A long and fascinating read Big Med by Atul Gawande in The New Yorker
Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?
David Luz, regional manager for the eight Cheesecake Factories in the Boston recounts the story of his 78-year-old mother who had early Alzheimer's disease and required a caretaker at home….
"Getting her adequate medical care was, he said, a constant battle….“It is unbelievable to me that they would not manage this better,” Luz said. I asked him what he would do if he were the manager of a neurology unit or a cardiology clinic. “I don’t know anything about medicine,” he said. But when I pressed he thought for a moment, and said, “This is pretty obvious. I’m sure you already do it. But I’d study what the best people are doing, figure out how to standardize it, and then bring it to everyone to execute.”
John Wright, an orthopedic surgeon has spent the past 10 years in an experiment to standardize joint-replacement surgery
“Customization should be five per cent, not ninety-five per cent, of what we do,” he told me. A few years ago, he gathered a group of people from every specialty involved—surgery, anesthesia, nursing, physical therapy—to formulate a single default way of doing knee replacements. They examined every detail, arguing their way through their past experiences and whatever evidence they could find. Essentially, they did what Luz considered the obvious thing to do: they studied what the best people were doing, figured out how to standardize it, and then tried to get everyone to follow suit.
\Wright has become the hospital’s kitchen manager—not always a pleasant role. He told me that about half of the surgeons appreciate what he’s doing. The other half tolerate it at best. One or two have been outright hostile. But he has persevered, because he’s gratified by the results. The surgeons now use a single manufacturer for seventy-five per cent of their implants, giving the hospital bargaining power that has helped slash its knee-implant costs by half. And the start-to-finish standardization has led to vastly better outcomes. The distance patients can walk two days after surgery has increased from fifty-three to eighty-five feet. Nine out of ten could stand, walk, and climb at least a few stairs independently by the time of discharge. The amount of narcotic pain medications they required fell by a third. They could also leave the hospital nearly a full day earlier on average (which saved some two thousand dollars per patient).
My mother was one of the beneficiaries.
And we are seeing glimpses of this change. In my mother’s rehabilitation center, miles away from where her surgery was done, the physical therapists adhered to the exercise protocols that Dr. Wright’s knee factory had developed. He didn’t have a video command center, so he came out every other day to check on all the patients and make sure that the staff was following the program. My mother was sure she’d need a month in rehab, but she left in just a week, incurring a fraction of the costs she would have otherwise. She walked out the door using a cane. On her first day at home with me, she climbed two flights of stairs and walked around the block for exercise.
We’ve let health-care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous. The Cheesecake Factory model represents our best prospect for change.
A physician writes Before You Ditch The Hospital, Don't Forget To Do These 5 Things
The day we get to go home from the hospital after a surgery or sickness …[is] a major step from illness to recovery, but it is also a potential disaster for the ill-prepared.
Hospital stays are getting shorter every year and discharge doesn't occur when you are healed, but instead at a point where you can go to a less expensive location to recover. Most commonly, that place is your home. The only guaranteed aspect of your transition home is that it will not go as planned. You will be bombarded with more information than you can keep straight.
1. MEDICATIONS: It seems obvious, but this is the greatest source of confusion. …. You need to have your nurse or doctor carefully go over your old and new list [of medications] to make sure everyone is on the same page. Another tip: Only use one pharmacy, so that the pharmacist will have a record of all your medicines and can identify any potential problems. Have the hospital or pharmacy fax your final list of medications to your primary doctor. So often the doctor who takes care of you in the hospital is not the doctor who will follow you once you go home.
2. RED FLAGS:…Don't settle for the computer-generated form that the hospital hands out to patients. Ask your doctor for your specific condition's red flags. How much pain is too much pain? How long will it continue to hurt when you urinate? How much longer will I be coughing? Is there anything special that should make me run to the hospital, rather than call my doctor?
