Some of you know my history . . . for a decade I was a totally dedicated follower of the Dr. Dean Ornish coronary artery disease reversal program.

For example, for the past ten years, the only thing that would typically pass between my lips at a holiday party would be party garnishes. No kidding; decorations, twigs, sticks… and the occasional veggie. No dips, no chocolates, no meats or shell fish, no cookies, no pie, no fat.

One interesting factor that evolved from embracing that philosophy is that, in spite of all of my efforts to enlongate my life, my personal challenges never really decreased. It hit me one day when I was looking in the mirror that I was actually peering at the enemy, and it was me. It has been pointed out to me that, for all intents and purposes, I am a crisis magnet.

During those years of complete passion for the Ornish program, there were many days where my adrenaline flowed freely. It usually happened when Dr. Ornish and Dr. Atkins had debates on television about their very different diets. Truthfully, the diet was such a small part of the Ornish program that it angered me when so much emphasis was placed on the complete disparity between these two very different programs.

Well, tonight I felt closer to Dr. Atkins than I had ever felt. In 1976, my buddy Jim and I went on the Atkins diet and lost about 30 pounds. That diet ended because the pork rinds, hard boiled eggs, and thousands of chicken wings, rashers of bacon, sides of beef, and pounds of cheese just became too much for me, and they probably resulted in my needing the Ornish diet.

What made me feel close to Dr. Atkins this time? Ice. He had slipped and fallen on the ice, hit his head, and eventually died from the injury. Well, tonight provided me with a bonding opportunity with Dr. A. It was the beginning of the holiday season. The kids had gathered for dinner with the four and a half grandkids, the soon to be deployed son-in-law, Moosie the dog, and Kiki the cat. It was a nice gathering and, as I walked off the porch and onto the walk, my feet went out from under me, my body went air borne, and I fell directly on my back with the force of a meteor hitting a dry lake. The wind left my body. Stars were flying around my head like a Road Runner cartoon, and pain began sweeping through my limbs in waves.

The difference between Dr. Atkins and me was that my head did not hit the ground. Was it a conscious decision to hold it up, or was it just pure luck? Don’t know, but, at least for now, it seems like I might live. The last time this happened to me was on a cold winter afternoon in 1978. After teaching for eight hours, I was leaving school with a baritone saxophone case in one hand and a euphonium case in the other, both destined to go to the repair shop. It was then that my feet left the ground. Once again, the air completely evacuated my lungs. It was that very day that I vowed to always wear rubber-soled shoes in the winter. Didn’t help tonight. Oh, well, at least my fall didn’t include a head injury. Dr. Atkins and I both needed more salt in our diets.

No fear. I’m still here.

One imperative for any leader is a positive mental attitude. We must work tirelessly on believing in ourselves, and then we must work constantly to reinforce that belief with positive self-talk. If we embrace that concept that we can, there’s a very good chance that we indeed can. If, on the other hand, we believe that we won’t, we probably won’t. This single belief can initiate all forward movement. Winners in life constantly encourage themselves to think that I can, I will, and I am, and they don’t focus on the past —the should have, would have, or can’t do’s are gone forever. We can never make a better past for ourselves.

Last year, one of our employees attended a non-traditional educational seminar whose primary focus was directed toward the analysis of different personality types. When the employee returned, I asked, “What did you learn?” Their response was, “I learned that the primary function of people with my personality type is to pee on your cornflakes, to rain on your parade, and to frustrate your every creative idea, because that’s just what we do.”

Hence the opening paragraph of this piece. We are in difficult economic times, and the general counsel from our advisors is more often going to be to take no risks. If they are doing their jobs, we will be inundated with reasons why we should be against almost everything. In fact, words like growth, expansion, and opportunity all seem to be put away as this storm cellar mentality prevails. They will argue that they are saving their organizations by “shrinking to greatness” while opportunity after opportunity slips away.

One of my favorite visuals of this mind set comes from the 1990 movie Ghost where the people were helped to find their place in eternity by little demons that came out of the sewer grates to drag their souls into Hell. As leaders, we are surrounded every day by people who see their job as one of hard, cold, black and white facts. There are the extremists who spend their days spreading pessimism, fear, gloom, and negative energy; looking at the down side as they constantly undermine not only growth, but the attitudes that foster growth. The blacker the sky, the deeper the reinforcement of their concerns, and the more intense the corporate paralysis becomes throughout the organization.

