Health“care”: The Rant Tom Peters/10.30.2004

There are many problems with Healthcare There are many problems with Healthcare. I am not aiming to provide a comprehensive diagnosis or a comprehensive Rx. I am instead cherrypicking two, and only two, Core Issues: (1) The wretched (Damning!) quality problem; (2) and the almost 100% emphasis on after-the-fact-fixes, rather than Wellness-Prevention-Healing-Care. With respect, Tom Peters

Healthcare’s 1-2 Punch Hospital “quality control,” at least in the U.S.A., is a bad, bad joke: Depending on whose stats you believe, hospitals kill 100,000 or so of us a year—and wound many times that number. Finally, “they” are “getting around to” dealing with the issue. Well, thanks. And what is it we’ve been buying for our Trillion or so bucks a year? The fix is eminently do-able … which makes the condition even more intolerable. (“Disgrace” is far too kind a label for the “condition.” Who’s to blame? Just about everybody, starting with the docs who consider oversight from anyone other than fellow clan members to be unacceptable.) 2. The “system”—training, docs, insurance incentives, “culture,” “patients” themselves—is hopelessly-mindlessly-insanely (as I see it) skewed toward fixing things (e.g. Me) that are broken—not preventing the problem in the first place and providing the Maintenance Tools necessary for a healthy lifestyle. Sure, bio-medicine will soon allow us to understand and deal with individual genetic pre-dispositions. (And hooray!) But take it from this 61-year old, decades of physical and psychological self-abuse can literally be reversed in relatively short order by an encompassing approach to life that can only be described as a “Passion for Wellness (and Well-being).” Patients—like me—are catching on in record numbers; but “the system” is highly resistant. (Again, the doctors are among the biggest sinners—no surprise, following years of acculturation as the “man-with-the-white-coat-who-will-now-miraculously-dispense-fix it-pills-for-you-the-unwashed.” (Come to think of it, maybe I’ll start wearing a White Coat to my doctor’s office—after all, I am the Professional-in-Charge when it comes to my Body & Soul. Right?)

Tom’s Rant Patient Safety (Curb the Killing Fields Tom’s Rant Patient Safety (Curb the Killing Fields!) Planetree Alliance/Griffin Hospital (Put the “Care” back in Health“care”!) Canyon Ranch (Re-imagine: Wellness-Prevention!)

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

XYZ Corp: Complete Vision & Values Any Service or Product of ours is yours for absolutely NO CHARGE if any employee says—or implies—to you at any point … “It’s Not My Fault.” V. Big Cheese, Founder, CEO & Dictator

Tom’s Cold Fury at Healthcare “Professionals,” Especially Acute Care Operatives 1. You are killers: “Quality” remains a bad joke. 2. Pick off bunches of Low-hanging Fruit. (E.g., Tom’s 1st Executive order as Your Next President: Providing a Handwritten Prescription is punishable by not less than 60 days of Hard Time.) 3. The “science” in “medicine” is often fanciful: Most “scientific” “treatments” are unverified. (So quit the kneejerk denigration of alternative therapies—trust me, Breathing Meditation beats Univasc; Good Nutrition beats Lipitor; Regular Exercise beats bypass surgery.) 4. You continue to obsess only on after-the-act “fixes,” the automatic resort to Chemicals and Knives, rather than P-W-H-C … Prevention-Wellness- Healing-Care. 5. Your Mindful Lifelong (mine) Failure to focus on P-W-H-C will probably cost me a decade of longevity, Canyon Ranch/Lenox not withstanding. THAT PISSES ME OFF. (For one thing, I need those 10 years to spread the P-W-H-C Credo to “health‘care’” “professionals.”) 6. You are hereby ordered to stop using the term “healthcare”: You haven’t earned the right to utter the word “care”! 7. $$$$$ Are Not the Issue/Excuse I: Quality is free!!! (There are MANY who are … Getting This Right … without Buckets of $$$$$.) 8. $$$$$ Are Not the Issue/Excuse II: Planetree Alliance/Griffin Hospital “Models The Way” … on P-W-H-C … Every Day. IT CAN BE DONE! 9. ALL THESE PROBLEMS CAN BE FIXED! WE KNOW HOW! THERE ARE NO EXCUSES … EXCEPT LACK OF GUTS & WILL! “It’s Attitude, Baby!” 10. All “members of staff”—regardless of “professional discipline”—are Healing Arts Practitioners. OR TURN IN YOUR EMPLOYEE BADGE. NOW. 10.27.2004/La Jolla

