The document discusses challenges with the current state of medical care in the United States, including overemphasis on subspecialization, high costs due to unnecessary diagnostic testing and interventions, poor quality of care according to several studies, geographic variation in care, and influence of the pharmaceutical industry. It notes upcoming shortages of primary care physicians and specialists. Opportunities for collaboration between institutions via educational programs are highlighted.

1. Excellence is a fleeting quality- Adaptation is key
• 1912 US Steel, the largest company in the word, 221,000 workers. Today US
Steel is not even in the top 500 companies.
• 1912- “the top ten titans” Jersey Standard, General Electric, Shell, J&P coats,
Anaconda, International Harvester, Pullman and Singer were in the top 10,
by 1995 none of the top ten titans was in the top 100.
• 10 of the top 100 companies vanished within a decade, more than half
disappeared over the next 83 years.
• 1982 Tom Peters and Robert Waterman List of 43 “Excellent” companies.
• 1984 Business Week: Oops! Who’s Excellent Now? 14 of the 43 companies
(1/3) were in serious financial trouble.

2. Excellence is a fleeting quality- Adaptation is key
• Time is “the mother of all stressors”.
• Time is an eraser rather than a
builder, and a good one at breaking
the fragile.
• In a complex domain, only time-a long
time-is evidence.

3. A Turkey’s Cognitive Illusion
From Antifragile, by Nassim Nicholas Taleb
• Mistaking Absence of evidence (of harm) for evidence of absence (of harm).
• Our mission: not to be a turkey, which starts figuring out the difference between true
and manufactured stability.
• In business and economic decision making, reliance on data causes severe side effects.
• Data is toxic in large and even in moderate quantities.
• The more frequently you look at data, the more noise you are disproportionately likely to
get.
• Even when reviewing data with yearly frequency, half the changes are real improvements or
degradations, the other half come from randomness.
• People are under the illusion that “science”
means more data.
• Strategic planning is superstitious babble. It is
based on an error of thinking that things always
have a reason that is accessible to us, that we
can comprehend easily.
• Do not invest in business plans but in people.

4. Antifragility and Collaboration
• Collaboration helps make you antifragile. The
difference between humans and animals lies in
the ability to collaborate. Collaboration has
explosive upside, what is mathematically called
a “super additive function”. 1 + 1 > 2
• Create an environment that facilitates these
collaborations and lay the foundation for
prosperity.

5. The Future of Larkin Community Hospital
What you need to know about the past is that no
matter what has happened, it has all worked
together to bring you to this very moment. And
this is the moment you can choose to make
everything new, right now.

6. The Future of Larkin Community Hospital
• The current state of Medical Care in the United
States (identify volatility).
• Strategy

7. • Characterized for its emphasis in sub-specialization.
• High costs due to an emphasis in diagnostic studies and premature
interventions and its associated complications.
• The Institute of Medicine (IOM) reports that 45% of the Medical Care
provided in the country is not evidenced based.
• Training of new physicians is susceptible to a hidden curriculum.
• The sinister influence of the Pharmaceutical Industry aggravates the
problem.
• The economic repercusions are significant due to our budget deficit and the
long term unsustainability of the Medicare program.
Medical Care in the United States

8. The Quality of Health Care Delivered to Adults in the United States
Elizabeth A. McGlynn, Ph.D., Steven M. Asch, M.D., M.P.H., John Adams, Ph.D., Joan Keesey, B.A., Jennifer Hicks, M.P.H.,
Ph.D., Alison DeCristofaro, M.P.H., and Eve A. Kerr, M.D., M.P.H.
N Engl J Med 2003; 348:2635-2645 June 26, 2003 DOI: 10.1056/NEJMsa022615
• 439 indicators of quality of care for 30 Acute and Chronic diseases as well as preventive
care.
• Participants received only 54.9 % of the recommended care.
• Americans receive approximately half of recommended care.
-Only 24% of diabetic participants received three or more Hemoglobin A1C serum tests ina 2 year period.
Poor glycemic control can lead to renal failure, blindness and lower extremity amputations.
-Participants with Hypertension received 64.7% of the recommended care.
Poor blood pressure control is associated with a higher risk of coronary artery disease, cerebrovascular accidents and death and
contributes to more than 68,000 preventable deaths per year in the U.S.
-Participants with coronary artery disease received 68% of recommended care, only 45% of participants presenting with an acute
miocardial infarction received Beta blockes and only 61% of participants with an Acute miocardial infarction who were
appropriate candidates for aspirin therapy, actually received aspirin. Medications which can reduce the risk of death by more
than 20%.
-Among elderly participants, only 64% received or were offered a pneumococcal vaccine.
• There is substantial geographic variation.