Positive Mental Attitude Psychologist, Denis Waitley helped to change my life when he lectured on this topic nearly 30 years ago. He had been the U.S. Olympic athletes’ psychologist. Dr. Waitley taught us to learn from the past, set vivid, detailed goals for the future, and live in the only moment of time over which you have any control: now. He always spoke about the reality that life is inherently risky and that there is only one big risk you should avoid at all costs, and that is the risk of doing nothing.

Don’t get me wrong, conservative thinkers are important in the balancing act of leadership, but they must never be given the power to control all aspects of an organization. It is a recipe for disaster. The result will be stagnancy and eventually, business failure. There must be a means to carefully look at what they have to say, to evaluate the risks outlined, and then to make a decision based upon the prudent person process, but, having said that, remember that leadership is not a gutless proposition.

If you are not interested in some sleepless nights, tension filled meetings, or numerous failures, don’t get into the game. As Waitley says, the winner’s edge is not in a gifted birth, a high IQ, or in talent. The winner’s edge is all in the attitude, not aptitude. Attitude is the criterion for success. There are two primary choices in life: to accept conditions as they exist, or accept the responsibility for changing them.

A leader’s world is not always black and white.

The One Slide

Several dozen bloggers in the health care field and beyond are today engaged in a blog rally*, simultaneously posting the item below to encourage conversation about a topic that’s often avoided but needs to be addressed in every family: How we want to die. I’ve written about this before, with regard to my mother. Please try it, using the slide above as a discussion guide. It’s not that hard to have the conversation with your loved ones once you get started.

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We make choices throughout our lives - where we want to live, what types of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we don’t express our intent or tell our loved ones about it.

This has real consequences. 73% of Americans would prefer to die at home, but up to 50% die in hospital. More than 80% of Californians say their loved ones “know exactly” or have a “good idea” of what their wishes would be if they were in a persistent coma, but only 50% say they’ve talked to them about their preferences.

But our end of life experiences are about a lot more than statistics. They’re about all of us. So the first thing we need to do is start talking.

Engage With Grace: The One Slide Project was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences. And we’re asking people to share this One Slide – wherever and whenever they can…at a presentation, at dinner, at their book club. Just One Slide, just five questions.

Lets start a global discussion that, until now, most of us haven’t had.

Here is what we are asking you: Download The One Slide (that’s it above) and share it at any opportunity – with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started.

Let’s start a viral movement driven by the change we as individuals can effect…and the incredibly positive impact we could have collectively. Help ensure that all of us - and the people we care for - can end our lives in the same purposeful way we live them.

Just One Slide, just one goal. Think of the enormous difference we can make together.

(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team. )

Sharon Begley wrote for Newsweek Magazine an article entitled Where Are the Cures? Scientists call the gulf between a biomedical discovery and new treatment the “valley of death.” This has been a topic about which I have written several times. As a relative newcomer to the world of scientific research, my journey has been somewhat perplexing and always disconcerting. Every day articles, web stories, and scientific papers cross my desk touting the amazing discoveries that are being made at the basic research level. When I query my insiders, however, they point out that these discoveries very rarely ever get to the public for their care and treatment.

Some of the reasons behind this gap in medical science lead back to a broken system with inappropriate incentives locked firmly into place. How do we get the basic discoveries to be translated and moved into actual treatments?

Why are so few of the discoveries making their way to both treatments and cures? It is because our system of NIH-sponsored science is set up to discover things; plain and simple. Once the discovery is made, articles can be written, which is the sought after reward in academia since these publications lead to more grants from the NIH, and so the circle goes round and round.

Image Credit: Corbis

The obstacles to translational research in which the studies actually move from the scientist’s bench to the patient’s bedside are so intense that they are referred to in some areas of the scientific community as the “valley of death.” According to Begley’s article, “The valley of death is why many promising discoveries-genes linked to cancer and Parkinson’s disease; biochemical pathways that ravage neurons in Lou Gehrig’s disease-never move forward.”

