Transparency promotes quality?

For a while now, I have been fan of Paul Levy, the President and CEO of Beth Israel Deaconess Medical Center in Boston. I studied his turnaround of BIDMC when I was doing the Advanced Management Programme in Harvard 2007, but it is how he has advocated transparency in management and quality through his blog www.runningahospital.blogspot.com that I am really a fan of.

It is not uncommon that he publishes communication with his staff on various issues. Here is one from his Director Critical Care Quality...

The good thing is, he does not publishes only the good stuff but also when things go wrong. I believe this creates direct pressure on his hospital to make the necessary improvements while they celebrate when they achieve success. It is a double edge sword that Paul Levy has used to good effects.

So far, my sense for BIDMC is that transparency does seems to promote quality... you think?

The Healthcare conundrum to avoid...

When I was last at Houston Texas, I could not help but be amazed by the medical enterprise at an entire district known as Texas Medical Centre. Brand name hospitals and specialist centres are there and the hotel where I stayed was practically filled with patients. Hotels run shuttle bus services to and from hospitals for patients and their next-of-kin.

It is in this setting that this new BBC article reports the Healthcare conundrum, ie more spending per patient in Texas is not translated into better patient outcome, and that the "business" of healthcare is inducing unnecessary demand for services that patients do not need.

Prof Christensen is right. Doing more of what we currently have in healthcare cannot help. We need to disrupt the way healthcare is being provided through coherent solution shops, value-added Process (VAP) clinics for illnesses that are already well understood and where precision/ empirical medicine may be practiced; and facilitated networks (disease management plans) where providers are rewarded to keep patients well, and patients are incentivised to comply with their therapy.

What do lawyers really do?

...well at least I call this into question for the lawyer that my wife just met!

Late last week, the lawyer's office called my wife. The assistant conveyed to my wife the lawyer's question, "do you want to settle for a 50-50" in the traffic accident claim. To which my wife replied, "No". "Then you will need to come down to the lawyer's office, because our lawyer needs to speak with you", came the reply.

This call came some 7 months after the traffic accident that my wife had the misfortune to encounter with a huge truck/ lorry while on her way to fetch my daughter along Bukit Timah. Silence for 7 full months, then a call to ask the client to "settle". What a way to earn their fees, probably wrote one letter to the other party, waited for the response, and ask the client to settle? I thought, surely they must have done more, and wife will do well to find out more by meeting the lawyer.

My wife turned up at the lawyer's office today.

The lawyer looked at my wife and the first sentence that he uttered was "I think you better settle for 50-50"!

When asked why, he said that based on the reply from the other driver, he said that because there are no witnesses, it will be very difficult to prove my wife's version of how the accident happened. Then he said, "only God knows whether you are telling the truth!" To which, the only correct reply should have been "only God knows why you are a lawyer!"

He went on to try to "scare" my wife into accepting the 50-50 settlement. He said that if she were to reject the 50-50 settlement, the case will have to go to mitigation/ court and whatever the outcome my wife would have to be responsible for his fees of $2500! The keyword emphasised was "whatever the outcome". Of course, he went on to say that "for heaven sake, this is just a road traffic accident claim, I have 1600 other cases, and you want to pursue this case?!"

I am glad my wife gave the only correct answer, "what's the point you are trying to make?"

All these prompted my question, "what do lawyers really do?"

(1) Nothing that he said or shown my wife at his office has shown that he has gone beyond the information and forms that we have completed as part of insurance claim.

(2) Based on his words and behavior, he has already given up "fighting" for the case - although I am not even convinced that he even attempted to try.

(3) Nothing that he will say during mitigation/ court hearing will be any attempt to argue the case for his client. In fact, he discredited his client by asserting without evidence that my wife had lied about the facts of the accident by his statement "only God will know whether you are telling the truth."

(4) Why should he as the lawyer be paid regardless of his effort and outcome?

My conclusion is that he has done nothing for his client (my wife) and come to think about it, we did not even appoint him as our lawyer, maybe he was signed up by the insurance company.

So, it begs the question: what does he as a lawyer really do (looks like nothing)? With his behavior and performance ANY client with a sound mind and half a kidney could do a better job.

What IS the role of a lawyer in such situations?

The Silver Tsunami - doctors in America need to learn how to treat the elderly

I was forwarded an email containing the following article that I find so interesting as we prepare for the Silver Tsunami in Singapore...

July 2, 2009
Op-Ed Contributor

The Patients Doctors Don’t Know
By ROSANNE M. LEIPZIG

AS they do every July, hospitals across America are welcoming new interns,
fresh from medical school graduation. Given how much these trainees have
yet to learn, common wisdom holds that it’s not a good time of year to get
sick. This may be particularly true for older patients, because American
medical schools require no training in geriatric medicine.

