by Nick Jacobs

From the local paper, " Hospital A's mortality rates improved, while Hospital B, Hospital C and Windber Medical Center received poorer marks. The truth, the whole truth and nothing but the truth, . . . or so it would seem.

As many of you know, we are very passionate about transparency in health care and, as a Planetree Hospital, we are committed to demystifying health care. One of the problems that we face, however, is a nuance problem.

We have a palliative care unit, a hospice that is utilized by a five county area. It is a center that provides pain control, respite and end of life care. My opinion of this service is that every hospital should offer it to every family. Bottom line though is that each year, our hospital is penalized statistically because of the number of deaths that occur. Why does this happen? It is because the conventional thinking in this country is still that, even if a patient has a do not resuscitate order, death is not acceptable and must be statistically noted as something bad.

Consequently, even though patients elect to come to our unit to die surrounded with dignity and peace and embraced by their loved ones, their death shows up as a negative State statistic without differentiation.

If the terminal patient was there because of heart failure, the ultimate end of that condition is not life, it is, in fact, death. Unfortunately, the statistics will show an inordinately high number of deaths for heart failure in the category that graphically depicts our medical center's death rate. Then the newspaper will cover this statistic, and we will, once again, attempt to respond to the public by explaining what hospice services are and how their impact on our numbers should be calculated.

As Ronald Reagan once said, "Here we go again."

Transparency in death rates must be carefully monitored so as not to penalize those facilities that help families by providing transitional hospice services. We know of some heart centers that will not operate on patients with high risks because it will skew their statistics.

Numbers can do whatever you want them to do, and we want them to be honest and carefully depicted to demonstrate truth and clarity. We're not blaming the press, but we are, once again, questioning the Health Care Cost Containment Council's mechanism for production of these statistics.

by Tony Chen

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by Tony Chen

Well, it's that time of year again when we take a moment to reflect on Healthcare in '07. Go here to check out FierceHealthcare's Annual Review where they highlight these trends and get this conversation started:

1. The push for price and quality data transparency
2. Growing acceptance of retail clinics
3. Broader use of pay-for-performance programs
4. A shift away from payment for medical errors
5. Proliferation of physician ratings by consumers and health insurers
6. Tremendous pressure to adopt electronic medical records
7. Controversy over the future of regional health information organizations
(Source: FierceHealthcare.com)

I'm not convinced that P4P is really "business as usual." And I'd put 4 & 5 more as early trends, not very widespread quite yet. But nonetheless, I think this is a great list.

A few things I would add:

- 2007 was a banner year for the biggest hospital transactions ever - think back to all the M&As and all the public-to-private transactions (i.e. HCA!). Outsiders see potential even as we are missing it.

- Speaking of outsiders, 2007 will also be remembered as a year when many outsiders are starting to get in. RevolutionHealth, Virgin, Google, and Microsoft all made big announcements and/or launches into the healthcare arena. Time will tell.

- 2007 was also the first year in a long while that we've heard the words "universal healthcare" beyond just the typical wonkish journals. For better or worse, the idea caught some attention, no doubt with the help of Sicko

- 2007 was the year health 2.0 was born. I've done numerous posts on web 2.0 sites, facebook, and social media. The Health Care Blog held its first Health 2.0 conference as a smashing success (400+ attendees). Not much relevant to hospitals at this point. But lots more patients will be using these technologies, so ignore them at your own peril.

What did we miss? What else?

by Tony Chen

Definitely not the phrases you see together very often, right? Maybe it won't be so foreign in a few years.

I've posted in the past on whether hospitals should blog. I've also previously mentioned how pleasantly surprised I was to see a hospital classified ad on facebook. Where exactly are hospitals at when it comes to social media?

Obviously, as a whole, hospitals aren't even close to implementing (or even understanding) these new social media technologies. However, you might be surprised at how savvy some hospitals already are. Here are a few examples:

1. Cleveland Clinic is on Facebook. I think you have to be a facebook user to see these, but you too could join the Cleveland Clinic Lerner College of Medicine Group (currently 84 members) and the Cleveland Clinic Group (55 members). Their group description: This group is for all employees, interns, volunteers, patients, or anyone who is associated with the Cleveland Clinic or the CCF health system. If you look around, there are other hospitals that are also dabbling with various groups. Do a search for other hospitals (try MD Anderson), and you'll find all kinds of different groups and people who are associated as employees/volunteers.

2. Mayo Clinic Health Policy Center is also on Facebook with fans. This is different than a "group." As of just a few months ago, companies and organizations can join facebook, and individuals can declare themselves as "fans." This is a way for people to show their friends what they're excited/passionate about. Viral marketing at its best (and worst).

3. Partners Healthcare is on SecondLife. Check out their website for how they explain SecondLife and why they believe it is important. Some folks may have heard of Second Life as a 3D virtual world for gamers and slackers. Obviously, this isn't the case anymore. Tons has been written about it recently - everything from the pros/cons of job interviews done on second life to why GM created a pretend virtual dealership. CNN even has a blog that solely covers second life developments.

4. Hospital CEO blogs - I think we are all already familiar with these. Just in case you aren't, check out Nick's Blog (CEO of Windber Medical Center in PA) and Paul Levy's blog (CEO of Beth Israel Deaconess Medical Center in Boston)

5. Some hospitals are using internal collaborative tools (like Microsoft's SharePoint) to better facilitate cross-functional collaboration. Once organizations get over the initial hurdle of learning a new system, lots of synergies are to be had - worklists, wikis, lists, and calendars.

There are more, but this is a pretty representative list.

The bottom line is this: While some hospitals are embracing social media, hospitals as a whole won't be getting into social media anytime soon. But, many patients will. And as such, hospitals that take the plunge as early adopters will be well-known as savvy and transparent.

by Nick Jacobs

The other night I was surfing the net and saw a comment written in a blog by an employee who is working in a Planetree hospital. She explained her interpretation of what the Planetree philosophy means. The author objected to showing support and warmth to a family by hugging or touching in any way.

Part of the beauty of Planetree is that it isn't just about hugging or touching someone in pain or comforting someone who is afraid. It is about loving and nurturing, and it is about providing the type of care for your patients that you would for your own loved ones. Planetree is an attitude. Planetree is what's between your ears; a mind-set, an approach, a way of thinking, a frame of mind.

When we first introduced the Plantree philosophy of care, the Balanced Budget Amendment Act was wreaking havoc on our urban, non-teaching hospital. Because our payroll levels were behind those of one of our neighboring hospitals, we alternated between a revolving door exodus of our nurses and a disgruntled group of individuals who, regardless of the circumstances, wanted higher salaries immediately. Because of our passion for the Planetree philosophy, it became a target of those disgruntled employees. You would constantly hear people say, “We are not being paid well enough to be Planetree.”

During that time we did everything that we could to adjust those salaries and, about 16 months into the unrest, were finally able to do just that, but, more importantly, we realized that the Planetree philosophy could not be deployed with 100 percent dependence upon nursing alone. It was during that period of consternation that we began to circulate volunteers, reiki masters, massage, pet and music therapists throughout the patient floors.

Most importantly, however, we worked very hard at helping every one of our employees understand that it is not about customer service, it is way beyond customer service. Planetree is about sensitivity, passion for appropriate care, and loving, nurturing kindness. It is about creating a healing environment.

by Tony Chen

Sorry I haven't been posting as often recently. All the long-term bloggers know - blogging is fun, but it is indeed a lot of work. There are waves of ups and downs. A lot of people ask me, "how do you find the time to blog?" My answer for the last couple of months is that I don't.

Nonetheless, even as I've been preoccupied with other things, the blog has continued to surprise me. Got calls from editors of Spirit Magazine and the American College of Physicians to get quotes from me as an "industry expert" (little do they know how little I know). Through the blogosphere, I also met up with long-time blogger and knowledge management guru Jim McGee. Tomorrow I've got lunch with someone who I was introduced to via facebook from someone I met at a blogging conference.

Yes, blogging is about great insights and great content. But for me, the greatest value has come from the real-life conversations with real-life people I met through the blog. It's about community and relationships as much as it is about information. Look out for an announcement related to this in the next few weeks.

guest post by Mike Pringle

The Boston Globe today (December 11, 2007) reported out on a precedent setting legal battle that the Massachusetts’ Supreme Judicial Court ruled is likely to broaden the liability challenges that physicians already face.

A 10-year-old boy standing on a sidewalk with his friend was struck and killed by a moving vehicle when the driver passed out on March 22nd 2002. The court ruled that the mother of the boy can sue the physician who prescribed a number of medications to the driver that could cause drowsiness as a side effect.

Justice Roderick L. Ireland who presided over the case equated…”that the actions of a doctor who fails to warn a patient about a drug’s side effect that could endanger others to a bartender who serves an intoxicated customer”.

The ramifications, both potential and real, of this type of ruling are far reaching. Certainly responsibility needs to rest with someone for this and similar type tragedies, however I think pointing the smoking gun at healthcare providers is not the way to adjudicate this type of event. My bias is simply this, if you are impaired from alcohol, lack of sleep, or medications and driving a vehicle it should be considered a “DUI”. Massachusetts is likely opening Pandora’s Box on this one.

What do you think?

Guest Post by Mike Pringle (a nursing supervisor) of the Mike's Viewpoint blog

An article in the Washington Post reports out on a survey conducted between November 2003 and June 2004 contrasting physicians’ beliefs about medical errors and incompetence reporting compared with what they really do when they know of a colleague who is not maintaining standards. The survey which was printed in the Annals of Internal Medicine incorporated 1600 physician responses which noted about 45 percent didn’t always report an incompetent or impaired colleague -- even though 96 percent agreed that doctors should turn in such people.

Chris Lee who authored the article describes how many providers are unwilling to provide negative feedback about other peers when asked questions by their patients regarding who is and who is not a “good doctor”. The article also describes how some physicians order expensive diagnostic tests for patients even though there isn’t any reasonable medical indication for such testing. The work up is done at the request of the patient. Other tests are ordered as a defensive measure mainly in hopes to stave off any future litigation.

Primum non nocere, -- do no harm, widely believed to come from the Hippocratic Oath but in fact this dictum actually comes from the Hippocratic Corpus, at least in essence. Noble words to guide ones practice of medicine for sure. Providing high quality healthcare is no easy task and in today’s world, it is expensive. For each measure of medicine that we practice there is an equally sized dose of law that most healthcare providers and institutions are practicing as well. Trying to cover all the bases with expensive diagnostic work ups, or ordering test just because your patient who comes to the emergency department and is insistent on having an MRI for chronic low back pain are common place.

Healthcare is not a drive up window for prescription medications and diagnostic workups. It is certainly not an opportunity for gaining financial freedom as is the lottery when your provider makes an honest mistake and a bad outcome prevails.

Defensive medicine is much more costly and time consuming and doesn’t demonstrate the appropriate use of precious resources. The focus needs to be on higher professional standards and doing the right thing for the patient.

by Tony Chen

Click here for some info on Nick Jacobs' podcast. Nick shares his "blogging story" - how he got started, how it evolved, how it has benefited his organization. Check it out!

by Nick Jacobs

The November 25th, Sunday, New York Times editorial provided an in depth analysis of "The High Cost of Health Care." Six possible solutions were identified that could possibly assist in ameliorating this accelerating problem: Geography, the wide variances that occur in pricing based upon location of the service; Stick to What Works, a demonstration that only those treatments that actually have proven merit should be utilized by the physicians; Managed Care, it worked for a while, but too heavy of a hand would cause passionate kickback by both the population and the physicians; Information Technology, knowledge is power and this will produce more efficient use of the system; Prevention, everyone knows that attention to prevention works; Disease Management through comprehensive management of chronically ill patients; and finally, Drug Prices, drugs are more expensive in the United States.

The seventh and probably most important means to reduce health care costs was omitted by the Times, and by what seems like 75 percent of physicians most days, and that is Hospice care. Approximately 30 percent of all health care dollars spent in the United States are spent on the last thirty days of life. If we are close to 2.2 trillion dollars in expenditures, then divide by three and see what an impact Hospice could have on our expenditures.

by Tony Chen

First time seeing a hospital ad on facebook! This one was for careers/jobs at Rush University Medical Center. I'll have more on Hospitals and Facebook in a few days - some hospitals have a deeper presence there than you might think.

As we've been saying, it's not a "build it and they will come" mentality anymore. It's "go where they already are."

by Nick Jacobs

If the Material's Management Director receives a favor in the form of a trip or a gift from a vendor, and that gift is beyond a limited value, that may be considered problematic for the organization. If a senior officer, though, is flown to a reception in the vendor's corporate jet, wined and dined, and then taken to a professional sporting event in an attempt to influence that officer into using that company's product, does that present the same problem? If a U.S. Congressman is flown at no cost by a lobbyist, that now is considered problematic, but if the lobbyist is from an academic institution, that is considered okay.

If a board member puts undue influence on an executive to do business with his company, how does that play out? Sarbanes-Oxley sends a very clear message that the business community is expected to do things differently than the way they have been done in the past, but I've already heard of cases in health care governance where specific board members have required the calculation of just how much business is too much business to be pushed to the extreme before the law kicks in for non profit corporations.

According to the Columbus Dispatch, in 2000, 13 of central Ohio’s corporate boards were dominated by insiders — company executives, consultants and lawyers. Some owned jets that they leased to their companies. Others owned office buildings that their companies rented. Still others were relatives of the CEO.

Bottom line? Corruption by any other name is often called doing business in many countries, and in some countries, it is truly considered an art form. Who do you know? How do you take care of your friends and the friends of your friends? What financial favors do they do for each other? Unfortunately, in many cases, if you don't play by the rules of the GOB's (Good Ole Boys), there can be a heavy price to pay, unemployment.

So, for all of you who are looking at a high powered future, study the rule books and stick to your guns, but, unless you work for an absolutely wonderful board, hold onto your hats because situational ethics can be very difficult to surmount.

Regarding ethics in the military, Robert Prentice, a professor of business law at the McCombs School, said, "Nobody up the line is taking responsibility. Everyone is trying to pin it on the little guys." Remember, that little guy could end up being YOU.

Final thought, putting on make-up or shaving in the morning usually requires one to look in the mirror, and that can become challenging for those who are better known as the players. Of course, that depends on the situation.

by Jeff McKune

Having attended a couple of Joe Tye’s seminars, I was eager to read The Healing Tree, a book he first published in 2005. The book is now in its second printing.

The story begins with an evening with Mark and Carrie Anne Murphy and the tragedy that enters their lives. Carrie Anne’s struggle towards recovery is one thread that is carried through the narrative. But a deeper and richer fabric is found in her personal awakening, guided initially by young Maggie, a fellow patient at the hospital who provides unique therapy to Carrie Anne and other patients. Carrie Anne’s despair eventually leads to her discovering a new path for her life, more meaningful and rewarding than anything she had previously imagined. The story alone touched me, and I found myself sometimes both uncomfortable and inquisitive with the introspection it created in me. That alone made the book worth the reading.

It was impossible for me to ignore the glimpses that Joe provides into the healing environment that was a part of the fictional Memorial Hospital. I wondered how some of the innovations Joe discussed would ever get past a Board of Directors. But clearly Memorial Hospital was a hospital focused on much more than physical healing. The hospital’s ongoing transformation was a result of visionary leadership. One phrase that I cannot forget is “the soul of the hospital.” What is the soul of your hospital? How do your efforts contribute to the development and sustaining of that soul?

Throughout the book, Joe also reveals some thoughtful insights into nursing and those that serve in caregiver roles. The bidirectional aspect of the nurse-patient relationship is developed in a discussion between Carrie Anne and Maggie. And toward the end of the book, the hospital CEO reminds us that patients are not the only ones that need healing. Joe is a strong advocate of nursing, and it is no surprise to see this emphasis in The Healing Tree.

I consider The Healing Tree to be one of those books that takes a hospital administrator beyond mechanics and methodology – it invites and encourages visionary and transformational leadership. A section containing discussion questions is included at the end of the book for the purpose of initiating dialog regarding that transformation. Also, there is a website for the book at www.healing-story.com where you can download the companion workbook Healing the Hospital, which I understand has been popular at caregiver and leadership retreats. If you want to spark discussions as to how your hospital can better serve both patients and staff, I invite you to read and share this compelling book.

by Tony Chen

This is easily the most frequently asked question I get at healthcare conferences. I usually answer this by asking another question: what's the best way for the hospital to utilize the web to engage your stakeholders?

The web is quickly becoming the place where conversations happen and perceptions are being formed. And new technologies make it easier than ever to be a part of that conversation. I've seen it first hand here on hospital impact where a particular post gets linked to by other blogs, which are then linked to by others. All of the sudden, you've got a whole web of links that started with one good post. 1,000s of people found my site for the first time that day.

Beyond the increasing viral trend, there is also a trend towards open innovation - i.e. the line between "corporation" and "customer" is blurring. Corporations in all industries are realizing that customers have valuable, superior ideas that can't be generated within the 4 walls of even the smartest corporation. So, why not draw those ideas in? Everyone has seen that Superbowl ad that Chevy paid for - it was a raw, amateur home video of a loyal customer talking about his Chevy.

So, what does this all mean? There are people talking about your hospital and your physicians as we speak. Just go to RevolutionHealth, RateMDs, DrScore, and many other websites. So at the very least, we need to dedicate some resources (maybe even just 10% of one person's time) to be the "e-community relations manager" and be aware of what conversations about us are happening now.

In terms of starting a blog or a facebook profile, I do think it's a good idea for the right hospital. But I would first get educated about the web. Go find out what people are saying about you now. Does your hospital have free wi-fi? I heard about a patient who was blogging at her bed. "Nurse Betty just came in, and she was so cold to me..." In some instances, maybe it even warrants a response.

If you want to start a blog, check out other hospital CEO blogs (like Running a Hospital and Nick's Blog). It's a lot of work and there is no hard-core ROI, but for the right type of person, it pays off in other ways. Both of these CEOs can probably point to examples where their blog put out a PR fire before it could start. They've built trust and credibility through the blog. They've humanized the hospital through the blog. So when fires do come (and of course, they will), they're well positioned to engage authentically. We are entering an age where proactive transparency is rewarded and reactive transparency is lame.

One word of warning. Don't blog if your organization:
* Doesn't trust their employees.
* Doesn't want to hear bad news.
* Wants absolute control over their message and reputation (this isn't happening anymore anyways)
* (the kicker) Doesn't have someone who's really wired to do it.

And finally, all of this gets back to what we've been talking about all along - a great patient experience. Every patient that comes through our doors now can be our greatest champion or our greatest detractor. And now, through the power of blogs & social media, they can tell the world about your hospital.

by Tony Chen

Some of you may have seen that the Massachusetts Hospital Association (MHA)recently announced that all MA hospitals will take responsibility for preventable errors. Part of the press release:

"Massachusetts Hospitals will voluntarily adopt a policy to not charge patients or insurers for certain preventable adverse events. While many hospitals already follow such a policy, Massachusetts becomes only the second state in the nation to take the step of voluntarily adopting a concrete, uniform policy."

Read the ABC story here on a good overview of hospital preventable errors. Also worth checking on is MHA's patientsfirst website that highlights what have hospitals done for you lately?

guest post by Dr. Marc Rothman

We already have the Pediatric ER, the Psychiatric ER… so why not a Geriatric ER as well? That’s the upshot of an interesting article from last months Journal of the American Geriatrics Society. A prominent leader in emergency medicine and geriatrics from Mount Sinai writes that the special care needs of older adults are just not aligned with current ER priorities, practice patterns, or physical design. Think about it: your average adult over age 70 has multiple chronic diseases and comorbidities, takes around a dozen meds, and may have functional and cognitive impairments. Acute illness in these folks never looks the way it does in younger healthy adults.

Case in point: we had a man in our Veteran’s Hospital ER last month with back pain. He was obviously ill but nothing on exam or labs was a slam dunk. It took over 6 hours to rule out all the usual suspects and eventually diagnose him with acute appendicitis! A rare diagnosis in the elderly, presenting in a most unusual way.

Think about how the ER feels to an older person with poor hearing, vision, and memory who is weak and dehydrated. The constant din of voices, the appearance and disappearance of faces as shifts change, the glaring lights, and the lack of windows; these things can only disorient people or cause delirium. Stretchers are high, bays narrow, and floors slippery; a recipe for falls and injuries. And the rapid ‘diagnose and treat’ approach of emergency room care increases the risk of misdiagnosis and adverse drug effects (when the medicine given interacts with one of a dozen meds the patient is taking).

I’d have to ask my colleagues, but I think delirium, falls/injuries, and medication errors are among the top three in-hospital complication today (and coincidentally where most of the dollars are being spent to improve inpatient outcomes?). Maybe we need to back our quality improvement strategies all the way to the point-of-entry to our hospitals… the ER?

by Tony Chen

Thanks again to all who attended our New Media/Blogging session today at the MCHC Conference. I sensed a lot of curiosity and interest around the opportunities of blogging in healthcare. As promised, let me share some of my key take-aways as well as some key sites for you to let through to get more acquainted with the blogging/social media phenomenon.

Key Take Aways
- Blogging is just one tool in your marketing/PR toolkit. It's not going to take over the world. It's not going to replace traditional PR outlets. But it's a great complement to your existing structure because of the speed & authenticity that you're able to interact with your stakeholders. Start there. The real innovators will use blogs/social media to engage their community far beyond what traditional PR/marketing represents today.
- There is no hard/financial business case established yet for an organization to start blogging. This is a new media, and many organizations are experimenting with various models. Nonetheless, I believe there is a real value to the organization to: (1) be proactive instead of reactive to addressing issues; (2) be transparent and build long-term credibility and trust (maybe your most precious asset); (3) lower the walls between you and your stakeholders in this new era of open innovation. Bottom line - you get better, faster information, and so do your stakeholders, and that can lead to increased trust, higher-quality ideas, and increased loyalty & referrals.

Healthcare Blogs/Social Media sites
1. Nick Jacobs' Blog - the first hospital CEO with a blog recently posted about his "journey to web 2.0" - he shares how he almost got fired for his blog. Good thing he didn't.
2. Running a Hospital - Paul Levy (CEO of urban hospital in Boston) takes transparency to the next level, asking the public if he makes too much money and posting the intimate details for their plans and quality metrics.
3. Hospital Impact - One day, Hospital Impact will truly be community, a two-way street, where best practices in hospital leadership can be shared more quickly, thoughtfully, and practically.
4. ratemd.com - 100,000+ doctors rated by patients, is yours?
5. Revolution Health - ratings for doctors, hospitals, and health plans + shopping comparisons + tools to keep your medical records & insurance straight. This is Steve Case's bet that consumer-driven healthcare is the next big thing.
6. Carepages - Patients can blog from their hospital bed about their hospital experience and their experience with their disease.
7. patientslikeme.com - a very powerful patient community whereby patients with the same illnesses can share notes AND compare test results. There's no way we could provide this kind of support for these specific patients, so shouldn't we providers be enthusiastically referring patients to this?
8. webmd.com - Everyone goes to WebMD for their medical information now (they've even recently come out with a magazine that sits in physician waiting rooms). Attention physicians: Find out what your patients are reading (and what they're being coached to ask you) before their physician visit.
9. The Paris Site - I'm somewhat hesitant to link to this site, as I'm sure they will comment on this. We talked about the "horror stories." A group of bloggers have been very vocal about the hospital's quality and performance - so much so that they've been sued by hospital.
10. Dr. Wes - A specialist who blogs that has actually gained referrals from his blog.

In addition, check out my "consumer's guide to health 2.0 sites" post.

Blog & web tools
1. Search blogs at Technorati - I think this is best blog-only search engine out there. Just type in a search term/word & hear what bloggers are saying about it.
2. Start a blog at Blogger - the most popular place to start your own blog. You can be literally up and running within minutes.
3. Aggregate blogs with a blog reader. I use igoogle. Choose to "add content" and type in the url's of your favorite websites and blogs. Pretty soon, you'll have a snapshot one-pager with the headlines of all your favorite blogs.

What were your main take-aways from today's conference?

by Nick Jacobs

Sometimes we all have to chug down a big glass of reality and begin to take a hard look at where we are, what we have become and what we need to do to take charge of those things about which we may have some control. We are well aware of the challenges that we, as a nation and a world, are facing every day. Yet, in the last election approximately 65% of us didn't bother to vote, again. Admittedly, in the presidential election about 50% of us may vote, but not this time.

If the premise of James Surowiecki's 2004 book, The Wisdom of Crowds: Why the Many Are Smarter Than the Few and How Collective Wisdom Shapes Business, Economies, Societies and Nations, is as he argues, then decisions made by groups are often better than could have been made by any single member of the group. Maybe 65% of us know something that the other 35% don't know, but in this case, I sincerely hope not.

It is my strong belief that we have simply allowed apathy to take over. Furthermore, it seems evident that some elected officials have grown to count on the fact that we don't care enough to vote. They continue doing business as usual because of our lack of commitment to endorse those things about which we should be passionate.

Where's this all coming from? It's coming from the fact that every day our emergency rooms are still dealing with the 47M uninsured human beings who are called Americans. Yet, even the very poorest countries in the rest of the industrialized world do a better job than we do of making sure that their citizens are cared for in some way.

So, the wisdom of crowds says, get an education, get your flu shot, don't drink and drive, look both ways before you cross the street and allow your country to continue endorsing a system that does not provide for nearly 50 M people? We endorse those elected officials in our country and states that have not paid serious attention to tort reform, that embrace a system of health care that is not adjusting from acute to chronic illness and that compensates some pediatricians and family practice physicians less than many blue collar professions.

Be it children's health care, health care for single, under employed mothers with children, or those who just fall between the cracks, something must happen in the next election.

It can still be about supporting capitalism, but we must find a more equitable way to embrace our fellow man.

by Nick Jacobs

How do you stop a speeding freight train? Short of placing a tanker truck on the railroad crossing, the only thing that will work is education. That is the challenge that public health is facing world wide.

It used to be, twenty years ago, that, if you wanted someone to know about something, they had to be exposed to a specific piece of information about seven times from multiple sources.

