Thursday, March 31, 2011

I'll Take My Business Elsewhere

I went to a Chicago Bulls game a couple of weeks ago with my friend Phil and during a 40-point rout of the hapless Sacramento Kings, we started talking about health care. Sad, I know. But with a 20-point lead at halftime and Da Bulls' superstar point guard Derrick Rose resting on the bench, it was hard to stay focused on the game. Plus, Phil and I are both in our 40s, so after touching base on the kids' schools, the start of t-ball and Little League practice, home repairs and Libya, what was left?

I asked Phil, who's been in health care communications for more than a decade, if he likes his primary care doctor. I happen to be in the market for one. True confession: I haven't seen my primary care doctor for at least two years. True confession II: I falsely claimed I would schedule an annual physical just to get a prescription renewed. I've grown less enamored with the practice over the years for a variety of reasons and have been using retail clinics for routine illnesses and a specialist for a chronic condition. As an aside, my allergy-asthma doctor would not renew a prescription without actually seeing me for my annual appointment. She was wise to my crafty ways of avoiding doctors.

Phil has a doc he likes, but astutely noted, "I have nothing to really judge him against, or a solid basis for that opinion." In a Yelp-like review, Phil rattled off some positive attributes: the doctor takes time to explain things, he listens, it's relatively easy to get an appointment, and so on. As Da Bulls' bench players widened the score, we had a deeper conversation about how and why patients choose a provider.

To be sure, highly educated health care consumers can look up quality indicators on Hospital Compare or at the Joint Commission's website, or on any of a dozen other public databases. But we also know that many, if not most patients rely on recommendations from friends and family. As we've reported in H&HN over the past year or so, that conversation is now extending to Facebook and Twitter. Reviews are also being posted on such sites as Angie's List, Yelp and even Zagat. Often the recommendations are based on, shall we say, softer measures, rather than concrete quality metrics.

The patient experience will only grow in importance during the next few years. Under CMS' proposed value-based purchasing regulation, HCAHP scores will be incorporated into a hospital's overall ranking, and thus impact Medicare reimbursements. But that's not all. An article in our forthcoming April issue looks at how some hospitals are beginning to assess the patient experience across the care continuum. Officials at these hospitals understand that as health care becomes more integrated, and they are held more accountable, what happens to a patient post-discharge is extremely important. They've expanded their patient satisfaction surveys to understand how care coordination is being managed.

This isn't to minimize a provider's top priority—to provide safe, effective and quality health care. But we need to keep in mind the impact satisfaction has on a provider's reputation. I am loyal to my allergy-asthma doctor because she is responsive to my needs, she spends time explaining things to me, she's proactive in getting me to do follow-up appointments and she e-prescribes to the pharmacy. I can't say the same things about my primary care doctor's practice, which is why someone else will be getting my business. I welcome your thoughts. E-mail your thoughts and suggestions to
Wednesday, March 30, 2011

Don't Use That Kind of Language Here

The other day, I was glancing at a new report from AHRQ announcing that 75 million Americans have limited health literacy, when I stopped abruptly. Unsurprisingly, the report found that low health literacy is linked with high risk of mortality and more visits to the ED, and recommended increased communication and education for all patients. But what piqued my interest the most was a line buried at the end of the report, which describes the National Action Plan to Improve Health Literacy, developed by HHS last year.

"The plan calls for improving the jargon-filled language, dense writing, and complex explanations that often fill patient handouts, medical forms, health web sites and recommendations to the public."

It made me wonder—how much of improving health literacy comes down to producing easily understood signs and pamphlets that ordinary patients can understand and act on?

As it happens, I read the report the same day I interviewed Spencer Hamons, a corporate project manager for Yukon-Kuskokwim Health Corporation in Alaska and formerly CIO at San Luis Valley Regional Medical Center in Colorado, for a podcast running Friday on the challenges and opportunities of rural health IT. During a conversation about ACOs, Hamons argued that successful providers in the accountable care age will need to see their facilities through the eyes of an average patient—and communicate accordingly.

"The terms that we use—we take those for granted, and…they create apprehension for the patient," Hamons told me. "Think about what goes through the mind of a 75-year-old patient, who's spent his entire life as a longshoreman. He goes into a room with a sign on the door that says nuclear medicine and has warning signs plastered everywhere. We expect that patient to give up a certain amount of control while they're in the hospital, but we don't do a very good job of explaining why."

Of course, effective signage is precisely the sort of low-tech solution that good hospitals already do every day. I've been in hospitals as a patient where the signs and pamphlets are written in clean, simple language that most patients and visitors, regardless of their familiarity with the health care system, can understand—and I've been in facilities where a medical degree is seemingly necessary to decipher the myriad warnings and protocols on the walls.

I'm not discounting the difficulty of reaching patients with limited understanding of the health care field and the challenges they face when interacting with doctors, nurses and other hospital staff. But communication is a two-way street, and effective signage and reading materials can go a long way in educating patients and making an often bewildering experience a little less so.

E-mail your thoughts and suggestions to
Tuesday, March 29, 2011

Age Rage: How Does Any Work Get Done?

A couple of weeks ago in this column I wondered if readers had seen signs of tension between different generations of staff in their workplace. Little did I know what a hornet's nest I was stirring up.

The reaction was immediate, emphatic and unanimous. Everybody who responded said they are acutely aware of colleagues of one age group who hold colleagues from another age group in low regard. In most cases, the disdain simmers just below the surface. But several of you described contempt so extreme it occasionally erupts in front of co-workers and even patients.

"Our youngest staffer lost it last summer and yelled at the supervisor to get off her back. The supervisor shouted that she was a spoiled brat who ought to move back home with Mommy and Daddy," one e-mailer reported, adding dryly, "It went downhill from there."

Thankfully, the tension tends to be more subtle, though the attitudes are strongly held.

Gen Xers and Yers "are only interested in collecting a paycheck and doing the minimum they need to do to get by," a boomer wrote. "If it isn't required, they aren't interested"—a theme echoed by a number of other respondents in the 40-and-over age range. To wit:

"Younger employees view their jobs as jobs, not as professions or careers."

"They don't want to pay their dues by taking night shifts, etc…"

"They lack commitment to the mission. They're only committed to having fun."

"As soon as they're hired they ask, ‘When can I take time off?' That is irritating to me."

