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

2 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 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

3 This presentation has taken me about 10 years to producesome recent books took me over the top. Nonetheless, it is an amateurs 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 the preceding slide. I have chosen not to use the Notes feature of PowerPoint, because so few in Notes feature of PowerPoint, because so few in fact avail themselves of notes in that formatand fact avail themselves of notes in that formatand I am optimistic that some of you will read the notes slides in this format. I am optimistic that some of you will read the notes slides in this format.

4 45

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

6 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: Its about a whole lot more than health insurance! the twain rarely meet: Its about a whole lot more than health insurance! Tom Peters/03.31.08

7 This presentation is not about Hillarycareor 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.

8 Outline: 17 Chapters

9 1.Some Resources 2.Bottom Line (??): U.S. Life Expectancy 3.K.I.A. & Wounded: A House (Hospital) of Horrors 4.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 in the American Economy 8. Pick of the Litter: Our Best Hospitals? 9. See No Evil: A Culture of Cover-up

10 10. And They Call It Science I: The Overwhelming Lack of Treatment Validation Overwhelming Lack of Treatment Validation 11. And They Call It Science II: Astounding Geographic Treatment Variation Geographic Treatment Variation 12. Shining Star, A/The … 13. IS/IT: The Dark Ages Saga Continues 14. 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 Thousands Lives and Extend Hundreds of Thousands of Others of Others 15. Wellness-Prevention: No Good Deed Goes Unpunished Unpunished 16. From Healthcare to Health: The Oughtas The Oughtas 17. Healthcare Meets Health: The Case of the Planetree Alliance the Planetree Alliance Bonus: Toms Nobels

11 1. Some resources

12 *** 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]

13 2. Bottom line (??): U.S. Life Expectancy

14 45 th.* *Rank of U.S. life expectancy, { "@context": "http://schema.org", "@type": "ImageObject", "contentUrl": "http://images.slideplayer.com/1/678626/slides/slide_14.jpg", "name": "45 th.* *Rank of U.S. life expectancy,

15 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.)

16 This [life expectancy] is sorta the point, isnt it … or am I missing something?*

17 Id think this (life expectancy) would (obviously) be the principal point of the overall exerciseits not How much healthcare do we get? but How healthy are we? Right???

18 This [life expectancy] is sorta the point, isnt 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 ?

19 Pay by procedure is the operative (insane) funding algorithm in our healthcare systemthere is no premium on helping us get healthy in fact there are severe penalties for so doing. for so doing.

20 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

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

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

23

24 Stunning.

25 Americas 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. 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

26 Stunning.

27 3. K.I.A. & Wounded: A house (hospital) of horrors

28 3DHC = 5YI

29 Quality: COULD IT TRULY BE THIS AWFUL ?

30 3DHC = 5YI: 3 days healthcare- caused deaths = 5 years of American soldiers deaths in the Iraq War* *Not including most of the deaths forgone annually if prevention- wellness became the primary arm of health-healthcare industry

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

32 Study: Medical Errors Affect 20 Percent of Patients Study: Medical Errors Affect 20 Percent of Patients headline, Boston Herald

33 RAND: 50%, appropriate preventive care. 60%, recommended treatment, per medical studies, for chronic conditions. 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.

34 Typical statsmore to come.

35 Welcome to the Homer Simpson Hospital, a/k/a … The Killing Fields

36 American life expectancy is relatively lowand the delivery of healthcare in the U.S. is notoriously unsafe.

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

38 This 1998 report was a shocker and bitterly contested by the healthcare establishment. Now its taken for granted, and perhaps understatessignificantly. More grim estimates follow. its taken for granted, and perhaps understatessignificantly. More grim estimates follow.

