Saturday, December 31, 2011

Into 2012

Welcoming a new year filled with possibility

It’s hard to believe it is already a new year. The fact that many of us have spent time in the last few weeks reflecting on the past year and making resolutions for the new, speaks of the hope that we hold for the future. As Chief Executive Officer of Contra Costa Regional Medical Center (CCRMC) and the Health Centers (HC), it has been my privilege to support the compassionate work performed by all of you this year. Together we have faced unprecedented upheaval in our national, state and local economies. Trying times expose our values because they force us to make critical choices.

This year will be no less trying. Economic crisis continues to clench much of the world. Initially centered on the financial sector, this crisis has caused business failures and job losses and, ultimately, an increased demand for service from the safety net. I will not downplay the fact that once again we will most certainly face another year of immense challenges – because, indeed, much hard work and hard choices are ahead. Yet, before us lies an even bigger opportunity to renew and recommit to our mission in response to the urgency of challenging times. Throughout our county’s history, tough times have seen us not lower our sights but raise them. We need to display an ambition equal to our future. We are in a time of profound change. We must continue to improve and invigorate our system as one that goes beyond a “place of last resort”, to a system that exists within a community where no one is left out.

Together, and in partnership with our community, we will achieve:
• Better Care: Improve overall quality, by making health care more patient-centered, reliable, accessible, and safe.

• Healthier People and Communities: Improve the health of the population by supporting proven interventions to address behavioral, societal, and environmental determinants of health in addition to delivering higher-quality care.

• Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and our county.
We must rise to these challenges because nothing less will do. I don’t expect that we will always agree with each other or with our colleagues across the public sector about the path forward. This is not a bad thing. Differences of opinion do not need to weaken us, they can make us stronger. Expressing divergent thinking, or raising a question often spurs introspection and brings daylight.

I am thankful that this last year provided the opportunity to deeply examine our system. After many months, the sustainability study of our Regional Medical Center and Health Centers was completed. The report described our strengths and the work we have underway to further improve and transform our system in order to continue to care for our community and help implement changes as part of Health Care Reform. The study summarized our current efforts to improve service delivery and patient experience, providing an excellent overview of our planned transition to Health Care Reform into 2014 and beyond. The findings validate that we have been - and continue to be - on the right path.

We are at a critical crossroads in health care in America and here in Contra Costa County. Together we will move forward on the basis on our shared ideals. As our community’s health system, we must continue to focus and prepare for the full implementation of Health Care Reform in 2014. Our goal is to provide care for our patients that is more coordinated and integrated, that will allow for earlier intervention, fewer avoidable emergency department visits and hospital stays and, ultimately, a healthier population while containing costs across our system and our community.

Contra Costa Regional Medical Center and Health Centers (CCRMC & HC) will expand access to health care and enhance quality through our Delivery System Reform program, also known as DSRIP. The improvements we are implementing as part of this plan are seen as key concepts of Health Care Reform. This critical effort builds on the extensive, innovative, work already underway at CCRMC & HC and contributes to important knowledge for our country.

We are also well into the implementation of our electronic health record (EHR): ccLink. Based on the Epic software system, ccLink, which will "go live" in July 2012, is more than a state-of-the-art health record technology — it will help further transform the care experience by linking patients with the best care and people. The implementation of ccLink, increasing access to our delivery system, shortening response times for appointment scheduling, integrating behavioral health and primary care, the realization of landmark health reform concepts and many other improvements are all well underway thanks to your efforts.

There is still much work to be done, but we should not forget how much we have accomplished this past year. Your commitment and partnership are making a difference. Please accept my sincere best wishes to you and your families for a happy, healthy and prosperous new year.

I look ahead with confidence and optimism.

Monday, December 26, 2011

Something to smile about

If you can't see the slides below, click here to view the PowerPoint.
Fluoride Varnish at CCRMC and HC
I wanted to share some results from what began as a “small test of change” to improve dental health in children here in Contra Costa County. Fluoride application is one improvement in our health care system that stands out as having a positive and immediate impact.

