break the health care industry

NOTENOTE:: To appreciateTo appreciate this presentation this presentation [and [and

insure that it is not ainsure that it is not a messmess],], you need Microsoft you need Microsoft

fonts:fonts: “Showcard Gothic,”“Showcard Gothic,” “Ravie,”“Ravie,” “Chiller”“Chiller”

and and “Verdana”“Verdana”

Part 9Part 9

Tom Peters’ Tom Peters’

EXCELLENCEXCELLENCE. ALWAYS.E. ALWAYS.

New Master/21 August 2008New Master/21 August 2008

Slides at …

tompeters.comtompeters.com

Ten PartsTen PartsP1.1, P1.2, P1.3, P1.4/GenericP1.1, P1.2, P1.3, P1.4/GenericP2/LeadershipP2/LeadershipP3/TalentP3/TalentP4/“Value-added Ladder”P4/“Value-added Ladder”P5/“New” Markets P5/“New” Markets P6/“The Equations”P6/“The Equations”P7.1/ImplementationP7.1/ImplementationP7.2/ActionP7.2/ActionP8/13 “Guru Gaffes”P8/13 “Guru Gaffes”P9/Health“care”P9/Health“care”P10/“The Lists”P10/“The Lists”

Part Part ninenine

Some ReflectionsSome ReflectionsOn the sorry state of American On the sorry state of American “health,” circa 2008, and the “health,” circa 2008, and the sorry state of the “delivery of sorry state of the “delivery of

Healthcare,” and whyHealthcare,” and why the twain rarely meet; and the twain rarely meet; and

how easy it would be to do a how easy it would be to do a few things right, such as few things right, such as

remind adults of a certain age remind adults of a certain age to take their aspirinto take their aspirin

Tom Peters/08.21.2008Tom Peters/08.21.2008

This presentation has taken me about This presentation has taken me about 10 years10 years to produce—some recent to produce—some recent

books took me over the top. books took me over the top. Nonetheless, it is an amateur’s view—Nonetheless, it is an amateur’s view—

albeit a 65-year-old amateur with albeit a 65-year-old amateur with “skin in the game.”*“skin in the game.”*

*These gray-background slides are notes on*These gray-background slides are notes on the preceding slide. I have chosen not to use thethe preceding slide. I have chosen not to use the Notes feature of PowerPoint, because so few inNotes feature of PowerPoint, because so few in

fact avail themselves of notes in that format—andfact avail themselves of notes in that format—and I am optimistic that some of you will read the “notes” I am optimistic that some of you will read the “notes”

slides in this format.slides in this format.

4545

Keep this Keep this ## in mind. in mind. (Throughout this presentation.)(Throughout this presentation.)

3737

Keep this Keep this ## in mind. in mind. (Throughout this presentation.)(Throughout this presentation.)

Some ReflectionsSome ReflectionsOn the sorry state of American On the sorry state of American “health,” circa 2008, and the “health,” circa 2008, and the sorry state of the “delivery of sorry state of the “delivery of

Healthcare,” and whyHealthcare,” and why the twain rarely meet: the twain rarely meet: It’s It’s

about a whole lot more than about a whole lot more than health insurance!health insurance!

Tom Peters/08.21.08Tom Peters/08.21.08

This presentation is not about This presentation is not about HillarycareHillarycare—or —or ObamacareObamacare or or McCain-McCain-

care.care. While the perverse nature of While the perverse nature of financial incentives is discussed (e.g., financial incentives is discussed (e.g.,

their bias toward “medicine” and their bias toward “medicine” and away from “health”), this is not a away from “health”), this is not a

treatise on financing overall or the # treatise on financing overall or the # of uninsured. It focuses on “my turf”—of uninsured. It focuses on “my turf”—the operational aspects of healthcare the operational aspects of healthcare

delivery. There is an enormous amount delivery. There is an enormous amount to do in healthcare within our grasp to do in healthcare within our grasp todaytoday, and not dependent upon new , and not dependent upon new

legislation.legislation.

Outline: 22 Outline: 22 “Chapters”“Chapters”

1.1. ““Bottom Line” Bottom Line” (??)(??): U.S. Life Expectancy: U.S. Life Expectancy2.2. My TakeMy Take3.3. John Hammergren’s TakeJohn Hammergren’s Take4.4. K.I.A. & Wounded: A House (Hospital) of K.I.A. & Wounded: A House (Hospital) of

Horrors Horrors 5.5. How “It” “Works” (And Feels) …How “It” “Works” (And Feels) …6. You Must Be Your Own Boss! 6. You Must Be Your Own Boss! 7. Over-treatment7. Over-treatment!!!!!!!!!!!!!!!!!!!!!!!!8. F.Y.I.: The Dominating 8. F.Y.I.: The Dominating (!)(!) Role of Healthcare Role of Healthcare in the American Economyin the American Economy9. Pick of the Litter: Our 9. Pick of the Litter: Our “Best”“Best” Hospitals? Hospitals? 10. See No Evil: A Culture of Cover-up10. See No Evil: A Culture of Cover-up11. And “They” Call It “Science” I: The11. And “They” Call It “Science” I: The Overwhelming Lack of Treatment ValidationOverwhelming Lack of Treatment Validation12. And “They” Call It “Science” II: Astounding12. And “They” Call It “Science” II: Astounding Geographic Treatment VariationGeographic Treatment Variation

13. Shining Star, A/13. Shining Star, A/TheThe … …14. IS/IT: The “Dark Ages” Saga Continues 14. IS/IT: The “Dark Ages” Saga Continues 15. K.I.S.S./Keep it simple, stupid: Un-sexy 15. K.I.S.S./Keep it simple, stupid: Un-sexy

“Stuff” Could Save Tens of Thousands of“Stuff” Could Save Tens of Thousands of Lives and Extend Hundreds of ThousandsLives and Extend Hundreds of Thousands of Othersof Others16.16.““Organizational effectiveness” “Tools” that Organizational effectiveness” “Tools” that

would put the focus on the patientwould put the focus on the patient17.17.Wellness-Prevention: No Good Deed GoesWellness-Prevention: No Good Deed Goes UnpunishedUnpunished18. From “Healthcare” to “Health”: 18. From “Healthcare” to “Health”: The “Oughtas” The “Oughtas” 19. Healthcare Meets Health: The Case of 19. Healthcare Meets Health: The Case of the Planetree Alliancethe Planetree Alliance20. My concerns, My Ideal20. My concerns, My Ideal21.TP’s Nobels21.TP’s Nobels22. Some Resources22. Some Resources

1. “Bottom 1. “Bottom line” line” (??)(??): : U.S. Life U.S. Life

ExpectancyExpectancy

4545thth.*.* *Rank of U.S. life expectancy, *Rank of U.S. life expectancy, <Bosnia, Cuba<Bosnia, Cuba

Problems notwithstanding, many-most Problems notwithstanding, many-most Americans, at the end of the day, Americans, at the end of the day,

consider their-our healthcare to be the consider their-our healthcare to be the best in the world. best in the world. If so, whIf so, whyy do we do we rank behind the likes of Bosnia and rank behind the likes of Bosnia and

Cuba in life exCuba in life exppectancectancy?y? Our global life Our global life expectancy rank? Forty-five. expectancy rank? Forty-five.

(And falling-dropping-plummeting.) (And falling-dropping-plummeting.)

““This” This” [life expectancy][life expectancy] is sorta the is sorta the

point, isn’t it … point, isn’t it … or am I missing or am I missing

something?*something?*

I’d I’d thinkthink this (life expectancy) would this (life expectancy) would (obviously) be the principal point of (obviously) be the principal point of the overall exercise—it’s not “How the overall exercise—it’s not “How much healthcare do we get?” but much healthcare do we get?” but “How healthy are we?” Right??? “How healthy are we?” Right???

““This” This” [life expectancy][life expectancy] is sorta the point, is sorta the point, isn’t it … or am I missing something?isn’t it … or am I missing something?**

*Should I, for instance, *Should I, for instance, measure my health by measure my health by

“number of “number of operations,” or operations,” or

“number of tests,” “number of tests,” where, where, MoreMore = = BetterBetter

HealthHealth??

““Pay by procedure” is the operative Pay by procedure” is the operative (insane) funding algorithm in our (insane) funding algorithm in our healthcare system—there is no healthcare system—there is no

premium on helping us get healthypremium on helping us get healthy——in fact there are severe penaltiesin fact there are severe penalties

for so doing.for so doing.

““Bottom line” :Bottom line” : 19001900--19601960, , life expectancy grew life expectancy grew 0.64 0.64 %% per year; per year; 19601960--20022002, ,

0.24%0.24% per year, half from per year, half from airbags, gun locks, airbags, gun locks,

service employment …service employment …

Source:Source: Best Care Anywhere: Why VA Healthcare Is Better Than YoursBest Care Anywhere: Why VA Healthcare Is Better Than Yours /Phillip Longman/Phillip Longman

Historically, much-most of the gain in Historically, much-most of the gain in life-expectancy comes from non-health life-expectancy comes from non-health system factors—especially cleanliness system factors—especially cleanliness

and nutrition in the past.and nutrition in the past.

3737thth.*.* World Health Organization/WHO World Health Organization/WHO rank of U.S. health system performance rank of U.S. health system performance

More.More.

State of Healthcare/U.S.A.State of Healthcare/U.S.A.

*Spend more per capita*Spend more per capita*Overall system*Overall system performance/WHO: 37 performance/WHO: 37thth

*Relatively low life expectancy*Relatively low life expectancy*High # of uninsured*High # of uninsured

Source: Source: ConsultingConsulting, 07-08.06, 07-08.06

State of Healthcare/U.S.A.State of Healthcare/U.S.A.

*Spend more per capita*Spend more per capita*Overall system*Overall system performance/WHO: 37 performance/WHO: 37thth

**Relatively low life expectancyRelatively low life expectancy*High # of uninsured*High # of uninsured

Source: Source: ConsultingConsulting, 07-08.06, 07-08.06

Stunning.Stunning.

““America’s elites are very good at attracting America’s elites are very good at attracting money and prestige, and they have a huge money and prestige, and they have a huge technology arsenal with which they attack technology arsenal with which they attack

death and disease.death and disease. But theBut theyy have no have no ppositive medical results to ositive medical results to

show for it in the ashow for it in the aggggrereggate ate and manand manyy indications that indications that thetheyy are are pprovidinrovidingg lower- lower-

qqualitualityy care than the much- care than the much-malimaliggned HMOs and assorted ned HMOs and assorted

St. ElsewheresSt. Elsewheres.”.”Source:Source: Best Care Anywhere: Why VA Healthcare Is Better Than YoursBest Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman/Phillip Longman

Stunning.Stunning.

2. My Take2. My Take

The Healthcare14: U.S. Healthcare Trauma in 2008The Healthcare14: U.S. Healthcare Trauma in 2008U.S. Life expectancy rank: U.S. Life expectancy rank: #45.#45.WHO, overall American healthcare system performance: WHO, overall American healthcare system performance: #37#37 (#1 in cost).(#1 in cost).Access: Denied to 10s of millions un/underinsured.Access: Denied to 10s of millions un/underinsured.Unnecessary annual health-system deaths: 200,000-400,000 orUnnecessary annual health-system deaths: 200,000-400,000 or more.*more.*Performance/top med centers: Problematic re quality of carePerformance/top med centers: Problematic re quality of care and follow-up.*and follow-up.*Over-treatment (meds, tests, procedures): Pandemic.*Over-treatment (meds, tests, procedures): Pandemic.*Use of hard evidence in medical decision-making: Spotty at best.*Use of hard evidence in medical decision-making: Spotty at best.*Collection of evidence based on reported treatment errors: Low.*Collection of evidence based on reported treatment errors: Low.*Use of S.O.P.s in treatment regimes: Spotty.*Use of S.O.P.s in treatment regimes: Spotty.*Incentives for appropriate care: Low.*Incentives for appropriate care: Low.*Incentives for Incentives for inin-appropriate care: High.*-appropriate care: High.*Emphasis on prevention and wellness: Low.*Emphasis on prevention and wellness: Low.*Emphasis on chronic-care: Low.*Emphasis on chronic-care: Low.*State-of-the-art IS/IT: Rare.*State-of-the-art IS/IT: Rare.*

*Fixable without legislation or major societal change—eg can by and large be improved dramatically without *Fixable without legislation or major societal change—eg can by and large be improved dramatically without some form of mandated universal access to care and in the absence of, say, a full-fledged War on Obesity. some form of mandated universal access to care and in the absence of, say, a full-fledged War on Obesity. (Evidence in support of this proposition is the fact that in every category starred above there are Pockets of (Evidence in support of this proposition is the fact that in every category starred above there are Pockets of Excellence—hospitals and other health-service organizations, facing the same realities as their peers, that Excellence—hospitals and other health-service organizations, facing the same realities as their peers, that really “get it.”)really “get it.”)

Data to follow.Data to follow.

DVM/Lyme/2005-2008DVM/Lyme/2005-2008**Multiple diagnoses (>5)**Multiple diagnoses (>5)**Specialist self-certainty**Specialist self-certainty**Health deterioration failed to produce urgency-**Health deterioration failed to produce urgency- communication. communication.**Virtually no communications between specialists**Virtually no communications between specialists**Follow-up very spotty unless bugged incessantly**Follow-up very spotty unless bugged incessantly**Lost major test results, and mis-placed 3 or 4**Lost major test results, and mis-placed 3 or 4 occasions occasions**Near fatal drug mistake (one nurse takes charge)**Near fatal drug mistake (one nurse takes charge)**Effectively, disinterest in chronic-care**Effectively, disinterest in chronic-care**Lack of curiosity in general**Lack of curiosity in general

Home in Vermont, I happened to run Home in Vermont, I happened to run into a vet (Doctor of Veterinary into a vet (Doctor of Veterinary

Medicine), who has dealt with Lyme Medicine), who has dealt with Lyme disease for years. In the course of a disease for years. In the course of a half-hour conversation, these points half-hour conversation, these points arose. Alas, none were in the least arose. Alas, none were in the least surprising—and, of course, they are surprising—and, of course, they are

the observations of an expert.the observations of an expert.

3. John 3. John Hammergren’Hammergren’

s Takes Take

Skin in the Game: How Skin in the Game: How Putting Yourself First Putting Yourself First

Today Will Revolutionize Today Will Revolutionize Healthcare TomorrowHealthcare Tomorrow

——John Hammergren (CEO, McKesson) & Phil HarkinsJohn Hammergren (CEO, McKesson) & Phil Harkins

John Hammergren is the CEO of $100 John Hammergren is the CEO of $100 billion+ McKesson Corp. In a 2008 billion+ McKesson Corp. In a 2008

book, he paints a bleak picture of U.S. book, he paints a bleak picture of U.S. healthcare systemic performance—but healthcare systemic performance—but

als sees steps that would improve als sees steps that would improve things dramatically.things dramatically.

“ … “ … 25 to 30 percent of our 25 to 30 percent of our $2.2 trillion goes to wasted $2.2 trillion goes to wasted

care* in the form of care* in the form of preventable errors, incorrect preventable errors, incorrect

diagnoses, redundant diagnoses, redundant treatment, unnecessary treatment, unnecessary

infections, and extra time infections, and extra time spent in the hospital.spent in the hospital.

*and *and another 20%another 20% to paperwork to paperwork

Source: John Hammergren & Phil Harkins, Source: John Hammergren & Phil Harkins, Skin inSkin in the Game: How Putting Yourself First Today the Game: How Putting Yourself First Today

Will Revolutionize Healthcare Tomorrow Will Revolutionize Healthcare Tomorrow

Stunning.Stunning.

140,000,000 140,000,000 illegible illegible

prescriptions prescriptions per yearper year

——John Hammergren & Phil Harkins, John Hammergren & Phil Harkins, Skin in the Game: How Skin in the Game: How Putting Yourself First Today Will Revolutionize Healthcare Putting Yourself First Today Will Revolutionize Healthcare

Tomorrow Tomorrow

**1,500,000,000,000**1,500,000,000,000 claims per year claims per year**30% errors**30% errors**15% lost**15% lost**25% paper-based**25% paper-basedSource: Source: John Hammergren & Phil Harkins, John Hammergren & Phil Harkins, Skin in the Game: Skin in the Game: How Putting Yourself First Today Will Revolutionize How Putting Yourself First Today Will Revolutionize Healthcare Tomorrow Healthcare Tomorrow

Stunning.Stunning.

