by Nick Jacobs

There you have it. The end of our worries. We don't need to have a nuclear holocaust to thin out the world's population, nature is planning to do it herself. With six billion or so of us on the planet, 81 million isn't such a large number, but, then, if it's personal, you might just consider paying some attention to this, the latest and direst prediction. Actually this study showed a range of death from 50 to 81 M and decided that the average would be around 62 M, a number that is considerably higher than the 15 to 20 million that they had expected to predict.

This article will be printed in the Lancet and, if the worst prediction, the headline prediction, is true, it will be about 40 M more people than the number lost in the 1918 flu outbreak. In 1957 and 1968 we only lost two million and one million respectively, small numbers compared to this avian flu prediction. Now, if you're from the United States, you can take some comfort in reading that 96% of the deaths will occur in developing nations. If, on the other hand, you are a human being, the location of the tsunami is not really relevant because these are lost human being statistics, not widgets.

So, as we watch our children or grandchildren cry over opening the last of their 34 gifts because they wanted more, and as we see our pharmaceutical companies back away from the desire to produce vaccine for the masses due to our litigious society, we are forced to sit back and say, "Do we have our priorities in line?"

In that same vein, we need to honestly ask, "Could we ever be ready?" At a physician's meeting a few weeks ago, one of the docs was lamenting the fact that the Democrats want universal health coverage for all of the citizens of the United States. He was worried because it would cost an estimated $6 B, only a few billion more than the Iraq war cost this year.

Maybe, we need to verify our humanness and realign our priorities to ensure that 81 M of our friends, relatives, and fellow human beings are not lost to this pending epidemic. Maybe we should begin to take serious steps to ensure that our pharmaceutical friends have the same priorities that we do, and, just maybe, we need to double and triple check the planning mechanisms put in place by the CDC, our State, local and regional agencies to be certain that our assigned staff is "doing all that we can do" to be prepared.

By Nick Jacobs

For the first time in twenty years, something has happened that has never happened at our hospital before. Our Emergency Room Physicians have refused to provide full coverage for the department for Christmas Day. Now, don't get me wrong, they have contracts, and this shouldn't BE a negotiation, but, due to the extreme shortage of physicians nationwide and the inability to curb liability insurance costs in Pennsylvania, many of these physicians are working the system to their advantage.

In a normal situation, it would be simple. Hire more docs, and give notice to the offenders. The problem is that Emergency Room physicians aren't really easy to recruit right now. This creates an interesting situation. It is also clear that these phenomena may be a sign of the times for those of us running hospitals. As we see more and more shortages in the medical field, those available may become more selective about their availability.

We have seen leveraging that borders on financial blackmail, their version of supply and demand. When neighboring hospitals will hire them at per diem rates, sans benefits, those of us who pay contracted salaries and benefits find our hospital's schedules conflicted as the employees embrace both worlds as often as possible. Two days here, three days there, three days somewhere else . . . with a salary range that can vary by 60 or more dollars per hour.

Fortunately, a friendly, partner doc from our sister facility has agreed to cover the Christmas shift that is OPEN, but the fact that we were in this situation is NOT something that feels good to those of us who have hundreds of other employees who are always willing to work for all of the Holidays.

So, brace yourself America for challenges like this, or open the borders and let our neighboring physicians come to work in the U.S. because, as we Boomers ride off into the sunset, this is NOT going to be an easy or comfortable transition.

by Nick Jacobs

This is a personal medical journey meant to demonstrate the fact that "medicine is not a science. It is truly an art." It also demonstrates accurately why we use the term "practice" when we refer to physicians.

The date is 1996. After having suffered with tightness in my chest after meals which had been diagnosed as GERD for about six years, I went in for a physical. Now, don't get me wrong, I'd gone in for a physicial every year for the past ten. It was a great physicial. I ran on the treadmill for about 14 minutes, no discomfort. Everything was great. Two days before Christmas, my doc was at the front door of my house. He'd never been to my house before.

His visit? "Nick, you need to get a heart cath. I think your scan was one of the 30% false positives because I exercised you too hard, but you won't know until you get a cath."

The cath was positive and it resulted in the opening of three blockages 60, 80, and 90%. All in the right main coronary artery. They were opened by two uncoated stents and a balloon angioplasty. It was then that I started on the Dean Ornish Program. Two years later, chest discomfort and two more stents.

This time they were on the corner of the right descending coronary artery, and, according to some of my cardiologist friends, it was from the damage caused by the first cath. Because it's a blind procedure, the docs sometimes push too hard on that corner. The after affects of that cath was an ancient torture device applied to my inner thigh that required me to take morphine while it was being used.

Six years later, 16 Slice Pet CT shows a blockage in the area of my first non-medically coated stents. Sure enough, it was the body's protective mechanism growing to cover the stents with tissue. Kind of like when they can't get the bullet out. Thank God, they have medically coated stents that should protect me for three years. Since I lasted six years the last time, it seemed like a no brainer.

A little complication this time. After the 30 minute cath where two more medically coated stents were inserted inside the old stents, life was on its way to being good again. Except for one small issue. Because I had complained about the ancient torture device, the doc came to my bedside and held the incision for about 20 minutes. As he left the room he told the male nurse to continue to work out the gel that he could still feel. The nurse put a wedge bandage in place and left. The second male nurse came into my room every hour for the next seven hours and checked the pulse in my foot. He NEVER checked the site of the incision. At 7:30, the night shift nurse came in, lifted the sheet and called the cath lab with these words, "Houston, we have a problem."

Four nurses came crashing into my room and began to push the massive hematoma (blood clot) into a sacred part of my body that I've tried to protect since I was a little boy. I went into shock. My blood pressure dropped to 60/30, and I started trying to remember exit prayers. It was the worst pain of my life, and it went on for 45 minutes. Then the aftermath lasted for nearly a month.

Obviously, I was thrilled to read a few weeks ago that coated stents now are resulting in deaths from throwing off blood clots. My recommendation to all of you? Avoid trans fats, exercise. meditate, and don't trust the for profit companies who are anxioius to make up their R & D funds before there's been enough time for discovery.

