Transcript The Challenge: To Create More Value in All Negotiations

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Part 9
Tom Peters’
EXCELLENCE.
ALWAYS.
New Master/21 August 2008
Slides at …
tompeters.com
Ten Parts
P1.1, P1.2, P1.3, P1.4/Generic
P2/Leadership
P3/Talent
P4/“Value-added Ladder”
P5/“New” Markets
P6/“The Equations”
P7.1/Implementation
P7.2/Action
P8/13 “Guru Gaffes”
P9/Health“care”
P10/“The Lists”
Part
nine
Some Reflections
On the sorry state of American
“health,” circa 2008, and the
sorry state of the “delivery of
Healthcare,” and why
the twain rarely meet; and
how easy it would be to do a
few things right, such as
remind adults of a certain age
to take their aspirin
Tom Peters/08.21.2008
This presentation has taken me about
10 years to produce—some recent
books took me over the top.
Nonetheless, it is an amateur’s view—
albeit a 65-year-old amateur with
“skin in the game.”*
*These gray-background slides are notes on
the preceding slide. I have chosen not to use the
Notes feature of PowerPoint, because so few in
fact avail themselves of notes in that format—and
I am optimistic that some of you will read the “notes”
slides in this format.
Keep this
#
in mind.
(Throughout this presentation.)
Keep this
#
in mind.
(Throughout this presentation.)
Some Reflections
On the sorry state of American
“health,” circa 2008, and the
sorry state of the “delivery of
Healthcare,” and why
the twain rarely meet: It’s
about a whole lot more than
health insurance!
Tom Peters/08.21.08
This presentation is not about
Hillarycare—or Obamacare or McCaincare. While the perverse nature of
financial incentives is discussed (e.g.,
their bias toward “medicine” and away
from “health”), this is not a treatise on
financing overall or the # of
uninsured. It focuses on “my turf”—
the operational aspects of healthcare
delivery. There is an enormous amount
to do in healthcare within our grasp
today, and not dependent upon new
legislation.
Outline: 22
“Chapters”
1.
2.
3.
4.
“Bottom Line” (??): U.S. Life Expectancy
My Take
John Hammergren’s Take
K.I.A. & Wounded: A House (Hospital) of
Horrors
5. How “It” “Works” (And Feels) …
6. You Must Be Your Own Boss!
7. Over-treatment!!!!!!!!!!!!
8. F.Y.I.: The Dominating (!) Role of Healthcare
in the American Economy
9. Pick of the Litter: Our “Best” Hospitals?
10. See No Evil: A Culture of Cover-up
11. And “They” Call It “Science” I: The
Overwhelming Lack of Treatment Validation
12. And “They” Call It “Science” II: Astounding
Geographic Treatment Variation
13. Shining Star, A/The …
14. IS/IT: The “Dark Ages” Saga Continues
15. K.I.S.S./Keep it simple, stupid: Un-sexy
“Stuff” Could Save Tens of Thousands of
Lives and Extend Hundreds of Thousands
of Others
16.“Organizational effectiveness” “Tools” that
would put the focus on the patient
17.Wellness-Prevention: No Good Deed Goes
Unpunished
18. From “Healthcare” to “Health”:
The “Oughtas”
19. Healthcare Meets Health: The Case of
the Planetree Alliance
20. My concerns, My Ideal
21.TP’s Nobels
22. Some Resources
1. “Bottom
line” (??):
U.S. Life
Expectancy
th
45 .*
*Rank of U.S. life expectancy, <Bosnia, Cuba
Problems notwithstanding, many-most
Americans, at the end of the day,
consider their-our healthcare to be the
best in the world. If so, why do we
rank behind the likes of Bosnia and
Cuba in life expectancy? Our global life
expectancy rank? Forty-five.
(And falling-dropping-plummeting.)
“This” [life expectancy]
is sorta the
point, isn’t it …
or am I missing
something?*
I’d think this (life expectancy) would
(obviously) be the principal point of
the overall exercise—it’s not “How
much healthcare do we get?” but “How
healthy are we?” Right???
“This” [life expectancy] is sorta the point,
isn’t it … or am I missing something?*
*Should I, for
instance, measure my
health by “number of
operations,” or
“number of tests,”
where, More = Better
Health?
“Pay by procedure” is the operative
(insane) funding algorithm in our
healthcare system—there is no
premium on helping us get healthy
—in fact there are severe penalties
for so doing.
1900-1960, life
expectancy grew 0.64 %
per year; 1960-2002,
0.24% per year, half from
airbags, gun locks,
service employment …
“Bottom line” :
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
Historically, much-most of the gain in
life-expectancy comes from non-health
system factors—especially cleanliness
and nutrition in the past.
th
37 .*
World Health Organization/WHO
rank of U.S. health system performance
More.
State of Healthcare/U.S.A.
*Spend more per capita
*Overall system
performance/WHO: 37th
*Relatively low life expectancy
*High # of uninsured
Source: Consulting, 07-08.06
State of Healthcare/U.S.A.
*Spend more per capita
*Overall system
performance/WHO: 37th
*Relatively low life expectancy
*High # of uninsured
Source: Consulting, 07-08.06
Stunning.
“America’s elites are very good at attracting
money and prestige, and they have a huge
technology arsenal with which they attack
But they have no
positive medical results to
show for it in the aggregate
and many indications that
they are providing lowerquality care than the muchmaligned HMOs and assorted
St. Elsewheres.”
death and disease.
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
Stunning.
2. My Take
The Healthcare14: U.S. Healthcare Trauma in 2008
U.S. Life expectancy rank: #45.
WHO, overall American healthcare system performance: #37
(#1 in cost).
Access: Denied to 10s of millions un/underinsured.
Unnecessary annual health-system deaths: 200,000-400,000 or
more.*
Performance/top med centers: Problematic re quality of care
and follow-up.*
Over-treatment (meds, tests, procedures): Pandemic.*
Use of hard evidence in medical decision-making: Spotty at best.*
Collection of evidence based on reported treatment errors: Low.*
Use of S.O.P.s in treatment regimes: Spotty.*
Incentives for appropriate care: Low.*
Incentives for in-appropriate care: High.*
Emphasis on prevention and wellness: Low.*
Emphasis on chronic-care: Low.*
State-of-the-art IS/IT: Rare.*
*Fixable without legislation or major societal change—eg can by and large be improved dramatically without
some form of mandated universal access to care and in the absence of, say, a full-fledged War on Obesity.
(Evidence in support of this proposition is the fact that in every category starred above there are Pockets of
Excellence—hospitals and other health-service organizations, facing the same realities as their peers, that
really “get it.”)
Data to follow.
DVM/Lyme/2005-2008
**Multiple diagnoses (>5)
**Specialist self-certainty
**Health deterioration failed to produce urgencycommunication.
**Virtually no communications between specialists
**Follow-up very spotty unless bugged incessantly
**Lost major test results, and mis-placed 3 or 4
occasions
**Near fatal drug mistake (one nurse takes charge)
**Effectively, disinterest in chronic-care
**Lack of curiosity in general
Home in Vermont, I happened to run
into a vet (Doctor of Veterinary
Medicine), who has dealt with Lyme
disease for years. In the course of a
half-hour conversation, these points
arose. Alas, none were in the least
surprising—and, of course, they are
the observations of an expert.
3. John
Hammergren’s
Take
Skin in the Game: How
Putting Yourself First
Today Will Revolutionize
Healthcare Tomorrow
—John Hammergren (CEO, McKesson) & Phil Harkins
John Hammergren is the CEO of $100
billion+ McKesson Corp. In a 2008
book, he paints a bleak picture of U.S.
healthcare systemic performance—but
als sees steps that would improve
things dramatically.
“ … 25 to 30 percent of our
$2.2 trillion goes to wasted
care* in the form of
preventable errors, incorrect
diagnoses, redundant
treatment, unnecessary
infections, and extra time
spent in the hospital.
*and another 20% to paperwork
Source: John Hammergren & Phil Harkins, Skin in
the Game: How Putting Yourself First Today
Will Revolutionize Healthcare Tomorrow
Stunning.
140,000,000
illegible
prescriptions
per year
—John Hammergren & Phil Harkins, Skin in the Game: How
Putting Yourself First Today Will Revolutionize Healthcare
Tomorrow
**1,500,000,000,000
claims per year
**30% errors
**15% lost
**25% paper-based
Source: John Hammergren & Phil Harkins, Skin in the Game:
How Putting Yourself First Today Will Revolutionize
Healthcare Tomorrow
Stunning.
”I can receive a BlackBerry
message from a colleague
climbing a mountain, yet I still
show up at a doctor’s office
[and after a 45-minite wait]
learn that my hospital test
results have not arrived weeks
after they should have.”
—John Hammergren & Phil Harkins, Skin in the Game:
How Putting Yourself First Today Will Revolutionize
Healthcare Tomorrow
Stunning.
