Behind the scenes

Recent international negotiations have reached a very high level. We were able to get security clearance and obtain this picture from behind the scenes. Sorry, but I cannot divulge the location or tell you which countries were involved.

Painfully slow

You can already imagine the responses. "That's just in North Carolina." "Our patients are sicker." "There are problems with the data."

What would prompt that? This New York Times article, citing a forthcoming NEJM study about medical errors in North Carolina. Here's the lede:

Efforts to make hospitals safer for patients are falling short, researchers report in the first large study in a decade to analyze harm from medical care and to track it over time.

The study, conducted from 2002 to 2007 in 10 North Carolina hospitals, found that harm to patients was common and that the number of incidents did not decrease over time. The most common problems were complications from procedures or drugs and hospital-acquired infections.

Other excerpts:

Dr. Landrigan’s team focused on North Carolina because its hospitals, compared with those in most states, have been more involved in programs to improve patient safety.

But instead of improvements, the researchers found a high rate of problems.

. . . The findings were a disappointment but not a surprise, Dr. Landrigan said. Many of the problems were caused by the hospitals’ failure to use measures that had been proved to avert mistakes and to prevent infections from devices like urinary catheters, ventilators and lines inserted into veins and arteries.

And another:

Dr. [Bob] Wachter said the study made clear the difficulty in improving patients’ safety.

“Process changes, like a new computer system or the use of a checklist, may help a bit,” he said, “but if they are not embedded in a system in which the providers are engaged in safety efforts, educated about how to identify safety hazards and fix them, and have a culture of strong communication and teamwork, progress may be painfully slow.”

Exactly right, Bob! What does it take to motivate this profession? What does it take to make process improvement part of medical school and residency training programs.

Painfully slow, and painful or worse to patients.

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Addendum: Dr. Wachter also discusses this study on his blog, here.

Things we are grateful for this year

For three years running now, many of us bloggers have participated in what we’ve called a “blog rally” to promote Engage With Grace – a movement aimed at making sure all of us understand, communicate, and have honored our end-of-life wishes.

The rally is timed to coincide with a weekend when most of us in the United States are celebrating Thanksgiving and are with the very people with whom we should be having these unbelievably important conversations – our closest friends and family.

At the heart of Engage With Grace are five questions designed to get the conversation about end-of-life started. We have included them at the end of this post. They are not easy questions, but they are important -- and believe it or not, most people find they actually enjoy discussing their answers with loved ones. The key is having the conversation before it’s too late.

This past year has done so much to support our mission to get more and more people talking about their end-of-life wishes. We’ve heard stories with happy endings … and stories with endings that could have (and should have) been better. We have stared down political opposition. We have supported each other’s efforts. And we have helped make this a topic of national importance.

So in the spirit of the upcoming Thanksgiving weekend, we’d like to highlight some things for which we’re grateful.

Thank you to Atul Gawande for writing such a fiercely intelligent and compelling piece on “letting go”– it is a work of art, and a must read.

Thank you to whomever perpetuated the myth of “death panels” for putting a fine point on all the things we don’t stand for, and in the process, shining a light on the right we all have to live our lives with intent – right through to the end.

Thank you to TEDMED for letting us share our story and our vision.

And of course, thank you to everyone who has taken this topic so seriously, and to all who have done so much to spread the word, including sharing The One Slide.



We share our thanks with you, and we ask that you share this slide with your family, friends, and followers. Know the answers for yourself, know the answers for your loved ones, and appoint an advocate who can make sure those wishes get honored – it’s something we think you’ll be thankful for when it matters most.

Here’s to a holiday filled with joy – and as we engage in conversation with the ones we love, we engage with grace.

To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team. Please feel free to join our blog rally by copying this post and putting it on your own blog for this holiday weekend.

Checklists ain't all

I am often approached by people who have read Atul Gawande's excellent work and who ask me if we use checklists to improve the quality of care in our hospital. We do, in order to reduce variability where appropriate, but stating the issue in terms of checklists is simplistic. This 2009 Lancet article by Charles Bosk, Peter Pronovost and others, entitled "Reality check for checklists," states it clearly:

The emphasis on checklists is a Hitchcockian “McGuffan”, a distraction from the plot that diverts attention from how safer care is really achieved. Safer care is achieved when all three—not just one—of the following are realised: summarise and simplify what to do; measure and provide feedback on outcomes; and improve culture by building expectations of performance standards into work processes. We propose that widespread deployment of checklists without an appreciation of how or why they work is a potential threat to patients' safety and to high-quality care.

