Archivi del mese: dicembre 2012

@Richard56 We need more doctor entrepreneurs @Medici_Manager

Richard Smith

The NHS, UK PLC, and the wider world will all benefit if we have more doctor entrepreneurs willing to take risks and start up companies. Starting up a company can be exhilarating, but it’s also complex and exhausting.Healthbox has been founded to help health start ups, and last week it’s managing director, Nick Rosa, offered extremely useful advice to those bold enough to start a company.

Rosa was a “corporate guy” who was among other things the chief executive officer ofNutraSweet and a senior manager at Monsanto. When he retired young (presumably having made a fortune) he didn’t know what to do and so started Sandbox, “a place where business creation and exploration could thrive.”

Sandbox flourished, and Rosa and colleagues started Healthbox, “a health accelerator company” that offers mentorship and support to those starting companies. Now Healthbox has come to Britain.   (I’m one of its unpaid mentors but missed the launch and haven’t yet mentored anybody.)

Wearing a roll neck black sweater, which is almost the uniform of entrepreneurs, Rosa illustrated how he has moved on from his corporate days by telling the story of being at a meeting of the senior managers of Monsanto discussing diversity—all white, middle aged men in country club that didn’t admit women or blacks. Pointing out the irony didn’t make him popular.

Rosa started by describing the “endemic flaws” of entrepreneurs: a bias against recognising serious difficulties; unrealistic optimism; limited management capabilities; and an inclination to incremental growth rather than big leaps. The first two, I couldn’t help thinking, are what allow entrepreneurs to keep going when failure is the most likely outcome.

To overcome these flaws entrepreneurs should ask the killer questions early. The killer question is “Why will this business fail?” By anticipating the likely causes of failure, you hope to avoid them—but there are many ways to fail. The challenge to entrepreneurs seems to have the conviction that you can succeed while simultaneously thinking why you might fail.

You need, said Rosa, 500 ideas to get a successful business. Keep a book of ideas, and think of your start up as a hypothesis. The hypothesis will keep evolving, and a failed hypothesis will lead to a new hypothesis. “Your business,” he said, “will fail, and you’ll need to move on.”

Perhaps the best—but hardest—advice that Rosa offered was “to celebrate failure.” Risk implies failure, and in Silicon Valley failure is a badge of honour. If you haven’t failed you haven’t taken a risk, and you can’t start a company without taking a risk and being willing to fail. American business culture celebrates failure in a way that British public life doesn’t—and that’s a big problem for entrepreneurs in Britain. It’s easier to climb the familiar hierarchy of British medicine than take the risk of starting a company.

As in any enterprise you should chose your partners carefully—be they staff, directors, or investors. One of the big questions for investors is “whether to bet on the horse or the jockey.” A study of a thousand start ups suggests the jockey: “a good team with a mediocre idea will beat a mediocre team with a good idea.” Rosa urged the entrepreneurs at the meeting to take time with boring things like job specifications, interview skills, and checking references. Many start ups (and I can think of one) have gone bust because they “fell in love” with a candidate for a job and didn’t check references.

An investor himself, Rosa talked about what he looks for in a team. First comes commitment and desire. Starting a company and working for a start up can’t be “just a job”: passion is essential. Next Rosa looks at how well the team functions: Is there lots of talk? Is everybody contributing? The team must have “deep knowledge of the space in which they work.” Flexibility is essential because things will not go as planned. Rosa also looks for things that might be surprising: a capacity to say “I don’t know”; and a willingness to ask blunt questions of him like “How do you manage your company?”

Every team needs a hacker and a hustler. The hacker is a problem solver, and the hustler is the leader of the charge, the holder of the passion. (When I heard this I thought of Tim Kelsey, National Director of Patients and Information for the NHS Commissioning Board, whom I listened to earlier this week. He is the Chief Hustler for the new NHS.

Do you ask about education, asked somebody in the audience. “I couldn’t care less which school they went to” was Rosa’s straight answer.

But culture is important–even if there are only two of you, insisted Rosa. Each organisation has its own culture, and a good cultural fit within an organisation makes for success. It doesn’t mean everybody has to be and think the same—indeed, that’s bad—but people must enjoy working together. In the best cultures people take pleasure in the success of others. And it’s important to articulate the culture, which might be done, suggested somebody in the audience, through icons. Putting a sandbox in the middle of your office shows that you have a creative culture and becomes embarrassing if you cease to be creative.

Funding is a never ending debate within a start up, and, said Rosa “You should take funding if offered it [by investors] and not worry about dilution [of equity]. Go get it.” Others, he acknowledged, might take a different line, and he did say that founders are always ahead of investors in understanding business opportunities. Indeed, he described investors as “clueless.”  It’s very hard to grow your business from customer payments, and classically a start up will take a long time, perhaps years, to generate sales “and then it will go crazy.” When it goes crazy may be the time to take money from investors—to realise your full growth potential.

With start ups, Rosa concluded, you are “swimming upstream most of the time” and “most deals don’t work out.” You need “determination and flexibility” to succeed, but when you succeed—and if you can live with enough failures you will—you can create huge value for your customers (perhaps NHS patients), your country, and yourself.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

Competing interest: RS is an unpaid mentor for Healthbox but hasn’t mentored anybody yet. He is also the chair of a start up, Patients Know Best, in which he has equity and invested but receives no salary.