OK, so what do people in their 20s and 30s think? Well…

"I work with two people in their 50s and I can tell you, they are just coasting toward retirement."

"The tenured staff have a sense of entitlement. They don't think they should have to take call or learn the new technology."

"The baby boomers get mad when we wonder why things are done a certain way. They're defensive about their sacred cows."

"Some older staff withhold information from the younger staff to make themselves indispensable."

"My older co-workers feel threatened by me. They're scared of change and I'm not. They think I want their job and I do. If I'm better at it, why not?"

All righty, then …

Happily, nearly everybody who e-mailed me—even those who lamented most emphatically what they view as the shortcomings of their younger or older colleagues—understand how destructive generational friction can be to a work unit. A common theme in the responses: Employees, supervisors and top executives must recognize the unique strengths each generation brings to the workplace and capitalize on those traits so they complement rather than clash with each other. As one writer put it: "Respect for what each generation contributes and avoiding 'us vs. them' discussions is essential."

Though one R.N. was writing specifically about nurses, I think her comments could apply to staff wherever they work in the hospital: "Older nurses have the experience that can predict how things will occur in patient care. Younger nurses bring a sense of risk to the workplace. They're definitely not intimidated by technology and are more resourceful in finding needed solutions/answers. I view these unique practices as the yin and yang needed to move patient care into the next phase of health care services … delivering quality care for less."

Nicely put.

Lots of people had good ideas about what hospital management can do to ease generational friction. I'll share some of those next Tuesday in this space. Many thanks to everyone who responded to my questions. And as always, I enjoy hearing your thoughts about how generational shifts are impacting American health care. E-mail me at

Monday, March 28, 2011

When Employee Satisfaction Means Firing a Doctor

Employee satisfaction and engagement are intangibles every institution wants to possess, especially with the daily stresses of hospital work. But they're more than just buzzwords—the time will come when every organization has a choice between genuinely listening to their employees and merely giving lip service to terms like "inclusiveness" and "open door policy."

I was reminded of these hard choices during last week's ACHE 2011 Congress in Chicago. During her keynote address, Commonwealth Fund President Karen Davis discussed efforts to drive employee engagement at El Camino Hospital in Mountain View, Calif., which ultimately led to recognition by the Commonwealth Fund as a top-performing institution.

When I interviewed Davis later in the week, she pointed to a critical moment in the evolution of El Camino Hospital—when the hospital had to choose whether to retain a difficult physician that staff had repeatedly complained about.

The hospital chose to let the physician go—Davis said, a clear sign to staff that leadership was not only listening to employees but willing to act on their feedback. Davis, an economist by background, had expected to find that financial incentives and structures drove high performance at El Camino, but ultimately concluded that employee buy-in was the key factor in its results.

Erik Steele, CMO of Eastern Maine Health System, made a similar point to me in a interview we ran last Friday about his system's efforts to sustain its electronic medical records. Despite the difficulties of adjusting to new systems that don't always work intuitively the first time around, Steele noted that the hospital's leadership made genuine efforts over time to continually listen to doctors about their concerns and suggestions and integrate them into the platform.

"If we can find areas where it helps me as a physician achieve extraordinary outcomes in things I really want my patients to have, then I begin to feel like it's a partnership," Steele said. For Steele and the other doctors at Eastern Maine, the success of the EMR wasn't based on mastering the technical details—it was getting to feel like partners.

Getting staff to feel engaged, of course, is notoriously difficult, even for institutions that make real efforts at it. Ultimately, though, employees either feel like trusted partners in their hospital or they don't. And gaining that critical buy-in requires a bit of the courage to make the tough decisions when the moment demands it—as at El Camino—and the patience to listen to employees over time, as at Eastern Maine.

Has your hospital had to make tough choices that signal whether employee concerns are truly valued or not? E-mail your stories to
Thursday, March 24, 2011

Medicaid on the Chopping Block

One of the first things I do every morning after booting up my iMac is peruse the headlines in the gazillion e-mails I get from the bazillion news amalgamation services to which I subscribe (wait, is a gazillion bigger than a bazillion?). There are, of course, a fair number of articles about the Affordable Care Act and how it will bring about the end of the world, or prove to be the greatest achievement since man walked on the moon. Honestly, I rarely click on those links. I'm a bit tired of the Inside Baseball reporting on the daily political posturing.

No, what's really catching my eye these days are the machinations in the states. Every day, there are dozens of headlines that read something like this: State Budget Standoff Could Give Us Minority Rule, or Hospitals, Families Bear Brunt of NH Budget Cuts, or Demonstrators Across Texas Demand Fairness in Budget Cuts.

Across the nation, governors and legislators are grappling with severe budget crises. In some instances, the debates have played out in very public and high-stakes games of hide-and-seek. Democrats in Wisconsin and Indiana fled to Illinois to protest budget plans put forward by Republican governors. Lawmakers in other states are pushing politically unpopular proposals to drastically cut services, while some states, like Illinois, are both raising taxes and looking to cut services.

The Center of Budget and Policy Priorities last month reported that 44 states and the District of Columbia have projected budget shortfalls in FY 2012, which begins this July for most states. At least 26 states are already predicting shortfalls totaling $75 billion for FY 2013. Talk about having to bend a cost curve! Many states have a balanced budget law, which means they have to close the gaps as they did in 2009 and 2010. CBPP noted that most states instituted spending cuts, drew down on their reserves, increased taxes and deferred some very difficult decisions on pension programs.

Since it is one of the biggest line items in any state budget, Medicaid is a big target for budget cutters. This isn't necessarily anything new. Year after year, budgets get balanced on the back of Medicaid cuts, higher eligibility requirements, increased provider taxes or, often, all of the above. But the situation is slightly different now. Although the economy seems to recovering from the Great Recession, unemployment remains high. "Continued sluggish job growth will keep state income tax receipts at low levels and increase demand for Medicaid and other essential services that states provide," CBPP noted. Added to that is the fact that federal aid to the states will be severely trimmed as Congress and the Obama administration struggle to get the national debt under control. And we know what's scheduled to come starting in 2014—Medicaid expansion, assuming the Affordable Care Act isn't overturned. So, budgetary pressures on Medicaid will only grow and the impact on health care providers will certainly be dramatic. In Texas, lawmakers are considering a budget that would leave a $6 billion hole in Medicaid. Nursing home, safety net and other providers say that would force many facilities to close. Similar debates are raging across the nation, from New York to Ohio to Nevada.