Oh, yeah, and say a little prayer for your doctor.

by Tony Chen

One of the things that fascinates me the most about being in the healthcare industry is this tension between providing societal good and driving for profits. Ya'll know how I feel about this by now - these goals are not mutually exclusive, in fact, we have to be passionately two-minded. The moment we lose sight of either fundamental purpose is the moment we've failed.

As I was studying for my CHE (well, now it's FACHE) exam, I was reminded by one of our founding fathers. Good ole Ben Franklin, while conducting a fund drive, built his case for our nation's first hospital (The Pennsylvania Hospital, 1760) like this:

1. We need a refuge for the unfortunate, and Christianity will reward you for your generosity to this cause.
2. You might need it yourself this very night
3. Among other things, we can keep contagious people off the streets.
4. We can certainly handle this better as a community than as individuals.
5. Grants from the Crown and the Commonwealth will lower the out-of-pocket costs.

a nice little reminder...

by Nick Jacobs

Why do many cardiologists forget to encourage their patients to take advantage of health insurance covered cardiac rehab?

Why do insurance companies pay for $45,000 full gastric bypass surgeries that can have some relatively serious negative side effects while not paying the $15,000 for bariatric banding surgeries?

By Nick Jacobs

Why, when it comes to hospital care, do family members go against their loved ones wishes so often?

When you have a mammogram, a thallium stress test or a myriad of other tests that are 20 to 30% less than 100% accurate, do they remind you often enough?

Why is it that most hospital food tastes worst than any food you can buy in England?

Can anyone tell me why teachers who hate kids stay in teaching, why physicians who hate patients don't become radiologists, anesthesiologists or pathologists and why hospital administrators who hate physicians don't just run widget factories?

Finally, why is it that so many people have only black and white opinions? Is it possible that they've never read a book?

This one is a good example of a botched job and a good recovery. You'll hear this all the time in the hotel industry. Something doesn't go right forthe customer's experience and they're mad. You do something above and beyond what they expect to make it better for them. All of the sudden, the fuming customer who was going to campaign against you is your best supporter. Enter viral marketing...

My mom was a patient of your hospital last month. She is 96 years old and I am her 73 year old daughter. Mom hated the food because your diet lady said she shouldn't have salt. So, I stopped at KFC and brought her dinner every night. I know your nurses said that she didn't have teeth when she was admitted, but I brought her teeth with me that first night and we kept them in the Styrofoam, KFC cup. So, someone threw away her teeth. Don't get me wrong, I am grateful that you were willing to buy her new teeth, but I think it's important that your nurses and cleaning ladies check the KFC cups in the future. You never can tell when you'll find more teeth.

Connie P.

more fan mail for Windber. How do we get all of our patients to feel this way about our hospitals?

Dear Mr. Jacobs,

I graduated from nursing school 42 years ago and have watched with interest the changing health care environment of this area. It is amazing to me that, after 100 years, Windber Medical Center only continues to grow and get stronger at a time when other organizations your size are closing all around. My life has taken me to many different places, but this hospital is the most amazing hospital I have ever seen. It is gratifying to me that the very essence of Windber's Hospital has never really had to change. It has always strived to provide national and now international quality care. I am proud of this hospital, and proud of the wonderful people who work here who never quit providing the most friendly, warm and loving care possible. Our doctors are the best, and your employees simply can't be beat. Why would anyone want to go to any other hospital?

Keep up the great work.
Anne K.

as always, keep sending your great patient stories to me: tony[at]hospitalimapct[dot]org.

I'm doing this for the sake of better hospitals - we can learn from the mistakes as well as the successes. Read previous stories on string quartets & Surgeries, Christmas, Crayons, and Cramps, and Harry Potter, Hamburgers, and Hemmorroids, and nakedness.

Part I: Life Falling Apart.
Part II: Carpet Pieces
Part III: Please, anything but hospitals!

By Nick Jacobs

After working in health care management for eight years, the opportunity came for me to assume a hospital presidency. We also won’t discuss the fact that my election to this position was by a one-vote majority.

The hospital was nearly one hundred years old, was started by a coal mining company to take care of its workers. When Western Pennsylvania coal went out of style due to high pollution levels, the hospital and the town also fell out of favor.

The population dropped from 12,000 to 4,500, and my first visit to the facility revealed PeptoBismol looking pink, painted walls, indoor outdoor carpeting in the maternity area with duct tape over the torn sections, furniture that looked like a bad sequel to the Brady Bunch, snow leaking through the windows of the conference room and a bottom line generated almost completely by not paying the employees an appropriate salary.

The hospital is seven miles away from nearly a four hundred bed tertiary care center in a fiercely competitive area where the population has continued to drop precipitously for the past three decades. The other trait not unfamiliar to areas such as this is that, because the population has dropped so dramatically, the wealthy have fought to remain in control financially and politically at whatever cost to and, most times to the determent of the area.

The hospital needed a vision, and that vision was one that had been part of me since my walks along the streets of East Liberty with Pittsburgh Press paper bag slung snugly over my shoulder. It was to become a hospital that was owned and used by the people in a way that would not only save their lives in an emergency, but would save their quality of life on a daily basis.

My commitment to public health was well documented, and my commitment to courtesy, service and cleanliness were always present. To convert this old, tired coal mining hospital into the hospital of the future as stated by Donna Shalala on her visit to Windber, PA two years ago, would take an inordinate amount of work and some luck.

The Planetree philosophy of care was a topic of my studies at both Carnegie Mellon and Harvard, and, although it was dismissed as too soft by the business professors, it was truly an answer that was waiting to be discovered. Planetree was the Sycamore tree under which Hypocrites lectured. More importantly, it is a belief in patient centered care.

“Planetree embraces the concept that the mind and body are intricately interrelated and that healing must address the needs of the mind and spirit as well as the body. All facets of the Planetree model – open communication, patient choices, family/friend involvement, music, art, massage, architecture, use of complementary therapies, and others – work to uphold this concept.

Because the hospital had a hospice, it was relatively easy to convince the board that the need existed to be kind, caring, compassionate, loving, and nurturing to patients. Why not?

