a change in priorities. For example, the IOM committee points to a disconnect between what the health care system desperately needs right now — more cost-conscious doctors capable of improving patient care, managing population health, and committed to primary care — and residency programs that remain overwhelmingly hospital-based and focused on medical specialties.

This is not the first time we’ve heard calls to reform GME, or the first time we’ve seen efforts to respond by the accrediting body itself, the Accreditation Council for Graduate Medical Education (ACGME). They’re in the midst of rolling out a new set of residency training expectations that are more aligned with delivering value and helping patients achieve optimal health. The program is called the Clinical Learning Environment Review — CLER for short. On the September 24 WIHI we’re going to explore the potential for CLER to bring about the most dramatic changes yet for medical residents, and we hope you’ll tune in.

ACGME’s Dr. Kevin Weiss and Robin Wagner will explain the goals of CLER and some of the specific ways residents are being asked to contribute to progress in six areas: Patient Safety, Quality Improvement, Transitions in Care, Supervision, Duty Hours Oversight (including Fatigue Management and Mitigation), and Professionalism. Dr. Maren Batalden from the Cambridge Health Alliance (CHA) now has a CLER site visit under her belt, and she’s plenty excited about the potential for the program to better align residency training with an organization’s overall safety and quality improvement agenda. Finally, we welcome Dr. James Moses from Boston Medical Center, who has been in the trenches of helping to steer residency training in a new direction for years and also serves as academic advisor for IHI’s Open School.

Whether or not you are directly involved in GME, its priorities have implications for all of health care. WIHI Host Madge Kaplan looks forward to your participation and your comments on the September 24 WIHI. To get ready for the program, we invite you to check out this blog post by IHI’s Dr. Goldmann about the IOM report on GME.

We hope you will tune in and learn more with us! You can enroll for the broadcast here.

Monday, September 22, 2014

The irony of on-line advertising algorithms

Sometimes the irony of on-line advertising algorithms is made evident.  How about this article in the New York Times--focused on the adverse impacts of hospital mergers--being tagged with an ad from Partners Healthcare System!  ("We're rethinking health care," says the corporation.  Are we convinced?)

Mores seriously, this article explains why Partners needed the buy-in from the Massachusetts Attorney General in the recently filed settlement of its anti-trust case: "State action" precludes a more thorough federal involvement.  But the real question is why the federal government agreed to defer to the state in the first place, as opposed to pursing an FTC and/or DOJ case:  Was this a favor from the Obama administration to their preferred Democratic candidate?

Screening the screenings

Here's an excellent piece about "wellness screenings" by John Lundy at the Duluth News Tribune.  The underlying theme about unnecessary testing and the business of selling such tests is important.  John's presentation is very well done.

As Gary Schwitzer notes in a message to health care reporters, "Imagine the impact if this kind of story was published by papers big and small across the country."

An excerpt:

The screenings — for stroke, atrial fibrillation, abdominal aortic aneurysm, peripheral arterial disease and osteoporosis — “aren’t just routine procedures,” an enclosure in the envelope [a 74-year-old man] stated. The words were next to a photo of a solemn-faced man in a white jacket, with a stethoscope hanging around his neck.

“They can help save your life,” it concluded, with the final three words underlined.

But some health experts argue that some of the screenings offered by Life Line and similar companies actually can do more harm than good.

“The layman would be shocked to know we actually do not have science to show that these screening, early detection tests actually decrease mortality or are beneficial to the patient,” Dr. Otis Brawley said in a telephone interview.

The chief medical officer for the American Cancer Society and a professor at Atlanta’s Emory University, Brawley wrote the 2011 book “How We Do Harm” on practices he argues benefit everyone except the patient.

Sunday, September 21, 2014

In memoriam: Katherine McQuade Toig

The world lost of one its true angels this week with the death of Katherine McQuade Toig, RN.  Katie was a beacon of light to all who knew her.

We first met when she was a nurse in training at BIDMC.  She was always dropping by my CEO office with questions and ideas. As a colleague said, "She wanted to save the world."  In so doing, she constantly questioned her role and her place and was searching for the best way she could serve humanity.

Here's an excerpt from a blog she wrote while on a volunteer mission in Kenya, which inspired her to remain involved in that region:

I am uncomfortable. My senses did their job in Kenya. They collected sights, sounds and information for me to wrestle with. My mind will not be the same. Old beliefs and realities cannot accommodate the new information. The process of reconciliation is not tidy. It won’t work for me to come to simple explanations and conclusions. I will need to sit in the dissonance for a while and build new constructs of thought. 