Often even experienced doctors are unaware that 80-year-olds are not the
same as 50-year-olds. Pneumonia in a 50-year-old causes fever, cough and
difficulty breathing; an 80-year-old with the same illness may have none of
these symptoms, but just seem “not herself” confused and unsteady, unable
to get out of bed.

She may end up in a hospital, where a doctor prescribes a dose of
antibiotic that would be right for a woman in her 50s, but is twice as much
as an 80-year-old patient should get, and so she develops kidney failure,
and grows weaker and more confused. In her confusion, she pulls the tube
from her arm and the catheter from her bladder.

Instead of re-evaluating whether the tubes are needed, her doctor then asks
the nurses to tie her arms to the bed so she won’t hurt herself. This only
increases her agitation and keeps her bed-bound, causing her to lose muscle
and bone mass. Eventually, she recovers from the pneumonia and her mind is
clearer, so she’s considered ready for discharge but she is no longer the
woman she was before her illness. She’s more frail, and needs help with
walking, bathing and daily chores.

This shouldn’t happen. All medical students are required to have clinical
experiences in pediatrics and obstetrics, even though after they graduate
most will never treat a child or deliver a baby. Yet there is no
requirement for any clinical training in geriatrics, even though patients
65 and older account for 32 percent of the average doctor’s workload in
surgical care and 43 percent in medical specialty care, and they make up 48
percent of all inpatient hospital days. Medicare, the national health
insurance for people 65 and older, contributes more than $8 billion a year
to support residency training, yet it does not require that part of that
training focus on the unique health care needs of older adults.

Medicare beneficiaries receive care from doctors who may not have been
taught that heart attacks in octogenarians usually present without chest
pain, or that confusion can be due to bladder infections, heart attacks or
Benadryl. They do not routinely check for memory problems, or know which
community resources can help these patients manage their conditions.
They’re uncomfortable discussing goals of care, and recommend screening
tests and treatments to patients who are not going to live long enough to
reap the benefits.

I was part of a group of doctors and medical educators who recently
published in the journal Academic Medicine a set of minimum abilities that
every medical student should demonstrate before graduating and caring for
elderly patients. Nicknamed the “don’t kill Granny” list, it includes being
able to prescribe medicines, assess patients’ ability to care for
themselves, recognize atypical presentations of common diseases, prevent
falls, recognize the hazards of hospitalization and decide on treatments
based on elderly patients’ prognosis and their personal preferences.

The 2008 Institute of Medicine report “Retooling for an Aging America”
resolved that all licensed health care professionals should be required to
demonstrate such competence in the care of older adults. But this
resolution lacks teeth. Medical resident training programs that receive
Medicare money should be required to demonstrate that their trainees are
competent in geriatric care. Medicare should finance medical training in
nursing homes. And state licensing and medical specialty boards should
require demonstration of geriatric competence for licensing and
certification.

Basic geriatric knowledge is preventive medicine. Nurses, social workers,
pharmacists and other health care professionals should have it, too, in
order to improve care for older people. But until doctors get this basic
training, we can’t even begin to give 80-year-olds the care they need.

Rosanne M. Leipzig, a physician, is a professor at Mount Sinai School of
Medicine.

Effective CEOs spend more time on less things

An article in the New York Times caught my eye today. Entitled "How to be an Effective CEO", it is a good reminder of timeless advice that need to be brought from "the back of the mind to the front of the mind."

Basically, a CEO needs to spend more time on less things. The most consistent "thing" among the few things is PEOPLE. Hire the right people to do the things that CEO should not spend his time on, spend time with good people, and counsel people who need improvement.

The article talks about 2 timeless classics, Peter Drucker and Steven Covey's 7 Habits of Highly Effective People.

Peter Drucker's advice to CEO:

(1) Find time for uninterupted work.

(2) Spend time on people

(3) Focus on allocating resources

(4) Focus on strengths rather than managing weaknesses.

Steven Covey's 7 Habits:

(1) Be proactive

(2) Begin with the end in mind

(3) Put First thing first

(4) Think win/ win

(5) Seek first to understand, then be understood

(6) Synergise

(7) Sharpen the saw

These are not new concepts, but important reminders for leaders leading others through change and challenging times.

Another important point that my chairman recently reminded us, "Work in Quadrant 2" - Work that are important but not urgent. He is really talking about spending time "Planning" and not fighting fire all the time. In fact, if we plan well, we will fight less fire! How true. The book "The Living Company" is really a great book about planning for the future...

Let's not get carried away, while we plan for tomorrow...Let's LIVE today!

Preparing for the new iPhone 3G S

SingTel will have a launch event on 10 July 2009 (Friday) for the new iPhone 3G S in Singapore.

Enthusiasts who signed up with SingTel got an email on Friday - me included!

