How to Stop Hospitals from Killing Us @Medici_Manager

Medical errors kill enough people to fill four jumbo jets a week. A surgeon with five simple ways to make health care safer. http://online.wsj.com/article/SB10000872396390444620104578008263334441352.html

By MARTY MAKARY

When there is a plane crash in the U.S., even a minor one, it makes headlines. There is a thorough federal investigation, and the tragedy often yields important lessons for the aviation industry. Pilots and airlines thus learn how to do their jobs more safely.The world of American medicine is far deadlier: Medical mistakes kill enough people each week to fill four jumbo jets. But these mistakes go largely unnoticed by the world at large, and the medical community rarely learns from them. The same preventable mistakes are made over and over again, and patients are left in the dark about which hospitals have significantly better (or worse) safety records than their peers.

WSJ’s Gary Rosen talks to author and surgeon Marty Makary about his ideas for making American hospitals more transparent about their safety records and more accountable for the quality of their care.

As doctors, we swear to do no harm. But on the job we soon absorb another unspoken rule: to overlook the mistakes of our colleagues. The problem is vast. U.S. surgeons operate on the wrong body part as often as 40 times a week. Roughly a quarter of all hospitalized patients will be harmed by a medical error of some kind. If medical errors were a disease, they would be the sixth leading cause of death in America—just behind accidents and ahead of Alzheimer’s. The human toll aside, medical errors cost the U.S. health-care system tens of billions a year. Some 20% to 30% of all medications, tests and procedures are unnecessary, according to research done by medical specialists, surveying their own fields. What other industry misses the mark this often?

It does not have to be this way. A new generation of doctors and patients is trying to achieve greater transparency in the health-care system, and new technology makes it more achievable than ever before.

I encountered the disturbing closed-door culture of American medicine on my very first day as a student at one of Harvard Medical School’s prestigious affiliated teaching hospitals. Wearing a new white medical coat that was still creased from its packaging, I walked the halls marveling at the portraits of doctors past and present. On rounds that day, members of my resident team repeatedly referred to one well-known surgeon as “Dr. Hodad.” I hadn’t heard of a surgeon by that name. Finally, I inquired. “Hodad,” it turned out, was a nickname. A fellow student whispered: “It stands for Hands of Death and Destruction.”

Leonard Mccombe/Time Life Pictures/Getty Images; Photo Illustration/The Wall Street Journal‘Doctors absorb an unspoken rule: to overlook the mistakes of our colleagues.’

Stunned, I soon saw just how scary the works of his hands were. His operating skills were hasty and slipshod, and his patients frequently suffered complications. This was a man who simply should not have been allowed to touch patients. But his bedside manner was impeccable (in fact, I try to emulate it to this day). He was charming. Celebrities requested him for operations. His patients worshiped him. When faced with excessive surgery time and extended hospitalizations, they just chalked up their misfortunes to fate.

Dr. Hodad’s popularity was no aberration. As I rotated through other hospitals during my training, I learned that many hospitals have a “Dr. Hodad” somewhere on staff (sometimes more than one). In a business where reputation is everything, doctors who call out other doctors can be targeted. I’ve seen whistleblowing doctors suddenly assigned to more emergency calls, given fewer resources or simply badmouthed and discredited in retaliation. For me, I knew the ramifications if I sounded the alarm over Dr. Hodad: I’d be called into the hospital chairman’s office, a dread scenario if I ever wanted a job. So, as a rookie, I kept my mouth shut. Like the other trainees, I just told myself that my 120-hour weeks were about surviving to become a surgeon one day, not about fixing medicine’s culture.

25% Hospitalized patients who are harmed by medical errors Source: New England Journal of Medicine

Hospitals as a whole also tend to escape accountability, with excessive complication rates even at institutions that the public trusts as top-notch. Very few hospitals publish statistics on their performance, so how do patients pick one? As an informal exercise throughout my career, I’ve asked patients how they decided to come to the hospital where I was working (Georgetown, Johns Hopkins, D.C. General Hospital, Harvard and others). Among their answers: “Because you’re close to home”; “You guys treated my dad when he died”; “I figured it must be good because you have a helicopter.” You wouldn’t believe the number of patients who have told me that the deciding factor for them was parking.

There is no reason for patients to remain in the dark like this. Change can start with five relatively simple—but crucial—reforms.

Online Dashboards

Every hospital should have an online informational “dashboard” that includes its rates for infection, readmission (what we call “bounce back”), surgical complications and “never event” errors (mistakes that should never occur, like leaving a surgical sponge inside a patient). The dashboard should also list the hospital’s annual volume for each type of surgery that it performs (including the percentage done in a minimally invasive way) and patient satisfaction scores.

A survey of New Yorkers found that approximately 60% look up a restaurant’s “performance ratings” before going there. If you won’t sit down for a meal before checking Zagat’s or Yelp, why shouldn’t you be able to do the same thing when your life is at stake?

Nothing makes hospitals shape up more quickly than this kind of public reporting. In 1989, the first year that New York’s hospitals were required to report heart-surgery death rates, the death rate by hospital ranged from 1% to 18%—a huge gap. Consumers were finally armed with useful data. They could ask: “Why have a coronary artery bypass graft operation at a place where you have a 1-in-6 chance of dying compared with a hospital with a 1-in-100 chance of dying?”

Instantly, New York heart hospitals with high mortality rates scrambled to improve; death rates declined by 83% in six years. Management at these hospitals finally asked staff what they had to do to make care safer. At some hospitals, the surgeons said they needed anesthesiologists who specialized in heart surgery; at others, nurse practitioners were brought in. At one hospital, the staff reported that a particular surgeon simply wasn’t fit to be operating. His mortality rate was so high that it was skewing the hospital’s average. Administrators ordered him to stop doing heart surgery. Goodbye, Dr. Hodad.

Safety Culture Scores

Imagine that a surgeon is about to make an incision to remove fluid from a patient’s right lung. Suddenly, a nurse breaks the silence. “Wait. Are we doing the right or the left chest? Because it says here left, but that looks like the right side.” The surgery was, indeed, supposed to be on the left lung, but an intern had prepped the wrong side. I was that doctor, and that nurse saved us all from making a terrible error. It isn’t every hospital where that nurse would have felt confident speaking up—but it’s this sort of cultural factor that is so important to safety.

98,000 Annual deaths from medical errors in the U.S. Source: Institute of Medicine

If anyone knows whether a hospital is safe, it’s the people who work there. So my colleagues and I at Johns Hopkins, led by J. Bryan Sexton, administered an anonymous survey of doctors, nurses, technicians and other employees at 60 U.S. hospitals. We found that at one-third of them, most employees believed the teamwork was bad. These aren’t hospitals where you or I want to receive care or see our family members receive care. At other hospitals, by contrast, an impressive 99% of the staff reported good teamwork.

These results correlated strongly with infection rates and patient outcomes. Good teamwork meant safer care. The public needs to have access to such information for every hospital in America.

Cameras

It may come as a surprise to patients, but doctors aren’t very good at complying with well-established best practices in their fields. One New England Journal of Medicine study found that only half of all care follows evidence-based guidelines when applicable. Fortunately, there is a technology that could work wonders to improve compliance: cameras.

CorbisYou wouldn’t believe the number of patients who have told me their deciding factor in choosing a hospital was parking.

Cameras are already being used in health care, but usually no video is made. Reviewing tapes of cardiac catheterizations, arthroscopic surgery and other procedures could be used for peer-based quality improvement. Video would also serve as a more substantive record for future doctors. The notes in a patient’s chart are often short, and they can’t capture a procedure the way a video can.

Doug Rex of Indiana University—one of the most respected gastroenterologists in the world—decided to use video recording to check the thoroughness of colonoscopies being performed by doctors in his practice. A thorough colonoscopy requires meticulous scrutiny of every nook and cranny of the colon. Doctors tend to rush through them; as a result, many cancers and precancerous polyps are missed and manifest years later—at later stages.

