Engaging and Empowering Patients

Tom has been very outspoken about problems with the healthcare industry (a few examples). In August, he spoke at Harvard on a panel called Engaging and Empowering Patients for Quality and Safety, which was part of the Eleventh National Quality Colloquium: The Leading Forum on Patient Safety, Quality Enhancement, and Medical Error Reduction. His fellow panelists were Michael Millenson, author of Demanding Medical Excellence and president of Health Quality Advisors, Rajni Aneja, EVP of the Joslin Diabetes Center, and "e-patient Dave" deBronkart, former cancer patient and patient care activist. (To see the speeches, go to the end of this post for the links.)

All of the panelists are working toward a common goal, well summarized by the title of Millenson's book: Demanding Medical Excellence. Medical Excellence includes reduction of medical errors, greater quality of care, improved communication between patients and healthcare professionals, increased decision making power for patients, as well as the ability to manage their own care. While Excellence is an aspirational word, the current state of the healthcare industry demands more than interest in lofty goals. The statistics on medical errors are not improving, and it is extremely difficult to change the habits and practices of an entire industry. Not to mention the fact that you'd be hard pressed to find anyone who hasn't been frustrated or angered by a healthcare experience whether its their own or their loved one's.

One clear example of the persistence of medical errors was shown in the article, "Study Finds No Progress in Safety at Hospitals": "The study, conducted from 2002 to 2007 in 10 North Carolina hospitals, found that harm to patients was common and that the number of incidents did not decrease over time. The most common problems were complications from procedures or drugs and hospital-acquired infections.... Dr. Landrigan's team focused on North Carolina because its hospitals, compared with those in most states, have been more involved in programs to improve patient safety."

Panelist "e-patient Dave" deBronkart passed along an anecdote from Atul Gawande of a man who was in a head on crash. His recovery was a medical miracle, he only lost his spleen. Two years later, he lost his fingers and toes from an infection because he was not given the standard three vaccines after his splenectomy. DeBronkart was using the story as an example of the lack of information given to patients and their families. He raised the questions, "What if the family had googled splenectomy? What if they'd found that giving three vaccines was standard practice? What if they'd paid close attention and asked if he'd received them?" It may seem to be the doctor's place, but it's increasingly true that families and advocates can make a big difference in the quality of care their loved one receives. [Ed. note: anecdote corrected]

My personal experience bears this out. What seemed like a minor detail to the pharmacist—switching a prescription refill from one generic manufacturer to another manufacturer—caused severe nausea, vomiting, and five days of debilitating migraines. One would think that the same drug in the same dose would not cause such a reaction. The only change was the companies that manufacture it. What's even more frustrating was the fact that several healthcare professionals couldn't identify the cause of the symptoms as the drug switch. Could it be stomach flu? A sudden onset of migraines? It wasn't until I did online research and read other patient stories identical to my own that I confirmed the cause of my symptoms. I don't have to ask, I already know my story brings to mind another story in your own experience (Steroid shot for back pain, anyone?).

Panelist Millenson colored a stark picture by asking, "How many doctors have to die before our current level of medical errors becomes a 'crisis'"? Answering his own question, Millenson invoked the AIDS epidemic, which was termed a crisis not after reaching a particular patient death toll, but only after 3-10 medical professionals died from the syndrome. Moving on from medical errors to patient care issues, Millenson laid out the root of the physician-patient communication problem by quoting the American Medical Association's panel on ethics from 1847. It stated that the patient should obey the physician. This may explain physicians' longstanding paternalistic and patronizing attitudes and practices, extending from withholding information from patients to taking patients' tissue without consent (e.g., the case of Henrietta Lacks). While there may be a few curmudgeonly holdouts, the majority of healthcare professionals today are not expecting to be obeyed so much as to be in a problem-solving relationship with their patients. According to Millenson, the change is more recent than you would imagine. Today, clinicians are being taught more about shared decision making and coordinated care. He said that wasn't happening twenty years ago.

Millenson's intention, of course, was to highlight our lack of progress in reaching anything close to Medical Excellence. That's not from lack of effort in some areas. There are beacons of hope if you begin to look.

The au courant fascination with behavioral economics—notably with the success of such books as Freakonomics, Predictably Irrational, Nudge, and Switch—has popularized behavior experiments producing counter-intuitive results. For example, Chip and Dan Heath, in their book Switch, feature a study involving nurses who administer medication. The nurses who wear bright vests indicating they need a cone of silence around them with no disruptions (meaning even doctors can't speak to them), reduced their errors drastically compared to those who did not wear the vests. As it turned out, a concern for fashion sense was more dangerous than anyone expected. Continuing with seemingly irrational or unexpected experimentation can only lead to greater learning.

Peter Pronovost's work with checklists was similarly dismissed at first. Doctors claimed they knew their procedures thoroughly. But after instituting his simple, common sense checklists, hospitals have saved thousands of lives and millions of dollars. His checklist protocol is now being used across the country. Tom mentioned the Mayo Clinic during the panel, and how their organizational culture's focus on collaboration has impacted their physicians. The physicians report that they feel like they're part of an organism, not a single cell, and therefore they feel like they're doing a better job. Working closely with peers would certainly lend itself to new learning and rigor rather than a lone wolf environment.

As you can see, it is not all doom and gloom on the horizon. Change for the better is starting to gain momentum. The panelists discussed the repercussions of errors, and how significantly they can be mitigated by the simple act of apology. Rather than an admission of error leading to disaster, healthcare professionals are discovering that apologizing can be an enormously effective salvo and balm.

The benefits reaped from greater patient involvement at all levels of care was the overwhelming message from the panel. Millenson described how bringing patients into hospital boardrooms can provoke high levels of change. He also mentioned the Robert Wood Johnson Foundation's Open Notes Project: "The OpenNotes project tests the radical yet simple idea that physicians' notes should be for the patient, not just about the patient. This 12-month study has primary care physicians sharing with their patients the notes they record from office visits through a secure electronic medical record.... The OpenNotes team will assess whether the intervention effectively breaks down communication barriers among physicians and patients and promotes shared decision-making, making the relationship more open and democratic."

Millenson also described how nurses have been taught to think they're patient educators, an improvement over past practices of dispensing medical care only, but educating implies delivering information from on high. Currently, the patient-friendly attitude of defining nursing as "self-management support" is recommended. The intention being that nurses help patients manage their own health problems.

Shifting the power from the physician to the patient is not a smooth transition. DeBronkart described how patients typically act in a healthcare situation this way:
"We don't want to seem pushy, so we're afraid to speak up. Doctors then assume that we want them to make the decision for us. Doctors need to invite the patient to communicate by asking, 'What's important to you?' Think about how you would like to be spoken to. Give the patients time, listen." He provided a powerful example of the importance of listening to the desires of the patient. A woman at 50 decided against a physician-recommended double mastectomy. She said, "I understand I'll die at 75 instead of 90, but I want to keep the breasts." Only the patient can determine what the correct choice about her/his healthcare is. In order to make that choice, patients need the most complete information.

Tom "You can't shrink your way to greatness!" Peters is not known for his reserve, but admitted his own fear of speaking up in conversations with his doctors. The panel as a whole concluded that the all-too-common reticence of patients to make their wishes or questions known has to change.

The essential takeaways for the general public from the panel were: 1. Be more aggressive with your healthcare professionals, despite your fear of being rude. 2. Pay attention. 3. Ask more questions. 4. Check your own electronic medical records for errors when you're healthy. Don't wait until something happens.

All the panelists agreed that the quality of healthcare will improve—and perhaps the achievement of Medical Excellence can only happen—once patients are empowered and involved more closely in the medical decision-making process.

Note
Tom was impressed by the content of the panelists' talks and noted that they were not made available to the public. With a little work, we were able to obtain some of the speeches and would like to share them with you. To see "e-patient Dave" deBronkart's speech, click here. To see Michael Millenson's speech, click here. To see Tom speak, followed by the question and answer period, click here. Two technical notes: first, unfortunately, the speakers' slides are not visible in the video. Second, while we've not included Rajni Aneja's speech, she is doing some very innovative work using technology to eradicate diabetes, and we do encourage you to follow her amazing work at the Joslin Center.

I Do NOT "Have It In" for Mass General Hospital! (Or at Least, Not Much)

Lunch at the Harvard Club in Boston. First time. Age 68. Friend in publishing. I idly mention I'm vaguely thinking about a book on "patient safety." Words barely out of my mouth when a story explodes from her about a relative who'd recently suffered a series of blunders, some agonizing, at a "leading med center" in Boston.

A week before I'd paid a visit to a company I work closely with in Washington D.C. Chatting with the president about this and that. Healthcare came up because I was in the area for a couple of medical appointments. Kaboom! From her mouth explodes a horror story regarding her 90+ mom at a "leading med center" in Northern Virginia, which, like Boston, is chock-a-block with "leading med centers."

