Wednesday, May 06, 2015

How do I invest?

Here is a new, groundbreaking EHR vendor with an amazing website.  It offers the most honest presentation in the industry.  I'm sure it will do well, and I write this post as I wait on hold with the VC people to learn how to invest.

Excerpts:

At the confluence of extortion and conformity lies Extormity, the electronic health records mega-corporation dedicated to offering highly proprietary, difficult to customize and prohibitively expensive healthcare IT solutions. Our flagship product, the Extormity EMR Software Suite, was recently voted “Most Complex” by readers of a leading healthcare industry publication.

The Extormity EMR software suite requires wholesale, revolutionary workflow change that dramatically impacts practice patterns. Our slow and painful change process significantly interrupts patient volumes and revenues, and this cumbersome transformation can only be appreciated in hindsight and with the aid of prescription medication (which can be prescribed via the Extormity EMRX Upgrade Module and Pharmacy Interface Pack).

Under the Extormity Uptime Guarantee section, we see:

** This section of the site is experiencing technical difficulty. Please check back in 30 days…better make that 45 days, just to be safe.** 

Taking steps to achieve more steps

I've noted the unsupported assertions of many wellness programs, but it's also important to acknowledge the interventions that can make a difference.  Here's an excellent article from the European Respiratory Journal that documents how affixing pedometers to people with COPD can make a difference in their health.  From the abstract:

Physical inactivity is a cardinal feature of chronic obstructive pulmonary disease (COPD), and is associated with increased morbidity and mortality. Pedometers, which have been used in healthy populations, might also increase physical activity in patients with COPD. COPD patients taking part in a 3-month individualised programme to promote an increase in their daily physical activity were randomised to either a standard programme of physical activity encouragement alone, or a pedometer-based programme. 

Both groups had comparable characteristics at baseline. The pedometer group had significantly greater improvements in: physical activity 3080±3254 steps·day(-1) versus 138.3±1950 steps·day(-1) (p<0.001); SGRQ -8.8±12.2 versus -3.8±10.9 (p=0.01); CAT score -3.5±5.5 versus -0.6±6.6 (p=0.001); and 6MWD 12.4±34.6 versus -0.7±24.4 m (p=0.02) than patients receiving activity encouragement only. A simple physical activity enhancement programme using pedometers can effectively improve physical activity level and quality of life in COPD patients.

Oregon CCOs on WIHI

Madge Kaplan notes:
The next WIHI broadcast — Leaning In: Oregon's Coordinated Care Organizations (CCOs) — will take place on Thursday, May 7, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:
  • Chris DeMars, MPH, Director, Systems Innovation, Oregon Health Authority - Transformation Center
  • Ronald Stock, MD, MA, Director of Clinical Innovation, Oregon Health Authority - Transformation Center
  • Trissa Torres, MD, MSPH, FACPM, Senior Vice President, IHI
Far from the epicenter of Washington, DC, and the federal government’s efforts to expand health insurance coverage and usher in health care delivery and payment reform, states are moving ahead with amazing innovations of their own these days. Medicaid waivers, which offer states running room to experiment with public dollars, are one big reason. And one big example of what’s possible is unfolding in Oregon.

No stranger to trail-blazing with transformative ideas and initiatives, Oregon’s latest efforts to provide better care and value to nearly one million Medicaid recipients will be the focus of the May 7, 2015, WIHI: Leaning In: Oregon’s Coordinated Care Organizations (CCOs). The groundwork and the enabling policies and legislation for CCOs have been several years in the making, and the careful shaping of the program is leading to some impressive results. Since 2011, emergency department visits are down 21 percent, preventable hospital admissions among adults for complications associated with diabetes have decreased nearly 10 percent, and enrollment in Patient-Centered Primary Care Homes has increased 55 percent.

And what about Oregon putting itself on a global budget with a fixed rate of growth — how is that going? We’re going to find out about the money, the care, the measures, how the 16 CCOs across the state function as one system, the innovative use of community health workers and more, thanks to two key people in the know from the Oregon Health Authority’s Transformation Center: Chris DeMars and Ronald Stock. They’re eager to share what they’re learning and to field your comments and questions. IHI’s Trissa Torres will offer commentary about this work, discuss how it relates to the Triple Aim and changes in primary care happening everywhere, and suggest ways to apply what’s happening in Oregon to your own state and setting.

Please join us on May 7. You can enroll for the broadcast here. 

Tuesday, May 05, 2015

I would have guessed they were Tories

A true story I heard from a colleague in London:

My nine-year-old daughter came up to me and said, "Dad, Kate is voting for the Labour party."  

"How do you know that?" I asked.

"I just heard on the radio that she's into Labour."

Success in surgery? Not so fast.

Richard Harris at NPR interviewed Marty Makary on the subject of how to know if your surgery was successful.  The summary in a nutshell:

For 99 percent of people in America, when they go in to have surgery, the outcome [of that operation] is not measured. Nobody's keeping track. So I'm amazed at how one-fifth of the economy, [the share accounted for by the healthcare system], functions with so little measure of its performance.

