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NOTE : To appreciate this presentation [and ensure that it is not a mess ], you need Microsoft fonts: “Showcard Gothic,” “Ravie,” “Chiller” and “Verdana”. Some Reflections On the sorry state of American “health,” circa 2008, and the sorry state of the “delivery of Healthcare,” and why

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Some Reflections


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slide1

NOTE:To appreciate this presentation [and ensure that it is not a mess], you need Microsoft fonts:“Showcard Gothic,”“Ravie,”“Chiller”and“Verdana”

slide2

Some Reflections

On the sorry state of American “health,” circa 2008, and the sorry state of the “delivery of Healthcare,” and why

the twain rarely meet; and how easy it would be to do a few things right, such as remind adults of a certain age to take their aspirin

Tom Peters/03.31.2008

slide3

This presentation has taken me about 10 years to produce—some recent books took me over the top. Nonetheless, it is an amateur’s view—albeit a 65-year-old amateur with “skin in the game.”*

*These gray-background slides are notes on

the preceding slide. I have chosen not to use the

Notes feature of PowerPoint, because so few in

fact avail themselves of notes in that format—and

I am optimistic that some of you will read the “notes” slides in this format.

slide5

Keep this # in mind.

(Throughout this presentation.)

slide6

Some Reflections

On the sorry state of American “health,” circa 2008, and the sorry state of the “delivery of Healthcare,” and why

the twain rarely meet: It’s about a whole lot more than health insurance!

Tom Peters/03.31.08

slide7

This presentation is not about Hillarycare—or Obamacare or McCain-care. While the perverse nature of financial incentives is discussed (e.g., their bias toward “medicine” and away from “health”), this is not a treatise on financing overall or the # of uninsured. It focuses on “my turf”—the operational aspects of healthcare delivery. There is an enormous amount to do in healthcare within our grasp today, and not dependent upon new legislation.

slide9

Some Resources

  • “Bottom Line” (??): U.S. Life Expectancy
  • K.I.A. & Wounded: A House (Hospital) of Horrors
  • How “It” “Works” (And Feels) …
  • 5. You Must Be Your Own Boss!
  • 6. Over-treatment!!!!!!!!!!!!
  • 7. F.Y.I.: The Dominating (!) Role of Healthcare
  • in the American Economy
  • 8. Pick of the Litter: Our “Best” Hospitals?
  • 9. See No Evil: A Culture of Cover-up
slide10

10. And “They” Call It “Science” I: The

  • Overwhelming Lack of Treatment Validation
  • 11. And “They” Call It “Science” II: Astounding
  • Geographic Treatment Variation
  • 12. Shining Star, A/The …
  • 13. IS/IT: The “Dark Ages” Saga Continues
  • K.I.S.S./Keep It Simple, Stupid: Un-sexy
  • “Stuff” Could Save Tens of Thousands of
  • Lives and Extend Hundreds of Thousands
  • of Others
  • 15. Wellness-Prevention: No Good Deed Goes
  • Unpunished
  • 16. From “Healthcare” to “Health”:
  • The “Oughtas”
  • 17. Healthcare Meets Health: The Case of
  • the Planetree Alliance
  • Bonus: Tom’s Nobels
slide12

***Best Care Anywhere: Why VA Healthcare Is Better Than Yours—Phillip Longman***Medicine & Culture—Lynn Payer***Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs—Melody Petersen***Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer—Shannon Brownlee***Demanding Medical Excellence: Doctors and Accountability in the Information Age—Michael Millenson ***Putting Patients First—Susan Frampton, Laura Gilpin, Patrick Charmel [The Planetree story]

slide13

2. “Bottom line” (??):

U.S. Life Expectancy

slide15

Problems notwithstanding, many-most Americans, at the end of the day, consider their-our healthcare to be the best in the world. If so, why do we rank behind the likes of Bosnia and Cuba in life expectancy? Our global life expectancy rank? Forty-five.

(And falling-dropping-plummeting.)

slide17

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

slide18

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

*Should I, for instance, measure my health by “number of operations,” or “number of tests,” where, More = Better Health?

slide19

“Pay by procedure” is the operative (insane) funding algorithm in our healthcare system—there is no premium on helping us get healthy

—in fact there are severe penalties

for so doing.

slide20

“Bottom line” :1900-1960, life expectancy grew 0.64 % per year; 1960-2002, 0.24% per year, half from airbags, gun locks, service employment …

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

slide21

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

slide22

State of Healthcare/U.S.A.*Spend more per capita*Overall system performance/WHO: 37th*Relatively low life expectancy*High # of uninsuredSource: Consulting, 07-08.06

slide23

State of Healthcare/U.S.A.*Spend more per capita*Overall system performance/WHO: 37th*Relatively low life expectancy*High # of uninsuredSource: Consulting, 07-08.06

slide25

“America’s elites are very good at attracting money and prestige, and they have a huge technology arsenal with which they attack death and disease.But they have no positive medical results to show for it in the aggregate and many indications that

they are providing lower-quality care than the much-maligned HMOs and assorted St. Elsewheres.”

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

slide29

“Quality of care is the problem, not managed care.”Source: Institute of Medicine (from Michael Millenson, Demanding Medical Excellence)

study medical errors affect 20 percent of patients headline boston herald
“Study: Medical Errors Affect 20 Percent of Patients”—headline, Boston Herald
slide31

RAND:50%, appropriate preventive care. 60%, recommended treatment, per medical studies, for chronic conditions. 20% , chronic care treatment that is wrong. 30% acute care treatment that is wrong.

slide34

American life expectancy is relatively low—and the delivery of healthcare in the U.S. is notoriously unsafe.

cdc 1998 90 000 killed and 2 000 000 injured from hospital caused drug errors infections
CDC 1998:90,000killed and 2,000,000injuredfrom hospital-caused drug errors & infections
slide36

This 1998 report was a shocker

—and bitterly contested by the “healthcare establishment.” Now

it’s taken for granted, and perhaps understates—significantly. More grim estimates follow.

slide37

HealthGrades/Denver:195,000hospital deaths per year in the U.S., 2000-2002 = equivalent of 390 full jumbos/747s in the drink per year—more than one-a-day.Comments: There is little evidence that patient safety has improved in the last five years.”—Dr. Samantha CollierSource: Boston Globe/2005

slide38

1,000,000“serious medication errors per year” … “illegible handwriting, misplaced decimal points, and missed drug interactions and allergies.”Source: Wall Street Journal /Institute of Medicine

slide39

Throughout, we will see that much of this horrorshow is the product of “simple” problems—e.g., bad handwriting.