Previous weeks I've eluded to the fact that as patients, we remember the little extra touches of compassion. We remember the "above-and-beyond" moments. Sometimes, though, what we remember is really all in a day's work for caregivers.

I am not sure this is the type of patient story you are looking for. I want to write about the impact that one nurse had on me prior to my surgery (cholecystectomy) earlier this year. I was a naive, scared patient. I’m sure it was all in a day’s work to the nurse, but to me, she was exceptional. Here is my “Thank You” note to the nurse who was in the room with me prior to surgery:

Dear Nurse:

To be honest, I can’t recall the nursing duties you performed. All I know is that when you were in the room with me, I wasn’t afraid. It wasn’t really anything you said, it was your demeanor and personality. You weren’t worried, so I shouldn’t be either. And thank you for not laughing (too hard) when I came to the realization that if all I was wearing was a hospital gown, and they were going to be operating on my stomach, someone was going to see me naked! You told me a couple of funny OR stories (no names, of course) and we giggled like schoolgirls. Like I said, when you were in the room with me, I wasn’t afraid. Thank you for that.

as always, keep sending your great patient stories to me: tony[at]hospitalimapct[dot]org.
I'm doing this for the sake of better hospitals - we can learn from the mistakes as well as the successes. Read previous stories on string quartets & Surgeries, Christmas, Crayons, and Cramps, and Harry Potter, Hamburgers, and Hemmorroids.

by Nick Jacobs

Part I: Life Falling Apart.
Part II: Carpet Pieces
Part III: Please, anything but hospitals!

After five years of exponential growth and State recognition, the three county, Laurel Highlands convention and visitors bureau recruited me to take over the tourism effort for the area.

A week after taking the job, the truth came out. Two of the three counties represented by the bureau had withdrawn their funding. Round three began. We were nearly broke. It took me a few months to realize the power of the 23 senators and representatives and the 15 county commissioners who were providing the funds to help support our efforts.

We hired sales representatives from the radio industry who were hungry and put them on the road. They tripled our membership base. We opened donated buildings as tourism centers in five counties. We hired employees from government-supported programs for senior citizens. We opened a convention service and went on the road with busloads of costumed volunteers representing our festivals and tourist sites. We delivered presents to every media outlet in a five State area. We began speaking nationally about the beauty of the area and produced a song about the area recorded by the Cleveland Symphony. (Pittsburgh wasn’t available.)

Within a year we had grown into one of the largest tourism agencies in Pennsylvania and within three years had created over 3500 jobs for the area.

It was in January of 1988 when job offers began to pour into my offices in Town Hall in Ligonier PA. Having just turned forty, it was clear to me that my prime income earning years were here, and my nonprofit salary was not going to easily help me get the kids through college. Oddly, within a two-week period, job offers from former board members, a U.S. Senator and a local hospital all came tumbling through my hands.

In the past few years there had been several opportunities to move to Cambridge, Massachusetts; Ft. Lauderdale, Florida; and the Hamptons on Long Island, New York. Each of these offers had been met with tears in our house from my wife and children.

My family did not, could not and would not leave. My wife was a local television celebrity and was performing as a vocalist in several groups in the area. Consequently, when the offer to head up a marketing division of a bank, be an administrator for a U.S. Senator, a broker in commercial real estate or the executive director of a to be formed hospital foundation came my way, it was a tough decision for me, but easy for her, stay here.

There was one thing that was clear to me. After having produced outstanding performing ensembles in a city that had the largest out migration of population of any city in the U.S. except East St. Louis, Missouri, I knew the taste of success. (The student population dropped from 13,000 to 3400 in ten years.) After having taken a bankrupt arts organization and moving it into one of the largest rural arts organizations east of the Mississippi, and finally, after creating 3500 jobs in only three years in tourism, failure was not going to be part of my future.

Create a new image, a new grandiose vision, recruit top notch people, and fund raise. If the dream is large enough the money does come.

As I traveled to Washington D.C. for my Senatorial interview, my wife contacted me to tell me that the local Hospital, rumored to be listed for sale in the Wall Street Journal, wanted to interview me before my D.C. interview.

It was always clear to me that a hospital was not a place that would make me happy. There was nothing about a hospital that appealed to me. They didn’t smell good. They didn’t feel good. They were not sensitive.

This would be an easy decision. Let me do anything except work in a hospital.

After spending the pre-interview night at the Washington Hilton, my phone rang, and it was a recruiter hired by the hospital who had been sent to Washington D.C. from Salem, Massachusetts. He had been sent to intercept me at breakfast prior to my interview with the Senator. His geographic center should have clearly indicated to me that there was Juju or at least witchcraft at work.

His advice was simple. Make the most outrageous demands, and you’ll be rejected for the hospital job. Little did I know that this was the way every physician negotiated with every hospital president and it just made me a more attractive candidate to the CEO. The demands included a second master’s degree from Carnegie Mellon, a certification from Harvard, a significant raise, and training to become the president of the hospital. My demands were met immediately, and the trap snapped closed on me.

Part I: Life Falling Apart.
Part II: Carpet Pieces
Part III: Please, anything but hospitals!

It was in December of 1979 that my wife saw an advertisement in the Washington Post for an executive director of an arts organization in Somerset County, Pennsylvania. Somerset County borders Johnstown, Pennsylvania and was most recently both the sight of the crash of heroic Flight 93 and the successful delivery of nine coal miners from the flooded Quecreek mine.

After carefully crafting my resume and filling it with references from local luminaries harvested through my teaching experiences, the call came to us for an interview. Upon arriving at the old building serving as the headquarters for this rural arts center, the search committee welcomed me into what had obviously been a bedroom.

Because my experience included no training or skills in arts management, it was easy for me to decide which of my interview skills to move to the forefront. It was my decision to make jokes with the committee.

When things began to look seriously like we were heading toward a second interview, it was obvious that we needed professional help. After some extensive exploration, a mentor and old friend floated back to the surface of my life. One of my college professors in both my graduate and undergraduate work was serving as the Director of the Arts for Pennsylvania. After one frantic and desparate call, he agreed to meet me in a Greek restaurant on the North Side of Pittsburgh. We ate gyros for three meals. We spent the better part of an entire Saturday discussing the answers to the questions that were sure to be posed by the committee at the second interview.