I've noticed this, too, but an even more insidious fashion.  Lately, I've been reading published, apparently peer reviewed, medical papers about certain surgical procedures in which the authors (usually the surgeons in question) claimed that the surgery was successful.  But I've learned of a number of high profile cases of this sort in which the patient or the organ donor later suffered long-term complications that were not evident in the few short weeks following the procedure.

My problem here is piercing the veil of physician and hospital self-interest and patient confidentiality to present those cases to you. I'm working on it, though.  I welcome stories from my readers that fit into this category, particularly when patients or families are willing to share their confidential information or when the information is otherwise public (e.g., in court documents).

Sunday, May 03, 2015

First aid class turns out to be dangerous

This could be one of the strangest stories I've read in a while, from The Globe and Mail. Here's the lede:

Randy Theriault spent 30 years captaining ships and was praised as an expert seafarer who honed his craft through experience. So, when the Nova Scotia man landed a well-paying job as first mate on a massive fishing vessel this spring, only one small hurdle stood in his way – a first aid course that seemed to be merely a formality.

Now his grieving family is struggling to understand how the 48-year-old Mr. Theriault could die suddenly of pneumonia during a first-aid course designed to deal with such situations. On the morning of April 17, after suffering through fever, shortness of breath, nausea and chest pains while attending the week-long Maritime Advanced First Aid course at Nova Scotia Community College, Mr. Theriault was found dead at a Port Hawkesbury bed and breakfast where he had been staying.

Later in the story:

The college says it is investigating what went on inside the classroom. The first-aid course is run by St. John Ambulance, which says Mr. Theriault exhibited normal vital signs during the course, although he “complained from time-to-time of flu-like symptoms.” In a statement, St. John Ambulance spokeswoman Clara Wicke said “instructors agreed to provide Mr. Theriault with reasonable accommodation to complete his certification by allowing him to make up missed time at a later date.”

That statement has upset Mr. Theriault’s family, who say text messages in the days leading up to his death indicate he was faced with the choice of staying in class or failing the course because it was not offered regularly. 

They want to know how Mr. Theriault could die while learning how to deal with emergencies such as respiratory ailments at sea, which includes pneumonia.

The family questions the assertion that Mr. Theriault displayed normal vital signs in the class. In one of his final texts to Ms. Tobin, he says he has a fever, and that he felt embarrassed about his laboured breathing in the classroom.

(Thanks to Dr. Susan Shaw for citing this story on Twitter.)

Like Canada, like the world

“When asked to think about their end-of-life planning, 75% of Canadians express a desire to die in their own homes. Yet in actual fact, 70% of Canadians die in hospital."

That's the summary of recent poll, as reported in the Ottawa Sun. I imagine there would be similar results in much of the developed world.

The article continues:

How we want our lives to end is not how they’re ending. That’s a tragedy. It’s also a clear sign that we need to adjust our public policy priorities to better reflect the needs of the people that the system was created to serve.

Right.

(Thanks to Dr. Susan Shaw for forwarding the article.)

Friday, May 01, 2015

Courage to Live

A remembrance from my friend John Brock:

On May 26, 2012 I died.

I didn't almost die; I died. My heart stopped pumping blood. In most of the world and through most of history that means death. No pulse. No breath. Dead.

I was fortunate, privileged some would say, to be on a street in a wealthy suburb with easy access to some of the best treatment in the world. I live in a place where we fight death. At great expense we maintain a huge apparatus of people and buildings and technology to wage that war.

A cell phone call was made. Police cars, fire trucks, and an ambulance showed up in minutes. Trained and dedicated people jumped out of those vehicles. They electrocuted me. They strapped me into a machine that pushed so hard on my chest it broke my ribs as it forced blood through my body. They raced me to a hospital. They blasted my body back to life.

That was my body. Living was another process.

Someone saw me and knew me. She called my pastor who dropped what she was doing and came to support Sheila, my wife, who was, without any preparation, making life and death decisions with strength, with love and trust for me, and with faith and hope for whatever was going to happen next.

Over the next weeks, Sheila and our children would sit with me listening to the technology. One machine breathed for me; another recorded every blip of my restarted heart; another fed me; another pumped water and death-defying drugs into me; another massaged my legs; another, buried in the bed, shifted the pressure on my back ever so gently.

There were a lot of machines and a lot of drugs involved.

Friends and family celebrated when I moved my tongue; and when I raised my arm, and when I sat up, and when I walked. Later, when I could speak, folks came to see me and to listen to me talk, even though much of what I had to say was nonsense. Pain killers and even temporary oxygen starvation will do that to a person.

I am deeply grateful for all the people and technology that waged war against death on my behalf. They helped me beat death…but they didn’t bring me into life.

What brought me into life was faith, hope, and above all from the love in everything around me.