I am not sure whether I count as an iPhone enthusiast? "Yes"...because I owned the last 2 versions of the iPhone but ... "Maybe" - because I sold them within 2 weeks! Main reasons, smallish screen keypad, inability to forward sms and slow.

My recent ownership of a brand new 24" iMac piqued my interest in many things Apple. The launch of the new iPhone 3G S cannot be more timely. You can say, it sort of "completes" my conversion from Windows to Mac.

The new iPhone 3G S took care of all my pet peeves. It is not only faster, it provides a larger screen keypad in landscape position, sms forwarding function and like all things Apple, other sexy functions and programmes such as video and a better camera.

Since Singtel's announcement of the 10 July launch, I have been making preparations for my impending ownership. I sold my Nokia E71 today and then just an hour ago, I used a programme PocketMac to transfer all my contacts from my Blackberry phone to mac Address Book. I must say that for someone who owns a Mac and Blackberry, the free PocketMac software is very neat and handy. Just remember to run the driver update as well for the new Bold, Storm and Curve handset before launching the programme. The synchronisation was flawless and effortless!

I know, yes, I am aware of the many reports talking about the overheating problem for the new iPhone 3G S. I understand that this only becomes a problem when multiple programmes are run at the same time, and for long conversations. Unless one is trying to stress-test the phone, I do not think that a normal user like me will face such problems. Afterall, my new Nokia E71 also becomes quite hot when I am on the phone for a long time! This morning, I was trading sms with a friend who is also waiting for the new iPhone. I texted him that "not bad, buy one phone and get a toaster for free", and his reply was quite humorous and telling..., he replied "Being toasted is better than getting microwaved on windows based phone."

I wonder how the new iPhone 3G S will work out for my kind of lifestyle. In any case, I am prepared to give iPhone a 3rd chance. Hopefully, this time my ownership will be much more enduring. If not, I will sell it within 2 weeks again.

Developing a conscience of being environmentally friendly...

The Inconvenient Truth by El Gore about global warming...

A recent video entitled "Home" talks about the damage being inflicted on mother earth and that mankind has 10 years to change the way we live and to avert depletion of natural resources and catastrophic damage to earth's climate. My reservist colleague alerted me to this video. He said that he watched the hour long video with his 11 year old daughter and it changed the way she thought about the importance of being environmentally friendly. Tonight, I watched the video on youtube, as I key in my thoughts on my blog.

Personally, I've observed that the weather has become noticeably hotter, especially in recent times. Has the hole in the ozone layer become bigger? Freak weather has also become sort of the norm as we tune in to the news. I am trying to reason away the changes that I am seeing before my very eyes, but I could not. The damage being inflicted on our environment and consequently the impact on our climate has become quite clear.

The last few days, I turned my attention on the vehicle that I drive. Instinctively, my love for old mercedes benz took over. I chanced upon a rare 1984 Mercedes 380 SEC and it gripped my attention. As I thought about the prospect of buying that car, I reflected on the impact it will have on the environment and evoked a self discussion on whether it is indeed a need or want. Why do I need a 3.8 litre car? The consumption of the car will be almost twice that of my current car. Other than the cost of petrol, what will that mean in terms of my carbon footprint? Obviously there was tug-of-war between my heart, which indicate the MB 380 SEC would be such a lovely purchase and would satisfy my emotional being; and my head, which question the purchase from the angle of excess and impact on the environment. My heart, gave in today (just a little bit) and I swung by to Borneo motors to look at the new 1.8 Litre Toyota Prius. The hybrid car can do 23km on one litre of petrol, a saving of at least 60% of my current car. My head was nodding but my heart hurts as I stared at the Prius - it is so ugly, so plain, so lacking in character...but most of all, so inaccessible because there is a 5 months wait for the car!

I am thinking, the new Toyota Prius will be such a statement that I can carry regarding the message of environmentally friendly to others. Maybe, it may trigger a conversation around why do I still buy a car that I know is so plain? ... not to mention to pay a premium for it!

I am positive that my conscience of being environmentally friendly is currently being shaped in a significant manner. Even as this happens, I am determined that I will be a good advocate for the environment but one who will be practical in the world that we live in. By this I mean, I will continue to ask for a plastic bag when I need one for it is not practical for me to tuck a bag in my pocket wherever I go. But where I can do without one, such as my recent visit to Ikea, I will do without one.

So, should go for the MB 380 SEC or the Toyota Prius 1.8 ?

Are we Ugly Singaporeans?

This morning, I got up really early. My wife who was up early too to get my daughter ready for school told me that the Ikea sale is on, and for "Friends of Ikea", we get to have free breakfast starting from 7.30am.

Thrilled by the idea of "free" breakfast and the prospect of spending time with my wife, we were soon quickly making our way to the Ikea at Tampines. By the time we arrived, the crowd was thin and people were only beginning to arrive. Without having to wait in line, we got our free coffee, an apple and a cinnamon roll each and made our way to the table and started on our breakfast.