””I can receive a BlackBerry I can receive a BlackBerry message from a colleague message from a colleague

climbing a mountain, yet I still climbing a mountain, yet I still show up at a doctor’s office show up at a doctor’s office [and after a 45-minite wait] [and after a 45-minite wait] learn that my hospital test learn that my hospital test

results have not arrived results have not arrived weeks after they should weeks after they should

have.”have.” ——John Hammergren & Phil Harkins, John Hammergren & Phil Harkins, Skin in the Game: Skin in the Game:

How Putting Yourself First Today Will Revolutionize How Putting Yourself First Today Will Revolutionize Healthcare Tomorrow Healthcare Tomorrow

Stunning.Stunning.

Up To 500,000 Lives:Up To 500,000 Lives: “The medical “The medical system has been unable to turn proven system has been unable to turn proven

remedies into everyday care.* Half the people remedies into everyday care.* Half the people who need to be treated to prevent heart who need to be treated to prevent heart attacks are not treated and half who are attacks are not treated and half who are

treated are treated inadequately. Patients go treated are treated inadequately. Patients go home with the wrong drugs or the wrong home with the wrong drugs or the wrong

doses or misimpressions about the doses or misimpressions about the importance of taking their medications.”importance of taking their medications.”

*More: 55% chance of “receiving the best *More: 55% chance of “receiving the best recommended care—which means getting scientifically recommended care—which means getting scientifically

appropriate, evidence-based medical treatment”appropriate, evidence-based medical treatment” ——The New York TimesThe New York Times, from John Hammergren &, from John Hammergren &

Phil Harkins, Phil Harkins, Skin in the Game:How Putting YourselfSkin in the Game:How Putting Yourself First Today Will Revolutionize Healthcare Tomorrow First Today Will Revolutionize Healthcare Tomorrow

Stunning.Stunning.

““The private insurance industry The private insurance industry has little incentive to see people has little incentive to see people live healthy lives beyond 65 when live healthy lives beyond 65 when

their customers automatically their customers automatically drop out of the employer-based drop out of the employer-based

system and enter the system and enter the government-based system.”government-based system.”

—John Hammergren & Phil Harkins, —John Hammergren & Phil Harkins, Skin in the Game:Skin in the Game: How Putting Yourself First Today Will Revolutionize How Putting Yourself First Today Will Revolutionize

Healthcare TomorrowHealthcare Tomorrow

StupidStupid

““How will you know when the healthcare industry has finally How will you know when the healthcare industry has finally entered the 21entered the 21stst century? When error rates at hospitals are century? When error rates at hospitals are close to zero. When doctors and nurses use evidence-based close to zero. When doctors and nurses use evidence-based

protocols in your treatment. When you can decide how protocols in your treatment. When you can decide how much to spend on treatment, and you have the information much to spend on treatment, and you have the information

and the opportunity to determine the best value. When and the opportunity to determine the best value. When your primary care physician is in charge of your extended your primary care physician is in charge of your extended care team, operating as your command central. When all care team, operating as your command central. When all

members of the medical community—nurses, doctors, members of the medical community—nurses, doctors, pharmacists and specialists—work together seamlessly on pharmacists and specialists—work together seamlessly on

your behalf. When their combined efforts are tracked, your behalf. When their combined efforts are tracked, measured, and reported on—and the insurance measured, and reported on—and the insurance reimbursements awarded to them are based on reimbursements awarded to them are based on

performance. When you see that hospitals, pharmacies and performance. When you see that hospitals, pharmacies and doctors are working harder in all aspects to make sure you doctors are working harder in all aspects to make sure you are an informed consumer who has trust and confidence in are an informed consumer who has trust and confidence in

the services they offer and the prices they charge.” the services they offer and the prices they charge.” —John Hammergren & Phil Harkins, —John Hammergren & Phil Harkins, Skin in the Game: How PuttingSkin in the Game: How Putting

Yourself First Today Will Revolutionize Healthcare Tomorrow Yourself First Today Will Revolutionize Healthcare Tomorrow

Hammergren says we know theHammergren says we know the shape of revised system …shape of revised system …

“ … “ … 25 to 30 percent of our $2.2 trillion goes to25 to 30 percent of our $2.2 trillion goes to wasted care in the form of preventable errors, wasted care in the form of preventable errors,

incorrect diagnoses, redundant treatment, incorrect diagnoses, redundant treatment, unnecessary infections, and extra time spent in the unnecessary infections, and extra time spent in the

hospital.hospital. Team-based medicine, bar-Team-based medicine, bar-code prescription scanning, code prescription scanning,

evidence-based medicine—all of evidence-based medicine—all of these are systems and these are systems and

innovations that are being put innovations that are being put into place to eliminate waste so into place to eliminate waste so

that we can that we can re-apply the money.”re-apply the money.”

—John Hammergren & Phil Harkins, —John Hammergren & Phil Harkins, Skin in the Game:Skin in the Game: How Putting Yourself First Today Will Revolutionize How Putting Yourself First Today Will Revolutionize

Healthcare TomorrowHealthcare Tomorrow

Hammergren says we know theHammergren says we know the shape of revised system … shape of revised system … and the and the

way to get from here to there.way to get from here to there.

4. K.I.A. & 4. K.I.A. & Wounded: A Wounded: A

house house (hospital) of (hospital) of

horrorshorrors

“Quality”:

COULD IT TRULY BE

THIS AWFUL?

3DHC = 3DHC = 5YI5YI

3DHC = 5YI:3DHC = 5YI:

3 3 dadayys’s’ health“care”-caused health“care”-caused deaths = 5 ydeaths = 5 yearsears of of American soldiers’ American soldiers’ deaths in the Iraq deaths in the Iraq

War*War**Not including most of the deaths forgone annually if *Not including most of the deaths forgone annually if

prevention-wellness became the primary arm of health-prevention-wellness became the primary arm of health-healthcare industryhealthcare industry

““QQualituality of y of carecare is the is the problem, problem, notnot

managed care.”managed care.”Source: Institute of Medicine (from Michael Millenson, Source: Institute of Medicine (from Michael Millenson,

Demanding Medical ExcellenceDemanding Medical Excellence))

““Study: Medical Study: Medical Errors Affect 20 Errors Affect 20

Percent of Percent of Patients”Patients” —headline, Boston Herald

RANDRAND:: 50%, appropriate 50%, appropriate preventive care. 60%, preventive care. 60%,

recommended treatment, per recommended treatment, per medical studies, for chronic medical studies, for chronic conditions. conditions. 20% , chronic

care treatment that is wrong. 30% acute care treatment

that is wrong.

Typical stats—more to come.Typical stats—more to come.

Welcome to the Homer Simpson Hospital, a/k/a …

The Killin

g Fields

American life expectancy is relatively American life expectancy is relatively low—low—andand the delivery of healthcare in the delivery of healthcare in

the U.S. is notoriously unsafe.the U.S. is notoriously unsafe.

CDC 1998CDC 1998:: 90,00090,000 killedkilled and and 2,000,0002,000,000 injuredinjured from from

hospital-caused drug hospital-caused drug errors & infectionserrors & infections

This 1998 report was a shockerThis 1998 report was a shocker——and bitterly contested by the and bitterly contested by the

“healthcare establishment.” Now“healthcare establishment.” Now it’s taken for granted, and perhaps it’s taken for granted, and perhaps

understates—significantly. More grim understates—significantly. More grim estimates follow.estimates follow.

HealthGrades/Denver:HealthGrades/Denver:

195,000195,000 hospital deaths per hospital deaths per

year in the U.S., 2000-2002 = equivalent of year in the U.S., 2000-2002 = equivalent of 390 full 390 full jjumbos/747s in the drink umbos/747s in the drink pper er yyear—more than one-a-daear—more than one-a-day.y.

Comments: Comments: There is little There is little evidence that patient evidence that patient safety has imsafety has impproved in roved in the last five yearsthe last five years.”.” —Dr. Samantha —Dr. Samantha CollierCollier

Source: Source: Boston Globe/2005Boston Globe/2005

1,000,0001,000,000 “serious medication errors per “serious medication errors per year” … “illegible handwriting, year” … “illegible handwriting, misplaced decimal points, and misplaced decimal points, and missed drug interactions and missed drug interactions and

allergies.”allergies.”

Source: Source: Wall Street Journal /Wall Street Journal /Institute of MedicineInstitute of Medicine

Throughout, we will see that much of Throughout, we will see that much of this this horrorshowhorrorshow is the product is the product

of “simple” problems—e.g., bad of “simple” problems—e.g., bad handwriting.handwriting.

““The Institute of Medicine The Institute of Medicine calculated that drug errors calculated that drug errors [on [on

average, average, one per patient per visitone per patient per visit—various —various sources; some estimates go as high as one-per-sources; some estimates go as high as one-per-

patient-per-day, on average]patient-per-day, on average] alone add alone add on average nearly on average nearly

$5,000$5,000 to the cost of to the cost of every hospital visit.”every hospital visit.” Overtreated: Why Too Much Medicine Is Making UsOvertreated: Why Too Much Medicine Is Making Us

Sicker and Poorer Sicker and Poorer, Shannon Brownlee, Shannon Brownlee

““HosHosppital infections kill an ital infections kill an estimated 103,000 estimated 103,000 ppeoeopplele

in the United States a in the United States a yyear, ear, as manas manyy as AIDS, breast as AIDS, breast

cancer and auto accidents cancer and auto accidents combinedcombined.. … Today, experts estimate that more than 60 percent of … Today, experts estimate that more than 60 percent of

staph infections are M.R.S.A. [up from 2 percent in 1974]. Hospitals in Denmark, staph infections are M.R.S.A. [up from 2 percent in 1974]. Hospitals in Denmark, Finland and the Netherlands once faced similar rates, but brought them down to below Finland and the Netherlands once faced similar rates, but brought them down to below

1 percent. How? Through the rigorous enforcement of rules on hand washing, the 1 percent. How? Through the rigorous enforcement of rules on hand washing, the meticulous cleaning of equipment and hospital rooms, the use of gowns and meticulous cleaning of equipment and hospital rooms, the use of gowns and

disposable aprons to prevent doctors and nurses from spreading germs on clothing disposable aprons to prevent doctors and nurses from spreading germs on clothing and the testing of incoming patients to identify and isolate those carrying the germ. … and the testing of incoming patients to identify and isolate those carrying the germ. … Many hospital administrators say they can’t afford to take the necessary precautionsMany hospital administrators say they can’t afford to take the necessary precautions ..””

—Betsy McCaughey, founder of the Committee to Reduce Infection Deaths (—Betsy McCaughey, founder of the Committee to Reduce Infection Deaths (New York TimesNew York Times/06.06.2005)/06.06.2005)

““1-in-7 Chance 1-in-7 Chance of Medical of Medical

Mishap: Health Mishap: Health Ministry Report”Ministry Report”

Source: Headline, The Press, Christchurch, NZ, Source: Headline, The Press, Christchurch, NZ, 0216.08 (odds of a screwup during a hospital stay)0216.08 (odds of a screwup during a hospital stay)

“When I climb Mount When I climb Mount Rainier I face less Rainier I face less

risk of death than I’ll risk of death than I’ll face on the face on the

operating table.”operating table.” ——Don BerwickDon Berwick

Berwick is the uber-guru of theBerwick is the uber-guru of the patient safety movement.patient safety movement.

““The results are deadly. In addition The results are deadly. In addition to the to the 98,00098,000 killed by medical killed by medical

errors in hospitals and the errors in hospitals and the 90,00090,000 deaths caused by hospital deaths caused by hospital

infections, another infections, another 126,000126,000 die die from their doctor’s failure to from their doctor’s failure to

observe evidence-based protocols observe evidence-based protocols for for jjustust fourfour common conditions: common conditions:

hypertension, heart attack, hypertension, heart attack, pneumonia, and colorectal cancer.” pneumonia, and colorectal cancer.”

[TP: total [TP: total 314,000314,000]]Source:Source: Best Care Anywhere: Why VA Healthcare Is Better Than YoursBest Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman/Phillip Longman

11mm4242ss

The 314K per year, very conservative, The 314K per year, very conservative, translates into an unnecessary death translates into an unnecessary death

every every one-minute-and-forty-two one-minute-and-forty-two secondsseconds. ..... ....

5959

... which in turn translates into 59 ... which in turn translates into 59 unnecessary deaths in the course of a unnecessary deaths in the course of a healthcare presentation, a little over healthcare presentation, a little over an hour long, that I recently made.an hour long, that I recently made.

““Plus God alone Plus God alone knows how many knows how many

casualties in casualties in doctors’ offices, doctors’ offices,

Tom”Tom” —Thom Mayer—Thom Mayer

Thom Mayer, renown ER doc and Thom Mayer, renown ER doc and consultant on patient-centric care, consultant on patient-centric care, reminded me that the grim stats reminded me that the grim stats

above leave out the likes what goes on above leave out the likes what goes on in docs’ offices all over the land. in docs’ offices all over the land.

(Arguably a staggering number in its (Arguably a staggering number in its own right.)own right.)

““I had done what doctors do well in I had done what doctors do well in this country, which is to treat this country, which is to treat

people when they come in with a people when they come in with a disease. disease. MMyy ppatients had atients had ggood ood

medical care but not, I bemedical care but not, I beggan to an to think, think, ggreat healthcarereat healthcare.. For most, their For most, their

declines, their illnesses, were thirty-year declines, their illnesses, were thirty-year problems of lifestyle, not disease. I, like most problems of lifestyle, not disease. I, like most doctors in America, had been doing the wrong doctors in America, had been doing the wrong job well. Modern medicine does not concern job well. Modern medicine does not concern itself with lifestyle problems. Doctors don’t itself with lifestyle problems. Doctors don’t

treat them, medical schools don’t teach them treat them, medical schools don’t teach them and insurers don’t pay to solve them. I began to and insurers don’t pay to solve them. I began to

think that this was indefensible.”think that this was indefensible.” —Henry Lodge, —Henry Lodge, Younger Next YearYounger Next Year

Also left out are the folks who’d be Also left out are the folks who’d be with us if the system focused on with us if the system focused on

health—wellness, prevention, etc..health—wellness, prevention, etc..

““ExExpperts estimate that moreerts estimate that more than a hundred thousand than a hundred thousand

Americans die each Americans die each yyear notear not from illness but from their from illness but from their pprescrirescripption drution druggss.. Those deaths, Those deaths,

occurring quietly, almost without notice in hospitals, emergency occurring quietly, almost without notice in hospitals, emergency rooms, and homes, make medicines one of the leading causes of rooms, and homes, make medicines one of the leading causes of death in the United States. On a daily basis, prescription pills are death in the United States. On a daily basis, prescription pills are

estimated to kill more than 270 Americans. … Prescription estimated to kill more than 270 Americans. … Prescription medicines, taken according to doctors’ instructions, kill more medicines, taken according to doctors’ instructions, kill more

Americans than either diabetes or Alzheimer’s disease.”Americans than either diabetes or Alzheimer’s disease.”

Source:Source: Our Daily Meds: How the Pharmaceutical Companies Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs Hooked the Nation on Prescription Drugs —Melody Petersen—Melody Petersen

And on it goes ....And on it goes ....

Primary-care Primary-care docs = docs =

Second-class Second-class citizens.citizens.Sources: too numerous to mentionSources: too numerous to mention

The people who ought to be the The people who ought to be the gatekeepers who would oversee the gatekeepers who would oversee the

co-ordination of specialists work—the co-ordination of specialists work—the dis-organized results thereof which are dis-organized results thereof which are responsible for most of the likes of the responsible for most of the likes of the

prescription-med errors—are prescription-med errors—are secondclass citizens in the specialist-secondclass citizens in the specialist-

centric “World of Modern centric “World of Modern Health“care.”Health“care.”

11m m 2828ss

Maybe I undershot onMaybe I undershot on the earlier slide??? the earlier slide???

““In 2006 when In 2006 when TimeTime magazine magazine had the brilliant idea of asking had the brilliant idea of asking doctors what scared them most doctors what scared them most

about being a patient, three about being a patient, three frequent answers were fear of frequent answers were fear of

medical errorsmedical errors, fear of , fear of unnecessary surgeryunnecessary surgery, and fear of , and fear of contracting a contracting a staph infectionstaph infection in in

teaching hospitals.” teaching hospitals.”

