Medical education reform on WIHI

Today's edition of WIHI (2pm-3pm EDT) promises to be timely and informative. The topic is "The Next Wave of Reform for Medical Education." The guests are Donald M. Berwick, MD, President and CEO, Institute for Healthcare Improvement; Lucian L. Leape, MD, Chair, Lucian Leape Institute at NPSF, and Adjunct Professor of Health Policy, Harvard School of Public Health; Dennis S. O’Leary, MD, President Emeritus, The Joint Commission; and Diane C. Pinakiewicz, President, Lucian Leape Institute at NPSF.

We've covered this topic a bit on this blog, but there is more to be said. Get more information and instructions as to how to participate here. You can join in from anywhere in the world!

My friend Katherine . . .

. . . today learned that she had been accepted by the college of her choice. That she was headed to college before today was already clear, in that she had been admitted by others, but she was anxiously awaiting the news from this particular school.

I'm just a family friend, so when I called to congratulate her, I asked, "Am I allowed to be proud of you?" Her reply, "Oh, yes you can!"

I was really happy to get that response. I had nothing to do with her success. But I reserve the right to be proud. She worked hard for this -- academics, athletics, volunteer service -- and she did it her way. Notwithstanding a college application system that sometimes felt like a random process, she deserved to get in.

But, I am not just proud of her. I am proud of the dozens of kids I know and the many more I don't know who made a multi-year commitment to personal and academic excellence in high school and who are now set for the intellectual and social growth they will experience in college.

But what of that random process, the one that left equally hard working and talented kids disappointed? For many years, the late Boston Globe columnist David Nyhan published a column at this time of year entitled, "The college rejection letter." It has probably helped thousands of kids deal with the disappointment of not being accepted at their hoped-for college. The final paragraph says it nicely, in the somewhat rough language David would sometimes employ:

And the admissions department that said no? Screw them. You've got a life to lead.

Berwick --> CMS

The New York Times reports that President Obama will name Don Berwick, CEO of the Institute for Healthcare Improvement, to be head of the Medicare agency, CMS. Don is an extraordinary leader in the quality and safety movement, and his appointment would send a strong signal as to the direction of US health care policy.

The Real Life Body Book

There is a new book coming out this week. It is called The Real Life Body Book, and is written by Dr. Hope Ricciotti (from BIDMC's Ob/Gyn Department) and Monique Doyle Spencer. You can read an excerpt and pre-order it now.

In the words of one reviewer*:

"I predict this will be the current generation's Our Bodies, Ourselves. The awesome talents of Ricciotti and Spencer are brought to bear on the hardest question of the day: how to provide young women with accurate and helpful health and wellness advice that is interesting and engaging enough to want to read. They have nailed it."

The publisher says,

"When you have questions about your health, you want answers from a trustworthy source. In The Real Life Body Book, a Harvard ob-gyn has joined forces with a humor writer to explain the full range of health issues facing young women today. This comprehensive and authoritative guide focuses on whole body wellness and prevention.... If you’re between the ages of twenty-one and thirty-five and you want the latest facts about your health in a language you can understand, The Real Life Body Book is the go-to resource for keeping your body healthy today and for the rest of your life."

---
* er, me!

The future of publishing

Worth watching.

What standards would you apply?

There were several comments on my blog post and also on the Boston.com story about the sale of Caritas Christi to Cerberus Capital Management that expressed skepticism about the wisdom of the sale and the transformation of this non-profit hospital system to a for-profit one.

Some legal background. The transaction is governed by Mass. General Laws Chapter 180, Section 8A. That section provides, in relevant part:

Prior to a sale, notice is required to be given to the Attorney General, not less than 90 days prior to a sale or other disposition of the assets or operations to a for-profit entity;

The AG is required to investigate the transaction, and consider any relevant factors, including whether:
-- Due care was followed in the process;
-- Conflict of interest was avoided;
-- Fair value is being received; and
-- The proposed transaction is in the public interest;

There will be at least one public hearing, preceded by public notice. Prior to the hearing, copies of all the transaction documents will be made available upon request;

Any charitable fund resulting from the transaction shall be subject to AG and Court approval. A public hearing in connection with the AG review of the governance of the charitable fund is also required; and

Following the transaction, a monitor will be in place to monitor community health access and the levels of free care provided by the entity for three years.

Pretend you are testifying as a citizen in the public hearings. What standard would you want to be applied to these issues? Assume for the moment that the first three tests have been met (due care, conflict of interest, and fair value), what theory or facts do you want to be used to determine if the transaction is in the public interest? And, if a charitable fund results from the transaction, how large should it be; for what purposes would you want it to be used; and how would you want it to be governed?

And before you answer, read Steve Syre's column in today's Boston Globe.