3. WHO TO CALL: Get the specific phone numbers of who to call if there is a problem. My wife had surgery on a Friday, so I asked the doctor for the name of who would be on call that weekend, and if he would let them know that we were out there. Make sure that someone at the hospital you are leaving lets your primary care doctor know that you are loose on the street. I always give patients a copy of their entire lab and x-ray reports to carry back to their main doctor. If they get into trouble before a scheduled appointment, then they have the critical information with them.
4. FOLLOW-UP: One of the main causes of readmission to the hospital is that the patient has not had appropriate follow-up after they leave the hospital. You may be told to see your regular doctor in 10 days, but when you call, they cannot see you for six weeks. Have the nurse or case manager at the hospital you are leaving call and make the appointment. Insist on it.
5. START A NOTEBOOK: . As a rule, when you come home from the hospital you have bundles of papers, some important and others destined for the recycling bin. Stick the important ones in a notebook or folder….. Take your notebook with you to each doctor's visit so you have a list of your medicines, doctor's names, laboratory results, and instructions all in one place.
If you cannot get all of these questions answered yourself, then assign one family member to be in charge of the process. It is our -- your healthcare providers' -- responsibility to make sure you get the information, but ultimately, it is going to be your responsibility to remember everything, and make sure you have all of your facts straight. Whether you believe it is fair or not, no one is going to organize all this for you -- it is your responsibility, and in your best interests, to get it together.
From the Art of Manliness, 13 Things a Man Should Keep in His Car
1. Fully charged cell phone.
2. Jumper cables.
4. Roadside flares/reflective triangle.
6. Warm blankets.
7. Ice scraper.
8. First aid kit. .
9. Water bottles.
10. Tow strap.
11. Folding shovel.
13. Portable air compressor.
I don't have 10-13, but I do have old paperback books just in case I'm stuck anywhere without anything to read.
Oh, and old running shoes just in case I'm wearing heels and for some reason have to take a hike.
And moisturizer with sunscreen.
And extra sunglasses.
And a nail file.
Harvard researchers report in the Boston Globe
Deaths and complications dropped by an astounding one-third when operating room doctors and nurses completed a simple safety checklist before, during, and after surgery, according to a study led by Harvard researchers.
The eight hospitals that participated in the international study collectively reduced complications during hospital stays from 11 percent of patients before they began using the checklist to 7 percent of patients when using the checklist. Deaths dropped from 1.5 percent of patients to 0.8 percent.
"It was beyond anything we expected," said Dr. Atul Gawande, senior author of the Harvard School of Public Health paper and a surgeon at Brigham and Women's Hospital. The impact of all the items on the checklist "put together seems to have produced these really remarkable results," he said.
Completing the checklist out loud as a team is crucial to uncovering lapses that lead to problems, said Dr. Alex Haynes of the Harvard School of Public Health, the lead author and a surgeon at Massachusetts General Hospital.
"Saying it verbally codifies things more than simply having one person check a box," Haynes said. It requires more attention, he said, and a greater sense of collective responsibility.
I posted The Art of Managing Extreme Complexity in the ICU over a year ago which excerpted chunks of Atul Gawande's article in the New Yorker.
One doctor looked at what happens when procedures are too complex to carry out reliably from memory alone by taking a page from pilot checklists.
Checklists help people with memory recall and make explicit the minimum, expected steps in complex processes.
What checklists do you use?
Too many people don't know how to go about Making the Most of Doctor Visits
Though medical information has never been more accessible to consumers, many patients still don't have the skills to talk to their doctors and cram all the questions they have about their health into a brief visit. They often ignore what they don't understand, or leave delicate but important issues to the end and then run out of time. So to help patients get answers, health-care officials are offering new discussion aids, providing sample questions patients can ask, and offering advice ranging from making a list of your drugs, to starting with the biggest questions first, to checking that a doctor has your lab results before going to an appointment.
Laura Landro who writes The Informed Patient column for The Wall Street Journal has put together some good practical tips.
