Supply and demand have more to do with readmission rates over illness severity and care quality, according to new research presented at the American Heart Association’s Quality of Care & Outcomes Research Scientific Sessions. Differences in regional hospitals for heart failure, in fact, have more to do with the number of hospital beds (availability of care) and income levels (socioeconomics), rather than hospital performance, the American Heart Association said Friday.

Heart failure–one of the three conditions that the Centers for Medicare & Medicaid Services will ding high-readmission hospitals for with reduced Medicare payments in October–has wide variations across the country. Heart failure readmissions range from 10 percent to 32 percent. The new research found that areas with higher rates were likely to have more physicians and hospital beds, and their populations were likely to be poor, black and relatively sicker.

Supply factors like the availability of doctors and beds accounted for 17 percent of the variation in readmission rates, and poverty and minority makeup accounted for 9 percent. Hospital quality performance, on the other hand, only accounted for 5 percent, and degree of illness accounted for 4 percent.

With readmission rates linked to reimbursement, the study suggests that Medicare penalties may be ineffective at improving care, according to the research announcement.

“We need to think less about comparing hospitals to each other in terms of their performance and more about looking at improvement in hospitals and communities,” lead study author Karen E. Joynt, an instructor at Brigham and Women’s Hospital, Harvard Medical School and the Harvard School of Public Health in Boston, said in the announcement. Joynt stressed thinking about readmissions in terms of community and population health.

The American Hospital Association also expressed concerns in its advocacy papers this month regarding low-income areas and the forthcoming Medicare penalties. “There is compelling evidence that safety-net hospitals and others serving large numbers of low-income individuals will have difficulty reducing readmissions due to the lack of some of these resources in the communities they serve. This creates an unfair system that puts these hospitals at greater risk for substantial readmission penalties.”

Read more: Readmissions linked to beds, income more than quality – FierceHealthcare http://www.fiercehealthcare.com/story/readmissions-linked-beds-income-more-quality/2012-05-14#ixzz1uwo6xQat

Patients that are discharged during the busiest times for hospitals are 50 percent more likely to come back in within three days, according to research published in Health Care Management Science. Two new studies from the University of Maryland suggest that that revenue from surgery is driving patients going home too early.

They looked at occupancy rates, day of the week, staffing levels and surgical volume at the large, academic medical center and concluded that readmissions come from poor planning.

“Too often, the biggest problem is that hospitals just don’t plan ahead, and this is what gets them in trouble,” Bruce Golden, a university professor, said in a Friday statement. “There are logistical alternatives to sending a patient home too soon.”

Study authors did note that the problem was more likely to happen at large hospitals not only because they have resources to provide advanced surgeries, but patients traveling to the facilities also may put pressure on the hospital to avoid delays.

Study authors recommended hospitals use checklists before discharge to avoid infections, for example. Golden also suggested moving patients to units with empty beds rather than sending patients home prematurely. Although doing so might up costs initially, Golden said it will save the hospital in the long-term.

Read more: Busy hospitals discharge patients too soon, see higher readmissions – FierceHealthcare http://www.fiercehealthcare.com/story/busy-hospitals-discharge-patients-too-soon-see-higher-readmissions/2012-05-14#ixzz1uwmDE2Oo

By Alicia Caramenico
Fierce Healthcare

In a recent Hospital Impact blog post, Jonathan H. Burroughs recalled an instance early in his medical career when he disrespected an inexperienced nurse and drove her to tears.

“In my most caustic and superior tone I told her so that everyone could hear, ‘If you don’t know what epinephrine and atropine are, you should not be here; please send me a nurse who knows what [he or she] is doing’,” wrote Burroughs, a certified physician executive and American College of Physician Executives fellow.

With a daughter entering the healthcare field, Burroughs wondered whether physician-nurse relationships have since improved.

His disrespect–and subsequent apology–struck a chord with readers and spurred a lot of interesting feedback. And according to most of the readers, the industry still has room for improvement.

“I do think that nurse-physician relationships have improved,” one reader wrote. “However, there is still a very long way to go to having truly collaborative relationships. The residents I see daily have so much more respect towards the nursing staff and the amazing knowledge and skill we have. I think a lot of this has to do with the fact that nursing is seen much more as a profession than it had in years past. The culture of healthcare is changing.”

Wrote another: “I think this type of situation is far from over, but just like most fields the medical field is slowly leveling the notion of equality between providers and staff.”

One reader shared a similar experience to the one Burroughs described–and her story illustrates that physician-nurse relations are still a sore subject:

“I am sorry to say it is not better. Just last week I informed an M.D. on the unit of a critical lab. I was laughed at by him and his colleague. Mind you I am a seasoned 20 year veteran.  I had to interrupt their comments to tell them it is my responsibility to inform them within 30 minutes or less of critical values and to document that transaction. [I] really don’t think they got it. [I'm] feeling angry and hope to avoid any future interaction with them.”

But what struck me in the reader feedback were the calls for education and training. Those readers appear to be onto something, as recent research found that hospital training programs aimed at increasing physician-nurse communication and teamwork helped reduce surgery-related complications, including blood clots and infections. Moreover, hospitals that used teamwork training saw a 15 percent decrease in patient deaths, compared to a 10 percent drop at hospitals that didn’t use the program, according to a December 2011 study in the Archives of Surgery.

That approach was echoed in a study published February in Nursing Management, which advised that education and training play a key role in conflict management so that nurses learn how to effectively mediate disputes themselves. It recommended using case scenarios and role-playing to teach skills to handle conflicts. Hospital leaders should consider offering such lessons to their physicians, technicians and other hospital staff.

