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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.
Thursday, August 28, 2008 in bullies, Healthcare, Healthcare Transparency, Hospital, Hospital Administration, Hospitals, Integrative Health, patient-centered care, Wellness, workplace | Permalink | Comments (4) | TrackBack (0)
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.
What's happening in medicine and in health care overall? The Government is taking a three-pronged approach to improve quality in health care:
1. They are pushing quality through public reporting. (Check a website near you.)
2. Enforcing quality through the False Claims Act. (Check a prison near you.)
3. Incentivizing quality through payment reform. (Check a checkbook near you.)
Senator Chuck Grassley is quoted as saying, "Today, Medicare rewards poor quality care. That is just plain wrong, and we need to address this problem."
HMO's are currently embracing "pay for performance" plans for physicians and hospitals. Medicare is introducing value-based purchase plans. Medicare is proposing the linking of quality outcomes to physician payments.
As I have written before, hospitals will no longer be paid for hospital acquired conditions. That seems like a rather simple fix, but to appropriately determine if the condition was not acquired at the hospital, extensive testing must be added pre-admission at considerable costs to the hospitals.
James G. Sheehan, Medicaid Inspector General of New York said, "We are reviewing assorted sources of quality information on your facility to see what it says and if it is consistent. You should be doing the same."
Except for the financial implications, not unlike my competitive band story, the goal was to work toward perfection. The public reporting of quality of care is intended to:
1. Correct inappropriate behavior
2. Identify overpayment's
3. Deny payments
The False Claims Act, on the other hand has different goals. When asked how he viewed the False Claims Act, Kirk Ogrosky, U.S. Deputy Chief for Health Care Fraud said, "You will see more and more physicians going to jail." I guess the prisoners will be receiving better care.
Where's it all going? Competitive band. Will it improve health care delivery? Probably, for the patients who can find the few docs and hospital that will be left? I recently had a conversation with a young computer specialist who took care of physician practices. He said, "Doctors and hospitals haven't figured it out yet, but they are simply becoming data entry centers for 'Big Brother' as the facts and figures are accumulated to be used against them any way the payers decide to move forward."
Looking back at the school year that included gym class twice a week for the entire year, rich courses in music and art, and remembering a time when priorities included those classes intended to make every student well rounded, we have to ask, "Is education today better?"
Maybe this is all too complicated to get our arms around, but if there are 78 million Baby Boomers, and the Medicare Trust Fund is heading toward bankruptcy, then we probably will see every rule in the book being applied to keep from paying out money, because there is simply not enough money to go around.
Will health care improve? Once we understand that technology is not the end all and cure all that creates healing; once we endorse prevention, wellness, optimal healing environments, and systems approaches to health and wellness, health care will improve. I'll bet you that it will have very little to do with the rules that are unfolding right now and much more to do with the creation and acceptance of a National Health Policy.
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."
Healthleaders magazine had a cover story entitled "The Hospital of the Future" written by Molly Rowe. The line below the title read: "Sure, your organization offers sophisticated, compassionate care. But the patient of tomorrow will want much more than that. Here's how some hospitals are creating facilities for a new vision of healthcare."
Rather than re-write the entire story, I'd like to list eleven of the bullet points that were identified as qualifiers for future care in these new hospitals. Then I'd like to ask those of you who have known, followed, or otherwise used us for your healthcare needs to identify which of those eleven are currently missing from this hospital environment, and, for that matter, which have not been a part of our experience here for the past decade?
Maybe the better question to ask is: are there any ideas listed here that have not been put forth as challenges for implementation to our vice presidents, directors, or physician leaders? Okay, we're not completely there yet, but we surely are close, and for Windber Medical Center the future has been NOW for quite some time. The things not on this list that we do include:
I rest my case...
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
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.
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.
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.