1. Write down questions/issues for the doctor beforehand, in order of priority.
2. If it's a diagnostic visit, prepare a detailed list of symptoms
3. Bring a list of current medications and dosages.
4. Ask for decision-support aids, and print or reliable web-based information about condition and treatments.
5. Make sure before the visit that the doctor has received test results/reports from other labs or doctors.
6. If you're unsure whether you can effectively interact with the doctor, bring a family member or friend.
7. Take notes and/or ask the doctor if you can record the session for later review.
Engaged couples spend far more time planning their wedding than planning their marriage. No wonder post-bridal depression is so widespread. It's the things you don't know that can hurt you. Marriage Is Not Built on Surprises
Too often, people planning to marry don't ask some questions because they don't want to rock the boat.
Considering the time this has spent on the New York Time's most emailed stories, it's past time I resurrect an old draft to lay out Questions Couples Should Ask (Or Wish They Had) Before Marrying in the extended entry.
Readers pile in with more questions to ask on bended knee.
Earlier I've written about the financial questions engaged couples should ask in Money is a Life Skill.
Know what the single most destructive attitude in a marriage is.
Know that hard marriages can harden your arteries and arguments can dramatically slow wound healing. So you certainly need to know about the Care and Feeding of Husbands. The latter works well with Animal Training Techniques for Husbands.
Maybe you're just thinking about living together in which you should know the Four Myths About Living Together. Guys, the Case for Marriage shows that you will benefit financially, socially, sexually and have a better career when you make that commitment.
Above all, remember Love is not a feeling. Love is a doing. Do love.
1) Have we discussed whether or not to have children, and if the answer is yes, who is going to be the primary care giver?
2) Do we have a clear idea of each other’s financial obligations and goals, and do our ideas about spending and saving mesh?
3) Have we discussed our expectations for how the household will be maintained, and are we in agreement on who will manage the chores?
4) Have we fully disclosed our health histories, both physical and mental?
5) Is my partner affectionate to the degree that I expect?
6) Can we comfortably and openly discuss our sexual needs, preferences and fears?
7) Will there be a television in the bedroom?
8) Do we truly listen to each other and fairly consider one another’s ideas and complaints?
9) Have we reached a clear understanding of each other’s spiritual beliefs and needs, and have we discussed when and how our children will be exposed to religious/moral education?
10) Do we like and respect each other’s friends?
11) Do we value and respect each other’s parents, and is either of us concerned about whether the parents will interfere with the relationship?
12) What does my family do that annoys you?
13) Are there some things that you and I are NOT prepared to give up in the marriage?
14) If one of us were to be offered a career opportunity in a location far from the other’s family, are we prepared to move?
15) Does each of us feel fully confident in the other’s commitment to the marriage and believe that the bond can survive whatever challenges we may face?
When to-do lists become a business.
Recipething Organize your favorite recipes, tag them, share them with others.
Squirl is a site to catalog, organize and share your collectibles and track others
I've never found a planner that really suits me, so as soon as I get time, I'm trying out the do it yourself planner at DIYPlanner.
Collaborate on a to-do list with Tadalist.com, whoever does an item gets to check it off.
All of these from the Wall St Journal article The Way We List Now
Here's a handy checklist from my local Service Magic which connects homeowners to prescreened service professionals
Gutters and Downspouts
• Clean gutters and downspouts frequently throughout fall to prevent build up of leaves and other debris. Neglected gutters can lead to wood rot problems, pest infestations, wet basements, foundation damage and many other expensive complications.
• Be sure water is not coming down behind gutters and that all support brackets are securely in place.
• Check to ensure water drains properly and doesn't pool, which can cause damage to foundations, driveways, and walkways.
Windows and Doors
• Change summer screens to cool weather storm windows and doors.
• Inspect and repair any loose or damaged window or door frames.
• Install weather stripping or caulking around windows and doors to prevent drafts and lower heating bills.