Without telling his partners, Dr. Rex began reviewing videotapes of their procedures, measuring the time and assigning a quality score. After assessing 100 procedures, he announced to his partners that he would be timing and scoring the videos of their future procedures (even though he had already been doing this). Overnight, things changed radically. The average length of the procedures increased by 50%, and the quality scores by 30%. The doctors performed better when they knew someone was checking their work.

• The same sort of intervention has been used for hand washing. A few years ago, Long Island’s North Shore University Hospital had a dismal compliance rate with hand washing—under 10%. After installing cameras at hand-washing stations, compliance rose to over 90% and stayed there.
• Following Dr. Rex’s camera study, he did a follow-up, asking patients if they would like a copy of their procedure video. An overwhelming 81% said yes, and 64% were willing to pay for it. Patients are hungry for transparency.

Open Notes 

Sue, a young accountant, came to my office complaining of abdominal pain. She wasn’t sure what was causing it. She offered various theories: “Could this be from my Bikram yoga?” “Did my late-night ice cream cause the pain?” “Does having unprotected sex have anything to do with it?” Throughout her visit, I took notes. When we were done, she looked down at them suspiciously.

“What did you write about me?” she asked.

She was concerned that I thought she was either nuts or an ice-cream addict. In the course of our conversation, I also learned that she wasn’t quite sure why I was recommending an ultrasound, though I thought I had told her.

I decided to start dictating my notes with the patient listening in at the end of his or her visit. “I also have high blood pressure,” was a correction one older patient blurted out. Another said, “My prior surgery was actually on the right, not the left side.” Another patient interrupted me and said, “No, I said I take 20 milligrams, not 25 milligrams, of Lipitor.” Being able to review your doctor’s notes in writing might be even better than my method, particularly if you could add your own comments, perhaps via the Web.

Harvard doctor-researchers Jan Walker and Tom Delbanco are using “open notes” at Harvard and Beth Israel Hospital in Boston, and my hometown hospital, Geisinger Medical Center in Pennsylvania, has begun giving patients online access to their doctors’ notes. So far, both patients and doctors love it.

No More Gagging

Though there are many signs that health care is moving toward increased transparency, there is also some movement backward. Increasingly, patients checking in to see doctors are being asked to sign a gag order, promising never to say anything negative about their physician online or elsewhere. In addition, if you are the victim of a medical mistake, hospital lawyers will make never speaking publicly about your injury a condition of any settlement.

We need more open dialogue about medical mistakes, not less. It wouldn’t be going too far to suggest that these types of gag orders should be banned by law. They are utterly contrary to a patient’s right to know and to the concept of learning from our errors.

Political partisans can debate the role of government in fixing health care, but for either public or private approaches to work, transparency is the crucial prerequisite. To make transparency effective, government must play a role in making fair and accurate reports available to the public. In doing so, it will unleash the power of the free market as patients are better able to take charge of their own care. When hospitals have to compete on measures of safety, all of them will improve how they serve their patients.

Transparency can also help to restore the public’s trust. Many Americans feel that medicine has become an increasingly secretive, even arrogant, industry. With more transparency—and the accountability that it brings—we can address the cost crisis, deliver safer care and improve how we are seen by the communities we serve. To do no harm going forward, we must be able to learn from the harm we have already done.

—Dr. Makary, a surgeon at Johns Hopkins Hospital and a developer of the surgical checklists adopted by the World Health Organization, is the author of “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” published this month by Bloomsbury Press.A version of this article appeared September 22, 2012, on page C1 in the U.S. edition of The Wall Street Journal, with the headline: How to StopHospitals From Killing Us.

Andrea Silenzi, MD, MPH, PhD

Roma, 1 ago. (Adnkronos Salute) – Più che di un ‘mercoledì da leoni’ si può parlare di ‘mercoledì nero’: oggi in Gran Bretagna è il primo giorno in corsia per 7 mila giovani medici specializzandi. Un giorno ‘nefasto’ per i pazienti ricoverati, tanto da spingere gli inglesi a ribattezzarlo ‘Black Wednesday’. Secondo una ricerca, nell’esordio sul campo dei giovani camici bianchi si registra infatti un aumento del 6% del tasso di mortalità tra i pazienti ricoverati.

Un dato allarmante che ha spinto i responsabili del servizio sanitario britannico a prendere delle contromisure ed evitare una nuova ‘killing season’: per i primi 4 giorni, già da quest’anno, gli specializzandi saranno seguiti passo passo da un collega più anziano, nel tentativo di ridurre il numero degli errori e garantire più sicurezza ai pazienti. Una soluzione che ha raccolto consensi, ma anche qualche critica. Per Gayna Hart, amministratore delegato di Quicksilva, una società privata…

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Hospital Rankings Get Serious @ashishkjha @Atul_Gawande @drsilenzi

Le “classifiche” degli ospedali diventano una cosa seria. Straordinario post  di Ashish Jha sul suo blog “An Ounce of Evidence”. Medico, ricercatore di politica sanitaria, Ashish Jha sostiene il concetto che un’oncia di dati vale molto di più di migliaia di libbre di opinioni.

Il post riporta i dati sulle “classifiche” degli ospedali da parte di tre organizzazioni: The Leapfrog Group; Consumer Reports; US News & World Report.

Metodologie diverse, risultati diversi!

Analisi molto approfondita e commenti immediati da parte di Consumer reports e The Leapfrog Group.

http://blogs.sph.harvard.edu/ashish-jha/

Anche in Italia il programma nazionale esiti di AGENAS  e la partecipazione di alcune Aziende Ospedaliero-Universitarie ( al momento Udine e Verona ) a Global Comparator di Dr Foster va nella giusta direzione.

Keynes blog

di Felice Roberto Pizzuti – da il manifesto

L’editoriale di Alberto Alesina e Francesco Giavazzi pubblicato sul Corriere della Sera di domenica scorsa con il titolo «C’era una volta lo stato sociale» ribadisce con chiarezza alcuni luoghi comuni conformi alla visione neoliberista la cui applicazione ha concretamente contribuito alla crisi globale; la loro convinta riproposizione è un segno della difficoltà di uscire da quella visione e dalle sue conseguenze (per timore che ciò possa accadere, in un precedente articolo Giavazzi ha proposto perfino che il Parlamento attuale blindi per la futura legislatura quanto già attuato della «Agenda Monti»!). Secondo i due economisti, il nostro sistema di welfare non è compatibile con la crescita, dunque dovrebbe essere «profondamente» ripensato affinché garantisca i suoi servizi solo alle classi meno abbienti e non anche alle classi medio-alte le quali, però, dovrebbero essere sgravate dai corrispondenti oneri fiscali e contributivi; in tal modo si…

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4 things every medical student should know about health policy @Medici_Manager

by ELISABETH ASKIN on July 18th, 2012in POLICY

http://www.kevinmd.com/blog/2012/07/4-medical-student-health-policy.html

When I first got interested in medicine, I also got interested in health policy. I was already out of college and so I decided to educate myself – not a bad discussion topic for med school interviews, after all – and found it much, much harder than expected. There were so many topics, so many opinions, and so little that seemed to connect up to give me the big picture. I had wanted a short, wide-reaching, neutral book and was surprised not to find one. Thus, a year and a half ago, I partnered with another medical student to write the book we wish we’d had.

In my journey from naïve pre-med then medical student and now to health care systems author, I’ve learned a lot about the American health care system, and wanted to share a few of the major points with you.

