You Can Unleash This Horsepower!

Paul Levy

Posted 5/6/12 on Not Running a Hospital

Among the great hospital leaders in America, Jeffrey Thompson, CEO of the Gundersen Lutheran Health System in Wisconsin, stands out for going beyond achieving marvelous results in patient quality and safety.  Jeff’s commitment that his system will not accept mediocrity shows up in other arenas as well.  He and his board have adopted a corporate strategic plan that sets a goal of being “the best regionally and nationally on environmental stewardship and accountability.”

This is outlined in a recent keynote speech he gave at CleanMed 2012 in Denver.  Jeff pointed that hospitals have a large impact on the environment and on public health because of their use of electricity.  Noting that his system alone produces 500,000 pounds annually of airborne particulates tied to its electricity consumption, he concluded that reducing that impact can and should be tied into the culture of a health care institution.  He asserted, “We are going to be responsible to members of the community.  We are going to be transparent, and we are going to act to fix things.”

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The Great Experiment

Paul Levy

If you read only one book about state and federal health care policy, it should be The Great Experiment: The States, the Feds and Your Healthcare.  Published by the Boston-based Pioneer Institute, it is the most articulate and rigorous presentation of issues that I have seen, a stark contrast from many papers, articles, and speeches that slide by as “informed debate” in Massachusetts and across the country.  I learned more about health care policy from this book than from anything else I have read in the last decade.

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How To Get Better At Harming People Less

Paul Levy

Posted 4/09/12 on Not Running a Hospital

Every day, a 727 jetliner crashes and kills all the people on board.  Not really.  But every day in America, the same number of people in American hospitals lose their lives because of preventable errors.  They don’t die from their disease.  They are killed because of hospital acquired infections, medication errors, procedural errors, or other problems that reflect the poor design of how work is done and care is delivered.

Imagine what we as a society would do if three 727s crashed three days in a row.  We would shut down the airports and totally revamp our way of delivering passengers.   But, the 100,000 people a year killed in hospitals are essentially ignored, and hospitals remain one of the major public health hazards in our country.

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Free Our Data and Improve Public Health!

Paul F. Levy and W. David Stephenson

Published in the current issue of the Boston Business Journal

Massachusetts has a stunning opportunity to break open many of the mysteries surrounding delivery of health care. Doing so will help resolve important public policy issues. It will help contain rising health care expenses. And, it will even help save lives and improve the public health.

Doing this requires no new state law. The law is already on the books. It requires no addition to the state budget. The costs have already been incurred.
What could cause so dramatic an impact? Liberating data that is already in the hands of the state government.

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Pay Some Doctors More to Save Money

Paul Levy

Posted 3/26/12 on Not Running a Hospital

One of the strange things about health care in America is the manner in which decisions are made about how different kinds of doctors should get paid for their services.  It turns out that the system is controlled in a way most consumers would find unbelievable. As noted by the Wall Street Journal:


Three times a year, 29 doctors gather around a table in a hotel meeting room. Their job is an unusual one: divvying up billions of Medicare dollars.

The group, convened by the American Medical Association, has no official government standing. Members are mostly selected by medical-specialty trade groups. Anyone who attends its meetings must sign a confidentiality agreement.

Yet the influence of the secretive panel, known as the Relative Value Scale Update Committee, is enormous. The Centers for Medicare and Medicaid Services, which oversee Medicare, typically follow at least 90% of its recommendations in figuring out how much to pay doctors for their work. Medicare spends over $60 billion a year on doctors and other practitioners. Many private insurers and Medicaid programs also use the federal system in creating their own fee schedules.

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Our Aim Is At 100%. Other Than That, We Are At Zero

Paul Levy

Posted 3/21/12 on Not Running a Hospital

The power of transparency, as I have noted, is that it provides creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

MIT’s Peter Senge explains this more fully in his book The Fifth Discipline:

[T]he gap between vision and current reality is . . . a source of energy. If there was no gap, there would be no need for any action to move toward the vision. Indeed, the gap is the source of creative energy. We call this gap creative tension.

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Stop Smiling. It’s Not Good Enough

Paul Levy

Posted 3/13/12 on Not Running A Hospital

Ok, call me a sourpuss, or call me a contrarian, but I am put off by the self-satisfaction evident in this graphic in the Boston Globe. To be fair to the newspaper, its coverage reflects how the story about a reduction in the rate of central line infections was reported by the state Department of Public Health’s Bureau of Health Care Quality and Safety. That report presents data for the period July 1, 2009 through June 30, 2011.

The good news is that the rate of such infections dropped by 24% during that period. The bad news is inherent in this description:

Central Line Associated Blood Stream Infections (CLABSIs): A central venous catheter (CVC), sometimes known as a central line, is a special type of flexible tube that is placed through the skin into a large vein in a patient’s chest, arm, neck or groin and ends in or close to the heart or one of the major blood vessels. . . . While central venous catheters are considered an essential part of providing critical care, their use also places patients at increased risk for infection. Central line associated blood stream infections (CLABSIs) are serious, costly, and most can be prevented by following accepted practices for inserting and caring for central lines (my emphasis).

