Planetaki Planet saludygestion

Please wear these. via

2012-02-12T00:13:40Z

Please wear these.

Casualidades cotidianas

2012-02-11T09:50:09Z

Instantes especiales que se repiten, miradas cómplices casi desconocidas, canciones y coincidencias... Y pedir un deseo, como dice la canción. El jueves, Manel fue uno de los protagonistas (involuntarios) de la tarde en el Cibernarium, junto con las armaduras, y las sonrisas.

Sábado de música, volviendo a los orígenes.

Curling up with a drink, and a song

2012-02-11T00:22:41Z

I need to turn from my soccer compulsion and address the sport of curling. Before today, I was not aware of the wisdom that can be derived from this sport and applied to hospital safety and quality improvement. Fortunately, a recent blog post by Mary Smillie, Health Quality Consultant, Saskatchewan, on Open Medicine helped me overcome my inadequacies in this regard. It is entitled, "Improvement on Ice: Curling and Quality Improvement Science."

Here's an exemplary excerpt:

Every stone thrown presents an opportunity for testing and learning as does the overall strategy for each end. The team with the last rock advantage will try and set up the end to score at least two points. The opposition will work to cover up the center of the rings to counteract the last rock advantage and ideally ‘steal’ one or two points through a defensive strategy. The skip for each team will have a plan (and prediction) at the start of the end based on whether or not they have last stone. If, as the end progresses, the skip recognizes the strategy will not work as planned, he/she will modify the strategy based on the opposition’s performance and the strengths and weaknesses of the other team members. It is a perfect incarnation of continuous improvement theory and practice in real time.

This is a good article, but I see no mention of a key aspect of the game. As noted here: It not only is a curling tradition to share a drink with opponents after the game, but most clubs specifically spell out "Have fun" as part of their official rules (some of them even list it twice).

Now, that's more like it. Imagine how much faster process improvement would occur in hospitals if we adopted a similar attitude. Even more so if songs were included.

If you cannot see the video, click here.

Romance and litter, Mt. Ida style

2012-02-11T00:22:41Z

It's a class college sequence. A warm winter day in the sunshine. Boy meets girls while waiting for the shuttle bus. Conversation ensues. Both of them have to see the used coffee cups left behind by their fellow students -- nicely aligned on the curb -- and leave them as litter. Ten feet from the trash container.

Back in October, I noted the tendency of Mt. Ida College students to leave behind such litter while waiting for their shuttle bus from the public transit system. I was assured by college administrators that this issue would be handled.

Well, snow is due tomorrow. It will just cover this over anyway, right?

Trabajo en eSalud – experiencia personal

2012-02-10T16:09:19Z

Fuente: elMundo.es Tromso, a veces llamada la ‘puerta del Ártico’, es una pequeña ciudad, de alrededor de 66.000 habitantes, en el norte de Noruega. Es también uno de los principales focos de desarrollo de la telemedicina y la informática médica o ‘e-salud’, motivo por el cual Luis Fernández Luque, onubense de nacimiento e ingeniero informático [...]

Citizens and ICT for Health in 14 EU countries: results from an online panel survey

2012-02-10T16:09:21Z

Citizens and ICT for Health in 14 EU countries: results from an online panel survey View more presentations from Francisco Lupiáñez-Villanueva.

Cool Technology of the Week

2012-02-10T16:09:19Z

I recently did an interview about distracted doctoring for National Public Radio. Typically, when I speak on Morning Edition or All Things Considered, I travel to our local NPR affiliate (WBUR) and use their high fidelity dedicated ISDN lines in a soundproof booth.

This time, I used my iPhone 4S.

How does it work? I used a free application called Report IT Live which NPR has selected to capture interviews in the field via the high fidelity microphones built into the iPhone and a high digital sampling rate.

When the interview was complete, I uploaded the file securely to NPR servers.

Here's an overview of how it works in the field.

High fidelity radio interview recording on your iPhone with all the sound quality of a studio. That's cool!

Quotation of the Day: On Wickedness

2012-02-10T16:09:24Z

‘I’ll let you know as soon as I can, Danglars. I shall try to speak to Monsieur de Villefort and intercede with him on the prisoner’s behalf. I know that he is a rabid Royalist; but, dammit, though he’s a Royalist and a crown prosecutor, he is also a man and not, I believe, a wicked one.’

‘No,’ said Danglars. ‘Though I have heard it said that he is ambitious, which is much the same.’