I will continue to collaborate with Tatua. My energy will be aimed at empowering and supporting the Community Health Workers in the slums of Ngong, Ngando and Rongi. It isn't enough to provide mission work to the slums. The solution has to grow from within. The CHWs are uniquely positioned as access points to healthcare. My mind can rest on this. 

A new chapter begins for me here with the CHWs.  

Little did I know that Katie would help me heal after a difficult period I had in the hospital.  Here's how she responded to an email I sent to the staff apologizing for my bad judgment:

"I am moved by your letter and want to thank you for all your work. As for any transgressions you may have had, I feel you are only human and we all make mistakes. As I’m sure you know, it is how we handle them that makes us who we are."

Wisdom beyond her years.  Compassion and empathy that set an example for all who knew her. Deep sadness for all who will now miss her.

How fast can a proton go down a drain?

I've had a number of people write to me upon seeing Jaimy Lee's story in Modern Healthcare:

The Indiana University Proton Therapy Center will close in December, marking the first time a proton-beam therapy center in the U.S. has shut its doors since the rapid proliferation of the costly treatment centers began about a decade ago.

University executives and an independent review committee attributed the center's financial losses to a range of issues, including the cost of maintaining its aging cyclotron, but the committee also suggested the industry may be on the verge of a “proton bubble” as the centers struggle to serve a sufficiently large patient population.  


"Is this a trend?" they ask me.  The UI had a special committee to help them in this matter:

In the committee's report, the reviewers highlight many of the issues affecting the proton industry as a whole, including the lack of completed randomized clinical trials, improvements in alternative treatments, changing care patterns for patients with prostate cancer, and the rise in new payment models, such as bundled payments that may remove incentives to use the therapy.

“It is, therefore, quite possible that we are on the verge of a 'proton bubble' with the more indebted centers or those without a strong patient supply line closing,” the committee said in the report. 

Well maybe and maybe not.  Maybe there were local conditions at work: 

The losses and challenges were clearly outlined in the report. The IU center requires 63 people to staff the cyclotron, spelling high labor costs. The technology, which was adapted from a research cyclotron, needed a $30 million upgrade. The Bloomington site, which is an hour's drive from Indianapolis, is not ideal for clinical-trial participation because it requires most patients to travel.

The center reported a $3.5 million operating loss in fiscal 2013. Another challenge it faced: newer centers are expected to be opened by University Hospitals in Cleveland, Ohio, and by the Mayo Clinic in Rochester, Minn., key referral markets.



But one thing is for sure.  The investment in this machine represents a huge opportunity cost for the University and the patients served by it and, indeed, for other clinical departments.  That tax on the University will persist, as the bonds must still be paid off.  Millions of dollars have and will go down the drain in support of a technology with limited clinical applicability--all part of the edifice complex supported by selected physicians and hospital administrators.  (See the pride with which it is described on the website above and in this 2010 press release announcing a renaming: "We will be proud to be known as IU Health Proton Therapy Center," stated Dr. Peter Johnstone, president and CEO, who shared this important information with staff via executive email.)

And all of this is aided and abetted by perverse Medicare payments that CMS persists in maintaining--even as private insurers declare the treatment ineligible for payment.

Saturday, September 20, 2014

We use autonomy as a defense to the need to appear to be impossibly perfect

Gene Lindsey's weekly email letter invariably contains some gems.  Here's one from this week. He cites Sally Kilgore, president and CEO of Modern Red School House Institute, from her co-authored book Silos to Systems. The book is about how the education system might be improved. Gene says:

Her introduction concludes with insight that is applicable to healthcare.
Envisioned by Donald Schon (1973), a learning organization is one that is “capable of bringing about its own transformation.” But creating that condition requires that we pay attention to how we organize professional life at schools—how information flows, the form in which leadership is shared, the diversity of perspectives we use to solve problems, and the degree to which our interdependence as educators becomes an opportunity rather than a nightmare.
Her words are sweet notes to my ear. I love the construct that in a learning organization, interdependence could become an opportunity rather than a nightmare. Read this next excerpt:
Organizational systems theorists emphasize that solving important problems requires multiple perspectives and seemingly diverse approaches to the solution. Ian Mitroff and Abraham Silvers (2010) find that lacking diverse perspectives, we often solve the wrong problem.
In my own recent thinking, based on observations of hospitals and medical practices across the country, I have evolved an image of the toxic triangle that makes improvement in healthcare so difficult today. Our current sense of despair seems to arise from increasingly negative externalities that we all feel but do not understand. The culture of autonomy and our tendency to be in tribes of various states of understanding preludes progress. We are like a sailor in “irons”.
We use autonomy as a defense to the need to appear to be impossibly perfect, and the result is isolation or the use of silos for protection when the solutions to the problems of our patients, which are our professional responsibility, lie in interdependence.