No one has provided me with the updated version of this statistic, but several of my marketing friends have indicated that, between the hundreds of cable stations, the Internet, numerous new media opportunities like podcasts, wikis the target has moved. The new estimate is that an individual must be exposed to the topic at least 21 times. If it is going to sink in with the masses, they need to be exposed to a piece of information over 20 times.

Of course that piece of information is not going to apply to people who are looking specifically for the information, but if you are attempting to change the habits of people, if you are hoping to change behavior, to improve life, to move civilization forward, then 20+ times is probably accurate.

Some of my younger friends are convinced that vegetables and fruits can easily be replaced by gummy bears and chocolate. They love cookie dough, white bread and pasta and nacho chips for dinner with extra cheese. Of course, they are blessed with good teeth, strong bones and YOUTH. When, however, the attributes of fruits and vegetables are touted, the passion of indestructible youth takes over.

So, what's the answer? Twenty plus times? Tell them twenty plus times in twenty different ways. You have to love the commercial where the man orders his meal at the drive up window and deletes the vegetables, the employee reaches into his car window and smacks him on the forehead. Get the message?

Maybe the answer is to employ the Ad Council? White bread is bad. Broccoli is great.

Or maybe we should just wait until they are all over weight, diabetic and having dental implants . . . Oops, too late.

(originally posted at the World Health Care Blog)

by Tony Chen

I'm sure most of us are very familiar with Zagat, the "go-to" resource for rating restaurants all across the world. I wore out my NYC Zagat's guide when I lived in NJ - there is a sense that you're getting the "insider scoop" on each restaurant along with objective ratings. Their success has led them to also rate nightlife, golf courses, hotels, shopping, and other entertainment destinations.

And now, Zagat will be rating physicians, or to be more specific, WellPoint physicians. The methodology will be quite similar - they'll use real patient comments that are representative of the larger pool of comments. And they'll provide numerical scores (up to 30) for 4 key factors: trust, communication, availability, and office environment.

I have to say - I think this is brilliant on a few different levels. First, I can't think of any brands more trusted than Zagat's when it comes to peer-to-peer info sharing & rating. Second, the 4 factors are perfect. Some may say - what about clinical quality? clinical outcomes? cost? I think WellPoint purposely decided not to touch quality, cost, or other factors that would draw on claims data - this keeps them from being part of recent controversies. Plus, this is a consumer-driven tool - in the mind of consumers, quality is a subset of trust. Let other sites deal with the complexity of costs.

What do you think? Any physicians out there that care to comment on this?

UPDATE: read more conversations and reactions here.

by Christopher Cornue

At the ISQua Annual Meeting I attended in October, we heard from leaders in Thailand about the Bumrungrad International Hospital, in Bangkok. Its evolving “state-of-the-art” facility is in the process of being converted. This hospital, which has over 1,000,000 patients per year (a third of which are from outside of Thailand) and serves 150 nationalities, is creating family & patient-centered private rooms, similar to those VIP rooms in major academic medical centers and some hospitals ststeside.

This type of room is quickly becoming the standard in an emerging and booming economy of medical tourism. Each of the rooms will have dedicated family space (for family members to live during their loved one’s stay), a kitchenette, all “hospital-looking” items (e.g., drapes, supplies, oxygen, etc.) will be hidden, and a top-notch entertainment system (e.g., 1,000 satellite music stations, hundreds of international tv channels, on-demand movies, wi-fi, i-Pod connection, etc.) will be provided. Their driving forces for creating these individual rooms over the next 18 months are:

•Provide patients a sense of control;
•Allow for family involvement;
•Provide for caregivers at the bedside;
•Create a sense of privacy and confidentiality;
•Develop a patient-centered model of care;
•Encourage a quiet and comfortable environment.

It’s amazing to see and while this is becoming a reality in Thailand (and some other hospitals internationally), it’s most likely several years off before becoming the norm within the industry.

by Nick Jacobs

What can you do for just $186E per year? If you're located in the small Balkan country of Serbia, the answer is relatively simple, that's what you have per person to provide health coverage to all of your eight million citizens. On a recent trip to Belgrade for a medical conference, I had the privilege of meeting privately with the Crown Prince; the Prime Minister of Health; also with the Major General in charge of the country's primary military hospital, and hundreds of physicians. Their primary message to me was that everyone needs to move on as we begin to seek co-operative opportunities to explore medical research that will provide a brighter future for all mankind.

We visited a rehabilitation hospital that provided spa coverage for its patients in the form of massage, mud wraps, heat treatments, saunas, hot springs, and numerous other amenities. At this spa hospital, the average stay for a joint replacement and rehabilitative treatment is about 21 days. In the U.S. you are usually released to Home Health and Home Physical Therapy after three.

We had an opportunity to visit a primary teaching hospital that does approximately 1200 invasive heart procedures annually and is fortunate enough to have over 30 cardiologists on staff. Although the average physician in this country makes less than a first year school teacher in the United States, they are so abundant because government supported education is still provided to all citizens.

But what of this challenge to care for the masses with less than $200 per year per capita compared to a nearly $6000 per year per capita expenditure in the United States? Obviously, there are not three MRI's per hospital in a country where the MRI was made possible through the work of Nicholas Tesla, a phenomenal Serbian scientist and inventor.

It's also a fact that their society is not so litigious as ours. In fact, during a presentation by a British MD/PhD he alluded to the fact that their guidelines were not written like those of the United States by and for the attorneys. Because of that fact alone, medicine is practiced very differently. It was interesting to watch a physician examine a patient without millions of dollars of diagnostic equipment meant to protect that physician from potential legal exposure and litigation. It seems like twenty years ago when you could observe a physician in the U.S. make a diagnosis from examining a patient by looking at them and listening to their breathing, heart beat and blood flows.

When patients ask me why an emergency room visit takes hours, the usual answer is that no one wants to take the chance of diagnosing or, worst yet, miss diagnosing a patient because of the lack of back up from numerous pieces of diagnostic equipment.

Moral to this post? Under $200 per year per capita is not nearly enough to protect and help an entire country's population, but $6000 with still questionable outcomes is probably significantly more than needed in a normal world.

by Christopher Cornue

During a routine inspection of a hospital in England by the Healthcare Commission in the late 1990s, a concern was raised regarding hospitals not having consistent, evidence-based, standardized care paths. From this, approximately a decade later, the Map of Medicine was launched.

Developed for use by the National Health Service in England and Wales, this tool was created as a framework for sharing knowledge across care settings and providing evidence-based care pathways to clinicians at the point of care. This electronic, website-based tool is an impressive collection of more than 700,000 articles and resource materials. While it is “localizable” as needed, it’s an awesome repository of information. As stated on their website, “for the first time all NHS staff such as doctors, nurses, midwives, allied health professionals, healthcare scientists and trust managers will have access to a single view of the best clinical information and latest guidelines relevant to a patient’s pathway and approved by NHS experts.”

While most physicians have a good sense of particular pathways to follow with patients, this tool is best used for those situations and conditions that are less familiar to the general practitioner. Research conducted has indicated that 80% of physicians will change the care they provide as the result of evidence-based knowledge. Among other desirable results, it’s been estimated that 12% more hospitalizations could be avoided and a 19% reduction in length of stay could be achieved as a result of practice changes based upon evidence-based information.

The Map of Medicine is being rolled out to all hospitals in England and Wales as an additional resource for physicians and to assist in NHS’ clinical governance. Dr. Michael Stein, Chief Medical Officer for the Map of Medicine, stated they are in discussion with some other countries to see if this would be adopted elsewhere. Who knows if it (or something similar) might be a resource available in your hospital in the near future?

by Tony Chen

Recently, I had the opportunity to experience a live demo of Microsoft's Azyxxi software. A lot of buzz has been circulating around the software for a few reasons:
- It was designed by physicians
- It's already working in 20+ hospitals across the country
- Pundits wonder whether Google or Microsoft will be the one to make the mark on healthcare. Personally, I think there's enough room for both of them.

Anyway, I have to say that I was actually quite impressed with what I saw. Azyxxi basically takes continuous data feeds from all the relevant hospital systems (lab, finance, patient, scheduling, ER, any system within the hospital) and rolls it up into one elegantly simple interface. While it's still unclear to me how these feeds are set up, I could quickly see the power that such a system could represent. Think about it - live data feeds in real time.

Anyway, here's the long-awaited screenshot:

You can't really see it well in the screenshot, but basically, users can:
- tailor their view & the data fields to be seen
- double click on any data field to get more info
- perform quick trending, graphing, averages, etc on any data element
- easily perform custom analysis
- easily get to key metrics, dashboard metrics, daily census, etc

Maybe the most impressive part of the demo was the person giving us the demo, Jon Handler, one of the original ER physicians that helped Azyxxi get off the ground. If you ever have a chance to meet him, I think you'll also quickly see that his passion for patients and consequently, for the right info in the right hands at the right time is refreshing. It almost makes me optimistic about the future of healthcare. Almost.

by Christopher Cornue

The retiring President for the Joint Commission, Dr. Dennis O’Leary, led a panel discussion at the ISQua annual meeting in October '07 focusing on the Hospital of the Future. Introducing the topic, Dr. O’Leary discussed the challenges that the Hospital of the Future will face, including:

•Increased cost of providing care;
•Reducing (or eliminating) preventable injuries and deaths;
•Increased scrutiny in a world of transparency;
•Increased number of uninsured and underinsured;
•Increased staffing and workforce challenges;
•Competition resulting from “disaggregation”

He also suggested we’re in the midst of several opportunities, including a boom in hospital construction, new / advancing technology, and new care models & concepts. These opportunities provide us the ability to meet several of the challenges he outlined and allow us to ensure we:

•Avoid doing more of the same in the future;
•Consider several factors and implications, including healthcare economics, professional staffing, patient & family-centered care, physical environment and technology;
•Allow that principles should guide development of the Hospital of the Future.

Do you agree with his assessment? What do you think is the biggest challenge facing the hospital of the future?

by Christopher Cornue

Dr. Don Berwick, President for the Institute for Healthcare Improvement (IHI), spoke to the delegates at the 24th Annual Meeting of the International Society for Quality in Healthcare (ISQua) about bringing improvements in healthcare to “full scale” and discussed the current IHI campaign to prevent harm to 5 million patients. I’m certain most of our readers are either aware of the initiative or probably active participants in it.

Dr. Berwick offered that 45% of needed care is not received, 22% of chronically ill adults report “serious errors” in their care, and 74% of these chronically ill adults say the healthcare systems needs “fundamental change.” He spoke about the vast variation in care and mentioned research by the Commonwealth Fund and the Dartmouth Atlas project. These data support the assertion that this high variation in the industry is not delivering better care or better access. He further suggested that our industry’s usual response of “demanding that things be changed” is not working. We aren’t addressing the fundamental flaws in the system, so our focus should really be on redesign of our systems. This is a foundation for the 100,000 lives initiative, as well as the campaign to reduce harm to 5 million lives.

In a discussion about where IHI has been, Dr. Berwick talked about the organization’s focus over the past several years, with each approach building upon the previous. So, the approaches for IHI have been Awareness, Education, Collaborative Improvement, Redesign, Movement and finally, currently, Full Scale efforts. He was proud of the evolution of the IHI, rightfully so, and is excited about what he expects to be a successful campaign to prevent harm to 5 million individuals. Visit the IHI website for more information about the campaign and the work Dr. Berwick and his organization have led the past few decades.

by Nick Jacobs

The World Congress on Cardiology met last week in Belgrade, Serbia, and, as an invited speaker, we are going to be exploring the efficacy of the coronary artery disease reversal program currently being studied at our research institute. One of the most unique findings of our studies, as identified by our lead researcher on this topic, Dr. Darrell Ellsworth, is a major reduction in measurable depression scores. After having personally gone through the program nearly ten years ago, it is very clear to me exactly why this is the case.

When any type of serious medical reality hits us, be it a cancer, heart disease, or neurological dysfunction, we are thrown into a spiral that feels irreversible. All of our lives, we have worked very hard to ensure that we had as much control over our personal situation as possible. At the same time, we tend to live in denial of our own mortality until we are staring it directly in the face.

What we/I have found with programs like the Dean Ornish Coronary Artery Disease is that, not unlike the old factory experiment directed toward seeing if low lighting or bright lighting made the employees happier, the outcome was that either worked equally well because the act of changing the lighting demonstrated that someone was paying attention to them.

In our research, a group of highly trained medical professionals work carefully with each participant to explain his or her condition, risks, challenges and alternatives. The most important outcome, however, is that the patients are taught how NOT to be victims of their disease anymore.

It is my deep belief that every human being would benefit from this type of exposure to medical professionals, people who take the time to help us sort through our personal situations, to give us hope and to ensure that we will have mental and physical support while working toward improving our health both mentally and physically.

by Christopher Cornue

I was recently at the ISQua Annual meeting where an interesting panel discussion involved three leaders from the Czech Republic, Thailand and France. Much of the discussion was on the imminent workforce challenges.

Information from the Global Health Workforce Alliance (which estimates we’re dealing with a worldwide shortage of 4 million professionals) and the World Health Organization (WHO)’s Global Atlas were shared with attendees. Among the most striking pieces of information is the Global distribution of health workers in WHO Member States chart at this link (pdf) . This shows the disparity in Health Management and Support workers across the WHO Member States. Specifically, it shows a density of healthcare workers for the USA is 24.76 per 1,000 people and UK 21.20 per 1,000 people in contrast to 0.00 per 1,000 for Sierra Leone, 0.01 per 1,000 for Sri Lanka and 0.04 per 1,000 for Zimbabwe. This WHO website offers other revealing information, including health expenditure ratios, and per capita expenditures on health. It’s worth a look!

Guest post by Dr. Marc D. Rothman

A sobering article this summer in Archive of Internal Medicine highlighted yet another way in which, despite all the good intentions of high-tech folks like us and our reliance and devotion to our digital tools, some of the most basic differences between groups of people continue to predict who does well and who does not when it comes to health care for older people.

As if income, insurance coverage, and race weren’t enough… enter ‘health literacy;’ the ability to read, understand, and utilize basic health-related information like prescription bottle labels and appointment slips. The authors looked at more than 3500 people over 65 years, tested their initial health literacy and followed them for 6 years. The results were eye-opening:

A quarter of the folks had inadequate health literacy, meaning they misread prescription bottles and appointment slips. This group had a greater chance of dying over the next 6 years (40% chance vs. 18% for those with good literacy), even when adjusting for everything else under the sun (race, income, smoking, diseases, meds, etc.).

The difference in death rates was most pronounced for cardiovascular deaths (as compared to, say, cancer), possibly because managing heart disease takes lots of appointments, medications, tests, etc.? And what’s most upsetting is that the magnitude of this association between inadequate health literacy and mortality is about the same as the association between low income and mortality.

Though the study was well done and interesting, it doesn’t come as much of a surprise to me. As a geriatrician it’s astounding to see the complexity of a patient’s diseases and management.

Six or eight chronic diseases, ten to twenty pills taken four times a day to treat them, five other docs each managing only one ailment, and so on.

In the future it’s not only the pill box label that will need to be read. It’s a maze of competing interests and trade-offs, decisions about how or whether to treat, possible complications and side-effects which sometimes resemble the diseases themselves. And harder still, the fact that so much is uncertain: the physician cannot always be sure, and neither can the patient. This last concept is the most complex, but ALL of it is complicated to a degree that is difficult to appreciate.

If you think I’m nuts, go to your grandparents house and ask them to show you and explain what pills they take, what they’re for, how that disease is doing, and what their system is for managing it all. They you’ll know what it’s like on a good day. Just imagine putting it all together the first day back from the hospital after a two week stay, when three pills were stopped and two new ones added.

I’m not saying it takes a PhD to understand one’s own health and health care, but it wouldn’t hurt either!

Dr. Rothman is a specialist in geriatrics and long-term care. He is finishing up his fellowship at Yale University School of Medicine.

by Tony Chen

Check out the list from Nursing Online Education Database:

1. Uninsured millions affecting everyone
2. Obesity is dangerously on the rise
3. Pharma companies control more than you think
4. Hospital Staff shortages are killing people
5. Veterans are being neglected

For us healthcare folks, these are probably pretty well-known and maybe even assumed. But for the general public, these are the issues that need to be raised.

Are there other issues that need to be on this list? Patient Safety/medical errors (sort of tied to #4)? Medicare bankrupt in our lifetime?

by Christopher Cornue

During one of the sessions at the recent International Society for Quality in Healthcare (ISQua) Annual Meeting in Boston, three thought leaders in physician practices discussed the physician’s role in patient-centered care. At the heart of their discussion was a document from the UK titled “Good Medical Practice”. This document details what is expected from each physician and sets the expectations for both physician and patient. In 2007, the National Alliance for Physician Competence completed their work creating a similar document for use in the United States, based largely on the document from the UK, as well as Canada and some other countries. Detail of their work is available at gmpusa.org.

They also discussed the apparent gap in preparing our professionals for their roles in healthcare. Specific to the discussion was the example of physicians vs. nurses. Physicians go through years of training, as do nurses. However, there’s no “transition” to the active role as practitioner for nurses. After medical school, doctors go through residency which then validates their training and they achieve in depth experience before they take care of their first patient. There are a series of accreditations that occur, with checks and balances to ensure every needed aspect of medical training is covered in residency and before they can obtain their license and become credentialed. In nursing, once they’ve completed their coursework, they start working at the bedside without a similar “transition” as with medical students. They asked the question … should there be something formal in place before they receive their license and start taking care of patients?

Finally, the session concluded with a discussion about research showing that, according to patients, a doctor is good if he/she: 1) has expert medical knowledge & skills; 2) is empathetic & respectful; 3) has excellent interpersonal skills; and 4) is honest. These are very realistic expectations by patients. The Good Medical Practice document is offered as a foundation of expectations between patients and physicians, and will hopefully help to bring additional attention to these very real expectations.

by Nick Jacobs

The World Congress on Cardiology is meeting this week in Belgrade, Serbia, and, as an invited speaker, we are going to be exploring the efficacy of the coronary artery disease reversal program currently being studied at our research institute. One of the most unique findings of our studies, as identified by our lead researcher on this topic, Dr. Darrell Ellsworth, is a major reduction in measurable depression scores. After having personally gone through the program nearly ten years ago, it is very clear to me exactly why this is the case.

When any type of serious medical reality hits us, be it a cancer, heart disease, or neurological dysfunction, we are thrown into a spiral that feels irreversible. All of our lives, we have worked very hard to ensure that we had as much control over our personal situation as possible. At the same time, we tend to live in denial of our own mortality until we are staring it directly in the face.

What we/I have found with programs like the Dean Ornish Coronary Artery Disease is that, not unlike the old factory experiment directed toward seeing if low lighting or bright lighting made the employees happier, the outcome was that either worked equally well because the act of changing the lighting demonstrated that someone was paying attention to them.

In our research, a group of highly trained medical professionals work carefully with each participant to explain his or her condition, risks, challenges and alternatives. The most important outcome, however, is that the patients are taught how NOT to be victims of their disease anymore.

It is my deep belief that every human being would benefit from this type of exposure to medical professionals, people who take the time to help us sort through our personal situations, to give us hope and to ensure that we will have mental and physical support while working toward improving our health both mentally and physically.

by Tony Chen

I had the pleasure of reviewing a new site, Huspital.com, which officially launched just last week. "Healing Us and Changing Healthcare," Huspital is a perfect example of web 2.0 in which consumers, scientists, physicians, and just about anyone can connect and share healthcare-related information.

From the founder, Jason Schultz:

"The old Industrial Age paradigm, in which health professionals were viewed as the Exclusive Source of medical knowledge and wisdom, is gradually giving way to a New Information Age worldview in which patients, family caregivers, and the systems and networks they create are increasingly seen as important healthcare resources."

To give you a snapshot of the conversations that have been going on within the site, here are a few snip-its:

"If I mention that I read something about a health condition on the internet, my doctor immediately gets an attitude and tells me not to believe anything I've read on the internet. It doesn't seem to matter that I've gotten this information from well known sources..."

"I took an article I had printed out from the internet to my family practice doctor and had her react with great anger and throw the paper in the trash..."

Like I've said in the past, the "magic" for these social media sites is to attract a critical mass of users to have consistently high quality and highly specific content. And apparently, there are ~1,000,000 users on a private site that will be transitioned over in the next few months. The site I previewed was the beta site with just a handful of test users.

As most of you know, RevolutionHealth has also tried to create this healthcare vertical social network. I think they've experienced only limited success because it is too exclusively consumer-driven (let's not throw out the baby with the bath water). I believe the "magic" of a successful healthcare social network will be intelligently blending the opinions & ratings of consumers with real medical/clinical insights from practitioners. Let's see if Huspital.com can do just that.

See the PR releases here and here.

by Christopher Cornue

As a follow-up to my previous post on the ISQua annual meeting, I wanted to share some thoughts on one keynote speech by Dr. Karen Davis of the Commonwealth Fund. She delivered an impressive and humbling assessment of healthcare in the US and internationally. There is a great deal of work ahead of us all. The premise of her discussion is that if we, as a global community, are to achieve long and healthy lives, we need to have: 1) high quality of care; 2) access & equity; 3) efficient care; and 4) system & workforce innovation and improvement.

Recent studies conducted by the Commonwealth Fund have focused on some 30+ metrics (as part of a scorecard they created) and their findings may or may not be surprising to all of us. In the Why Not the Best report (2006), the United States scored 66th out of 100 – ranking it one of the lowest in the provision of healthcare. Another report released by the Commonwealth Fund compared six top countries, based upon 69 indicators, and the United States ranked last.

With regard to information technology, these reports indicate that the United States and Canada lag other developed countries significantly in primary care physicians usage of electronic patient medical records, with compliance percentages of 28% and 23% respectively. Denmark has 98% of their records electronically based … and have implemented a fee-based structure to encourage physician compliance. Specifically, physicians are paid for communicating with their patients electronically (e.g., through email), for “phone visits,” and are not paid until all electronic health information is submitted. The Danish health system has created a central data repository for patient information, which can be accessed by patients at any time – in fact, they can track who has accessed their information, so that privacy has a “check and balance” associated with it.

Preventative information is built into this central repository (e.g., they are contacted for routine, preventative appointments, screenings, etc.) and patient satisfaction has increased to a level that is top across Europe. The Danish health system also has 24-hour physicians available for consultation if a patient needs to access medical advice or help at 2:00 in the morning, for example.

Another example cited was the Geisinger Health System in Pennsylvania, who has been an early adopter of electronic healthcare information. They’ve implemented an electronic medical record and have created a portal for patients to access the hospital’s services, their records and have developed a “virtual” closer relationship with their healthcare providers. Patients can now schedule their own appointments, which has led to reduced no-show rates and increased participation by patients. There isn’t enough space in this posting to do their work justice, but suffice to say this is an excellent example of a well coordinated, patient-focused technology that will most likely change healthcare.

In closing, Dr. Davis charged the attendees, and in fact everyone in healthcare, to work toward a series of solutions she feels will rectify our healthcare crisis. Among them are: 1) extending healthcare insurance to all; 2) coordinating care around the patient; 3) pursuing and raising the benchmark, while decreasing variability in care; and 4) ensuring the private and public sectors work in harmony. Finally, she discussed the concept of a “medical home” for everyone – where a patient can feel comfortable knowing there’s one place one can go for coordinated and good health care. Patients all want their information in one place. They also want physicians who know them and provide specific care to their needs. These are laudable concepts that I believe are becoming the foundations for our work going forward in healthcare. Thank you Dr. Davis, for your charge to, and willingness to work with, all of us in healthcare.

by Jeff McKune

Tony posted an entry about HealthVault, and it looks like Microsoft has multiple healthcare irons in the fire. HealthVault appears to be more of a consumer oriented PHR platform, while Azyxxi is a data warehousing and query tool that is directed at healthcare organizations such as hospitals. It should not be any surprise that the healthcare industry has caught the eye of one of the world's largest information technology companies. We hope to see a demonstration of Azyxxi soon, and one of us will provide an update with additional details at that time.

To add to the discussion regarding using generalized networking tools such as Facebook in a healthcare context, we should mention the Joint Commission's most recent efforts. The Joint Commission has started a wiki called WikiHealthCare based on the TWiki enterprise collaboration and knowledge management solution. A wiki is a tool that allows knowledge to be shared and edited by multiple contributors. Wikipedia is good example of a very popular wiki.

It looks like smoking cessation was the sprout from which WikiHealthCare grew, and it now includes the following general discussion categories:

Quality Improvement Discussion & Solutions
Smoking Cessation Counseling Programs
Smoke Free Hospital Campus

Standards Development & Research
The Transfer of Health Information
Pharmacist Review and Use of Protocols for Contrast Agents in Radiology
Microsystems and Patient-Centered Care

WikiHealthCare was announced on September 12 and in less than a month, there are 2,774 registered users of the system.

It would seem that the vision of online collaboration using multiple information technology tools and covering a wide variety of consumer and management healthcare topics is unfolding as we discuss this. So what will the future bring as these systems develop? The key concepts of integration, consumerism, transparency, and quality will no doubt shape these systems. Will there continue to be separate and distinct physician, hospital management, and patient wikis, blogs, and networking tools? These are growing now, but I believe that we are not very far from a time when patients, physicians, and hospital administrators will be sharing information, expectations, challenges, and collaborative solutions using these online tools. You may be seeing some of this already at your hospital.

The technical walls for sharing information are, for all practical purposes, non-existent. The expansive school of hard knocks, coupled with business models that demand trust (HealthVault won't stand a chance if there is a breach), are forcing companies to more stringently address online security issues. It's not technical and security bricks in these walls - it is more likely legal and cultural issues that hinder open communications.

The pieces are falling into place. How will this change health care when we all sit down at the virtual table and talk on a global scale? It sounds sci-fi, but it isn't. It's happening.

by Nick Jacobs

I'll admit it. I'm a Starbucks addict. It's not a coffee thing. It's the chai tea thing. My cup last week had one of those "The Way I See It" quotes, actually it was #251, and it hit me right between the eyes. "Our greatest prejudice is against death. It spans age, gender and race. We spend immeasurable amounts of energy fighting an event that will eventually triumph. Though it is noble not to give in easily, the most alive people I've ever met are those who embrace their death. They love, laugh and live more fully." This was a quote from Andy Webster, a Hospice chaplain in Plymouth, Michigan.