With professional conflict linked to medical errors and poor outcomes, what else can hospital leaders do to keep the peace between physicians and nurses and ensure high-quality care? According to Gus Geraci, vice president of physician leadership in quality and value at the Pennsylvania Medical Society, it’s more about the willingness and cooperation of both parties involved than executive intervention.

“When execs come to both groups and ask them to work together to improve, it works if both sides understand each other’s roles and are both flexible,” Geraci told FierceHealthcare. “Working harder is not the solution. Working together and including others is what works.”

http://www.fiercehealthcare.com/story/doc-nurse-relationships-sore-subject-sore-need-solution/2012-05-04?utm_campaign=linkedin-Share-NL

About Morgan Hunter HealthSearch
Morgan Hunter HealthSearch (MHHS) provides Executive Search and Interim Leadership solutions for hospitals and health systems throughout the United States.  Our services include executive healthcare recruiting, retained healthcare executive search, healthcare interim management, executive placement for hospitals. 

By Rob Markey
Harvard Business Review

Employee happiness is becoming a hot topic among CEOs and in boardrooms, and it’s about time. The current issue of Harvard Business Review, which includes a series of articles focused on employee happiness, is just one more sign of the growing recognition that happy, engaged employees are more productive and generate better outcomes for their companies.

But there’s also a risk in all this attention to “happiness.” Happiness for its own sake is not the right outcome to seek. If you want happy employees, you can just pay them more. You can give them more time off. You can give them free lunches by celebrity chefs. Only a few of the things that make employees “happy,” however, result in real, sustained benefit for the company. As Gretchen Spreitzer and Christine Porath note in one of the recent HBR articles, “It’s not about contentment, which connotes a degree of complacency.”

My colleagues and I agree with that. We have been studying the links between employee engagement and customer loyalty for a few years now, and we’ve found that the only route to employee happiness that also benefits shareholders is through a sense of fulfillment resulting from an important job done well. We should aspire not just to make employees “happy,” but to do so by helping them achieve great things. In short, we should earn our employees’ passionate advocacy for the company’s mission and success by helping them earn the passionate advocacy of customers.

That’s an ambitious goal, of course. And it necessarily links employee engagement to customer outcomes, the ultimate source of a company’s success. Most companies’ approaches to employee engagement fail to achieve the right sort of engagement. Here’s some of what’s needed:

1. True ownership by line managers. Most large companies depend on HR to measure and manage employee engagement. HR collects the feedback, analyzes it, and then “cascades” it through the organization, beginning with the CEO and then at progressive levels down to the front line, along with recommendations for improvement. But this keeps control, ownership, and responsibility firmly in the hands of a central team.

Real engagement — passionate advocacy — comes from making customers’ lives richer, and there isn’t much that HR alone can do to help employees achieve that. So Apple stores, JetBlue Airways, and others deliver employee survey results directly to operating managers, who can then sponsor shop-floor change initiatives. Perhaps more important, they feel full ownership of the results and for making progress. At Apple, for instance, employee focus groups identify key themes and issues from the surveys; employee teams then help develop solutions, which they present to store management. By the time the next survey comes around, managers can see whether the solutions have had the desired effects.

2. Simpler measurement. Most companies gauge employee satisfaction through the time-honored annual survey, managed centrally and comprising a huge number of questions. They often result in tremendously detailed reports across a large number of metrics. But many companies are taking a page from the Net Promoter playbook: They survey employees more often, ask just a few simple questions, and simplify the reporting. How likely would you be to recommend this company to a friend as a place to work? How likely would you be to recommend the company’s products or services to a potential customer? What’s the primary reason for your response? These companies allow employees to use their own words to identify opportunities and issues. The feedback can be difficult to hear — employees tend to be tough graders. But it can be much more powerful as a motivation to take action.

3. Direct feedback from customers. The most important step, of course, is providing a steady stream of feedback from customers and then “closing the loop” quickly by sharing it directly with employees in its most raw form. When frontline employees and managers hear directly from customers — when they see how customers scored their experience, when they hear what went right and wrong in the customer’s own words — the effect is dramatic. Applause in the form of positive feedback inspires them to keep up the good work. Criticism often inspires employees to improve their performance on their own or to seek additional coaching so they can do better next time.

And it isn’t just customer-facing personnel who can learn from customer reactions. Logitech, for instance, compiles Net Promoter scores for each of its products and ensures that the engineering teams responsible for each one see and hear what customers think. When one new keyboard got negative reviews, the company was able to identify the problems and quickly bring out an improved model.

Loyal, passionate employees bring a company as much benefit as loyal, passionate customers. They stay longer, work harder, work more creatively, and find ways to go the extra mile. They bring you more great employees. And that spreads even more happiness — happiness for employees, for customers, and for shareholders.

http://blogs.hbr.org/cs/2012/01/transform_your_employees_into.html?cm_mmc=email-_-newsletter-_-management_tip-_-tip050112&referral=00203&utm_source=newsletter_management_tip&utm_medium=email&utm_campaign=tip050112

About Morgan Hunter HealthSearch
Morgan Hunter HealthSearch (MHHS) provides Executive Search and Interim Leadership solutions for hospitals and health systems throughout the United States.  Our services include executive healthcare recruiting, retained healthcare executive search, healthcare interim management, executive placement for hospitals. 

Hospitals are bracing themselves for some significant reimbursement changes under health reform that could hit their pocketbooks. The American Hospital Association (AHA) outlined top issues in its 2012 advocacy papers, including how hospitals will be measured for performance this year and beyond.

