Nick's Blog

Knowing Enough About Systems to be Dangerous

From the age of about eight until 20 years ago, my entire life was immersed in music, education, the arts and, in a very pure way, people in general.  It was a complex world that required a deep, intuitive understanding of the human condition on multiple levels.  In a very general way, that life, (pre-health care management) was all about systems.  

Obviously, it was never just about one or two individuals, and it was not about life and death, but it was magnificently complex in its own way. It involved working with  people to do something that was extremely challenging, that required incredible hand/eye co-ordination, and an ensemble mindset of co-operativeness that was paramount to success.  Most importantly, it required them to listen intently to each other so as to find the perfect balance, blend and intonation. 

The nuances of taking a systemic approach to the creation of music through the efforts of an ensemble in many ways have escaped our world of healing, at least until now. 

At a recent visit to my dentist, he and his hygienist were talking about the fact that the doc had just taken a continuing medical education course.  When he was asked if anything new had evolved from his class, he smiled and said, "Well, for the first time in 28 years of practice, they admitted that the mouth is connected to the body."  He went on to elaborate about the fact that each and every day he sees the destruction caused by inflammatory disease of the gums, and then told me about his attempts to communicate that information to a physician friend several years ago.  "It just didn't register," he said. 

What little we know about inflammatory disease has us dutifully brushing our dog's teeth to prevent a heart condition, yet we still do not have direct lines of communication between our primary or cardiac physicians and the the dentists who see these problems as they manifest themselves in our body.  

Someone once told me that Descartes' Treatise of Man played a major role in the imposed medical and emotional separation of the brain from the body, as it clearly took the stand that "Hospitals and physicians should take care of the body while the church takes care of the mind and the soul."

One of our scientific collaborators, Dr. Lee Hood, is famous for his work in Systems Biology.  Another collaborator, Georgetown University, is involved in the creation of a medical school program revolving around Systems Medicine, and finally, our Optimal Healing Environment collaborator, the Samueli Institute, is focused on Systems Wellness.  In spite of these wonderful leaps into what would have to be considered common sense approaches to health and life, we still sometimes miss the ensemble approach.

My recommendation? 

Maybe it would help our healers to take their place on the podium, look at every one of the 30 plus lines of music on the score, raise the baton and begin to direct their way through every nuance, inflection, and harmonious signature present in a score of music with the appropriate rhythm, intonation and accents just to remind themselves that; we human beings are basically all made up of systems as well, and those systems will not function smoothly if one is completely out of sync with the other." 

This is something that we all know intuitively.  Maybe immersing ourselves in that world for a while will help bring that concept totally back into focus.  It's all about harmony, balance and nature's perfection, and a disjointed approach to health is as potentially harmful as a disjointed approach to life.   

Transparency

Transparency is a hot subject in health care these days.  The front page of last Sunday's New York Times carried a story about a physician who told his patient immediately after surgery that he had made a mistake, and basically apologized and asked for forgiveness.   Even with about 1,000,000 active attorneys in the United States working to make a living, the concept of telling the truth before it evolves into a lawsuit is more and more in the forefront of our literature. 

This week, I received a three page E-mail that was transparent, but it was not from us, it was about us.  It was so transparent that it should rock our collective souls.  As a patient-centered hospital that has reached some degree of recognition nationally, this letter represented not an A in patient centered care, but very close to a C, or worse. 

The person who took the time to record their stay at Windber Medical Center was painfully thorough.  Their hospitalization was over a 74 hour period when the house was full.  We were extremely busy, and somewhat short on some staff members, and a few key physicians were away.  This patient recorded every aspect of their experience.  They let us know when water was or wasn't delivered to the room, when the rooms were cleaned, where the nurses were and how often they delivered meds, checked their IV's, provided them with medicine, and met the patient's medical and/or personal needs. 

If it were not possible to determine who this patient was from the content of the letter, in the spirit of full disclosure, I would have reprinted it here for everyone to read. Instead, I will simply delineate the lowlights of its content.

The hardest thing about this letter for me was that we have been working for eleven years to bring improvement to the entire process, to improve health care delivery, and to provide an optimal healing environment. But, when things get rough, we seem to revert back to business-as-usual, circa 1997, and from the transparent report that this former patient provided, we did not always act appropriately. 

At a board, physician, and senior leadership meeting last week, I found out that one of our patient-centered practices had simply been discontinued without notification. This practice provided appropriately for patients, families and staff.  When it was discontinued, only the patients were being taken care of, and they were being cared for in an inferior manner compared to the original practice.  We have met with the appropriate staff members, and we are now back in the business of nurturing all of our stakeholders.