One of my concerns is that we pay so much attention to news coming from D.C., that we often lose sight of events in our backyard. During the next couple of months, state lawmakers will be making very hard and very significant decisions. Health systems need to brace themselves for some serious belt tightening.

E-mail your thoughts to
Wednesday, March 23, 2011

ACHE 2011: Disparities Reduction Moves From Luxury to Necessity

CHICAGO—During a keynote presentation at the ACHE 2011 Congress Tuesday, Joseph Betancourt, M.D., director of the Disparities Solution Center and program director for multicultural education at Massachusetts General Hospital in Boston, argued that as increasing regulatory pressure mounts to improve health care outcomes for all Americans, work to reduce disparities in health care outcomes for minorities is no longer a matter of choice.

Pointing to emerging Joint Commission standards around patient-centered communication, set to take effect next year, and federal mandates in the Affordable Care Act to reduce readmissions and improve overall outcomes—areas where major disparities gaps persist—Betancourt said the financial stakes are too high for hospitals to remain on the sidelines.

"Disparities reduction is moving from a luxury to a necessity," Betancourt said.

Betancourt, who said his first encounter with the challenges of navigating the health care system came as a 7-year-old serving as a translator for his grandmother during a visit to the doctor, noted that health care providers can reduce disparities while simultaneously improving outcomes for all patients. He pointed to the Chelsea Diabetes Disparities Program, a pilot effort launched by Mass General in Chelsea, Mass., that has reduced the gap in diabetes outcomes between Latino patients and white patients while improving overall outcomes for patient control of diabetes. Those gains were made in part with the use of a bilingual health coach working with all patients to drive home the importance of diet, exercise and medication adherence.

"Addressing disparities and quality in one fell swoop…is the way we hope the field will go," Betancourt told me afterwards.

His co-presenter, Joseph Swedish, president and CEO of Michigan-based Trinity Health, made a similar argument about the need for diversity in health care organizations, noting that minorities are expected to comprise 41 percent of the health care work force by 2030, up from 18 percent back in 1980. Hospitals must begin more aggressively recruiting minorities, Swedish argued, or miss out on cultivating the next generation of leaders.

At Trinity Health, Swedish said, all hospital CEOs are expected to also serve as chief diversity officers, a move he said underscores the significance of diversity in hiring practices.

"I wanted my associates to understand the importance of this issue," Swedish said, "and I wanted my senior leadership to be publicly accountable for these results."

E-mail your thoughts to

Tuesday, March 22, 2011

Making Him Better Ruined His Life

Dan was 83 when he was admitted to the hospital with a lung condition, and the medical staff did a stellar job of treating it. In a matter of days, the condition had cleared up and Dan was discharged. But back home, he felt weak and anxious, and was occasionally disoriented. He no longer participated in the activities that had so enriched his life before he went into the hospital. His family worried that the independence Dan prized was about to end.

It didn't have to be that way. Typically, health care providers zero in on a patient's single, dominant ailment. But for Dan and the rapidly expanding cohort of elderly patients like him, other issues—physical and emotional—often complicate the picture, and the chances of robust recovery.

Far too few people working in hospitals today understand the unique needs of their elderly patients, a fact that must change as increasingly millions of Americans live far into their 80s and beyond and consume a larger share of the health care you provide. It's startling to realize that while almost every physician and nurse receives at least some education in pediatrics, only a tiny fraction get any training whatsoever for patients at the other end of the age scale.

Hospital executives are beginning to recognize the problem. "A lot of CEOs see improving geriatric care as good business," says Marie Boltz, R.N., associate director for practice at the Hartford Institute for Geriatric Nursing and an assistant professor at NYU School of Nursing. It can avoid costs due to complications, reduce readmissions, and increase patient and staff satisfaction.

Moreover, she says, "it resonates with them on a personal level because they have loved ones who are elderly."

One program that's tackling the geriatrics gap is called NICHE—Nurses Improving Care for Healthsystem Elders. Administered by Boltz's Hartford Institute, NICHE offers a series of modules that hospitals can implement to ramp up their clinicians' skills when it comes to such things as preventing falls, ensuring proper use of medications, reducing urinary tract infections, involving patients and their family members in decision-making, and preventing, diagnosing and treating delirium.

NICHE's six-week, Web-based Leadership Training Program gives a hospital the tools to conduct an internal evaluation of its strengths in geriatrics, the level of its staff's expertise and, importantly, how it might need to change policies, the environment and even its mission statement to foster improvement. "You can have a nurse with all the knowledge in the world in these areas, but if the culture doesn't support her, she can't put that knowledge to good use," Boltz says.

The results of the internal evaluation are benchmarked against other hospitals, and NICHE staff help prioritize educational and clinical initiatives. A team of at least three hospital staff members is trained to lead the effort internally and make sure improvements spread from unit to unit.

Nearly 300 hospitals have signed onto NICHE so far, representing all types and sizes. Collaboration among those participants is vital, Boltz says, with hospitals from across the continent sharing their experiences and advice with colleagues. The program is compiling data to identify best practices. And NICHE staff members mentor participants throughout the process and beyond. You can learn more at NICHE's web site.

Last Tuesday I asked readers if there was any tension among employees of different generations in their hospitals. The responses so far have been eye-opening and I'll share some of them next week. You still have time to respond by clicking on "I Can't Work With Anybody That Age." And as always, I welcome feedback and ideas about how the aging of America and other generational issues are affecting our health care system, from a patient's, clinician's and hospital executive's perspective. E-mail me at

Monday, March 21, 2011

ACHE Chair: Safety Alarmists Scare Some From Seeking Care

CHICAGO—Rulon Stacey, CEO of Poudre Valley Health System in Fort Collins, Colo., got the American College of Healthcare Executives 2011 Congress off to a rousing start this morning, asserting in his opening keynote that some health care pundits have exaggerated the risk posed by medical errors and other patient safety issues. That's led to a widespread misperception that hospitals present substantial risks to incoming patients.

Stacey, the 2011-11 ACHE Chairman, singled out "politicians looking for votes and consultants looking for clients" for suggesting that "American hospitals kill more patients than they save."

Stacey said those perceptions "have created a subculture of Americans who refuse to get needed treatment because they are afraid the system will do them more harm than good."