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

40 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

41 Throughout, we will see that much of this horrorshow is the product of simple problemse.g., bad handwriting.

42 The Institute of Medicine calculated that drug errors [on average, one per patient per visitvarious 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

43 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 cant afford to take the necessary precautions. Betsy McCaughey, founder of the Committee to Reduce Infection Deaths (New York Times/06.06.2005)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 cant afford to take the necessary precautions. Betsy McCaughey, founder of the Committee to Reduce Infection Deaths (New York Times/06.06.2005)

44 When I climb Mount Rainier I face less risk of death than Ill face on the operating table. Don BerwickWhen I climb Mount Rainier I face less risk of death than Ill face on the operating table. Don Berwick

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

46 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 doctors failure to observe evidence-based protocols for just four common conditions: hypertension, heart attack, pneumonia, and colorectal cancer. [TP: total 314,000 ] Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman

47 1 m 42 s

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

49 59

50 ... 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.

51 Plus God alone knows how many casualties in doctors offices, Tom Thom Mayer

52 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.)

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

54 Also left out are the folks whod be with us if the system focused on healthwellness, prevention, etc..

55 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 Alzheimers disease. Source: Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs Melody PetersenExperts 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 Alzheimers disease. Source: Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs Melody Petersen

56 And on it goes....

57 Primary-care docs = Second- class citizens. Sources: too numerous to mention

58 The people who ought to be the gatekeepers who would oversee the co-ordination of specialists workthe dis-organized results thereof which are responsible for most of the likes of the prescription-med errorsare secondclass citizens in the specialist- centric World of Modern Healthcare.

59 1 m 28 s

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

61 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

62 The docs get it … And you?

63 Put a muzzle on that boy.

64 In my 30 years of speechifying, I have said a few controversial thingsin 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 statisticmostly 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 messagethe first and only time in my careerfrom 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 upand quit propagating that scurrilous number. Naturally the speakers bureau told him that my content was up to me, not them. I was of course delightedit 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 embarrassedthey damn well should have been!! And still should be!!)

65 4. How it works (and feels) …

66 Journalist Tim Noah writes about his wifes 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 wasnt 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 [Williams] 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 Marjories 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 Healthcare Is Better Than Yours, Phillip Longman

67 My most memorable brushes have been with an eminent surgeon, Marjorie [Longmans 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 cant perform an operation on you, and then snap at your husband to stop taking notes, since he cant possibly follow the complexity of the doctors thinking. Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman

68 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 not by analytic deduction, but by the insane frequency of errors in his wifes treatment at a prestigious Boston medical center. the insane frequency of errors in his wifes treatment at a prestigious Boston medical center.

69 5. You must be your be your own boss! own boss!

70 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 Jordans cancer diagnosis)

71 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 advocatea caring, calm, shrewd relative or friend at least. at least. Source: Best Care Any where: Why VA Healthcare Is Better Than Yours, Phillip Longman Better Than Yours, Phillip Longman

72 For the patient, the immediate answer to this sad state of affairs is to become ones own healthcare quarterback and to quit trusting the guys in the white coats. the white coats.

73 TP: Just one second, please. You do know Ive got a pacemaker, lower limit only, 60bpm, no defib? And that I Ive 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 at least, No including set-up for an echo stress cardio test (reading and results dependent on the above info)

74 My own pitiful experienceI was and am enraged. (March 2008, prestigious Boston medical center.)

75 6. Over- treatment !!!!!!!!

76 3%

77 This section buggers the imagination.

78 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, 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 Is Better Than Yours, Phillip Longman

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

80 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 Sicker and Poorer, Shannon Brownlee

81 400,000 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

82 Americans undergo millions of tests MRIs, CT scans, blood tests We undergo back surgery for pain in the absence of evidence that the surgery works. 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 Us Sicker and Poorer, Shannon Brownlee

83 [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. [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

84 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 Sicker and Poorer, Shannon Brownlee

85 Teach to test is the Achilles heel of our education systemthe 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 healthcare systemdenigrating the very health for which we were intended to care.

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

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

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

89 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. Theyd cut that one back, then enhance another. At 95, she was simply wearing outbut 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.) my M.D. pals.)

90 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.)