 
It seems to me that our reaction to stress and hard work might be like that of a rubber band.  As soon as the tension reaches its peak, that rubber band attempts to go all the way back to its original shape.  We are a Planetree Hospital.  We DO NOT do brain surgery, heart surgery, trauma or neonatal care.  We DO NOT have hundreds of specialists surrounding our campus like most academic medical centers.  Rather, we are a primary acute care hospital and our differentiation is patient and family centered care.  We are philosophically dedicated to treating our patients and their loved ones with dignity.  We are known for providing the highest touch care in the region.  After reading this patient's letter, it seems to me that they could have been in any hospital USA. 

If we believe that our mission is to provide the most wonderful, nurturing care, then we need to do that consistently.  A few weeks ago, a patient who was leaving the hospital said to one of our vice presidents, "Do you ever empty bedpans here?"  The question struck her as unusual . . . until she read the letter. 

We are all in this together.  We can only be as good as our weakest employee, and our future depends totally upon working not only as a team, but as a humane, caring, nurturing, loving team. 

Between our nurses, Integrative Health Team, our volunteers, pastoral care, our aids, housekeepers, dietary department and couriers, we should be in and out of rooms dozens of times a day.  No one should have to  wait for an overdue medication or just a cold glass of water. 

In closing, this is not a blog that is intended to demean, take unfair shots, or berate our staff, it is meant to say that transparency is exactly that: transparent.  Between the State Inspections, the Joint Commission and our own secret shoppers, transparency is here to stay, and we won't continue to grow without the total commitment from each and every one of us to work above and beyond the call of duty on all shifts.

In closing, the letter said, "You had one Golden Girl who was amazing in every way throughout my entire stay.  Her name is Debbie, and she is the pinnacle of everything you stand for as a Planetree hospital."

So, special thanks from us to you, Debbie.  You and people like you are our future. 

CEO Talk. . . To Our Employees

Mickey Meece of the New York Times recently wrote an article entitled, "Doing the unexpected for employees pays off." He described a small company, Vurv Technology, a developer of human resources software, where the supervisor of two employees came to the founder and CEO, Derek Mercer, and suggested that they purchase two good used cars for two employees who were having trouble making the commute to work.

The alternative for the company would have been to pay out much more than the $10,000 paid for those two vehicles to find replacement employees. Valuable time would also have been lost during the search and training of those new employees as well.

In this case, it was a relatively simple analysis where both the risk and the opportunity were examined. It is often a balancing act of helping people while not destroying company profits. In the case of a nonprofit hospital, if there is no money, there can be no mission, but the mission requires passion and commitment that can only come from helping our staff do their work and experience the satisfaction of being a healthcare employee.

Recently, one of our competitors bragged about the improvement of their employee satisfaction ratings on a scale from 1 to 100% from the low to the mid sixties. Your ratings of WMC are about thirty points higher than their best score. The secret, according to Dan Rozycki, president of the Transtec Group in Austin Texas, is to attempt to build the ultimate workplace.

That has always been our goal, to make Windber the employer of choice, and with the full support of the Board of Directors we have tried very hard to make WMC a very special place to work. Of course, it is not Utopia. Our pension took a real beating a few years back and just now is beginning to move toward competitive levels. The benefits are good, and, over the past few years we have made significant progress with our salaries as compared to other hospitals, nursing homes and medical offices, i.e., the marketplace.

The real differences, however, come in the form of the various qualitative offerings that are not always widely utilized. Yes, we still have tuition reimbursement, reduced fees for Healthstyles, prescription, dental, optical and other normal benefits, but we also have staff members who are employed to help you and our patients to experience optimal healing within our environment; massage, reiki, music and aroma therapy, drum circles, spiritual healing services, acupuncture, picnics, a Pirate's game, and a medical staff that is willing to step up to the plate to defend you from abuse from their peers, i.e., an anti-bullying philosophy. That is not only significant; it is also very rare in most hospitals.

No, we haven't had the money to buy anyone cars lately, but we sure are trying to do the right thing  while we move forward in an unbelievably competitive environment. We know that some of our staff has the mistaken belief that we are flush with money. Let me assure you, after being woefully under funded for years, we are always struggling to take care of all of the needs of this organization.  In spite of that, the good news is that people have voted with their feet to come to Windber for their care, and we are seeing daylight and growth. The better news is that we are committed to continue to work toward becoming the healthcare employer of choice for this region. You are our most important asset, and you are doing an unbelievable job.  On behalf of the board and administrative staff, all I can say is thank you for caring.  Thank you for being the amazing people that you are.  Buildings, equipment, and publicity are not the determining factor.  Day after day people tell us about your great work, your caring work, your kind and gentle touch.  Windbercare care is YOU.

