This is only a test of the aggregator emailing all new postings to a mail list. If a person is subscribed to that mail list, the intent is that Radio emails the new posting to the mail list, which then emails the posting to all subscribers. ... Right now there are only two subscribers, Marc and myself.

Building Trust, by Flores and Solomon is a really good book. I rank it with The Wisdom of Insecurity, by Alan Watts as two of the most mind altering books I have read. Watts turned the conventional wisdom of insecurity on it's head, essentially showing that security or fixedness is closer to death and that insecurity or uncertainty is closer to life. When his wisdom sinks in, one comes to appreciate insecurity for what it is--the experience life-giving growth. On can then quit amplifying a certain amount of natural stress, by dropping the judgment that insecurity is bad.

Flores and Solomon turn broken trust and betrayal on their heads, as Watts did with insecurity. They allow one to see that trust and betrayal are sides of the same coin (one meaningless without the possibility of the other) and they also allow one to see that creating and rebuilding trust is the key act in creating a better and shared future. Without such acts of trusting and rebuilding of trust from moments of betrayal, no better future is possible. Trust is not a thing to be shattered. Trusting is a competency for all forward looking people to practice and learn--a verb, not a noun.

Below is a kind of relationship diagram that captures some of the ideas that filled my head as I read the book.

A friend of mine, Gervase Bushe, wrote a very useful book: Clear Leadership. The insights and framework are based upon his career as a professor and business consultant

Clear Leadership is full of practical and immediately useful mental models and advise. Organizations are beginning to use is as a framework for leadership training at all levels.

After reading this book, I created a mnemonic and drawing that help me keep a few of the book's key points in mind and handy for my use. I give them to you with Gervase's permission.

SOFTeNeD stories and maps.

Sensing--what is my body telling me? Am I poised for a fight, to flee, to hear, to learn, to have fun, etc.

Observing--what would others agree happened, what was objective, what data can we agree upon and share?

Feeling--awareness of feelings is very useful early on, as feeling color everything else.

experience, each person has a different one

Need (want)--what do I want to happen, what do I want in the way of agreements.

experience, our stories come from our experience, we can share these and ask others to share their's. Experience is subjective and has numerous aspects (SOFTND)

Do--what will I do and what will I agree to do?

This little graphic represents for me Gervase's four profound senses of self and matching sets of skills:

Appreciative self--the halos, understand what you and the other have done that you would like to see more of. It is a kind of "assets based" approach or "appreciative" approach and comes form the appreciative inquiry framework.

Aware self--the recursive loop, suggests that we spend time first going over the SOFTeNeD algorithm personally, before trying to tell others or ask others.

Descriptive self--the arrow from my mouth to the other's ear, suggests that I must describe my SOFTeNeD stories and maps to the other in an appreciative frame and expressing understanding that it is only my experience, not all facts.

Curious self--the arrow from the other's mouth to my ear, suggests that I must have skill in asking and hearing about their experiences and if possible their SOFTeNeD stories and maps. I try to hear in an appreciative frame.

It has been about a year since I read this book and I have not reviewed it for this post. I hope you will pick the book up and work with the concepts in it. We can all do our parts to reduce the "interpersonal mush" in our organizations and communities as well as at home.

 

I have gradually come to realize that I unconsciously make a binary choice each time I think or act. I get out of my bed either on the defensive side or the learning side.

I either start my day holding on to... you name it. Or, I start my day open, willing and interested in learning, being vulnerable, wrong, embarrassed, over worked, surprised, delighted...open to a different future than I had yesterday. I think that it is this almost unconscious step that determines what is possible and what happens.

This is a short and somewhat personal post. I doubt that it requires more explaination.

I am just trying to be more aware of that first step each morning and each moment.

A friend sent me a link to this poem. I pass it on to you. It is good and it rings true. It is by a doctor and more or less for doctors. But all may appreciate the sentiments.

A few lines:

"For the head will explain
      but the final common pathway is the heart
      whatever kingdom may come
For what matters finally is how the human spirit is spent"

Click here. 

