Two stories about transparency

Here are a couple of stories about transparency of clinical outcomes. I present them for your review and comment.

The first is one from the Los Angeles Times, entitled "'Error-free' hospitals scrutinized." Here are some excerpts:

California public health officials are scrutinizing hospitals that claim to be error-free, questioning whether nearly 90 facilities have gone more than three years without any significant mistakes in care.

Eighty-seven hospitals — more than 20% of the 418 hospitals covered under a law that took effect in 2007 — have made no reports of medical errors, according to the California Department of Public Health.

The high percentage has raised concerns that errors have gone unreported. Some patient advocates say it is an indication that hospitals are unwilling to police themselves. State officials have given hospitals until Tuesday to verify their records as error-free or to report errors, as required by law.

Next, a report from The Health Foundation in the United Kingdom. Martin Marshall, Clinical Director and Director of Research and Development, and the late Vin McLoughlin, Director of Quality Performance and Analysis, have published a paper called, "How might patients use information comparing the performance of health service providers?" It is on the BMJ website. They note:

There is a growing body of evidence . . . describing what happens when comparative information about the quality of care and the performance of health services is placed in the public domain. The findings from research conducted over the last 20 years in a number of different countries are reasonably consistent and provide little support for the belief that most patients behave in a consumerist fashion as far as their health is concerned. Whilst patients are clear that they want information to be made publicly available, they rarely search for it, often do not understand or trust it, and the vast majority of people are unlikely to use it in a rational way to choose ‘the best provider’. The evidence suggests that the public reporting of comparative data does seem to play a limited role in improving quality but the underlying mechanism is reputational concern on the part of providers, rather than direct market-based competition driven by service users.

. . . How should policy makers, managers and clinicians respond to these findings? Some might be tempted to suggest that we should focus only on those who work in the health service and discount patients as important stakeholders. We believe that this would be wrong. The public has a clear right to know how well their health system is working, irrespective of whether they want to use the information in an instrumentalist way. Improving the relevance and accessibility of the data should be seen as a good thing in its own right and may start to engage a large number of people in the future.

. . . That patients might want to view health as something other than a commodity presents a conceptual as well as a practical challenge to those responsible for designing and producing comparative performance information. We suggest that for the foreseeable future presenting high quality information to patients should be seen as having the softer and longer term benefit of creating a new dynamic between patients and providers, rather than one with the concrete and more immediate outcome of directly driving improvements in quality of care.

Sign congestion

Sometimes, with "new eyes," you see things you walk by every day. As I went to visit a sick friend yesterday, not as the hospital CEO but just a visitor, here was the scene I found at the elevator in one of our main lobbies.

Each one of these signs was likely added for good reason. But, in combination, they are problematic -- too cluttered.

Also, they are not culturally competent. The blue sign on the left has several languages. None of the others do.

Perhaps it is time for a Lean rapid improvement event about our signs.

Is this normal?

This is a story about consumer choice using publicly available information. Unfortunately, it is also about the power of suggestion as used by an incumbent provider organization.

The friend who sent me this note is a research fellow at one of the Boston teaching hospitals, so I guess he is more likely than most to do the kind of research he summarizes. Most people would have taken the referral advice offered without question. If they ever did ask to see a different doctor, most would never get past the "need" for asking for "special permission."

Hi Paul,

I had a strange encounter, and I was wondering if you could tell me if this is normal.

A few months ago my primary care physician recommended I see dermatology for my eczema. His clinic recommended the names of two dermatologists within the same health care system. I looked up both dermatologist on healthgrades.com and found that their patients had given them luke-warm reviews. (There were many reviews, so this wasn't a sampling problem). Also, I have been reading the medical literature about eczema, and knew there were a lot of recent advances, so I wanted somebody who had published and was familiar with the research.

I found another dermatologist, Dr. Caroline Kim. Her patients loved her (according to healthgrades.com), she had published articles in dermatology research (from scholar.google.com), and she trained at top institutions: Harvard Medical School and MGH. I made an appointment with her.