Actually, that morning I got a call from home that our dog of 15 years was going down hill fast and that it was my turn to handle this situation. Actually, it has always been my turn, but that's another story. So, I took him to the vet, held him close and petted him as they tranquilized him and helped him transition. It was very difficult, but it was absolutely the right thing to do for him.

During that visit, my fourth time to the vet for a similar situation during the last several decades, my mind went back to the Netherlands, to the very moving scene in Soylent Green where Edward G. Robinson visits a euthanasia clinic and is put to sleep amid montages of a peaceful green world and finally to the nearly 78,000,000 people in my generation of Baby Boomers.

My prediction for my peers is that we will change health care in the United States. My prediction is that we will, as a generation, embrace death, and that, as Andy Webster said, we will not give in easily. We will get plastic surgery, exercise, watch our diets, do our yoga, take our fish oil, and laugh, love and live life fully until it's time to go. Just like Brody.

by Tony Chen

Is your organization seeking to make an impact in healthcare?

If you are interested in purchasing a link (see the sidebar) under our "Healthcare Impacters" area or learning more about other partnership opportunities at hospital impact, please feel free to contact me for more information.

tony [at] hospitalimpact [dot] org

Hospital Impact consistently attracts ~10,000 unique visits per month. Our readers tend to be tech-savvy, progressive, forward-thinking healthcare and hospital leaders - could be a great niche for the right company.

by Christopher Cornue

The overarching theme of this year’s annual International Society for Quality in Healthcare (ISQua) meeting, being held in Boston last week, is how information technology is shaping and advancing healthcare on an international level. Many of the speakers touched upon how technology is being used effectively to improve healthcare – one example, Denmark is approximately 98% electronic medical record compliant (this is for the whole country, not just one hospital!). More about Denmark later, but first, you need to meet a remarkable person, Karen Davis, Ph.D.

I’ve had the pleasure of spending time with Karen Davis, and she’s one of the nicest and most down to earth people I’ve met. She wields a great deal of power in Washington, D.C. and across the globe & she’s absolutely brilliant. Dr. Davis, recently named one of the 100 Most Powerful individuals in Healthcare and one of the top Women Leaders in Healthcare by Modern Healthcare, is President of the New York City-based Commonwealth Fund.

All healthcare leaders should become familiar with The Commonwealth Fund, an organization engaged in independent research on health and social issues, and a leader in the discussion of international healthcare issues. Just peruse their website and you’ll get a flavor of their work and pay special attention to two recent reports:
- Why Not the Best? Results from a National Scorecard on U.S. Health System Performance
- Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care

More on Dr. Davis's plenary talk in my next post.

by Tony Chen

In the past, we've talked about a "GlucoPhone" that can read and transmit blood sugar results. We've also talked about the wisdom of incorporating healthcare into everyday life (versus compartmentalizing healthcare as a separate destination). Well, here's one idea that aligns with that concept: a (prototype) wellness phone that assesses your stress level, measures your body fat %, takes your pulse, analyzes your breath, and gives you pep talks.

Still in prototype (and they're only testing it in Japan for now), but nonetheless, a great idea. See more pictures and more on how they fit it all in there here.

Sooner or later, someone is going to figure out how to make wellness un-annoying enough (or maybe even fun!). How great would it be if hospitals could be a part of that conversation?

by Tony Chen

Read my post over at World Health Care Blog on Microsoft's announcement today on HealthVault. Props to NY Pres Hospital for being a part of this. And get ready for Google's announcement within the next 6 months.

by Tony Chen

Okay, I think it's time to talk about the big pink elephant in the middle of the room. Time and time again, we have skirted the issue. But no more.

Has anyone read the book Men are from Mars,Women are from Venus? I skimmed it quickly once standing at a Borders, and it's surprisingly good. It's like men and women are talking a completely different language. A lot of words are exchanged, but somehow nothing is connecting. Is there that much of a difference?

In the hospital world, the stereotypes go like this:

Physicians are greedy. All they care about is money, money, money, just trying to make that extra buck, squeezing in that extra patient.

On the other extreme, physicians and nurses don't care about money or business at all - they don't care if we lose our shirts and close shop. While we applaud their compassion, they have no sense of the system and how things need to be run to be sustainable.

As for adminstrators, they are just heartless and clueless. They have no idea what happens on the front lines of patient care. They have no idea that every patient has different needs, different issues. Every patient has a family. Administrators are just about bean-counting. They just care about numbers and metrics and these spreadsheets that have nothing to do with anything. Isn't healthcare about helping people in their greatest moments of need?

Okay, so there, I said it. It's out there.

Now, let me just be clear that most of the physicians and administrators I know don't fall into these extreme stereotypes. Most physicians are patient-focused to the core but also have a sense of the bigger systems picture. Most administrators care about healthcare, care about the long-term health of the hospital, and desire better results for the right reasons.

The problem is that this perception has been ingrained by so much previous bad experience and miscommunication. How do we begin to turn the tide?

1. Spend a day in my shoes. This goes both ways. Spend a day (or even just an hour or two) shadowing your counterpart. So many people gave me this advice when I first started working for the hospital. For administrative and corporate folks, go on rounds with physicians. Spend 4 hours on a nursing floor (during a shift change) and you'll begin to understand how many split-second decisions are made with such precision and finesse by your front-line clinicians. And for clinicians, take some time to listen to the pressures and challenges that the administrator faces. Think about how one seemingly "small" decision sets a precedent for a thousand others and the potential impact on the whole organization.

2. Get to know the people behind the roles. This probably goes without saying, but I haven't seen this done nearly as much as it should. And I'm just as guilty of this, too. When you know that Lucy has 3 kids and one of them is having a hard time at school, when you know that Dennis went into healthcare finance because his 3 aunts went broke from hospital bills, it's that much easier to work together. We're all just people. And eventually, we are all patients, too.

3. Begin to learn each other's lingo. This goes with the previous points. More and more, I'm realizing that it really is a different language. Literally. The acronyms, the abbreviations, the slang, the inside jokes - sometimes we spend so much time in our own little world, we forget that others don't understand (or worse yet, misunderstand) what we're trying to say.

4. Give people the benefit of the doubt. I know this is soft and fluffy, but remember that those stereotypes above probably don't apply to 90-95% of the people you work with (Nick just commented that only 10 out of his 550 physicians fall into that "greedy" category).

5. Realize that you need each other. Like it or not, someone has to see each patient, and yet someone has to focus on the aggregate. More importantly, there are some issues and problems that may never be solved without the two working together. Some finance guy looking a spreadsheet doesn't understand why a cost started going up, while the clinician may not even notice that it's gone up. Working together and bringing both expertises/perspectives, a better, more creative solution can be found.

What else would you suggest?

by Nick Jacobs

It dawned on me the other day that several of my recent posts have been about problems, but many of them do not prescribe solutions. This one has a solution. If your doctor doesn't give you alternatives, fire him. If he or she doesn't encourage you to get a second or even third opinion, get another physician. If, as a man over 40, you have not had your prostate checked, question your physician's ability to practice. If you're a female over 40 and you are not receiving advice relative to your breast or pap exams, your physician is not doing his or her job.

Where is this coming from? Over the past twenty plus years, it has been my very bad experience to have known a number of physicians who are completely driven by finance. The goal of these physician is to do the fastest, least thorough medicine possible, just above the lawsuit level. It is their challenge each day to get as may patients through their practice as humanly possible, and skip the details. We've all known people like this, but in medicine they can be lethal.

When questioned about the percentage of patients recommended to have mammography each year from one of these practices, the reply is short and sweet. "Don't know, don't care. Takes time to write prescriptions and make arrangements. Probably less than 10% of those who need it."

When asked how much can be made by selling drugs to patients from an in-house pharmacy, though, you will receive a price quote per pill, per ounce, per patient or per hour. If there is a piece of equipment for which this physician can receive a professional fee on the property, every patient possible will be run through it as often as insurance will allow. Chest x-ray? Stress tests? Halter monitors? If it's part of the financial base, it will be part of your bill. In chiropractic they call these practitioners churners.

Somewhere along the way docs like this get off the Hippocratic path. They stop remembering what medicine is about, and many times stop caring about those people who have placed their lives in their hands. Nothing infuriates me more than a physician in a meeting who ignores three pages and three cell phone calls. It makes me ask the question, “What if that page was about someone that I loved?” These physicians usually avoid admitting patients to a hospital for even severe situations, and they are most often extremely rich.

Watch out for the signs of greed displayed by your personal physician because they are not always materially visible. Sometimes it's ownership of a lot of land, a place in Aspen, the newest Porsche, more diamond rings on their fingers than could be mined in a week; but, most often, it's a detached, cold, fast paced, business-like approach to you that makes you feel more like a widget than a person.

If you experience this, say, “Thank you doc. Please give me a copy of my medical record,” and then run like hell.

by Christopher Cornue

If you aren't familiar with the International Society for Quality in Healthcare (ISQua), you should be! This organization, based currently in Australia, has been leading efforts the past quarter century to advance quality and safety in healthcare on an international front. They have representatives from more than 100 countries and have the majority of their membership based in Europe (38%), USA (roughly 1/4) and Pan-Asian (roughly 1/4).

Their 24th Annual Meeting is occurring this week in Boston, and it's guaranteed to be thought-provoking and innovative. Approximately 750 attendees are meeting in Boston to discuss quality, patient safety, international healthcare collaboration and research efforts. The theme this year is integrating information technology in efforts to improve quality. Keynote speakers include Karen Davis (President for The Commonwealth Fund) and Don Berwick (President for IHI), among other noteworthy leaders in the industry. I've been proud to be a part of this organization the past four years and look forward to offering insights from the meeting through upcoming postings. Look ISQua up on the web and stay tuned for more postings regarding this meeting and organization.

by Jeff McKune

My Dad and I were recently discussing healthcare issues, and he told me that he argued healthcare topics when he was on his high school debate team. In fact, in 1947 he was given the debate topic "Should the Federal government provide a system of complete medical care available to all people at public expense?" Sixty years later, the question of government's involvement in healthcare is still a hot topic, and it is one of the leading topics of the 2008 presidential race.

A little over a week ago, John Stossel hosted a 20/20 program titled "Sick in America: Whose Body Is It, Anyway?" One of the things I liked most about the program was the way that Stossel covered some challenging issues such as the linking healthcare insurance to employment, over utilization, and the profit motive. He also had a nice segment comparing the system in the United States with those in other countries, specifically Canada. I found the whole program to be refreshingly frank.

The last part of the program focused on private solutions to healthcare problems versus government solutions, and the importance of competition and individual choice. Stossel gave a couple of examples where competition among healthcare providers has led to improved quality and lower prices, even during a time when most of the industry is experiencing higher prices. Those two examples were LASIK eye surgery and cosmetic surgery, both of which are usually not covered by insurance. LASIK prices have dropped 30%, and the quality has improved. Providers have to compete because patients are shopping around knowing they will pay for the procedure out of their own pocket.

When discussing healthcare challenges, we often focus on what does not work. But what does work? The things that work for healthcare are the things that have worked for our country in many other industries: Freedom of choice, competition, innovation, and the availability of information for potential buyers. If we know these things work, as hospital leaders, how can we best connect to these basic tenants?

by Tony Chen

All this talk about health care policy, healthcare blogging, and hospitalk, sometimes it's easy to forget that we are talking about real people, real sons, daughters, fathers, mothers, wives, husbands, and loved ones.

Yes, we have to run tight ships financially to ensure the long-term sustainability and advancement of our hospitals. Yes, we need to learn the business of healthcare. Yes, we have to think aggregate in numbers. But let's always remember that we are serving individual people, many who are in the most scaring, vulnerable moments in their lives.

I ran across this story at Blog, MD about Derek Madsen, a 10-year patient who had a rare childhood cancer. Please take a moment today and go through these 20 gripping Pulitzer prize photos of his journey.

Also, we've collected a few other patient stories here.

by Craig Ahrens

I have not blogged in a long time and I apologize. As most of you know, I attempted to launch www.thebusinessofhealthcare.tv months ago and unfortunately had to pull back on the website official launch again until next month. Long story short, it is difficult to start any business – legally the loops you have to jump through are extreme especially when it comes to this type of business model. It has been an all consuming effort and fortunately I have partnered with individuals who are going to ensure a smooth startup. So, look for it again and I appreciate your support and welcome your ideas!

At the same time, I left the consulting world to work for one of my clients. They offered me the opportunity to work in one of the most competitive markets and service lines in the country – Indianapolis as a Neuroscience Service Line Executive Director. Normally, I would not have been interested in this position, but the chance to work in a non-CON, advanced specialty hospital, competitive market with an excellent health system was too enticing. I thought that it would be interesting to post my experiences working in a new role.

Service line executives are difficult roles to manage. They are difficult primarily because of three reasons:

1. Many of the relationships with operational staff are matrixed through Chief Nursing Executives.
2. Physicians and CEOs are used to negotiating business development opportunities minus a “middleman”.
3. Operationalizing plans and business development initiatives is difficult given the myriad of relationships to navigate.

How does one overcome these issues? In my opinion, the most important thing is for the CEO/executive team to visibly communicate to administrators and physicians that you are the go to person for the service line. Without this support, you are dead in the water with the matrixed relationships. Further, the physicians will continue to pursue the pattern of going straight to the CEO to discuss any opportunity. To some this may seem odd, but you need to market yourself internally and to be seen as the person who shepherds initiatives and gets them done through navigating the internal political hospital dynamic. I will continue with part II next week. Any comments?

Craig Ahrens, MHA, MBA, FACHE is the Executive Director of Neurosciences for St Vincent Health in Indianapolis, Indiana (part of Ascension Health System). He is also President of www.thebusinessofhealthcare.tv (due to launch in late 2007), which is the web’s first internet tv program dedicated to healthcare business news and interviews. He can be reached at info@thebusinessofhealthcare.tv

by Nick Jacobs

From MSN Money: "Patients in the highest-rated, five-star hospitals in the United States are at a 65 percent lower chance of dying than patients in the lowest-rated, one-star hospitals, according to a study released by HealthGrades, a health-care ratings company. If all hospitals included in the study performed at the five-star level, the lives of more than 273,000 Medicare patients could have potentially been saved over a two year period. Fifty percent of these potentially preventable deaths were associated with four diagnoses: heart failure, community acquired pneumonia, sepsis and respiratory failure."

From "Health Daily News:"

Today, some health care executives, insurers and physicians are . . . fully embracing disclosure and apologies, not only because they believe it will reduce malpractice claims, but also because it's ethically the right thing to do."

Larry Dossey, M.D. from "Reinventing Medicine," "For more than a century the profession of medicine has tried to become increasingly scientific and technical, because this is where we believed the future of healing lay. Now a monumental shift is occurring, empowered by the evidence that consciousness is a powerful factor in the world."

Finally, Dr. Karen Donelan, Senior Scientist in Health Policy, Massachusetts General Hospital, gave a wonderful description of her experience in the health care system. A dear member of her family received timely access when the pcp's answering service worked, the receptionist, technician and doctor all showed compassion and demonstrated their desire to be there for the family and the patient. At every step information and decisions were shared, so much so that the family felt part of the care team, and finally the doctors were highly trained and had all of the right tools. She described this as truly, significantly different care than they had ever observed with other family members. According to Dr. Donelan, "It was seamless, high quality , accessible, compassionate and expert with a fully disclosed price and plan of treatment."

It was the care that her dog, Rico was given by the vet. Surprised, don't be.

by Jeff McKune

In an earlier blog entry, Tony wrote about upcoming offerings by both Google and Microsoft. It looks like the name of Microsoft’s offering is Azyxxi (“ah ZIK see”). Microsoft describes Azyxxi as a tool for integrating disparate healthcare IT systems to provide better management of patient data for clinicians and quality managers, as well as better decision support for financial managers and hospital administrators.

I have not been able to dig up many details about Azyxxi as yet, but it appears to be a collection of interfaces to “best of breed” healthcare IT systems which categorize and feed data into a generalized data warehouse. On the user side, data is presented through “on the fly” views to provide for real-time queries and decision support.

At first blush, it would be easy take the position that “Hey, we already have an integrated HIS.” My experience thus far has been that integration is a good word for HIS vendors to toss around, but when it comes to answering everyday questions about hospital operations, many existing systems are frustratingly inept. Will Azyxxi be able to fill the gap? Time will tell. There is certainly a lot of hype about the product. I would love to see it first hand and have a nuts and bolts discussion with someone who really knew the architecture of the system.

Though an incomplete and informal article, the entry in Wikipedia lists some of the hospitals using Azyxxi. With several of us blogging here, we should be able to provide more details as they become available. If you know more about Azyxxi, please share it. We would also be interested in seeing some good quality screen shots, as well as a list of compatible existing HIS products. Here are a couple of additional links:

Microsoft Pairs with MedStar Health and Washington Hospital Center on Healthcare IT Solution to Improve Patient Outcomes
(Background article on 2006 acquisition)

Azyxxi: New Clinical Informatics System Improves Practice of Medicine
http://www.georgetownuniversityhospital.org/documents/Physician%20Update/PhysnUpdJan06.pdf (actual link provided because blog software isn't accepting it as a link)
(article on page 2 of this document)

Microsoft Azyxxi One Year Later; 21 hospitals and counting
(August 2007 blog article by Microsoft’s Worldwide Health Director Bill Crounse, MD)

by Tony Chen

"We're all about making children happy, they are all about health and making children healthy. I think when you combine that together it's a very powerful one-two combination. - Disney Rep"

Just in case you hadn't seen it, Disney is going into the hospital business. With its $10MM donation, this newly renovated children's hospital in Orlando will bear the Disney name and benefit from Disney "imagineers" for how the patient (and family) experience should be. Previously we wondered in great detail what would happen if Disney ran your hospital. Now we're going to find out.

(by the way, after I wrote that series, I got a lot of criticism from people who thought Disney & fun just can't mix with the serious business of healthcare.)

Nonetheless, I continue to believe that this is a great development for healthcare. Customer delight and hard-core clinical outcomes are not mutually exclusive (in fact, some would argue that they are positively correlated!) How much better can a kid fight off a life-threatening disease if the environment isn't so intimidating, cold, or unfamiliar? This will be a great little test case.

I wish I could have been a fly on the wall when Disney execs discussed the pros and cons of this fairly risky business decision. Did they think about the risk of having their name on a facility where kids may die? Did they think this could be so successful that other Disney hospitals would start popping up all around the world? Did they think about whether this would be a brand-diluting move? Did they realize what a sleeping giant they may have awakened? Did they realize that this move may eventually challenge all hospitals to "imagineer" and redefine the patient experience? Do they know what they are getting themselves into with bad debt, collectibles, malpractice, and lawsuits?

Then again, $10MM for them is a drop in the bucket (they made $3.4 billion in net income last year). To them, this is probably a little experiment that could generate a lot of positive PR & leverages their brand/core segment perfectly.

What do you think? Physicians - how would you feel working at "the Disney Hospital?"

by Nick Jacobs

Tony said that he would write a summary of the happenings at the Consumer Health World Blogging Conference, and he did. Here's my take, overall, for as hard as everyone tried, it would have been cheaper for me to snail mail each participant a copy of my last blog with cash inside the envelope. When you consider the airfare, hotel, meals and tips, plus all of the money invested in my time by my employer, we are into some fairly serious numbers.

Truthfully, it reminded me of the first year that we did patient evaluations through a leading U.S. company that was completely insensitive to small hospitals. It cost so much to hire the company, and to use their forms and evaluations, that we could have stood at the door and handed each exiting patient a crisp new $100 bill and said, “So, how was your stay here?” I’m sure we would have gotten an even better set of responses than we had already.

The good news about this event was that there were savvy people in attendance who created podcasts, streaming videos and other means of communicating, and the people who were there were gracious, polite, serious and engaged.

Truthfully, as the earth’s first hospital CEO blogger, I feel a little like Christopher Columbus. I’m sure that eventually my peers will get this. They will somehow learn about the power of viral marketing, and realize that the earth is flat, but, like Chris, the big money, big acceptance, land grab, and recognition will probably comes years after I am just a memory in the blogsphere. They will say, “That Nick was certainly ahead of his time. He was such a genius.” Okay, maybe it won’t be that nice, but I’ll bet at least my grandkids will say that. Okay, maybe not.

Just so you know, this was NOT sour grapes. I got to hang out with some nice people, meet and work up close and personal with my hero, Tony Chen, had a two day reprieve from work reality and loved every minute of it. Besides, I’ve lived to see Elvis on Ed Sullivan, The Beatles, Man’s First Step on the Moon and me blogging. My share of the excitement is right up there with the best of them.

So, let me close by saying, “First is not always the best, but, when you’re first, you do get a much better view of the scenery.”

by Tony Chen

I'm here at the Consumer Health World Conference in Chicago, IL. Though at first the crowd seemed a bit sparse, it is shaping up to be an interesting conference. Smaller conferences with the right people make for very productive networking and conversations.

Today Nick Jacobs and I spoke at a session about Blogging & Social Media for Providers (after hundreds of emails and phone calls, this was the 1st time Nick and I have met face to face!). Thanks again to all for attending. As promised, here's my list of top 10 sites to check out as we think about the impact of social media on providers.

1. Nick Jacobs' Blog - the first hospital CEO with a blog recently posted about his "journey to web 2.0" - he shares how he almost got fired for his blog. Good thing he didn't.
2. Running a Hospital - Paul Levy (CEO of urban hospital in Boston) takes transparency to the next level, asking the public if he makes too much money and posting the intimate details for their plans and quality metrics.
3. Hospital Impact - One day, Hospital Impact will truly be community, a two-way street, where best practices in hospital leadership can be shared more quickly, thoughtfully, and practically.
4. ratemd.com - 100,000+ doctors rated by patients, is yours?
5. Revolution Health - ratings for doctors, hospitals, and health plans + shopping comparisons + tools to keep your medical records & insurance straight. This is Steve Case's bet that consumer-driven healthcare is the next big thing.
6. Carepages - Patients can blog from their hospital bed about their hospital experience and their experience with their disease.
7. patientslikeme.com - a very powerful patient community whereby patients with the same illnesses can share notes AND compare test results. There's no way we could provide this kind of support for these specific patients, so shouldn't we providers be enthusiastically referring patients to this?
8. webmd.com - Everyone goes to WebMD for their medical information now (they've even recently come out with a magazine that sits in physician waiting rooms). Attention physicians: Find out what your patients are reading (and what they're being coached to ask you) before their physician visit.
9. The Paris Site - I'm somewhat hesitant to link to this site, as I'm sure they will comment on this. We talked about the "horror stories." A group of bloggers have been very vocal about the hospital's quality and performance - so much so that they've been sued by hospital.
10. Dr. Wes - A specialist who blogs that has actually gained referrals from his blog.

In addition, check out my "consumer's guide to health 2.0 sites" post.

The bottom line is exactly what Nick said this afternoon - blogging and social media will never become mainstream within healthcare. Nonetheless, the brave ones that do authentically and purposely engage their community, their patients, and their employees will reap the benefits of the collective intelligence, collaboration, and good will of all.

What were your main take-aways from today's conference?

by Nick Jacobs

As a young teacher, it was increasingly difficult for me to understand the system. It never made sense to me that the publicly funded buildings in which we worked were not made available to the community 24/7. After all, these buildings were purchased by the public funds but, for the most part, except for those special days when games or programs were scheduled, the buildings were locked up every afternoon and evening.

After leaving education and migrating to health care, I had an opportunity to hear Ken Dychtwald of the "Age Wave" speak in 1988 about the fact that hospitals were, for the most part, not available to be utilized appropriately by the people who ultimately paid for them and not built to take care of the aging population. The lighting was not appropriate, the stairs were not the correct rise, the furniture was built for people in their 30's, and, most importantly, they were used primarily for acute situations.

He talked about a new hospital that had been built in Scottsdale and how it had a regular driveway and a golf cart driveway. He spoke about how it was built to attract the community. It was a special experiment, and this presentation captured my imagination. Why NOT?

Over the past ten years we have added a community work out facility, a wellness center; labyrinths, gazebos, walking trails, fountains, meditation gardens, a caring park, therapy pool, and hills filled with flowers. Inside we used furniture that fit the average age of our patients, invited the Area Agency on Aging to move into our building, a building that we condo- minimized, for them. We built several community rooms, added an indoor walking track, decorative fountains and gardens inside and out and then worked to educate our market service area to utilize our space as their own.

My favorite memory of this entire community project came on the day that we had a dozen prisoners from the county jail carving out the walking trails in the back. It began to rain and the Department of Corrections provided them with bright yellow rain coats with the D.O.C. abbreviation on the back. One of our patients walked up to me, umbrella in hand and said, "How wonderful it is that your physicians would take the time to build a walking trail for you."

Moral of the story? Make all hospitals community centers for health and wellness. The pictures for the Senior (Citizen) Prom are taken inside on our grand staircases by the indoor gardens. Meanwhile, the High School Senior Prom pictures are taken outside by the magnificent fountain. Our employees use the outdoor areas for picnics, mental health breaks, drumming circles, and generally for overall personal healing. And that’s the way it should be.

by Nick Jacobs

In the middle of a board committee meeting, my vice chairman turned to me and said, "Hospitalk." "Listen to all the hospi-talk." I hesitated for a second while I focused on the word he was using . . . Hospi-talk, the talk that is specific to our profession, our business, our environment. As a judge I'm sure he deals in courti-talk, but this meeting wasn't about attorneys. He was listening to abbreviations: QD, PRN, C.C., increased CPK? How about an elevated BUN? In the kitchen that is probably a good thing.

Now, it's not unusual to read or hear medical terms during these meetings, but this meeting was loaded with medical banter, you know, separating the we know people from the we sure don't know people. It's funny how the use of these terms increase proportionately when the pressure increases. This particular meeting was about the "New Joint Commission." Clearly, the Joint has evolved into a tough, yet somewhat absurd version of its old self. The pendulum has swung to the opposite extreme, from everybody is perfect to every hospital is inferior, and hospital Boards have taken notice. Read the Boston Globe; April 21, 2007, by Liz Kowalczyk: Five hospitals release data on inspections . . . Surprise visits revealed some flaws in patient care.

