Putting a little Ritz in health care

Recently, I had an enlightening encounter with Horst Schulze, who led Ritz-Carlton Hotels to national awards and has since opened his own hotel chain, Capella. Hortz gave an informal presentation to members of a program that I’m taking part in, the Baldrige Executive Fellowship, and we continued to talk afterwards. Capella has five ultraluxury hotels from New York to Singapore, and all have been recognized as tops in their region. Horst spoke to us of a culture of excellence. He knows—he has built such a culture time and time again. Excellence does not occur by chance. It requires clear goals and a system.

Horst explained that to be great, everyone in the organization needs to know the goals, in order of importance. For Capella, the goals are 1) keep existing customers, 2) add new customers, and 3) optimize the spend of each customer. Every employee not only needs to know the goals, but they need to know the behaviors to achieve them. The Capella employees ensure a warm welcome, compliance with and anticipation of guests’ needs, and a fond farewell.

All employees are required to know service standards. Twenty-five of them. One of them states that you are responsible to identify and immediately correct defects before they affect a guest—for example, getting customers food when the restaurant is closed. Defect prevention is key to service excellence, just as it is to delivering safe health care. Another service standard states that when a guest encounters any difficulty, you are responsible to own it and resolve the problem to the guest’s complete satisfaction.

Capella has standard processes for everything—how to submit defects, how to resolve them. And they trained staff in the goals, the behaviors and the processes. Each hotel, every morning is required to have a huddle at which all staff attend. They review the goals for the company and read one of the behaviors, called service standards. Every day they read a different one. They cycle repeats every 25 days.

If a manager did not do this, Horst said, they would be fired.

Capella also had unique hiring process. Horst described how Capella did not hire people, they selected them. The difference may seem subtle, but it is vitally important. Capella employees were joining a cause to be the global leader in service business. The employees they selected were special, and they needed to feel it. The motto Horst used at Ritz and continues to use at Capella, is “Gentleman and ladies serving gentleman and ladies.” Horst wants his employees to take pride in their work.

Horst went on to tell me that health care talks a lot about safety culture and teamwork. Yet we mostly focus on how people feel, how well they collaborate, how well they like management. Teams, he said, require goals and need to be accountable toward realizing them. The whole purpose of a team is to achieve a goal. The idea of goals and accountability seems to be missing in health care.

I reflected on this discussion and explored what are the top goals in a health care delivery system. I believe they would be, in order of importance: 1) to eliminate preventable harm, 2) to optimize patient outcomes and experience, 3) to reduce unnecessary health care costs. Now, I know that caring for patients is a whole lot more complex than caring for hotel guests, even the most discriminating ones. Yet the concepts could apply and we could specify some expected behaviors. For example:

• We will ensure we meet the patient’s needs.
• We will always introduce ourselves on rounds and invite patients and family members to participate.
• We will ensure patients know how to care for themselves when they go home.
• We will always practice evidence-based medicine.
• We will treat our colleagues with respect and appreciate them.
• We will work collaboratively with other members of the care team
• We will be accountable to continuously improve
• We will greet patients with a smile
• We will act humbly.
• We will listen.

Imagine what health care could do for patients, if all employees knew our goals, if they had clear behaviors for achieving them, and if they got feedback on performance and were accountable for results. For one, staff on individual units would identify and learn from local defects so that harm did not reach patients. Units would have standards of service excellence and review their scores on patient satisfaction surveys. Managers whose units did not improve performance would be trained and ultimately removed if they continued to lag.

Excellence is a process. It requires clear goals that all staff must know. Let’s try setting clear goals in health care and ensure all staff know them.

Walter Unger, MD: Follicular unit hair transplantation

Most men develop early signs of male pattern baldness by the age of 40. However, few realize that modern hair transplant techniques can be extremely effective at halting the inevitable and more noticeable balding.

Dr. Walter Unger, Professor at Mt. Sinai School of Medicine in dermatology and full-time hair restoration expert discusses the modern technique called follicular unit hair transplantation. Older techniques that caused the infamous “doll’s head” look used large plugs of hair. He explains more in the video discussion below.

 

Comparing radiation leaks from major nuclear events

March 15, 2011

Now that the multiple nuclear reactors in Japan are in meltdown, possibly on the scale of Chernobyl in 1986, the key safety questions are “How will this radiation accident compare to other previously documented events, such as Chernobyl and Three Mile Island, and will the radiation cause cancer?”

Using reports from our US NCR and the United Nations BEIR VII report, we tabulated rough estimates of radiation exposure and compared them to the gold standard of data, the WW2 Atom-bomb survivor studies (BEIR). The long-term cohort studies of the survivors of Hiroshima and Nagasaki are the best medical data available to correlate cancer risks to exposure.

