Driving While looking in the Rear View Mirror Saturday, Mar 1 2014 

Summer nights in Birmingham Alabama carry the humid burden of its journey through history which includes slavery, peonage, Jim Crow and the 1960 civil rights movement.

Birmingham was named one of the most dangerous cities in the USA just this week. Inequality and racism continue to rise over this city and my home state just as the green brown smoke lingered over the steel mills back in the 1950’s and 1960’s.

We have all seen the videos of Bull Connor, police dogs and water hoses that were unleashed on non-violent protesters which all culminated in the bombing and killing of four young girls a the 16th Street Baptist Church.

Dr. Alvin Poussiant, Black and White police officers of Birmingham gathered for a symposium at the University of Alabama Birmingham circa 1978. I was in the audience.

At that time, Birmingham led the nation in police shootings of Black men, for a mid-sized city. This one of the main reasons for the symposium.

During these presentations, the police officers gave their views of what should happen if they encountered a domestic (husband and wife) disturbance. A Black officer stated that he would attempt to de-escalate the situation with structured communication. The white police officer stated that he would use his shot gun and shoot the legs of the aggressors then attempt to communicate but that he would shoot both husband and wife if he had to. The audience recoiled from his words as if his bullets had penetrated us all. He was very stoic and matter of fact in his position. It was, after all, what he was trained to do. He went on to say that he would never hire a police officer who was afraid of black people and that he preferred to hire young rural white males who knew how to “handle” black people.

During this meeting, the Black officers gave us a set of instructions to follow if stopped by a white Birmingham police officer.

These are instructions are:

  1. Pull into a well-lighted area
  2. Roll the car window down just far enough to slip the officer your driver’s license
  3. Make no sudden moves
  4. Always say “yes sir”
  5. Keep both hands on the steering wheel at all times
  6. Look straight ahead and make no sudden moves

At the time, I lived in a place called Montevallo Gardens (MV). After two failed attempts to be admitted to medical school, I moved to Birmingham and Montevallo Gardens was close to the University of Alabama Birmingham (UAB) campus and affordable. MV was adjacent to a public housing community that was known as one of the toughest in Birmingham. It was not rare to hear gun fire in the night or witness fights in the parking lot. There were no sidewalks. The street lights did not work. I did not live in fear for where I lived. As long as I minded my business and showed respect for everyone around me I felt safe. I was enrolled in classes at UAB and working 330 AM until 930 as a pre-loader at the UPS center in Homewood Alabama. UPS was a twenty minute drive from where I lived and I typically left my apartment at 3 AM.

One morning, in mid-July, I left my apartment as usual. My route took me onto a very dark street that lead to a major intersection. One morning as I proceeded through the intersection, the heavy moist darkness was interrupted by blue lights and a single squelch of a siren that surrounded my consciousness causing my pulse to prepare for the encounter. As I was approached on the driver’s side of my car, all of the rules that I was to flow began to drip from my lips in agonizing whispers.

The police officer asked me where I was going. I told him to work at UPS. He said “I do not believe you”. He told me that I had not come to a full stop at a stop sign and that was a violation. I said “yes sir”.

His reply was “yes sir what”? At that moment, I felt as if I were being watched by something else. I was frozen in place by the officer’s tone and his stance and his hand on his gun. I continued to sense something that felt uncomfortable so I took a very slow glance to my right.

Birmingham is very hot in July and the nights are weighted down with the humid anticipation of the next day. My old Toyota corona was not air conditioned, so my windows were all the way down until my consciousness was penetrated by the whirl of blue lights. Following my “how to survive” being stopped by the Birmingham police, I had rolled up my driver’s side window but not the passenger side window.

The uncomfortable sensation that I had felt was the other police officer who had approached the car from the passenger side. He was leaning into my vehicle with his side arm pointed at my head.

I asked the officer “what now”?

He said, I don’t believe you work at UPS. So, “we will follow you to work”.

They trailed me to the security shack at UPS and into the parking lot.