Anyway, I digress, back to hospi-talk.

After the Judge pointed out how abstract the meeting had become to the lay people present, I literally had to stop five different speakers to translate their jargon into something a little more meaningful to the masses, and, as the shields were lowered, we could all settle into the knowledge that this meeting was about people, how to cure them, how to protect them, and how to ensure that every detail is being addressed . . . it just took a wrong turn down semantics alley started by a specialist's specialist who probably doesn't even know what a Game Boy is.

by Nick Jacobs

Recently, a $3 B initiative was proposed in Texas for cancer research. Not unlike the Stem Cell research program launched in California, this program could create a powerful source of funds for research. Because of cuts in the NIH/NCI budget, the efforts by these two states may contribute to both funding and economic growth for both Texas and California. In both cases there should be a boost to the biotech industry as well.

The only caution that comes immediately to mind is that of having a "top notch peer-review process." If the top notch peer review process is similar to the system currently in place at both the NIH and the NCI, it is clearly a top notch "Good Ole Boy" process that protects the status quo, discourages funding to new organizations that do not look exactly like every other organization funded by them, and it contributes continuously to the "small science" approach of discovery.

Maybe this will be the new world order. Each State will become the center of some type of specific research specialty funded through a state bond issue. One of the responders, Lance Armstrong, said about this new program, "It could be incredibly powerful, particularly if it were salted with a bunch of new people."
Right on, Lance. Make that your message. Salt this program with NEW PEOPLE. Keep the politics out and encourage co-operation.

by Jeff McKune

This past week was certainly busy, and the last half of it was packed with our annual leadership retreat. My head is filled with tasks and action plans as a result of our leadership development sessions with the Advisory Board. Then Joe Tye challenged us with building the invisible architecture of our organization. I have so many action plans that I need to develop, that I may start with an action plan for my action plans!

There is a strong sense of being equipped that comes out of a retreat. With all of the collective enthusiasm that accompanies that sense, I have to wonder how much will survive the onslaught of the reality of daily operations at the hospital. There has to be more than just "retreat-speak" that follows me back to the job. Certainly there are a myriad of projects that I could attempt to tackle. However, I know that time and energy are not unlimited, and that I still have to maintain some sense of balance in my life - time for family, friends, and self (exercise, reflection, and spiritual growth).

So now that I am armed, to which efforts can I fully commit? First, I will renew my commitment to formally developing my own leadership skills. If my dream is to help build a better hospital, to have a positive impact on healthcare, I have to start with building a better Jeff. That will mean taking a critical and introspective look at my skill set, determining where the opportunities for growth are, and committing time each week to addressing those gaps. My second commitment will be to focus on bringing out the very best in each member of my staff. What are their dreams? What baggage are they carrying that I can help them overcome? What would it take to make them feel like this is the greatest place on the planet to work?

Maybe armed and dangerous is not the right phrase: How about aimed and determined!

Did you recently return from a leadership retreat or similar experience? What initiatives were you able to take back to your organizations?

by Christopher Cornue

Our organization just went through another “re-organization” and the phrase “Physician Integration” was added to my title in a slightly revised role in the Table of Organization. By raising the question of what this means, I’m being somewhat facetious (I had better be clear about it, since it is in my title after all) … but shouldn’t we all have “Physician Integration” formally, or informally, after our titles? Since we are leaders in healthcare, aren’t we all expected to integrate physicians into what we do on a day-to-day basis? So, instead of Chief Operating Officer or Vice President for Strategic Planning … the roles should read Chief Operating Office & Physician Integration or Vice President for Strategic Planning & Physician Integration. These revised titles speak more to a “matrix” style Table of Organization emphasizing the role of physicians in everything we do.

Let’s not make light of this – it is key that physicians are part of our operations meetings, service line discussions, marketing/planning, nursing leadership, etc. Too often I have heard physicians separate leadership between “physicians” and “administration.” Quite frankly, I get a little frustrated when I hear this stated … I truly believe we’ve moved beyond this “old school” style of thinking of separate accountabilities and we really need to marry physician and administrative leadership as supportive, not exclusive managing styles. Another one of my soapboxes, I guess.

While it might not be necessary to specifically identify the term “Physician Integration” in each of our titles, it is important that we remember, recognize and reinforce the importance that physicians play in everything we do. This is the true nature of a dynamic, progressive and successful organization and a moniker I am proud to attach to my new title, and any other title I hold in my future care in healthcare.

by Tony Chen

Previously, I wrote a post on what we healthcare folks can learn from facebook. I'm very happy about this post, not because it's that insightful, but because it probably swayed a certain hospital CEO to join facebook (chalk up yet another 1st for Nick).

Just a few days after that, I found out that Healia just launched a new healthcare application on facebook called the Healia Health Challenge - it quizzes your healthcare knowledge (and challenges your friends to do the same). Read Laurie's interview with Healia's marketing associate Jonathan Shaw. How refreshing that there are some web 2.0 savvy healthcare people out there!

by the way, I scored a 661 out of 800 on the quiz, landing me a lowly "resident" status.

by Tony Chen

Head over to the World Health Care Blog to read my latest post on 4 healthcare proposals that have been unveiled this week:
- John Edwards wants mandatory MD visits for all Americans
- The UK Tories want to deny care for people with bad healthcare lifestyles
- The UK and Germany want to improve healthcare for 7 developing nations
- Steve Case wants to start a healthcare (you guessed it) revolution

by Nick Jacobs

On my hospital blog (Windberblog.typepad.com), my entry this week was about twisted truths, not ours, but others. As the art of spin has become more and more refined, we begin to reach a point in communications where reality is whatever the loudest voiced pundit can emphasis the longest and the most intently. This practice has become true in health care as well. Especially in areas of high competition.

Last year I wrote another blog about an author by the name of S. I. Hayakawa and his book, Language in Thought and Action. As a freshmen college student my impression of the book was that it was about thought and mind control through the use of disinformation.

"The original version of this book, published in 1941, was in many respects a response to the dangers of propaganda, especially as exemplified in Hitler's success in persuading millions to share his maniacal and destructive views. It was the writer's conviction . . . that everyone needs to have a habitually critical attitude towards language — his own as well as that of others — both for the sake of his personal well-being and for his adequate functioning as a citizen.

The reality now, however, is that this art has evolved into a science, and the science has become an accepted part of our world. It is fascinating to observe the use of disinformation as a means to attract patients, to see the truth twisted just enough to confuse the public so as to appeal to their lack of technical and medical knowledge through misrepresentations that lead to business.

A few weeks ago, one of our visiting sub specialists told a patient that they had to be transferred from our facility because we didn't have the necessary equipment for his surgery. As it turned out, the piece of equipment was an orthopedic nail that, had we not had cases of them, could have been delivered almost instantly by a local sales rep. The reality is that a competitor requires each surgeon to do a certain number of surgeries each day that they have scheduled. If they do not, they will have a decreased number of slots to work from in the future that are exclusively designated for their use.

What is the definition of an Open MRI? It is not a larger bore device, it is, indeed, open. Who cares? A facility that has purchased a larger bore device cares. Say that it is OPEN, confuse the public, and take business away from the facilities who purchased the OPEN MRI. A nuance, you say? A tiny twist, you think? Well, if you have a $34,000 a month payment to make, it is just good business, right? Twist to sell.

Finally, we hear, everyday, the little whispers about skill level. Perception is reality, and unless or until total and complete transparency becomes the guiding light of health care, we will be in the same boat that we were in before "Consumer Reports."

Buy our gasoline, "It will put a tiger in your tank!" It wasn't that long ago when we believed that there was a huge difference between the quality of different brands in that business as well, at least we believed that until we were informed that all of the gas was coming from the same refinery or, in some cases, all of the stations were being fed from the same truck!

Bring on open communication, just don't let some of the major, existing evaluators take the lead. They are from a different paradigm, a world where, many times the twisted, interpreted detail is the basis for a pronouncement that has no bearing on the reality of the care.

by Christopher Cornue

Unfortunately, I cannot take credit for this very accurate description of leadership in healthcare at the moment. This was a resounding theme at a recent Health Care Advisory Board meeting I attended a few weeks ago. Supporting this assertion, the Advisory Board discussed changing reimbursement methodologies, revised DRG structure later this year, global competition for paying patients, increased costs, expected growth/volume decline, shift from inpatient to outpatient, proposed legislation forcing hospitals to absorb costs for adverse events that occur during a patient’s hospitalization, a more informed consumer, increased transparency of quality outcomes for hospitals, evolution of “retail clinics,” workforce challenges, etc. No need to go through the whole list – you get the point! While many of these issues have challenged hospital leaders for several years, it’s probably safe to say that a “perfect storm” type scenario is on the horizon, whereby all of these are impacting hospitals simultaneously. Which issue do we spent the majority of our time focusing on first? How do we manage this change going forward? Regardless of our focus, I just wanted to share this “Leading Through Disruptive Change” statement, as I think it’s a perfectly appropriate label for our efforts in healthcare at the moment.

by Nick Jacobs

A few years back while listening to a presentation from Dr. Leland Kaiser, my interest was peaked when he said, "If you are not doing genomics at your hospital, you are already behind the curve." In a recent H&HN magazine article (www.hhnmag.com) by Haydn Bush entitled "Practical Genomics," the author carefully outlines the current state of the science. He quotes Lyle Berkowitz, M.D., director of clinical information systems at Northwestern Memorial Healthcare who says, "In the near future . . .physicians will be able to integrate genomic maps, or complete, individual accounts of a person's 6 billion-piece DNA code into care."

At Windber Medical Center we have been working for six years with our partners at the Windber Research Institute and Walter Reed Army Medical Center to do just that, translational medicine. We believe that the best way to rapidly improve individual patient care, outcomes, and quality of life is by translating molecular research, driven by clinical questions, into new standards of patient care. Our primary focus is improving patient care and the quality of life for the patient and their family by rapidly translating molecular and clinical research into action.

Sound good? It will be. As the article goes on to explain, "If better genetic testing for heart disease emerges, patients with increased genetic risks could conceivably undergo more regular CT scans to check on artery blockage, while also improving their diets." We have been doing this for the past five years.

The idea is for the physician to work with the patient to start a lifelong treatment of the identified risk factors. This treatment includes stress management, diet, exercise and group support. As the article states, " . . . the physician is retooled into a lifelong coach or partner to go through your entire risk report, almost as a financial adviser would manage a portfolio."

Also as pointed out by the article, let's look at the details of why we're not there just yet. First, there aren't enough genetic counselors nationwide to achieve this goal quickly. Second, most hospital information systems have no capacity to handle genomic data. Third, the fears of most patients concerning the use of genetic data to keep them from buying insurance or worse yet, from getting a job are real and definite.

Finally, there is the question of whether the patient would embrace the steps necessary to alter the potential progression of disease. In the book Change or Die the author, Alan Deutschman, discusses the reality that when cardiologists tell their patients with heart disease that they have to "change or die," nine out of ten fail to switch to healthier lifestyles. It appears as if 90% of us would knowingly select death rather than change.

So, as we push forward with our efforts to promote behavioral change through the use of integrative health through programs like the Dr. Dean Ornish Coronary Artery Disease Program, and as we work toward making translational medicine a reality through the fusing of knowledge provided by M.D's and PhD's in our labs and hospital, we work and wait for the rest of the world to understand that the future is here and the future is now.

"If you are not going genomics at your hospital, you are already behind the curve."

by Jeff McKune

If you are looking at developing a new service line or you just want to have a better understanding of business patterns that impact your hospital, you may have some questions. What are the most prevalent DRGs in our market area? What percentage of patients in our market area are coming to our hospital? If they are not coming to our hospital, where are they going? Are we holding our own on surgeries? Are we capturing our share of cardiovascular business?

I did a quick survey of state hospital associations across the country, and it looks like most, if not all, have some means of collecting and providing admissions and utilization data for hospitals in that state. Some associations make the data available on the web, while others may provide it on CD or provide summary reports of various kinds. In Missouri, an MHA member hospital can purchase this data on CD for under a thousand dollars. It is interesting how much you can learn from data like this when you have a quiet afternoon, perhaps during some down time during business travel. In fact, each of the questions above can often be answered without a lot of effort.

Microsoft Excel has a powerful feature call pivot tables. Pivot tables allow you to easily summarize and digest large amounts of data, viewing it in different ways to answer relevant business questions. Using pivot tables with statewide hospital data can provide some valuable, and often hidden, insights. There is no programming involved, and a basic pivot table takes just a few clicks and a couple of drag-and-drops to complete. There are three steps: Determine what data you are going to use, run the Pivot Table Wizard, and drag-and-drop your row and column definitions into place.

Your data can be a list of data in an Excel worksheet, a Microsoft Access database, or some larger external database. You will need to know a little about the data you are wanting to study. For example, if you want to look at inpatient admissions you will need to make sure that the data source has that kind of data in it. The Pivot Table Wizard is found under the Data menu in Excel. It will walk you through selecting your data source and determining where you want to put your new pivot table. You will probably want to put it in a new worksheet. Finally, drag-and-drop the data fields you want to study onto your pivot table.

Do you want to understand the relationship between specific hospitals and counties where patients live? From your field list drag "Hospital Name" (or whatever the data field name is) to the left of your pivot table. Boom! Excel quickly lists all of the hospitals along the left of your pivot table. Similarly, drag "County" to the top of your pivot table. Excel will list the counties across the top of the table. Drag "Admission Date" (again an example name) to the Data area of the pivot table, and Excel will provide a count of all admissions by county for every hospital. Granted, this may be a large pivot table, but drop-down lists are provide for you to select just the hospitals and counties in which you are interested. If you want to look at DRGs or physicians, drag "County" off the pivot table and back to the list of data fields, and then drag "DRG" or "Physician" to the top of your pivot table.

Yes, there are a lot of benchmarking and data analysis services available, but it is amazing what you can discover on your own using pivot tables. If you would like some more guidance, Google "building an Excel pivot table" and you will get more than 400,000 hits. One of the links is a video that shows you how to build a pivot table in Excel 2007. Or, post a question here or email me, and I will be happy to help. If you have used pivot tables in an interesting way, be sure to share it with the rest of us!

by Christopher Cornue

Literature suggests that the “proper” Service Line model consists of all operational and other entities reporting up into a Service Line Director or Vice President. So, for example, in the Cardiovascular Service Line, the Vascular Lab, Catheterization Lab, Surgery Components, etc. would report into the Cardiovascular Service Line Director and it would be his/her responsibility to oversee the functions contained within this Service Line (e.g., physician recruiting, establishment of quality & operational metrics, operational oversight of these areas, FTE oversight, capital acquisition oversight, etc.).

But, what do you do when you are in a financially strapped institution? Furthermore, what do you do when you are in an organization that is slow to move away from the “silo” mentality toward a “matrix” one, as the previously mentioned “Proper” model would support? I have spent time in such an environment, which is moving in a thoughtful & deliberate manner from the “silo” model to the integrated “matrix” model. To support this direction, and address the immediate needs around Service Lines, I have created a structure that provides administrative support across the silos, and partners that with strong clinical (mostly RN) oversight in each of the key Service Lines in which we are concentrating. This is one approach, which obviously has pro’s and con’s associated with it. In the “pro” column – one can align individuals in an interdisciplinary manner; rally people to support a focus on a specific service line; integrate quality, financial, growth and satisfaction metrics to support the service; etc. Among those items in the “con” column – there is a lack of direct responsibility over all the components within a service line; control is more dispersed among several individuals; not all “key players” are aligned and “bought into” the efforts of the service line; and fiscal and capital priorities are more difficult to direct or influence. There are other models out there … if your organization is unable to adapt the “ideal” model, what has worked for you? Furthermore, has the implementation of the “ideal” model worked?

Regardless of which model to use … a focus on 2-3 key service lines, supported by the full organization, is probably all that should be attempted in a given period (e.g., fiscal year). A focus on more than 2-3 will dilute organizational efforts for fully supported, integrated, and successful service lines. It is clear the service line structure will continue to evolve in response to external (and internal) forces. I guess we all need to buckle up and make sure we’re able to be flexible and adapt the structure that best suits our respective organizations – and make that model successful!

by Nick Jacobs

According to an article by Harold Meyerson in the Washington Post this week, Dennis G. Smith, director of the administration's Center for Medicaid and State Operations announced standards intended to restrict families from purchasing health coverage if the parents’ employers choose not to supply it. It will also block states from providing health care coverage to uninsured children from families with yearly incomes in the order of $50,000.

According to Meyerson, this new pronouncement was in direct response to governors like California’s Schwarzenegger and others who have chosen to provide health coverage to children from families earning two to three times more than the federal poverty level or $20,650 for a family of four.

He goes on to say that it appears that this administration fears that parents in the selected income groups will abstain from enrolling their children in private plans. As we have stated so many times before in these blogs, nearly 9 million American children are without health insurance coverage, and this number is fast approaching nearly 400,000 more uninsured children than last year.

Smith told the New York Times that the states must institute a minimum of a one-year period of no insurance for individuals before children become eligible, and they must also show that the number of children insured by private employers has not dropped over a five year period by more than two percent.

According to Meyerson, if a state wants to provide coverage for a chronically ill 2-year old whose parents’ have lost their health coverage, the state has to wait until she’s a chronically ill 3-year old. The somewhat passionate opinion of Mr. Meyerson is that the administration’s fervor on this position is to ensure that we cannot permit our children to obtain health coverage that may diminish the market share of big insurance. Opinions please?

by Jeff McKune

Early in my IT career, I specialized in a particular series of personal computers. One interesting feature of these systems was a self-diagnostic capability that would draw a picture of the internal boards in the computer, highlighting a defective board. It was pretty cool to watch, and I couldn't wait for my first customer demonstration. In the demo, I showed the customer how easy it was to access the boards by removing the one-piece cover. I then loosened one of the boards to simulate a "failure", put the cover back on, and hit the power switch to start the self-diagnosis process. But, nothing happened - the screen remained black. Unfortunately, it was the customer who saw the problem and spoke first: "You might want to check your connections. Looks like the power cord is not plugged in."

It would not take much to get so caught up in the administrative concerns associated with the delivery of healthcare, that we forget what connected us to healthcare in the first place. Sometimes it is a good idea to make sure we "check our connections" to remind us of our purpose.

There are a couple of things that I try to do on a regular basis to keep me connected to my team and more importantly to our patients. We handle many pediatric dental patients each week. Frequently they arrive afraid, wondering about the people in funny looking clothes and what the procedure will be like. I enjoy sitting down with these little ones and reading them a story, or playing a guessing game to take their mind off things. Making a difference to kids means a lot to me, and helping others is one of the reasons I connected with healthcare a few years ago.

I also enjoy dressing out in scrubs and helping my team. Being a former IT guy with no clinical training beyond my BLS, I cannot provide direct patient care. But I can help my team clean and make beds between patients, wheel a patient outside to their waiting family, or just help the housekeeper empty the trash. I have found that this powerfully connects me to my team like nothing else.

What do you do to stay connected to your purpose and direction in healthcare? I would be interested in hearing how you "check your connections."

by Tony Chen

Recently, I had 3 experiences that are really changing the way I think about the future of healthcare.

We had GeekSquad (sort of like the IT dept for home computers) come in to look at the persistent network problems that had been plaguing us for almost a year. The consultant, who couldn't have been more than 20 years old, was very professional, got on the phone with AT&T, reset our modem, and fixed the problems in 2 hours. We started talking honestly about his job and he said, "No offense, but it's your generation that's clueless about technology and needs this service. Trust me, I don't have any job security - I know 7-year-old kids who could have fixed your network just as quickly as I did." (side: my generation?)

Speaking of AT&T, I heard a story on NPR about this lifeblogger who received a 300-page phone bill from AT&T for her iPhone. The bill listed every single text message she received/sent (all 30,000 of them!) for that month. Yes, that's 30,000 text messages in one month. Many of those text messages were "status changes" within her friend's facebook profiles. If you don't know what I'm talking about, it's hard to explain - just register onto facebook and check it out yourself. Professionals hang out at bars. Others hang out at cafes. A whole generation is hanging out at facebook. (don't even get me started about SecondLife)

And speaking of Facebook, I did check it out. What is all this fuss about? 3 million people joining Facebook per week? I invited all my friends from gmail who already had facebook accounts, found a long-lost childhood friend who lived across the street from me, "poked" a few friends, and sent them some virtual "beer." I watched videos of my friend's kids, saw some not-so-flattering party pictures, and joined a group called, "unlike 99.99% of other facebook users, I was born in the 70s." I tried to find other ACHE members (I think I found 3).

All in all, I got a taste of what this generation is growing up with. While I had MTV, Nintendo, and a neighborhood basketball hoop, they have Facebook, iPhones, and txt msgs. They are extremely tech-savvy and extremely connected (30,000 txt msgs is 1,000 per day?!). They value authenticity and relationships just as much as we do. Despite their tech obsession, they value community just as much as we do.

So how does this all relate to healthcare?

- Don't build it - they won't come. All of the technology we are investing in is trying to get people to come to us. Instead, maybe we need to develop technology that brings healthcare to where they are already. For example, I could totally envision a Facebook application or community group that helps Facebookers with diabetes manage their diabetes. Since users are loggging on all the time (20-30 times/day), isn't that where a smart diabetes company would want to be? Plus, the community that is built online gives them the value of a virtual support group (though don't call it that).
- Integrate healthcare into everyday life - make it easy. I was reminded that while healthcare is my world, healthcare is only part of the world for everyone else. The more we integrate healthcare into every day life habits/gadgets/products ( see my post on the Glucophone), the better. And if we have to carve out healthcare as a separate compartment in people's lives, it has to be as one-stop-shop as possible (maybe RevolutionHealth is the best example of this, though they have other issues).
- We healthcare professionals need a better network. We could learn a thing or two from these high school kids. Some new development happens and it gets picked up virally. No PR release. No marketing. Some kid adds it to their profile, their friends see it and add it to theirs, and it explodes. Where is that mechanism of information sharing in healthcare? 15 years from now, will doctors be going to their facebook physicians group to look for best practices? will administrators facing the same question/problem/challenge be able to find each other that much faster? We need a stronger healthcare community than we were are getting through current channels.

So, what do you think? Is Facebook irrelevant to our hospital leadership discussion? Will healthcare innovation evolve at a faster pace to truly impact the next generation?

UPDATE: Amy Tenderich of DiabetesMine is asking her readers - what do you want in a health care site/community?

by Tony Chen

Just a quick note: Christopher Cornue, Andrew Barna, and I were all quoted in this week's Modern Healthcare cover story (reg req) about ACHE's decision to change their certification program.

by Tony Chen

Are we hospitals only going to be transparent enough to appease the outcries? Or should we lead the way and proactively provide info before people ask?

I say we lead. Here's how we can start - by defining exactly what should be transparent. Also, learn from what others are doing. Check out this hospital's 6 principles that guide their transparent reporting. And read about what what Michigan has done to get all of its 146 nonprofit hospitals to post prices of 50+ common procedures, representing 80% of their business.

Where is your hospital at? How urgent of a priority is transparency at this point? Who would typically lead such an effort?

by Tony Chen

Our very own secretary of health and human services, Mike Leavitt, has started blogging about his work. He started it exactly a week ago and already has 3 posts up addressing everything from SCHIP to health literacy in Africa to Tamiflu. And contrary to my expectation, this isn't a corporate PR machine. Nor are others ghost-writing for him. He's promised that he's personally writing these posts.

(I'm honored to be the 5th blogger to link to the blog. Hat tip: Bob Coffield of the health care law blog.

by Tony Chen

Check out this post from DiabetesMine on the new GlucoPhone brought to us by HealthPia. An exerpt from the post:

The GlucoPhone is not just for SENDING blood glucose data over the net. It's actually a special glucose meter (GlucoPack™) that's fitted onto the back of a cell phone. So yes, you stick your test strip into a little slot on the side of the phone and bleed on it, just like you would any meter. Then you can immediately "text" your results to a database available online with the subscriber's permission, i.e. you set the access rights.

How cool is that! It'll be interesting to see how new technology potentially leapfrogs our current provider-based and payer-based attempts to address diabetes management. Because the diabetes market is so large (probably 20 million people) and impacts every day life, there are mountains of start-ups now trying to capitalize.

Going back to the same DiabetesMine post, here's an extremely insightful quote from the HealthPia CEO on the "felt need" of people with diabetes:

"The fact of the matter is that most people with diabetes are more concerned with the daily hassle of managing the disease than the long-term complications. But with something like this, we can help cut the hassle and focus on what's important"

by Tony Chen

This past week, the NYT reported on that both Google and Microsoft are each unveiling a major healthcare product in the next 12 months. While they remain hush-hush on specifics, one thing is for sure - both see the avalanche of consumer-driven healthcare coming. For better or worse, consumers will be in control of their health.

From the NYT article:

The Google and Microsoft initiatives would give much more control to individuals, a trend many health experts see as inevitable. “Patients will ultimately be the stewards of their own information,” said John D. Halamka, a doctor and the chief information officer of the Harvard Medical School.

Already the Web is allowing people to take a more activist approach to health. According to the Harris survey, 58 percent of people who look online for health information discussed what they found with their doctors in the last year.

It is common these days, Dr. Halamka said, for a patient to come in carrying a pile of Web page printouts. “The doctor is becoming a knowledge navigator,” he said. “In the future, health care will be a much more collaborative process between patients and doctors.”

The blogosphere has been ablaze since the article came out. Some screenshots of Google's patient interface/record have surfaced on the web here. The WSJ Health blog and other blogs make note of recent healthcare acquisitions by Microsoft (bought MedStory, a healthcare web search engine) and Google (23andme, a genetic profiling company).

As noted in this ZDNET blog, the future direction seems imminent:

In the future of the “data Web,” healthcare information and alerts relevant to an individual will show up in the same way Amazon recommendations surface. With the data online, you could input symptoms, upload images and the “system” could check against your history, medications, allergies, etc., prior to an online video consult with a physician thousands of miles away.