As they say on the streets, “we kicked ass and took names” at that interview. The other 137 candidates became fish food as the board elected me to head up a rural umbrella arts organization in Somerset County, Pennsylvania.

It was 1980. Jimmy Carter had just left office and Ronald Reagan decided to eliminate funding for the arts wherever possible. Welcome to round two of “Reality Bites.”

Upon reaching the office for the first day of work on February 2, 1980 in my Johnny Carson three piece, polyester, brown suit, it was obvious that things were not quite the same as had been portrayed to me by my search committee friends. The 66 year old semi-volunteer secretary informed me that it was my responsibility to fire up the wood burner. She also informed me, “All of our money was spent on advertisements for this job in the Wall Street Journal, Washington Post, and New York Times. We’re broke.”

It wasn’t clear how totally correct she was until Price Waterhouse completed the very first audit ever a month or so later and informed me that they had good new and bad news. The good news was that there was $2500 left in our accounts. The bad news was that the audit had cost $2600.

It was clear, however, that the right side of my brain, the creative side, would be my only salvation. Creativity was always my strong suit. When it was clear to me that payroll was going to be a problem, my first thought was transportation. In short, if you have a truck in Somerset County, you can find money.

The only problem at that time was that we hadn’t been in the job long enough to make plans. At 33 years of age, in a small town where you have just been named head of a nonprofit umbrella arts organization, saving face was important and collecting enough money to pay salaries became the first order of business.

We needed money, and one of my board members and later my board chairman was the President of a local bank. It did not seem feasible that anyone would just provide money to me, the new guy. He did have a repossessed truck in his parking lot that always burst into flames upon ignition.

This very generous man and his very generous bank donated that fire (making) truck to the art center. The Pennsylvania Department of Public Welfare provided us with two employees to man the vehicle.

The new director of art center (i.e. yours truly) instructed them to follow carpet trucks. That’s right, carpet trucks. Each time the truck stopped at someone’s home to deliver and install new carpeting, we asked to have the old carpet donated to the art center for a tax deduction. Then on Saturday night at the local auction barn, the carpet was sold, and we made payroll until our new plans to become the leading rural arts presenting organization in Pennsylvania took hold.

This practice only went on for a few months. During that time we had bricks and labor donated to replace the front steps. We found an artist who painted acrylic portraits of athletes, and in a rural, farming/mining community, that was art. We planned a German beer festival with cotton candy and some more art. We offered dog training classes. We built a room that was made from scraps from the Coleman Trailer Company that was just like a cloud. Nearly 2000 people visited that room over nine months. We discovered something called “goof” at the paint store, paint that was mixed incorrectly. For a dollar a can that became our new look in the galleries.

The real change came when one day a young ad man between jobs made an offer to help me tell the story. He made a slide show that was all about my dreams. We never indicated that any of it was true or that it was a dream. Within two years we had made presentations to over 163 groups and organizations and had grown into one of the largest rural arts organizations east of the Mississippi. Our membership grew from 300 to 3000, and we were working with every school district in the County. We had 125 arts classes running in six different locations, had 10 gallery shows, two festivals and a dozen concerts each year. Things were really starting to click into gear.

All of you know that Nick Jacobs' hospital is a Planetree facility - here are a few letters from patients who've experienced it. Does anyone else have a string quartet in residence at their hospital? wow...

as always, please send your patient letters/stories to tony[at]hospitalimpact[dot] org. if you missed last's weeks edition, click here. Why am I collecting your great patient stories? For the sake of better hospitals.

This String Quartet played for a dying patient's family in our Palliative Care unit. They (the string players) were in residence with us for an entire summer.

"Your playing is so beautiful, it made me cry. My Dad is in Heaven now, and he played the violin so sweetly, like you guys. I just wanted you to know that my Dad is playing with you and thanks so much for letting me hear your beautiful music that I've missed so much. I just wish I could sit and listen all day to you and DAD. Thanks, Kris

(here's proof that folks do look up quality statistics, or at least, they hear about it)

Dear Mr. Jacobs,

I am writing to you to tell you how grateful and happy both my husband and I are with Windber Medical Center. My husband is in the critical care unit now with an infection after open heart surgery at X* Hospital. It's three weeks post surgery and he refused to go back to that hospital because there is no comparison between the care there and here. There's also no comparison between their infection rate and yours. I know for a fact that there are so many people who would rather be here at Windber Hospital. The care is so great here and I know most of our health problems can be taken care of just fine here. So, each day I thank God and you and your people for everything that you do. This hospital is a very special place and we love it.

Thank you,

Nancy H.

During the next few weeks, Nick Jacobs, our beloved hospital CEO blogger will be sharing his unconventional journey to becoming a hospital CEO. I doubt you'll find a hospital CEO out there today with a more colorful, varied, and interesting path as Nick.

Part I: Life Falling Apart.
Part II: Carpet Pieces
Part III: Please, anything but hospitals!

by Nick Jacobs

It was after ten years of loving kids, but hating the former football coach principals who controlled the schools that it became obvious to everyone around me that a career change was needed. It was not being able to afford winter tires or even a trip to New York City to see a Broadway show that reinforced my decision.

After a six-month job search, the only company willing to embrace my skills was a fund raising organization made up of 123 sales representatives, 122 of who had been successful band directors. The owner of this particular company, a former bible salesman, had come to realize that anyone who was willing to stay inside and practice an instrument while his friends were hanging out at the corner store had self discipline to do whatever life warranted in order to achieve both personal and company goals.

The training offered by this company was exceptional. We had the time management expert from IBM. He successfully moved my scheduling capabilities into a new era of total and complete anal retentiveness. Dr. Denis Waitley, the U.S. Olympic and Miami Dolphins positive mental attitude psychologist taught us about taking control of our own life and making things happen by being positive. It was an amazing education.

The company assigned me to cover fourteen school districts, eleven of them had teacher strikes. Then the first gasoline crisis hit, and gasoline was not something that anyone could buy. We also discovered an insufficient beam held up by building jacks in our new home in suburban Pittsburgh. Needless to say, our life almost fell apart.