9. The First National Report Card of Quality of Health Care in America
2006
The Assessing Care of Vulnerable Elders (ACOVE) indicators
• The first group of indicators of quality of care developed specifically for the elderly.
• The elderly receive on average half of the recommended care, however, in conditions which primarily affected the elderly they receive
recommended care less than 1/3 of the time.
• The patients who received the recommended care are more likely to survive three years later than those who did not.

10. The Darmouth Institute for Health Policy & Clinical Practice
February 6 2012
End of life care and its effect on Residency Training
Variation in resource utilization among 22 academic medical centers
Hospital City State
Hospital Care
Intensity (HCI)
index
Hospital days per
decedent, last 6
months of life
Physician visits
per decedent, last
6 months of life
Percent of deaths
occurring in
hospital
Percent of deaths
associated with
ICU admission
Percent enrolled in
hospice, last 6
months of life
Percent seeing 10 or
more MDs, last 6
months of life
Cedars-Sinai Medical Center Los Angeles CA 2.06 19.0 72.6 42.1 38.2 32.8 65.3
NYU Langone Medical Center New York NY 1.73 19.1 58.5 34.3 23.8 39.2 66.6
Mount Sinai Medical Center New York NY 1.50 18.3 49.1 44.8 17.0 23.1 66.3
Ronald Reagan UCLA Medical Center Los Angeles CA 1.48 16.8 49.7 44.1 40.6 34.2 62.9
New York-Presbyterian Hospital New York NY 1.37 20.2 39.1 44.2 16.2 24.5 60.9
University of Pittsburgh Medical Center Pittsburgh PA 1.28 12.8 42.5 31.7 23.6 48.8 59.2
Northw estern Memorial Hospital Chicago IL 1.28 14.9 42.0 38.4 29.1 44.2 62.8
Massachusetts General Hospital Boston MA 1.19 15.5 34.7 34.4 17.9 44.9 59.9
Cleveland Clinic Cleveland OH 1.12 16.0 35.3 35.4 26.2 46.2 60.4
Hospital of the University of Pennsylvania Philadelphia PA 1.08 14.7 30.6 26.0 19.8 57.9 61.7
University of Michigan Medical Center Ann Arbor MI 1.07 14.3 30.8 22.8 11.9 59.1 60.8
Brigham and Women's Hospital Boston MA 1.06 14.9 31.5 34.6 19.4 41.5 61.5
Johns Hopkins Hospital Baltimore MD 1.01 13.6 23.4 30.2 19.9 49.4 45.7
Indiana University Health (Clarian Health) Indianapolis IN 0.96 12.6 30.3 26.2 21.2 51.2 57.0
Barnes-Jew ish Hospital/Washington University St. Louis MO 0.95 14.1 28.9 31.4 17.8 48.7 52.9
UCSF Medical Center San Francisco CA 0.92 13.2 28.3 37.8 22.7 39.0 53.4
Duke University Medical Center Durham NC 0.87 13.6 24.2 30.7 22.1 47.9 54.8
Vanderbilt University Medical Center Nashville TN 0.80 11.5 26.6 25.9 21.1 56.3 56.3
University of Washington Medical Center Seattle WA 0.78 11.3 22.6 30.2 20.5 46.9 53.1
Stanford Hospital and Clinics Stanford CA 0.78 11.4 27.0 38.0 33.1 44.2 53.1
St. Mary's Hospital, Mayo Clinic Rochester MN 0.70 9.9 21.3 22.8 16.8 44.7 52.4
Scott & White Memorial Hospital Temple TX 0.62 8.9 19.8 24.9 15.7 58.1 42.5
University of Utah Health Care Salt Lake City UT 0.62 8.6 19.7 23.2 17.0 55.0 47.2
United States average 1.00 11.8 33.7 28.3 18.2 47.9 49.5
Notes:
Variables w ere adjusted for age, sex, race, and primary chronic diagnosis.
The study population includes fee-for-service Medicare beneficiaries w ho died in 2010 and w ho w ere hospitalized for a chronic illness at least once during their last tw o years of life.
Patients w ere assigned to the hospital they used most frequently during their last tw o years of life. If there w as a tie betw een hospitals, the patient w as assigned to the hospital associated w ith the last inpatient admission prior to death.
Hospitals are ranked in order from the highest Hospital Care Intensity (HCI) index to the low est.
Hospital Care Intensity (HCI) based on 2 measures: the hospital length of stay and the average number of physician visits they received in the
hospital.

