Jack F. Mancilla: P2-Aggregate

I could not have said it better. Mary Minniti's summary after the first month.. Reflection - Building a Healthcare System- The First Month (June 2002).

Hard to believe it has been a month since we hired 8 staff to support healthcare redesign across a community. 2 more individuals will join us this week and soon the final data analyst position will be filled. During this past month, we have built a cohesive team both excited and overwhelmed by the task ahead. Role clarification is an ongoing process. This is to be expected as roles have not existed quite like this before and the human dynamic of change and transition does not elude even the most talented and gifted staff. Passion about the vision of patient-centered has not waned. Some milestones achieved in the month include:

Identification of referral criteria for patients who need the services of a clinical care specialist, forms and the process of service have been developed. The first patients were referred last week! We are already making a difference in the lives of patients.
Development of a communication/document management website to post all work/documentas and teams that will implement the vision of a healthcare system across organizations is complete . This site will work in partnership with Radio. Feedback is welcome.
Began the data analysis of each organization's costs and payment for diabetes services in anticipation of Systems Dynamics modeling to occur this week. This has attracted the attention of Medicare Region 10 and congressional representatives. Opportunity to highlight this work because of the leadership of Mark Donaldson of Group Health Cooperative has resulted in an important meeting of the minds tomorrowl.
Networking and the building of relationships with the pilot sites has begun. Visits to Fernadale Family Medical Center and Center for Senior Health has introduced the project staff to clinic staff who everyday strive to make a positive difference in the lives of patients in Whatcom County.
Presentations have been made to community groups, hospital staff and a bi-weekly article called the Pursuing Perfection Corner has been launched in the St. Joseph Staff newsletter
A single medication list across the community is closer to reality due to the excellent work of a CHF Medication Team under the guidance of Carol Boston-Fleischauer. This team with 3 patients as full participants, retail pharmacy, and home health joined clinicans from the pilot sites to identifiy significant barriers to safety. They have made recommendations about first steps and implementation teams will begin the work of process improvement in this area.

.......and we have just begun!

[Mary Minniti's Site]

Stuck in the Patient Portal.

Patient portal... what to do and who to ask... that's the latest dilemma. In order to build the portal with a proper interface, questions need to be answered. In order for the questions to be answered, people need to be identified to be asking the questions of. Identifying the people likely requires understanding of the process and what might work into the natural course of things best. Questions such as the following are arising and possibly keeping development from moving forward:

Who has access to the portal?
Are there varying levels of access depending on who is accessing?
Which providers are given access?
Is the provider portal inter- or intranet based?
What is the process for assigning logins?
What support is provided and by whom?
What is the process for re-assigning lost passwords?
What is acceptable proof of identity to get re-assigned a lost password?
Are there legal implications to the decisions made surrounding any of these questions?

...and I'm certain there are plenty more. The real issue is identifying the who's and how's in getting questions such as these answered. Do we form a committee? If so, who resides on it? etc..... Perhaps this has already been thought out and a solution exists. If so, it's time to share those thoughts with Web Services (especially Michael Sheehan). Perhaps some of the Shared Care Plan Summit can be spent in discussion around this issue?

Here's some information Michael has shared about his vision of the portal will work:

Patient

Comes in from the Internet always

Initial registration will require staff process to validate

Patient will be linked to their Medical Manager number; LastWord Number if they have one; and any other clinic ID number used in the practice

Demographics that may be fairly detailed will be entered by the patient initially (assume that longer term there will be data moving between systems - lots of things to consider here)

This creates a Patient Portal that will evolve over time to include more and more patient specific information and eventually prompts

The patient will connect with a secure link connection and will see ONLY their information

For shared care plan - will be able to view, enter, and edit all information for them (we will need an audit trail)

Their will be education links that are specific to the patient's disease and in the longer term that will be segmented by things like learning style for the individual patient

Staff

Comes in from behind our firewall generally (this will be a good discussion to see how to handle staff - I assume that everyone will be on our network - something to confirm - Do we allow access to this over the Internet from home or if they are off-site for some reason)

Initial user name and password will need to be set up

Very limited user demographics entered

The security may evolve over time - initially I recommend that a staff member has access to the Shared Care Plan application and that they can access any patient that has a shared care plan - I really hope that we can keep this process simple

Staff person will need a look-up feature to access a patient and their care plan (audit trail on who they access)

Staff will be able to see the shared care plan in the same format as the patient

Staff can enter and edit information (audit trail)

Dialogue Proposal.

My favorite piece of Bohm, et al's Proposal on Dialogue is the final paragraph:

"The spirit of Dialogue is one of free play, a sort of collective dance of the mind that, nevertheless, has immense power and reveals coherent purpose. Once begun it becomes continuing adventure that can open the way to significant and creative change."

