Nick's Blog

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. 

 

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. 

$4.3 Trillion in U.S. Health Care Spending?

"Money doesn't make you happy.  I now have $50 million, but I was just as happy when I had $48 million."
–Arnold Schwarzenegger

According to an article in Internal Medicine News by Mary Ellen Schneider, spending on health care in these United States is projected to reach 20% of the gross domestic product on the one hundredth anniversary of my father's birth, 2017.  Of course that projection is only an estimate made by CMS, the Centers for Medicare and Medicaid Services.  That estimate is, of course, based upon a continued escalation of nearly 7% each year for the next nine years.  In lay terms, that escalation would mean that the total dollars spent on health care would hit $4.3 trillion...Whatever a trillion is? I still can't fathom a billion of anything.) 

 We all should realize by now that this spending in the public sector, Medicare and Medicaid, will increase due to the first wave of Baby Boomers entering the Medicare system in 2011.  My 78 million peers, like the lemmings, are working their way toward the proverbial wall, and for those of you who will have to carry the load until we are wearing our wings, that is not a pretty financial picture. 

The same economists from CMS are predicting a decrease in reimbursements to physicians over the next several years while Home Health will likely grow faster than most other sectors except perhaps prescription drugs. 

What does it all mean?  We are spending more on health care in the United States than any industrialized country in the world and, truthfully, our overall age of death is significantly surpassed by many of those "spending less" countries.  How can that be?  Well, for one thing, we have 47 million uninsured citizens in this country and no one really knows how many illegal aliens. Why so many uninsured?  They don't vote.  The vast majority are young, single mothers with small children, and this does not take into consideration the illegal aliens who are also not insured. 

Back to the answer. . . prenatal care is inadequate and infant mortality in the United States is still an embarrassment.  A few of the countries that do better than us in the world in infant deaths per thousand are:  Australia, Austria, Canada, Czech Republic, Denmark, Finland, France, Germany, Greece, Ireland, Japan, South Korea, New Zealand, Norway, Portugal, Spain, Sweden Switzerland and the United Kingdom.  Hmmmmmm?  Could it be because we spend 30% of our annual health care dollars on the last thirty days of life, and less than 4% of our monies on preventative and wellness care? 

Of course, Hospice would be a tremendous help.  We could reduce expenditures on end of life care, properly care for our babies with the excess funds, and ensure that our uninsured are properly covered as well, but what politician is willing to touch that electric third rail of the electorial subway tracks? 

We could begin by putting in a network of sidewalks, bike trails, and walking trails.  We could actually walk once in a while and treat our bodies like a true temple, not the "Temple of Doom."

One of the least often heard issues revolving around these expenditures is the continuation of our archaic hospital system.  It is based on the acute care model, and the vast majority of our diseases are chronic.  We rush the victim to the hospital, patch them up, send them home and then rush them back again without any commitment to behavioral modification.  I have seen individuals reverse their heart disease from diet, exercise, and stress management.  Why can't we embrace this concept, reward these activities, and change our society?  The millions of bicycles in Europe are no accident. 

So, as I've quoted in some other blogs, "Change or Die," or just spend ourselves into oblivion as we attempt to prop up a system that should have gone out with the Industrial Revolution.  Good luck kids, your ole man needs you to keep working to cover my health insurance.   

Managers, Smanagers...It's Over

Kenneth Cloke and Joan Goldsmith wrote a very interesting book entitled The End of Management. In this book, they assert that managers are the dinosaurs of our modern organizational ecology. They go on to assert that the "'Age of Management' is finally coming to a close."  Their treatise is that "the need for overseers, surrogate parents, scolds, monitors, functionaries, disciplinarians, bureaucrats, and lone implementers is over. . . "

If, by now, you managers are wondering what comes next, our authors assert that the new need, the true need in modern day business is for "visionaries, leaders, coordinator coaches, mentors, facilitators, and conflict resolvers." 

In a recent conversation with an "old school" manager/friend, I reached out to explain to him why he was alienating his subordinate.  I explained very carefully that management as a self-contained system fails to open the heart or free the spirit.  This approach has truly taken our organization to new heights.  Of course, one can only work within one's comfort zones, and many managers, especially, old school managers, only know one approach, and that is, the industrial revolution way. 

Let me suggest that you analyze the quality of the individuals with whom you work.  Then, step back and realize just how amazing those individuals are with "butterfly" qualities.

Do not penalize your charges because of your insecurities.  Build a team that "has your back" by empowering them to be all that they can be.