Best Care Any where: Why VA Healthcare Is Best Care Any where: Why VA Healthcare Is Better Than Yours,Better Than Yours, Phillip Longman Phillip Longman

The docs “get it” …The docs “get it” …And you?And you?

““Put a Put a muzzle on muzzle on that boy.”that boy.”

In my 30 years of speechifying, I have said a few In my 30 years of speechifying, I have said a few controversial things—in fact I have a bit of a reputation for controversial things—in fact I have a bit of a reputation for so doing. But no one has tried to put a muzzle on me. Well, so doing. But no one has tried to put a muzzle on me. Well, no one except the … no one except the … American Hospital AssociationAmerican Hospital Association. When . When

the CDC 98,000 hospital deaths study appeared, it was the CDC 98,000 hospital deaths study appeared, it was fought tooth and nail by “the establishment.” I was appalled fought tooth and nail by “the establishment.” I was appalled by the statistic—mostly as a prospective patient. Along the by the statistic—mostly as a prospective patient. Along the

way, I used the stat in a talk (the CDC is a pretty damn way, I used the stat in a talk (the CDC is a pretty damn reliable source!); and then I got a message—the first and reliable source!); and then I got a message—the first and only time in my career—from my speakers’ bureau. The only time in my career—from my speakers’ bureau. The

American Hospital Association is a big client of theirs. And American Hospital Association is a big client of theirs. And the AHA chief executive had called the president of the the AHA chief executive had called the president of the

speakers’ bureau and more or less speakers’ bureau and more or less demandeddemanded that he order that he order me to shut up—and quit propagating that scurrilous number. me to shut up—and quit propagating that scurrilous number. Naturally the speakers’ bureau told him that my content was Naturally the speakers’ bureau told him that my content was up to me, not them. I was of course delighted—it suggested up to me, not them. I was of course delighted—it suggested that the number was correct, and that I had drawn blood. that the number was correct, and that I had drawn blood. But my point here is that this was the only time in three But my point here is that this was the only time in three

decades that such censorship has been sought. (Of course I decades that such censorship has been sought. (Of course I can see why the AHA was embarrassed—they damn well can see why the AHA was embarrassed—they damn well

should have been!! And still should be!!)should have been!! And still should be!!)

5. How “it” 5. How “it” “works” “works”

(and feels) (and feels) ……

Journalist Tim Noah writes about his wife’s cancer Journalist Tim Noah writes about his wife’s cancer treatment in a high-rep private med center:treatment in a high-rep private med center: “ “Much Much

of our effort involved retrievinof our effort involved retrievingg information from one source and information from one source and

sendinsendingg it to another it to another.. This wasn’t something This wasn’t something we could count on happening on its own. Very we could count on happening on its own. Very expensive blood test results, we observed, had expensive blood test results, we observed, had

perhaps a perhaps a 50%50% chance of being misplaced under a chance of being misplaced under a pile of faxes and therefore not finding their way into pile of faxes and therefore not finding their way into

Marjorie [William’s] medical chart. So we made a habit Marjorie [William’s] medical chart. So we made a habit of getting the labs to fax to our house. Films of CT of getting the labs to fax to our house. Films of CT

scans would be misfiled perhaps scans would be misfiled perhaps 30%30% of the time and of the time and thus become permanently irretrievable. So I took my thus become permanently irretrievable. So I took my

checkbook to all of Marjorie’s CT scans and purchased checkbook to all of Marjorie’s CT scans and purchased my own spare copy on the spot.”my own spare copy on the spot.”

Source: Foreword toSource: Foreword to Best Care Any where: Why VA Best Care Any where: Why VA Healthcare Is Better Than Yours,Healthcare Is Better Than Yours, Phillip Longman Phillip Longman

““My most memorable brushes have My most memorable brushes have been with an eminent surgeon,” been with an eminent surgeon,”

MarjorieMarjorie [Longman’s wife, on the receiving end of cancer [Longman’s wife, on the receiving end of cancer treatment]treatment] wrote in her next-to-last column wrote in her next-to-last column

for the for the Washington PostWashington Post, “whose , “whose method is to stride into the examining method is to stride into the examining room two hours late, pat your hand, room two hours late, pat your hand,

pronounce your certain death if he can’t pronounce your certain death if he can’t perform an operation on you, and then perform an operation on you, and then

snap at your husband to stop taking snap at your husband to stop taking notes, since he can’t possibly follow the notes, since he can’t possibly follow the

complexity of the doctor’s thinking.” complexity of the doctor’s thinking.” Source:Source: Best Care Anywhere: Why VA Healthcare Is Better Than YoursBest Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman/Phillip Longman

These are all too common reports. These are all too common reports. Patient safety guru Don Berwick, a Patient safety guru Don Berwick, a renowned M.D. and Harvard Med renowned M.D. and Harvard Med

School faculty member, was moved to School faculty member, was moved to his vociferous patient-safety advocacy,his vociferous patient-safety advocacy,

not by analytic deduction, but bynot by analytic deduction, but by the insane frequency of errors in his the insane frequency of errors in his

wife’s treatment at a “prestigious wife’s treatment at a “prestigious Boston medical center.”Boston medical center.”

6. You must6. You must be yourbe your

own boss!own boss!

““He shook me up. He put his hand He shook me up. He put his hand on my shoulder, and simply said, on my shoulder, and simply said,

‘Old friend, ‘Old friend, yyou have ou have ggot to take charot to take chargge e

of of yyour own our own medical caremedical care.’ ”.’ ”Source: Source: Hamilton Jordan, Hamilton Jordan, No Such Thing as a Bad DayNo Such Thing as a Bad Day, on a, on a

conversation with a doctor pal following Jordan’s cancer diagnosis) conversation with a doctor pal following Jordan’s cancer diagnosis)

Longman (his wife, Robin, treated for cancer):Longman (his wife, Robin, treated for cancer): “The “The more time we spent in the Lombardi Center and more time we spent in the Lombardi Center and

Georgetown hospital, the more I was disturbed by the Georgetown hospital, the more I was disturbed by the way they managed way they managed ‘the little things.’‘the little things.’ … I was similarly … I was similarly shocked at how little the various specialists involved shocked at how little the various specialists involved in her care seemed to consult with one another, or to in her care seemed to consult with one another, or to

keep up to date on the results of tests. … There keep up to date on the results of tests. … There seemed to be little attention given to managing seemed to be little attention given to managing information and coordinating care. …information and coordinating care. … I came I came awaawayy feelin feelingg that no that no ppatient atient should ever enter a hosshould ever enter a hosppital ital without havinwithout havingg some kind of some kind of

fulltime advocate—a carinfulltime advocate—a caringg, calm, , calm, shrewd relative or friendshrewd relative or friend

at leastat least.”.”Source: Best Care Any where: Why VA Healthcare IsSource: Best Care Any where: Why VA Healthcare Is

Better Than Yours,Better Than Yours, Phillip Longman Phillip Longman

For the patient, the immediate answer For the patient, the immediate answer to this sad state of affairs is to become to this sad state of affairs is to become

one’s own healthcare quarterback—one’s own healthcare quarterback—and to quit trusting “the guys inand to quit trusting “the guys in

the white coats.” the white coats.”

TP:TP: “Just one second, “Just one second, please. You do knowplease. You do know

I’ve got a pacemaker, I’ve got a pacemaker, lower limit only, 60bpm, lower limit only, 60bpm,

no defib? And that I no defib? And that I take 150 mg of take 150 mg of

Coumadin a day? …”*Coumadin a day? …”**In 3 of 4 cases, in a 2-day period, the answer was in part,*In 3 of 4 cases, in a 2-day period, the answer was in part,

at least, at least, “No”“No” —including set-up for an echo stress —including set-up for an echo stress cardio test (reading and results dependent on the above cardio test (reading and results dependent on the above

info)info)

My own pitiful experience—I was and My own pitiful experience—I was and am enraged. (March 2008, “prestigious am enraged. (March 2008, “prestigious

Boston medical center.”)Boston medical center.”)

7. Over-7. Over-treatmenttreatment

!!!!!!!!!!!!!!!!

3%3%

This section buggers the imagination. This section buggers the imagination.

““The big cause of skyrocketing The big cause of skyrocketing healthcare costs has been healthcare costs has been

increasingly intensive use of increasingly intensive use of technologies and treatments that, technologies and treatments that, when we look at their effects on when we look at their effects on the population as a whole, the population as a whole, have

brought only negligible improvement in public health

and longevity.”

Best Care Any where: Why VA HealthcareBest Care Any where: Why VA Healthcare Is Better Than Yours,Is Better Than Yours, Phillip Longman Phillip Longman

The previous slide and the next four The previous slide and the next four that follow presumably require no that follow presumably require no

elaboration—except for me to say that elaboration—except for me to say that I could have offered a 20-slide array, I could have offered a 20-slide array, not just these few, had I so desired. not just these few, had I so desired.

““We spend between one-fifth We spend between one-fifth and one-third of our healthcare and one-third of our healthcare dollars, an exorbitant amount dollars, an exorbitant amount of money, of money, between five between five hundred and seven hundred and seven

hundred billion dollarshundred billion dollars,, on care that does nothing to on care that does nothing to

improve our health.”improve our health.”Source:Source: Overtreated: Why Too Much Medicine Is Making UsOvertreated: Why Too Much Medicine Is Making Us

Sicker and PoorerSicker and Poorer, Shannon Brownlee, Shannon Brownlee

400,000400,000 heart bypass surgeries, heart bypass surgeries, 1,000,000 1,000,000 angioplasties per angioplasties per year:year: “Yet recent studies show “Yet recent studies show

that only about that only about threethree ppercentercent of the patients of the patients

who receive such operations who receive such operations benefit from them; most would be benefit from them; most would be better served better served jjust takinust takingg as asppirin irin

or low-cost beta blockersor low-cost beta blockers.”.”Source:Source: Best Care Anywhere: Why VA Healthcare Is Better Than YoursBest Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman/Phillip Longman

““Americans undergo millions of tests—Americans undergo millions of tests—MRIs, CT scans, blood tests—MRIs, CT scans, blood tests—that do little to help doctors diagnose disease, and sometimes lead

them to find and treat conditions that would never have bothered

their patients had they never been found. We undergo back We undergo back

surgery for pain in the absence of surgery for pain in the absence of evidence that the surgery works.”evidence that the surgery works.”

Source:Source: Overtreated: Why Too Much Medicine Is MakingOvertreated: Why Too Much Medicine Is Making Us Sicker and PoorerUs Sicker and Poorer, Shannon Brownlee, Shannon Brownlee

““[Dartmouth Professor Elliott][Dartmouth Professor Elliott] Fisher and his Fisher and his colleagues discovered that colleagues discovered that

patients who went to hospitals patients who went to hospitals

that spent the most— that spent the most— and and did the most did the most

pproceduresrocedures —were 2 to —were 2 to 6 percent more likely to die than 6 percent more likely to die than patients that went to hospitals patients that went to hospitals

that spent the least.”that spent the least.”Source:Source: Overtreated: Why Too Much Medicine Is Making Overtreated: Why Too Much Medicine Is Making

Us Sicker and PoorerUs Sicker and Poorer, Shannon Brownlee, Shannon Brownlee

““The most powerful The most powerful reason doctors and reason doctors and

hospitals overtreat is hospitals overtreat is that most of them are that most of them are

paid for how much care paid for how much care

they deliver, they deliver, not not how how well they care for their well they care for their

patients.”patients.”Overtreated: Why Too Much Medicine Is Making UsOvertreated: Why Too Much Medicine Is Making Us

Sicker and PoorerSicker and Poorer, Shannon Brownlee, Shannon Brownlee

““Teach to test” is the Achilles heel of Teach to test” is the Achilles heel of our “education” system—the only our “education” system—the only

acquired skill is test-taking; and the acquired skill is test-taking; and the essential love-of-learning is essential love-of-learning is

diminished, not enhanced. Likewise, diminished, not enhanced. Likewise, “pay for procedure” is the perverse “pay for procedure” is the perverse

centerpiece of our health“care” centerpiece of our health“care” system—denigrating the very health system—denigrating the very health for which we were intended to care.for which we were intended to care.

Hospital intake interview with yours Hospital intake interview with yours truly, Boston, March 2008truly, Boston, March 2008

Physician’s Assistant:Physician’s Assistant: “What did“What did your mother die of?” your mother die of?”TP:TP: “Too many specialists.”“Too many specialists.”

PA:PA: “No, really?“No, really?TP:TP: Really!!”Really!!”

Hospital intake interview, Boston, March Hospital intake interview, Boston, March 20082008

Physician’s Assistant:Physician’s Assistant: “What did“What did your mother die of?” your mother die of?”TP:TP: “Too many“Too many

[excellent][excellent] specialists.”specialists.”


Hospital intake interview, Boston, March Hospital intake interview, Boston, March 20082008

Physician’s Assistant:Physician’s Assistant: “What did“What did your mother die of?” your mother die of?”TP:TP: “Too many“Too many [excellent][excellent] specialists specialists [who never [who never communicate/d with communicate/d with one another]one another] .” .”


I was not joking. As the end hove in I was not joking. As the end hove in sight, my Mom was being treated for a sight, my Mom was being treated for a sizeable number of problems (she was sizeable number of problems (she was 95); it seemed as though no more than 95); it seemed as though no more than

a couple of days passed before she a couple of days passed before she was over-reacting to one med that was over-reacting to one med that

other docs were not aware of. They’d other docs were not aware of. They’d cut that one back, then enhance cut that one back, then enhance another. At 95, she was simply another. At 95, she was simply

wearing out—but her overload of non-wearing out—but her overload of non-coordinated specialists pretty clearly coordinated specialists pretty clearly pushed her out the door. (This is not pushed her out the door. (This is not

just my conclusion, but that of a just my conclusion, but that of a couple ofcouple of

my M.D. pals.)my M.D. pals.)

““If we sent 30 percent If we sent 30 percent of the doctors in this of the doctors in this country to Africa, we country to Africa, we

might raise the level of might raise the level of health on both health on both

continents.”continents.” —Dr Elliott Fisher, —Dr Elliott Fisher, Center of Evaluative Clinical Sciences, Dartmouth Medical SchoolCenter of Evaluative Clinical Sciences, Dartmouth Medical School

(“Overdose,” (“Overdose,” AtlanticAtlantic, Shannon Brownlee.), Shannon Brownlee.)

He’s not kidding! (Elliott Fisher is one He’s not kidding! (Elliott Fisher is one of the real super-heroes among those of the real super-heroes among those trying to push the rock-of-reform up trying to push the rock-of-reform up

the mountain of med system the mountain of med system resistance.)resistance.)

““America has America has twice as many hospitals and physicians as it needs.” —Med Inc., Sandy

Lutz, Woodrin Grossman & John Bigalke

Ditto Fisher.Ditto Fisher.

$PD(USA) $PD(USA) >> $PD(J + G $PD(J + G + F + I + S + UK + A+ F + I + S + UK + A

+ NZ + C + M + B + A)+ NZ + C + M + B + A) >> $G(USA) $G(USA) >> $HEX2(USA)*$HEX2(USA)*

*U.S. spending on prescription drugs in 2005 *U.S. spending on prescription drugs in 2005 ($250,000,000,000)($250,000,000,000) is greater than is greater than the the combinedcombined spending on prescription drugs by spending on prescription drugs by JapanJapan plus plus GermanyGermany plus plus FranceFrance

plus plus ItalyItaly plus plus SpainSpain plus the plus the United KingdomUnited Kingdom plus plus AustraliaAustralia plus plus New ZealandNew Zealand plusplus Canada Canada plusplus MexicoMexico plusplus BrazilBrazil plusplus ArgentinaArgentina (all except Mexico, Brazil and (all except Mexico, Brazil and Argentina have longer life expectancies than we do); and our prescription drug Argentina have longer life expectancies than we do); and our prescription drug

bill also is more than our bill also is more than our gasolinegasoline bill and two times more than our bill and two times more than our higher edhigher ed bill. bill.