Rule #1. Attend the “Duh Factor”. Model The Way Rule #1. Attend the “Duh Factor”! Model The Way! DO NOT … SERVE BOUNTIFUL BASKETFULS OF FATTY-SUGARY CRAP & BUCKETSFUL OF HIGH-OCTANE COFFEE AT BREAKS DURING “HEALTH”“CARE” MEETINGS. Think: Fruit! Think: Tea! Think: Duh!

TP to Healthcare CIOs: “You are not ‘CIOs TP to Healthcare CIOs: “You are not ‘CIOs.’ You are … ‘Executive Members of an … Integrated Healing Services Team’ (‘Healing Arts Team’?) …with a specialization in IS/IT.”

Dear Mr. & Mrs. Smith, XYZ hospital regrets to inform you …… Dear Mr. & Mrs. Smith, XYZ hospital regrets to inform you ……. ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………. Sincerely, A. S. Jackson, Administrator T. D. Jones, M.D. L.S. Donald, CFO W.N. Arnold, CIO

You want “implementation tips You want “implementation tips.” I want … Ownership, Accountability & Attitude!

Excerpt from Tom Peters’ Presentation to Healthcare CIOs: “Quality”: COULD IT TRULY BE THIS AWFUL?

“Quality of care is the problem, not managed care “Quality of care is the problem, not managed care.” Institute of Medicine

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

HealthGrades/Denver: 195,000 hospital deaths per year in the U. S HealthGrades/Denver: 195,000 hospital deaths per year in the U.S., 2000-2002 = 390 full jumbos/747s in the drink per year. Comments: “This should give you pause when you go to the hospital.” —Dr. Kenneth Kizer, National Quality Forum. “There is little evidence that patient safety has improved in the last five years.” —Dr. Samantha Collier Source: Boston Globe/07.27.04

“This should give you pause when you go to the hospital “This should give you pause when you go to the hospital.” “There is little evidence that patient safety has improved in the last five years.”

2m38s Tragedy! [Doesn’t remind you of Churchill or Gandhi or Betty Friedan, does it?]

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

Various studies: 1 in 3, 1 in 5, 1 in 7, 1 in 20 patients “harmed by treatment” Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

RAND (1998): 50%, appropriate preventive care RAND (1998): 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.

“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.” Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

“A healthcare delivery system characterized by idiosyncratic and often ill-informed judgments must be restructured according to evidence-based medical practice.” Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

“In a disturbing 1991 study, 110 nurses of varying experience levels took a written test of their ability to calculate medication doses. Eight out of 10 made calculation mistakes at least 10% of the time, while four out of 10 made mistakes 30 % of the time.” Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

YE GADS! New England Journal of Medicine/ Harvard Medical Practice Study: 4% error rate (1 of 4 negligence). “Subsequent investigations around the country have confirmed the ubiquity of error.” “In one small study of how clinicians perform when patients have a sudden cardiac arrest, 27 of 30 clinicians made an error in using the defibrillator.” Mistakes in administering drugs (1995 study) “average once every hospital admission.” “Lucian Leape, medicine’s leading expert on error, points out that many other industries—whether the task is manufacturing semiconductors or serving customers at the Ritz Carlton—simply wouldn’t countenance error rates like those in hospitals.”—Complications, Atul Gawande