Despite his concerns about misinformation, Stacey called on the gathered executive audience to take the lead in improving patient safety through the adoption of best practices, noting that Poudre Valley Health System has reduced mortality by 14 percent over the last several years with an aggressive patient safety initiative. That translates into roughly 83 lives saved each year, he said.

"Somewhere, right now, a father can play catch with his son because the employees, physicians and volunteers at Poudre Valley made a high level of investment," Stacey said.

Karen Davis, CEO of the Commonwealth Fund, followed Stacey, and, after discussing several Commonwealth Fund reports on health care outcomes, lamented "unacceptable variation in patient safety."

Davis then expressed hope that the payment and delivery system provisions of the Affordable Care Act would ultimately produce more substantive changes to health care than the more highly publicized coverage provisions, arguing that accountable care organizations can produce real changes in care delivery if proper coordination occurs and if CMS gives budding ACOs enough flexibility to experiment with different structures.

"It is my belief that the delivery and payment system reforms will go furthest in achieving the Triple Aim," Davis said.

The underlying question that Davis and Stacey ruminated on, of course, is how health care leaders can improve both patient safety and public perceptions of the health care system in the difficult years to come. Both noted the upcoming shift from fee-for-service to global payment structures, value-based purchasing and other pay-for-performance arrangements. Stacey's provocative comments got a huge reaction from the audience—some of whom gave him a loud of round of applause. But I'd like to hear from you—is misinformation about patient safety risks keeping some people from seeking needed medical care? E-mail your thoughts to And read the full text of Stacey's speech at his blog.

Friday, March 18, 2011

Friday Data Snapshot: U.S. Life Expectancy Reaches All-Time High

Friday's Data Snapshot features the CDC's report this week finding that estimated life expectancy at birth in the U.S. rose in 2009 to an all-time high of 78.2 years, up from 78 in 2008. Female life expectancy rose to 80.6 years; the life expectancy for men rose slightly to 75.7.

Other interesting findings: the CDC reported that "significant decreases" in mortality occurred for children under one year of age, who saw their mortality rates drop 4.2 percent. Children aged 1-4 saw mortality drop 7.7 percent. Mortality rates for young adults between the ages of 15-24 fell 6.7 percent, and Americans between the ages of 75 and 84, who registered a 4.9 percent drop in mortality.

The report also found that heart disease remains the leading cause of death in the U.S., followed by cancer, respiratory diseases, strokes and accidents.

Read the full report here.

Thursday, March 17, 2011

Have You Gone the Extra Mile?

It's likely to become one of the lasting images of the disaster in Japan—a soldier holding a four-month old baby saved from the rubble. I don't know about you, but after watching countless clips on YouTube of the raging waters ripping houses off of their foundation, or seeing pictures of medics scanning people for radiation exposure, I needed something to lift my spirits. That picture did it. It's a reminder that amidst the devastation, there are signs of hope.

My guess is that many U.S. health care workers are already trying to figure out ways to help in the ongoing relief efforts, to be part of that hope. Some, like Kelly Kreisler, M.D., are already on their way. Kreisler is a physician at the University of Kansas Hospital and is part of a relief mission organized by Heart-to-Heart International. "I am the mom in the car pool line that you see and not some really special kind of person. Because of that, other people can do something too," she told her local news channel.

There are sure to be similar reports about clinicians, technicians and others from your community. We saw the same response to last year's devastating earthquake in Haiti. I recall talking with Andy Davidson, president and CEO of the Oregon Association of Hospitals & Health Systems, for more than an hour about his experience heading up a relief mission and serving as temporary administrator of King's Hospital in Port-Au-Prince. And early this year, at our Rural Health Leadership Conference, Paul Auerbach, M.D., spoke passionately about the herculean efforts of clinicians at University Hospital, also in Port-Au-Prince.

So often those of us in the media only highlight these heroic efforts in times of disaster. They are dramatic and compelling human-interest stories. But we know that there are many untold tales of hospital staff doing amazing things right here at home. That's why a couple of years ago H&HN started the Extra Mile column. In the pages of the magazine each month, we profile the efforts of hospital workers who go above and beyond the call of duty. Some of the stories are big, some are small, but in the end, they are all about health care workers making a difference. There's the ICU nurse who created a colorful picture book called "What's This Stuff?" to try and put children at ease before they go see a parent in the ICU. There's the midwife who travels to war-torn Afghanistan to deliver babies. And then there's the trauma registrar who awoke from a coma after an ATV accident to become a vocal proponent of rider safety.

Whether they are heading to international disasters, or responding to needs in your local community, we want to hear about staff who are doing extraordinary things.

Email your stories to me at

Wednesday, March 16, 2011

Would You Live-Stream a Surgery?

It's Tuesday morning and I'm still waiting for my coffee to fully kick in. Reading through the day's news from our clipping service, I learn that the Orthopedic Institute at Swedish Medical Center in Seattle is minutes away from broadcasting a knee replacement surgery live on their website, with the opportunity for audience participation via a web chat and Twitter. The event was designed to promote the use of new robotics equipment during the surgery—all with the consent of the patient.

A little curious and a little in need of a kick to complement my coffee, I tuned in to a bird's-eye view of the surgery already in progress, with occasional cuts to the docs' computer monitors. Questions on the surgery technique, infection risks and the robotics equipment used to perform the surgery poured in from the viewers, estimated at one point at more than 1,500. The surgeon involved in the procedure occasionally added his own commentary as he removed pieces of bone with a bone-cutting burr implement, raising his voice over the din of the burr.

This isn't my first experience with the use of social media to publicize a new surgical technique. Two years ago, I traveled to Sherman Hospital in Elgin, Ill., to watch a clinical team perform a robotic hysterectomy while I jostled for space in the operating room with other journalists, including cameramen. The hospital's PR reps tweeted the proceedings, occasionally asking the surgeons questions about the procedure.

At the time, I quoted other hospital execs—including social-media savvy bloggers like former Beth Israel Deaconess CEO Paul Levy—who said they wouldn't consider it. Too many risks, Levy said. The advocates, meanwhile, pointed to the promotional benefits of getting in on the ground floor of the live-tweeted surgery industry, hastening to point out they had plans to cancel the social-media experiment if anything went awry.

Two years, of course, is a lifetime in social media, and tweeting a surgery is apparently old hat—now you need a live webcast to get noticed.