And then there was the recent dinner with fellow-sorta-oldies when health arose. (As it usually does these days.) In a flash, pretty much unbidden by me in this instance, every one offered a story of rather recent major med center f___-ups. (This may have been the 10th time this ritual has occurred—so far, alas, I'm batting 1.000. EVERY ONE in my un-scientific sample has offered a RMHFS/Recent Major Hospital F___-up Story involving themselves or someone close to them.)

My own: At a "leading med center" in Boston, was seeing an internal medicine guy of significant repute. Go over everything in an hour-plus intake interview—including, obviously, my pacemaker.

He calls up my electronic records (hooray!) and finds a heart test with questionable results. He wants to follow up ASAP, and, at 5:30 p.m. orders an MRI for 7 a.m. the next morning. Some of you will sputter at that. I didn't (great responsiveness on his part, novel indeed!); or at least I didn't until midnight when I woke up with a start and did sputter, "Holy shit, pacemaker patients can't have MRIs." I quickly went on Google and confirmed what I was 99% sure of; we can have MRIs if a cardiologist is in attendance and if, as I recall, the pacemaker has been turned off‐otherwise a high chance of fry city!

Oh, and I forgot one other thing. As I said the test the EMR system spit out indicated a problem. Well, another doc who'd ordered that test a year before had immediately ordered a follow-up which had been clean. But, um, the EMR system which had coughed up the 1st test had inexplicably failed to spit out the results of the follow-up test which was clean—at the same hospital, of course. Hence, the doc who subsequently ordered the unsafe test for me was dealing with incorrect (incomplete) data provided by the electronic medical record system.

A twofer. Screwed-up EMRs. Dumb-ass "famous" doc at "leading med center" who'd ordered a test that could have caused significant harm. He is no longer my doc. One of my friends who is a leading cardiologist was appalled—he suggested that I "do something about it," but I declined.

(But back to the Harvard Club. I'd come to Boston from Vermont for a med visit. A 350-mile round trip. Office I'd been to before. A small procedure to be done. Except, though it was in my records, they'd forgotten to write me an order for the monster antibiotic I needed to take before I came. Must do it to prevent problems that might occur, thanks, again, to that pacemaker. Whoops, 350-mile round trip pissed away!)

Enough!

I've been studying patient safety for going on 10 years. The story is appalling. Hundreds of thousands of unnecessary deaths each year in the USA alone. And the story overseas, as far as I can tell, is much the same. And then there are the millions of blunders that are not fatal. And the millions of mis-recorded or mis-interpreted prescriptions. And the recent article that says we under-count med errors by a factor of ... 10. And the un-recorded more jillions of blunders in doctors' offices.

(I've also studied the failure of docs to follow standard protocols, which comes more or less under the heading of "evidence-based medicine"—lack thereof.) (And I've studied unexplained bizarrely high differences in procedure rates from one town to the next with similar demographics.) (And I've studied over-testing and over-treatment that in the USA causes huge harm, not to mention over a half-TRILLION dollars in annual healthcare costs/waste.) (And studied the charming practice of "inventing diseases" followed upon occasions by pharmaceutical companies.) (And, speaking of pharmaceutical companies, one of my wife's best friends, at Johns Hopkins, is a/the leader in the effort to get pharmaceutical companies to report all their trials data, not just the data from the trials that support their pre-ordained conclusions.) (Etc.) (Etc.)

Often I have to pinch myself, the stories are so horrendous. Sometimes I tear up. And I am, I admit, pissed off 100% of the time. Yup, I was long one of the dumb-assed bastards who was nutty enough to think that the folks in the white coats had their collective heads screwed on right—or at least screwed on.

(Oh, meant to tell you I had leukemia one weekend about a year ago. Yup, the lab had blown the blood work. Re-test fine. Phew. And did I tell you that my doc hasn't suggested to me—age 68—in two years that I might want to have a physical? Well, stupidly, I haven't had one, though on my own I have a doc pal prescribe blood work about every nine months which he then reviews.)

Back to "leading med centers"—the evidence shows that they rank high on the lists of sinners on these issues. They often are chock-a-block with genius specialists who indeed perform near miracles (good on them!!!), but I always wonder if, on net, these famous places do more harm than good. It may not be true, but it's not a wholly lame hypothesis.

(NB: Don't get me wrong, I'm sure most healthcare workers "care." But so did the UAW guys who were making defective cars in the 70s. Caring is nice. Caring is not enough.) (Well, sadly, I'm not all that sure on the "most care" dimension. My wife's mom was just at a "leading med center." Her assessment: "They got the work done, but there was nary a sign that they cared about what they were doing"—but that's just one datum.)

At any rate, the night after the wasted 350-mile trip and the productive and enjoyable lunch at the Harvard Club, I stayed at Boston's Liberty Hotel, which happens to be about 50 yards from Massachusetts General Hospital. The next morning I went out for papers, and as I came back to the hotel I found myself amidst a shift change at Mass General. The folks looked lively and intelligent. Nonetheless, I got to wondering—maybe triggered by the lunchtime tale of woe and/or the futile 350-mile trip. And I turned my "got to wondering" into a series of rather harsh, though from the heart and not unwarranted, tweets.

Herewith:

See employees pouring into Mass General: Wonder how many will be party to NON-patient-centric, UN-safe acts?

Employees pouring into Mass General: Will help-to-harm ratio be > 1.0?

Employees pouring into Mass General: What % docs will treat nurses, techs as the equals they are?

Employees pouring into Mass General: Wonder how many will be party to UN-necessary tests per statistical likelihood of usefulness?

Employees pouring into Mass General: Wonder how many will be party to UN-necessary surgeries per statistical likelihood of usefulness?

Employees pouring into Mass General: Wonder if ER will be as ILL-managed as usual?

Employees pouring into Mass General: Wonder how many specialists will give two thoughts to the rest of the patient's body?

Employees pouring into Mass General: Wonder how many WRONG-med-doses or WRONG-meds-per se will be administered?

Employees pouring into Mass General: Wonder how many arriving non-ambulatory patients will be accompanied by some sort of advocate?

Employees pouring into Mass General: Wonder how many patients will be given courses of treatment IN-consistent with generally agreed-upon evidence?

I have NEVER BEEN a patient at Mass General. Hence these queries (which all, in effect, start with "I wonder") are not aimed at Mass General per se. As I said in a follow-up tweet, if I'd been staying at a hotel near some other "leading med center," I would have said the exact same thing with its name substituted. (NB: One close observer of this scene suggests that if you want the best results on safety, go to "St. Elsewhere." Or, I'd add, if you qualify, a VA hospital—the VA is perennially tops in almost all patient safety categories.)

(Fact: I've only had ONE de facto direct Mass General encounter. I must say, in all fairness, it was ... HORRENDOUS. It was my wife's ER experience following her slipping and breaking her ankle. Five hour mid-day wait—she was told by a tech, and I do not jest, that she was lucky the wait was so short. All five hours on a gurney in a charmless/chaotic/very public corridor amidst very sick people and ceaseless hubbub. Virtually no staff contact other than less than two minutes with a harried staff doc who said, "We'll have to get an x-ray"—for that she went to med school? Extreme pain, five hours with no palliative—not even water for the 1st two or three hours. Subsequent X-ray guy on loan from another hospital's staff; he was (VERY) un-necessarily rough. And nobody who really seemed to give a shit—don't get me started on "patient-centered care," virtually total lack thereof. I am, of course, dead certain that July 2009 experience does not color in any way my view of Mass General. At an American Hospital Association meeting a few weeks after my wife's "experience," I said I thought the "leading med center"—I didn't ID them, though everybody figured it out—CEO "ought to be fired." ERs are a bitch and lose money, I acknowledged, but the dude signed up to be CEO of the whole hospital, so it's his problem 100%.)

Enough! I could write a book! Maybe I will. Title already picked, taking off from In Search of Excellence: Lessons from America's Best Run Companies. This one: In Search of Excellence: Lessons from America's Safest Hospitals"—yup, there are some who do this stuff incredibly well!!

(FYI: My favorite response to the tweets came from a friend I'd sent the set to. He is one of the USA's most renowned docs. Said he'd laughed and laughed and that he and his wife had picked their favorites, which he sent on to me. Nice!) (No, it wasn't Don Berwick, more or less father of the patient safety "movement," but it sure as heck might have been. Currently, Dr. Berwick is trying, as top dog, to introduce this stuff into Medicare-Medicaid. My favorite Berwick-ism on the topic of patient safety: "When I climb Mount Rainier I face less risk of death than I'll face on the operating table"—Berwick's safety crusade was largely triggered by mistreatment his wife received at a "leading med center" in, uh, Boston; he was a Harvard Med School guy.)

I am pretty ineffective in declaiming on this topic. To be an effective speaker one must follow the dictum of John Knox: "You cannot antagonize and influence at the same time." I ordinarily slavishly follow that rule—but on the topic of patient safety I have no sense of humor at all.