Up To 500,000 Lives: “The medical
system has been unable to turn proven
remedies into everyday care.* Half the people
who need to be treated to prevent heart
attacks are not treated and half who are
treated are treated inadequately. Patients go
home with the wrong drugs or the wrong
doses or misimpressions about the
importance of taking their medications.”
*More: 55% chance of “receiving the best
recommended care—which means getting scientifically
appropriate, evidence-based medical treatment”
—The New York Times, from John Hammergren &
Phil Harkins, Skin in the Game:How Putting Yourself
First Today Will Revolutionize Healthcare Tomorrow
Stunning.
“The private insurance industry
has little incentive to see people
live healthy lives beyond 65 when
their customers automatically
drop out of the employer-based
system and enter the
government-based system.”
—John Hammergren & Phil Harkins, Skin in the Game:
How Putting Yourself First Today Will Revolutionize
Healthcare Tomorrow
Stupid
“How will you know when the healthcare industry has finally
entered the 21st century? When error rates at hospitals are
close to zero. When doctors and nurses use evidence-based
protocols in your treatment. When you can decide how
much to spend on treatment, and you have the information
and the opportunity to determine the best value. When your
primary care physician is in charge of your extended care
team, operating as your command central. When all
members of the medical community—nurses, doctors,
pharmacists and specialists—work together seamlessly on
your behalf. When their combined efforts are tracked,
measured, and reported on—and the insurance
reimbursements awarded to them are based on performance.
When you see that hospitals, pharmacies and doctors are
working harder in all aspects to make sure you are an
informed consumer who has trust and confidence in the
services they offer and the prices they charge.”
—John Hammergren & Phil Harkins, Skin in the Game: How Putting
Yourself First Today Will Revolutionize Healthcare Tomorrow
Hammergren says we know the
shape of revised system …
“ … 25 to 30 percent of our $2.2 trillion goes to
wasted care in the form of preventable errors,
incorrect diagnoses, redundant treatment,
unnecessary infections, and extra time spent in the
Team-based medicine, barcode prescription scanning,
evidence-based medicine—all of
these are systems and innovations
that are being put into place to
eliminate waste so that we can
re-apply the money.”
hospital.
—John Hammergren & Phil Harkins, Skin in the Game:
How Putting Yourself First Today Will Revolutionize
Healthcare Tomorrow
Hammergren says we know the
shape of revised system … and the
way to get from here to there.
4. K.I.A. &
Wounded: A
house
(hospital) of
horrors
COULD
IT TRULY BE
THIS AWFUL?
“Quality”:
3DHC = 5YI
3DHC = 5YI:
3 days’ health“care”caused deaths = 5
years of American
soldiers’ deaths in
the Iraq War*
*Not including most of the deaths forgone annually if preventionwellness became the primary arm of health-healthcare industry
“Quality of
care is the
problem, not
managed care.”
Source: Institute of Medicine (from Michael Millenson,
Demanding Medical Excellence)
“Study: Medical
Errors Affect 20
Percent of
Patients”
—headline, Boston Herald
RAND: 50%,
appropriate
preventive care. 60%,
recommended treatment, per
medical studies, for chronic
conditions. 20% , chronic
care treatment that is wrong.
30% acute care treatment
that is wrong.
Typical stats—more to come.
Welcome to the Homer Simpson Hospital, a/k/a …
The Killing
Fields
American life expectancy is relatively
low—and the delivery of healthcare in
the U.S. is notoriously unsafe.
90,000 killed
and 2,000,000
CDC 1998:
injured from
hospital-caused drug
errors & infections
This 1998 report was a shocker
—and bitterly contested by the
“healthcare establishment.” Now
it’s taken for granted, and perhaps
understates—significantly. More grim
estimates follow.
HealthGrades/Denver:
195,000
hospital deaths per year
in the U.S., 2000-2002 = equivalent of 390 full
jumbos/747s in the drink per year—more than one-a-day.
There is little
evidence that patient
safety has improved in the
last five years.”
Comments:
—Dr. Samantha Collier
Source: Boston Globe/2005
1,000,000
“serious medication errors per
year” … “illegible handwriting,
misplaced decimal points, and
missed drug interactions and
allergies.”
Source: Wall Street Journal /Institute of Medicine
Throughout, we will see that much of
this horrorshow is the product of “simple”
problems—e.g., bad handwriting.
“The Institute of Medicine
calculated that drug errors [on
average, one per patient per visit—various
sources; some estimates go as high as one-per-
alone add
on average nearly
patient-per-day, on average]
$5,000
to the cost of
every hospital visit.”
Overtreated: Why Too Much Medicine Is Making Us
Sicker and Poorer, Shannon Brownlee
“Hospital infections kill an
estimated 103,000 people
in the United States a year,
as many as AIDS, breast
cancer and auto accidents
combined.
… Today, experts estimate that more than 60 percent of
staph infections are M.R.S.A. [up from 2 percent in 1974]. Hospitals in Denmark,
Finland and the Netherlands once faced similar rates, but brought them down to below
1 percent. How? Through the rigorous enforcement of rules on hand washing, the
meticulous cleaning of equipment and hospital rooms, the use of gowns and
disposable aprons to prevent doctors and nurses from spreading germs on clothing
and the testing of incoming patients to identify and isolate those carrying the germ. …
Many hospital administrators say they can’t afford to take the necessary precautions.”
—Betsy McCaughey, founder of the Committee to Reduce Infection Deaths (New York Times/06.06.2005)
“1-in-7 Chance
of Medical
Mishap: Health
Ministry Report”
Source: Headline, The Press, Christchurch, NZ,
0216.08 (odds of a screwup during a hospital stay)
“When I climb Mount
Rainier I face less
risk of death than
I’ll face on the
operating table.”
—Don Berwick
Berwick is the uber-guru of the
patient safety movement.
“The results are deadly. In addition
to the 98,000 killed by medical
errors in hospitals and the 90,000
deaths caused by hospital
infections, another 126,000 die
from their doctor’s failure to
observe evidence-based protocols
for just four common conditions:
hypertension, heart attack,
pneumonia, and colorectal cancer.”
[TP: total 314,000]
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
1 42
m
s
The 314K per year, very conservative,
translates into an unnecessary death
every one-minute-and-forty-two
seconds. ....
... which in turn translates into 59
unnecessary deaths in the course of a
healthcare presentation, a little over
an hour long, that I recently made.
“Plus God alone
knows how many
casualties in
doctors’ offices,
Tom”
—Thom Mayer
Thom Mayer, renown ER doc and
consultant on patient-centric care,
reminded me that the grim stats above
leave out the likes what goes on in
docs’ offices all over the land.
(Arguably a staggering number in its
own right.)
“I had done what doctors do well in
this country, which is to treat
people when they come in with a
disease. My patients had good
medical care but not, I began to
think, great healthcare. For most, their
declines, their illnesses, were thirty-year
problems of lifestyle, not disease. I, like most
doctors in America, had been doing the wrong
job well. Modern medicine does not concern
itself with lifestyle problems. Doctors don’t treat
them, medical schools don’t teach them and
insurers don’t pay to solve them. I began to
think that this was indefensible.” —Henry Lodge,
Younger Next Year
Also left out are the folks who’d be
with us if the system focused on
health—wellness, prevention, etc..
“Experts estimate that more
than a hundred thousand
Americans die each year not
from illness but from their
prescription drugs. Those deaths, occurring
quietly, almost without notice in hospitals, emergency rooms, and
homes, make medicines one of the leading causes of death in the
United States. On a daily basis, prescription pills are estimated to kill
more than 270 Americans. … Prescription medicines, taken
according to doctors’ instructions, kill more Americans than either
diabetes or Alzheimer’s disease.”
Source: Our Daily Meds: How the Pharmaceutical Companies
Transformed Themselves into Slick Marketing Machines and
Hooked the Nation on Prescription Drugs —Melody Petersen
And on it goes ....
Primary-care
docs = Secondclass citizens.
Sources: too numerous to mention
The people who ought to be the
gatekeepers who would oversee the
co-ordination of specialists work—the
dis-organized results thereof which are
responsible for most of the likes of the
prescription-med errors—are
secondclass citizens in the specialistcentric “World of Modern Health“care.”
1 28
m
s
Maybe I undershot on
the earlier slide???
“In 2006 when Time magazine
had the brilliant idea of asking
doctors what scared them most
about being a patient, three
frequent answers were fear of
medical errors, fear of
unnecessary surgery, and fear of
contracting a staph infection in
teaching hospitals.”
Best Care Any where: Why VA Healthcare Is
Better Than Yours, Phillip Longman
The docs “get it” …
And you?
“Put a
muzzle on
that boy.”
In my 30 years of speechifying, I have said a few
controversial things—in fact I have a bit of a reputation for
so doing. But no one has tried to put a muzzle on me. Well,
no one except the … American Hospital Association. When
the CDC 98,000 hospital deaths study appeared, it was
fought tooth and nail by “the establishment.” I was appalled
by the statistic—mostly as a prospective patient. Along the
way, I used the stat in a talk (the CDC is a pretty damn
reliable source!); and then I got a message—the first and
only time in my career—from my speakers’ bureau. The
American Hospital Association is a big client of theirs. And
the AHA chief executive had called the president of the
speakers’ bureau and more or less demanded that he order
me to shut up—and quit propagating that scurrilous number.