A chance to invest in quality and safety

Big news today in Boston. Rob Weisman at the Boston Globe reports that the Caritas Christi hospital system will be acquired by New York private equity firm Cerberus Capital Management in a $830 million deal. A formal state approval process is needed for the transaction to be consummated.

This would be the largest switch of hospital assets from non-profit to for-profit status that the state has seen. Where will the CEO show up on Jim Conway's chart below under the new arrangement? With the new financial resources being provided by Cerberus, Caritas has the potential to make investments in quality and safety that could help propel it to a leadership role in process improvement. That's the kind of competition that Massachusetts needs.

The article notes:

In such cases, the state Supreme Judicial Court reviews findings from the attorney general’s office, which considers such criteria as whether the transaction is in the public interest, whether the nonprofit has received “fair value’’ for its assets, and whether the nonprofit avoided conflict of interest during its decision-making. As part of a conversion to for-profit status, companies are generally required set aside money for the public’s benefit, such as by setting up a foundation.

A thought about this. If a foundation is set up, why not have its proceeds support quality and safety improvement training in medical schools and at hospitals generally in the state, perhaps stewarded by the Massachusetts-based Institute for Healthcare Improvement?

Still missing the boat

Many of my readers know of and admire Jim Conway, former COO of the Dana Farber Cancer Institute, and more recently a senior associate at the Institute for Healthcare Improvement and a faculty member at the Harvard School of Public Health. A regular feature of Jim's speeches and lectures is a presentation of this slide, an indication of the relative priority given by hospital CEOs to various current issues. He uses it to demonstrate that safety and quality are well down the list for most CEOs.

You might expect that ranking of quality and safety would have risen over the past several years. But there was a major disappointment in 2009, as its place was lowered substantially.

But we can't blame just the CEOs for missing the boat on elevating safety and quality. It is the governing bodies of the hospitals, behind and above the CEOs, who should hold them accountable on this front.

Award to WBUR for End of Life series

Congratulations to WBUR's Rachel Gotbaum and her colleagues for winning the first place radio award from the Association of Health Care Journalists for her series, Quality of Death - End of Life Care: Inside Out.

They could have each other, but don't

Susannah Fox at Pew Internet, a project of the Pew Research Center, has just released a very interesting report entitled "Chronic Disease and the Internet." She says to me:

I love all the reports I've written over the last 10 years, but I am especially proud of this report since it combines the best of what can be done with RDD (random digit dial) survey data (nailing down once and for all that chronic disease has a significant, independent effect on online behavior) and with qualitative data (i.e., the stories patients tell about what they do, how they thrive or bravely slog on). The increase of chronic disease worldwide is one of the great challenges of our time.

Here are some excerpts from the press release:

WASHINGTON, DC - MARCH 24, 2010 - Only 62% of adults living with chronic disease go online, compared with 81% of adults who report no chronic diseases.

"We can now add chronic disease to the list of attributes which have an independent, negative effect on someone's likelihood to have internet access, along with age, education, and income level," says Kristen Purcell, an associate director of the Pew Internet Project and a co-author of the report.

The internet access gap creates an online health information gap. More than any other group, people living with chronic disease remain strongly connected to offline sources of medical assistance and advice such as health professionals, friends, family, and books. However, once they have internet access, people living with chronic disease report significant benefits from the health resources found online.

The report, "Chronic Disease and the Internet," is based on a national telephone survey which included 2,253 adults, 36% of whom are living with chronic disease (heart conditions, lung conditions, high blood pressure, diabetes, cancer). Illustrative quotes from patients were gathered through online surveys conducted by PatientsLikeMe.com and HealthCentral.com.

Looking at the population as a whole, 51% of American adults living with chronic disease have looked online for any of the health topics included in the survey, such as information about a specific disease, a certain medical procedure, or health insurance. By comparison, 66% of adults who report no chronic conditions use the internet to gather health information.

Lack of internet access, not lack of interest in the topic, is the primary reason for the gaps. In fact, when demographic factors are controlled, internet users living with chronic disease are slightly more likely than other internet users to access health information online.

"The deck is stacked against people living with chronic disease. They are disproportionately offline. They often have complicated health issues, not easily solved by the addition of even the best, most reliable, medical advice," says Susannah Fox, an associate director of the Pew Internet Project and a co-author of the report. "But those who are online have a trump card. They have each other. Those who have access use the internet like a secret weapon, unearthing and sharing nuggets of information found online."

Not making a splash

A note this week from Dr. Michael Howell to the doctors, nurses, and respiratory therapists in the ICUs.

All –

(For those I haven’t met, I’m the Director of Critical Care Quality and one of the ICU docs.)