Idiosyncratic reading list:

Best Care Anywhere: Why VA Healthcare Is Better Than Yours, Phillip Longman
Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe, Sorrel King
Safe Patients, Smart Hospitals: How One Doctor's Checklist Helped Us Change Healthcare From the Inside Out, Peter Pronovost & Eric Vohr
Putting Patients First: Best Practices in Patient-Centered Care, Susan Frampton & Patrick Charmel
Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, Shannon Brownlee
Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson
Hardwiring Flow: Systems and Processes for Seamless Patient Care, Thom Mayer and Kirk Jensen
Inviting Everyone: Healing Healthcare Through Positive Deviance, Arvind Singhal, Prucia Buscell, and Curt Lindberg

NB: Ho hum, and just off the wire, as I write this, from the Journal of Internal Medicine: "Medication errors are the second-leading cause of accidental death, and the only kind of accidental death that is increasing over time." As I said, ho hum.

Little BIG Video #40
Strategy: Sock Solution

In video number 40 from The Little BIG Things Video Series, Tom asks us to look for solutions that are astonishingly powerful, yet astonishingly unsexy.

You can find the video in the right column of the front page of tompeters.com or you can watch the video on YouTube. [Time: 2 minutes, 54 seconds] You can also download a PDF transcript of the video's content: Strategy: Sock Solution.

The Grameen Lesson?

When Nobel Peace Prize winner Muhammad Yunus began his micro-lending efforts at Grameen Bank in Bangladesh, he had no preference as to whether loans went to men or women. To make a long story very short, male recipients often frittered the money away (alas, drank it away in many instances), while women overwhelmingly devoted their loan proceeds to their business, their family, and their community. As a result, through trial and error, Grameen has ended up with over 90% female recipients. (This is all the more startling given that Bangladesh is a Muslim country.) (And the story has been repeated, pretty much chapter and verse, elsewhere by Grameen and others.) (In the NGO aid-dispensing business, it's a given that getting the local women's network on your side is a 100.00% necessity.)

All this got me thinking about the controversial new healthcare bill. Women pretty much everywhere are the principal decision makers in family affairs. And, among other things, they make upwards of 80% of family healthcare decisions. (Actually about 90%, but I'm being conservative.) Moreover, the old saying goes, as you get older you had better hope that you had a daughter; when it comes to old-parent affairs, "boys" are notoriously, uh, not "girls." (I've observed this numerous times; and I am stepfather to two boys; and I am non-young.)

Oddly, most of the polls on the healthcare legislation were not divided by gender. But the two readings I did get, courtesy Newsweek and Princeton Research Associates, did not surprise me. In short, women were 12% more favorable in one case and 20% more favorable in the other (in the latter, women were +14%, men –6%). Also, alas, it doesn't take a genius to recognize that most of the intemperate public remarks came forth from the mouths of males. (The most memorable women's quote on the House floor, to my mind, went more or less, "With this bill, being a woman will no longer be a 'pre-existing condition.'" Insurers in several states, nine as I recall, tag spousal abuse as a pre-existing condition.)

There is honestly no "bottom line" to this post; but as I have been vociferously championing women's issues (women as underserved market opportunity #1, women in leadership positions in greater numbers to match market power) for about 15 years (pretty much the only "guru" to do so), I simply wanted to see how it played out in healthcare legislation.

(NB: God knows, I'm not claiming that men don't care about their families. I am suggesting that men are less likely, far less likely, to be decision-makers concerning family issues.) (In the Grameen case, it's, of course, a little more extreme than that.)

Dear God!

So my aunt, age 94 (??), being treated for a little lung goop with meds. (No such thing as "little" at that age.) Apparently it's getting better but not 100%. She goes to see a doc and he says she'll need surgery. (Big deal for any of us, VERY big deal at her age.) She insists on X-rays first. X-rays performed. She goes back to doc, asks if she needs surgery. His answer: No.

Why the hell did he quick trigger on a major diagnosis for a 94-year-old w/o "simple" evidence? Bastard!

Same aunt, some joint trouble. (Ain't it true of all of us post-55.) Referred to physical therapist. Referring doc says she'll need to stay in med facility for several days, not return to her small condo in assisted living center. She sees therapist, asks why she can't go home, describes her place in great detail. He says, "Of course you can go home."

What I've just described is inexcusable medical practice, especially for a 90+ patient, where odds of problems from surgery or significant in-patient stay are sky high; hence one should be twice as careful in making diagnosis.

Classic-garden variety outcome where overtreatment would most likely have been the result if she'd not been at the top of her game. Most, half her age, wouldn't have made the enquiries she made.

Alas, health reform package barely touches on this.

Health Care:
Must Read

Best thing I've read so far. T.R. Reid, The Healing of America: Global Quest for Better, Cheaper, and Fairer Health Care. Reid takes us on a global tour. Among other things, in many countries with "universal access," the programs are anything but "socialist"—available choices often beat ours, and the free market plays the lead role.

(Above: Winter "on the farm" in VT ... the real thing!)

Maybe ...

Maybe all the bitching about the ephemeral economy is justified. And the death of non-virtual (real) stuff, that is, manufactured stuff that absorbs lots of jobs, is a fact-of-life.

Yesterday, the Wall Street Journal (I think—four consecutive midnights in the air, remember) reported the amazing and wildly increased share of our gross domestic profits that come from financial services. Today's Financial Times comments on new cars, labeled by the headline writer "a shiny new software appmobile." The author, Chris Nuttall, reports "a new iPhone app from Ahamobile allowing drivers to record 'Caraoke' [sic] singalongs to the car radio and post them straight to their Facebook page."

Dear God—that's, in effect, Mr. Nuttall's response as well.

I read awhile back an analysis that suggests that our "age of abundance" only dates back perhaps 40 years. That is, in the OECD nations at least, we've pretty much all got all the stuff we need and are "reduced" to consuming non-necessities. Maybe that's it, an economy that produces mainly, mostly, almost totally ephemeral things we don't need. Hence huge amounts are spent on healthcare (with not much improvement in health), financial services scarfs up huge bucks for, often, doing absolutely nothing (derivatives of derivatives of derivatives) and "high tech" that lets us "record 'Caraoke' singalongs to the car radio and post them straight to their Facebook page."

Think about it.
I am.

(NB1: When I landed in Boston at about 1:00 a.m. yesterday, literally, at 1:00 a.m., all 9 people I could see were checking their email within 30 seconds of wheels-on-the-tarmac. [Yes, no kidding, 9 for 9—and me feeling bad because I wasn't.] I'm right, right: Talk about the absolutely-totally-completely un-necessary! Age of Abundance indeed!)

(NB 2: A friend had prostate surgery recently, a bright and technologically brilliant guy. He went on and on about the robotic surgery he'd decided upon. Statistically minimal side effects, etc. Well, yesterday's Boston Globe reported a new study from the Harvard Med School concluding that nasty side effects from the robotic procedure are twice as prevalent as side effects from old-fashioned knife stuff. One more time our medical profession's passionate love affair with very sexy stuff scores. This time, incontinence and impotence are the winning lottery ticket.)

AHA Redux:
A Matter of Leadership!

I began my remarks to the American Hospital Association last week with an outline of the situation as I saw it. I called the outline "Principal Management & Leadership (as opposed to Policy) Issues." That is, it was-is my contention that hospital leaders have a choice; they are beset with constraints (aren't we all?), but such constraints do not keep some enlightened folks from performing miracles—management and leadership miracles!

Herewith my outline, also included in the slides attached to my previous post:

1. Should we be doing what we're doing? Will it work? How do we know? [In a surprising # of cases, it's not clear whether "X" or "Y" is the most effective treatment for a particular problem—e.g., my 2005 ablation vs taking a pill. "Evidence-based medicine" and "comparative effectiveness" research, ticketed to receive major federal funding, are part of the answer. And controversy is huge; i.e., who's to judge?]

2. Are we doing what we decide to do safely? [Various studies suggest that in the U.S. there are several hundred thousand preventable hospital deaths per year—again, some of the stats are very controversial.]

3. Do we do too much—are we in the "overuse" category as determined by agreed upon standards-measures? [It is "generally agreed" that perhaps $750 billion is spent annually on unnecessary tests and treatments—a "piecework" ethos, by the procedure payment, is the major culprit.]

4. Are we doing what we're doing effectively? By local standards? By global standards (as determined by "best practices," best hard evidence, and minimal internal variation) in terms of outcome, quality, safety, and cost? Do we aim, for example, to be "top quartile" in terms of measurable outcomes, quality, safety and "bottom quartile" in terms of cost? [This ought to be a "no brainer"—it's not. A revolution is required here—and it has damn little to do with the insurance payment process, though some would disagree.]

5. Is the institution systematically organized to very consistently deliver the goods in a more or less optimal fashion (low variation in outcome)? [There are a thousand experiments in process, but true systemically organized processes with clear measures and accountability are, alas, rare.]