Rilke captured some powerful and precious some 100 years ago. He wrote:
Animals see the openness of creation with their whole eyes.
Our eyes, turned back upon themselves, encircle and seek to snare creation, setting traps for freedom.
The faces of the beasts show what truly IS to us: we who upend the infant and force its sight to fix upon things and shapes, rather the freedom that the beasts occupy, that openness that lies so deep within their faces, free from death!
We alone face death.
The beast, death behind and God before, moves free through eternity like a river running.
Having died, I no longer fear dying.

What I fear is a return to a state of not living—of being so concerned about what I’ve done; what others have done to me; what others have thought of me; and of what I will do or others will do or what others will think—that often I cannot see the openness.

Three years on, and a lot of recovery behind me, I long to gaze into that openness. And sometimes I find a moment, an hour, a day when I can.

So I write this for myself each morning as a reminder:

Have the courage to live.
To do what is right.
To do what is important.
To act with thought and awareness.
To act with kindness.

Thursday, April 30, 2015

Thieves of State

I'm pleased to recommend to you a book I just read, Sarah Chayes' Thieves of State, Why Corruption Threatens Global SecurityHere are some excerpts from a review provided by Budd Shenkin:

Chayes' thesis is that failed states are not really failed states, they are countries captured and run by criminal associations. Their modus operandi is the shakedown at all levels. Therefore, the strategy of the United States – first to establish stability and only afterwards to root out corruption – does not and cannot work. Oppression is not a good strategy for the long term.

Chayes starts with Afghanistan, where she started out working for NPR and then left to work for an NGO headed by the older brother of one Hamid Karzai. She soon discovered that the Karzai's could easily have been directed by Francis Ford Coppola, the only problem being to decide who was Michael, who was Sonny, and who was Fredo. She literally watched the CIA hand over large bills to one of the brothers wrapped in aluminum foil. She did not witness the obtaining of a receipt.
 
Chayes' thesis to end corruption first is based on obtaining the good will of the people. They are the ones who are actually oppressed and extorted. Chayes cites four or five “mirror” would-be ruler advisers, the most familiar being Machiavelli, who have sought to bring reason to rulers through the ages. They all say the same thing, that you have to be basically fair to the people, responsible for them in rooting out the corruption of your subordinates, etc. If you don't act this way, they will revolt, and that the revolt will often be based on an extreme religious element, such as Martin Luther. Viewed this way, one comes to think of the Taliban and other Islamic movements as a typical reaction to official corruption.  
 
It's nice to think of a Westphalian world where states respect each others' boundaries and internal politics, where legitimacy is respected inside and outside of the state. Unfortunately, with these kleptocratic states, that's not going to be possible. They will experience upheaval and threaten those around them and increasingly the rest of the globalized world. It's not a bad idea to try to help the states develop internal legitimacy and coherence. But to help them, the helpers need to understand both those states and the mirror-writers and history. There is little evidence that this is happening at anything like the scale we need.

It's a powerful argument in a short book.

Wednesday, April 29, 2015

The healthier your hospital the better your outcomes

I recently attended an Oslo meeting of the Dr Foster Global Comparators, an international group of hospitals that have been working together to share data and insights related to quality and safety.  What makes the group particularly interesting is their attempts to draw comparisons across national boundaries. This is no easy task, given the different manner (and for different purposes) in which countries collect administrative and clinical data; but the group has made good progress in several areas—notably GI, stroke, sepsis, and orthopaedics. At this session, I met committed and interesting folks from the UK, US, Denmark, Norway, China, Saudi Arabia, the Netherlands, and Australia.

While all the presentations were engaging, the one that most intrigued me was one offered by two surgical fellows from Imperial College, Christopher Nicolay and Stephen Williams. As I understand it, Christopher conducted much of the original research, and Stephen is now going to pick up on it and carry it forward. I’ll just present a quick outline here, as I’m confident they will formally present the results elsewhere, and I don’t want to steal their thunder. 

The session was entitled, “The healthier your hospital the better your outcomes.” The hypothesis being tested was whether there might be a correlation between organizational health and clinical outcomes. The fellows first drew on the literature to help think about the elements of organizational health in hospitals. An initial definition by Chris Argyris (1958) set the stage: “A healthy organization is one that enables mature human functioning.” Then, a quote from Christin Shoaf et al (2004): “Organizational health blends the pursuit of individual wellness with organizational effectiveness to yield a strategy for economic resilience.”

Using interviews with many folks, a thoughtful model was derived for assessing organizational health for 22 acute care NHS trusts in the UK. Those assessments were then correlated with patient outcomes like mortality rates and critical incident reporting. Sure enough, there was a positive correlation.

While we’ll all look forward to the formal publication of these results, I can already predict two reactions to this kind of study. The naysayers will say that the concept of organizational health is just too fuzzy to quantify, much less correlate with measure of clinical outcomes (which, they will also say, are themselves too uncertain to use and rely upon.)

Others of us who have run hospitals, visited others, and studied others have seen that the quality of the work environment inevitably has an impact on patient outcomes. An organization in which staff wellbeing, effective communication, resilience, efficiency, and servant leadership are extant tends to be very good as a learning organization and tends to be more alert to the needs of its patients and more adept at clinical process improvement.