With our community on the verge of significant and creative change in the delivery of healthcare through Pursuing Perfection, and the health care 'system' so desperately in need of that change, it is essential that we engage in Dialogue to get us past our habits of repeating what we are used to saying, and defending what we think we want, to be open to creating something new. We need to explore our reactive thoughts, mistrust and fears together, and see whether they can be replaced with a new appreciation for our community partners' intent to do what is best for patients.

Dialogue for Transformation.

Please see Marc's post, and do contact me if you would like to join our Dialogue Group. Click on this link to view a short slide show which sets the stage for Dialogue.

Marc's Weblog. Notes from Marc Pierson before you read this proposal by David Bohm and others: This is proposal is kind of long and kind of technical and abstract. You may not like it or finish it. You may want to read at least the last section on dialogue in existing organizations. Dialogue itself is simple (if you join a group with some experience), immediately rewarding, and profoundly eye opening. You can read about it and/or just do it. In either case if you want to join our dialogue group in Whatcom County--if you are in healthcare or you are a patient or you are in a patient's support system--contact Lori Nichols (LNichols@hinet.org) for dates and times. The meetings are usually every other Wednesday from 1-3 PM. [WWPP]

Reflection - Building a Healthcare System- The First Month (June 2002).

Identification of referral criteria for patients who need the services of a clinical care specialist, forms and the process of service have been developed. The first patients were referred last week! We are already making a difference in the lives of patients.
Development of a communication/document management website to post all work/documentas and teams that will implement the vision of a healthcare system across organizations is complete . This site will work in partnership with Radio. Feedback is welcome.
Began the data analysis of each organization's costs and payment for diabetes services in anticipation of Systems Dynamics modeling to occur this week. This has attracted the attention of Medicare Region 10 and congressional representatives. Opportunity to highlight this work because of the leadership of Mark Donaldson of Group Health Cooperative has resulted in an important meeting of the minds tomorrowl.
Networking and the building of relationships with the pilot sites has begun. Visits to Fernadale Family Medical Center and Center for Senior Health has introduced the project staff to clinic staff who everyday strive to make a positive difference in the lives of patients in Whatcom County.
Presentations have been made to community groups, hospital staff and a bi-weekly article called the Pursuing Perfection Corner has been launched in the St. Joseph Staff newsletter
A single medication list across the community is closer to reality due to the excellent work of a CHF Medication Team under the guidance of Carol Boston-Fleischauer. This team with 3 patients as full participants, retail pharmacy, and home health joined clinicans from the pilot sites to identifiy significant barriers to safety. They have made recommendations about first steps and implementation teams will begin the work of process improvement in this area.

.......and we have just begun!

A Dialogue Proposal, David Bohm--Community, Realtionships and Shared Meaning. As we come to understand (admit?) that organizations are not very much like mechanical systems at all, how will we deal with the complex, adaptive nature of our organizations and create a better future? I think that a special kind of dialogue will be essential. Please read some of David Bohm's Proposal.

Suggestions for Directory on 7/14/02 by Jack F. Mancilla. Now that we are beginning to have a directory structure, our structure needs some content or directions. ... Are there any specific topics we should pursue under the WWPP banner? Our current directory is here ->Directory Then we can build our structure based on our interests and our focus. ... They can include anything we are interested in because we can just add another heading to the topic tree. For instance, I have started a WWPP weblogs source based on state. We can also have a WWPP weblogs source based on the realm of health care that the author is working in. ... Anything else?

Directories. Good weekend! You may, or may not have noticed a new sub-heading under the "Common Links" navigation area in the left-hand column of our site pages. ... If you do not see it in your pages yet, it is because those pages have not been "published" since I updated the "Common Links." In order to have that link added, just republish your weblog pages from the RadioUserland Program. The intent for "Directories" is to create a logical way of finding our contributors as we get larger. It also gives us a very good way to organize our sources of information. "Directories" is an outline that is housed on a single manila page. That makes it easy for us to have several people organize the outline.

Useful web links from Connie Golas' friend at CDC.

I have received some great gems of web sites from Gwen Hosey, a former colleague, who has just been assigned to the CDC to do population education re: DM and other diseases. She's offered us assistance and links to others involved in similar efforts. Hopefully all of us can use the references, but especially Annie and the web folk.

The Kaiser site was provided by Peg McClure and is another goldmine of info for both pts and providers.

http://kpcmi.org/

www.ihs.gov/medicalprograms/diabetes This is a resource directory and clinical practice guidelines for DM

www.aadenet.org Order professional resource material; comprehensive curriculum. (Gwen thinks this is the best site for this type of info)

www.ada.org Curriculums for pt education; also professional resources.

http://ndep.nih.gov/ National Diabetic Education Program (sponsored by NIH & CDC) to get current scientific based concepts into family practice more rapidly.