The Count of Monte Cristo by Alexandre Dumas

Aprendiendo del cine: Moneyball y la sanidad

2012-02-10T09:19:56Z

Estos días pude disfrutar de la película Moneyball, que si bien puede ser considerada un producto recreativo muy americano, tiene su gracia por lo trasladable a nuestro sector. Me sorprende agradablemente que este punto de vista sea compartido con el Dr Weidner en KevinMD.com . La película enfoca el dilema del trabajo de héroe a partir de la necesidad autoimpuesta por un directivo de mejorar los resultados con el mismo dinero. Cansado del viejo adagio einsteniano de “si buscas resultados distintos, no hagas siempre lo mismo”, el manager cambia radicalmente el diseño de su equipo. A partir de análisis numéricos, se cree capaz de mejorar radicalmente los resultados cambiando el enfoque, dejando de pensar en individuos y haciendo que la gente haga lo mejor que sabe hacer según sus resultados anteriores. Esto choca frontalmente con el rechazo del establishment de su equipo, especialmente basado en mitos, famas y creencias intangibles pero admitidas y reconocidas por todos. El cambio se efectúa, manteniendo su posición el manager a pesar de los malos resultados iniciales, desastrosos. Pero a partir de un punto, con una implicación personal en el proyecto, los resultados acompañan. No quiero hacer más spoiler de la película, por la que estará nominado al Oscar Brad Pitt y Jonah Hill, que cambia su registro a empollón con éxito, pero realmente puede dar que pensar a los que estamos dentro de un sector basado a menudo en creencias de que solo pueden hacerse las cosas como siempre se han hecho, y que los mejores lo son porque se les supone que lo fueron en su momento. La desintermediación de información y servicios, la tecnología de contacto interpersonal asequible, la previsible y posible sensorización, la información compartida en la nube y tantas innovaciones que ya existen en otros sectores pero aún no están en el cuidado personal de la salud esperan que cada organización, por pequeña que sea, encuentre su Billy Beane, para que los grandes aprendan de esas mejoras aplicadas en un entorno real.

It's the people

2012-02-10T07:51:33Z

Here's a wonderful post by David Lee Scher, who retired from the practice of medicine to pursue a career in mobile health technologies. Some excerpts:

What I will surely miss most are the priceless personal interactions I experienced on a daily basis. I spent most of my days in the hospital. I will miss the janitorial and food service workers with whom I would have chats ranging from the weather to their families. I will miss the therapists (physical, respiratory, occupational, and others) who I encountered when seeing my patients. I will remember fondly the talks with nurses asking how a certain patient was doing when I arrived on the floor to make follow-up rounds after procedures, or listening to the gallows humor in the middle of the night when in the hospital after seeing a patient in the ER or a consultation on the floor.

The camaraderie among hospital workers is unique, and one that many will attest to as being as important as family. I have shared profound experiences involving patients with them

[T]he myriad of persons involved in the care of those patients is a culture of dedication, teamwork, and human kindness that I will always treasure and hope is never under-appreciated by anyone.

A Special Cavalcade of Risk

2012-02-09T23:26:19Z

The Sesquicentennial Edition of the Cavalcade of Risk is posted at My Wealth Builder. Check it out.

eSalud- fundamental para los países en desarrollo

2012-02-09T23:26:14Z

Fuentes: The Express Tribune, Dawn.com Lahore: Los países de todo el mundo están recurriendo a la salud electrónica para mejorar la prestación de servicios de asistencia sanitaria y Pakistán deberían hacer lo mismo, según dijeron los ponentes en la jornada de clausura de la International eHealth conference en la Universidad de Ciencias de la Salud. [...]

Hospital marketers need to think like graphic designers

2012-02-09T14:46:45Z

by Jenn Riggle

A picture is worth a thousand words--especially when it comes to social media.

Hospital marketers have typically relied on words to create content and build brands. However, times have changed, and marketers need to think more like graphic designers and focus on images.

While it may seem like a drastic shift, it actually follows a basic tenet of good journalism: Don't tell me, show me. So it really shouldn't be surprising that the hottest social media trends today have a strong visual component. Let's consider four: Pinterest, Infographics, SlideShare and YouTube.

Pinterest
Something between visual social bookmarking and scrapbooking, Pinterest is a virtual bulletin board, where users create "boards" where they "pin" items to share. The only caveat is that items need to have a visual component, such as a photo or graphic, in order to be pinned to a board. Launched two years ago, Pinterest's been named the breakout social network of 2012 and saw the number of unique visitors to the site grow 400 percent from September to December 2011.

So why should healthcare marketers care about Pinterest? Since its users are predominately female, it's a great way to reach women, who are healthcare decision makers for families. Only a handful of healthcare organizations currently engage on Pinterest, so there's a real opportunity for hospitals to become a great health resource for people. But you better move fast--the word is getting out.

Hospitals can use Pinterest as a content curation tool to pull content from different parts of the web to help with education and patient engagement. They could be creating boards about exercise for their orthopedic or physical therapy groups or creating boards for chronic diseases (e.g., diabetes and heart disease) that compile recipes, success stories and exercise tips.

However, Pinterest can difficult to search, so it's important for hospitals to promote their boards through social media.

Infographics
Research shows that people spend more time using social media than going to church, talking on the phone, sending email or exercising. In this age of information overload, we're bombarded with information, all the time. Maybe that's why infographics have become all the rage--they use graphics to provide a user-friendly way to present of information, making it easily understood at a glance.

But it's important to note that all infographics aren't created equal. Successful infographics entice people to share them with others. Therefore, they need to present new and interesting facts and be visually compelling; so be sure to have a professional designer design them. But it's not enough to create a great infographic--people need to see it. Lee Odden offered some great recommendations about how to promote your infographic.

SlideShare
Commonly referred to as the "YouTube of Presentations," SlideShare is the largest professional content sharing community. It allows organizations to upload PowerPoint presentations onto a social network where they can be easily shared. SlideShare may have flown under the radar in healthcare because it's been focused on the business community.