The revolution quoted by Cloke and Goldsmith is one of "turning the inflexible, autocratic, static, coercive bureaucracies into agile, evolving, democratic, collaborative, self-managing webs of association."  From our perspective, the object is to allow those butterflies the freedom to fly. 

How do you manage a butterfly?  Work together on the goals and then get out of its way.  Provide it with just the very basic, fundamental needs and goals of your organization, and then trust it, love it, empower it, and encourage it.

If I could possibly find one example that would clearly embrace our success as an organization, it is that of doing everything possible to kill "parent to child management."  It is not enough to move into the 21st century with our thinking; it is most important to identify those individuals who get it and then give them the space "to do it." 

Are they traditional?  Do they do everything the way you were taught in the "dark ages of the industrialized style of management?"  Nope.  Will it drive you crazy when you look for them, and discover that they are not on the flower where you expected to find them?  Sometimes.  Will they accomplish more than you have ever dreamed if you treat them with dignity, respect, love and freedom?  Oh, yeah. 

You see, it is not about control.  Control is only necessary for those who are not trustworthy.  Better than trying to control a non trustworthy individual, simply help them find work somewhere else.  If they don't get the mission, don't understand the philosophy, and don't work to their capacity, they shouldn't be there. 

On the other hand, if they are loyal, trustworthy, committed, and caring, back off and allow them to soar, and you will never see results of the kind they that they will deliver to you or your organization. 

If they look at it as a job, if they are only comfortable with myriad rules, time clocks and books of policies, they are stuck in the past. 

Leadership means trust.   

The End of Management, Kenneth Cloke & Joan Goldsmith

An Editorial Comment

Several years ago, we decided to be progressive and build a new building to house the Windber Research Institute.  Yes, it was risky.  Yes, it would take an enormous amount of hard work and good luck to even make the organization sustainable on a long term basis, but the optimists won, and we launched the effort to build. 

The journey to completion on that building was not only significant, it turned out to be extremely difficult.  Don't get me wrong, the architects did a great job.  Engineering was fine, and all of the members of our building committee worked hard to bring it to fruition. 

Interestingly enough, due to nearly 18 months in delays and some difficult publicity, we ended up losing three biotech companies that had intended to locate here in Windber.  They went to New York State, New Jersey and Harrisburg.

Now, several years later, after trying to attract new biotech organizations to our building, we found several physicians who were willing to move in, but, unlike the companies that had previously chosen us, these physicians cannot do their work without contiguous parking spaces for their patients.  Consequently, a year ago, we began our quest to assist our neighbors at St. Mary's Byzantine church by providing a parking lot for their use on weekends.  This would also provide the needed spaces for the doctors offices during the week.  It was all about neighbors helping neighbors, for which the community would be richer.

Fortunately, or—depending upon your point of view—unfortunately for some, our medical facilities are currently being stressed because of increased use.  We are growing fast and, to meet those demands, must continue to expand.  This growth cannot take place in a vacuum.  To continue to grow takes both money and co-operation, and both are sometimes very hard to come by. 

If we want a sub specialist on our campus, parking must be a consideration.  If the emergency room is to be large enough to accommodate the demand, it needs to be doubled in size.  If there is no place for education, large meetings, or significant activity space for children's exercise programs, a building must be built.  Finally, the need to accommodate the birth of numerous babies will also require more physicians and more space.

If we cannot grow, we will all pay the price, and that price will include inconvenience and lack of adequate expansion capabilities.   

Let's hope and pray that co-operation will become the key to forward movement.  Otherwise, we will spend countless dollars, hours and energy staying small.  Our future rests in our ability to treat more people more efficiently, and that cannot happen without co-operation. 

Success in EVERY direction!

Remember the story about the frog in the pot of water?  If the temperature goes up little by little, the frog stays put and it finally gets cooked.  Well, the magic number there was 212 degrees!  Windber Medical Center is right now at 210 degrees.   We are COOKIN'!!   But, in our case, it is not only positive, it is also amazing and exciting.

The Pennsylvania Mountains Healthcare Alliance recently received a $1+ million grant to begin connecting all of our hospitals together through fiber connectivity.  The potential ramifications of this network are virtually limitless.  They include the ability to do everything from provide disaster recovery for our network hospitals to all types of clinical and entrepreneurial activities.

WMC's as-yet-unannounced fund drive is already up to $2M, and our employees have donated more than $75,000 in the past few weeks.  That's a million a month with months to go.  These funds will allow us to put in our new emergency department, expand the obstetrics/nursery area, to add a new entrance from Somerset Avenue and much more.  Thanks to everyone who has donated and to Attorney Tim Leventry, Campaign Chair, and the hard working team that is making this happen. 