Healthcare is science, reason and caring. May none be missing.

PatientPowered.org wins award!

My invaluable assistant, Jill Hickok, told me about an NPR presentation on the use of story telling in medicine. We are trying to do something similar in Whatcom County to heighten the awareness and understanding of the relational aspects of medicine, especially chronic conditions.

We are coming to believe that among all the change and stresses of medicine the experience is loosing it's meaning for some providers and patients. Focusing on people and their stories is one way to combat the cynicism fostered by a broken or non-existent system of care. Most of us came into the profession because of a love people and a deep interest in people and their stories.

Here is a link to the NPR piece: http://www.npr.org/features/feature.php?wfId=1480863   (I hope their RealPlayer download works better for you than it did for me. May be a firewall issue. I will try it at home tonight.)

Here is a link to a piece on the physician that is spearheading the effort, Rita Charon, M.D., Ph.D.

http://litsite.alaska.edu/uaa/healing/medicine.html

Here is a link to a biosketch on Dr. Charon. http://www.medinfo.ufl.edu/other/histmed/charon.html

I hope to learn more about this approach.

 

I have heard Dr. Rachel Remen talk about the power of story telling.  I find stories more transformative than powerpoint and analytical data. Perhaps it is because they contain what we find most interesting and important--other people.

Here are links to her work: http://www.rachelremen.com/; http://www.meaninginmedicine.org/about_fmm.html; http://www.almanacnews.com/morgue/2000/2000_04_12.hfa.html.

"Great ideas come into the world as quietly as doves. Perhaps then , if we listen attentively we shall hear, among the uproar of empires and nations, the faint fluttering of wings, the gentle stirrings of life and hope. Some will say this hope lies in a nation; others in a man. I believe rather that it is awakened, revived, nourished by millions of solitary individuals whose deeds and works every day negate frontiers and the crudest implications of history. Each and every one, on the foundations of their own suffering and joy builds for all." --Albert Camus -

On June 9th 2001, on another site http://marpie.weblogs.com/2001/06/09 I posted the above quote from Albert Camus. I like it so much I am reposting it.

The Bureau of Primary Health Care has successfully jump started the 100% Access 0 Disparity movement in America. Spokane, WA area is implementing a similar approch.

There is a summary of the BPHC experience that is very enlightening, if you wish to switch from projects and programs to "movements". I highly recommend reading it if you need to scale up some initiative to include more stakeholders.

A remarkable overview of the journy and the liberating concepts is chronicaled by John Scanlon in "Extrordinary Results on National Goals: Networks and Partnerships in the Bureau of Primary Healht Care's 100%/0 Campaign". The PDF file can be downloaded from THIS LINK on IBM Center for The Business of Government site. The site section is "New Ways to Manage". I agree that it is a real revolutionary way to think about how to manage large scale change.

Several doctors at the WA State Medical Society meeting ask for more information on what Advanced Access is. So I put a web page together with some good references. Just click on "web page".

I am skeptical that rapid improvement can occur until most physicians have taken this step. It is a happy circumstance that their profit should increase about 9% and their number of visits should simultaneously decrease about 16%.

Yesterday I had the privilege of talking about our Pursuing Perfection initiative with the house of delegates for the Washington State Medical Society. Below I have included to content of my 11 slides and my notes.

PURSUING PERFECTION in Whatcom County, WA

SLIDE 1, TITLE SLIDE:

PURSUING PERFECTION

WHAT'S IN A NAME?

Perfection? ...when things seem pretty bleak. When the pace and complexity of practicing medicine is at this highest yet. When frustration or even cynicism seems ready to overwhelm many. But in a culture that takes the charge "first do no harm" seriously. A culture where each of us carries the desire and burden for faultless care with us each working moment. I suggest that  by admitting to ourselves and to the public that we are all in the pursuit of perfect care may allow each of us to get some help. As the Chasm Report points out, the problem is with the system. The system that should help us do the right thing. The problem is not with the effort of doctors and nurses nor with a lack of desire or to do the right thing. The pursuit of perfect care leads directly into systems thinking.