$4.3 Trillion in U.S. Health Care Spending?

"Money doesn't make you happy.  I now have $50 million, but I was just as happy when I had $48 million."
–Arnold Schwarzenegger

According to an article in Internal Medicine News by Mary Ellen Schneider, spending on health care in these United States is projected to reach 20% of the gross domestic product on the one hundredth anniversary of my father's birth, 2017.  Of course that projection is only an estimate made by CMS, the Centers for Medicare and Medicaid Services.  That estimate is, of course, based upon a continued escalation of nearly 7% each year for the next nine years.  In lay terms, that escalation would mean that the total dollars spent on health care would hit $4.3 trillion...Whatever a trillion is? I still can't fathom a billion of anything.) 

 We all should realize by now that this spending in the public sector, Medicare and Medicaid, will increase due to the first wave of Baby Boomers entering the Medicare system in 2011.  My 78 million peers, like the lemmings, are working their way toward the proverbial wall, and for those of you who will have to carry the load until we are wearing our wings, that is not a pretty financial picture. 

The same economists from CMS are predicting a decrease in reimbursements to physicians over the next several years while Home Health will likely grow faster than most other sectors except perhaps prescription drugs. 

What does it all mean?  We are spending more on health care in the United States than any industrialized country in the world and, truthfully, our overall age of death is significantly surpassed by many of those "spending less" countries.  How can that be?  Well, for one thing, we have 47 million uninsured citizens in this country and no one really knows how many illegal aliens. Why so many uninsured?  They don't vote.  The vast majority are young, single mothers with small children, and this does not take into consideration the illegal aliens who are also not insured. 

Back to the answer. . . prenatal care is inadequate and infant mortality in the United States is still an embarrassment.  A few of the countries that do better than us in the world in infant deaths per thousand are:  Australia, Austria, Canada, Czech Republic, Denmark, Finland, France, Germany, Greece, Ireland, Japan, South Korea, New Zealand, Norway, Portugal, Spain, Sweden Switzerland and the United Kingdom.  Hmmmmmm?  Could it be because we spend 30% of our annual health care dollars on the last thirty days of life, and less than 4% of our monies on preventative and wellness care? 

Of course, Hospice would be a tremendous help.  We could reduce expenditures on end of life care, properly care for our babies with the excess funds, and ensure that our uninsured are properly covered as well, but what politician is willing to touch that electric third rail of the electorial subway tracks? 

We could begin by putting in a network of sidewalks, bike trails, and walking trails.  We could actually walk once in a while and treat our bodies like a true temple, not the "Temple of Doom."

One of the least often heard issues revolving around these expenditures is the continuation of our archaic hospital system.  It is based on the acute care model, and the vast majority of our diseases are chronic.  We rush the victim to the hospital, patch them up, send them home and then rush them back again without any commitment to behavioral modification.  I have seen individuals reverse their heart disease from diet, exercise, and stress management.  Why can't we embrace this concept, reward these activities, and change our society?  The millions of bicycles in Europe are no accident. 

So, as I've quoted in some other blogs, "Change or Die," or just spend ourselves into oblivion as we attempt to prop up a system that should have gone out with the Industrial Revolution.  Good luck kids, your ole man needs you to keep working to cover my health insurance.   

Under Which Shell is the Pea?

It started in the fall of 2001. In fact, the official opening was about a month after 9/11.  The potential seemed limitless, and the future appeared to be incredibly bright.  We would start a research institute, discover a few cures, design some specific drugs or vaccines, collect some tissues and the money to support us could easily be garnered through intellectual property, patents, contracted services, and value added research.

The first challenge that appeared was the question mark?  "Windber?" They would say.  "Windber?" No matter if it was a potential hire, a potential lender or investor, a prominent scientist or a health care luminary.  "Windber?" They would say.  "What is Windber?"   "Where is Windber?"  Many of them spelled it Winder or Wimber, and the fact that the CEO was not an MD or a PhD made it all the more ominous to the traditionalists.  There were no major hits on Pub MED, and the only piece of information that was broadly recognized was that we were a DOD subcontracted research center.  I remember Dr. Dean Ornish saying, "What do you want from me?"  My response, "Help me take the question mark away from the word Windber."

