tom peters’ toward health ( care ) excellence ! version.23january2006

Tom Peters’ Toward

Health(care) Excellence!

Version.23January2006

Slides at …

tompeters.com

Health(care): Seven Main Messages1. Quality (Error reduction/ Evidence-based Medicine)2. “Healthcare” vs. “Health” (Wellness + Prevention)3. “Models of Excellence” available4. Life sciences (“Singularity”)5. Dubai as global/unique/“insanely great” “Center of Excellence”6. Avian flu7. Africa

Manifesto(s)

!!!!!!!!!!!!!

“Healthcare” vs “Health”

TP’s Healing & Wellness Manifesto2006(1) Acute-care facilities are “killing fields.” (WE KNOW WHAT TO DO.)(2) Shift the “community” focus 90 degrees (not 180, but not 25) from “fix it” to “prevent it.” (WE KNOW WHAT TO DO.)(3) There are three primary aims for “all this”: Wellness-Healing-Health. (WE KNOW WHAT TO DO.)(4) I’m mad as hell and I’m not going to take it anymore. (I KNOW WHAT TO DO.)

Tom’s Rant2006

1. Hospital “quality control,” at least in the U.S.A., is a bad, bad joke: Depending on whose stats you believe, hospitals kill 100,000 or so of us a year—and wound many times that number. Finally, “they” are “getting around to” dealing with the issue. Well, thanks. And what is it we’ve been buying for our Trillion or so bucks a year? The fix is eminently do-able … which makes the condition even more intolerable. (“Disgrace” is far too kind a label for the “condition.” Who’s to blame? Just about everybody, starting with the docs who consider oversight from anyone other than fellow clan members to be unacceptable.)

2. The “system”—training, docs, insurance incentives, “culture,” “patients” themselves—is hopelessly-mindlessly-insanely (as I see it) skewed toward fixing things (e.g. me) that are broken—not preventing the problem in the first place and providing the Maintenance Tools necessary for a healthy lifestyle. Sure, bio-medicine will soon allow us to understand and deal with individual genetic pre-dispositions. (And hooray!) But take it from this 63-year old, decades of physical and psychological self-abuse can literally be reversed in relatively short order by an encompassing approach to life that can only be described as a “Passion for Wellness (and Well-being).” Patients—like me—are catching on in record numbers; but “the system” is highly resistant. (Again, the doctors are among the biggest sinners—no surprise, following years of acculturation as the “man-with-the-white-coat-who-will-now-miraculously-dispense-fix it-pills-and-surgical-incisions-for-you-the-unwashed.” (Come to think of it, maybe I’ll start wearing a White Coat to my doctor’s office—after all, I am the Professional-in-Charge when it comes to my Body & Soul. Right?)

BIGGEST DEAL OF

ALL

!!!!!!!!!!!!!

“Healthcare” vs “Health”

TP Recce #1:

Dubai Healthcare City to

Dubai Health City*

*Cleveland Clinic and Canyon Ranch

“Quality”:

COULD IT TRULY BE

THIS AWFUL?

“When I climb Mount Rainier I face less

risk of death than I’ll face on the operating table.” —Don Berwick, “Six Keys to Safer Hospitals: A Set of Simple

Precautions Could Prevent 100,000 Needless Deaths Every Year,” Newsweek (1212.2005)

CDC 1998: 90,000 killed and 2,000,000 injured

from hospital-caused drug errors & infections

HealthGrades/Denver:

195,000 hospital deaths per year in the U.S., 2000-2002 = 390 full jumbos/747s in the drink per year.Comments: “This should give you pause when you go to the hospital.” —Dr. Kenneth

Kizer, National Quality Forum. “There is little evidence that patient safety has improved in the last five years.” —Dr. Samantha Collier

Source: Boston Globe/07.27.04

Welcome to the Homer Simpson Hospital

a/k/a

The Killing Fields

1,000,000 “serious medication errors per year” …

“illegible handwriting, misplaced decimal points, and missed drug

interactions and allergies.”