The officer again approached me and said, “we will be there waiting for you in the morning and we want to see you come to a full stop”. I replied “yes sir”.

On my third attempt, I was accepted into medical school and became the first Black Internal Medicine Chief Medical Resident at the St Louis University School of Medicine. My travels took me from Birmingham, to Atlanta, St. Louis, Huntsville Alabama, Washington DC and now Chicago. In all the places that I have been, I have noted that police cars almost all have these words emblazoned on the side, ‘to serve and protect”.

I have asked family and friends, all Black males, how they feel when they are driving and a police car is behind them or they pass a police car at an intersection. The responses are unanimous. We all feel a bit nervous and bit uneasy. We all look in the rear view mirror. These feelings retreat when the police car is no longer visible. The same occurs when I pass a police car that is sitting in place or is even traveling in the opposite directions. Over the years, I noticed that my son’s did the same thing.

To be clear, I am not disparaging law enforcement. Whether you are Black, Hispanic, mixed race, elderly, obese, LGBT, poor, or under-educated there is a visceral over regulation associated with how society reacts to you. Some have the courage to resist, fight, sit down or stand up. We hear the labels in some subtle and some not so subtle ways, like, over achiever, very formal, you speak good English, too academic, or as I have been “complimented” many times as being “different”. One patient even said to me that he would bet that I was accepted into med school on a special program and a quota. These encounters remind me of that dark night that I was stopped by the Birmingham police. These words tell me that I remain under some lingering suspicion or that i (we) a remain somehow illegitimate.

For over 40 years, I have lived my life looking in the rear view mirror. We look in the rear view mirror when driving, while practicing medicine, while seeking employment, applying for rent or a home loan, when at work, whether it is unskilled labor or in corporate America. It is time to stop looking in the rear view mirror. We need to see and know what is coming around the next turn in the road.

My choice has been to make the road as I go and leave all else behind. Every day I try to avoid looking in the rear view mirror, but I am not there yet.

-ron

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It is about the Patient’s Wednesday, Jan 1 2014 

Happy 2014.

Yes, i am back..at least for now.

The journey continues and the hope lives on. The Accountable Care Act lives! Lest we forget, the real name is not Obamacare but it it the Patient Protection and Accountable Care Act. The aim is value not volume. The goal is to remove “health care error” from the lexicon.

Latest estimate is that as as many as 440,000 preventable deaths occur annually in US Health care settings. That is the same as one jumbo jet crashing weekly.

Health care must become more reliable..as Don Berwick describes reliability. “Do not hurt me, make me better, no not make me wait and do not waste my time, do nothing to me without me”.

Yes, we can.

Ron

New Beginings Wednesday, Dec 29 2010 

Hi All.. Its been a while. After the IHI year, I returned to Madison Alabama from July-November.
After weeks of deliberating, my family and I decided to move on.
I was offered the position of Director of the Patient Safety Analysis Center at the Department of Defense.
While I am sad to lose my 4000 patients in Huntsville, I inherited 10 million with the DOD.
There is much work to be done in patient safety and I am elated to be with an organization with the aims and will to execute actions that will engage families and save lives.
As we start a new year, lets reflect on the past year with joy and delight and peace:

On Peace

“Peace demands the most heroic labor and the most difficult sacrifice. It demands greater heroism than war. It demands greater fidelity to the truth and a much more perfect purity of conscience.”

Thomas Merton

Happy New Year!
–Ron

The Road Ahead Friday, Jun 18 2010 

I know it has been a while since I updated this blog. This is, sadly, my last entry.

My year as a fellow at IHI has come to a close. We had a fantastic end of year sponsors meeting that was highlighted by the IHI Fellow’s presentations as well as presentations by Don Berwick, Howard Hiatt and Julio Frenk (Dean Harvard School of Public Health).

Larry Johnston and Nate Richardson traveled here from Huntsville to participate in this end of year celebration and I extend my most heart felt thanks to them.

I will leave you with a favorite poem of mine and nothing more:

‘Traveler, there is no path.
The path is made by walking.