?!!? Information overload?!

Subscriptions. ....
General subscription capability will increase readership and feedback. I am looking for the ability for PeaceHealth employeesand HInet FCA users to subscribe to RSS feeds. Do we have that capability somewhere in our arsenal of web tools? This would allow us to dramatically limit the number of people who need Radio and increase the number of people who can listen in to the conversations and comment (without posting).

Yes Marc. We do. ... I am not certain about the actual software on a PC, but I am sure it is there, and probably for free. Click on the image and you will be refered to Ranchero.coms free rss newsreader.

Systems Dynamics Model, RWJF National Advisory Committee's comment. The "systems dynamics model" that you have built with two consultants is a breakthrough. This model would be of help to every Pursuing Perfection site, and gives a new tool to the industry for exploration of the "business case for improvement."

Of Islands and Bridges? The "Chasm" needs a matching metaphor..

How do we begin to see more clearly the importance of connections?

What mental models and physical models can help us see the connections and the connected actions that can link the parts and pieces of health care?

The Chasm report challenges us to focus on the separations and the need for linkages. The ten simple rules or ideas essential for crossing the chasm include: cooperation among clinicians, knowledge is shared and information flows freely, care is based on continuous healing relationships, the patient is the source of control, safety is a property of the system, transparency is necessary, needs are anticipated, and waste is continuously decreased.

Simple yet compelling metaphors are needed. Bridges may be such a simple strong image that can help us change the culture to focus on the gaps and barriers that prevent the system from working on the patient's behalf. These same gaps constantly frustrate and demoralize health care workers. Can we begin to see ourselves and our organizations as islands that the patient must get to and from? Our patients may be swimming in cold water between our islands. If we can see ourselves as islands then we may be able to begin to see the bridges, or land fills, or boats that can connect the patient to us and each of us to the other island that patients must navigate to and from. I believe that the patient frequently must carry the cargo from island to island, since it does not reliably get across the gulf or chasm consistently in any other way. How shall we assist our patients as the journey from our island to other islands?

General subscription capability will increase readership and feedback..

I am looking for the ability for PeaceHealth employeesand HInet users to subscribe to RSS feeds. Do we have that capability somewhere in our arsenal of web tools? This would allow us to dramatically limit the number of people who need Radio and increase the number of people who can listen in to the conversations and comment (without posting).

We know what would be required with MicroSoft products to get this capability.

I believe that following the Pursuing Perfection community and their communication across the community and the corporation will be enhanced by this "subscription" capability.

Presentation to Whatcom Coalition for Health Communites.

Today I made a presentation on Pursuing Perfection to the Whatcom Coalition for Health Communites. It was well recieved. I made 3 key points:

1) It is about SYSTEMS, specifically Complex Adaptive Systems. This is the new paradigm. The essential shift in perspective from parts to connections, from mechanical systems to adaptive systems.

2) PATIENTS must be at the center, of everything. This is the key to the successful design of a system of care that works and that can be funded.

3) COOPERATION among clinicians (teams, leadership) is the real frontier. Healthcare cannot be improved in any substantial way until we develop competencies in cooperating on the patients behalf to build the systems they need.

I gave everyone Berwick's Users' Manual to the Chasm Report and Plesk's appendix on Complex Adaptive Systems. I talked from this graphic of our project.

There was much discussion of "social capital" or the lack there of. More later.

Sharing the research we all paid for.

The Chronicle of Higher Education: 'Superarchives' Could Hold All Scholarly Output. Several colleges are now looking to share more of that work by building "institutional repositories" online and inviting their professors to upload copies of their research papers, data sets, and other work. The idea is to gather as much of the intellectual output of an institution as possible in an easy-to-search online collection. [Tomalak's Realm]

È Interesting article. Here's a taster:

Several colleges are now looking to share more of that work by building "institutional repositories" online and inviting their professors to upload copies of their research papers, data sets, and other work.

Some imagine a day when every research university gives its research away through the Web, allowing scholars and nonacademics to mine it for ideas and information.

Institutional repositories could create an alternative to journals, fans of the archives say.

Journal publishers, meanwhile, say that such repositories are unlikely to supplant their publications.

Journals, they argue, are still the best means of distributing and preserving research.

And even some of those supporting the new archives recognize the difficulty of getting professors to change their habits.

"We've had pretty serious interest in the system from about 30 major institutions," Ms.