However, with the growing popularity of infographics, this may change. Infographics, like this one entitled "SlideShare is the Quite Giant of Content Marketing," can be divided into slides and posted onto SlideShare. This provides another opportunity to reach people and provide them with health information.

YouTube
Hospitals have embraced YouTube as a way to post videos that position their physicians as experts, discuss new medical procedures and showcase patient testimonials. It's has a huge following. The latest statistics report that it has 800,000,000 users (about the same as Facebook) who watch 3,000,000,000 hours of video a month.

Needless to say, a big part of YouTube's appeal is the visual nature of streaming video. YouTube recently enlarged the thumbnail images very slightly, and that change alone increased clicks to the watch page by 2 percent.

The takeaway: Next time you're developing a press release or marketing brochure, think again. In the age of information overload, strong visuals are needed to encourage people to act. Maybe there's a better way to tell your story.

Jenn Riggle is an associate vice president and social media leader of the Health Practice at CRT/tanaka. She has 20 years of public relations experience in issues, such as healthcare marketing and public relations, social media in healthcare, national media relations, and strategic communications planning. She regularly engages in social media, both on Twitter (@riggrl) and frequently blogs about social media and healthcare issues for The Buzz Bin, a PR and marketing blog.

Our Cancer Journey - Week 8

2012-02-09T14:46:42Z

Kathy finished Cycle 3 of Adriamycin/Cytoxan, has weathered the most difficult treatment symptoms, had a positive rebound of her blood cell counts, and continued to receive an outpouring of support from the community.

Per the screen print above from BIDMC's web-based Online Medical Record, her neutrophil count increased from 3610 to 5660, ensuring she can fight infection. Neutrophils are significantly affected by chemotherapeutic agents but Neulasta, a bone marrow stimulant, prevents cancer patients from the neutropenic nadirs that once caused multi-day hospitalizations requiring antibiotics.

Dr. Robin Schoenthaler, a Radiation Oncologist in the MGH Department of Radiation Oncology at Emerson Hospital and Director of Medical Education at Emerson wrote to me with very helpful advice for husbands and families supporting breast cancer patients:

"I am a radiation oncologist at MGH specializing in the treatment of women with breast cancer and I have been following your blog (from which I heard about that very cool I-phone charger; thank you very much!) for some time. My heart goes out to you and your wife. I hope that things go as swimmingly as possible for you during and after the acute phase of treatment.

I have many many thoughts about what you have written; but yesterday's column which touched on the issues of 'causality' rang a real bell for me in three areas.

First off, it may interest you to know that, as far as I can find, there are no good studies that absolutely link breast cancer (or any cancer) with stress. Studies looking at extreme stress (eg war, famine, rape) have not shown a clear-cut link with the later development of cancers. Studies looking at day-to-day stressors have been negative, and studies evaluating severe stressors (recent divorce, death of loved one) are extremely mixed -- some show perhaps a small link and some actually show that severe stressors are associated with a LOWER rate of breast cancer (eg the Women's Health Initiative). This stuff is terribly hard to tease out so all we can say at the present time is that while there MAY be a link, and although there are hypothetical reasons to be concerned about a link, thus far many good studies do NOT show an absolute connection between being under stress and then getting breast cancer.

This may well be because 'cancer' is such a heterogenous disease, and it may also be related to the fact that cancers grow at such different rates, so that it's nearly impossible to say that a defined 'stressor' (and who can say exactly what stress is -- for some people it's their mother-in-law!) is linked to a very slow-growing breast cancer (or a fast one) or a lightning-fast lymphoma. It's just too hard to connect the dots.

The second idea I would like to convey to you is that your search for a cause -- wondering if it's paints, or stress, or radicals (or for other women: fertility treatments, or living under power lines, or pesticides) is a specifically AMERICAN response to disease, or more fundamentally, why bad things happen to good people. If you and your wife lived in India, you would probably think this disease occured because of something harmful you did in a past life prior to this reincarnation (karma, etc). If you lived in Mexico, you might well think your wife was bound to suffer this way so she could offer it up and then sit at the right hand of Mary in heaven.

But here in America, we always, always, think it's something we did. We think we are the cause. We ALWAYS think we are the cause, and if only we had done x or y or z maybe this wouldn't have happened. We like to think we are in control, us Americans (especially the engineers and computer people amongst us, despite the fact Mother Nature that is constantly showing us who rules.

I do think this is an important thing to think about -- maybe it wasn't environmental, maybe it had nothing to do with behavior, maybe it was just stone cold bad luck. I think it changes the way one approaches disease sometimes and I offer it to you as a possibility.

The third thing I want to say to you is that you are really being a model Husband/Caretaker, and my hat is off to you and to all such wonderful men. I call men like you 'Purse Holders' and in fact I wrote an essay in the Globe about them a couple of years ago. If you care to read it you can find it here.

I send you my very best regards and wishes, and if you would like to further discuss these or any other breast-cancer-related issues or questions, please consider me your go-to person."

Thanks Robin, your support is much appreciated. And you're right, since treating breast cancer is a partnership, all aspects of treatment including the driving, the listening, and the purse carrying are a shared responsibility.

