The Joy of Healing: Bridgton, Maine 1975 -1985

Berry Pond, Sweden, Maine

Why would a city boy from New York, go from Miami, Florida to work in rural Maine?  Short answer: Life and Lifestyle.  I was done with the NY hustle and the Miami frenzy.  Finished with outrageous prices and people rushing around for … what reason?  Tired of talk and not enough action.   This was the “dream” place and these were the best years for my family and my Family Medicine career.  Sure, there are dreams and there are Dreams.  And there is no perfect place for anything.  Let me be blunt.  It is not easy to earn a living and to live in rural Maine, and it is not “perfect” for many reasons.  But, for now I will focus on the positive.

We chose Bridgton because it was a great place for me to work and think; to provide comprehensive and “definitive care” to patients who appreciated it, a setting that would allow me to use all my knowledge and skill, to care for and treat those in need, to teach, to do research, to promote programs that would help build the health and health care of individuals, families and the community.  Plus it gave me time and a place to recover with and for my young family.  It was a chance to live and grow together in a beautiful rural New England location.  We were just far enough away from the “inlaws and outlaws” (a phrase borrowed from my father) and we had every intention of staying here for the long haul.  So, in July 1975 the Lakes Region of Maine became the place to put my dreams into action.

What was it about this place that made it right for us?  “Do what you love and Love what you do,”  “You have to go where you find your Renaissance.”  These are phrases I have used over the years to encourage patients, friends, family and especially my children.  As I look back on it, as odd as it may sound, Bridgton, Maine provided a Renaissance opportunity for me and my family … an opportunity to put my ideas into Action.  How did it play out?  In retrospect, I would have to say that these were probably the most productive years of my life.  But, it was not about me and I was not alone … it was about reciprocity, give and take, or in the words of Hans Selye, it was “altruistic egotism”.  Do what you love in ways that are good for others.  And, I have to say, as best I can tell, we were, for the most part, all on the same page for about ten years.

In other words, we were a group of young and dedicated physicians, nurses and other providers, we all loved what we did, we did it for the patients and the community, and we were “the only game in town” for the bulk of the community.  And all patients and providers benefited from the work.  It was out of this soup that came many remarkable things.  But the focus of this message is on Quality Improvement, Performance Improvement and Building Best Practices (QIPI & B2).  During these years at the hospital, we developed an exemplary, robust and scientific Quality and Performance Improvement process that included, Non punitive Morbidity and Mortality Reviews, Peer Review and a Continuous QIPI process that was complete with, remediation, Targeted CME and report cards.  For the time, it was way ahead of the curve.  And, we had good results … good outcomes.  For example, our hospital length of stay was the shortest in the state, and our patients did remarkably well overall.  We worked hard, played hard, got good results and had fun.

But, this good work could not continue.  1985 was a remarkable year in US Health Care for many reasons.  I called it the perfect storm and it hit us hard.  The bottom line is this: it marked the end of an era that allowed our health care community to provide optimal care for and treat the members of our community at large.  Third parties with vested interest in the stealing our patients made sure of that.  I will speak of the details later on, but at the time my options to care for the sick diminished and I began to explore other opportunities to put my knowledge and skill to work.

Despite the complexities, I moved to my second medical career in Academic Anesthesiology and Critical Care, and the QIPI & B2 work we did in Bridgton, became the foundation for continued work in Quality and Performance Improvement and the creation of more tools that help work toward best care.  Within the last few years, it has become obvious that administrative shifts toward money and away from quality were obstructing our efforts to use rational cost containment strategies that improved quality first.  This fact made it perfectly clear that it would take Patient Engagement to move QIPI & B2 in the right direction.  So, the process has now moved to include Patients (an obvious flaw in earlier designs) and the only way to get Health Care Institutions to pay attention and to change their ways.  That is the short story of how the B2 system for building best practices was born.  It is a scoring system to rate both process and outcome and the patient is a key player in the use of the tool.

A few members of the Society for Participatory Medicine have encouraged me to share this work.  And, so it is that I share the latest version for your personal use and to keep in synchrony with the principle that patients are the center of the care team.  I ask our readers, patients and providers to use it and give feedback.  If you copy, request by email works best.  mfmascia@VeritasHC.org   Please comment, so we can improve it.  And, we thank you in advance.   IF you need help with it ask me.  IF anyone wants to use it for commercial purposes, talk to me and we can go from there.