Value-based purchasing (VBP) – October 2012
Medicare will launch the hospital VBP program, in which pay-for-performance programs will receive incentives for demonstrated excellence and improvements in patient safety and effective care. The Centers for Medicare & Medicaid Services released the final rule in August last year. The AHA had serious concerns about CMS’ proposal to include hospital-acquired conditions measures because a separate HAC provision would penalize hospitals, as well as the weighting of patient experiences. CMS will likely propose additional measures over the next several years, AHA said, with certain measures retiring when hospitals reach the maximum performance, that is, when hospitals can improve no further.

Readmissions – October 1, 2012 (FY 2013)
Under the Affordable Care Act provision, hospitals will face penalties for excess readmissions for heart attack, heart failure and pneumonia, starting in October. CMS did account for planned readmissions from heart surgeries following a heart attack, based on the AHA’s urging.

The AHA also is pushing the agency to include community factors that could affect readmission reimbursements, which, “thus far, CMS has refused to account for,” the association said.

“CMS needs to recognize that readmissions are the result of many factors, some are within a hospital’s control, and some are related to the lack of resources elsewhere in the community, such as adequate numbers of primary care clinicians and access to pharmacies,” AHA said. “There is compelling evidence that safety-net hospitals and others serving large numbers of low-income individuals will have difficulty reducing readmissions due to the lack of some of these resources in the communities they serve. This creates an unfair system that puts these hospitals at greater risk for substantial readmission penalties.”

Hospital-acquired conditions – FY 2015
Hospitals also will face Medicare penalties for hospital-acquired conditions, starting in fiscal year 2015. Those that do well in the top quartile of national rates will receive 99 percent of their Medicare payments for all discharges. Some hospitals, however, will face penalties each year if they fail to progress–a position that AHA strongly opposes.

AHA stated, “Provisions from the Patient Protection and Affordable Care Act (ACA) must be implemented in a way that is fair and equitable for hospitals while seeking to avoid adverse unintended consequences.”

However, an American Journal of Infection Control study this week found that CMS-issued penalties from 2008 did boost infection-control efforts, in which infection preventionists reported increased focus on stopping catheter-associated urinary tract and central line-associated bloodstream infections.

Read more: 3 reimbursement changes for hospital performance – FierceHealthcare http://www.fiercehealthcare.com/story/3-reimbursement-changes-hospital-performance/2012-05-02?utm_medium=rss&utm_source=rss#ixzz1uIB86tet

Physician relationships with executive leadership have always been important at hospitals and health systems, but there is a history of distrust on both sides, to put it mildly. Executives often view physicians as a huge impediment to many important initiatives within the hospital, from cost-cutting to process reengineering.

Meanwhile, physicians habitually distrust senior executives who are looking out for what’s best for the hospital or health system—or maybe just the bottom line and the executives’ own bonuses—but not the physicians and not even necessarily patients, in the worst case. But despite that historical backdrop, the optimist can see that economic incentives for hospitals and physicians are now aligning as never before.

For some healthcare leaders, physicians (especially those in high-revenue specialties) are to be coddled and complimented, but such relationships are often condescending on both sides and depend on finding a sometimes convoluted and inefficient way to meet the economic interests of both. Trouble is, those economic incentives rarely align, a fact that is not lost on either side; yet the playing out of those competing incentives often ends up poisoning relationships on both sides.

Positive physician relationships have never been more important, but perhaps it’s now becoming easier to cultivate them as legislative and contractual changes are aligning hospital and physicians incentives and forcing the parties, especially independent physicians, to reconsider their relationships, move forward from past discord, and begin anew.

“Certainly economic changes and regulatory and legislative factors are creating the proximate reason, but the real reason is you cannot achieve high-quality care without a high level of integration between physicians and the facilities that deliver that care,” says Darrell Kirch, MD, president and CEO of the Association of American Medical Colleges and a former medical school dean and health system CEO. “Ultimately, it should be driven by the quality of care issue.”

Incentives are now strong
Favorable incentives for both sides are necessary in providing high-quality care. The relatively recent move by commercial plans and government payers toward risk-based contracting attempts to ensure that outcomes are rewarded, not volume of service.

So while quality of care is important, physicians are now seeing benefit with hospitals on quality and safety initiatives and cost-control programs because their financial fate is more closely aligned to hospitals’ fiscal well-being, says Michael Murphy, the executive vice president of heath networks at Trinity Health in Novi, MI. Murphy works with physicians in senior leadership roles at Trinity to execute the health system’s clinical integrated network strategy as well as its accountable care organization strategy, which work in tandem.

Trinity, which owns 35 hospitals and manages 12 others, also has a vast network of outpatient, long-term care, home health, and hospice programs in 10 states, which means the benefits of cooperation accrue directly to the health system in most cases. That’s not always true in situations where the pieces of the care continuum are more disconnected.

Murphy says many times in the past, promising collaboratives have found it difficult to get coordinated care because the incentives have not been aligned. That meant cooperative efforts that may not have had positive results right away were prematurely abandoned, or that well-meaning attempts to improve care handoffs, for example, were entered into halfheartedly. As soon as a more pressing issue came up, they might have been tabled. No more.

“What’s great is the payment system is catching up,” says Murphy, whose organization has had a head start on some innovative collaborative efforts, such as coordinated treatment of patients with chronic disease. “That question has been debated forever,” he adds. “Do you put the financial incentives first to drive behavior, or do you create a model that is more focused on quality, which attracts the payers?”

