Regarding the slides based on information described in the excellent New Yorker article by Atul Gawande, "The Checklist": [checklists] are ever so important.

The next chapter in this story is extremely important, as described in the NY Times Op-Ed piece by Dr. Gawande.

I urge you to read the Op-Ed piece.

The gist: A simple checklist, similar to pre-flight checklists used by pilots, has been proven to reduce ICU deaths. People die less ... much less ... as a result of this. Plans to spread this nationally in the US were underway. Simple. Elegant. And primed for implementation on a broad scale, BUT ...

The Office for Human Research Protections (OHRP), upon learning of this, stopped the project immediately.

Why? The OHRP treats this as research (despite the fact that results are proven). Because they see it as research, they feel that it was unethical that patients were not informed that a checklist was being used, and that its use was being measured. In essence, they treated this in the same way that they would a study in which patients were being given a medication with unknown efficacy.

Can they really do this? Sure. And in fact, they can cut off all federal funding to groups (hospitals, researchers, etc.) that fail to obey.

Since that 12/30/07 decision, health care institutions and quality improvement specialists across the country have been running scared, fearing the wrath of the OHRP and the subsequent loss of funding. They've asked their quality improvement folks to stop doing what they're doing immediately, based on these legal and regulatory concerns.

A number of prominent healthcare bloggers share their concerns. Check out healthbeatblog.org to see Maggie Mahar's blog.

We all are left asking, "WHY?"

With such great results, who would want to stop this work? Maybe it's the folks who fear exposure of how truly bad our hospitals currently are. Imagine the loss in market share for those that don't use the checklist! Maybe it's about money.

Analogy: We've done process improvement work to look at and improve compliance with ideal handwashing guidelines (yes ... not all doctors wash their hands as much as they should). But imagine if we had to get informed consent for patients to participate in this work! "You may be subject to an intervention ... your doctor may actually wash his/her hands, and, as such, you may be exposed to something that isn't consistently done."

Innovation isn't common when it comes to healthcare operations and processes. When it happens, (even if it's something simple like a checklist), do we really want to squelch it? The lesson for implementation: Watch out for the barriers to implementation. And when barriers sometimes seem insurmountable, there are times when radical action is necessary. When our Denver-based healthcare think tank met last night, I suggested civil disobedience as one approach. Do it anyway, and worry about the consequences later. Be radical ... be remarkable!

Manoj Pawar, MD, MMM
Posted by Manoj Pawar at January 19, 2008 12:13 AM

Hospital administrators are screaming about more paperwork snarls. I agree. Paperwork will get worse. Definitions are mushy. Cheating—attributing adverse outcomes to nonpreventable causes—will take place. Willingness to admit errors will decline, even plummet.

While I acknowledge the problems associated with the new regime, and even acknowledge the severity of said problems, I can only say to my hospital administrator friends, "You asked for it!" Medicare is using a blunt weapon out of frustration. Hospitals are, in my experience, now focusing on preventable errors, no doubt of it. But there is an enormous gap between "focusing on" and becoming "fully devoted to." That is, there are now numerous patient safety "programs"—but few on the order, say, of American industry's 179-degree about face-strategic realignment on product quality in the 1980s. There is little doubt that we lose far more lives to preventable errors (like those that stem from the failure to wash hands carefully!) than we save via sexy new surgical procedures. I once told a group of hospital CIOs that implementing electronic medical records would allow them to save more lives than the entire surgery department—perhaps that's an exaggeration, but not by much.

So I pray on bended knee, especially as an "old guy," that such blunt instruments as the new Medicare policy will encourage, at gunpoint if necessary, hospital administrators to move patient safety off the "important programs" list and instead to the top of the "strategic survival right f***ing now" issues list—and keep it there until the problem is brought under control. Remember, the definition of "preventable" is "preventable"—and the bulk of the fix is not cost intensive. Recall how "quality is free" went from consultants' gag line to Holy Writ in industry—and turned out to be true.