slide40

“The Institute of Medicine calculated that drug errors [on average, one per patient per visit—various sources; some estimates go as high as one-per-patient-per-day, on average] alone add on average nearly $5,000 to the cost of every hospital visit.”Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, Shannon Brownlee

slide41

“Hospital infections kill an estimated 103,000 people in the United States a year, as many as AIDS, breast cancer and auto accidents combined.… Today, experts estimate that more than 60 percent of staph infections are M.R.S.A. [up from 2 percent in 1974]. Hospitals in Denmark, Finland and the Netherlands once faced similar rates, but brought them down to below 1 percent. How? Through the rigorous enforcement of rules on hand washing, the meticulous cleaning of equipment and hospital rooms, the use of gowns and disposable aprons to prevent doctors and nurses from spreading germs on clothing and the testing of incoming patients to identify and isolate those carrying the germ. … Many hospital administrators say they can’t afford to take the necessary precautions.”—Betsy McCaughey, founder of the Committee to Reduce Infection Deaths (New York Times/06.06.2005)

slide42
“When I climb Mount Rainier I face less risk of death than I’ll face on the operating table.”—Don Berwick
slide43

Berwick is the uber-guru of the

patient safety movement.

slide44

“The results are deadly. In addition to the 98,000 killed by medical errors in hospitals and the 90,000 deaths caused by hospital infections, another 126,000 die from their doctor’s failure to observe evidence-based protocols for justfour common conditions: hypertension, heart attack, pneumonia, and colorectal cancer.” [TP: total 314,000]

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

slide46

The 314K per year, very conservative, translates into an unnecessary death every one-minute-and-forty-two seconds. ....

slide48

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

slide50

Thom Mayer, renown ER doc and consultant on patient-centric care, reminded me that the grim stats above leave out the likes what goes on in docs’ offices all over the land. (Arguably a staggering number in its own right.)

slide51

“I had done what doctors do well in this country, which is to treat people when they come in with a disease. Mypatients had good medical care but not, I began to think, great healthcare. For most, their declines, their illnesses, were thirty-year problems of lifestyle, not disease. I, like most doctors in America, had been doing the wrong job well. Modern medicine does not concern itself with lifestyle problems. Doctors don’t treat them, medical schools don’t teach them and insurers don’t pay to solve them. I began to think that this was indefensible.”—Henry Lodge, Younger Next Year

slide52

Also left out are the folks who’d be with us if the system focused on health—wellness, prevention, etc..

slide53

“Experts estimate that more than a hundred thousand Americans die each year not from illness but from their prescription drugs.Those deaths, occurring quietly, almost without notice in hospitals, emergency rooms, and homes, make medicines one of the leading causes of death in the United States. On a daily basis, prescription pills are estimated to kill more than 270 Americans. … Prescription medicines, taken according to doctors’ instructions, kill more Americans than either diabetes or Alzheimer’s disease.”Source: Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs —Melody Petersen

slide56

The people who ought to be the gatekeepers who would oversee the co-ordination of specialists work—the dis-organized results thereof which are responsible for most of the likes of the prescription-med errors—are secondclass citizens in the specialist-centric “World of Modern Health“care.”

slide58

Maybe I undershot on

the earlier slide???

slide59

“In 2006 when Time magazine had the brilliant idea of asking doctors what scared them most about being a patient, three frequent answers were fear of medical errors, fear of unnecessary surgery, and fear of contracting a staph infection in teaching hospitals.”

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

slide62

In my 30 years of speechifying, I have said a few controversial things—in fact I have a bit of a reputation for so doing. But no one has tried to put a muzzle on me. Well, no one except the … American Hospital Association. When the CDC 98,000 hospital deaths study appeared, it was fought tooth and nail by “the establishment.” I was appalled by the statistic—mostly as a prospective patient. Along the way, I used the stat in a talk (the CDC is a pretty damn reliable source!); and then I got a message—the first and only time in my career—from my speakers’ bureau. The American Hospital Association is a big client of theirs. And the AHA chief executive had called the president of the speakers’ bureau and more or less demanded that he order me to shut up—and quit propagating that scurrilous number. Naturally the speakers’ bureau told him that my content was up to me, not them. I was of course delighted—it suggested that the number was correct, and that I had drawn blood. But my point here is that this was the only time in three decades that such censorship has been sought. (Of course I can see why the AHA was embarrassed—they damn well should have been!! And still should be!!)

slide64

Journalist Tim Noah writes about his wife’s cancer treatment in a high-rep private med center: “Much of our effort involved retrieving information from one source and sending it to another. This wasn’t something we could count on happening on its own. Very expensive blood test results, we observed, had perhaps a 50% chance of being misplaced under a pile of faxes and therefore not finding their way into Marjorie [William’s] medical chart. So we made a habit of getting the labs to fax to our house. Films of CT scans would be misfiled perhaps 30% of the time and thus become permanently irretrievable. So I took my checkbook to all of Marjorie’s CT scans and purchased my own spare copy on the spot.”

Source: Foreword to Best Care Any where: Why VA

Healthcare Is Better Than Yours, Phillip Longman

slide65

“My most memorable brushes have been with an eminent surgeon,” Marjorie [Longman’s wife, on the receiving end of cancer treatment] wrote in her next-to-last column for the Washington Post, “whose method is to stride into the examining room two hours late, pat your hand, pronounce your certain death if he can’t perform an operation on you, and then snap at your husband to stop taking notes, since he can’t possibly follow the complexity of the doctor’s thinking.”

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

slide66

These are all too common reports. Patient safety guru Don Berwick, a renowned M.D. and Harvard Med School faculty member, was moved to his vociferous patient-safety advocacy,

not by analytic deduction, but by

the insane frequency of errors in his wife’s treatment at a “prestigious Boston medical center.”

slide67

5. You must

be your

own boss!

slide68

“He shook me up. He put his hand on my shoulder, and simply said, ‘Old friend, you have got to take charge of your own medical care.’ ”Source: Hamilton Jordan, No Such Thing as a Bad Day, on a conversation with a doctor pal following Jordan’s cancer diagnosis)

slide69

Longman (his wife, Robin, treated for cancer):“The more time we spent in the Lombardi Center and Georgetown hospital, the more I was disturbed by the way they managed ‘the little things.’ … I was similarly shocked at how little the various specialists involved in her care seemed to consult with one another, or to keep up to date on the results of tests. … There seemed to be little attention given to managing information and coordinating care. …I came away feeling that no patient should ever enter a hospital without having some kind of fulltime advocate—a caring, calm, shrewd relative or friend

at least.”