What: Massachusetts Institute of Technology's project to develop a superarchive, as well as software tools for creating and maintaining the repository.

The tools will be offered to other colleges that want to use them.

When: DSpace has been under development for two years.

The university is testing it this summer, and plans to make the software available free to anyone in the fall, when the university will invite all professors at MIT to contribute to its archive.

What: Free software developed at the University of Southampton, in Britain, to help individual scholars, departments, or universities create archives of research papers online.

An updated version was released this year.

What: A series of "metadata" codes that librarians or others can attach to research papers to help search engines pull out desired information.

Universities are funded out of taxation. The fruits of their research should be made available to all, for the benefit of all.
[Curiouser and curiouser!]

Infectious Disease Expert Will Lead National Health Agency. Dr. Julie L. Gerberding, an infectious disease expert noted for her work against AIDS and anthrax, will be the next director of the federal Centers for Disease Control and Prevention. By Warren E. Leary. [New York Times: Health]

You Snooze You Win, Learning Study Reveals. You Snooze You Win, Learning Study Reveals [Scientific American]
You Snooze You Win, Learning Study Reveals Work-aholics take note: new research indicates that morning sleep and afternoon naps aid mental and physical learning. Scientists have known for some time that sleep can improve the brain[base ']s acquisition of new facts and skills, but its effect on previously learned knowledge was not known. To that end, two studies published this month in the journals Neuron and Nature Neuroscience suggest that snoozing can reverse "burnout" from information overload and improve motor skill development.

WWPP themes versions 1.0.3. Themes, one more time. There are new themes for both versions of our WWPP sites. Click on the title and go to the instructions page. At the bottom of the instructions page is a part of our instructions outline meant to help you upgrade your theme. That area has links for the new parts and instructions on how to protect and reinstall your personal ownerPicture.jpg

Heart Pump Saves Lives, and Raises Questions. Heart Pump Saves Lives, and Raises Questions. The F.D.A. is considering a heart pump for people too old or sick for a transplant. But who should get the $60,000 pumps? Who should pay for them? By Sheryl Gay Stolberg. [New York Times: Health]

Learning about Interdisciplinary Teams. Chronic Care and Geriatric Resources-Innovations.

Met with Ron Stock re: Learning about Interdisciplinary Teams in a Geriatric Outpatient Setting. He has discovered that change is most effective when you complete steps in the following order: 10 create a team culture- where people understand their roles. 2) Introduce evidence based protocols - change in practice 3) Redesign the work. Sounds like we're on the right track.

He also suggested there are some good resources about Acute Care of Elder program based on interdisciplinary teams. They are exploring these for the new hospital in Eugene. Maybe a direction to explore with St. Joseph's. The link is attached.

Opportunities to connect with others abound- Medicaid Case Mangement set for July 25th, Greenfield Site Visit July 29th, perhaps a Seattle presentation with CMS on Systems Dynamics Modeling/Simulation for July 15th. Life is full of possibilities.

[Mary Minniti's Radio Weblog] [Marc's Weblog]

Fossil Flora Suggest Rain Forest Once Flourished Where Colorado Now Burns..
Fossil Flora Suggest Rain Forest Once Flourished Where Colorado Now Burns [Scientific American]
Some 65 million years ago, a mass extinction of global proportions stamped out much of the earth[base ']s flora and fauna, perhaps most notably the dinosaurs. The fossil record indicates that worldwide species diversity did not recover from this catastrophic event for another 10 million years. It came as a surprise, then, when researchers recently discovered near Denver, Colo., remnants of an incredibly plant-rich rain forest dating to just 1.4 million years after the devastation. - DMNS/PAINTING BY JAN VRIESEN

LA Weekly: News: Health-System Meltdown. Health-System Meltdown A prescription for needless suffering and death by Marc B. Haefele King-Drew: Not worthy of life support (Photo by Slobodan Dimitrov) CAN HEALTH CARE FOR THE POOR AS IT NOW exists be saved in Los Angeles County? The answer looks like "no." Even the Department of Health Services' (DHS) usual strong supporters -- Supervisor Gloria Molina, for instance -- seem resigned to an "inevitable" downsizing that will make for longer lines at fewer facilities. Or as the Times quoted her, speaking of her own constituents: "They're just going to have to drive farther, wait longer."

Initial Radioland Voyage Radio Userland. Initial Radioland Voyage. Today Radioland becomes a communication link on activities related to Pursuing Perfection in Whatcom County. As Project Manager, I will link to activities and help create connections between many individuals who are making a new patient-centered healthcare delivery system a reality in Whatcom County, Washington. [Mary Minniti's Radio Weblog]

Progress and transparency.