Thanks for helping me to help you.

Dr. Mike

PS. Please forgive my comments (ITALICS) today and the formatting errors.  Word Press does not give me a way to stick the PDF form in here.

PPS. Please focus your comments on the patient sections and, if you are a provider, pretend you are a patient.

THIS IS THE FORM AS WE STARTED TO USE IT AT GEISINGER A LITTLE OVER A YEAR AGO.  I HAVE SINGLE PAGE PROCESS AND OUTCOME SCORE CARD THAT IS USED ON ROUNDS.  WILL PUT THAT UP, IF THERE IS INTEREST.

CRITICAL PREEXISTING CONDITIONS INCLUDING ALLERGIES AND IDIOSYNCRATIC REACTIONS TO PRIOR TREATMENTS SHOULD GO IN THE BASIC DATA THAT DOES NOT CHANGE FROM

PATIENTS, PLEASE FOCUS ON PROCESS TARGET #1

FAMILY INTEGRITY PROTECTION & PRESERVATION

(MFM NOTE: There should be UP TO 10 items listed under each process target, maybe more. Add if you like. Don’t subtract.  Just add and I will edit in time. Thanks)
(WE NEED 10TARGETS IN EACH GROUP)

StepWisely® Stompp™©* B²â„¢Â© GMC PILOT #1 V12212013 Not for commercial use.  Not to be used without permission. Not part of the patient record.

STRATEGIC TARGETED OPERATIONS MANAGEMENT for Patient Protection*ICU daily rounds checklist: care coordination and integration tool.

GOAL: OPTIMAL PATIENT CARE through team development & teamwork (“get everybody on the same pageâ€)

Demographics & Basic Data:

Patient name: sticker	Today’s date:
Admit date:	Consulting services:
Admit service:	Reason for admission:
Primary Diagnosis/problem:	Reason in ICU:
Primary service:	Referring physician:
Primary family contact:	Power of Attorney:
CODE STATUS:	ADVANCED DIRECTIVES ON THE CHART:
Other?	Other?

 

Top 10ⁿ TARGETS For Best Care = T10^NT™© 4 B²: See separate Guidelines1, Protocols2, Bundles3, Initiatives4 & Packs5 for details. Use QI/PI Data Sheet to List Need for new Guidelines.

1. Process Target # 1 = FAMILY INTEGRITY PROTECTION & PRESERVATION

Guidelines: Are we doing everything possible to help the family deal with the Patient’s illness and care?

Score 0-1 points for this target = max score 1.0 for this target. 0.1 point for each completed task.

(MFM NOTE to HL: There should be UP TO 10 items listed here, maybe more. I will fix the first target and you can go back to the original with all my scribbles on it to put all the stuff in there. Don’t take anything out. Just format/add and I will edit in time)

√	CATEGORY and SCORE (No = 0/Yes =1)	SCORE
	Comfort: Physicial, emotional, financial issues addressed? (0 or 0.1)
	Family Leader/MPA Established? (0 or 0.1)
	Family daily communication? (0 or 0.1)
	Family conference scheduled? (0 or 0.1)
	Discharge planning in the works? (0 or 0.1)
	Long term care considerations in the works? (0 or 0.1)
	Optimal Patient Support Network Established? (0 or 0.1)

Feedback needed here via mfmascia@VeritasHC.org, or comments on the bottom of the blog page.

2. Process Target #2 = PATIENT INTEGRITY PROTECTION & PRESERVATION

Guidelines: Are we doing everything possible to optimize the Patient’s outcome?

Score 0-1 points for this target = max score 1.0 for this target. 0.1 point for each completed task.

(MFM NOTE to HL: There should be UP TO 10 items listed here, maybe more. I will fix the first target and you can go back to the original with all my scribbles on it to put all the stuff in there. Don’t take anything out. Just format/add and I will edit in time. You can finish Target #2 and move on to Target #3- Target #10, OK?)