Source: Best Care Any where: Why VA Healthcare Is

Better Than Yours, Phillip Longman

slide70

For the patient, the immediate answer to this sad state of affairs is to become one’s own healthcare quarterback—and to quit trusting “the guys in

the white coats.”

slide71

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

I’ve got a pacemaker, lower limit only, 60bpm, no defib? And that I

take 150 mg of Coumadin a day? …”**In 3 of 4 cases, in a 2-day period, the answer was in part,

at least, “No” —including set-up for an echo stress

cardio test (reading and results dependent on the above info)

slide72

My own pitiful experience—I was and am enraged. (March 2008, “prestigious Boston medical center.”)

slide76

“The big cause of skyrocketing healthcare costs has been increasingly intensive use of technologies and treatments that, when we look at their effects on the population as a whole, have brought only negligible improvement in public health

and longevity.”

Best Care Any where: Why VA Healthcare

Is Better Than Yours, Phillip Longman

slide77

The previous slide and the next four that follow presumably require no elaboration—except for me to say that I could have offered a 20-slide array, not just these few, had I so desired.

slide78

“We spend between one-fifth and one-third of our healthcare dollars, an exorbitant amount of money, between five hundred and seven hundred billion dollars, on care that does nothing to improve our health.”

Source:Overtreated: Why Too Much Medicine Is Making Us

Sicker and Poorer, Shannon Brownlee

slide79

400,000 heart bypass surgeries, 1,000,000 angioplasties per year:“Yet recent studies show that only about three percent of the patients who receive such operations benefit from them; most would be better served just taking aspirin or low-cost beta blockers.”

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

slide80

“Americans undergo millions of tests—MRIs, CT scans, blood tests—that do little to help doctors diagnose disease, and sometimes lead them to find and treat conditions that would never have bothered their patients had they never been found. We undergo back surgery for pain in the absence of evidence that the surgery works.”

Source:Overtreated: Why Too Much Medicine Is Making

Us Sicker and Poorer, Shannon Brownlee

slide81

“[Dartmouth Professor Elliott] Fisher and his colleagues discovered that patients who went to hospitals that spent the most— and did the most procedures—were 2 to 6 percent more likely to die than patients that went to hospitals that spent the least.”

Source:Overtreated: Why Too Much Medicine Is Making

Us Sicker and Poorer, Shannon Brownlee

slide82

“The most powerful reason doctors and hospitals overtreat is that most of them are paid for how much care they deliver, not how well they care for their patients.”

Overtreated: Why Too Much Medicine Is Making Us

Sicker and Poorer, Shannon Brownlee

slide83

“Teach to test” is the Achilles heel of our “education” system—the only acquired skill is test-taking; and the essential love-of-learning is diminished, not enhanced. Likewise, “pay for procedure” is the perverse centerpiece of our health“care” system—denigrating the very health for which we were intended to care.

slide84

Hospital intake interview with yours truly, Boston, March 2008Physician’s Assistant:“What did your mother die of?”TP:“Too many specialists.”PA:“No, really?TP:Really!!”

slide85

Hospital intake interview, Boston, March 2008Physician’s Assistant:“What did your mother die of?”TP:“Too many[excellent]specialists.”PA:“No, really?TP:Really!!”

slide86

Hospital intake interview, Boston, March 2008Physician’s Assistant:“What did your mother die of?”TP:“Too many[excellent]specialists [who never communicate/d with one another] .”PA:“No, really?TP:Really!!”

slide87

I was not joking. As the end hove in sight, my Mom was being treated for a sizeable number of problems (she was 95); it seemed as though no more than a couple of days passed before she was over-reacting to one med that other docs were not aware of. They’d cut that one back, then enhance another. At 95, she was simply wearing out—but her overload of non-coordinated specialists pretty clearly pushed her out the door. (This is not just my conclusion, but that of a couple of

my M.D. pals.)

slide88

“If we sent 30 percent of the doctors in this country to Africa, we might raise the level of health on both continents.”—Dr Elliott Fisher,

Center of Evaluative Clinical Sciences, Dartmouth Medical School(“Overdose,” Atlantic, Shannon Brownlee.)

slide89

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

slide90
“America has twice as many hospitals and physicians as it needs.”—Med Inc., Sandy Lutz, Woodrin Grossman & John Bigalke
slide92

$PD(USA) > $PD(J + G

+ F + I + S + UK + A

+ NZ + C + M + B + A)

> $G(USA) > $HEX2(USA)*

*U.S. spending on prescription drugs in 2005 ($250,000,000,000) is greater than the combined spending on prescription drugs by Japan plus Germanyplus France plus Italy plus Spainplus the United Kingdom plus Australia plus New ZealandplusCanada plusMexicoplusBrazilplusArgentina(all except Mexico, Brazil and Argentina have longer life expectancies than we do); and our prescription drug bill also is more than our gasoline bill and two times more than our higher ed bill.

Source: Our Daily Meds: How the Pharmaceutical Companies

Transformed Themselves into Slick Marketing Machines and

Hooked the Nation on Prescription Drugs —Melody Petersen

slide93

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

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

*U.S. spending on prescription drugs in 2005 ($250,000,000,000) is greater than the combined spending on prescription drugs by Japan plus Germanyplus France plus Italy plus Spainplus the United Kingdom plus Australia plus New ZealandplusCanada plusMexicoplusBrazilplusArgentina(all except Mexico, Brazil and Argentina have longer life expectancies than we do); and our prescription drug bill also is more than our gasoline bill and two times more than our higher ed bill.

Source: Our Daily Meds: How the Pharmaceutical Companies

Transformed Themselves into Slick Marketing Machines and

Hooked the Nation on Prescription Drugs —Melody Petersen

slide94

Again, words like “insane” or “ridiculous” or “outrageous” are the only ones that come to mind.

slide95

“a grossly overprescribed nation”—Arnold Relman, professor emeritus, Harvard Med; former editor, The New England Journal of MedicineSource: Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs —Melody Petersen

slide96

“Creating a disease”—from a slide by Neil Wolf, Pharmacia, at the 2003 Pharmaceutical Marketing Global Summit (Philadelphia)Source: Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs —Melody Petersen

slide97

I am not an instinctive basher of the pharmaceutical industry. Yet the evidence is clear—the industry has repeatedly made mountains (worth $$$$$billions) out of mole-hills. (Or “no-hills.”)

slide99

“What’s Really Propping Up the Economy: Healthcare has added 1.7 million jobs since 2001. The rest of the private sector?None.”Source: Title, cover story, BusinessWeek,0925.2006

slide100

We spend over $2,000,000,000,000 on healthcare in America—and it is also our engine of job growth. Increasingly, “healthcare economics” are “American economics.” Tinkerer beware!

slide101

8. Pick of the litter:

Our “best” hospitals?

slide102

“Generally, the more prestigious the hospital you check into, and the more eminent and numerous the physicians who attend you, the more likelyyou are to receive low-quality or even dangerous and unnecessary care.”