‘Traveller, the path is your tracks
And nothing more.
Traveller, there is no path
The path is made by walking.
By walking you make a path
And turning, you look back
At a way you will never tread again
Traveller, there is no road
Only wakes in the sea.

by Antonio Machado

The Conversation: Can We Talk? Monday, May 31 2010 

I was raised by my great aunt Mollie Cannon in Perry County Alabama. She died a few years ago of pneumonia. In the late 1980’s she began to show signs of dementia. Through the years, she had talked on and off about life and the end of life. One of her favorite saying was ” We got sick days coming..you just gotta to live”, and she lived! In the pre-dementia days Aunt Mollie made her end of life plans clear to all of us( my brother and two sisters). She had a peaceful transition. We celebrated her life and times with joy and gratitude.

A few weeks ago, I was privileged to take part in a gathering of end of life experts. Noted journalist Ellen Goodman was instrumental in bringing the distinguished  group together at IHI (Institute for Health Care Improvement). I was honored to share a table with Joanne Lynn MD, author of “Handbook for Mortals”. The purpose of this gathering organize a  coalition of experts in the field to begin a nation wide movement to encourage “The  Conversation” about end of life. Handbooks for Mortals can be found free on-line at:

http://www.growthhouse.org/educate/flash/mortals/layouts/frameset1.html

This is an excerpt for Chapter 10 of Handbook for Mortals:

“How can you get started? First, think in very general terms. Do you want every possible treatment tried, even when it involves mechanical support for body functions, or even when it is not likely to work? Do you want to die at home, even if doing that means not having a way to get some treatments? Have you talked with your family about the kind of care you want? Does your physician know how you feel? Many of us don’t take the time to figure out our wishes and hopes for the end of our lives. Others write living wills, but don’t tell anyone what they really want that document to accomplish. These conversations are an important part of living and dying well with a serious illness.”

Below are nine important issues to discuss with family, loved ones and health care providers as you make end-of-life decisions.

Talking about these issues may be difficult, but it will help your loved ones decide what to do if you are not able to make these decisions yourself.

1.Your Choice of a Spokesperson. If you have designated a patient advocate or a spokesperson to express your wishes, make sure your loved ones and health care providers know who that person is, how to contact them and why you made that person your patient advocate.
2.Your Beliefs and Values. Talk about what makes life worth living to you, what would make it unbearable, and why.
3. Health Conditions. Explain how you feel about being kept alive if you are not able to speak for yourself.
4. Life-prolonging Treatments. How do you feel about life-prolonging treatments? Do you want them?
5. Your Vision of Dying. If you hope to die in a certain way—at home, in your sleep, free from pain—talk about it.
6. Organ and Tissue Donation. Discuss your wishes with family members. To register as an organ and tissue donor.
7. Funeral Arrangements. Share your thoughts about the type of service you would like to have and what you want to have done with your remains.
8. Documentation of Your Wishes. If you have completed an advance directive or other similar statement, make copies for your physician, your patient advocate, family members, friends and health care institutions. Carry with you the name and telephone number of your patient advocate.
9. How Others Should Use Your Advance Directive. Your instructions and personal statements can be understood either as specific instructions or general guidelines. You can help others interpret your wishes by including something like this in your document:
♦ “I would like the statements in my advance directive followed to the letter.”
♦ “I would like the statements in my advance directive to be used as a general guide.”
♦ “I want those statements that I have marked with a star (*) followed to the letter because I feel very strongly about them. Use the rest of my statements as a general guide.”

Adapted from the advance care planning workbook, “Your Life, Your Choices” and from the website http://www.completingalife.msu.edu.

I still miss those I loved who are no longer with me but I find I am grateful for having loved them. The gratitude has finally conquered the loss.

