Jul 25, 2009

Caveat Emptor

As the healthcare reform effort moves forward, one of the most difficult sticking points has been how to reign in costs. After President Obama's primetime address on healthcare this week, several questions from reporters were directed at what sacrifices the American public would be asked to make to keep healthcare affordable. The President alluded to the need to spend money on care that works, and stop spending money on what doesn't work. But unsurprisingly, a noncontroversial specific example has been elusive.

Costs of Care team member Devin DeCiantis recently posted a blog entry on this topic: http://costsofcare.blogspot.com/

What do you think? What are some things we routinely spend money on in healthcare that don't work or don't help people get healthier?

Add your comments here or join us at Facebook.

Jul 22, 2009

Want to get published?

Many of us dream of writing and publishing our work ... and others go out and actually do it. How can the dreamers become the doers?

During today's On Call teleconference, Quality and Safety in Health Care editor David Stevens and IHI's executive editor Frank Davidoff suggested a few ideas:

1. If you dread writing, as many do, try breaking the work up into manageable chunks.
2. If you don't have time, just set aside 15 minutes a day to write, maybe first thing in the morning.
3. Just decide that writing is going to be a priority for you. Just DO it.
4. Carry a little notebook and capture your thoughts, ideas, and phrases as they occur to you.
5. Find a writing teacher or mentor -- everyone needs a coach.
6. Find a faculty co-author to work with. It's a great learning experience.

And a few thoughts about publishing:

1. Journal editors consider several points when they look at submissions. Is it original? Do readers care about the subject? Does the paper reflect clear thinking? Are there actual results that are statistically sound? Do the discussion and conclusion reflect good insight? And is the paper well written?
2. You don't have to take every bit of advice from every reviewer. You can talk with the editor and engage in a type of negotiation about which points to adopt.
3. Sometimes reviewers are downright mean. Don't let it get you down. Feel free to talk to the editor if a reviewer is really malicious.

If the call gave you the urge to get publishin', check out the IHI Open School's brand-spanking-new Writer's Corner -- an online resource loaded with tips and support for student writers.

The audio recording of this call will be up on the Open School site within a week or so -- and you can check back for it here too.

What advice do YOU have for students who want to write and publish? What works for you? What's your routine to stay motivated?

Swiffer Solutions for Health Care

Eva Luo “co-blogs” with guest contributor Curtis Chan, an analyst at Innosight, an innovation consulting firm in Watertown, MA co-founded by HBS professor and innovation expert Clay Christensen.

When I imagine a world without the Swiffer, I see it as a post-apocalyptic dustscape. Dead skin cells sublimate and overtake nitrogen as the most prevalent constituent of the atmosphere. People have acclimated to the ubiquity of filth, spills, and dirt: soil is no longer tracked into the house – your mom yells at you for adding a fresh coat to the carpet of mud. And, fully unbridled, wanton dust bunnies spawn like, well, bunnies.

Fortunately, Swiffer does exist. Launched by Proctor & Gamble (P&G) in 1999, the cleaning product had 75% market share of the quick-clean market, which totaled $750 million in revenue in 2005. (1) With the massive success of the product, have you ever stopped to think to yourself: “It’s a disposable towel. On a stick. Where the heck did Swiffer come from? And how in the heck did P&G dream it up?”

The answer, it seems, is by just looking. As revealed in The Innovator’s Guide to Growth, Swiffer was the product of an observational study conducted by P&G that followed consumers around their homes, looking around the house, observing behaviors, and generally hunting for clues as to what kinds of things consumers need to get done throughout the day. (2) The observed consumer needs and desires that the researchers observed helped inform P&G how to create and design innovative products or processes to help meet those needs and desires.

For fun, I’m going to take more than a few liberties with the details of an anecdote from the observational study here, but the message is faithful. This is how I would imagine an episode of the P&G study:

    Two P&G researchers followed a nice, grandmotherly lady as she ambled about, showing them around her house. When she flung the doors of her closet open, the researchers noticed that a broom covered with dust stood in the corner. In another closet, a vacuum cleaner sat, unused and forlorn. The researchers nodded conspiratorially at each other as they jotted notes.

    They all wandered into the kitchen. Jarring the researchers from their note-taking frenzy, the woman asked them, “Would you nice boys like some coffee?” The researchers agreed, blushing at being called “nice boys.” As the woman took a can of coffee grounds down from the pantry and opened it, the can slipped from her hands. She cried out as the can tumbled to the ground, strewing coffee grounds across the floor.