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

slide104

“The more doctors and specialists around, the more tests and procedures performed. And the results of all these tests and procedures? Lots more medical bills, exposure to medical errors, and a loss of life expectancy.

“It was this last conclusion that was truly shocking, but it became unavoidable when [Dartmouth’s Dr. Jack] Wennberg and others broadened their studies.They found it’s not just that renowned hospitals and their specialists tend to engage in massive overtreatment. They also tend to be poor at providing critical but routine care.”

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

slide105

“[Dartmouth’s Dr. Jack] Wennberg and others … found it’s not just that renowned hospitals and their specialists tend to engage in massive overtreatment. They also tend to be poor at providing critical but routine care. For example, Dartmouth researcher Elliot S. Fisher has found that among Medicare patients, who share the same age, socioeconomic, and health status, their chances of dying in the next five years are greater if they go to a high-spending hospital. One reason is that patients in high-spending hospitals with lots of specialists and high technology are also less likely to receive many proven routine treatments [e.g. aspirin, flu vaccine]. … This general lack of attention to prevention and follow-up care in high-spending hospitals helps to explain why not only heart-attack victims but also patients suffering from colon cancer and hip fracture stand a better chance of living another five years if they stay away from ‘elite’ hospitals and choose a lower-cost competitor.”

Best Care Any where: Why VA Healthcare Is

Better Than Yours, Phillip Longman

slide106

“The more doctors and specialists around, the more tests and procedures performed. And the results of all these tests and procedures? Lots more medical bills, exposure to medical errors, and aloss of life expectancy.”

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

slide109

“culture of cover-up that pervades healthcare”

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

slide110

One begins to feel that there is no end to the insults to which patients-citizens are subjected by this most “modern” of American industries.

slide111

“When a plane crashes, they ask, ‘What happened?’ In medicine they ask: ‘Whose fault was it?’ ”—James Bagian, M.D. & former astronaut, now working with the VHA

slide112

Success Through Positive Acknowledgement of FailuresWernher Von Braun, re the Redstone missile engineer who “confessed” to a screw-up and was awarded a bottle of champagne. Award to the sailor on the aircraft carrier Carl Vinson—for reporting a lost tool on the deck (that could have caused a crash). Amy Edmonson on successful nursing units—with the highest reported adverse drug events.Source: Karl Weick & Kathleen Sutcliffe, Managing the Unexpected

slide114

Ken Kizer/VA 1997: “culture of cover-up that pervades healthcare” “Patient Safety Event Registry” … “looking for systemic solutions, not seeking to fix blame on individuals except in the most egregious cases. The good news was athirty-fold increasein the number of medical mistakes and adverse events that got reported.”

“National Center for Patient Safety Ann Arbor”

slide117

The enormity of the possible improvement is staggering—perhaps one of the few hopeful signs.

slide118

10. And “they”

call it “science” I: overwhelming Lack of treatment validation

slide119

“stunning lack of scientific knowledge about which treatments and procedures actually work.”

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

slide121

“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 colleagues..” “Wennberg came to an unsettling conclusion.Medicine wrapped itself in the mantle of science, yet much of what doctors were doing was based more on hunches than good research. … In fact, as research would show over the coming decades, stunningly little of what physicians do has ever been examined scientifically, and when many treatments and procedures have been put to the test, they have turned out to cause more harm than good.In the latter part of the twentieth century, dozens of common treatments , including the tonsillectomy, the hysterectomy, the frontal lobotomy, the radical mastectomy, arthroscopic knee surgery for arthritis, X-ray screening for lung cancer, proton pump inhibitors for ulcers, hormone replacement therapy for menopause, and high-dose chemotherapy for breast cancer, to name just a few, have been shown to be unnecessary, ineffective, more dangerous than imagined, or sometimes more deadly than the diseases they were intended to treat.”

Overtreated: Why Too Much Medicine Is Making Us

Sicker and Poorer, Shannon Brownlee

slide122

“As unsettling as the prevalence of inappropriate care is the enormous amount of what can only be called ignorant care. A surprising 85% of everyday medical treatments have never been scientifically validated. … For instance, when family practitioners in Washington were queried about treating a simple urinary tract infection, 82 physicians came up with an extraordinary 137 strategies.”Source: Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

slide124

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

slide126

“Most people think that quality of care is defined by medical interventions, such as a hip replacement, lens implant, or coronary bypass operation, but genuine quality of care is defined by action based on good information.Definitions of quality are often counterintuitive. Multiple lab tests do not constitute quality medicine. … Entrepreneurial physicians have a greater stake in doing more than in doing good. Medicare, for example, provides funding for autopsies of every hospitalized beneficiary, and good science suggests that at least 30 percent of deaths should be autopsied. Very few are.. … In fact, lack of autopsy is the ultimate cover-up in medicine, and the signature of poor quality care. … The whole issue of patient safety is based on honesty, and the autopsy is central in a system that finds truth, deals with it honestly, and tries to improve patient care.”Source: “The Search for Quality: It All Begins on the Autopsy Table,” chapter title, Severed Trust: Why American Medicine Hasn’t Been Fixed, George Lundberg

slide127

11. And “they” call

it “science” II: Astounding Geographic treatment variation

slide128

“In health care …geography is destiny.”Dartmouth Medical School 1996 report, from Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

slide130

“What [Wennberg and his Dartmouth colleagues] found was that medicine was all over the map, literally. If Wennberg had been using a microscope to look at medical care in New England, his team was now standing on a mountaintop looking at the entire nation, yet they were seeing precisely the same patterns he had found in Vermont and Maine. Only now they could tell it wasn’t just tonsillectomies; hysterectomies and prostatectomies were being used far more in one region than another. It was CT scans, office visits, cardiac catheterizations. It was blood tests and hospitalizations, back surgery, chest X-rays, and knee replacements. In one part of the country, practically every woman with breast cancer was still getting a mastectomy long after clinical trials had shown that a breast-sparing lumpectomy with radiation was just as effective. In another, babies were being put in neonatal intensive care when they didn’t need it. They found that patients with back pain were 300 percent more likely to get surgery in Boise, Idaho, than in Manhattan. Doctors affiliated with Harvard Medical School admitted patients to the intensive care unit four times more often than their colleagues at Yale University School of Medicine. Arthroscopic knee surgery –which would later be shown to be entirely ineffective at treating knee pain due to arthritis—was performed five times more often on arthritic patients in Miami than Iowa City.Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, Shannon Brownlee