On Sunday, I must fly to China to fulfill a promise I made a year ago to assist with healthcare IT design in Shanghai and Hong Kong. My absence is timed for those treatment days when Kathy is at her best and her energy has returned. I'll be back before the symptoms of Cycle 4 begin. I'll write my post next week during the first time we've been apart overnight since her diagnosis in December. As we travel the treatment path together, the experience of caring for Kathy long distance will bring new emotions.

Intraemprendizaje en el sector público: la hora de la confianza radical

2012-02-09T14:46:06Z

El día 7 de febrero participé, junto con Jordi Graells, en una mesa redonda del Master en Gestión Pública Directiva del INAP. El tema era “intremprendizaje en el sector público” y la moderación corría a cargo de Tíscar Lara, de la EOI. Enfrente teníamos a un alumnado perteneciente a las capas superiores del funcionariado de la AGE, que es un mundo que desconozco, lo que me provocaba cierta inquietud. ¿Cómo iban a encajar las ideas contraculturales de mi presentación?

Para mi ponencia, rescaté ideas que ya expuse en la Thinking Party 2010 y que fueron la base de mi capítulo en el libro “INprendedores“. Esto es, partiendo de la historia de la caza del mamut lanudo, aventuré algunas reflexiones y expuse experiencias nuestras acerca de la aplicación de la confianza radical en la Administración pública. La consecuecia directa para la gestión es que las personas ganan protagonismo frente a los métodos. Por lo tanto, hay que evitar rigurosamente la hipergestión, para fomentar el entusiasmo y el emprendizaje interno, a cargo de personas libres y equipos cohesionados.

El resumen de las ideas presentadas puede ser este mínimo manifiesto, que bebe de las fuentes del “Manifiesto Ágil“:

Preferimos:

la acción frente a la planificación

la libertad frente a la organización

la confianza frente al control

la red frente a la jerarquía

¿Cómo reaccionó el alumnado? Estupendamente. Hubo un cálido debate en el que no nos centramos sobre los impedimentos, sino sobre cómo llevarlo a cabo. Me quedé con una muy buena sensación del colectivo. ¡Hay que llegar a más gente! Debemos ser más las personas de la Administración que reflexionamos en claves del siglo XXI.

Jordi hizo una ponencia complementaria en la que dio un repaso a las principales ideas y buenas prácticas de innovación pública, que llevó después a debtes muy interesantes sobre, por ejemplo, la propiedad intelectual abierta.

Aquí os dejo las dos presentaciones:

Will competitive bidding work in Medicare?

2012-02-09T14:46:46Z

In my opinion the answer is yes. A book by Coulam, Feldman and Dowd also would agree with me.

Recently, Medicare began a competitive bidding process for durable medical equipment. Is it working? According to the Wall Street Journal, the answer is no.

“Normally when the government wants to buy something, it asks companies how much they can provide and to name their price. Winners are selected from the lowest bid up until the government has what it needs at the lowest possible cost, and thereby finds competitive equilibrium prices.

Under Medicare’s highly unusual version of competitive bidding, it will pay the winners the median price of all the winning bids, rather than using the clearing price. Bids are also for some reason nonbinding.

This matters because it creates incentives for unscrupulous third-party companies to make low-ball “suicide bids.” If the median price shakes out high enough, they automatically win the contract, buy the medical products from manufacturers and turn a profit. If it isn’t, they can dump the contract since bidding involves no commitment.”

I still think competitive bidding in Medicare will work; the auctions just have to be set up in a more logical way.

Turnos y guardias

2012-02-09T08:03:31Z

Una reciente entrada en nuestra segunda casa está generando un debate muy interesante, así que hemos decidido sacarla de paseo por saludconcosas. Podéis leer la entrada y los comentarios en La Otra Orilla. El texto lo tenéis a continuación:

Cada vez más se agolpan dudas acerca de las guardias y los turnos... En las últimas decadas, gracias a la presión de los profesionales y a las normas laborales, se ha generalizado la libranza después de una guardia, el descanso obligatorio entre turno y turno, etc. Algo que era necesario y además justo, dado el tipo de trabajo que se desarrolla en el entorno sanitario.

Sin embargo, la realidad es desconcertante:

- Algunos residentes se resisten a librar la guardia, aunque sepan que tienen derecho a ello. Argumentan que en su servicio está mal visto, que se pueden perder alguna cirugía "interesante" o cosas parecidas. Cada vez son menos, pero ocurre.

- Existen facultativos que hacen la guardia, y cuando son las 8, en vez de irse, trabajan por la mañana y es el siguiente día cuando libran. Es decir, el argumento de que 24 horas son demasiadas, desaparece y el profesional pasa unas cuantas horas más con actividades de "bajo riesgo" como pasar planta o dar algunas altas.

- Respecto de los turnos, desde hace años se han limitado las horas de trabajo semanales en toda la Unión Europea para permitir el descanso de los trabajadores. Sin embargo, muchos profesionales pasan de esos límites y para conseguir más días libres unen su turno con el de algún compañero, realizando casi 70 horas semanales de trabajo. De esta forma, puede conseguir semanas completas de libranza.

¿Entonces? ¿Y la protección de la salud del trabajador? ¿Y el cansancio a la hora de atender pacientes? ¿Los supervisores, directivos o jefes lo ponen fácil para librar? Toda moneda tiene dos caras... ¿Qué opinas?

