8 Top Hospital and Health System Trends of the Past Decade

1. Loosened cost controls. HMOs in the late 1990s had successfully slowed growth in healthcare spending, but by the end of that decade they had come to be regarded as heartless conservators of the bottom line. Managed care’s tight controls began to loosen and “the negotiating power slipped back into the hands of the providers,” says Dick Clarke, president of the Healthcare Financial Management Association. Healthcare costs again began increasing faster than the general rate of inflation. “It’s not clear yet how much of that will change if providers come under more pressure to contain prices,” he says. 

2. Healthcare IT. Healthcare information technology, still rough around the edges in 2000, became a major force in hospital operations by the end of the decade, says Michael Rowan, COO and executive vice president of Catholic Health Initiatives in Denver. Innovations like computerized physician order entry and electronic medical records have been shown to improve safety as well as efficiency. Now, thanks to billions of dollars in incentives in the 2009 HITECH legislation, healthcare IT holds the promise of becoming virtually universal in the next few years. But Mr. Rowan reports that HITECH funds will pay for only about a quarter of the cost of the new technology. 

3. Patient safety movement. At the start of the decade, hospitals were just beginning to hear word of one of the most influential reports in the history of U.S. healthcare: “To Err Is Human: Building a Safer Health System,” published in Nov. 1999 by the Institute of Medicine. It concluded that from 44,000- 98,000 people die annually — the equivalent of 10 fully loaded 757 commercial airliners crashing each week, the report stated — due to errors in inpatient hospital treatment.

As a result, “hospitals started to get much more serious about quality and safety,” says Mr. Clarke at HFMA. The industry embraced continuous quality improvement, adds Thomas Dolan, president and CEO of the American College of Healthcare Executives. “Everybody realized that we have to constantly improve quality and it actually lowers costs because it reduces waste,” he says.

4. Physician entrepreneurialism. Many physicians became entrepreneurs, investing in ASCs, imaging centers and specialty hospitals as a way to supplement declining income due to lack of increases in reimbursements and become more efficient. The trend, however, put physicians into conflict with hospitals, who were concerned about losing market share to the leaner, physician-run organizations. By the end of the decade, it seemed that hospitals and regulators had blunted the trend.

“The ban on physician-owned hospitals in the health reform legislation signals the decline of the entrepreneurial physician,” says Nicholas Wolter, MD, a former MedPAC commissioner and CEO of the Billings (Mont.) Clinic. However, ASCs seem to have become a permanent fixture in U.S. healthcare, offering discounts too big for payors to pass up. 

5. Healthcare consumerism. “The future of market-oriented health policy and practice lies in ‘managed consumerism,’ a blend of the patient-centric focus of consumer-driven healthcare and the provider-centric focus of managed competition,” declared Jamie Robinson, a professor of health economics at the University of California, Berkeley, School of Public Health, in 2005 in the journal Health Affairs.

With the decline of HMOs, consumer-driven healthcare became a new way to contain costs. High deductible plans, with or without tax-free health savings accounts, would make patients cost-conscious consumers. Ratings of doctors and hospitals, from HealthGrades to CMS’ Hospital Compare site, would aid patients in choosing the best providers. Retail clinics opened to serve these new consumers. Hospitals developed a new fascination with patient satisfaction surveys. Brand-new hospitals lavished spending on patient-friendly design features, such as single rooms, sunlit atriums and concierge services, and these features seemed to shift market share. 

6. Shortages of healthcare personnel. In July 2007, the American Hospital Association reported 116,000 open positions for registered nurses in hospitals, and the existing RN workforce was aging. Mr. Rowan at Catholic Health Initiatives observes that the recession has erased the shortage for now, at least, as RNs were forced back into the workforce or into full-time work as family income fell.

Physician shortages also emerged. In a dramatic about-face at the beginning of the decade, the federal Council on Graduate Medical Education abandoned its long-held forecast of a physician surplus and predicted a shortage of 85,000 physicians by 2020. Since then, medical schools have been substantially increasing class sizes, but Congress has not removed a cap on the number of Medicare-funded graduate medical education positions for physicians that has been in place since 1997.

“Current evidence suggests that the United States is headed toward an aggregate shortage of physicians,” the Association of American Medical Colleges declared in 2009. “Given the extended time required to increase U.S. medical school capacity, and to educate and train physicians, the nation must begin now to increase medical school and GME capacity to meet the needs of the nation in 2015 and beyond.”

