Nobody's Perfect, But............

The other day, I received a series of announcements from the American Hospital Association on their selected Quality and Patient Safety winners for 2014.  I am sure that these awards are well deserved for the work at each of these hospitals and health systems.  What I found interesting is that in two of the hospitals that received awards, I visited one not that long ago and, in fact, blogged about what I saw as to the serious lack of cleanliness et al, at least in one particular patient care tower and that I recently heard a story about the other hospital.  

The story is that there is a particular cancer drug that should be infused over a longer period of time like three and half hours.  Strangely enough, I have two friends suffering from the same cancer; one is receiving his treatments at WMHS and the other out-of-town.  The two friends of mine are also friends of each other and, of course, talk with great frequency about their cancers, their care and their treatments.  The out-of-town friend mentioned to the in-town friend as to the difficulty that he is having with one particular drug.  He said that after the drug is infused that it gives him severe headaches which last for quite a while.  Since they are taking the same drug, the in-town friend probed further and realized that he receives the drug over the three and half hour time frame while the out-of-town friend gets the drug infused in one hour.  

When the in-town friend had to be somewhere else on a particular treatment day, he asked to have the drug infused at a quicker rate and was told absolutely not. That if he couldn't stay the three and a half hours that the appointment could be rescheduled.  The reason that our folks gave him was that if you infuse the drug too rapidly, you will get severe headaches for a prolonged period of time.  After learning this revelation, the in-town friend shared the information with the out-of-town friend, who, you guessed it, now gets his drug infused over a three and a half period of time. 

Unfortunately, it took this exchange to realize what was happening to the out-of-town friend.  It was either a matter of convenience for the staff at the out-of-town hospital or sheer incompetence.  I guess my point is that nobody is perfect in that we are doing so much in our hospitals and health systems to deliver safe, quality patient care, but there will always be some challenge somewhere else within those same hospitals.  Now, I am not letting that out-of-town hospital off the hook. What they were doing was egregious and it sickens me.  I have encouraged my out-of-town friend to pursue the issue to the highest level of that hospital.  No patient should be subjected to what he has been subjected to in his care and treatment.  Health care is certainly both an interesting as well as challenging business.

The Rest of the Story on the New Missouri Law

One of my blog followers pointed out from yesterday's blog that even though Missouri appears to be progressive with their new law creating an assistant physician, they could have easily addressed their primary care shortage situation in the rural parts of their state by relaxing the restrictions that exist for nurse practitioners.  Point very well taken.  

In Maryland, we have certainly benefited from the ability to use nurse practitioners in a variety of settings, including primary care, due to the practice autonomy that they are afforded in this state.  That is certainly not the case in Missouri, where nurse practitioners are highly restricted in what they can and cannot do in the care of their patients.  How unfortunate.

A New Missouri Law

This morning, I read Paul Levy's blog, Not Running a Hospital, and found it most interesting.  His blog is as follows:

Here's a fascinating story in Governing about Missouri's approach to alleviating a physician shortage in rural areas.  (Thanks to the folks at Commonwealth Magazine for the tip in one of their daily newsletters.)  The lede:

A new Missouri law allows recent medical school graduates to practice primary care in underserved areas without completing a residency in a teaching hospital.

The Missouri State Medical Association, the law’s chief backer, is calling it an unprecedented effort to help deal with doctor shortages in rural and other underserved areas, but opponents raise questions about whether circumventing the traditional path to the exam room will do more harm than good. 

The article goes on to explain:

Missouri’s law, signed by Gov. Jay Nixon earlier this month, carves out a new classification called “assistant physician.” The law allows medical school graduates who have completed their licensing exams but haven't finished a residency to practice immediately in underserved areas. These graduates have to join a primary care practice of a “collaborating physician” who agrees to accept responsibility for an assistant physician. An assistant physician, who can legally be called a doctor, has to practice continually with his or her collaborating physician for one month before being able to serve independently. 