In spite of all of these setbacks, my customer visitation statistics were the highest in the United States. We worked harder and longer than anyone in the company. Unfortunately, because of the strikes, there were not enough sales to earn even one fourth of the salary expected by my family.

My wife cried nearly every day. She missed our friends and neighbors. Nine months into the only major life failure that had ever touched my world, we made a decision to move back to Johnstown. It cost us our life savings, and after ten years of marriage, placed a great deal of strain on everyone involved.

What would I do now?

Like I mentioned last week, fridays here at Hospital Impact will be all about patient stories - both great and gruesome. Feel free to share your story anonymously - email me at tony [at] hospitalimpact [dot] org.

Here's one from a frequent hospital impact reader. Many times, it's not big things, it's a lot of little things...

from anonymous

When I was a sophomore in college and home on Christmas break, I experienced a horrible pain and lump in the back of my throat. After my family physician took a look, he advised me to get to the hospital ASAP – I had an abscess on my tonsil that needed to be drained immediately before it continued to grow. My mother took me to Columbus Children’s Hospital where the necessary (and painful!) surgery was performed and I was kept overnight. Not only was I in a tremendous amount of pain, but I was apprehensive about spending the night in a hospital, especially because I was 19 and all the other patients were under 10. My nurse put me at ease right away, checking on me every half hour, bringing me as much Jell-O as I needed. She wheeled in the book cart to offer me something to read, but we both soon discovered that there was nothing on the cart over a 6th-grade reading level. She brought me her own personal copy of a Harry Potter book that she had been reading. She insisted that I read it and keep it for myself. I still have that book on my bookshelf at home and remember her every time I look at it.

Here's an instant classic...

Dear Sir:

Seventy three years, no hemorrhoids. One colonoscopy at your hospital, hemorrhoids.

Sincerely yours,

John D.

Here's one from a nurse about a female tech whose hamburgers (and well-being!) were in jeopardy.

In the ER where I volunteer, a young female tech (who I think was about to head off either to nursing or medical school) told me a story about a frequent flyer, a homeless patient she often helped treat in the ER.

One evening she'd left the hospital to go get dinner for her co-workers at a burger place nearby. She cut through an alley to save some time, and found her way blocked by a homeless man who said menacingly, "Where are you going with all that food?"

She was terrified, convinced that she was about to be mugged for her hamburgers. But then another homeless man -- the frequent flyer -- rose from the shadows and said, "You leave her alone! She works at the hospital, and she was nice to me when I was there!"

The first guy backed off, and she returned safely to the ER, hamburgers intact.

Sometimes good deeds really are rewarded, and conscientious care of indigent patients can pay off in very tangible ways.

Keep 'em coming!

by Tony Chen

Earlier this week, I submitted that the #1 thing that we aren't talking about enough in healthcare is great patient experience stories. Jason Dinger also pondered the day when now-Google-ite YouTube would be a forum to hear memorable patient stories. Great patient stories need to be heard. In some sense, it's shocking that hospitals haven't done more of this already.

I started hospital impact to answer the question: what will it take for our hospitals to be the best run organizations on the face of the planet? More and more, I think the answer sits right at the patient. If we want great hospitals, let's find out what those great patient experiences look like, right?

So, starting next week, I would like to begin posting great patient stories here at hospital impact. I'll post the best stories I receive every Friday. If you have had a great hospital experience, or you know someone who has, please share it with us, and we'll share it with the world. What made it so great? Why was it so memorable?

Please send your great patient stories to tony[at]hospitalimpact[dot]org

I'm not doing this as some slick PR thing to pump up hospitals. Nor am I trying to minimize the fact that so many have bad or terrible experiences within hospitals. In fact, I would welcome those stories as well - we have to learn from our triumphs as well as our failures. With that being said, I just think those terrible stories are told again and again, but the great stories never seem to be shared.

Let me start this series of Great Patient Stories with Peter Gammons, one of the most beloved sports reporters of our time. After recovering from a brain aneuyrsm in June, he went back to reporting, making his first column back more about thankfulness than baseball.

"I was fortunate enough that I'd never spent much time in hospitals, so I never realized how much everyone in the medical world cares. The nurses and technicians at Brigham's were incredible. On the Cape, under the care of Dr. David Lowell, I had a speech therapist, Jeannine Annis-Young, who cut weeks off my recovery, as did my occupational therapist, Beth Kerr, and Kathleen Bobo, who got me back on the road to physical recovery. Understand, the more I came back, the more the trading deadline and pennant races drove me to distraction, which made life for nurses like Denise Meiners, Richard Erdman and Linda nearly impossible. Sorry, I have omitted dozens of names." - Peter Gammons

"How was your stay with us? What did we do well and what could we improve?"

"I employ a home nurse who stayed with me through the night, even while I was here at your hospital. When one of your new-shift nurses came in to adjust my IV really quick, she stopped to introduce herself to my home nurse and chit-chatted for a bit. And then she left. I thought that was perfect. You don't see that very much these days any more. Greetings others, saying hi, not rushing around - it's just simple civility"

"The only complaint I have is that I wish my bread this morning came with butter."

By Nick Jacobs

As I reflect on the sacred role that has been bestowed upon us as healthcare providers, I recognize the depth of trust, commitment and sharing that we are privy to in our jobs, and I breathe deeply, close my eyes and allow those thoughts to wash over me like a healing light.

The experience is so profound and so moving that many people never fully grasp the significance of the every day miracles that are so much an ingredient of our work lives.

We are there when new life arrives.

We are there when life passes.

We are there for all aspects and challenges of life as the deck is dealt on a daily basis to our patients and their families.

Each of these experiences provide connections at a spiritual level that can only be imagined by a non healthcare worker.

When I see the play unfold as it should with the appropriate light cues, the correct lines, apt expressions of emotion, and displays of kindness, it truly can be a beautiful thing.

When we, as caregivers, understand it at every level, and break from our normal gate to move in lockstep with the grieving family or the petrified parents, it is a cadence that can only be appreciated by them as we carry out our journey through this sometimes lonely world.