7. Accountable health organizations. While entrepreneurial physicians continued to spin off from hospitals throughout the decade, Dr. Wolter, the former MedPAC commissioner, says an opposing trend also emerged. Many young physicians were eagerly becoming employees. Accountable health organizations such as Mayo Clinic, the Cleveland Clinic and Geisinger Health System thrived by closely aligning hospitals and doctors to make care more efficient and effective.

Mr. Rowan at Catholic Health Initiatives says accountable health organizations seemed to be taking a lesson from the ASC playbook. Incentivizing physicians can make healthcare more efficient. But he adds that the trend is not easy for hospitals. “Many hospitals have no expertise in running practices,” Mr. Rowan says. “We’re hospital people, not group management people.” Hospitals used to hire doctors merely to generate business. Now, he says, “hospitals want doctors to take financial responsibility for outcomes.”

8. Recession. “The decade will be known for the financial turmoil that came at the end,” says Mr. Clarke of HFMA. In March 2009, Thomson Reuters reported that the median profit margin of U.S. hospitals has fallen to zero percent. Hospitals tightened their belts and many of them ended the decade solidly in the black. But the numbers of non-paying patients are still high and many leaders like Clarke believe we are entering an era of having to do more with less.

AAAHC Surveyor Gayle Lowe Discusses Industry Emphasis on Patient Safety Initiatives, New Prevention Programs

Gayle Lowe, an AAAHC surveyor, discusses patient safety initiatives and increased efforts on the part of healthcare providers to implement practices and policies that further increase patient safety.

Q: Several healthcare accreditors, including AAAHC, revised their patient safety criteria for accreditation for 2010. Do you think this reflects an increased emphasis on patient safety by the industry overall?

Gayle Lowe: Healthcare has always had an emphasis on patient safety. However, healthcare has been in the forefront of the news in 2009 through political agendas as well as many discrepancies in the way patient safety has been compromised. There certainly have been many opportunities for improvement identified in our healthcare systems that have reached the public’s notice such as flu prevention, procedural safety, medication safety and infection control. 

Q: What are some things AAAHC has done to further emphasize patient safety in its accrediting processes?

GL: AAAHC identified that in order to clarify and delineate patient safety issues in 2010, a chapter of the AAAHC’s Handbook for standards has been dedicated and focused on patient safety and infection control. Even though these issues have always been addressed by AAAHC, the emphasis on newly identified best practices and evidence-based procedures have been incorporated into the standards.

Q: What are some initiatives or processes that you have observed within ASCs that can further improve patient safety within facilities?

GL: One of the more impressive changes seen in centers is the improvements in education for staff, patients and leadership, with an emphasis on basic processes for infection control, such as handwashing. Infection control programs in the centers have been established, reevaluated and improved to ensure the program is designed to prevent, control and investigate infections and communicable diseases.

Having infection control programs is a condition for participation in the Medicare program. Medicare goes on to require, as does AAAHC, that infection control must include prevention aspects and that the centers have implemented nationally-recognized infection control guidelines.

Q: How has requiring ASC to implement nationally-recognized control and prevention guidelines affected ASCs?

GL: The centers have had to reevaluate what they have been doing and now must ensure that their processes meet nationally recognized guidelines. They must have a designated infection control professional (ICP) to assume the leadership of the program. This person should have the training in infection control and qualifications to organize, implement and monitor the program. The ICP must be delegated or appointed by the facility’s governing body to ensure they have the overall responsibility of the program. Benefits of these programs are evident in safe outcomes for patients, staff and visitor.

The first drawback you hear from centers is, of course, the time element for implementation and continuation for monitoring a successful program. I have tried to encourage centers to work “smarter” by looking for best practices of implementation and monitoring by sharing information with successful infection control programs.

Learn more about AAAHC at www.aaahc.org.

Gastroenterology, Hepatology Societies Release Recommendations for Nonanesthesiologist-Administered Propofol for GI Endoscopy

In a joint statement by the American Association for the Study of Liver Diseases, the American College of Gastroenterology, the American Gastroenterological Association Institute and the American Society for Gastrointestinal Endoscopy, nonanesthesiologist-administered propofol (NAAP) for GI endoscopy can be safe if “administered by a team of individuals who have received training specific to the administration of propofol,” according to an AGA news release.