• Clean and lubricate garage door hinges, rollers, and tracks and be sure screws are tight.
• Replace the filter in your furnace.
• Consider having a heating professional check your heating system to ensure optimal performance and discover minor problems before they turn into costly major repairs.
• Clean your ducts to better your heating system's efficiency as well as to reduce household dust and to provide relief to those with respiratory problems. Also check for air leakage especially around joints.
• Clean your thermostat's heat sensor, contact points, and contacts. Check accuracy and replace if necessary.
• Lubricate hot water heater's pump and motor. Bleed air from radiators or convectors.
• To prevent pipes freezing and bursting, ensure that the pipes, as well as the wall cavities where they reside, are well insulated.
• Be sure that you know how to locate and turn off the water shut-off valve in case pipes do freeze.
Chimney and Fireplace
• Call a professional in to inspect and clean your chimney. Fireplaces that are regularly used during the season should have an annual cleaning to prevent dangerous chimney fires.
• Test your fireplace flue for a tight seal when closed.
• Consider installing a carbon monoxide alarm near the fireplace and furnace.
• Be sure attic insulation doesn't cover ventilation vents in the eaves to prevent winter ice dams on the roof.
• Be sure ridge vents and vents at eaves are free of plants and debris.
• Check bird and rodent screens for attic vents to prevent any unwanted guests.
Landscape and Yardwork
• Although grass appears to stop growing in the fall, the roots are actually growing deeper to prepare for winter. Now is the best time to fertilize and reseed your lawn.
• Prune your trees and shrubs after the leaves turn to encourage healthy growth in the spring.
• Trim any tree limbs that are dangerously close to power lines or the roof of your house.
From Real Simple, what to do before you pack up to head out.
What would you add?
I'm going to add a category to this blog for checklists, some of my own and others I find on the web. I'm hoping that you good readers will make them even better.
Three Days Before...
Suspend mail and newspaper delivery. Contact the post office www.usps.com to hold your mail; you no longer have to do this in person. Do the same for your newspaper delivery. Or have a trusted neighbor collect mail, packages, and newspapers while you're away so they don't accumulate in front of the door, a sure sign you're not home.
One Day Before...
Set timers. To keep your house from sitting dark all evening, install plug-in timers ($4 to $10 each, Home Depot or Lowe's) on lamps in several rooms. Set them to turn on and off at different times. Consider putting a radio and a television on timers, too (use the same plug-in timer models).
Discard perishables. Don't return to a smelly refrigerator. Toss dairy products, cold cuts, and produce, or donate the food to a local shelter.
Adjust the refrigerator temperature. Make sure the thermostat isn't on the supercool setting. This will keep the refrigerator from blowing a circuit while you're away. A closed-up house can raise the kitchen temperature, thereby increasing a refrigerator's energy use by up to 50 percent in summer.
Three Hours Before...
Adjust shades and blinds. Leave them partially open so your house looks lived-in. You also want to be sure passersby can see that the lights are on at night.
Leave a car in the driveway. If you're taking yours with you, ask a neighbor to park her car there while you're away.
Set the air-conditioner. If you have central air-conditioning, raise your thermostat so that it's set about 10 degrees below the average outside temperature. But don't turn it off. Without the help of air-conditioning, mold and mildew can develop in houses in humid climates.
Unplug appliances. Your toaster, coffeemaker, dryer, radios, televisions, and phones not connected to an answering machine can be unplugged. You'll save electricity and also eliminate the risk of a power surge blowing out a machine.
Turn off water and gas. If you use gas, turn off the pilot light and shut down the water heater. Shut off the water to the dishwasher and the clothes washer, too; pressure surges while you're gone could otherwise burst a hose.
Empty trash cans. You don't want ants and flies feasting while you're away.
Fifteen Minutes Before...
Lock all doors and windows. Believe it or not, people often forget to lock their doors after loading up the car. If you have an attached garage, lock the inside door in addition to the garage door.