How many times have you done this procedure, Doc? @Medici_Manager @kevinmd

Questions such as this from proactive, increasingly knowledgeable patients place a physician on the horns of an ethical dilemma.  Although fellows are closely supervised and trained under a gradually increasing responsibility principle (based upon subjective evaluation), a time will come when there is no one available to back you up in the catheterization lab.

Fact: Someone has to be a physician’s first case of any given type. However, no one really wants to be that person.

Access to extensive medical information on the web has satiated some of our patient’s desire for information and expectations regarding medical procedures, which is a good thing. However, increased transparency and public awareness of medical errors has opened up a Pandora’s box regarding a physician’s skill level and experience.  The September 2012 issue of Men’s Health went as far as publishing peer reviewed data regarding the minimum numbers for particular procedures taken directly from medical journals. Specifically, coronary angioplasty and angiography minimums were reported as 50 and 82 procedures respectively.

Take home message: Hard numbers to meet your first month into fellowship.

Similar experience-responsibility disparities exist in commercial aviation.  However, in contradistinction to the patient-doctor encounter, passengers are neither cognizant of their captain’s flight hours nor face-to-face prior to boarding.  Further increasing the stakes, a new pilot’s first manifest could be 50 passengers or more. In response to public demand for greater safety, the airline industry was an early adopter of systems to increase reliable pilot performance including flight simulation technology and pre-flight checklists, which were quite effective in reducing fatal incidents for air travelers.  As a result, the latest National Safety Council in the U.S.A. calculated the lifetime odds of death for flying to be 1:7178 in 2008 compared to 1:98 for automobile deaths.

Interestingly, even experienced pilots are required scheduled simulation training to maintain their skills and prepare for rare-but-catastrophic events, which cannot be realistically produced in the air.  The auto industry, unique in their in inability to increase motorists’ skills, have been forced to develop safety technology to make the highways safer.

Reality check: Patients do not come with air bags or crash sensors.  Simulation and checklists are proven methods to increase safety.

Virtual reality simulation training programs allow students of all levels to gain familiarity with equipment selection, proficiency of the detailed steps for a given procedure as well as an awareness of the potential pitfalls and crucial moments in a safe environment. Furthermore, under experienced tutelage during practice, a modicum of fingertip finesse may be learned prior to laying hands upon their first patient.

While “ain’t nothing like the real thing” is unarguably the best way to learn any motor skill, having solid theoretical and practical experience makes the transition to live cases easier and might ameliorate the patient’s and the beginner’s shakes.

Max Berry is a vascular and interventional radiology fellow.

Girolamo Sirchia

  1. Antibiotici per le infezioni delle vie aeree superiori
  2. Coronarografia
  3. Endoarteriectomia carotidea
  4. Bypass aorto-coronarico
  5. Trattamenti per il mal di schiena(1)
  6. Statine negli anziani(2)
  7. Costosi test diagnostici (es. risonanza magnetica)(3, 4)

Un contributo alla non-qualità in sanità è dato dalle re-ammissioni in ospedale. Ad esempio il 10% dei pazienti operati in dilatazione coronarica viene riammesso in ospedale entro 30 gg post-intervento(5).
Purtroppo la ricerca sull’eccessivo uso di alcuni servizi sanitari è molto carente(6).
Inoltre, vi sono prestazioni sanitarie usate troppo poco; tra queste in particolare spiccano le pratiche di prevenzione secondaria tese a prevenire le recidive della malattia (ad es. uso dell’aspirina nei soggetti che hanno avuto infarto del miocardio, controllo della pressione arteriosa nei soggetti che hanno avuto ictus, ecc.).

1) Deyo RA et al – Overtreating chronic back pain: time to back off?
J Am Board Fam Med 22, 62-68, 2009


View original post 97 altre parole

4 essential elements of true health reform @Medici_Manager @kevinmd

 | POLICY | DECEMBER 8, 2012

I recently said I would describe the essential elements of “true reform.” I realize others might add or subtract from my list, but here it is – at least for today:

Payment reform. I put this first because no matter what form or structure healthcare takes, without payment reform it will be doomed to failure. And by “payment reform” I mean switching from the “fee for service” model I discussed in an earlier column – which basically pays more for doing more whether or not it is needed – to some kind of “outcomes” payment system.

There are many “outcomes” payment ideas – bundling, global, etc. – but they are all designed in theory to force providers to live within a certain budget for a given patient. Obviously, this is a huge culture change and will require many years – and many mistakes – to figure out.

But I think it is probably the most essential ingredient of true reform. (I would also include malpractice reform in this category; by switching to a no-fault system we would remove a large incentive to do unnecessary testing and treating.)

Electronic records. While I recognize there are many issues (privacy, compatibility, etc.) to be yet worked out before electronic records can become near universal in our hospital and personal healthcare, I believe it will be impossible to intelligently cut costs and improve safety without them. Imagine, again, the U.S. commercial airline industry in this country without computers able to “talk to each other” with the same language no matter the location.

Comparability data. And once such a computer system is widely in place, we can start making better use of “outcomes” data – i.e., data from studies that tell us what works best at the lowest cost.