Source: Wall Street Journal/Institute of Medicine

YE GADS! New England Journal of Medicine/ Harvard Medical Practice Study: 4% error rate (1 of 4 negligence). “Subsequent investigations around the country have confirmed the ubiquity of error.” “In one small study of how clinicians perform when

patients have a sudden cardiac arrest, 27 of 30 clinicians made an error in using the defibrillator.” Mistakes in administering drugs (1995 study) “average once every hospital

admission.” “Lucian Leape, medicine’s leading expert on error, points out that many other industries—whether the task is

manufacturing semiconductors or serving customers at the Ritz Carlton—simply wouldn’t countenance error rates like those in

hospitals.” —Complications, Atul Gawande

RAND (1998): 50%, appropriate preventive care. 60%,

recommended treatment, per medical studies, for chronic

conditions. 20% chronic care treatment that is wrong. 30% acute care treatment that is

wrong.

Various studies: 1 in 3, 1 in 5, 1 in 7, 1 in 20 patients “harmed by

treatment” Demanding Medical Excellence: Doctors and Accountability

in the Information Age, Michael Millenson

“In a disturbing 1991 study, 110 nurses of varying experience levels took a written

test of their ability to calculate medication doses. Eight out of 10 made calculation

mistakes at least 10% of the time,

while four out of 10 made mistakes 30% of

the time.”Demanding Medical Excellence: Doctors and Accountability


20%: not get prescriptions filled50%: use meds inconsistentlySource: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation

“In health care, geography is

destiny.”Source: Dartmouth Medical School 1996 report

Geography Is Destiny“Often all one must do to acquire a

disease is to enter a country where a disease is recognized—leaving the

country will either cure the malady or turn it into something else. … Blood pressure

considered treatably high in the United States might be considered normal in England; and the low blood

pressure treated with 85 drugs as well as hydrotherapy and spa treatments in Germany would entitle its sufferer to lower life insurance rates in the

United States.” – Lynn Payer, Medicine & Culture

Geography Is DestinyE.g.: Ft. Myers 4X Manhattan—back surgery. Newark 2X New Haven—

prostatectomy. Rapid City SD 34X Elyria OH—breast-conserving surgery. VT, ME, IA: 3X differences in hysterectomy

by age 70; 8X tonsillectomy; 4X prostatectomy Breast cancer screening: 4X NE, FL, MI vs. SE, SW. (Source: various)

“A healthcare delivery system characterized by idiosyncratic and often ill-informed judgments mustbe

restructured according to

evidence-based medical

practice.”Demanding Medical Excellence: Doctors and Accountability


“Without being disrespectful, I consider the U.S. healthcare delivery system the largest cottage industry

in the world. There are virtually no performance

measurements and no standards. Trying to measure

performance … is the next revolution in healthcare.”Richard Huber, former CEO, Aetna

“Practice variation is not caused by ‘bad’ or ‘ignorant’ doctors. Rather, it is a natural consequence

of a system that systematically tracks neither its processes nor its outcomes,

preferring to presume that good facilities, good intentions and good training lead automatically to good results. Providers

remain more comfortable with the habits of a guild, where each craftsman trusts his fellows, than with the

demands of the information age.”

Michael Millenson, Demanding Medical Excellence

“As unsettling as the prevalence of inappropriate care is the enormous amount of what can only be called

ignorant care. A surprising 85% of everyday medical treatments have never been scientifically

validated. … For instance, when family practitioners in Washington State were queried about treating a simple urinary tract infection, 82 physicians

came up with an extraordinary 137 strategies.”Demanding Medical Excellence: Doctors and Accountability


“Most physicians believe that diagnosis can’t be reduced to a set

of generalizations—to a ‘cookbook.’ … How often does my intuition lead me astray? The radical implication of the

Swedish study is that the individualized, intuitive approach that lies at the center of modern medicine is flawed—it causes more mistakes

than it prevents.” —Atul Gawande, Complications

Deep Blue Redux*: 2,240 EKGs … 1,120 heart attacks.

Hans Ohlin (50 yr old chief of coronary care, Univ of

Lund/SW) : 620. Lars Edenbrandt’s

software: 738.

