Nick's Blog

I Fired a Fish This Week

The closest I’ve ever come to admitting my obsession with bullies came this week.  As I was walking toward the Men’s Room, my cell phone rang. Coincidentally, I was standing near a chair that was almost directly in front of one of our many fish tanks.  As the conversation went on, my eyes were drawn to the fish.  That’s when I noticed him; the biggest fish in the tank. He had little orange fins coming out of the bottom of its belly.  This dude was out of control.  He was chasing and biting every one of the fish in the tank, Alpha fish. 

This attacking went on during my entire conversation.  Chase, bite, chase bump, bite, chase; it was a flashback from my eighth grade year when some big, dumb junior used to grab my hat and throw it around the bus. Then, the coward would take my lunch and smash it into a baseball sized, brown wad of inedible nothingness.  He harassed me until I had one of my bigger friends threaten him one day. 

Now, this fish was really getting me riled up.  I was annoyed, then irritated, then exasperated, and finally infuriated.  What the heck?  This hospital is famous for treating its workforce, patients and physicians with dignity, compassion, and respect, and here was this bully fish chasing everyone around.  No matter where they went in the tank, he swam as fast as he could to scare and try to scar them.

 I went back to my office and ruminated for awhile about this aquatic creep, and my blood pressure kept going up until I could hear my heart thumping in my ears. No more. This fish had to go. I walked out to the tank and got the phone number of the fish tank maintenance people.  It was then that I realized that all of this was pretty silly. It is simply what nature is all about, survival of the fittest.  “Okay, alright, calm down, sleep on it,” I said to myself.  It’s just a big, mean, despicable fish. It’s not a person. It’s not disrupting the balance of life.  Just because it’s a wicked, shameful, loathsome, contemptible, wicked son of a #!%$ fish, there was no reason for me to continue to obsess over it.  

That night, I kept waking up, thinking about that fish and all of the nice little fish who were being attacked, threatened, and terrorized because of this storm trooper.  When I got to work, I walked into the office of the closest fish attendant, a wonderful employee who feeds them and makes sure the lights get turned on and off each day, and I said, “Get rid of the fish with the orange fins.”   She smiled and replied, “Really?”   “Yep, I want him fired,” I replied.  “Send him to some other fish tank full of fish that are bigger than he is.”  Just get him out of here!”   She laughed quietly, and said something like, “No one is safe when you’re in one of these moods.”

That day, the fish tank attendant came for a visit, placed our aquatic terrorist in a big plastic bag, and said, “Don’t you worry, I’ll take him to a safe place.”  Heck, safe was the last thing I wanted for this guy.  Later that afternoon, I was standing in front of the other fish tank at our research center and what I saw was nothing short of a war.  They made our orange finned guy look like Nemo.  “What’s this all about,” I asked our receptionist.  She smiled and said, “These are bad, bad fish. They are Cichlids, and all they do is chase each other all day, eat their young, and make life miserable."  No leadership there.  Fish tanks can be just like work.  Guess it depends on who you have for a boss.HTML

The Future?

When someone tries to predict the future, it always reminds me of the story of the man who looked in the crystal ball. He got crystal in his eye. In spite of that challenge, here is my shot at 21 years of observing the area's health care competition.

We have been permitted, and that word was not accidentally selected, to have two very good years here at WMC.  We have had 24 months of considerable growth; growth that has allowed us to feel the comfort of at least believing that we can have a positive future.  Having worked with the individuals currently charged with creating success at the neighboring hospital, it is not difficult to predict what they would need to accomplish to claim complete success in the local market. 

A few weeks ago, we saw the announcement and local editorial endorsement of a Back to the Future health care decision to create a MedWell type facility less than two miles away from WMC that will be open to patients on off hours. Obviously, one of the measures of success that would be applied to this facility would be that of capturing those patients now coming to Windber Medical Center's Emergency Room between the hours of 3 and 8 PM and on weekends.  If their service is fast, inexpensive, and thorough, they will impress patients, and perhaps capture market share that has shifted to WMC from the local geography.  The new target will also be the hundreds of employees coming into the region this summer and fall.  After all, convenience and the prejudice of bigger is better will both potentially come into play at a facility like this.

The other phenomena that has taken place locally has been one of uniting numerous independent surgeons into one group. This is something that only one or two things might have caused; the Pennsylvania malpractice insurance crisis that has discouraged seasoned surgeons from attempting to pay exceptionally high insurance premiums and the potential promise of a new surgi-center would both fit into the category of "tipping point" phenomena that would contribute to this perfect storm.  Realizing that these individuals have been in fierce competition for decades makes this union even more suspect.  Following the logic previously outlined, it would also make sense that these surgeons would consider moving their secondary, less complicated work to a new surgery center in the area where the most growth is occurring, the East Hills, about 1.5 miles away from the only even slightly serious competition in the area, WMC.