6. Do all the bits talk to-engage-consult "obsessively" with the other bits? Is the delivery of services truly a turnkey team effort? [Cross-functional communication is arguably enterprise issue #1; in healthcare it's about as bad as it gets—the normal problems are compounded by the hospital "class system," with docs at the tippy-top, and no one else even a close second.]

7. Are the patient and the patient's family at the epicenter of the universe? [Bizarrely, the answer is a resounding "no" in 9 cases out of 10.]

8. Is our institution acknowledged as a "best place to work"? [13 of the top 100 places to work in the U.S., per Fortune, are healthcare institutions—i.e., it is possible!!]

9. Do we acknowledge that people issues-capabilities involving the entire staff affect outcomes far more than capital-technology issues? [For lots of reasons, re-imbursement included, many hospitals are "technology crazy"—owning the latest stuff is more important than ascertaining its usefulness.]

10. Is sustained follow-up at least as much a priority as the "event" itself? [Post-op follow-up and chronic-care are both poor cousins in general in the hospital system setting. Again, the payment system is a culprit—but some manage to do it.]

11. Were we/Are we successful in terms of outcome-quality of life-patient satisfaction with the overall "experience"? [This obviously should be the primo concern—for a host of reasons it's not.]

12. Are all connected with all via an effective electronic network that extends from EMR to Social Networking? [Still not the norm!]

13. Do we acknowledge that most of the choices involved in executing items #1 through #12 are mostly within our discretion regardless of the nature of Obamacare? (And that Obamacare or its successor will almost surely eliminate piecework compensation—which drives the immediacy of much of the above.) [Of course, a health bill changes things—but, fact is, if the determination is there, and it is in some instances, a committed leadership team can move miles and miles down the road specified above.]

14. Do we acknowledge that throughout the system there are, today, enormous variations in outcome concerning every one of the above issues—which can mostly (almost entirely?) be explained in terms of institutional leadership effectiveness (vision, will, systems)? [SOME ARE DOING IT DAMN WELL UNDER TODAY'S CONSTRAINTS—AND THEY ARE IN AWFUL SETTINGS AS WELL AS BETTER OFF SETTINGS. "IT" CAN BE DONE—IT IS BEING DONE!]

Health Forum/American Hospital Association

On Thursday I had the great privilege of being a keynote at the Health Forum/AHA conference in my beloved San Francisco—putting "feet on the ground" there always sends my spirits soaring. While the health bill, or the likelihood of something, was on every mind, my job was to talk about leadership, regardless of the shape of any legislation. In fact I obsessed on the idea of "your choice"—the idea that incredible amounts of progress were possible in any case. Proof more or less positive is the variance that exists in the system we have today, in spite of existing ass-backwards incentives that reward "piece work" (pay-per-procedure) rather than outcomes and quality-safety. Organizations like Geisinger in Danville PA, Mayo in Rochester MN, Dartmouth-Hitchcock in Hanover NH, and Griffin in Derby CT do wonders already in terms of quality, safety, minimization of unnecessary tests and procedures, and putting the patient and patient's family first.

My main thrust was "controlling what you can control" and creating an "experimentation machine"-"innovation machine" (and a "culture" that supports it) devoted to "letting 1,000 flowers bloom" as the way forward in creating and designing systems that promote 100% employee involvement, patient-patient family engagement, safety, quality, elimination of variation in outcome, and the like. I avoided my usual hectoring (the nature of the likes of quality-safety is now more or less accepted), and urged "getting on with it" ASAP.

I have rarely felt so engaged and have rarely so enjoyed myself—as to impact, the proof will be in the doing. (Glenn Steele, CEO of Geisinger, was immeasurably helpful—he joins my "hero entrepreneurs" shortlist, next to the likes of Teach For America's Wendy Kopp!)

Attached you'll find my PowerPoint presentation; it's less helpful than usual, since so much of the tone was beyond the slides.

PPT is attached.

TomChirp #19

I desperately want to see a thoroughgoing healthcare overhaul (patient safety, an end to pay-by-procedure, and the exaltation of primary care docs are the main planks in my platform). But I was nonetheless fascinated by the lead article in the June 29 IBD/Investors Business Daily—"Uninsured Figures Overhype the Lack of Health Coverage." IBD points to several reasonable analyses that tally the involuntarily uninsured in the U.S.A. at about 20 million, or even less, rather than the "popular" 45 million+ stat. IBD is a conservative rag, to be sure, but this analysis points up the always obvious state of affairs: it's a dead flat cinch, left or right, to "interpret" statistics about the same phenomenon in RADICALLY different ways.

TomChirp #15

Robert Samuelson is no right-wing nut. But he is a severe critic of President Obama's health plan. And I agree with almost every word he wrote in an Op-ed in the 15 June IBD. Here are a few of those words:

"Much medical spending is wasted. It doesn't improve Americans' health; some care is unneeded or ineffective. [TP: Some estimates of unnecessary care hit the trillion-dollar mark per annum; and some estimates suggest that in cases like bypass surgery, over 90% of the time it's used it's unnecessary.] The central cause of runaway healthcare is clear. Hospitals and doctors are paid mostly on a fee-for-service basis. ... The open-ended payment system encourages doctors and hospitals to provide more services—and patients to expect them. ... That's the crux of the healthcare dilemma, and Obama hasn't confronted it."

[NB: The same day I read Samuelson's piece, I also perused "The Health Reform We Need and Are Not Getting," by Arnold Relman, in the 2 July New York Review of Books. A brief excerpt: "Economists say that the primary reason for high costs is the ever-expanding use of expensive kinds of diagnosis and treatment, such as new drugs, diagnostic tests, imaging methods and surgical procedures. Physicians in most other advanced countries have access to virtually the same resources, but use them less. This difference is partly explained by a higher proportion of specialists in the U.S. who rely more than primary care physicians on expensive technical procedures for their livelihood, and in general are much more highly paid than primary care physicians—one reason why primary care doctors are now in short supply. The American College of Physicians attributes much of the high cost of the US health system to its relative excess of well-paid specialists and lack of primary care doctors. ... In seeking consensus, Obama's health reform policies do not address the central causes of rising costs, and propose nothing likely to have much effect on them."]

[NB: In short, per Samuelson, Relman and me, if you don't go after (1) fee-for-service, (2) unnecessary care, (3) mal-practice tort reform, (4) evidence-based medicine, (5) geographic spending variations, (6) redirection of resources to wellness, prevention, and chronic-care, and (7) the excess of specialists and shortage of primary care physicians, then healthcare reform is a joke. Ergo, healthcare reform is a joke.]

On a cheerier note: above, an aptly named "beauty bush" outside my studio; below, one of Susan's Peonies.

TomChirp #4

Hospitals in general "stealing" the relatively simple-inexpensive-Excellent VA Hospitals' approach to Electronic Medical Records—hooray! The Big Consultants such as McKesson, are pissed off—hooray! (Wall Street Journal 04.30)

TomChirp #8

As part of a new healthcare initiative, a big ad (Financial Times, 05.07) from Philips tells us, in large, veeery large, type: "WHEN IT COMES TO MATTERS OF THE HEART, MEN AND WOMEN DIFFER."

Waaaaaaay to go, Philips!!!

TomChirp #10

Oh my God, science about effectiveness may be used in healthcare! What will they think of next!

What works and doesn't work in terms of treatments remains a mystery. (One study claims 97%—a pretty big number—of bypass surgeries unnecessary.) (Take an Aspirin instead!) New York Times (05.07) reports the federal budget includes $1.1 billion in the next few years to study treatment effectiveness. The prestigious New England Journal of Medicine is highly supportive—but Rush Limbaugh calls it socialism, naturally.

Yup, evidence comes to medicine—and the world wobbles on its axis!

Chirp!
(Re chirps, we have an Oriole, gorgeous bird—flies too fast for a pic.)

Wrong Answer!

I'm returning to Vietnam later this month—for the first time in 41 years. Hence my mind drifts occasionally to the 4-decade-old events that marked the beginning of my professional career.

One rather strange occurrence crossed my mind while driving home to VT from Boston last week.

I was out in the field, deep in the jungle, in fact, building a camp for a U.S. Army Special Forces team. I was choppered back to Danang in a rush for a brief meeting with the Commandant of the U.S. Marine Corps, General Leonard Chapman, who was paying a visit to I Corps, the northern part of South Vietnam, which was under USMC command—more specifically under the command of General Lew Walt.

What the hell was a LTJG (very junior officer) doing visiting with a 4-star general? Simple. My uncle, General H.W. Buse, was USMC Chief of Staff back in D.C., and my aunt had insisted that General Chapman see me in the flesh. (Aunts are like that, even, or especially, at the Mrs. 4-star general level.) (Also, her son, my cousin, was in Vietnam as well—a USMC captain.)

