Nick's Blog

In their Own Words: What patients, staff, and physicians have to tell us about their experience at Windber

Patients, staff, and physicians describe their unique, positive experiences at Windber Medical Center.

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The Wheels on the Bus Go Round and Round (Jacobs Announces Retirement December 31st)

Okay, so the word is out, way way out, that my tenure at WMC/WRI is beginning to wane.  As I look toward the next chapter of my life, there is something that you all need to know.  The board has met with both leadership teams to reiterate their complete support of my position until I am no longer here.  What does that mean?  It's like the old saying, "It ain't over until it's over."  

Interestingly, when one of my senior leaders heard my plans, he turned to me and said, "I can see it now. In about a year after you are gone, there will be weeds growing in the fountains, the trees will all be cut down, and all of the bullies will rise again!"  In fact, the rubber band seems to have started to return to its original shape already.  Last week we had an employee make one of our most important sponsors the offer of an appointment sometime next year. That sponsor selected another physician at another facility.  We then had another employee inappropriately question a guest's intentions. 

Let me tell you that, until they pry my retired fingers from my presidential desk, the weeds will not take over, the bullies will not be tolerated, and anyone who does not demonstrate love and respect for our patients and their families will be offered a transfer to any of our neighboring hospitals.  There is NO ROOM here for tolerance of anything that does NOT produce an optimal healing environment, that is NOT PLANETREE in every way, that does not embrace the vision of prevention, wellness, respect, and love.

I'm sorry if I sound upset, but this is an extremely serious situation. If any of you believe that we can go back to being a "NORMAL" hospital and survive, your head is buried deeply in the sand.  If any of you think we can be unpleasant and continue to capture the imagination of our patients and their families, you are completely delusional.  We are engaged in a struggle that will not easily be put to rest.  There is an urgi-care center, a surgery center, and a medical mall being built less than two miles from our walls. 

This, my last regular WMC blog post, is directed to the 15 or 20 people who are falsely being lured into believing that those of us who have embraced this nearly Utopian philosophy will permit you to run rough shod over our healing environment.  We will not.  The 600 other employees who do get it WILL WIN, and I will not let go unless or until I am no longer in a position to influence our work.  Our search committee has been charged to look for a replacement that also embraces this vision.

Get Your Hips on Route 56

In case you ever hear someone ask, "Windber?," we've complied a short list of attributes that have become part of our landscape over the past decade. Windber's ascendancy to the top tier of national hospitals and research centers this size and scope has been an amazing journey. With nearly 600 employees and a payroll of more than $21 Million, not acknowledging our Healing Hillside has become more and more difficult for even those oblivious narcissists who have ignored us for 100 years.

We are closing in on $3 M of successful fund raising activities being lead by Attorney Timothy Leventry and our Foundation office. These funds will be used for a new Emergency and expanded OB departments, and we are thrilled to report that the two highest operational income producing fiscal years in the hospital's 100+ year history are now "in the bag." These funds have enabled us to begin a massive installation of an entirely new computer system. The research institute also has nearly $20 M in the pipeline for significant research projects over the next two years with $10 M more pending for the third year.

With the announcement of the breast coil on our 3T MRI, WMC continues our bent of embracing innovative hospital care and treatment. As one of the first hospitals in the nation to adapt the patient-centered Planetree philosophy which pays particular attention to the environment in which patients pursue wellness, we now have clinical partners like the Cleveland Clinic along with us on this journey. The decision to promote the Dr. Dean Ornish Program for Heart Disease Reversal started us on our track to integrative medicine which uniquely places us internationally. Reiki, drum circles, labyrinths, pet, aroma, music, and massage therapy, accupuncture and energy medicine are just a few of the modalities offered here at Windber.

The research made possible by the opening of the Joyce Murtha Breast Care Center, one of the most innovative facilities of its kind in the United States, just adds further evidence of Windber’s uniqueness, and leadership there has literally opened the doors to numerous programs for woman's health that will further establish our commitment to this segment of our population.

We have successfully rallied important legislative support for far reaching projects here in cooperation with local, regional, state and national government through co-operation and support from Congressman John Murtha, Governor Ed Rendell and other public leaders. With the infusion of public contributions these include but are not limited to the a state-of-the-art HealthStyles Wellness Center, numerous research initiatives, the breast center and WindberPlace.

WMC has received top awards for excellence from AARP, numerous Planetree and Telly awards, was the first institution to win the coveted Fierce Healthcare Award for Hospital Innovation, and has been recognized by Forbes, The Wall Street Journal, USA Today, and numerous other media leaders.

If that's not enough . . . our HCHAPS scores were in the top 10% of the country, infection rates among the lowest, at 1%, readmission rates are low, lengths of stay are below average, and employee turnover is some of the lowest in the business. People like us because we like people.

Hospital Bullies take a Toll on Patient Safety

That was the title of an article written by JoNel Aleccia for MSNBC.com.  When I thought about writing this blog, a cold chill went down my spine. The last time I attempted to address this issue, I was attacked, not here, but from other places. My family was hassled, there were letters written to the paper, to my board, to the Medical Society and demands for apologies all around. This article, however, took a much tougher stand than I did, and made its point much better than I did as well. 