Stephen’s next step is to try to extend the research across national boundaries and investigate whether similar patterns might show up around the world. Congratulations to these two young men for taking on this topic and helping us gain deeper insights into the matter. 

Tuesday, April 28, 2015

Monday, April 27, 2015

Dr Foster offers advice on performance measurement

The folks at Dr Foster recently published a thoughtful paper about the uses and abuses of clinical data for the purposes of measuring performance.  While their thoughts are directly applicable to government regulatory agencies, they are also worth considering with regard to benchmarking within the profession and by hospital governing bodies. The paper is well worth a look.

They note that while measurement of performance in the healthcare sector is essential for transparency and accountability, and to support improvement, performance measurement can have a range of unintended adverse consequences:

Tunnel vision: Focusing on aspects of clinical performance that are measured and neglecting unmeasured areas;

Adverse selection/inequity: Avoiding the most severely ill patients or excluding disadvantaged groups;

Bullying: Intimidating staff to achieve performance targets or to adjust data;

Erosion: Diminution of intrinsic professional motivation as a key driver of high quality healthcare;

Ceiling effect: Removing incentives for further improvement and potentially influencing top performers to reduce quality;

Gaming: Distorting the process of care in order to meet targets or manipulating data to misrepresent actual performance;

Distraction: Challenging, obfuscating or denying data which suggests underperformance instead of fixing performance problems.

They suggest countermeasures to help avoid these adverse consequences:
  1. Make data quality as important as hitting targets – By initiating a long term audit programme to tackle misreporting and incomplete or inaccurate data recording.
  2. Measure the context not just the indicator – Keeping performance measures under constant review, perhaps by multi-disciplinary specialist groups, including Royal Colleges and patient organisations.
  3. Avoid thresholds and consider the potential to incentivise ‘gaming’ in the design of metrics – Performance measures should be assessed according to the likelihood they will encourage abuse. Thresholds should be avoided wherever possible.
  4. Be more open – Making data underlying performance management widely available and promoting ongoing assessment of the degree to which metrics are being gamed.
  5. Apply measures fairly – In order to recognise legitimate mitigating factors such as resources and pressures outside the control of the organisation.

Sunday, April 26, 2015

Is solidarity forever?

As the US remains splintered about the rights of the public with regard to health care, things have often been different in Europe.  But is this changing?  Richard Saltman and colleague offer an interesting article in the Israel Journal of Health Policy Research. The title: "Health Sector Solidarity: A Core European Value but with Broadly Varying Content."

Here's the abstract:

Although the concept of solidarity sits at the center of many European health sector debates, the content of the services and benefits that solidarity ensures has changed considerably over time. In prior economic periods, solidarity covered considerably fewer services or groups of the population than it does today. As economic and political circumstances changed, the content of solidarity changed with them. Recent examples of these shifts are illustrated through a discussion of health reforms in Netherlands, Germany and Israel (although not in Europe, the Israeli health system is structured like other European social health insurance systems). This article suggests that changed economic circumstances in Europe since the onset of the 2008 financial crisis may require a further re-set of the content of services covered by solidarity in many European health systems. A key issue for policymakers will be protecting vulnerable populations as this re-design occurs.

Thursday, April 23, 2015

Creating the safe place for patients and caregivers

Here's a beautiful video presented by David Mayer, Vice President of Quality and Safety for MedStar Health, as an attachment to a column he recently posted on Educate the Young,  He says:

High Reliability science is one area we are looking to for answers to systems failures in healthcare. High reliability organizations stress the importance of “Stopping the Line” when a worker senses something doesn’t feel right. The concept has been shown to help reduce harm in many high risk environments. What if something similar existed for communication concerns in the healthcare environment?

The following short video, entitled Please See Me, created by patients and caregivers for patients and caregivers, offers a possible solution. Can “Please See Me” become that safe space, where patients and family members can stop the line and share those words if they feel their needs are not being heard or addressed? At the same time, can caregivers use the same phrase when they feel they are not being understood by patients and family members?

Wednesday, April 22, 2015

The next bend up in the cost curve: Rising prices for old proven drugs?

A anesthesiologist friend sent me the note below. If accurate, as this doctor says, "The expense of the surgical robot will pale in comparison to the coming tsunami of overpriced drugs!"  I'm hoping some full-time health care reporters take a look, as this seems to be a major story that has been neglected.

A short while ago, our office-based OR discovered it could not get neostigmine* from our usual suppliers but could find only an exorbitantly expensive "new" one. I emailed back and forth with the company whose product we used to use and all they could tell me was "per FDA regulations we can no longer market this drug."  The price we had to pay went from a few dollars to over $160/vial.   So I did a little digging and found out the following:

This relates to an FDA initiative to get "unapproved drugs" off the market.  Sounds like a great idea, right?  Well, these unapproved drugs are the ones we've been using safely for decades and were grandfathered in to not needing to go through the FDA approval process that started in the early 1960s.  So . . . some drug companies have realized that they can jump through the hoops to get one of these drugs approved, at which point all other companies' version of the drug is now "unapproved" and cannot be sold.

