The Quandary of Cracks

Cracks present a quandary.

When you are trying to coordinate a health ecosystem comprised of multiple, dedicated but widely different parts with potentially disparate agendas it’s usually not the individual components that are the challenge. It is dealing with the cracks between them.

In recognizing and responding to the cracks, there are several options. You can rail against the lack of a single, synchronized system. You can ignore the cracks and just deal with the separate parts. You can work around the cracks by building a myriad of small bridges with each different entity. These tend to be fragile and dependent on the individuals involved. They also tend to collapse if circumstances change (including transitions of the bridge-building brokers). Alternatively, you can press into the strength of the range of expertise and experience and develop the language and formalized relationships that can unite the different entities into a single system for a singular purpose.

Consider this example. A nurse practitioner who regularly works in a city hospital is attached for 12 months to augment the City Health Department’s street medicine program that is focused on overdose prevention. Her paycheck, paid time off, evaluation process and all administrative aspects of her job remain with the hospital. But the Street Medicine director determines which of the health department’s street teams she is assigned to, when they go into the community and to which geographic area. Negotiations regarding the funding of her position would be conducted between the two entities.

For all intents and purposes, that nurse practitioner is now a part of the health department’s operations, but at the same time still belongs to the hospital that “loaned” her. Her hospital provides continued “administrative control” (ADCON) for her. The health department’s street medicine director provides “operational control” (OPCON) of the practitioner’s time and effort. The City Health Commissioner, who in this hypothetical case is responsible for decreasing deaths from overdose in the city provides strategic oversight; determining how much of her budget is devoted to the street teams as a part of this effort based on the mayor’s guidance and strategic priorities. The nurse practitioner on loan from one of the city’s hospitals is now a vital component of her overarching strategy and provides a direct professional link between the street team and the hospital allowing for improved communication, enhanced referrals and greater understanding of the components by all the elements of the ecosystem.

The military has a long history of working with different agencies and services in settings where one service or organization leader has operational leadership authority. In Baltimore City during the COVID-19 pandemic, we demonstrated that this model could work outside the military. The Baltimore Convention Center Field Hospital (BCCFH) was staffed and run by a combination of nursing staff from University of Maryland Medical System (UMMS), providers from Johns Hopkins Medicine (JHM) and a range of contracted staff (e.g. security, logistics, information technology, convention center staff).

Executive leaders for the BCCFH came from both health systems and worked together as a team. The medical systems and contractors retained ADCON for their assigned staff. The BCCFH Director was a Johns Hopkins faculty member who provided OPCON over the contractors, Hopkins and UMMS staff assigned. The BCCFH Director was accountable to the Maryland Secretary of Health (whose department funded the operation) as well as a board of senior leaders from the state health department, Hopkins and University of Maryland health care systems. The Secretary and this board exercised strategic oversight for all BCCFH operations (e.g. inpatient care, ambulatory infusion, testing, vaccination etc.)

Three blocks to the north during the pandemic, the TRI (“Triage, Respite, Isolation”) Support Center located at the Lord Baltimore Hotel was a Baltimore City operation for individuals with COVID-19 who had no safe place to isolate. Thus, OPCON fell to the City of Baltimore’s designated leaders: the site clinical directors who were Hopkins employees attached to the city for this COVID-19 effort. They had OPCON over individuals working in the hotel including all nursing personnel from UMMS and staff from other city agencies. These leaders set policy and procedures in collaboration and consultation with leaders from the other engaged organizations: UMMS, the Mayor’s Office of Homeless Services (MOHS), the Mayor’s Emergency Operations Center (EOC), and Hotel Management.

The operational leaders were accountable to an executive leadership board that included a representative from UMMS, one from the Mayor’s office and the City Health Commissioner, who served as the board chair. The three executives provided strategic oversight and guidance for the operational leadership. The individual organizations responsible for the staff working in the hotel (e.g. UMMS, MOHS, Mayor’s Office, Hotel Management, and contracted security) retained ADCON of their personnel.

While the specific terms “OPCON” and “ADCON” were not used during the pandemic to delineate these operational relationships, this model of centralized authority, shared resources and clearly defined accountability were key to the city’s remarkable success in the pandemic.