— Rita Mae Brown

Medical Loss Ratios = Quality…When Pigs Fly Sunday, May 16 2010 

My year as one of two George W. Merck Fellows at IHI will end June 30, 2010. This  has been a tremendous immersion in the science of quality improvement, attaining and honing leadership skills and having a front row seat to the re-framing of the US health care system to one that has more value as opposed to more volume (costs and revenue generation). We celebrate the beginnings of health reform with the beginning of health insurance reform. The aim remains to change the world. While writing this post, I am watching Ken Burns:  The Civil War, maybe no coincidence. The battles for health care reform are only warming up. This war will be fought on thousands of fronts.

Over the next half year, the health insurance industry will continue it’s attempts to out flank the law.

With the passage of the Affordable Care Act, the US health insurance lobby has rapidly focused on so called medical loss ratios:

effective Jan. 1,  the law requires that a minimum percentage of premium dollars be spent on true medical costs related to patient care — not retained by insurers as profits or used to cover administrative expenses. Insurers must refund money to consumers if they do not meet the standards, known as minimum loss ratios.

The definition of medical loss ratio is currently under construction by the insurance industry so that it can most benefit their interpretation of the law.

As reported by Robert Pear, in the New York Times (May16, 2010) Senator John D. Rockefeller IV, Democrat of West Virginia, said the definition would be just as important for consumers and small businesses.

“The health insurance industry has shifted its focus from opposing health care reform to influencing how the new law will be implemented,” he said.

The law requires insurers to spend a minimum percentage of premiums on health care services and “activities that improve health care quality” for patients.

Insurers are eager to classify as many expenses as possible in these categories, so they can meet the new test and avoid paying rebates to policyholders.

Thus, insurers are lobbying for a broad definition of quality improvement activities that would allow them to count spending on health information technology, nurse hot lines and efforts to prevent fraud. They also want to include the cost of reviewing care by doctors and hospitals, to determine if it was appropriate and followed clinical protocols.

Senator John Rockefeller is coming out as an opponent of attempts by Health Care insurance companies to define loss ratios in certain ways:

Insurers are to report the data this year, with a provision, stating anything over those amounts be returned to customers, taking effect Jan. 1, 2011.

Part of what the two groups are working on is the definition of what constitutes “medical costs” and what constitutes “administrative costs,” one of the concerns noted by Rockefeller in his letter.

“To the extent insurers try to invent ways to ‘game’ the minimum medical loss ratio requirement without changing their actual business practices, they are defeating the purpose of the medical loss ratio provision,” the senator wrote.

He added that this stipulation is “one of the most important events for consumers and small businesses” prior to the creation of health insurance exchanges in 2014.
Deceptive data

Rockefeller made two recommendations to both the NAIC and HHS in his letter: that minimum medical loss ratios be aggregated and reported in a way that benefits consumers, and that insurers be required to demonstrate that quality-improving expenditures actually benefit consumers.

Regarding reporting efforts, Rockefeller pointed out that medical loss ratio is reported differently among health insurers, using frequent target WellPoint as an example. The senator noted that there were not only a great deal of variation between different market segments, but variation within market segments.

As an example, Rockefeller used data submitted by the insurer to show an individual market medical loss ratio of 62.9% in New Hampshire through its Anthem subsidiary, while Maine’s Anthem reported a 95.2% ratio.

To solve this issue, Rockefeller proposes reporting medical loss ratio “at a level of aggregation that would allow consumers living in a particular state or other definable geographic region” to determine how insurers are spending their premiums.

“Aggregating this information at too high a level will present consumers with misleading averages of multiple, disparate markets,” Rockefeller said. “For the same reason, I also recommend that insurers provide separate medical loss ratio information for the individual, small and large group market segments.”

The new reform law adds to the definition of medical loss ratio a new accounting category for expenditures on activities “that improve health care quality,” that are not considered administrative expenses, but medical expenses that are included in the calculations of the 80% and 85% levels.
from http://ifawebnews.com/2010/05/12/rockefeller-extremely-concerned-over-medical-loss-ratio-mandate/

Sec. 10101(f) of the Affordable Care Act, concerning minimum loss ratios  will require:

Health insurers offering group or individual insurance coverage must submit an annual report to the Department of Health and Human Services for each group and individual coverage for each medical plan year. This report must describe the ratio of the incurred claims plus a loss adjustment expense to earned premiums, typically called a medical loss ratio.