Propofol is an ultra-short-acting sedative agent with no analgesic properties, which, at subhypnotic doses, provides sedative and amnestic effects, according to the release. Currently, its use is advised by the FDA for use by trained anesthesia professionals, but its use has been expanded for use in procedural sedation, warranting the investigation into NAAP.

The four societies listed many benefits for the application of NAAP for GI procedures including an equivalent safety profile to that of “standard sedation,” greater efficacy in certain endoscopic procedures and cost-effectiveness.

The statement also includes the following training guidelines for NAAP for GI endoscopy:

• NAAP requires the acquisition of skills and abilities that are distinct and apart from those necessary for standard sedation. Training programs should provide didactic and practical, hands-on learning experiences.
• Individuals administering propofol should be proficient in the management of upper and lower airway complications, including manual techniques for re-establishing airway patency, use of oral and nasal airway devices, and proper bag-mask ventilation. Basic life support or advanced cardiac life support certification is required. Training with life-size manikins and/or human simulators improves the acquisition of these skills.
• Preceptorship (practical experience and training that is supervised by an expert such as an anesthesiologist or qualified endoscopist) is an important element of training for physicians and nursing personnel acquiring the skills to administer propofol.
• Capnography (a monitoring device that measures the concentration of carbon dioxide in exhaled air and displays a numerical readout and waveform tracing) reduces the occurrence of apnea and hypoxemia during ERCP/EUS and upper endoscopy/colonoscopy.

Read the entire Position statement: nonanesthesiologist administration of propofol for GI endoscopy (pdf).

Steroids helpful for DME

For patients with diabetic macular edema (DME), intravitreal triamcinolone (IVTA) was able to improve vision in eyes that had continued to deteriorate despite receiving standard laser treatment, researchers at the University of Sydney, Australia, said in a university news item.  In the first three months after treatment, the patients initially treated with both IVTA and laser showed significantly better gains in vision than control group patients who were treated with laser only. After 2 years, patients in the original control group were also treated with IVTA. The beneficial effects persisted in most IVTA-treated patients throughout the 5-year study; however, 80% of patients in the initial IVTA group developed elevated intraocular pressure and 56% of them required therapy, the university said. Also, two-thirds of all patients required during the study period. Similar outcomes have been noted in other studies of steroid-based treatment and thus were not considered new safety concerns by the group.

Biologics can treat some cases of inflammatory bowel disease

INFLAMMATORY BOWEL DISEASE (IBD) includes ulcerative colitis and Crohn’s disease, two distinct conditions with similar symptoms, in which the intestines become inflamed, probably as a result of the body’s immune reaction mobilized against intestinal tissue. Ulcerative colitis affects the colon and the rectum, while Crohn disease’s may affect any portion of the gastrointestinal tract (most often the small intestine and/or the colon.) Symptoms typically include diarrhea, abdominal pain, nausea and vomiting, fever and weight loss. Sometimes there are associated complaints such as arthritis or skin problems.

Most patients have sporadic symptoms. About 20% to 25% have frequently relapsing disease, or chronically active disease. Drugs to treat IBD include mesalamine (a substance that helps control inflammation), antibiotics, corticosteriods, and immunosuppressants.

“For patients with mild to moderate disease, initial treatment would depend on their specific condition,” says Bruce Sands, MD, MS, vice chair of the American Gastroenterological Association Institute. “A person with moderate disease might have diarrhea three or four times a day, and some degree of urgency and belly pain, but they can take in adequate nutrition, and they are able to function in daily life.”

However, a significant proportion of patients, perhaps 15% to 20%, do not respond to conventional treatment. The introduction of tumor necrosis factor (TNF) inhibitors in 1999 dramatically altered treatment for these patients.

These medications are biologic substances that can locate and bind to the specific molecules involved in causing inflammation. Today, three TNF inhibitors are approved by the FDA for treatment of moderate to severe Crohn’s disease that has not responded to other drugs: Cimzia (certolizumab pegol), Humira (adalimumab), and Remicade (infliximab).

Remicade is also approved for treatment of moderate to severe ulcerative colitis that has not responded to other therapies. Tysabri (natalizumab) a monoclonal antibody, has been approved by the FDA for treatment of moderate to severe Crohn’s disease that has not responded sufficiently to other treatments.