The author challenges the incoming Obama administration and Congress to take a look at this daunting dilemma and to begin to revamp our biomedical research system by creating what Richard Boxer, a urologist at the University of Miami, and Lou Weisbach, a Chicago entrepreneur, call a “Center for Cures” at the NIH. Interestingly enough, the model that they endorse is exactly what was created here in Windber where multidisciplinary teams of biologists, proteomic and genomic scientists, technicians, and biomedical informatics specialists work together with Walter Reed Army Medical Center to move a discovery to an actual cure.

Of course, with the cuts made to the NIH funds, creating anything new that is unfunded could take away from basic research, and limit hopes for these cure discoveries. The article explains that while the NIH budget was doubling, new drug approvals fell from 53 in 1996 to 18 in 2006. What’s wrong with this picture? Twice the money, less than half the discoveries.

The sad case, however, is that even those organizations that try to establish these new world order cure centers are not funded by the NIH because of this fundamental design to enhance only basic research. The article ends with this: “I’d be willing to put up with potholes in exchange for a new administration spending serious money to take the discoveries taxpayers have paid for and turn them into cures.”

There was a television show on at about 3:00 AM the other morning that, once again, predicted the end of the world. This time, it was the manifestation of predictions from two ends of the earth: both the ancient Chinese and the Mayan Indians concluded 5,000 years ago that the world would end on December 21, 2012. (I think that Merlin the Magician was involved too, but he would have been just a kid 5,000 years ago!) Both predictions were written at nearly the same time, and both predicted the same date, but I believe that I have discovered what may contribute to this major catastrophe:

It is my prediction that the collapse of the planet as we know it will come from HIPAA.

According to Wikipedia,

“The Health Insurance Portability and Accountability Act was enacted by the U.S. Congress in 1996. The Centers for Medicare and Medicaid Services explain that Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers.”

Sounds pretty reasonable, doesn’t it? Just hire a full time security person for your electronic medical records, oh and don’t forget to spend millions to create the medical records in the first place. After that, life will be just fine? Right? Wrong.

If you have had little training in what the term oxymoron means, this would be a classic example; “The Administrative Simplification provision.” This provision was intended to deal with the privacy and security of health data. That is also a very noble idea. If two patients are in the same room, and someone is discussing the status of either patient, there should be a sound proof curtain between them. Soundproof curtains would also qualify as an oxymoron. For those of us who have lived this nightmare called HIPAA, Senator Kennedy has often been quoted regarding the fact that his intentions when designing this act have become grossly bureaucratic in their implementation.

Here’s the totally mystifying, Merlin-type description; the standards are meant to improve the effectiveness of our health care system by encouraging the extensive use of electronic data interchange in the U.S. health care system. Seriously, all of this sounds good. The problem comes when hundreds or thousands of government bureaucratic health care wonks and healthcare attorneys are introduced into the equation.

Well, a few weeks ago, according to Managed Healthcare Executive Magazine, the department of Health and Human Services, Office of Civil Rights (OCR) and the Centers for Medicare and Medicaid (CMS) and Providence Health Services, Providence Health System, and Providence Hospice and Home Care entered into the first case where a monetary settlement was paid to resolve a potential violation of the HIPAA privacy and security standards.

Providence agreed, without admission of liability, to pay $100,000 to the government over a data breach. This case did not involve a single egregious violation. So, it appears that, HHS may believe that enforcement time has come as they become more aggressive in their investigations and enforcement of these laws. Hence, the end of the world may be approaching. If all of the hospitals are fined into closure, and then the avian flu hits, the most often heard phrase will be “Hasta la vista, Baby.”

I don’t mean to make light of such an important topic as patient confidentiality or the potential portability of health insurance, but, if any of us mere mortals could objectively step back and witness the chaos, expense, and outright insanity created by the current implementation of these statutes, the only objective phrase that could eventually emit from that experience would be, “Holy, $%#@&!”

My Facebook friend, Anne Zieger, editor of Fierce Health Finance, wrote a compelling piece the other day regarding the potential demise of hundreds of hospitals. Her prediction is based upon some very valid financial realities, and we are witnessing them locally as well as nationally. Not unlike the little banks in our area that seemed to have been insulated from Wall Street’s collapse, some of these national problems seem to be washing over some of the smaller hospitals with relatively minimal damage. Yes, many of us have seen as much as a 10% decrease in elective, outpatient procedures.