1. There is no American health care system. In fact, there are lots of them.  There’s the Department of Defense – a single payer, universal health care delivery system with employed providers similar to the UK.  There’s Medicare – a public insurance program that reimburses independent physicians and hospitals, similar to the system in Australia.  A big chunk of the population has no insurance at all – a situation usually found in the third world.  Then consider employer-sponsored insurance, Medicaid, individual markets, the Veterans Affairs system, HMOs, consumer-driven health plans, TRIcare, and a new system of government-subsidized health insurance exchanges.  We haven’t even started with the different arrangements seen in hospitals, clinics, physician groups, and with other health care providers.

This means that whenever anyone talks about “the American health care system” they are really talking about a mish-mash of systems that organically grew to meet our needs over time, not a planned organization. And keep in mind that any suggestions for reform must account for this decentralized mish-mash.

2. Figuring out the facts can be very tough. Anyone who has tried to search for physician salary averages has an inkling of what I mean here. Different sources give different numbers, and you’re left unsure of what to believe. As I researched topics for the book, I was surprised to find that there’s not just disagreement about what the facts mean, or how the facts should influence policy – there’s often disagreement about what the facts even are.

For example, we had a hard time ascertaining how Emergency Department (ED) usage has changed in Massachusetts when their health reform law was implemented in 2006. This was a major issue, since one of the commonly cited reasons for universal insurance is that it will reduce ED usage by uninsured patients, as these patients will (a) receive more preventive care, and (b) go to their primary care provider when sick instead of the ED. Question was: did this “common sense” view of behavior actually happen?

Well, it depends on the study. In the past year, one study said there was no change in ED usage, and another said there was a 3% decrease. The problem may be that we need to wait longer for the data to make more sense, but still – most people would be surprised that there is disagreement about what seems like it should be a simple count.  Issues like this arise in medicine and in health care all the time, and what should be cleared up by evidence continues as a debate about the issue and the evidence.

3. Comparisons can only go so far. Comparative effectiveness research pits treatments against each other to see which is more effective in treating patients. Whichever does better can then be used to form clinical practice guidelines that all doctors use to treat their patients. Sounds great, right? But what about if your patient is a 65 year old female with diabetes and cardiovascular disease, but the clinical practice guideline suggests a treatment that was tested mostly on men and women ages 40-60 who have never had cardiovascular problems? Does the same effectiveness apply?

And then there’s Pay For Performance (P4P), a recent innovation in how physicians are paid. Rather than paying a salary or a set fee for each procedure, P4P seeks to pay physicians a low base salary and then add bonuses for those providers whose patients are healthier or get healthier. Sounds great! Except how do you account for providers who see patients who are already sicker? Who are affected by poverty, or who won’t be active in their care, or who came to the doctor because none of the others she’d seen could help her and this one was supposed to be the best? Did that doctor really perform “worse” than her peers?

Then how about this. The USA clearly has some problems to fix in our health care system, yet countries like Germany and France have, by all measures, excellent health systems. Why not implement some of their systems here? Sounds great! But those countries have relatively more homogeneous populations, larger social welfare programs, denser environments, different medical education…and the list goes on. Point #2 shows us that even tiny details are important, and these are huge details. So how can we know that a program that works in France will work here, in a quite different context?

Comparisons may give us ideas, be illustrative, or seriously help guide policy and practice. But we should never assume they are equivalences, and we should always note the exceptions.

4. Everything is more complicated than you think. The above examples barely scratch the surface of the complications in learning about health care and how to make it better. Yes, it is frustrating to run into so many obstacles, to know so much yet know so little. The fact is that very little in health care isknown. The way forward is instead based on our best guess about what works. So my recommendation is to approach research, policy, and opinion with a healthy dose of questioning, skepticism, and eye for detail.  This will put you a step ahead of the game, and, hopefully make your best guesses a little better than the rest.

Elisabeth Askin is a medical student and co-author of The Health Care Handbook: A Clear and Concise Guide to the U.S. Health Care System, also available in paperback.  

It’s time for less research and more thinking @drsilenzi @trishgreenhalgh @muirgray

Less research is needed

By Trisha Greenhalgh http://blogs.plos.org/speakingofmedicine/2012/06/25/less-research-is-needed/

The most over-used and under-analyzed statement in the academic vocabulary is surely “more research is needed”.  These four words, occasionally justified when they appear as the last sentence in a Masters dissertation, are as often to be found as the coda for a mega-trial that consumed the lion’s share of a national research budget, or that of a Cochrane review which began with dozens or even hundreds of primary studies and progressively excluded most of them on the grounds that they were “methodologically flawed”. Yet however large the trial or however comprehensive the review, the answer always seems to lie just around the next empirical corner.

With due respect to all those who have used “more research is needed” to sum up months or years of their own work on a topic, this ultimate academic cliché is usually an indicator that serious scholarly thinking on the topic has ceased. It is almost never the only logical conclusion that can be drawn from a set of negative, ambiguous, incomplete or contradictory data.

Recall the classic cartoon sketch from your childhood. Kitty-cat, who seeks to trap little bird Tweety Pie, tries to fly through the air.  After a pregnant mid-air pause reflecting the cartoon laws of physics, he falls to the ground and lies with eyes askew and stars circling round his silly head, to the evident amusement of his prey. But next frame, we see Kitty-cat launching himself into the air from an even greater height.  “More attempts at flight are needed”, he implicitly concludes.

On my first day in (laboratory) research, I was told that if there is a genuine and important phenomenon to be detected, it will become evident after taking no more than six readings from the instrument.  If after ten readings, my supervisor warned, your data have not reached statistical significance, you should [a] ask a different question; [b] design a radically different study; or [c] change the assumptions on which your hypothesis was based.In health services research, we often seem to take the opposite view. We hold our assumptions to be self-evident. We consider our methodological hierarchy and quality criteria unassailable. And we define the research priorities of tomorrow by extrapolating uncritically from those of yesteryear.  Furthermore, this intellectual rigidity is formalized and ossified by research networks, funding bodies, publishers and the increasingly technocratic system of academic peer review.

Here is a quote from a typical genome-wide association study:

“Genome-wide association (GWA) studies on coronary artery disease (CAD) have been very successful, identifying a total of 32 susceptibility loci so far. Although these loci have provided valuable insights into the etiology of CAD, their cumulative effect explains surprisingly little of the total CAD heritability.”  [1]

The authors conclude that not only is more research needed into the genomic loci putatively linked to coronary artery disease, but that – precisely because the model they developed was so weak – further sets of variables (“genetic, epigenetic, transcriptomic, proteomic, metabolic and intermediate outcome variables”) should be added to it. By adding in more and more sets of variables, the authors suggest, we will progressively and substantially reduce the uncertainty about the multiple and complex gene-environment interactions that lead to coronary artery disease.

If the Kitty-cat analogy seems inappropriate to illustrate the flaws in this line of reasoning, let me offer another parallel. We predict tomorrow’s weather, more or less accurately, by measuring dynamic trends in today’s air temperature, wind speed, humidity, barometric pressure and a host of other meteorological variables. But when we try to predict what the weather will be next month, the accuracy of our prediction falls to little better than random. Perhaps we should spend huge sums of money on a more sophisticated weather-prediction model, incorporating the tides on the seas of Mars and the flutter of butterflies’ wings? Of course we shouldn’t. Not only would such a hyper-inclusive model fail to improve the accuracy of our predictive modeling, there are good statistical and operational reasons why it could well make it less accurate.

Whereas in the past, any observer could tell that an experiment had not ‘worked’, the knowledge generated by today’s multi-variable mega-studies remains opaque until months or years of analysis have rendered the findings – apparently at least – accessible and meaningful. This kind of research typically requires input from many vested interests: industry, policymakers, academic groupings and patient interest groups, all of whom have different reasons to invest hope in the outcome of the study. As Nic Brown has argued, debates around such complex and expensive research seem increasingly to be framed not by régimes of truth (what people know or claim to know) but by ‘régimes of hope’ (speculative predictions about what the world will be like once the desired knowledge is finally obtained). Lack of hard evidence to support the original hypothesis gets reframed as evidence that investment efforts need to be redoubled.[2] And so, instead of concluding that less research is needed, we collude with other interest groups to argue that tomorrow’s research investments should be pitched into precisely the same patch of long grass as yesterday’s.