11. The Darmouth Institute for Health Policy & Clinical Practice
October 30 2012
Surgical Procedure rates in Hospitalized patients
(per 1.000 Medicare recipients 2008-2010)
Hidden Curriculum?
Hospital Service Area
(HSA) CABG PCI
Hip replace-
ment
Knee
replace-
ment
Back
surgery
Carotid
endarter-
ectomy
Lower
extremity
bypass
TURP for
BPH (males)
Radical
prostat-
ectomy
(males)
Cholecyst-
ectomy
Mastectomy
(females)
Los Angeles, CA 1.6 6.5 2.3 5.9 4.6 0.8 0.8 3.6 1.6 3.2 0.7
San Francisco, CA 1.2 5.5 2.5 4.3 2.9 0.8 0.7 3.2 0.8 2.5 0.2
Stanford, CA 1.5 3.7 5.3 6.8 4.3 0.8 0.6 3.2 1.5
Chicago, IL 3.1 8.0 3.3 6.3 2.9 1.4 1.1 3.6 1.3 3.4 0.9
Indianapolis, IN 3.5 9.7 4.3 9.4 4.0 2.2 1.1 1.9 1.5 2.6 0.5
Baltimore, MD 3.8 9.8 4.0 9.9 5.9 2.8 2.1 2.2 0.8 3.3 1.0
Boston, MA 2.0 5.5 3.1 5.9 2.8 1.4 0.7 4.1 1.0 2.5 0.6
Ann Arbor, MI 3.2 6.7 4.9 9.2 3.8 1.8 0.8 2.1 1.6 2.5 0.8
Rochester, MN 2.9 7.3 5.8 11.7 3.5 1.3 0.5 1.0 2.2 2.5 0.8
St. Louis, MO 3.5 8.4 3.8 10.1 4.1 1.9 1.0 2.1 1.8 3.9 0.6
Manhattan, NY 1.8 8.9 3.5 4.5 3.0 0.8 0.8 3.2 1.4 1.9 0.9
Durham, NC 2.6 4.5 3.8 8.8 5.1 1.0 0.5 3.5 2.0 2.4 0.6
Cleveland, OH 2.9 7.7 4.4 8.6 3.3 1.7 1.0 2.3 0.9 3.1 0.7
Philadelphia, PA 2.4 7.3 3.0 5.8 2.7 1.1 0.8 3.0 1.0 2.9 1.0
Pittsburgh, PA 3.4 7.6 3.9 8.1 5.2 1.4 1.0 2.7 0.8 3.5 0.8
Nashville, TN 3.8 6.9 3.5 8.1 6.3 1.6 1.2 2.0 2.4 3.1 0.4
Temple, TX 3.6 4.4 2.9 10.2 2.4 1.2 0.4 0.9 1.7 2.8
Salt Lake City, UT 2.1 5.2 5.1 11.9 5.7 1.1 0.5 1.8 2.5 3.1 0.6
Seattle, WA 1.7 5.3 4.3 7.3 4.4 1.1 0.8 1.7 1.2 1.9 0.6
United States average 3.4 8.2 3.8 8.8 4.7 2.1 0.9 2.7 1.4 3.4 0.9
Notes:
Rates are per 1,000 Medicare beneficiaries for inpatient surgical procedures occurring during the period 2008-10.
All rates were adjusted for age, race, and sex (when appropriate) using the U.S. Medicare population as the standard.
TURP and radical prostatectomy were restricted to males. Mastectomy was restricted to females
Blank cells indicate that there were not enough procedures performed in the HSA to produce statistically significant rates

12. The Darmouth Institute for Health Policy & Clinical Practice
October 2012
Evidence-Based Medicine?
or
Medicine based in the hospital bed supply or the supply of specialists?