Progress in information sharing, got Mary up and running with Radio, although she has not yet adopted the Radio theme. Facilitated posting of the project plan on the Pursuing Pefection Web see link in title. Scheduled to load Radio Monday on Annie Gort's pc.

Please let me know what you think about posting the error messages during this implementation phase. I consider it doing our part for transparency. Will continue to post meaningful text relative to installations in the interest of making this easier each time.

I am excited to participate in starting this new and exciting forum for sharing information as we forge bravely ahead with the transformation.

[Lori's site]

Two powerful ideas for pursuing perfection.

1) Patients truly at the center, "radical patientcentricity"

2) First design the healtcare system that is needed. Then and only then, design the payment system to support the idealized system design.

Too frequently we have tried to create as system through manipulation of the payment structures. That is like trying to make a marionette dance through strings held by puppeteers who can't see each other, can't see the marionnette and don't agree on the dance. Together we can get the dance steps right. This is the first order of business if we are to improve the patients' and providers' experience, and deliver the needed quility and value.
In our Pursing Perfection project will use group systems dynamics modeling and simulation to design the dance for a couple of chronic diseases first.

[Marc's Pursuing Perfection Weblog]

Better Medical Decisions, Not Higher Costs. Better Medical Decisions, Not Higher Costs By MILT FREUDENHEIM The Supreme Court ruled this month that states had the right to insist on an independent review for patients whose managed health care plans refused to pay for a treatment or drug prescribed by their doctor.

New Theme for WWPP. We have a new Theme for the WWPP group. To be a little more precise, we have two new themes, but they both look almost the same. We have a WWPP 1.0.2 theme to be used with Marc Barrots activeRenderer tool. Marc has his own site called S L A M. Check it out if you get the chance. We also have a WWPPflat 1.0.2 theme to be used without Marc's tool. They both can be reached through our new installation directions page. Link -> Instructions

Welcome the first two Members of our team.
We are moving along with the introduction of the WWPP theme to the first of our beta team. The first two are Marc Pierson's Pursuing Perfection and Lori Nichols' Site. Check out their sites. We should have four more this week. (Apologies to LORI ... That's Lori with an "I", Lori.)

Week three (for the old timers). What a team!.

Pursuing Perfection Team,

I just want to tell you all how impressed I am with the work you are doing. I include in "the work" the team building, the dealing with change and stress and remaining positive while not denying the difficulty. We have less than a month under our belts and look how far we've come together in pursuing perfection.

I hope each of you feel as privileged to work with the group as I do.

Thanks for being who you are and for keeping the patient in the center.

Here's my second try at showing you the shared care plan. This is the document that focuses providers and healthcare teams to support patients in self-management goals.

Opportunity to work together with Medicare on exploring payment restructure of healthcare presents itself in many ways. Monday, July 15,2001, a contingent of Pursuing Perfection stakeholders in Whatcom County spend time with them. Our agenda:

Welcome - Mark Donaldson 5 minutes

Introduction of those present and their role/why are they here- All 10 min

Quick summary of P2 in Bellingham- Marc 15 min

Systems Dynamics Overview and Demo- Gary Hirsch Jack Homer 1 hr

Key principles, steps of process, why they are important, relationshiip of cost, quality, issues of overuse and underuse affects the system, our work so far, , how this can help inform healthcare payment policy

Q& A and discussion on how by working together we can create a more robust simulation All 30 minutes

Outcomes: Shared knowledge, generate some interest in cooperation in this area

First Log Title. First log

The Depth of Chaos.

What a week and it's not over yet. It has been an exhausting challenge to absorb as much information as possible about who all the "players" are, what teams they are on and at what meetings/events they need to be at and when. It has been an amazing race given the time frame we had to work in and that it feels like everyone is on vacation right now. I think its finally starting to sink in. I have to keep reminding myself that I have only been here for the past three weeks.

Our schedule for the Systems Dynamic consultants should be out by tomorrow.

Our Discussion group now has RSS Feed. This is a link to our discussion group's RSS Feed. You will need to have Radio Userland running when you click on that link.

Subscribe to this and you will receive all the new postings to our discussion group in your Radio news aggregator. The first time you view your news feed you will see all the previous posts. Everytime after that, you will only see the newest posts. There will be a link in the news representation of the posting that will take you right to the post so you can respond.

Patient Education.

I met with Mary Minniti and Sharon Sheremeta today regarding patient education. A work team is to be formed with Sharon as the lead and me as the liason to P2. Our primary deliverables will be:
(1) Database of all current resources for patient education and evaluation of all resources for compatibility with the goals of P2.
(2) Spread of the IOM aims and rules - educate educators on this view and create a process for creating and evaluating educational materials that is consistent with these goals.
(3) Research and implementation of electronic education for patients (e.g. development of patient web sites)

I'm hopeful that we will be educating the patients and community on what this "new health care system" is that we're creating and provide information on how to navigate it most effectively and how to get the most out of it. I'm hoping we will successfully involve numerous patients in the process of creation.