Here are some intellectual fallacies based on the more-research-is-needed assumption (I am sure readers will use the comments box to add more examples).

1. Despite dozens of randomized controlled trials of self-efficacy training (the ‘expert patient’ intervention) in chronic illness, most people (especially those with low socio-economic status and/or low health literacy) still do not self-manage their condition effectively. Therefore we need more randomized trials of self-efficacy training.
2. Despite conflicting interpretations (based largely on the value attached to benefits versus those attached to harms) of the numerous large, population-wide breast cancer screening studies undertaken to date, we need more large, population-wide breast cancer screening studies.
3. Despite the almost complete absence of ‘complex interventions’ for which a clinically as well as statistically significant effect size has been demonstrated and which have proved both transferable and affordable in the real world, the randomized controlled trial of the ‘complex intervention’ (as defined, for example, by the UK Medical Research Council [3]) should remain the gold standard when researching complex psychological, social and organizational influences on health outcomes.
4. Despite consistent and repeated evidence that electronic patient record systems can be expensive, resource-hungry, failure-prone and unfit for purpose, we need more studies to ‘prove’ what we know to be the case: that replacing paper with technology will inevitably save money, improve health outcomes, assure safety and empower staff and patients.

Last year, Rodger Kessler and Russ Glasgow published a paper arguing for a ten-year moratorium on randomized controlled trials on the grounds that it was time to think smarter about the kind of research we need and the kind of study designs that are appropriate for different kinds of question.[4] I think we need to extend this moratorium substantially. For every paper that concludes “more research is needed”, funding for related studies should immediately cease until researchers can answer a question modeled on this one: “why should we continue to fund Kitty-cat’s attempts at flight”?

 

This blog was informed by contributions to my Twitter page @trishgreenhalgh

Trish Greenhalgh is Professor of Primary Health Care at Barts and the London School of Medicine and Dentistry, London, UK, and also a general practitioner in north London.

[1] Prins BP, Lagou V, Asselbergs FW, Snieder H, & Fu J (2012). Genetics of coronary artery disease: Genome-wide association studies and beyond. Atherosclerosis PMID: 22698794

[2] Brown N (2007). Shifting Tenses: Reconnecting Regimes of Truth and HopeConfigurations DOI: 10.1353/con.2007.0019

[3] Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M, & Medical Research Council Guidance (2008). Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ (Clinical research ed.), 337 PMID: 18824488

[4] Kessler R, & Glasgow RE (2011). A proposal to speed translation of healthcare research into practice: dramatic change is needed. American journal of preventive medicine, 40 (6), 637-44 PMID: 21565657

Characteristics of Lean Leaders @Lean_Academy @MarkGraban @Medici_Manager

by MARK GRABAN on AUGUST 30, 2012 http://www.leanblog.org/2012/08/characteristics-of-lean-leaders/?utm_source=dlvr.it&utm_medium=twitter

Ted Stiles is one of the handful of key recruiters I know in the world of Lean healthcare. Disclosure: I recently joined the advisory board for the firm Stiles & Associates, for which I receive a stipend. He was interviewed recently for Healthcare Finance News for this piece: “7 best qualities of healthcare’s lean leaders.”

In this post, I’ll list the seven qualities and give my own commentary… and you can read Ted’s thoughts on the HFN page. I’m also curious to hear your thoughts about these seven and others you would add.

1. Experience

This experience leading a Lean transformation can come from the manufacturing world or other service sectors… or, increasingly, it comes from within as executives move between healthcare organizations – such as Kathryn Correia leaving ThedaCare to be the CEO at a health system in Minnesota.

2. Process-oriented thinking

I agree with Ted’s point that you can’t be only oriented around results. Traditional leaders will say “get results at any cost and I don’t care how you get them”) while Lean leaders think “the right process will bring the right results.” But, you also need strategy and vision along with the rest of these traits below…

3. Ability to slow down

This applies to folks coming out of industry. I talked yesterday with a former Dell executive who is now working in a healthcare related company. Compared to the fast-paced “Dell Speed” world, he had to adjust his expectations a bit about how much you can accomplish in a given month or year (but he’s also trying to get them to move faster). Moving faster is about recognizing the “burning platform” and motivating people… creating a vision about what’s possible and arming them with that they need to get there.

Speeding up the pace of change might be necessary, given the challenges in healthcare, but there’s something to be said for the Lean saying “go slow to go fast.” Sometimes you can’t try to do it all overnight (as this Lean Meme states).

4. Brutal honesty

Maybe we need more honesty than brutality. We need to be able to speak openly and honestly about problems, waste, and challenges. ThedaCare refers to this as “candor with respect” — teaching people to be more honest (they already have respect down, since there’s a lot of “midwestern nice” going on there). One east coast hospital in the Healthcare Value Network with them said once “we’re good at candor, but need to work on respect.”

5. Exceptional relationship-building skills

I’ll just quote Ted here, from the HFN piece:

“Candidates in healthcare won’t lead with results, they’ll lead with relationship- and trust-building, which is really the only way to get physicians or high-ranking clinical leaders – even nurses on the frontline – to talk to you about what their hopes and fears are, or where they believe the biggest amount of improvement needs to be done,” said Stiles.

6. Motivational

Yes, Lean is about change. We need more than managers (people who can oversee an existing process), we also need leaders (people who can get others to move in a new direction or try new things). There’s so much pressure on healthcare to improve quality and cost… I think everybody realizes that by now. But, effective leaders help people see that change is possible, not just necessary.

7. Operational management experience

This is something that manufacturing leaders generally excel at and can bring to healthcare… if they can adapt to the softer side of a caring and relationship-driving industry. Leaders have to know how to get things done… and get the right things done.

What would you add to this list? Comments on the seven suggested by Ted Stiles and summarized in HFN?

About LeanBlog.org: Mark Graban is a consultant, author, andspeaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and the newly-released book Healthcare Kaizen. He is also the Chief Improvement Officer for the technology startup KaiNexus.

7 best qualities of healthcare’s lean leaders @HarvardSPH_ECPE @drsilenzi

Proponents of lean management argue that whether or not healthcare providers realize it yet, there is a major demand within their organizations for the model because, they will tell you, lean improves patient safety and reimbursement rates, and creates new standards around transparency. But getting healthcare organizations on the lean bandwagon takes leadership.

Healthcare Finance News talked to Ted Stiles, director of Stiles Associates, a lean-focused executive search firm, about lean management and leadership.

“In the manufacturing world, lean needs a ‘burning platform’ to motivate leadership in the middle of organizations to do something significant… and significantly different,” said Stiles. And healthcare is more than a burning platform – it’s a raging inferno.

Because of the value it returns to the patient, lean is experiencing a huge demand within the healthcare industry, Stiles said.

“One large organization I worked with, in five years, has seen financial results with lean leadership that were roughly worth over $100 million. The numbers are real. And the amount of opportunity is really kind of boundless at this point,” Stiles said.

But many healthcare organizations have departments that are not functioning at the level they need to. The fastest way to get a lean program highly operational is to bring in someone who’s been through multiple cycles of transformation before, Stiles said. Unlike quality initiatives where a person can receive a certificate saying they’ve passed some test now making them a qualified leader, lean is very experiential, he explained. The most effective classroom is in the environment itself, trying the work hands-on and accumulating scars because of it.

1. Experience
You need people leading this kind of work who’ve actually done it before. “You can’t be an effective lean leader by simply staying one chapter ahead of class. This mode has failed in other industries. Lean looks very basic and simple – but the magic is in the execution,” said Stiles. A qualified leader knows where pitfalls are and can help an organization navigate away from them. Transformational experience is critical.