    Instantly, she grabbed a paper towel and attacked the mess, muttering to herself as she crouched on the floor. When she stood again, the researchers were staring at her, befuddled. “What?” she asked, the look of puzzlement on their faces engendering a puzzlement of her own. “You didn’t use the broom,” one researcher remarked. “Or the vacuum cleaner,” the other chimed in.

    With a sigh, the lady vented her frustration –the broom wouldn’t do a good-enough job and would leave coffee grounds on the floor, and the vacuum cleaner was heavy, cumbersome, needed to be plugged in, and was just overkill for the small mishap.

    The researchers nodded and wrote. Then, flipping their notebooks closed, they smiled and glanced at each other again with that same conspiratorial look, the gleam of excited insight shining from their eyes.

P&G took the findings from their observational research and created the Swiffer, a dispensable electrostatic cloth fixed on the end of a long handle, which got the job done of cleaning up small spills just right. By employing an observational approach – in the natural setting of consumption – the researchers were able to see what the old lady would never have been able to tell them in a survey or a focus group; they were able to notice products around the home that went unused and were able to watch actual behaviors during real-time events. Based on real environments and behaviors, researchers can ask more informed questions to garner more useful, reality-based consumer responses. Indeed, by employing observational research, P&G was able to understand their customers and precisely what they needed and wanted to get done in the day.

Are there health care Swiffer stories? Can observational research help us better understand our patients and what they both need and want in order to achieve better health and experience better health care? The answer, it seems, is yes.

One such example is Project HEALTH, a non-profit organization located in Boston, MA that seeks to break the link between poverty and poor health outcomes. The story of Project HEALTH’s birth is a story of observational research, just like the Swiffer story. Dr. Barry Zuckerman, Chief of Pediatrics at Boston Medical Center and Co-Founder of Project HEALTH often tells this story:

    A six-year-old boy who suffered from uncontrolled asthma arrives at the Boston Medical Center for care. Despite receiving daily oral doses of corticosteroids, a common asthma prevention medication, he was absent from school once or twice every six weeks. As a result, his mom was forced to miss work in order to take care of him and bring him to the hospital for care. The boy has insurance, so access is not the problem. He is also seeking care at Boston Medical Center, a reputable teaching hospital, so neither is quality of care the cause for his frequent visits to the hospital. Why then is asthma a major disruption in his life and the life of his family?

    On a visit to the young boy’s home, the visiting nurse discovered asthma triggers: mold due to a leaky water pipe and wall-to-wall carpeting harboring dust mites. Thus, each step of improvement the young boy tried to make was inevitably countered by his poor living conditions. Dr. Zuckerman often says, “I can provide the most updated form of medical care for low income families, but they would still get sick.” Upon discovery of the asthma triggers in the young boy’s home, negotiations with the landlord led to replacement of the leaky pipe, clean-up of the mold, and removal of the carpet. Within six weeks, the young boy had stopped corticosteroid asthma treatment and was attending school regularly. (3)

Rebecca Onie, Co-Founder of Project HEALTH adds another layer to Dr. Zuckerman’s observational research. Onie notes that several physicians understand this connection between poverty and poor health outcomes but are “frustrated because the clinical interventions that they can do in 18 minutes are not enough to change the health of their patients.” Furthermore, physicians are often unaware of what they can do to help address these psychosocial issues. This physician and caregiver inaction is a systems design problem.

Combining these two parts of observational research has led to a health care Swiffer: an innovative new care model that meets the patients’ needs called Project HEALTH. This is the logic: The hospital is the site where health care is delivered—and with just a minor stretch is also a convenient site where psychosocial interventions can be introduced to better and more comprehensively improve the health of kids and their families. The systems redesign answer is a crew of motivated college students stationed in the hospital. If doctors feel their patients need assistance obtaining housing, have food insecurities, or can benefit from utilities bills discount programs, doctors can now refer patients to Project HEALTH volunteers who work with patients to obtain those resources right there in the hospital.

A simple solution that has achieved great positive change, Project HEALTH now has locations in New York, Providence, Chicago, Baltimore, and Washington D.C. Project HEALTH was also just recognized by Michelle Obama at Time’s 100 Most Influential People Awards Gala. This year, 600 Project HEALTH volunteers will dedicate 100,000 hours to connect over 15,000 low-income children and adults with the resources they need to be healthy. (4)

How could health care improve if observational research was more commonly used? Are there Swiffer-like solutions for every health care problem?

Following the model of observational research itself: Let’s look and see.