Hot Links

2012-02-09T06:36:58Z

Check out these interesting articles as we head toward the weekend.

How much do you know about Medicare?
Coming apart.
Rents in Beijing higher than New York?
Patients=sheep? Docs=dogs?
Governmental business is increasingly important.

Telemedicina: Alternativa práctica para la falta de especialistas en regiones Chilenas

2012-02-08T22:28:50Z

Fuente: Nacion.cl Según los datos del Colegio Médico chileno, en Chile existe un médico por cada 800 personas. La escasez de médicos es una realidad en las zonas extremas de su país, según las estadísticas, la mayoría de los profesionales se concentran en la zona central. Un grupo de profesionales se presentan como alternativa para [...]

When is a comparison not a comparison?

2012-02-08T22:28:46Z

I guess we shouldn't be surprised when a website called "Hospital Compare" chooses to adopt a methodology that presents comparisons, but leaves us with less-than-useful information. According to Modern Healthcare:

The CMS' Hospital Compare website has been updated with facility-specific data on central line-associated bloodstream infections, a move the agency says will “hold hospitals accountable for bringing down these rates, saving thousands of lives and millions of dollars.

Here is the approach used by CMS:

The Central Line Associated Blood Stream Infections (CLABSI) Score is reported using a Standardized Infection Ratio (SIR). This calculation compares the number of central line infections in a hospital’s intensive care unit to a national benchmark based on data reported to NHSN from 2006 – 2008. The result is adjusted based on certain factors such as the type and size of a hospital or ICU.

A score of less than 1 means that the hospital had fewer CLABSIs than hospitals of similar type and size.
A score of 1 means the hospital's CLABSI score was no different than hospitals of similar type and size.
A score of more than 1 means the hospital had more CLABSIs than hospitals of similar type and size.

What's wrong? The hospital data presented "reflect experiences of patients treated between October 2008 and June 2010," an untimeliness that would render them useless if were we interested in comparisons. But, what is this business about benchmarking to a period of time four to six years ago, an ancient era in the world of hospital safety and quality? Further, why are the data also adjusted based on the type and size of a hospital? These three flaws act together to present an untrue impression of precision and relevance.

If there was ever a metric that did not need a benchmark or an adjustment, it is the rate of central line infections. The target for this metric should be zero. The numbers reported on the CMS site should be the raw rate, the number of cases per thousand patient days.

But, why are we comparing hospitals to one another? The more valuable presentation would be one that showed the trend for each hospital, comparing its performance against its own previous performance. We don't have to wait several years for data to arrive. Each hospital knows its infection rate and calculates it in real time, every month. If these numbers were presented, consumers could see if the hospital was getting better and sustaining its gains. That would tell you more about a hospital than a flawed comparison presenting a useless metric based on a faulty methodology.

WIHI on Better Care and Lower Costs

2012-02-08T22:28:46Z

The Social Imperative to Demonstrate That Better Care = Lower Costs

February 9, 2012, 2:00 - 3:00 PM Eastern Time

Guests:

Donald Berwick, MD, MPP, Former Administrator, Centers for Medicare & Medicaid Services; Former President and CEO, Institute for Healthcare Improvement (IHI)

Gerard M. Shea, Assistant to the President for External Affairs, American Federation of Labor and Congress of Industrial Organizations (AFL-CIO)

Imagine this. You’re driving or walking or maybe even bicycling by your local hospital and you notice a big sign over the entrance that you’ve never seen before. Here’s what it says: “This hospital saved 5 Million Dollars in 2011 by improving patient care and reducing unnecessary procedures. We have returned the money to local employers, local unions, and the state.” Sound preposterous? Hopefully not, because this is the kind of bold commitment and public declaration that Don Berwick and Gerry Shea would like everyone in health care to start thinking about, seriously. It’s just that urgent, they say, and they’ll explain why on the February 9 WIHI.

Host Madge Kaplan is pleased to welcome Berwick and Shea to the program, fresh off Dr. Berwick’s 18 months overseeing change at the Centers for Medicare & Medicaid Services (CMS), and building on Gerry Shea’s extensive knowledge of quality improvement and the promise of better care and lower health care costs for working Americans. The problem is, we’re nowhere near there yet, especially where costs are concerned, and both Berwick and Shea believe one of the reasons is that there’s still too much of a disconnect between what better use of health care services and improvement initiatives can achieve, and what health care payers (Medicare and Medicaid, employers, individuals, etc.) are able to reap in return. As Berwick puts it, “Payers aren’t seeing it yet,” and this means that anyone footing the bill, and that’s pretty much all of us, continues to be squeezed in ways that society can’t afford.

So, what can dedicated legions of health professionals, already deeply immersed in improvement work, do differently or better? Berwick started to lay this out on December 7, 2011, at IHI’s National Forum; if you missed or would like to be reminded of his speech, you can find it here. Berwick and Shea both say that one area ripe for review is the conceptual and often actual way in which health care organizations separate their quality and “lean” strategies, when these should be one and the same. Implementing greater efficiencies has everything to do with safety and better care, the two say. Getting this right would speed things up and generate greater savings. The question then becomes, where should the money go?

Don Berwick and Gerry Shea are eager to continue this conversation with all of you. Come join this most timely discussion on the February 9 WIHI!

