Monday, January 31, 2011

Gluten-free January Participants: Take the Survey!

Matt Lentzner, Janine Jagger and I have designed a survey for participants of Gluten-free January, using the online application StatCrunch. Janine is an epidemiologist who studies healthcare worker safety at the University of Virginia; she has experience designing surveys for data collection so we're glad to have her on board. The survey will allow us to systematically gather and analyze data on the results of Gluten-free January. It will be 100 percent anonymous-- none of your answers will be connected to your identity in any way.

This survey has the potential to be really informative, but it will only work if you respond! The more people who take the survey, the more informative it will be, even if you didn't avoid gluten for a single day. If not very many people respond, it will be highly susceptible to "selection bias", where perhaps the only people who responded are people who improved the most, skewing the results.

Matt will be sending the survey out to everyone on his mailing list. Please complete it, even if you didn't end up avoiding gluten at all! There's no shame in it. The survey has responses built in for people who didn't avoid gluten. Your survey will still be useful!

We have potential data from over 500 people. After we crunch the numbers, I'll share them on the blog.

Hearing Thursday on transparency for health insurer rate increases

A state Senate committee will hold a hearing at 1:30 p.m. Thursday in Olympia on a couple of our key legislative requests.

The first -- and the less controversial -- is that we retain the authority to review health insurance rate hikes in the individual market (e.g. insurance you buy yourself, instead of get through an employer.) If this bill doesn't pass, our authority do review those rates on behalf of consumers will end at the end of the year -- and the feds will do it instead. This is Senate Bill 5398.

The more controversial bill -- at least among insurers -- is our proposal to make public all the information that health insurers send us when filing for a rate increase. As things stand now, much of that information is secret. Hundreds of consumers have told us that they feel they have a right to see it. And we agree.

We're arguing that consumers should have the right to see what they're paying for, and exactly what's driving the large premium hikes in recent years. Everyone's data would be released, making it a level playing field for all the companies. (The bill is SB 5120.)

We don't have to look far to see how this process would work, because Oregon is already doing it. What's more, that state's largest health insurer said it supports a transparent filing process.

Washington State Insurance Commissioner Mike Kreidler testified about the transparency proposal last week in front of a House committee. Here's an excerpt:

Thailand's 'Lean' Hospitals

Bangkok Blog #6 – Friday, January 28, 2011

By Michele Jordan, VP Quality Improvement and Transformation, RVHS

There are five Thailand hospitals that participated in the first phase of the Lean demonstration project. We visited three of them this week. The other two are somewhat far from Bangkok so it was more cost-effective to have their representatives come and present to us.

We started by hearing two case study presentations by physician leaders at the Songklanagarind Hospital. Songklangarind is an 860 bed university teaching hospital with a very advanced Health Information System (HIS). They have made very impressive progress and have a really good grasp of how to apply Lean tools.

Dr. Rungsun Bhurayanantachai discussed how Lean was used to improve flow in the chemotherapy program. Problems included: long waits to get an available bed; patients turning up at hospital for admission without adequate prep, unnecessarily long lengths of stay, too much time spent on documentation and lack of a team approach. A few of the many Lean solutions they put in place to alleviate all of these problems included:

• Completing patient documentation and the medical order before admission- patient asked to do the medical condition checklist before they come to the hospital; order written and saved in the computer system to be activated when the patient is admitted; when patient arrives on day of admission they go directly to the ward.

• Implemented an “e-Kanban” system – pharmacy sends an alert through the computer system to let the ward know that the chemo drug is ready for pick up.

• Visual controls - a sticker is placed on the chemo bag to mark when there is 3 hours left for chemo administration; this gives the doctor 3 hours to complete the discharge summary; when the last bottle of chemo has been put up, the nurse puts a sign on the door to alert housekeeping that discharge will be today and when the patient leaves the room they are asked to turn the sign around to the other side which indicates that the room is ready to be cleaned.

The one-year results of the combination of these actions are:

• A reduction in length of stay for chemotherapy from 72.3 hours to 53 hours;

• An increase in bed utilization (i.e. the number of patients per bed per week) from 2.3 to 3.2;

• An increase in patient satisfaction scores from 3.2 to 4.6;

• Staff satisfaction increased for all indicators related to work speed, work process and team work.

Dr. Nipat Aui-aree, a Neuro-Opthamologist, discussed how load leveling principles were applied to the Bolulinum Eye Clinic. This clinic uses botox injections to treat people experiencing involuntary facial spasms. Before the Lean initiative, it was not unusual for patients to arrive at 8am even though the clinic did not open until 1pm. After applying Lean, turnaround has been reduced from 333 minutes (5.5 hours) to only 50 minutes. The number of steps in the process has been reduced from 15 to 11. Patient satisfaction is up from 2.77 out of 4 to 3.5 out of 4 and continues to rise.

Next we heard about the progress being made at the Suratthani Hospital, an 800-bed facility that sees 2,000 outpatients and 150 admissions per day. Dr. Suwicha Saringkarnpoonperm described the interesting approach the hospital is using to promote Lean. They are using the concept of “Dr. Lean”. They launched their process by visiting all departments of the hospital and using value stream mapping, spaghetti diagrams and genchi genbutsu to ‘diagnose’ problems. The 7 wastes are described as ‘symptoms’. The various Lean improvement tools are described as ‘drugs’ for treating the symptoms. They do 3 to 5 corporate projects per year. Their first corporate initiative was aimed at streamlining and leveling flow in the outpatient department. The improvements they implemented based on Lean Thinking included:

• Set up satellite units with general practices and well-trained nurses

• Set up call centre (a non-medical team) for management of the consulting system

• Set up an improved appointment management process and better communication with the GP and the patient

As a result, their outpatient process time has dropped from 5 hours to 2 hours and 40 minutes.

In the afternoon, we had a lengthy discussion with the international delegates on their learnings from the conference and each delegate had to describe one-specific action they will taken when they return home to advance Lean in their country. We also discussed how to get started with Lean. Professor Philip Choo and I shared the lessons we have learned in our individual hospitals.

Today was the final day of the conference. The week went by very quickly and it was somewhat sad to see it all come to an end. There was a lot of picture taking and exchanging of gifts. I gave each of the delegates a Rouge Valley pen and they were all very appreciative. We have all vowed to stay in touch so I’m looking forward to being part of this dynamic international network. Bangkok was a great host city for this conference and the organizers did an outstanding job.