*Only this time it matters!

Dr Larry Weed/POMR (“problem-oriented medical

record”)/Etc: “It’s impossible to keep up with the avalanche of knowledge. Therefore it’s essential to use a valid diagnostic-decision

aid like Larry’s” —Neil de Crescenzo, VP Global

Healthcare/IBM Consulting “There is no other profession that tries to operate in

the fashion we do. We go on hallucinating about what we can

do.” —Dr Charles Burger (using Weed’s software for 20 years)

Probable parole violations: Simple model (age, # of previous offenses, type of crime) beats M.D.

shrinks.

100 studies: Statistical formulas > Human

judgment. “In virtually all cases, statistical thinking equaled

or surpassed human judgment.” —Atul Gawande, Complications

PARADOX: Many, many formal case reviews …

failure to systematically/ systemically/ statistically

look at and act on evidence.Source: Complications, Atul Gawande

Genius Required?

Leapfrog Group:

CPOE/Computerized Physician Order Entry*ICU staffing by trained intensivists**EHR/Evidence-based Hospital Referral***

Source: HealthLeaders

The Benefits of … FOCUSED EXCELLENCE

Shouldice/Hernia Repair: 30-45 min, 1% recurrence.

Avg: 90 min, 10%-15% recurrence.

Source: Complications, Atul Gawande

About Time!

100,000 Lives Campaign*

*Don Berwick/Institute for Healthcare Improvement

“What’s your name? When’s your birthday?”

Hospitals Pay Appropriate Attention To Medical Errors

Yes ………………………………. 1%Aware and Trying Hard ……... 8%Aware But Tepid Response … 22%No ………………………………... 25%An Inexcusable Tragedy …….. 44%

Source: 12.2005 Poll/tompeters.com

Attention/ “Being There”:

Job One!

You = Your

Calendar

“You must be the change you

wish to see in the world.”

Gandhi

The Necessary

IS/Web REVOLUTION

We all live in Dell-Wal*Mart-

eBay-Google World!

We [almost] all live in

Dell-Wal*Mart-eBay-Google

World!

“Some grocery stores have better

technology than our hospitals and

clinics.” —Tommy Thompson, HHS Secretary

Source: Special Report on technology in healthcare, U.S. News & World Report (07.04)

Computerized Physician Order

Entry/CPOE: 5% of U.S.

hospitals

source: HealthLeaders/06.02

Henry Lowe, U. of Pitt. School of

Medicine: “Broadband, Internet-based,

‘multimedia’ electronic medical records”

Telemedicine: E.g. …

HANC* [Home Assisted Nursing Care]

*BP, ECG, pulse, temp, etc

Telemedicine …Reduces days/1000 patients and

physician visits for the chronically illDecreases costs of managing chronic

diseaseExpands service areas for providers

Reduces travel costs to and from medical ed seminars

Source: Douglas Goldstein, e-Healthcare

“Our entire facility is digital. No paper, no film, no medical records. Nothing. And it’s all integrated—from the lab to X-ray to records to physician order entry. Patients don’t have to wait for anything. The information from the physician’s office is

in registration and vice versa. The referring physician is immediately sent an email telling him his patient has shown up. … It’s wireless in-house. We have 800 notebook computers that are wireless. Physicians can walk around with a computer that’s

pre-programmed. If the physician wants, we’ll go out and wire their house so they can sit on the couch and connect to the

network. They can review a chart from 100 miles away.” —David Veillette, CEO, Indiana Heart Hospital (HealthLeaders/12.2002)

Health**vs Healthcare

Health

*vs Healthcare

“Sanitary revolution”: mortality in major cities

down 55% between 1850 and 1915

Source: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation

“Gwen [former healthcare exec] has wonderful health insurance and an abundance of healthcare. What Gwen does not have is

health. And there is nothing our health system can do to give it to her.” “The battle cry is always health, but in fact the struggle has always been over healthcare.” “For all its inspiring, high-

tech cures, medicine is just not very effective at curing our era’s

major killers.” “Medicine doesn’t do much chronic disease.” “When the most

common killers of our era are mostly incurable and our preventive treatments pretty feeble, you have to wonder about

medical care as a whole.” “There is a widely held view that medical care contributes little to health.” (John Bunker/ Journal of the

Royal College of Physicians)


Smoking, excess

drinking, lack of exercise, shitty diet:

40% of deaths


“Our mistake is not that we value medical care—but that

we have misunderstood what it can and cannot do.”


