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.

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.)

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!]

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.

Waaaaaaay to go, Philips!!!

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.)

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.

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.]

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.)

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!

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.")

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.

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.

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!

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]

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]

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.

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

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

I urge you to read the Op-Ed piece.

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

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

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

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

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

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

We all are left asking, "WHY?"

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(My current picks re healthcare reading:

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

Both are excellent writers.)