The same thing has happened with colchicine, which has gone from 5 cents/pill to $5/pill, and all kinds of other drugs are in this pipeline, e.g. epinephrine, and it's only a matter of time before the same will happen to atropine, calcium, bicarb, ephedrine, etc.  This is an unmitigated disaster for healthcare spending.

The initiative is described on Bloxiverz.com (the "new approved" version of neostigmine) (not "new improved") under the "FDA Initiative" tab.
  [And here's the link to the FDA site.]

I did a little sleuthing and found this article on Medscape from last year.  The story set forth there is that the unapproved supplies of neostigmine were becoming scarce:

Bloxiverz is the first FDA-approved version of neostigmine, which has been on the market as unapproved, grandfathered products under the Food, Drug, and Cosmetic Act of 1938. Flamel expects to launch Bloxiverz in July 2013 in 0.5 and 1.0 mg/mL strengths.

The cost difference between the branded and generic version remains to be seen.

"Based on our marketing experience, we believe that hospitals will welcome the addition of Bloxiverz as an FDA-approved version of neostigmine," Mike Anderson, Flamel's chief executive officer, said in statement.

He noted that unapproved versions of neostigmine have been in "short supply for nearly a year, which may add to the need for a reliable source of FDA-approved product."

I'm not sure, but this document appears to be the summary of the drug company's proposal to have its version of neostigmine approved.  (The timing of the report seems just right, but the company's name is deleted from the document.)  Sure enough, the agency mentions that the drug has been in use since the 1930s and that there is no reason to doubt its efficacy. The report seems to be one of "the hoops" mentioned by my friend.

So, the question is why the unapproved version was in short supply. There seems to be a correlation with knowledge by other companies that an approved version is on the way.  Look at this article from an investment analyst:

[The FDA guidelines are such] that it will typically remove unapproved product from the market in approximately one year from the approval date of an NDA (5/31/2013) led many investors to believe that the FDA had notified the companies privately that they had to wind down inventories and prepare to leave the market entirely at some future date. This was cleared up today for me, when I learned that Cardinal Health, a distributor of West-Ward Pharmaceuticals' unapproved formulation of neostigmine, had updated its National Drug Code information to indicate that neostigmine methylsulfate supplied by West-Ward would no longer be available for marketing after September 30, 2014. 

So, while Mr. Anderson correctly noted the shortage, his firm's filing, was in essence, the cause of the shortage.

The investment analyst offers his prognostication of the financial benefit of this change in market conditions:

I believe that this new information is clear public evidence that the neostigmine competitors to Flamel's BLOXIVERZ were told to cease marketing of their products by the end of September. From channel checks, I estimate that there was approximately six weeks of inventory of unapproved product in the channel and as much as six weeks of inventory in-process at the two unapproved manufacturers. As this inventory is wound down, I would expect Flamel's BLOXIVERZ, as the only remaining player, to continuously gain this share, and I conservatively project more than 50% share by September 1 and close to 100% share by the end of that month. 

While I may be off a few weeks on the timing of the inventory drawdown, I am pretty certain that Flamel's BLOXIVERZ will be the only neostigmine product on the market after September 30th and that the product is truly transformational for the company, as the drug should drive annual earnings power of $1.00-$2.00 per share beginning in the fourth quarter and in 2015 and 2016. Based on my discussions with industry experts and a review of drug pricing during periods of market dominance, I believe that BLOXIVERZ could generate revenues of approximately $150 million in 2015 and more than $200 million in 2016, with peak revenues of $250 million later that year.

Neostigmine methylsulfate is used to reverse the muscular blocking agents following surgical procedures that require anesthesia. It is a critical drug that must be used, and therefore does not require much of a selling effort, and Flamel is able to sell the drug with just two employees, who are mainly responsible for order entry and supply management. As such, margins are quite high in the 65-70% range, after manufacturing costs and royalties tied to previous owners of a Flamel subsidiary of 20%.

I imagine there is some good reason for the FDA's unapproved drug regulations, but it is hard to imagine that no one in the federal government understood the potential cost impacts of this policy direction.

---
* Per Wikipedia: Neostigmine is used to improve muscle tone in people with myasthenia gravis and routinely in anesthesia to reverse the effects of non-depolarizing muscle relaxants such as rocuronium and vecuronium at the end of an operation, usually in a dose of 25 to 50 μg per kilogram.

Never mind, I'll wait till Monday

Lisa Rapaport at Reuters summarizes the findings of an intriguing BMJ article. The lede:

Patients admitted to the hospital on weekends are more likely to get a preventable illness or injury during their stay than people admitted during the week, a large U.S. study finds.

Even after adjusting for patient characteristics, including the severity of the condition that brought them to the hospital, weekend admission was still linked with more than a 20 percent increased likelihood of hospital-acquired conditions when compared to weekday admissions, lead author Dr. Frank Attenello, a researcher at the University of Southern California, said by email. 