Over the first few years, we traveled more than 200,000 air miles following leads that were produced from the Washington D.C. connections: Austin, Houston, Seattle, Miami, Boston, New York, San Jose, San Diego, Philadelphia, Las Vegas, Pittsburgh and Chicago to name a few.  We met with companies and scientists all over the United States and then Italy, England, The Netherlands, Germany, Nigeria, Serbia, Greece and Asia.  At one point, we counted over 200 organizations that "wanted to work with us," but, as we sorted the wheat from the chaff, we discovered that most of them either wanted to try to take OUR grants away, or just to leverage us to get to our grant sources.

During that time, we had several leaders go through our door: six to be precise.  From 2001 to 2007, we  attempted to stabilize the scientific and medical leadership role for the organization.  Some did not like the lack of cultural stimulation in Windber and refused to move here.  Others were intent on furthering their own careers by endearing themselves to our sponsors, while still others were just not comfortable with the culture that we were attempting to create.

Our original vision for WRI was to create a research center that was unlike any in the world.  As a former professional musician, it was my desire to not build a theater and fill it with individual stars, but to create an ensemble, an interdisciplinary team of genomics, proteomics, histopathology and biomedical informatics specialists; to have the highest quality, largest and most pristine regulated, tissue, blood and serum collection; to have one central data repository; to literally build Disney World for scientists with the newest and most comprehensive list of equipment they could ever need, and then to tie it all together with fiber lines that allowed nanosecond communications of huge quantities of data.  All of that would be wrapped around centers of clinical excellence that would help us advance our research by implementing/translating appropriate discoveries to the bedside almost immediately.

It was a dream that everyone now admits was, to say the least, bodacious, but it was ours.  At first we ran into resistance because the PhD's were trained to be individualists. What's the old saying?  There's no "I" in team.  Then we ran into problems because there was too much data to be analyzed in the data repository and created a new group to analyze that data.  Everyone had problems with the disconnect between Hospital Administrator and Academic, but things are getting better there on both sides, and what dream would be complete without huge challenges. 

We made numerous discoveries regarding the truth or dare  aspects of the world of science.  What was truth?  What was not?  What was replicable?  What was smoke?  What was for the good of the patient, and what was for the good of the individual scientist?  Just like the worlds of insurance, architecture, engineering, music or academia, there are always those who are better at wool pulling than reality, but that also goes with the territory.  In fact, the only thing that was consistent throughout all of this was our Principal Investigator, Dr. Craig Shriver.  He was our rock every day, week, month and year of this journey. 

Our greatest challenge has been that of working with the bureaucracy that controls our finances.  Generally, those within the bureaucracy are insensitive about timely distribution of finances, i.e., making payroll.  No one cares if the interpretation of a rule removes an entire family from your employ, or alters the future of science for all of mankind.  One of my most vivid memories was a discussion with a bureaucrat about the devastating consequences of a decision that was being made against our mission.  She looked at me and replied in a very cold hearted way, "We don't care about cures for cancer."  "This is about our interpretation of those words."

And so, eight years later, I can say with complete confidence that, like so many other systems at the national level, be it health care, science or government; It's broken, and change, comprehensive change is what is needed.  We must find ways to create the appropriately aligned incentives so that scientist are connected at the hip on all projects relating to the good of mankind.  Keeping the final ingredient to what may prove to be the secret sauce hidden in a computer is not acceptable.

We must also remove the aliquot syndrome and replace it with human interaction so that the scientist does not feel the lack of attachment to an anonymous human sample but instead looks that patient in the eye and realizes the intensity of the mission.  To save the life of a 37 year-old with a four year old child is not aliquot theory.  It is human to human.

We must find a way to move our research dollars away from pure basic science and toward big science.  We must reward our pharmaceutical companies to seek out vaccines and individual treatments, not just blockbuster drugs. 

We must find connecting links that make ensembles the future, not individuals.   

Finally, we must replicate the model of the Windber Research Institute because, with all of its challenges, I'm still convinced that it is years ahead of the other more traditional science models.  We study people.  We share our data.  We work in multi disciplinary teams.  We actually meet our patients and hear them speak about the challenges of their diseases.  We have MD's and PhD's working side by side.  Our goal is to move answers from the bench to the bedside as soon as possible.  We are passionate about our work and your lives. 

WRI in Windber, Pennsylvania, is on track to break the rules to find the discoveries that will change healthcare for our fellow man in ways that could only have been a dream just seven years ago.  Thank you to all of our dedicated scientists and employees.

The rest of you may consider joining us.   We're outside of that box where you live, and out here there is an entire universe of opportunity.  It just takes an ensemble to play the song.