When I got back from the field, covered with mud (it was rainy season), I was sent directly to the Commandant with no time to change into a respectable uniform—a great embarrassment. General Chapman engaged in all of about 15 seconds of chitchat, and having done his duty to my aunt, sent me on my way. As I was literally walking out of his temporary field office, he summoned me back, and said, out of the blue, "Tom, are you taking care of your men?" (I had a little detachment, about 20 guys as I recall, doing the work described before.)

Yup, 40 years plus later, I remember his exact words—which is the point of this Post. I replied to the General, "I'm doing my best, sir." To this day, with a chill going up my spine (no kidding—as I type this), I can see his face darken, and his voice harden, "Mr Peters, General Walt and I and General Buse are not interested in whether or not you are 'doing your best.' We simply expect you to get the job done—and to take care of your sailors. Period. That will be all, Lieutenant."

The line echoes to this day—as you can tell. You are there to "get the job done"—not just-merely "do your best." I recall many years later seeing a Churchill quote that was much the same; more or less this: "It is not enough to do your best or try as hard as you can—you must succeed in doing what is necessary."

I guess it was all this stuff that, about a year ago, caused me to more or less lose it during a Q&A session at a healthcare conference. We were talking about medical errors and patient safety. And people kept saying, "We're understaffed." "This is a 'caring profession'—and everybody cares despite the stress." "We're doing our best with the resources available." "The docs resist this, that, and the other." Etc. Etc. Yup, I lost it, and sang the General Chapman-Winston Churchill song: "It really doesn't matter how much everybody cares, or that you're doing your damnedest—you must get the job done and stop unnecessarily wounding and killing patients." The response gave new meaning to the term "stony silence."

And so the lesson sticks, on this, the 43rd anniversary, of my first "visit" to Vietnam. The lesson sticks, and the voice and demeanor of General Chapman are as clear and commanding and unequivocal as they were four decades ago.

I'll conclude with a simple "thank you" to the late General Chapman. I think I can say with some certainty that the story of my life would not have unfolded as it has, had the General not made his views on success and failure so succinct and so crystal clear.

Let's Hope Main Street Performs Better Than Wall Street!

Wall Street's behavior continues to boggle the mind. With government help, some of the financial news is good—hence, in the mind of the "players," it's time to re-open the bonus spigots! Fail to do so, and, OMG, we might not be able to retain some of the "superstars" whose 275 IQs and Excellence-in-Greed got us into this mess.

I'm not sure what the Psychiatric Diagnostic Manual # is, but these people are certifiably insane:

HAVETHEYABSOLUTELYNOSHAMEORSENSEOFSHAREDBURDEN-WHATSOEVERARETHEYINFACTHUMANS????!!!

Miserable.
Rotten.
Immoral.
Scumbags.*

Well, let's hope Main Street does better than Wall Street!

We may be (50-50 odds?) on the verge of a true pandemic. One important-crucial way to fight it is to stay home if you think there's even a small chance that your symptoms match up to the H1N1 profile. While the possibility of malingering is never zero, I pray that employers, despite their often pinched straits circa Spring 2009, will be hyper-generous in encouraging people to stay home with pay if they think there's a chance they are infected. Alas, with the horrid economy, if you have a job at all you sure as hell don't want to test your employer's patience. Hence, there must be a lot of bending over backwards by all parties to do every damn thing we can to behave sensibly and thence reduce the spread of H1N1.

Let's all get down on bended knee and pray that Main Streeters have better sense and a greater commitment to the greater good than the Wall Streeters.

[*"Scumbags" is an entirely inappropriate word to use here—my only defense is that I thought long and hard about this, and I arrived at the conclusion that the only word I could think of to describe those seeking re-instatement of large bonus pots at this point is, well, scumbag.]

Mr Speaker, May I Respectfully Offer An Amendment ...

A couple of years ago, outgoing HHS Secretary Mike Leavitt said that obesity, especially childhood obesity, was a bigger longterm problem than terrorism. And surely there are numbers to support that point—numbers from which there's no place to hide.

To deal with this issue, a host of governmental, as well as private sector, programs have been launched with varying degrees of success here, there, and surely not yet everywhere.

Massachusetts is the latest to jump toward the bandwagon. The first page of the Boston Globe of 8 January led with this headline: "State Readies Campaign to Curb Obesity Epidemic." Among other things, 1st, 4th, 7th, and 10th graders will be sliced, diced, and weighed, and the results in the form of Body Mass Index will be the hallmark of a health Report Card that will be sent home to the parents of the heavyweights, along with guides to abet remedial action. There's a lot more to the story, but the report card is the centerpiece.

In my own small way, I've been among those railing for years at the pronounced bias of our health system toward fixing things after they're broken rather than obsessing on prevention; e.g., Wired recently reported that the National Cancer Institute spends only 8% of its research budget on early detection. Hence, I am a vociferous champion of any and all prevention-wellness programs such as Mike Bloomberg's trans fat ban and the likes of the proposed Massachusetts program.

But there's a hitch.

If there is a single trait of leaders which is of unchallenged importance, it's the notion that the leader must exhibit in a very personal way the values he-she is attempting to inculcate in the organization. My colleague Jim Kouzes was, I believe, the first to use the powerful phrase "model the way." And, of course, the Old Faithful from Gandhi, "You must be the change you wish to see in the world."

In short, if you ain't modeling it, fuggedaboutit.

Have I told you about my speech to MHHA/the Michigan Health and Hospital Association a couple of years ago? We discussed obesity, and I used a slide with the following three words: "Bust fat docs!" You could have heard that proverbial pin drop. In particular, I singled out pediatricians. There's no group of docs I respect more, and that's not hyperbole; but I nonetheless said, "A significantly overweight [we're not talking 10 pounds, or maybe even 15] pediatrician is simply not credible lecturing young patients, or their parents, about obesity. In fact, the lecturing-hectoring will necessarily be self-defeating."

You can probably see what's coming.

I buy MA's idea of the Body Mass Index report card. Which, of course—of course!—means that we have to follow the exact same ritual for teachers, and particularly principals.

Right?

There is no group of human beings, except maybe for those pediatricians, whom I respect more than our underappreciated teachers—again, no hyperbole. (And their likewise underappreciated principals.) They clearly deserve as much adulation and support as our soldiers and sailors and airmen in battle zones.

So this is not about respect or appreciation.
It's about childhood obesity.

In short, a significantly overweight teacher-classroom leader [again, we're not talking 10 pounds, or maybe even 15], or principal-school leader, lacks any semblance of credibility relative to this issue which is arguably "more important than terrorism"—childhood obesity.

Fire fat teachers? Of course not. Post their BMIs on the school bulletin board, or at least in the teachers' room? It's appealing, but I guess not; I'm a privacy freak.

But send the teacher-principal report card home in an envelope with District Office of BMI Report Cards as the sending address?
Semi-annual high BMI Teacher-Principal conference?
Semi-annual high BMI Principal-District Administrator conference?
Official annual letters-of-warning in the personnel jackets of offenders?
Deny superhigh BMI teachers tenure if they are not progressing relative to a sane weight-BMI reduction program?
Deny the high BMI-ers access to any of the increasingly popular bonus-incentive programs?

I believe my suggestions are rather Draconian. But there's ample reason to believe that the terrorism analogy is not much over the top—so, Draconian measures are urgently called for. (I also acknowledge that the teachers unions would scream bloody murder—a pretty good sign that I'm onto something.)

Leaders lead to the extent that they are role models for the change they aim to make and the values they aim to instill.
Period.
Classroom teachers, and their principals, are the Ultimate Leaders when it comes to our nation's future.
Period.

Bust fat pediatricians!
Bust fat teachers-principals!
Or lose the war before it's launched on the terror of childhood obesity.

Mr Speaker, I offer the above, appropriately reformatted, as an Amendment to any obesity program passed into legislation in the great and glorious Commonwealth of Massachusetts.

NB: Alas, I'm one of the kids whose parents would have gotten the damn report card. And I could damn well afford to lose 20 pounds right now without fear of becoming emaciated. But I am neither pediatrician nor classroom teacher nor school principal. (Bust high BMI management gurus? Hmmmm, maybe not such a bad idea.)

"Scan" or "Scam"?

"'A patient comes in because he's in pain,' said Dr. Nelda Wray, a senior research scientist at the Methodist Institute for Technology in Houston. 'We see something in a scan and we assume causation. But we have no idea of the prevalence of the abnormality in routine populations.'"—Science Times/New York Times, 1209.08, "The Pain May Be Real, But the Scan Is Deceiving"

As I've said again and again (piggybacking on the "evidence-based medicine" "movement" championed by the likes of Michael Millenson and the peerless Dartmouth Institute for Health Policy and Clinical Practice), there's a lot that goes on in medicine, even in the most hallowed halls (especially in the most hallowed halls?), that has no basis in fact or hard evidence. This telling-frightening article is one more compelling example of medical witchcraft (sorry to use such strong language); and one more good reason to avoid hospitals whenever you can; and one more reason to question-the-living-bejesus out of any test the doc wants to perform; and one more reason to take charge of your own treatment—for God's sake, grow up, the guy in the white coat is flying blind half the time.