To enroll, please click here.

How to keep docs from going broke

2012-02-08T22:28:51Z

by Anthony Cirillo

It's hard to ignore a headline that reads "Doctors Going Broke." But that was the gist of the article in CNN Money last month.

According to the article, half of all doctors in the nation operate a private practice. And many are on the verge of financial disaster.

The usual litany of blame was cited--shrinking reimbursements, changing regulations, rising business and drug costs.

"Many are too proud to admit that they are on the verge of bankruptcy," Beau Donegan, senior executive with a hospital cancer center in Newport Beach, Calif., commented to CNN. "These physicians see no way out of the downward spiral of reimbursement, escalating costs of treating patients and insurance companies deciding when and how much they will pay them."

But hold on. What was revealed as a more systemic cause was the doctors' lack of business acumen. And that is an issue we know about.

Dean Burrow, Practice Leader, Healthcare for The Performance Group (and for transparency, a strategic partner of our company), works with us to help practices shift their culture from a practice mindset to a business mindset without compromising on the ultimate customer--the patient.

As the article noted, doctors are trained in medicine but not how to run a business. Burrow agrees.

"If physician-owned practices are not creating, retaining and deploying profit to their advantage, they have chosen a linear path that will limit their ability to reap rewards commensurate with their preparation and hard work," he says.

Here are some of the common pitfalls we see in medical practices:

They follow an "eat what you kill" approach: Providers are solely focused on compensation; therefore, all strategic investment decisions are filtered through the "income impact" sieve.
Limited cash is available for investment: The income model does not set predetermined dollar amounts marked for investment in a planned and methodical way. At every turn, the need or idea for investment dollars by the physicians results in an inefficient process of proving each capital expenditure, resulting in disparate viewpoints and often halfhearted commitment.
Personal guarantees required for bank financing is eroding: While physicians typically have been viewed as good credit risks, today's economic environment has caused banks to begin looking for more guarantees on monies loaned to physician practices, largely due to the fact that there is minimal working capital in the practice.
New partners receive legacy value for almost nothing: Most medical groups have created a situation where new physicians can enter in to the practice and in a very short period of time have the same income earnings potential as those who have "paved the way."
A physician's equity goes to zero dollars on first day of retirement: Owners/partners who have worked to build the business and have done so successfully have a value--a real dollar value for his/her ownership stake in the company. The income-based model does not allow for this. Therefore, in the end there is no equity that can be transferred.

You get the idea.

So what to do ... have a practice that creates value.

Paying for it: In an Equity Value Creation model, the practice sets up a predetermined investment amount with modest growth over an extended period of time. While physicians may see a small impact to their take-home pay, this also can simply redirect the physician's current investments to reflect an investment back into the one thing they have the most control over--their own business.

Expected Buyout: At the end of the day an equity-minded practice can create a buyout premium for its physicians at 2 to 3 times the normal levels.

With that in mind, Burrow recommends practices:

Evaluate the idea of the Equity Value Creation model within the practice.
Determine what the Equity Value Creation model looks like for them.
Conduct current state assessment and identify impediments to value creation.
Build a strategic and operational plan and commit investment to it.
Implement and measure.

If a business does not have equity value, it is truly not a business asset. Physician-owned medical practices are not exempt from the business model reinvention underway in America. A change must take place deep down in the fiber of the organization to embrace a new way to think, grow and thrive.

Interested in a whitepaper on this? Contact me.

Anthony Cirillo, FACHE, ABC, is president of Fast Forward Consulting, which specializes in experience management and strategic marketing for healthcare facilities. He is also the expert guide in Assisted Living for About.com.

A hospital-wide approach to combating compassion fatigue

2012-02-08T22:28:51Z

by Teresa L. Deshields

There is growing recognition of compassion fatigue as a challenge to healthcare professionals engaged in difficult clinical work. Certainly, exposure to patients who are suffering increases vulnerability to compassion fatigue. Some have even suggested that clinical researchers can be vulnerable to it.

How can you tell if compassion fatigue is a problem for you, your coworkers or your colleagues? Here are a number of "symptoms" of compassion fatigue:

Physical symptoms include:

Feeling "not well"
Feeling exhausted
Feeling "hyper"
Suffering from insomnia

Psychological symptoms include:

Feeling numb
Having work-related bad dreams
Growing cynicism or pessimism
Not enjoying things that were previously enjoyable

Emotional symptoms include:

Increasing anger or irritability
Dread going to work
Feeling overwhelmed
Feeling nervous

Professional symptoms include:

Inability to get work out of your head
Desire to quit work
Reduced productivity at work

Barnes-Jewish Hospital, a 1,200-bed academic medical center with about 9,500 employees, developed a Compassion Fatigue Resiliency Program after being approached by nurse managers from oncology treatment areas. The managers were concerned about what they perceived as sagging morale among their staff.

From an organizational perspective, the program's aims to increase staff engagement, reduce turnover and increase patient satisfaction. From a staff perspective, the goal is compassion satisfaction, or the ability to derive meaning and satisfaction from your work.

Our program focuses on giving staff skills to recognize signs and prevent compassion fatigue. It also addresses compassion fatigue in those already suffering from it.