Now both can work at the same time because of the increasing emphasis employers and commercial insurers are putting on delivering measurable high-quality, safe, and coordinated care—and they are backing up that emphasis with better reimbursement. If the targets are met, the incentives are delivered. And all of the agreements are covered in a contract.

Still, “for these arrangements to work for the patient and the employer, there needs to be joint risk-sharing” between physicians and hospitals, says Jeff Wasserman, vice president of strategy and executive leadership services with Culbert Healthcare Solutions, a consultancy based in Woburn, MA. “It’s hard to share risk if you can’t work cooperatively.”

Who’s in control?
Many conversations with healthcare senior leaders begin or end with some version of the statement, “If only we could get our physicians to …” This thinking is not suited to the types of seismic changes facing healthcare today that require not only the physician’s cooperation, but also his or her financial commitment. It also suggests a paternalistic view of the relationships between hospitals and physicians.

The biggest change that has to occur is finding new ways for hospital and health system leaders to cooperate with physicians. A second and no less important driver is simple economics. Physicians who in the past have seen themselves as being in competition with the hospital are now finding that reimbursement rule changes are making it more difficult to remain independent, says Wasserman.

In fact, he predicts that at some point in the next two years, about 50% of primary care physicians will be employed by hospitals, and “specialists will follow behind in a couple of years.”

One might think that hospitals and health systems will be able to leverage physicians into following the protocols necessary for achieving performance targets in the hospitals’ commercial contracts, not to mention avoiding penalties and sharing in incentives offered by CMS under healthcare reform. But employment does not ensure that doctors will be willing partners in improving care. An important hurdle is encouraging and requiring physicians to agree to hold themselves to certain standards.

“If you don’t develop a genuine way to make physicians feel just as important as the hospital, it’s hard to make the progress that needs to occur,” Wasserman says.

That means giving leadership roles to physicians, who are expected to set their own standards by which the hospital will hold them accountable. But both sides have to give up some control, says Trinity’s Murphy.

“We believe strongly that only collaboration will be successful in the future, so we all have to give up a certain amount of control.”

Governance for good relationships
Many hospitals and health systems have found a degree of success in improving quality and safety through new governance structures that set standards for every physician in the group.

The traditional medical staff structure, for example, is not one that works to facilitate coordination of care, says Wasserman. It’s too big and unwieldy. He encourages his clients to develop smaller work groups that are designed to address a particular challenge “instead of having one system where every doc has his head under a single tent,” he says.

Though hospitals are required by the Joint Commission and other accrediting and certification bodies to have a formal medical staff organization, Wasserman suggests limiting its official duties to those required by law: credentialing and review of inpatient quality measures.

And don’t make the mistake of assigning your “high-revenue” physicians or the heads of very large practices to lead these efforts, he says. Leaders of quality and safety committees should have an economic stake, but if you really want a meaningful leader, “you have to find someone who has that understanding of the patient process and factors that drive quality care,” he says.

Wasserman suggests looking for key physician leaders on the primary care side who care about their patient loads and understand the interrelationships.

“The degrees don’t matter as much as their willingness to get engaged in some really definitive activity,” he says. “It’s not easy, but they’re out there. Sometimes, young physicians are the best.”

He cautions hospitals that giving up some authority is difficult, but that physicians will generally hold themselves to higher standards anyway, if given enough leeway.

“Often it’s the hospital that won’t give up authority,” he says. “Sometimes giving up a little authority is the best way to get movement, and they’ll see right through it if it isn’t genuine.”

Trinity’s Murphy sees a lot of advantages of focusing on chronic disease because such patients need high levels of care, and because poor coordination of their care is one major reason healthcare can sometimes be expensive, and it relates to the quality of care received. As more evidence comes out regarding how the patchwork care coordination such patient populations receive increases the cost of care and hurts quality, Murphy says clinicians feel a professional responsibility, outside of economic incentives, to improve.

“Providers have really started examining the fact that we are incredibly expensive, and they know we can get better outcomes,” he says. “They can do that by agreeing as clinicians on guidelines for clinical care.”

Not only that, says Murphy, but the technological solutions to guiding patients through the care process are getting better and better.

“In some ways, technology is driving this,” he says. “Now you have help in managing patients in a proactive way, with disease registry programs, by knowing what populations are at higher risk, where they are, and how to approach them. We didn’t really have those clusters of attribution in the past. We didn’t have the data to manage them better before.”

Redefining physicians’ leadership role
A few hospitals and health systems have historically been led by physicians, but more often, doctors have had less than ideal representation on the leadership team. Organizations where physicians have been in charge and that employ all their physicians have often been held up as exemplars of the type of coordinated, safe, and high-quality care that others should emulate. But many hospitals and health systems still have a long way to go in incorporating doctors into their senior leadership team.

In fact, in the most recent HealthLeaders Media Industry Survey, 36% of hospital and health system CEOs reported that they have zero physicians on their senior leadership team, which includes titles from senior vice president and up. Meanwhile, 45% did report that between 1% and 20% of their senior leadership team is made up of physicians. Many experts were not surprised at the high number of organizations where physicians are not in senior leadership, but were quick to add that the statistic is changing very rapidly.

Senior physician leadership “is a piece of our success,” says Murphy. “Our clinical integrated network strategy has been developed by our Unified Clinical Organization, which is led by P. Terrence O’Rourke [MD], who is our chief clinical officer at the home office.”

Within Trinity are several other physician leaders, including Paul Harkaway, MD, vice president for clinical integration and accountable care, who is working in tandem with Murphy and O’Rourke in launching the system’s ACO strategy and its clinical integrated network strategy.

