Not so fast

I have been flooded with emails from people sending me the link to the newest report from the Centers for Disease Control about the "dramatic" reductions in CLABSIs:  "A 41 percent reduction in central line-associated bloodstream infections since 2008, up from the 32 percent reduction reported in 2010."

The CDC reminds us:

A central line is a tube that is placed in a large vein of a patient's neck or chest to give important medical treatment. When not put in correctly or kept clean, central lines can become a freeway for germs to enter the body and cause serious bloodstream infections. CDC estimates that 12,400 central line-associated bloodstream infections occurred in 2011, costing one payer, the Centers for Medicare & Medicaid Services (CMS), approximately $26,000 per infection.

Not to mention killing people unnecessarily.

I say without hesitation that this is not good enough. First, the CDC insists on using flawed standardized infection ratios.  Per the CDC, "the SIR is a summary measure used to track healthcare-associated infections over time. It adjusts for the fact that each healthcare facility treats different types of patients. The SIR compares the number of infections reported to NHSN in 2011 to the number of infections that would be predicted based on national, historical baseline data."

"The predicted number is an estimated number of HAIs based on infections reported to NHSN during January 2006–December 2008."

In other words, a period of time during which most hospitals were doing very, very little to prevent infections.

There is no virtue in benchmarking yourself to a substandard norm. As noted by Catherine Carson, Director, Quality & Patient Safety at Daughters of Charity Health System: 

When the goal is zero – as in zero hospital-acquired infections, or falls – why seek a benchmark? A benchmark would then send the message  - that in comparison to X, our current performance level is okay, which is a false message when the goal of harm is zero.

Second, whatever metric you choose, the overall progress is just too slow.  In terms of protocols and training and auditing, we know what it takes to avoid CLABSIs.  For details, call Peter Pronovost.  This is not a technical problem:  It is a problem of leadership. It takes clinical leadership, administrative leadership, and supportive governance to make it happen.  At least one of these ingredients is missing in too many hospitals.

Like mother, like daughter

It is really satisfying when I see US college students engaged in world health issues.  They bring a wonderful level of idealism and enthusiasm, plus new ideas.  Of course, too, they get to meet and work with people from different cultures and economic situations, something important to their own development as world citizens.

How much more so when their activities follow in the footsteps of parents who have likewise made contributions to the world.  So, I was really pleased to see this story from Notre Dame University in which Katherine Spencer is quoted as explaining the purpose and goals of a program called GlobeMed.  Kate is the daughter of the late Monique Doyle Spencer, who is well known to my regular readers.

Kate carries her own well in this story, and her mother would have been proud.  Excerpts:

The new chapter became part of a student-run non-profit organization with 50 chapters at universities across the United States, according to junior Kate Spencer, a campaign coordinator with GlobeMed. As part of the organization, each chapter partners with a community-based grassroots organization facing health disparities in Africa, Asia, North America, and South America, Spencer said.

“[Our] chapters build these partnerships through frequent communication and innovative fundraising initiatives for collaborative health projects that help our partner organizations achieve their missions,” she said. Discussions on global health issues prevail in the classroom while internships are also arranged with partner organizations overseas.

Spencer said the GlobeMed organization paired the Notre Dame chapter with the Laos network and students were thrilled to be working with them. PEDA is a non-profit organization based in Vientiane, Laos.

“Working with PEDA would give [GlobeMed members] the opportunity to make a tangible difference in Laos, but also educate students at Notre Dame about a country halfway around the world with a rich culture and history,” she said.

Spencer noted that the excitement to participate in GlobeMed was mutual.

“This is an opportunity for us to collaborate with GlobeMed and its students to improve the health of the communities, to exchange experiences about our works, open our ear to listen to new ideas from young generation...” chairman assistant and project coordinator at PEDA Thipphavanh Thammachith said through GlobeMed’s Notre Dame chapter. “That we may apply new ideas to our work and on the community projects, as our work is to provide technical information and education to support the community potential in solving socio-economic, health issues and so forth. 

Offering a unique and opening environment, GlobeMed provides many windows for involvement for all majors and those interested in global health. Spencer said the chapter is always looking for more members.

“We truly believe that health is a human right, and that we, as students, can be powerful agents of change,” Spencer said.

Why I write: Only hope can carry us aloft

It has been two years since I left my job as CEO of a hospital, and I have had many opportunities to reflect upon what I learned during my nine-year tenure there as well as during this period afterward.  It was a privilege to serve in that role, working with so many well-intentioned people, both on the staff and among the governing bodies and the hospital’s supporters in the community.  As someone who had had no exposure to the health care world, it was also a revelation to me to see how difficult it was to consistently offer high-quality, patient-centered care.  I learned, too, how much harm is inadvertently caused by the way work is organized in hospitals and how ill-suited professional training programs are in enabling clinicians to engage in process improvement.  I also made my share of mistakes, one of which in particular received a great deal of public attention, punishment from my Board of Directors, and apologies from me to them, the hospital staff, and even to you, my loyal readers.