Of course, all the same old data issues have to be worked out - privacy, malpractice, storage, interoperability, and security. Plus, there's a little problem with funding and business model (hopefully we will never see a Google banner ad within our medical record!) Nonetheless, Microsoft already has their products in lots of hospitals, and Google obviously dominates search (12% of people consult Google before visiting their doctor!). And both have mounds of cash.

Make no mistake about it- this is not a continuation of the Google vs. Microsoft War that's been going on for years. This is Google or [insert brave company name here] against the most powerful force of them all: the healthcare industry status quo.

by Jeff McKune

In my former life in IT, I worked on a number of biotech research projects. The company organized resources around the different portions of their biotech pipeline. For each segment of the pipeline, a user steering committee was responsible for overseeing the systems and projects that affected that segment.

These committees were comprised of key stakeholders of systems at different geographical locations, project managers, and IT representatives. Even though these were IT systems, the end users had ownership, and it showed in the ratio of users to IT staff on the committees - usually three to one.

The steering committee responsibilities were fairly comprehensive. They recommended changes to systems based on their changing business needs. They reviewed and approved all changes, including those proposed by IT subgroups such as the database team or the networking team. In short, to a great extent they controlled their own destiny with regards to their operational systems.

When I joined PCRMC early in 2006, I was pleased to see the hospital beginning to use this same structure. A "user" steering committee had been organized around the management of the complexities of the revenue cycle. The committee is comprised of several department directors, as well as representatives from coding, finance, and compliance. Having the stakeholders all in one room at one time smoothes the coordination and discussion around issues that impact each of them, and it has led to significant improvements in revenue cycle efficiency.

In what other areas could steering committees be deployed in hospitals? Would it make sense to have an admissions steering committee that managed that portion of the hospital "pipeline"? In this case, the "users" would be patients - more specifically, non-hospital representatives of our patient community. What about a nursing care steering committee, or a discharge management steering committee, each with a higher ratio of patient representatives than hospital staff? Without a doubt we would gain new insights from those we serve, and the effort would bring more meaning to patient-centric care.

Perhaps your hospital is already using steering committees in this way. If so, please share your experiences with the rest of us.

by Tony Chen

This week's medical blogosphere grand rounds is up at Swiss blog Med Journal Watch, where the theme is sudden changes of all sorts.

A few links to check out:
- ChronicBabe has come to accept her chronic disease
- A gut-wrenching story and picture about parents coming to accept that they can't do anything to change their newborn's disfiguring birthmark.
- DiabetesMine tells us about the "GlucoPhone" - a cell phone combined with a glucose meter. Now people with diabetes can test their blood sugar, let their phone read the results, and then text those results into a database.

by Tony Chen

Now, here's a great way to use a hospital CEO blog. Nick Jacobs is asking for everyone's help to get the word out on his hospital, Windber Medical Center. Turns out that Windber is actually one of the most progressive hospitals in the country. It may even be the best hospital that no one's ever heard about.

Maybe I'm biased since Nick blogs here at hospital impact, but point me to another rural hospital that has 3T MRIs, one of the largest (I believe) tissue banks in the country, numerous videos up at YouTube, and a hospital CEO whose in the board at Planetree. (And what other hospital has a link to hospital impact from its front page!)

Now, Nick's blog still has a relatively small following. But because he's been blogging for so long, he's built a readership that is loyal. And we all know how word-of-mouth marketing works - a few intensely loyal fans can take you so much further than thousands of lukewarm fans.

by Nick Jacobs

In a recent meeting with one of our most senior surgeons and a relatively new surgeon, the discussion revolved around the older physician's extremely successful career. It was one of those moments that locks into your memory as the senior doc stated the following, "If you want to be successful, you need to embrace the three "A's." To which we all moved forward in our chairs with an obvious question mark in our eyes.

He said, "You must be available all the time, 24/7. When the calls come, you need to say, "Yes, I'll be there." "It doesn't matter if it is morning, noon or night, drop what you are doing, and make yourself available."

Then he said, "You must be affable, affability is the key to continued support from the various primary care physicians who will refer to you. If you are not polite, pleasantly easy to approach and talk to, cordial, courteous, warm and friendly, neither the patients nor the referring physicians will be inclined to continue to refer to you.

Finally, he said with a smile on his face, "You must have ability." To which he went on to add, and ability, by the way, is a very distant third priority in this scenario. People will tolerate imperfection if you are available and affable.

So, there you have it, Availability, Affability, and Ability. I watched curiously at the wheels turning in the young docs mind. I'm not sure that his training has ever embraced such simple, common sense advice.

by Jeff McKune

It is interesting to visit with those at other hospitals and see commonalities between institutions. One of the first of these commonalities that I noticed was the five pillars. Sometimes the pillars are expressed as part of an organization's values, and other times they serve as a means of categorizing strategic plans. Perhaps your hospital has these same pillars, or something similar: People, Service, Growth, Finance, and Quality. Each time I have heard of these pillars, the "People" pillar is listed first, and often someone will say something like "Our People pillar is first, because we put our people first."

A quick glance at an income statement will certainly confirm that people costs - salaries and benefits - typically comprise 55 to 60 percent of a hospital's operational expenses. But do those expenses really count as investments in those all important human resources that make healthcare work? Fundamentally, healthcare, at least in the context of a hospital, is delivered by people. I won't downplay the importance of facility expansions and technology purchases that keep a hospital in the forefront of quality care. But let's remember that it is not the facilities or the technology that are actually delivering the care - it is our people.

We can look back at our institutions and remember a timeline of growth. It often goes something like this: "We added our East Addition in 1990 at a cost of $20M, increasing our capacity by 50 beds. In 2000 we added two 16-slice CT systems to our imaging department at a cost of $3M. Our new Cardiology Department has allowed us to provide new services to our community at a cost of $25M."

These are all good things, but when was the last time you heard a healthcare leader say "In 2002 we recognized a need to improve staff retention and maximize the productivity of our human resources, and we invested $3M in our new leadership development program. Seeing significant improvements in several areas, including employee satisfaction and patient satisfaction, we continued our investment in our people in 2005 by establishing an in-house university, improved tuition reimbursement for academic education and professional certifications, and mandatory annual HR training for all leaders at the director level and up - all at an initial cost of $7M with annual operational expenses of $2.5M. In addition, all of our senior staff are actively involved in our leadership development efforts, participating both as students and instructors on a regular basis."

There are ample research studies to demonstrate the benefits of this kind of HR focus in an organization. Would it make a difference in our hospitals if we really took that first pillar seriously?

by Tony Chen

Not every day that a hospital CEO is featured in mainstream media. Jim Citrin, a columnist for Yahoo Finance, wrote an article on Ochsner CEO, Dr. Patrick Quinlan, applauding the resourceful, dedicated, and nimble organizational culture he's created. Quinlan and his crew have been an inspiration and a beacon of light for the folks in New Orleans.

Dr. Quinlan stresses that it's the job of management to support the decision-making of employees on the frontlines. "Fear robs people of their ability to make decisions," he said. "If they feel they'll get in trouble, people will avoid making decisions, leading to inaction. But at Ochsner, whatever we do has a common path. There are no recriminations.

"When the crunch time came [during Katrina]," he continues, "our people exercised calm courage and selfless behavior. They saw problems and owned them. Their attitude was, 'We're just doing our jobs,' and 'What can I do to help?'" What did Dr. Quinlan himself do to help? For one thing, he led from the front. "You have to be there with your people. I stayed in the office for seven weeks straight."

by Tony Chen

Dr. Alan Adler, Medical Director of Independence Blue Cross, recently wrote an excellent article in Managed Care Magazine entitled, "Why Blogs?"

Not everyday that a stodgy industry trade publication addresses blogs in such a thoughtful way. Dr. Adler argues that blogs are increasingly relevant for providing consumer health information and for providing refreshingly candid insights, perspectives, and conversations amongst the medical and healthcare professionals.

Though he failed to mention hospital impact, his list of blogs is definitely worth checking out!

by Tony Chen

Most hospitals have some sort of employee wellness program. You know what I'm talking about - walking programs, smoking cessation classes, seminars for healthy eating, maybe even discounts to local gyms.

Clarian Health in Indianapolis is taking an unconventionally aggressive approach - they'll dock your paycheck $10 for every pay period your BMI is 30+. Starting next year, they'll dock $5 per paycheck if you smoke.

A few questions do come to mind:

- Do sticks work better than carrots? Maybe a better approach would have been to increase healthcare costs for employees by $15 per paycheck, and reward the non-smoking, <30 BMI folks with cash back. Same cost, but different mentality.
- Will this have a positive or negative impact on employee retention? Nurse recruitment efforts? Inevitably, they may lose a pool of employees and/or candidates. $15 every two weeks is $400/year, not an insignificant amount for some. Then again, maybe this attracts a healthier candidate pool.
- Will others try this incentive-based health, too? We'll see how many people actually change their behavior & how much costs are reduced. I suspect these type of programs will begin to show real ROI, and then the floodgates will open quickly.

What do you think?

by Tony Chen

Yes, it's true - a grocery store chain with almost 700 stores in 5 southern states will be offering 7 popular prescription antibiotics for free. Like most retail strategies, this has been done in the name of increased foot traffic.

by Nick Jacobs

As a leader, your days are filled with problem solving tasks. Every day your cohorts present you with their problems, and they look to you for the solutions. There have been numerous books about management that teach us to deflect those invitations to suffer with them by refusing to accept their monkeys on your back. The 4-Hour Work Week, by, Timothy Ferriss, boldly proclaims, “Escape 9-5, live anywhere, and join the new rich.” The book tells you how Tim went from $40,000 a year and 80 hrs. per week to $40,000 per month and 4 hours per week. He suggests that you find out which customers generate the most money for your company and only recruit customers like that. Easy enough. Then he suggests that you should find out which customers waste most of your time and get rid of them, however, you know for sure that Tim's not talking about hospital administration.

Having spent several college summers on the railroad in the yard master's office, it became obvious to me that the problem solving techniques established by that particular industry were primarily directed toward triage. The proposition went something like this: listen very carefully in an engaging and somewhat sympathetic manner, when possible take whatever steps necessary to help move or remove barriers that had become the road blocks to the resolution of the problem being presented, and encourage the presenter to continue to move forward to solve the problem by triaging it to the appropriate levels within the organization. When this method doesn't work, it reminds me of a picture in my office of fifteen well dressed professionals pointing at each other. It should have been entitled, "Spread the Blame."

Actually, as an act of impatience, frustration or simply boredom, I often times come up with the solution on my own, immediate, timely and definitive, and most often in a vacuum. Usually when a unilateral decision comes from me, the response is phenomenal. It starts out with a smile and a nod of agreement from the visiting party, a commitment to move forward and a sincere thank-you. Then the push back begins. Clearly, in this type of decision making situation, there is a lack of endorsement and the outward resistance intensifies like a tropical storm, ensuring damage or at the very least failure.

On the other hand, when the problem is triaged back to those presenting it in a constructive manner that offers support but not a complete solution, the results are phenomenal as well. It's about a combination of empowerment and encouragement that directs them toward embracing the scientific method. We talk through the observation phase, help them in the creation of potential hypothesis that is consistent with what has been observed, try to make predictions from that hypothesis, encourage them to modify it in the light of their results, and finally, remind them to repeat steps three and four until there are no discrepancies between theory and end result.

The amazing thing about even this method is that, if we apply it very purely, we will probably fail miserably because, for the most part, we are working with moving targets that are enveloped in emotions, politics, unpredictable outcomes and yet to be defined options, but, having said that, it is the basic premise for engaging our personal hard drives in a way that will move/triage the problem forward toward solution.

Bottom line? As I re-read this post, it is obvious at least to me that I have no real answer, no definitive solution, no optimal choice, but that some order, some persistence, some method is better than just forcing your solutions down everyone's throat, and it will help to keep at least a few more monkeys off your back.

by Nick Jacobs

As a 40ish rookie in health care management, the common conversation around the board table in the late 80's was a chorus of woeful sobs directed toward the good ole days of cost based reimbursement. That was a time when hospital CEO's could pretty much count on getting checks equal to their costs to pay for services rendered. In fact, a book entitled, The Hospital That Ate Chicago, was a good example of how hospitals could actually make a profit from the government from building projects.

Ah, to have been an Executive Director or Superintendent in that era. If you didn't golf several days a week, you were not considered competent enough to be an administrator. One of my early mentors used to say, "Son, If you want to survive and thrive in this field, you are obligated to learn to golf and play a good game of bridge."

Needless to say, I sometimes drive over a bridge, on my way back from Washington D.C.this week, I actually filled up at a Gulf station?

Today, we are seeing the beginning of an end of another era. As the tide begins to sweep the post WWII generation closer to retirement, it is clear that the System is about to change. It is about to change or die, and, once again, the ole timers will wish for better days when they actually got reimbursements that, for at least a small amount of time, would allow them to pay the bills and make a little profit for the organization.

One problem with writing a blog like this is that it's easy to criticize, easy to point out, and easy to suggest, but it will take an engaged group of hard working, deep thinking leaders to set the path for the future, a path that pays attention to the infrastructure, that will work to ensure the bridges don't collapse, the discoveries aren't curtailed, and the future becomes all that it can be. That path should be inclusive, comprehensive and for the good of mankind. Hopefully, we can help make the directional signs for that journey because, our future depends on it.

by Tony Chen

It's probably not every day you see someone in their late 40s in a classroom full of 23-year-olds learning about healthcare administration. But that's what happened a few years ago to Jeff McKune - our newest blogger at hospital impact. Read his previous post on hospital strategy here and his bio below:

In 1981 I graduated from Harding University with a B.B.A. in Business Systems Analysis. I worked in information technology in Dallas for several years, and it was there that I met and married my wife. We moved to Missouri in 1985 where I started a systems integration and computer consulting business serving small businesses, county governments, and Fortune 500 companies throughout the state. A number of personal and professional factors, including the illness of my parents, drew me towards healthcare. At the age of 47 I began my graduate studies, completing my Masters in Health Administration at the University of Missouri at Columbia in 2005. I then completed a one-year administrative fellowship at Phelps County Regional Medical Center with the Chief Financial Officer and the Administrative Director of Human Resources as my co-mentors. These days I serve as Director of the Ambulatory Surgery Unit at that same hospital, enjoying each day with a great team of physicians, nurses, and clinical staff. If you would like to learn a bit more about me, please visit my personal site at http://www.mckune.net.

I'm definitely excited to see what topics Jeff ends up posting on - with such a unique path into hospital management, I'm sure he'll have some fresh perspectives to share.

by Tony Chen

Sorry I have not posted in a while. Thanks for your patience.

It's a busy time at work right now. Plus, I've been preparing for out-of-town guests, getting ready to sing & play guitar at a wedding, spending time with the little one, fulfilling local board responsibilities, and fulfilling my blogger role at World Health Care Blog. Read my posts about the AMA and obesity.

I'll have more for you in the next few days, including the introduction of our newest blogger. Stay tuned!

by Tony Chen

Usually it's California that gets all the attention - the governator, progressive policies, Kaiser, and 4 of the 17 best hospitals in the nation. Nonetheless, California, in all it's glory, is fairly average when it comes to health.

One state is always near the top of the list - Minnesota. They are the #1 healthiest state according to the UHC Foundation and 3rd healthiest state in the country according to Morgan Quitno. The key metrics behind these rankings are things like: cardiovascular death rates, premature death rate, uninsured population %, children in poverty %, total mortality rate, infant mortality rate, motor vehicle deaths, and a high rate of high school graduation.

Beyond the healthier culture that seems to pervade Minnesotians, Minnesota seems to be a hotbed for medical and healthcare innovation - everything from medical devices to Mayo to retail clinics. Here are a few more facts about Minnesota:
- Largest Bridges to Excellence Program in the country (780,000 lives).
- "Smart Buy Alliance" - a collaboration between the state, union groups, big & small businesses to improve quality and affordability of healthcare (thought results have been slow).
- State employee health plan boasts a zero-premium increase for 3 straight years.
- Of course, it helps to have great hospitals like Mayo, Abbott Northwestern, and Park Nicollet.

So what is it about Minnesota anyway? What can we learn from them?

by Nick Jacobs

Senator Chuck Grassley (R) Iowa while still the chairman of the Committee on Finance, directed his staff last September to create a discussion draft of potential reforms to ensure adequate levels of charitable care from the nation's non-profit hospitals. His desire to pursue this topic was rooted in his belief made by interpretive assertions by IRS Commissioner Mark Everson and the Government Accountability Office that there is little difference between for-profit and non-profit hospitals when it comes to charity care and community benefits provided. As stated by Grassley, the staff draft of potential ideas was the beginning of a discussion, not the end. Public comments are strongly encouraged at this point. Public comment should be sent to hospital_comments@finance-rep.senate.gov by Friday August 24, 2007.

The above paragraph is the premise for this post and my submission to Senator Grassley for public comment.

Let me begin by saying that I have no personal ax to grind with the for profit world. Having stated that, however, unless you live the day to day challenges of survival in the non profit health care arena, your viewpoints cannot possibly include every aspect of the decision making process necessary to keep it all together.

Having previously worked with a half dozen former executives from the for profit health care sector, it seems to me that the current governmental leadership has missed some very important points.

As an employee of the former for profit leaders, it was perfectly clear that, at least the motivation of those individuals for whom I had worked was directed toward their salaries, bonuses, and, as they stated it to me, a solid commitment toward making money for their stockholders. How do you measure the nuances created in a system that has a profit motivation leading to the creation of wealth for owners as compared to a system that exists only to create the common good?

Their typical description of their functioning as a for profit vs a not for profit CEO was that, if the neonatal, OB, trauma or psych units were not profitable, you would be strongly encouraged to close them down. Public good vs stockholder's shares become the measure of success.

What is this about? For any government official to paint a picture depicting that the non profit motivation is the same as that of the for profits, it is clear that he is living in only the numbers that are obvious to him, not in the realities of the mission and challenges present in vast majority of small and medium sized, hospitals just struggling to stay alive.

by Tony Chen

Our warm welcome to two new health blogs to the burgeoning healthcare blogosphere. First, check out WSJ's Health Blog, which covers "health and the business of health." Recent posts cover topics ranging from chili dog contaminants to Mass. retail clinics to pharma big wigs. Their two bloggers and other staffers are posting 5 or 6 posts per day.

Also check out My Prevention Blog, brought to you by U.S. Preventive Medicine Execs Chris Fey and Briam Baum. These guys really seem to be thoughtful and sincere about wanting the American people to live healthy and get "more good years." While I'd like to see them post more often (and maybe add some shorter, quick-hit posts), I'm looking forward to what else these blue ocean strategy thinkers will come up with next. Read Chris Fey's first post on how his personal experiences made him passionate about preventive health.

by Tony Chen

Recently, I've been doing a lot of reflecting and thinking around the real impact of this hospital impact blog. I know how it's impacted me: it's opened my eyes to new perspectives and innovations, it's challenged me to synthesize and make sense of the cluttered healthcare news arena, and it's brought me to lots of interesting people and opportunities. Besides getting hacked, getting squatted, & getting plagiarized, I've had a grand ole time blogging and I hope it shows.

But my question today is this: What is the impact of hospital impact on you? What have you found to be most valuable? What's still missing?

If you want to provide feedback confidentially, email me.

by Tony Chen

Take a quick look at two conversations going on right now on the web.

21 comments and counting on my previous post on Sicko Reviews.

Also, read my post at World Health Care Blog on the Changemakers' competition on disruptive innovation in healthcare. Currently, there are 147 entries to the competition - and these aren't just ideas/concepts in a vacuum, these are real organizations with real budgets trying to disrupt healthcare as we know it. As this is a collaborative competition, go comment and add your input on any of the ideas submitted.

by Nick Jacobs

Once, while seated beside my board chair at a very elite meeting set up for only 15 board leaders and their guests from across the nation, Dr. Leland Kaiser looked out across the group and said, “Give me a creative CEO over a traditional CEO any day of the week.”

Dr. Kaiser went on to say (and I paraphrase as my memory serves me) that “If you don’t already have genomic testing in your hospital, you are already behind.” “If you aren’t looking at advanced imaging, electronic records and patient centered care, integrative health and behavior modification practices, you need to examine your leadership.”

My chairman looked at me and smiled. We were knee deep in all of these things six years ago.

We started participating six years ago in an insurance reimbursed program with Highmark Blue Cross on a wellness program that replaced heart surgery and angioplasty with a natural approach to healing, the Dean Ornish Coronary Artery Disease Program.

Yoga, stress management, no trans fats, massage, a work out facility for our employees, personal trainers, aroma, music and pet therapy but most of all, candor and respect are keys to our performance. If we can be sensitive to each other’s needs and treat patients as if they are our loved one, health care and health can change.

Innovation is indeed the key to survival. We have just completed our greatest financial year in the past 101 years, not because our facility is the biggest, not because it has the most tertiary care, or helicopters, or complex bureaucracy but because we treat our employees and patients with dignity and respect and because we embrace innovation.

To those who are waiting for the first two thousands hospitals to take the jump before they do, it's almost time. We boomers are getting impatient for the care we know you're capable of delivering.

by Tony Chen

Recently, I posted an open question to my linkedin network: "what innovative partnerships with hospitals have you seen?" The answers I got were basically summed up by one of my contacts: "that's probably the first time I've ever seen 'innovative partnership' and 'hospital' in the same sentence. what are you talking about?"

Nonetheless, this hospital CEO is out to prove you wrong. Read this HealthAffairs interview with Virginia Mason CEO Gary Kaplan. Yes, this is the hospital that periodically flies out their leaders and physicians to Japan to learn Toyota's production process improvement approach. Passionate about "getting rid of all waste" in their system, they have cut everything from unnecessary supplies to unnecessary physical steps staff members used to walk to expensive medical procedures (for a loss).

If that weren't enough, they have partnered with (gasp!) payers as well as local employers. Yes, Virginia Mason is losing money by eliminating more expensive procedures, but amazingly Aetna has agreed to pay them more for less expensive procedures.

Even though the hospital is getting the smaller slice of the pie, this seems to be a rare example in which incentives are more aligned. And maybe this provides long-term benefits that we've yet to identify - better reimbursement for a whole slew of activities (e.g. diabetes education, patient education, prevention/screening) that could really make a tangible impact on an entire community.

Add on top of that these new insurance plans that financially reward healthy living, and we could be on our way to a drastically different health culture. The risk of death typically won't change our lifestyle, but maybe $2,000 will.

by Tony Chen

Last week, my new car was parked (legally) on the street and my neighbor backed into it. She drove off, but we tracked her down and so her insurance will obviously pick up the tab.

I brought the car into this great-looking autobody shop near my house. They really had their act together - nice decor, coffee/treats for customers, toys for waiting customers with kids, a plasma screen TV, friendly staff, and even a direct link to the insurance company (think EMR). They even had one of those mini european cars in the driveway.

Anyway, everything was very impressive except for one fact. When I drove off with the rental car they provided, I looked down and saw that the gas tank was empty. Not 1/4 full, but literally empty. I was already late to work so I just begrudgingly filled it up myself.

Even if the bodywork they do is perfect, ask me if I'll refer anyone to this outfit.

It just goes to show. We can have wonderful facilities, we can have great staff, but one little mishap, one little mistake turns a "highly-likely-to-refer" customer (5 out of 5) into a "detractor" (2 out of 5). Even though the actual work (read: patient care) was exceptional, the customer experience (i.e. patient experience) was negative.

This gets back to all we've been talking about with "patient experience," "If Disney Ran Your Hospital", and seemingly small things like housekeeping.

Of course, they still have a chance to turn me into a loyal referring customer. When I go back a week from now to pick up my car and inform them of my rental car gas deficiencies, they could delight me by picking up my gas bill for my troubles. I'm not holding my breath.

Check out this week's Grand Rounds at Aetiology. Interesting post at Emergiblog on what patients owe their healthcare provider.

by Christopher Cornue

While I never profess to be an expert about acuity-based staffing models, I have dabbled a bit and have been aware of the debates in California regarding mandated staffing ratios. Several other states have attempted to pass legislation to create models for staffing that enhance patient safety and are based in the foundation of addressing the appropriate needs of the sickest patients. One such model has recently been passed in Illinois. In short, this new legislation (which was passed on 29 May 2007) will mandate that each hospital create a team to develop acuity-based staffing models. Each team must be comprised of at least 50% direct-patient care nurses. The hope is that each hospital, with the involvement of their nurses, can create a model which best suits that organization’s unique needs and challenges. Instead of me rambling on about it, interested folks can view some of the detail at the following link on the Illinois Hospital Association’s website: http://www.ihatoday.org/advocacy/state/sb867.html. A very cursory review of other models suggests that California, Kentucky, Nevada, and Oregon are among the states that have passed legislation around acuity-based models. One report indicated that more than 25 states have considered such legislation. So, what are your thoughts regarding this?

by Nick Jacobs

In a recent article from USA Today, Dennis Cauchon elaborated on numerous health related laws that are currently being implemented across the United States. According to the article; in New York City and Windber Medical Center, (I added the part about Windber Medical Center) trans fats have officially been banned.

As we look toward a generation where one of every three children will be devastated by Type II diabetes, California has officially banned soda sales during regular school hours and limits have been placed on sugar and fat content in school prepared food.

Three States have taken on the challenge of cervical cancer as Indiana and North Carolina schools must tell parents of girls about the link between human papillomavirus and cervical cancer. They must also inform them about the availability of the new vaccine to prevent this cancer. In Nevada they now require insurers to cover the costs of that new vaccine.

Colorado has banned abstinence-only sex education in all school districts but one, and they are requiring schools to teach sex education based on scientific research. They also are requiring that information on contraception will be provided to the students.

As our society is continuously challenged by professional athletes in the use of performance enhancing drugs, the state of Florida has voted to initiate a one-year, pilot program of random steroid testing with high school athletes who participate in baseball, football and weightlifting.

The Massachusetts' health care insurance law will take effect requiring everyone to have health insurance — either purchased privately or with the help of the State.

Finally, New Mexico legalized the medical use of marijuana, and Rhode Island has made permanent its medical marijuana program. Simultaneously, Vermont has expanded the use of medical marijuana from only those with terminal diseases to those with some chronic diseases, too.