It is premature to estimate the radiation amounts being leaked from Japan, but given that there are at least four reactors melting down, it is safe to assume that the Japan disaster will be on par, if not worse, than Chernobyl. Chernobyl contaminated areas of Europe and thousands of miles away. Some areas were extremely high doses that were in cancer-causing range, but the average doses were not.

At this time, it is likely that radiation will reach Alaska and the continental U.S., but that the levels will be very low.

(click table to enlarge)

Thanks to Johns Hopkins Chief Medical Imaging Physicist Mahadevappa Mahesh, MS, PhD for contributing to this article

Jon Resar, MD: The PARTNER B trial

Interviewed by Steven Greer, MD

Dr. Jon Resar, Cath Lab Director for Johns Hopkins, discusses the PARTNER B cohort trial data and what this means for the field of TAVI. He comments on:

• Is it ethical to continue to randomize patients in TAVI trials to balloon valvuloplasty?
• Will the stroke rate become a problem as it has with carotid stenting in the general population?
• How can the vascular complications and bleeding be reduced?
• Why does the Sapien valve have a lower rate of post-implant heart block?

 

The new hybrid career as doctor/corporate-lobbyist

Update: February 22, 2012

An FDA advisory committee of doctors voted to approve the Vivus drug Qnexa despite the unknown risk to heart valves and know risk of birth defects. David Letterman’s doctor, Lou Aronne, internist and weight loss expert, had visited the FDA as a hybrid lobbyist/doctor.

Update: May 27, 2011

The Senate Finance Committee is investigating the conflicts of interests between medical societies and individual doctors paid millions of dollars by drug companies, who then double as lobbyists and petition the FDA for causes favoring the branded drugs. The Healthcare Channel was the first to recognize this as pure lobbying, in our April 29th story, below.

April 29, 2011

Steven Greer, MD for The Healthcare Channel

Medical societies have long been officially-registered lobbyist organizations with offices in Washington, DC. However, what seems to be an alarming new trend is now for individual doctors, receiving industry funding, to visit The Hill or The FDA to lobby on behalf of those companies’.

The Wall Street Journal reported that an epidemiologist, Emily Gower, PhD, of the Johns Hopkins Bloomberg School of Public Health, was funded by Roche/Genentech to create a retrospective study comparing the safety of Lucentis versus “generic” Avastin for the treatment of wet macular degeneration. This study was commissioned to offset the negative effects of the NIH-funded CATT trial that showed the much more expensive Lucentis, at an 8000% premium to Avastin, was no more effective and equally safe to Avastin. Dr. Gower’s study claims that Lucentis is safer, justifying the huge expense and $1.6 Billion in revenue to Roche.

According to the WSJ, Dr. Gower was taken along with Roche executives to The Hill to lobby for maintaining reimbursement of Lucentis in the wake of the CATT results. Roche characterized her discussions as “scientific” rather than lobbying.

Dr. Gower is yet to present or publish the aforementioned Roche-funded study. If she discussed these data and conclusions with anyone, including congress, CMS, or the FDA, it would be violating most medical journal and medical society rules.

Dr. Gower did not reply to our calls or emails.

Something similar to the Dr. Gower lobbying described above occurred in 2007 when Cleveland Clinic cardiologist Steve Nissen went to The Hill to push his agenda: that the diabetes drug made by GlaxoSmithKline, Avandia, was unsafe. Like Dr. Gower, he had a “smoking gun” white paper set to be published that concluded Avandia was unsafe, and he revealed the results to numerous groups prior to publication. This is according to some members of congress who questioned him before an oversight hearing.

More recently, David Letterman’s doctor, Lou Aronne, internist and weight loss expert based in Cornell’s New York Presbyterian Hospital, went to the FDA to lobby on behalf of several small struggling biotechnology companies that have suffered regulatory setbacks with their weight loss pills. Dr. Aronne has a lengthy list of financial disclosures indicating that he receives payments from the companies for which he was lobbying on their behalf (Orexigen, Vivus, Arena Pharmaceuticals).

As state and federal budgets are running with significant deficits, and the states unable to print money to survive as the federal government does, the lucrative funding from industry has become more powerful within state-funded medical centers. The biggest controversies twenty years ago might have been whether a doctor received too many free meals or trips from a healthcare company. Now, it seems that it is acceptable for active faculty members to double as paid lobbyists for the industries.

Julie Freischlag, MD: The general surgeon and female surgeon shortages

(In full screen 1080i HD)

Surgeon-in-Chief of Johns Hopkins Hospital, Dr. Julie Freischlag, explains how their program dramatically increased the percentage of female residents in the general surgery program. She also discusses the RUV reimbursement and other financial reasons for the overall shortage of general surgeons.