There were unexpected complications Tuesday—but not with the procedure. A problem with the live streaming web site UStream forced the docs to switch over to JustinTv, delaying the start of the broadcast. As the editor of a daily e-newsletter, my sanity dependent on cooperation from the IT systems that store our blogs and videos, it's heartening to know even live-streaming, tweeting orthopedic surgeons have to contend with the same mundane technical difficulties the rest of us do.

I'm interested in your thoughts, though. Do you think your facility should stream a live surgery to promote a new service line or technique? E-mail your thoughts to

Tuesday, March 15, 2011

I Can't Work With Anybody That Age (3 Questions)

People that age feel entitled. They don't put in the hours. They won't do the hard work. They just don't get it.

I heard those comments at a roundtable last year on multi-generational staffing in hospitals. Panelists included executives, middle managers, physicians and nurses, and they ranged in age from late 20s to early 60s.

I bet you can guess which end of the spectrum that particular speaker came from. Can't you?

The fact is, I've been hearing comments like those for years, and not always from the obvious suspects. Sometimes it's a department manager lamenting the lack of a successor willing to put in the same hours he's worked for 20 years. Sometimes it's a 30-something nurse complaining that her supervisor is delegating all the most strenuous tasks to others while waiting for her own retirement to kick in. Sometimes it's fresh-faced physicians scoffing at their baby-boomer colleagues' discomfort with the latest technology—or boomer physicians shaking their heads at younger clinicians' refusal to take call or sit on any hospital committees.

The generation gap is nothing new. Way back in the ‘60s, whipper-snappers like myself weren't supposed to trust anybody over 30. Now we've been over 30 for nearly half our lives and can hardly believe we're working on the same floor with people who weren't around during the heyday of student activism or the Beatles or fondue.

The difference these days is that we're talking generation gaps. At no time before this very one have so many employees from so wide a range of ages toiled side by side in the same workplace. You know the labels—we've got the boomers, born between 1945 and 1964, and the Xers (1965-1980) and the Yers, (aka Millennials, born after 1980). We've even got the so-called Matures, men and women born before 1946 who are still out there on the front lines either because the Great Recession took a nasty bite out of their retirement accounts or because they remain energetic and engaged enough to keep doing the thing they've dedicated their lives to doing.

It all adds up to a boiling kettle of clashing values, expectations and sensitivities. And it takes a deft chef to keep the kettle from blowing its lid to kingdom come.

Hospital CEOs recognize the benefits of having a staff that reflects the world we live in. They understand that older employees bring a strong work ethic and an institutional knowledge that would be sorely missed. They understand that younger workers have a lust for innovation that will keep their hospital, and American health care, pushing the boundaries of patient care ever forward.

What they need to learn is where the generations might scrape up against each other in ways that could be hurtful to individuals and to the organization as a whole. They need to consider whether they themselves have certain built-in age-related biases. And they need to find ways to ease the tensions and harness the energy that diversity produces.

On future Tuesdays in this space, I'll offer background and guidance from experts on generational issues in the hospital workforce. In the meantime, I invite you to respond to three simple questions. You don't need to tell me your name, but please include your job title and which generational category you fall into. Have no fear: When I report back on this very informal survey, I won't include e-mail addresses or anything else that might identify respondents.

And the questions are:

1. Have you witnessed any tensions between staff of different generations in your workplace?

2. Are employees who are significantly older or younger than yourself as good at their jobs as they should be? Why not?

3. What, if anything, can management do to help the generations work together more effectively?

E-mail me your answers at And thanks for your time.
Monday, March 14, 2011

Study: Doctors' empathy tied to better outcomes

No matter which quality improvement philosophy your organization subscribes to—accountable care, medical home or Lean, the end goal is the same: better care for the patient. And beneath all those clinical integration frameworks, improved processes and hand-washing protocols are the personal relationships patients have with their doctors and nurses, for better or worse. An intriguing new study on diabetic patients, to be published this month in Academic Medicine, suggests that the relative empathy of a given doctor can play a substantial role on clinical outcomes.

Researchers asked physicians to take a 20-question empathy assessment, and then compared their scores with the progression of their patients on key indicators for diabetics. The researchers found that the rate of good control for patients' hemoglobin and cholesterol levels—indicators of improvement for diabetics—was significantly higher for patients whose doctors scored high on the empathy assessments.

Anecdotally, this study makes sense. The only time I've ever been hospitalized, when I was 8, the situation was made much worse by a physician who thought I was complaining too much about the pain I was in. Conversely, the times I've encountered doctors with good communications skills are when I've been most engaged in my care, and comfortable divulging exactly what's bothering me.

But what can hospitals, medical schools and other health care institutions do to foster empathy in clinicians? Mohammadreza Hojat, director of the Jefferson Longitudinal Study of Medical Education—which conducted the survey on behalf of Jefferson Medical College at Thomas Jefferson University—suggests making empathy "an integral component of a physician's competence."

"This study supports the recommendations of such professional organizations as the Association of American Medical Colleges and the American Board of Internal Medicine of the importance of assessing and enhancing empathetic skills in undergraduate and graduate medical education," Hojat stated in a release accompanying the survey.

None of this should be surprising—I've sat through enough conference seminars on dealing with difficult or abusive physicians to know that managing physicians' demeanor is a fairly central HR concern for most hospitals. But instead of dealing with the problems that arise from difficult docs on the back end, this study suggests that finding physicians who already possess strong interpersonal skills should be more of a priority for hospitals.

"These findings, if confirmed by larger scale research, suggest that empathy should be viewed as an integral component of a physician's competence," Hojat added.

Email comments and thoughts to

Friday, March 11, 2011

Friday Data Snapshot: CDC Identifies 'Diabetes Belt'

In the first installment of our Friday data snapshot, we're highlighting a new CDC report identifying a "diabetes belt" stretching across the South, where the rate of diabetes exceeds 11 percent, compared to the 8.5 percent national average.

According to the report, which will be published in full in the April issue of the American Journal of Preventive Medicine, the so-called diabetes belt stretches through 644 counties in 15 states, including parts of Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia and West Virginia. Roughly 23.9 percent of the people living in the affected counties were obese, and 30.6 percent reported living a sedentary lifestyle—both significantly higher than national averages.

Here's a link to a map of national diabetes prevalence.

And here's a related article with some background and explanation from the CDC.