But I think the financial-coverage debate should be secondary to a debate-dialogue about what the hell we're buying with the megabucks going into our current healthcare investment.

We spend a ton and a half of money on patching ourselves up ... and rank 40th in life expectancy worldwide.

Correctable, in the main, errors in hospitals cost us over 100,000 lives per year.

Correctable errors cost us perhaps 2 or 3 million wounded in hospitals, doctors offices, etc.

Spending wildly overemphasizes after-the-fact fixes rather than prevention and wellness.

Incentives wildly favor specialists who save a few lives (e.g., mine) and their specialist tools over Internists, Family Practice, and Public Health.

My rant: Let's spend as much time and energy fixing the fixable enumerated above, 99% independent of the insurance debate, and seeing if we can tease out longer lives as a result of our investment. If our life expectancy is so damn low compared to those spending much less, aren't we at some level getting screwed? I know that's crude and bizarrely over-simplistic—but there's also a big kernel of truth to the intemperate statement, isn't there?

(My current picks re healthcare reading:

Better: A Surgeon's Notes on Performance, by Atul Gawande
How Doctors Think, by Jerome Groopman

Both are excellent writers.)

As you saw from an earlier Post this week, I spoke at the remarkable Johns Hopkins Bloomberg School of Public Health. As in the case immediately above, I was put to shame by my ignorance as I "read in" to the event. The Hopkins story is peerless—and has resulted in successes since 1916 that are responsible for millions upon millions of lives saved and more millions upon millions of years added to people's lives. Healthcare (or, rather, health—there's an enormous difference) has become a recent professional obsession of mine; and the fire was fuelled by this Hopkins opportunity. Wellness, prevention, mass public health, and family practice are my hot buttons (in addition to the hapless state of acute care safety). I intend to fatten my public health library in the months to come—my newfound JHU friends have agreed to mentor me. And a new "Tom Campaign," as my colleagues sometimes call it, is in the offing.

Part of the survey has revealed that 9 out of 10 hospitals have implemented procedures to avoid wrong site surgeries. In our language, that means they assure operating on the right part of the body! Hmmm, do you wonder what the rest of the hospitals are doing?

The Leapfrog Group publishes and updates hospital data regularly, and it can be viewed by consumers at no charge on their website, www.leapfroggroup.org.

See if your hospital has made the top fifty-nine list: Leapfrog_Top_Hospitals_2006_list.pdf

Nurse practitioners staff the centers, a charge of $25–$50 is the norm, and a series of common tests and the likes of flu shots are the product. As at his travel firm, Hal is utilizing the most advanced software, including artificial-intelligence systems to be part of a featured self-diagnostic process.

I am still appalled at the lack of health care availability at a reasonable price for many Americans, including children. But, without being a radical on the topic, I'm also intrigued at the way the market is responding. A couple of weeks ago the Wall Street Journal did a front page piece on how members of high-deductible plans were responding. Most have, as hoped, become far more involved in healthcare decision-making than before. Web-based information and the likes of Take Care are also part of the burgeoning portfolio of options.

Shortcomings and abuses will be part of the shakedown process, though they could hardly be worse than the current system that features such things as ambulances aimlessly circling cities with acutely ill people aboard—as they seek an ER willing to take them.

Good show, Hal. May a hundred hundred flowers—imaginative experiments—bloom! Though, as I said, deeply distressed by holes in our system, certainly this portfolio of experiments is preferable to a centralized government-run system fecklessly controlling 20% or so of our economy!

All advice on weight reduction is suspect—that is, there are three, if not thirteen, sides to every suggestion. Nonetheless, I came across the following somewhere or other, and it's been devastatingly effective (though, indeed, counter to much conventional wisdom). Namely: WEIGH IN EVERY MORNING!