Due to the tireless work of Susan Ott and our Joint team, preparation for Joint Commission seems to be moving along very well, too.

The Windber Research Institute has finally begun to receive all of the grant funds that were caught up in bureaucratic bottlenecks over the past year and a half.  This will ensure our continued expansion and growth with the addition of several new employees at both the research PhD and technical levels.

A new local company, Illumina, is providing our physicians with the opportunity to begin sophisticated clinical trials for their patients, potentially a national or international patient draw. 

The new team at the Joyce Murtha Breast Care Center includes several RN's, our psychologist, and numerous other staff members.  This combined team is making amazing progress.  The new Woman'sCare program at the Breast Center is only two months away from formal launch, and will include several sophisticated new modalities, treatments and opportunities to help women in our area and around the world.

Financially, we are having the best year in our 102 year history.  Of course, it is critical that our financial performance is at this level so as to allow us to purchase and install our new computer system.  That project is making us all a little crazy, but is coming along very well, too. 

So, for the nay sayers, the disbelievers, the cynics and the worry warts; all we can say is too bad, so sad.   

WindberCare is thriving, patient numbers are growing, and nothing, absolutely nothing will get in the way of the wonderful optimism that our employees demonstrate toward our patients and stakeholders every day. 

Person Tim Leventry

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Random Thoughts. . . Learn From Your Mistakes

Make sure you know the question before you give the answer.

My kids taught me a lot about this job. At age seven, my son said, "Dad, where did I come from?" I knew that question was coming, but I had not expected it that soon. "Son," I said, "Let me explain about life" As I began my meticulously rehearsed tale of the birds and the bees, I slowly explained the nuances of life, love and more bees.

I was perspiring profusely as I stumbled over these sensitive descriptions. After about ten minutes of squirming, stuttering and stammering I said, "Do you understand, son?" To which he turned to me and said, "Heck, Dad, I knew all that stuff. I just wanted to know what hospital I came from, Mercy or Windber?"

Learn to share.

Hospitals deal every day in life and death issues. They are extremely complex and multifarious places. Emotions can run very high as well as we deal with the challenges and mysteries of life. Helping people to share has been a very large part of my life. Helping them to share resources, time, space and all aspects of life is a very important contributor to our success as both care givers and human beings. When I was eight, my Aunt Mildred gave me three pieces of bubble gum. As I was walking home with all three pieces stuffed into my jaw, a group of kids jumped me, pinned me down, took my gum right out of my mouth and divided it up between them. It would have been a lot easier on me if I had just kept a few pieces out to share.

Finally, don’t repeat it if you don’t understand it.

In any organization there always seems to be someone who takes great pleasure in telling the story when they aren't really sure of its meaning. After standing near Jack, a 15 year old sixth grader at school one day, my vocabulary expanded exponentially. He talked about mysterious things that made no sense to me, but he was big and I was small. In my world, that meant that Jack knew all. That night when my mom told me, the little third grader, to get ready for bed, I looked up at her standing beside my grandmother, aunt and dad and said, "I don’t have to go to bed, you @$#%&*$@!"

My limp cleared up right before I had to walk across the stage to pick up my college diploma thirteen years later.

Learn from your mistakes.

Horses and Health

Due to my personal fund raising commitments this year, the staff here at Windber Medical Center probably feels like hiding under their desks when they see me coming.  You see, this is the year that we did a feasibility study to decide if we will have enough community support to raise needed funds to construct expanded emergency and obstetrics facilities and to provide WMC with a reserve for the future.  That effort will be made public in a very few weeks. 

The reason for their angst, has been that, for whatever reason, this is the year that their boss, me, has been solicited to solicit contributions for numerous other organizations in the area.  As a board member for the Keystone Chapter of the American Red Cross, we worked with a tremendous group of local leaders, including our Congressman Jack Murtha, who helped us conduct a  successful $300+K campaign that literally gave that organization new life.

Then we were approached by the Boy Scouts of America for their annual dinner to help generate enough cash to support their efforts as well.  Over $110,000 was raised for that effort, the results of which will ensure the continued growth of the Penns Woods Council of the Boy Scouts of America.

Next, came the Girl Scouts of Talus Rock; that project is currently underway and hopefully, will produce the needed funds for expansion and growth.  Oh, yeah, and the Winter Jazz Concert is coming up, too. Finally, this is the tenth anniversary of the Arcadia Performing Arts Theater, and that place surely needs to be endowed with a reserve fund that will ensure its continued success.