Finally, with surgeons and walk-in patients coming to the very old Richland High School where the neuroscience center, MRI, PET/CT and other x-ray modalities are located, only one other major move would make sense to attempt to capture the 150,000 plus patient visits coming to WMC. That would be to move as many Richland based physicians into that same building as well.  These physicians could then feed the new center.  Because they already own the building, construction costs would be minimal, and potential profits would be higher.  (Watch for construction crews at an old school near you.)

So, as I look into my crystal ball, the solution seems to be very clear. We at Windber Medical Center must prepare for the worst, and "continue to work to be the best."  

The only way that WMC will survive into the future is for our employees to provide service that is so far above and beyond the norm that any potential patient would literally have to be dragged away from our optimal healing environment. 

Although the percentage of patients represented at WMC is only about 8% of the health care volume in the area, it is the closest and easiest 8% to target.  If anyone looks at Bedford, Somerset, Altoona and Indiana's growth since Lee was closed, it is clear that leakage of patients from this area is occurring at much higher volumes, but, like Willie Sutton supposedly said when asked why he robbed banks, "It's where the money is."  If you asked our neighbor why they have abandoned the heart of town and targeted the East Hills, they would have to say, "It's where the patients are." 

My friends, this is neither brain surgery nor rocket science, it is what it is -- competition, and only the best and brightest with the most carefully laid out survival plan will succeed.  Remember, our patients are our future, and our philosophy, our smile, our skill and our attitudes will result in our future being bright. 

A Time to Reflect On Life

With the passing of Tim Russert, we are all made critically aware of the fragile nature of life and our need to embrace every moment as a gift.  Obviously, within a split second, every aspect of our lives can change, and, as in Mr. Russert's case, can end.  This is not a blog about instant death, and it is not just about recognizing our mortality.  It is about preparing for our passing carefully.

Liz Szabo, a writer with USA Today described in a recent article the cancer patient experience by saying, "Patients with advanced cancer often don't know how long they have to live or how chemotherapy will affect their lives."  According to a study by the Journal of the American Medical Association, many physicians either don't give patients that type of information or the patients only "hear what they choose to hear, or very often misunderstand what is said to them."

This situation often leads to patients requesting incredibly disruptive and sometimes painful therapies that have no hope of succeeding.  According to the study, more than 20% of Medicare patients who have advanced cancer begin a new chemo regimen two weeks before they die.  Many times patients are admitted to hospice days or hours before they die. 

What has been observed in cases like this was that the patient often misses the opportunity to repair relationships, get their spiritual house in order or even prepare the necessary documents such as advanced directives.

Where is this going?  Sarah Harrington, an assistant professor at Virginia Commonwealth University School of Medicine in Richmond, co-author of the quoted article, indicated that "in the last few weeks or months of life, a lot of good work can be done." 

One of the points brought up in the article was that only about 37% of physicians told patients how long they had to live. This fact was not surprising to us because we have seen dozens of patients who were admitted to hospice over the years return home and live several more months or years. This particular prediction is not always dependable. The other fact quoted in the article, however, was that many patients learned more about their cases from other patients than from their physicians. 

The article concluded with the suggestion that "patients and their families may have to take the initiative in finding answers to important questions."  Thomas Smith, co-author and Chairman of Hematology and Oncology at VCU's Massey Cancer Center suggested that the following questions should be asked by any patient in this situation:   What are my options?  Can I be cured?  Will I live longer with Chemo?  Should I consider Hospice or Palliative Care?  Who could help me cope?  What do I want to pass on to my family to tell them about my life?  

Palliative care is not limited to cancer.  All end-of-of life diagnoses qualify patients for hospice and palliative care.  Tim didn't need or have this opportunity, but for those who do, embrace it.  The primary thing that can be delivered to the patient and their family is the comfort of having caregivers dedicated to helping you move through your transition.  It is what they do.  These amazing people, volunteers, employees and physicians are dedicated to "paying it forward." 

So, as we eventually face our own mortality, as we evaluate what it is that we want to share with our families, as we consider the legacy that we wish to leave, having a clear mind and looking to those professionals who can help us is not only necessary, it is imperative. This transition can come in the blink of an eye. 

Medicare Penalties . . . This Could Clarify Priorities in Some Hospitals

If you do the math, you can rather quickly determine that, as the Silver Tsunami continues with the Boomer generation, federal funding for health care will become more and more scarce.  There have been some very serious cutbacks in funding to hospitals recently, and we have not seen even the tip of the iceberg.  As a matter of fact, Windber's total increase in reimbursement from Medicare this year for all inpatient expenses will amount to about $8,000 for twelve months. 

When all expenses are taken into consideration for even a hospital our size, $8,000 won't cover  a  tiny fraction of the cost increases that we will be dealing with from the implementation of new federal regulations alone this month.