Loss adjustment expenses usually include legal and other fees and expenses related to the settlement of an insurer’s claims. Earned premium in health care usually means the portion of a premium that has been “used up” during a policy term. With a one-year policy, half of the total premium has been earned after six months.

Reports also must be made for grandfathered plans.

The report must include the percentage of total premium revenue that such coverage expends on the following:

(1)      reimbursement for clinical services;

(2)      activities that improve health care quality; and

(3)      all other non-claims costs, including an explanation of the nature of such costs, but excluding Federal and State taxes and licensing or regulatory fees.

HHS is directed to make the reports available to the public on an HHS internet site.

Required minimum loss ratios. Minimum loss ratios are established for large group plans, small group plans, and individual plans:

The minimum loss ratio for large group plans is 85%, or a higher percentage if a state requires it.

The minimum loss ratio for individuals and small group plans (plans with 100 or fewer employees is 80%, or a higher percentage if a state requires it. HHS may adjust the percentage if it determines that an 80% loss ratio would destabilize the individual market.

Beginning no later than January 1, 2011, health insurers providing coverage that does not meet the minimum loss ratios must provide an annual rebate to each enrollee under such coverage, on a pro rata basis.

The annual rebate is calculated by multiplying the amount by which the coverage fails to meet the minimum loss ratio by the total amount of premium revenue. Premium revenue excludes federal and state taxes, licensing and regulatory fees, and payments or receipts for risk adjustments, risk corridors, and reinsurance.

Example

Quality First Insurance Company earns $1.5  million on premiums for coverage for Good Employer, Inc.’s 140 employees. Incurred claims plus a loss adjustment expense total $1.23 million, which results in a loss ratio of 82%. Assuming the earned premium already has excluded taxes, fees, and other adjustments, 3% is the amount by which the coverage fails to meet the minimum loss ratio by the total amount of premium revenue. That 3% is multiplied by $ 1.5 million, resulting in a total annual rebate of $45,000. This would produce an average pro rata rebate of $321.40 (45,000 divided by 140 employees) for each enrollee.

IT’S OUR MONEY

John Reichard of CQ HEALTHBEAT recently reported , an internal memo by an official with the America’s Health Insurance Plans (AHIP) says that various types of insurance company activities could be in jeopardy if regulators aren’t convinced that they should be designated as medical on the grounds that they improve quality of care.

“As we approach the May 14 deadline for submitting comments, it is critically important for you to explain what you are doing to improve quality of care, reduce readmissions, eliminate unnecessary procedures, improve safety and reduce fraud and abuse,” says the memo to AHIP member companies from AHIP Senior Vice President Scott Styles.

“We urge you to explain how these activities meet the statutory definition of “activities that improve health care quality” for purposes of calculating MLRs, “because they improve patient health outcomes and reduce unnecessary and potentially harmful care.”

The memo further advises that “you… describe your innovative case management, disease management, and care coordination initiatives including: health risk assessments, including maternity and neonatal risk assessment,” and programs to promote “wellness” and “nurse advice lines to help patients get the care they need while reducing the likelihood of adverse health problems.”

However, consumer activists say that some of these programs involve denial of care that harms patients and that it’s perverse to count them as medical care.

In a recent post on the website of Consumer Watchdog.org, the group’s research director, Judy Dugan, took exception to a recent earnings report by United HealthCare that credited good results in part to “expense management.”

“‘Strong expense management’ refers to the pencil-pushers in the back room whose job is to delay and deny the care your doctor prescribes,” Dugan blogged. “Delay is almost as profitable as denial. Every day a dollar is not spent is a day it earns interest for the company. Yet this is one of the functions that insurance companies are now transferring into the ‘medical care’ column.”

“By moving administrative jobs into the medical care category, United HealthCare will be able to meet health reform requirements for medical loss ratios of up to 85% without sweating, and still make just as much profit,” Dugan added. “A lot of what insurance companies can get away with will depend on how new regulations to govern the health care reforms are written — and who gets to write them.”