Naturally the speakers’ bureau told him that my content was
up to me, not them. I was of course delighted—it suggested
that the number was correct, and that I had drawn blood.
But my point here is that this was the only time in three
decades that such censorship has been sought. (Of course I
can see why the AHA was embarrassed—they damn well
should have been!! And still should be!!)
5. How “it”
“works” (and
feels) …
Journalist Tim Noah writes about his wife’s cancer
“Much
of our effort involved retrieving
information from one source and
sending it to another. This wasn’t something
treatment in a high-rep private med center:
we could count on happening on its own. Very
expensive blood test results, we observed, had
perhaps a 50% chance of being misplaced under a
pile of faxes and therefore not finding their way into
Marjorie [William’s] medical chart. So we made a habit
of getting the labs to fax to our house. Films of CT
scans would be misfiled perhaps 30% of the time and
thus become permanently irretrievable. So I took my
checkbook to all of Marjorie’s CT scans and purchased
my own spare copy on the spot.”
Source: Foreword to Best Care Any where: Why VA
Healthcare Is Better Than Yours, Phillip Longman
“My most memorable brushes have
been with an eminent surgeon,”
Marjorie [Longman’s wife, on the receiving end of cancer
treatment] wrote in her next-to-last column
for the Washington Post, “whose
method is to stride into the examining
room two hours late, pat your hand,
pronounce your certain death if he can’t
perform an operation on you, and then
snap at your husband to stop taking
notes, since he can’t possibly follow the
complexity of the doctor’s thinking.”
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
These are all too common reports.
Patient safety guru Don Berwick, a
renowned M.D. and Harvard Med
School faculty member, was moved to
his vociferous patient-safety advocacy,
not by analytic deduction, but by
the insane frequency of errors in his
wife’s treatment at a “prestigious
Boston medical center.”
6. You must
be your
own boss!
“He shook me up. He put his hand
on my shoulder, and simply said,
you have got
to take charge of
your own medical
care.’ ”
‘Old friend,
Source: Hamilton Jordan, No Such Thing as a Bad Day, on a
conversation with a doctor pal following Jordan’s cancer diagnosis)
Longman (his wife, Robin, treated for cancer): “The
more time we spent in the Lombardi Center and
Georgetown hospital, the more I was disturbed by the
way they managed ‘the little things.’ … I was similarly
shocked at how little the various specialists involved in
her care seemed to consult with one another, or to keep
up to date on the results of tests. … There seemed to be
little attention given to managing information and
I came away feeling
that no patient should ever enter a
hospital without having some kind
of fulltime advocate—a caring,
calm, shrewd relative or friend
at least.”
coordinating care. …
Source: Best Care Any where: Why VA Healthcare Is
Better Than Yours, Phillip Longman
For the patient, the immediate answer
to this sad state of affairs is to become
one’s own healthcare quarterback—
and to quit trusting “the guys in
the white coats.”
“Just one second,
please. You do know
I’ve got a pacemaker,
lower limit only, 60bpm,
no defib? And that I
take 150 mg of
Coumadin a day? …”*
TP:
*In 3 of 4 cases, in a 2-day period, the answer was in part,
“No”
at least,
—including set-up for an echo stress
cardio test (reading and results dependent on the above info)
My own pitiful experience—I was and
am enraged. (March 2008, “prestigious
Boston medical center.”)
7. Overtreatment
!!!!!!!!
This section buggers the imagination.
“The big cause of skyrocketing
healthcare costs has been
increasingly intensive use of
technologies and treatments that,
when we look at their effects on
the population as a whole, have
brought only negligible
improvement in public health
and longevity.”
Best Care Any where: Why VA Healthcare
Is Better Than Yours, Phillip Longman
The previous slide and the next four
that follow presumably require no
elaboration—except for me to say that
I could have offered a 20-slide array,
not just these few, had I so desired.
“We spend between one-fifth
and one-third of our healthcare
dollars, an exorbitant amount
of money, between five
hundred and seven
hundred billion dollars,
on care that does nothing to
improve our health.”
Source: Overtreated: Why Too Much Medicine Is Making Us
Sicker and Poorer, Shannon Brownlee
400,000 heart bypass surgeries,
1,000,000 angioplasties per
year: “Yet recent studies show
that only about
percent
three
of the patients
who receive such operations
benefit from them; most would be
better served just taking aspirin or
low-cost beta blockers.”
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
“Americans undergo millions of tests—
MRIs, CT scans, blood tests—that do
little to help doctors diagnose
disease, and sometimes lead
them to find and treat conditions
that would never have bothered
their patients had they never
been found. We undergo back
surgery for pain in the absence of
evidence that the surgery works.”
Source: Overtreated: Why Too Much Medicine Is Making
Us Sicker and Poorer, Shannon Brownlee
“[Dartmouth Professor Elliott] Fisher and his
colleagues discovered that
patients who went to hospitals
and
did the most
procedures —were 2 to 6
that spent the most—
percent more likely to die than
patients that went to hospitals
that spent the least.”
Source: Overtreated: Why Too Much Medicine Is Making
Us Sicker and Poorer, Shannon Brownlee
“The most powerful reason
doctors and hospitals
overtreat is that most of
them are paid for how
much care they deliver,
not
how well they
care for their patients.”
Overtreated: Why Too Much Medicine Is Making Us
Sicker and Poorer, Shannon Brownlee
“Teach to test” is the Achilles heel of
our “education” system—the only
acquired skill is test-taking; and the
essential love-of-learning is
diminished, not enhanced. Likewise,
“pay for procedure” is the perverse
centerpiece of our health“care”
system—denigrating the very health
for which we were intended to care.
Hospital intake interview with yours
truly, Boston, March 2008
“What did
your mother die of?”
TP: “Too many specialists.”
Physician’s Assistant:
PA:
TP:
“No, really?
Really!!”
Hospital intake interview, Boston, March 2008
“What did
your mother die of?”
Physician’s Assistant:
“Too many
specialists.”
TP:
[excellent]
“No, really?
TP: Really!!”
PA:
Hospital intake interview, Boston, March 2008
“What did
your mother die of?”
TP: “Too many [excellent]
Physician’s Assistant:
specialists [who
never
communicate/d with
one another] .”
“No, really?
TP: Really!!”
PA:
I was not joking. As the end hove in
sight, my Mom was being treated for a
sizeable number of problems (she was
95); it seemed as though no more than
a couple of days passed before she was
over-reacting to one med that other
docs were not aware of. They’d cut
that one back, then enhance another.
At 95, she was simply wearing out—but
her overload of non-coordinated
specialists pretty clearly pushed her
out the door. (This is not just my
conclusion, but that of a couple of
my M.D. pals.)
“If we sent 30 percent
of the doctors in this
country to Africa, we
might raise the level of
health on both
continents.” —Dr Elliott Fisher,
Center of Evaluative Clinical Sciences, Dartmouth Medical School
(“Overdose,” Atlantic, Shannon Brownlee.)
He’s not kidding! (Elliott Fisher is one
of the real super-heroes among those
trying to push the rock-of-reform up
the mountain of med system
resistance.)
“America has twice
as many hospitals
and physicians as
it needs.” —Med Inc., Sandy
Lutz, Woodrin Grossman & John Bigalke
Ditto Fisher.
$PD(USA) > $PD(J + G
+ F + I + S + UK + A
+ NZ + C + M + B + A)
> $G(USA) >
$HEX2(USA)*
*U.S. spending on prescription drugs in 2005 ($250,000,000,000) is greater than the
combined spending on prescription drugs by Japan plus Germany plus France plus
Italy plus Spain plus the United Kingdom plus Australia plus New Zealand plus
Canada plus Mexico plus Brazil plus Argentina (all except Mexico, Brazil and
Argentina have longer life expectancies than we do); and our prescription drug bill
also is more than our gasoline bill and two times more than our higher ed bill.
Source: Our Daily Meds: How the Pharmaceutical Companies
Transformed Themselves into Slick Marketing Machines and
Hooked the Nation on Prescription Drugs —Melody Petersen
$PD(USA) > $PD(J + G + F + I + S + UK + A + NZ + C
+ M + B + A) > $G(USA) > $HEX2(USA)*
*U.S. spending on prescription drugs in 2005
($250,000,000,000) is greater than the
combined spending on prescription
drugs by Japan plus Germany plus France plus
Italy plus Spain plus the United Kingdom plus
Australia plus New Zealand plus Canada plus
Mexico plus Brazil plus Argentina (all except
Mexico, Brazil and Argentina have longer life
expectancies than we do); and our prescription
drug bill also is more than our gasoline bill and
two times more than our higher ed bill.