Another name for this would be “cost effectiveness” data but those two words strike fear – understandably – in the hearts of doctors and patients who assume that means choosing the cheapest option regardless of quality concerns.

Right now there is a paucity of such data – in part because the “medical industrial complex” has often fought true comparison studies. But the need for such data will only grow as cost issues become paramount.

Primary care. Ultimately, all of the above will only work well in the setting of good primary care – meaning a place and professionals readily available, at least by phone, when a person thinks they (or a member of their family) might be sick.

The phrase so often used to describe this “place” today is “the medical home.” Obviously a “medical home” – like any home – can physically exist in many different kinds of settings ranging from a traditional office to a clinic to a setting in a hospital.

But the key ingredients of such a home, in my judgment, are the traditional three A’s: availability, affability, and affordability.

Timothy Johnson trained as an emergency room physician but switched careers in 1984 when he joined ABC News as its first full time Medical Editor. Although he retired from that role in 2010, he continues as Senior Medical Contributor.  He blogs at Timothy Johnson, MD: On Health.

How Obamacare will create a new normal for medicine @Medici_Manager @kevinmd

 | POLICY | DECEMBER 7, 2012

The 2012 Presidential election is over. Obamacare is the law of the land and is certain to remain so.  There was tremendous uncertainty not knowing whether the law would be repealed, revised or remain.  Many of us opposed the bill, and there certainly are negatives.  Like it or not, it is time to “get over it,” and not a second later than now.  The new-found certainty offers an opportunity to reassess and adapt to the coming changes.

In addition to Obamacare, other pillars of our “new normal” include patient satisfaction surveys, threats of reimbursement cuts, increasing pressure from administrators obsessing over “metrics,” more time drained by cumbersome electronic health records, resentment from patients who blame us for the failings of the healthcare system, as well as a steady stream of frivolous lawsuits with no end in sight.  It’s time to adapt to our “new normal.”

Comparing and contrasting with other industries

In this modern age of Medicine, these factors have been piled on top of the traditional responsibilities of physicians such as life and death, health and wellness, and paradoxically have seemed to rise above them in importance like unstoppable flood waters drowning the ghosts of Hippocrates, Osler and Marcus Welby M.D.  This contributes to poor morale among physicians and understandably so.  Other industries have had to deal with the same concepts for decades, however.  The service industries are bound by “patient satisfaction” measures and always have been.  Businessmen also have to guard against lawsuits. They expect them and manage the risk and accept it as a norm. I doubt they perceive a lawsuit where they did nothing wrong, as life altering like so many physicians do.  Companies often times have decreases in sales just as our reimbursements may drop and constantly have to adapt.  Just about everyone else in the “real world” has to deal with a “boss” of some variety and a necessary part of their job is to keep that person or entity happy, regardless of whether they like them personally or not.  So why do we find it so difficult to deal with such factors?

Are we special?

Are we different?

In a word, “No.”  Not anymore.  It’s time to accept that fact and move on.  We are now cogs, replaceable de facto employees of a massive business-medico-legal-political machine; nothing more.  All indications are that it will remain this way.  Much can be learned from such other industries that have had to adapt to the stark realities ahead of us.  I think for the profession of Medicine to reinvigorate itself, and for us to truly value what we do have again, we must properly manage expectations.

What government will (or will not) do

Though we might each individually be very replaceable, the reality is that we still have extremely high paying jobs in a profession that is relatively recession proof with greatly increasing demand for our services. There are some other positives and ironic realities that I think many physicians are glaringly overlooking.  One is that Obamacare proposes to commit about 1 trillion more dollars towards healthcare over the next 10 years, with tens of millions newly insured.  Necessarily, demand for our services will go up, way up.  And the best (or worst) news is that despite all the talk about “severe rationing” and “draconian reimbursement cuts” there’s good reason to believe that talk is a big load of … nonsense.  That’s right; they’re not going to cut a damn thing.  How can I be so sure?

There has been essentially no real political will, whatsoever, by either political party to make any significant cuts from the federal budget, ever.  Even the most “harsh” and “cruelest” proposals only call for a decrease in the rate-of-increase, of overall spending.  There never has been any, and there’s no reason to predict there ever will be, any policy other than kicking the can down the road until after the next election, and the next one and the next one. The voters have spoken and they want to spend an extra $1,000,000,000,000 on healthcare.  Santa Claus is in fact coming to town! That may be terrible for the country, but it may well be very good for doctors; that is the smart ones.  There may be more hoops to jump through, more requirements and regulations, as well as creative strategies needed to get a “piece of the pie,” but demand for doctors’ services will necessarily increase, and tremendously so.  Also, despite much posturing, tough talk and threats of showdowns year after year, the SGR-fix has always been passed and the budget debt ceiling has always been raised.  Medicare expenditures will necessarily continue to go up, and up, and up. More patients will be insured wanting our services. The elderly baby-boom population will be sick and growing older and need us desperately.