√	CATEGORY and SCORE (No = 0/Yes = 0.1)	SCORE
	Determine Patient’s Capacity to make decisions? (0 or 0.1)
	Can the patient make decisions? YES or NO?	Y/N
	Are we providing care according to Patient’s wishes? (0 or 0.1)
	Do we know the Patient’s Wishes?
	Are the Patient’s wishes in writing? (When in doubt, err on the side of life, unless medical futility has been established. See separate futility docs.)
	Does the Patient have advanced directives?
	On Target with Diagnosis and treatment?
	Is Patient Progressing toward therapeutic goals?
	Patient/MPOA/Family in the loop?

Feedback needed here via mfmascia@VeritasHC.org, or comments on the bottom of the blog page.

3. ALL GENERAL PATIENT PROPHYLAXIS GUIDELINES: NOSOCOMIAL COMPLICATION PROPHYLAXIS AND ENVIRONMENTAL CONTROL. ARE WE DOING EVERYTHING POSSIBLE TO PREVENT HOSPITAL, ILLNESS AND TREATMENT ASSOCIATED COMPLICATIONS?

 

ID: SEPSIS, LINES, HARDWARE, VAP, UTI, GEN IMMUNIZATION AND IMMUNE BOOST.     SPECEFIC: Line Holidays? Line Changes?   Abx& prophylaxis end points?
NON INFECTIOUS: DVT-PE, ASHD. EYE, SKIN, DELERIUM, GLUCOSE, FALL, MALNUTRITION, DECUBITUS ULCER, GI BLEEDING, GENERAL DEBILITY SPECIFIC: RESTRAINTS, INSULIN, KINETICS, ROOM (LIGHT, NOISE, TEMP CONTROL)

 

4. SPECIFIC ORGAN PROTECTION & PRESERVATION AND TREATMENT OPTIMIZATION GUIDELINES: (GENERIC AND DISEASE SPECIFIC). ARE WE DOING EVERYTHING POSSIBLE TO OPTIMIZE PRIMARY, SECONDARY AND TERTIARY DISEASE PREVENTION?

 

CNS (BRAIN & SPINAL CORD): PERFUSION & BP CONTROL? ^Na+? ^ Mg++?                                 TEMP CONTROL? H/H = 10/30? EUGLYCEMIA? EUVOLEMIA?
HEART: PERFUSION? BETA BLOCKER? HEART RATE CONTROL? ASPIRIN?
LUNG: PERFUSION? ASNJMB Guidelines?   VENT: Smallest tidal volume and lowest pressures?     Weaning vent? Minimize ABG draws? Sedation Holiday? VAP prophylaxis? TOF?
KIDNEY: PERFUSION? High Cardiac Filling Pressures? Euvolemia +?
GUT:   PERFUSION?
LIVER: PERFUSION?
MUSCULOSKELETAL: PERFUSION? KINETICS?
SKIN:   PERFUSION? KINETICS

 

 

5. DOCUMENTATION IN RECORD:

Diagnoses and Problems listed in PRIORITY order?
PROGRESS NOTES?
Procedure notes include DX?
Separate Procedure note for each procedure?
ORDERS?
BILLING: Proper documentation to reflect charges?

 

6. QUALITY AND PERFORMANCE IMPROVEMENT ISSUES

: Q & PI Documentation on separate encounter form?

 

7. STAFFING

Physicians
RNs
Other

 

8. PHYSICIAN’S TIME WELL SPENT? (staffing use of time)

High value
Breaks
Sleep

 

9. SURGE CAPACITY

 

1. OVERALL

Smooth
Quiet
Swift
Timely
Precise
Accurate
Effective
Communication
Coordination
Control

 

 

TODAY’S TARGETS & PLANS:

 

NAMES/SIGNATURES:

SICU RESIDENT:	SICU ATTENDING:
PATIENT, or FAMILY REPRESENTATIVE/MPOA:	TEAM PHARMACIST:
BEDSIDE NURSE:	TEAM RESPIRATORY THERAPIST:
TEAM DIETICIAN:	PRIMARY ATTENDING:
CONSULTANT ATTENDING:	OTHER:

 

StepWisely® Stompp™©* B2™© MFM GMC PILOT #1 V12212013
STRATEGIC TARGETED OPERATIONS MANAGEMENT for Patient Protection*ICU daily rounds checklist: care
coordination and integration tool.
GOAL: OPTIMAL PATIENT CARE through team development & teamwork (“get everybody on the same pageâ€)