The three work to set the agenda for the organization’s physician councils in different markets, not only to engage physicians who are leaders in the employed network, but also those independents who belong to physician-hospital organizations and independent physician associations with Trinity.

These small work groups “collaborate and share knowledge on how to move to value-based purchasing,” he says. “We needed to engage with the primary care community, and you can’t do that one-on-one. We do it through the IPAs and the PHOs.”

Smaller hospitals have a tougher time integrating physicians into senior leadership, but that doesn’t mean they don’t create opportunities, says Mark Adams, chief executive officer at Ogden (UT) Regional Medical Center, a 160-staffed-bed hospital owned by Nashville-based HCA Healthcare.

The low level of physician leadership reported in the HealthLeaders Media Industry Survey “doesn’t surprise me,” he says. “But it’s changing fairly quickly. We don’t have full-time physician executive leadership at this hospital—we’re fairly small—but we are engaging physicians in part-time formal relationships, such as part-time medical director.”

Ogden also has physicians in part-time liaison roles for executive relationships and in a position for director of quality and process improvement. In service lines, such as cardiovascular, Ogden has deployed an employment-alignment model with shared governance where physicians who practice there participate in operational decision-making for their service line. Other physician service line leaders have been appointed for the hospitalist program, the ED, surgical, and the neonatal ICU.

“Those leaders meet regularly with other service line leaders in our network to discuss how we can work together as a healthcare system,” Adams says.

Some healthcare organizations have worked to increase the influence of the chief medical officer on the executive leadership team. Count Trinity among those.

“In most of our organizations, we have transitioned to having that CMO role more broadly defined,” Murphy says. “They’re far more focused on developing the value-based model of the future and how physicians will be integrated into that strategy.”

The AAMC’s Kirch is optimistic about the future of physicians in senior leadership. “Today’s physicians are actively involved in redesign of clinical systems and clinical safety,” he says, adding that there’s a growing pool of more recently trained physicians who are eager to take on these tasks.

“You might continue to see a relative deficit of MDs occupying the CEO or COO position, but I’m very impressed by the strength of the cadre who are occupying the chief innovation, quality, or medical officer chairs at hospitals and health systems. A number of those will evolve into the higher leadership positions.”

But Kirch adds that, generally, physicians are ultimately concerned with delivering excellent patient care, and, “in many ways, the CMO or CQO is able to have a much greater direct impact on patient care than the CEO.”

Put physicians in charge
A saying that has been around for years in healthcare goes like this: There are the suits and the white coats, and the twain shall never meet.

That stalemate won’t be broken until physicians are more liberally placed in top-level positions—and the doctors are prepared to face business challenges, says Kirch.

“Only relatively recently do we have the advantage of people trained to wear the white coat who are more able to assume those executive positions,” he says. “In terms of the rapidity of change, a lot of it is being stimulated by economic forces. When you have docs moving this rapidly into employed status at the health system, you need leaders who can speak their language and understand their world.”

Even at smaller hospitals like Ogden, independent physicians are taking ownership of challenges that in the past might have simmered for years as a source of discontent. A little more than a year ago, Ogden’s senior leadership began to have serious concerns about limitations in the OR. Much of the increased demand was coming from growth in the region and community, but that led to serious capacity limitations. Although the facility performed nearly 6,500 procedures per year with seven operating rooms, the surgical schedule was blocked at 89%.

“We had a very highly blocked surgery schedule that did not allow for flexibility with open/elective cases,” says Adams.

The hospital was losing referrals amid a ramp-up of a urology service line initiative, had opened a new orthopedic unit in the hospital, and faced a growing level of demand from the cardiovascular service line. 

“All those factors together put us in a position to do something different,” he says. “Docs who already had block time were happy, but others were not.”

Ogden has about 300 physicians on the staff, with about 15% employed, so independent physicians are an important constituency. Medical and staff leadership met to discuss the bottlenecks and possible solutions—without the option of adding physical space.

Together, they decided to undertake a process improvement plan with the help of GE Healthcare Performance Solutions, with the idea that changes in policy and practice could open up significant time in the existing configuration.

In a departure from standard procedure, physicians held eight of the 10 positions on the OR block committee that developed the plan, but Adams says many other surgeons were skeptical about what the exercise could accomplish, given that previous attempts at policy and practice changes had achieved very limited results.

“We then went a step farther and formed an OR governance committee, to whom the block committee directly reports,” says Adams. “They make final decisions on OR policy and practice.”

That committee is made up of 13 members, of which three are hospital management staff and 10 are surgeons. (Each service line has one representative.)

“Previously, we would see input through the committee structure, and management would filter those and make the decision,” Adams says. “This new structure sent the message that we wanted to engage them, and they feel and act more accountable to the recommendations, which we give them the authority to make. There still has to be give and take, and management is represented, but those two committees are largely responsible for the change in culture.”

The change in culture led to a gain in prime-time (7 a.m.–3:30 p.m.) utilization from 69% to 81%, and Ogden’s OR went from 89% blocked to 70%. That gave Ogden significant flexibility to add elective cases that did not meet block-scheduling criteria. On-time starts have also increased from 33% to 81%.

“That has huge implications on efficiencies and operations throughout the day,” he says. “We still have some more to do efficiency-wise, but our goal was to try to get two years’ additional capacity before physical expansion, and we did that.”

The recovery of operating time has led to a potential increase of $3.78 million to the hospital’s bottom line, he says, although final results are not yet available. But Adams and the surgeons were so pleased with the effort that he’s rapidly trying to replicate this collaborative effort in the emergency department.