I was told a story by a retired physician about his long deceased cardiologist father who practiced before Medicare was instituted.  He tells of his father who was a very compassionate physician, but a staunch free-market conservative who like many physicians at the time vehemently opposed the proposed Medicare system.  His father would say that physicians provided charity care for free to the disabled and elderly all the time and that Medicare was just a Trojan-Horse for socialists who wanted to take over the American healthcare system.  He may or may not have been correct, but ultimately to his dismay, Medicare passed and became law.  All of a sudden and very unexpectedly, his salary … doubled.  He never complained about Medicare again.

The point of this anecdote is not to suggest that physicians’ salaries will double as a result of Obamacare.  They will not.  However, it is to suggest that despite the 2000 pages of regulations and requirements in the cloud of Obamacare that hangs over our heads, there will be an unexpected silver lining, somewhere.  I think we can simultaneously work vigorously to reform our profession, yet shed the “culture of victimhood” that has grown like mold upon physician attitudes and search for positive opportunities.

Some physicians will “opt-in”

Such new opportunities will not be the same as in the dead era of Osler, Hippocrates and Marcus Welby M.D.  Also, I cannot say that chugging along with the same old strategy, expectations, and disappointments of a bygone Golden Age will be a winning plan, either.  It may involve simply being content as a cog in a large machine or “system.”  It may involve thriving in the role of “corporate soldier,” learning how to “play the game” while finding ways to save costs, increasing efficiency for your group or other groups and “promoting” your hospital.  Others may move into the government side of healthcare and find opportunities in healthcare policy planning and consulting.  Clearly, knowing “the medicine” isn’t enough anymore and in fact, seems the least important of that which is expected of us.

Other physicians will “opt-out”

Greater numbers of physicians will find opportunity in opting-out of the system by making their practices cash only, concierge, or declining to participate in Medicare and a more dominant Medicaid system.  Another option may be for more Emergency Physicians and surgeons to exploit technicalities in Obamacare and States with liberal certificate of need laws and open their own centers that offer services for a flat fee outside of traditional government or private insurances.  As more insurance plans require deductibles in the thousands of dollars and refuse to pay for certain services entirely, such centers may gain more traction where they are feasible.

Others may “opt-out” more insidiously.  The new generation of physicians may very well evolve into protocol-following, brown-nosing, corporate mantra-spewing clock-punchers, indistinguishable from other “providers” all while refusing to make the tremendous sacrifices of doctors past, such as incredibly long hours, over-burdensome call schedules with great sacrifice to marriage, family, and personal well-being.  Maybe that’s okay, and maybe that’s what our new Overlords of Healthcare want and will reward.

More primary care physicians and other specialties likely will take the “9-5, no call” route and leave the after-hours hassles to the ED and hospitalists.  More medical students may pick careers in cosmetics over critical care.  More Emergency Physicians may leave high-stress clinical shift work in the Emergency Department for Administration, group management, Hospice and Palliative care fellowships, Urgent Care ownership or anything else seen as less stressful.  More surgeons and specialists may opt out of emergency call for a less stressful life and a focus on elective cases with higher reimbursement to liability ratios.  I see more Anesthesiologist moving to “lifestyle” positions at ASCs doing elective cases, or pain procedures with little or no call.  Many physicians will consider early retirement.

The silver lining

The pioneers of Medicine did not have to worry about our “new normal” of Obamacare and all of its 2000 pages of regulations and requirements.  They didn’t have to worry about $300,000 of medical school debt, mega-million dollar frivolous lawsuits or being fired over patient satisfaction surveys based on complaints that may or may not even be valid.  But they also didn’t have our modern-day luxuries, salaries, exploding technologies, or a nation of patients soon to be more widely insured and in demand of our services than ever.  There is much worth fighting to reform, yet even more worth fighting to preserve.  All things considered, we are tremendously better off.

Be sure, Obamacare will change modern medicine, and it will change it mightily.  Also be sure, that with us or without us, and whether we look forward to seize new opportunities or look back upon shattered expectations, the profession of Medicine will be alive and well, and thriving more than ever before.

“BirdStrike” is an emergency physician who blogs at WhiteCoat’s Call Room at Emergency Physicians Monthly.


Andrea Silenzi, MD, MPH, PhD

Cosa dice l’agenda Monti in tema di Sanità? Ecco l’estratto:

[…] L’Europa e la sua agenda di disciplina delle finanze pubbliche e riforme strutturali sono nemiche del welfare? No. Lo Stato sociale è il cuore del modello sociale europeo e della sua sintesi tra efficienza ed equità, mercato e solidarietà. Realizzare obiettivi di redistribuzione e di lotta contro le diseguaglianze senza attenuare le energie per la crescita è la sfida politica centrale del nostro tempo. Di per sé l’Europa non limita i modi in cui si possono perseguire fini sociali e di equità, ma impedisce di finanziarli con una illimitata creazione di debito. E ci impone di capire che il modello che abbiamo costruito si sta incrinando sotto il peso del cambiamento demografico e della sempre più difficile sostenibilità finanziaria.
Abbiamo due alternative. O cercare di conservare il welfare state com’è, rassegnandoci a tagli e riduzioni di servizi per far…