“Curve Shifting”Source: Tom Farley & Deborah Cohen,

Prescription for a Healthy Nation

“Bump into factor”: Extra-size portions, eat more. Higher %

shelf space snacks, more obesity. More liquor stores, more crime. High vs low fat: Japanese who

emigrate to U.S. suffer 3X increase in heart disease.


Context Change: The Most Powerful Force (??)

Wastebaskets: Japan v U.S.; Christchurch NZ v

Sydney AUS*

*“Broken windows”

+10: Sardinians, Adventists, Okinawans

Don’t smoke. Put family first. Be active every day. Keep socially engaged. Eat fruits, vegetables,

whole grains. [Other: nuts, red wine, pecorino cheese, small portions.]

Source: National Geographic (National Institute on Aging), November 2005

“An estimated 60 to 90 percent of doctor visits involve stress-related

complaints.” —Newsweek/09.27.2004

Wellness

“The ‘curative model’ narrowly focuses on the goal of cure. …

From many quarters comes evidence that the view of health

should be expanded to encompass mental, social and

spiritual well-being.” Institute for the Future

“Ontario To Split Health Ministry” —Headline/

Globe And Mail /06.05 (New ministry will focus on Prevention/

Wellness/Eldercare)

“Savior for the Sick”vs.

“Partner for Good Health”

Source: NPR

“Companies Step Up Wellness Efforts: Rising

health costs provide incentive to promote healthier employee

lifestyles” —headline/USA Today/08.05

“Prevention Program At Dow Chemical

Aims To Save Money” —IBD/08.05

Sprint/Overland Park KS: Slow elevators, distant parking lots with infrequent buses, “food

court” as “poorly” placed as possible, etc.

Source: New York Times

Tom’s Story

Obesity/-79(-36); BP (140-85 to 90-60); Blood sugar (180-

87); Blood chemistry (normal+); Cholesterol (140-

58); Metabolic rate/RMR (+250); Mental state

(dramatic improvement*)

“Fixes”Diet (eg small portions, slow down)

Extreme exercise!Meditation

Dietary supplementsNo alcohol

(Psychotropic meds/others reduced)(No work reduction)

Aging reversal!!!!

**Why wasn’t I “informed”

until age 59?

Determinants of Health

Access to care: 10%Genetics: 20%

Environment: 20%

Health Behaviors: 50%Source: Institute for the Future

Planetree: A Radical Model for New

Healthcare/Healing/Health/Wellness Excellence*

* “It” can be done!

“It was the goal of the Planetree Unit to help patients not only get well faster but also to

stay well longer.” —Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

“Much of our current healthcare is about curing.

Curing is good. But healing is spiritual, and healing is

better, because we can heal many people we cannot cure.” —Leland Kaiser, “Holistic Hospitals”

Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

The Nine Planetree Practices1. The Importance of Human Interaction2. Informing and Empowering Diverse Populations: Consumer Health Libraries and Patient Information3. Healing Partnerships: The importance of Including Friends and Family4. Nutrition: The Nurturing Aspect of Food5. Spirituality: Inner Resources for Healing6. Human Touch: The Essentials of Communicating Caring Through Massage7. Healing Arts: Nutrition for the Soul8. Integrating Complementary and Alternative Practices into Conventional Care9. Healing Environments: Architecture and Design Conducive to HealthSource: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

1. The Importance of Human Interaction

“There is a misconception that supportive interactions require more staff or more time and are therefore more costly.

Although labor costs are a substantial part of any hospital budget, the interactions themselves add nothing to the budget.