As usual, email comments and thoughts to

Thursday, March 10, 2011

The Actual Retail Price Is...

There's nothing we journalist types like better than a good-old-fashioned he said, she said story. The tension. The name-calling. The finger pointing. It all makes for good drama, which in turn makes for great headlines. And if the story involves two former business partners, associates or colleagues, well, that's all the better. Why else would the Charlie Sheen-CBS saga command 24-hour news coverage? And is there any other rational explanation for the fact that Sheen now has 2.4 million followers on Twitter?

While it may not rival the Sheen-CBS hysteria, we have our own share of headline-grabbing stories in health care these days, most of them full of bravado and hyperbole surrounding health reform. There's another drama playing out that hasn't received quite the same level of coverage, but could have a huge impact on that cost curve everyone keeps talking about. Back in late February, medical device manufacturer Medtronic Inc. cancelled its contracts with several GPOs. I know, I know. Whoopee, a supply chain story. But we both know that aside from labor, the supply chain represents a hospital's largest line item and one where there's still considerable opportunity to generate savings.

Medtronic made the move as part of restructuring. In announcing its third quarter earnings, the company also said it plans to cut 1,500-2,000 jobs, between 4-5 percent of its workforce. As you can imagine, GPOs aren't very happy about the move. The Health Industry Group Purchasing Association, in a sternly worded statement, said that Medtronic was "putting greed ahead of patients" and that this was "nothing short of an attack on America's hospitals."

There's been a fair amount of discussion on the blogosphere about whether we'll now see a rash of manufacturers cutting ties with GPOs and doing more direct sales with hospitals. Only time will tell if this is a harbinger of things to come or an isolated situation, but the finger wagging and name calling has blunted a more significant issue that lies just beneath the surface: transparency.

There is a dearth of information available to the public, let alone hospitals, on the cost of medical devices. For years, hospital materials managers have been signing supply contracts that prevent them from releasing any pricing information. GPOs presumably bring some balance to the equation by negotiating bulk discounts with vendors, but typically the GPOs also keep quiet on the details. Every few years, the situation garners attention from lawmakers, as our now-defunct sister publication Materials Management reported in 2009. Last fall, the Government Accountability Office got into the action, issuing a report that closely examined GPO practices and transparency.

Overall, the lack of transparency prevents hospitals from doing their full due diligence and comparison-shopping, let alone ensure that they are leveraging fair prices. The result is tremendous cost variation, as the ECRI Institute revealed in another article in Materials Management.

As we see in the current debate coming from D.C., the larger cost problem vexing health care is not going away any time soon. As the financing system evolves, particularly to global or bundled payments, the supply chain is certain to be drawn into the debate. That's been the experience of hospitals in early demonstrations on bundled payments. The first place they looked for savings was the supply chain. So the question is: Whether it is a vendor or GPO knocking on the door, how much longer can the system support the status quo? E-mail your thoughts to
Wednesday, March 9, 2011

Is It Time For The Kindler, Gentler CEO?

Traditionally, hospital CEOs are thought of as decision-makers—men and women who can digest a complex array of data and analysis, come up with an action plan, delegate the appropriate responsibilities and then take responsibility for the results when the board comes calling. And having a CEO with the ability to drive change by sheer force of personality is usually seen as a sign of institutional strength—I can't tell you how many stories I've written on successful hospital initiatives where a nurse, doctor or mid-level administrator told me, "This wouldn't have happened if not for the CEO," or, after a change in management, "This wouldn't have happened before, but now we've got the right person in charge."

Recently, though, I've come across an unmistakable trend in my reporting; the notion that thriving as a hospital CEO in an increasingly integrated, more patient-focused world, is less about leading from the top and more about building strong relationships with physicians and other community providers.

When I recently chatted with IHI CEO Maureen Bisognano, the subject of today's H&HN Daily podcast, she observed that back when she ran a hospital, her job was primarily focused on running the business of the institution: hiring staff, overseeing the physical plant and managing the financial operation. Gradually, the job of CEO evolved to more responsibility for clinical care. Now, Bisognano says, the job of hospital CEO is in the middle of another evolution—to deftly managing an increasingly broad set of relationships with physicians, patients and the wider community.

"Now it requires new negotiation and integration skills, and it requires seeing the patient across the entire continuum, so it requires collaboration and planning with entities that there's no legal connection to," Bisognano told me.

In his column for H&HN Daily yesterday, Dan Beckham, president of the health care consulting firm The Beckham Company, wrote that hospital boards, which "have seen the number of physicians on the payroll swell into the hundreds," want CEOs who have the people skills to manage all those new relationships.

"Relating productively with physicians is the core of a CEO's responsibilities," Beckham wrote.

As the old media saw goes, three makes a trend, and as I was putting the finishing touches on this piece, I happened to glance at the March cover article for the print edition of H&HN: "Simple Steps to Improve Relations with Physicians," which outlines informal steps hospital leaders can take to build better relationships with docs—including things as simple as asking personal questions and inviting troublesome employees out for coffee.

But I'm interested in hearing from you, the reader. Is running a hospital evolving from a strong leader who can drive change from the top to a more people-friendly relationship builder who can negotiate with physicians and lead with a more collaborative approach? E-mail your thoughts to
Monday, March 7, 2011

'All I Wanted to Know: Is Mom Still Alive?’

Jamie's mother was well into her 70s when she was first diagnosed with a serious heart condition that sent her to the hospital. Prior to that, both mother and daughter had enjoyed amazingly robust health that required little more than routine doctor visits over the years.

"We were novices when it came to hospitals," Jamie recalls. "I was nearly 50, but I really knew nothing at all. I mean, I knew what doctors and nurses were, but that was about it." When a woman in a flowered smock introduced herself as an "R.N.," Jamie had to ask what that meant.

"They took it for granted that we knew the lingo," she says. "Here I was already a nervous wreck over my mother, and every time anybody said anything to me it seemed to be in code, with initials and abbreviations and acronyms." Information about things like her mother's heart rate or blood pressure was delivered strictly by the numbers, with little context. "I didn't know what X over X meant, whether that was high, low or normal."

Unlike many patients and their family members, Jamie was not meek. When she didn't understand what she was being told, she made the clinician stop and explain it in a way she could grasp. The hospital staff was patient, allowing her to ask all the questions she needed to. But really, she says, they all came down to the same question: What does that mean?