View original post 244 altre parole

Andrea Silenzi, MD, MPH, PhD

E’ successo qualche giorno fa che a fianco al mio solito posto al Social Media Council, si sedesse uno degli speaker che erano stati invitati per quella particolare sessione. Si trattava di Nick Jones, Head of Digital Communication per il n.10 di Downing Street la sede dell’ufficio del primo ministro David Cameron. Prendendo spunto dal suo intervento ho colto anche l’occasione per farci una breve chiacchierata, poi continuata via email, su come vengano utilizzati i Social per promuovere l’immagine del primo ministro. Nick ha avuto modo di spiegarmi come ad oggi i Social siano diventati un canale di comunicazione imprescindibile per l’ufficio di Cameron: “Forniscono – spiega – un efficiente e poco costoso canale diretto per comunicare i messaggi chiave del governo. In più, i contenuti digitali trasmessi attraverso questi canali, vengono spesso ripresa da altri media. Ad esempio Sky News che mostra uno screen shot del primo incontro del…

View original post 561 altre parole

Solving the Health Care Cost Challenge: Leveraging RAND Expertise @Medici_Manager @RANDCorporation

In its second term, the Obama Administration and the 113th Congress must address the relentless growth of health care spending, a major contributor to America’s long-term fiscal imbalance.

Growing health care spending is fueling the federal budget deficit, crowding out other priorities in state budgets, hindering the competitiveness of American businesses, restraining job growth, and jeopardizing the finances of American families. Victor Fuchs, considered by many to be the father of health economics,summarized the enormous payoff of confronting this issue: “If we solve our health care spending, practically all of our fiscal problems go away.”

However, while there is no lack of ideas for how to slow spending, action is hindered by a lack of consensus.

In a series of research briefs dedicated to flattening the trajectory of health care spending, RAND Health outlines four broad strategies for constraining spending growth in our market-oriented health care system:

Medically necessary: Who should decide? How to decide? @Medici_Manager

Canadian Medical Association Journal

Interesting US report on healthcare payment reform from UnitedHealth Group @Medici_Manager @helenbevan


A “Real World” Strategy For Health Care Payment Reform

Qualche spunto interessante anche per il SSN italiano?


To Change the Culture, Stop Trying to “Change the Culture” @muirgray @Medici_Manager

by Robert H. Schaffer  |  11:00 AM December 6, 2012

When people aren’t achieving what they should be achieving and things aren’t going the way they should be — and if senior managers can’t pin the blame on some specific issue — they often declare: “We have to change the culture around here.”

Not many of them feel they know how to do that, so an army of consultants has obliged by creating processes for help. Most of these experts recommend beginning with a diagnosis of the present culture. After the diagnosis you need to get clear about where you want to head. That’s another piece of work. Then you have to plan how you are going to get there.

Finally, when you are ready to get moving, the consultants are happy to jump aboard to help implement a multitude of programs — training, re-organization, systems redesign, and communications campaigns. A Google search on the term “organizational culture change programs” yields 273,000,000 entries.

The total effort generated by these processes is guaranteed to be complex and to cost huge amounts of time, money and effort. Some of these interventions may prove useful at an individual level, but sweeping, large-scale culture change efforts rarely cure those aspects of culture that were so frustrating in the first place.

There is another way.

One reason these efforts are disappointing is that companies are trying to transform a whole lot of cultural dynamics all at once. We’ve found that managers get better results when they start with a few smaller successes, which then provide a basis for expanding. Start with one problem — or a few. Get some people to plan a couple of modest experiments to make progress on that issue, with guidance on the kinds of innovation you’d like to see. Build in some learning on the cultural issues that need to change. Try it out. Pay careful attention to what works and how. Incorporate the successful ideas into subsequent steps.

Public Service of New Hampshire, the state’s electric utility, provides an example: the company’s managers were focused almost exclusively on immediate issues (vs. strategic ones) and on their own jobs (rather than co-functional collaboration). Since the company was facing some major strategic decisions changing this culture was urgent. Instead of big, complex planning steps they began by working on two important performance challenges. The first was getting electric service back more quickly after an outage. The second was maximizing the productivity of maintenance crews (for example, ensuring that when a work team traveled to a site, the necessary preparations had been carried out). As these projects achieved their goals, new projects, aimed at more strategic issues, were launched. As their people displayed the capacity to accomplish more, senior management set more ambitious strategic goals.

After a number of months of this accelerating progress, the company president observed, “Success has pushed out our strategic horizon. As we have empowered people to set directions and get results, they have developed a new level of self-confidence.”

In another example, when Patrick O’Sullivan took over as the sixth CEO in as many years at the Eagle Star Insurance Company in the UK, the company was losing huge amounts of money — a product of its growth-at-any-cost approach. Managers, in denial, were passively waiting for a turnaround. O’Sullivan began by bringing together 50 claims people from a number of branches in a GE Workout-style session. He told them their task was to reduce $10 million in claims payments in 100 days. They developed recommendations which were approved immediately, and teams were formed and given the job of putting the ideas to work.

By the end of the 100 days the $10 million was almost reached. A second round of Workout events was held to define and launch additional projects. By the end of six months several hundred claims people were at work on such projects. With this momentum in claims, O’Sullivan gathered the top 150 managers across the company and got most of them started on improvement projects in their own areas. And he kept such activity going for the next four years — during which time the company was acquired and re-named “Zurich U.K.”

By then the bottom line had improved by over $100 million, and it had become a fast-moving, high-performance company.