Source: Our Daily Meds: How the Pharmaceutical Companies
Transformed Themselves into Slick Marketing Machines and
Again, words like “insane” or
“ridiculous” or “outrageous” are the
only ones that come to mind.
“a grossly
overprescribed
nation”
—Arnold Relman, professor emeritus,
Harvard Med; former editor, The New England Journal of Medicine
Source: Our Daily Meds: How the Pharmaceutical Companies
Transformed Themselves into Slick Marketing Machines and
Hooked the Nation on Prescription Drugs —Melody Petersen
“Creating a
disease”
—from a slide by Neil Wolf,
Pharmacia, at the 2003 Pharmaceutical Marketing Global
Summit (Philadelphia)
Source: Our Daily Meds: How the Pharmaceutical Companies
Transformed Themselves into Slick Marketing Machines and
Hooked the Nation on Prescription Drugs —Melody Petersen
I am not an instinctive basher of the
pharmaceutical industry. Yet the
evidence is clear—the industry has
repeatedly made mountains (worth
$$$$$billions) out of mole-hills. (Or
“no-hills.”)
8. F.Y.I.: The
dominating (!)
Role of
healthcare
in the American
economy
“What’s Really Propping
Up the Economy:
Healthcare has added 1.7
million jobs since 2001.
The rest of the private
sector?
None.”
Source: Title, cover story, BusinessWeek,
0925.2006
U.S. Healthcare Expenditures
2008: $2.2 trillion
2016: $4 trillion
Source: John Hammergren & Phil Harkins, Skin in the Game:
How Putting Yourself First Today Will Revolutionize
Healthcare Tomorrow
We spend over $2,000,000,000,000
on healthcare in America—and it is
also our engine of job growth.
Increasingly, “healthcare economics”
are “American economics.”
9. Pick of the
litter:
Our “best”
hospitals?
the more
prestigious the hospital
“Generally,
you check into, and the more
eminent and numerous the
physicians who attend you,
the more likely you are
to receive low-quality or
even dangerous and
unnecessary care.”
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
Flabbergasting.
“The more doctors and specialists
around, the more tests and procedures
performed. And the results of all these
tests and procedures? Lots more medical
bills, exposure to medical errors, and a
loss of life expectancy.
“It was this last conclusion that was truly shocking, but it
became unavoidable when [Dartmouth’s Dr. Jack]
They
found it’s not just that renowned
hospitals and their specialists tend to
engage in massive overtreatment. They
also tend to be poor at providing critical
but routine care.”
Wennberg and others broadened their studies.
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
“[Dartmouth’s Dr. Jack] Wennberg and others … found it’s not
just that renowned hospitals and their specialists tend to
engage in massive overtreatment. They also tend to be poor at
providing critical but routine care. For example, Dartmouth
researcher Elliot S. Fisher has found that among
Medicare patients, who share the same age,
socioeconomic, and health status, their chances of
dying in the next five years are greater if they go to a
high-spending hospital. One reason is that patients in
high-spending hospitals with lots of specialists and high
technology are also less likely to receive many proven
routine treatments [e.g. aspirin, flu vaccine]. … This
general lack of attention to prevention and follow-up
care in high-spending hospitals helps to explain why not
only heart-attack victims but also patients suffering
from colon cancer and hip fracture stand a better
chance of living another five years if they stay away
from ‘elite’ hospitals and choose a lower-cost
competitor.”
Best Care Any where: Why VA Healthcare Is
Better Than Yours, Phillip Longman
“The more doctors and specialists around, the more tests
and procedures performed. And the results of all these
tests and procedures? Lots more medical bills, exposure
loss of
life
expectancy.”
to medical errors, and a
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
Flabbergasting.
10. See no
evil: A
culture of
cover-up
“culture of
cover-up that
pervades
healthcare”
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
One begins to feel that there is no end
to the insults to which patientscitizens are subjected by this most
“modern” of American industries.
“When a plane crashes,
they ask, ‘What
happened?’ In medicine
they ask: ‘Whose fault
was it?’ ”
—James Bagian, M.D. & former
astronaut, now working with the VHA
Success Through Positive
Acknowledgement of Failures
Wernher Von Braun, re the Redstone
missile engineer who “confessed” to a
screw-up and was awarded a bottle of
champagne. Award to the sailor on the
aircraft carrier Carl Vinson—for reporting a
lost tool on the deck (that could have
caused a crash). Amy Edmonson on
successful nursing units—with the highest
reported adverse drug events.
Source: Karl Weick & Kathleen Sutcliffe, Managing the Unexpected
Reward admissions of mistakes …
it can be done.
“culture of cover-up
that pervades healthcare”
“Patient Safety Event Registry” …
“looking for systemic solutions, not seeking
to fix blame on individuals except in the
Ken Kizer/VA 1997:
most egregious cases. The good news was a
thirty-fold
increase
in the number of medical
mistakes and adverse events that got reported.”
“National Center for Patient Safety Ann Arbor”
The VA
“gets it.”
(Again.)
thirty
-fold
The enormity of the possible
improvement is staggering—perhaps
one of the few hopeful signs.
11. And “they”
call it “science” I:
overwhelming
Lack of treatment
validation
“stunning lack of
scientific knowledge
about which
treatments and
procedures actually
work.”
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
Here we go again: “flabbergasting.”
“The high rates of surgery were not being driven by patients, but rather by
doctors.” “They had no idea how different their practices were from their
Medicine
wrapped itself in the mantle of science, yet
much of what doctors were doing was based
more on hunches than good research. … In fact,
as research would show over the coming
decades, stunningly little of what physicians do
has ever been examined scientifically, and when
many treatments and procedures have been put
to the test, they have turned out to cause more
harm than good. In the latter part of the twentieth century, dozens of
colleagues..” “Wennberg came to an unsettling conclusion.
common treatments , including the tonsillectomy, the hysterectomy, the frontal
lobotomy, the radical mastectomy, arthroscopic knee surgery for arthritis, X-ray
screening for lung cancer, proton pump inhibitors for ulcers, hormone
replacement therapy for menopause, and high-dose chemotherapy for breast
cancer, to name just a few, have been shown to be unnecessary, ineffective, more
dangerous than imagined, or sometimes more deadly than the diseases they were
intended to treat.”
Overtreated: Why Too Much Medicine Is Making Us
Sicker and Poorer, Shannon Brownlee
“As unsettling as the prevalence of inappropriate care is
the enormous amount of what can only be called
A surprising 85% of
everyday medical
treatments have never
been scientifically
validated. … For instance, when family
ignorant care.
practitioners in Washington were queried about treating
a simple urinary tract infection, 82 physicians came up
with an extraordinary 137 strategies.”
Source: Demanding Medical Excellence: Doctors and
Accountability in the Information Age, Michael Millenson
%
“The Search for
Quality: It All
Begins on the
Autopsy Table”
Source: Chapter title, Severed Trust: Why American
Medicine Hasn’t Been Fixed, George Lundberg
“Learning organization”—the typical
hospital ain’t.
“Most people think that quality of
care is defined by medical
interventions, such as a hip
replacement, lens implant, or
coronary bypass operation, but
genuine quality of care is defined
by action based on good
information. Definitions of quality are often counterintuitive.
Multiple lab tests do not constitute quality medicine. … Entrepreneurial
physicians have a greater stake in doing more than in doing good. Medicare,
for example, provides funding for autopsies of every hospitalized beneficiary,
and good science suggests that at least 30 percent of deaths should be
autopsied. Very few are.. … In fact, lack of autopsy is the ultimate cover-up in
medicine, and the signature of poor quality care. … The whole issue of patient
safety is based on honesty, and the autopsy is central in a system that finds
truth, deals with it honestly, and tries to improve patient care.”
Source: “The Search for Quality: It All Begins on the Autopsy Table,” chapter title,
Severed Trust: Why American Medicine Hasn’t Been Fixed, George Lundberg
12. And “they” call
it “science” II:
Astounding
Geographic
treatment
variation
“In health care …
geography
is destiny.”
Dartmouth Medical School 1996 report, from Demanding Medical Excellence:
Doctors and Accountability in the Information Age, Michael Millenson
Sound absurd? Read on.
“What [Wennberg and his Dartmouth colleagues] found was that medicine was all
over the map, literally. If Wennberg had been using a microscope to look at medical
care in New England, his team was now standing on a mountaintop looking at the
entire nation, yet they were seeing precisely the same patterns he had found in
Vermont and Maine. Only now they could tell it wasn’t just tonsillectomies;
hysterectomies and prostatectomies were being used far more in one region than
another. It was CT scans, office visits, cardiac catheterizations. It was blood tests and
hospitalizations, back surgery, chest X-rays, and knee replacements. In one part of the
country, practically every woman with breast cancer
was still getting a mastectomy long after clinical trials had shown that a breastsparing lumpectomy with radiation was just as effective. In another, babies were being
put in neonatal intensive care when they didn’t need it. They found that patients with
back pain were 300 percent more likely to get surgery in Boise,
Idaho, than in Manhattan. Doctors affiliated with Harvard Medical School admitted
patients to the intensive care unit four times more often than their
colleagues at Yale University School of Medicine. Arthroscopic knee surgery –which
would later be shown to be entirely ineffective at treating knee pain due to arthritis—
was performed
five times more often on arthritic patients in Miami
than Iowa City.