One growing response to the above, fostered by Web 2.0 and social networking, is patient involvement. BusinessWeek (12.15) offers "Can Patients Cure Healthcare?" Discussing websites such as PatientsLikeMe.com, sometimes collectively called "Health 2.0," the article explains that some groups of patients are going so far as doing their own clinical trials. Mounting health-establishment pushback is clear evidence that these increasingly informed patients, even when they get it wrong, are up to something good!

Never Walk Alone!

If airline self-inflicted errors matched hospital self-inflicted errors, we'd need a special daily newspaper section to record the crashes and associated obits. (And there's no hyperbole in that last remark.) Still, we do get sick—and catastrophic error rate notwithstanding, we must necessarily subject ourselves to these health"care" danger zones. But, if there is any possible way at all—never walk [into a hospital] alone.

Melinda Beck writes the "Health Journal" column in the Wall Street Journal. Her page D1, 28 October column, "Bedside Manner: Advocating For a Relative in the Hospital," begins, "Don't go to the hospital alone if you can possibly help it." She begins with an, alas, garden variety story of a friend in a hospital for hip surgery following an accident. Her friend's daughter was the one "who noticed that she was having an adverse reaction to a pain medication." And it was her daughter who recognized that her mom's "IV drip had pulled out of a vein and was pumping her arm full of fluid." And it was her daughter who observed that "the blood-sugar test she was about to be given was meant for her roommate instead." The hospital, not to my surprise, was described as "one of the best hospitals in the country."

[P.S. I admit this stuff pisses me off. Really, really pisses me off.]

At any rate, I commend the article to your attention, especially the suggestions with which Ms Beck concludes. If I were offering one of my "success tips," the only thing I can think of is the ever-helpful "Don't get sick." (And if you do, "Bring a friend.")

Addendum

Susan read yesterday's post, and informed me that in her conversations at the dinner in question there was discussion of one of our friends' sisters having a recent colonoscopy—in which the intestine was inadvertently punctured, with a nasty infection ensuing. (The victim, uh, patient, did live—I guess that's something.) Could it be that the odds of a screwed-up colonoscopy are higher than the odds of detecting a problem relatively early enough to justify the risk? I don't know the answer in this instance, but I do know that in any number of situations "Stay the f#^* away from the hospital" is the statistically correct choice.

Furious!

Do most healthcare professionals care? My evidence is clear: Yes! (Exclamation mark deserved.)

Docs.
Nurses!!
Lab techs.
CFOs.
CIOs.
Etc.

Not good enough.

Hang out with old people, and the topic invariably turns to health—or the lack thereof. Well, I was at a small dinner last night, four couples. Among the men I was the youngster at 65, though 70 was the upper end. I've gotten in the habit, for professional reasons, of digging a little when the likes of surgery is discussed.

So, here's last night's scorecard:

***Bypass surgery: nearly died of infection in ICU.
***Other open-heart surgery: nearly died due to anesthesia problem; nurse caught it when patient's color went all haywire.
***Kidney surgery: nearly bit the dust due to badly wrong meds administered during recuperation—nurse caught it when patient turned odd color.
***Death: best friend of one of us died last year when pneumonia went un-diagnosed, patient was sent home and croaked in 72 hours.
***TP (me): bought my farm because 52-year-old prior owner had bypass surgery, went home, had severe pain, was told by phone it was routine—and died of infection in 48 hours.
***Etc.

Conclusions:

(1) Every one of us had relatively recent personal (family, close friend) horror stories.
(2) None of us, except for the installation of my pacemaker, could recall a personal hospitalization without errors worthy of remark.
(3) None of the horror stories involved the "it;" e.g., the surgeon's work during the procedure.
(4) Hence, all the above are preventable errors.
(5) Thank God for nurses!!!
(6) All agreed, not prompted by me, that a fulltime, "24/7" advocate (family or friend) was needed for any hospitalization.
(7) None of the above took place at a small "boondocks" hospital—all were in med centers of high repute.
(8) None of us or our friends in question was uninsured—we all had at least Buick coverage. viagra from canada paypal

This really pisses me off.
And I shall continue to say so at every opportunity.

There are no excuses.
None.
Zip.
Zero.

Make no mistake, this is a story of lousy management and sloppy leadership—not, primarily, the result of lousy health policy.

Make no mistake, this is a story of unconscionably lousy management and almost criminally sloppy leadership—not, primarily, the product of bad health policy.

Creeping (Raging?) Cynicism

My absence is a tribute to a good summer. Last weekend we broke from VT's deluges and went to visit friends in Sunny Chicago—awesome theater at Steppenwolf (Tracy Letts' Superior Donuts) and my 1st Wrigley Field visit were highlights. This week vigorous brushcutting has topped the agenda, plus a visit by some wonderful friends.

But last night, right after Michael Phelps' 6th and latest, my spirits plummeted. Admittedly, I am in a deep-deep funk over Georgia. (Humankind sucks.) But it was two back-to-back articles in the Wall Street Journal that iced the cake.

On Page A1, "Bad Blood: New Therapy For Sepsis Infections Raises Hope But Many Questions." We die by the freighterload from sepsis infections, and a relatively new therapy looks promising. But wait: The basic supporting research apparently has enough holes to drive my Kubota through. For example, in one sample, 30% of folks getting the new therapy died, compared to 46% mortality for those treated using traditional approaches—fine, except a ton of un-cited studies show that in general 30% mortality is the norm. Then there is the "missing subjects" problem—25 cases that have evaporated. And, surprise, the folks who performed the "unbiased research" seem to be hooked up to the folks who are providing the fix. There's a lot of contention over the facts, but there's a distinct odor to the air.

Move on to page B6, and the headline shouts: "Research Study For Boston Scientific Stent Is Found To Have Flaw." The BS study (excuse the abbreviation) reports a statistically positive outcome—but 16 other data analysis regimes provide different and non-positive conclusions.

While I am well aware of the contention that revolves around research activities, and I am also aware that two similar articles in the same day's paper is doubtless coincidental, I am nonetheless overwhelmed by the Infinitely Long Encyclopedia of Horrors that seems to attend the Wonderful World of American Healthcare. (Our system performance is ranked #37 by the World Health Organization—though we do come in 1st in costs.)

Attached you'll find some new slides I'm adding to my Master Health"care" Presentation. They are from Skin in the Game: How Putting Yourself First Today Will Revolutionize Healthcare Tomorrow, by John Hammergren (CEO, McKesson) & Phil Harkins. To preview, there is the report of 140,000,000 illegible prescriptions a year in the U.S. of A. And the fact that of the annual 1,500,000,000,000 healthcare claims filed annually, 30% have errors—which is not quite as bad as it sounds, because 15% of the claims are simply lost.

Georgia tops my short-term nausea list—but, increasingly, American healthcare seems to border on hopeless. (You know there's a problem when Hammergren and Harkins use the airline industry as a good example.)

On a brighter note, go Cubbies!

Proposed Hospital "Organization Chart"

What follows is obviously hopelessly bureaucratic—hence, tongue mostly in cheek. The idea is to demonstrate the mostly missing elements at senior levels in the typical hospital, as suggested by yesterday's Post, "The Healthcare14: U.S. Healthcare Trauma in 2008." However, the post of "Deputy CEO/Patient Safety & Quality" is not bureaucratic—it is a non-negotiable "must-do-now" in "my" hospital, regardless of size.

CEO, CMO/CHIEF MEDICAL OFFICER, CNO/CHIEF NURSING OFFICER, CFO, ETC. [traditional jobs]
DEPUTY CEO/PATIENT SAFETY & QUALITY
   Director "Hands Clean" Mandate
   Director Error-free Medications Program
   Director Simple-Tools-That-Save-Lives Programs
   Director Over-treatment Evaluation & Management
CHIEF CLINICAL EVALUATIONS OFFICER
   Director Evidence-based Medicine Initiatives
   Director Best-practices Program
   Director Error Reporting & Evaluation Initiative
CISO/CHIEF INFORMATION SYSTEMS OFFICER
   Director Electronic Medical Records
   Director Cross-functional IS Engagement &
      Implementation Teams
DEPUTY CEO/HEALTH & HEALING & COMMUNITY OUTREACH
   Director Wellness & Prevention Programs
   Director Follow-up Patient Behaviors Program
   Director Public Health Initiatives
   Director Wellness Programs
   Director Kids' Education Programs
CPCCO/CHIEF PATIENT-CENTRIC CARE OFFICER
   Director Patient Experience Programs
   Director Planetree Practices Programs
   Director Patient "Home Port" & Self- & Family-
      Management Programs
DEPUTY CEO/PEOPLE
   Director Teams-based Organization
CCCO/CHIEF CHRONIC-CARE OFFICER

DEPUTY CEO CROSS-FUNCTIONAL COORDINATION OFFICER
   Director Patient-Treatment Teams Implementation
   Director Cross-functional Communications Initiatives

[See Tom's Healthcare Master (PPT) posted 9 April 2008.—CM]

The Healthcare14: U.S. Healthcare Trauma in 2008

I have screamed and shouted about customer service—to the point of physical and mental exhaustion and near collapse. I have screamed and shouted about our failure to embrace design as a rock-solid basis for differentiation. I have hissed and booed from on high and on low at the mis-direction of our education system in an age where creativity counts most. I have screamed and shouted and harangued and begged and cajoled and sworn like the sailor I once was on the topic of truly putting people first. I have screamed and shouted and been vicious and rude on the topic of women in leadership roles. I have insulted, with maximum verbal violence, every marketer I can find on the topic of inattention to the market power of women and boomers-geezers. I have pilloried every CEO I can lay voice on over the utter stupidity of 9 out of 9.1 major mergers. And I have begged and begged and begged some more on the topic of ... Stop talking, get on with it, whatever your "it" may be.