But AHIP spokesman Robert Zirkelbach said that insurers seek through their management programs to determine appropriate levels of care, which he said means correcting underuse of care in some instances and overuse in others that could be dangerous. He said for example that overuse of medical imaging is hazardous because of exposure to radiation that can be unsafe.

WHEN PIGS FLY !!!

Effective date. The provision is effective for plan years beginning on or after Sept. 23, 2010.

“We are here to make another world.”

W. Edwards Deming quote

Obesity-Who Is Responsible? Sunday, Apr 25 2010 

It is a cool overcast morning here in Boston. I set out on a walk this morning and after about 25 minutes, I was inside Whole Foods. Suddenly I was surrounded by a bouquet of fresh fruits and vegetables. I swirled through a constellation of healthy foods.  This 25 minute walk for me is a mere two day drive from Triana Alabama, Norwood Birmingham, Heiberger Perry County Alabama and the St. Thomas community in New Orleans. I have visited or been in contact with these communities over the last year.

While in Birmingham, I visited with an old friend, Sandral Hullett MD CEO Cooper Green Hospital, Joanice Thompson at the UAB Health Disparity Program and Sue Thompson with Bethesda Life Organization. We all share the same passion. We must work to end obesity in the Deep South. Joanice says if possible she would put fresh fruit and vegetable stands on as many Norwood or West End corners possible. Sandral told me that she has to drive 3.5 miles to get quality produce. Dr. Don Erwin and the Peoples Institute told me that people are dying in New Orleans due to the impact of the environment and the visciousness of institutionalized racism.

A high ranking Blue Cross of Alabama official told me that BCBS of Alabama attributes over 40% of their expenditures on medical problems that can be directly traced to obesity. Alabama is sick and people are dying as a result of poor nutritional habits, their environment and a failure of policy-makers to act. Yes, I believe in “personal responsibility” but there is no evidence that a willingness to be more personally responsible will change this epidemic that has its roots in culture and non-medical health determinants such as poor transportation, violence, chronic unemployment, safe neighborhoods and a general poor social safety net.  I suspect that the high calorie, high fat foods sold in lower income neighborhoods costs more that quality foods sold at Whole Foods.

Take a look at this snap shot of Health Status in Alabama according to Condition and Value/Rank (out of 50 states):

Prevalence of Obesity – 32.2%/49th

Cancer Deaths ( per 100,000)  – 211.4/44th

Cardiovascular Deaths (per 100,000) – 358.8/49th

Prevalence of Diabetes – 11.2/48th

Infant Mortality ( per 1000) – 9.2/48th

These data should be a battle cry to all concerned about the health and wellness of the people of Alabama. To a person, those I have talked with state emphatically that the time for study and publishing academic papers is over.

The NIH, CDC, OMHD, FDA , USDA and all the other alphabets need to know that it is time that the millions of dollars being sent to Alabama to improve lives, be put to accountable use. We have to get over regional politics, racial and cultural differences and turf issues and come together so that the common pool of resources can used to save lives. Our future demands that we act.

According to a recent HealthAffairs reports, “Despite a number of programs combating childhood obesity on federal, state, and local levels, the trends show obesity rates on the rise. Among children ages 10-17, the number
who were obese grew significantly — from 14.8 percent in 2003 to 16.4 percent in 2007. This translates into a stunning 10,580,000 obese
American children. And research findings suggest that the obesity epidemic among children may not yet have reached a plateau”.

The report goes on to state that experts  believe that there needs to be “collective responsibility for taking on the problem along the lines of the movement to fight smoking and tobacco. Studies using laboratory animals show that the animals gain weight when their environment promotes foods high in sugar and fat, and that even when healthy foods are freely available, the animals eat the unhealthy ones, gaining much weight and exhibiting deteriorating health”.