Another arm of P2 beginning to reach out.

What is Dialogue?. We have started talking about Dialogue, a communication tool dedicated to learning Click on the title for a brief power point presentation of the concepts. For more on the topic, including perspectives of those in Whatcom County who have been practicing Dialogue for the last couple of years, see Lori's Stories...

What is Dialogue. We have started talking about Dialogue, a communication tool dedicated to learning Click on the title for a brief power point presentation of the concepts. For more on the topic, including perspectives of those in Whatcom County who have been practicing Dialogue for the last couple of years, see Lori's Stories...

Spell checker for Radio/IE?.

I haven't had time to check this out but I use a similar product on my Mac and it is useful. My readers would probably appreciate it since I really cannot spell, even if my life depended on it. And I'm not a great typist either.

Spelling checker for IE (and Radio!). To Answer Kate Z's Question!.

"I urge any serious bloggers out there who haven't tried ieSpell yet to go over to www.iespell.com and do so. Immediately! The newest version now provides support for rich edit tools (like Radio's for instance) as well as AOL and other IE based browsers. Worthy of a micro-donation for sure.

I'm going to suggest the possibility of user-defined short-cuts (or smart tags) to the author. It seems like the perfect tool to provide all those cross-system, bloggers like myself a way to maintain a central list of shortcuts." [...useless miscellany]

[The Shifted Librarian]

È Well spotted Jenny, downloading now....

[Curiouser and curiouser!]

A future enhancement to our WWPP.org Radio implementation?.

A little esoteric but I chose to post it on the my Home page as well as the Radio Category page, due to the low volume of Radio traffic at this poing.

This feature seems useful as more users particiapte. I hope that Jack Mancilla watches this one closely on our behalf.

Why TrackBack?.

More on TrackBack for KM. If Gammel and Mower both think there is something useful in TrackBack who am I to argue? I don't undersand it, but I'm open minded about it. [Blunt Force Trauma]

È I didn't get it at first either, and nor has everyone I've mentioned it to.

What makes TrackBack so important is, I think, the following:

Imagine that I read someone like Jon Udell (which I do) and I find an item of his particularly noteworthy or relevant to me. I post it from my news page and add some editorial content of my own.

But if, like me, you are a relatively new blogger then maybe very few people read my item and nobody bothers to click through to Jon's original. My item never appears in his list of referrers.

This means Jon, likely, will not know that it exists. We could imagine further that Jon would have liked to know what comments I made but he never gets the opportunity.

TrackBack addresses this problem. It allows me as the author of an item to "ping" the original during the act of publishing. This ping does not require someone to read my item and then click through to his. Simply by publishing he is notified that someone has referenced him.

I think this is a very powerful idea and will help to get new bloggers into the space. For those with interesting things to say the time to migrate from the fringe to the centre will be drastically reduced.

Gimme! Gimme! Gimme!

[Curiouser and curiouser!]

Radio Trial - give it a KICK!. I agree with Annie! ... It may be a little hard to open your mouth the first time, but let me tell you something. As soon as you start talkin, writing, posting, you will begin to have more to say. People will take what you say seriously. What you say, can make a difference. ... Besides that, you will start to enjoy it along with the rest of us.

Radio Trial - give it a KICK!.

We need to get more people posting consistently. I'm trying to convince Heather that she has worthwhile stuff to post, but, as you can see by her lack of NEWS, I haven't been successful. Perhaps we should begin a heated debate or an intense discussion, only to be continued via this format... something intriguing to get people more active and involved.

When we spread this, I think it will be very important to begin it by stimulating responses of new participants. Once you get rolling, it's much easier. The first post was definitely the most difficult. Perhaps we could prompt people for posts with questions? Maybe we could have some sort of dialogue session? Pass a "posting stick" rather than the talking stick? I know we're low on numbers, so perhaps these concerns are unwarrented. I'll keep my daily postings coming as promised, even if the are sparse in content as this one is =)

[Annie's Weblog]

I agree with Annie! ... It may be a little hard to open your mouth the first time, but let me tell you something. As soon as you start talkin, writing, posting, you will begin to have more to say. People will take what you say seriously. What you say, can make a difference. ... Besides that, you will start to enjoy it along with the rest of us.
Radio Trial - give it a KICK!.

[Annie's Weblog]

Presentation to Whatcom Coalition for Health Communites.