More:

Even though most admissions - 81 percent - were on weekdays, preventable complications were more common on weekends. Hospital-acquired conditions occurred in 5.7 percent of weekend admissions, compared to 3.7 percent in people admitted on weekdays.

"This increased hospital-acquired condition rate is significant because we found presence of at least one hospital-acquired condition to be associated with an 83 percent likelihood of increased healthcare cost and a 38 percent increase in the likelihood of a prolonged hospital stay," Attenello said. 

Those of us who are Lean adherents would likely conclude that this phenomenon is an indication of a lack of "standard work" in caring for patients during different times of the week.  Yes, staffing patterns differ, but a Lean organization would have noticed a difference in the quality of service offered (aka, defects) and would have acted to improve it.

Indeed, it would be fascinating to repeat the study and compare results between non-Lean and Lean hospitals to see if there were any difference.

The study also stimulated a BMJ editorial--"Patients need safer hospitals, every day of the week."   It's hard to argue with that.  The level of patient harm, worldwide, in hospitals remains unacceptably high--every day of the week.

Defeating defects on WIHI

Madge Kaplan writes:
The next WIHI broadcast — Reducing Risks and Defects in Real Time with Help from the Frontlines — will take place on Thursday, April 23, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:
  • Andrea Kabcenell, RN, MPH, Vice President, Institute for Healthcare Improvement
  • Steven J. Spear, PhD, MS, Senior Lecturer, MIT Sloan School of Management, Senior Fellow, IHI
  • Alexia Green, PhD, RN, FAAN, Professor and Dean Emerita, Texas Tech University Health Sciences Center
  • Roger Resar, MD, The Mayo Clinic Health System, Senior Fellow, IHI
As health care quality improvement has matured, it’s common to hear the phrase, “Quality is everyone’s responsibility.” But what does that mean more precisely, and how does the concept apply day-to-day? Also, how feasible is it for those on the frontlines of delivering care to not just detect defects in systems and processes, but also solve many of them, right then and there? It turns out this is quite doable, especially if frontline staff and providers are empowered to do far more than patch up problems AND if they can count on operational guidance and leadership from others, including middle managers.

We have some exciting work to tell you about on the April 23 WIHI: Reducing Risks and Defects in Real Time with Help from the Frontlines. The goal is first and foremost to reduce harm to patients and improve safety, but in the process it’s also about raising joy in work and frontline confidence to address problems as they emerge and create replicable solutions as part of daily work. Our guides on the benefits and particular tactics include Roger Resar and Andrea Kabcenell, who’ll be drawing on a deep dive they’ve been involved in, looking at frontline tactics that are proving effective coming from Lean Management, Situational Awareness, and something called the Frontline Dyad Model. Alexia Green will share how a group of nursing graduate students took this approach in multiple settings with good results. And Steve Spear, who developed some of the Frontline Dyad Model with Roger, Andrea, and IHI's Kathy Luther, will weigh in with insights from other health care organizations and industries. Steve will also offer guidance on what leaders can do to ensure defects are addressed at the point of care.

The April 23 WIHI promises to be as specific as you probably need it to be, while offering fresh frameworks to help you develop practices of your own. Come learn how to “See, Solve, Share, and Lead.” We look forward to your interest and participation on this next WIHI!
Please join us on April 23. You can enroll for the broadcast here.

Tuesday, April 21, 2015

Coming soon to the US?

The English press have a love-hate relationship with the National Health Service.  On one day, you might find a story about the extreme dedication of a given nurse who goes above and beyond the call of duty to help a sick or disabled old man or woman. On the next, you’ll find an article excoriating the system and its leaders for allowing long wait times at the A&E's (emergency rooms). And during an election campaign of the sort now taking place in the UK, both extremes are presented almost every day.  And that’s in the responsible press. The tabloids even more so.

Knowing this, I should not have been surprised to find a story in the Daily Mail with the dual headline:

Greed of the NHS Fat Cats
High Rollers Who Are Never Paid Through The Books

The thrust of the story was to expose senior level managers who had been hired as contract employees by several of the NHS hospital trusts that were facing financial or operational difficulties.  This happens from time to time.  As the chairman of one trust said, “It was clear that we needed a high caliber individual to successfully steer the trust through some extremely challenging times.”

The Mail’s complaint goes to the level of pay offered to these turn-around agents.  Also, it raised concerns that several of them took their jobs under the auspices of private companies. Accordingly, payments for taxes, pensions, and the like were made by companies the executives own rather than by the trusts. (This is legal, but the Mail calls it morally wrong.)

Stories about salaries of corporate executives are always grist for the media’s mill, and my point today is not to question the editorial judgment of a newspaper that decides such matters are newsworthy. Indeed, stories about high salaries for executives when nurses and other staff have faced salary freezes can be quite compelling.

No, what really struck me was how inflammatory the reporters and editors chose to be in the extraneous material they inserted into the story. Ultimately, the story was about the lifestyles of the executives.  I don’t know, but perhaps it was designed to tap into some sense of latent class warfare.