My buddy Rosemary Gibson, a board member at the Accreditation Council for Graduate Medical Education, doesn't like the idea.  She is:

warning other states not to follow Missouri's lead because rural residents are sicker, older and poorer, on average, than the country as a whole. She said the Missouri law goes well beyond the scope-of-practice laws that have popped up in state legislatures. 

“On the surface, it looks like a quick fix, but I think it really behooves [policymakers] to do their homework, to understand what it means to have a graduate of a medical school be called doctor, to have prescriptive authority for powerful drugs like narcotics, to accurately dose and treat people,” she said. “Primary care is not simple. If you have a lot of older people living in rural areas, they have a lot of co-morbidities [such as diabetes combined with heart disease].”

I've run the story by other experts in medical education.  Another buddy, Dave Mayer, said:

I don't like the new law either. But it made me think and ask myself the following question: What is worse...Putting a new medical school graduate on an acute care hospital floor July 1st and asking them to take care of many hospitalized patients into the evening with little in-house supervision or asking a new medical school graduate on July 1st to take care of a few non-acute, non-hospitalized patients in a clinic where there is another fully trained/completed residency MD on site during the time they are working? Both have serious flaws but the second non-acute scenario sounds less scary to me. 

  

Of course, it can be a false choice to compare one scenario to the other, but the point is well made.  What's your take?

POSTED BY PAUL LEVY AT 7/27/2014 01:04:00 PM 

What I found so interesting is the a dramatic departure from "this has always been the way that it's been done.”  I find the new Missouri law extremely progressive and an effective response to a growing crisis in rural America.  At the same time, I can certainly see the threat that this law brings to traditional academic medicine.  (Just to clarify, under the Missouri law, an assistant physician is recognized as a medical doctor and that is different from a Physician's Assistant.)  

In the blog, Rose Mary Gibson of the Hastings Center recognizes the vulnerability of the underserved due to their poor health status and the importance of well trained physicians caring for such patients.  However, the model that we have adopted in our region to care for the patients in our region is the use of Advanced Practice Professionals in addition to primary care physicians.  In a perfect world, we would love to have the most highly trained providers on staff and we are fortunate to have many who are just that.....extremely well trained.  Quite honestly, our Advanced Practice Professionals have done a great job with our most vulnerable patients; and our nurse practitioners in the Center for Clinical Resources are a perfect example.

As our physicians are well aware, it has become very difficult to recruit for primary care physicians due to the shortage nationwide and that trend will continue.  At WMHS, we have not had a Maryland-trained physician come directly from their residency or fellowship in quite sometime. We have had many discussions, but to no avail.  

In Paul's blog, Dr. Dave Mayer's perspective is interesting in that he doesn't see a difference between going out and caring for patients in underserved areas under the direction of a MD or DO versus entering a residency and caring for patients in the hospital under the auspices of a physician preceptor.  If those in academic medicine feel threatened by the Missouri law, they should recognize the crisis that exists and is only worsening by doing so much more in developing new physicians to embrace a rural environment for their practice setting post training.  Why not make it a requirement for a percentage of those admitted to medical school that they practice in a rural setting for at least three years after completion of their residency?

The Buy Local Challenge

I was asked last week to provide a blog to Fierce Healthcare on the Buy Local Challenge in which many members of the Maryland Hospitals for a Healthy Environment's are participating.  It was scheduled to run in their publication today.  My blog was as follows:

The Western Maryland Health System is a member of the Maryland Hospitals for a Healthy Environment (MD H2E) and has been since the inception of the organization in 2005.  MD H2E advances a culture of environmental health and sustainability in Maryland's health care community.  WMHS is one of twenty eight Maryland hospitals / health systems participating in MD H2E's latest initiative, Buy Local Challenge.  Simply put, we have agreed to support farms by serving / eating local during Buy Local Week, which is this week, July 19-27.  We have pledged through our Food and Nutrition Service at WMHS to serve at least one local food item each day during Buy Local Week.  Our staff understands the importance of providing the freshest produce whenever possible to our patients and employees while supporting our local farmers.  Such support expands our regional food system as well as our local economy.  