91 Hes 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.)

92 America has America has twice as many hospitals and physicians as it needs. Med Inc., Sandy Lutz, Woodrin Grossman & John Bigalke

93 Ditto Fisher.

94 $PD(USA) > $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) > $HEX2(USA)* > $G(USA) > $HEX2(USA)* *U.S. spending on prescription drugs in 2005 ($250,000,000,000) is greater than the combined spending on prescription drugs by Japan plus Germany plus France plus Italy plus Spain plus the United Kingdom plus Australia plus New Zealand plus Canada plus Mexico plus Brazil plus Argentina (all except Mexico, Brazil and Argentina have longer life expectancies than we do); and our prescription drug bill also is more than our gasoline bill and two times more than our higher ed bill. Source: Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs Melody Petersen Hooked the Nation on Prescription Drugs Melody Petersen

95 $PD(USA) > $PD(J + G + F + I + S + UK + A + NZ + C + M + B + A) > $G(USA) > $HEX2(USA)* + M + B + A) > $G(USA) > $HEX2(USA)* *U.S. spending on prescription drugs in 2005 ($250,000,000,000) is greater than the combined spending on prescription drugs by Japan plus Germany plus France plus Italy plus Spain plus the United Kingdom plus Australia plus New Zealand plus Canada plus Mexico plus Brazil plus Argentina (all except Mexico, Brazil and Argentina have longer life expectancies than we do); and our prescription drug bill also is more than our gasoline bill and two times more than our higher ed bill. Source: Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs Melody Petersen Hooked the Nation on Prescription Drugs Melody Petersen

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

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

98 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

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

100 7. F.Y.I.: The dominating (!) Role of healthcare in the American economy in the American economy

101 Whats 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

102 We spend over $2,000,000,000,000 on healthcare in Americaand it is also our engine of job growth. Increasingly, healthcare economics are American economics. Tinkerer beware!

103 8. Pick of the litter: Our best hospitals?

104 Generally, the more prestigious the hospital you check into, and the more eminent and numerous the physicians who attend you, the more likely you are to receive low-quality or even dangerous and unnecessary care. Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman

105 Flabbergasting.

106 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 [Dartmouths Dr. Jack] Wennberg and others broadened their studies. They found its 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

107 [Dartmouths Dr. Jack] Wennberg and others … found its 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

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

109 Flabbergasting.

110 9. See no evil: A culture of cover-up

111 culture of cover-up that pervades healthcare Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman

112 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.

113 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

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

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

116 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 a thirty-fold increase in the number of medical mistakes and adverse events that got reported. National Center for Patient Safety Ann Arbor National Center for Patient Safety Ann Arbor

117 The VA gets it. (Again.)

118 thirty -fold

119 The enormity of the possible improvement is staggeringperhaps one of the few hopeful signs.

120 10. And they call it science I: overwhelming Lack of treatment validation call it science I: overwhelming Lack of treatment validation

121 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

122 Here we go again: flabbergasting.

123 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

124 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

125 85 %

126 The Search for Quality: It All Begins on the Autopsy Table Source: Chapter title, Severed Trust: Why American Medicine Hasnt Been Fixed, George Lundberg

127 Learning organizationthe typical hospital aint.

128 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 Hasnt Been Fixed, George Lundberg

129 11. And they call it science II: Astounding Geographic treatment variation it science II: Astounding Geographic treatment variation

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

131 Sound absurd? Read on.

132 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 wasnt 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 didnt 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 arthritiswas 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

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

134 Geography Is DestinyOften all one must do to acquire a disease is to enter a country where a disease is recognizedleaving 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

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

136 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

137 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

138 35 years.

139 12. Shining star, a/the …

140 Whats 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

141 There is an exception among big systemsthe Veterans Administration/VA hospitals. And yes, everyone is amazed. (Mr Longmans book, Best Care Anywhere: Why VA Healthcare Is Better Than Yours, is a masterpiecerequired reading for any healthcare professional, as I see it.)

142 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

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

144 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 Better Than Yours, Phillip Longman

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

146 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, frailtyespecially vulnerable to medical errors ) Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman

147 Key point, the VA is dealing with a tougher than normal populationso they arent blessed with any systemic advantage on that score.