More problems with muscles and cholesterol meds such as Lipitor. Are they really necessary

  Recently, I have had a number of patients who, because of their cholesterol medication (Lipitor, etc.) have had the side effect of muscular spasms and mechanical problems in their bodies that have been exacerbated.  This disturbing trend continues to get worse because people are being scared into taking these medications when their cholesterol numbers are not very high (under 300 for triglycerides).  The drug companies have become great at selling doctors on the preventative nature of these drugs which are quite dangerous (this is why, you must have your blood taken every three months - to discover if it is causing damage to the liver or muscles).
    What's worse, is current epidimiological studies show that at best, these medications may give you an additional year, while treating a questionable disease calling it prevention. 
    Years ago, we did not have these drugs and some people had heart attacks. The question is Do these drugs prevent them and at what cost?
    The other question is - when do the benefits outweigh the risks?
    In my opinion, this is not preventative but interventional and the general public needs to understand the difference.  The other question is, with all the potential health problems out there, with this being one small piece of the puzzle, does health care by the triglyceride numbers really make people healthy?  Based on my findings, dealing with real people, and seeing the creation of problems they never needed to have because of the medication, primary care and cardiologists as well need to re look at this question and reevaluate who really needs these meds to stay healthy.
    In my humble opinion, if your triglycerides are under 300, stay away. What is your opinion?  As always, I value your thoughts.

Sunday, January 30, 2011

The China Study II: A look at mortality in the 35-69 and 70-79 age ranges

This post is based on an analysis of a subset of the China Study II data, using HealthCorrelator for Excel (HCE), which is publicly available for download and use on a free trial basis. You can access the original data on the HCE web site, under “Sample datasets”.

HCE was designed to be used with small and individual personal datasets, but it can also be used with larger datasets for multiple individuals.

This analysis focuses on two main variables from the China Study II data: mortality in the 35-69 age range, and mortality in the 70-79 range. The table below shows the coefficients of association calculated by HCE for those two variables. The original variable labels are shown.


One advantage of looking at mortality in these ranges is that they are more likely to reflect the impact of degenerative diseases. Infectious diseases likely killed a lot of children in China at the time the data was being collected. Heart disease, on the other hand, is likely to have killed more people in the 35-69 and 70-79 ranges.

It is also good to have data for both ranges, because factors that likely increased longevity were those that were associated with decreased mortality in both ranges. For example, a factor that was strongly associated with mortality in the 35-69 range, but not the 70-79 range, might simply be very deadly in the former range.

The mortalities in both ranges are strongly correlated with each other, which is to be expected. Next, at the very top for both ranges, is sex. Being female is by far the variable with the strongest, and negative, association with mortality.

While I would expect females to live longer, the strengths of the associations make me think that there is something else going on here. Possibly different dietary or behavioral patterns displayed by females. Maybe smoking cigarettes or alcohol abuse was a lot less prevalent among them.

Markedly different lifestyle patterns between males and females may be a major confounding variable in the China Study sample.

Some of the variables are redundant; meaning that they are highly correlated and seem to measure the same thing. This is clear when one looks at the other coefficients of association generated by HCE.

For example, plant food consumption is strongly and negatively correlated with animal food consumption; so strongly that you could use either one of these two variables to measure the other, after inverting the scale. The same is true for consumption of rice and white flour.

Plant food consumption is not strongly correlated with plant protein consumption; many plant foods have little protein in them. The ones that have high protein content are typically industrialized and seed-based. The type of food most strongly associated with plant protein consumption is white flour, by far. The correlation is .645.

The figure below is based on the table above. I opened a separate instance of Excel, and copied the coefficients generated by HCE into it. Then I built two bar charts with them. The variable labels were replaced with more suggestive names, and some redundant variables were removed. Only the top 7 variables are shown, ordered from left to right on the bar charts in order of strength of association. The ones above the horizontal axis possibly increase mortality in each age range, whereas the ones at the bottom possibly decrease it.


When you look at these results as a whole, a few things come to mind.

White flour consumption doesn’t seem to be making people live longer; nor does plant food consumption in general. For white flour, it is quite the opposite. Plant food consumption reflects white flour consumption to a certain extent, especially in counties where rice consumption is low. These conclusions are consistent with previous analyses using more complex statistics.

Total food is positively associated with mortality in the 35-69 range, but not the 70-79 range. This may reflect the fact that folks who reach the age of 70 tend to naturally eat in moderation, so you don’t see wide variations in food consumption among those folks.

Eating in moderation does not mean practicing severe calorie restriction. This post suggests that calorie restriction doesn't seem to be associated with increased longevity in this sample. Eating well, but not too much, is.

The bar for rice (consumption) on the left chart is likely a mirror reflection of the white flour consumption, so it may appear to be good in the 35-69 range simply because it reflects reduced white flour consumption in that range.

Green vegetables seem to be good when you consider the 35-69 range, but not the 70-79 range.

Neither rice nor green vegetables seem to be bad either. For overall longevity they may well be neutral, with the benefits likely coming from their replacement of white flour in the diet.

Dietary fat seems protective overall, particularly together with animal foods in the 70-79 range. This may simply reflect a delayed protective effect of animal fat and protein consumption.

The protective effect of dietary fat becomes clear when we look at the relationship between carbohydrate calories and fat calories. Their correlation is -.957, which essentially means that carbohydrate intake seriously displaces fat intake.

Carbohydrates themselves may not be the problem, even if coming from high glycemic foods (except wheat flour, apparently). This post shows that they are relatively benign if coming from high glycemic rice, even at high intakes of 206 to 412 g/day. The problem seems to be caused by carbohydrates displacing nutrient-dense animal foods.

Interestingly, rice does not displace animal foods or fat in the diet. It is positively correlated with them. Wheat flour, on the other hand, displaces those foods. Wheat flour is negatively and somewhat strongly correlated with consumption of animal foods, as well as with animal fat and protein.

There are certainly several delayed effects here, which may be distorting the results somewhat.  Degenerative diseases don’t develop fast and kill folks right away. They often require many years of eating and doing the wrong things to be fatal.