The time to act is now if inroads are to be made. Policy must be changed to include:

• The executive branch and Congress should make fighting childhood obesity a signature domestic initiative for the health and well-being of future generations, and to ensure high productivity for industry in the years ahead.
• Congress should enact new taxes designed to discourage consumption of high-calorie foods and beverages and should invest the resulting revenues in obesity prevention.
• Congress should pass federal legislation that requires restaurants to list calories of all items on the menu.
• Federal regulators should set federal nutrition standards in schools for foods not covered now, including snacks, sodas, and candy sold in school stores and canteens and at events.
• Federal officials should set new agriculture policy that encourages farmers to grow more fruit and vegetables, and relatively fewer crops that are key ingredients for high-calorie foods.
• Federal officials should work with states that are now trying to make healthful foods and beverages more widely available, especially in low-income areas; expand numbers of parks and playgrounds; and make more funding available to promote biking, walking, and use of public transit.

Provide increased opportunities for physical activity by using more federal funding to improve communities’ existing trail or path systems and sidewalks, and to create bike trails, playgrounds, and recreational facilities.
• Launch educational or media campaigns that encourage parents to limit children’s television viewing and other recreational screen time.
• Devote additional resources to state and local agencies so that they can do more surveillance, monitoring, and prevention of obesity, as well as conduct more research on intervention strategies.
• Increase access to healthy foods in socioeconomically disadvantaged neighborhoods by encouraging the development of grocery stores and farmers’ markets through grants, loans, and tax benefits.

Source: HealthAffairs Obesity Brief March 2. 2010 http://www.healthaffairs.org

“If I am not for myself, then who will be for me? And if I am only for myself, then what am I? And if not now, when?” –Hillel.


Holy Smoke….This Has Not Been Nice Tuesday, Apr 20 2010 

One of the highlights of the IHI Fellowship is the opportunity to attend the BMJ (British Medical Journal)/IHI Global Safety Summit. The 2010 Summit began today in Nice France on the French Riviera.It was scheduled to begin one day ago.

My wife traveled from Madison Alabama to meet me, then on to Nice. Funny thing happened last week. A volcano erupted in Iceland.

Our flight was canceled on the day we were scheduled to depart. Just so happens last weekend was also the running of the 114th Boston Marathon. Boston was crowded. We had no hotel. I live in a very small room in Arlington Massachusetts.

So, we trekked to 3 different hotels over the last 4 nights before my wife returned to Alabama. But, we saw a bit of Boston. We went down to the Boston Marathon finish line and the third hotel actually had a ocean view.

I returned to IHI and congratulated Don Berwick on his official nomination by President Obama to be the next CMS Administrator and got back to work.

In the end, the Sun came up today and the sky was a beautiful blue. Life’s stream resumed it’s normal rhythms.

Stream Of Life by Rabindranath Tagore

The same stream of life that runs through my veins night and day
runs through the world and dances in rhythmic measures.

It is the same life that shoots in joy through the dust of the earth
in numberless blades of grass
and breaks into tumultuous waves of leaves and flowers.

It is the same life that is rocked in the ocean-cradle of birth
and of death, in ebb and in flow.

I feel my limbs are made glorious by the touch of this world of life.
And my pride is from the life-throb of ages dancing in my blood this moment

–Ron

Alexis Blow Your Horn Saturday, Apr 10 2010 

I have the most beautiful and most talented daughter in the world.Alexis Victoria Wyatt is 13 years old and is the apple of my eye.

Alexis has asthma and has lot’s of trouble this time of year because of the pollen counts. She is also a bit on the shy side and has a beautiful singing voice.

This is her first year in middle school and after scoring well on her musical aptitude testing, she and the band director decided that it would be good for her (because of asthma) to try the trumpet.

Alexis had her first band competition today. She did very well. I am very proud of her and I am convinced that she will be the next Miles Davis, my favorite musical artist.

So I say to you Alexis…..

“Do not fear mistakes. There are none.”