148 ***2003, New England Journal of Medicine publishes quality study results: 11 measures of quality compare VA and fee-for-service plans. VA significantly better on 11 out of 11 … ***2004, Annals of Internal Medicine, RAND study: VA vs commercial managed care; VA outperforms all other sectors of American healthcare in 294 measures of quality … ***National Committee for Quality Assurance 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

149 Wow.

150 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

151 Pretty damned impressive. (Understatement.)

152 VA/Strengths/Foci *Safety *Evidence-based medicine *Health promotion and wellness programs programs *Unparalleled adoption of electronic medical records electronic medical records and other information and other information technologies technologies Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman

153 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 regimensresearch center in Durham NC. Doc measures & guidelines; e.g., pneumonia vaccinations from 50% to 84%. Blame-free system, modeled after airlines. Whats 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

154 13. IS/IT: The dark ages saga continues

155 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. Worlds Best Medical Care?, New York Times, August 2007

156 Dark ageshere we go again!

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

158 Were in the Internet age, and the average patient cant email their doctor. Don Berwick, Harvard Med School

159 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

160 VA/Strengths *Safety *Evidence-based medicine *Health promotion and wellness programs programs *Unparalleled adoption of electronic medical records electronic medical records and other information and other information technologies technologies Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman

161 Information technology: group of off-the- radar experiments, performed surreptitiously by the Hard Hats. 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. 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

162 The VA got it earlyand with a homegrown system!

163 As with many other institutions, the software these [VA] high priests wrote, or more often procured from private vendors, wasnt very good, in large part because the people who actually had to use it had little role in its development. Best Care Anywhere: Why VA Healthcare Is Better Than Yours, Phillip Longman

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

165 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 549,000 errors 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 didnt get around to giving patients or didnt get around to giving patients their meds. their meds. Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman

166 Again, the numbers are staggering. Im hardly suggesting that putting this system in place was a cakewalkon the other hand, the basic idea is hardly rocket science! (Most of these breakthrough ideas arent; e.g., rewarding the reporting of errors so that learning can ensue.)

167 Our entire facility is digital. No paper, no film, no medical records. Nothing. And its all integratedfrom the lab to X-ray to records to physician order entry. Patients dont have to wait for anything. The information from the physicians office is in registration and vice versa. The referring physician is immediately sent an email telling him his patient has shown up. … Its wireless in-house. We have 800 notebook computers that are wireless. Physicians can walk around with a computer thats pre-programmed. If the physician wants, well 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 Our entire facility is digital. No paper, no film, no medical records. Nothing. And its all integratedfrom the lab to X-ray to records to physician order entry. Patients dont have to wait for anything. The information from the physicians office is in registration and vice versa. The referring physician is immediately sent an email telling him his patient has shown up. … Its wireless in-house. We have 800 notebook computers that are wireless. Physicians can walk around with a computer thats pre-programmed. If the physician wants, well 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

168 It helps to have a greenfield facilitybut this is also a non-VA demo of making effective IS the centerpiece of the enterprise.

169 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

170 A lot of the fix is very straightforward; in fact, the systems infatuation with clever, complex tools is part of the problem. (A big part of the problem.)

171 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 patients weight gain …, they lose money. Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, Shannon Brownlee Us Sicker and Poorer, Shannon Brownlee

172 More on the perverse losing money for doing the right thing in a moment.

173 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 [Dartmouths Dr. Jack] Wennberg and others broadened their studies. They found its 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

174 Aspirin saves lives. (Lots of.)

175 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 hes in for. Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman

176 And your name is …

177 If God spoke to me by saying, Mark, youre down to your last three words: What would you want to say to your fellow humans that would make the most positive impact? It would be a close call between Love Thy Neighbor and Wash 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

178 Sanitary revolution: mortality in major cities down 55% between 1850 and 1915 Source: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation

179 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

180 One study I came across concluded that you could save 20,000 lives per year in UK hospitalsby issuing compression hose-socks to virtually every hospitalized patient. (As I said, we aint talkin rocket science.)

181 The EMS Myth: Speed* has never saved anybodys life. Period.W.H. Leonard, Medical Transportation Insurance Professionals *Ambulance, accident site to hospital Source: USA Today

182 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.