10 Reasons to Eat Your Greens

Did you know that greens are the most missing food group in the modern American diet? It's true! Eating greens will help to build your internal rain forest and protect your body from viruses. Here are 10 more reasons to eat greens on a consistent basis:

1. Greens help to purify the blood.

2. Greens help prevent cancers.

3. Greens are high in calcium, magnesium, iron, potassium, phosphorous and zinc.

4. They are packed full of micronutrients and phytochemicals.

5. Greens contain vitamins A, C, E and K.

6. They help to strengthen the immune system.

7. Eating plenty of greens will help improve circulation in the body.

8. Greens contain fiber that the body needs to function optimally.

9. They also contain folic acid and chlorophyll.

10. Eating green vegetables helps life the spirit and eliminates depression.

What Are Greens?

There are many types of green vegetables to choose from. Find some that you enjoy eating and eat them often!

Dark leafy greens include broccoli, kale, bok choy, napa cabbage, collards, mustard greens, watercress, broccoli rabe, dandelion, arugula, endive, chicory, lettuce, spinach, swiss chard & beet greens.

How to Cook Greens

1. Wash greens well to remove any dirt or sand.

2. Remove the stems if they're thick. Don't toss them; chop them into bite-sized pieces. You can cook them later or eat them with the greens. (They'll take a little longer to cook, so start them first.)

3. Boil the greens for 3 to 5 minutes in salted water, or until just tender. (Add the stems a few minutes before the leaves.)

4. Steam the greens for 2 to 3 minutes.

5. Braise greens by heating a little olive oil over medium heat. Add some minced garlic and red pepper flakes and sauté for 30 seconds, then add the greens, along with the water that clings to their leaves from washing. Sauté the greens until they're slightly wilted, then cover and braise until tender (just a few minutes). Season with salt and pepper.

6. Pair greens with beans such as chick peas (garbanzo beans) or white beans. The beans make for a hearty dish and mellow out the taste of the greens.

7. Spruce up greens with diced tomato and a dash of lemon juice or hot pepper sauce.

8. ENJOY!

Keep it fresh!
- Lauren

Friday, January 28, 2011

Seattle Times weighs in on health insurer surpluses

Speaking of our legislation involving large surpluses held by nonprofit health insurers, the Seattle Times just posted an editorial on the topic.

It recounts testimony at Thursday's hearing in a state House of Representatives committee:

The companies testified against any penalty for piling up surplus, raising the specter of earthquakes, epidemics and President Obama's health-care reform. The first two might bite into their holdings, and the third, they said, surely would. They said they need every cent they have.

"How much is enough?" asked Rep. Kevin Van De Wege, D-Sequim.

Their answer was a thing with no defined form — something about consumers needing "strong, muscular companies." Van De Wege asked his question again, and again received vapor.

Kreidler re: health insurer surpluses: "How much is enough?"

On Wednesday and Thursday, Insurance Commissioner Mike Kreidler testified in front of Senate and House committees about his proposal to limit further contributions to non-profit health insurers' already-large surpluses.

Here's an excerpt from the Senate hearing:

Superfruit: Goji Berries!

Goji berries – pronounced “go-gee” – are a recent hot commodity in the increasingly trendy high-end health food industry. They are a nutritious powerhouse, packed with antioxidants and are so very tasty! Discovered in the Himalayan Mountains, Goji berries are regarded in the Orient as an anti-aging, strength-building superfood. This sacred Goji berry is so cherished by Tibetan monks that they traditionally honor it for a two-week celebration at the end of every year. Dried Goji berries are a deep-red fruit, about the same size as a raisin. It is very sweet, slightly sour and tastes somewhat like a cross between a cranberry and a cherry. They have a similar shape and chewy texture as raisins. A good daily intake of Goji berries is 3-4 tablespoons. Read below for 10 great ways to incorporate them into your diet!

Benefits of Goji Berries

Goji berries have been used for 6,000 years by herbalists in China, Tibet and India to protect the liver, help eyesight, improve sexual function and fertility, strengthen the legs, boost immune function, improve circulation and promote longevity.

Goji berries contain the complete spectrum of food antioxidant carotenoids, including beta-carotene (a better source than even carrots) and zeaxanthin (supports the eyes). The Goji berry is among the highest source of carotenoids of all known common foods. Gojis contain 500 times the amount of vitamin C, by weight, than oranges making them second only to camu camu berries as the richest known vitamin C source on earth. Plus vitamins B1, B2, B6 and vitamin E are bountiful. About 11mg of iron per 100 grams can be found in the Gojis, as well as betasisterol, sesquiterpenoids (cyperone, solavetivone, an anti fungal compound), tetraterpenoids and betaine for digestion. Goji berries also contain polysaccharides, which support the immune system. Goji berries are high in essential fatty acids, the healthy omegas, which are required for the body's production of hormones and the smooth functioning of the brain and nervous systems. In particular, linoleic acid is abundant.

Also, goji berries are safe and healthy for kids!!! Yay!

10 Ways to Add Goji Berries to Your Diet:

1. Eat Them Up!
Delicious by the handful. Eat as little as 1-2 tablespoons of dried fruits every morning and evening. Keep some dried Goji berries at work, it is a healthy snack to eat in between meals.
To soften the dried berries, soak the berries overnight in a glass of water and drink the water as well as eating the soaked berries.

2. Goji Juice
Add a handful of dried Goji berries to a glass of water and let them sit and hydrate for a few minutes or all day as you drink your own Goji berry juice, chewing the Gojis as you drink. It is a great pick-me up between meals and the most delightful way to enjoy a glass of water.

3. Goji Shake
Blend 2 tablespoons of berries with your favorite juice to make a healthy drink. Use your imagination.
Blend together equal amounts of dried Goji berries, blueberries, cherries, peaches, apples, raspberries and blackberries. Put in a blender and add a cup of water or orange juice for easier blending.

4. Goji Tea
Boil 1 tablespoon of Goji berries, make a Goji berry tea and drink it every day. It helps to alleviate the effects of high blood pressure and high blood sugar. It also helps you to loose weight.

5. Goji Stew
Stew (organic, free-range) pork, beef, chicken or fish, add 1-2 tablespoons of Goji berries 10 minutes before the meat is done.

6. Goji Breakfasts
Mix 1 tablespoon of Goji berries with your cereal/muesli or yogurt to make a healthy breakfast.

7. Goji Salad

Add some pre soaked dried Goji berries to your salad mix. Or throw them on dried for some texture.