In fact, while visiting a really upscale mall for a photo session with my two year old granddaughter, Lucy, an employee engaged me in a conversation about the rotten economy. About five minutes into the conversation, she indicated that there are currently 150 stores in the chain for which she works, and that only five percent of them made budget last month. Portrait pictures must fall into the category of a luxury as their business is severely impacted by this economy. More directly, however, she indicated that she needed stitches removed the other day, and that, “she did it herself” rather than spend the $20 co-pay.

So, are we seeing decreases in important tests? Are we seeing patients avoiding emergency room visits? Are we seeing patients cutting their prescriptions in half? Yes, to all of these questions. Anne, however, seemed to be talking about the “big boys,” where their millions or billions in investments have recently tanked. If you are so big that your income from running the hospital is not a major source of protection, and your income from your investments is propping you up, then the problems begin to manifest themselves exponentially.

“Some hospitals are responding by digging into their investment income more deeply than usual, using it to finance capital projects, or even meet operational needs. Others are issuing bonds with the scary codicil that they’ll buy them back if finicky investors want to dump them,” states Zieger in her column.

She further goes on to explain that “both of these situations put a huge squeeze on hospitals’ long-term viability. One robs from their long-term assets to solve medium-term problems, while the other puts the hospitals at risk of being bled dry by investors who get spooked.”

Well, wouldn’t ya know? Yes, we are seeing a few challenges due to decreased electives, but not because we were living off of our investments. The other good news is that, because we froze our fixed pensions several years ago, we are seeing very little impact upon them from the huge drop in those investments as well. Unlike many of our larger peers, neither of these issues is similar. Between the drops in the market, the loss of pension funds, the decrease in electives, and the down-grading of their viability by the bond markets, their challenges look galactic in size compared to ours.

Sometimes smaller is just safer.

A Note from Nick Jacobs

On October 23, it was my honor and privilege to speak at the PATIENT-CENTERED CARE CEO CONFERENCE in Chicago with some very impressive CEO’s and Leaders. My topic was “Linking a Patient-Centered Approach to Quality Improvement and HCAHPS,” but my deeper theme was “Leadership with a Heart - Developing Love and Respect in the Workplace by Nurturing Staff, Physicians, and Patients.” For those of you who were able to attend, thank you for your kind words of encouragement and support.

As was explained during my introduction, I have made the very difficult decision to leave Windber Medical Center, but I leave with a commitment to spread the word both nationally and internationally about the journey to Patient Centered Care and how to achieve it.

Obviously, it is a risky time to attempt to begin this endeavor, but, because no time is ever completely safe, it was my decision to reach out to my peers and friends to offer my commitment to work with you with that same passion to help you achieve your goals regarding this effort.

Because Sunstone Consulting is an organization that has specialized in finding additional financial support for hospitals, we can bring you not only the formula for Patient Centered Care, but also the needed additional financial support to achieve your goals in this area.

Although I will not officially complete my assignment at WMC until December 31st of this year, my current schedule permits me two days per week to begin to develop new relationships with my friends and peers. Should you have interest in contacting us for a visit to Windber, or if you would just like to make inquiry regarding engaging us for work at your facility, please feel free to either respond to this letter by E-mail or to call me at the following contact address below.

Once again, thank you for the privilege of working with you on such a significant topic.

Warmest Regards,

Nick Jacobs

Nick Jacobs

F. Nicholas Jacobs, FACHE
International Director
SunStone Consulting, LLC
1411 Grandview Avenue Apt. 803
Pittsburgh, PA 15211
nickjacobs@sunstoneconsulting.com
jacobsfn@aol.com
Mobile: 412-992-6197
Fax: 866-381-0219

Over the years people who’ve liked me have referred to me as a real visionary, but, in all fairness, the people who thought that I was an incompetent also called me a visionary. One group called me that as a compliment. The other group used the description as a put down. Considering that my physician discontinued my prescription of Atromid S medication back in the late 70’s because he said the it caused early cataracts, I’m not all that sure about my actual vision.

As a kid it was fair to say that my approach to any problem that came my way was, well, it was just different. In fact, I’d spend hours trying to come up with unique solutions to problems that otherwise might have only taken a few minutes to solve the normal way. It was my thing.