Get organized
Wasserman says the No. 1 goal for his clients surrounds methods of helping the physicians get organized around patient care and care coordination and begin to get them—whether they are employed or independent—into a structure where they can work as colleagues.

“Then take that structure and link it to the system. The second big goal concerns the incredible rise of the employed physician group,” he says. “That doesn’t mean alignment,” he says, but hospital leaders are realizing that such equal governance partnerships help get physicians focused on improved care and cost reduction rather than quarreling among themselves or, worse, blaming the hospital for such problems.

“Leaders have realized that employing is not enough,” he says.

On either side of this important debate, playing the blame game does no one, least of all the patient, any good. If you’re pointing at your physicians for being obstinate, there are four fingers pointed back at you.

http://www.healthleadersmedia.com/page-5/LED-279531/Physicians-Hospital-Executives-Get-Collaborative

About Morgan Hunter HealthSearch
Morgan Hunter HealthSearch (MHHS) provides Executive Search and Interim Leadership solutions for hospitals and health systems throughout the United States.  Our services include executive healthcare recruiting, retained healthcare executive search, healthcare interim management, executive placement for hospitals. 

Despite his health problems, Parish voiced hope on that midwinter morning. His medical team had developed a plan to help alleviate his dental pain. By the end of the month, his infected teeth would be removed and replaced with dentures. He still has intermittent chest pain, but he is learning to cope with it.

Parish is one of about 950 patients identified by Spectrum Health System in Grand Rapids, Mich., as having used their hospital EDs 10 times or more during the previous year. These patients accounted for more than 20,000 total visits and at least $40 million in costs during that period. In November 2011, Spectrum launched the Center for Integrative Medicine, a $1 million multispecialty clinic modeled on a pilot program that slashed ED use by nearly 90%, to help patients like Parish address the source of the problems that keep bringing them back to the ED.

“A lot of doctors, they just say, ‘Take this [drug] and see how it goes.’ They don’t really try to figure out your problems,” Parish says.

That is not the approach he encountered at the center, where Medical Director R. Corey Waller, MD, works with a staff of six to deliver intensive medical and case management interventions to patients over the course of three to six months before transitioning them to primary care physicians in the community or within Spectrum, an integrated health system.

The Spectrum clinic is part of a fledgling movement to devise new methods to help some of the most challenging patients in medicine — those who visit the ED frequently. The reasons why these patients visit the emergency department vary, and there are no easy fixes. But initiatives that seek to address patients’ medical, psychological and social needs are showing promise.

The efforts come as states around the country target emergency department use among Medicaid patients. Democratic Washington Gov. Christine Gregoire suspended a plan that was set to take effect April 1 and would have restricted Medicaid pay to EDs for more than 400 conditions. The American Medical Association was among the physician organizations that objected to the policy.

Meanwhile, starting in October, hospitals face up to 1% in Medicare pay cuts for high readmission rates. That penalty threat is giving hospitals another incentive to do what they can to help patients avoid the ED.

Understanding repeat ED users

There is no standard definition for what constitutes frequent emergency department use, but researchers set four or more annual visits as a cutoff. The 8% of patients who use the emergency department four-plus times a year account for 28% of adult ED visits, according to a July 2006 Annals of Emergency Medicine study.

Compared with patients who use the ED less often, frequent users are much likelier to have poor physical health and live below the poverty threshold, said the study, based on a nationally representative household survey. Frequent ED users are more likely to be uninsured or publicly insured and 70% likelier to have poor mental health. And these patients do not rely solely on the emergency department; they are three times more likely to have made five or more outpatient visits in the last year.

The notion that most frequent ED users are abusing the system is not backed by evidence, says Dr. Weber, professor of clinical emergency medicine at the University of California, San Francisco School of Medicine.

“They’re not necessarily coming to the ED because it’s easier or convenient, or for minor reasons,” she says.

Maria C. Raven, MD, MPH, agrees.

“People aren’t coming to just hang out,” says Dr. Raven, assistant professor of clinical emergency medicine at UCSF. “They’ve got some real issue that’s bringing them in. They’re scared.”

Coordinating care is critical

Before coming to UCSF, Dr. Raven helped start a pilot program at New York City’s Bellevue Hospital Center that enrolled 19 patients who had a total of 106 ED visits and 64 hospital admissions in the previous year. Of the 19 patients, all men, 18 had substance-abuse problems and 17 were homeless. The hospital hired a care manager to coordinate care inside and outside the hospital.

In-depth interviews at the bedside identify the patients’ housing, transportation and medical needs such as substance-abuse rehabilitation. Instead of discharging patients to the streets, staffers work to find permanent housing and put them up at the YMCA while housing applications get processed. Often, patients are given prepaid cellphones to facilitate planning.

Weekly conference calls with primary care doctors, visiting nurse services, methadone programs, substance abuse programs and others are conducted to make sure everyone is “on the same page,” Dr. Raven says. Overall, ED visits were cut by 10%, and hospitalizations were slashed by nearly 40%, according to results published Oct. 13, 2011, in BMC Health Services Research.

“One of the most problematic things is that the medical side of things is not well-aligned with the mental and behavioral-health services, and things are often very fragmented,” Dr. Raven says. “There’s not really the ability for the medical system to communicate with the welfare system.”

Without help, it is difficult for physicians in the hospital to address the root cause of what is bringing patients back to the ED so often, she adds.

“Often where things break down during the hospital or ED visit is that the medical team working with these patients may not know them or what’s going on with them outside of the hospital,” Dr. Raven says. “There’s pressure to get them out of the hospital, depending on the payment structure. They sort of do what they can to wrap up the individual episode of care neatly and discharge the patient. There’s not someone doing the simple things like postdischarge follow-up with a phone call.”