Today I made a presentation on Pursuing Perfection to the Whatcom Coalition for Health Communites. It was well recieved. I made 3 key points:

1) It is about SYSTEMS, specifically Complex Adaptive Systems. This is the new paradigm. The essential shift in perspective from parts to connections, from mechanical systems to adaptive systems.

2) PATIENTS must be at the center, of everything. This is the key to the successful design of a system of care that works and that can be funded.

I gave everyone Berwick's Users' Manual to the Chasm Report and Plesk's appendix on Complex Adaptive Systems. I talked from this graphic of our project.

There was much discussion of "social capital" or the lack there of. More later.

http://www.wwpp.org/users/0000002/images/PtCtr.jpg

Radio Trial - give it a KICK!.

Computer programs as patient. Or, Backup.. While I am thinking about it, I just thought I would pass along this little bit of information. A computer program is a complex bundle of instructions like a patient is a complex bundle of all kinds of things. Occasionally the patient needs surgery to remove something bad or to add something good like a new hip. We sometimes upgrade our software and, like surgery on a human, we must have all of our instruments and our team in place. ... Still, things go wrong. If something goes wrong with software upgrades, we are lucky, we only lose some information we have already set into the computer. We must minimize the effects of an upgrade gone wrong. Backup! Whenever we do something to the guts of our computers or our computers software. Backup! I am working on a Radio tool that will backup all the important parts of Radio automatically, but in the meantime it is a good idea to save a copy of your Radio folder, every once in a while. That means about once a week to me, AND right before you do surgery on your program.

Systems approach to a community's ACCESS to healthcare, a proposal by Gary Hirsch. I'm writing to summarize the approach that I suggested in our phone conversation.

The project we discussed will help to develop an initial, shared understanding of the problems concerning access to health care in Whatcom County. Merely listing the problems and their components is not enough. In examining these problems, we will use elements of the System Dynamics approach to understand the interrelationship of:

á the availability of physicians and other care providers,

á payment patterns and rates,

á the nature and volume of care delivered,

á consequences of that care for the health of the population,

á impact of health status on future demand for care,

á efforts to solve the problems such as physician recruiting, provision of alternative sources of care, demand reduction strategies, and changes in the nature of care that is delivered, and

á effects of all of the above on residents, providers, payors, and employers and responses of each of these groups to the problems.

A System Dynamics approach should be especially helpful because the situation in Whatcom County is not likely to remain static. These interrelationships have the potential for making problems worse over time and for thwarting attempts at solving the problems. For example, delays in receiving care because of limited physician availability may lead to patients having more serious health problems that increase the demand for care, create additional costs that stress individuals, employers, and payors, make existing health care resources even less adequate, and potentially drive overworked providers out of the community. Attempts to solve these problems such as recruiting more physicians may not succeed unless they are coordinated with changes in payment mechanisms and rates and the manner and efficiency with which care is delivered.

Jack Homer and I will work with a group of health care providers and other stakeholders to identify the nature of the problem and its key indicators. We will use System Dynamics diagramming techniques with the group to map causal factors that:

á Create and maintain the problems

á Produce consequences for community health status and costs to residents and employers

á Can help to provide remedies for the problems, and

á Potentially work against those remedies succeeding.

With the group and in analyses afterwards, we will use these maps to:

á Enumerate potential impacts of the problems on various stakeholders

á Identify data required for more extensive analysis and richer set of policy questions to be explored

á Identify potential remedies for the problems including some that might not have been apparent without taking this systemic view, and

á Examine how these remedies might interact and combinations likely to be most effective.

We would meet with the group one additional time to discuss and expand on these analyses and help think through next steps for the community. At this point, we will also be in a better position to determine the value of going further with the System Dynamics approach which could include the development of a simulation model to project the impact of various sets of remedies. The effort we are now proposing would be limited to mapping the causal factors and analyzing the implications of these maps as described above. The results will be preliminary in nature and provide a good context for further analysis and action.

We will limit the costs by "piggybacking" travel on work we are already doing in Bellingham on chronic illness. We will also be alert for potential overlaps between this project and the chronic illness effort in order to avoid any duplication. We estimate that the cost of the project I have outlined above would be in the range of $10,000-15,000 for consulting fees plus any extra travel costs such as extra meals and hotel nights and possibly a share of our air fare.

Please let me know if you have any questions or would like to discuss any aspects of the proposal further.

Sincerely yours, Gary Hirsch [gbhirsch@attbi.com]

Graphing Relationships, Specifically referrals from one web site to another, but look at the possibilities. TouchGraph GoogleBrowser.