2. Process-oriented thinking
The classic American industrial management theory is based on result-oriented thinking. Lean is the opposite. A good lean leader needs to be almost obsessive about processes – dismantling the techniques a healthcare organization uses to figure out if they’re the cleanest methods to deliver the highest level of value. If organizations can have faith in this style of thinking, results do happen over time.

3. Ability to slow down
Hospitals have much more red tape to go through than manufacturing companies, and sometimes they lack clarity and alignment, Stiles noted. “So people who are transferring from a different type of lean to healthcare lean need to realize that moving things forward can take much more time. There’s more listening and learning involved. Seeking to understand the complexity of the healthcare industry is integral before jumping in and changing the world,” Stiles said.

4. Brutal honesty
Lean work is hard. At its most basic level, deploying a successful lean program means people need to talk honestly about what they do well and what they don’t. Organizations need to be open about their shortcomings, too. In a lot of management cultures, the key to success is hiding or deflecting that. A good lean leader is going to push the organization to be more transparent. Once problems are visible then, and only then, can you dig in and fix whatever needs fixing.

5. Exceptional relationship-building skills
If you have someone that’s built a career in manufacturing on results, those skills won’t necessarily translate well into the healthcare space. “Candidates in healthcare won’t lead with results, they’ll lead with relationship- and trust-building, which is really the only way to get physicians or high-ranking clinical leaders – even nurses on the frontline – to talk to you about what their hopes and fears are, or where they believe the biggest amount of improvement needs to be done,” said Stiles.

6. Motivational
Lean is about change. It’s about pushing people out of their comfort zones. Lean leaders ask aggressive questions that challenge why things are done the way they are within an organization, especially when the topic of transparency arises. Lean leaders need to motivate people to be able to take that step out of their box. “If you can get someone who can tap into various different levels within organizations to find out what the hope is, what the optimism can be, that’s very powerful stuff,” Stiles said.

7. Operational management experience 
There needs to be some level of operational management thinking. That operations leadership piece is where you get into good sustainable, repeatable management systems, Stiles said. Setting up some kind of tracking board helps measure the right signals within key performance indicators (KPI), and once you develop that – you have those visual controls within a lean organization – you can begin the practice of daily “huddles” where leadership and other frontline supervisors can look at these boards to see whether the things that needed to happen happened. And if they didn’t, they can begin to spot any abnormalities developing where a process redesign is needed so that it can be attacked and rooted out with good cause analysis, nipping problems in the bud before it’s too late.

Steff Deschenes

New Media Producer for Healthcare Finance News

Changing health care delivery at academic medical centers @kevinmd @drsilenzi @agnescheer

by MICHAEL K. MAGILL, MD | in POLICY http://www.kevinmd.com/blog/2012/08/changing-health-care-delivery-academic-medical-centers.html

At academic medical centers (AMCs) all over the country, health care delivery and payment reform are becoming reality. AMCs need to think in a new way about the markets they serve. Timing for AMCs transforming care delivery is critical. We need to find the perfect middle ground, or what I like to call the “Goldilocks Factor.” AMCs need to transform delivery, definitely not too slowly, but not too fast for their markets either.  And finding “just fast enough” is not easy.

The services we provide are, now more than ever, about comprehensive care and population management to achieve the “Triple Aim” of improved quality, improved health, and controlled cost.  Primary care is key to successful care of defined populations under payment models such as Patient Centered Medical Homes, capitation, and shared savings. But some highly subspecialized services will likely remain fee-for-service, at least for a time and maybe indefinitely, while value-based payment covers increasing fractions of AMCs’ total care.

We have to learn how to balance managing population risk and health along with continuing  to provide subspecialized care paid fee-for-service. If we reduce utilization of subspecialized care by populations quickly without replacing this fee-for-service volume, we will reduce our revenues and get in financial trouble.

If we are too slow and do not learn how to manage market risk, and then the market changes abruptly to heavily risk-based contracting, we won’t be ready for it and will get in financial trouble.

We have to build comprehensive care for populations while reaching regional or even national markets to “backfill” subspecialized care that will decrease for defined local populations. This will require competing to provide these services on the basis of cost, quality and patient satisfaction.  So, just like the porridge in “Goldilocks and the Three Bears,” we have to be just right.

At the University of Utah School of Medicine, we have been working to redesign primary care delivery to improve efficiency and quality and lead us to the care model that is just right for our patients. Our primary care system includes eight production-oriented clinics in various neighborhoods and communities of northern Utah plus two teaching sites for family medicine faculty and residents. The clinics together deliver about 1/4 of all outpatient visits provided by University of Utah Health Care.

One of our initiatives, the University of Utah Community Clinics’ patient centered medical home model, “Care by Design,” has had substantial success in implementing a team-based model of care that increased the ratio of medical assistants (MAs) per provider to 4-5:2 with expanded MA roles, enhanced access, and prospective care management for chronic conditions and prevention.

We had to find a way to balance the two sides of the equation. The primary care and specialty sides must work together to provide quality care at a controlled cost. Investment in primary care builds institutional capability for population management.  Investment in controlling utilization and cost of fee-for-service specialty care prepares the organization to compete in a transformed payment environment. AMCs should become “medical neighborhoods,” incorporating advanced medical homes and a continuum of coordinated services including highly subspecialized care.

For the future of academic medicine, we need to think about what services to provide defined local and regional populations, and what services to provide patients who may travel from surrounding states or beyond. Going forward, everyone is going to have to diversify their care delivery methods and explore new opportunities not just to stabilize revenue and reduce costs, but to improve patient experience and health of populations, while also supporting the full range of academic missions of the AHC. It will not come overnight, and it will take work, but we will eventually find our “just right” bowl of porridge.

Michael K. Magill is Chairman, Department of Family and Preventive Medicine, University of Utah School of Medicine.  He blogs at Wing of Zock.

Learning from European and U.S. health care. @HealthyDebate @muirgray@drsilenzi

By Jason Sutherland & Nadya Repin –JULY 24, 2012

TAGS: ABF, Activity Based Funding, HBAM, Hospital Funding

http://healthydebate.ca/opinions/learning-from-european-and-u-s-health-care-2

There’s been a seismic shift in health policy taking place in Canada that has been largely ignored by the mainstream media and gone unnoticed by the general public.  Provinces are starting to change the way they fund hospitals.  This is no small change and will directly affect the care patients receive — potentially improving access to hospital care.

Ontario and British Columbia, for example, have announced initiatives to fund hospitals partially based on the services they provide and the characteristics of the patients they treat.  It seems intuitive to pay hospitals for what they do, but our rural-urban divide, how we arrange specialty care in big cities, and limits to the amount we want to spend on hospital care, complicate the issue.

Under the current ‘global budget’ approach used in all provinces, hospitals receive a fixed funding amount, regardless of the types of patients they treat.  The value of this approach is the power to restrain growth in hospital spending.

So what’s the problem?  In a word, inertia.

Since exceeding budgets is penalized in the traditional hospital funding model, hospitals typically avoid adding services that may increase costs, which means hospitals don’t aggressively attack wait times for fear of running up a deficit.

The belief was that, in order to improve care and reduce wait times, we needed to increase staff and hospital beds.  This is the most expensive option and such a move would empty provincial coffers quickly.

It’s also unnecessary.

We now have good data that indicates we are not using our current hospital beds effectively.  We have too many patients in beds that can be safely discharged home — in some regions, above 15% of beds are currently occupied by those who no longer need to be in hospital — translating into thousands of “extra” hospital beds.