"I know they were in a hurry. Wouldn't it have saved time if they'd just said it in plain English from the beginning?"

After Jamie reluctantly left her mother in the hospital and went home, communication with the clinicians remained frustrating. Whenever her cell phone rang and caller ID showed it was the hospital, she'd start to panic. "But the person calling would begin haltingly by asking, 'Is this, um …?'," Jamie says. "I could hear her shuffling papers to try to find the right form. She'd finally say my name, I'd confirm it was me, and she'd continue, 'I'm calling about, um …' and I could hear the papers being shuffled again while she tried to find my mother's name."

"The whole time, all I wanted to know was: Is Mom still alive?"

Jamie assured me that overall the hospital staff did a wonderful job of treating her mother and that she has nothing but gratitude for their skill, hard work and obvious commitment to care. I told her that a number of health care groups and individual hospitals are encouraging clinicians to adopt a more patient-centered approach to communication by, among other things, being better prepared before meetings and phone calls with patients or family members and by jettisoning the jargon.

"Well, good," she replied, pleased if a little skeptical. "Because you really shouldn't need a medical degree to have a reasonable conversation with people who work in the hospital."

Every Tuesday in this column, I address issues that touch, sometimes peripherally, on generational shifts in the American population and the effect on health care from both a patient and hospital perspective. I welcome feedback and ideas. E-mail me at

As ACO Rules Loom, Skepticism Sets In

Later this week, I hear, CMS may finally release its rules for accountable care organizations. Pardon my skepticism, since the rules were originally expected out last fall, then in January. But sometime soon—and it better be, since the program is slated to launch next New Year's Day—the tough work of turning ACOs, often dubbed unicorns for their mysterious nature, into a tangible being will commence.

Despite the confusion about the finished product, ACOs have been seemingly everywhere since their inclusion in the Affordable Care Act a year ago. In nearly every interview I've done this year—from hospital CEOs to health IT gurus to industry thought leaders—and in nearly every health care article I've read, ACOs have crept into the conversation, often dominating it. Hospitals want to join them, the IT folks want to build systems to support them and everyone wants them to bend the cost curve.

Any new innovation with that much buzz was bound to invite a backlash, which is now in full swing. Lately, the conversations I've had about ACOs have swung from measured enthusiasm to skepticism. Some folks are worried that ACOs are too focused on the structural work of linking providers together, at the expense of the equally, if not more important work of redesigning clinical care. Others think many would-be ACO players, including hospitals, haven't fundamentally prepared for the seismic changes in payment and care delivery poised to shake things up in the next decade. Still others think that the age-old challenges of working with physicians—whether they are employed, as is increasingly the case, or in affiliated medical groups—will bedevil many a would-be ACO.

But no matter how well your average ACO ends up functioning, Medicare and private payers are moving to new models designed to increase accountability. Whether ACOs are around in 10 years remains to be seen. But it's unquestionable that hospitals will be held much more accountable for their work in the very near future, whether as part of a formal partnership or not. Valinda Rutledge, CEO of CaroMont Health in North Carolina, sums up this new reality in today's H&HN Daily podcast.

"We will have to assume some responsibility and accountability for health outcomes in which we will have some type of risk," Rutledge told me. "… We have to move from hospital-centric to community-centric in terms of our delivery of care."

Friday, March 4, 2011

iPads at the bedside

A few days ago, while Apple CEO Steve Jobs introduced the iPad2—the latest device that will instantly transform all of our lives—he made a point to specifically talk up the flashy new device's formidable collection of health care applications designed for physicians and other health care providers. And in an accompanying video, John Halamka, CIO of Beth Israel Deaconess Medical Center in Massachusetts, was featured extolling the virtues of the iPad in the clinical setting.

"What we've tried to do on the iPad is give doctors at the point of care the tools they need at the exact moment a doctor can make a difference," Halamka said.

In general, I'm hearing more and more buzz lately from the field about the potential for tablets, smartphones and accompanying applications to change how hospitals and physicians think about and use health IT. When I interviewed Steve Lieber, CEO of HIMSS, last month, he offered his opinion that mobile technologies are poised dramatically alter the delivery of care—as the technologies enable doctors and other providers to extend out of hospital IT departments and into patients' homes and other settings. Ultimately, Lieber said, hospitals will have to change their IT departments from in-house systems to those that work collaboratively with a variety of devices out in the field.

Still, there are skeptics about whether the technology is quite there yet to support meaningful clinical change will. A friend of mine who's a business consultant is wary of how much capacity the current generation of tablets has for applications he uses to manage his projects—an issue to keep in mind for physicians, too. Then there's that pesky 10-hour battery life—which could be an issue for busy clinicians.

Overall, though, looking at the online reaction to Tuesday's announcement, the general consensus from health care observers appears to be measured enthusiasm. And in the long run, it's more a question of when, than if, a more mobile delivery system emerges where nurses and docs deliver care and share data on a diverse array of devices, both in the hospital and out in the field.

Thursday, March 3, 2011

Is Patient Safety Part of Your DNA?

I'm working on a feature for the April issue of H&HN profiling a rural health system that has taken a zero-defect approach to medical errors. From top to bottom, eliminating preventable errors has become part of the organization's DNA. It is ingrained in everyone from admission clerks and back-office staff, to nurses, doctors and top administrators. Executive compensation is even tied to error rates. I've been reporting the article for a couple of months and have interviewed a number of people at the health system, as well as several outside experts, and they all reinforce the same theme, which Helen Darling, president and CEO of the National Business Group on Health, summed up pretty well during an interview we did on Tuesday: "Patient safety is fundamental. It isn't just something that is nice to do, it is fundamental to the care process."

Now, that's not really "news." No one goes to work at a hospital wanting to harm a patient, but preventable errors happen. We are all familiar with the groundbreaking work done by the IOM in this arena, which spawned any number of safety initiatives over the past couple of decades. The good news is that some gains are being made. Just this week, the CDC released data showing a 58 percent drop in central line bloodstream infections for ICU patients between 2001 and 2009. Up to 27,000 lives were saved as a result. An estimated 3,000 to 6,000 lives were saved in 2009 alone.