8. Goji Rice Dishes

Add a handful of Goji berries to rice dishes and stir-fries. The warmth helps them soften and expand, adding a sweet burst of flavor to your meals!

9. Goji Breads
Use dried Goji berries to make banana bread, muffins or fruit cakes just like raisins. Goji berries provide much more nutrients than raisins.

10. Goji Energy Bar
1 cup of dried Goji berries
½ cup nuts (almonds or cashews are good)
½ tablespoon of honey or maple syrup
mix in food processor. Then press into pan and refrigerate.

For a variation, add any of the following:

½ tablespoon coconut oil
¼ cup pumpkin seeds
3-4 dates
1-2 tablespoons cacao beans or cacao powder
1 tablespoon shredded coconut
1 teaspoon spirulina or chlorella
a dash of vanilla extract

Depending on your choice of ingredients, you may add more sweetener, dates, or coconut oil to better hold the mixture together.

Possible drug interactions - Goji berries may interact with anticoagulant drugs (commonly called "blood-thinners"), such as warfarin (Coumadin®). There was one case report published in the journal Annals of Pharmacotherapy of a 61-year old woman who had an increased risk of bleeding, indicated by an elevated international normalized ratio (INR). She had been drinking 3-4 cups daily of goji berry tea. Her blood work returned to normal after discontinuing the goji berry tea.

Keep it fresh!
- Lauren

Tangible Results in Egypt after Two Years of Program Development

Imagine going into the doctor’s office at 7 a.m., sitting in the waiting room with 60 other patients and their families. If you’re one of the lucky few, you’ll be among the first five patients seen by the doctor. If you happen to be a part of the majority, you could wait for more than 16 hours just to see the doctor.

This may be difficult to imagine here in the United States, but in Egypt, this is a reality. Erika Linnander, associate director for the Global Health Leadership Institute (GHLI) at Yale, sat down with me to explain the role of GHLI’s program in Egypt. Cutting waiting times in half was just one of the main accomplishments.
GHLI’s involvement with Egypt began with collaboration between Dr. Harlan Krumholz, a faculty member at GHLI, and Dr. Adel Allam, an Egyptian cardiologist with connections to Yale. Dr. Allam wanted to initiate a study to improve cardiovascular outcomes, and Dr. Krumholz saw this as an opportunity for GHLI to actively drive health care quality improvement in Egypt. Linnander explained how opportunities for potential partnering countries, like Egypt, are evaluated by matching a country’s need to GHLI’s core values.



Linnander and Elizabeth Bradley recently spent four days in Egypt working with the National Bank. She explained that the project has two main goals: to improve quality of care for patients with cardiovascular disease and to improve management systems to make sure that hospitals are working well over the long term.  Based on early successes in Egypt, the team believed that the project could be replicated on a large scale nationally. Linnander and her partners went directly to the Ministry of Health to outline their strategy. The Ministry supported GHLI’s ideas, but wanted to see  how this plan could be implemented. This is where GHLI stepped in by drafting specific details, such as staffing requirements, timelines and budgets.

Linnander explained how testing earlier pilot models for Egypt’s cardiovascular care helped develop a health care management system. The approach to building management systems in Egypt is similar to what’s used in GHLI’s other programs, such as Ethiopia, but is also tailored to Egypt’s unique needs.  

Cutting waiting times in half is only one of the results of GHLI’s program in Egypt. Creating a registry, in collaboration with the National Bank and five local hospitals, helps Linnander and her team acquire data and understand the type of care that patients with heart attacks receive.  This foundation of evidence makes results for GHLI’s program in Egypt, improving quality of care, possible.

Amanda Sorrentino, GHLI Intern

Second semester, by blogger of the month Claire Gahm

Hypertrophied heart.
We hit the ground running as soon as we all arrived back from break. Most of our class returned home, but a few embarked on an Italian adventure or the Swiss Alps for skiing. Now it’s back to presentations, papers, meetings, quizzes and a final in the not too distant future.

But today I got to hold a hypertrophied heart in my hands! There was a HEART. In my HANDS.

So I thought this 1st deserved its own post. I've never taken anatomy or worked with cadavers – though I imagine about half our class has this experience - so I felt slightly star struck to be hand-to-heart with physical proof that I am studying medicine. Our pathology course is taught by a Cardiothoracic/ER surgeon who also studied and now teaches Pathology. He is FANTASTIC - an excellent teacher and full of interesting stories from his years of work.  The lectures are so engaging which makes the lab that much more hands-on and interesting.

Today for our hour of lab I was reminded that I am a student of medicine and not just a student trying to successfully navigate school in Israel. Not to mention the fact that I was holding a heart, examining its thick muscular walls and valves and vessels, the calcified valve and fatty deposits covering its surface. However, I was also struck by the reality that I am able to learn and examine the pathology of gross anatomy because it tragically killed someone. One of the specimens we examined was a section of a child's heart with a congenital defect: As an aspiring Pediatrician, I may never adjust to the wave of recognition and sadness for the child's short life (and the fresh hole in the lives of the parents).

Jono taking a study break in
Caroline House
I am off to fix dinner for Irene and Caitlin – were supposed to be reviewing Biostatistics, but my guess is well be too immersed in Caitlins hilarious stories by the end of the night – laughing is no doubt the best medicine for any kind of stress!  On the menu – Moroccan couscous, sweet potato fries, pita & zatar (a common Israeli spice – hyssop + sesame seeds) and chocolate chip cookies from a U.S. mix (I brought it back from break in Colorado, ha). Finding ways to use the fresh produce and natural ingredients here has been a fun challenge for me!  I love to cook and bake and make more time than I might practically have to unwind in the kitchen.  The fruit and vegetable markets are always bringing in a new seasonal fruit or vegetable – and my limited Hebrew sometimes means I pick up an ingredient at SuperSol I think is one thingThen it becomes a google search for a recipe I can use so as not to waste it!
Jess and Aubrey in Bari.
Adam in the French Alps

Lean requires leadership buy in, support


 Bangkok Blog#5 – Written on Thursday, January 27, 2011 
By Michele Jordan, VP Quality Improvement and Transformation, RVHS

Today was another busy but very educational day.  Again we set off from the hotel before 7am for a hospital site visit.  (One thing I’ve learned is that you don’t want to get stuck in Bangkok’s rush hour traffic.)