The changes to hospital funding in Ontario and B.C. tackle inertia head-on and employ approaches used around the world.  Known as activity-based funding (ABF), hospitals are paid for the kind of care they deliver and the complexity of the patients that are cared for.  This approach is ‘equal pay for equal work,’ and creates incentives for hospitals to discharge patients more quickly, since new patients generate additional revenue for the hospitals.

There are legitimate concerns among stakeholders that under the ABF model patients will be discharged “quicker and sicker.”

This particular phrase was borrowed from early evaluations in the U.S. that indicated that elderly patients were discharged sooner under the ABF model.  The same concerns are now echoing across the Canadian health care landscape in response to ABF policies in Ontario and B.C.

First, do the financial incentives of ABF shorten patient hospital stays?  While not all patients stay a shorter time in hospital under this system, there is good evidence from many countries that, on average, the duration of hospitalization shortens.  This results in more patients treated per bed and improved access to hospital care.  A panel study of 28 countries that moved from global budgets toABF reported a reduction of 3.5% in average length of hospital stay.

The evidence regarding the effectiveness of ABF is consistent — health systems that implementABF for hospital funding tend to experience shorter lengths of stay which lowers wait times in the system.

That’s ‘quicker,’ but what about ‘sicker’?

A criticism leveled against ABF is that it creates incentives for hospitals to shorten lengths of stays to the point where patients’ safety and quality of care are jeopardized.  In other words, patients being discharged from hospital before they are healthy enough to go home.

Canada, as a late-comer to this type of hospital funding, can learn from the evidence from other countries that have adopted similar policies.  Evidence from the U.S. indicates patients in ABFhospitals are discharged in less stable condition, but that processes of care have improved and mortality rates are unaffected.

Findings from the U.K. and other European countries are more positive: there is no association with increased mortality in the ABF model, and even some reports of lower mortality.  Recent work is even suggesting that ABF may encourage hospitals to provide higher quality care to reduce costly complications or readmissions.

So, while some patients are discharged earlier and possibly in less stable condition, patients do not appear to return to hospital more often (readmissions) or die prematurely.

“Quicker,” yes, but “not sicker.”

Hospitals provide the most expensive type of care in our health system and are hungry for new sources of funding.  While this change is one successfully used elsewhere to expand access, in Canada we will still have to make sure that quality of care doesn’t suffer — nor should priority access be granted to ‘profitable’ patients.

Other provinces are vigilantly watching the experiments in Ontario and B.C.  It’s been decades since the status quo has been challenged.  If access improves, quality is unaffected, and cost growth is moderate, other provinces will surely be tempted to follow a similar path.

Jason M. Sutherland is an Assistant Professor at the Centre for Health Services and Policy Research, University of British Columbia.

Nadya Repin is a research coordinator with the Centre for Health Services and Policy Research, UBC.

This guest post is provided courtesy of the EvidenceNetwork.ca and is reproduced under a CreativeCommons Attribution No-Derivatives license.

Dieta di Stato. Un altro punto di vista – di Vincenzo Atella su @chicago_blog @Medici_Manager

Il decreto sulla Sanità appena approvato dal Consiglio dei Ministri, ha rianimato non poco la discussione sulla capacità di questo governo di fare riforme e di farle in modo oculato. Le tante critiche che che sono piovute dapprima sulla bozza di decreto e che, forse, continueranno sul decreto stesso con le più diverse motivazioni lasciano aperto qualche dubbio. Provando a raggruppare le opinioni espresse, si può dire che esistono due gruppi: uno che contesta lo Stato paternalista ed etico, ed è irriducibile nel difendere la libertà dell’individuo; un secondo che non contesta lo Stato paternalista, ma contesta il modo come si cercava di intervenire (via tasse). In quel che segue proverò prima a ragionare sui motivi per cui sia giusto o sbagliato che lo Stato intervenga in tali contesti e poi mi concentrerò sugli aspetti, più tecnici, di come sia meglio intervenire e cosa si è fatto di simile all’estero.

Le ragioni dell’intervento dello Stato

Secondo Montesquieu (1750), “Nello stato di natura, gli uomini nascono, è vero, nell’eguaglianza, ma non potrebbero rimanervi. La società gliela fa perdere, ed essi non ridiventano uguali se non in grazia alle leggi.” Si suggerisce quindi che l’unico modo con il quale è possibile ripristinare livelli di eguaglianza tra i cittadini è attraverso l’imposizione di leggi e, quindi, l’intervento di uno Stato morale e paternalista. Trasportando il concetto di eguaglianza al nostro caso, è possibile dire che l’equità nella salute impone che tutti gli individui, una volta nati, abbiano uguali opportunità di migliorare e mantenere il loro livello di salute. Se queste opportunità vengono per qualche motivo a mancare è necessario imporre correttivi attraverso l’uso delle leggi. Questi principi sono stati sostenuti dal premio Nobel Amartya Sen (1999), il quale ritiene che evitare le patologie che possono essere prevenute sia strumentale per godere in pieno della libertà. Prima di lui anche Nussbaum (1992) aveva sviluppato il concetto di “capability to function”, secondo cui le società “giuste” erano quelle che riuscivano meglio a dare ai propri cittadini alcune capacità funzionali di base, tra cui “…quella di riuscire a vivere fino alla fine della loro vita, quanto più in là possibile, senza morire prematuramente . . .godere di un buono stato di salute; essere adeguatamente nutrito; ricevere protezione…”. Anche l’Organizzazione Mondiale della Sanità (OMS) ha adottato questi principi.

Ovviamente, esistono teorie fondate su valide motivazioni filosofiche che contestano l’intervento dello Stato (Nozick), sostenendo che se le disparità dipendono dalle libere scelte di individui liberi, lo Stato non ha alcun diritto di intervenire. Il vero problema è capire se e fino a che punto la scelta possa essere veramente libera e non condizionata dall’ambiente esterno. Pertanto, ritengo esistano forti e fondate ragioni di tipo filosofico e sociale che giustificano l’intervento dello Stato in un settore come quello della salute, al fine di ridurre le disparità che la società crea.

Come lo Stato deve intervenire

Su questo secondo punto ritengo ci sia molta meno chiarezza, sia tra i commentatori che tra gli addetti ai lavori. Nel caso specifico del decreto, sono stati utilizzati diversi strumenti: le tasse per le bevande zuccherate (poi abolite), i divieti per il video poker, disincentivi (multe) per i tabaccai che vendono sigarette ai minori, e maggiori informazioni per il trattamento di cibi quale pesce e sushi. L’idea di fondo è che esistono strumenti diversi per raggiungere obiettivi diversi, ed è giusto operare secondo questa logica.

L’intervento che aveva fatto maggiormente discutere è stato, però, quello dell’introduzione della tassazione delle bevande zuccherate, successivamente  cancellato. In buona sostanza, si metteva in evidenza come l’intervento avrebbe fatto fare solo “cassa” allo Stato senza alterare gli stili di vita degli italiani, sostenendo che la politica fiscale non è adatta per questo tipo di interventi. Esiste, invece, un’ampia letteratura sull’argomento, legata principalmente ai paesi nordici e anglosassoni (sicuramente più liberali del nostro!). Tale letteratura è stata di recente sintetizzata in un articolo pubblicato sul Bollettino del WHO (Thow et al, 2010). Il risultato che ne è venuto fuori è che, sebbene le politiche fiscali possano avere effetti potenziali sui cambiamenti delle abitudini alimentari degli individui, le evidenze a oggi disponibili non permettono di trarre delle conclusioni definitive sull’argomento. Si potrebbe quindi concludere che era buona l’intenzione (ridurre il consumo di zuccheri elaborati), ma sbagliato lo strumento.

Conclusione

Le conclusioni penso siano abbastanza facili da trarre (almeno dal mio personale punto di vista!). Innanzitutto, lo Stato può e deve intervenire se è necessario ripristinare alcune condizioni di base per garantire l’equità nella società: il totale laissez faire in questo settore può essere devastante per la società nel suo complesso. Poter intervenire impone, però, sapere in che modo funziona il sistema per evitare di aggravare la situazione con interventi poco mirati.