Upon leaving BIDMC, I decided I would devote this next period of my life to reflecting on what I had learned, trying to consolidate the lessons, and then offering myself to other hospitals and communities to pass along things that might be helpful to them.  Almost immediately, I was challenged by some people with doubts.  Shortly after publishing my book Goal Play!, one reporter asked: 

I’m sure you know, there are some people out there who feel like you lost the ability to write a book about leadership and management because of this failure in leadership in this incident when you were at Beth Israel. How much credibility do you think you still have as someone who can talk about leadership and management?

I responded by saying:

Well, if you lose the ability to talk about leadership because you make a mistake, even a big mistake, then there aren’t going to be many people who can talk about leadership. I think the sign of any good leader — or, for that matter, any person — who wants to improve is [that] you acknowledge your mistakes and you see if there are lessons to be drawn from them and, in the case of this book, perhaps teach other people from that experience and go on. 

That was easy enough to say, but the proof of the pudding would be how I was actually received as I wrote the book and this blog and traveled the globe telling stories and offering advice. On that front, so far so good, and I am grateful to my readers here, to those who have sent me kind notes about the book, and to other folks for their respectful attention, engagement, and encouragement.

Nonetheless, I make no claims to bringing the level of eloquence and persuasion that might be possible.  I am inspired, though, by  these remarks made by E. B. White (in absentia) upon receiving the National Medal for Literature in December 1971.  If I ever become as good a writer and presenter as he, I shall die happy.  Meanwhile, I keep at it, trying not to be discouraged at the degree of harm caused by well intentioned people in the health care field and my inability to motivate, teach, and help as much as I would like.

The Egg Is All 

Ten years ago they pulled the railroad out from under me, and this almost severed my connection with New York. Then sixteen months ago, I met with a motor accident, and this made the highway a problem for me. As for the skies, I quit using the flying machines in 1929 after the pilot of one of them, blinded by snow, handed the chart to me and asked me to find the Cleveland airport.

The world of letters sometimes seems as remote or inaccessible to me these days as the City of New York, and it would be foolhardy of me to comment at length on that wonderful, untidy and seductive world. I drifted into it a long time ago with no preparation other than an abiding itch. I fell in love with the sound of an early typewriter and have been stuck with it ever since. I believed then, as I do now, in the goodness of the published word: it seemed to contain an essential goodness, like the smell of leaf mold. Being a medalist at last, I can now speak of the "corpus" of my work--the word has a splendid sound. But glancing at the skimpy accomplishments of recent years, I find the "cadaver of my work" a more fitting phrase.

I have always felt that the first duty of a writer was to ascend--to make flights, carrying others along if he could manage it. To do this takes courage, even a certain conceit. My favorite aeronaut was not a writer at all, he was Dr. Piccard, the balloonist, who once, in an experimental moment, made an ascension borne aloft by two thousand small balloons, hoping that the Law of Probability would serve him well and that when he reached the rarefied air of the stratosphere some (but not all) of the balloons would burst and thus lower him gently to earth. But when the doctor reached the heights to which he had aspired, he whipped out a pistol and killed about a dozen of the balloons. He descended in flames, and the papers reported that when he jumped from the basket he was choked with laughter. Flights of this sort are the dream of every good writer: the ascent, the surrender to Probability, finally the flaming denouement, wracked with laughter--or with tears.

Today, with so much of earth damaged and endangered, with so much of life dispiriting or joyless, a writer's courage can easily fail him. I feel this daily. In the face of so much bad news, how does one sustain one's belief? Jacques Cousteau tells us that the sea is dying; he has been down there and seen its agony. If the sea dies, so will Man die. Many tell us that the cities are dying; and if the cities die, it will be the same as Man's own death. Seemingly, the ultimate triumph of our chemistry is to produce a bird's egg with a shell so thin it collapses under the weight of incubation, and there is no hatch, no young birds to carry on the tradition of flight and song. "Egg is all," quote Dr. Alexis Romanoff, the embryologist, who spent his life examining the egg. Can this truly be the triumph of our chemistry--to destroy all by destroying the egg?

But despair is no good--for the writer, for anyone. Only hope can carry us aloft, can keep us afloat. Only hope, and a certain faith that the incredible structure that has been fashioned by this most strange and ingenious of all the mammals cannot end in ruin and disaster. This faith is a writer's faith, for writing itself is an act of faith, nothing else. And it must be the writer, above all others, who keeps it alive--choked with laughter, or with pain.

Who are today's heroes?

My daughter (right, above, with her sister) turns 30 this week, and I decided to send her copies of books by or about people that I have admired.  I wanted her to have real books, not virtual books, because they sit there on your shelf as a reminder that you haven't read them, and eventually you do.  Then, the smell of them cements the memory of their contents:  Smell and memory are closely linked because the olfactory bulb is part of the brain's limbic system  They will start arriving at her house today or tomorrow, in time for her Valentine's Day celebration.