We spent the day at the Siriraj Hospital. Before describing some of the hospital’s many, many Lean initiatives you cannot talk about Siriraj without mentioning two things – its size and its history. Siriraj is huge!  It is a sprawling ‘empire’ consisting of 74 buildings.  They have about 3,000 beds, 1200 physicians, approximately 8,000 nurses and about 4,000 other staff. They have 24 medical departments, a cardiac centre, the medical education technology centre and 8 paramedical schools. Their enormous medical library is the most amazing any of us on the tour had ever seen.  The hospital is currently in the midst of a major redevelopment project that would see them expand even further on their current site as they seek to become the Centre of Excellence in southeast Asia. Siriraj Hospital is situated right on river and the views from most buildings are spectacular.  Because of the traffic situation, water ambulances are common.

In terms of its rich history, Siriraj is the oldest hospital in Thailand.  It was established in 1888. The official opening was presided over by King Chulalongkorn. The hospital is named after his young son, Prince Siriraj, who died of dysentery while the hospital was being built. The hospital has always received strong support from Thailand’s royal family.  The father of the current King was a Harvard-educated doctor and his original medical school notebooks are displayed in the hospital library.  Interestingly, Siriraj is currently the residence of the  much beloved King of Thailand.  He is in his 80s and has been hospitalized there for over a year.  Each day hundreds of loyal subjects and busloads of school children come to the hospital to pray for the King. You can imagine the implications that having a King as an inpatient has for hospital security!

My day at Siriraj went something like this – official picture taking in the courtyard, formal presentation by hospital leaders on their Lean journey, two hour press conference for myself and the two experts from Singapore, lunch, tours of a few departments (the oncology unit, the trauma unit, the lactation clinic and postpartum area), discussion of what we saw, dinner with select hospital leaders and finally after-dinner presentations by Dr. Choo and myself on Lean leadership.  We left the hospital at 9pm!

Several things impressed me about Siriraj:
·         Their leadership team is strongly committed to Lean.  This was demonstrated in many ways including the promotion of our visit as part of the Lean in Healthcare conference (there were posters everywhere), the arrangement of a press conference just to talk about Lean, and at least four physician leaders gave us detailed presentations on Lean initiatives in which they are involved.  Like RVHS, Siriraj has a strategic plan-on-the-page and a strong set of core values that they have actually set to music.
·         Understanding of Lean is spreading throughout the hospital and improvement ideas have tended to come from the frontline.  On every unit we visited, nurses in traditional white dresses, white shoes and starched white caps were able to explain in detail the Lean principles and tools that they have chosen to apply to their areas – everything from process control boards, to Kanban systems, to visual management and some of the best 6S results I have ever seen.  One nurse was asked where she learned the Lean techniques she has applied to reorganize her supply room. She replied that she learned these techniques from her own research using books and the internet.
·         They have incredible discipline. Like everywhere else, staff  report that changing mindsets was tough at first but having made changes they are able to sustain them.  Everything is kept up-to-date. When asked whether they have trouble getting nurses to maintain the discharge board, one head nurse replied ‘no, it is what we do as nurses’.
·         Their data collection is rigorous.  For every Lean initiative they presented, there was good baseline and future state data. They have solid statistics to back up their successes.
·         They are fostering a healthy workplace for innovation.  They have recently launched a program called ‘R2R’(Routine to Research).  They are de-mystifying the concept of research as something only for scholars and showing how research and innovation can be part of everyone’s role.  This was very evident in the breastfeeding program.  Breastfeeding is a centre of excellence for Siriraj and they are leaders in breastfeeding research.  Five nurses and 2 practical nurses see 60 mothers a day in the lactation clinic.  Nurses that work in this program are encouraged to be very creative.  They walked us through the various types of breastfeeding-friendly hospital gowns they have designed, the breastfeeding pillows they have created for both comfort and infection control purposes, the Madonna jacket (unofficially known as the “Lady Gaga Jacket” -- see the photo) they designed to teach expecting mothers how to breastfeed and the application of Lean principles to create a reliable system for storage of breastmilk.  
·         They have invested in internal resources to support their Lean implementation.  They have a “Utilization Management/Lean Office” that is very similar to our TMO.  Six nurses spend 80% of their time in this Office coaching staff on how to make improvements.  They also offer 3 levels Lean training – Lean Basic, Lean Supervisor and Lean Manager.

Siriraj has too many Lean initiatives underway to describe each one but here are a few highlights of their achievements:
·         By reorganizing their model of nursing care using Lean’s cell concept, they have reduced average length of stay from 8 days to 4 or 5 days in less than 2 years.  It took 6 months to implement the changes.  Nurses meet once per week to discuss how to improve quality.
·         They have done a lot of work on end of shift handover rounds and reduced the time this takes from 45-60 minutes down to 15-30 minutes.  Now, nurses and doctors round together.  Nursing satisfaction has increased significantly for all indicators tracked including a sense of harmony on the team and feeling respected by doctors.
·         Patient satisfaction has increased to 95%!
·         They have used Lean in their clinics and reduced outpatient turnaround time by 35%.  They actually see 65% of outpatients earlier than their booked appointment time.
·         Given the vast size of the Siriraj campus, transporting lab specimens is time consuming.  By applying Lean to this process they reduced the staff required from 13 people to 1 person! Of course, there were no layoffs, and the staff time saved has simply been redeployed to meet other important patient needs.

The amount of positive change this large institution has been able to achieve in a relatively short period of time is quite phenomenal.  


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Read Bangkok Blog#4 

Less waiting as a result of Lean around the world

Bangkok Blog#4 – Written on Wednesday, January 26, 2011 

By Michele Jordan, VP Quality Improvement and Transformation, RVHS

Sawadee Ka!  (That means ‘hello’ in Thai.  Actually Sawadee means hello and ‘ka’ is added because I’m a female).  The Thai people are so friendly and welcoming that I’m starting to feel like a local.  I can see why they call Thailand ‘the land of smiles’.