Overtreated: Why Too Much Medicine Is Making Us
Sicker and Poorer, Shannon Brownlee
Geography Is Destiny
E.g.: Ft. Myers 4X Manhattan—back
surgery. Newark 2X New Haven—
prostatectomy. Rapid City SD 34X Elyria
OH—breast-conserving surgery. VT, ME,
IA: 3X differences in hysterectomy by
age 70; 8X tonsillectomy; 4X
prostatectomy (10X Baton Rouge vs.
Binghampton). Breast cancer screening:
4X NE, FL, MI vs. SE, SW. (Source: various)
Geography Is Destiny
“Often all one must do to acquire a
disease is to enter a country where
a disease is recognized—leaving
the country will either cure the
malady or turn it into something
else. … Blood pressure considered treatably
high in the United States might be considered
normal in England; and the low blood pressure
treated with 85 drugs as well as hydrotherapy
and spa treatments in Germany would entitle
its sufferer to lower life insurance rates in the
United States.” – Lynn Payer, Medicine & Culture
Almost funny. (If the stakes were not
so high.)
“Practice variation is not caused by ‘bad’ or
‘ignorant’ doctors. Rather, it is a natural
consequence of a system that
systematically tracks neither its
processes nor its outcomes,
preferring to presume that good
facilities, good intentions and good
training lead automatically to good
results. Providers remain more comfortable
with the habits of a guild, where each craftsman
trusts his fellows, than with the demands of the
information age.”
—Michael Millenson, Demanding Medical Excellence
“Nothing has
changed since our
Science paper in
1973. …”*
—Dr Jack Wennberg
*“Nothing of course, except the fact that American
medicine has swelled into a behemoth industry equal in
size to the entire economy of Italy.”—SB
Overtreated: Why Too Much Medicine Is Making Us
Sicker and Poorer, Shannon Brownlee
35 years.
13. Shining
star, a/the …
“What’s needed in the U.S. is
nothing short of a medical
revolution and the VHA has
gone further than most any
other organization to
revamp its culture and
systems.” —RAND
There is an exception among big
systems—the Veterans
Administration/VA hospitals. And yes,
“everyone” is amazed. (Mr Longman’s
book, Best Care Anywhere: Why VA
Healthcare Is Better Than Yours, is a
masterpiece—required reading for any
healthcare professional, as I see it.)
Ken Kizer, 1994, per Longman:
“reorienting the VHA away from a
system that emphasized acute
care delivered in hospitals by
specialists and toward one that
put overwhelming emphasis
on prevention and patientcentered management of
chronic conditions.”
Best Care Any where: Why VA Healthcare Is
Better Than Yours, Phillip Longman
Ah,
health
is the goal! (What a fascinating idea.)
“Because the VA lacks any
financial incentive to
engage in overtreatment, it
saves money by avoiding
unnecessary surgery and
redundant testing.”
Best Care Any where: Why VA Healthcare Is
Better Than Yours, Phillip Longman
No doubt at all, the VA incentive
scheme, the antithesis of the
mainstream programs, is a big help.
VA costs up
0.8% in 10
years, Medicare
up
40.4%
(Note: VA patients “older, sicker, poorer and more prone to
mental illness, homelessness, and substance abuse;” ½ > 65,
1/3 smoke, 1/5 diabetes vs 1/14 overall; chronic diseases,
frailty—especially vulnerable to medical errors )
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
Key point, the VA is dealing with a
tougher than normal population—so
they aren’t blessed with any systemic
advantage on that score.
***2003, New England Journal of Medicine publishes
quality study results: 11 measures of quality compare
VA and fee-for-service plans. VA “significantly better”
on
11 out of 11 …
***2004, Annals of Internal Medicine, RAND study: VA
vs commercial managed care; VA “outperforms all
other sectors of American healthcare in
294
measures of quality” …
***National Committee for Quality Assurance toprated, JHU, Mayo, Mass General; “In
single category
every
the veterans
healthcare system outperforms the highest-rated nonVA hospitals”
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
Wow.
E.g.: On-time appointments, appointment with
specialist, Institute for Health Care
Improvement/Don Berwick:
“[VA is]
spectacular”
Best Care Any where: Why VA Healthcare Is
Better Than Yours, Phillip Longman
Pretty damned impressive.
(Understatement.)
VA/Strengths/Foci
*Safety
*Evidence-based medicine
*Health promotion and wellness
programs
*“Unparalleled adoption of
electronic medical records
and other information
technologies”
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
The VHA gets it! E.g.: Laptop at bedside calls
up patient e-records from one of 1,300 hospitals.
Bar-coded wristband confirms meds. National
Center for Patient Safety in Ann Arbor. Docs
and researchers discuss optimal treatment
regimens—research center in Durham NC. Doc
measures & guidelines; e.g., pneumonia
vaccinations from 50% to 84%. Blame-free
system, modeled after airlines. “What’s needed
in the U.S. is nothing short of a medical
revolution and the VHA has gone further than
most any other organization to revamp its
culture and systems.”—Rand
14. IS/IT: The
“dark ages”
saga
continues
“Shockingly, despite our vaunted
prowess in computers, software and the
Internet, much of our healthcare system
is still operating in the dark ages of
paper records and handwritten scrawls.
American primary care doctors lag years
behind doctors in other advanced nations
in adopting electronic medical records or
prescribing medications electronically.
This makes it harder to coordinate care,
spot errors and adhere to standard
clinical guidelines.” —”World’s Best Medical Care?”,
New York Times, August 2007
“Dark ages”—here we go again!
“Some grocery
stores have better
technology than
our hospitals
and clinics.”
—Tommy Thompson, former HHS Secretary
Source: Special Report on technology in healthcare, U.S. News & World Report
“We’re in the
Internet age, and
the average patient
can’t email their
doctor.”
—Don Berwick, Harvard Med School
“Home Depot does a
better job of tracking a
box of nails than your
local hospital does in
tracking you.”
Overtreated: Why Too Much Medicine Is Making
Us Sicker and Poorer, Shannon Brownlee
VA/Strengths
*Safety
*Evidence-based medicine
*Health promotion and wellness
programs
*“Unparalleled adoption of
electronic medical records
and other information
technologies”
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
Information technology:
group of off-theradar experiments, performed surreptitiously by
“the Hard Hats.”
Dr Kenneth Dickie, 1979, brought together, as
VistA, 20,000 software protocols “originally
written by individual doctors and other professionals
working secretly in VA facilities all around the country”
“This unique, integrated information system has
dramatically reduced medical errors at the VA while
also vastly improving diagnoses, quality of care,
scientific understanding of the human body, and the
development of medical protocols based on hard data
about what drugs and procedures work best.”
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
The VA got it early—and with a
homegrown system!
“As with many other institutions,
the software these [VA] high
priests wrote, or more often
procured from private vendors,
wasn’t very good, in large part
because the people who actually
had to use it had little role in its
development.”
Best Care Anywhere: Why VA Healthcare Is
Better Than Yours, Phillip Longman
Homegrown … makes all the
difference, especially where adoption
is concerned, the Achilles heel of most
systems.
Scanner:
“Skunkworks” project started in Kansas, 1992,
hand-held scanner, idea from nurse Sue Kinnick when she
observed usage in rental-car return area.
“It wound up
549,000 errors by 2001;
there was a 75% decrease in errors
involving the wrong medication, a 62%
eliminating some
decrease in errors involving the wrong dosage,
93% reduction in the wrong patients
receiving medicine, and a 70% decrease
a
in the number of times nurses simply forgot
or didn’t get around to giving patients
their meds.”
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
Again, the numbers are staggering.
I’m hardly suggesting that putting this
system in place was a cakewalk—on
the other hand, the basic idea is hardly
rocket science! (Most of these
breakthrough ideas aren’t; e.g.,
rewarding the reporting of errors so
that learning can ensue.)
“Our entire facility is
digital.
No paper, no film, no medical records.
Nothing. And it’s all integrated—from the lab to X-ray to records
to physician order entry. Patients don’t have to wait for
anything. The information from the physician’s office is in
registration and vice versa. The referring physician is
immediately sent an email telling him his patient has shown up.
… It’s wireless in-house. We have 800 notebook computers that
are wireless. Physicians can walk around with a computer that’s
pre-programmed. If the physician wants, we’ll go out and wire
their house so they can sit on the couch and connect to the
network. They can review a chart from 100 miles away.”
—David Veillette, CEO, Indiana Heart Hospital
It helps to have a “greenfield”
facility—but this is also a non-VA demo
of making effective IS the centerpiece
of the enterprise.