 

Thomas Smith, MD: Generic cancer drug shortages caused by private practice oncology economics

By Steven Greer, MD

The shortages of generic cancer drugs (and other injectable drugs) have reached such a critical level that President Obama issued an executive order on October 31 for the FDA and DOJ to take action. Thomas Smith, MD, the Director of Palliative Medicine at the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center published an essay in the NEJM focusing on how private practice oncology economics create a perverse incentive to use the most expensive cancer drugs even when cheap generic alternatives exist.

Medicare and private insurance allow oncology offices to charge a 6% markup over their drug acquisition costs. Therefore, a 6% of a $5,000 drug is far better for the oncology group than 6% of a $100 generic drug.

In many cases, the generic cancer drugs are so inexpensive, that the 6% markup does not cover the overhead expenses. As a result, the demand for the drugs plummeted, and the suppliers stopped producing the drugs.

In Part 2, Dr. Smith discusses some possible policy changes that would solve the problem. He mentions how oncologists in large cancer centers like his are paid a salary, obviating these financial pressures to use the most expensive drug. He also suggests payment systems similar to in-patient DRG’s for outpatient cancer care.

Medical imaging is more dangerous than the Japan or Chernobyl accidents

Update April 20, 2011

The NEJM has a paper out about the clinical effects of radiation fallout from nuclear reactor accidents. Our previous work below is consistent with their findings. Our table, below, is similar to the NEJM table 2 on page 5. It required finding data from obscure Chernobyl reports and WW2 A-bomb studies.

The importance of those charts is that one can now judge how bad or not is the Japan crisis. Recently, reports from Japan were that one reactor was leaking more than 40 mSv per hour. People living near Chernobyl received less radiation than that, in total, over the entire period of exposure.

March 16, 2011

By Steven Greer, MD   The Healthcare Channel

The developing nuclear disaster in Japan is generating much press about radiation and cancer risks. CurrentMedicine.TV developed a condensed table comparing the radiation doses from Three Mile Island, Chernobyl, and common medical imaging studies. Astonishingly, many common medical imaging tests deliver doses of radiation far greater than doses received by populations around nuclear plant accidents.

If one were unfortunate enough to have been in the heavy fallout zones of the Russian Chernobyl accident in 1986, they would have received 17 to 31 mSv of radiation. However, if one undergoes a common cardiology procedure called PCI to unblock coronary arteries, they receive 15 mSv (see charts below). Even worse, a thallium “stress test”, a completely optional procedure, delivers 40 mSv: far more than the heaviest-hit areas of Chernobyl. Now, cardiology practices have purchased profit-generating “64-slice CT-scans” to be used as screening tests for coronary artery disease. These tests deliver up to 32 mSv.

Common chest CT-scans can also deliver 40 mSv, and patients often have repeat scans. At one New York Hospital, for example, it is routine on the cardiac surgery service to send a patient not awakening from CABG surgery to the head CT-scanner daily for medicolegal reasons. In the rare event that the patient had suffered a stroke, the hospital and doctor would be liable for not treating the hemorrhagic stroke. In fact, many CT-scans are performed for defensive medicine reasons, such as “rule out appendicitis” abdominal scans.

To determine the cancer risk from radiation exposure, scientists still have only the WW2 Hiroshima/Nagasaki survivor cohort data as the gold standard. The United Nations BEIR VII report is the bible of radiation risk. Most Japanese survivors of the atomic bombs received less than 100 mSv (or two cardiac stress tests). From the BEIR reports, we know that radiation doses of just 10mSv or more are now believed to be correlated with increased future cancer risks. Therefore, all of the medical imaging studies discussed above increase the risk of cancer down the road.

In addition to the dangerous nature of many medical imaging studies, this category of medical cost has ballooned to become one of the biggest costs to the Medicare/Medicaid and private insurance payers. MedPAC recently issued another report on this problem. These often-unnecessary procedures not only hurt your DNA but also your IRA (and federal deficit).

(Click on figures to enlarge.)

From the journal “Radiology”, Mahesh et al

Peter Pronovost, MD, PhD: The medical checklist concept to reduce adverse events

By Steven Greer, MD

(Viewable in full screen 1080iHD)

Dr. Peter Pronovost, Professor of anesthesiology and critical care at the Johns Hopkins Hospital, discusses his paradigm changing medical checklist concept that has greatly reduced adverse events in hospitals. Starting with reducing central line infections dramatically, the concept was expanded to reducing ventilator pneumonias and then to reducing mortality in the operating room.

Dr. Pronovost was named one of Time Magazine’s “Most Influential People in the World” and is a recipient of the MacArthur Foundation “Genius” award. Dr. Steven Greer took a tour of his ICU and discussed his advances.

 

Mahadevappa Mahesh, PhD: The cancer risk from CT scan exposure

Mahadevappa Mahesh, PhD, Chief Physicist at Johns Hopkins medical center, discusses the real increased risk of cancer from excessive amounts of radiation as delivered by certain modern CT scan procedures such as 64 slice coronary artery scans.