The program has been expanded to a total of three hospitals that are part of the New York City Health and Hospitals Corp. and is being funded by the state’s Medicaid plan to prevent costly ED and hospital use.

In neighboring New Jersey, a nonprofit effort chronicled in The New Yorker and on TV’s “Frontline” is targeting frequent emergency department users in the city of Camden. In 2007, the physician-led Camden Coalition of Healthcare Providers organized a collaborative of primary care, behavioral health and social service professionals to help these patients avoid the ED. Among the first 36 patients identified for extra help, the total average monthly number of hospital and ED visits dropped from 62 to 37, a 40% cut. Meanwhile, hospital bills were slashed by 56%.

Rerouting frequent ED users

These fledgling quality initiatives are not only critical to improving patients’ lives and controlling health care costs, but to sustaining the morale of emergency physicians. A survey of more than 400 emergency physicians presented at the Society for Academic Emergency Medicine’s June 2011 annual meeting found that about 60% reported having less empathy for patients who use the ED more than 10 times a year, sometimes derisively dubbed “frequent fliers.” Experts fear that hardening of the heart could translate into worse patient care.

And while nearly all the emergency doctors reported experience with frequent ED users, only 30% said they work in a hospital that has a program dedicated to helping these patients avoid the hospital through programs involving case managers and social workers.

Dr. Waller, of the Spectrum Center for Integrative Medicine in Grand Rapids, said he grew so frustrated during his time working in the emergency department that he considered quitting medicine. He never had the time to delve deeply into the complex conditions that were bringing patients back to the ED so often. And most frequent ED users have a constellation of physical and mental illnesses that go beyond the scope of emergency medicine, he says.

“If you’ve been smashed by a truck, or you have a laceration from the top of the chest to the bottom of the toe, that’s perfect for the ER,” says Dr. Waller, who also specializes in addiction and pain medicine. “What it’s not perfect for is someone with a chronic, debilitating mental-health disorder who shows up and is seen by a physician who’s had one lecture on that in their entire training.”

So far, the center has seen about 100 high-volume ED patients, and about a third have been completely stabilized and transferred to a primary care physician. Other patients randomly wait-listed for the clinic’s services act as a control to determine the effectiveness in reducing ED visits. The first visit to the clinic can last as long as four or five hours, with patients seeing a case manager and then a medical social worker before visiting Dr. Waller for a complete work-up.

The vast majority of the center’s patients have chronic pain and mental health problems, and the goal is to find the medical source of the pain and address it directly. Patients sometimes have major undiagnosed conditions such as Crohn’s disease or spinal pathology, or simply have poorly managed chronic conditions. For patients with no discernible source of pain, Dr. Waller works to wean them off opiates by using buprenorphine and similar medications. Meanwhile, patients receive counseling on how to use cognitive-behavioral and other techniques to cope with the aches, pains and stressors of daily life.

“We have no official appointments,” says Dennis Potter, one of the center’s social workers. “We just want to give patients a chance to hang out and talk through what’s going on in their lives. It’s designed to relieve the anxiety or the issues they’re bringing in, and hopefully assist them in learning that every time you’re in distress, it doesn’t mean you have to go to the ED. Every time you have a pain, it doesn’t mean you have to have a pill.”

Patients who use the ED frequently deserve better care than what they typically get, Dr. Waller says.

“These are patients who have been marginalized, verbally beaten in the hospital and called drug addict, dirt bag, drug seeker. Those are terms I’ve heard from my colleagues about these patients, and it made me angry and it’s not right,” he says.

“It’s really fulfilling to do the right thing for a patient, where the last time you saw that patient in the ER they hated you and the next time they hug you and say, ‘Thank you for helping me.’ Doing the right thing is the right thing to do. It’s not just a theory.”

http://www.ama-assn.org/amednews/2012/04/30/prsa0430.htm

About Morgan Hunter HealthSearch
Morgan Hunter HealthSearch (MHHS) provides Executive Search and Interim Leadership solutions for hospitals and health systems throughout the United States.  Our services include executive healthcare recruiting, retained healthcare executive search, healthcare interim management, executive placement for hospitals. 

The Consumer Price Index for all items went up 0.3% in March and 2.7% in the previous 12 months, according to Bureau of Labor Statistics data released April 13. Prices paid for physician care, which includes the amount from an insurer as well as the patient portion for a single service, went up 0.2% for the month and 1.3% during the past year.

The annual physician services inflation rate has been below the overall number for the past 12 months, and the month-to-month physician numbers have been lower than general inflation for eight of the past 12 months.

The BLS determines the inflation rate through monthly interviews of a statistically representative sample of providers of goods and services. They include nearly 1,500 who speak for physician practices about the prices paid for the most common procedures and office visits.

For physicians faced with a low inflation rate, compared with the overall rise, payments have not kept up with practice costs in recent years.

The American Medical Association said there is a 20% gap between what Medicare pays — a major factor in keeping down physician prices — and what it costs physicians to treat patients.

“The cost of providing care is going up,” said Glen Stream, MD, president of the American Academy of Family Physicians. “There’s a downward pressure on physician payment. At some point, something is going to break.”

Analysts often cite the lag between practice revenues and costs as the reason why many physicians are seeking what they view as the financial stability of hospital employment over the pressures of owning an independent practice.

In 2001, 3% of residents surveyed by physician recruiting firm Merritt Hawkins & Associates wanted to work as hospital employees. In 2011, that number was 32%.