“TNF inhibitors were a completely different type of agent that could produce a response in patients who had been refractory to all existing therapies,” says Dr. Sands. “Before the advent of TNF inhibitors, I had patients who were completely homebound by the disease. Not every patient responds, and some have a partial response, but in many cases patients were able to return to work and a normal lifestyle.”

These medications have side effects, which may include the risk of infection or rare cases of lymphoma, says Dr. Sands. When patients have mild symptoms, typically those medications are not recommended.

MAKING CHOICES

MCOs often rely on a prior authorization process for TNF inhibitors.

“We provide a number of options for members who have IBD, and we ask them to work with their physicians for a choice of agent,” says Brian Sweet, PharmD, MBA, chief pharmacy officer for WellPoint.

At WellPoint, pharmacists answer front line calls for prior authorizations and work with physicians to obtain documentation.

“If appropriate documentation is not met, then [the request] is sent to a medical director for medical review.” he says. “The medical director is the only person who can actually determine that the claim would not be paid or that the prior authorization criteria are not met.”

The prior authorization criteria WellPoint uses for TNF inhibitors for IBD treatment are aligned with FDA recommendations and the organization’s medical policy.

“Remicade is the only biologic approved for treatment of ulcerative colitis,” says Sweet. “If the doctor demonstrates the patient has not responded to conventional treatments, then Remicade would be approved for ulcerative colitis.”

Humira, Cimzia, and Remicade have been approved for Crohn’s disease, and Tysabri has been approved for moderate to severe Crohn’s disease that has not responded to conventional therapies or to TNF inhibitors

“There are significant safety concerns with Tysabri, related to the risk of PML [progressive multifocal leukoencephalopathy], so in that case there is an additional step edit,” says Sweet.

Sometimes the claims are paid as a medical claim, and sometimes as a pharmacy claim. Criteria must be consistent to ensure consistent access across the organization, he says. Specialty pharmaceuticals often are placed in the highest tier of the formulary and require the highest out-of-pocket costs.

“That’s because we want to ensure an appropriate amount of member coinsurance, so they understand the expense of these agents,” says Sweet.

Coinsurance for these medications is about $50 on average, although it may vary widely across different benefit designs.

This article is based on information supplied by The Medical Letter ( www.medicalletter.org), a non-profit organization that publishes newsletters offering critical appraisals of new drugs and comparative reviews of older drugs. The Medical Letter is completely independent of the pharmaceutical industry. It is supported entirely by subscription sales and accepts no advertising, grants or donations. Institutional site license inquiries can be sent toinfo@medicalletter.org. [info@medicalletter.org.]

AAAHC Announces 2010 Standards

The Accreditation Association for Ambulatory Health Care has announced its 2010 Standards, including the addition of a new core chapter and revisions to many existing core and adjunct chapters, according to an AAAHC news release.

The revisions will be effective with the publication in Feb. 2010 of the 2010 Accreditation Handbook for Ambulatory Health Care, according to the release.

The new chapter, chapter seven, includes all standards for infection prevention, control and safety. The chapter pulls standards from several existing chapters into one chapter for the ease of the user and also includes new standards, according to the release. It is a core chapter that applies to all organizations seeking accreditation and is the first new core chapter to be added since the first edition of the Handbook.

“The new chapter emphasizes the importance that the Accreditation Association has always placed on the highest standards for infection control and safety in ambulatory organizations,” John Burke, PHD, AAAHC executive director, said in the release. “This new core chapter, as well as other chapters in the 2010 Handbook, reflect current best practices and are designed to enhance the high quality of patient care provided by the

Organizations we accredit. Organizations seeking to achieve or maintain AAAHC Accreditation should familiarize themselves with all standards changes and additions for 2010.”

Beginning with the 2010 Handbook, all AAAHC/Medicare deemed information, which appears in chapters throughout the Handbook, will also be contained in a separate Handbook section, entitled Policies and Procedures for Ambulatory Surgery Centers Seeking AAAHC Accreditation and Medicare Deemed Status. This new section provides user-friendly directions and details for organizations seeking AAAHC/Medicare deemed status, according to the release. Included is a reference document demonstrating the “crosswalk” between AAAHC standards and Medicare requirements for ASCs.