slide131

Geography Is DestinyE.g.: Ft. Myers 4X Manhattan—back surgery. Newark 2X New Haven—prostatectomy. Rapid City SD 34XElyria OH—breast-conserving surgery. VT, ME, IA: 3X differences in hysterectomy by age 70; 8X tonsillectomy; 4X prostatectomy (10X Baton Rouge vs. Binghampton). Breast cancer screening: 4X NE, FL, MI vs. SE, SW. (Source: various)

slide132

Geography Is Destiny“Often all one must do to acquire a disease is to enter a country where a disease is recognized—leaving the country will either cure the malady or turn it into something else. … Blood pressure considered treatably high in the United States might be considered normal in England; and the low blood pressure treated with 85 drugs as well as hydrotherapy and spa treatments in Germany would entitle its sufferer to lower life insurance rates in the United States.”– Lynn Payer, Medicine & Culture

slide134

“Practice variation is not caused by ‘bad’ or ‘ignorant’ doctors. Rather, it is a natural consequence of a system that systematically tracks neither its processes nor its outcomes, preferring to presume that good facilities, good intentions and good training lead automatically to good results. Providers remain more comfortable with the habits of a guild, where each craftsman trusts his fellows, than with the demands of the information age.”—Michael Millenson, Demanding Medical Excellence

slide135

“Nothing has changed since our Science paper in 1973. …”*—Dr Jack Wennberg*“Nothing of course, except the fact that American medicine has swelled into a behemoth industry equal in size to the entire economy of Italy.”—SB Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, Shannon Brownlee

slide138

“What’s needed in the U.S. is nothing short of a medical revolution and the VHA has gone further than most any other organization to revamp its culture and systems.”—RAND

slide139

There is an exception among big systems—the Veterans Administration/VA hospitals. And yes, “everyone” is amazed. (Mr Longman’s book, Best Care Anywhere: Why VA Healthcare Is Better Than Yours, is a masterpiece—required reading for any healthcare professional, as I see it.)

slide140

Ken Kizer, 1994, per Longman:

“reorienting the VHA away from a system that emphasized acute care delivered in hospitals by specialists and toward one that put overwhelming emphasis on prevention and patient-centered management of chronic conditions.”

Best Care Any where: Why VA Healthcare Is

Better Than Yours, Phillip Longman

slide141

Ah, health

is the goal! (What a fascinating idea.)

slide142

“Because the VA lacks any financial incentive to engage in overtreatment, it saves money by avoiding unnecessary surgery and redundant testing.”

Best Care Any where: Why VA Healthcare Is

Better Than Yours, Phillip Longman

slide143

No doubt at all, the VA incentive scheme, the antithesis of the mainstream programs, is a big help.

slide144

VA costs up

0.8% in 10 years, Medicare up 40.4%

(Note: VA patients “older, sicker, poorer and more prone to mental illness, homelessness, and substance abuse;” ½ > 65, 1/3 smoke, 1/5 diabetes vs 1/14 overall; chronic diseases, frailty—especially vulnerable to medical errors )

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

slide145

Key point, the VA is dealing with a tougher than normal population—so they aren’t blessed with any systemic advantage on that score.

slide146

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

***2004, Annals of Internal Medicine, RAND study: VA vs commercial managed care; VA “outperforms all other sectors of American healthcare in 294measures of quality” …

***National Committee for Quality Assurance top-rated, JHU, Mayo, Mass General; “In every single category the veterans healthcare system outperforms the highest-rated non-VA hospitals”

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

slide148

E.g.: On-time appointments, appointment with specialist, Institute for Health Care Improvement/Don Berwick:“[VA is] spectacular”

Best Care Any where: Why VA Healthcare Is

Better Than Yours, Phillip Longman

slide150

VA/Strengths/Foci

*Safety

*Evidence-based medicine

*Health promotion and wellness

programs

*“Unparalleled adoption of

electronic medical records

and otherinformation

technologies”

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

slide151

The VHA gets it!E.g.: Laptop at bedside calls up patient e-records from one of 1,300 hospitals. Bar-coded wristband confirms meds. National Center for Patient Safety in Ann Arbor. Docs and researchers discuss optimal treatment regimens—research center in Durham NC. Doc measures & guidelines; e.g., pneumonia vaccinations from 50% to 84%. Blame-free system, modeled after airlines.“What’s needed in the U.S. is nothing short of a medical revolution and the VHA has gone further than most any other organization to revamp its culture and systems.”—Rand

slide153

“Shockingly, despite our vaunted prowess in computers, software and the Internet, much of our healthcare system is still operating in the dark ages of paper records and handwritten scrawls. American primary care doctors lag years behind doctors in other advanced nations in adopting electronic medical records or prescribing medications electronically. This makes it harder to coordinate care, spot errors and adhere to standard clinical guidelines.” —”World’s Best Medical Care?”, New York Times, August 2007

slide155

“Some grocery stores have better technology than our hospitals and clinics.”—Tommy Thompson, former HHS SecretarySource: Special Report on technology in healthcare, U.S. News & World Report

slide156
“We’re in the Internet age, and the average patient can’t email their doctor.”—Don Berwick, Harvard Med School
slide157

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

Overtreated: Why Too Much Medicine Is Making

Us Sicker and Poorer, Shannon Brownlee

slide158

VA/Strengths

*Safety

*Evidence-based medicine

*Health promotion and wellness

programs

*“Unparalleled adoption of

electronic medical records

and otherinformation

technologies”

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

slide159

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

“the Hard Hats.”

Dr Kenneth Dickie, 1979, brought together, as VistA, 20,000 software protocols “originally written by individual doctors and other professionals working secretly in VA facilities all around the country”

“This unique, integrated information system has dramatically reduced medical errors at the VA while also vastly improving diagnoses, quality of care, scientific understanding of the human body, and the development of medical protocols based on hard data about what drugs and procedures work best.”

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

slide161

“As with many other institutions, the software these [VA] high priests wrote, or more often procured from private vendors, wasn’t verygood, in large part because the people who actually had to use it had little role in its development.”

Best Care Anywhere: Why VA Healthcare Is

Better Than Yours, Phillip Longman

slide162

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

slide163

Scanner: “Skunkworks” project started in Kansas, 1992, hand-held scanner, idea from nurse Sue Kinnick when she observed usage in rental-car return area.“It wound up eliminating some 549,000errors by 2001; there was a 75% decrease in errors involving the wrong medication, a 62% decrease in errors involving the wrong dosage, a 93% reduction in the wrong patients receiving medicine, and a 70% decrease

in the number of times nurses simply forgot

or didn’t get around to giving patients

their meds.”

