You think you are all alone...but then realize she has been there, too

A couple of weeks ago, Michael Spencer and I offered readers of this blog free copies of The Courage Muscle, A Chicken's Guide to Living with Breast Cancer, by his late wife Monique Doyle Spencer (seen above with friends).  Among those requesting a copy was a gentlemen who works with a group of women who call themselves "The Sunshine Girls."  I told him I would send along enough copies for all of the women. This lovely email arrived today--Monique's birthday!--from Cheryl.

I just want to thank you for sending Richard Buchanan the books "The Courage Muscle" - He came to a meeting/dinner with our group of ladies - "Sunshine Girls" in our small rural Georgia town to deliver these to us.....How special we felt!  Now that it has been delivered............and I must say read without putting it down before it was finished..........laughing (sometimes out loud) all the way............enjoying every minute of it..............she actually knew how to put the words in there that we can all understand and relate.

I wish more could see this wonderful message she gave.  For us who are survivors it was awe inspiring - you think you are all alone with some of the experiences you go through but then realize she has been there too.  Makes one feel better just knowing she knew it as well. 

Thanks again for your generosity in sending the books.  We are truly blessed by it!

Some of the Sunshine Girls

The bus crash: Charges? Against whom?

One more comment with regard to the bus crash.  The Boston Globe reports today:

No charges had been filed or citations issued Monday against the driver of the bus, Samuel J. Jackson, as State Police continued their investigation. They are scrutinizing witness statements and physical evidence, examining the bus driver’s route just before the crash as well as posted road signs along the route and preliminary results of a collision reconstruction. Final results could take two to six weeks.

If charges are filed, I'd sure like to be Mr. Jackson's lawyer.  First, bring in Bill Geary as a witness and have him explain what he did to make the roads safer in the late 1980s:

“What just occurred this weekend was something I lived in fear of for six-plus years,” said Bill Geary, who from 1983 to 1989 served as commissioner of the former Metropolitan District Commission, the agency that used to be responsible for maintaining Soldiers Field Road. The approach “was kind of primitive, but it worked. It reduced these episodes dramatically.”

Then bring in state officials and have them admit in court to a recent up-tick in crashes along these roadways--and how an "awareness campaign" was planned for later this year.  Then, have them prepare work orders showing how often DCR people have been asked to survey the condition of the road signs.  "Over the years, some signs faded, got lost, or became tangled on the stanchions that support them."  Have DCR produce invoices as to how it often it purchased replacement rubber signs indicating the oncoming height of the underpasses.

Whatever you might think of Mr. Jackson's fault with regard to this accident, a judge or jury reviewing the full record is likely to find that fault equally shared by the agency that is the custodian of these roadways.  I'm sure poor Mr. Jackson feels terrible about being involved in hurting those children, and there is no purpose served in punishing him further.  If I were the State Police, I'd let him go home and live with his own terrible memories of the event. 

How not to deal with an up-tick in crashes

The story of the Boston bus crash this past weekend takes on a new dimension with the revelation by a spokesperson for the state agency that it had "seen an uptick" recently in the number of vehicles that had been hitting overpasses, "mostly by box trucks, vehicles that you can rent," by people who are not used to driving them.  Listen to this interview on Radio Boston.

The inaction by DCR in response to this trend is all the more striking when one considers that the solution to the problem was put in place 30 years ago.  It was low-cost, low-tech, and effective: Hang rubber signs saying "cars only" at every entrance to the river roads, at a height equivalent to the coming underpasses.  Much has been made of the cowbells that were attached to the signs, but the significant innovation were the signs themselves.

The "up-tick", I 'd like to suggest, is the result of the deterioration of the system Bill Geary put in place in the 1980s.  Because of my personal interest in this bit of urban infrastructure, over the last year or two, I have noticed a growing number of instances where the signs have been missing.  Often, all that was left were the chains that used to hold the signs.  Indeed, sometimes the only things left hanging on the chains were the cowbells!

Based on this interview, it appears that DCR thinks that an awareness campaign is the way to go.  Do you really think that an "awareness campaign" will reach those students with U-Hauls every September and June (or the tour bus operators who pass through Boston once or twice in their lives)?  Please don't reinvent the wheel.  Just restore what worked so well for so many years.

Why the bus crashed

Over two dozen people were injured in a bus crash on Boston's Soldiers Field Road this past Saturday evening when a too-tall bus tried to go under the Western Avenue underpass.  WCVB-TV tweeted:  "Three passengers are in critical condition at BMC [Boston Medical Center] and Brigham & Women's; 29 others suffered non-life-threatening injuries"  Above is a picture from the Boston Fire Department.

The BFD tweeted that 60 firefighters and "many, many" EMS folks came to the rescue: "Professionalism at its highest level at this incident by all first responders."