And it doesn't stop there.  At WMHS, we support our local farmers though a weekly on-site Farmers' Market throughout the summer and our Dietitians work cooperatively with our staff and visitors with menu ideas and recipes while promoting the Farmers' Market.  They also have an Exhibition Cooking Day around the items that are available at the Farmers' Market for that day.  I am so very much encouraged by the active participation of our staff in every aspect of the Buy Local Challenge.  They are engaged participants in the various activities as well as regular purchasers of the produce. We clearly recognize that by providing healthier food choices for our patients, visitors and staff that we are fulfilling our mission of "superior care for all we serve."

Community Garden

I was recently in a conversation with one of our employees who is engaged with the City of Cumberland in the creation of a community garden in one of our more economically depressed areas of Cumberland.  After telling her of my admiration for her initiative, I asked to her to please keep the health system in mind as she is furthering her plans with the City.  I want WMHS to take more of an active role in healthy eating throughout our region.  

One of our physicians said at a recent meeting that "it is too expensive for poor people to eat healthy" and he's right.  If you have the opportunity to visit some of our smaller grocery stores in our more depressed areas, the fresh produce leaves a great deal to be desired. And in the more "affluent" areas, the costs can be prohibitive, especially if you are on a very fixed income.  So the doctor is right and we need to do more.  

As a result, we will be reaching out to a variety of potential partners in order to bring fresh produce to those who cannot afford or have access to such items.  It may take a while to get the concept up and running, but rest assured, it will be brought to fruition.  I will keep you posted; and if you are interested in working with us, let me know.

Proud to be a Part of WMHS

I had the opportunity to use the services of WMHS over the last two weeks; and quite honestly, I was left both proud and extremely impressed by what I saw and experienced.  Clearly, I realize that I am the CEO and that I was treated differently and I was.  With that said, I had the opportunity to see the staff in action; and at times not being in my suit and tie and in eye glasses rather than contacts, I wasn't immediately recognized.  I was also able to observe staff from a distance and in some cases they didn't know that I was right around the corner.  

Whenever I reflect back on what I saw and heard, I am immediately reminded of our mission, our values and our service excellence standards.  As they say in tennis, game, set and match.  A clean sweep.  These folks were demonstrating our mission in every instance by providing superior care, not only to me but to those around me.  They were caring, compassionate, respectful, funny, thorough, well organized, straightforward and pretty much excellent in their delivery of my care and the care of others in every instance.  To see these folks care for patients who are in an extremely vulnerable state cared for in such a manner was so rewarding for me.   

We focus on being a values-driven organization and, for the most part, that is supported by our patient satisfaction scores, but to see it evolve in front of me was both heartwarming and reassuring.  These people were truly excellent in all that that did.  As for those areas that could be improved upon, they were process oriented or documents that needed to be revised.  I am certainly pleased with the outcomes from the services that I personally took part in; but overall, I am thrilled with the consistent fulfillment of our mission, values and service excellence standards on the part of our staff.

It's WESTERN MARYLAND HEALTH SYSTEM

Why do so many have so much trouble with the name of our System?  What is so hard about Western Maryland Health System?  It's not Western Maryland Health Systems, there is only one WMHS.  It's not the Western Maryland Hospital Center, that is located in Hagerstown, Maryland.  It's not Western Maryland Health Center as we were called in a recent article in a Cecil County newspaper.  It shouldn't be that hard.  

When it was announced recently that Meritus in Hagerstown was assuming operating control and interim responsibility of the Western Maryland Hospital Center, I started getting emails and calls as to why was I, along with my leadership team, fired based on poor performance?  In fact, another Maryland CEO saw me at a meeting shortly after the announcement, gave me a hug and asked what happened?  Last he had heard was that there were many successes that WMHS was experiencing through value-based care delivery and then he is reading that I was fired.  I laughed and let him know that apparently, the leadership team at Western Maryland Hospital Center was terminated by the Secretary of Health and Mental Hygiene after a state survey. The CEO at Meritus was then asked to assume control for an interim period which they did.  The names are similar, but not the same.  