Some of the other revisions to the AAAHC standards include:

• Additional requirements for risk management (Chapter five)
• New directions for demolition, construction or renovation of ambulatory organizations (Chapter eight)
• Changes to pharmaceutical standards (Chapter 11)
• Modifications to various other standards

FDA prioritizes drug safety, expects industry to be proactive

Early last month, the FDA launched the Safe Use Initiative, which aims to create and facilitate public and private collaborations within healthcare to reduce preventable harm associated with medication misuse, errors and other medication-related problems.

Through this initiative, the FDA hopes to improve upon current approaches, many of which were put in place over the last century as reactionary measures to specific needs or emergencies.

“Too many people suffer unnecessary injuries from avoidable medication misuse, errors and other problems.” says FDA Commissioner Margaret A. Hamburg, MD, “The FDA is launching the Safe Use Initiative to develop targeted solutions for reducing these injuries.”

Specifically, the initiative plans to unite federal agencies such as the FDA, Agency for Healthcare Research and Quality (AHRQ), Centers for Disease Control (CDC) and Drug Enforcement Agency (DEA), together with professional societies, pharmacies, hospitals, drug developers, manufacturers and distributors, as well as patients and their representative organizations in order to manage medication risk.

“All participants in the healthcare community have a role to play in reducing the risks and preventing injuries from medication use.” says Janet Woodcock, MD, Director of the FDA’s Center for Drug Evaluation and Research.

At present, millions of Americans require prescription and/or over-the-counter (OTC) medications to improve or preserve their health; with as many as 3 billion prescriptions written annually. As a result of this vast use of medications, it is estimated that at least 1.5 million preventable adverse drug events occur annually, resulting in hundreds of thousands of injuries and deaths.

Adverse events from medication use have been linked to more than 4 million visits to emergency departments, provider offices or other outpatient settings and greater than 100,000 hospitalizations each year. According to FDA officials, “many injuries associated with medication use could be prevented with currently available knowledge.”

In fact, current estimates suggest anywhere from 11% to 50% of injuries could be preventable.

During the initiative’s first year, the FDA plans to implement a small number of safety programs. Some key interventions include evaluating consumer medication information; communicating the risk of overexposure to acetaminophen; safeguards for alcohol-based surgical preparations and avoiding contamination of multiple use medication vials. FDA intends to hold a series of public meetings to gather feedback.

Teamwork and Talent Drive the ASC of Union County

Teamwork is a way of life for the 21 staff members and 50 physicians at the ASC of Union County, a two-OR, multi-specialty, physician-owned ambulatory surgery center in Union, N.J. At the heart of that teamwork lies a commitment to patient care that exceeds expectations and a family spirit that pervades everything at the center, which opened in 2000. And helping to drive that commitment are two individuals who work as the facility’s dynamic duo — Marcy Sasso, director of operations, and Debbi Holley, RN, BSN, director of nursing.

Nominating the duo for this year’s Who’s Who in Ambulatory Surgery is Glenn Davison, DPM, FACFAS, a board-certified podiatrist who is one of the owners of the center. He credits Sasso and Holley with leading the team to a number of notable achievements, including growing the physician pool and the center’s staff while cutting costs and increasing collections, as well as driving down the infection rate and causing patient satisfaction scores to skyrocket.

“Recruiting physicians is always challenging for any ASC,” Sasso acknowledges. “In New Jersey there are 300-plus ASCs so that translates into most doctors having their own place. We were fortunate in retrospect that our area hospital closed; we hired an outside marketing person to assist with recruitment. In 2008 we were at 80 percent capacity of our 7 a.m. to 3 p.m. block time so that marketing ended. Since then I found that word of mouth to other doctors was really our best means of recruitment. We have had several requests for credentialing packets every month for the past two years. I have a nice marketing packet put together that includes a brochure with our owners’ information, a physicians guide, all of our specific booking forms and criteria, information on our center from transportation to patient instructions, not to mention the give-aways such as letter openers, rolodex cards, sticky notes and pens. We also market all of our credentialed physicians on our Web site, and we place their business cards in our waiting room. When they come to tour the center we promote cross referrals and they meet with one of our financial coordinators to assist in educating their patients about our billing procedures.”