So, there will be no soda in California. No trans fats in New York or Windber, vaccines in Indiana, North Carolina and Nevada, sex education in Colorado, and Massachusetts will make sure you have insurance. Florida will stop your steroids, and New Mexico, Vermont and Rhode Island will let you toke for medical reasons. Now, we only have 39 more States to get on the band wagon, or, depending on your viewpoint, only eleven to get off! Wonder where Puerto Rico is in all of this?

guest post by Jeff McKune

Andrew touched on the central point of strategy when he said that it is "where you want to be." As with solving any problem, understanding the problem is the first step. Understanding where a hospital wants to be in the future is the first step in strategy development. There is a strategy development methodology known as complex adaptive systems that overcomes some of the shortcomings to other approaches. None would question that the healthcare industry is dynamic, with players and variables changing so quickly that adapting a static approach to strategy development is, for all practical purposes, hopeless. Perhaps those more static methodologies, and the resulting frustrations, are one of the reasons why senior leadership often reverts to a more operationally focused "what do we need today" approach.

In brief, the complex adaptive systems methodology starts simply with a series of scenarios. Write several brief scenarios about aspects of healthcare in the future - just a few paragraphs for each is sufficient. Base each scenario on your current knowledge as well as trends that you see. Where will healthcare be in five or ten years? Write in the present tense, placing yourself in the new world of healthcare as if it actually existed. Select two or three of the most compelling scenarios as the seeds of your strategy. From here, the strategy development is a series of straightforward but thoughtful steps.

* Identify the stakeholders in your scenarios. What skills and capabilities do they have? How will your organization relate to them?
* The keystone organization is that organization through which other services will flow. It is the cornerstone of the socioeconomic business system - the healthcare environment in which you operate. What skills, capabilities, equipment, and other resources will you need to be that keystone organization in your scenario? Do you have the right people? This will hopefully lead to another entirely separate discussion on strategic human resources management.
* Decide how you will acquire the skills, capabilities, resources, equipment, and people that you will need. This is much more than "we need a 64 slice CT scanner". This is acquisition with intent and a clear view of where the acquisitions will place you in your future scenario.
* The plan for acquiring what you will need becomes an action plan that is the basis for your implementation plan for your strategy. Implementation is where so many organizations fall short, so developing project plans and milestones is crucial.

At least once a year, revisit your scenarios. What has changed? How have the complexities of your system reshaped your scenario? Simply restate your scenario and reiterate through the steps once again. What you learned from the previous effort and your new perspectives will sharpen your next strategic plan. This is the advantage to the complex adaptive systems approach.

When your entire organization is focused on making your hospital successful five or ten years in the future, it is much more difficult for other organizations to compete or deflect you from your target. It is like playing chess with someone who can think ten moves ahead of you - you don't stand a chance.

Jeff is Director of the Ambulatory Surgery Unit at Phelps County Regional Medical Center

by Tony Chen

Here's a roundup of Sicko reviews. Overall, everyone agrees that this is Moore's most "neutral" movie. In other words, he doesn't go as extreme in confronting people and he doesn't fudge as many facts. But he makes his point because it's an easy one to make: our healthcare system is broken. Obviously, this isn't exactly breaking news, but his method of storytelling (juxtapositioning "facts" and gut-wrenching stories) makes it real, entertaining, and memorable for the audience.

Washington Post: "Ladies and gentlemen, I think we can agree on two things: The American health-care system is busted and Michael Moore is not the guy to fix it."

AP: "Moore's 'Sicko' gives accused little say"

NYT: "Mr. Moore has hardly been shy about sharing his political beliefs, but he has never before made a film that stated his bedrock ideological principles so clearly and accessibly. His earlier films have been morality tales, populated by victims and villains, with himself as the dogged go-between, nodding in sympathy with the downtrodden and then marching off to beard the bad guys in their dens of power and privilege. This method can pay off in prankish comedy or emotional intensity — like any showman, Mr. Moore wants you to laugh and cry — but it can also feel manipulative and simplistic"

LATimes: "Moore is back again examining America's healthcare system in the aptly named "Sicko." It's likely his most important, most impressive, most provocative film, and it's different from his others in significant ways."

LATimes commentary: "Sens. Hillary Rodham Clinton of New York and Barack Obama of Illinois and former Sen. John Edwards of South Carolina all have staked out positions sharply at odds with Moore's approach. But none of them is eager to have that fact dragged into the spotlight."

Chicago Tribune: " "Sicko" represents a subtle but distinct shift in tone for Moore. Realizing he has in his mitts a great and genuinely bipartisan issue, the writer-director from Flint, Mich., moderates his attack strategy for the better."

Boston Globe: "Whatever you call his movies -- agitprop, advocacy entertainment, Commie propaganda, the Truth -- "Sicko" is built to persuade. It succeeds by making us ill with laughter and with shame."

Rolling Stones: "Does Moore cut a few corners? Sure. Some of the European hospitals he visits might be spiffing up for the camera. The drugs an American patient buys in Havana (five cents there, $120 at home) might not be up to FDA standards. And maybe the French are pushing it by doing a patient’s laundry. But the weight of evidence Moore marshals for taking the profit motive out of medicine is overwhelming. In a summer of dumb, shameless drivel, Moore delivers a movie of robust mind and heart. You’ll laugh till it hurts."

Capital Hill Blue: "Michael Moore's new movie, "Sicko," should be called "Skipo," since it skips over so many facts en route to government medicine."

Salon: There's no other way to come at Michael Moore's "Sicko" than to state upfront that his essential argument -- that it's shameful that America, the richest country in the world, fails to provide healthcare for all its citizens -- is irrefutable. No matter how you feel about Moore or his filmmaking tactics, there's little here that any sane, reasonable human could argue with: We've fashioned a system in which big corporations get rich off our illnesses, or even just off the regular preventive steps that most of us take to avoid getting sick.

Anyone see it already? what's your take?

by Nick Jacobs

Back in 1963 my philosophy professor challenged me to prepare an analysis of intrinsic (taking) versus altruistic (giving) behavior. My conclusion at that time was that there clearly was no such thing as altruism. No one did anything unless it was good for them. Even those individuals who so generously gave of their time, money or wisdom, did it because it made THEM feel a little better about themselves.

Interestingly enough, that sophomoric knowledge (I was a sophomore.) did not keep me from embracing a life in not for profit management. Throughout my career in the various nonprofit organizations with whom I have worked; education, arts, economic development, and healthcare, it has been clear to me that there are two types of people who volunteer, the givers and the takers.

When questions are raised regarding how much is personally too much to those individuals who are the takers, the answer is obvious, “You can never have too much.” But when the same question is posed to the givers, the answer is entirely the opposite, “We enter with nothing, and we should leave with nothing. We are here to serve mankind.”

Well, over the last thirty plus years, it has also become clear to me that controls are necessary in order to keep the takers in tow because, many of them have no boundaries in regards to their material needs, and not for profit organizations are not the appropriate setting for pursuing those endless needs.

After Enron there appeared to be a glimmer of hope relating to controlling these takers, and there also appeared to be a strong movement toward a Sarbanes-Oxley-type legislation for nonprofit's. That proposal has now evolved into a new proposal called the Nonprofit Accountability Bill. Unfortunately, it does not yet have enough teeth to be really meaningful.

Let’s examine carefully the rolls of our nonprofit board members and simply track back the amount of business done by their companies within the nonprofit corporation for which they volunteer. Then check to see if bids were solicited, if influence was not placed on executives in charge through board compensation committees and if the business/member excused him or herself from the meetings when these issues were being decided. The Nonprofit Accountability Bill proposed certain limitations regarding the amount of business that actually constituted a conflict of interest, but, it is relatively clear that those numbers have also not been activated.

Bottom line? Ask questions about your nonprofit boards. Thankfully, for the past ten years I have worked for a board that is free of conflict, but this clearly is not the norm.

The difficult proposal that requires you to buy board member products, embrace their services, and use their consultants in order to ensure that they will be good board members is not acceptable behavior in a world that needs our help.

by Nick Jacobs

Why 2034? It’s actually the date that my actuarial has indicated that my individual involvement in this discussion should no longer have any viability. In other words it’s the projected date of my passing, but, believe me, there will be tens of thousands of we boomers contributing to this discussion until then.

A few years ago, during a scientific mission to Boston for a conference at MIT, it was my privilege to participate in a conference directed toward the challenge of keeping our senior citizens viable, active and out of long term care for as long as possible. We met with several health care professionals, engineers, and scientists who had taken on the challenge of miniaturizing every known type of monitoring system for the human body.

They had begun the effort to successfully decrease the size of these devices to the diameter of a nickel, the relative thickness of a potato chip and a cost of about twenty five cents each. We saw demonstrations of some of these miniaturized devices in actual use. They were adapting systems for monitoring the heart, blood pressure, brain function and respiratory system. With all of the flexibility that wireless communication can deliver, the unencumbered participants would be literally, wired for sound, as they moved freely through the special apartment that had been constructed for this research.

Each and every movement could be monitored all day, every day. The signals generated from the participants various organs were sent directly to a computer that was housed at a physician’s office where any missed beat could be reported through an alarm system that immediately notified the physician in charge.

Think of it. Pappy gets up from his chair, feels a little dizzy, sits back down, and the videophone rings with a healthcare professional checking to see if all is well.

Because of the 1984 feeling that some of we 1960’s free spirits might feel from this “Big Brother” type monitoring, it was suggested that the grandparent might also like to have her sibling monitored as well, thus giving the affect that they are indeed checking on each other.

Think of it. This system could very well keep us out of some offensive, under staffed, insufficiently reimbursed nursing home for at least an additional year or two.

In closing, however, I did receive an e-mail the other day with this suggestion. If you like to cruise, it would be more fun to live on the Pacific Princess for the rest of your life than in the Sunset Valley Nursing Center. The cost is similar, and when you trip and break your hip, they will upgrade you to a suite and deliver meals to your room.

by Nick Jacobs

Is it possible that we do not know everything there is to know about healing and health? In 1974 my neighbor asked me to help him with a piece of concrete that had been dislocated by the winter's frosts. We both bent over, lifted the 250 lb. slab, and his instructions were to drop it into place on the count of three. Well, at the count of three I glanced and saw his foot still firmly planted under the concrete. He had planned to pull it out. I didn't realize that, and held onto the concrete. I then could not stand up straight, and was bent like the letter L. Clearly, something had happened to my young year old back.

My neighbor carefully placed me into the front seat of his car, drove me straight to the emergency room, and the treatment began. First an x-ray where the physician asked if I had ever been a professional football player. When I had stopped laughing, I wiped the tears away from my eyes, and said, "Nope, but thanks." We can't miss the nuance of what occurred next. Muscle relaxants and the threat of what has been described as traction resulted in nothing, absolutely nothing. I couldn't walk, couldn't sit, couldn't stand, and felt as if a long hot knife was stuck in my back.

Two weeks later another friend saw me struggling to walk, put me in his car and drove me to a physician's office. This was a doctor that I was not familiar with, but he was pleasant, took my blood pressure, suggested that I have a Martini every night before dinner, looked at my feet and said, "Oh, this is simple, your sacro is out." He pulled on my right foot and said, "Okay, we're done here." I stood up and felt fine.

He was a DO, a doctor of osteopathic medicine who had been trained in manipulation. Although I was a teacher at the time, it seemed perfectly clear to me that medical professionals with varying views on treatments don't necessarily talk much.

In 1997 when I became the CEO of a hospital, my first decision was to become a Planetree Hospital and to create a menu of options for our patients. Because I am not clinical or medical, nothing was particularly sacred to me. My only concern was that our patients got better, and that we didn't fill our halls with quacks and unqualified tricksters.

Consequently, we introduced many aspects of complementary and alternative medicine, but the difference at our facility was that we used only medical professionals to deliver those modalities. We opened our patient rooms to accommodate family members 24hrs. a day, seven days a week. We placed double beds in our OB suites. We employed musicians, aroma and massage therapists. Our therapy dogs are there for the asking.

The concept is to provide a healing environment. The concept is to allow certified accupuncturists, manipulation trained DO's, PT's, OT's and others to provide those treatments chosen by our patients. The United States citizens are spending billions of dollar each year on these treatments, and many times they are administered by uncertified individuals.

It is my desire to give our patient partners choices. If they get better because their loved one is permitted to stay with them around the clock, or if a dog's love moves them back to health, it doesn't really matter to me. Just so they get better.

We use a very strenuous allied health professional credentialing process to approve these clinical specialists. We take medicine very seriously, and we pay out more than a million dollars each year on general liability and malpractice insurance but have paid out, on average, less than $20,000 a year for all claims in these areas because, if you treat people as partners, not patients, if you treat them with kindness and love, and if you don't make them leave their diginty at the door, they will be your partner. If you create a healing environment void of negative energy, mean employees and limited access to their loved ones, they will heal.

As a consumer, does it make you wonder why we all aren't embracing this philosophy?

by Tony Chen

Ah, the joys and travails of the wild wild west of the healthcare blogosphere.

This past week, I discovered a website (I won't dignify it with a link) that was squatting on hospital impact. They copied hospital impact content, the hospital impact design and likeness, and created a site with a very related url. All the on-going links on the site were to hospital impact. Except that they added a few ... shall we say... "not safe for work" pictures and links.

So you could imagine my dismay when I saw my thoughtful post on Cleveland Clinic's Chief Executive Officer "by Tony Chen" on their site accompanied by very suggestive pictures and links.

I emailed some blogging and lawyer friends for advice. I went to DomainTools to figure out who the culprit was (someone from Istanbul). So I emailed them, their web hosting company, as well as the Turkish Embassy. I was also about to email Google to see how to get their site de-indexed.

Nonetheless, the site was completely changed within 24 hours - all of the hospital impact content/likeness was removed. In my opinion, it was the email to their hosting company threatening legal action that did it.

Word to the wise blogger: check out this link about bloggers FAQ and IP protection.

I guess lots of popular blogs go through this, it's almost a rite of passage. So maybe I should be honored that hospital impact was popular enough to rip off!

by F. Nicholas Jacobs

The rise and fall of the Cardiac surgeon as the star around which the medical universe rotates has been an interesting phenomenon to observe. In fact, three years ago when I was approached by a physician placement agency to hire a newly graduated, Ivy League trained, cardio thoracic surgeon to fill a vascular surgery position at our acute care hospital, all of my "spidey senses" kicked into action.

Why would a multi-million dollar man, a top trained, cardiac surgeon want to come to a primary care hospital for a vascular surgery assignment? It was at that very instant that I dove into heart surgery research. As the age and acuity level of our patients had continued to climb almost exponentially, heart surgeries had dropped in our area from approximately 600 to 450 to 350 a year during the previous ten year period. Then I saw the national figures that revealed a decline from a high in 1997 of 350,000 to about 250,000 coronary artery bypass surgeries in 2004.

As the recipient of six coated stents over the same ten year period, it had always been clear to me that the new, multi-million dollar men were the invasive cardiologists. Having read the latest reports on coated stents, we Boomers with six packs in our chests are nervously taking our aspirin and Plavix and waiting for that potentially fatal clot to materialize during our next stress filled situation?

I personally was a member of that very small club of 1% that had an injury to my artery ensue during my first procedure and a near fatal misfortune take place after my last invasive procedure. So much for the 1% rule. For me it’s been a 66% complication rate, two out of three procedures, but my physicians had thousands of otherwise successful procedures to their credit before and after me.

One autumn morning I overheard a conversation between a local cardiac surgeon and an Emergency Room physician. The surgeon said, "Yeah, he has 15 stents and finally wants a bypass. The problem is, it's going to take a giraffe's leg vein to bypass all of that metal." That would be another potential complication from the “full metal jacket” rule of stent implantation.

So, as it turned out, our cardiac surgeon was looking for a medically under served area where he could work to get his Green card and eventually his American citizenship, but, in general, graduating residents are having a challenge just finding the job they want. In fact, according to a recent article in USA Today, 12% of the finishing 88 cardio thoracic residents received no job offers in 2004, and that was before the bottom nearly dropped out of the open heart surgery business.

So, what do you call a heart surgeon who finishes in the last quadrant of his program? You still call him Doctor, but, to find work, he may have to specialize in lung or heart valve surgeries instead of bypass.

Maybe someday we will discover, like Dr. Dean Ornish has professed, that diet, exercise, group support and stress management will completely reverse heart disease, or maybe, like the 1973 Woody Allen movie, "Sleeper," proclaimed, it will be determined that chocolate cake, deep fried foods and smoking will be the cure. Either way, changes continue to be a reality in the world of heart disease treatment, and, until we stop lounging on our couches, over eating inappropriate food, working too many hours a day, and not practicing regular stress management program; we will continue to add to those negative statistics.

by Nick Jacobs

As a seasoned student in Graduate School for Master's number two, I remember my professor's very carefully positioned discussion around the concept of Situational Ethics. Joseph Fletcher (1905-1991) was given credit for conceiving of this philosophy, and numerous religious philosophers have been uncomfortable with him ever since.

It has been described as a system of ethics that evaluates acts in light of their situational context rather than by the application of moral absolutes. The concept of ethics tailored to a specific situation certainly seemed like a great way to explain away the gray or, depending upon your geography, the grey issues with which we are confronted every day.

Regardless of the moral or religious implications, it is what it is, and I have come to learn that our society and most societies embrace this philosophy in a multitude of ways. If the Material's Management Director receives a favor in the form of a trip or a gift from a vendor, and that gift is beyond a limited value, that may be considered problematic for the organization. If a senior officer, though, is flown to a reception in the vendor's corporate jet, wined and dined, and then taken to a professional sporting event in an attempt to influence that officer into using that company's product, does that present the same problem? If a U.S. Congressman is flown at no cost by a lobbyist, that now is considered problematic, but if the lobbyist is from an academic institution, that is considered okay.

If a board member puts undue influence on an executive to do business with his company, how does that play out? Sarbanes-Oxley sends a very clear message that the business community is expected to do things differently than the way they have been done in the past, but I've already heard of cases in health care governance where specific board members have required the calculation of just how much business is too much business to be pushed to the extreme before the law kicks in for non profit corporations.

According to the Columbus Dispatch, in 2000, 13 of central Ohio’s corporate boards were dominated by insiders — company executives, consultants and lawyers. Some owned jets that they leased to their companies. Others owned office buildings that their companies rented. Still others were relatives of the CEO.

Bottom line? Corruption by any other name is often called doing business in many countries, and in some countries, it is truly considered an art form. Who do you know? How do you take care of your friends and the friends of your friends? What financial favors do they do for each other? Unfortunately, in many cases, if you don't play by the rules of the GOB's (Good Ole Boys), there can be a heavy price to pay, unemployment.

So, for all of you who are looking at a high powered future, study the rule books and stick to your guns, but, unless you work for an absolutely wonderful board, hold onto your hats because situational ethics can be very difficult to surmount.

Regarding ethics in the military, Robert Prentice, a professor of business law at the McCombs School, said, "Nobody up the line is taking responsibility. Everyone is trying to pin it on the little guys." Remember, that little guy could end up being YOU.

Final thought, putting on make-up or shaving in the morning usually requires one to look in the mirror, and that can become challenging for those who are better known as the players. Of course, that depends on the situation.

by Tony Chen

Cleveland Clinic has hired Dr. Bridgett Duffy to the post of Chief Experience Officer, "a newly created role designed to ensure all aspects of the patient experience at Cleveland Clinic meet the highest standards." Dr. Duffy was previously the Chair of the Brain-Heart Institute at the Cleveland Clinic and an accomplished healthcare consultant.

This "experience designer" job is one of the "hot jobs of 2007" according to Fast Company. Here's Fast Company's take on what the job is really like:

Experience designers go beyond the look of a place, creating a unique experience in which shoppers can immerse themselves. From cellular boutiques to the American Girl doll store on New York's Fifth Avenue, the shops created by an experience designer are often considered works of art; mini universes unto themselves. Experience designers are involved in every aspect of creation -- from choosing accent colors on walls to slanting the windows in the right direction. The next time you go into a boutique and you feel as if you've just had an "experience" -- you have, and someone went to a lot of trouble to make you feel at home.

Now of course, I'm sure Dr. Duffy won't be picking out wall colors. Nonetheless, she will be looking at "small things" that will collectively add up to a patient experience. This is particularly important for Cleveland Clinic, so that patients walking into their Florida site get the same "experience" as those walking into their Cleveland site.

This could be great development for the hospital sector. By definition, hospitals will always be difficult, messy, complex, and scary places to be in. Life and death, disease and sickness, brokenness and fear will always be walking down our bleached hallways. So doing whatever we can do make hospitals as enjoyable (relatively speaking, of course) and unintimidating; whatever we can do to make patients feel at home and to feel like people (On one blog, the comment was "it's about time, that place is a human warehouse!") will go a long way in delighting patients (and as Nick would say, clinical outcomes!). In some sense, this is really Planetree and also the If Disney Ran Your Hospital Series are all about.

Dr. Duffy has her work cut out for her - the patient experience isn't her job - it's everyone's job. She'll be the champion and the cultural architect. She'll also have to be a mountain-mover to change people's behavior in an environment that is structurally centered around functional expertise, not patients.

By the way, Healthleaders has a how-to guide on creating "experiences" in hospitals.

by Tony Chen

There has been some very thoughtful posts lately in the healthcare blogosphere on topics near and dear to my heart:
- The future of integrated health systems by Scott MacStravic highlights Carilion Health System's recent attempt at becoming an IHS.
- First Name or Last by David Williams on a patient complaint about being called by their first name at a hospital. Personally, I prefer Tony over Mr. Chen any day.
- Google Health: A Virtual-Doctor in Your Family by Bob Coffield wonders what Google is up to in healthcare. I have no doubt there are dozens of folks right now at Google thinking up new, crazy ideas that will change the healthcare landscape significantly.
- More on storefront clinics by Paul Levy, going against some of his counterparts and supporting these clinics. If you hadn't heard, a lot of folks in MA are trying to make it hard for these clinics to operate.
- Paul Levy also offers up the highlights of his hospital's FY07 Operating Plan. How does his areas of focus differ from our hospital's?
- Matthew Holt's got some goodies on Health 2.0, including an interview with Sermo (who've been getting a lot of attention lately) and news of the acquisition of an early-stage healthcare 2.0 company, Healia. Health 2.0 is coming!

by Tony Chen

Paris Regional Medical Center has sued health blog the Paris Site for defaming the hospital and releasing confidential patient information.

Paris Regional Medical Center is seeking damages in an amount sufficient to compensate the hospital for its injuries and losses resulting from defamatory statements on the blog, as well as punitive damages for the "willful, malicious and reckless attacks" on the hospital's reputation, the News reports.

Click here to read the blog's response. An excerpt:

"This site has been an outlet for pent-up frustrations for many of us, and only a few have actually put in their real names. 'twould be a shame if they should bear the brunt of Essent's wrath."

There has been some (very random) threads here at Hospital Impact as well - click here.

What do you think?

by Nick Jacobs

Having been an observer of scientific research projects for the past seven years, I have recently made an observation that undoubtedly proves irrefutably that parallel universes do exist. On a recent beach trip, six young mom's in our family and our extended family decided to send their hunters off to deep sea fish for Father's Day, leaving two grandfathers and a four year old boy behind to protect the house.

Because he was not included in the fishing trip, the boy would have been crushed, but the old dudes bailed out his dad and mom by inviting him to go fishing with us. Neither of us had been fishing since we were young dads, about thirty years ago, so the day was already predetermined to be interesting. We strapped the little guy into his car seat and left in search of a fishing pier. It took us about forty minutes and fifty four dollars for gasoline, a bottle of Superman apple juice, some Halloween candy corn and a piece of beef jerky.

When we arrived at the fishing pier and entered the main building, it was like a time warp. In a large glass case there sat a talking humanoid Pirate that told fortunes. Then we passed 70 different pinball, video, basketball and bowling machines. When we finally arrived at the cashier's corner, eight more bucks lighter; we saw reality in a completely different light. Renting two poles with sinkers and hooks required an $80 deposit. Miscellaneous fishing fees were $48, and that included a bag of blood worms. Our wrists were then stamped, and we went out onto the pier and into the blazing, morning sun.

We were instructed to cut the blood worm which contained what seemed to be about a pint of blood. The little boy became very quiet, looked at me and said, "You're killing him." At that point I taught him about regeneration. Then we launched the baited hooks into the Atlantic Ocean and five minutes later caught a four inch fish which we promptly threw back into the sea. After about 90 seconds more, the little guy looked up and said, "Poppa, I want to go home now." He turned and started walking toward the exit.

On the way home he cried out for a toy, we stopped and bought him a little pirate, armed to the teeth, and a motorcycle for a grand total of $5.34. When we walked into the beach house, he opened his motorcycle and the wheel fell off. He stopped crying 20 minutes later when his mom convinced him that it would go to the broken toy hospital and be fixed.

If you're wondering about my introduction to parallel universes, it should be perfectly clear to you by now that this trip was exactly like scientific research. You start out not knowing where you're going; spend lots of money trying to get there; have great expectations; end up with much less than you or anyone had anticipated; have to throw it back in, and too many times, the wheels fall of.

Parallel universes.

by Tony Chen

Two great articles by two guys named Scott. Both are tracking the pulse of "consumer-driven" healthcare in different ways.

Go over to the World Health Care Blog for a great strategy forecast for retail clinics by Scott MacStravic

And head over to Matthew Holt's blog for a Healthcare 2.0 priming the pump post by Scott Schreeve, MD.

by Christopher Cornue

As we organize services across our organizations, there are multiple strategies we use to align the various individuals affecting a specific disease-state or service. These groups and services are often referred to as Service Lines, or, as I am reluctant to actually put into writing, Product Lines. Since I am so hesitant to actually use this term, I guess I need to explain further. In the 70s and 80s, I believe the general terminology used for this structure was Product Line; however, the meaning was very different. Although I wasn’t involved in healthcare until the mid-90s, my understanding was that Product Lines focused more on marketing and growth efforts, not on the broad scope of current Service Lines. I’ve always had a hard time labeling these efforts under the scope of “Product Lines” … as the connotation is that we’re taking care of widgets, not patients.