Friday, September 19, 2014

Goal Play! hits 10K

I just received notice that Goal Play! has sold 10,000 copies.  I am honored that so many people have read and enjoyed these leadership lessons and recommended the book to their friends and colleagues.  Thank you!

Thursday, September 18, 2014

2014 Sepsis Heroes

I was so pleased to be invited by Dr. Jim O'Brien to participate in the Sepsis Alliance 2014 Sepsis Heroes ceremony in New York City.  Here are the awardees:

Laura Messineo is a critical care nurse who is passionate about increasing sepsis awareness among healthcare professionals and the public. Although she has been a nurse since 1991, it would be several years before she first heard the word "sepsis" being used. She has since become a driving force in her healthcare facility and community in promoting sepsis awareness and education.

"I have challenged myself to learn everything I can about sepsis through lectures, articles, and attending conferences such as the American Association of Critical Care Nurses' (AACN) National Teaching Institute (NTI) and the Society of Critical Care Medicine's Annual Congress."

According to Ms. Messineo, sepsis awareness is important because it is a treatable disease process, which can result in a positive outcome if early goal directed therapy is initiated quickly. Community awareness and clinician education is vital in decreasing septic shock mortality and improve the lives of sepsis survivors. Laura plans on continuing to speak nationally on sepsis, writing grants for more sepsis education, and championing national regulations for sepsis screening.
--
Sepsis remains a leading cause of maternal mortality around the world, even in the 21st century. Raising awareness about prompt treatment of infections, and improving hygiene and conditions where women deliver their babies will reduce the risk of sepsis and help to make pregnancy and childbirth safer for both mother and child.

Every Mother Counts is an advocacy and mobilization campaign founded to increase education and support for the global reduction of maternal mortality around the world. EMC's work in the United States ensures that more mothers have access to prenatal care and childbirth education.

"People are shocked when they learn that women are still dying in childbirth. We are committed to informing the public about the challenges and solutions."
--
The timing of sepsis suspicion, diagnosis, and management are essential to improved outcomes. That first hour in treating sepsis is as vital as that first hour after someone has a heart attack or stroke. Intermountain Health, a nonprofit system in Utah, has put into place a sepsis bundle for its dianosis and management. This bundle, which included 11 clinical elements to be addressed during the first 24 hours of treatment, resulted in a drop in mortality rate from sepsis from 25 percent to around 9 percent. This equates to saving about 100 lives per year.

Virtually everyone on the healthcare team is involved in the sepsis bundle, including nurses, emergency medicine physicians, hospitalists, critical care physicians, transport specialists, respiratory therapists, radiologists, laboratory technicians, and other providers. Intermountain Health hopes to expand sepsis awareness beyond their emergency departments in order meet patients with wherever sepsis is diagnosed, be it in the general hospital wards, clinics, or at home.
--
Helene and Jeff Zehnder were nominated and chosen as 2014 Sepsis Heroes for their work in raising sepsis awareness. While Helene is a nurse and is familiar with sepsis, when a family friend died of the illness, the couple realized that work needed to be done to raise sepsis awareness in their community. The result was the inaugural 5K Walkathon/Road Race, called Step on Sepsis.

Helene Zehnder has been a nurse for 35 years. She is currently the Director of Medical-Surgical Nursing and Magnet Program Director at Rex Healthcare in Raleigh, N.C. She has a BSN from the University of Pennsylvania and has a masters degree in nursing from Widener University in Chester, Pa. Member – of the NC Nurses Association, the Academy of Medical-Surgical Nurses and the American Association of Critical Care Nurses (AACN), she is the current president of the Greater Raleigh Chapter of AACN. Helene was named one of the Great 100 Nurses in North Carolina in 2013.

Jeff Zehnder is a graduate of Stockton State University in New Jersey with a degree in business administration. He worked in the corporate world for many years and now is a home inspection business owner in Cary, N.C. He is an avid reader and participates in multiple sprint triathlon and 5K events. He is the president of the neighborhood homeowners association and volunteered with Boy Scouts of America for many years.