SLIDE 2, OUR JOURNEY

• 1990 vision
• Persistence
• Access for uninsured, level 2 trauma system, seamless care?, Whatcom Integrated Delivery System, Community Health Record, Whatcom Health Information Network, Whatcom Community Health Improvement Consortium, diabetes collaborative, registry system
• IOM: To Err is Human & Quality Chasm
• Pursuing Perfection, Robert Wood Johnson Foundation & Institute for Healthcare Improvement, +16 others

Like many of your communities, cooperation has a long history in the community. Community wide efforts developed access for under-insured OB patients and others including dental patients. The community developed a common sense, yet bold vision to have seamless care and the best outcomes in the state within 10 years (It will happen but it will take 20 years. Who knew?) A series of large-scale initiatives have occurred in Whatcom County. The most audacious effort may be the current P2 initiative to transform healthcare in our community and in the nation.

SLIDE 3, PARTNERS & FRIENDS LOCAL AND REGIONAL
This P2 initiative has caught the imagination of lots of folks.

• 3000 patients with diabetes & congestive heart failure
• Family Care Network
• SeaMar Clinic
• NorthCascade Cardiology
• SJH Center for Senior Health
• St. Joseph Hospital/PeaceHealth
• Group Health Cooperative
• Regence Blue Shield,
• Community Health Plans of Washington
• Olympic/Sterling/Aon

SLIDE 4, PARTNERS & FRIENDS NATIONAL & INTERNATIONAL

• NATIONALLY
• Cambridge Health Alliance,
• Cincinnati Children?s Medical Center,
• Tallahassee Memorial Hospital,
• Hackensack University Medical Center,
• HealthPartners,
• McLeod Medical Center, and
• Whatcom County coalition
  
• INTERNATIONALLY
• 8 communities in Great Britain,
• 1 in the Netherlands,
• 1 in Sweden

SLIDE 5, LEARNING

• Advanced Access
• Patient input into design
• We did not have to wait
• Collaboration among all sectors
• Leadership by physicians for collaboration

So, in this P2 initiative what have we learned to date: a year and a half into it? Doing Advanced Access, in primary care and specialty care, seems to me to be the only thing that can free up people and time to take on the work of redesigning the acute care system into one that provides chronic care. HealthPartners and Jonkoeping County, Sweden point to this conclusion. We have been working with Catherine Tantau, RN. Others have worked with Mark Murray, MD. Patients are of surprising help in redesigning care systems. Their insights are generally lead to simpler and cheaper solutions that we imagine on our own. We could have been doing this 5 years ago. Without working together little will occur. The innovations almost all require cooperation of others beyond your organization. Fortunately the benefits are that diffuse too. Physicians can lead their organizations into cooperation. It will not happen otherwise.

SLIDE 6, 80/20 SYSTEMS THINKING

• Baby boomer demographic bulge
• Chronic care in acute care system
• Winners and losers (modeled)
• Collaborators (relationships between parts on behalf of all stakeholders)

There are a lot of things we all consider doing. but which are the most important? The biggest problem and opportunity is heading our way--the aging baby boomers. Chronic care accounts for almost 80% of the healthcare costs and it is going to get higher. If we can effect this dynamic it will have more impact that almost any other change. (Possibly at the same or lower cost for a given population.) We have reviewed the literature on chronic care, we have worked with our patients and our physicians. We have designed a system for patient-centered, community-wide chronic care management. We have modeled the outcomes. We know who the winners and losers are likely to be. Nothing big will happen if the winners don?? help the losers. Medicare, pharmaceutical companies, employers, and taxpayers will need to rethink their roles if the benefits are to be gained and sustained.