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

slide164

Again, the numbers are staggering. I’m hardly suggesting that putting this system in place was a cakewalk—on the other hand, the basic idea is hardly rocket science! (Most of these breakthrough ideas aren’t; e.g., rewarding the reporting of errors so that learning can ensue.)

slide165

“Our entire facility is digital.No paper, no film, no medical records. Nothing. And it’s all integrated—from the lab to X-ray to records to physician order entry. Patients don’t have to wait for anything. The information from the physician’s office is in registration and vice versa. The referring physician is immediately sent an email telling him his patient has shown up. … It’s wireless in-house. We have 800 notebook computers that are wireless. Physicians can walk around with a computer that’s pre-programmed. If the physician wants, we’ll go out and wire their house so they can sit on the couch and connect to the network. They can review a chart from 100 miles away.” —David Veillette, CEO, Indiana Heart Hospital

slide166

It helps to have a “greenfield” facility—but this is also a non-VA demo of making effective IS the centerpiece of the enterprise.

slide167

14. k.i.s.s./Keep it simple, stupid: Un-sexy “stuff” Could save tens of thousands of lives and extend hundreds of thousands of others

slide168

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

slide169

“The simplest treatments often fall through the cracks —making sure a patient knows how to use an asthma inhaler, for instance. And when doctors and hospitals try to deliver the right kind of care, such as keeping track of a heart patient’s weight gain … , they lose money.”

Overtreated: Why Too Much Medicine Is Making

Us Sicker and Poorer, Shannon Brownlee

slide171

“For most Americans, the two biggest determinants of what kind of treatments they receive are how many doctors and specialists hang a shingle in their community and which one of them they happen to see. The more doctors and specialists around, the more tests and procedures performed. And the results of all these tests and procedures? Lots more medical bills, exposure to medical errors, and a loss of life expectancy. It was this last conclusion that was truly shocking, but it became unavoidable when [Dartmouth’s Dr. Jack] Wennberg and others broadened their studies. They found it’s not just that renowned hospitals and their specialists tend to engage in massive overtreatment.They also tend tobe poor at providing critical but routine care.For example, Dartmouth researcher Elliot S. Fisher has found that among Medicare patients, who share the same age, socioeconomic, and health status, their chances of dying in the next five years are greater if they go to a high-spending hospital.One reason is that patients in high-spending hospitals with lots of specialists and high technology are also less likely to receive many proven routine treatments [e.g. aspirin, flu vaccine]. … This general lack of attention to prevention and follow-up care in high-spending hospitalshelps to explain why not only heart-attack victims but also patients suffering from colon cancer and hip fracture stand a better chance of living another five years if they stay away from ‘elite’ hospitals and choose a lower-cost competitor.”

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

slide173

K.I.S.S./Keep It Simple, Stupid:Wrong site surgery: “The most effective part of the drill is simply asking the patient, in language he can understand, to state (not confirm) who he is, his birth date or social security number, and what he’s in for.”

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

slide175

“If God spoke to me by saying, ‘Mark, you’re down to your last three words: What would you want to say to your fellow humans that would make the most positive impact?’ It would be a close call between Love Thy Neighbor andWash Your Hands. A close third would be Move, Move, Move.”—Mark Pettus, M.D., The Savvy Patient“The most important thing you can do to keep from getting sick is to wash your hands.”—CDC/National Center for Infectious Diseases

slide176

“Sanitary revolution”: mortality in major citiesdown55%between 1850 and 1915Source: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation

slide177

Compression hose would mostly fix the hospital problem:“According to the American Heart Association, up to two million Americans are affected annually by deep vein thrombosis. Of those who develop pulmonary embolism, up to 300,000 will die each year. ... Deep vein thrombosis also is among the leading causes of preventable hospital death. Even more disturbing is the fact that, according to a U.S. multi-center study published by two of ClotCare's editorial board members,58% of patients who developed a DVT while in the hospital received no preventive treatment despite the presence of multiple risk factors and overwhelming data that prophylaxis is very effective at reducing these events.”—Marie B. Walker, clotcare.com, March 2008

slide178

One study I came across concluded that you could save 20,000 lives per year in UK hospitals—by issuing compression hose-socks to virtually every hospitalized patient. (As I said, we ain’t talkin’ rocket science.)

slide179

The EMS Myth:“Speed* has never saved anybody’s life. Period.”—W.H. Leonard, Medical Transportation Insurance Professionals*Ambulance, accident site to hospitalSource: USA Today

slide180

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

slide181

20%: not get prescriptions filled50%: use meds inconsistentlySource: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation

slide182

Market ForcesRediClinic.CheckUps.Take Care.MinuteClinic*(*“We treat these 16 rules-based disorders”/ “Go-no go” tests.15 minutes.$39)Wal*Mart.CVS.Target.Walgreens.RiteAidSource: FT (10.06.06); NYT (12.31.06)

slide183

I am an unabashed champion of such non-conventional healthcare delivery vehicles—hospitals are fighting them tooth and nail. (Hilariously, hospitals have declared them unsafe—talk about pots calling kettles black!) (Interestingly, these convenient-care operations may significantly push the greater “system” in the direction of electronic medical records—the CC clinics are

100% electronic.)

slide185

I absolutely love

this story!

slide186

90K in U.S.A. ICUs on any given day; 178 steps/day in ICU.50% stays result in “serious complication”Source: Atul Gawande, “The Checklist” (New Yorker, 1210.07)

slide187

**Peter Pronovost, Johns Hopkins, 2001**Checklist, line infections**1/3rd at least one error when he started**Nurses/permission to stop procedure if doc, other not following checklist**In 1 year, 10-day line-infection rate:11% to … 0%Source: Atul Gawande, “The Checklist” (New Yorker, 1210.07)

slide189

**Docs, nurses make own checklists on whatever process-procedure they choose**Within weeks, average stay in ICU down 50%Source: Atul Gawande, “The Checklist” (New Yorker, 1210.07)

slide191

**Replicate in Inner City Detroit (resource strapped—$$$, staff cut 1/3rd, poorest patients in USA)**Nurses QB the process**Project manager for overall process implementation**Exec involvement (help with “little things”—it’s all “little things”)**Blue Cross/insurers, small bonuses for participating**6 months, 66% decrease in infection rate; USA: bottom 25% in hospital rankings to …top 10%Source: Atul Gawande, “The Checklist” (New Yorker, 1210.07)

slide193

“[Pronovost] is focused on work that is not normally considered a significant contribution in academic medicine. As a result, few others are venturing to extend his achievements.Yet his work has already saved more lives than that of any laboratory scientist in the last decade.”—Atul Gawande, “The Checklist” (New Yorker, 1210.07)

slide195

“Beware of the tyranny of making SmallChanges to SmallThings. Rather, make Big Changes to BigThings.”—Roger Enrico, former Chairman, PepsiCo

slide197

“Beware of the tyranny of making SmallChanges to SmallThings.Rather, make BigChanges to Big Things … using Small, Almost Invisible Straightforward Levers with Big Systemic Impact.”—TP

slide198

Think checklist.