Day 3 of the conference was a fantastic experience.  We visited two hospitals to see their Lean improvements. First stop was the Saohai Hospital .  This is a small, rural hospital located about 90 minutes outside of Bangkok so we boarded our convoy of vans around 6:30am.  The hospital has 30 beds and an occupancy rate of 82%.  They serve an average of 280 outpatients daily.  There are 3 doctors, 2 dentists, 3 pharmacists, 48 nurses, 4 medical technicians and 100 supporting staff.  The hospital is a beautiful open-air facility that resembles a spa more than an institution.  This is not a far-fetched comparison because the hospital offers a blend of modern medicine and alternative medicine including massage, acupuncture, infrared sauna, music therapy, 'past life regression' and more.

As we disembarked from the van we were greeted by several hospital staff who presented each of us with a beautiful bracelet made of flowers.  We proceeded to a large auditorium where, to our surprise, we were treated to a local dance performance.  This was followed by a formal presentation on the hospital’s Lean initiatives.   Like all of the demonstration projects, Saohai began their Lean journey in mid/late 2008.  For a small facility they have made tremendous progress.  One of their projects focused on reducing the waiting time in their outpatient diabetes mellitus clinic.  They implemented visual management, a 6S, an A3 and a series of kaizen events.  The biggest change they put in place was to work with the 13 Primary Care Units (PCUs) in the community to reassign roles.  Before Lean, patients arrived at the hospital clinic very early in the morning so they could have their blood taken before seeing the doctor.  Now, patients are asked to go their local PCU the day before their clinic appointment to have their blood taken by the PCU.  For many patients this reduced the travel distance significantly and meant they didn’t have to come as early to their clinic appointment.  Skype is used for communication between the PCUs and the hospital clinic if needed.  When one considers that the 13 PCUs are completely separate from the hospital, this is a huge system integration achievement. Here are some of the results of this initiative:
·         Reduced total Turnaround time in the clinic from 258 min to 196 min (59% improvement)
·         Reduced waiting time for consultation with the doctor from 72 min to 30 min (58% improvement)
·         Increased patient satisfaction rate from 81% to 91%

They have also used Lean techniques to educate and empower patients to use self-care.  After lunch, more dancing and group picture we boarded the van for our second stop – the Saint Louis Hospital in Bangkok .  The two hospitals are in stark contrast to one another.

Saint Louis is a non-profit, private general hospital that is run by the Sisters of Saint Paul de Chartres.  The 500-bed facility is extremely modern and includes escalators, a new state of the art cardiac clinic and a large board room with computer terminals and microphones at every seat.

The hospital leadership is strongly committed to Lean.  They said that they chose Lean because it fits well with their vision – ‘to be a leader of hope in health care and health promotion’. Their first Lean project was focused on improving the cardiology outpatient care process.  Improvements include:  setting up a schedule to phone patients 3 days after their visit, streamlining the process for preparing the medical record, creating a handover sheet for the patient’s next clinic/service, using visual controls and standard work.  The biggest change was renovating the entire clinic based on Lean’s cell concept.  The cell concept requires co-locating all the services that are part of the patient’s value stream in one area to reduce walking for the patient/family. They also have several large screen monitors that display who and how many patients are waiting for each doctor at any given time.   These changes have resulted in a 23% reduction in the waiting time for doctor consultation (from 43 min to 33 min); a 20% reduction in total patient turnaround time (from 186 min to 149 min), improved patient satisfaction and improved staff satisfaction.

This hospital also used Lean to improve the non-emergency patients care process in the ED. An analysis of ED volumes by time of day found that the peak period is between 4pm to 10pm (just like at RVHS) so the team focused their efforts on this time period. They set up a new flow for patients who need only medical treatment and set up a new medical treatment room near the ED.  Patients who just require a wound dressing and are not first time patients are seen and treated by a nurse.  Cycle time and takt time calculations have been used to establish a process control board that lays out the timing for each step in the dressing change process. They introduced lots of visual management and standard work is posted in the department.  An x-ray alert card has been created to communicate when x-ray results are ready.  This hospital has empowered and trained nurses to function independently.  They can order x-rays before the doctor has seen the patient to reduce waiting time.  As a result of all these changes they have improved ED turnaround time by 69% - from 96 minutes to 30 minutes!

Saint Louis Hospital has a clear plan for where they wish to go with Lean.  They have a ‘Lean Council’ and invest in training. They are introducing a ‘unit optimization’ program whereby each unit will be asked to identify 3 priority problems they need to fix and they will pick one problem to work on.  There will be awards for the best performing teams.

All in all, this was a very interesting day. Both hospitals – one large and one small- have made very impressive progress and seem motivated to stick with Lean for the long term.


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Thursday, January 27, 2011

The Diabetes Epidemic

The CDC just released its latest estimate of diabetes prevalence in the US (1):
Diabetes affects 8.3 percent of Americans of all ages, and 11.3 percent of adults aged 20 and older, according to the National Diabetes Fact Sheet for 2011. About 27 percent of those with diabetes—7 million Americans—do not know they have the disease. Prediabetes affects 35 percent of adults aged 20 and older.
Wow-- this is a massive problem. The prevalence of diabetes has been increasing over time, due to more people developing the disorder, improvements in diabetes care leading to longer survival time, and changes in the way diabetes is diagnosed. Here's a graph I put together based on CDC data, showing the trend of diabetes prevalence (percent) from 1980 to 2008 in different age categories (2):


These data are self-reported, and do not correct for differences in diagnosis methods, so they should be viewed with caution-- but they still serve to illustrate the trend. There was an increase in diabetes incidence that began in the early 1990s. More than 90 percent of cases are type 2 diabetics. Disturbingly, the trend does not show any signs of slowing.

The diabetes epidemic has followed on the heels of the obesity epidemic with 10-20 years of lag time. Excess body fat is the number one risk factor for diabetes*. As far as I can tell, type 2 diabetes is caused by insulin resistance, which is probably due to energy intake exceeding energy needs (overnutrition), causing a state of cellular insulin resistance as a defense mechanism to protect against the damaging effects of too much glucose and fatty acids (3). In addition, type 2 diabetes requires a predisposition that prevents the pancreatic beta cells from keeping up with the greatly increased insulin needs of an insulin resistant person**. Both factors are required, and not all insulin resistant people will develop diabetes as some people's beta cells are able to compensate by hypersecreting insulin.

Why does energy intake exceed energy needs in modern America and in most affluent countries? Why has the typical person's calorie intake increased by 250 calories per day since 1970 (4)? I believe it's because the fat mass "setpoint" has been increased, typically but not always by industrial food. I've been developing some new thoughts on this lately, and potentially new solutions, which I'll reveal when they're ready.