Source: Our Daily Meds: How the Pharmaceutical CompaniesSource: Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines andTransformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs Hooked the Nation on Prescription Drugs —Melody Petersen—Melody Petersen

$PD(USA) $PD(USA) >> $PD(J + G + F + I + S + UK + A + NZ + C $PD(J + G + F + I + S + UK + A + NZ + C + M + B + A) + M + B + A) >> $G(USA) $G(USA) >> $HEX2(USA)* $HEX2(USA)*

*U.S. spending on prescription drugs in 2005 *U.S. spending on prescription drugs in 2005 ($250,000,000,000)($250,000,000,000) is greater than the is greater than the

combinedcombined spending on prescription spending on prescription drugs by drugs by JapanJapan plus plus GermanyGermany plus plus FranceFrance plus plus ItalyItaly plus plus SpainSpain plus the plus the United KingdomUnited Kingdom plus plus AustraliaAustralia plus plus New ZealandNew Zealand plusplus Canada Canada plusplus MexicoMexico plusplus BrazilBrazil plusplus ArgentinaArgentina (all except (all except Mexico, Brazil and Argentina have longer life Mexico, Brazil and Argentina have longer life

expectancies than we do); and our prescription expectancies than we do); and our prescription drug bill also is more than our drug bill also is more than our gasolinegasoline bill and bill and

two times more than our two times more than our higher edhigher ed bill. bill.

Source: Our Daily Meds: How the Pharmaceutical CompaniesSource: Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines andTransformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs Hooked the Nation on Prescription Drugs —Melody Petersen—Melody Petersen

Again, words like “insane” or Again, words like “insane” or “ridiculous” or “outrageous” are the “ridiculous” or “outrageous” are the

only ones that come to mind.only ones that come to mind.

““a grossly a grossly overprescribed overprescribed nation”nation” —Arnold Relman, professor —Arnold Relman, professor

emeritus, Harvard Med; former editor, emeritus, Harvard Med; former editor, The New England Journal The New England Journal of Medicineof Medicine


““Creating a Creating a disease”disease” —from a slide by Neil Wolf, —from a slide by Neil Wolf,

Pharmacia, at the 2003 Pharmaceutical Marketing GlobalPharmacia, at the 2003 Pharmaceutical Marketing Global Summit (Philadelphia) Summit (Philadelphia)


I am I am notnot an instinctive basher of the an instinctive basher of the pharmaceutical industry. Yet the pharmaceutical industry. Yet the

evidence is clear—the industry has evidence is clear—the industry has repeatedly made mountains (worth $$repeatedly made mountains (worth $$$$$billions) out of mole-hills. (Or “no-$$$billions) out of mole-hills. (Or “no-

hills.”) hills.”)

8. F.Y.I.: The 8. F.Y.I.: The dominating dominating (!)(!)

Role of Role of healthcarehealthcare

in the American in the American economyeconomy

““What’s Really Propping What’s Really Propping Up the Economy: Up the Economy:

Healthcare has added 1.7 Healthcare has added 1.7 million jobs since 2001. million jobs since 2001. The rest of the private The rest of the private

sector?sector? NoneNone.”.”Source: Title, cover story, Source: Title, cover story, BusinessWeekBusinessWeek,, 0925.20060925.2006

U.S. Healthcare ExpendituresU.S. Healthcare Expenditures

2008: $2.2 trillion2008: $2.2 trillion2016: $4 trillion2016: $4 trillion

Source: Source: John Hammergren & Phil Harkins, John Hammergren & Phil Harkins, Skin in the Game: Skin in the Game: How Putting Yourself First Today Will Revolutionize How Putting Yourself First Today Will Revolutionize Healthcare Tomorrow Healthcare Tomorrow

We spend over We spend over $2,000,000,000,000$2,000,000,000,000 on healthcare in America—and it is on healthcare in America—and it is

also our engine of job growth. also our engine of job growth. Increasingly, “healthcare economics” Increasingly, “healthcare economics”

are “are “AmericanAmerican economics.” economics.”

9. Pick of the 9. Pick of the litter: litter:

Our Our “best”“best” hospitals? hospitals?

““Generally, Generally, the more the more pprestirestiggious the hosious the hosppitalital you check into, and the more you check into, and the more eminent and numerous the eminent and numerous the physicians who attend you, physicians who attend you, the more likelthe more likelyy yyou are ou are

to receive low-to receive low-qqualitualityy or or even daneven danggerous and erous and unnecessarunnecessaryy care care.”.”

Source:Source: Best Care Anywhere: Why VA Healthcare Is Better Than YoursBest Care Anywhere: Why VA Healthcare Is Better Than Yours /Phillip Longman/Phillip Longman

Flabbergasting.Flabbergasting.

““The more doctors and specialists The more doctors and specialists around, the more tests and procedures around, the more tests and procedures performed. And the results of all these performed. And the results of all these

tests and procedures? Lots more medical tests and procedures? Lots more medical bills, exposure to medical errors, and a bills, exposure to medical errors, and a

loss of life exloss of life exppectancectancy.y. ““It was this last conclusion that was truly shocking, but it It was this last conclusion that was truly shocking, but it

became unavoidable when [Dartmouth’s Dr. Jack] became unavoidable when [Dartmouth’s Dr. Jack] Wennberg and others broadened their studies.Wennberg and others broadened their studies. They They

found it’s not just that renowned found it’s not just that renowned hospitals and their specialists tend to hospitals and their specialists tend to

engage in massive overtreatment. They engage in massive overtreatment. They also tend to be also tend to be poor at poor at pprovidinroviding critical g critical

but but routine careroutine care.”.”Source:Source: Best Care Anywhere: Why VA Healthcare Is Better Than YoursBest Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman /Phillip Longman

““[Dartmouth’s Dr. Jack] Wennberg and others … found it’s [Dartmouth’s Dr. Jack] Wennberg and others … found it’s not just that renowned hospitals and their specialists tend to not just that renowned hospitals and their specialists tend to engage in massive overtreatment. They also tend to be poor engage in massive overtreatment. They also tend to be poor

at providing critical but routine care. at providing critical but routine care. For example, For example, Dartmouth researcher Elliot S. Fisher has found that Dartmouth researcher Elliot S. Fisher has found that among Medicare patients, who share the same age, among Medicare patients, who share the same age, socioeconomic, and health status, their chances of socioeconomic, and health status, their chances of

dying in the next five years are greater if they go to a dying in the next five years are greater if they go to a high-spending hospital. One reason is that patients in high-spending hospital. One reason is that patients in

high-spending hospitals with lots of specialists and high-spending hospitals with lots of specialists and high technology are also less likely to receive many high technology are also less likely to receive many

proven routine treatments [e.g. aspirin, flu vaccine]. … proven routine treatments [e.g. aspirin, flu vaccine]. … This general lack of attention to prevention and This general lack of attention to prevention and

follow-up care in high-spending hospitals helps to follow-up care in high-spending hospitals helps to explain why not only heart-attack victims but also explain why not only heart-attack victims but also

patients suffering from colon cancer and hip fracture patients suffering from colon cancer and hip fracture stand a better chance of living another five years if stand a better chance of living another five years if they stay away from ‘elite’ hospitals and choose a they stay away from ‘elite’ hospitals and choose a

lower-cost competitor.”lower-cost competitor.”


““The The moremore doctors and specialists around, the doctors and specialists around, the moremore tests tests and procedures performed. And the results of all these and procedures performed. And the results of all these

tests and procedures? Lots more medical bills, exposure tests and procedures? Lots more medical bills, exposure

to medical errors, and ato medical errors, and a loss of loss of life life

expectancy.”expectancy.”

Source:Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman /Phillip Longman

Flabbergasting.Flabbergasting.

10. See no 10. See no evil: A evil: A

culture of culture of cover-upcover-up

““culture of culture of cover-up that cover-up that

pervades pervades healthcare”healthcare”

Source:Source: Best Care Anywhere: Why VA Healthcare Is Better Than YoursBest Care Anywhere: Why VA Healthcare Is Better Than Yours /Phillip Longman /Phillip Longman

One begins to feel that there is no end One begins to feel that there is no end to the insults to which patients-to the insults to which patients-

citizens are subjected by this most citizens are subjected by this most “modern” of American industries.“modern” of American industries.

““When a plane crashes, When a plane crashes, they ask, ‘What they ask, ‘What

happened?’ In medicine happened?’ In medicine they ask: ‘Whose fault they ask: ‘Whose fault was it?’ ”was it?’ ” ——James Bagian, M.D. & former James Bagian, M.D. & former

astronaut, now working with the VHAastronaut, now working with the VHA

Success Through Positive Success Through Positive Acknowledgement of FailuresAcknowledgement of Failures

Wernher Von Braun, re the RedstoneWernher Von Braun, re the Redstone missile engineer who “confessed” to a missile engineer who “confessed” to a screw-up and was awarded a bottle of screw-up and was awarded a bottle of champagne. Award to the sailor on the champagne. Award to the sailor on the

aircraft carrier Carl Vinson—for reporting a aircraft carrier Carl Vinson—for reporting a lost tool on the deck (that could have lost tool on the deck (that could have caused a crash). Amy Edmonson on caused a crash). Amy Edmonson on

successful nursing units—with the successful nursing units—with the highesthighest reported adverse drug events.reported adverse drug events.

Source: Karl Weick & Kathleen Sutcliffe, Source: Karl Weick & Kathleen Sutcliffe, Managing the UnexpectedManaging the Unexpected

Reward admissions of mistakes …Reward admissions of mistakes … it can be done.it can be done.

Ken Kizer/VA 1997: Ken Kizer/VA 1997: “culture of cover-up “culture of cover-up that pervades healthcare” that pervades healthcare”

“Patient Safety Event Registry”“Patient Safety Event Registry” … “looking for systemic solutions, … “looking for systemic solutions, not not

seeking to fix blameseeking to fix blame on individuals on individuals except in the most egregious cases. The good news except in the most egregious cases. The good news

was awas a thirtthirtyy-fold -fold increaseincrease in the number of medical in the number of medical mistakes and adverse events that got reported.” mistakes and adverse events that got reported.” “ “National Center for Patient Safety Ann Arbor”National Center for Patient Safety Ann Arbor”

The VA The VA “gets it.” “gets it.” (Again.)(Again.)

thirty-thirty-foldfold

The enormity of the possible The enormity of the possible improvement is staggering—perhaps improvement is staggering—perhaps

one of the few hopeful signs.one of the few hopeful signs.

11. And “they”11. And “they” call it “science” I: call it “science” I:

overwhelming overwhelming Lack of treatment Lack of treatment

validationvalidation

““stunning lack of stunning lack of scientific knowledge scientific knowledge

about which about which treatments and treatments and

procedures actually procedures actually work.”work.”

Source:Source: Best Care Anywhere: Why VA Healthcare Is Better Than YoursBest Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman/Phillip Longman

Here we go again: “flabbergasting.”Here we go again: “flabbergasting.”

““The high rates of surgery were not being driven by patients, but rather by The high rates of surgery were not being driven by patients, but rather by doctors.” “They had no idea how different their practices were from their doctors.” “They had no idea how different their practices were from their

colleagues..” “Wennberg came to an unsettling conclusion.colleagues..” “Wennberg came to an unsettling conclusion. Medicine Medicine wrawrapppped itself in the mantle of science, ed itself in the mantle of science, yyet et much of what doctors were doing was based much of what doctors were doing was based

more on hunches than more on hunches than ggood research. … In fact, ood research. … In fact, as research would show over the coming as research would show over the coming

decades, stunningldecades, stunninglyy little of what little of what pphhyysicians do sicians do has ever been examined scientificallhas ever been examined scientificallyy, and , and

when manwhen manyy treatments and procedures have treatments and procedures have been been pput to the test, theut to the test, theyy have turned out to have turned out to

cause more harm than cause more harm than ggoodood.. In the latter part of the In the latter part of the twentieth century, dozens of common treatments , including the tonsillectomy, twentieth century, dozens of common treatments , including the tonsillectomy, the hysterectomy, the frontal lobotomy, the radical mastectomy, arthroscopic the hysterectomy, the frontal lobotomy, the radical mastectomy, arthroscopic

knee surgery for arthritis, X-ray screening for lung cancer, proton pump knee surgery for arthritis, X-ray screening for lung cancer, proton pump inhibitors for ulcers, hormone replacement therapy for menopause, and high-inhibitors for ulcers, hormone replacement therapy for menopause, and high-

dose chemotherapy for breast cancer, to name just a few, have been shown to be dose chemotherapy for breast cancer, to name just a few, have been shown to be unnecessary, ineffective, more dangerous than imagined, or sometimes more unnecessary, ineffective, more dangerous than imagined, or sometimes more

deadly than the diseases they were intended to treat.”deadly than the diseases they were intended to treat.”

Overtreated: Overtreated: Why Too Much Medicine Is Making Us Why Too Much Medicine Is Making Us Sicker and PoorerSicker and Poorer, Shannon Brownlee, Shannon Brownlee

““As unsettling as the prevalence of inappropriate care is As unsettling as the prevalence of inappropriate care is the enormous amount of what can only be called the enormous amount of what can only be called

ignorant care. ignorant care. A surA surpprisinrisingg 85% of 85% of evereveryydadayy medical medical

treatments have never treatments have never been scientificallbeen scientificallyy

validatedvalidated.. … For instance, when family … For instance, when family practitioners in Washington were queried about treating practitioners in Washington were queried about treating a simple urinary tract infection, a simple urinary tract infection, 8282 physicians came up physicians came up

with an extraordinary with an extraordinary 137137 strategies.” strategies.”Source:Source: Demanding Medical Excellence: Doctors and Demanding Medical Excellence: Doctors and

Accountability in the Information Age Accountability in the Information Age, Michael Millenson, Michael Millenson

8585%%

““The Search for The Search for Quality: It All Begins Quality: It All Begins

on the Autopsy on the Autopsy Table”Table”

Source: Chapter title, Source: Chapter title, Severed Trust: Why AmericanSevered Trust: Why American Medicine Hasn’t Been Fixed Medicine Hasn’t Been Fixed, George Lundberg, George Lundberg

““Learning organization”—the typical Learning organization”—the typical hospital ain’t.hospital ain’t.

““Most people think that quality of Most people think that quality of care is defined by medical care is defined by medical

interventions, such as a hip interventions, such as a hip replacement, lens implant, or replacement, lens implant, or

coronary bypass operation, coronary bypass operation, but but ggenuine enuine qqualitualityy of care is defined of care is defined

bbyy action based on good action based on good informationinformation.. Definitions of quality are often counterintuitive. Definitions of quality are often counterintuitive.

Multiple lab tests do not constitute quality medicine. … Entrepreneurial Multiple lab tests do not constitute quality medicine. … Entrepreneurial physicians have a greater stake in doing more than in doing good. Medicare, physicians have a greater stake in doing more than in doing good. Medicare, for example, provides funding for autopsies of every hospitalized beneficiary, for example, provides funding for autopsies of every hospitalized beneficiary,

and good science suggests that at least 30 percent of deaths should be and good science suggests that at least 30 percent of deaths should be autopsied. Very few are.. … In fact, lack of autopsy is the ultimate cover-up autopsied. Very few are.. … In fact, lack of autopsy is the ultimate cover-up

in medicine, and the signature of poor quality care. … The whole issue of in medicine, and the signature of poor quality care. … The whole issue of patient safety is based on honesty, and the autopsy is central in a system patient safety is based on honesty, and the autopsy is central in a system that finds truth, deals with it honestly, and tries to improve patient care.”that finds truth, deals with it honestly, and tries to improve patient care.”

Source: Source: “The Search for Quality: It All Begins on the Autopsy Table,”“The Search for Quality: It All Begins on the Autopsy Table,” chapter chapter title, title, Severed Trust: Why American Medicine Hasn’t Been FixedSevered Trust: Why American Medicine Hasn’t Been Fixed, George Lundberg, George Lundberg

12. And “they” 12. And “they” callcall

it “science” II: it “science” II: Astounding Astounding Geographic Geographic treatment treatment variationvariation

““In health care …In health care …

geography geography is is

destiny.”destiny.”Dartmouth Medical School 1996 report, from Dartmouth Medical School 1996 report, from Demanding Medical Excellence: Demanding Medical Excellence:

Doctors and Accountability in the Information AgeDoctors and Accountability in the Information Age, Michael Millenson, Michael Millenson

Sound absurd? Read on.Sound absurd? Read on.