Obviously, the most important fact is that lives were saved, but it's also worth noting that the effort to cut infections resulted in huge cost savings—$1.8 billion in excess medical costs since 2001. Talk about bending the cost curve. Previous work from the CDC shows that health care-associated infections add between $28.4 billion and $33.8 billion to the system annually. In the assessment released this week, the CDC lists a host of steps that can be taken to make further improvements in curbing bloodstream infections. It recommends that the government develop and promote additional guidelines and tools for adopting best practices. It also suggests that providers join On the Cusp: Stop BSI, which is a joint effort between HRET, AHRQ, Johns Hopkins and the Keystone Center in Michigan.

If anything, the CDC data and programs like On the CUSP are evidence that strides can be made, especially when targets are set. That's something the rural health system I'm profiling in April has learned. For instance, one of the system's hospitals set a goal of 100 percent compliance with hand hygiene protocols. Right now, compliance hovers around 95-98 percent. Will they hit 100 percent? No one really knows, but that is the goal everyone is striving to meet. Efforts like these or those taken to reduce CLABSI are certain to become more important in the coming years as payment becomes linked directly to patient care, rather than patient volume. Regardless of what happens in the courts or Congress, the Affordable Care Act makes it clear that providers will be held more accountable for the care they provide. The law institutes payment penalties for hospital-acquired conditions, for instance. And as you've likely heard, CMS any day now will unveil a new national patient safety initiative. Details have been slow to trickle out, but a confidential draft dated Jan. 11 did, of course, find its way to the Internet. It shouldn't come as a surprise that CMS, under Donald Berwick's leadership, would pursue an ambitious patient safety agenda.

For hospital leaders, the issue is making sure that safety becomes part of your institution's DNA. "We find it over and over again," Darling says, "if you look at patient safety or anything that requires significant redesign and reengineering, there is strong executive leadership and insistence that this happens in a very comprehensive way."

Wednesday, March 2, 2011

Patients Catch Up to Information Age

We all have a hypochondriac relative for whom the Information Age is really the Age of Worry. Case in point: those regular calls from my sister informing me that according to her latest midnight Google search, that harmless bump on her arm is really a symptom of a life-threatening malady.

A new study by the Pew Internet Project confirms the widespread use of the Internet for people like my sister; a whopping 80 percent of Internet users look online for health information, making it the third most popular online activity among those tracked by the study, trailing only e-mail and using search engines. Roughly 44 percent of Internet users look online for information about doctors and other health professionals; 36 percent look up information on hospitals and other medical facilities.

There are still economic barriers to online use, though; according to the survey, roughly 95 percent of adults in a household with $75,000 or more annual income are online, compared with only 57 percent of adults in households with $30,000 or less in income.

And many of the folks who may need access to information about health care the most may not have it; only 64 percent of adults living with at least one chronic condition have regular access to the Internet, compared with 81 percent of adults reporting no chronic conditions. Once online, though, adults with chronic conditions reported higher rates of searches for health information than those without.

The big-picture lesson for hospitals is that patients are increasingly comfortable with self-educating themselves on their care journeys, and may finally be ready to play a more active role in their care. And this convergence couldn't happen at a better time; a recent report from PriceWaterhouseCooper's Health Research Institute cautions hospitals that Stage 2 of the federal meaningful use initiative calls for greater communication with patients via electronic communication and personal health records.

And while the PwC survey found that only 14 percent of Americans currently access their medical records electronically, the upward trends in online health engagement suggest those numbers will climb dramatically in the next few years. At the very least, I look forward to fewer worried calls from my sister, who can transition from WebMD searches to constantly updating her PHR. One can only hope.
Tuesday, March 1, 2011

Martha Stewart, Mount Sinai and You

As a general policy, I refuse to sew, arrange flowers or cook anything that requires more than three steps and four ingredients.

So you might think invoking Martha Stewart's name is nothing more than a transparent attempt to draw more eyeballs to this column, which most Tuesdays will be light on decorating and entertaining tips and heavy on generational issues that are profoundly impacting our nation's hospitals and health networks.

Turns out Stewart has become something of a crusader for "healthy aging," and whatever you might think of her multimedia dynasty or of the woman personally, her work on this particular issue is worth applauding. On a recent ABC News roundtable discussion called "Families on the Brink," she pointed out that even as baby boomers plunge headlong into senior citizenship, many are being called upon to care for their own elderly parents. Both old child and older parent need all the support they can get to maintain optimal physical, mental and emotional fitness.

Hospitals are finding themselves deeply involved—not only as acute care providers, but also as conveners of clinicians, support services and other resources in their communities. Mount Sinai Medical Center in New York City might be the shiniest example of that.

A few years ago, the medical center teamed up with the DIY diva to create the Martha Stewart Center for Living, which takes an impressively comprehensive approach to helping older adults and caregivers. In addition to medical care, it provides diet and exercise advice and activities that stimulate creativity, intellect and fellowship.

Mount Sinai has a long history when it comes to geriatrics. The term itself was coined in 1909 by I.L. Nascher, a Mount Sinai physician who is considered the father of geriatrics in this country. These days, in recognition of the severe shortage of geriatricians and of other physicians with even a modest understanding of the unique issues involved in caring for elderly patients, the Mount Sinai School of Medicine requires all students to do a monthlong rotation in geriatrics. It's Seniors as Mentors program matches every incoming student with an older Mount Sinai patient. And it offers "mini-fellowships" in geriatrics to non-geriatricians who teach in residency programs or medical schools. Mount Sinai faculty members continue to mentor participants after they return home.

Hospitals throughout the country are doing admirable things to meet the needs of their local aging populations. Many don't have the head start or resources—not to mention celebrity connections—to go as far as Mount Sinai has. But they can take giant steps by encouraging their own clinical staff to acquire at least a basic understanding of geriatrics, by keeping up with new technologies that allow patients to remain in their own homes, by offering advice and moral support to family caregivers, and by implementing best practices when it comes to discharge and follow-up care.

On most Tuesdays in this space, I'll pass on good ideas from the field. I invite you to share what you're doing in this area by e-mailing me at But whatever you do, please, don't ask me how to bake a souffle.

H&HN Daily

H&HN Daily extends the conversations that readers began in other health care management publications and media. Each daily e-newsletter contains at least two topics with exclusive insights from high-visibility, recognized names in health care. All comments are welcome and may be posted to the blog. Comments may be edited for clarity or length.


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H&HN Senior Online Editor

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H&HN Managing Editor

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H&HN Senior Editor

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