The program is presented as a one-day, all-day workshop. The elements of the program are:

Education about compassion fatigue
Instruction in and practice of self-regulation/relaxation
Discussion of personal mission and covenant for work
Education in self-care strategies for management or prevention of compassion fatigue

According to the feedback from our participants, the most effective elements are the education about compassion fatigue, the peer support involved in learning that others struggle with the impact of the work we do, the reminder of personal mission, as well as the introduction to the specific coping strategies.

One interesting aspect of our program is that after being piloted on the oncology floors and the emergency department, it was opened up to all hospital employees--a recognition that even if employees are not giving direct clinical care or treatment, they still may be involved in caring for the hospital's patients, and are vulnerable, too, to the cost of caring.

Teresa L. Deshields, Ph.D., is a licensed clinical psychologist and the manager of Psycho-Oncology Services for the Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine in St. Louis. Her clinical practice is devoted to treating cancer patients and survivors and their family members, and her research is focused on issues related to psychological adjustment and quality of life in cancer patients and survivors.

Desde USA con innovación

2012-02-09T00:02:47Z

Desde hace unos años colaboro en ESADE en un juego de rol sobre gestión de empresas llamado INTOP, viejo en cuanto a su origen en la Universidad de Rotterdam, pero que no puede estar más de actualidad. Sin entrar en los entresijos del mismo, porque su descubrimiento es la esencia de la experiencia de aprendizaje que conlleva, tiene reglas que pretenden hacerlo cercano al mundo real. En concreto, y acerca de la innovación, se tiene en cuenta que puede tener un porcentaje de éxito atribuible a la casualidad, pero el esfuerzo mantenido cumple una norma de causalidad. Es decir, el esfuerzo mantenido en investigación e innovación tecnológica tiene premio.
En mi reciente estancia en San Francisco me ha quedado subjetivamente claro por qué el Silicon Valley es como es, y por qué es un ecosistema donde florecen grandes proyectos empresariales, especialmente en temas de alta escalabilidad. Es un entorno “nerd”, de ingenieros prácticamente entregados a la causa (propia o ajena) de mejorar. Eso ha provocado la aparición de un “star system” propio, que se renueva en tanto en cuanto se renuevan los proyectos exitosos. El summum son los Crunchies, los Oscar de las empresas de internet, que son conocidos los unos de los otros. Todos cumplen un patrón de entusiasmo monacal por la tecnología y la búsqueda del Santo Grial, con héroes/mesías que se perpetúan dentro de esa tribu.
Curiosamente, parece que no hay mucho entusiasmo por entrar en el mundo de la salud. Los todopoderosos lo han intentado, y han tenido que hincar la rodilla, rebajando expectativas como Microsoft Healthvault o incluso cancelando grandes proyectos, como Google Health. El principal motivo es, a mi entender, lo alejado de la realidad “cotidiana” de los ingenieros respecto al hombre de la calle y al profesional sanitario. La innovación más potente en esa parte de la costa Oeste es One Medical Center, un centro médico que por un sobrecoste de 200 dólares anuales ofrece lo que para nosotros es atención médica continuada, además del coste habitual de la visita por el seguro médico. Este servicio extra, su ubicación céntrica en San Francisco y su utilización de las TICs para contactar con sus pacientes les hacen especialmente populares. ¿El truco? Es un centro nuevo, con gente joven, y pensado desde el principio con este formato.

El Centro de Innovación en Garfield de Kaiser Permanente es un enfoque innovador en pleno vuelo, no tras un diseño experto. Se trata de tener un espacio de 9000 metros cuadrados que simula las diferentes áreas de un hospital. Cabe destacar que al frente de Kaiser Permanente, en contra de lo que podemos creer, no hay médicos. El objetivo es proponer mejoras que aporten mejoras fácilmente realizables que incrementen la salud de los asegurados. Es espectacular ver un hospital como si fuese un plató, a trozos, que son convenientemente analizados. El diseño del mínimo espacio posible para una uci neonatal unifamiliar es un ejemplo, como lo es rediseñar la forma de colocar los enchufes, cables y tubos de las máquinas para que puedan dejar el máximo espacio posible, como se ve en la imagen adjunta. Son pequeñas tareas que pueden mejorar el trabajo de mucha gente, y que atenderán a muchísima más. Los pequeños cambios son poderosos.
Pero el verdadero poder se basa en prever el futuro. Que la Mayo Clinic tenga a alguien destacado en Palo Alto para estar cerca de los cambios que los ingenieros pueden tener sobre la sociedad digital es un signo de inteligencia. Es una inteligencia activa, sin esperar a recortes o crisis. Es saber que el queso va a cambiar de sitio, y tener claro donde están las claves: Es el ingenio de los innovadores, porque innovar no requiere necesariamente de maquinaria, sino de ingenio. Y esto requiere algo de dinero, pero sobre todo, mucho de visión. En Europa, salvo excepciones, seguimos necesitando gafas…

Cullen and friends helped show the way

2012-02-08T22:28:47Z

Putting aside my occasionally snarky attitude about its slow-to-innovate health care market, one of the pleasures of living in Boston is casually running into some of the intellectual greats in the field. These are extremely well-intentioned and thoughtful people who have done some of the seminal work in health care quality improvement.