Think “wash your hands.”

Think “take your aspirin.”

Think “What’s your name?”

Think compression hose.

Etc.

Etc.

slide200
“Every $1.00 spent on its wellness program ended up saving [Citigroup] $4.70, according to an academic study.”—WSJ/0329.07
slide201

We can demonstrate the

enormous value of emphasizing wellness-prevention.

slide202

Pursuing “Health”:1995, Duke Medical Center, “Nurses regularly called patients [with congestive heart failure] at home to monitor their well-being and to make sure they took their medications. Nutritionists offered heart-healthy diets. Doctors shared data about their patients and developed evidence for what treatments and dosages had the best results. And it worked—at least in the sense that patients became healthier. The number of hospital admissions declined and patients spent less time in the hospital.

“Quality doesn’t pay”:“By 2000, the hospital was taking a 37% hit in its revenue due to the decline in admissions and the absence of complications. Ten hospitals in Utah had a similar experience after implementing integrated care for pneumonia.”“No investment in quality goes unpunished.” “But there is a problem: Who will pay for it? … An idealistic commitment to best practices doesn’t pay the bills.”

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

slide203

Whoops. (Alas.)

(FYI, I also read recently that Duke shut down its “family practice” specialty program—for lack of interest.)

tp recommendation 1 dubai healthcare city to dubai health city cleveland clinic and canyon ranch
TP Recommendation #1:Dubai Healthcare City to Dubai Health City**Cleveland Clinic and Canyon Ranch
slide206

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

call it “Health City.”

(Words do matter.)

slide209

“I had done what doctors do well in this country, which is to treat people when they come in with a disease. Mypatients had good medical care but not, I began to think, great healthcare. For most, their declines, their illnesses, were thirty-year problems of lifestyle, not disease. I, like most doctors in America, had been doing the wrong job well. Modern medicine does not concern itself with lifestyle problems. Doctors don’t treat them, medical schools don’t teach them and insurers don’t pay to solve them. I began to think that this was indefensible.”—Henry Lodge, Younger Next Year

slide212

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

(Behavioral, not medicinal!)

slide214

“Model the way” is leadership “Rule One.” Fat docs hectoring kids to give up fast foods is not on … as far as

I’m concerned.

slide218

I’ve always been lucky enough to have “very good doctors”—starting with my pediatrician, Dr Elizabeth Peabody, in Annapolis in the 1940s. But in 2003 I went to Canyon Ranch (Berkshires) aiming to “get my shit together.” There I met nutritionists and others—the first “healthcare folks” I’d met, especially M.D.s, focused on “health.” In short order, I had wildly reversed most of the adverse readings in my blood tests. I had in effect reversed aging—and that is not an exaggeration.

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

slide219

Behavioral Primacy!E.g.: plate size; location of platters, 6.5 feet Away = -63% “Seconds”Source: Brian Wansink, Mindless Eating (20 lbs per year; 200 decisions per day)

slide220

Working on the basic “behavioral stuff”—no mean feat—provides enormous payoff. (Yes, it’s difficult to do—but, mainly, it is most definitely not the focus of our $2,000,000,000,000 health“care” industry.)

slide221

Sprint/Overland Park KS:Slow elevators, distant parking lots with infrequent buses, “food court” as “poorly” placed as possible, etc.Source: New York Times

slide223

Health + Social Factors combination = 20% fewer admissions, 40% less bed occupancy [over 65]Source: Unicare/UK/Dr David Lyon/Pulse, 1123.06

slide224

(Can work for the VA, NHS—but, as noted above, thwarted by our “pay per procedure” “culture.”)

slide228

I will conclude this presentation

with a “good news” case, that

of the Planetree Alliance.

planetree a radical model for new healthcare healing wellness excellence tom peters
Planetree: A Radical Model for New Healthcare/Healing/Wellness ExcellenceTom Peters
slide230

"All sane persons agree that 'healthcare needs an overhaul.' And that's where the agreement stops. Healthcare issues are thorny, and system panaceas are about as likely as the sun rising in the West. But there is good news here and there—and great news courtesy the Planetree Model.

"In the midst of ceaseless gnashing of teeth over 'healthcare issues,' the patient and frontline staff often get lost in the shuffle. Enter Planetree. While oceanic systemic solutions remain out of reach, Planetree provides a remarkable demonstration of what healthcare—with the patient at the center—can be all about; and is all about among Planetree Alliance members.

"I know this may sound ridiculous, but everything about the 'model' works. It is great for patients and their families—and is truly about humanity and healing and health and long-term wellness, not just a 'fix' for today's problem. It is great for staff—Planetree-Griffin is rightly near the top of the 'best places to work in America' list, year in and year out. And Planetree also works as a 'business model'—any effectiveness measure you can name is in the Green Zone at Griffith.

"For 25 years my 'gig' has been 'excellence.' Put simply, there is no better exemplar of customer-centered, employee-friendly excellence, in any industry, than Griffin-Planetree. The Planetree model works—and in my extensive work in the health sector, I 'sell' it shamelessly, and pray that my clients are taking it all in."

tom peters/response to request for comment on Planetree

slide233

“It was the goal of the Planetree Unit to help patients not only get well faster but also to stay well longer.”—Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide234

And this is done within the context

of the private-incentive scheme

—i.e., it can be done.

slide235

“Much of our current healthcare is about curing . Curing is good. But healingis spiritual, and healing is better, because we can heal many people we cannot cure.”—Leland Kaiser, “Holistic Hospitals”

slide236

“The most basic question we need to pose in caring for others is this: Is this a loving act?”—Leland Kaiser, “Holistic Hospitals”Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide237
Determinants of HealthAccess to care: 10%Genetics: 20%Environment: 20%Health Behaviors: 50%Source: Institute for the Future
slide238

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

slide240

Press Ganey Assoc:139,380 former patients from 225 hospitals:noneof THE top 15 factors determining Patient Satisfaction referred to patient’s health outcomePSdirectly related to StaffInteractionPSdirectly correlated with Employee SatisfactionSource: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide241