In fact, my problem solving skills could only be described as journeys down the “Road Less Traveled.” Kind of the McGyver approach. What can I do to meet this challenge by using a Zippo, some thread, a chewing gum wrapper, and piano wire? Of course there were sometimes periodic episodes of near tragedy from this approach, you know, like the time I watched the front right wheel on my wagon roll past me as my journey took me down the 80% grade that my parents called the backyard. Thank God the axle dug in just enough to stop me before the approaching cliff. (The bobby pin didn’t hold.) Between Evelyn Wood’s Speed Reading course and Cliff Notes, I read Moby Dick in about 13 minutes.

By the time college rolled around, it was clear that my addiction had spread from alternative methodologies of problem solving to a pure and simple love affair with anything that was new, cutting edge, leading (or even bleeding) edge or avant garde. “Contemporary” was the catch word all those years ago. From art films to modern music, there was no end to my attraction to new and novel things.

Well, Inside Healthcare ran an article by Clay Sherman that was entitled Think Global and Act Local that contained some great tips for survival in healthcare. Mr. Sherman talked about the Joint Commission the way that most hosptial CEO’s would like to, but do not have the guts to do so. He described the Joint’s role as one of minimalism, and that was where his description stopped. His suggestion was to drop the Joint and to engage some larger, more aggressive organizations like NCOA or Leapfrog. His words of wisdom here were, “Either embrace a rigorous standards process, or watch your successor do it.”

Mr. Sherman went on to suggest the need for us to embrace best practices methodologies, new standardization techniques, online communities for patients with similar diseases, and he closed by saying “Stay centered focused in building human assets — its their brains that are going to get you there.” Hmmm? Sounds a little like last week’s blog.

What do you do when you don’t have enough money to do what you need to do for you or your family’s health? I know, it’s a redundant question? You go without, delay or borrow from your future in the form of debt. According to Reed Abelson and Milt Freudenheim of the New York Times in their recent article Even the Insured Feel the Strain of Health Costs, as employers struggle to keep up with mounting costs to cover their employees, the average cost of an annual health care premium for that employee has nearly doubled since 2001, from $1800 to nearly $3300 a year.

Example after example is delineated in the Times article regarding those individuals who just can’t afford the challenges presented by the rising food and gasoline prices. Those featured families and individuals skip meds, wait longer to take sick children to their pediatrician or are facing staggering bills from health care institutions. According to the accounting firm, Deloitte, the average American income that goes toward health care expenses is now approaching 1/5 of their total household spending annually.

As a hospital administrator, it is never easy to listen to the general public throw stones at the medical industrial establishment, but when it comes to fancy, esoteric diagnostic tools, unproven drugs that can cost $6000 a dose or the very best physicians known to man, bring ‘em on becomes the hue and cry as we, the health care consumer wants nothing but the best for ourselves and our families. This is America. We deserve it.

Of course, if you are looking for elective surgery and you happen to live in England, you will wait on average 1.5 years for that intervention, and if you are in Scotland, it will be very close to 2.5 years before that same surgery is available.

My Democratic friends embrace the hope of the future through proposed health plans that insure the masses. My Republican friends warn of the horrible train wreck those plans will cause in hospital emergency rooms as every George, Dick and Conde will make their way to our hospitals with no barrier in place to prevent them from over running our already strained bastions of care.

Regardless of your political bent, it does seem unconscionable that we have nearly 48,000,000 uninsured accounted for by the government. Most of these uninsured are young, single moms and kids who either can’t or choose not to vote. (No one has ever believed that to be a co-incidence.) This figure also does not include the underinsured and quite possibly may not include any of the 50,000,000 illegal aliens. We are the only industrialized nation in the free world that does not have a true health policy for our citizens.

So what is the answer? The iron triangle of the best, fastest and cheapest health care is something that cannot exist in a system that is still hanging on ever so completely to an acute care based model when the vast majority of our health care challenges are now chronic care cases. We 78,000,000 Baby Boomers are taking more pills to control our varied maladies than existed in total just 20 years ago. Ask your pharmacist how many drugs there are now compared to 1988.

One very real answer to this health problem sometimes seems too simple. Our nearly $2 trillion in yearly health care expenditures includes less than four percent of its total dollars for preventative care. Much of our problems are about wellness.

So, wash your hands, drop some weight, exercise, cut out the saturated fats, stop smoking and live a less stressful life by doing something other than stare at the television…or else just wait for that little blue pill that will help you be skinny, tan and sexy, and then sell the family car to pay for it.