183 20%: not get prescriptions filled 50%: use meds inconsistently 20%: not get prescriptions filled 50%: use meds inconsistently Source: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation

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

185 I am an unabashed champion of such non-conventional healthcare delivery vehicleshospitals are fighting them tooth and nail. (Hilariously, hospitals have declared them unsafetalk about pots calling kettles black!) (Interestingly, these convenient- care operations may significantly push the greater system in the direction of electronic medical recordsthe CC clinics are 100% electronic.)

186 Case: The simple Checklist!

187 I absolutely love this story! this story!

188 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)

189 ** Peter Pronovost, Johns Hopkins, 2001 **Checklist, line infections **1/3 rd 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)

190 Wow. (Zerooooooo.)

191 **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)

192 Wow.

193 **Replicate in Inner City Detroit (resource strapped$$$, staff cut 1/3 rd, poorest patients in USA) **Nurses QB the process **Project manager for overall process implementation **Exec involvement (help with little thingsits 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)

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

195 [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)

196 Medicine Nobel, anyone?

197 Beware of the tyranny of making Small Changes to Small Things. Rather, make Big Changes to Big Things. Roger Enrico, former Chairman, PepsiCo

198 Are we sure? Or …

199 Beware of the tyranny of making S mall Changes to Small Things. Rather, make Big Changes to Big Things … using Small, Almost Invisible Straightforward Levers with Big Systemic Impact. TP

200 Think checklist. Think wash your hands. Think take your aspirin. Think Whats your name? Think compression hose. Etc.Etc.

201 15. Wellness- prevention: No good deed goes unpunished

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

203 We can demonstrate the enormous value of emphasizing wellness-prevention. enormous value of emphasizing wellness-prevention.

204 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 workedat least in the sense that patients became healthier. The number of hospital admissions declined and patients spent less time in the hospital. Quality doesnt 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 doesnt pay the bills. Source: Best Care Anywhere: Why VA Healthcare Is Better Than Yours/Phillip Longman

205 Whoops. (Alas.) (FYI, I also read recently that Duke shut down its family practice specialty programfor lack of interest.)

206 16. from healthcare to health: The oughta s 16. from healthcare to health: The oughta s

207 Dubai Healthcare City to Dubai Health City* TP Recommendation #1: Dubai Healthcare City to Dubai Health City* *Cleveland Clinic and Canyon Ranch

208 Dubai is investing billions in a Healthcare Cityin a keynote presentation I begged them to call it Health City. call it Health City. (Words do matter.)

209 MHHA/Michigan Health and Hospital Association

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

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

212 Medicine to Health.

213 Childhood Obesity > Terrorism Childhood Obesity > Terrorism Source: Mike Levitt/Secretary HHS

214 A/the health problem that is becoming a/the medicine problem. (Behavioral, not medicinal!)

215 Bust fat docs!

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

217 Go Mayor Mike!

218 Three hearty cheers for Mayor Bloombergs transfats ban.

219 TPs Canyon Ranch epiphanyand rage!

220 Ive always been lucky enough to have very good doctorsstarting 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 othersthe first healthcare folks Id 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 thishealth stufffor the first time? (Despite my continuous care by terrific docsStanford trained, etc.)

221 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) 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)

222 Working on the basic behavioral stuffno mean featprovides enormous payoff. (Yes, its difficult to dobut, mainly, it is most definitely not the focus of our $2,000,000,000,000 healthcare industry.)

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

224 Lovely!

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

226 (Can work for the VA, NHSbut, as noted above, thwarted by our pay per procedure culture.)

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

228 Toms bias.

229 17. HEALTHCARE MEETS HEALTH: The Case of the PLANETREE ALLIANCE

230 I will conclude this presentation with a good news case, that with a good news case, that of the Planetree Alliance. of the Planetree Alliance.

231 Planetree: A Radical Model for New Healthcare/Healing/ Wellness Excellence Tom Peters

232 "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

233 Five pianos

234 (Explanation to come.)

235 It was the goal of the Planetree Unit to help patients not only get well faster but also to stay well longer. 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

236 And this is done within the context of the private-incentive scheme of the private-incentive scheme i.e., it can be done.