Kindness is free. Listening to patients or answering their questions costs nothing. It can be argued that negative interactions—alienating patients, being

non-responsive to their needs or limiting their sense of control—can be very costly. … Angry, frustrated or frightened patients may be combative, withdrawn and less cooperative—requiring

far more time than it would have taken to interact with them initially in a positive way.” —Putting Patients First, Susan

Frampton, Laura Gilpin, Patrick Charmel

Press Ganey Assoc/1999: 139,380 former patients from 225 hospitals

0 of top 15 factors determining Patient Satisfaction referred to patient’s health outcome

PS directly related to Staff Interaction

PS directly correlated with ES (Employee Satisfaction)


“Perhaps the simplest and most profound of all human interactions is KINDNESS. … But if it is so simple, it is surprising how

frequently it is absent from our healthcare environments. … Many staff members

report verbal ‘abuse’ by physicians, managers and coworkers.” —

Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

“Planetree is about human beings caring

for other human beings.” —Putting Patients First, Susan

Frampton, Laura Gilpin, Patrick Charmel (“Ladies and gentlemen serving ladies and gentlemen”—4S credo)

2. Informing and Empowering Diverse

Populations: Consumer Health Libraries and

Patient Information

Planetree Health Resources Center/1981Planetree Classification System

Consumer Health LibrariansVolunteers

Classes, lecturesHealth Fairs

Griffin’s Mobile Health Resource CenterOpen Chart Policy

Patient Progress NotesCare Coordination Conferences (Est goals, timetable,

etc.)


3. Healing Partnerships: The

Importance of Including

Friends and Family

“When hospital staff members are asked to list the attributes of the ‘perfect patient

and family,’ their response is usually a passive patient with no family.” —Putting

Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

The Patient-Family Experience

“Patients are stripped of control, their clothes are

taken away, they have little say over their schedule, and

they are deliberately separated from their family

and friends. Healthcare professionals control all of the information about their patients’ bodies and access

to the people who can answer questions and

connect them with helpful resources. Families are

treated more as intruders than loved ones.”

—Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

“Family members, close friends and ‘significant others’ can

have a far greater impact on patients’ experience of illness, and on their long-term health

and happiness, than any healthcare professional.” —Through

the Patient’s Eyes

“A 7-year follow-up of women diagnosed with breast cancer

showed that those who confided in at least one person in the 3

months after surgery had a 7-year survival rate of 72.4%, as

compared to 56.3% for those who didn’t have a confidant.”

Institute for the Future

Institute of Medicine/ “Crossing the Quality Chasm”

Respect for preferencesInvolvement in Decision Making

Access to careCoordination of care

Information and educationPhysical comfort

Emotional supportInvolvement of Friends and Family

Continuity of care


Care Partner Programs (IDs, discount meals, etc.)

Unrestricted visits (“Most Planetree hospitals have eliminated visiting restrictions altogether.”) (ER at one hospital “has a policy of never

separating the patient from the family, and there is no limitation on how many family members may be present.”)

Collaborative Care ConferencesClinical Guidelines Discussions

Family SpacesPet Visits (POP: Patients’ Own Pets)


4. Nutrition: The Nurturing Aspect

of Food

Meals are central eventsvs

“There, you’re fed.” *

*Irony: Focus on “nutrition” has reduced focus on “food” and “service”


KitchenBeautiful cutlery, plates, etc

Chef rep


“Aroma therapy” (eg “smell of baking cookies”)


5. Spirituality: Inner Resources for Healing

Spirituality: Meaning and Connectedness in Life

1. Connected to supportive and caring group2. Sense of mastery and control3. Make meaning out of disease/find meaning in suffering


6. Human Touch: The Essentials of Communicating

Caring Through Massage

“Massage is a powerful way to

communicate caring.” —Putting Patients First, Susan Frampton,

Laura Gilpin, Patrick Charmel

Mid-Columbia Medical Center/Center for Mind and Body

Massage for every patient scheduled for ambulatory surgery (“Go into surgery with a good attitude”)

Infant massageStaff massage (“caring for the caregivers”)

Healing environments: chemo!