And now I'm engaged in another hysterical, and perhaps quixotic, campaign. This time the topic and target is American health"care." No doubt of it, I am the beneficiary of incredible care and have been aided by extraordinary medical devices and the skilled hands of exceptionally well-trained surgeons. (Just as I have gotten great service at the gazillion-dollars-a-night Four Seasons hotels in which I sometimes park my weary carcass.) Nonetheless, the American healthcare story is by and large a nightmare—and I don't just mean the un-insured. Below, after a dozen-years study, the last two of which have been rather intense, you will find my summary, shorthand List of American Healthcare Sins. Moreover, and most important, you will see that, in my opinion, most of these problems could be reversed without resort to either Mr McCain's or Mr Obama's Big Policy Initiatives. Using a simple, paper airline pilot-like checklist in ICUs can reduce infections and stays dramatically. Supplying simple compression socks to in-patients could avoid thousands upon thousands of deaths via deep-vein thrombosis. Clean hands—don't get me started. Scanners to certify accurate drug administration to in-patients—don't get me started.

As with customer-care and people practices, we have the wherewithal within to make Giant Performance Leaps. So when will we do so with the Total Determination the issue demands?

Tom Peters/The U.S. Healthcare14

U.S. Life expectancy rank: #45.
WHO, overall American healthcare system performance: #37 (#1 in cost).
Access: Denied to 10s of millions un/underinsured.
Unnecessary annual health-system deaths: 200,000-400,000 or more.*
Performance/top med centers: Problematic re quality of care and follow-up.*
Over-treatment (meds, tests, procedures): Pandemic.*
Use of hard evidence in medical decision-making: Spotty at best.*
Collection of evidence based on reported treatment errors: Low.*
Use of S.O.P.s in treatment regimes: Spotty.*
Incentives for appropriate care: Low.*
Incentives for inappropriate care: High.*
Emphasis on prevention and wellness: Low.*
Emphasis on chronic-care: Low.*
State-of-the-art IS/IT: Rare.*

*Fixable without legislation or major societal change—e.g., can by and large be improved dramatically without some form of mandated universal access to care and in the absence of, say, a full-fledged War on Obesity. (Evidence in support of this proposition is the fact that in every category starred above there are Pockets of Excellence—hospitals and other health-service organizations, facing the same realities as their peers, that really "get it.")

NB1: Many of these problems are equally applicable to other nations. But as is true with education issues, various nations use various approaches, so de facto generalization is dangerous.

NB2: This rant was triggered by a testy conversation with a client who inferred (in no uncertain terms) that I was being too hard on the healthcare folks. And to think, I thought I was letting them off too easily!

[Michael Millenson, author of Demanding Medical Excellence: Doctors and Accountability in the Information Age, which Tom has been quoting since its Y2000 publication, sent him this link to Millenson's 8-Day Health Care Diary (it mentions Tom, by the way).—CM]

The HFMA Event: More

Tom spoke to the Healthcare Finance Managers Association on June 26. In his speech he touted their magazine Leadership, and he insisted that we point you to its website. It provides stories about "compelling and inexpensive efforts" from all over the U.S. to address such pressing issues as patient safety. Tom added that "it proves this stuff can be done—and a million bucks of funding, or a twentieth of that, is not required to get on with it."

As a result of this engagement, Tom also got a chance to meet Michael Millenson in person for the first time. For years Tom has been quoting Millenson's book, Demanding Medical Excellence, and he credits it with fueling his interest in healthcare. I found this quote from the book in a Master presentation dated 20 June 2001: "A healthcare delivery system characterized by idiosyncratic and often ill-informed judgments must be restructured according to evidence-based medical practice." You can read more of Millenson 's commentary at his website, HealthQualityAdvisors.com.

Ten Years in the Making!

The attachment herein [updated 7 April], more heavily annotated than any I have done before, took 10 years of preparation. I have been working on and off with healthcare issues for a decade. Thanks in part to a slew of gangbuster books that have recently appeared, I have been able to reach some temporary closure. Hence, you will find here my best shot at compassing the healthcare issue as I see it. As I say at the outset in my annotation, this presentation is not about Hillarycare or some such. It is about turf upon which I can claim some expertise—organizational and operational effectiveness. For instance, healthcare financing—except as it causes horrid distortions in priorities, a bias against improving our health—is not dealt with. (By choice.)

I hope that you will "enjoy" this, though most of the story is grim. And I hope that some of you might spend some serious time on the presentation, and give me your feedback. And of course, as always, I hope you will "rob me blind"—and use some of this material in your own work.

Americans mostly think we have the best healthcare in the world, even if the most expensive. In short, that doesn't fit with the fact that our life expectancy is 45th globally and dropping, that our hospitals unnecessarily kill hundreds of thousands of us each year, and that seeking care at our most prestigious healthcare centers will surely reduce our lifespan compared to care at "St Elsewhere," as one writer put it.

Read on!

Beyond Belief!
(Not!)

In my ever-changing, annotated "Implementation" Presentation, version 0119, at Slides 137-145 you will find a riff on the power of "simple" checklists in reducing hospital errors. My presentation drew this incredible—ever so credible!—Comment by Manoj Pawar, M.D.:

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

Patient Safety as Job One

Good for Medicare! It will stop covering claims that stem from preventable errors. [NYT, 19 Aug 2007]

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.

The Wrong Debate?

I agree. It's appalling that such a wealthy country as the U.S. has over 25 million people, including many children, without healthcare insurance. (Which is not to say I want a Socialist solution.)

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.)

The Patient Experience

I am sure many of us have been in the hospital or other health care facility and experienced less than satisfactory care. Quality of care isn't just about how the doctor or nurse performs their duties, but everyone you come in contact with. As Mike Neiss said in an earlier blog, we would call these encounters "touchpoints." I can recall being in the hospital and the janitor was mumbling and stumbling around my room early one morning. He seemed to be indifferent to the fact that I was there. Or perhaps it was the technician who came in to draw blood (never a fun activity), who scored zero in bedside manners. There are tons of stories out there, I'm sure.

But recently at the Cleveland Clinic, they have decided to give the total patient experience a high priority. According to the Cleveland Plain Dealer, the clinic has hired a person to be their Chief Experience Officer, and her job is to ensure that the patient receives a great experience throughout the process of the hospital stay. The process starts long before a patient arrives in the hospital, unless it is an emergency, so this new CEO has her hands full. But what a wonderful challenge to take on!

What suggestions would you offer this new CEO (or, as Tom calls it, cXo) for improving the patient experience?

More to Come

It's a "twofer."

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.

Leapfrog Measures Safety

You have to be intrigued by a group that calls themselves "Leapfrog!" The Leapfrog Group is an organization that focuses on promoting health care quality and safety. They have created an assessment to determine the safety readiness of hospitals across the country. According to a recent press release, "Fifty-nine U.S. hospitals have been named to the first Leapfrog Top Hospitals list, based on ... results from the Leapfrog Hospital Quality and Safety Survey, a national rating system that offers a broad assessment of a hospital's quality and safety. The survey results from over 1,200 hospitals ... reveal significant findings ..."

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

Outsourcing Surgery

Thursday on ABC News, I watched a special on Outsourcing Surgery in India. At a hospital in India, some Americans are finding a solution to having surgeries that aren't approved by their health insurance. One woman flew 30 hours to have a 30-minute surgery at 1/3 the cost in America. Because her condition was considered "pre-existing," she was not covered by her health plan. Her condition made it painful to walk and sit for any length of time, and she was in constant pain—not how we should want people to live their lives. But she worked for a small company, and the insurance wouldn't cover it. Her employer, however, kept searching for a different solution to help her fix the situation. The answer was PlanetHospital.

PlanetHospital takes care of all the details, meets the patient at the airport, and takes them right to the hospital. Even though this particular patient arrived during late hours, the hospital received her and prepared her for surgery. The hospital in India supposedly has lower infection rates when compared to the U.S. Interestingly enough, India is in the process of building more medical facilities closer to the airport.