““What [Wennberg and his Dartmouth colleagues] found was that medicine was all over What [Wennberg and his Dartmouth colleagues] found was that medicine was all over the map, literally. If Wennberg had been using a microscope to look at medical care in the map, literally. If Wennberg had been using a microscope to look at medical care in

New England, his team was now standing on a mountaintop looking at the entire New England, his team was now standing on a mountaintop looking at the entire nation, yet they were seeing precisely the same patterns he had found in Vermont and nation, yet they were seeing precisely the same patterns he had found in Vermont and

Maine. Only now they could tell it wasn’t just tonsillectomies; hysterectomies and Maine. Only now they could tell it wasn’t just tonsillectomies; hysterectomies and prostatectomies were being used far more in one region than another. It was CT prostatectomies were being used far more in one region than another. It was CT

scans, office visits, cardiac catheterizations. It was blood tests and hospitalizations, scans, office visits, cardiac catheterizations. It was blood tests and hospitalizations, back surgery, chest X-rays, and knee replacements. In one part of the country, back surgery, chest X-rays, and knee replacements. In one part of the country,

ppracticallracticallyy ever every y woman with breast cancerwoman with breast cancer was was still getting a mastectomy long after clinical trials had shown that a breast-sparing still getting a mastectomy long after clinical trials had shown that a breast-sparing

lumpectomy with radiation was just as effective. In another, babies were being put in lumpectomy with radiation was just as effective. In another, babies were being put in neonatal intensive care when they didn’t need it. They found that patients with back neonatal intensive care when they didn’t need it. They found that patients with back pain were pain were 300 300 ppercent more likelercent more likelyy to get surgery in Boise, Idaho, to get surgery in Boise, Idaho,

than in Manhattan. Doctors affiliated with Harvard Medical School admitted patients to than in Manhattan. Doctors affiliated with Harvard Medical School admitted patients to the intensive care unit the intensive care unit four times more oftenfour times more often than their colleagues at than their colleagues at Yale University School of Medicine. Arthroscopic knee surgery –which would later be Yale University School of Medicine. Arthroscopic knee surgery –which would later be shown to be entirely ineffective at treating knee pain due to arthritis—was performed shown to be entirely ineffective at treating knee pain due to arthritis—was performed

five times more oftenfive times more often on arthritic patients in Miami than Iowa City. on arthritic patients in Miami than Iowa City.

Overtreated: Why Too Much Medicine Is Making UsOvertreated: Why Too Much Medicine Is Making Us Sicker and Poorer Sicker and Poorer, Shannon Brownlee, Shannon Brownlee

Geography Is Destiny

E.g.: Ft. Myers E.g.: Ft. Myers 4X4X Manhattan—back Manhattan—back surgery. Newark surgery. Newark 2X2X New Haven— New Haven—

prostatectomy. Rapid City SD prostatectomy. Rapid City SD 34X34X Elyria Elyria OH—breast-conserving surgery. VT, ME, OH—breast-conserving surgery. VT, ME,

IA: IA: 3X3X differences in hysterectomy by differences in hysterectomy by age 70; age 70; 8X8X tonsillectomy; tonsillectomy; 4X4X

prostatectomy (prostatectomy (10X10X Baton Rouge vs. Baton Rouge vs. Binghampton). Breast cancer screening: Binghampton). Breast cancer screening: 4X4X NE, FL, MI vs. SE, SW. NE, FL, MI vs. SE, SW. (Source: various)(Source: various)

Geography Is DestinyGeography Is Destiny

““Often all one must do to acOften all one must do to acqquire a uire a disease is to enter a countrdisease is to enter a countryy where where

a disease is recoa disease is recoggnized—leavinnized—leavingg the countrthe countryy will either cure the will either cure the

maladmaladyy or turn it into somethin or turn it into somethingg elseelse.. … Blood pressure considered treatably … Blood pressure considered treatably high in the United States might be considered high in the United States might be considered normal in England; and the low blood pressure normal in England; and the low blood pressure treated with 85 drugs as well as hydrotherapy treated with 85 drugs as well as hydrotherapy and spa treatments in Germany would entitle and spa treatments in Germany would entitle its sufferer to lower life insurance rates in the its sufferer to lower life insurance rates in the

United States.”United States.” – Lynn Payer, – Lynn Payer, Medicine & CultureMedicine & Culture

Almost funny. (If the stakes were not Almost funny. (If the stakes were not so high.) so high.)

““Practice variation is not caused by ‘bad’ or Practice variation is not caused by ‘bad’ or ‘ignorant’ doctors. ‘ignorant’ doctors. Rather, it is a natural Rather, it is a natural

conseconseqquence of a suence of a syystem that stem that ssyystematicallstematicallyy tracks neither its tracks neither its

pprocesses nor its outcomes, rocesses nor its outcomes, ppreferrinreferringg to to ppresume that good resume that good

facilities, facilities, ggood intentions and ood intentions and ggood ood trainintrainingg lead automaticall lead automatically y to good to good resultsresults.. Providers remain more comfortable Providers remain more comfortable with the habits of a guild, where each craftsman with the habits of a guild, where each craftsman trusts his fellows, than with the demands of the trusts his fellows, than with the demands of the

information age.”information age.”

—Michael Millenson, —Michael Millenson, Demanding Medical ExcellenceDemanding Medical Excellence

““Nothing has Nothing has changed since our changed since our ScienceScience paper in paper in 1973. …”* 1973. …”* —Dr Jack Wennberg—Dr Jack Wennberg

*“Nothing of course, except the fact that American *“Nothing of course, except the fact that American medicine has swelled into a behemoth industry equal in medicine has swelled into a behemoth industry equal in

size to the entire economy of Italy.”—SB size to the entire economy of Italy.”—SB Overtreated: Why Too Much Medicine Is Making UsOvertreated: Why Too Much Medicine Is Making Us

Sicker and Poorer Sicker and Poorer, Shannon Brownlee, Shannon Brownlee

35 years. 35 years.

13. Shining 13. Shining star, a/star, a/thethe

……

““What’s needed in the U.S. What’s needed in the U.S. is nothing short of a medical is nothing short of a medical revolution and the VHA has revolution and the VHA has gone further than most any gone further than most any

other organization to other organization to revamp its culture and revamp its culture and

systems.”systems.” —RAND—RAND

There is There is anan exception among big exception among big systems—the Veterans systems—the Veterans

Administration/VA hospitals. And yes, Administration/VA hospitals. And yes, “everyone” is amazed. (Mr Longman’s “everyone” is amazed. (Mr Longman’s

book, book, Best Care Anywhere: Why VA Best Care Anywhere: Why VA Healthcare Is Better Than Yours, Healthcare Is Better Than Yours, is a is a

masterpiece—required reading for any masterpiece—required reading for any healthcare professional, as I see it.)healthcare professional, as I see it.)

Ken Kizer, 1994, per Longman:Ken Kizer, 1994, per Longman: ““reorienting the VHA away from a reorienting the VHA away from a

system that emphasized acute system that emphasized acute care delivered in hospitals by care delivered in hospitals by

specialists and toward one that specialists and toward one that put put overwhelminoverwhelmingg em empphasis hasis on on pprevention and revention and ppatient-atient-centered manacentered managgement of ement of

chronic conditionschronic conditions.”.” Best Care Any where: Why VA Healthcare Is Best Care Any where: Why VA Healthcare Is

Better Than Yours,Better Than Yours, Phillip Longman Phillip Longman

Ah, Ah, healthhealth is the goal! (What a fascinating idea.)is the goal! (What a fascinating idea.)

““Because the VA lacks any Because the VA lacks any financial incentive to financial incentive to

engage in overtreatment, engage in overtreatment, it saves money by avoiding it saves money by avoiding unnecessary surgery and unnecessary surgery and

redundant testing.”redundant testing.”

Best Care Any where: Why VA Healthcare IsBest Care Any where: Why VA Healthcare Is Better Than Yours,Better Than Yours, Phillip Longman Phillip Longman

No doubt at all, the VA incentive No doubt at all, the VA incentive scheme, the antithesis of the scheme, the antithesis of the

mainstream programs, is a big help.mainstream programs, is a big help.

VA costs up VA costs up 0.80.8%% in 10 in 10

years, Medicare years, Medicare up up 40.440.4%%

(Note: VA patients (Note: VA patients “older, sicker, poorer and more prone to “older, sicker, poorer and more prone to mental illness, homelessness, and substance abuse;”mental illness, homelessness, and substance abuse;” ½ > ½ >

65, 1/3 smoke, 1/5 diabetes vs 1/14 overall; chronic diseases, 65, 1/3 smoke, 1/5 diabetes vs 1/14 overall; chronic diseases, frailty—especially vulnerable to medical errors )frailty—especially vulnerable to medical errors )


Key point, the VA is dealing with a Key point, the VA is dealing with a tougher than normal population—so tougher than normal population—so

they aren’t blessed with any systemic they aren’t blessed with any systemic advantage on that score.advantage on that score.

******2003, 2003, New England Journal of MedicineNew England Journal of Medicine publishes publishes quality study results: 11 measures of quality compare quality study results: 11 measures of quality compare VA and fee-for-service plans. VA and fee-for-service plans. VA “significantly VA “significantly

better” on better” on 11 out of 1111 out of 11 ……

******2004, 2004, Annals of Internal MedicineAnnals of Internal Medicine, RAND study: VA , RAND study: VA vs commercial managed care; vs commercial managed care; VA “outperforms all VA “outperforms all

other sectors of American healthcare in other sectors of American healthcare in 294294 measures of quality”measures of quality” … … ******National Committee for Quality Assurance top-National Committee for Quality Assurance top-

rated, JHU, Mayo, Mass General; rated, JHU, Mayo, Mass General; “In “In evereveryy sinsinggle catele categgororyy the veterans the veterans healthcare system outperforms the highest-rated non-healthcare system outperforms the highest-rated non-VA hospitals”VA hospitals” Source:Source: Best Care Anywhere: Why VA Healthcare Is Better Than YoursBest Care Anywhere: Why VA Healthcare Is Better Than Yours /Phillip Longman/Phillip Longman

Wow.Wow.

E.g.: On-time appointments, appointment E.g.: On-time appointments, appointment with specialist, Institute for Health Care with specialist, Institute for Health Care

Improvement/Don Berwick:Improvement/Don Berwick: “[VA “[VA is] is]

spectacularspectacular””


Pretty damned impressive. Pretty damned impressive. (Understatement.)(Understatement.)

VA/Strengths/FociVA/Strengths/Foci

*Safety*Safety*Evidence-based medicine*Evidence-based medicine*Health promotion and wellness*Health promotion and wellness programsprograms*“Unparalleled adoption of*“Unparalleled adoption of electronic medical records electronic medical records and otherand other informationinformation technologies”technologies”Source:Source: Best Care Anywhere: Why VA Healthcare Is Better Than YoursBest Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman/Phillip Longman

The VHA gets it!The VHA gets it! E.g.: Laptop at bedside calls E.g.: Laptop at bedside calls up patient e-records from one of 1,300 hospitals. up patient e-records from one of 1,300 hospitals. Bar-coded wristband confirms meds. National Bar-coded wristband confirms meds. National Center for Patient Safety in Ann Arbor. Docs Center for Patient Safety in Ann Arbor. Docs

and researchers discuss optimal treatment and researchers discuss optimal treatment regimens—research center in Durham NC. Doc regimens—research center in Durham NC. Doc

measures & guidelines; e.g., pneumonia measures & guidelines; e.g., pneumonia vaccinations from 50% to 84%. Blame-free vaccinations from 50% to 84%. Blame-free

system, modeled after airlines.system, modeled after airlines. “What’s needed “What’s needed in the U.S. is nothing short of a medical in the U.S. is nothing short of a medical

revolution and the VHA has gone further than revolution and the VHA has gone further than most any other organization to revamp its most any other organization to revamp its

culture and systems.”—Randculture and systems.”—Rand

14. IS/IT: 14. IS/IT: The “dark The “dark

ages” saga ages” saga continuescontinues

““Shockingly, despite our vaunted Shockingly, despite our vaunted prowess in computers, software and the prowess in computers, software and the Internet, much of our healthcare system Internet, much of our healthcare system

is still operating in the dark ages of is still operating in the dark ages of paper records and handwritten scrawls. paper records and handwritten scrawls. American primary care doctors lag years American primary care doctors lag years

behind doctors in other advanced behind doctors in other advanced nations in adopting electronic medical nations in adopting electronic medical

records or prescribing medications records or prescribing medications electronically. This makes it harder to electronically. This makes it harder to

coordinate care, spot errors and adhere coordinate care, spot errors and adhere to standard clinical guidelines.” to standard clinical guidelines.” —”World’s —”World’s

Best Medical Care?”, New York Times, August 2007Best Medical Care?”, New York Times, August 2007

““Dark ages”Dark ages”—here we go again!—here we go again!

““Some grocery Some grocery stores have better stores have better technology than technology than

our hospitals our hospitals and clinics.”and clinics.” —Tommy Thompson, former HHS Secretary—Tommy Thompson, former HHS Secretary

Source: Special Report on technology in healthcare, Source: Special Report on technology in healthcare, U.S. News & World ReportU.S. News & World Report

““We’re in the We’re in the Internet age, and Internet age, and

the averathe averagge e ppatient can’t email atient can’t email their doctortheir doctor.”.” —Don Berwick, —Don Berwick,

Harvard Med SchoolHarvard Med School

““Home Depot does a Home Depot does a better job of tracking a better job of tracking a box of nails than your box of nails than your local hospital does in local hospital does in

tracking you.”tracking you.”

Overtreated: Overtreated: Why Too Much Medicine Is Making Why Too Much Medicine Is Making Us Sicker and PoorerUs Sicker and Poorer, Shannon Brownlee, Shannon Brownlee

VA/StrengthsVA/Strengths

**SafetySafety**Evidence-based medicineEvidence-based medicine**Health promotion and wellnessHealth promotion and wellness programsprograms**““UnUnpparalleled adoaralleled adopption oftion of electronic medical records electronic medical records and otherand other informationinformation technolotechnologgiesies””Source:Source: Best Care Anywhere: Why VA Healthcare Is Better Than YoursBest Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman/Phillip Longman

Information technology:Information technology: group of off-the- group of off-the-radar experiments, performed surreptitiously byradar experiments, performed surreptitiously by

“ “the Hard Hats.” the Hard Hats.”

Dr Kenneth Dickie, 1979, brought together, as Dr Kenneth Dickie, 1979, brought together, as

VistAVistA, 20,000 software protocols “originally , 20,000 software protocols “originally written by individual doctors and other professionals written by individual doctors and other professionals

working secretly in VA facilities all around the working secretly in VA facilities all around the country” country”

““This unique, integrated information system has This unique, integrated information system has dramatically reduced medical errors at the VA while dramatically reduced medical errors at the VA while

also vastly improving diagnoses, quality of care, also vastly improving diagnoses, quality of care, scientific understanding of the human body, and the scientific understanding of the human body, and the

development of medical protocols based on hard data development of medical protocols based on hard data about what drugs and procedures work best.”about what drugs and procedures work best.”


The VA got it early—and with a The VA got it early—and with a homegrown system!homegrown system!

““As with many other institutions, As with many other institutions, the software these [VA] high the software these [VA] high priests wrote, or more often priests wrote, or more often

procured from private vendors, procured from private vendors, wasn’t verwasn’t veryy ggoodood, in large part , in large part

because the because the ppeoeopple who actuallle who actuallyy had to use it had little role in its had to use it had little role in its

develodeveloppmentment.” .”

Best Care Anywhere: Why VA Healthcare Is Best Care Anywhere: Why VA Healthcare Is Better Than Yours,Better Than Yours, Phillip Longman Phillip Longman

Homegrown … makes all the Homegrown … makes all the difference, especially where adoption difference, especially where adoption is concerned, the Achilles heel of most is concerned, the Achilles heel of most

systems.systems.

Scanner:Scanner: “Skunkworks” project started in Kansas, 1992, “Skunkworks” project started in Kansas, 1992, hand-held scanner, idea from nurse Sue Kinnick when she hand-held scanner, idea from nurse Sue Kinnick when she

observed usage in rental-car return area.observed usage in rental-car return area. “It wound up “It wound up

eliminating some eliminating some 549,000549,000 errors by errors by

2001; there was a 2001; there was a 7575%% decrease in errors decrease in errors

involving the wrong medication, a involving the wrong medication, a 6262%% decrease in errors involving the wrong dosage, decrease in errors involving the wrong dosage,

a a 9393%% reduction in the wrong patients reduction in the wrong patients

receiving medicine, and a receiving medicine, and a 7070%% decrease decrease in the number of times nurses simply forgotin the number of times nurses simply forgot

or didn’t get around to giving patientsor didn’t get around to giving patients their meds.”their meds.”