3. TouchGraph GoogleBrowser V1.00 (12.1 points). touchgraph googlebrowser ... TouchGraph ... The TouchGraph GoogleBrowser [( blogdex : recent )]

È Interesting to look at but I'm not sure of the practical applications for this yet.

What does a visualization of these backlinks tell you?

Why is it useful to be able to visualize these particular networks?

Are there useful metrics that can be applied to give conrete information?

[Curiouser and curiouser!]

Communications/Transparency Workgroup, Boston, May 2--30, by Carol Boston-Fleischhauer.

Observations

1. many of us went to this; so my observations are less relevant

Bottomline, what did I commit to:1. Actually, nothing; however, I think I should continue to partner with Terri Rambosek (who Stu is delegating to handle alot of this transparency stufff), as the seven P2 attorneys start to have conversations with each other. I am meeting with Terri Rambosek next week on the transparency issue; more from the standpoint of information/communication/education; Jim Scott and I both believe we need to keep talking with the inhouse attorneys to help keep them abreast of what we are trying to do.........

Thats it for now; again, an exhilirating experience; clearly, these Learning Groups are taking on lives of their own; that in some ways will go beyond the immediate project goals P2; I feel we are in a lifetime journey with P2/IHI colleagues, dont you! In other words, when the first round of grant money goes away, we wont...

CBoston-Fleischhauer@PeaceHealth.org

Workforce Learning Group, Boston, May 2--30, by Carol Boston-Fleischhauer.

Observations

1. This group was focused initially on various frameworks (AHA, VHA, etc.) that are being published as to how to deal with workforce shortages.........I think some exchange of innnovative learning will come out of this group as organizations start to share what they are doing to recruit, retain, develop the workforce; but the discussion is just getting off the ground

2. As best practice ideas come forward, this is a good conduit of information to go to our project teams and to others internally; ie.., Judy Hodgson

Bottomline, what did I commit to:

1. I will be getting info from this group that I can pass along; altho, it is not nearly as structured as the Med process group

2. PLEASE NOTE HOWEVER; as a sidebar, I volunteered to bring together a new learning group; i.e; the Patient Care Executives of the "seven" P2 organizations. Maureen from IHI was supportive; and has agreed to facilitate with me; goal of this learning group is to have the patient care executives collectively understand the new models of care that all P2 organizations are developing and to address the INPATIENT care model/unit/role changes that we need to accomodate a continuum/or chronic care model approach. You have heard me say that we have spent some time thinking about these model changes for physicians, but much more work from patient care/nursing is still in order. So, given my background and personal interests, I have committed to helping IHI with this. I think this will engage nurse executives; as well as provide us with an opportunity to infuse new thinking about this back to Whatcom as well as to our other regions. Again, Maureen B from IHI was very enthusiastic; my plan is to do this in July, and I believe the outcomes of this thinking would flow nicely into the Care Model Team in Whatcom.

CBoston-Fleischhauer@PeaceHealth.org

Medication Process/Safety Learning Group, Boston, May 2--30, by Carol Boston-Fleischhauer.

Per your request, the following is what I "gleaned" and committed to from the P2 meeting in Boston; May 29-30th; according to the learning groups that I attended.

Observations:

1. Most of the P2 projects are clearly inpatient ADE tracking/ improvement focused. Exception is Children's Cincinnatti, and to a lesser extent, Tallahassee.

2. IHI staff persons leading this group clearly wish all P2 organizations to use their ADE Trigger tools; regardless of P2 project focus; some of P2 organizations currently use it thru the IHI quantum series, others do not.

3. Our focus on the continuum is viewed by P2 project organizations as fascinating and frankly, I think we are thinking far beyond where IHI is currently at........

Bottomline; what did I commit to:

1. I am part of this group's subteam on Ambulatory/Continuum Medication Process Improvement--it is us, Cincinnati Childrens and Sweden(!----yes, they have done some really interesting things...). Also to be included is San Diego Children's--one of the P2 12

2. I and Cincinnati Children's have volunteered to beta test the IHI Outpatient ADE Trigger Tool; given the broad implications of this tool for all of PeaceHealth; let alone the Whatcom project, I am prepared to dedicate some of my staff's time to this as part of the Peacehealth contribution---remember, I am hiring a pharmacist as part of my expanded team, and I think this focus would be terrific.......

3. I have already connected with San Diego Children's regarding med list reconciliation ideas in the community; and I am using this work as I continue to "feed" the ATP project for CHF med list reconciliation; which, by the way, is going along swimmingly..................

4. This Learning Group overall is highly jazzed, motivated, and agressive; I anticipate a fair amount of regular work that I will be a part of; and frankly, is great for all.......

CBoston-Fleischhauer@PeaceHealth.org