Transparency and "dial tone" to fight market power

Back in August, I raised the question of whether the move to Accountable Care Organizations and capitated payments would lead to market dominance and a resulting reduction in competition in certain geographic areas. The summary of the argument was this:

On the one hand, ACOs offer the potential for a better integration of care across the spectrum of primary care, hospitalization, skilled nursing, rehabilitation, and hospice. If the ACO faces an annual budget per patient under a capitated payment scheme, there is an incentive to avoid unnecessary tests and procedures and also to help direct patients to the most cost-effective component of the health care continuum.

On the other hand, if an ACO becomes the dominant provider in a region and especially if it has a electronic health record that is not interoperable with others in the region, that ACO will have substantial market power and will negotiate a higher global payment than would occur in a more competitive marketplace.

Robert Pear raises similar questions in an article in the New York Times. Here are some excerpts:

[E]ight months into the new law there is a growing frenzy of mergers involving hospitals, clinics and doctor groups eager to share costs and savings, and cash in on the incentives. They, in turn, have deployed a small army of lawyers and lobbyists trying to persuade the Obama administration to relax or waive a body of older laws intended to thwart health care monopolies. . . .

. . . Consumer advocates fear that the health care law could worsen some of the very problems it was meant to solve — by reducing competition, driving up costs and creating incentives for doctors and hospitals to stint on care, in order to retain their cost-saving bonuses.

A related concern was raised by Attorney General Martha Coakley in a speech last week to the MA Association of Health Plans, as reported by Matt Murphy of the State House News Service:

Attorney General Martha Coakley cautioned Friday against a "full-scale push forward" on global payment reform to address spiraling health care costs without addressing the underlying issue of market clout that has led to a disparity in pricing among providers without any clear link to quality of care.

. . . [S]he has directed her staff to resume its effort of examining the health care market in Massachusetts to study models of care delivery and the associated costs.

. . ."A shift to global payments by itself is not the panacea to controlling costs," Coakley said. "Implementing payment reform without addressing the market leverage issue outlined in our report is like trying to fix the roof on a house without fixing the flawed foundation."

Because anti-trust regulatory action is often ineffective against market dominance, we should focus on self-reinforcing policy initiatives to mitigate against this possibility. Here are two suggestions.

The first is one mentioned often on these pages: Total transparency of rates paid by each insurance company to each provider. In Masachusetts, a good first step along these lines was taken by the Legislature and Governor Patrick this past summer. Only when subscribers can see the actual rates being paid will there be the moral force to ensure that rates are reasonably related to factors other than market power.

The second idea is a simple as dial tone: Complete interoperability of medical records among providers. As long as proprietary electronic medical record systems exist, a given provider network can control the degree to which patients can choose lower priced or higher quality doctors and hospitals outside of that network.

Instead, we need the equivalent of the "magic button" described in this post by our CIO, John Halamka, demonstrating interoperability between our hospital and Atrius, the state's largest multi-specialty practice:

By working with Epic and Atrius, we enabled a "Magic Button" inside Epic that automatically matches the patient and logs into BIDMC web-based viewers, so that all Atrius clinicians have one click access to the BIDMC records of Atrius patients.

If this capability existed among and between all provider systems, consumer choice would be possible. Without it, a dominant network will remain dominant.

A defining moment at Risky Business

Lord Ian Blair led London's Metropolitan Police through the investigations of the multiple bombings of July 7, 2005 and all that followed. His lessons about chain of command and the like are valuable to those who have to deal with disasters and emergencies. He presented this at the Risky Business conference in London this week.

If you cannot view the video, click here.

BP Oil Spill at Risky Business

Here is a very good perspective on what went wrong to cause the explosion on the BP Deepwater Horizon drilling rig and the resultant oil spill, presented by Nick Coleman, VP in charge of Group Safety Performance Reporting until three years before the incident. He is now non-executive chair of the Risk and Safety Committee of Royal Brompton Hospital. He presented this at the Risky Business conference in London this week.

If you cannot view the video, click here.