And when we move toward the hurting spouse or the sobbing family member and share in their pain, hurt, grief, or sorrow, that is when it begins to feel so absolutely correct.

Just knowing that we were invited to share those moments with perfect strangers is an amazing gift. In fact, it can be just what the doctor ordered for both patient and caregiver.

Healthcare is not perfect. Our lives are usually hectic, stressful and disconcerting. Our world is complex and it can drain us deeply each and every day, BUT it is a world of reality, a world of caring, a world of deep emotional attachment that is almost impossible to create in a non-hospital environment.

by Nick Jacobs

I'm writing this blog from my heavily padded board seat at a table filled with CEO's. In my roll as a President, I sit on a half dozen of these boards. Dark suits, conservative ties, perfect haircuts.

The ritual begins with a gathering of the "Big Dogs" around the coffee service discussing golf.

Interestingly, instead of the normal, rich, Half and Half, there is powdered, trans fat hydrogenated cream in a bowl beside the display of frisbee sized, fruit filled, glazed Danishes. The brewed decaf coffee tastes like the old, individual, powdered Sanka packets served at Wendy's.

Clearly, this may be an unveiled attempt to control Board overhead so as not to interrupt the limited funds flowing toward that annual golf outing.

Sometimes I wish I golfed and smoked. It seems like those guys get to take more breaks and legitimately miss lots more desk work to net-work on the course and at the nineteenth hole.

Behind the chairman's head is a wall covered with oil portraits of "old guys" who have served in some previous leadership capacity with the organization. Seventeen white shirts, one blue, eight maroon neckties, nine solid blue and a Brooks Brothers stripped, one mustache and one beard, are part of the look. Strangely consistent for the past thirty plus years.

Back around the table where I'm seated, the white shirts are blinding me.

The women arrive last, five of them, four staffers and one board member. They are all perfectly groomed and tailored, and they carry themselves with complete self assurance and comfort. Thank goodness for the women. They smile.

As the finance report draws on I hear buzzing in my ears reminiscent of the noise I always heard in my advanced algebra class during my junior year of high school. Then, comes the report on the new budget. We have a slight deficit, but it will be okay, or not.

My Palm TREO, a.k.a., crackberry, gives me a break from the patter as I check out my e-mail, Google the Board Chairman's name, look up a friend in an address search. I catch myself dozing off from my late night and early morning schedule.

The meeting slides along with no real earth shattering information or deep discussions until the administrative assistant says, "Lunch is here."

It is such an amazing journey with all of the power brokers.

Guess it's best to be conservative when you're dealing in such heavy decision making, but it can be soooooooooooooo boring here.

Burp . . . sorry, the Danish didn't agree with me.

"This patient is requesting a female provider," said Justin, my fellow OBGYN resident.

"I'll take her," I said. I quickly looked over her chart. She had a middle eastern/asian name - asking for a female provider was not uncommon. I scrambled to finish my calls and went into the patient's room.

Something wasn't right about this patient. She had long black hair, she was probably 26-28 weeks pregnant, and she obviously had been crying. As I walked in to her sniffling, I asked her "are you okay ma'am?" She couldn't even look at me and turned away to grab a tissue.

I started moving in to get a closer look and to comfort her. Suddenly, she whipped her head back around and looked at me straight in the eye. She had this weird nervous smirk on her face, but that wasn't even the most odd and memorable thing about this moment. She was easily the ugliest patient I had ever seen in my life. The mappy hair that covered one of her eyes, that big Asian flat nose, and overlyluscious lips.

Not a word came out of her mouth. After an awkward silence, she stood up. Not only was this woman ugly, but this woman was tall! At least six feet tall! And that nervous smirk had turned into a embarrassed smile. I started getting a bit nervous - what was wrong with this lady? should I call psych? should I call security?

As I instinctively started to backpeddle, this pregnant woman amazingly got down on one knee. *She* pulled out a shiny diamond ring, and said, "hey, babe. gotcha. will you marry me?"

And the rest is history.

By Nick Jacobs

In a conversation with my son recently, he reminisced about the "good ole days" when I was not working in healthcare. He talked about the fun that we had had with friends and relatives and the laughter that we shared.

I'll never forget running into a young man at the hospital several years ago whose father had worked with me back in the early pre-healthcare years. He said, "My dad told me that you were in healthcare management. He also told me that you had lost your sense of humor."

Both declarations were true. We deal everyday in a profession that involves life and death. In fact, our decisions can sometimes mean life or death to our patients.

And it takes its toll on us.

Yet, when it's all said and done, after being in each other's lives for over 30 years, the one thing that my son remembered as the definitive "missing piece" was the loss of my ability to just have FUN.

So, don't let your sense of humor slip away.

When something upsets me, my Chief Medical Officer, Director of Emergency Medicine looks at me and says, "It's okay. No one died." Truly the measure of success in his world.

It's clear that we need to find outlets that allow us to not be in the fish bowl for a while. Outlets that do not force us to put our sense of humor on hold.

At one point in my life, I knew four very successful, wealthy business CEO's, and, although they had serious philosophical differences, they had two common threads: 1. They NEVER watched television news. 2. They always found a way to laugh and make it fun. Okay, maybe there was a third. They were rich!

To quote Henny Youngman: "A man goes to a psychiatrist. The doctor says "You're crazy" The man says "I want a second opinion!" "Okay, you're ugly too!"

Okay, okay. I tried.

A post by Andrew Barna

The ink well has been running low for me lately, but I was recently reminded about a remarkable healthcare organization that is worthy of a post: Doctors Without Borders. While flipping through cable channels, my wife and I came across a series that tells the stories of Doctors Without Borders and their missions from locations as far reaching as war torn Africa and a remote village in South America. These physicians (and one psychologist) were operating in some of the worst conditions imaginable and with little supplies or support. In most cases they were the only medical personnel present and their treatment facility was a tent with dirt floors. In one case, the doctors had to flee their medical refuge because they heard gun-fire approaching. Their patients, of course, had no means other than by foot to escape.