In both cases, major culture change happened in the course of the incremental pursuit of better operations — with no proclamations, mission statements, or debates about “what we mean by culture change.” Senior management does have to provide some overall guidance in order to knit together the individual strands of progress, but the energy, the momentum, and the experimental ingenuity occur in the individual thrusts.

The moral of the story is that a company need never sink resources into “culture change” programs. If they keep advancing an increasing number of performance improvements that empower their people — and if they distill and exploit the learning from their achievements — they’ll wake up one day and discover that they are working in a radically new culture.


Robert H. Schaffer ( is the founder of Schaffer Consulting in Stamford, Connecticut. He is also a coauthor of Rapid Results! How 100-Day Projects Build the Capacity for Large-Scale Change (Jossey-Bass, 2005).

How influential are you inside your company? @Medici_Manager @HarvardBiz

Should Your Boss Care About Your Klout Score?

by Michael Schrage  |   9:00 AM November 27, 2012

A confession: I don’t know my Klout score.

A second confession: I don’t want to know my Klout score.

A third confession: I’m a hypocrite. I’m almost always looking for ways to meaningfully assess how influential — positively and negatively — my colleagues, collaborators and co-workers are.

“Influence” increasingly is the coin of the organizational realm. Influence defies title, credential and seniority. Somebody may be smart, talented and hardworking but do they have influence? Are they perceived as people who can move collegial hearts and minds? Employees with influence — or with reputations for influence — enjoy understandable competitive advantages in the organizational marketplace. But who decides who has influence? And who decides how to measure it?

Klout-ish services are simply logical and inevitable initiatives to measure that competitive advantage. Social media provide both the raw and the cooked material allowing algorithmic innovators to bring a bit of digital dazzle to “influencer metrics.” Decades ago in more analog times, Eugene Garfield and his Institute of Scientific Information pioneered “citations” as the way to quantitatively assess the influence of scientific papers (and their authors) on a discipline. Today, we have Klout, Peerindex, Twitalyzer and other “influence analytics” to give people — and their employers — the power to neurotically obsess over how influential the numbers say they are.

Memes that Klout scores can cost you a job — or at least a job interview — have already gone viral on social media. Not unlike recommendation engines, influence scores seem destined to become one of those low-cost, high-impact online presences that will cast virtual shadows of disproportionate length and darkness. You think that Facebook photo of you puking at the frat party is going to come back to haunt you? Perhaps it’s your single-digit — and falling — Klout score that should keep you up at night…

Of course, the Klouts and Twitalyzers are first-generation analytics that live web-wide in the digisphere. The real enterprise future of “influencer analytics” will soon be found inside the firewalls. With a few exceptions (salespeople, thought-leaders, marketers), most organizations don’t care about employee IQ — Influence Quotient — outside the enterprise. They’re more concerned with how influential employees are inside the organization. Do their colleagues and subordinates “cite” and reference them? Are their comments and contributions appropriately acknowledged? Are they — forgive the cliché — “team players” and appropriately influential as such?

If you’re running IBM, Siemens, Toyota, Exxon-Mobil, CNOOC or any Fortune 2000 global enterprise, you are going to invest in an internal Klout or Peerindex to assess your internal influence marketplace. Quantitative assessments of influence will — and must — become part of job and performance reviews, as well as indicators of leadership potential. This is part of the “googlefication” tide raised in an earlier post. Technology executives can talk about the “consumerization of IT” all they want but the real impact or — please excuse — “influence” is coming from the internalization of social media services. Enterprise social media services such as Jive, Sharepoint, Yammer and Socialtext — not to mention instant messaging and repurposed email — provide all the material necessary for importing a more enterprise-appropriate generation of Kloutish influencer metrics.

More sophisticated managements will make sure their enterprise analytics go beyond the Klout paradigm to identify “bad” influences and influencers. After all, if a business unit leader is as much a “bad” influence in some sectors as a “good” one in others, top management needs to know. Indeed, the future of influencer analytics may be in novel ways of identifying and categorizing the ratio between “positive” and “negative” influence impact inside the enterprise. How do you rate and rank an employee who is a positive influencer with customers and suppliers but a negative influence on colleagues and subordinates?

Quantifying influence removes these questions from the realm of the hypothetical. The new reality is that enterprise social media may come into the enterprise with the promise of promoting better communication, coordination and collaboration but will ultimately perform as the algorithmic arbiter of influence — good and bad. In other words, these metrics will enjoy enormous influence.


Insight Center: Putting Social Media to Work

More >>

Michael Schrage


Michael Schrage, a research fellow at MIT Sloan School’s Center for Digital Business, is the author of Serious Play and the new HBR Single Who Do You Want Your Customers to Become?

Andrea Silenzi, MD, MPH, PhD

Per tutti i medici specializzandi (soprattutto di area chirurgica), uno spunto interessante per dare valore alle proprie attività!

Impact of Resident Participation in Surgical Operations on Postoperative Outcomes: National Surgical Quality Improvement Program

Ann Surg. 2012 Sep;256(3):469-75. doi: 10.1097/SLA.0b013e318265812a.

Source: Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH 44195, USA.


To evaluate whether resident participation in operations influences postoperative outcomes.