I had heard about this technique before in other stories in the UK tabloids, but I had never read those stories as closely.  I offer some examples here as a “public service” to hospital executives in other countries, like the US, where such media practices might spread.

Here’s one:

Mr. Reading, who enjoys regular family holidays to exotic locations such as Antigua, where he can be seen posing on beach, as well as Thailand and Majorca . . .

Facebook provides good source material, too:

Just 12 days [after starting her NHS assignment on July 15], she was away in the Costa del Sol, according to her Facebook page. ‘On holiday,’ she wrote from Competa, a picturesque village in Southern Spain. ‘Got the most fabulous villa.’

Only 11 days later, Miss Ruskiewicz, 53, updated friends on her indulgent summer travels—from a nail salon in California.

‘Recovering with a mani pedi,” she boasted after a day in the Redwood national park.

The hospital boss, who has two daughters and lives in a £1.25 million four bedroom house in West London also went to the Indian Springs Resort and Spa in Napa Valley.  The luxury hotel, where rooms for a night cost between $359 (£239) and $999 (£665), specializes in mud bath treatments.

During her time in the city the extravagances continued . . . staying at the Queensbury Hotel, where rooms cost between £175 and £489 a night and a tasting menu at the restaurant costs £70 a head.

The Mail does include these quotes from Miss Ruskiewicz before going on to the next executive’s story: “I took a pre-booked holiday during that period.  My holiday time was not charged to the trust but was taken on my own time. I did not take any leave from the trust. I claimed no expenses or allowances from the trust.”

Mr. Morgan . . . recently sold his Texas mansion for nearly $2 million (£1,338,000).  It is clear from his Texan home that he is making the most of his lucrative career traveling across America and the UK as an interim hospital boss.  His huge family mansion has views over picturesque Lake Conroe, with its own jetty, two jet skis and a boat lift. It also has an infinity pool with Jacuzzi and fountains.

The five-bedroom house has sprawling manicured gardens. Photographs from inside show an extravagant spiral staircase, marble floors, chandeliers, grand oak furnishings and antiques throughout.  There are sunbathing terraces with palm trees and a games room with a huge television and pool table.

Then there is Mr. Hurst:

Pictures he posts online of his travels include shots of him stroking a cheetah in South Africa.

And Mr. Miller, who

[L]ives with his second wife Lucy in Ealing, West London, in an area where the average property price is in excess of £1.7 million.

And finally:

Sandy Spencer, who has been pictured posing in a fascinator and drinking wine on holiday, appears to live the life of a socialite. In fact, she has made her wealth by merry-go-rounding as a freelance NHS boss.

Monday, April 20, 2015

An advance in clinical excellence in NSW

I neglected to reference this excellent paper in the BMJ from a few months ago by Karen Luxford and Stephanie Newell.  Thanks to Marie Bismark for the reminder. Here's the introduction and an excerpt:

The principles of patient centred care and the mantra of “nothing about me without me”1 have gained broad support, but its proving hard to adopt and embed them in routine practice. New ways of thinking and tackling resistance to change are needed, and a range of initiatives are being pursued. We describe the approach being taken in New South Wales, Australia’s most populous state, with 7.4 million residents and 1.66 million public hospital admissions a year. This has focused on the development of a “patient based care challenge” aimed at spurring system-wide integrated change to promote patient centred care. The term patient based care was introduced with the aim of making patient centred care more broadly recognised as everyone’s responsibility—from the executive through to frontline clinicians and staff—with care systems included as well as bedside care. We discuss how the health districts have responded to this challenge.

The Clinical Excellence Commission was set up in 2004 to promote and support improved clinical care, safety, and quality across New South Wales. The commission monitors state-wide incident reporting and implements quality improvement initiatives to address key safety and quality problems identified. In 2010, a consumer adviser panel was established to actively involve patients, carers, and community members in all aspects of the commission’s work. In 2011 the commission developed a “patient based care challenge” for district healthcare services in collaboration with a partnering with patients advisory committee, which comprised patients, clinicians, managers, and policy makers. Patients and families highlighted the importance of engaging with patients in care at the bedside but also in health service governance and strategic decision making. 

The 26 strategies included were grouped under nine domains drawn from evidence of effective strategies used by leading patient based health services. Although some strategies are specific to hospital settings, most can be used across a range of healthcare settings. We framed the overall strategy as a challenge to health services to reflect the difficulties of making system-wide change and to infuse a competitive aspect into the process.

Thirteen of 15 local health districts committed to the challenge in the first year. The two remaining districts wanted to complete new district-wide strategic plans before committing. Most districts focused on two or three strategies, although six adopted more than three. The most common initial strategies selected were: start each board meeting with a story of patient care from your service (six districts), arrange for board and executive members to visit wards regularly (five), involve patients, families, and carers in governance through participation in committees (five); encourage staff to view patients, family, and carers as core members of the healthcare team (four); and implement processes to support patient or family activated escalation of care for deteriorating patients (two). By October 2014, the 13 districts had adopted an average of 19 (range 13-25) strategies.