Several years ago one of our employees explained philanthropy to me in this way.  Each one of us have several pockets, and each pocket can represent our varied fund raising interests.  In the spirit of giving, it is clear to us that, if you like the organization, believe in the mission or, for whatever reason, care about the vision provided by the board or the leadership involved, you make your decision to give or not to give. 

When my own mother passed away, we discovered that, although her pensions amounted to less than half of the average salary in our area —which is about $10,000 less than the average U.S. salary, she was donating at least 50% of that money to organizations in which she believed.   So, here's one more worthy cause.

A few years ago, a wonderful, caring, local physician approached us regarding children at risk.  During the numerous meetings that we held, we discovered the incredible healing qualities that equestrian therapies can provide.  Yesterday, this topic was reintroduced here at Windber Medical Center by a dedicated, committed physician, Dr. Deb Baceski.  She met with me to discuss the Somerset Therapeutic Association for Riders, S.T.A.R. located on the web at STA4R.org.  According to their website, "Established in 1995, STAR has been providing safe, closely supervised riding lessons to physically and/or mentally challenged children."  It goes on to explain that; "In a typical training session, a handicapped child is helped to mount a carefully trained horse, and is then escorted on a ride for twenty minutes by three volunteers . . . "

One of the challenges that STAR is facing right now is that of the sometimes brutal winter weather that residents of this area have grown to know and "?" love.  Dr. Baceski approached us for assistance in a program that she calls, The HORSE POWER Project.  This project involves constructing an indoor riding arena so that the free therapy provided through this program is not interrupted by frost bite.

Although Windber Medical Center is also quietly involved in soliciting assistance in our own expansion needs,  this horse power project is not financially overpowering.  The volunteer Physical Therapists, Physician Assistants, Teachers and Physicians who enable this empowering, socializing, learning program to go on for those individuals isolated by their disabilities, can't do it alone.

So, take a look at sta4r.org, and, if you personally believe in this volunteer effort, or if you know of someone who could help them network their way to an enclosed arena, we invite you to show your support.    Their address is 305 Highpoint Drive Somerset, PA 814-445-4909.  Give if you want, but at least talk to someone who might.

"The best and most beautiful things in the world cannot be seen or even touched.  They must be felt with the heart." 
—Helen Keller

What it is all about . . .

Recently, my opinions have created some serious buzz in both our hospital and around our area.  My philosophical stand on patient-centered care is well known.  It has been the driving passion behind my entire life's work.  As a teacher and as a hospital administrator, it has been my commitment to do whatever was necessary to protect first, the kids, and now, our patients; to make them the center of our universe.

It is essential that we are reminded that each of us is a part of a much larger community, mankind. Obviously, some of us internalize these musings as coming from a leader who is not getting his hands dirty in the trenches, and the observation is absolutely accurate.  Unlike Braveheart, I am not out there in the middle of the battle.  I am not dealing with the nuts and bolts of the day to day challenges of patient care, but my role as a leader is to provide clear direction and to enable Windber Medical Center to have a bright, successful future.  The only way that this can occur is through differentiation.  How can we be different from other care centers?

It is important, however, that we detach from the intensity of our emotions now and allow ourselves to cultivate a more global perspective.  How would you want your mother or child to be treated?  How would you, as a patient, want to be cared for here?  If the answer is that you would like to be the center of that care, you are being honest and forthright.  That is all that this is about.  It is about putting the patient first.

But we are reminded of our limitations.  We are, after all, only human, and the daily challenges are real; our ability to deal with every element of our lives is real, and the pressures of life and death challenges are not easy to overlook.  So, we must focus on the fact that "we are not the enemy."  We must be the shining spot where patients know they will be protected, loved and compassionately embraced.

A Short Clarification

Let me begin with a very sincere apology. I am truly sorry if I did not make clear the substance of my article in last Monday's Business Review of the Trib. It was about Love, Compassion, Nurturing, and most importantly, making the patient, not the professional, the center of care.  It doesn't matter if a physician, like the amazing doctors here at Windber Medical Center, makes rounds at midnight, 2:00 AM or 9:00 PM if the patient and their family is the center of their care. Our physicians and staff, carefully ensure that their patients do receive this type of care.  This is was what it should all be about, making the patient, not the professionals, the center of our healthcare world.  This is what makes Windber Medical Center the wonderful place that it is.