Again, the numbers are staggering. Again, the numbers are staggering. I’m hardly suggesting that putting this I’m hardly suggesting that putting this

system in place was a cakewalk—on system in place was a cakewalk—on the other hand, the basic idea is the other hand, the basic idea is

hardly rocket science! (Most of these hardly rocket science! (Most of these breakthrough ideas aren’t; e.g., breakthrough ideas aren’t; e.g.,

rewarding the reporting of errors so rewarding the reporting of errors so that learning can ensue.)that learning can ensue.)

““Our entire facilitOur entire facilityy is diis diggitalital.. No paper, no film, no medical No paper, no film, no medical

records. Nothing. And it’s all integrated—from the lab to X-ray records. Nothing. And it’s all integrated—from the lab to X-ray to records to physician order entry. Patients don’t have to wait to records to physician order entry. Patients don’t have to wait for anything. The information from the physician’s office is in for anything. The information from the physician’s office is in

registration and vice versa. The referring physician is registration and vice versa. The referring physician is immediately sent an email telling him his patient has shown up. immediately sent an email telling him his patient has shown up. … It’s wireless in-house. We have 800 notebook computers that … It’s wireless in-house. We have 800 notebook computers that are wireless. Physicians can walk around with a computer that’s are wireless. Physicians can walk around with a computer that’s

pre-programmed. If the physician wants, we’ll go out and wire pre-programmed. If the physician wants, we’ll go out and wire their house so they can sit on the couch and connect to the their house so they can sit on the couch and connect to the

network. They can review a chart from 100 miles awaynetwork. They can review a chart from 100 miles away.” .” ——David Veillette, CEO, Indiana Heart HospitalDavid Veillette, CEO, Indiana Heart Hospital

It helps to have a “greenfield” facilityIt helps to have a “greenfield” facility—but this is also a non-VA demo of —but this is also a non-VA demo of

making effective IS the centerpiece of making effective IS the centerpiece of the enterprise.the enterprise.

15. k.i.s.s./Keep it 15. k.i.s.s./Keep it simple, stupid: Un-simple, stupid: Un-sexy “stuff” Could sexy “stuff” Could

save tens of thousands save tens of thousands of lives and extend of lives and extend

hundreds of thousands hundreds of thousands of othersof others

A lot of “the fix” is very A lot of “the fix” is very straightforward; in fact, the system’s straightforward; in fact, the system’s infatuation with clever, complex tools infatuation with clever, complex tools is “part of the problem.” (A big part of is “part of the problem.” (A big part of

the problem.)the problem.)

““The simplest treatments often The simplest treatments often fall through the cracks fall through the cracks ——

making sure a patient making sure a patient knows how to use an knows how to use an

asthma inhalerasthma inhaler, for instance. , for instance. And when doctors and hospitals And when doctors and hospitals try to deliver the right kind of try to deliver the right kind of

care, such as keeping track of a care, such as keeping track of a heart patient’s weight gain … , heart patient’s weight gain … ,

they lose money.” they lose money.” Overtreated: Why Too Much Medicine Is MakingOvertreated: Why Too Much Medicine Is Making

Us Sicker and PoorerUs Sicker and Poorer, Shannon Brownlee, Shannon Brownlee

More on the perverse “losing money More on the perverse “losing money for doing the right thing” in a for doing the right thing” in a

moment.moment.

““For most Americans, the two biggest determinants of what kind of treatments they receive are For most Americans, the two biggest determinants of what kind of treatments they receive are how many doctors and specialists hang a shingle in their community and which one of them they how many doctors and specialists hang a shingle in their community and which one of them they happen to see. The more doctors and specialists around, the more tests and procedures happen to see. The more doctors and specialists around, the more tests and procedures performed. And the results of all these tests and procedures? Lots more medical bills, exposure performed. And the results of all these tests and procedures? Lots more medical bills, exposure to medical errors, and a loss of life expectancy. It was this last conclusion that was truly to medical errors, and a loss of life expectancy. It was this last conclusion that was truly shocking, but it became unavoidable when [Dartmouth’s Dr. Jack] Wennberg and others shocking, but it became unavoidable when [Dartmouth’s Dr. Jack] Wennberg and others broadened their studies. They found it’s not just that renowned hospitals and their specialists broadened their studies. They found it’s not just that renowned hospitals and their specialists

tend to engage in massive overtreatment.tend to engage in massive overtreatment. TheThey y also tend toalso tend to be poor be poor at at pprovidinrovidingg critical but routine care critical but routine care.. For example, For example, Dartmouth researcher Elliot S. Fisher has found that among Medicare patients, who share the Dartmouth researcher Elliot S. Fisher has found that among Medicare patients, who share the same age, socioeconomic, and health status, their chances of dying in the next five years are same age, socioeconomic, and health status, their chances of dying in the next five years are

greater if they go to a high-spending hospital.greater if they go to a high-spending hospital. One reason is that One reason is that patients in high-spending hospitals with lots of patients in high-spending hospitals with lots of specialists and high technology are also less specialists and high technology are also less likely to receive many likely to receive many pproven routine roven routine

treatments [e.g. treatments [e.g. aspirin, flu aspirin, flu vaccinevaccine]. … This general lack of attention ]. … This general lack of attention to to pprevention and follow-up care in high-revention and follow-up care in high-ssppendinendingg hospitals hospitals helps to explain why not only heart-attack victims but also helps to explain why not only heart-attack victims but also patients suffering from colon cancer and hip fracture stand a better chance of living another five patients suffering from colon cancer and hip fracture stand a better chance of living another five years if they stay away from ‘elite’ hospitals and choose a lower-cost competitor.”years if they stay away from ‘elite’ hospitals and choose a lower-cost competitor.” Best Care Any where: Why VA Healthcare Is Better Than Yours,Best Care Any where: Why VA Healthcare Is Better Than Yours, Phillip Longman Phillip Longman

Aspirin saves lives. (Lots of.)Aspirin saves lives. (Lots of.)

K.I.S.S./Keep It Simple, Stupid:K.I.S.S./Keep It Simple, Stupid: Wrong Wrong site surgery: site surgery: ““The most The most

effective effective ppart of the drill is art of the drill is simsimppllyy asking the asking the ppatient, in atient, in lanlangguauagge he can understand, e he can understand, to state (not confirm) who he to state (not confirm) who he

is, his birth date or social is, his birth date or social securitsecurityy number, and what number, and what

he’s in forhe’s in for.”.”Source:Source: Best Care Anywhere: Why VA Healthcare Is Better Than YoursBest Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman /Phillip Longman

And your name is …And your name is …

““If God spoke to me by saying, ‘Mark, you’re down to If God spoke to me by saying, ‘Mark, you’re down to your last three words: What would you want to say to your last three words: What would you want to say to

your fellow humans that would make the most positive your fellow humans that would make the most positive impact?’ It would be a close call between Love Thy impact?’ It would be a close call between Love Thy

Neighbor andNeighbor and Wash Your Wash Your HandsHands . . A close third would be Move, A close third would be Move,

Move, Move.”Move, Move.” —Mark Pettus, M.D., The Savvy Patient—Mark Pettus, M.D., The Savvy Patient

“The most important thing you can do to keep “The most important thing you can do to keep

from getting sick is to from getting sick is to wash wash your handsyour hands.. ”” ——CDCCDC/National /National

Center for Infectious DiseasesCenter for Infectious Diseases

““Sanitary revolution”: Sanitary revolution”: mortality in major citiesmortality in major cities

downdown 5555%% between 1850 and 1915between 1850 and 1915

Source: Tom Farley & Deborah Cohen, Source: Tom Farley & Deborah Cohen, Prescription for a Healthy NationPrescription for a Healthy Nation

Compression hose would mostly fix the hospital Compression hose would mostly fix the hospital problem:problem: “According to the American Heart Association, “According to the American Heart Association, up to two million Americans are affected annually by deep up to two million Americans are affected annually by deep

vein thrombosis. Of those who develop pulmonary vein thrombosis. Of those who develop pulmonary embolism, up to 300,000 will die each year. ... Deep vein embolism, up to 300,000 will die each year. ... Deep vein

thrombosis also is among the leading causes of thrombosis also is among the leading causes of preventable hospital death. Even more disturbing is the preventable hospital death. Even more disturbing is the

fact that, according to a U.S. multi-center study fact that, according to a U.S. multi-center study published by two of ClotCare's editorial board members,published by two of ClotCare's editorial board members,

58%58% of of ppatients who develoatients who developped a DVT ed a DVT while in the hoswhile in the hosppital received no ital received no ppreventive treatment desreventive treatment desppite the ite the

ppresence of multiresence of multipple risk factors and le risk factors and overwhelminoverwhelmingg data that data that pprophylaxis is rophylaxis is

ververyy effective at reducin effective at reducingg these events these events.”.” —Marie B. Walker, clotcare.com, March 2008—Marie B. Walker, clotcare.com, March 2008

One study I came across concluded One study I came across concluded that you could save that you could save 20,00020,000 lives per lives per

year in UK hospitals—by issuing year in UK hospitals—by issuing compression hose-socks to virtually compression hose-socks to virtually

every hospitalized patient. (As I said, every hospitalized patient. (As I said, we ain’t talkin’ rocket science.)we ain’t talkin’ rocket science.)

The EMS Myth:The EMS Myth:

“Speed* has never “Speed* has never saved anybody’s saved anybody’s life. Period.”life. Period.” ——W.H. Leonard,W.H. Leonard,

Medical Transportation Insurance Professionals Medical Transportation Insurance Professionals

*Ambulance, accident site to hospital*Ambulance, accident site to hospital

Source: Source: USA TodayUSA Today

I am always amused, in a perverse sort I am always amused, in a perverse sort of way, when I come across stuff like of way, when I come across stuff like this. Urban legend: Speeding EMTs in this. Urban legend: Speeding EMTs in ambulances are mainly a turn-on for ambulances are mainly a turn-on for

speeding EMTs in ambulances.speeding EMTs in ambulances.

20%:20%: not get not get prescriptions filled prescriptions filled

50%:50%: use meds use meds inconsistently inconsistentlySource: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation

Market ForcesMarket Forces

RediClinic.CheckUps.Take RediClinic.CheckUps.Take Care.MinuteClinic*Care.MinuteClinic* (*“We treat (*“We treat

these 16 rules-based disorders”/ “Go-no go” these 16 rules-based disorders”/ “Go-no go” tests.15 minutes.$39)tests.15 minutes.$39)

Wal*Mart.CVS.Target.Wal*Mart.CVS.Target.Walgreens.RiteAidWalgreens.RiteAid

Source: Source: FT FT (10.06.06); (10.06.06); NYT NYT (12.31.06)(12.31.06)

I am an unabashed champion of I am an unabashed champion of such non-conventional healthcare such non-conventional healthcare delivery vehicles—hospitals are delivery vehicles—hospitals are

fighting them tooth and nail. fighting them tooth and nail. (Hilariously, hospitals have (Hilariously, hospitals have

declared them unsafe—talk about declared them unsafe—talk about pots calling kettles black!) pots calling kettles black!)

(Interestingly, these convenient-(Interestingly, these convenient-care operations may significantly care operations may significantly push the greater “system” in the push the greater “system” in the

direction of electronic medical direction of electronic medical records—the CC clinics are records—the CC clinics are

100% electronic.)100% electronic.)

Case: The Case: The “simple” “simple” Checklist!Checklist!

I absolutely I absolutely lovelove this story!this story!

90K in U.S.A. 90K in U.S.A. ICUsICUs on any on any given day; given day; 178178 steps/day steps/day

in ICU. in ICU.

50%50% stays result stays result in “serious complication”in “serious complication”Source: Atul Gawande, “The Checklist” (Source: Atul Gawande, “The Checklist” (New YorkerNew Yorker, 1210.07), 1210.07)

****Peter PronovostPeter Pronovost, Johns Hopkins, , Johns Hopkins, 20012001**Checklist, line infections**Checklist, line infections**1/3**1/3rdrd at least one error when he started at least one error when he started**Nurses/permission to stop procedure **Nurses/permission to stop procedure if doc, other not following checklistif doc, other not following checklist**In 1 year, 10-day line-infection rate:**In 1 year, 10-day line-infection rate:

11% to … 11% to … 0%0% Source: Atul Gawande, “The Checklist” (Source: Atul Gawande, “The Checklist” (New YorkerNew Yorker, 1210.07), 1210.07)

Wow. (Zerooooooo.)Wow. (Zerooooooo.)

**Docs, nurses make own **Docs, nurses make own checklists on whateverchecklists on whatever process-procedure they choose process-procedure they choose**Within **Within weeksweeks, average stay in , average stay in

ICUICU down down 50%50%Source: Atul Gawande, “The Checklist” (New Yorker, 1210.07)Source: Atul Gawande, “The Checklist” (New Yorker, 1210.07)

Wow. Wow.

**Replicate in **Replicate in Inner City DetroitInner City Detroit (resource strapped—$$$, staff cut 1/3 (resource strapped—$$$, staff cut 1/3rdrd, poorest patients in USA), poorest patients in USA)

**Nurses QB the process**Nurses QB the process**Project manager for overall process implementation**Project manager for overall process implementation**Exec involvement **Exec involvement (help with “little things”—it’s all “little things”)(help with “little things”—it’s all “little things”)

**Blue Cross/insurers, small bonuses for participating**Blue Cross/insurers, small bonuses for participating

**6 months, **6 months, 66%66% decrease in infection rate; USA: decrease in infection rate; USA: bottom 25% in hospital rankings bottom 25% in hospital rankings to … to …

top 10%top 10%Source: Atul Gawande, “The Checklist” (Source: Atul Gawande, “The Checklist” (New YorkerNew Yorker, 1210.07), 1210.07)

Tough test. Initial resistance, in the Tough test. Initial resistance, in the face of resource cuts, enormous. face of resource cuts, enormous.

““[Pronovost] is focused on work that is [Pronovost] is focused on work that is not normallnot normallyy considered a siconsidered a siggnificant contribution in academic nificant contribution in academic

medicinemedicine. As a result, few others are venturing to extend . As a result, few others are venturing to extend

his achievements.his achievements. Yet his work Yet his work has already saved more has already saved more lives than that of any lives than that of any laboratory scientist in laboratory scientist in the last decadethe last decade.”.” —Atul Gawande,—Atul Gawande,

“The Checklist” (New Yorker, 1210.07) “The Checklist” (New Yorker, 1210.07)

Medicine Nobel, anyone?Medicine Nobel, anyone?

“Beware of the Beware of the tyranny of making tyranny of making SmallSmall

Changes to Changes to SSmallmall Things. Things. Rather, make Rather, make BiBig g Changes to Changes to BiBigg

Things.”Things.” —Roger Enrico, former Chairman, —Roger Enrico, former Chairman, PepsiCoPepsiCo

Are we sure?Are we sure?Or …Or …

““Beware of the tyranny of making Beware of the tyranny of making SSmallmall Changes to Changes to

SSmallmall Things.Things. Rather, Rather, make make BigBig Changes to Changes to Big Big ThingsThings … …

using using Small, Almost Small, Almost Invisible Invisible

Straightforward Straightforward LeversLevers with with BiBigg

SSyystemic Imstemic Imppactact.”.” —TP—TP

Think checklist.Think checklist.Think “wash your hands.”Think “wash your hands.”Think “take your aspirin.”Think “take your aspirin.”

Think “What’s your name?”Think “What’s your name?”Think compression hose.Think compression hose.

Etc.Etc.Etc.Etc.

16. “Organizational 16. “Organizational effectiveness” “Tools” effectiveness” “Tools”

that would put the that would put the focus on the patient.focus on the patient.

““Clinical Clinical microsystem,” linked microsystem,” linked

microsystems, microsystems, patient-centric “care patient-centric “care teams”teams” —Paul Batalden/DHMC —Paul Batalden/DHMC

Source: “What System?” Source: “What System?” Dartmouth MedicineDartmouth Medicine, Summer 2006 , Summer 2006 ((Quality By Design: A Clinical Microsystems ApproachQuality By Design: A Clinical Microsystems Approach, by , by

Eugene C. Nelson, Paul B. Batalden, and Marjorie M. Godfrey)Eugene C. Nelson, Paul B. Batalden, and Marjorie M. Godfrey)

The idea here is to break down the The idea here is to break down the functional barriers and bring all functional barriers and bring all

resources together in micro-units resources together in micro-units aimed directly at the patient. aimed directly at the patient.