Yup, water retention, or some such, is up one day and down the next. Sorry, if the base over the span of a few days is up, it means your weight is up. Obviously, the "demoralizing" counterargument is the most persuasive. I agree that it's often demoralizing. But, for me, if I don't do "it" every day, then I often find myself rationalizing why I "can just wait another few days" before hopping on the scales.

As I said, for what it's worth. (And it's been worth a lot to me.)

BusinessWeek has a barnburner of a cover story this week (0925), "What's Really Propping Up the Economy." Long-time, brilliant BW economics reporter Michael Mandel begins, "Since 2001, the healthcare industry has added 1.7 million jobs. The rest of the private sector? None." Paradox: We decry h-care spending—and without it, at one level, we're sunk. Interesting, no?

Speaking of healthcare & "amazing," on another note I remain fully captivated-blown away by the Planetree Alliance; their "patient-centered" acute-care model is more or less (more more than less per me) peerless. "Patient-centered" is no hollow slogan with these folks. Attached is an updated Plantree PowerPoint FYI. Not so incidentally, they are the only acute-care operation (their flagship Griffin Hospital in Derby, CT, that is) to make the "100 best companies to work for" list—7 times running, currently at a robust #4.

Health Rule #1: WASH YOUR HANDS! I've been (recently) turned into a gen-u-ine fanatic. Consider:

"If God spoke to me by saying, 'Mark, you're down to your last three words: What would you want to say to your fellow humans that would make the most positive impact?' It would be a close call between 'Love Thy Neighbor' and 'Wash Your Hands.' A close third would be 'Move, Move, Move.'"—Mark Pettus, M.D., The Savvy Patient

"The most important thing you can do to keep from getting sick is to wash your hands."—CDC/National Center for Infectious Diseases

Purell has 62% alcohol, which serves my purposes pretty well—though 80% or more is recommended. Of course in "speech world" I shake hundreds of hands—but that's not the point. If you don't shake a hand a week this matters—a lot.

Last year when I got my Medtronic pacemaker I survived the hospital—as I read the stats, I can only conclude that I was lucky. And I'd rather depend on something a little more solid than luck. Yes, damn it, I believe every word of what I said in Rancho Mirage yesterday: We are faced with an emergency, and a disgrace (we know how to fix the problem)—and the IT gang must lead the way out of the conflagration. Period.

(No surprise, some hospitals are doing a great job on safety and safety improvement. A couple of CIOs gave me their cards and invited me out; I will probably take them up on their offers, as I am determined to learn much more about this issue. Incidentally, the Veterans Administration's hospital system is, among big systems, leading the parade.)

Once we all dreamed of owning our homes, now many of us dream of affordable health care.

I want my Lipitor. Will I be able to keep it? It, too, is now under attack. Of course I don’t want anyone to have nasty side effects. But if a jillion of us are taking it, there will doubtless be a few problems, given the different wiring each of us brings to the party. Lipitor is saving (not too strong a word) tens of thousands of us. I am willing to face the odds of a one-in-a-jillion chance of harm in return for a, what, 50 percent chance of doing (lots of) good.

P-L-E-A-S-E don’t take my Lipitor away!

Above are the mashed potatoes that go with the fried chicken—I guess they fill that little hole in the picture below. While I think of obesity and the USA in the same breath, an M.D. in my Singapore audience told me, as I recall, that youth obesity there has soared from 10% to 40% in the last decade. Pandemic, anyone?

(Dan Quayle Award to TP. Thank God for spellcheck! Above, the LRL/Little Red Line appeared under "potatoes," which I initially spelled "potatos.")

I'm spending more and more time on healthcare issues, as many know. At or near the top of the list is hospital errors. Much of the fix requires driving "garden variety" quality improvement systems through our acute-care hospitals and clinics. One blanches—I did yesterday—to read a news bulletin reporting that there are about 1.5 million miscues per year in the administration of drugs; that's apparently one per day per patient. Then, if you dare, add in the number attendant to doctors' office visits. And yet so many players continue to balk at widespread use of tools and techniques that could make a profound difference.