Ma come spesso succede nella vita e nella politica italiana, piuttosto che aggiustare di poco il tiro per migliorare le cose, si preferisce sparare a zero chiedendo che lo Stato si faccia indietro e non intervenga. Nulla di più sbagliato: lo dimostrano i successi di tante campagne di prevenzione che faticosamente si stanno portando avanti in Italia, ma i cui effetti in termini di mortalità si vedono solo negli anni (si pensi al cardiovascolare e all’oncologia). E lo dicono soprattutto gli interventi fatti in passato (molto limitanti della libertà individuale!) quali la legge sul fumo nei luoghi pubblici, l’obbligo di vaccinazione (il vaiolo è stato debellato con le vaccinazioni non con la libera iniziativa dei singoli; la poliomielite è sparita con le vaccinazioni obbligatorie), l’obbligo delle cinture di sicurezza e via dicendo. In assenza di questi interventi “coercitivi” oggi, sicuramente, saremmo in presenza di tassi di mortalità più elevati (e anche di costi sanitari più elevati). E, tornando alla tassa sulle bevande zuccherate, se qualcuno lo avesse dimenticato, l’obesità è considerata dall’OMS una “pandemia” a livello mondiale. L’Italia non è esente da questo problema: abbiamo i tassi di obesità infantile più alti d’Europa. In alcune regioni del Sud i tassi di obesità e sovrappeso dei bambini di età inferiore a 15 anni è pari a circa il 50% (vedere i dati dello Studio PASSI del ISS). Inoltre, un obeso costa più del doppio di un normopeso in termini di cure sanitarie.

Non è necessario attendere di arrivare ai tassi di obesità americani per rendersi conto che occorre trovare una soluzione al problema. A quel punto sarà troppo tardi, meglio agire subito. Ma questo forse è il vero problema: i tempi della sanità (e della salute) non coincidono con i tempi della politica: i primi sono lunghi, i secondi molto corti…a meno di non trovare dei nuovi statisti che possano sostituire i nostri politicanti miopi.

Vincenzo Atella
Dipartimento di Economia e Finanza, Università di Roma Tor Vergata
CHP – PCOR Stanford University
Fondazione Farmafactoring

Braveman P.A., et al., Health Disparities and Health Equity: The Issue Is Justice, 101 Environmental Justice S149 (2011) (citing U.N. Committee on Economic, Social and Cultural Rights (CESCR), General comment No. 20: Nondiscrimination in economic, social and cultural rights, E/C.12/GC/20 (July 2, 2009), available at:http://www2.ohchr.org/english/bodies/cescr/comments.htm

Marmot M., Achieving Health Equity: From Root Causes To Fair Outcomes, 370 LANCET 1153, 1154 (2007).

Montesquieu C, Lo spirito delle leggi, Libro VIII, Sez. 3 (1750), Trad. di Beatrice Boffito Serra, 1967, Milano, Rizzoli disponibile su http://www.montesquieu.it/biblioteca/Testi/Spirito_leggi_1967.pdf

Nussbaum M.C., Human Functioning and Social Justice: In Defense of Aristotelian Essentialism, 20 POL. THEORY 2, 221-222 (1992).

Sen A., Development as freedom, pp. 36-37 (1999).

Thow A., Jan S., Leeder S. and B. Swinburn, The effect of fiscal policy on diet, obesity and chronic disease: a systematic review. Bull World Health Organ. 2010 Aug 1; 88(8):609-14. Epub 2010 Feb 22.

WHO, Fifty-second World Health Assembly, Health in Development, Keynote Address by Professor Amartya Sen, A52/DIV/9 (May 18, 1999) available at http://apps.who.int/gb/archive/pdf_files/WHA52/ewd9.pdf

http://www.chicago-blog.it/2012/09/07/dieta-di-stato-un-altro-punto-di-vista-di-vincenzo-atella/

Live & Learn

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↓ click for audio (“Woods” by George Winston From His Album “Autumn“)

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Sources & Credits for these shares (and many other autumn photos) can be accessed with a Tumblr account @ dkfalllights. Thank you Rob Firchau @ The Hammock Papers for the music inspiration.

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Quei miti andati in frantumi @Medici_Manager @mariocalabresi

Lucida analisi di Calabresi su La Stampa

Tre certezze ci hanno guidato in questi ultimi anni dominati dal malgoverno e dalla corruzione, erano tre pilastri su cui abbiamo pensato fosse possibile costruire una politica nuova: prima di tutto il federalismo, con la dote della maggiore vicinanza degli eletti agli elettori che rende possibile un controllo più serrato, poi il ricambio generazionale, con l’ingresso di giovani e volti nuovi non compromessi, infine una nuova legge elettorale per restituire il potere di scelta ai cittadini, con l’auspicato ritorno delle preferenze.Gli scandali delle ultime settimane e, in particolare, quest’ultimo della Regione Lazio, sbriciolano queste certezze, mostrandoci come federalismo, giovani e preferenze non garantiscano di per sé alcuna redenzione del sistema se non preceduti da una riforma dei meccanismi della politica che metta al centro la trasparenza e il principio di responsabilità.Partiamo dal federalismo: senza controlli, senza procedure chiare e facilmente verificabili, sprechi e scandali proliferano al centro come in periferia, sono possibili nel Parlamento nazionale come in un Consiglio comunale. Se non ci sono meccanismi di vigilanza e sanzioni immediate e certe non fa differenza che i centri decisionali siano accanto a casa nostra o a centinaia di chilometri di distanza. E i privilegi non abitano solo a Montecitorio ma possono essere anche locali, basti sapere che il caffè al bar interno del Consiglio regionale del Lazio costa solo 45 centesimi (un panino un euro…) contro gli 80 di Camera e Senato. Allo stesso modo se il sistema permette di arricchirsi e di fare la bella vita con i soldi pubblici allora ne saranno attratti i furbi e i gaglioffi di ogni età. Avete guardato le biografie dei personaggi coinvolti nel banchetto laziale? È pieno di facce giovani e pulite, baldanzosi trentenni che hanno immediatamente preso il vizio di usare le tasse dei cittadini per pagare servizi fotografici, interviste televisive, automobili, pranzi e cene. Forse anche inebriati dalle cifre senza senso che vengono garantite ai consiglieri regionali (Francesco Fiorito, ormai famoso alle cronache come «er Batman di Anagni», ha spiegato ai magistrati di guadagnare 30 mila euro al mese sommando le indennità regionali, più di Napolitano e Monti messi insieme). Essere giovani non significa necessariamente essere onesti e il ricambio generazionale ha un senso solo se la casa viene ripulita prima di dare ospitalità a nuovi occupanti e se questi mostrano di essere fatti di una pasta diversa. Per scoraggiare approfittatori e sciacalli in cerca di scorciatoie verso la ricchezza basterebbe ridurre drasticamente stipendi e indennità così da spingere in politica chi ha a cuore la cosa pubblica più di chi ha a cuore il proprio portafoglio. Veniamo infine alla legge elettorale: Fiorito, così come l’esponente romano del Pdl Samuele Piccolo coinvolto in un altro scandalo di fatture false poche settimane fa, erano campioni assoluti delle preferenze, candidati capaci di accaparrarsene decine di migliaia proprio grazie ad un uso disinvolto dei fondi pubblici o a macchine elettorali costruite con metodi poco raccomandabili. Vent’anni fa le preferenze vennero abolite, grazie a un referendum, proprio perché erano volàno di malaffare (oltre a far lievitare in modo astronomico i costi della politica), stiamo attenti oggi a non illuderci che rimetterle significhi eleggere i migliori. Ai cittadini va garantito il diritto di scelta ma questo si può ben fare anche con i collegi uninominali dove a sfidarsi sono i candidati dei vari partiti, auspicabilmente scelti con il meccanismo delle primarie. Perché il sistema funzioni è però necessario che non solo i cittadini ma anche l’informazione svolga il suo ruolo di controllore, di «cane da guardia» del potere. Se però scopriamo che in molte realtà locali i politici hanno l’usanza di fare veri e propri contratti con le televisioni, versando migliaia di euro in cambio di interviste, allora si capisce che il meccanismo di controllo non esiste più. Il ricambio italiano nasce da un’assunzione di responsabilità individuale che deve coinvolgere tutti, politici, giornalisti, insegnanti, imprenditori e semplici elettori, perché ognuno deve imparare a mettere davanti l’interesse generale, a pretendere senso di responsabilità ma anche a essere responsabile. MARIO CALABRESI http://www.lastampa.it/_web/cmstp/tmplRubriche/editoriali/gEditoriali.asp?ID_blog=25&ID_articolo=10553&utm_source=Twitter&utm_medium=&utm_campaign=