SLIDE 7, SOLUTION SPACES

• Care management and managers
• Navigators and insider advocates for patients
• Activated informed patients
• Group visits
• Shared care plan  (electronic and paper versions)
• Advanced access
• Results based advocacy

Our approach combines community-based care managers (nurses). Improved access to information for patients with DM and CHF and for the members of their care team. There are group visits, web access to tailored information and to a personal medical record called the shared care plan. I now call our previous medical records business medical records, not patient medical records. The shared care plan may be a step toward a real patient medical record. None of the changes are manageable in physician offices or with physician staff until excess capacity for seeing patients and for improvement work is created. Advanced access has this great side effect. Modeling the effects of the changes and getting those affected to participate in the solution is essential. Otherwise it is not sustainable. Medicare (thus Congress), pharmaceutical companies, local businesses and government, and patients as purchasers and voters.

SLIDE 8, INTERESTED PARTIES

• Robert Wood Johnson Foundation
• Institute for Healthcare Improvement
• Medicare (CMS)
• Healthcare insurance companies
• Our community as well as other communities and healthcare organizations
• Other foundations

The work and learning going on in Whatcom County has captured the interest of numerous organizations and communities. Many of whom we are working with. There are now 17 communities or healthcare provider organizations. We are hoping to spread this to Ketchikan, AK. beginning this year. We hope to spread to more of the patients and providers in Whatcom County.

SLIDE 9, COOPERATION

• Necessity or preference?
• System? ...or only parts?
• How? or YES!
• Leaders?
  

Somehow we think this is optional, on an organizational level. We do cooperate as individuals. Our organizations must understand the experience of the patients and design and connect our processes so that they work as a system. Peter Block has written a book called The Answer to How? Is Yes! It is a kind of Nike "Just do it!" attitude. On can delay starting assuming the worst and endlessly asking how, rather than experimenting and working our way forward together, with the patients. A new kind of leader is needed--courageous in collaboration, not in war.

SLIDE 10, MORE?

• http://www.patientpowered.org
• http://www.wwpp.org
• http://www.Google.com "Marc Pierson"
• Call Marc 360 756-6805
• http://www.ihi.org
• http://www.qualityhealthcare.org

You may find the details and the tools at these websites. Do feel free to contact me. I put some of what I think on my web log, as do many of the people working in this endeavor.

SLIDE 11, PARTNERS?

• Already down this road?
• Learn together?
• Tipping points?

The Institute for Halthcare Improvement is attempting to spread the learning from Pursuing Perfection communities.
We have time for those who want to transform healthcare locally, in their communities.

Thank you for your time and attention.

When we began the Pursuing Perfection journey with IHI and Robert Wood Johnson foundation, IDX leadership started that journey with us, traveling to Boston and meeting with all the participants.

Today we had the good fortune to meet Mark Leavitt, MD, an internist who started Medicalogic company and developed the ambulatory medical record Logician.

I must say that the similarity of vision that among Mark, Malcolm Gleser, (founder of Phamis--now IDX LastWord and CareCast), and this community is remarkable. Kindred spirits.

In an complex environment of medical information software and mal-aligned economic incentives for connecting and deploying electronic medical records--this alignment of vision and value is cause for hope and continued collaboration.

Mike Raymer, head of LastWord division of IDX, joined us for discussions with patients and several of the participants in Pursuing Perfection in Whatcom County, WA.

I hope to report on opportunities that arise from our common vision and from a real intention to work together on the behalf of the patients in this community.

Let's hope.

Imagine this. You are asked to create a human body. You choose a hospital in California to create a gastrointestinal system,  a health system in New York to create a heart and blood vessels, a city in Vermont to create a brain, a hospital Iowa to create a peripheral nervous system, a group of hospitals in Illinois to create the lungs, etc., etc.

Enough. Some things can't be done separately, some can. Organic things typically cannot. Some complex things can be "componentized" and assembled, some things must interact to even come into existence.

Some people at the Robert Wood Johnson Foundation read the Institute of Medicine Report, Crossing the Quality Chasm and ask organizations to make proposals to radically improve American health care.