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

238 The most basic question we need to pose in caring for others is this: Is this a loving act? 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

239 Determinants of Health Access to care: 10% Genetics: 20% Environment: 20% Health Behaviors: 50% Source: Institute for the Future

240 1. The Importance of Human Interaction Informing and Empowering Diverse Populations: Consumer Health Libraries and Patient Information Healing Partnerships: The importance of Including Friends and Family Nutrition: The Nurturing Aspect of Food Spirituality: Inner Resources for Healing 6. Human Touch: The Essentials of Communicating Caring Through Massage 7. Healing Arts: Nutrition for the Soul 8. Integrating Complementary and Alternative Practices into Conventional Care 9. Healing Environments: Architecture and Design Conducive to Health The 9 Planetree Practices 1. The Importance of Human Interaction 2. Informing and Empowering Diverse Populations: Consumer Health Libraries and Patient Information 3. Healing Partnerships: The importance of Including Friends and Family 4. Nutrition: The Nurturing Aspect of Food 5. Spirituality: Inner Resources for Healing 6. Human Touch: The Essentials of Communicating Caring Through Massage 7. Healing Arts: Nutrition for the Soul 8. Integrating Complementary and Alternative Practices into Conventional Care 9. Healing Environments: Architecture and Design Conducive to Health Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

241 The Importance of Human Interaction 1. The Importance of Human Interaction

242 none of THE top 15 factors determining P atient S atisfaction referred to patients health outcome PS directly related to Staff Interaction PS directly correlated with Employee Satisfaction Press Ganey Assoc: 139,380 former patients from 225 hospitals: none of THE top 15 factors determining P atient S atisfaction referred to patients health outcome PS directly related to Staff Interaction PS directly correlated with Employee Satisfaction Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

243 Kindness is free. 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 interactionsalienating patients, being non-responsive to their needs or limiting their sense of controlcan be very costly. … Angry, frustrated or frightened patients may be combative, withdrawn and less cooperativerequiring 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

244 But if it is so simple, it is surprising how frequently it is absent from our healthcare environments. abuse 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

245 Planetree is about human beings caring for other human beings. 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 gentlemen4S credo)

246 Informing and Empowering Diverse Populations: Consumer Health Libraries and Patient Information 2. Informing and Empowering Diverse Populations: Consumer Health Libraries and Patient Information

247 Planetree Health Resources Center/1981 Planetree Classification System Consumer Health Librarians Volunteers Classes, lectures Health Fairs Griffins Mobile Health Resource Center Open Chart Policy Patient Progress Notes Care Coordination Conferences (Est goals, timetable, etc.) Planetree Health Resources Center/1981 Planetree Classification System Consumer Health Librarians Volunteers Classes, lectures Health Fairs Griffins Mobile Health Resource Center Open Chart Policy Patient Progress Notes Care Coordination Conferences (Est goals, timetable, etc.) Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

248 Healing Partnerships: The Importance of Including Friends and Family 3. Healing Partnerships: The Importance of Including Friends and Family

249 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

250 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. The Patient-Family ExperiencePatients 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

251 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. 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 Patients Eyes

252 confided in at least one person 72.4%, 56.3% A 7-year follow-up of women diagnosed with breast cancer showed that those who confided in at least one person in the 3 months after surgery had a 7-year survival rate of 72.4%, as compared to 56.3% for those who didnt have a confidant. Institute for the Future

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

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

255 Meals are central events Meals are central events vs There, youre fed. * *Irony: Focus on nutrition has reduced focus on food and service Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

256 Kitchen Beautiful cutlery, plates, etc Chef reputation Kitchen Beautiful cutlery, plates, etc Chef reputation Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

257 Aroma therapy Aroma therapy (e.g., smell of baking cookiesfrom kitchenettes in each ward) Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

258 Spirituality: Inner Resources for Healing 5. Spirituality: Inner Resources for Healing

259 1. Connected to supportive and caring group 2. Sense of mastery and control 3. Make meaning out of disease/ find meaning in suffering Spirituality: Meaning and Connectedness in Life 1. Connected to supportive and caring group 2. Sense of mastery and control 3. Make meaning out of disease/ find meaning in suffering Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