The doctors also faced medical as well as ethical challenges. In the village in Africa, a baby girl was brought to the doctor with some kind of swelling in her head. The only hospital and physicians in the country that could have treated the girl were hundreds of miles away and the family would have had to come up with money for her treatment. Faced with this insurmountable obstacle, the doctor had little that she could offer the family and they ended up taking the girl back to their village, where she most likely perished.

After the program, my wife and I felt like there must be something more that could be done. The moral imperative seemed so tangible and clear. Simple vaccines or anesthetic, medical resources that are readily available in our country, could have saved people's lives in some of these situations, but none was available. There must be a way to get healthcare to where it is needed. Alas there are many complications and difficulties - financial, political, cultural - standing in the way of this goal. Regardless, the selfless volunteers for Doctors Without Borders are certainly doing their part.

By Nick Jacobs

It's the July the 4th weekend, and I'm sitting on the beach in Ocean City, Maryland, listening to Shostakovich on my I-Pod, drinking some polar water, writing this on my TREO and contemplating both luck and fate.

A 1000 gallon hot water heater almost directly above our OB suites decided to leak. That was 1000 gallons, count 'em. One thousand gallons of HOT water almost directly above our Obstetrics department, about ten feet from the nursery. What a chilling thought.

It's best if you don't even let your mind go there with this situation because, had things not turned out as they have, we surely would have been featured on the national news in a way that usually only occurs during really intense nightmares. Incidents like this are typically referred to, at the very least, as "career limiting events."

The beauty of this particular emergency is that no one got burned, no one got hurt, no one even got wet. The water began to fall into a benign hallway where the staff quickly collected a half dozen large garbage cans, our maintenance department was there within a few minutes, the water was diverted, and all else went extremely well. You have to love it when a plan comes together.

Most days we forget about timing, luck and fate. We just accept it for what it is. Today, however, with new babies, birthing mothers, and happy families, I thank the gods for protecting us because, no matter how many times the Joint Commission, the Department of Health or the 40 other regulatory agencies with whom we interact would have visited, the outcome would not have changed. There's no way to predict the internal rusting out of a 1000 gallon water tank or the potential directional flow of the water during an unpredictable event like this one. It's that Forest Gump quote about certain things that just happen.

So, for today, as the ocean breeze caresses my silky white, sun blocked legs protruding from under the umbrella, I say, thanks again for a little bit of good fate and a lot of luck. It sure was a nice break for all of us.

A post by Andrew Barna

Capping profits…the words bring a chill to the ears of capitalists everywhere, but the insurance commissioner in California is supporting legislation that would do just that for the state’s health insurers (see the LA Times story here). While I tend to fall in the government-non-interference camp, I do agree that something needs to be done about insurance industry profits. While most hospitals, being non-profit, return their profits to the community through re-investment, healthcare dollars are siphoned out of the system through for-profit insurers (there are of course other players in the industry that are for profit, physicians and IT companies, to name a few).

Rather than such a draconian intervention as capping profits, which will never be acceptable to the insurance industry, we should reach a different compromise. The public release of information is becoming a powerful tool in modifying provider behavior around cost and quality. We could and should exert the same pressure on health insurance companies by organizing and comparing their profit, administrative costs per dollar of premium, and charitable activities. Imagine adding that information to such health insurance comparison websites, such as insurance.com and healthia.com. When people shop for insurance they could compare a company’s corporate citizenship along side its premiums and benefit plans.

As with other cost and quality comparison sites, the mere presence of the information in the public eye motivates a change in behavior, whether or not there is a change in purchasing behavior. I think the public would actually be surprised at both the level of charitable work that insurance companies provide, as well as the size of their profits. As with most issues that hit the politicians’ radar, it is largely a matter of a lack of information that creates public anxiety and impetus for action. Let’s give the public the information it needs to moderate health insurance profits.

A post by Andrew Barna

In Back to the Future, Dr. Emmit Brown's great idea came to him when he hit his head on a toilet. It wasn't a great medical discovery, but the flux capacitor did "make time travel possible". Well my idea came in the middle of the night. It was the relationship between patient, provider, and payer that should exist. Now I have not discussed healthcare financing or "fixing healthcare" in a while, but it is an issue we should all participate in. So amidst all the talk about consumer directed healthcare (CDH), here are my 2 cents.

So here is the idea. The green lines show the flow of money and the red lines show value delivered. Notice the direction of the green lines. In exchange for healthcare services (red line from provider to patient), the patient, as the primary beneficiary of the services, is responsible for paying the provider. All the other green lines go to the patient. Why? Because the individual provides value to the employer and to society by being healthy; therefore, employers and society (i.e. - the government) should help people pay for their medical care. This is not to say that people should be put into debt because they have to have surgery or contract a terminal disease. Perhaps the government could subsidize personal medical debt based on income, diagnosis, or some medical debt/earnings ratio. The reality is that the patient is the true consumer of medical services and it is most natural to place the financial responsibility on the patient's shoulders.

The idea certainly needs alot more fleshing out and the healthcare marketplace is a bit more complex, but in a number of ways, we have already started moving in this direction. HSAs and CDH already have more of the healthcare expenditures flowing through the patient and tax incentives are a first step in the government's role of subsidizing healthcare for the individual. Imagine funneling more of the governments enormous healthcare expenditures through individuals. Rather than paying providers directly, the government would subsidize the patient's healthcare choices. If the patient (working with his or her provider) decide that the patient needs one more MRI, then the patient would take on that financial responsibility and the government would throw in its "two cents" to help the patient cover the cost. This is on top of the "two cents" that the employer is pitching in to ensure a healthy workforce.

In the end, it is a more equal distribution of the financial responsibility for healthcare (yes, that means individuals would pay more - right now most of us pay a small fraction out of pocket), while putting the patient, the true purchaser and beneficiary, at the center.

A post by Andrew Barna

Anyone who has read my posts in the past, knows that I am all about enhancing the patient experience, but an odd question occured to me recently. It came while reading the cover story on this month's Healthcare Executive magazine, entitled Reinventing the Patient Experience. On the first page of the story, the reader is told 3 different times that improving patient satisfaction is critical for the success of the hospital. Of course, I believe this, but the question still came: how do we know? The holy grail of patient satisfaction is the (positive) correlation of patient satisfaction scores with net income or volume. This is an OK proxy for the true outcome that we are looking for, but does it really tell us if our efforts are influencing where patients recieve their care?