One reason why folks may have jumped to the conclusion that it was WMHS may have been because of our Alliance relationship with Meritus through Trivergent.  Quite frankly, many people didn't even know that the Western Maryland Hospital Center existed.  It is a state specialty hospital serving the brain injured or those requiring Dialysis, long term and skilled nursing care.  

I guess many of us have to deal with the name issue.  A few years ago, Allegany College of Maryland changed its name from Allegany Community College.  The College then started getting threatening letters from the leadership at Allegheny College in Pennsylvania and their attorneys.  They said that it was too confusing for perspective students when they searched for Allegheny College on the Internet.  Really?  I thought that Allegheny College recruited the best and the brightest (which they really do) and they don't know the difference between Maryland and Pennslyvania?  Anyway, that situation finally was resolved when ACM said that they would always emphasize "Maryland" in the name of the College.  

Sooner or later, folks will get it right; after all, Western Maryland Health System has only been around for 18 years or so.

Leaders for Tomorrow

Recently, I was asked what I thought would be the skills required to be a successful health care leader in the future.  My take was that these same skills can be applied today as well as tomorrow and they are as follows:

• Embrace change
• Be a visionary
• Use common sense
• Surround yourself with the best
• Be flexible
• Be willing to adapt easily
• Be an effective communicator; most importantly, LISTEN
• Use your early adopter physicians to your advantage as you work to build a value- based care delivery model
• Encourage a learning environment by making sure that your staff understand what it is that you are doing and why you are doing it; you can't teach or communicate this enough
• Be tech savvy
• Lastly, and most importantly, act with integrity.

It's Working....at least at WMHS and in Maryland

I just read that the Robert Wood Johnson Foundation is embarking on a monitoring project to determine as to whether or not the Affordable Care Act is working.  Well, look no further as it is definitely working in Cumberland.  Remember the NY Times article in August of 2013 on the TPR demonstration project at WMHS?  The article said that "this hard-scrapple of a city at the base of the Appalachians is an unlikely hotbed of health care innovation that (through the Western Maryland Health System) is carrying out an experiment that could leave a more profound imprint on health care than President Obama's reforms.  That's exactly what we have been doing and the results are as follows. We have successfully reduced inpatient admissions by 32% from 19,000 four years ago to 14,000 today; readmissions by 42% with emphasis on heart failure, COPD and diabetes; nursing home readmissions by 38%; ED use rates by 3%; ED admissions by 6% and ED visits by 20% by around 10,000 over the last few years from almost 60,000 to just under 50,000.  

Collectively through these efforts, we have saved over $1.5 million; that's caring for patients in a location other than the inpatient acute care setting.  We continue to build upon the success that we have experienced over the last several years.  All of our efforts have translated to a FY '14 year to date operating margin of almost 9% and a total margin of close to 12%.  The experiment continues to be an ongoing success at WMHS.

US Health Spending: It's More Than Just the Economy

According to the Commonwealth Fund, US health care spending has been declining since 2009 in a similar manner to other industrialized nations.  However, they attribute the decline to the economic downturn from 2008 and beyond, not the Affordable Care Act (ACA).  I disagree that the reduction is exclusively due to the decline in each economy.   

Two factors related to the ACA are greater control of health care spending by government and a dramatic decrease in labor costs in US hospitals due to less admissions, readmissions and ED visits.  Now, price increases for supplies and small equipment having been significantly reduced and major equipment suppliers having excess inventory so equipment is priced to sell are directly attributable to the economy.  So, both have played a part, but it is not exclusively the economy; just my two cents for what it's worth.  

Actually, I am surprised that the Commonwealth Fund didn't take the opportunity to promote the ACA as they have been doing since its passage.