13. Additional Challenges and Opportunities
• According to the AAMC’s Center for Workforce Studies,
there will be 45,000 too few primary care physicians –
and a shortage of 46,000 surgeons and medical
specialists – in the next decade.
• By 2020 our nation will face a serious shortage of both
primary care and specialist physicians to care for an
aging and growing population.
• By 2025 it is estimated that we will have a physician
shortage of 130,600 (not taking in account the effect of
the Affordable Care Act, which will further exacerbate
physician demand).

14. Collaboration via Education
• Post-Graduate Medical Education
Programs
• Nursing School
• Larkin Health Sciences Campus

15. • AOA Accredited Family Medicine Residency
• AOA Accredited Psychiatry Residency
• AOA Accredited Neuromusculoskeletal Medicine Residency
• AOA Accredited Internal Medicine Residency
• ACGME Psychiatry Residency
• AOA Accredited Traditional Rotating Internship
• AOA Accredited General Surgery Residency
• AOA Accredited Dermatology Residency
• AOA Accredited Neurology Residency
• AOA Accredited Ophthalmology Residency
• AOA accredited Radiology Residency
• AOA accredited Anesthesiology Residency
• AOA Accredited PM&R Residency
• AOA Accredited Sports Medicine Fellowship
• AOA Accredited Rheumatology Fellowship
• AOA Accredited Geriatric Medicine Fellowship
• AOA Accredited Addiction Medicine Fellowship
• AOA Accredited Hospice and Palliative Care Fellowship
• AOA Accredited Endocrinology Fellowship
• AOA Accredited Allergy and Immunology Fellowship
• AOA Accredited Sleep Medicine Fellowship
• AOA Accredited Geriatric Psychiatry Fellowship
• AOA Accredited Forensic Psychiatry Fellowship
• AOA Accredited Hematology/Oncology Fellowship
• AOA Accredited Gastroenterology Fellowship
• AOA Accredited Infectious Disease Fellowship
• AOA Accredited Pain Medicine Fellowship
• AOA Accredited Correctional Medicine Fellowship
• AOA Accredited MOHS Micrographic Surgery Fellowship
Post-Graduate Medical Education Programs

16. • Jackson Memorial Hospital, Miami, FL
• West Penn Allegheny Health System Hospitals, Pittsburgh, PA
• Holtz Children’s Hospital, Miami, FL
• Miami Children’s Hospital, Miami, FL
• Nationwide Children’s Hospital, Columbus, OH
• Nemours Children’s Hospital, Orlando, FL
• Palmer Children's Hospital, Orlando, FL
• Borinquen Health Care Center, Miami, FL
• Miami Beach Community Health Center, Miami, FL
• Helen B. Bentley Health Care Center, Miami, FL
• Jessie Trice Health Community Health Center, Miami, FL
• Beraja Medical Institute, Miami, FL
• CMA clinics, Miami, Orlando y Tampa, FL
• Vitas Hospice and Palliative Care System, Miami, FL
Our Partners (collaboration: «Super Additive Function»)

17. • Private school offering a Registered Nurse Associate Degree title
established in 2012.
• Succesful completion of the program prepares our students to take
the National College Licensure Exam for Registered Nurses (NCLEX-
RN) and to obtain the Registered Nurse (R.N.) License.
Larkin School of Nursing

18. • Osteopathic College of Medicine
• Pharmacy School
• Nursing School
• Dental School
• Veterinary Medicine
• PA, Podiatry, other
• Student Housing
• Health Sciences Magnet High School

19. • New England Journal of Medicine 2003; 348:2635-2645 June 26,
2003 DOI: 10.1056/NEJMsa022615. The Quality of Health Care
Delivered to Adults in the United States. Elizabeth A. McGlynn, Ph.D., Steven M. Asch, M.D.,
M.P.H., John Adams, Ph.D., Joan Keesey, B.A., Jennifer Hicks, M.P.H., Ph.D., Alison DeCristofaro, M.P.H., and Eve A. Kerr, M.D., M.P.H.
• The Rand Corporation. The First National Report Card of Quality of
Health Care in America, 2006.
• The Darmouth Institute for Health Policy & Clinical Practice.
February 6, 2012. End of life care and its effect on Residency Training: Variation in
resource utilization among 22 academic medical centers.
• The Darmouth Institute for Health Policy & Clinical Practice.
October 30, 2012. Surgical Procedure rates in Hospitalized patients (per 1.000
Medicare recipients 2008-2010).
Bibliography