Yesterday marked 150 days without a single reported splash exposure in any of the nine adult ICUs. Previously, that would have been absolutely unbelievable.

Most of you will have noticed the box in the upper right corner of the Portal that lists the number of days since an employee injury. You’ve probably noticed that it’s always zero, meaning that one of our colleagues is hurt every day. Many of us were fairly agitated by that, and for almost the past year, we’ve been working on improving the safety not just of our patients, but of our staff and providers.

As our first target for improvement, we sought the elimination of exposure to blood borne pathogens by splashes. If you or a friend has ever gotten blood in your eye, you know it’s unpleasant, shocking, and scary. Some of our colleagues have, in fact, even been exposed to HIV and hepatitis this way. We know that nearly all exposures from splashes should be preventable by using personal protective equipment. And yet, before we started our work, someone got splashed with blood or body fluids about every week or two in our ICUs.

Because you reported splashes and were open and honest in talking about them, we learned a lot about things that we weren’t that cognizant of before, and we’ve been able to really reduce splashes’ occurrence. A few examples:
· ABGs and accessing arterial lines are especially risky procedures. In January 2009 alone we had *five* splashes from this mechanism.
· Glasses don’t offer adequate protection. Many people have gotten blood in their eyes (or mouth) while wearing their own eyeglasses.
· Splashes happen at unexpected times: disconnecting a Foley, flushing a PICC line, suctioning an ET tube, and being in the room while someone else was doing as ABG – people have been splashed in all of these ways.

Now, though, it’s been five months since a splash occurred. That’s amazing: If we’d done things like we used to, we would have expected ten of our colleagues to have gotten blood splashed in their eyes during this time period. Instead, no one did. For those of you who like rates, during the last six months we’ve seen a seasonally-adjusted splash rate that has fallen by more than 75%. (Yes, splashes seem to vary by season, though we’re not yet sure why.)

Finally, when I last wrote about this, in July, I made a particular appeal:
I want to make a special request of those of you who are more senior, with lots of ICU experience: please watch out for your junior colleagues, and if they are forgetting to wear a mask with visor, please remind them. Remember also that you set an extraordinarily powerful example with your own practice. By not wearing a mask, you may unconsciously be training your more junior colleagues to put themselves at risk.

Now, I want to say “thanks.” I’ve seen you not just wearing masks and visors as part of daily work, but also coaching more junior staff and coming up with ideas on how to further reduce splashes. Many of you have sought me out to talk about this issue, and at least one of you handed me a mask when I walked into a particularly and unexpectedly “active” room (as we euphemistically say in critical care) and forgot to put on eye protection. (Thanks in particular for that – I later found blood spatters on the visor …. yikes.)

Keep up the good work,
Michael

P.S. Now, as we get ready to enter our second year of this work on ICU staff safety, it’s time to start thinking about what’s next. We will continue to focus on splashes, but my sense is that we’re ready to begin other work in this arena, as well. I’d love to hear thoughts, advice, and suggestions.

Silverman Institute Poster Session

After grand rounds, the next item of business for the Silverman Institute symposium was a poster session displaying areas of quality and safety and general process improvement, and enhancement in the patient care environment. The short video below offers some of the posters and their presenters. It gives you a sense of the variety of issues facing an academic medical center, some seemingly simple, some complex.

But here's the thing that puts this in context. When I returned back from my visit to the poster session, the following email awaited me from Susan Megerman, Continuing Medical Education Course Administrator and Program Coordinator, Community Cancer Services:

Dear Paul,

The past several days have been one of ups and downs, but mostly ups. On Sunday, I had the privilege to say goodbye to a dear friend who was on Feldberg 7. I went as a visitor, but sat and watched the staff at work and became a fellow employee filled with the pride of being able to say I work at BIDMC.

M was fully unconscious by the time I arrived, yet every single member of the medical staff spoke to him as if he were fully awake, letting him know exactly what they would be doing: taking his blood pressure, taking blood, giving him an injection. I look back at that brief vignette of hospital care and know that this is what must be happening everywhere in the hospital and if it isn't exactly to that standard, that individuals and groups are working to make it so.

Sadly, M expired yesterday morning after a courageous battle in which his and the combined determination of the medical staff worked to keep him going for as long as possible.

Then, this morning, I'm walking through the lobby of Shapiro and I see the wonderful poster presentations for the Silverman Conference and again, I am deeply moved.

Having now worked at BIDMC for a little more than a year, I remain as grateful for being employed here as I was the first day I began and even more appreciative of the culture of the institution, its devotion to patients and employees. As I look toward my 65th birthday next week, I cannot think of a more wonderful place to complete my work career than at BIDMC.

Thank you.
Susan

All of the posters are available for viewing here.

If you can't see the video, click here.