The protective effect that fluoride varnish provides for kids is remarkable. Just one annual application is dropping the rate of dental cavities as much as 50% and two applications dropping it by 75%. In spite of the fact that this quick, painless procedure has been a covered Medi-Cal benefit for young children since 2006, less than five percent of eligible children received even one annual varnish application in 2009. Unfortunately, few low-income children see a dentist on a regular basis – if at all.

We realized that our young patients didn’t need to be sitting in a dentist’s chair to receive this treatment, but in fact could have it applied during their well-child visit at our primary care clinic. Physicians, nurses and certain other personnel are legally permitted to perform the varnish application, which only takes between 1-3 minutes. Contra Costa County, in partnership with UCSF School of Dentistry’s Center to Address Disparities in Children’s Oral Health (CANDO), embarked on a program to train staff to provide this very basic service to our youngest patients. What started as a pilot in two of our health centers has now been expanded to all eight.

The results have been impressive. More than 70% of eligible children have received the varnish through our primary care clinics. We’ve also increased our education on oral health for parents as well as all patients. Our Health Plan has begun to train community providers about the varnish application.

Although it’s gratifying to be able to make such a significant difference with this simple procedure, we know that it is not enough to protect children’s dental health. We are also moving forward with efforts to expand dental care for children in our dental clinics. There are many negative consequences as a result of not seeing a dentist. If you’ve ever suffered a toothache yourself or been with one of your children while they did, you realize how much children suffer from this pain that we know could be avoided in most cases. They also risk serious and chronic infections and along with the pain are major causes of school absences. I hope to be able to report on our progress in this area in the not-too-distant future.

More very soon.

Thursday, December 22, 2011

The Morning Commute: Perintal Services at CCRMC

I was told once that I am especially sensitive to anniversary dates. I think that's true.

Remembering my Dad on his birthday -

When I was growing up, my dad and I were always awake long before anyone else in the house and would use that time to have a good discussion. For years after starting my career, I began most days with a call to my father during my morning commute. I knew I could count on him for a good chat during the drive in. My dad was the chief engineer in charge of the water department. Though we were in very different lines of business, his goal was safety, quality and the continuous flow of a perfect product, ensuring its delivery to the customer every time it was wanted. Does this sound familiar? He instilled in me a strong sense of duty and pride in civil service. As my career evolved, the differences in our work became far fewer than the similarities. My dad seemed to have a story for every challenge I faced. This real life reflection from a veteran leader was a valuable part of our morning discussions. He would never give any direct advice. More often than not, he would share what he described as a failed or wrong decision. I, on the other hand, would describe it as wisdom.

I still catch myself making a list in my head of things I'd love to run past him during one of our discussions. Over the next few days (or weeks, depending on the pace of my posts), I'd like to share some of my thoughts during my "morning commute" with you.

I begin with how proud I was to see Contra Costa Regional Medical Center receive the Quality Leaders Top Honors Award from the California Association of Public Hospitals and Health Systems (CAPH) and its quality improvement affiliate, the California Health Care Safety Net Institute (SNI) for our Perinatal Unit’s innovative program, the “Vaginal Birth after Cesarean (VBAC) Improvement Project.” Judy Bliss, MD, chair of our ob/gyn department, and Brenda Stewart, RN, quality manager for Safety and Performance Improvement, accepted the award on behalf of the CCRMC team at the CAPH/SNI annual awards luncheon earlier this month.

The team developed this program more than two years ago to offer women who have had a prior C-section the option to avoid this surgery if it can be done safely. Although medical science supports VBACs and indeed acknowledges that in general C-sections carry a greater risk, some providers are reluctant to offer VBACs because of the challenges involved in assuring all safety measures have been taken. In collaboration with the Institute for Healthcare Improvement, we developed a series of interventions, known as a “bundle,” and other protocols so that we could ensure the safest outcome possible to our patients who chose a VBAC.