Well, now that I’ve had my say about Product Lines … let’s talk about Service Lines and why I think it does matter to call them such. With the label of “Service Line,” we can best incorporate the broad scope of a specialty, service or line. For example, when I’ve been creating service lines at my current hospital, we make them interdisciplinary with individuals involved in a patient’s care from presentation through discharge (as much as we can). Additionally, we focus on four “foundations” that drive our efforts & services: Quality, Growth/Outreach, Fiscal Responsibility/Accountability and Satisfaction (Patient & Provider). When we align these efforts (re: services) around a specific Service Line, we have the best opportunity to have quality outcomes (that are measurable and trending), control our expenses, enhance our revenue and leverage these successes to grow our volume responsibly. E. Preston Gee, author of Service Line Success, states that Service Lines allow “an organization to better understand the dynamics at play within the subcategories of its business.” A perfect example of this is the aligning of competing forces in a Cardiovascular Service Line (no small task … but very rewarding when it works!). Furthermore, Gee suggests that Service Lines force “the organization to institute a discipline of measurement and accountability” – which I believe is key in today’s environment. I could talk ad nauseam about this topic (trust me, ask anyone who works with me!!), and may discuss further in a future posting – so beware! So, that’s why I prefer the “Service Line” moniker and for me, yes it does matter. What do you think and what successes have you had?

by Tony Chen

I've been watching the NBA Playoffs this year. Arguably the story has been LeBron James skillz & basketball IQ versus the Spurs talented (and equally intelligent) trio. While it doesn't hurt to have boatloads of talent, it is really the mental game that has set apart the good teams so far.

This year, I noticed a lot of commentary about LeBron James and other players working tremendously hard at getting better. More specifically, they work tirelessly at leveraging their physical advantages and their mental game. I found myself almost inspired by these players who realize that the physical gift they've been given can be amplified many times over through good ole fashion hard work & clarity of mind. This is the one chance they get and they're taking it head-on.

This got me thinking - if the world watched our work lives on TV, would they be inspired by how hard (and smart) we work? Do we realize that this is our one chance to make an impact on thousands of people's lives? Are we more concerned about our stat line or if our team wins?

Even the superstar players work out and relentlessly practice fundamentals - passing, dribbling, & free throws. How much emphasis do we spend on working on our fundamentals - communication, meeting management, delegation, and project management? And how much time do we spend working on our "mental game" - our leadership IQ?

By the way, here's an interesting post from FastCompany on what business leaders can learn from LeBron James.

by Tony Chen

Check out this list of the world's top 100 healthcare blogs, based on GooglePageRank, Bloglines subscribers, technorati authority ranking, etc.

And yes, Hospital Impact is #57.

by Nick Jacobs

The Baby Boomers are not about to be plutoed.* (Plutoed, according to BuzzWhack.com means to be unceremoniously dumped or relegated to a lower position without an adequate reason or explanation.)

We Boomers have paid our dues and have spent a lifetime changing the world in many ways. Unlike the way our parents and their parents were treated by the health care system, we are not about to be ignored, uninformed or pushed aside by our hospitals and our physician's offices. We will not be treated as sheep or second class citizens, and we will not leave our dignity at the door. So, be prepared.

Remember, we are the generation that created free love, enormous credit card debt, the dot.com boom and bust, the Internet. (Sorry, that was Al Gore, but wait, he is a Baby Boomer!) We've had thousands of public schools built for us, seen our colleges expanded to accommodate us, and we've watched this country adapt to our needy, greedy ways for the last 50+ years. With this group of former, wild eyed, hippies and now conservative investors, it ain't over till it's over. We don't plan to go out quietly, easily or soon.

Look at the impact we have had on the stock market, the real estate market, the clothing industry. In fact, I specifically remember the day, at age 33, when I arrived home in a new pair of jeans that were supposedly one inch smaller in the waist than I was. It was a certifiably, braggable moment until my spouse pushed the Newsweek across the counter to me. Featured on the front cover was a picture of a person in blue jeans, and the caption was "Levi's changes their jeans to pear shaped to fit the growing Baby Boomers."

It's a given that we are not going to accept hospital gowns that expose our us. We are not going to wait for the convenience of the radiologist who decides to work out and take an extra long lunch in he middle of the day or the pathologist who just doesn't want to work on the weekend. We are not going to accept the medical center that puts us in a waiting room and never explains why they are so late meeting our needs. We are not going to embrace your green jello and high fat menus. We are not going to allow you to expose us to 10,000 unquestioned radiological procedures, the equivalent to living on the Sun for a year or two.

We are, however, going to need thousands of plastic surgeons, personal health coaches and medical liaisons to help us navigate the system, and, eventually, we'll want gerontologists who understand the nuances of the aging body.

My first heart cath was back in 1997. When I was taken back to my room, the dietary staff brought me bacon and eggs and a packet of instant Sanka. My first question was, "Who paid for the bacon and eggs, the heart surgeon who was grooming me for his next case?" Then my next question was "When can you bring me a decaf latte with soy milk?"

We are not really interested in excuses for nasty employees, dirty rooms and hallways, limited visiting hours, lack of wireless and cell phone access, poor signage, no parking, limited availability to massage therapists, burned toast. We are especially bored with completely disconnected medical care where the docs don't communicate with each other, or medical records that aren't available or on time. We will ask about your infection rate. We will ask why your emergency room doesn't provide access to relatives, and why your only 100% commitment to excellence is typically your financial department.

Oh, yeah, and who ever decided that homes for the aging should consist primarily of a semi-private bedroom and hallway for each patient? There is no way we're going to sit in the hall and be wheeled into the cafeteria to hear Lawrence Welk. We will demand video I-pods with all of the albums of The Rolling Stones and probably some legalized marijuana to alleviate eye pressure for glaucoma.

So, fasten the seat belt of your fancy, leather, boardroom chairs. The Boomers are coming. We're used to being catered to, pampered, respected and nurtured. We are not going to be plutoed, and, if you don't get it, we'll make sure that we give the trillions of dollars that we have to pass along to those who do. Love ya, man.

by Nick Jacobs

The topic of controlling health care costs has been the center of attention at the last three conferences at which I have been either a speaker or an attendee: Consumer Health World Conference in Las Vegas, World Healthcare Congress in Washington D.C. and the Health Forum Integrative Medicine Conference in San Diego. The general consensus has been that we need an overhaul, but what makes up a viable retooling that will be acceptable to all?

At the World Health Conference we heard that preventative medicine is one of the major cures applicable to our health system. If we could continue to make strides in the promotion and societal acceptance of exercise, smoking cessation, decreased consumption of saturated fats and complete deletion of Trans fats, we would see exponential changes in our overall health status as we reduce diabetes, obesity, heart disease and cancers.

Of course, the logical conclusion at the Forum was to make an entire menu of complementary and alternative medicine solutions available to everyone, a.k.a., bring to the mainstream those healing cures, traditions, and treatments that indigenous man has embraced for thousands of years. Consequently, those incurable maladies that typically have required surgery after surgery with no curative results will be addressed by embracing a holistic care to treat the root causes. Be it spirituality, stress management techniques, energy treatments or music therapy; there are sometimes cures in nontraditional complementary and alternative medicines that could never be uncovered with antibiotics, surgery or any other version of the presently accepted healing modalities that feed our current $2+ trillion dollar health system.

We have also explored the possibility of keeping our elderly citizens at home as long as possible. This can be achieved through the use of high-tech equipment intended to monitor and to help remind them to take their medicines. According to some experts, if only a quarter of the current nursing home residents could remain in their homes this would result in a savings of more than $12 billion a year.

Like it or not, retail medical clinics or basic health care centers in commercial outlets that can take care of problems that are expensively addressed in our overcrowded emergency rooms are seen as extremely viable alternatives to the high cost care currently being administered in our hospitals.

Another huge initiative will be the unification of medical records using the Internet. Every patient would then carry a USB drive containing his or her medical records. These records could be downloaded by any doctor anywhere, or better still, the individualized Patient Identification Number with a personal Pin would make those updated records available on line.

Several other major suggestions that were put forth during these conferences included the implementation of a Market-based Universal health system, financial assistance for low income individuals, and equal tax treatment.

The bottom line, however, is that we, as an industry will be consistently challenged to become more transparent in our charges, quality indicators, physician performance report cards, accreditation ratings, and more as our country searches for a way to care for the nearly 50 M uninsured, and the aging Baby Boomers

by Nick Jacobs

It's amazing to me how much and yet how very little has changed during the past ten years. The subtleness of the metamorphosis is similar to the 212th degree, the point at which water goes from hot to boiling. First, you're hot, and then you're cooked.

Today I put on a new suit. It was the same size, same cut, same style and same manufacturer, but today, I looked like a watermelon in a silk stocking. That extra pound must have been the tipping point. After 20 years, the 42 Regular was not happening. If the coat button had launched and become airborne, it could have killed someone.

Another thing happened today that was totally my fault. My words took the moment to a boil.

Many of you have read about my periodic consternation relating to scientists and the world of science. Sometimes, just sometimes, as they apply science to living, the participants view of life becomes a little skewed. Sometimes the brilliant scientists think about things too long, or they get into too much analytical detail, but the characteristic that is the most worrisome to me is that they come from a world where normalcy involved feeding, holding, loving and talking to bunnies for months, and then cutting them open to see what impact the experiment had on their arteries.

It was because of this trait that I decided to hire some hard working, fun loving, spirited, people to liven the place up a little. So, a few years ago, four terrific people joined us to bring additional life, spirit, fun, and spontaneity to the institute.

At 3:55 this afternoon, I was running out of the door on my way to a doc meeting in the hospital when I noticed something for the third time that week, new paper signs. No one could ever fully appreciate my hatred for paper signs unless they had spent the past twenty years living inside of my suits. You see, I had a boss who scoured the eight floors of the hospital building where I had worked to find these paper things, and then, rather than take them down, he just screamed at me. You see, paper signs represented transience, instability, poverty and unsupervised spontaneity to him and now to me. These signs in question had been breeding over the past few weeks, like the flimsy metal hangers that the laundry gives you. You start out with two, and by the end of the week you have a laundry bag full.

So, as I left the building, I turned to one of my happy souls and said, "What the heck are these signs doing here?" Unfortunately, she took it personally. She had been asked to help make the signs, and, as an artist, she took pride in her work. It was as if I had screamed, "Hey, your kid is ugly!" As Joe Lieberman would say, "Bipartisanship means never having to say you're sorry." Why couldn't I just have said, "Let's get some permanent signs?" Maybe it would have been better to have said, "This sign is so beautiful that we should get it memorialized by having it bronzed?"

Anyway, I was later informed that I had upset my friend very much. Running out the door with three other people who observed my despicable remark probably didn't help.

So, I'm dedicating this blog to all of those people who have been hurt by my curt, CEO, verbal shots. In Shakespeare's Twelfth Night, he writes, "Life is full of sadness. The best years of life are short. Events are cruel. And other people are cruel. In such a world, it is your DUTY to find and cherish whatever real happiness you can."

So, Cathy, and all the Cathy's I've boiled, I'm sorry. It wasn't personal. It's just that those paper signs are killin' me.

by Nick Jacobs

Almost every week someone says to me, "How did you make the transition from being a teacher and professional trumpet player to running a hospital and a research institute?" In so many ways, it is exactly the same job. Clearly, the human mind sometimes has trouble grasping non-traditional career paths. As a young man, my passion was for helping people through education. It was clear to me that you could change a person's life almost completely with enough information.

There is no question that my journey was out of necessity. During the 70’s and 80’s the area where my family decided to settle we experienced the highest out migration of any city in the United States except for East St. Louis, Missouri. This was due largely to something called the Johnstown Flood. Unemployment reached 19% and my most demanding job was to find a way to continue to be employed to care for my family. So, at age 40 with a B.S. and an M Ed in hand, I headed back to Carnegie Mellon University for a second Masters in Public Management/Health Systems Management. It was a good decision, a unique program and a very different approach from the typical MHA or MBA because it exposed us to all aspects of public management. After that the Executive Program for Health Systems Certification at Harvard put some meat on the bones, and finally, the Fellowship from the American College of Healthcare Executives finished the credentialing journey. It took nearly a decade in total and almost more hours than a typical day held, but it provided the ticket to passage.

Would I do it again? Truthfully, my desire to nurture and care for people has been fulfilled in every way. The gift of healthcare delivery is second only to helping a lost kid find their way through education. Am I disappointed in the Medical Industrial Complex? Sure, but nothing that man has touched is perfect. My only advice to the student readers is that sometimes the hard way is more meaningful. All but my B.S. degree were attained while employed. It was extremely difficult to put in a 70 hour week and then drive to Pittsburgh two hours each way after work, but the experience was very rich because of the direct applicability to my job on a daily basis. School is great, and continuing education is a must. Don’t stop.

by Nick Jacobs

The general public is totally dependent upon people in my position to stand up and take responsibility for running a competently staffed hospital. Each and every one of us is dependent upon those individuals trusted with our lives to be kind, competent, capable and sure of their skills.

There is no reason for staff members to treat you poorly. There is absolutely no rationale for anyone to ignore, talk down to, or mistreat either you or a loved one. Do not be afraid to stand up for yourself or your loved one. There is no reason for you to receive poor treatment. Allow yourself to become empowered.

You should not be exposed to unnecessary infections. You should not be subjected to an ineffectual physician or staff member. You should not be kept in the dark about your treatment. Your loved ones should not be kept away from you. You should do or have done what you want.

That’s my story, and I’m stickin’ to it.

by Tony Chen

Remember how Windows blew away DOS? Get ready for Windows to be blown away by a new technology: surface computing. Microsoft just announced this technology that will change how we humans interface with computers. Instead of mouse and keyboard, it's touch-based. Think about that movie "Minority Report" and how Tom Cruise could manipulate multiple items with his fingers. Click here for a great video tour from popular mechanics - it's a a lot easier to understand it by seeing it in action.

Now, this isn't a healthcare technology blog and I don't pretend to understand anything technology. But I have to wonder what applications are possible in healthcare.

Radiology - quick manipulation of multiple images or 3D models could lead to faster, more accurate diagnoses.
Surgery - will this interface make it easier for surgeons to manipulate laproscopic surgeries of very delicate and intricate areas? Essentially, this enables physicians to be smarter.
EMR - maybe this interface helps physicians quickly (and more intuitively) enter, view, analyze data within the EMR. Less clicks and less typing.

More news on Microsoft's Surface:
Washington Post
ABCNews
Reuters

by Tony Chen

Just in case you hadn't heard, go over to KevinMD for this post about Dr. Flea, a physician blog that was used against him in a lawsuit.

And yes, the blog is now non-existent.

by Tony Chen

I've been running into more and more hospitals recently that have developed a great new innovation and made it work so well in their own facilities that they are compelled to share it with the rest of us. Several had tried to offer their services to their fellow hospitals for free, but were overwhelmed with demand to the point of starting a fee-for-service enterprise.

I'll be using this post to keep a running list of these innovations. So if you have any others, please comment or email me, and I'll add it to the list. What are hospitals doing right now that is so successful and innovative that other hospitals want to get in, too?

- Memorial Hospital - Innovation Consulting - bring your team to visit their hospital & innovation lab.

- Memorial Hospital - Chocolate Cafe Medical Ventures - triple your cafe revenue by opening a "chocolate cafe"

- ValleyCare - Retail Strategies Visit/Tour/Consulting - Learn how they've embraced a truly retail approach to healthcare and diversified their revenue stream.

- Baptist Health Care - Baptist Leadership Institute offers a wide variety of consulting services (leadership, physician strategies) and tools (e.g. idea management, 360 feedback, etc)

- Harvard - Joslin Center for Diabetes - Open a Joslin-branded diabetes center at your hospital.

- Park Nicollet - International Diabetes Center - Same deal, open an IDC-branded diabetes center at your hospital.

By: Craig Allan Ahrens

It has been over three months since my last blog posting. Why? I have been busy starting a healthcare web based media company focused on providing primarily video and audio content dedicated to addressing healthcare business issues.

I believe in this industry's ability to be at the forefront of not only clinical technology, but also at the leading edge of business communication technologies. A weekly healthcare news video program, video interviews with healthcare executives, and audio editorials are only the beginning. Web based video is the future communication medium and I hope to help push what is seen as a dinosaur industry into the forefront.

It has been a long road and I have a new whole level of respect for business start ups. I want to thank the www.hospitalimpact.org team for their insight and support. Please take a moment to browse my website's top five weekly headline videos, video editorials/interviews, and podcast editorials/interviews sections. I appreciate your feedback.

The following is the press release scheduled to go out today:

Dear Healthcare Professionals:

The business side of healthcare; it's who you are, where you want to be, or who you want to reach. www.TheBusinessofHealthcare.tv is the first and latest in disseminating online healthcare videos and audio news, editorials and original content dedicated to the business issues impacting healthcare.

www.TheBusinessofHealthcare.tv is a perfect opportunity for you to:

• Learn about current hot topics in the industry
• Reach healthcare leaders
• Get your own message out
• Gain awareness
• Drive traffic to your own Web site or healthcare organization

Whether you have a featured video editorial posted to aid in product awareness and public relations, a desire to easily keep abreast on hot healthcare business topics, or a need for a company logo linking through to your own Web site, www.TheBusinessofHealthcare.tv connects you directly with healthcare leaders. Today's healthcare professionals are watching our video and audio podcasts, editorials and news on www.TheBusinessofHealthcare.tv. Are you there?

Sincerely,

Craig Ahrens, FACHE

President, www.TheBusinessofHealthcare.tv

Mr. Ahrens is President of www.theBusinessofHealthcare.tv and a healthcare strategy consultant with expertise in general hospital strategic planning, operational turn-arounds, physician business development, and service line planning. You can reach him at info@thebusinessofhealthcare.com.

by Nick Jacobs

USA Today ran an article last week questioning the great medical secret, hospital death rates. As many of you know, we are passionate about transparency in health care, but one of the problems that we face is a nuance problem.

For example, we have a palliative care unit, a hospice that is used by a five county area. It is a center that provides respite, pain control and end of life care. My opinion of this service is that every hospital should offer it to every family, but, bottom line, year after year, our hospital is penalized statistically because of the number of deaths that we have.

Even though the patients are coming to our unit to die, it just shows up as a State statistic without differentiation. If the terminal patient was there because of heart failure, the ultimate end of that condition is not life, it is, in fact, death. Consequently, the State statistics will show an inordinately high number of deaths for cancer and heart failure in the graphic depiction of our medical center's death rate. Then the newspapers cover this statistic, and we attempt to respond to the media by explaining what hospice services are and how they should be calculated.

Transparency in death rates must be carefully monitored so as not to penalize those facilities that help families by providing hospice services. We even have heard of some heart centers that will not operate on patients with high co-morbidities because it will skew their statistics. Numbers can do whatever you want them to do, and we want them to be honest and carefully depicted to demonstrate truth and clarity.

We Were All Created Equal – Man Made Us Different.

by Christopher Cornue

Our last post in the series focuses on collaborative efforts around disparities in cardiovascular disease for African-Americans and Hispanics.

A second approach has focused on cardiovascular disease and has its roots in the Institute of Medicine’s 2001 Crossing the Quality Chasm: A New Health System for the 21st Century, and the aforementioned 2003 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Using these reports as a basis for proof that racial and ethnic disparities exist in Healthcare, the Robert Wood Johnson Foundation launched the Expecting Success: Excellence in Cardiac Care collaborative project, led by The George Washington University, School of Public Health and Health Services’ Department of Health Policy. Through a rigorous selection process, 10 hospitals nationwide were selected to participate in this 29-month collaborative project, with the aim to improve the quality of health care provided to minority populations. The ten hospitals include: Del Sol Medical Center (El Paso, Texas); Delta Regional Medical Center (Greenville, Mississippi); Duke University Hospital (Durham, North Carolina); Memorial Regional Hospital (Broward County, Florida); Montefiore Medical Center (New York, New York); Mount Sinai Hospital Medical Center (Chicago, Illinois); Sinai-Grace Hospital (Detroit, Michigan); University Hospital (San Antonia, Texas); University of Mississippi Medical Center (Jackson, Mississippi); and Washington Hospital Center (Washington, DC). Based in the roots of the project is the assertion that hospital cannot improve the quality of care without gaining a better understanding of the community in which they operate and their patients live. Launched in September 2005, each of the hospitals use the established core measures for AMI and Heart Failure, in addition to Measures of Ideal Care, Readmission Rates, and other metric, to measure ongoing clinical improvement and success. Woven into each of these metrics, is an application of collected race and ethnicity data. By measuring these metrics, in conjunction with the race and ethnicity for the patients, each hospital can assess how well they are doing in narrowing any observed disparity gap. Indeed, the collection of these data was the first step that many of the hospitals took to ensure they are appropriately measuring the effect of their efforts. With improvement plans for both the inpatient and community settings, each hospital has identified numerous opportunities to address the fundamental cornerstones in efforts to address disparities … namely:

o educating patients, families, healthcare providers (including community physicians) as to the essentials of superior heart care;
o increased presence in the communities in which our patients live;
o development of partnerships with key community & professional organizations;
o collection of race, ethnicity and language data for each patient;
o consistent and appropriate collecting, reporting and sharing of data and metrics to wide audiences

More information about Expecting Success can be found at www.expectingsuccess.org including a First Year Summary report. Further detail, with a report about successes achieved through this project, will possibly be the subject of a future posting.

As this series concludes, I think it is safe to state that we know that disparities exist … the evidence in numerous research, literature, studies and publications is incontrovertible. As Unequal Treatment suggested … research and the identification of the problem is a first step, but now we need to move toward action. This is the challenge for, and charge to, all of us in healthcare.

This post is part of a 5-part series on healthcare disparities:
- Part 1: Introduction to Healthcare Disparities
- Part 2: A few healthcare organization role models to follow
- Part 3: Measuring disparities meaningfully
- Part 4: Two big disparities projects in the works
- Part 5: Cardio in African-Americans and Hispanics

by Tony Chen

I heard through the grapevine that Geisinger has offered a version of a "money-back guarantee." Basically, if a patient is re-admitted for the same reason, they won't charge the patient (or the patient's insurance company). I saw this article on it - it only pertains to heart surgery. And apparently, re-admits are way down.

What an interesting consumer-friendly, quality-driving philosophy?!

We Were All Created Equal – Man Made Us Different.

by Christopher Cornue

There are many programs and initiatives nationally that are working toward addressing these disparity issues in healthcare. To illustrate some of these efforts, two innovative large-scale projects, working to address the call to confront this disparity in healthcare issue, will be reviewed. The first (discussed in this posting) is a city-wide effort in America’s 3rd largest metropolitan area, Chicago, to address the disparities that exist in Breast Cancer mortality. The 2nd, which will be the focus of the next & final post in the series, is a national collaborative addressing cardiovascular disease disparities and quality outcomes.

In October 2006, the Sinai Urban Health Institute, the research arm of Chicago’s Sinai Health System, released Breast Cancer in Chicago: Eliminating Disparities and Improving Mammography Quality, which summarized their research and findings. They analyzed the Chicago portions of data from the Illinois State Cancer Registry, Illinois Vital Records files, the Illinois Behavioral Risk Factor Surveillance System and the United States Census. Through this analysis, they found a very disturbing trend in Chicago – that although progress has been made in reducing Breast Cancer mortality rate in whites, the rate for blacks is essentially unchanged since 1980. This gap, where the breast cancer mortality rate among African-American women was 68 percent higher than that of whites, is higher than the national average (37%) and New York City, as a comparison city, (17%). Several reasons have been suggested – including the fact that some studies suggest that African-Americans are predisposed genetically to aggressive forms of breast cancer; however, there is significant evidence to suggest there are socioeconomic causes, too. Some of these include the following:

o patients refusing biopsies or treatment because they cannot afford it;
o unwillingness to seek treatment because they live too far away and transportation is a real issue for them;
o continued “distrust” of the medical system.

One estimate from their studies suggests that each year 80 black women in Chicago die from breast cancer because their rates are not the same as the White rates. The publication is available at www.sinai.org/urban/publications.asp. This report provided a powerful impetus for the creation of a task force to address this issue. Late in 2006, a Chicago Breast Cancer Task Force was created and is chaired by three of Chicago’s most prominent health leaders: Sr. Sheila Lyne (CEO of Mercy Medical Center and past Commissioner of the Chicago Department of Public Health), Ruth Rothstein (former Chief of the Cook County Bureau of Health Services), and Donna Thompson (CEO of Access Community Health Network). This task force will charge healthcare leaders in Chicago, and the City of Chicago to address this healthcare disparity. This first step of this effort was the convening of the “Breast Cancer Quality Summit: A Call for Action,” which took place on Friday, 23 March 2007. Held at Rush University Medical Center, more than 100 leaders throughout the metropolitan Chicago area, including Northwestern Memorial Hospital, University of Chicago, Stroger Hospital of Cook County, University of Illinois at Chicago, American Cancer Society, Mercy Hospital & Medical Center, Mount Sinai Hospital Medical Center, Rush University Medical Center, Avon Foundation, Access Community Health Network, Sinai Urban Health Institute, Centers for Medicaid and Medicare Services (CMS), Y-ME, Harvard Medical School, Cook County Bureau of Health Services, among others, met to begin the process. Research presentations, national speakers about disparities, panel discussions and defined focus on three areas of the problem (1. Access to mammography, 2. Quality of mammography, and 3. Quality of treatment for breast cancer) highlighted the day. In the afternoon, three Action Groups, based upon the aforementioned focus areas, met to plan their course of action over the next six months with a report-out to occur in October. All of these activities, including the individual Action Groups will culminate in another Summit in Fall 2007 where recommendations will be presented to the City of Chicago, with actionable items soon to follow. More information about this Summit and these activities can be found at www.sinai.org/urban/summit/.

Next, a look at the Expecting Success: Excellence in Cardiac Care national collaborative, focusing on disparities in cardiovascular disease in African-Americans and Hispanics.