Experienced people in organizations in Whatcom County took the request very seriously. We had the same hopes and desires and we had been working separately and collectively for the same goal for more than ten years.

With much thought and discussion and in collaboration with patients we developed a radical plan for a radical change--no individual piece of it was radical, it was the understanding that it all had to be done together that was radical. To extend the analogy started above, we understand the we needed a small GI system, a small cardiovascular system, a small nervous system, etc. for any of it to work. And that with all the essential systems working to support each other they could grow together to a mature effective health system of care--better than anything in existence.

We have been at this for just over one year. It no longer seems unattainable. It is clearly attainable. What is difficult is getting all of this done in less than two years so that it is self-sustaining.

We are hopeful that some of the agencies and foundations that fund parallel, sequential, or distributed "demonstration" "projects" can see the difference here and fund an organic, systematic approach. Nothing less will create the radical transformation called for by the IOM Chasm Report and needed by the American public.

Reductionist approaches can do much. They cannot build an organism, not yet, perhaps never. Supporting the growth of a small, complete, organism (community health system) may be the right approach to radical transformation of US healthcare. We believe it is. Do you?

The minimum  essential small "parts" or "organ systems" that we have in Whatcom County, WA are:

1) direct patient involvement in all teams and in governance,
2) using evidence as the basis for care design,
3) starting with two chronic medical conditions[heart failure and congestive heart failure] and then moving to all others over a few years,
4) information systems designed and deployed so that everyone including the patient has the information that the patient wants them to have when and where they need it,
5) clinical office and hospital  work flow reconfituration so that the new work is integrated into the old and the old is made less frustrating and more efficient for everyone, and finally
6) modeling of the health care benefits and the economic impact on all of the stakeholders so that potential winners and losers can cooperate for the good of the patients and the whole community.

Link to Bellingham Herald Editorial

Link to more about program

Helping chronically ill manage care improves lives, cuts costs
HEALTH CARE: "Pursuing Perfection" program is so simple, it's brilliant.

The whole point of "managed care" started out, at least in theory, as an attempt to contain health-care costs through prevention. It's no secret that's not what happened. In fact, navigating the medical maze has become more difficult than ever, it seems.

But there is a solid movement afoot to change that and Whatcom County is one of the ground-zero sites for a program called "Pursuing Perfection: Raising the Bar for Healthcare Performance." Its method isn't complicated. It seeks to help people manage their own health care, sometimes by doing something as simple as regular telephone calls to check up on patients and answer their questions. By heading off potential problems, extensive and pricey hospital visits can often be avoided and a patient's health better maintained. It's so simple, it's brilliant.

The Whatcom Community Health Improvement Consortium last year was one of seven groups in the nation to win a $20.9 million grant from Robert Wood Johnson Foundation and the Institute for Healthcare Improvement that funds the program. It's not just some kind of feel-good program, either. The foundation wants to document measurable results in improvement of patients' access to care, patients' self-management and satisfaction, and a decrease in medical errors.

Caring for chronically ill people consumes as much as 70 percent of the nation's health-care dollars, so it makes sense that helping them manage their own conditions would reduce those costs and help those people lead more productive and less frustrating lives.

In Whatcom County, two of the most common chronic illnesses are diabetes and congestive heart failure. In 2000, St. Joseph Hospital had almost 700 admissions related to diabetes and almost 900 related to congestive heart failure.

Empowering patients with better information and better access to people who monitor their progress and can quickly answer questions can help keep many from becoming dangerously ill and compromising their health further. Medical advances happen quickly as new drugs are developed, more information is discovered about drug interactions and new technologies help people monitor their blood sugar. Keeping patients active in helping to make their own decisions will result in better outcomes. After all, who better to "manage" the care than the person living with the illness?