15. k.i.s.s./Keep it simple,
stupid: Un-sexy “stuff”
Could save tens of
thousands of lives and
extend hundreds of
thousands of others
A lot of “the fix” is very
straightforward; in fact, the system’s
infatuation with clever, complex tools
is “part of the problem.” (A big part of
the problem.)
“The simplest treatments often
fall through the cracks —
making sure a patient
knows how to use an
asthma inhaler, for instance.
And when doctors and hospitals
try to deliver the right kind of
care, such as keeping track of a
heart patient’s weight gain … ,
they lose money.”
Overtreated: Why Too Much Medicine Is Making
Us Sicker and Poorer, Shannon Brownlee
More on the perverse “losing money
for doing the right thing” in a moment.
“For most Americans, the two biggest determinants of what kind of treatments they receive are
how many doctors and specialists hang a shingle in their community and which one of them they
happen to see. The more doctors and specialists around, the more tests and procedures
performed. And the results of all these tests and procedures? Lots more medical bills, exposure
to medical errors, and a loss of life expectancy. It was this last conclusion that was truly
shocking, but it became unavoidable when [Dartmouth’s Dr. Jack] Wennberg and others
broadened their studies. They found it’s not just that renowned hospitals and their specialists
They also tend to be poor at
providing critical but routine care. For example, Dartmouth
tend to engage in massive overtreatment.
researcher Elliot S. Fisher has found that among Medicare patients, who share the same age,
socioeconomic, and health status, their chances of dying in the next five years are greater if they
One reason is that patients in
high-spending hospitals with lots of specialists
and high technology are also less likely to receive
go to a high-spending hospital.
many proven routine treatments [e.g.
aspirin,
flu vaccine]. … This general lack of
attention to prevention and follow-up care in highspending hospitals helps to explain why not only heart-attack victims but also
patients suffering from colon cancer and hip fracture stand a better chance of living another five
years if they stay away from ‘elite’ hospitals and choose a lower-cost competitor.”
Best Care Any where: Why VA Healthcare Is Better Than Yours, Phillip Longman
Aspirin saves lives. (Lots of.)
Wrong
site surgery: “The most
effective part of the drill is
simply asking the patient, in
language he can understand,
to state (not confirm) who he
is, his birth date or social
security number, and what
he’s in for.”
K.I.S.S./Keep It Simple, Stupid:
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
And your name is …
“If God spoke to me by saying, ‘Mark, you’re down to
your last three words: What would you want to say to
your fellow humans that would make the most positive
impact?’ It would be a close call between Love Thy
Neighbor and
Hands
Wash Your
. A close third would be Move, Move,
Move.” —Mark Pettus, M.D., The Savvy Patient
“The most important thing you can do to keep
wash
your hands. ”
from getting sick is to
—CDC/National Center
for Infectious Diseases
“Sanitary revolution”:
mortality in major cities
down
55%
between 1850 and 1915
Source: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation
Compression hose would mostly fix the hospital
problem: “According to the American Heart Association,
up to two million Americans are affected annually by deep
vein thrombosis. Of those who develop pulmonary
embolism, up to 300,000 will die each year. ... Deep vein
thrombosis also is among the leading causes of
preventable hospital death. Even more disturbing is the
fact that, according to a U.S. multi-center study published
by two of ClotCare's editorial board members,
58%
of patients who developed a DVT while in
the hospital received no preventive
treatment despite the presence of
multiple risk factors and overwhelming
data that prophylaxis is very effective at
reducing these events.” —Marie B. Walker,
clotcare.com, March 2008
One study I came across concluded
that you could save 20,000 lives per
year in UK hospitals—by issuing
compression hose-socks to virtually
every hospitalized patient. (As I said,
we ain’t talkin’ rocket science.)
The EMS Myth:
“Speed* has never
saved anybody’s
life. Period.”
—W.H. Leonard,
Medical Transportation Insurance Professionals
*Ambulance, accident site to hospital
Source: USA Today
I am always amused, in a perverse
sort of way, when I come across stuff
like this. Urban legend: Speeding EMTs
in ambulances are mainly a turn-on for
speeding EMTs in ambulances.
20%: not get
prescriptions filled
50%: use meds
inconsistently
Source: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation
Market Forces
RediClinic.CheckUps.Take
Care.MinuteClinic* (*“We treat these
16 rules-based disorders”/ “Go-no go” tests.15
minutes.$39)
Wal*Mart.CVS.Target.
Walgreens.RiteAid
Source: FT (10.06.06); NYT (12.31.06)
I am an unabashed champion of
such non-conventional healthcare
delivery vehicles—hospitals are
fighting them tooth and nail.
(Hilariously, hospitals have
declared them unsafe—talk about
pots calling kettles black!)
(Interestingly, these convenientcare operations may significantly
push the greater “system” in the
direction of electronic medical
records—the CC clinics are
100% electronic.)
Case: The
“simple”
Checklist!
I absolutely
love
this story!
90K in U.S.A. ICUs on any
given day; 178 steps/day
in ICU.
50%
stays result
in “serious complication”
Source: Atul Gawande, “The Checklist” (New Yorker, 1210.07)
**Peter Pronovost, Johns Hopkins,
2001
**Checklist, line infections
**1/3rd at least one error when he started
**Nurses/permission to stop procedure
if doc, other not following checklist
**In 1 year, 10-day line-infection rate:
11% to …
0%
Source: Atul Gawande, “The Checklist” (New Yorker, 1210.07)
Wow. (Zerooooooo.)
**Docs, nurses make own
checklists on whatever
process-procedure they choose
**Within weeks, average stay in
ICU down
50%
Source: Atul Gawande, “The Checklist” (New Yorker, 1210.07)
Wow.
**Replicate in Inner City Detroit
(resource strapped—$$$, staff cut 1/3rd, poorest patients in USA)
**Nurses QB the process
**Project manager for overall process implementation
**Exec involvement (help with “little things”—it’s all “little things”)
**Blue Cross/insurers, small bonuses for participating
66%
**6 months,
decrease in infection rate; USA:
bottom 25% in hospital rankings to …
top 10%
Source: Atul Gawande, “The Checklist” (New Yorker, 1210.07)
Tough test. Initial resistance, in the
face of resource cuts, enormous.
“[Pronovost] is focused on work that is not normally
considered a significant contribution in academic
medicine. As a result, few others are venturing to extend
Yet his work has
already saved more lives
than that of any
laboratory scientist in
the last decade.”
his achievements.
—Atul Gawande,
“The Checklist” (New Yorker, 1210.07)
Medicine Nobel, anyone?
“Beware of the
tyranny of making
Small Changes to Small
Things. Rather, make
Big
Changes to
Things.”
Big
—Roger Enrico, former Chairman, PepsiCo
Are we sure?
Or …
“Beware of the tyranny of making
Small
Things.
Small
Changes to
Rather, make Big
Big Things …
using Small, Almost
Invisible
Straightforward
Levers with Big
Systemic Impact.”
Changes to
—TP
Think checklist.
Think “wash your hands.”
Think “take your aspirin.”
Think “What’s your name?”
Think compression hose.
Etc.
Etc.
16. “Organizational
effectiveness” “Tools”
that would put the
focus on the patient.
“Clinical microsystem,”
linked microsystems,
patient-centric “care
teams” —Paul Batalden/DHMC
Source: “What System?” Dartmouth Medicine, Summer 2006
(Quality By Design: A Clinical Microsystems Approach, by
Eugene C. Nelson, Paul B. Batalden, and Marjorie M. Godfrey)
The idea here is to break down the
functional barriers and bring all
resources together in micro-units
aimed directly at the patient.
Numerous Experiments:
“Medical Homes”
And the idea here is to install coordinators who track and guide the
patient’s overall pattern of interaction
with the system—Medicare is
experimenting with this..
17. Wellnessprevention: No
good deed goes
unpunished
“Every
$1.00 spent
on its wellness program
ended up saving [Citigroup]
$4.70, according to an
academic study.”
—WSJ/0329.07
We can demonstrate the
enormous value of emphasizing
wellness-prevention.
Pursuing “Health”: 1995, Duke Medical Center, “Nurses
regularly called patients [with congestive heart failure] at
home to monitor their well-being and to make sure they took
their medications. Nutritionists offered heart-healthy diets.
Doctors shared data about their patients and developed
evidence for what treatments and dosages had the best results.
And it worked—at least in the sense that patients became
healthier. The number of hospital admissions declined and
patients spent less time in the hospital.
“Quality doesn’t pay”: “By 2000, the hospital was taking a 37%
hit in its revenue due to the decline in admissions and the
absence of complications. Ten hospitals in Utah had a similar
experience after implementing integrated care for pneumonia.”
“No investment in quality goes
unpunished.” “But there is a problem:
Who will pay for it? … An idealistic
commitment to best practices doesn’t
pay the bills.”
Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman
Whoops. (Alas.)
(FYI, I also read recently that Duke
shut down its “family practice”
specialty program—for lack of
interest.)