Although state and city lines of authority differed between these two efforts, in this case the City Health Commissioner and the health department coordinated the citywide pandemic response. There were obvious cracks. But to the average residents of our city, they were largely invisible. As an example, the Baltimore Mayor or Health Commissioner was much more likely to get compliments on Twitter or Facebook for the convention center vaccine or testing operation than the governor. Although the lines of authority were not always clear (or consistently followed) the city effort functioned as a crisis-driven system of health, ostensibly under the health commissioner as the strategic leader responsible for developing collaborative coordination and the city’s strategic communication plan.

Between 2018 and 2022, Baltimore became the per capita overdose capital of the Nation, boasting a fatal overdose rate that was nearly double that of other large US cities. However, for decades the city has had numerous dedicated civic and community-based organizations, daily addressing the challenges of this syndemic. For example, ten years ago, Baltimore was the first municipality in Maryland to allow naloxone to be obtained by individuals without a provider’s prescription. More recently, in part supported by the city’s opioid restitution funds, targeted efforts have been taken and the rate of death from overdose continues to decrease and is down 23% compared to last year. But insufficient clarity around operational relationships and the absence of a central coordinating authority remain, resulting in cracks in the efforts to provide a continuum of care for individuals at risk of overdose from OUD. In our city, aggressive efforts are underway to remedy this.

The COVID-19 pandemic was defeated by a city wide coordinated, cooperative and collaborative effort. Nationally, the opioid syndemic has raged for more than a quarter century at the cost of more than a million lives with more than six million adults and adolescents still suffering from OUD including thousands in Baltimore. While laudable efforts are underway, this population still lacks a unified system of health for their care.

The opioid restitution fund is an unparalleled opportunity for our city and for municipalities across the country. An infusion of new money is good. An infusion of new thinking might be even better. As with the pandemic, resources and reorganized health care operations could be coordinated to “close the cracks” in our city’s overdose syndemic response as well.

We have figured this out before.

 

Chuck Callahan Henry V 4.3 – Lead from the Front https://henryv43.com/

“The views expressed by Dr. Callahan are his own, and do not reflect the official policy or position of the BCORE project leadership, (“Baltimore’s Comprehensive Overdose Response to End the Epidemic”), the University of Maryland School of Medicine, the University of Maryland, Baltimore, or any agency or department of the Baltimore City, Maryland or U.S. Governments.”

 

 

 

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Why we need Goldie

The US military has been developing and evolving models to improve combat casualty care since the Civil War. However, over the past quarter century, military medicine dramatically improved combat survival by organizing care into a coordinated echelon system, where every role was clearly defined, rapid frontline response was prioritized, and clinical information moved quickly across a unified network.

Goldie applies that same “Golden Hour” logic to the opioid crisis by giving hospitals, peers, providers, community organizations, and civic agencies a secure, compliant platform to coordinate referrals, communicate in real time, close feedback loops, and operate as one synchronized system of health for people ready to pursue recovery.

This will take a little explanation, so bear with me.

And we will get to Goldie.

During the last Gulf War, the US Military Medical System exercised a tiered model of care that resulted in the lowest combat casualty fatality rate in history, despite the increased lethality of the wounds inflicted. In World War II, 30% of combat wounded U.S. soldiers died from their wounds. In Vietnam it was 24%. But in Iraq and Afghanistan (2001-2014), only 10% of those wounded succumbed. Ninety percent of combat wounded service members survived.

Much can be said about the improvements in personal protective equipment (e.g. Kevlar helmets, body army, ballistic glasses). But the biggest difference was the system.

During my military career, tiered levels of care (“Roles” or “Echelons of Care”) were clearly defined in the military medical system as were the standards for the definitive care delivered at each level, (table 1). I was assigned (part time) to a Medical Company of the 25th Infantry Division (Echelon II) and trained with them for six years in the 90’s before 9/11. Later, I deployed with the 8th Army Medical Brigade, responsible for care delivery in Operation Iraqi Freedom’s (OIF) Southern Theater, including Kuwait, Qatar as well as Afghanistan, (2004). Continue reading →

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On being a loose cannon.

It is a distant memory at this point. I remember a single feedback session during my years as a pediatric resident. It was probably early in my junior resident year when senior residents and staff took call from home. My mentor was a respected senior oncologist. When we met, I could tell that he was struggling to summarize the staff’s evaluation of me.

He was finally able to put it into a single sentence:
“Chuck, you’re kind of perceived as being a loose cannon.”

It was a fair assessment.

I was the one who was most apt to forget to call the staff on call before starting a procedure. I acted at times as though I thought that policies and protocols just slowed us down. And I could stretch the rules slightly to help patients move through the systems more efficiently.