Surgery, anyone?

Take Care

My old friend Hal Rosenbluth is up to something ... very good. Or at least I think so. He built his travel services firm, Rosenbluth International to a progressive giant with in excess of $3 billion in revenue, then peddled it to American Express. Now he's taking on healthcare. His vehicle is Take Care. Take Care establishes walk-in mini-clinics in retail establishments. The likes of CVS, Wal*Mart, and Target are on the implementers' list. With generous funding aboard, over 1,000 locations should be up and running by the close of 2007.

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!

Ouch!

Where do I get off offering weight loss advice? Dunno. I've fought the Forces of Heavy for decades. At the moment I'm in a "less worse than usual" hiatus. And I'd like to keep it that way.

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.)

Amazing!

In our realtime world I love to run across a thoroughly new, well-researched idea that hasn't been reported on. (Or at least hasn't caught my attention).

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.

Purell Time (Again)!

Fall, of course, is officially here. FluTime ain't that far away. While at my local/Boston pharmacy (a GREAT "small company," by the way—Gary Drug on Charles Street), I bought my Fall-Winter supply of PURELL. It's my favorite, easy-to-find anti-bacterial hand wipe. buy viagra australia generic

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.

Surgeons as Secondary Players

One of my favorite parts of talking to IT execs is the hospital CIOs. I call them "mass murderers" (with a smile, of course)—and I mean it (with a frown). We're finally making some halting progress in healthcare safety, but we still have a long, long, long way to go to tame the killing fields. And my point to my hospital CIOs was that they are far, far more important & central to the safety improvement process than a stadium full of surgeons. We are in desperate need of "EMR" (Electronic Medical Records); and the likes of DSS (Decision Support Systems) would help do the unthinkable—actually bring evidence to bear on docs' decision making!

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.)

The New American Dream?

The cost of health care continues to spiral out of control. I cringe when I get the annual envelope telling me how much my insurance will be for the upcoming year. I am a healthy individual, yet my insurance payments have escalated each year for as long as I can remember. I received an insert with my premium notice this year advising me to take advantage of the free health screenings that are available. Hmmm, was that a nice way to tell not to go to the doctor?

A recent survey, as reported in the August 15th Wall Street Journal noted that only about 58% of small businesses are offering health insurance and many are looking to drop coverage in the upcoming year.

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

P-L-E-A-S-E

Got my cholesterol test results back today. "Bad" cholesterol nicely under 100. Good for Tom. And: Thank You LIPITOR.

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!

Seconds!

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.")

Ye Gads! Holy S*&%!

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.

Alternatives, Please?

KFC/Yum Brands were sued over trans fat yesterday. I am unalterably opposed to regulating the dickens out of the food-fast food industry.

But ...

We literally can't live with trans fat. (Trans fat + high-fructose corn syrup USA = HIV/AIDS Africa?) So what the hell are we supposed to do-going to do?

On the Right Track

Our medically uninsured are a big problem—and, at least to me, a global embarrassment. But what if the care, once you do get in the system, is questionable? As readers of this Blog know, I've been on a tear about quality of care in acute-care facilities, emphasis on prevention & wellness & chronic care, erratic application of medical "knowledge," obesity, H5N1 preparedness, and the like. (See my recent healthcare "report card" PPT attached.)

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.

Healthcare Report Card

Attached as a one-slide PPT you'll find my healthcare Report Card, created for a recent presentation.

AirX. (Airport Exercise.)

Sometimes, all too often, my schedule makes it difficult to get in my 5-mile-daily-minimum exercise (power walking). Why it occurred to me at this late date I don't know. Since many of us, post 9/11, get to the airport early, there is a matchless opportunity to log an easy mile or so of decent, borderline aerobic exercise.

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.)

Breakthrough!!! (For me.)

Thanks to my noodling prior to my Dubai speech last week ("Arab Health Conference 2006"), I have come to a "definitive" conclusion:

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.

H5N1: More Sunday New York Times

I recommend "Why Revive a Deadly Flu Virus?" in the magazine section of yesterday's Times.

HC21.J1

I am becoming "health-obsessed." No. Not (just) my own, but the centrality of health-writ-large to our "survival of civilization" concerns today and in the years ahead. Concerns range from ... H5N1; to the acute-care quality catastrophe; to wellness M.I.A. (e.g., the diabetes, obesity plague in developed countries); to man-machine genetic re-engineering; to more-or-less near term, accelerating environmental degradation; to the aftermath of a WMD event. These are, mostly, multiplicative problems. (Also, from a crude business sense, incredible market opportunities—witness Immelt at GE.) Am I late to the party on most of this? Yes, alarmingly and embarrassingly so! Nonetheless, I do believe heartily in "better late than never." The following, in absurdly shorthand form, is my "starter list." (It's also attached, what else from me, as a 2-slide PP.) I've titled it "Health: Century 21, Job #1," or "HC21.J1":

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!

TP's Healthcare Twenty-seven/December 2005

In preparation for a healthcare client conference call, I hastily jotted down this list of my more or less "beliefs" about healthcare (no particular order, not in order of importance—but main points are BOLD):

1. Fully utilize Physician's Assistants to do routine work in a timely fashion. ("Doc in a Kiosk" at Wal*Mart is great!)
2. Maximize Outpatient Services!
3. Short hospital stays work!
4. Support home care to the max. (E.g., "Declaration of Independents"—Beacon Hill/Boston)
5. STOP THE 100K+ NEEDLESS DEATHS—much/most of the "quality stuff" is eminently fixable. (Don Berwick for President! AHA for Hall of Shame!) (Strong, vicious insurer incentives!!!)
6. FLIP HC 177 DEGREES TO EMPHASIZE PREVENTION & WELLNESS. ("Steps" are being taken but not enough. Med schools: Awful! Insurers: Little better. Support for appropriate-proven alternative therapies is an important part.) (HUGE INCENTIVES FOR EFFECTIVE WELLNESS-PREVENTION PROGRAMS-MEASURABLE SUCCESSES.)
7. "Boomers" will determine HC's (very different?) future. (They are from a different & demanding planet compared to yesterday's Oldsters.)
8. "Focus on Women." (It's my generic—and correct—rallying cry, and it applies to HC in spades, women-as-patients-with different-woes-than-men; women-as-HC decision makers at the "consumer"—and commercial—level.)
9. "Patient/Consumer-driven" may be a buzz phrase bandied about all to easily ... but it is true. (And changes the game.)
10. Reduce incentives for unnecessary tests. (Malpractice caps would help, though the issue is complex. Insurers-HMOs doing so-so on this.)
11. OUTCOME-BASED MEDICINE IS A MUST! (There is a long, long way to go!) (Measure until you're blue in the face!)
12. Science-based medicine is a terrific idea!! (Many-most "therapies" unproven scientifically, uneven in application when proven.)
13. Over the next 5-25 years, the Life Sciences Revolution will make the likes of the "info revolution" look like small beer. (Get ready.)
14. Radical increase in "best practices" utilization—inculcate in Med school!
15. Med school "revolution" imperative—outcome-based medicine, abiding emphasis on Wellness & Prevention, etc.
16. Get info to Patients! (HIPAA mostly good.—"I wanna see my records!") (Detailed hospital-by-hospital, disease-by-disease, doc-by-doc success records a must—despite controversy.)
17. Upgrade IS-IT in the entire system, starting with acute-care institutions. (Current grade: D-.) (Winners include: Indiana Heart Hospital; Inova Fairfax Heart Institute.)
18. Healtheon WebMD-like (if it had worked) mega-, integrated-info network will-should emerge. (A healthcare Google+?)
19. MOVE HEAVEN & EARTH TO IMPLEMENT ELECTRONIC MEDICAL RECORDS. NOW.
20. By hook or by crook, something approximating basic universal care, starting with kids—50 state partial experiments is a help; some are quite far along. ("Market-based" as much as possible—but this is far from a "perfect market.")
21. Deal with the enormous HMO "I want my doc" perception problem. (Fact: MARCUS WELBY, STATISTICALLY, AIN'T THAT GREAT A HEALER IN TODAY'S "HIGH SCIENCE" WORLD! Incidentally, same perception problem re Congress, schools. "My Congressman is great, Congress has 434 other crook-clowns." "My kids' school is good, the system is awful.")
22. Blitzkrieg of Patient/Customer/Citizen education (e.g., re "outcomes-based HC," "Get the most for your HC dollar"). (Corporate cuts should motivate this.)
23. "Healing-centric" care supported. (E.g., Planetree model—reduces future problems.)
24. Emphasize front-to-back "customer care" practices—cuts waaaaay down on malpractice claims among other things.
25. Specialization in acute care works wonders, regardless of howls! (E.g., Shouldice/hernia repair.)
26. Shorten the FDA approval process. (Tom, age 63, wants the good new stuff and will accept associated risk; so will most boomers-geezers.)
27. DON'T MESS AROUND WITH H5N1/AVIAN FLU!