Super Mario to the Rescue @Medici_Manager

By ROGER COHEN Published: September 10, 2012 http://www.nytimes.com/2012/09/11/opinion/super-mario-to-the-rescue.html

Germany’s Mannschaft has always been a formidable soccer team. Its chief quality has been a tenacity and tempo capable of overcoming all odds. This is not to say that Germany has failed to produce great footballers — Gerd Müller, Karl-Heinz Rummenigge and Franz Beckenbauer come to mind. It is merely to say collective power has trumped individual prowess.

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David Smith

Mario Draghi, president of the European Central Bank.

Damon Winter/The New York Times Roger Cohen

But against one team Germany always breaks down as if caught in a web. It pushes, it presses, it pounds — and it flounders. That team is Italy, whose 2-1 victory over the favored German side in this year’s European Championship extended a long run of major-tournament domination over Germany. Italian malleability and artistry are too much for German diktat.

All of this comes to mind as I watch Super Mario undo Germany with a series of feints that have left hardline Bundesbank bruisers looking as nimble and effective as beached whales. (With a battle cry of “You will not short me!” Super Mario has also gone mano-a-mano with the hedgies betting against the euro, but that is another story.)

Little by little, Mario Draghi, the Italian president of the European Central Bank, has taken an institution whose overriding mission was to keep inflation in check — the obsession that built the Deutsche Mark — and turned it into a lender of last resort prepared to throw everything into buying the distressed euro-zone sovereign debt of countries like Spain and Italy and so preserve the euro. “Whatever it takes,” Draghi says. He means it.

Many Germans are not happy, convinced an inflationary southern rot is setting in, but Draghi is right. Europe is irreversible; for that, at this point, the euro must be, too. The preamble to the U.S. Constitution speaks of “a more perfect union.” The founding European treaties speak of “ever closer union.” For neither has the road to union been devoid of battles between north and south. But the cause has been worth the fight on both sides of the Atlantic: There simply is no greater one. For Europe the approaching centennial of the outbreak of World War I should be sufficient reminder of that.

But people have short memories. They think the euro is a dispensable experiment, a technical construct or a hedgie’s plaything, when it is the solemn gage of German commitment to a united Europe — a project that, like most great undertakings, comes at a price.

For both Germany and Italy, the European Union was a way out of post-war devastation and shame. For Italy, in addition, it was a way “to scale the Alps,” to tie itself to the more developed parts of Europe and resist the chaotic tug of its southern half. Now a united Germany views Europe more as actuary than supplicant. In Italy, by contrast, a certain European idealism endures. One way to view Draghi’s battle with Jens Weidmann and the Bundesbank is this: A big idea (Europe) versus a smaller one (price stability).

But what good is a Europe where the treaty-stipulated role of the central bank is being finessed by Super Mario, where Germany becomes the permanent subsidizer of debtor nations like Spain and Italy, and where depression and unemployment become the enduring lot of poorer countries unable to regain competitiveness through devaluation?

The answer is that this is not a good Europe. The immediate future will be very tough, but it is a lot better than the tumultuous alternative of Europe’s unraveling; and in this crisis the seeds of ever greater European integration are being sown. (If the E.C.B. is now the Fed, what must the European Union become?) The euro was a hasty marriage precipitated by the end of the Cold War, the quid pro quo of Germany’s anxious neighbors for its unification. This crisis is a belated post-bubble reckoning with the implications of that act.

And so the push is now on toward necessary conditions of a shared currency like fiscal union — Draghi’s unlimited purchase of bonds is conditioned on tough fiscal adjustment programs — and a banking union built around a new euro-zone supervisor. The path to both will be rough. Politicians’ interests are at stake. Economies are shrinking. But whatever the howls it is clear enough this far into the euro crisis that “ever closer union” is an obstinate idea that has entered the European consciousness, even if it goes unmentioned.

Certainly, it is present in Chancellor Angela Merkel’s mind. She lived under Communism in a Germany divided by the consequences of fascism and so knew the two great scourges of 20th-century Europe. Slowly, cautiously, falteringly she has moved in the right direction and deserves credit.

Draghi the Jesuit has helped her, with his elliptical phrases and very Italian capacity to zigzag to the objective. It is tempting to compare him to Alexander Hamilton at the time of the U.S. assumption crisis. But I prefer to see him as Andrea Pirlo, the Italian midfielder with 360-degree vision, never hurried, always assured, master of the short and the long pass, bane of Germany, a fantasist who hits the target with precision.

You can follow Roger Cohen on Twitter at twitter.com/nytimescohen , and on Facebook at facebook.com/RogerCohenReporter .

 

 

Lean management improves employee satisfaction @Qualityworld @drsilenzi

July 6, 2012 | By Karen M. Cheung http://www.fiercehealthcare.com/story/lean-management-improves-employee-satisfaction/2012-07-06

In the first independent comparative study of 13 Lean projects, staff at all levels reported higher employee satisfaction at every institution, citing better front-line staff involvement in problem-solving and employee collaboration, according to the Agency for Healthcare Research and Quality.

However, some staff didn’t fully embrace Lean initiatives–the management approach rooted in quality efficiency–at their institutions, according to a column in Hospitals & Health Networks. Some employees noted they were frustrated that committing time to Lean and working with other departments took away from their regular duties.

“Physicians can be reticent to implement Six Sigma because the methodology has been incorrectly associated with huge resource output, their time specifically,” Marti Beltz, Six Sigma instructor for American Society for Quality and healthcare quality consultant, told FierceHealthcare in a previous interview.

But as Charles Hagood, president and founder of Healthcare Performance Partners, explained to FierceHealthcare, “If Lean Six Sigma is deployed correctly, [physicians] will see the value and will want to become a part of the equation.” He suggested carefully presenting the Lean Six Sigma approach rather than cramming it down, and physicians will come around in the long term and see its value.

Although healthcare leaders committed to Lean management as a way to boost quality and efficiency, none paid much attention to the implementation costs after adoption, Steven Garfinkel, managing director of the American Institutes for Research in Chapel Hill, N.C., wrote in the H&HN column.

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Sign up for our FREE newsletter for more news like this sent to your inbox!“We cannot be sure that Lean is more effective than other process improvement techniques,” he said.

Nevertheless, healthcare organizations can adapt the model successfully. For instance, one hospital conducted rapid process improvements to assess door -to-balloon time, a quality measure for treating heart attack patients. After emergency department staff and the catheterization lab met to find out why delays occurred, they concluded one reason was that a technician had to travel from home to set up the cath lab during night shifts. Instead, ED nurses and technicians then set up right after confirming a patient have ST segment elevation myocardial infarction. The result: Door-to-balloon time dropped from 89 minutes to 77.

For more information:
– read the H&HN column

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