In retrospect, the eighties were a time when hospitals were much more dangerous. This kind of thinking didn’t help. Continue reading →

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Community Health Work: “What do I need to know?”

A few months ago, an executive coach I’ve known since the early months of the pandemic asked me a question about the community health work I have been doing for the past several years.

“Tell me five things about working in the community that you think I should know.”

I have thought about the question and the answers I spontaneously gave him since, confident that one thing is certain: I don’t really know completely. And I know that I won’t ever completely know. So in that spirit of true humility, when asked I focused on what I was learning, and I gave it a try.

It is worth noting that I spent the first thirty of the forty years of my professional career in the U.S. Military, where everyone had a job, a house, education and access to free health care. It is clear to me now that military members are under greater stress from health related social needs than I realized while I was in uniform. Regardless, in the transition a decade ago from this successful, single-payer, government health system, the biggest wakeup call I experienced was coming face to face with the lack of the same social supports for the patients I now cared for.

For the past decade, I worked in population health as the payer systems evolved to include models of “value-based care.” Over time, it became clear that the greatest value we could provide would be to work with community partners to assure economic growth and stability, housing, transportation and food access as well as health education and seamless health care access for our patients. The individuals of the urban community where my wife and I have lived, worked and worshiped have vastly different life experiences than we do. We continue to learn from them.

Since stepping away from a hospital population health role eighteen months ago, my role has largely been in community health. Thus, my coach’s request. This is what I told him. Continue reading →

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The case for a cowboy.

For the last several years, I have been using Dr. Atul Gawande’s graduation speech to the Harvard Medical School Class of 2011 (“Cowboys and Pit Crews”) in teaching about the evolution of health care delivery I have witnessed over my years in practice.

When my medical career began (during Reagan’s first presidential term), hierarchical “parallel mono-disciplinary” care was the typical patient’s experience, where a patient was passed between specialists and hospitals until someone (hopefully) took the time to sit down and listen to their journey, piece together the story, mine the available paper records and validate the patient’s concerns with a reasonable differential diagnostic and therapeutic plan. This pattern of care delivery continues in many settings today.

In the closing decades of the last century we moved forward considerably with multidisciplinary (multiple specialties looking at the same patient at the same time, often in the same clinical space) and interdisciplinary teams (multiple specialties looking at the same patient at the same time, including the voice of patient and family, and agreeing on a single patient and family-centered set of treatment goals).

More recently, we have increasingly recognized that health is more than the absence of disease. The true drivers of health are determined by the 8,759 hours a year our patients spend at home in their community rather than the roughly one hour a year the average American spends in a provider’s office. In the future, the individual and population’s health will be addressed by a new model of integrated, community-care teams that include health care professionals but also community navigators and service providers as equal partners who are able to address issues like housing, food security, employment and economics. (But that’s the subject for another post.)

Time has proven that Dr. Gawande was right. The future of health care depends on our ability to function like pit crew teams with broad, horizontal, flexible, situational leadership structures.

But for the past several weeks, I wish we had a cowboy. Continue reading →

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“Do you ever forget?”

My niece asked me this question recently.

We were talking about a small black “tattoo” she noticed on my left wrist; a cross with the letters “s” and “a.” I explained that they represented the Latin phrase “Sequor Agnum,” or “I follow the Lamb.” The image is a reminder to me of my daily efforts to follow the life and teachings of Jesus Christ who is depicted more often as a lamb in the New Testament Book of Revelation than any other apocryphal image.

It was the unusual circumstance of this mark that drew her question. I confessed that the “tattoo” was actually something I drew on my wrist with a Sharpee every morning as part of my imperfect efforts to center my focus and attention on what I hoped would be the organizing principle of my day. When she asked the question, I confessed to occasionally forgetting to draw it in the morning and explained that when I noticed it missing I would find another pen and complete the daily ritual. I did forget. But as I recalled the conversation, my casual explanation of the remedy for my forgetfulness obscured a deeper realization.

We all forget.

Continue reading →

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On being the Ted Lasso of anything

At a conference recently, several of my colleagues referred to me as “the Ted Lasso” of our institutional discipline. I was taken back at first as I wondered which features of this popular television character they thought I brought to mind (beyond perhaps my slightly too generous mustache). But the more I have thought about what I know was intended as a supreme compliment, the more I have come to embrace it. It is both honorable and at the same time aspirational.