* In other words, it's the best predictor of future diabetes risk.

** Most of the common gene variants (of known function) linked with type 2 diabetes are thought to impact beta cell function (5).

Two Wheat Challenge Ideas from Commenters

Some people have remarked that the blinded challenge method I posted is cumbersome.

Reader "Me" suggested:
You can buy wheat gluten in a grocery store. Why not simply have your friend add some wheat gluten to your normal protein shake.
Reader David suggested:
They sell empty gelatin capsules with carob content to opacify them. Why not fill a few capsules with whole wheat flour, and then a whole bunch with rice starch or other placebo. For two weeks take a set of, say, three capsules every day, with the set of wheat capsules in line to be taken on a random day selected by your friend. This would further reduce the chances that you would see through the blind, and it prevent the risk of not being able to choke the "smoothie" down. It would also keep it to wheat and nothing but wheat (except for the placebo starch).
The reason I chose the method in the last post is that it directly tests wheat in a form that a person would be likely to eat: bread. The limitation of the gluten shake method is that it would miss a sensitivity to components in wheat other than gluten. The limitation of the pill method is that raw flour is difficult to digest, so it would be difficult to extrapolate a sensitivity to cooked flour foods. You might be able to get around that by filling the pills with powdered bread crumbs. Those are two alternative ideas to consider if the one I posted seems too involved.

Tuesday, January 25, 2011

Presenting Lean - Insights from Singapore hospitals and RVHS

Bangkok Blog#3 – Written on Tuesday, January 25, 2011
Michele Jordan
VP Quality Improvement and Transformation


The format for Day 2 of Seminar on Regional Sharing on Lean in Health Care was a little different than Day 1.  The first day was a small gathering of about 25 invited delegates from across Asia. The second day was open to the public, and there were approximately 250 participants from health care organizations in the local Bangkok area.

There was a poster exhibit with several hospitals promoting their Lean achievements. A range of clinical areas were covered, including cardiac outpatient care processes, chemotherapy for solid organ tumours, breastfeeding and surgery. I was very impressed with the work of a team at the King Chulilongkorn hospital that applied Lean to improve operating room utilization for colorectal surgery. In just one year, this hospital was able to increase OR utilization from 44% to 74% while also reducing cancellations from 35% to 10%!

The formal part of the conference included two speakers that I had been anxiously looking forward to meeting – Dr. Kelvin Loh and Dr. Philip Choo.

Dr. Kelvin Loh (MBBS, MBA) is the CEO of the Mount Elizabeth Hospital in Singapore. After introducing Lean in some Singapore hospitals, he was hired as the expert consultant for the five-hospital Lean demonstration project in Thailand. He talked about value stream mapping, sustaining the gains and spread. Dr. Loh promotes the concept of a combined ‘top down and bottom up approach’ to Lean implementation – something worth exploring at RVHS. Value stream mapping in Asia is more oriented to patient groups or specific procedures (e.g. total knee replacement). The VSM crosses clinical departments. Dr. Loh recommends that hospitals have three levels of coordination to support their value stream improvements:
  1. A ‘VSM Driver’ who owns the value stream that is being mapped -- i.e. someone who owns total knee replacement;
  2. A few process owners for departments that fall within the value stream (e.g. nursing, physiotherapy); and 
  3. An overall coordinating Lean Council or Quality Council that keeps track of all VSM projects and prioritizes activity.
Dr. Loh ended his talk with a few thought provoking ideas to use Lean to improve processes. For example, load leveling in outpatient clinics to eliminate what he calls the ‘morning tsunami’ that is so common in hospital clinics. He suggests scheduling non-fasting patients and those who live close to the hospital in the afternoon rather than have everyone come in the morning. He also challenged the notion of all departments running clinics and rounding at the same time. He suggests a model where clinic space could be shared between medicine and orthopaedics for example. Orthopaedics would use the clinic in the morning and do their inpatient rounding in the afternoon. Medicine would use the clinic in the afternoon and do their inpatient rounding in the morning. He also recommended one-stop shopping for patients, much like what we have introduced in our pre-op clinics at RVHS.

Professor Philip Choo, CEO of the Tan Tock Seng Hospital in Singapore is one of the strongest advocates for Lean I have ever met. He has visited hospitals all over the world, learning how they have approached Lean. His presentation was entitled, “Leadership at all levels - A Key Success Factor in Lean Paradigm Shift”. He shared some very insightful information on requirements for cultural change, the role of leadership and seven competencies of effective leaders. I had the opportunity to speak with Dr. Choo over lunch, where we compared notes on our efforts to improve the discharge process and our application of EDD (estimated date of discharge). In Dr. Choo’s hospital, the most responsible physician must identify the EDD for the patient within 24 hours of admission. They must communicate it to the clinical team and write it on the discharge whiteboard on the unit. If a doctor does not identify an EDD, Dr. Choo is informed and takes it up with the chief of the department and the individual doctor – he notes that no doctor want to experience this twice.  His hospital has made dozens of excellent improvements since starting Lean in 2007. For example, cataract surgery is now booked as a 15-minute procedure with high-quality outcomes.

After hearing Drs. Loh and Choo speak, I told them how excellent their presentations were and that my only complaint was that they had left very little for me to say because our tools and strategies are so similar.

In the afternoon, I had the opportunity to give a one-hour presentation. I covered:
  • Lean in the Canadian health care system
  • Application of Lean at RVHS
  • Lessons Learned
Everyone at RVHS should be very proud to know how impressed the audience was with our progress. I have already had two people express interest in coming to Canada to visit us.

The day ended with a two-hour panel discussion in which I took part. We focused on how to sustain Lean and took questions from the audience.

Monday, January 24, 2011

Blinded Wheat Challenge

Self-experimentation can be an effective way to improve one's health*. One of the problems with diet self-experimentation is that it's difficult to know which changes are the direct result of eating a food, and which are the result of preconceived ideas about a food. For example, are you more likely to notice the fact that you're grumpy after drinking milk if you think milk makes people grumpy? Maybe you're grumpy every other day regardless of diet? Placebo effects and conscious/unconscious bias can lead us to erroneous conclusions.