Numerous Experiments:Numerous Experiments: “Medical Homes”“Medical Homes”

And the idea here is to install co-And the idea here is to install co-ordinators who track and guide the ordinators who track and guide the

patient’s overall pattern of interaction patient’s overall pattern of interaction with the system—Medicare is with the system—Medicare is

experimenting with this..experimenting with this..

17. Wellness-17. Wellness-prevention: No prevention: No

good deed good deed goes goes

unpunishedunpunished

““Every Every $1.00$1.00 spent spent on its wellness program on its wellness program

ended up saving [Citigroup] ended up saving [Citigroup]

$4.70$4.70, according to , according to an academic study.”an academic study.”

—WSJ/0329.07—WSJ/0329.07

We can demonstrate theWe can demonstrate the enormous value of emphasizing enormous value of emphasizing

wellness-prevention.wellness-prevention.

Pursuing “Health”:Pursuing “Health”: 1995, Duke Medical Center, “Nurses 1995, Duke Medical Center, “Nurses regularly called patients [with congestive heart failure] at regularly called patients [with congestive heart failure] at home to monitor their well-being and to make sure they took home to monitor their well-being and to make sure they took their medications. Nutritionists offered heart-healthy diets. their medications. Nutritionists offered heart-healthy diets. Doctors shared data about their patients and developed Doctors shared data about their patients and developed evidence for what treatments and dosages had the best evidence for what treatments and dosages had the best results. And it worked—at least in the sense that patients results. And it worked—at least in the sense that patients became healthier. became healthier. The number of hospital admissions declined The number of hospital admissions declined and patients spent less time in the hospital.and patients spent less time in the hospital. ““Quality doesn’t pay”:Quality doesn’t pay”: “By 2000, the hospital was taking a “By 2000, the hospital was taking a 37% hit37% hit in its revenue due to the decline in admissions and in its revenue due to the decline in admissions and the absence of complications. Ten hospitals in Utah had a the absence of complications. Ten hospitals in Utah had a similar experience after implementing integrated care for similar experience after implementing integrated care for pneumonia.”pneumonia.” ““No investment in No investment in qquality uality ggoes oes ununppunishedunished.” “But there is a problem: .” “But there is a problem: Who will pay for it? … Who will pay for it? … An idealistic An idealistic commitment to best commitment to best ppractices doesn’t ractices doesn’t ppaayy the bills the bills.”.” Source:Source: Best Care Anywhere: Why VA Healthcare Is Better Than YoursBest Care Anywhere: Why VA Healthcare Is Better Than Yours /Phillip Longman/Phillip Longman

Whoops. (Alas.)Whoops. (Alas.)(FYI, I also read recently that Duke (FYI, I also read recently that Duke

shut down its “family practice” shut down its “family practice” specialty program—for lack of specialty program—for lack of

interest.) interest.)

18.18. from from “healthcare” “healthcare” to “health”: to “health”:

The “oughtaThe “oughtass””

TP Recommendation #1:

Dubai Healthcare Dubai Healthcare City City

toto Dubai Health City* Dubai Health City*

*Cleveland Clinic and Canyon Ranch

Dubai is investing billions in a Dubai is investing billions in a “Healthcare City”—in a keynote “Healthcare City”—in a keynote presentation I begged them topresentation I begged them to

call it “Health City.”call it “Health City.”(Words (Words dodo matter.) matter.)

MHHA/Michigan MHHA/Michigan HealthHealth and and

Hospital Hospital AssociationAssociation

Hats off to the MHHA for adding Hats off to the MHHA for adding “Health” to their association name!“Health” to their association name!

““I had done what doctors do well in I had done what doctors do well in this country, which is to treat this country, which is to treat

people when they come in with a people when they come in with a disease. disease. MMyy ppatients had atients had ggood ood

medical care but not, I bemedical care but not, I beggan to an to think, think, ggreat healthcarereat healthcare.. For most, their For most, their

declines, their illnesses, were thirty-year declines, their illnesses, were thirty-year problems of lifestyle, not disease. I, like most problems of lifestyle, not disease. I, like most doctors in America, had been doing the wrong doctors in America, had been doing the wrong job well. Modern medicine does not concern job well. Modern medicine does not concern itself with lifestyle problems. Doctors don’t itself with lifestyle problems. Doctors don’t

treat them, medical schools don’t teach them treat them, medical schools don’t teach them and insurers don’t pay to solve them. I began to and insurers don’t pay to solve them. I began to

think that this was indefensible.”think that this was indefensible.” —Henry Lodge, —Henry Lodge, Younger Next YearYounger Next Year

““Medicine” to “Health.”Medicine” to “Health.”

Childhood Childhood Obesity Obesity >> TerrorismTerrorism

Source: Mike Levitt/Secretary HHS

A/the “health” problem that is A/the “health” problem that is becoming a/the “medicine” problem.becoming a/the “medicine” problem.

(Behavioral, not medicinal!)(Behavioral, not medicinal!)

Bust Bust fat fat

docsdocs!!

““Model the way” is leadership “Rule Model the way” is leadership “Rule One.” Fat docs hectoring kids to give One.” Fat docs hectoring kids to give

up fast foods is not on … as far asup fast foods is not on … as far as I’m concerned.I’m concerned.

Go Mayor Go Mayor Mike!Mike!

Three hearty cheers for Mayor Three hearty cheers for Mayor Bloomberg’s transfats ban. Bloomberg’s transfats ban.

TP’s Canyon TP’s Canyon Ranch Ranch

epiphany—epiphany—and rage!and rage!

I’ve always been lucky enough to have “very I’ve always been lucky enough to have “very good doctors”—starting with my good doctors”—starting with my

pediatrician, Dr Elizabeth Peabody, in pediatrician, Dr Elizabeth Peabody, in Annapolis in the 1940s. But in 2003 I went to Annapolis in the 1940s. But in 2003 I went to

Canyon Ranch (Berkshires) aiming to “get Canyon Ranch (Berkshires) aiming to “get my shit together.” There I met nutritionists my shit together.” There I met nutritionists and others—the first “healthcare folks” I’d and others—the first “healthcare folks” I’d met, especially M.D.s, focused on “health.” met, especially M.D.s, focused on “health.” In short order, I had wildly reversed most of In short order, I had wildly reversed most of the adverse readings in my blood tests. I had the adverse readings in my blood tests. I had in effect reversed aging—and that is not an in effect reversed aging—and that is not an

exaggeration. exaggeration.

AndAnd I was furious! That is, why, at age 61, I was furious! That is, why, at age 61, was I “hearing about this”—”health stuff”—was I “hearing about this”—”health stuff”—for the first time? (Despite my continuous for the first time? (Despite my continuous care by “terrific docs”—Stanford trained, care by “terrific docs”—Stanford trained,

etc.)etc.)

Behavioral Primacy!

E.g.: plate size; E.g.: plate size; location of platters, location of platters, 6.5 feet Away = -63% 6.5 feet Away = -63%

“Seconds”“Seconds” Source: Brian Wansink, Source: Brian Wansink, Mindless EatingMindless Eating (20 lbs per year; 200 decisions per day) (20 lbs per year; 200 decisions per day)

Working on the basic “behavioral Working on the basic “behavioral stuff”—no mean feat—provides stuff”—no mean feat—provides

enormous payoff. (Yes, it’s difficult to enormous payoff. (Yes, it’s difficult to do—but, mainly, it is most definitely do—but, mainly, it is most definitely

not not the focus of our the focus of our $2,000,000,000,000 health“care” $2,000,000,000,000 health“care”

industry.)industry.)

Sprint/Overland Park KS:Sprint/Overland Park KS: Slow Slow elevators, distant elevators, distant parking lots with parking lots with

infrequent buses, “food infrequent buses, “food court” as “poorly” placed court” as “poorly” placed

as possible, etc.as possible, etc.Source: New York Times

Lovely!Lovely!

Health + Social Factors Health + Social Factors combination = combination = 20%20% fewer fewer

admissions, admissions, 40%40% less bed less bed occupancyoccupancy [over 65] [over 65]

Source: Unicare/UK/Dr David Source: Unicare/UK/Dr David Lyon/Lyon/PulsePulse, 1123.06, 1123.06

(Can work for the VA, NHS—but, as (Can work for the VA, NHS—but, as noted above, thwarted by our “pay per noted above, thwarted by our “pay per

procedure” “culture.”)procedure” “culture.”)

Q.W.P.Q.W.P. ** *Quality. Wellness. Prevention*Quality. Wellness. Prevention..

Tom’s “bias.”Tom’s “bias.”

19. HEALTHCARE19. HEALTHCAREMEETS HEALTH: MEETS HEALTH: The Case of the The Case of the

PLANETREE PLANETREE ALLIANCEALLIANCE

I will conclude this presentationI will conclude this presentation with a “good news” case, thatwith a “good news” case, that

of the Planetree Alliance. of the Planetree Alliance.

PlanetreePlanetree:: A Radical Model for A Radical Model for

New New Healthcare/Healing/Healthcare/Healing/Wellness Wellness ExcellenceExcellence

Tom PetersTom Peters

"All sane persons agree that 'healthcare needs an overhaul.' And that's "All sane persons agree that 'healthcare needs an overhaul.' And that's where the agreement stops. Healthcare issues are thorny, and system where the agreement stops. Healthcare issues are thorny, and system

panaceas are about as likely as the sun rising in the West. But there is good panaceas are about as likely as the sun rising in the West. But there is good news here and therenews here and there——and great news courtesy the Planetree Model.and great news courtesy the Planetree Model.

"In the midst of ceaseless gnashing of teeth over 'healthcare issues,' the "In the midst of ceaseless gnashing of teeth over 'healthcare issues,' the

patient and frontline staff often get lost in the shuffle. Enter Planetree. While patient and frontline staff often get lost in the shuffle. Enter Planetree. While oceanic systemic solutions remain out of reach, Planetree provides a oceanic systemic solutions remain out of reach, Planetree provides a

remarkable demonstration of what healthcareremarkable demonstration of what healthcare——with the patient at the centerwith the patient at the center——can be all about; and is all about among Planetree Alliance members.can be all about; and is all about among Planetree Alliance members.

"I know this may sound ridiculous, but everything about the 'model' works. It "I know this may sound ridiculous, but everything about the 'model' works. It

is great for patients and their familiesis great for patients and their families——and is truly about humanity and and is truly about humanity and healing and health and long-term wellness, not just a 'fix' for today's healing and health and long-term wellness, not just a 'fix' for today's

problem. It is great for staffproblem. It is great for staff——Planetree-Griffin is rightly near the top of the Planetree-Griffin is rightly near the top of the 'best places to work in America' list, year in and year out. And Planetree also 'best places to work in America' list, year in and year out. And Planetree also works as a 'business model'works as a 'business model'——any effectiveness measure you can name is in any effectiveness measure you can name is in

the Green Zone at Griffith.the Green Zone at Griffith.

"For 25 years my 'gig' has been 'excellence.' Put simply, there is no better "For 25 years my 'gig' has been 'excellence.' Put simply, there is no better exemplar of customer-centered, employee-friendly excellence, in any exemplar of customer-centered, employee-friendly excellence, in any

industry, than Griffin-Planetree. The Planetree model worksindustry, than Griffin-Planetree. The Planetree model works——and in my and in my extensive work in the health sector, I 'sell' it shamelessly, and pray that my extensive work in the health sector, I 'sell' it shamelessly, and pray that my

clients are taking it all in."clients are taking it all in."

tom peters/response to request for comment on Planetreetom peters/response to request for comment on Planetree

FiveFivepianopiano

ss

(Explanation to come.)(Explanation to come.)

““It was the goal of It was the goal of the Planetree Unit to the Planetree Unit to

help patients not help patients not only get well faster only get well faster but also to stay well but also to stay well longer.”longer.” —Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

And this is done within the contextAnd this is done within the context of the private-incentive schemeof the private-incentive scheme

——i.e., it i.e., it can can be done.be done.

““Much of our current Much of our current healthcare is about healthcare is about curing curing . . Curing is good. But Curing is good. But healinghealing is spiritual, and healing is is spiritual, and healing is

better, because we can heal better, because we can heal many people we cannot many people we cannot

cure.”cure.” —Leland Kaiser, “Holistic Hospitals”

““The most basic The most basic question we need to question we need to

pose in caring for pose in caring for others is this: others is this: Is Is this a lovinthis a lovingg actact?”?” —Leland Kaiser, “Holistic Hospitals”

Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

Determinants of HealthDeterminants of Health

Access to care: 10%Access to care: 10%Genetics: 20%Genetics: 20%

Environment: 20%Environment: 20%Health Behaviors: Health Behaviors: 5050%%

Source: Institute for the FutureSource: Institute for the Future

The 9 Planetree Practices1.1. The Importance of Human InteractionThe Importance of Human Interaction2. Informing and Empowering Diverse Populations: Consumer Informing and Empowering Diverse Populations: Consumer Health Libraries and Patient Information Health Libraries and Patient Information3. Healing Partnerships: The importance of Including Friends Healing Partnerships: The importance of Including Friends and Family and Family4. Nutrition: The Nurturing Aspect of Food Nutrition: The Nurturing Aspect of Food5. Spirituality: Inner Resources for Healing Spirituality: Inner Resources for Healing6.6. Human Touch: The Essentials of Communicating Human Touch: The Essentials of Communicating Caring Through Massage Caring Through Massage7.7. Healing Arts: Nutrition for the Soul Healing Arts: Nutrition for the Soul8.8. Integrating Complementary and Alternative Practices Integrating Complementary and Alternative Practices into Conventional Care into Conventional Care9.9. Healing Environments: Architecture and Design Conducive Healing Environments: Architecture and Design Conducive to Health to HealthSource: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

1. The The Importance of Importance of

Human Human InteractionInteraction

Press Ganey Assoc: 139,380 former patients from 225 hospitals:

nonenone of THE top 15 factors of THE top 15 factors determining determining PPatient atient SSatisfaction atisfaction referred to patient’s health referred to patient’s health outcomeoutcome

PSPS directldirectly related to y related to StaffStaff InteractionInteractionPSPS directldirectly correlated with y correlated with Employee Employee

SatisfactionSatisfaction


“There is a misconception that supportive interactions require more staff or more time and are therefore more costly. Although

labor costs are a substantial part of any hospital budget, the interactions themselves add nothing to the budget.

Kindness is Kindness is freefree.. Listening to patients or answering their

questions costs nothing. It can be argued that negative interactions—alienating patients, being non-responsive to their needs or limiting their sense of control—can be very costly. …

Angry, frustrated or frightened patients may be combative, withdrawn and less cooperative—requiring far more time than it would have taken to interact with them initially in a

positive way.” —Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

“Perhaps the simplest and most profound of all human interactions

is KINDNESS. … But if it is so But if it is so simsimpple, it is surle, it is surpprising how rising how

frefreqquentluentlyy it is absent from our it is absent from our healthcare environmentshealthcare environments.. … Many

staff members report verbal

‘abuse‘abuse’’ by physicians, managers and coworkers.” —Putting

Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

““Planetree is Planetree is about human about human

beings caring for beings caring for other human other human

beings.”beings.” —Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel (“Ladies and gentlemen serving ladies

and gentlemen”—4S credo)

2. Informing and Informing and Empowering Diverse Empowering Diverse

Populations: Populations: ConsumerConsumer Health Libraries and Health Libraries and

Patient InformationPatient Information

Planetree Health Resources Center/1981Planetree Health Resources Center/1981Planetree Classification SystemPlanetree Classification System

Consumer Health LibrariansConsumer Health LibrariansVolunteersVolunteers

Classes, lecturesClasses, lecturesHealth FairsHealth Fairs

Griffin’s Mobile Health Resource CenterGriffin’s Mobile Health Resource CenterOpen Chart PolicyOpen Chart Policy

Patient Progress NotesPatient Progress NotesCare Coordination ConferencesCare Coordination Conferences (Est (Est

goals, timetable, etc.)goals, timetable, etc.)