A total of 91,282 physicians and dentists had full-time employment at community hospitals in 2010, a 47% increase from 61,972 in 2001, and a 7% jump just from 2010, according to the American Hospital Assn.

What’s affecting physician prices

In the 1980s and 1990s, the physician services rate was well above inflation, but that gap began narrowing significantly in 2001. In fact, the physician services inflation rate also fell below the overall inflation total from August 2005 to September 2006 and from November 2007 to October 2008.

Economists and other experts said the trend is a result of tightening payments from government and private insurers.

Since 2002, the sustainable growth rate formula used by the Centers for Medicare & Medicaid Services to set Medicare pay rates has called for cuts in physician payments, including a more than 30% reduction set to begin Jan. 1, 2013. While Congress has reversed SGR-mandated cuts a dozen times, the results have been short-term freezes or small increases in Medicare pay.

To fix what it has labeled an “unsustainable” SGR, the AMA has called for its elimination, with five years of positive pay updates as Medicare tests pay models that would enhance care coordination, quality and appropriateness of care while addressing cost concerns.

Also, many states have cut Medicaid pay to address their budget problems during the past few years. In the private sector, economists said, physician practices have lost negotiating power to private insurers as they have become larger.

More than 400 health plan mergers were approved by federal and state regulators from 1996 to 2008, with only two deals required to sell operations in some markets because of questions about market domination. As a result, nearly every metropolitan area in the United States has one plan controlling at least 30% of the commercial insurance market, and in more than half, one plan controls at least 50%, according to numbers gathered by HealthLeaders-InterStudy and analyzed by the AMA. This is true even as a majority of physicians work in practices of five doctors or fewer.

“What we’re seeing is that, in general, over the past 10 years, physicians have had less and less power over their prices,” said Douglas Hough, PhD, associate professor at Johns Hopkins Carey Business School in Baltimore, who works on health economics issues. “It’s not that physicians could dictate the price before, but they certainly had more influence on what the price would be.”

Economists say physicians’ lack of negotiating clout is reflected in the fact that other parts of the health system have not consistently felt similar pressure on prices.

Growth in the prices paid for hospital care has continued to surpass overall inflation, according to the BLS. The cost of inpatient hospital services went up 0.1% in March but 5.3% for the past year. Outpatient services grew by 0.2% in March but 4.9% for the previous 12 months. The cost of health insurance went up as well. Health insurance premiums for a family of four increased 9% to $15,073 in 2011, according to data released Sept. 27, 2011, by the Kaiser Family Foundation and the Health Research & Educational Trust. Premium prices have increased by double-digit percentages in many years during the past decade.

With government and private efforts to control health costs, economists expect those sectors to feel more of the pricing pressure that physicians have felt for much of the past decade — and for doctors to keep feeling it.

“I just don’t see any factors that are going to allow physician prices to go above the overall Consumer Price Index again,” Hough said.

http://www.ama-assn.org/amednews/2012/04/30/bil20430.htm

About Morgan Hunter HealthSearch
Morgan Hunter HealthSearch (MHHS) provides Executive Search and Interim Leadership solutions for hospitals and health systems throughout the United States.  Our services include executive healthcare recruiting, retained healthcare executive search, healthcare interim management, executive placement for hospitals. 

Look up.

That’s the idea of some patient-safety experts, who today will discuss the formation of an independent patient-safety agency modeled on the National Transportation Safety Board, and other strategies to reduce errors at a summit in Washington.

Many of the safety and error-prevention strategies used in aviation are applicable to health care, such as investigating the root causes of accidents and developing programs to reduce fatalities, experts say. One pilot who will share lessons from aviation’s best practices at the summit: retired US Airways pilot Chesley “Sully” Sullenberger, who coolly brought down stricken Flight 1549 into the Hudson River with no loss of life.

“Surfing the Healthcare Tsunami,” a new patient-safety documentary looking at solutions such as safety protocols for hospitals, will also premier at the summit. The Discovery Channel will show the film on April 28, with repeats over subsequent weeks. It will feature actor and patient-safety advocate Dennis Quaid, whose 12-day old twins received an overdose of heparin, a blood thinner, in a Los Angeles hospital that put them at serious risk, as the Health Blog discussed in 2008.

The concept of an NTSB for health care first surfaced in a report by the Institute of Medicine and has been taken up by patient-safety advocates led by Dr. Charles Denham. He’s chairman of the Texas Medical Institute of Technology, or TMIT, a nonprofit research group that supports development and dissemination of patient-safety practices.

Denham tells the Health Blog that the idea isn’t to create another layer of health-care bureaucracy, or a new federal agency, but a public/private partnership that could be run at minimal cost to taxpayers — perhaps 10 to 25 cents a year per citizen.

“Consumers are absolutely shocked that that there is no safety entity for hospitals and health care,” Denham says.

In an article in the Journal of Patient Safety, Denham, Sullenberger, Quaid and aviation-safety expert John Nance argue that, just as the NTSB issues “Blue Cover” reports that detail findings on aviation accidents, a patient-safety board would publicly disclose the causes of preventable harm and outline strategies for keeping such events from happening again.

http://blogs.wsj.com/health/2012/04/27/aviation-is-an-inspiration-for-improving-patient-safety/?mod=wsj_share_linkedin#

About Morgan Hunter HealthSearch
Morgan Hunter HealthSearch (MHHS) provides Executive Search and Interim Leadership solutions for hospitals and health systems throughout the United States.  Our services include executive healthcare recruiting, retained healthcare executive search, healthcare interim management, executive placement for hospitals.