: Identification of potential differences in outcome associated with resident participation in operations may facilitate planning from educational and health resource perspectives.


From the National Surgical Quality Improvement Program database (2005-2007), postoperative outcomes were compared for patients with and without resident participation (RES vs no-RES). Groups were matched in a 2:1 ratio, based on age, sex, specialty, surgical procedure, morbidity probability, and important comorbidities and risk factors.


RES (40,474; 66.7%) and no-RES (20,237; 33.3%) groups were comparable for matched characteristics. Mortality was similar (0.18% vs 0.20%, P = 0.55). Thirty-day complications classified as…

View original post 103 altre parole

La Sanità di Iniziativa attraverso gli occhi dei pazienti @Medici_Manager

Anna Maria Murante, Laboratorio Management e Sanità della Scuola Superiore Sant’Anna di Pisa.

I risultati dell’applicazione del Chronic Care Model in Toscana.  Il 73 % dei pazienti dichiara che l’assistenza complessiva è migliorata e ora è in grado di gestire meglio la propria malattia. Il 67% dei pazienti dichiara che il suo stato di salute è migliorato.

Era il 1997 quando Edward Wagner portava la comunità scientifica a riflettere sui principali ostacoli che i sistemi sanitari incontrano nel dare risposta ai bisogni dei pazienti cronici, sui punti di forza e debolezza dei numerosi approcci assistenziali in uso in quegli anni e sugli effetti che le strategie adottate hanno sui pazienti cronici[1]. Dal dibattito che ne scaturì prese a delinearsi negli USA una nuova idea di assistenza per i pazienti cronici, poi tradotta nel modello organizzativo-assistenziale oggi noto a tutti come il Chronic Care Model. Un modello che ha nel self-managementdecision supportdelivery system design e clinical information system le sue principali componenti (Figura 1), e la cui implementazione dimostra sin da subito di poter assicurare migliori risultati in termini di processo e di outcome, oltreché una riduzione dei costi e degli accessi inappropriati ai servizi[2,3]. Questo modello viene presto esportato oltre oceano, arrivando ad essere applicato anche in alcune regioni italiane come la Toscana.

Figura 1. Il Chronic Care Model

Cliccare sull’immagine per ingrandirla

Con il Piano Sanitario Regionale 2008-2010 la Regione Toscana pone infatti le basi per un rinnovamento organizzativo e culturale che segna un cambio di rotta nell’assistenza dei pazienti cronici, definendo la strategia per il prossimo futuro: passare da una medicina d’attesa, re-attiva e pensata per i pazienti in fase acuta, ad una sanità che – basandosi sul modello del Chronic Care Model (vedi Assistere le persone con condizioni croniche) – va incontro al paziente, in maniera pro-attiva e programmata per «[…] assumere il bisogno di salute prima che la malattia cronica insorga, si manifesti o si aggravi […]». Nasce così la Sanità di Iniziativa, che muove i suoi primi passi nel 2010, quando 627 medici di famiglia, organizzati in 56 moduli multiprofessionali (composti oltre che dai medici di famiglia, anche da infermieri e operatori socio sanitari), aderiscono alla fase pilota del progetto (attualmente i medici che aderiscono al progetto sono oltre mille, circa il 38 % del totale dei mmg toscani). A livello regionale vengono definiti obiettivi chiari tanto per i moduli, il cui raggiungimento è monitorato con un set di indicatori (DGR 355 del 22/03/2010), che per i direttori generali delle aziende sanitarie, che a questi vedono legati una quota percentuale degli incentivi annuali.

I risultati che si ottengono dall’attività di monitoraggio sul processo e sugli outcome sulla base dei dati forniti direttamente dai moduli (che alimentano gli indicatori sopra citati) e sulla base della banca dati MaCro dell’Agenzia sanitaria regionale (ARS Toscana), da quest’anno sono completati dai risultati sull’esperienza dei pazienti presi in carico.

Tra febbraio e luglio 2012 è stata infatti condotta un’indagine telefonica (secondo la metodologiaComputer Assisted Telephone Interviewing) tra i pazienti presi in carico dai moduli della fase pilota della Sanità di Iniziativa. Un campione di circa 6500 pazienti, diabetici e scompensati, ha risposto al questionario costruito dai ricercatori del Laboratorio Management e Sanità della Scuola Superiore Sant’Anna di Pisa con il supporto di un panel di esperti a livello nazionale ed internazionale e approvato dalla Commissione Regionale CORMAS. Il questionario è strutturato in 7 sezioni: la fase di reclutamento, le visite di controllo, gli incontri di counselling, gli aspetti logistici, le visite specialistiche, il coordinamento tra le figure professionali e una valutazione complessiva in termini di informazione, empowerment, assistenza e benefici per lo stato di salute.

Il 72% dei pazienti intervistati ha più di 65 anni, soffre di diabete o di scompenso cardiaco in media da circa 11 anni.

I pazienti hanno accettato di essere assistiti secondo il nuovo paradigma assistenziale soprattutto perché hanno fiducia nel medico di famiglia che glielo ha proposto e perché desiderano avere un punto di riferimento nella gestione della malattia cronica. Hanno un minor peso in questa decisione l’auspicio di ottenere dei benefici in termini di salute o di migliorare la gestione della malattia. La presa in carico ha quindi un peso importante nelle scelte assistenziali dei pazienti cronici.