18. from
“healthcare”
to “health”:
The “oughtas”
TP Recommendation #1:
Dubai Healthcare City
to
Dubai Health City*
*Cleveland Clinic and Canyon Ranch
Dubai is investing billions in a
“Healthcare City”—in a keynote
presentation I begged them to
call it “Health City.”
(Words do matter.)
MHHA/Michigan
Health and
Hospital
Association
Hats off to the MHHA for adding
“Health” to their association name!
“I had done what doctors do well in
this country, which is to treat
people when they come in with a
disease. My patients had good
medical care but not, I began to
think, great healthcare. For most, their
declines, their illnesses, were thirty-year
problems of lifestyle, not disease. I, like most
doctors in America, had been doing the wrong
job well. Modern medicine does not concern
itself with lifestyle problems. Doctors don’t treat
them, medical schools don’t teach them and
insurers don’t pay to solve them. I began to
think that this was indefensible.” —Henry Lodge,
Younger Next Year
“Medicine” to “Health.”
Childhood
Obesity >
Terrorism
Source: Mike Levitt/Secretary HHS
A/the “health” problem that is
becoming a/the “medicine” problem.
(Behavioral, not medicinal!)
Bust
fat docs!
“Model the way” is leadership “Rule
One.” Fat docs hectoring kids to give
up fast foods is not on … as far as
I’m concerned.
Go Mayor
Mike!
Three hearty cheers for Mayor
Bloomberg’s transfats ban.
TP’s Canyon
Ranch
epiphany—and
rage!
I’ve always been lucky enough to have “very
good doctors”—starting with my pediatrician,
Dr Elizabeth Peabody, in Annapolis in the
1940s. But in 2003 I went to Canyon Ranch
(Berkshires) aiming to “get my shit together.”
There I met nutritionists and others—the first
“healthcare folks” I’d met, especially M.D.s,
focused on “health.” In short order, I had wildly
reversed most of the adverse readings in my
blood tests. I had in effect reversed aging—
and that is not an exaggeration.
And I was furious! That is, why, at age 61, was
I “hearing about this”—”health stuff”—for the
first time? (Despite my continuous care by
“terrific docs”—Stanford trained, etc.)
Behavioral Primacy!
E.g.: plate size;
location of platters,
6.5 feet Away = -63%
“Seconds”
Source: Brian Wansink, Mindless Eating
(20 lbs per year; 200 decisions per day)
Working on the basic “behavioral
stuff”—no mean feat—provides
enormous payoff. (Yes, it’s difficult to
do—but, mainly, it is most definitely
not the focus of our
$2,000,000,000,000 health“care”
industry.)
Slow
elevators, distant parking
lots with infrequent buses,
“food court” as “poorly”
placed as possible, etc.
Sprint/Overland Park KS:
Source: New York Times
Lovely!
Health + Social Factors
20% fewer
admissions, 40% less bed
combination =
occupancy [over 65]
Source: Unicare/UK/Dr David
Lyon/Pulse, 1123.06
(Can work for the VA, NHS—but, as
noted above, thwarted by our “pay per
procedure” “culture.”)
Q.W.P. *
*Quality. Wellness. Prevention.
Tom’s “bias.”
19. HEALTHCARE
MEETS HEALTH: The
Case of the
PLANETREE ALLIANCE
I will conclude this presentation
with a “good news” case, that
of the Planetree Alliance.
Planetree:
A Radical Model for New
Healthcare/Healing/
Wellness Excellence
Tom Peters
"All sane persons agree that 'healthcare needs an overhaul.' And that's where
the agreement stops. Healthcare issues are thorny, and system panaceas are
about as likely as the sun rising in the West. But there is good news here and
there—and great news courtesy the Planetree Model.
"In the midst of ceaseless gnashing of teeth over 'healthcare issues,' the
patient and frontline staff often get lost in the shuffle. Enter Planetree. While
oceanic systemic solutions remain out of reach, Planetree provides a
remarkable demonstration of what healthcare—with the patient at the
center—can be all about; and is all about among Planetree Alliance members.
"I know this may sound ridiculous, but everything about the 'model' works. It
is great for patients and their families—and is truly about humanity and
healing and health and long-term wellness, not just a 'fix' for today's
problem. It is great for staff—Planetree-Griffin is rightly near the top of the
'best places to work in America' list, year in and year out. And Planetree also
works as a 'business model'—any effectiveness measure you can name is in
the Green Zone at Griffith.
"For 25 years my 'gig' has been 'excellence.' Put simply, there is no better
exemplar of customer-centered, employee-friendly excellence, in any
industry, than Griffin-Planetree. The Planetree model works—and in my
extensive work in the health sector, I 'sell' it shamelessly, and pray that my
clients are taking it all in."
tom peters/response to request for comment on Planetree
(Explanation to come.)
“It was the goal of
the Planetree Unit to
help patients not only
get well faster but
also to stay well
longer.”
—Putting Patients First,
Susan Frampton, Laura Gilpin, Patrick Charmel
And this is done within the context
of the private-incentive scheme
—i.e., it can be done.
“Much of our current
healthcare is about curing .
Curing is good. But healing
is spiritual, and healing is
better, because we can heal
many people we cannot
cure.” —Leland Kaiser, “Holistic Hospitals”
“The most basic
question we need to
pose in caring for
others is this: Is this
a loving act?”
—Leland Kaiser,
“Holistic Hospitals”
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
Determinants of Health
Access to care: 10%
Genetics: 20%
Environment: 20%
Health Behaviors: 50%
Source: Institute for the Future
The 9 Planetree Practices
1. The Importance of Human Interaction
2. Informing and Empowering Diverse Populations: Consumer
Health Libraries and Patient Information
3. Healing Partnerships: The importance of Including Friends
and Family
4. Nutrition: The Nurturing Aspect of Food
5. Spirituality: Inner Resources for Healing
6. Human Touch: The Essentials of Communicating
Caring Through Massage
7. Healing Arts: Nutrition for the Soul
8. Integrating Complementary and Alternative Practices
into Conventional Care
9. Healing Environments: Architecture and Design Conducive
to Health
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
1. The Importance
of Human
Interaction
139,380 former
patients from 225 hospitals:
Press Ganey Assoc:
none
of THE top 15 factors
determining Patient Satisfaction
referred to patient’s health outcome
PS directly related to Staff Interaction
PS directly correlated with Employee
Satisfaction
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
“There is a misconception that supportive interactions require
more staff or more time and are therefore more costly. Although
labor costs are a substantial part of any hospital budget, the
interactions themselves add nothing to the budget.
Kindness is
free.
Listening to patients or answering their
questions costs nothing. It can be argued that negative
interactions—alienating patients, being non-responsive to their
needs or limiting their sense of control—can be very costly. …
Angry, frustrated or frightened patients may be combative,
withdrawn and less cooperative—requiring far more time
than it would have taken to interact with them initially in a
positive way.” —Putting Patients First, Susan Frampton,
Laura Gilpin, Patrick Charmel
“Perhaps the simplest and most
profound of all human interactions
is KINDNESS. … But if it is so
simple, it is surprising how
frequently it is absent from our
healthcare environments. … Many
staff members report verbal
‘abuse’
by physicians, managers
and coworkers.” —Putting Patients First, Susan
Frampton, Laura Gilpin, Patrick Charmel
“Planetree is about
human beings
caring for other
human beings.”
—Putting Patients First, Susan Frampton, Laura Gilpin,
Patrick Charmel (“Ladies and gentlemen serving ladies
and gentlemen”—4S credo)
2. Informing and
Empowering Diverse
Populations: Consumer
Health Libraries and
Patient Information
Planetree Health Resources Center/1981
Planetree Classification System
Consumer Health Librarians
Volunteers
Classes, lectures
Health Fairs
Griffin’s Mobile Health Resource Center
Open Chart Policy
Patient Progress Notes
Care Coordination Conferences (Est
goals, timetable, etc.)
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
3. Healing
Partnerships: The
Importance of
Including
Friends and Family
“When hospital staff members are
asked to list the attributes of the
‘perfect patient and family,’ their
response is usually a passive patient
with no family.”
—Putting Patients First, Susan
Frampton, Laura Gilpin, Patrick Charmel
The Patient-Family Experience
“Patients are stripped of control, their clothes are
taken away, they have little say over their schedule,
and they are deliberately separated from their family
and friends. Healthcare professionals control all of the
information about their patients’ bodies and access to
the people who can answer questions and connect them
with helpful resources. Families are treated more as
intruders than loved ones.”
—Putting Patients First,
Susan Frampton, Laura Gilpin, Patrick Charmel
“Family members, close friends
and ‘significant others’ can
have a far greater impact on
patients’ experience of illness,
and on their long-term health
and happiness, than any
healthcare professional.”
—Through the Patient’s Eyes
“A 7-year follow-up of women
diagnosed with breast cancer
showed that those who confided in
at least one person in the 3 months
after surgery had a 7-year survival
72.4%
rate of
, as compared
to 56.3% for those who didn’t have
a confidant.” —Institute for the Future
Care Partner Programs
(IDs, discount meals, etc.)