These efforts are an example of CCRMC employees putting patients at the center of their care experience. Our perinatal team was determined to respond to the needs and wishes of our patients while keeping safety as the number-one priority .

Friday, December 16, 2011

Rapid Improvement/Kaizen Event Reports are TODAY

The Rapid Improvement Event (Kaizen) Report are TODAY at:
7:45-8:15 AM - Richmond Health Center Lobby
10-10:30 AM - CCRMC Hospital Lobby
12:15 - 12:45 PM - Pittsburg Health Center Lobby

Sunday, December 11, 2011


Being a mother of many of them, I'll admit there are days I just can't seem to understand the new generation. I've complained that when we were young we used to actually talk to one another rather than text, email or update our status on Facebook. I've mistakenly viewed this type of communication as superficial. This subgroup of young people are now referred to as "GenWorld: The new Generation of Global Teens." My daughter, one of these "superconnecters," did confirm that just like good-old-fashioned, face-to-face conversations, some of these interactions are less than deep. As an example of a contrasting type of communication she offered the video below of Jonah. I was deeply moved.

As some of you may know, suicide prevention is near and dear to my heart. Others may not know this, but bullying is also something I am quite concerned about. One of the most heartbreaking stories I can recall is that of a 12-year-old girl who took her own life after being bullied. I will never forget the horror and heartbreaking cries of her parents as we informed them in a quiet room outside of our emergency department. When I watch this video and just a few of the responses (there are too many to list), it's clear the new generation is still connecting with one another in a very powerful way.

The following video's are quite sad. Yet the connection and words of hope and support are inspiring and prevail. Although not in the same way we did, I am reassured the new generation are connecting with each other in meaningful ways. I have much to learn.

Thank you, Elena.

Saturday, December 10, 2011

"Now comes the choice. To change, or not to change."

"Now comes the choice. To change, or not to change." - Don Berwick

Don Berwick joined the IHI Forum and outlined five principles to guide change in health care:
  • Put the patient first.
  • Among those, put the poor and disadvantaged first, “those in the beginning, the end, and the shadows of life. Let us meet the moral test.”
  • Start at scale. “There is no more time left for timidity. Pilots will not suffice.”
  • Return the money. “It is crucial that the employers and wage-earners and unions and states and taxpayers – those who actually pay the health care bill – see that bill fall.”
  • Act locally. Every community must mobilize
You can view his presentation here.

As he spoke I thought to myself, why can't this man run American health care?  Then I remembered, a small group of senators obstructed his nomination, putting political interests above the best interests of the American people. Sadly, they got away with it.

Below are a excerpts from his remarks that appear in White Coat Notes, by Chelsea Conaboy :

The time at CMS has been a privilege. I got the chance to work with thousands of career public servants, and to learn how much these people do for us all, unsung and too often unappreciated. These are the people who translate laws into regulations and regulations into deeds. In CMS these are the people who keep the lights on – they see that providers get paid, they protect the public trust, they help the most vulnerable people in America, and make sure that they get the care they need.

And, I got the chance to help pilot toward harbor the most important health care policy of our time – the Affordable Care Act. A majestic law. I learned that a law is only a framework; it’s like an architect’s sketch. If it’s going to help anyone, it has to be transformed into the specifications that regulations and guidance documents. Only then can become real programs with real resources that reach real people. On my expedition, that, mostly, was what I was doing.

I would have loved to keep at that job longer. But, as you know, the politics of Washington, and especially the politics of the United States Senate, said, “No.” But, overall, I don’t feel an ounce of regret. What I feel is grateful for the chance I had to serve, and for the generous support I felt, including from so many of you.
I want this afternoon to share with you a little of what I learned on the expedition; and what I think it means for you – for all of us. It’s a sort of good-news-bad-news situation. The good news: the possibility of change has never been greater – not in my lifetime. The bad news: if it’s going to be the right change, the burden is yours.
. . . .
Cynicism grips Washington. It grips Washington far too much, far too much for a place that could instead remind us continually of the grandeur of democracy. . .