7. Healing Arts: Nutrition for the Soul

Planetree: “Environment conducive to healing”

Color!Light!

Brilliance!Form!Art!

Music!Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

8. Integrating Complementary and

Alternative Practices into Conventional Care

Griffin IMC/Integrative Medicine Center

MassageAcupunctureMeditation

ChiropracticNutritional supplements

Aroma therapy


CAM (Complementary & Alternative Medicine):

83M in US (42%)CAM visits 243M, greater than to PCP (Primary Care

Physician) (With min insurance coverage)W-Educated-Hi inc

Don’t tell PCP (40%)And: <30% procedures used in conventional medicine

have undergone RCTs (randomized clinical trials)


Conclusion: Caring/Growth “Experience”

Care!Control!Connect! Engage!Grow!

De-stress!

9. Healing Environments: Architecture and

Design Conduciveto Health

“Planetree Look”

Woods and natural materialsIndirect lighting

Homelike settings

Goals: Welcome patients, friends and family … Value humans over technology .. Enable patients to participate in their care … Provide flexibility to

personalize the care of each patient … Encourage caregivers to be responsive to patients … Foster a

connection to nature and beauty


Access to nurses station:

“Happen to”vs

“Happen with”Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel

Learn more about Planetree/ The Planetree Alliance:

www.planetree.org

Life Sciences Revo Rocks Our World*

*Coming soon to a …

“On February 12, 2001, anyone with access to the Internet …

Could suddenly look at a new atlas …

One containing the whole human

genome.”

Source: Juan Enriquez, As The Future Catches You

“WE ARE BEGINNING TO ACQUIRE … DIRECT AND

DELIBERATE CONTROL … OVER THE EVOLUTION OF ALL LIFE FORMS …

ON THE PLANET.”Source: Juan Enriquez, As The Future Catches You

GRIN: Genetics, Robotics (nanotech),

Information, NanotechSource: Radical Evolution: The Promise and Peril of Enhancing Our Minds, Our Bodies—and What It Means to Be Human, Joel Garreau

“We face the biggest change in tens of thousands of years in what it means to

be human.” … “In just 20 years the boundary between fantasy and reality

will be rent asunder.” (Rodney Brooks, AIL/MIT) … “We are at an inflection point in history.”

… “It is about the defining cultural, social, and political issue of our age. It is about

human transformation.” Source: Radical Evolution: The Promise and Peril of Enhancing Our Minds,

Our Bodies—and What It Means to Be Human, Joel Garreau

Ray Kurzweil: “Singularity”

415-page doc, Department of Commerce/NSF: Converging Technologies for Increasing

Human Performance Source: Radical Evolution: The Promise and Peril of Enhancing Our Minds,

Our Bodies—and What It Means to Be Human, Joel Garreau

“Soldiers having no physical, physiological, or cognitive limitations will be key to survival and

operational dominance in the future.” —Michael Goldblatt, Director,

Defense Sciences Office/DARPA

Source: Radical Evolution: The Promise and Peril of Enhancing Our Minds, Our Bodies—and What It Means to Be Human, Joel Garreau

“Singularity”/“Bionic Tom,” circa 2006: Medtronic pacemaker (heart micro-

management) ; psychotropics (mental micro-management) ; Google (mind-extension—smart-

beyond-measure) ; Samsung cell phone (instant-permanent planetary connectedness) ;

Orvis shirt (“smart skin”)

“If you don’t like change, you’re going to like

irrelevance even less.” —General Eric Shinseki, Chief of Staff. U. S. Army

Kroll/SARS: “don’t over-react”Kroll/H5N1:

“devastating”Source: Newsweek/10.24.05

Health(care): Seven Main Messages1. Quality (Error reduction/ Evidence-based Medicine)2. “Healthcare” vs. “Health” (Wellness + Prevention)3. “Models of Excellence” available4. Life sciences (“Singularity”)5. Dubai as global/unique/“insanely great” “Center of Excellence”6. Avian flu7. Africa (Hats off to Bill & Melinda & Bono)

tom peters’ toward health ( care ) excellence ! version.23january2006

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