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

261 Human Touch: The Essentials of Communicating Caring Through Massage 6. Human Touch: The Essentials of Communicating Caring Through Massage

262 Massage is a powerful way to communicate caring.Massage is a powerful way to communicate caring.Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

263 Massage for every patient scheduled for ambulatory surgery (Go into surgery with a good attitude) Infant massage Staff massage (caring for the caregivers) Healing environments: chemo! Mid-Columbia Medical Center/Center for Mind and Body Massage for every patient scheduled for ambulatory surgery (Go into surgery with a good attitude) Infant massage Staff massage (caring for the caregivers) Healing environments: chemo! Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

264 7. Healing Arts: Nutrition for the Soul

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

266 People say the effect is only on the mind. It is no such thing. The effect is on the body, too. Florence Nightingale/Notes on Nursing/patients 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

267 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

268 Integrating Complementary and Alternative Practices into Conventional Care 8. Integrating Complementary and Alternative Practices into Conventional Care

269 Massage Acupuncture Meditation Chiropractic Nutritional supplements Aroma therapy Griffin IMC/Integrative Medicine Center Massage Acupuncture Meditation Chiropractic Nutritional supplements Aroma therapy Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

270 CAM (Complementary & Alternative Medicine): 83M people use in US (42%) CAM visits 243M, greater than to PCP (Primary Care Physician) (With minimum insurance coverage) Well educated-High income CAM users dont tell PCP (40%) Lack of true testing a red herring: <30% procedures used in conventional medicine have undergone RCTs (randomized clinical trials) CAM (Complementary & Alternative Medicine): 83M people use in US (42%) CAM visits 243M, greater than to PCP (Primary Care Physician) (With minimum insurance coverage) Well educated-High income CAM users dont 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

271 9. Healing Environments: Architecture and Design Conducive to Health

272 Woods and natural materials Indirect lighting Homelike settings Goals: Welcome patients, friends and family … Value humans over technology.. Enable patients to participate in their care … Provide flexibility to personalize the care of each patient … Encourage caregivers to be responsive to patients … Foster a connection to nature and beauty Planetree Look Woods and natural materials Indirect lighting Homelike settings Goals: Welcome patients, friends and family … Value humans over technology.. Enable patients to participate in their care … Provide flexibility to personalize the care of each patient … Encourage caregivers to be responsive to patients … Foster a connection to nature and beauty Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

273 Sound Texture Lighting Color Smell Taste Sacred space Sound Texture Lighting Color Smell Taste Sacred space Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

274 Happen to Happen with Access to nurses station: Happen to vs Happen with Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

275 The Eden Alternative* The Eden Alternative* *ElderCare

276 Planetree approach applied to eldercare.

277 The Ten Principals of the Eden Alternative 1. The three plagues of loneliness, helplessness, and boredom account for the bulk of suffering among Elders. 2. Life in an Elder-centered community revolves around close and continuing contact with children, plants, and animals. These ancient relationships provide young and old alike with a pathway to a life worth living. 3. Companionship is the antidote to loneliness. In an 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

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

279 The Ten Principals of the Eden Alternative 5. Variety and Spontaneity are the antidotes to boredom. The Elder-centered community is rich in opportunities to sample these ancient pleasures. 6. An Elder-centered community understands that passive entertainment cannot fill a human life. 7. The Elder-centered community takes medical treatment down from its pedestal and and places it into the service of genuine human caring. Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

280 The Ten Principals of the Eden Alternative 8. In an Elder-centered community, decisions should be made by the Elders or those as close to the Elders as possible. 9. An Elder-centered community understands human growth cannot be separated from human life. 10. Wise leadership is the lifeblood of any struggle against the Three Plagues. For it, there can be no substitute. Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

281 Conclusion: Caring/Growth Experience

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

283 F.Y.I.: It works!

284 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. 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)

285 Learn more about Planetree/ The Planetree Alliance: www.planetree.org

286 Tom s Nobels

287 TPs Nobels in Medicine Don Berwick John Wennberg Elliott Fisher Ken Kizer The VA Peter ProNovost Team Planetree

288 Thank you for your time!


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