Building relationships is also key to working well with a diverse group of patients, physicians, colleagues, payors and vendors, and Sasso says the secret is “letting each person bring their unique talent and personality to work everyday. Really believing in their talents and bringing out their strengths that may have been dormant.” She adds, “The clinical staff here by far makes a lasting impression on our patients. The patients are greeted with a warm smile and often leave with a great cup of coffee and a hug. Our three administrative staff members multi-task as if they were a team of five and always with a smile and a kind word. They always look for ways to improve patient care and outside office communications.”

Sasso says that what she and her colleagues enjoy about the ambulatory care environment in part is the autonomy allowed by the center’s owners. “It allows Debbi and me to use our creativity, common sense and charitable side to run the ASC of UC so efficiently,” Sasso explains. “Being a smaller facility, we are able to cross-train and be a part of every day-to-day occurrence here. We have the opportunity to get to know our patients and they get to know us. Debbi and I don’t have to micro-manage in any way because when you come to an ASC setting you know you become part of a team and most days we consider our team our second family. It’s a positive and enthusiastic environment that one won’t find in the hospital setting.”

The ASC made a true believer out of Holley, who says, “My background was always in a hospital setting and the fear of joining an ASC was quite scary. I always believed that ASCs took away business from the hospital. When the local hospital closed, I had no choice but to jump in feet first to an ASC. I now see that the ASC has a warm and relaxing atmosphere. Nurses have enough time to spend with their patients to make them feel comfortable. They can have that idle chit-chat and not feel rushed to get onto the next patient.” Holley continues, “ASCs make it easier for the patient from arrival to discharge. Since our OR scheduling is close to or on time, patient scheduling is more convenient for patients and their family members. The patient has a specific OR scheduled time and they come in, their family member can sit with them in pre-op while waiting to go into the OR. After their procedure, the patient is offered coffee or juice cookies or muffins, then they go home. The patients feel more relaxed and comfortable before going in for their procedure and leave in a positive state of mind for a successful recovery.”

Sasso says the center’s team spirit and reliable retention rate are attributable to a number of factors, including treating everyone with fairness, equality and honesty, promoting a true open-door policy, as well as mentoring, coaching and supporting each other.

“A center can only work as well as their team,” Holley says. “To me, I am only one piece of the pie. Without the other pieces, there would be no pie. I feel that I would not be able to run a smooth and efficient center when one piece is missing. Our consistent reputation and positive work environment is cause for employee retention and terrific patient satisfaction. Positive feedback to the staff for all that they do on a daily basis is essential. No one wants to hear only the negative things that happen during the day.

“We also have pride and ownership, and we celebrate our successes,” Sasso says. Those celebrations of success range from an annual holiday party and bonus to a family picnic, staff birthday celebrations and a staff appreciation day, plus employment perks such as a retirement plan, paid health coverage and continuing education for all staff members.

The center had much to celebrate when they achieved accreditation with the Accreditation Association for Ambulatory Health Care (AAAHC). “Due to Marcy’s and Debbi’s leadership, we have received the highest accreditation from the AAAHC for a three-year term,” Davison says.

“Accreditation was something we had been putting off for several years for fear of the unknown,” Sasso explains. “When our medical director, Dr. Thomas Ragukonis told us we were ready and deserved to be in this prestigious category we took his suggestion and plunged in. During the pre-accreditation process we were able to review and improve many of our ‘stale policies.’ We split into sub groups to tackle the process; empowering all staff to take ownership along the way. We repaired some cracks in our foundation and Debbi wrote 65 new policies and re-vamped more than 100. Our staff philosophy has been treating each day as if the inspection were to happen and there is no need to worry when it does. Our two-day survey was intense and thorough, as they ought to be, and during our exit interview they told us that ‘we should be very proud of what we do here’ and we were rewarded with a three-year accreditation. Going through the process was an outstanding learning experience for all staff. Now we routinely review the assessment manual to be sure we keep this prestigious accreditation.”

Davison says that Sasso and Holley “believe in and promote continuing education, and every staff member has attended at least one or more courses last year. All staff members take the BLS course and all of our nurses take the ACLS course which we sponsor right here in the center.”

It is this focus on patient safety that has propelled the ASC of Union County in everything it does, including making ambulatory care the best option for healthcare professionals and patients.