Sunday, April 19, 2015

Barbarians past the gate.

The moat has been crossed.  The ramparts have been breached.  Any hint that the invasion by the robotic surgery company will be slowed is off the table.  At least as seen by the investment advisory folks at LEERINK, analyzing the shares of Intuititve Surgical (emphasis added.)  Is this really the way you want to see health care policy developed in the US and other countries? Such momentum from this and other companies sure makes the proponents of the "Triple Aim" look like naive waifs.

We are attending SAGES in Nashville, TN, where physician discussions continue to highlight a growing level of physician interest/experience in newer general surgery areas such as colorectal, hernia, bariatrics--and the power of robotics as a marketing tool for docs & institutions in these areas. As usual, cost-benefit & clinical outcomes remain highly debated, but dv gen surgery momentum nevertheless seems to be building, and we believe uptake in these newer areas (i.e., hernia, colorectal) should continue to support our accelerating procedure growth outlook thesis.

Hernia continues to be an increasing area of interest for robotics as evidenced by a jam-packed inguinal hernia session on 4/15 that included a few talks/debates on da Vinci. While there continues to be much discussion around cost-benefit and best indications of use (i.e., inguinal vs. ventral)--and no real resolution leaving these panel sessions--there does seem to be some consensus forming around the notions: (1) more procedures should be done MIS with hernia penetration rates still hovering below 25%, (2) robotics may represent an enabling technology for furthering MIS penetration in more complex cases. With this and other recent feedback we head into 1Q earnings and 2015 with a higher level of conviction that potential near-term outperformance in the dV hernia category should to some degree help offset potential slowing trends in chole and ongoing sluggish growth momentum in GYN.

Investment thesis: ISRG continues to be a unique, robotic surgery franchise developing numerous promising new general surgery procedures—cholecystectomy, colorectal, bariatric, thoracic, head &  neck, and others; and accelerated growth and procedure adoption internationally (e.g., dvP [da Vinci Prostatectomy] in Europe, Japan). Recent challenges have called into question the sustainability of long-term revenue growth rates—in both system placements and its bread and butter prostatectomy and hysterectomy procedures. But a new product cycle (Xi) should help to reinvigorate system sales growth.

Saturday, April 18, 2015

"Who, after all, speaks today of the annihilation of the Armenians?" Adolf Hitler

I write from Lisbon, where I was surprised yesterday to see the government monument pictured above acknowledging the murder of two thousand Jewish people for "deicide and heresy."

And then, coincidentally, I saw that Andy Tarsy has written a thoughtful article at Tablet, called "Why Jewish Organizations Must Stop Denying the Armenian Genocide."  About 1.5 million Armenians were killed by those working under the auspices of the Ottoman Empire.

It's not the first time Andy has set forth opinions on this subject. The last time cost him his job as regional director of the Anti-Defamation League.

It is remarkable, and sad, to me, that there is still a need for Andy to make this case.  I supported him back in 2007, and do so again.  In his article, he appropriately pulls no punches:

National Jewish organizations in the United States have played a dangerous game for decades, giving safe harbor to denial of the Armenian Genocide. As its 100th anniversary arrives on April 24, there is an opportunity to turn the page on a dismal chapter of Jewish American history.

The bar is set higher now than simply uttering a particular word or posting a statement to a website. Jewish leaders and organizations have to demonstrate that they recognize the humanity of Armenian people who still live in the long shadow of genocide. These families have been robbed of everything they built and earned in centuries of cultural continuity. Their injuries are compounded by Turkish denial and the complicity of those who could be allies, including ourselves.

Over the past three decades, various national Jewish leaders have urged Armenians to address their need for validation by taking up the matter with the Republic of Turkey itself. Imagine Jews being told to do the same with Germans. Jewish leaders have made public comments that deliberately provide cover for those who willfully undermine the truth; and in our name, they habitually advocate against congressional efforts to acknowledge the genocide. Some even take steps to exclude the Armenian story from genocide education curriculums and Holocaust commemoration events.

The American Jewish community would be wise to retire two morally and strategically bankrupt imperatives that have contributed mightily to this morass.

The first of these feckless imperatives is that anything said to be necessary for Israel’s safety and Jewish security can be justified without rigorous and transparent analysis. The days of deference to the individual judgments of national leaders on issues of strategic importance have to end, no matter how experienced those leaders are.

A second imperative we must fully let go of is that the Holocaust has to be insulated from comparison and even commemoration alongside other catastrophic crimes like the Armenian Genocide. As media outlets have reported, the Anti-Defamation League has for decades had a policy prohibiting its regional offices from participating in Holocaust-related events jointly with organizations focused on the Armenian Genocide. If the ban has been lifted, there is certainly no evidence of the organization moving beyond it today. Holocaust museums and genocide-studies programs have crossed this bridge already. They have rigorous methods for managing the analysis responsibly, and there is no sign of damage to any of the important histories that need to be remembered.