As I assembled my list, it occurred to me that I do not have an understanding of who serves as heroes for this generation. When I was growing up, we had John and Robert Kennedy to motivate us, and Martin Luther King, Jr.  In life and death, they set standards and told us it was all right to dream.  Even people who had terrible flaws--like Lyndon Johnson and Robert Moses--were larger than life, changing the course of American society in a way that suggested that one person with energy and intent could make a difference. Authors like E. B. White taught us lessons about friendship in Charlotte's Web, but then also made us laugh while learning proper grammar.  It is not an accident that many of the students who were in Mr. Morton Harrison's fifth and sixth grade class on Long Island ended up devoting our lives to public service or education or environmental protection.  He was a great teacher who inspired and demanded rigor. Did my daughters receive this gift from any of their teachers?

My musings led to Dag Hammarskjöld.  He was the second Secretary General of the United Nations, at a time when we believed the UN represented the best of world diplomacy and the best chance for sustained peace during a time characterized by the Cold War.  You may recall that he died in an air crash in 1961 while flying to Northern Rhodesia to negotiate a cease-fire between UN and Katanga forces.  His book Markings has some remarkable entries.  I don't know if it has had any influence in your life, but I have always found it a touchstone.  Here's an excerpt about negotiation.  It is as valid about interpersonal relationships in an academic medical center or community hospital--where egos reign but underlying intentions are generally noble--as it is in a diplomat's resolution of a war.

"Concerning men and their way to peace and concord--?"
The truth is so simple that it is considered a pretentious banality.  Yet it is continually being denied by our behavior.  Every day furnishes new examples.
It is more important to be aware of the grounds for your own behavior than to understand the motives of another.
The other's "face" is more important than your own.
If, while pleading another's cause, you are at the same time seeking something for yourself, you cannot hope to succeed.
You can only hope to find a lasting solution to a conflict if you have learned to see the other objectively, but, at the same time, to experience his difficulties subjectively.
The man who "likes people" disposes once and for all of the man who despises them.
All first-hand experience is valuable, and he who has given up looking for it will one day find--that he lacks what he needs: a closed mind is a weakness, and he who approaches persons or painting or poetry without the youthful ambition to learn a new language and so gain access to someone else's perspective on life, let him beware.
A successful lie is doubly a lie, an error which has to be corrected is a heavier burden than truth: only an uncompromising "honesty" can reach the bedrock of decency which you should always expect to find, even under deep layers of evil.
Diplomatic "finesse" must never be another word for fear of being unpopular: that is to seek the appearance of influence at the cost of its reality.

But then note, too, this call to action:

 Never, "for the sake of peace and quiet," deny your own experience or convictions.

I don't want to hear that!

Kevlar vests must have been invented for people like Al Lewis.  He fearlessly goes where few dare to tread, attacking the fads and shibboleths that are propounded as truth in health care policy debates.  A sign of his success is that people try not to debate him.  They know they can't win, so they hope that ignoring him will allow the myths on which they are operating to persist.

His latest column on the The Health Care Blog is illustrative.  Here are some excerpts:

It’s not quite time to publish the obituary for by far the most extensive patient-centered medical home (PCMH) network in the country, Community Care of North Carolina (CCNC) but it’s certainly time to spellcheck it.

This wasn’t just any old medical home – it was the “poster child” for the PCMH movement, even making it onto NPR.

Meanwhile, the overall North Carolina Medicaid budgets were frequently exceeded, by considerable margins – $1.4-billion in the last three years alone. But few people made the connection between that unanticipated extra spending and CCNC, because CCNC hired gold-plated consultants — first  Mercer and later Milliman – to demonstrate dramatic savings from the PCMH itself.

Fortunately for Mercer, Milliman is bearing most of the scrutiny now, being the more recent of the two studies.  Their results were also obviously impossible, showing up to $250,000,000 in annual admissions savings despite the state spending only $114,000,000 in the year prior to the study and despite the fact that there was no decline in admissions.

The subsequent CCNC and Milliman defense strategy, invented by the tobacco industry and perfected by the fossil fuel interests, has been to “sow doubt” and emphasize tangents so that journalists need to write “he said-she said” stories and follow up on irrelevancies.

Meanwhile, CCNC and Milliman haven’t actually answered the questions that get to the heart of whether they misled people for so long on purpose or simply out of ignorance.  

This is not just about North Carolina.  As noted above, PCMH adherents embraced CCNC on its way up to the point where PCMH and CCNC are joined at the hip.  So what does the PCMH movement do about these folks on the way down? In Medicaid – the category where improved access should make the greatest difference — adoption has slowed to a crawl even with the 9-to-1 [federal] match.  Further, one of the pillars of the PCMH is prevention, which may not save money. At the very least, PCMH adherents, to quote the immortal words of the great philosopher Ricky Ricardo, will have a lot of ‘splaining to do.