3. Healing Healing Partnerships: Partnerships: The The

Importance of Importance of IncludingIncluding

Friends and Friends and FamilyFamily

“When hospital staff members are asked to list the attributes of the ‘perfect patient

and family,’ their response is

usually a passive patient with no

family.” —Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

The Patient-Family Experience

“Patients are stripped of Patients are stripped of control, their clothes are control, their clothes are

taken away, they have little taken away, they have little say over their schedule, and say over their schedule, and

they are deliberately they are deliberately separated from their family separated from their family

and friends. Healthcare and friends. Healthcare professionals control all of professionals control all of the information about their the information about their patients’ bodies and access patients’ bodies and access

to the people who can to the people who can answer questions and answer questions and

connect them with helpful connect them with helpful resources. Families are resources. Families are

treated more as intruders treated more as intruders than loved ones.”than loved ones.” —Putting Patients First,

Susan Frampton, Laura Gilpin, Patrick Charmel

““Family members, close friends Family members, close friends and ‘significant others’ can and ‘significant others’ can

have a far greater impact on have a far greater impact on patients’ experience of illness, patients’ experience of illness, and on their long-term health and on their long-term health

and happiness, than any and happiness, than any healthcare professional.”healthcare professional.”

—Through the Patient’s Eyes

“A 7-year follow-up of women diagnosed with breast cancer

showed that those who confidedconfided inin atat leastleast oneone personperson in the 3 months after surgery had a 7-year survival

rate of 72.472.4%%,, as compared to 56.3%56.3% for those who didn’t have

a confidant.” —Institute for the Future

Care Partner ProgramsCare Partner Programs (IDs, discount meals, etc.)

Unrestricted visitsUnrestricted visits (“Most Planetree hospitals have eliminated visiting restrictions altogether.”) (ER at one

hospital “has a policy of never separating the patient from the family, and there is no limitation on how many family members

may be present.”)

Collaborative Care ConferencesCollaborative Care ConferencesClinical Guidelines DiscussionsClinical Guidelines Discussions

Family SpacesFamily SpacesPet VisitsPet Visits (POP: Patients’ Own Pets)


4. Nutrition: Nutrition: The Nurturing The Nurturing Aspect of FoodAspect of Food

Meals are central Meals are central eventsevents

vs

“There, you’re fed.” *

*Irony: Focus on “nutrition” has reduced focus on “food” and “service”


KitchenKitchenBeautiful cutlery,Beautiful cutlery,

plates, etc plates, etcChef reputationChef reputation


Aroma therapyAroma therapy (e.g., “smell of baking cookies”—from kitchenettes

in each ward)


5. Spirituality: Spirituality: Inner Resources Inner Resources

for Healingfor Healing

Spirituality: Meaning and Connectedness in Life

1. Connected to supportive and1. Connected to supportive and caring group caring group2. Sense of mastery and control2. Sense of mastery and control3. 3. Make meaning out of Make meaning out of disease/disease/ find meaning in suffering find meaning in suffering


Griffin: redesign chapelredesign chapel (waterfall, quiet music, open prayer book)

Other: music, flowers, portablemusic, flowers, portable labyrinth labyrinth


6. Human Touch: Human Touch: The Essentials of The Essentials of CommunicatingCommunicating

Caring Through Caring Through MassageMassage

“Massage is a Massage is a powerful way to powerful way to

communicate communicate caring.”caring.” —Putting Patients First,

Susan Frampton, Laura Gilpin, Patrick Charmel

Mid-Columbia Medical Center/Center for Mind and Body

Massage for every patient scheduled for Massage for every patient scheduled for ambulatory surgery ambulatory surgery (“Go into surgery with(“Go into surgery witha good attitude”) a good attitude”) Infant massageInfant massageStaff Staff massage massage (“caring for the caregivers”)(“caring for the caregivers”)Healing environments: chemo!Healing environments: chemo!


7.7. Healing Arts: Healing Arts: Nutrition forNutrition for

the Soul the Soul

Planetree: “Environment conducive to healing”

Color!Color!Light!Light!

Brilliance!Brilliance!Form!Form!Art!Art!

Music!Music!Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

Florence Nightingale/Notes on Nursing/patient’s need for beauty, windows, flowers: “People People

say the effect is only say the effect is only on the mind. It is no on the mind. It is no

such thing. The effect such thing. The effect is on the body, too.”is on the body, too.”


GriffinGriffin:: Music in the parking Music in the parking lot; professional musicians in lot; professional musicians in

the lobby the lobby (7/week, 3-4hrs/day)(7/week, 3-4hrs/day) ; ;

5 5 pianospianos ; ;

volunteers volunteers (120-140 hrs arts & (120-140 hrs arts & entertainment per month).entertainment per month).

Source: Source: Putting Patients FirstPutting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel, Susan Frampton, Laura Gilpin, Patrick Charmel

8. Integrating Integrating Complementary and Complementary and

Alternative Practices Alternative Practices into Conventional into Conventional

CareCare

Griffin IMC/Integrative Medicine Center

MassageMassageAcupunctureAcupunctureMeditationMeditation

ChiropracticChiropracticNutritional supplementsNutritional supplements

Aroma therapyAroma therapySource: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

CAM (Complementary & Alternative Medicine):CAM (Complementary & Alternative Medicine):

83M people use in US83M people use in US (42%)(42%)

CAM visits 243M, greater than to PCPCAM visits 243M, greater than to PCP (Primary (Primary Care Physician) (With minimum insurance coverage)Care Physician) (With minimum insurance coverage)

Well educated-High incomeWell educated-High incomeCAM “users” don’t tell PCP CAM “users” don’t tell PCP (40%)(40%)

Lack of true testing a red herring: <30% Lack of true testing a red herring: <30% procedures used in conventional medicine procedures used in conventional medicine

have undergone RCTshave undergone RCTs (randomized clinical trials)(randomized clinical trials)


9.9. Healing Healing Environments: Environments:

Architecture andArchitecture and Design ConduciveDesign Conducive

to Healthto Health

“Planetree Look”

Woods and natural materialsWoods and natural materialsIndirect lightingIndirect lighting

Homelike settingsHomelike settings

Goals: Goals: Welcome patients, friends and Welcome patients, friends and family … Value humans over technology .. family … Value humans over technology .. Enable patients to participate in their care Enable patients to participate in their care

… Provide flexibility to personalize the … Provide flexibility to personalize the care of each patient … Encourage care of each patient … Encourage

caregivers to be responsive to patients … caregivers to be responsive to patients … Foster a connection to nature and beautyFoster a connection to nature and beauty


SoundSoundTextureTextureLightingLighting

ColorColorSmellSmellTasteTaste

Sacred spaceSacred spaceSource: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

Access to nurses station:

“Happen to”“Happen to”vs

“Happen with”“Happen with”Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

The Eden The Eden Alternative*Alternative*

*ElderCare

Planetree approach applied to Planetree approach applied to eldercare.eldercare.

The Ten Principals of the Eden AlternativeThe Ten Principals of the Eden Alternative

1. The three plagues of 1. The three plagues of loneliness, helplessness, and boredomloneliness, helplessness, and boredom account for the bulk of suffering among Elders.account for the bulk of suffering among Elders.2. Life in an Elder-centered community revolves around 2. Life in an Elder-centered community revolves around close and close and continuing contact with children, plants, and animalscontinuing contact with children, plants, and animals. These . These ancient relationships provide young and old alike with a pathway ancient relationships provide young and old alike with a pathway to a life worth living.to a life worth living.3. 3. CompanionshipCompanionship is the antidote to loneliness. In an Elder- is the antidote to loneliness. In an Elder-centered community we must provide easy access to human and centered community we must provide easy access to human and animal companionship.animal companionship.4. A healthy Elder-centered community seeks to balance the care 4. A healthy Elder-centered community seeks to balance the care that is being given with the care that is being received. that is being given with the care that is being received. Elders need Elders need opportunities to give careopportunities to give care and caregivers need opportunities to and caregivers need opportunities to receive care.receive care.


“The Eden paradigm allows elders to care for

animals, birds, and children as well as each

other.” —Susan Eaton, Harvard/JFK school



5. 5. Variety and SpontaneityVariety and Spontaneity are the antidotes to boredom. are the antidotes to boredom. The Elder-centered community is rich in opportunities to The Elder-centered community is rich in opportunities to sample these ancient pleasures.sample these ancient pleasures.6. An Elder-centered community understands that 6. An Elder-centered community understands that passive passive entertainment cannot fill a human life.entertainment cannot fill a human life.7. The Elder-centered community 7. The Elder-centered community takes medical treatment takes medical treatment down from its pedestal and and places it into the service down from its pedestal and and places it into the service of genuine human caringof genuine human caring..

Source: Source: Putting Patients FirstPutting Patients First, Susan Frampton,, Susan Frampton, Laura Gilpin, Patrick Charmel Laura Gilpin, Patrick Charmel


8. In an Elder-centered community, 8. In an Elder-centered community, decisions should be decisions should be made by the Elders or those as close to the Elders as made by the Elders or those as close to the Elders as possible.possible.9. An Elder-centered community understands human 9. An Elder-centered community understands human growth cannot be separated from human life.growth cannot be separated from human life.10. Wise leadership is the lifeblood of any struggle 10. Wise leadership is the lifeblood of any struggle against the Three Plagues. For it, there can be no against the Three Plagues. For it, there can be no substitute.substitute.


Conclusion: Conclusion: Caring/Growth Caring/Growth “Experience“Experience””

Care!/Love!/Spirit!Care!/Love!/Spirit!Self-Control!Self-Control!

Connect!/learn!/Connect!/learn!/involve!/Engage!involve!/Engage!

Understanding!/Growth! Understanding!/Growth! De-stress!/heal! De-stress!/heal!

Whole patient & family Whole patient & family & friends! & friends!

be well!/stay well!be well!/stay well!

F.Y.I.: It F.Y.I.: It works!works!

Griffin HosGriffin Hosppital/Derbital/Derbyy CT (Planetree Alliance “HQ”) CT (Planetree Alliance “HQ”) ResultsResults::

Financially successful. Financially successful. Expanding programs-Expanding programs-

physically.physically. Growing market Growing market share. share. Only hospital in Only hospital in

“100 Best Cos to Work for”—“100 Best Cos to Work for”—7 consecutive years, 7 consecutive years,

currently #6.currently #6. —“Five-Star Hospitals,” Joe Flower,

strategy+business (#42)

Learn more about Planetree/ Learn more about Planetree/ The Planetree Alliance:The Planetree Alliance:

www.planetree.orgwww.planetree.org

9 July/HealthLeaders9 July/HealthLeaders

2008 Top 2008 Top Leadership Team in Leadership Team in Healthcare: Griffin Healthcare: Griffin

HospitalHospital

And the awards flood in ....And the awards flood in ....

20. My 20. My Concerns … Concerns …

my idealmy ideal

TP & Healthcare/May 2008:TP & Healthcare/May 2008: ***Prevention and wellness***Prevention and wellness***Population outcomes, outcomes in general;***Population outcomes, outcomes in general; key metricskey metrics***EMR, info-tech for procedural integration***EMR, info-tech for procedural integration and guidance for evidence-based and guidance for evidence-based Treatment.Treatment.***Safety***Safety***Quality***Quality***Chronic care***Chronic care***Provision of the basics***Provision of the basics***Simple tools (Checklists)***Simple tools (Checklists)***Clinical micro-systems (Patient Care Teams)***Clinical micro-systems (Patient Care Teams)***Patient Quarterbacks (Family Practice specialists, PAs, Nurses)***Patient Quarterbacks (Family Practice specialists, PAs, Nurses)***Patient-centric/Healing environments (Planetree/Griffinn)***Patient-centric/Healing environments (Planetree/Griffinn)***Evidence-based medicine***Evidence-based medicine***Primary care***Primary care***Overtreatment***Overtreatment***Obesity***Obesity

In summary, the areas I worryIn summary, the areas I worry about most.about most.

TP’s Ideal Hospital Org Chart, Circa August 2008TP’s Ideal Hospital Org Chart, Circa August 2008

CEO, CMO/CHIEFCEO, CMO/CHIEF MEDICAL OFFICER, CNO/CHIEF NURSING OFFICER, CFO, ETC. [traditional MEDICAL OFFICER, CNO/CHIEF NURSING OFFICER, CFO, ETC. [traditional jobs]jobs]DEPUTY CEO/PATIENT SAFETY & QUALITYDEPUTY CEO/PATIENT SAFETY & QUALITY Director “Hands Clean” MandateDirector “Hands Clean” Mandate Director Error-free Medications ProgramDirector Error-free Medications Program Director Simple-Tools-That-Save-Lives ProgramsDirector Simple-Tools-That-Save-Lives Programs Director Over-treatment Evaluation & ManagementDirector Over-treatment Evaluation & ManagementCHIEF CLINICAL EVALUATIONS OFFICERCHIEF CLINICAL EVALUATIONS OFFICER Director Evidence-based Medicine InitiativesDirector Evidence-based Medicine Initiatives Director Best-practices Program Director Best-practices Program Director Error Reporting & Evaluation InitiativeDirector Error Reporting & Evaluation InitiativeCISO/CHIEF INFORMATION SYSTEMS OFFICERCISO/CHIEF INFORMATION SYSTEMS OFFICER Director Electronic Medical RecordsDirector Electronic Medical Records Director Cross-functional IS Engagement & ImplementationDirector Cross-functional IS Engagement & Implementation TeamsTeamsDEPUTY CEO/HEALTH & HEALING & COMMUNITY OUTREACHDEPUTY CEO/HEALTH & HEALING & COMMUNITY OUTREACH Director Wellness & Prevention ProgramsDirector Wellness & Prevention Programs Director Follow-up Patient Behaviors ProgramDirector Follow-up Patient Behaviors Program Director Public Health InitiativesDirector Public Health Initiatives Director Wellness ProgramsDirector Wellness Programs Director Kids’ Education ProgramsDirector Kids’ Education ProgramsCPCCO/CHIEF PATIENT-CENTRIC CARE OFFICERCPCCO/CHIEF PATIENT-CENTRIC CARE OFFICER Director Patient Experience ProgramsDirector Patient Experience Programs Director Planetree Practices ProgramsDirector Planetree Practices Programs Director Patient “Home Port” & Self- & Family-Director Patient “Home Port” & Self- & Family- Management Programs Management Programs DEPUTY CEO/PEOPLEDEPUTY CEO/PEOPLE Director Teams-based OrganizationDirector Teams-based OrganizationCCCO/CHIEF CHRONIC-CARE OFFICERCCCO/CHIEF CHRONIC-CARE OFFICERDEPUTY CEO CROSS-FUNCTIONAL COORDINATION OFFICERDEPUTY CEO CROSS-FUNCTIONAL COORDINATION OFFICER Director Patient-Treatment Teams ImplementationDirector Patient-Treatment Teams Implementation Director Cross-functional Communications InitiativesDirector Cross-functional Communications Initiatives

This is not really a “fix”—it amounts to This is not really a “fix”—it amounts to the injection of hopeless bureaucracy. the injection of hopeless bureaucracy. On the other hand, my “ideal” hospital On the other hand, my “ideal” hospital exec team emphasizes concerns that exec team emphasizes concerns that

seem to be second order in most seem to be second order in most institutions..institutions..

21. TP’21. TP’ss NobelsNobels

TP’s “Nobels” in MedicineTP’s “Nobels” in Medicine

Don BerwickDon BerwickJohn WennbergJohn Wennberg

Elliott FisherElliott FisherKen KizerKen Kizer

The VAThe VAPeter ProNovostPeter ProNovostTeam PlanetreeTeam Planetree

22. Some 22. Some resourcesresources

******Best Care Anywhere: Why VA Healthcare Best Care Anywhere: Why VA Healthcare Is Better Than Yours Is Better Than Yours —Phillip Longman—Phillip Longman

******Medicine & CultureMedicine & Culture —Lynn Payer—Lynn Payer

******Our Daily Meds: How the PharmaceuticalOur Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Companies Transformed Themselves into Slick Marketing Machines and Hooked the Slick Marketing Machines and Hooked the Nation on Prescription Drugs Nation on Prescription Drugs —Melody —Melody PetersenPetersen

******Overtreated: Why Too Much Medicine Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer Is Making Us Sicker and Poorer —Shannon Brownlee—Shannon Brownlee

******Demanding Medical Excellence: DoctorsDemanding Medical Excellence: Doctors and Accountability in the Information Age and Accountability in the Information Age

—Michael Millenson —Michael Millenson

******Putting Patients FirstPutting Patients First —Susan Frampton, —Susan Frampton, Laura Gilpin, Patrick Charmel [The Laura Gilpin, Patrick Charmel [The PlanetreePlanetree story] story]

Thank you Thank you for your for your

time!time!

ENDENDPart 9Part 9

Documents

break the health care industry