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Tom Peters’

Healt h(care )
Exce ll enc e!
Part I
Leaders in Healthcare/Dubai/22January2006
Slides at …

tompeters.com
Part I: Healthcare “Manifesto”
Part II: Getting It Done!
Health(care): Seven Main Messages
1. Quality (Error reduction/
Evidence-based Medicine)
2. “Healthcare” vs. “Health” (Wellness +
Prevention)
3. “Models of Excellence” available
4. Life sciences (“Singularity”)
5. Dubai as global/unique/“insanely great”
“Center of Excellence”
6. Avian flu
7. 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
• 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?)
“Quality”:
COULD IT
TRULY BE
THIS
“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 ,00 0 hospital deaths per


year in the U.S., 2000-2002 = 390 ful l
jumbos/ 747s in the drink per year .
Comments: “This should give you pause
when you go to the hospital.” —Dr. Kenneth
. “There is little
Kizer, National Quality Forum

evidence that patient safety has


improved in the last five years.” —Dr.
Samantha Collier
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.
“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,
four out of 10
while

made mistakes 30% of


the time.”
Demanding Medical Excellence: Doctors and Accountability
in the Information Age, Michael Millenson
20%: not get
prescriptions filled
50%: use meds
inconsistently
Source: 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
“A healthcare delivery system
characterized by idiosyncratic and
often ill-informed judgments must
be restructured according to

evidence-based
medical practice.”
Demanding Medical Excellence: Doctors and Accountability
in the Information Age, Michael Millenson
“Without being disrespectful, I consider the U.S.
healthcare delivery system the largest cottage industry

There are virtually


in the world.

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
A surprising 85% of
ignorant care.

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
in the Information Age, Michael Millenson
“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

: 620.
Lund/SW)

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)
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


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%
hospitals
of U.S.

source: HealthLeaders/06.02
“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
“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 [for] 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)

Source: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation
Smoking, drinking,
exercise, diet: 40% of
deaths

Source: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation
“Our mistake is not that we
value medical care—but that
we have misunderstood what it
can and cannot do.”

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


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)
“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 supplements
No alcohol
(Psychotropic meds/others reduced)
(No work reduction)
Aging
reversal!
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 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
The Nine Planetree Practices
1. The Importance of Human Interaction
2. Informing and Empowering Diverse Populations: Consumer
Health Libraries and Patient Information
3. Healing Partnerships: The importance of Including Friends
and Family
4. Nutrition: The Nurturing Aspect of Food
5. Spirituality: Inner Resources for Healing
6. Human Touch: The Essentials of Communicating
Caring Through Massage
7. Healing Arts: Nutrition for the Soul
8. Integrating Complementary and Alternative Practices
into Conventional Care
9. Healing Environments: Architecture and Design Conducive
to Health
Source: 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)

Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
2. Informing and
Empowering Diverse
Populations: Consumer
Health Libraries and
Patient Information
Planetree Health Resources Center/1981
Planetree Classification System
Consumer Health Librarians
Volunteers
Classes, lectures
Health Fairs
Griffin’s Mobile Health Resource Center
Open Chart Policy
Patient Progress Notes
Care Coordination Conferences (Est goals, timetable,
etc.)

Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
3. Healing
Partnerships: The
Importance of
Including
Friends and Family
staff members are
asked to list the
attributes of the
‘perfect patient
and family,’ their
response is usually
a passive patient
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
“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
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 Conferences


Clinical Guidelines Discussions
Family Spaces
Pet Visits (POP: Patients’ Own Pets)
Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
4. Nutrition: The
Nurturing Aspect
of Food
Meals are central events
vs

“There,
you’re fed.” *
*Irony: Focus on “nutrition” has reduced focus on “food” and “service”
Kitchen
Beautiful cutlery, plates, etc
Chef rep

Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
5. Spirituality: Inner
Resources for Healing
Spirituality: Meaning and Connectedness in Life

1. Connected to supportive and caring group


2. Sense of mastery and control
3. Make meaning out of disease/find meaning in
suffering

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


Charmel
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 massage
Staff massage (“caring for the caregivers”)
Healing environments: chemo!

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

Massage
Acupuncture
Meditation
Chiropractic
Nutritional supplements
Aroma therapy

Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
9. Healing Environments:
Architecture and
Design Conducive
to Health
“Planetree Look”

Woods and natural materials


Indirect 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

Source: Putting Patients First, Susan Frampton, Laura Gilpin, Patrick Charmel
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
“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
“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
GRIN: Genetics,
Robotics (nanotech),
Information, Nanotech
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”)
H5 N1
Kroll/SARS: “don’t
over-react”
Kroll/H5N1:

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