Obviously, a different kind of study (more longitudinal), conducted from a different perspective (community-wide versus hospital specific) would need to be done to determine the true answer to my question. Perhaps researchers have done or could do this kind of study. It would tell us with much more authority what aspects of the patient experience influence hospital or provider selection. Rather than what factors correlate with high likelihood to return scores, we could learn what factors influence actual patient utilization choices.

Come to think about it, this is a round about way of saying that the HCAHPS survey will likely reveal some new insights into patient satisfaction, just by virtue of the fact that this data will be standardized across the country and that it could be paired with all the other data that the government collects.

That reminds me: What's going on with HCAHPS? Tune in to my next post on Healthcare Tomorrow to find out.

A post by Andrew Barna

I received my first issue of Journal of Healthcare Information Management this week and it has an intriguing theme: nurse informatics. I have only read a few articles so far, but one of the central tenets of the issue strikes me as absolutely true: nurses are at the heart of patient care and therefore should play a central role in the selection and implementation of information technology. However, it seems to me that there is a truly sad reality about nursing today that prevents them from participating in IT selection as much as they should. With budgets stretched thin, nursing departments often do not have the resources to do more than patient care and a handful of other required functions.

More than just the expected seats on a selection committee, I could see nurses playing a significant role, not only in the selection of information technology, but in the creation of information technology solutions. With the front seat to healthcare delivery, nurses have a unique perspective on the processes that add value to patient care and the processes that are otherwise required. I think given the time and technical support, nurses could help develop innovative IT solutions that could significantly improve the lives of nurses and the quality of care delivered.

You can learn more about nursing informatics at the HIMSS Nurse Informatics website.

A post by Andrew Barna

Yesterday I introduced Baby Thomas and the Bickle's on Healthcare Tomorrow. Today I would like to post the rest of my interview with Sarah Bickle.

For those that haven't read my first post on the Bickle's. Baby Thomas is a 6 month old from Dallas, Texas that was diagnosed with a brain tumor. Baby Thomas's mother, Sarah Bickle was kind enough to share their hospital experience with me. You can read more about Baby Thomas at their website, The Official Thomas Bickle Blog.

Has there been any situation in which you wanted to stop what was going on?

A nurse in the ER busted 4 of Thomas's little access veins in his wrists and feet. He was bruised at every spot, and Scott [Sarah's husband] told the nurse to stop and get someone else. She gave a kind of sarcastic remark, and Scott kind of flipped out and told her to leave the room ...with swearing. That was probably the most awful thing that happened.

What is one thing you would change about Thomas's care?

It's weird to me that our neurosurgeon was and our oncologist is the person who's in charge of communicating the overall plan of Thomas's care to us. We're very impressed with them, and I suppose the advantage is that they have the expertise to answer all our questions immediately, but I would think some people-person would be in charge of walking us through the logistical questions.

What are you very pleased with?

The nurses and therapists and doctors and even housekeepers genuinely love kids. It's totally clear. ...and it sounds petty, but I am so relieved to have sunlight in every room. It would be so hard to go through this in a dark place. Really, the only bad thing is the unhealthy food, but that's really it!

Is there anything else that you would like to share?

You know, my insurance company was so unhelpful at first, but now I've been put in contact with a real person with a real phone number who's going to manage our case. I'm curious to see how it works out, but having a real person who knows enough to answer more than one question at a time is making a huge difference in my stress level already. Thank goodness.

By Nick Jacobs

It was September of 1974 when my 57-year-old father’s cough was diagnosed as a lung cancer. He had stopped smoking 14 years earlier, and none of us were totally cognizant of the ramifications of his working as an attendant at a service station or of wrapping our furnace pipes with asbestos paper each year, or smoking Kent cigarettes with asbestos filters, or living in the path of dust patterns from winds from Los Alamos. All we knew was that a great father had been given a death sentence.

Ironically, our 74-year-old neighbor was diagnosed with lung cancer on the same day. The health care paths that these two very different men from opposite ends of the socioeconomic spectrum pursued in their destination to death are notable and ironic.

My father did everything available to mankind in 1974-75 to arrest this disease and regain his life. This meant surgical removal of the lung, radiation, chemo and lots of morphine. He spent 18 months in hell with metastases to his spine, kidney, and finally the other lung. It meant unbearable pain and total disruption to life.

It was during the 18-month journey from his good health to horrible death that we had our first real experience with the healthcare system. It was a world that was cold, sterile, insensitive and parochial. It was like entering a negative control pressure chamber where questions were unanswered, rudeness was the norm, and no one knew or was willing to find out what was going on at any given moment. A total lack of control of the system was the norm for us. And, unfortunately, near the end, it only grew worse as death; the ultimate failure in modern medicine, was obvious.

As my father’s health deteriorated, we were all stunned by the lack of care that he received. We were crushed by the lack of sensitivity demonstrated toward either the patient or the family. And once it was clear that his death was imminent, the healthcare providers began to avoid the room. They began to avoid bathing him and to avoid speaking with us. It was a horrible journey into a system that, 30 years ago was well funded, well staffed and even then was on its way to becoming one of America’s largest employers. Unfortunately, nearly 30 years later, many of these realities still exist.

Our 74-year-old neighbor, on the other hand, had no health insurance and decided to have no treatment for his lung cancer. After living comfortably at home with his entire extended family surrounding him through 18 months of nurturing, loving care, he died. The two men, Charlie and Murph died on the same day.

My father went through the torturous treatment provided by the healthcare system. He was cut, poked, prodded, poisoned, radiated, drugged and ignored.

We nearly depleted our family savings trying to be near him, attempting to stay by him at the tertiary care center two hours from our home.

Charlie and Murph died on the same day. For my dad Charlie, no clergy was available. No counselors were available. No social workers were available. Murph had it all. He died bathed in the love of his children and grandchildren, and unhampered by attitudes of unhappy caregivers, overworked physicians trained in the white coat world of high tension, high stakes medicine.