I called my PCP and asked for a referral. The receptionist told me Dr. Kim was "out of network" and they would have to ask my PCP for special permission. I thought this was odd because I had Blue Cross PPO insurance (not HMO), so as far as I knew, there was no "out of network".

A month later, my referral had not been sent. I called my PCP again, and asked for them to send it. After I gave her the name and phone number of the dermatologist, this was the conversation.

Receptionist: I am sorry, that is out of network. We will have to check with Dr. X.

Me: What does "out of network" mean? I thought I had PPO insurance.

Receptionist: You won't get the best care if you go out of network.

Me: Is this a [health care system] policy?

Receptionist: We might not know what medications you are prescribed if you go out of network. Your medical records might not get transferred back to our office.

Me: Is this a [heath care system] policy?

Receptionist: Yes.

A week later I had my referral.

It seems like this health care system is using an insurance term -- "out of network" -- to trick patients into going to specialists that work for the same company. Am I wrong?

En route to True North

"True North" is a key concept in Lean process improvement. It might be viewed as a mission statement, a reflection of the purpose of the organization, and the foundation of a strategic plan.

Here are illustrative thoughts from two observers:

The "ideal vision" or "True North" is not metrics so much as a sense of an ideal process to strive for. It sets a direction, and provides a way to focus discussion on how to solve the problems vs. whether to try.

If we don't know where we're going, we will never get there. "True North" expresses business needs that must be achieved and exerts a magnetic pull. True North is a contract, a bond, and not merely a wish list.

Lean is inherently the most democratic of work place philosophies, relying on empowerment of front-line staff to call out problems. The definition of True North, however, does not rely on that same democratic approach. Instead, it is established by the leadership of the organization.

At BIDMC, we have been engaged in a slow and steady approach to adoption of Lean. Our actions have been intentionally characterized by "Tortoise not Hare," as we methodically train one another, carry out rapid improvement events, and integrate the Lean philosophy into our design of work. As you have seen on this blog, staff members have come to embrace Lean and have used it in a variety of clinical and administrative settings.

(For more examples, enter "Lean" in the search box above. I have been presenting them here for some time in the hope that they would be useful to those in other hospitals who are thinking of adopting this approach.)

We have intentionally not, until now, tried to define True North, but things have now progressed sufficiently in terms of our application of the Lean philosophy that the organization is crying out for it. This is just as we had hoped. Establishment of True North before this time, i.e., without an understanding of its role, would not have been as useful in our hospital.

So, the clinical and administrative leaders recently met to try to nail this down. The process is not over. Indeed, our Board of Directors has yet to pitch in and offer their thoughts. But, we are far enough along that I thought you would enjoy seeing the draft.

Here it is:

BIDMC will care for patients the way we want members of our own families to be treated, while advancing humanity's ability to alleviate human suffering caused by disease. We will provide the right care in the right environment and at the right time, eliminating waste and maximizing value.

Here is some commentary to help you interpret and deconstruct this. The first sentence is based on the long-standing tradition of our two antecedent institutions, the New England Deaconess Hospital and the Beth Israel Deaconess hospital. The late doctor Richard Gaintner used to refer to the Deaconess as, "A place where science and kindliness unite in combating disease." That could just as well have been applied to the BI. As an academic medical center, our public service mission of clinical care is enhanced by -- and enhances -- our research and education programs. Our mission is to help humanity, not just the people who live in our catchment area.

The second sentence is offered in realization that the Ptolemaic view of tertiary hospitals as the center of the universe is no longer apt (if it ever was!) We need to view ourselves as being in service to primary care doctors, community hospitals, and other community-based parts of the health care delivery system.

On another level, it is also reflective of the fact that society expects us to be more efficient both within our own walls and in cooperation with our clinical partners, adopting approaches to work that do not waste societal resources.

In contradistinction to what I just said about this not being a democratically established statement, I offer our draft to you -- both those within BIDMC and worldwide -- for your criticism and suggestions. I don't know of other places that engage in this form of crowd-sourcing with regard to True North, but readers of this blog are unusually informed about health care matters, and I welcome your observations.

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.