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Change Will Not Come From DC

Paul Levy

Posted 2/22/12 on Not Running a Hospital

A New York Times editorial — “A Real ‘Doc Fix’” — provides a wonderful example of how a dogmatic adherence to a particular policy prescription causes one to develop constructs that are politically impractical.  This editorial is about how to tackle Medicare costs.  The proposed solution:

  1. Cut fees for specialists and then hold them flat;
  2. Have the Secretary of HHS identify overpriced and overused services and reduce the fees paid for them;
  3. “Protect primary care doctors” by holding their fees flat for a decade; and
  4. Establish a fee schedule that pays doctors more if they leave fee-for-service and form organizations that will coordinate care or take on the financial risk of managing a patient’s care for a year at a fixed fee.

There are germs of good ideas in here, but it doesn’t hold together.  Let’s look at reality.

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Hope Lies with Residents

Paul Levy

Posted 3/1/12 on Not Running a Hospital

I remain relatively new to the health care field, but even in that short time, it has become evident to me that the pace of quality and safety enhancements and front-line driven process improvement in hospitals is inadequate given the scale and scope of harm that occurs to patients.  Indeed, it can be viewed as a paradox that the doctors of America, a group of dedicated, well-intentioned, intelligent, and highly trained individuals, constitute one of the top-ranked public health hazards in the county when as they work together in the nation’s hospitals.  That they collectively have not made much of a dent in the problem of reducing harm is, I believe, a product of their training.

As Brent JamesJay Kaplan, and others have noted, doctors are trained to be artists, to apply their intellect, creativity, intuition, and judgment to the care of each patient. That is well and good when the case is complex, but the vast majority of medical care is not complex.  It calls for standardization, adoption of protocols, and scientific experiments of process improvement to modify those protocols to enhance care and reduce harm.

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UNM Residents Start to Go Lean

Paul Levy

Posted 2/28/12 on Not Running a Hospital

Following Dr. Kaplan’s talk, UNM the residents retreat broke into work groups.  I attended the one about emergency department patient flow.  The UNM hospital handles 90,000 emergency room visits per year but suffers from major congestion problems.  The number of hours of boarding patients as they await rooms on the medical floors has grown, and there are also a substantial number of patients (14%) who leave without being seen because of the waiting times.  This is not an unusual problem in American hospitals, particularly the safety net hospitals, which face financial limitations in increasing capacity.

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The Joint Commission Tries To Lead Hospital Leaders

Paul Levy

Posted 1/23/12 on Not Running A Hospital

I was intrigued to read of a new standard, effective July 1, 2012, adopted by The Joint Commission regarding the need for hospital leaders to create and maintain a culture of safety and quality throughout a hospital.  Here it is:

I do not know how to find the previous standard for this topic, so I don’t know how different it is.  But this one seems to reflect comments made in the past by JC president Mark Chassin that the industry needs to get better creating and maintaining a true culture of process improvement.  For example, an article by him and Jerod Loeb in Health Affairs centers on this topic.  In a town hall meeting back on April 13, 2011, Mark also noted:

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Canadian Court to Address End of Life Support

Paul Levy

Posted 1/15/12 on Not Running A Hospital

The Supreme Court of Canada will soon be taking up the issue of whether doctors need consent before taking a patient off life support. As reported here in The Globe and Mail:

The country’s top court has granted leave to appeal to the doctors of . . . a man who has been in a coma at Toronto’s Sunnybrook Health Sciences Centre since October, 2010. His doctors diagnosed him as being in a “permanently vegetative state” and recommended he be taken off life support, but his wife and substitute decision-maker . . . strongly opposed. Now the doctors have turned to the Supreme Court in hopes of disconnecting Mr. Rasouli from the medical machines that are keeping him alive.

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Tracking Adverse Events

Paul Levy

Posted 1/08/12 on Not Running a Hospital

recent report from the Office of Inspector General at the US Department of Health and Human Services finds, unsurprisingly, that hospital incident reporting systems do not capture most patient harm.  A summary of major points:

All 189 sampled hospitals had incident reporting systems to capture events, and administrators we interviewed rely heavily on these systems to identify problems.

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Better Than Printing Money

Paul Levy

Posted 12/22/11 on Not Running A Hospital

John McDonough, one of the health care experts in Massachusetts, writes on his blog about the three-year renewal of the state’s Medicaid waiver.  John presents a history of the waiver and notes that it provides the “green glue,” i.e., the infusion of federal cash, that makes possible the health care reform process approved by this state several years ago.

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Really? The Most Significant?

Paul Levy

Posted 12/19/11 on Not Running A Hospital

Medscape Today has an article featuring “The Most Significant Medical Advances and Events in 2011.”  The list includes things like some FDA drug warnings; the fact that the Supreme Court will review the health care reform law; some finding about cellular phone use and brain activity; withdrawal of propoxyphene from the market; and new listings of top hospitals.

To which I say, “Bah, humbug!”  Most of the things mentioned have had and will have little or no impact on you, me, our relatives and friends as we seek to get care or avoid care.

What are the most significant advances and events?  They are the ones that have occurred by communities, patients, and clinicians in their home towns or their home regions that demonstrate the potential for real improvement in clinical care.  These are the ones that save lives now.  These are the ones that empower patients to be true partners with their caregivers and vice versa.  These are the ones that have nothing to do whatsoever with government mandates, accreditation actions, and the like.

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