Then, I overheard a conversation. Someone said in a rather cynical and almost mocking manner, "look at all these Singaporeans, got free food only they come and bring the whole family... Singaporeans." It started me thinking...

By now, Singaporeans would have heard about this phrase "Ugly Singaporeans" and perhaps used the phrase on our fellow countrymen a number of times. Unbeknown to many of us, probably the same phrase has been used on us, by others. Usually the circumstances where the phrase is used include: people forming/ joining long queues to get a good deal, free drinks/ food attracting many people to get their hands on them, people on MRT not giving their seats to the elderly/ pregnant ladies, etc; people not giving way to other drivers who wishes to switch lanes...While I personally do not condone such behavior and attitudes, I question whether such stereotypical labeling of the Singapore society and people is justified.

Take this morning experience at Ikea for example. Is it only "ugly Singaporeans" who would turn up when there is free food? I do not think so and I also think there is nothing wrong doing so. At least I think Singaporeans appreciate good value when they see one. In fact, I will feel extremely sorry for Singaporeans when they see a good deal, do not know it is a good deal and hence not avail themselves. Does turning up at Ikea for free breakfast make us "ugly Singaporeans?" I think not.

Even when we see the set of bad behavior by some Singaporeans listed above, is it justified to lavishly use the label "ugly Singaporeans" for the whole society? In my many travel overseas and having lived in the US for 3 years, I have seen similar behavior but I have never heard or heard so consistently people say..."Ugly Americans", "Ugly British", "Ugly Chinese" as we do in Singapore.

Labels when used consistently can conjure a false image of society and people. In psychology, we know that when a person for example is consistently labelled as stupid will after some time believe that his mental capacity is limited and adverse affect his development. I believe the same can be said at the societal level. An eagle will soar like a real eagle when she believes she is one, otherwise she will bump around like a chicken and never realise her full potential.

By now, I believe there are already other labels of Singaporeans that are already deeply ingrained... remember "Kia Su" (afraid to lose) ? Are we "Ugly Singaporeans" and "Kia Su"?

I implore all of us to stop using undesirable labels on ourselves. In every society, there will be black sheep (us included) but we must not brand/ label the whole society because of a few black sheep. Address the behavior, make the improvements and move on. Let us not be too hard on ourselves.

We are not "Ugly Singaporean" but like all human beings, we do fail sometimes.

We are the World

This is such a powerful song. I remember I waited to watch the live broadcast on TV when I was much younger. I am very glad in the age of youtube, I get to watch it again with such clarity.

There is a cause bigger than ourselves, our own success...

Keep this in mind as we get caught up in this rat race going nowhere. Pause...know how fortunate we are, and help make a difference in the world that we live in.

WE ARE THE WORLD...

There comes a time
When we head a certain call
When the world must come together as one
There are people dying
And it's time to lend a hand to life
The greatest gift of all

We can't go on
Pretending day by day
That someone, somewhere will soon make a change
We are all a part of
God's great big family
And the truth, you know love is all we need

[Chorus]
We are the world
We are the children
We are the ones who make a brighter day
So let's start giving
There's a choice we're making
We're saving our own lives
It's true we'll make a better day
Just you and me

Send them your heart
So they'll know that someone cares
And their lives will be stronger and free
As God has shown us by turning stone to bread
So we all must lend a helping hand

[Chorus]
We are the world
We are the children
We are the ones who make a brighter day
So let's start giving
There's a choice we're making
We're saving our own lives
It's true we'll make a better day
Just you and me

When you're down and out
There seems no hope at all
But if you just believe
There's no way we can fall
Well, well, well, well, let us realize
That a change will only come
When we stand together as one

[Chorus]
We are the world
We are the children
We are the ones who make a brighter day
So let's start giving
There's a choice we're making
We're saving our own lives
It's true we'll make a better day
Just you and me

The beginning of evidence based medicine?

The New York Times reported that a high powered panel appointed by the Obama administration as part of healthcare reforms has recommended that priorities be given to comparing effectiveness of competing drugs, medical devices, operations and other treatment for various medical conditions.

Prof Christensen in his book said that medicine as it is practiced today is largely in the realm of intuitive medicine where medical therapy is left largely to the judgement and experience of the doctor. Even where there are evidence to suggest rule-based treatment, the current system is not atuned to it.

The NYT article went on to give the example of abnormal heart rhythm known as atrial fibrillation. In such cases, a doctor may recommend drugs or a surgical procedure known as ablation, with little evidence as to which strategy works better or has fewer side effects.

Could this be the beginning of the push for evidence based medicine with new reimbursement incentives tied to it to drive the right "business models" to make healthcare more affordable, better quality and more convenient?