This post is part of a 5-part series on healthcare disparities:
- Part 1: Introduction to Healthcare Disparities
- Part 2: A few healthcare organization role models to follow
- Part 3: Measuring disparities meaningfully
- Part 4: Two big disparities projects in the works
- Part 5: Cardio in African-Americans and Hispanics

by Nick Jacobs

This is not the first time that I have written about the impact of access to religious or spiritual support for our patients during hospitalization. It is something about which I am passionate. This passion is not because of my personal religious zealot tendencies. It is because our basic philosophy is one of inclusiveness and existentialism in that there should be few if any limits as to the numbers and types of religious options that are made available to your patients, and, overall, we also embrace the philosophy that there should be no unreasonable limit to the availability of choices for patients when it comes to the type of modality or treatment philosophy that is available.

As often stated on this blog, it does not matter to me if our patients are brought closer to mental, physical or spiritual healing by pet, aroma, massage or music therapy; meditation, drumming circles or reiki. We don't care what the ingredient is that brings our patients closer to a cure, just that the healing environment gives them choices. Our labyrinths, walking trails and healing gardens provide just a few alternatives. Our 24 hour open visiting policy fits some, but not all patient families. The right to sleep in the same room with your loved one is a belief that we embrace to the point of having double beds in our OB suites and fold out beds in many of our patient rooms.

So, what about religion?

Recently featured on WebMD Medical News a piece on spiritual and religious doctors by Jennifer Warner which was reviewed by Louis Chang, MD agrees that religion and spirituality have a significant effect on a person's health. But doctors who themselves are religious or spiritual are more likely to see the impact of religion and spirituality on a patient’s health and believe it strongly influences their health.

It concludes by saying that consensus seems to begin and end with the idea that many if not most patients draw on prayer and other religious resources and overcome the spiritual challenges that arise in their illness.

Bottom line, if it works, don't limit access. Our wired world is not going to tolerate intolerance in any aspect of life, and, as we are exposed to truths that are effective all over the world, our decisions to reject them here in the United States will be questioned, as well they should.

Move on; open your mind, your eyes, your brain and your heart. We do not possess the definitive answers to every question. We are not the end all.

by Tony Chen

Mark Achler, CEO of patient communications pioneer Emmi Solutions, was gracious enough to answer a few questions about health literacy and the value of effective patient communications.

1. What are the top 3 things all hospital leaders need to know about health literacy?

1. It’s a bigger problem than most of us may realize. Over 90 million Americans have difficulty understanding and acting on health information. Even well-educated people have trouble understanding instructions on pill bottles, discharge sheets, informed consent documents, and the brochures and handouts that are supposedly there to help.

2. The health literacy problem is a patient satisfaction problem. It’s a quality and safety problem. It’s a risk problem.

3. Health literacy has huge economic consequences for hospitals. The IOM found that the US healthcare system spends an average of $993 every year per patient with low health literacy in excess hospitalization expenses. So, improving the health literacy level of patients should be on the top of hospital leaders to do lists and action items. It’s fundamental.

2. What is the value proposition for a hospital to augment its patient communications/education resources? Can you give any examples of concrete results from Emmi's experience?

Hospitals benefit in four major ways when EmmiPrep™, our perioperative product line, is fully implemented. 1) Improving patient satisfaction 2) Quality and safety improvement 3) Creating operational efficiencies and 4) Supporting their risk management efforts. It starts with engaging patients in their treatment process. When you can engage and inform patients about their treatment and options, you will have a more satisfied and loyal patient. And that engages the physicians. Happier patients who feel that the hospital and their doctor went the extra mile to educate them and their family in a personal and relevant way are more loyal to that organization. So you have multiple benefits here.

Now, about patient safety. EmmiPrep walks patients through what they need to know to have a safe experience before, during, and after their treatment – like the universal protocol around preventing wrong site, wrong person errors that the Joint Commission has established. We encourage disclosures around allergies, medications, and health history. And we help deepen their understanding of what to expect. In fact, 96% of 41,057 patients surveyed said Emmi improved their understanding of what to expect from their procedure.

Choosing to have surgery (and where to have it) is a big decision and our programs help patients really understand, in plain language, what’s involved, what the risks are, what are the alternatives. Interestingly, Press Ganey has found that patients feel safer when provided with more information, specifically, information that aids decision-making. In fact, patient’s perception of safety increases with the number of pieces of information they receive. Not only do Emmi programs address key elements of patient safety, by virtue of offering these programs to patients and promoting them throughout the organization, it impacts a patient’s perception of safety.

3. How does Emmi make communications "emotionally-engaging?"

We work with real patients throughout the development process. They tell us about their experiences, fears and wishes. We listen and incorporate those insights and coping strategies into our programs. The voice of the program creates a very intimate experience. It’s the voice that addresses those embarrassing questions without judgment and anticipates the questions you didn’t know you had. Patients and their families are extremely responsive to this method of communication. It’s empathic. We have a high response rate to a survey that patients can go through after watching an Emmi program. And often people say how soothing the experience was and valuable. It’s filling a gap in communication that doctors and patients appreciate.

4. Are there particular types of hospitals that would benefit the most from Emmi's products and services?

Our hospital customers are forward-thinking. They believe in and invest in the power of communication and how it can transform their business.

5. There seems to be more and more companies that are attempting to address the health litreracy gap and the patient communications gap. What sets Emmi apart from the rest of the pack?

You really know it when you see it. It’s why an iPod is better than other mp3 players. You want to interact with Emmi. It’s the design, the methodology, the trustworthiness of the content, the whole approach. And our technology platform is very sophisticated. Unlike DVDs and brochures and web content, Emmi can be measured. Our clients know, in real time, that a patient was informed. You can’t tell if someone read content on your website or your brochures or other materials. With Emmi, our clients track and gather data, including patients’ questions and concerns. It’s 2-way communication. That’s a huge benefit for hospitals.

by Tony Chen

Check out this exclusive TIME interview w/ Michael Moore on his new movie, Sicko (no, the movie isn't an autobiography, it's a healthcare industry-bashing "documentary").

Pretty funny:

TIME: What was the hardest thing about making this movie?

Michael Moore: Getting insurance. How do you convince an insurance company to insure a film about insurance? I finally found this guy who’s got a little company out in Kansas City. I think he’s the only Democrat who owns an insurance company.

I can think of a lot of things to say about Mr. Moore. But regardless of what we think of them, I'm guessing there will be negative hospital images in this movie that will be etched in people's memories forever. While the healthcare insurance industry seems to be the main target, our hospitals will be guilty by association.

by the way, I emailed Mr. Moore to see if I as a hospital blogger could get a pre-screening of the film. Still waiting to hear back from him.

And I'm still waiting for the AHA or someone to tell the other side of the hospital story: the medical miracles, the lifetimes of tireless service, the relentless compassion of nurses against all odds, and the unexpected 2nd chances patients & families get through a skilled surgeon's hands. I applaud Rush for starting to tell their stories.

by Nick Jacobs

These blogs are supposed to help us move toward a better health system, a more perfect hospital. Well, a few weeks ago, I ran across a corporation that is as close to perfect as mankind is capable of delivering. It's a corporation that has been formed as a federation of like hospitals to help them survive and thrive.

What's the big deal? Well, this corporation isn't dominated by a large hospital. In fact the budget sizes range from $30 to 120 M a year. There are twelve of them, and their combined gross annual budgets hang well over $1B. They each pay monthly dues until enough money has been generated to operate the corporation, and then they don't take any more money; usually that means no dues in April, May or June.

They work together in the obvious areas like purchasing, health insurance for their employees and liability insurance. What they do that is not normal is provide their docs to each other for peer review of difficult cases. They are positioned to assist each other with virtual, telemedicine pharmacists, data repositories, a blood bank, and dozens of other creative initiatives that will virtually save each participant hundreds of thousands of dollars each year.

The beauty of this virtual organization is that it does not require the individual hospitals to give up their boards, their presidents, their autonomy, their strategic planning, their connectivity to their cities, towns and villages, their pride or their place in history.

Is it possible that all of the small and medium sized hospitals in the United States could find eleven friends to hang out with, to work together, and to help support each other? We've just applied to be hospital number 13 in this gaggle, and it is our hope and prayer that it will enable us to miss not one beat as we move into the next chapter of our history. There is absolutely a place for independent, well run, high touch hospitals, and there is a place for communities to stay plugged in to their hospital.

Find some friends and emulate this federated model of non strategic partners as they pull together to fend off the predators. Not a new idea, but a near perfect alternative model.

We Were All Created Equal – Man Made Us Different.

by Christopher Cornue

Next, how do we measure disparities? Most commonly, it can be accomplished through the collection of race, ethnicity and language data. While this may appear to be easy, many hospitals struggle to identify the best manner to collect this information. Many hospitals struggle with the categories they create. Others struggle with their healthcare employee’s belief that this may be offensive to patients and/or they feel awkward about asking the question. Organizations such as the Health Research and Education Trust (HRET) arm of the American Health Association (www.hret.org) have been helping organizations to address this issue for several years. Using well established classification systems, organizations can systematically collect and monitor the type of care they are providing to their patients. Some initiatives have incorporated the collection of these data, such as the Robert Wood Johnson Foundation’s Expecting Success: Excellence in Cardiac Care project, a national project looking to address disparities in cardiovascular care. This project will be discussed in an upcoming posting. Regardless of the approach, however, it is clear that all organizations will be expected to pay closer attention to disparities, and with that, collect this race, ethnicity and language data.

The collection of this information is on all of our “front doorsteps.” As recently as 29 March 2007, The Joint Commission released a report recommending broad strategies designed to help hospitals overcome issues, such as language and cultural competency in the delivery of care. The report reviewed 60 hospitals nationwide and found that interpreter services and culturally appropriate care is practiced inconsistently. Reasons such as staffing challenges and financial strains were most commonly cited. The report stated that hospitals should establish a centralized program to coordinate these services. Additionally, a uniform system of capturing racial, ethnic and lingual information for each patient should be implemented. Further, they recommended that hospitals adopt policies to ensure patient family members do not become the medical interpreter, unless in extreme emergencies. Finally, they encouraged an increased engagement of the community in these issues. It has been widely believed that the Joint Commission will be requiring that surveyors review each hospital to ensure they are collecting race, ethnicity and language data in the hospital accreditation surveys, and this report confirms that it will be occurring soon, possibly as soon as your next survey…

Our final two posts will look at specific, large-scale efforts to eliminate disparities. One focusing on breast cancer mortality and the other on cardiovascular disease in African-Americans and Hispanics.

This post is part of a 5-part series on healthcare disparities:
- Part 1: Introduction to Healthcare Disparities
- Part 2: A few healthcare organization role models to follow
- Part 3: Measuring disparities meaningfully
- Part 4: Two big disparities projects in the works
- Part 5: Cardio in African-Americans and Hispanics

by Nick Jacobs

Will the next ten years provide the answers required to make our health system functional into the future? If we give serious attention to the tangible challenges presently at play, it becomes very apparent that our structure will not work without a unified, bipartisan approach to the issues in consideration. For example, the flooding of our emergency rooms with marginated patients, lack of health insurance coverage for 47,000,000 American citizens; the looming failure of Medicare; the outrageous demands of an incident by incident system aimed at intervention at a time of crises rather than a lifetime of well articulated preventative health related personal decisions.

It is well documented that, if we can embrace even a limited exercise regime, discontinue the consumption of saturated and Trans fats, and stop smoking, our country will experience a surge in the length of life.

If we, as a country, could conclude that our priorities should be directed more completely toward our own citizens’ well-being, we could end up far ahead of the game. The United States has just surpassed all other industrialized nations in the separation between rich and poor. We have now reached a ratio of rich to poor that is 500 times more pronounced than in Japan.

When asking these hard questions, it is important to realize that this is not liberal vs. conservative; it is not blue vs. red; or D vs R; it is about human beings caring about other human beings. It is about the irrefutable rights of all Americans. It is about embracing our fellow man and providing a net for those of us who are not as fortunate as others. It is about getting our collective act together as a country to put together a health policy for our country. Finally, it is about prioritizing our values in a mature, caring way.

Sorry if this ended up being a rant. Maybe that’s why I have been in nonprofit management my entire life?

We Were All Created Equal – Man Made Us Different.

by Christopher Cornue

As we take a further look at the “disparities in health care” issue confronting all of us, this post will highlight a few of the individual organization/hospital efforts underway to increase culturally-specialized care and decrease disparities.

o In March 2007, UnitedHealthcare announced a partnership with the US Department of Health and Human Services’ Office of Minority Health to create a web-based cultural competency program for physicians. The intent is to create an increased sensitivity among care providers to improve care for racial and ethnic minorities. Among the areas of focus for the CME, self-directed courses are culturally competent care, linguistic services and organizational support.

o In Northeast Philadelphia, Frankford Hospitals System has implemented cultural outreach programs to address the needs of their increasing diverse patient population. Many hospitals across the United States have implemented similar initiatives to those adopted by Frankford Hospitals System, including:

- Spanish-speaking operators & a patient liaison to help patients navigate their hospital system and assist with scheduling appointments and treatments;
- Modified visiting hours for patients’ extended families;
- Spanish-language television stations;
- Menus, signs and other materials written in Spanish;
- Certification program for hospital employees, allowing for more medically trained healthcare interpreters.

o The Journal of the American Medical Association published an online study on 19 March 2007 detailing improvements in HIV, unintentional injury and other factors that demonstrate a narrowing of the life-expectancy gap between African Americans and Whites. While researchers from McGill University in Montreal, Canada note that significant disparities in care still endure, they found this gap dropped to an “all-time” low of 5.3 years in 2003, a reduction from 7.1 years in 1993. Among the factors contributing to this decline are lower relative heart disease mortality, reductions in mortality from homicide, HIV and unintentional injury. A further note from the researchers indicates that this decline doesn’t appear to come from general mortality improvements among African-Americans, but from specific improvement among specific age groups and causes of death. Heart disease mortality for older African-Americans did not improve.

o Ongoing efforts to address these disparities continue at the Disparities Solutions Center (DSC) at Massachusetts General Hospital. To help promote these efforts, the DSC, in collaboration with the National Committee for Quality Assurance and Joint Commission Resources, is leading a year-long executive education program called the Disparities Leadership Program, expected to launch in late May 2007. Healthcare organizations across the county applied to be a part of this program, and 15-20 organizations have already been selected to participate. For more information, please visit their website at http://www.massgeneral.org/disparitiessolutions/ .

There are many, many more examples illustrating efforts to address this issue. Through these examples and discussions about the literature, reports and publications supporting the evidence of disparities, it’s easy to see there are significant implications to everyone. If individuals are unable to receive treatment in a timely basis, a grim conclusion can often be appropriately drawn: patients may be more likely to die and the costs for more advanced treatments will rise. Additionally, our commitment to improve the health of individuals is decidedly compromised and as we move toward increased efforts to provide more preventative medicine, these examples are very compelling to say the least. So, what can we do to address this issue? How do we measure this “disparities issue” at our own institutions? The next few posts in this series will attempt to answer these questions.

This post is part of a 5-part series on healthcare disparities:
- Part 1: Introduction to Healthcare Disparities
- Part 2: A few healthcare organization role models to follow
- Part 3: Measuring disparities meaningfully
- Part 4: Two big disparities projects in the works
- Part 5: Cardio in African-Americans and Hispanics

by Tony Chen

It's not everyday that a patient's blog makes the front page of CNN.com - check out this great write-up of a teen cancer patient's blog. His blog, along with many other patients blogs, are at CarePages - a free, easy-to-use website that helps family/friends communicate when a loved one is receiving care. It's sponsored by RevolutionHealth and Edward Hospital.

Read this story about 5-year-old Matthew Langshur - CarePages was really started by his parents when they had to go through a difficult period right after Matthew's birth.

CarePages has been used by over 1 million families worldwide (~45k patient sites). It definitely stresses emotional support and seems to be more geared towards traumatic difficult events (their resource center is focused around 4 diseases: breast cancer, lung cancer, premature birth, and congenital heart defects). These are diseases that we really can't fathom unless we are living it - no wonder some have said that CarePages is the most meaningful use of the internet.

PatientsLikeMe, a similar site (and one of the healthcare 2.0 sites I've highlighted previously) seems to be more focused on longer-term diseases where you can track clinical progress with patients like you (current focus is on Lou Gehrig's, MS, and Parkinson's). As such, the focus is more on education and support for newly diagnosed.

CarePages seems to be the one getting all the attention, though older sites also exist: CaringBridge (1.8MM people use visit per month, viewing ~60k patient sites) and theStatus.

Regardless of which one is utilized, patients blogs are changing the way patients educate themselves. I heard a physician say the other day that most of the formal diabetes and congestive heart failure websites out there are terrible and that you can get much more useful information about those diseases on blogs (for example, go to our friend diabetesmine!)

I applaud forward-thinking hospitals like Edward Hospital, High Point Regional Health System, Via Christi, UPENN, and many others that are joining with this to support their patients. I convinced that this level of emotional support invariably improves outcomes & patient loyalty.

For patients, they can connect in a meaningful way to the people they need most - family/friends & the select others who know what they're going through.

UPDATE: also check out DailyStrength

by Tony Chen

FierceHealthcare just announced their Top Hospital Innovators for 2007.

Glad to see familiar names that I've posted on previously (Congrats to Nick over at Windber).

From buying monthly newspaper ads to publicize quality metrics to building sister hospitals in Italy to offering the best of spa/hotel/hospital to negotiating directly with drug-makers, these are an innovative bunch!

by Tony Chen

did anyone else start using iGoogle? I'm lovin' it as a way to keep track of my favorites blogs and news sites. Here's a nice comparison between iGoogle and Netvibes.

by Nick Jacobs

Each and every day hospital CEO's are faced with the reality of the sometimes overwhelming responsibility of ensuring that life is carefully delivered, maintained and, eventually transitioned. We are ultimately responsible for the appropriate allocation of funds for addressing all of these life transition situations.

Each day we face the challenges of probability and statistics as we attempt to deal with whatever the odds parse out. Some days the chiller stops and the house heats up. Some days we have a crush of sick people who all hit the emergency room at the same time, and each time we think the day is running smoothly, a major piece of equipment breaks or one of our twenty plus regulatory agencies shows up with a check list. It's all part of the day.

When you think about running a $50M, $100 M or $1B business with 500, 1000 or 30,000 employees, consider that each one of them typically represents a family of four. Consider the fact that each and every one of those family members in some way, shape or form also come under the umbrella of your responsibility.

If that isn't enough for you to consider, then look into the eyes of a family member who's loved one died because of something that one of your physicians or employees might have either done or forgotten to do.

Bottom line, if you're thinking about trying to make it to the Big Show, just remember that you've gotta pay to play.

By Tony Chen

There's been a lot of good discussion at the World Health Care Blog around preventive health as a essential piece of the healthcare solution of the future. These past week, Intel Chief Andy Grove said in no uncertain terms that prevention is not the answer. As I mentioned in this previous post, I agree that changing human behavior is hard. But it is doable with the right framing.

by Tony Chen

Here's an interesting article from the Boston Globe about Boston-area hospital CEO salaries. Doctors and nurses not washing their hands between patients? If so, Paul Levy, CEO of Beth Israel Deaconess Medical Center loses almost $70,000 of his bonus. This is the same guy who asked his blogging audience whether he makes too much? Not surprisingly, commenters are impressed/shocked at his openness, though some were cynical about his real intentions. So, what's fair? There are a few schools of thought around CEO compensation:

- Market Value - "whatever the market will bear" is of course the most American, capitalistic answer. It becomes purely a supply/demand question. If you don't offer market value, the person you're trying to woo for the spot will go somewhere else. Typical factors to consider include the individual's unique characteristics (qualifications, experience, responsibilities, skills), the company's situation (revenues, geography, competitive positioning), and the industry's status (market conditions, availability of talent, economic conditions).

- Entrenched Executive Compensation Committee - Some would say that it's all a conspiracy. Executive compensation is typically set by a subcommittee of the board working in conjunction with an executive committee consultant. These consultants perform benchmarking research to determine market value. I've heard (someone please verify this for me) that they are sometimes paid a bonus if the candidate accepts the position. So it would seem their incentive is to recommend a higher salary? Plus, in some companies, many board members have existing and strong relationships with the CEO, and you wonder how much sway the CEO has in selecting committee members.

- Value - Some also think about the real value/impact of a CEO. For $1MM spent on this CEO, is s/he bringing in more than $1MM in value? For a $1B company with $20MM in net profits, this person would have to increase profits by 5%. This becomes a straight-up ROI calculation. Of course, this value is difficult to measure, but some have argued that this money would yield a higher return elsewhere.

At the end of the day, there's no denying that the CEO position is a very difficult position. Stress levels are high (hospital CEOs like other CEOs get death threats, too), the hours are long, the skill set needed is unique, and the long-term impact to the organization is tremendous. And I think it's a good development to have incentives more closely tied to key non-financial metrics.

Check out the most recent Fortune 100 CEO Salaries. And go to Guidestar for non-profit executive compensation information. I should note, too, that American CEOs are much better compensated than their European and Asian counterparts.

(Note from Tony: you may ask why we're dedicating two posts to hospital housekeeping! For Nick's hospital and for many others, housekeeping is a key factor for patient safety, quality, infection control, and patient loyalty!) Read Part I here. Read why I dedicated my first hosting of Grand Rounds to a hospital cleaning lady.

by Nick Jacobs

The Critical Care Unit is always a priority area in the hospital. There is never any waiting at all there. When the CCU calls, the staff goes immediately into action. All equipment is cleaned, disinfected, and cared for after each patient. Special care is taken in this unit due to the nature of the types of services performed there, i.e., blood borne pathogens, special emergency procedures, and critical cases sometimes lead to extra maintenance issues for staff, but there are no short cuts taken here.

The Palliative Care Unit also presents special challenges. It is used for pain control, respite for the families and end of life situations. This unit often times might have its own washer and dryer and housekeeping takes care of the patient’s personal items here. This includes special types of care, i.e., Afghans are cleaned, folded and made available for patients.

Some hospitals use walkie talkies for housekeeping staff to keep in constant contact with nursing stations, and whomever is closest helps on the call.

The Operating Room Floor is scrubbed and buffed every week constantly. Each surgical suite is disinfected after each case, and special mops specifically for the OR are used there only.

Generally the public areas and public restrooms are monitored throughout the day to be sure that everything is available and clean. The same holds true for patient lounges. Because patient lounges have refreshments for families, they are monitored very closely.

Infectious areas are also addressed very watchfully. Depending on the type of infection, various precautions can be taken. Usually all equipment that typically is in a patient’s room that is not needed by the infected patient is removed. That limits the need for infection control to just the area immediately around the patient.

Specific chemicals can be used to kill respiratory infections. The housekeeping staff will wear masks, use gloves, and separate cleaning cloths will be used for each room. Special hand sanitizers are also used.

Finally, chemicals can be added to disinfectants to improve the aroma. It is a nicer, non-antiseptic odor. Air fresheners are also used in bathrooms and all throughout hospital.

by Christopher Cornue

Our daily lives in healthcare are focused addressing crises that arise, managing our expenses, developing new growth opportunities through Service Lines, implementing new ground-breaking technology and the like. However, one area that many safety-net & inner-city hospitals confront on a daily basis is our ability to address disparities in healthcare. As reports and studies have demonstrated, this is becoming an increasingly difficult issue to address. In Chicago alone, there are many examples of groups and organizations that are leading efforts to address this. These will be discussed in upcoming posts. But first, what are disparities and how do they impact all of us?

General information suggests that by 2050, racial and ethnic minorities will account for 90% of our US population growth. As a result, there will be increasing racial and ethnic minorities seeking healthcare at our hospitals and health systems.

The Institute of Medicine’s groundbreaking 2003 book, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, brought to light, on an international scale, the issue of disparities in healthcare. Their argument is that “racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities.” At the urging of Congress, the IOM conducted a study to assess the “differences in the kinds & quality of health care received by US racial and ethnic minorities and non-minorities.” Examples of disparities they found in their research were 1) overuse & underuse of treatments and services; and 2) mortality rates among difference racial & ethnic groups, among others.

Their analysis and assessment demonstrated that 1) evidence of racial and ethnic disparities is consistent among many illnesses and healthcare services; 2) they are associated with socioeconomic differences; and 3) these disparities, if adjusted for socioeconomic differences, often remain.

The following five findings provide the foundation for most initiatives working to address this issue, and are a sobering reminder to us of our call to action in our roles as healthcare leaders:

o Finding 1 – Racial and ethnic disparities in healthcare exist, and because they are associated with worse outcomes in many cases, are unacceptable.
o Finding 2 – Racial and ethnic disparities in healthcare occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimination in many sectors of American life;
o Finding 3 – Many sources (including health systems, healthcare providers, patients, etc.) may contribute to racial and ethnic disparities;
o Finding 4 – Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare. While indirect evidence from several lines of research supports this statement, a greater understanding of the prevalence and influence of these processes is needed and should be sought through research;
o Finding 5 – A small number of studies suggest that racial and ethnic minority patients are more likely than white patients to refuse treatment. These studies find that differences in refusal rates are generally small and that the minority patient refusal does not fully explain healthcare disparities.

Next week, we’ll look at some nationwide initiatives that are attempting to address this significant issue in healthcare.

This post is part of a 5-part series on healthcare disparities:
- Part 1: Introduction to Healthcare Disparities
- Part 2: A few healthcare organization role models to follow
- Part 3: Measuring disparities meaningfully
- Part 4: Two big disparities projects in the works
- Part 5: Cardio in African-Americans and Hispanics

by Tony Chen

I'm pleased to announce that Christopher Cornue has joined the hospital impact blogging team. Christopher is currently a Vice President at Mount Sinai Hospital Medical Center and brings a great breadth and depth of healthcare experience. His bio is below.

Mr. Cornue has been leading operational, quality, clinical and growth strategies at Mount Sinai Hospital Medical Center (MSHMC), a 325-bed Level-1 Trauma Center, on Chicago’s near West side since 2004. Included among his areas of responsibility are the Departments of Medicine, Surgery, Anesthesiology, Pathology, Perioperative Services, Laboratories, Physician Development, Trauma Services and Service Line Development. In addition to these responsibilities, he is leading efforts to address disparities and improve quality in the Chicago Metropolitan Area as an Executive Sponsor of the Robert Wood Johnson Foundation’s Expecting Success: Excellence in Cardiac Care national collaborative project. Prior to his time