But those statistics didn't come close to upsetting my applecart as much as the _______ (disgusting? tragic?) picture above. Our HHS secretary tells us that obesity, especially childhood obesity, is a bigger problem than terrorism. What you see above looks pretty much to me like a clogged artery (but what do I know?). Instead, it's a close-up, taken with my garden-variety Sony, of a tiny section of a KFC photo-poster on the window of a shop near me here in Singapore. What can I say (sorry) other than: Holy shit!

I am, I suppose, not surprised—but I am wholly disgusted.

Nonetheless I am delighted to report that my "right stuff" healthcare FILE is bulging from recent reportage. E.g.: "Medical Guesswork: From Heart Surgery to Prostate Care, the Medical Industry Knows Little about Which Common Treatments Really Work" (cover, BusinessWeek, 0529). "What Doctors Hate about Hospitals: An Insider's View of What Can Go Wrong—and How You Can Improve Your Odds of Getting the Right Treatment" (cover, Time, 0501). "Pushing Pills: How Big Pharma Got Addicted to Marketing" (cover, Forbes, 0508). "Hey, You Don't Look So Good: As Diagnoses of Once-rare Illnesses Soar, Doctors Say Drugmakers Are 'Disease-mongering' to Boost Sales" (BusinessWeek, 0508). "Teaching Doctors to Care: The Problem With Most Medical Students Is That They've Never Been Really Sick. Now Some Are Learning What It's Like to Be Chronically Ill." (Headline, Time, 0529). "The Politics of Fat" (Time, 0327). "Obesity Tests: Every Four-year-old in the Country to Be Officially Screened" (The Independent on Sunday, UK, 0521*). (Later in the same paper there was a story about McDonald's new XL burger.) "Call for Switch to Preventive Measures as 29 Billion Pound Cost of Heart Disease Is Revealed" (The Independent, UK, 0515).

Great, more or less! At least these issues are beginning to work their way into the consciousness of our citizenry. And hacking at Big Pharma is way overdue, as I see it; the recently retired CEO of a giant med devices company told me last week that for last year's roughly $15 billion in pharmaceutical research among the U.S. Giants, we got exactly ZERO approved drugs. I haven't checked the accuracy of that statement, but given the source I'm assuming it's right on or damn (damningly?) close.

Many of you have been to the Atlanta airport, I suspect. You ride an underground tram to your gate. You can, in Atlanta and several other airports, walk if you wish. Yesterday I left from the B concourse, but I walked from security out to the end, the E concourse I think, and then back to B. As I casually measured it, I logged about 1.25 miles ... at a very brisk pace further enhanced by carrying a heavy backpack and pulling a roller bag. Even in smaller airports (e.g., Nashville, recently) I've discovered that if you "do" every concourse from end to end, and maybe but no more than twice, it's pretty easy to log a mile while receiving only a few odd glances. You get in some pretty effective exercise, relax pretty effectively from a perhaps stressful day ... and the only price I've found is being a little sweaty for a few minutes when you're done.

(To state the obvious, on longer flights I am a big, big advocate of the in-seat stretches! Most airline mags offer rather complete suggestions—and hats off to British Airways for the best "program," in my opinion.)

STOP ... using the term "healthcare."
START ... using the term "health."

Better HEALTH is the goal—and if we did "it" (focus on "health"), then "healthcare" would be far, far, far less necessary. (Understatement.)

"HOW YESTERDAY" OBSESSION: healthcare.
"HOW NOW/TOMORROW" OBSESSION: health.

HC21.J1

Quality
"Evidence/Outcomes-based" medicine
Prevention
Wellness
Med-school re-orientation
"Public health" emphasis
Mind-boggling 15-(20-?) year social-moral-technological impact of life sciences ("the Singularity"?)
H5N1
WMDs
Environmental degradation
Risk assessment (private, public)
Public vs/+ Private responsibilities & partnerships
Africa!