Miles Davis quote

Don Berwick :The Patient Centered Extremist Saturday, Apr 3 2010 

Over the last week, reports of President Obama nominating Don Berwick, CEO of the Institute of Health Care Improvement(IHI) to become the next Centers for Medicare and Medicaid Services (CMS) Administrator  have flooded the world media. The nomination has not been officially made.

I have had the unparalleled honor of sitting between Don Berwick  and Maureen Bisognano(COO IHI), for 4 of the last 7 months. I have come to know Don from up close.

Don Berwick’s Desk

The culture here at IHI is unlike any I have ever seen or experienced. The walls are either glass or non-existent. The doors to the COO and all Senior leaders, Maureen Bisognano, Jim Conway, Don Goldmann, Penny Carver, Joanne Healy, Frank Frederico, Carol Beasley, Pat Rutherford, Paul Hammett, are always open. In fact doors are barely noticeable.

The IHI staff consist of a little over 100 highly motivated, talented and very committed people.  When you enter IHI you are met by the incomparable Marva, who embodies the spirit of IHI with her smile.  I often say that I hit the good people lottery just having been chosen to be one of two George W. Merck Fellows for 2009-2010.

Then there is Don Berwick. I first met Don when I interviewed with him in October 2007. The next time I saw him was at the 2008 IHI National Forum. I introduced myself to him and not only did he remember me, he asked me how my daughter was doing! I now know that this is not unusual but common place.  Dr. Berwick is one of the most gracious, unassuming and driven persons anyone will ever encounter. Don treats all of the people that he encounters like they are family. His family is the world. Don is without pretension, without bluster, without arrogance, but he glows with a confidence and vision that ignites as few as 7 IHI fellows or a room crowded with thousands all hanging on his every motion and word. Yet, he seems to go out of his way to extend kindnesses and words of encouragement to all that he encounters.

On a recent visit home to Huntsville Alabama, I encountered Robert Centor MD Dean of the University of Alabama Birmingham School of Medicine Hunstville campus. Dr. Centor, an long time Don Berwick friend, said to me with a smile and a twinkle in his eye, ” Don Berwick is over the top”. What did he mean?  To me it means what Don has been saying for all of his career.. the IHI community will change the world and crucial to this effort is that we all become patient-centered extremists. If that scares you or makes you feel uncomfortable, then great! So, what does Don mean by being an extremist?

Read these excerpts from “Confessions of an Extremist” by Don Berwick:

An Extreme View
I freely admit to extremism in my opinion of what patient-centered care ought to mean. I find the extremism in a specific location: my own heart. I fear to become a patient. Partly, that fear comes from what I know about technical hazards and lack of reliability in care. But errors and unreliability are not the main reasons that I fear that inevitable day on which I will become a patient. For, in fighting them, I am aligned with the good hearts and fine skills of my technical caregivers, and I can use my own wit to stand guard against them.  What chills my bones is indignity. It is the loss of influence on what happens to me. It is the image of myself in a hospital gown, homogenized, anonymous, powerless, no longer myself. It is the sound of a young nurse calling me, “Donald,” which is a name I never use—it’s “Don,” or, for him or her, “Dr. Berwick.” It is the voice of
the doctor saying, “We think…,” instead of, “I think…,” and thereby placing that small verbal wedge between himself as a person and myself as a person. It is the clerk who tells my wife to leave my room, or me to leave hers,without asking if we want to be apart. Last month, a close friend called a clinic for her mammogram report and was told, “You have to come here;we don’t give that information out on the telephone.” She said, “It’s OK, you can tell me.” They said, “No, we can’t do that.” Of course, they “can” do that. They choose not to, and their choice trumps hers: period. That’s what scares me: to be made helpless before my time, to be made
ignorant when I want to know, to be made to sit when I wish to stand, to be alone when I need to hold my wife’s hand, to eat what I do not wish to eat, to be named what I do not wish to be named, to be told when I wish to be asked, to be awoken when I wish to sleep. Call it patient-centeredness, but, I suggest, this is the core: it is that property of care that welcomes me to assert my humanity and my individuality. If we be healers, then I suggest that that is not a route to the point; it is the point. -Don Berwick.

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