The beauty of the scientific method is that it offers us effective tools to minimize this kind of bias. This is probably its main advantage over more subjective forms of inquiry**. One of the most effective tools in the scientific method's toolbox is a control. This is a measurement that's used to establish a baseline for comparison with the intervention, which is what you're interested in. Without a control measurement, the intervention measurement is typically meaningless. For example, if we give 100 people pills that cure belly button lint, we have to give a different group placebo (sugar) pills. Only the comparison between drug and placebo groups can tell us if the drug worked, because maybe the changing seasons, regular doctor's visits, or having your belly button examined once a week affects the likelihood of lint.

Another tool is called blinding. This is where the patient, and often the doctor and investigators, don't know which pills are placebo and which are drug. This minimizes bias on the part of the patient, and sometimes the doctor and investigators. If the patient knew he were receiving drug rather than placebo, that could influence the outcome. Likewise, investigators who aren't blinded while they're collecting data can unconsciously (or consciously) influence it.

Back to diet. I want to know if I react to wheat. I've been gluten-free for about a month. But if I eat a slice of bread, how can I be sure I'm not experiencing symptoms because I think I should? How about blinding and a non-gluten control?

Procedure for a Blinded Wheat Challenge

1. Find a friend who can help you.

2. Buy a loaf of wheat bread and a loaf of gluten-free bread.

3. Have your friend choose one of the loaves without telling you which he/she chose.

4. Have your friend take 1-3 slices, blend them with water in a blender until smooth. This is to eliminate differences in consistency that could allow you to determine what you're eating. Don't watch your friend do this-- you might recognize the loaf.

5. Pinch your nose and drink the "bread smoothie" (yum!). This is so that you can't identify the bread by taste. Rinse your mouth with water before releasing your nose. Record how you feel in the next few hours and days.

6. Wait a week. This is called a "washout period". Repeat the experiment with the second loaf, attempting to keep everything else about the experiment as similar as possible.

7. Compare how you felt each time. Have your friend "unblind" you by telling you which bread you ate on each day. If you experienced symptoms during the wheat challenge but not the control challenge, you may be sensitive to wheat.

If you want to take this to the next level of scientific rigor, repeat the procedure several times to see if the result is consistent. The larger the effect, the fewer times you need to repeat it to be confident in the result.


* Although it can also be disastrous. People who get into the most trouble are "extreme thinkers" who have a tendency to take an idea too far, e.g., avoid all animal foods, avoid all carbohydrate, avoid all fat, run two marathons a week, etc.

** More subjective forms of inquiry have their own advantages.

Non-profit health insurer surpluses: Hearings scheduled for Weds and Thurs

The state House of Representatives and state Senate are holding hearings this week on some of our key bills.

We want to:
  1. Limit the rate increases of nonprofit health insurers once they build up a large cash surplus.
  2. Make health insurer rate filings public, like Oregon does. Much of the data is now considered a trade secret, meaning we can't release it.
  3. Renew our authority -- now set to expire at the end of this year -- to review individual health insurance rates.
The first hearing only includes the surplus bill, HB 1301/SB 5247. It's at 8 a.m. on Wednesday in Hearing Room 4 of the J.A. Cherberg Building, on the capitol campus in Olympia.

The second hearing -- which includes all three bills mentioned above -- is at 10 a.m. on Thursday in Hearing Room B of the John L. O'Brien Building, which is also on the capitol campus in Olympia.

HealthCorrelator for Excel (HCE) is now publicly available for free trial

HealthCorrelator for Excel (HCE) is now publicly available for download and use on a free trial basis. For those users who decide to buy it after trying, licenses are available for individuals and organizations. If you are a gym member, consider asking your gym to buy an organizational site license; this would allow the gym to distribute individual licenses at no cost to you and your colleagues.

HCE is a user-friendly Excel-based software that unveils important associations among health variables at the click of a button. Here are some of its main features:

- Easy to use yet powerful health management software.

- Estimates associations among any number of health variables.

- Automatically orders associations by decreasing absolute strength.

- Graphs relationships between pairs of health variables, for all possible combinations.

The beta testing was successfully completed, with fairly positive results. (Thank you beta testers!) Among beta testers were Mac users. The main request from beta testers was for more illustrative material on how to use HCE for specific purposes, such as losing body fat or managing blood glucose levels. This will be coming in the future in the form of posts and linked material.

To download a free trial version, good for 30 use sessions (which is quite a lot!), please visit the HealthCorrelator.com web site. There you will also find the software’s User Manual and various links to demo YouTube videos. You can also download sample datasets to try the software’s main features.

2011: Innovation

Imagine a panacea pill, the most innovative novel product to date. Dr. Ahmed Mushfiq Mobarak from the Yale School of Management studies why it may fail. He began Monday night’s Global Health Seminar series for the professional schools with: “It’s not that we don’t have the solutions, but that once they’re on the market, people aren’t buying them.”

In true economist form, his presentation was entitled “Low Demand from ‘Apparently Beneficial’ Products and Behaviors.” His field research took us to Rangpur, one of the poorest and famine-ridden regions of Mobarak’s native Bangladesh where seasonal migration rates are also the lowest in the country. Mobarak’s research piloted cash and credit migration facilitation programs and found that having a migrant worker in the family was an effective source of income and thus, an increase in the health measurement of caloric intake. So why were there not more migrant workers before? Mobarak’s explanation is a behavioral one: regardless of the slim probability, the consequences of failure are too overwhelmingly devastating. No “culturally salient educational” intervention would be effectual enough to override this behavior but further development of his intervention programs might.

In the same way, Mobarak’s second project in the presentation involved discovering why technologically improved cook stoves that reduce indoor pollution were not being “taken up,” or used. You can read the details of his positive conclusions on social network marketing here, but what I’d like to note was how freely Mobarak shared the criticisms of his own projects, which will drive his next. The act of building a cheap, resource-sensible stove is a “complex engineering problem with a lot of constraints” and acknowledged that he was going back to the drawing board with engineers on developing more powerfully efficient stoves to market.

The Global Health Seminar promises themes of innovation, implementation, and maternal and child health for the semester. Although Mobarak lectured under the banner of innovation, I might say that his focus was implementation – on the difficult and oftentimes unexpectedly perplexing movement of technologies out of the lab and academia and into the real, developing world.

Connie Cho, GHLI Intern