“There is a misconception that supportive interactions require more staff or more time and are therefore more costly. Although labor costs are a substantial part of any hospital budget, the interactions themselves add nothing to the budget. Kindness is free. Listening to patients or answering their questions costs nothing. It can be argued that negative interactions—alienating patients, being non-responsive to their needs or limiting their sense of control—can be very costly. … Angry, frustrated or frightened patients may be combative, withdrawn and less cooperative—requiring far more time than it would have taken to interact with them initially in a positive way.”—Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide242

“Perhaps the simplest and most profound of all human interactions is KINDNESS. … But if it is so simple, it is surprising how frequently it is absent from our healthcare environments. … Many staff members report verbal ‘abuse’ by physicians, managers and coworkers.”—Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide243

“Planetree is about human beings caring for other human beings.”—Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel (“Ladies and gentlemen serving ladies and gentlemen”—4S credo)

2 informing and empowering diverse populations consumer health libraries and patient information
2.Informing and Empowering Diverse Populations: ConsumerHealth Libraries and Patient Information
slide245

Planetree Health Resources Center/1981Planetree Classification SystemConsumer Health LibrariansVolunteersClasses, lecturesHealth FairsGriffin’s Mobile Health Resource CenterOpen Chart PolicyPatient Progress NotesCare Coordination Conferences (Est goals, timetable, etc.)Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide247

“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

slide248

The Patient-Family Experience“Patients are stripped of control, their clothes are taken away, they have little say over their schedule, and they are deliberately separated from their family and friends. Healthcare professionals control all of the information about their patients’ bodies and access to the people who can answer questions and connect them with helpful resources. Families are treated more as intruders than loved ones.”—Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide249

“Family members, close friends and ‘significant others’ can have a far greater impact on patients’ experience of illness, and on their long-term health and happiness, than any healthcare professional.”—Through the Patient’s Eyes

slide250

“A 7-year follow-up of women diagnosed with breast cancer showed that those who confidedinatleastoneperson in the 3 months after surgery had a 7-year survival rate of 72.4%, as compared to 56.3% for those who didn’t have a confidant.” —Institute for the Future

slide251

Care Partner Programs(IDs, discount meals, etc.)Unrestricted visits(“Most Planetree hospitals have eliminated visiting restrictions altogether.”) (ER at one hospital “has a policy of never separating the patient from the family, and there is no limitation on how many family members may be present.”)Collaborative Care ConferencesClinical Guidelines DiscussionsFamily SpacesPet Visits(POP: Patients’ Own Pets)Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide253

Meals are central eventsvs“There, you’re fed.” **Irony: Focus on “nutrition” has reduced focus on “food” and “service”Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide254
KitchenBeautiful cutlery, plates, etcChef reputationSource: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
slide255

Aroma therapy(e.g., “smell of baking cookies”—from kitchenettes in each ward)Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide257

Spirituality: Meaning and Connectedness in Life1. Connected to supportive and caring group2. Sense of mastery and control3. Make meaning out of disease/ find meaning in sufferingSource: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide258

Griffin:redesign chapel(waterfall, quiet music, open prayer book)Other: music, flowers, portable labyrinthSource: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide260
“Massage is a powerful way to communicate caring.”—Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
slide261

Mid-Columbia Medical Center/Center for Mind and BodyMassage for every patient scheduled for ambulatory surgery (“Go into surgery witha good attitude”) Infant massageStaff massage (“caring for the caregivers”)Healing environments: chemo!Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide263

Planetree: “Environment conducive to healing”Color!Light!Brilliance!Form!Art!Music!Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide264

Florence Nightingale/Notes on Nursing/patient’s need for beauty, windows, flowers:“People say the effect is only on the mind. It is no such thing. The effect is on the body, too.”Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide265

Griffin:Music in the parking lot; professional musicians in the lobby (7/week, 3-4hrs/day) ; 5 pianos; volunteers (120-140 hrs arts & entertainment per month).Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide267

Griffin IMC/Integrative Medicine CenterMassageAcupunctureMeditationChiropracticNutritional supplementsAroma therapySource: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide268

CAM (Complementary & Alternative Medicine):83M people use in US(42%)CAM visits 243M, greater than to PCP(Primary Care Physician) (With minimum insurance coverage)Well educated-High incomeCAM “users” don’t tell PCP (40%) Lack of true testing a red herring: <30% procedures used in conventional medicine have undergone RCTs(randomized clinical trials)Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide270

“Planetree Look”Woods and natural materialsIndirect lightingHomelike settingsGoals: Welcome patients, friends and family … Value humans over technology .. Enable patients to participate in their care … Provide flexibility to personalize the care of each patient … Encourage caregivers to be responsive to patients … Foster a connection to nature and beautySource: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

slide271
SoundTextureLightingColorSmellTasteSacred spaceSource: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
slide272
Access to nurses station:“Happen to”vs“Happen with”Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
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The Ten Principals of the Eden Alternative1. The three plagues of loneliness, helplessness, and boredom account for the bulk of suffering among Elders.2. Life in an Elder-centered community revolves around close and continuing contact with children, plants, and animals. These ancient relationships provide young and old alike with a pathway to a life worth living.3. Companionship is the antidote to loneliness. In an Elder-centered community we must provide easy access to human and animal companionship.4. A healthy Elder-centered community seeks to balance the care that is being given with the care that is being received. Elders need opportunities to give care and caregivers need opportunities to receive care.Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

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“The Eden paradigm allows elders to care for animals, birds, and children as well as each other.”—Susan Eaton, Harvard/JFK schoolSource: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

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The Ten Principals of the Eden Alternative5. Variety and Spontaneity are the antidotes to boredom. The Elder-centered community is rich in opportunities to sample these ancient pleasures.6. An Elder-centered community understands that passive entertainment cannot fill a human life.7. The Elder-centered community takes medical treatment down from its pedestal and and places it into the service of genuine human caring.Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

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The Ten Principals of the Eden Alternative8. In an Elder-centered community, decisions should be made by the Elders or those as close to the Elders as possible.9. An Elder-centered community understands human growth cannot be separated from human life.10. Wise leadership is the lifeblood of any struggle against the Three Plagues. For it, there can be no substitute.Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

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Care!/Love!/Spirit!Self-Control!Connect!/learn!/involve!/Engage!Understanding!/Growth! De-stress!/heal! Whole patient & family & friends! be well!/stay well!

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Griffin Hospital/Derby CT (Planetree Alliance “HQ”) Results:Financially successful. Expanding programs-physically. Growing market share. Only hospital in “100 Best Cos to Work for”—7 consecutive years, currently #6.—“Five-Star Hospitals,” Joe Flower,strategy+business (#42)

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TP’s “Nobels” in MedicineDon BerwickJohn WennbergElliott FisherKen KizerThe VAPeter ProNovostTeam Planetree