Unrestricted visits (“Most Planetree hospitals
have eliminated visiting restrictions altogether.”) (ER at one
hospital “has a policy of never separating the patient from the
family, and there is no limitation on how many family members
may be present.”)
Collaborative Care Conferences
Clinical Guidelines Discussions
Family Spaces
Pet Visits (POP: Patients’ Own Pets)
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
4. Nutrition:
The Nurturing
Aspect of Food
Meals are central events
vs
“There, you’re fed.” *
*Irony: Focus on “nutrition” has reduced
focus on “food” and “service”
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
Kitchen
Beautiful cutlery,
plates, etc
Chef reputation
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
Aroma therapy
(e.g., “smell of baking cookies”—from kitchenettes
in each ward)
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
5. Spirituality:
Inner Resources
for Healing
Spirituality: Meaning and Connectedness in Life
1. Connected to supportive and
caring group
2. Sense of mastery and control
3. Make meaning out of disease/
find meaning in suffering
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
Griffin:
redesign chapel (waterfall,
quiet music, open prayer book)
Other:
music, flowers, portable
labyrinth
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
6. Human Touch:
The Essentials of
Communicating
Caring Through
Massage
“Massage is a
powerful way to
communicate
caring.”
—Putting Patients First,
Susan Frampton, Laura Gilpin, Patrick Charmel
Mid-Columbia Medical Center/Center for Mind and Body
Massage for every patient scheduled for
ambulatory surgery (“Go into surgery with
a good attitude”)
Infant massage
Staff massage (“caring for the caregivers”)
Healing environments: chemo!
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
7. Healing Arts:
Nutrition for
the Soul
Planetree: “Environment conducive to healing”
Color!
Light!
Brilliance!
Form!
Art!
Music!
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
Florence Nightingale/Notes on
Nursing/patient’s need for beauty,
“People say
the effect is only on
the mind. It is no
such thing. The effect
is on the body, too.”
windows, flowers:
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
Griffin:
Music in the parking
lot; professional musicians in
the lobby (7/week, 3-4hrs/day) ;
5 pianos
volunteers (120-140 hrs arts &
entertainment per month).
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
;
8. Integrating
Complementary and
Alternative Practices
into Conventional Care
Griffin IMC/Integrative Medicine Center
Massage
Acupuncture
Meditation
Chiropractic
Nutritional supplements
Aroma therapy
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
CAM (Complementary & Alternative Medicine):
83M people use in US (42%)
CAM visits 243M, greater than to PCP (Primary
Care Physician) (With minimum insurance coverage)
Well educated-High income
CAM “users” don’t tell PCP (40%)
Lack of true testing a red herring: <30%
procedures used in conventional medicine
have undergone RCTs (randomized clinical trials)
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
9. Healing
Environments:
Architecture and
Design Conducive
to Health
“Planetree Look”
Woods and natural materials
Indirect lighting
Homelike settings
Goals: Welcome patients, friends and
family … Value humans over technology ..
Enable patients to participate in their care
… Provide flexibility to personalize the
care of each patient … Encourage
caregivers to be responsive to patients …
Foster a connection to nature and beauty
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
Sound
Texture
Lighting
Color
Smell
Taste
Sacred space
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
Access to nurses station:
“Happen to”
vs
“Happen with”
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
The Eden
Alternative*
*ElderCare
Planetree approach applied to
eldercare.
The Ten Principals of the Eden Alternative
1. The three plagues of loneliness, helplessness, and boredom
account for the bulk of suffering among Elders.
2. Life in an Elder-centered community revolves around close and
continuing contact with children, plants, and animals. These
ancient relationships provide young and old alike with a pathway
to a life worth living.
3. Companionship is the antidote to loneliness. In an Eldercentered community we must provide easy access to human and
animal companionship.
4. A healthy Elder-centered community seeks to balance the care
that is being given with the care that is being received. Elders need
opportunities to give care and caregivers need opportunities to
receive care.
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
“The Eden paradigm
allows elders to care for
animals, birds, and
children as well as each
other.” —Susan Eaton, Harvard/JFK school
Source: Putting Patients First, Susan Frampton,
Laura Gilpin, Patrick Charmel
The Ten Principals of the Eden Alternative
5. Variety and Spontaneity are the antidotes to boredom.
The Elder-centered community is rich in opportunities to
sample these ancient pleasures.
6. An Elder-centered community understands that passive
entertainment cannot fill a human life.
7. The Elder-centered community takes medical treatment
down from its pedestal and and places it into the service
of genuine human caring.
Source: Putting Patients First, Susan Frampton,
Laura Gilpin, Patrick Charmel
The Ten Principals of the Eden Alternative
8. In an Elder-centered community, decisions should be
made by the Elders or those as close to the Elders as
possible.
9. An Elder-centered community understands human
growth cannot be separated from human life.
10. Wise leadership is the lifeblood of any struggle
against the Three Plagues. For it, there can be no
substitute.
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
Conclusion:
Caring/Growth
“Experience”
Care!/Love!/Spirit!
Self-Control!
Connect!/learn!/
involve!/Engage!
Understanding!/Growth!
De-stress!/heal!
Whole patient & family
& friends!
be well!/stay well!
F.Y.I.: It
works!
Griffin Hospital/Derby CT (Planetree Alliance “HQ”) Results:
Financially successful.
Expanding programsphysically. Growing market
share. Only hospital in “100
Best Cos to Work for”—
7 consecutive years,
currently #6.
—“Five-Star Hospitals,” Joe Flower,
strategy+business (#42)
Learn more about Planetree/
The Planetree Alliance:
www.planetree.org
9 July/HealthLeaders
2008 Top
Leadership Team in
Healthcare: Griffin
Hospital
And the awards flood in ....
20. My
Concerns …
my ideal
TP & Healthcare/May 2008:
***Prevention and wellness
***Population outcomes, outcomes in general;
key metrics
***EMR, info-tech for procedural integration
and guidance for evidence-based
Treatment.
***Safety
***Quality
***Chronic care
***Provision of the basics
***Simple tools (Checklists)
***Clinical micro-systems (Patient Care Teams)
***Patient Quarterbacks (Family Practice specialists, PAs, Nurses)
***Patient-centric/Healing environments (Planetree/Griffinn)
***Evidence-based medicine
***Primary care
***Overtreatment
***Obesity
In summary, the areas I worry
about most.
TP’s Ideal Hospital Org Chart, Circa August 2008
CEO, CMO/CHIEF MEDICAL OFFICER, CNO/CHIEF NURSING OFFICER, CFO, ETC. [traditional jobs]
DEPUTY CEO/PATIENT SAFETY & QUALITY
Director “Hands Clean” Mandate
Director Error-free Medications Program
Director Simple-Tools-That-Save-Lives Programs
Director Over-treatment Evaluation & Management
CHIEF CLINICAL EVALUATIONS OFFICER
Director Evidence-based Medicine Initiatives
Director Best-practices Program
Director Error Reporting & Evaluation Initiative
CISO/CHIEF INFORMATION SYSTEMS OFFICER
Director Electronic Medical Records
Director Cross-functional IS Engagement & Implementation
Teams
DEPUTY CEO/HEALTH & HEALING & COMMUNITY OUTREACH
Director Wellness & Prevention Programs
Director Follow-up Patient Behaviors Program
Director Public Health Initiatives
Director Wellness Programs
Director Kids’ Education Programs
CPCCO/CHIEF PATIENT-CENTRIC CARE OFFICER
Director Patient Experience Programs
Director Planetree Practices Programs
Director Patient “Home Port” & Self- & FamilyManagement Programs
DEPUTY CEO/PEOPLE
Director Teams-based Organization
CCCO/CHIEF CHRONIC-CARE OFFICER
DEPUTY CEO CROSS-FUNCTIONAL COORDINATION OFFICER
Director Patient-Treatment Teams Implementation
Director Cross-functional Communications Initiatives
This is not really a “fix”—it amounts to
the injection of hopeless bureaucracy.
On the other hand, my “ideal” hospital
exec team emphasizes concerns that
seem to be second order in most
institutions..
21. TP’s
Nobels
TP’s “Nobels” in Medicine
Don Berwick
John Wennberg
Elliott Fisher
Ken Kizer
The VA
Peter ProNovost
Team Planetree
22. Some
resources
***Best
Care Anywhere: Why VA Healthcare
Is Better Than Yours —Phillip Longman
***Medicine
& Culture
—Lynn Payer
***Our
Daily Meds: How the Pharmaceutical
Companies Transformed Themselves into
Slick Marketing Machines and Hooked the
Nation on Prescription Drugs —Melody Petersen
***Overtreated:
Why Too Much Medicine
Is Making Us Sicker and Poorer
—Shannon Brownlee
***Demanding Medical Excellence: Doctors
and Accountability in the Information Age
—Michael Millenson
***Putting Patients First —Susan Frampton,
Laura Gilpin, Patrick Charmel [The Planetree story]
Thank you
for your
time!
END
Part 9