JoNel started by writing, "They're the bullies of the operating room, the brow beaters of bedside manner; doctors, nurses and other clinicians who make a habit of behaving badly."  Before you start sending me your hate E-mails and trying to get me fired, censured, and publicly whipped again, let me begin by saying that there are only about 4 to 6% of workers and staff nationwide who typically fall into this category, and, in our case, I can honestly and proudly say that at Windber Medical Center there are less than 1%, but that's not the point.  The point is that this type of behavior is still tolerated ANYWHERE. 

Ms. Aleccia goes on to say, "They yell, they cuss, they throw things. Or they engage in more subversive behaviors; ignoring questions, acting impatient, insulting colleagues or speaking to them in condescending tones."  Any of us in this industry who have not observed this behavior should please stand and be recognized.  Interestingly, the Joint Commission has recently taken a stand against bullying behavior with a first-ever alert, and the reason for their alert is patient safety.

Dr. Mark Chassin, President of the Joint Commission, says, "It's a problem that goes underreported, threatens patient safety and has become so ingrained in healthcare that it's rarely talked about."  (So, send your evil E-mails to Mark, and let me alone.)

Dianne Felblinger, an associate professor of nursing at the University of Cincinnati who studies medical intimidation goes on to state that "About 70% of nurses studied believe there's a link between disruptive behavior and adverse outcomes, and nearly 25 percent said there was a direct tie between the bad acts and patient mortality."

The great news is that Windber Medical Center's Administration, Medical Executive and Credentials Committees and Human Resources Department deal with these behaviors immediately. They do not and will not tolerate bullying.  Oh, and before we end this blog post, remember, this behavior is NOT limited to care givers; clearly, administrators, department heads, and others can be just as guilty.   

The advice given in the article is the same advice that we adhere to here at WMC as well.  When someone is disruptive we should simply say, "You know what...? That doesn't work here...And we're going to have to do this together as a team because that's what it's all about."

Amen!

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.   

Transparency

Transparency is a hot subject in health care these days.  The front page of last Sunday's New York Times carried a story about a physician who told his patient immediately after surgery that he had made a mistake, and basically apologized and asked for forgiveness.   Even with about 1,000,000 active attorneys in the United States working to make a living, the concept of telling the truth before it evolves into a lawsuit is more and more in the forefront of our literature. 

This week, I received a three page E-mail that was transparent, but it was not from us, it was about us.  It was so transparent that it should rock our collective souls.  As a patient-centered hospital that has reached some degree of recognition nationally, this letter represented not an A in patient centered care, but very close to a C, or worse. 

The person who took the time to record their stay at Windber Medical Center was painfully thorough.  Their hospitalization was over a 74 hour period when the house was full.  We were extremely busy, and somewhat short on some staff members, and a few key physicians were away.  This patient recorded every aspect of their experience.  They let us know when water was or wasn't delivered to the room, when the rooms were cleaned, where the nurses were and how often they delivered meds, checked their IV's, provided them with medicine, and met the patient's medical and/or personal needs. 

If it were not possible to determine who this patient was from the content of the letter, in the spirit of full disclosure, I would have reprinted it here for everyone to read. Instead, I will simply delineate the lowlights of its content.

The hardest thing about this letter for me was that we have been working for eleven years to bring improvement to the entire process, to improve health care delivery, and to provide an optimal healing environment. But, when things get rough, we seem to revert back to business-as-usual, circa 1997, and from the transparent report that this former patient provided, we did not always act appropriately. 

At a board, physician, and senior leadership meeting last week, I found out that one of our patient-centered practices had simply been discontinued without notification. This practice provided appropriately for patients, families and staff.  When it was discontinued, only the patients were being taken care of, and they were being cared for in an inferior manner compared to the original practice.  We have met with the appropriate staff members, and we are now back in the business of nurturing all of our stakeholders.

 
It seems to me that our reaction to stress and hard work might be like that of a rubber band.  As soon as the tension reaches its peak, that rubber band attempts to go all the way back to its original shape.  We are a Planetree Hospital.  We DO NOT do brain surgery, heart surgery, trauma or neonatal care.  We DO NOT have hundreds of specialists surrounding our campus like most academic medical centers.  Rather, we are a primary acute care hospital and our differentiation is patient and family centered care.  We are philosophically dedicated to treating our patients and their loved ones with dignity.  We are known for providing the highest touch care in the region.  After reading this patient's letter, it seems to me that they could have been in any hospital USA. 

If we believe that our mission is to provide the most wonderful, nurturing care, then we need to do that consistently.  A few weeks ago, a patient who was leaving the hospital said to one of our vice presidents, "Do you ever empty bedpans here?"  The question struck her as unusual . . . until she read the letter. 

We are all in this together.  We can only be as good as our weakest employee, and our future depends totally upon working not only as a team, but as a humane, caring, nurturing, loving team. 

Between our nurses, Integrative Health Team, our volunteers, pastoral care, our aids, housekeepers, dietary department and couriers, we should be in and out of rooms dozens of times a day.  No one should have to  wait for an overdue medication or just a cold glass of water. 

In closing, this is not a blog that is intended to demean, take unfair shots, or berate our staff, it is meant to say that transparency is exactly that: transparent.  Between the State Inspections, the Joint Commission and our own secret shoppers, transparency is here to stay, and we won't continue to grow without the total commitment from each and every one of us to work above and beyond the call of duty on all shifts.

In closing, the letter said, "You had one Golden Girl who was amazing in every way throughout my entire stay.  Her name is Debbie, and she is the pinnacle of everything you stand for as a Planetree hospital."

So, special thanks from us to you, Debbie.  You and people like you are our future.