Universal Hub reported:

The bus had just left Harvard on its way to Pennsylvania with 42 people on board, from a non-profit group's day trip to Harvard and Harvard Square. Federal records show Calvary Coach is a small charter company based in Philadelphia - with just two buses. He was taking some Pennsylvania students from a tourist visit to Harvard Square and had chosen to head downtown on Soldiers Field Road.   

UHub said:

WPVI in Philadelphia talked to the owner of the bus that crashed into the Western Avenue overpass last night:

"He said he looked at the GPS, looked down to make the turn and when he looked back up, the bridge was a low bridge, he hit the low bridge," said Talmedge. 

Massachusetts State Police, however, say the driver should never have been there in the first place and that the entrances to Soldiers Field Road all have warning signs.

Within moments, judgements were coming in on the Internet:  "Buses are not allowed on that road. There are signs everywhere. Hang the bus driver."

Some were sympathetic, though: "I don't think native Bostonians understand how bizarre the low bridges on Storrow/Soldiers Field are to non-natives."

Let's do the root cause analysis:

Here's the view of the entrance to Soldier's Field Road that you would have seen if you were the driver:

 In contrast, here's what you would see if you enter Storrow Drive just a mile or two down the road:

I told this story in my book Goal Play!  Here's an abridged version:

When Bill Geary took over as Commissioner of the Metro­politan District Commission (the regional parks and roadway agency for the Boston area) in 1983, he noticed an odd traffic phenomenon. About once a week, a truck that was too tall would enter one of the two main roads along the Charles River and attempt to go through the underpasses below the main bridge crossing at Massachusetts Avenue. Those underpasses had only ten feet of headroom. The truck would hit the bottom of the bridge assembly, its roof would roll up like the top of a sardine can, and it would get stuck, blocking one or both of the two lanes of traffic. Traffic would back up two miles or more. The MDC police and road crews would go to work, rescue the truck driver, deflate the tires, and tow the truck away. Meanwhile, thousands of drivers would be delayed. 

He said to his staff: “What if,” he said, “we put signs up at every entrance to the river roads, at the height of the underpasses, with a pictogram warning taller trucks to stay out?”

“Commissioner,” someone replied, “Can you imagine the liability if our sign breaks a windshield and sends glass flying into the face of a truck driver?”

“Well, what if we make the signs out of rubber so they don’t break the windows?”

“But Commissioner,” someone said, “What good is a rubber sign? Truck cabs are noisy places. A trucker will just hit the sign and drive right through without even hearing that he has hit it." 

“Well, then, let’s hang cow bells on each sign, so drivers will hear a noise as they approach our roadway if their vehicle is too high to go through the underpass.” 

“Where will we get cow bells?” he was asked.

“I don’t know. Call a dairy farmer and ask where they get their cowbells.” 

The signs were installed, cow bells and all. The frequency of crashes in the underpasses went from one per week to less than one per year. Absent Bill’s persistence and personal involvement, we would still be cleaning up those weekly truck crashes three decades later.

Now, look at the two pictures again. Do you see those lonely chains hanging down from the Soldiers Field Road entrance sign?  There used to be a rubber sign (and cowbells!) there--placed carefully at the height of the Western Avenue underpass.

In contrast, now, all you have is a sign--way up high--indicating that there is a low bridge ahead.  It does not tell you the height of the underpass, and by the placement of the sign, most people would assume that it is pretty high up.

Now, imagine you are an out-of-town bus driver, with a busload of noisy kids, driving at night, using your GPS to find your way to the Massachusetts Turnpike.  While we can find fault with the driver if we want, I think we have to acknowledge that what happened to him could happen to anybody.

Here, as in the hospital world, the phrase, "what happened to him could happen to anybody," is usually evidence of a systemic problem, not a personal problem.  The Commonwealth of Massachusetts solved the problem of bus crashes on this road 30 years ago.  A lack of maintenance or will or understanding on the part of the state administration caused this problem to recur this past weekend.  It was, in a sense, inevitable.

And it will happen again and again unless the state agency gets it act together.

Update on the Boston scene

It's been a while since I prepared a summary of the hospital industry in the Boston area.  Some things have changed.  Some remain the same.

Partners Healthcare System (Massachusetts General Hospital, Brigham and Women's Hospital, Brigham and Women's Faulkner Hospital, Newton Wellesley Hospital, North Shore Medical Center, Martha's Vineyard Hospital, Nantucket Cottage Hospital, and more.)  An expansion is in process with the pending acquisition of South Shore Hospital and Cooley-Dickinson Hospital.  There are numerous clinical affiliations with other hospitals, also.  PHS is doing very well, thanks to above market contracts signed with Blue Cross Blue Shield and other insurers.  Do not ever expect to see above average earning reports, though, as the system is a master at burying its money in new buildings, information systems, and the like. Let there be no doubt that Partners has won the Massachusetts market for years to come.  The rest of this post is about how the others will fight for the remaining scraps.