Cynicism diverts energy from the great moral test. It toys with deception, and deception destroys. Let me give you an example: the outrageous rhetoric about “death panels” – the claim, nonsense, fabricated out of nothing but fear and lies, that some plot is afoot to, literally, kill patients under the guise of end-of-life care. That is hogwash. It is purveyed by cynics; it employs deception; and it destroys hope. It is beyond cruelty to have subjected our elders, especially, to groundless fear in the pure service of political agendas.
The truth, of course, is that there are no “death panels” here, and there never have been. The truth is that, as our society has aged and as we have learned to care well for the chronically ill, many of us face years in the twilight our lives when our health fades and our need for help grows and changes. Luckily, palliative care – care that brings comfort, company, and spiritual and emotional support to people with advanced illness and their families – has grown at its best into a fine art and a better science. The principle is simple: that we can and should offer people the very best of care at all stages of their lives, including the twilight.

The truth is, furthermore, that patient-centered care demands that the ways in which a person is cared for ought always to be under his or her control. The patient is the boss; we are the servants. They, not others, should direct their own care, and the doctors, nurses, and hospitals should know and honor what the patient wants. . . It is one of the great and needless tragedies of this stormy time in health care that the “death panel” rhetoric has denied patients the care that they want, denied caregivers the information they need to give that care, and denied our nation access to a mature, open, informed, and balanced discussion of the challenge of advanced illness and the commitment to individual dignity. It is a travesty.

If you really want to talk about “death panels,” let’s think about what happens if we cut back programs of needed, life-saving care for Medicaid beneficiaries and other poor people in America. What happens in a nation willing to say a senior citizen of marginal income, “I am sorry you cannot afford your medicines, but you are on your own?” What happens if we choose to defund our nation’s investments in preventive medicine and community health, condemning a generation to avoidable risks and unseen toxins? Maybe a real death panel is a group of people who tell health care insurers that is it OK to take insurance away from people because they are sick or are at risk for becoming sick. Enough of “death panels”! How about all of us – all of us in America – becoming a life panel, unwilling to rest easy, in what is still the wealthiest nation on earth, while a single person within our borders lacks access to the health care they need as a basic human right? Now, that is a conversation worth having.

And, while we are at it, what about “rationing?” The distorted and demagogic use of that term is another travesty in our public debate. In some way, the whole idea of improvement – the whole, wonderful idea that brings us –thousands – together this very afternoon – is that rationing – denying care to anyone who needs it is not necessary. That is, it is not necessary if, and only if, we work tirelessly and always to improve the way we try to meet that need.

The true rationers are those who impede improvement, who stand in the way of change, and who thereby force choices that we can avoid through better care. It boggles my mind that the same people who cry “foul” about rationing an instant later argue to reduce health care benefits for the needy, to defund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people – elders, the poor, the disabled – who are least able to bear them.

When the 17 million American children who live in poverty cannot get the immunizations and blood tests they need, that is rationing. When disabled Americans lack the help to keep them out of institutions and in their homes and living independently, that is rationing. When tens of thousands of Medicaid beneficiaries are thrown out of coverage, and when millions of Seniors are threatened with the withdrawal of preventive care or cannot afford their medications, and when every single one of us lives under the sword of Damocles that, if we get sick, we lose health insurance, that is rationing. And it is beneath us as a great nation to allow that to happen.

And that brings me to the opportunity we now have and a duty. A moral duty: to rescue American health care the only way it can be rescued – by improving it. I have never seen, nor had I dared hope to see, an era in American health care when that is more possible than this very moment. . .We can do this, we who give care. And nobody else can. The buck has stopped. The federal framework is set by the Affordable Care Act and important prior laws, such as the HITECH Act, and, quite frankly, we can’t expect any bold statutory movement with a divided Congress within the next year or more.

The buck has stopped; it has stopped with you.
Now comes the choice. To change, or not to change.