 We have written extensively about the amazingly low infection rates here at Windber Medical Center, but, you have also read those sobering national statistics regarding deaths from hospital missteps.  CMS (the Center for Medicare and Medicaid Services), has recently introduced a form of pay for performance, or more appropriately, no pay for performance which will very likely cause a great deal of change in the American Healthcare System. 

CMS has decided to literally stop paying for the treatment costs of preventable medical complications.  At the present time, only seven hospital-acquired conditions are on the no-pay list, but it may include up to seventeen conditions by fiscal 2009, this October. 

This approach is referred to as visibility for good care,and it will very well represent the beginning of a stampede from the third party insurance payers to follow "the CMS Big Dog," and discontinue payments based on the same criteria.  In fact, Cigna Corp recently announced that it will not be reimbursing hospitals for certain errors as well.  

So, what's on the list of "no pays?"  Let's start with the obvious: Objects left in after surgery...clearly, that would seem to come under the duh category.  Then there are the pressure ulcers or bed sores, falls and trauma, catheter associated urinary tract infections, and surgical-site infections after heart surgery. 

As a small hospital in an area where the percentage of octogenarians statistically mirrors Dade County Florida, nursing home admissions often come in with these problems, but CMS contends that the hospital should make sure the infections or bruises were there upon admission. Otherwise, it's a free ride for the government. 

Analysis of the source of infections can often times be almost impossible to determine. Having said that, however, only about 9% of U.S. hospitals use daily reminders to help physicians remember which patients have urinary catheters in place.  According to the University of Michigan's Sanjay Saint, a professor of internal medicine, about 74% don't keep tabs on how long the catheters are in place.

Modern Healthcare had an article by Linda Wilson on this topic, and in that article quoted the number, $23,772, as the approximate loss that each hospital would endure from this first wave of no pays.  Accepting that number as a guide would be like determining how much damage one termite might do to your home.  The decision to impose these no-pay penalties should surely get the attention of those of us in this business whose job it is to keep the place open because the next nine conditions, and the next nine, and the next nine could possibly lead to very serious financial challenges for every hospital.  It is bureaucracy at its finest.

In the carrot and the stick scenario, there will be lots of hits. Some will be fatal to smaller hospitals. Wouldn't it have been better to just reward hospitals like Windber?  Everyone would have lined up to learn our secrets.  Carrots work, too. 

 

Knowing Enough About Systems to be Dangerous

From the age of about eight until 20 years ago, my entire life was immersed in music, education, the arts and, in a very pure way, people in general.  It was a complex world that required a deep, intuitive understanding of the human condition on multiple levels.  In a very general way, that life, (pre-health care management) was all about systems.  

Obviously, it was never just about one or two individuals, and it was not about life and death, but it was magnificently complex in its own way. It involved working with  people to do something that was extremely challenging, that required incredible hand/eye co-ordination, and an ensemble mindset of co-operativeness that was paramount to success.  Most importantly, it required them to listen intently to each other so as to find the perfect balance, blend and intonation. 

The nuances of taking a systemic approach to the creation of music through the efforts of an ensemble in many ways have escaped our world of healing, at least until now. 

At a recent visit to my dentist, he and his hygienist were talking about the fact that the doc had just taken a continuing medical education course.  When he was asked if anything new had evolved from his class, he smiled and said, "Well, for the first time in 28 years of practice, they admitted that the mouth is connected to the body."  He went on to elaborate about the fact that each and every day he sees the destruction caused by inflammatory disease of the gums, and then told me about his attempts to communicate that information to a physician friend several years ago.  "It just didn't register," he said. 

What little we know about inflammatory disease has us dutifully brushing our dog's teeth to prevent a heart condition, yet we still do not have direct lines of communication between our primary or cardiac physicians and the the dentists who see these problems as they manifest themselves in our body.  

Someone once told me that Descartes' Treatise of Man played a major role in the imposed medical and emotional separation of the brain from the body, as it clearly took the stand that "Hospitals and physicians should take care of the body while the church takes care of the mind and the soul."

One of our scientific collaborators, Dr. Lee Hood, is famous for his work in Systems Biology.  Another collaborator, Georgetown University, is involved in the creation of a medical school program revolving around Systems Medicine, and finally, our Optimal Healing Environment collaborator, the Samueli Institute, is focused on Systems Wellness.  In spite of these wonderful leaps into what would have to be considered common sense approaches to health and life, we still sometimes miss the ensemble approach.

My recommendation? 

Maybe it would help our healers to take their place on the podium, look at every one of the 30 plus lines of music on the score, raise the baton and begin to direct their way through every nuance, inflection, and harmonious signature present in a score of music with the appropriate rhythm, intonation and accents just to remind themselves that; we human beings are basically all made up of systems as well, and those systems will not function smoothly if one is completely out of sync with the other." 

This is something that we all know intuitively.  Maybe immersing ourselves in that world for a while will help bring that concept totally back into focus.  It's all about harmony, balance and nature's perfection, and a disjointed approach to health is as potentially harmful as a disjointed approach to life.