La pro-attività dei moduli nell’attività di follow up è buona, confermando che la sanità d’iniziativa «non aspetta sulla soglia dei servizi il cittadino» (PSR 2008-2010), ma va loro incontro,  ad esempio contattando i pazienti prima della visita di controllo per ricordare o fissare la data dell’appuntamento (è quello che accade al 73% dei pazienti intervistati).

Durante le visite di controllo l’infermiere del modulo lavora per aumentare l’empowerment del paziente, in primis attraverso un’educazione volta ad intervenire sugli stili di vita, e il paziente sembra apprezzare. Le informazioni fornite su una sana alimentazione,sull’attività fisica, sul consumo di alcolici e sul fumo (Figura 2) soddisfa infatti la quasi totalità dei pazienti (97%), e porta il 67% dei pazienti a dichiarare di sentirsi più informato sulla propria malattia cronica.

Figura 2. Le informazioni che il paziente riceve durante le visite di controllo

Cliccare sull’immagine per ingrandirla

Rispetto al monitoraggio dello stato di salute dei pazienti, emerge che la misurazione della pressione e della glicemia (o la verifica dei valori registrati a casa), e della circonferenza della vita (o del peso corporeo) avvengono regolarmente, mentre non è ancora una prassi il controllo del piede (Figura 3).

Figura 3. Le attività di follow up svolte durante le visite di controllo.

Cliccare sull’immagine per ingrandirla

Sono davvero pochi (9%) i pazienti che dopo aver incontrato l’infermiere si rivolgono al medico di famiglia per chiedere conferma o spiegazioni. Alla base di quest’ultimo risultato c’è sicuramente la completa fiducia che l’88% dei pazienti nutre nell’infermiere. Inoltre, il team composto dal medico di famiglia e dall’infermiere riceve valutazioni molto positive, soprattutto quando si parla di lavoro di squadra ( 91 volte su 100 è ottimo o buono). Il paziente dunque non ha alcun pregiudizio rispetto al ruolo assegnato all’infermiere nella gestione del proprio percorso assistenziale e risponde positivamente al cambiamento organizzativo, e al tempo stesso culturale, posto in atto dalla Regione Toscana con la Sanità di Iniziativa.

La pro-attività del sistema è invece ancora poco strutturata quando il paziente ha bisogno di una visita specialistica. La prenotazione della visita il più delle volte viene fatta dal paziente o da un suo parente/amico attraverso il CUP, e solo poche volte è realizzata dal personale del modulo (15%). La figura dello specialista è ancora collocata fisicamente fuori dall’ambulatorio della sanità di iniziativa, se non in rari casi. Questi elementi identificano certamente degli ampi spazi di miglioramento su cui intervenire nella costruzione di un solida ed efficace continuità assistenziale.

Per finire, la rilevazione condotta tra i pazienti ha permesso di ottenere le prime valutazioni sull’efficacia della Sanità di Iniziativa in Toscana, direttamente dai pazienti. Il 73 % dei pazienti dichiara che l’assistenza complessiva è migliorata e ora è in grado di gestire meglio la propria malattia. Un altro risultato importantissimo in termini di outcome segnala che questa nuova modalità di presa in carico produce dei benefici sullo stato di salute dei pazienti nel 67% degli intervistati, vedi Figure 4 e 5.

Figura 4. Le valutazioni dei pazienti sul miglioramento dell’assistenza

Cliccare sull’immagine per ingrandirla

Figura 5. Un risultato di outcome: l’impatto della Sanità di iniziativa sulla salute dei pazienti.

Cliccare sull’immagine per ingrandirla

La rilevazione condotta in Regione Toscana conferma dunque i risultati presenti in letteratura sull’efficacia del Chronic Care Model, e fornisce alla governance regionale e agli operatori impegnati sul campo informazioni utili sugli ambiti in cui la presa in carico può essere ancora migliorata.


  1. Wagner, Managed Care and Chronic Illness: Health Services Research Needs, Health Services Research, 1997; 32(5): 702-714.
  2. Bodenheimer et al, Improving Primary care for Patients with Chronic illness: the chronic care model, Part 2, JAMA, 2002; 208: 1909-1914.
  3. Coleman et al, Evidence On The Chronic Care Model In The New Millennium, Health Affairs, 2009; 28(1):75-85.

Scarica il PDF

International Profiles of Health Care Systems @Medici_Manager @SIHTA_Italia @HPHitaly

International Profiles of Health Care Systems: Australia, Canada, Denmark, England, France, Germany, Japan, Iceland, Italy, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States

This publication presents overviews of the health care systems of Australia, Canada, Denmark, England, France, Germany, Japan, Iceland, Italy, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States. Each overview covers health insurance, public and private financing, health system organization, quality of care, health disparities, efficiency and integration, care coordination, use of health information technology, use of evidence-based practice, cost containment, and recent reforms and innovations. In addition, summary tables provide data on a number of key health system characteristics and performance indicators, including overall health care spending, hospital spending and utilization, health care access, patient safety, care coordination, chronic care management, disease prevention, capacity for quality improvement, and public views.