“In health care, geography is destiny “In health care, geography is destiny.” Source: Dartmouth Medical School 1996 report

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

Geography Is Destiny E. g. : Ft. Myers 4X Manhattan—back surgery Geography Is Destiny E.g.: Ft. Myers 4X Manhattan—back surgery. Newark 2X New Haven—prostatectomy. Rapid City SD 34X Elyria 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)

PARADOX: Many, many formal case reviews … failure to systematically/ systemically/ statistically look at and act on evidence. C.f., Complications, Atul Gawande

Deep Blue Redux. : 2,240 EKGs … 1,120 heart attacks Deep Blue Redux*: 2,240 EKGs … 1,120 heart attacks. Hans Ohlin (50 yr old chief of coronary care, Univ of Lund/SW) : 620. Lars Edenbrandt’s software: 738. *Only this time it matters!

“Most physicians believe that diagnosis can’t be reduced to a set of generalizations—to a ‘cookbook.’ … How often does my intuition lead me astray? The radical implication of the Swedish study is that the individualized, intuitive approach that lies at the center of modern medicine is flawed—it causes more mistakes than it prevents.” —Atul Gawande, Complications

“Practice variation is not caused by ‘bad’ or ‘ignorant’ doctors “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

Genius Required?

Leapfrog Group: CPOE/Computerized Physician Order Entry Leapfrog Group: CPOE/Computerized Physician Order Entry* ICU staffing by trained intensivists** EHR/Evidence-based Hospital Referral*** *Duh I: Welcome to the computer age. **Duh II: How about using experts? ***Duh III: If you do stuff a lotta times, you tend to get/be better. Source: HealthLeaders

The Benefits of … FOCUSED EXCELLENCE Shouldice/Hernia Repair: 30-45 min, 1% recurrence. Avg: 90 min, 10%-15% recurrence. Source: Complications, Atul Gawande

Doing It Right! Planetree: A Radical Model for New Healthcare/Healing/ Wellness Excellence

“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

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

The 9 Planetree Practices 1. The Importance of Human Interaction 2 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

1. The Importance of Human Interaction

“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

Press Ganey Assoc/1999: 139,380 former patients from 225 hospitals 0 of top 15 factors determining Patient Satisfaction referred to patient’s health outcome PS directly related to Staff Interaction PS directly correlated with ES (Employee Satisfaction) Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

Mgrs re staff: wages, security, promotion opportunities Staff re staff: interesting work (M:5 of 10), appreciation (5 of 10), sense of being “in” about what’s going on (10 of 10) Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

“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 gentlemen”—4S credo)

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

Planetree Health Resources Center/1981 Planetree Classification System Consumer Health Librarians Volunteers Classes, lectures (CR) Health Fairs Griffin’s 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

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

“When hospital staff members are asked to list the attributes of the ‘perfect patient and family,’ their response is usually a passive patient with no family.” —Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

The Patient-Family Experience “Patients are stripped of 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

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

“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 didn’t have a confidant.” Institute for the Future

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

4. Nutrition: The Nurturing Aspect of Food

Meals are central events vs “There, you’re fed. ” Meals are central events vs “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

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

5. Spirituality: Inner Resources for Healing

Spirituality: Meaning and Connectedness in Life 1 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

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

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

“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

7. Healing Arts: Nutrition for the Soul

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

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

8. Integrating Complementary and Alternative Practices into Conventional Care

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

9. Healing Environments: Architecture and Design Conducive to Health

“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

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

Conclusion: Caring/Growth “Experience”

Care! Control! Connect! Engage! Grow! De-stress!

“An estimated 60 to 90 percent of doctor visits involve stress-related complaints.” —Newsweek/09.27.2004

CR 07.03: 60/264/180/145-85/140 10.04: 61/195/092/097-60/058

Univasc (<1/2) Bextra Lipitor Toprol Propranolol