One such person is David Cullen, whom I ran into at our dentist's office. (I trust it is not a HIPAA violation here to report that he was smiling as he left!) David, a former anesthesiologist at MGH, participated in a very important systems analysis of adverse drug events (ADEs), published in JAMA in 1995.*

This was a great piece of work, conducted with Lucian Leape, David Bates, and other notable folks. Here were the conclusions:

Results. —During this period, 334 errors were detected as the causes of 264 preventable ADEs and potential ADEs. Sixteen major systems failures were identified as the underlying causes of the errors. The most common systems failure was in the dissemination of drug knowledge, particularly to physicians, accounting for 29% of the 334 errors. Inadequate availability of patient information, such as the results of laboratory tests, was associated with 18% of errors. Seven systems failures accounted for 78% of the errors; all could be improved by better information systems.

Conclusions. —Hospital personnel willingly participated in the detection and investigation of drug use errors and were able to identify underlying systems failures. The most common defects were in systems to disseminate knowledge about drugs and to make drug and patient information readily accessible at the time it is needed. Systems changes to improve dissemination and display of drug and patient data should make errors in the use of drugs less likely.

Importantly, Cullen and his colleagues found that incident reporting systems in hospitals did not capture these events. In a second study in the Journal of Quality Improvement, they noted:

Of 54 adverse drug events identified by the study, only 3 patients (6%) had a corresponding incident report submitted to the hospital's quality assurance program or called into the pharmacy hotline. One additional ADE was identified by an IR, but not by the ADE study. Of the 55 ADEs, 15 were preventable, and 26 were serious or life-threatening, yet only 2 of the 26 led to an incident report. The three voting groups agreed that most ADEs justified an IR, but judged that in actual practice, an IR would infrequently have been filed.

After these studies, Cullen and the other authors quantified the costs of these types of errors. As reported in JAMA,

After adjusting for our sampling strategy, the estimated postevent costs attributable to an ADE were $2595 for all ADEs and $4685 for preventable ADEs. Based on these costs and data about the incidence of ADEs, we estimate that the annual costs attributable to all ADEs and preventable ADEs for a 700-bed teaching hospital are $5.6 million and $2.8 million, respectively.

I was not involved in health care in those days, and so I don't know how these reports were received by the profession. Reading them today, you have to be impressed with the methodologies employed and the clear statement of conclusions. They should have been hard to ignore.

I am guessing that the articles led to an accelerated adoption of computerized provider order entry (CPOE) systems. CPOE can be an excellent technological fix to several of the problems noted in the study. The algorithms in CPOE can protect against drug-drug interactions, can ensure that dosing is proportional to the size and weight of the patient, can avoid allergic reactions, and the like. CPOE also gets rid of transcription errors resulting from bad handwriting!

That being said, "accelerated" may be an overstatement, as the roll-out of CPOE in the nation's hospitals was very, very slow. When I was at BIDMC, we had a very good system in place, but at the time, fewer that 10% of the nation's hospitals did. In this article published by Kevin, MD, our CIO John Halamka summarized our results: "Our experience with CPOE over the past 7 years is that it has reduced medication error by 50%, it paid for itself within 2 years, and clinicians have embraced it." He then catalogued obstacles faced by others. These, ironically, are often indicative of systems failures in themselves. John explains with this example:

Automating a bad process does not improve anything. When I was a resident, I was told that heparin should be dosed as a 5000 unit bolus then an infusion of 1500 units per hour for every patient. I was not taught about relating heparin dosing to body mass index, creatinine clearance or the presence of other medications. Unfortunately, it often took days to get the heparin dosing right because 5000/1500 is definitely not a one size fits all rule. Creating an automated CPOE order for 5000/1500 is not going to improve the safety or efficacy of heparin dosing. Implementing a new protocol for dosing based on evidence that includes diagnosis, labs, and body mass index will improve care. Our experience is that it is best to fix the process, then automated the fixed process. By doing this, no one can blame the software for the pain of adapting to the process change.

What are the lessons of all this?

There is no substitute for good research. In a data-driven world, well performed studies help demonstrate that there is scientific basis for quality improvement. We could be making even more progress if academic medical centers supported and rewarded this kind of work -- in terms of faculty career advancement and recognition -- as much as they reward basic science research. Likewise, medical schools and residency programs should be teaching their students how to conduct this kind of research.

The spread of technology in the health care field is as slow as molasses. My theory is that this is a function, in part, of the difference in priorities between clinicians and administrators in hospitals. Shared governance of health care quality and safety issues is essential to moving forward. Technological solutions are expensive and resource-intensive. The care delivery and management teams must have a common vision of needs and priorities to make this happen.

The manner in which information technology is applied in the health care field is often counterproductive. Building on Halamka's observations, unless a hospital first studies and enhances the manner in which its work is done, it will simply codify bad processes into machine language. That is no solution to a quality or safety problem. Shared governance and commitment between clinicians and management to Lean process improvement or some other philosophy is essential.

Thanks to David Cullen for reminding me of the great work done by him and his colleagues and giving me an excuse to riff off of those studies to offer these observations fifteen years later.

---

* (JAMA being JAMA, you still can't get a full text version through their site without paying for it -- even though they claim that anything older than six months is available for free. Luckily, you can read the whole thing here.)