The Bellingham Herald, Whatcom County, ran a Sunday front page spread on Pursuing Perfection in Whatcom County, WA--Power to the Patient (the link to this edition lasts only two weeks)

Chronically ill patient finds a health-care advocate

(Original photo Unavaialbe at this time)

NEW OUTLOOK: The new Pursuing Perfection program aims to help chronically ill patients such as Keith Robinson, who suffers from diabetes, a heart condition and sleep disorders. MAME BURNS HERALD PHOTO

Balanced human interactions will make sense of some of the craziness that is US healthcare.

I would like you to read the very thoughtful and humane comments that Daniel Shurman makes. After a very difficult year he and his wife Bonnie have insights we should all reflect upon. There is nothing I can say that will add to his message.

Dan is responding to my post on Sunday, June 22, '03.

 

Wholism. Where is the patient in all of this?.

After reading the though provoking article Chronic Illness, Comorbidities, and the Need for Medical Generalism, by Kevin Grumbach, MD, in the first edition of Annals of Family Medicine. I had these thoughts:

The idea of non-reductionist thinking and wholistic planning is so important and so non-western. A reductionist nightmare.

Placing the patient at the center begins to make sense of things. I am not yet sure that we aren't trying to put the PCP at the center; even though that may move in the right direction in some cases.

With the help of Robert Wood Johnson Foundation, we in Whatcom County, WA are building a system to deliver "patient-centered, community-wide, chronic disease management" based upon Wagner's chronic care model. Even that model may be too physician centric. See my post.

Conidering the chaotic non-system and it's misaligned reimbursement, I am not sure that the overburdened PCP can help all the patients navigate. We are using nurse care coordinators Connie Golas and Nancy Stothard to assist, and we also use a patient centered/patient designed Shared Care Plan

I will follow your new journal with interest. As you poit out in the article, we should not be too self congratulatory. For even the best approaches in the US are very inadequate from the patient's perspective. See the Commonwealth Fund report (pdf)

A chasm exists. Any narrow focus on the parts, even the PCP role, risks a further Balkanization of US healthcare. We must focus on the patient and their family, we must include the patient in all the discussions. So long as the journals exclude patients from the dialogue they will miss an opportunity for truly integrative solutions. Even the PCPs may be a "specialists" compared to patients and their families.

Bertha Safford has shown the way to improve patient care as long as I have know her.

She helped shape the disease registry collaboration between Family Care Network and PeaceHealth.  She can clearly see her way across organizational boundaries in support of patient care. She goes for what is best for patients, not what is convenient for herself.

Here is a link to Washington' Doctor of the Year-County family doctor recognized by peers. (I don't know how long the Bellingham Herald keeps this archive links available.)

Group Visit for Heart Failure Patients Across Organizations. Click to read Terry Wagner's post.

Usually it takes a large organization to do this. I love seeing a community working together providing this patient centered care.

"Kudos to Erin Baumgart and Roland Trenouth ~ true pioneers. They piloted the First Heart Failure Group Visit across organizations (CSH and NCC) and did a wonderful job - the patients loved it and want to come back again! " ........

[Terry's Weblog]

If you want to have a public voice in health care innovation and improvement you can. Too few are being heard. Too few are taking a proactive positive approach. Join the discussion. 

Here are some testimonials and details about Radio the weblog tool that we use to create these web sites and web pages. One really nice recent addition is FM Radio, a user friendly place to write (and spell check) your material, as well as a great place to collect "news feeds" from other sources and review them.

http://radio.userland.com/

Whatcom's Pursuing Perfection weblogs mentioned in American Medical News.

Welcome to the blogosphere: A brave new world of Web dialogue  (CLICK here)

A growing number of physicians are sharing their thoughts and opinions on online diaries known as Web logs, or blogs.

By Bob Cook, AMNews staff. April 28, 2003.

 

A nice "editorial" was published by the Institute for Healthcare Improvement on Whatcom County's Purusing Perfection in healthcare.

It begins,

"The Synapse Between Silos (Link to the article)

Patient-Centered Care in Whatcom County

In the human nervous system, dendrites reach into the synapses between nerve centers to gather and deliver information needed to perform almost every living function. When these fluid routes of communication break down, the entire human body falters."