Here I have to add something of a disclaimer. There was a pretty long time between when I watched the first Ted Lasso episode and when – following someone’s recommendation – I give the series another try. I thought the premise was another example of the ridiculous situations that characterize television sitcoms: an American football coach called upon to coach a British football (“soccer”) team with zero knowledge of the game who at the same time appears as the stereotypical caricature of a “good-old-boy” American. And frankly, there have been other moments watching that I have taken a pause on the series because some of the themes and language were a bit too much for my relatively conservative background. We eventually watched all three seasons and some episodes more than once. (The dart game may rank among my favorite of any television scene I have ever watched, S1E8.)

Still as I consider what Ted Lasso represents – especially through the filter of analyses like the Steve Cuss Podcasts and his approach to systems theory (Managing Leadership Anxiety: Yours and Theirs) – I embrace the metaphoric compliment and in specific have contemplated several aspects of the Ted Lasso character that I hope my colleagues intended in likening me to him. (These are grouped in an outline from Paul of Tarsus in a letter from prison to his “team” in Philippi). Continue reading →

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Perspective on a “speed limit” birthday

There are speed limit birthdays throughout life. They are times for us to take our foot off the gas, check the speedometer, maybe pump the brakes a little and make sure we’re still going the direction we intended. (We may also look around and make sure someone didn’t notice that we weren’t going too fast!)

This month I hit one of those speed limit birthdays. As I thought about this point on the journey, I found myself with a list of things I wish I could reach back and tell my younger self at similar, significant mile-per-hour moments. Here is a short list of some of what I wish I could say:

1973 – 15 years old.
High school -> college

  • Don’t be in such a hurry to get to medical school. Life is more than the next rung on the ladder. (It is going to take you most of your life to figure this out.)
  • You don’t need everyone to like you. Some just won’t. And it’s OK.
  • When your Dad tells you that he doesn’t care what you do as long as you’re the best at whatever it is, he doesn’t mean you have to be better than everyone else. He just means for you to be the best you can be. (It will take you most of your life to figure this out, too.)
  • You are going to take a lot of decades trying to lose the sense that you continually have to please your mother. She is already proud of you. You might as well get started on working that through.
  • And be nice to that cute girl you met in American History class. You are going to spend the rest of your life with her.

Continue reading →

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Bow Ties and Leader Orthopraxy

Early in our time as the Baltimore Convention Center Field Hospital (BCCFH) COVID Contingency hospital I started wearing a bow tie to work every day. My co-director Dr. Jim Ficke and I made the decision together and it became something of a trademark for us as we worked in the various testing, vaccination and treatment sites across Baltimore and Maryland. We joked with the staff that if anyone had a complaint, they should tell them to look for one of the guys with a bow tie. We got plenty of feedback from our patients. But it was largely compliments about our team rather than criticism. Several of the other executive leaders also wore bow ties as they came on board. They thought it was part of the uniform.

The tie is part of a larger set of lessons about professionalism that I have been learning throughout my health care career. A med school professor told me that he never wore blue jeans to the hospital because he didn’t want to create too casual an impression with patients. Since then, I haven’t either. I started wearing bow ties as a medical student when I decided on a career in pediatrics because I thought they were less likely to get urinated on than a neck tie. (The latter have been suspected of carrying pathologic bacteria. Though disputed, it’s another reason for a bow tie preference). Continue reading →

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The Bat-Phone and Leader Presence

Recently I had the opportunity to speak to the mother of an infant hospitalized with respiratory illness in a hospital in another state. She was the daughter of a friend of a relative but it was a joy to speak to her, talk through some of her concerns and reassure her that from what she was telling me, she was in good hands. (Her baby did well!)

In the course of the conversation, I remembered that I knew a senior physician at the hospital and I send him a quick text. By the time I caught up with him a little while later, he had already been to the patient’s room. He missed the baby’s mother but left his card with his cell-phone number in case she needed anything.

His generous gesture reminded me of the “Bat-Phone” we instituted when I was a hospital CEO (Commander) a decade or so ago. I am relatively sure that I stole the idea from Quint Studer or another of the quality and patient experience gurus to whom we owe so much of the great things we were able to do at that facility while we were shaping a “Culture of Excellence.” We shared the Bat-Phone cell phone number with all of our staff, our hospitalized and ambulatory patients – probably thousands of people. I carried the phone with me every day. It was a visible symbol of our efforts to be accessible to our staff and patients. In addition to the phone number, we also had a link on our public and internal websites where people could reach out to the CEO by email directly. Continue reading →

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