Steward Health Care System (St. Elizabeth's Medical Center, Carney Hospital, Good Samaritan Medical Center, St. Anne's Hospital, Holy Family Hospital, Merrimack Valley Hospital, Morton Hospital, Nashoba Valley Medical Center, Norwood Hospital, Quincy Medical Center, New England Sinai Hospital.)  This is the big for-profit system, owned by private equity firm Cerberus, which acquired it from the former Caritas Christi system.  Tongues were wagging recently when the Attorney General issued her first report on this system, showing operating losses in its first year of ownership.

For example, a colleague who studies municipal bonds said, "We are sitting here in tax-exempt bond land saying 'What was Cerberus thinking?' and 'How long are they going to stick it out, but on the other hand, what can they do, is somebody else going to buy them out at this point?' All very interesting, especially since the for-profit guys are so confident that they can play the game better. Perhaps not always."

Not so fast.  Don't jump to conclusions.  The report only covered operations for the year ending September 30, 2011. And remember that operating losses on the income statement are not the main concern for a private equity firm.  Cash flow is what matters, earnings before depreciation and taxes.  Depreciation is a non-cash expense.  Taxes are subject to all kinds of IRS rules and loopholes.

Nonetheless, there are some things to watch.  Recall that Steward has promised to be the low-cost alternative in the communities it serves.  The AG found:

While 2011 prices were not available for this Report, 2009 and 2010 data shows that prices for the Caritas hospitals vary insurer by insurer, and by inpatient versus outpatient services, with the result that some Caritas hospitals are on par with competitors, others are less expensive, and others are more expensive. Given this variation in price by local market and service category, whether Steward’s activities will raise or lower costs in its markets ultimately depends on a variety of factors, from “endogenous” factors like the services Steward chooses to develop and the prices it seeks for those services, to factors “exogenous” to Steward, such as market activity by its competitors and changes in the regulatory landscape.

Steward has also been in the forefront of signing risk contracts with Blue Cross Blue Shield.  Those contracts were front-end loaded to be made more attractive the health systems.  Over time, their provisions will bind and can affect earnings.  Even those provider groups with the most experience with risk contracts are now finding how difficult it is to generate surpluses.  Does Steward have the care management system in place to be successful under this payment scheme?  How does it control the costs of tertiary referrals now that St. Elizabeth's really isn't a high-end hospital and when its main clinical partner for those referrals is MGH?

Personnel changes in recent months might be indicative of cultural problems or concerns about specific hospital business plans.  Highly regarded Bill Walczak, the former head of the Codman Square Health Center, was hired to be CEO of Carney Hospital but then was quickly fired.  More recently, well respected John Polanowicz left the helm of St. Elizabeth's to join the state government less than two years after signing on.    There are rumors, too, that the system's consolidated hospital billing system has had start-up problems.  Effective operational management is necessary even for a system that plans to do a flip in a few years.

Beth Israel Deaconess Medical Center (BIDMC, BID Hospital~Needham, Milton Hospital.)  After the recent merger with Milton Hospital, an expansion continues with the acquisition of Jordan Hospital.  It maintains clinical affiliations with several other hospitals, including the two other Caregroup hospitals, Mt. Auburn Hospital and New England Baptist Hospital.  BIDMC is apparently engaged in a strategy of acquisitions to provide a tighter network in the world of Accountable Care Organizations.  Are others in the offing?  While this strategy is understandable, the challenge will be how to integrate the governance and operations of a system of hospitals, as contrasted with what has essentially been a lone academic medical center with one small community hospital outpost.  The governance and operation of a health system require a different set of skills and approaches.  (Of course, I am loyally rooting for success!)

Tufts Medical Center.  I'm sorry to report that I haven't heard anything about the smallest of the academic medical centers, except the loss of Jordan Hospital as a referral source.  The hospital has had and continues to have thoughtful and excellent leadership, but it is not clear where their strategic path is to a happy future.  I'm hoping I just don't have the wisdom to see the path, as this is a treasured Boston institution, going back to 1796: "A group of public-spirited Bostonians founded the Boston Dispensary, funding tickets that enabled the city's poor to receive treatment. One of the original tickets was signed by subscriber Paul Revere." Hmm, maybe there is a deal to be done with BIDMC?

Switzerland.  Places that have some geographic advantage like Southcoast Health System (owner St. Luke's Hospital in New Bedford, Tobey Hospital in Wareham, and Charlton Hospital in Fall River) seek to maintain independence and offer affiliations with all the others.  As noted by the Boston Business Journal:  "Southcoast Health System is strengthening its clinical offerings and financial position as it strives to endure as an independent community health care system, with no ties to a Boston academic medical center or an out-of-state company."