“It is proven by all of the benchmarking statistics that ASC’s provide a cost-effective, top-notch setting for patients as opposed to the standard hospitals,” Sasso says. “The physicians feel that the latest technology is more available here and we are more patient-friendly. The doctors are able to perform more cases in one day here than they would be able to in the hospital. ASCs don’t have the ‘I am a number’ mentality, and patients are referred to by name and are remembered when they return for an additional visit. The infection control rate of most centers is 1 percent or less, and hospitals cannot offer that same optimistic statistic. (Ours, over the past eight years, is less than 1 percent). ASCs typically have better control of the flow over their patients, less red tape than a hospital from the registration process to the patient discharge much faster and fewer mistakes!”

Holley concurs, adding that ASCS must be prepared to face unique clinical challenges such as patient safety practices, especially proper identification. “What we do here is at registration, the patient is asked for the last four numbers of their Social Security number, birth date and a picture ID,” she explains. “In the pre-op area, the patient again is asked for their last four digits of their Social Security number, their birth date, what procedure they are having and where will be the incision site will be. The last four numbers of their social security number is on their identification band. This same list of questions is asked again during the consent period. Another challenge is having the patient bring in a list of medications that they are currently taking in order to complete the medication reconciliation at their time of discharge. Both the nurse and physician must sign the completed form at discharge. ASCs may find identifying the correct patient and information a little more difficult than in a hospital setting but with our process in place, we have not encountered any problems. We feel confident that we have the right patient here for the right procedure.”

Holley says that the ASC enhances patient satisfaction through positive encouragement and communication. “During our pre-op admission we instruct the patient that their discharge instructions and survey is in their envelope and hope that they will help us serve our community better by their comments. When patients are discharged we know something about them and we make a mention about this to let them know we heard them. We wheel or walk out every patient and wish them well. By the time they are leaving at least four people have said goodbye to them. We encourage patients to send back the survey when we make our next day post-op calls. We treat every patient as if they were a family member from start to finish.”

Holley adds that the ASC’s low infection rate is another accomplishment. “The most important part of keeping infections down is hand hygiene,” she says. Nurses must wash their hands immediately before and after touching a patient to prevent cross-contamination. We have constant monitoring; we have a full-time RN trained in infection control who runs in-services and is routinely changing signs in the patient/visitor areas. We also book 15-minute intervals between cases to clean and sterilize the ORs between cases.” Holley adds that in order to prepare for impending inspections, the ASC has a staff member do spot checks to ensure handwashing is done properly, and they also conduct mock surveys frequently to observe and educate staff on potential problems.

Contributing to the ASC’s clinical success is staff’s investment in the center and in their work. “I think ‘team’ and ‘ownership’ are the two words that describe our staff,” Holley says. “Each staff nurse has a specific job that they take ownership of. One nurse will be in charge of all the contracts for the center; it is her responsibility to update expired contracts on a monthly basis. Another nurse is responsible for the QA projects; she does monthly audits and chart reviews. Another staff nurse is responsible for keeping abreast of any OSHA problems and updates. This nurse will give monthly reports on any OSHA criteria. The nurses feel a sense of pride and accomplishment in their specific area. We also have two OR techs in nursing school and the other RNs take time to mentor them.”

Bringing staff together is the ASC’s quality assurance program, which also serves to audit physicians and their time in the OR. “Many book a case for a specific amount of time, and we are detecting some run-over in their allotted time and push other physicians back in their start time,” Holley explains. “This leads to physician and patients becoming frustrated with wait time. To improve patient satisfaction, we need to determine which physicians need extra allotted time for certain procedures. Dialogue between physicians and staff has improved by having an open communication policy. Physicians are asked on a monthly basis if anything needs to be improved or if they need a specific piece of equipment. The physicians educate the staff on procedures that are new or unfamiliar, and physicians allow any staff nurse to observe their cases. And during monthly staff meetings, they are encouraged to think of new ideas to make the center run smoothly.”

“Our staff enjoys coming to work and seeing the patients get well and leave happy,” Davison confirms.

The ASC staff echo this sentiment. Clinical coordinator Kathy Melnick, RN, BA, CCRN, emphasizes, “I have been a nurse for more than 40 years and I have never worked anywhere where the patient satisfaction surveys have come back with such glowing accolades; from the admitting process to the discharge, every staff member tries to make the patient stay as pleasant as possible. The staff prides themselves on a professional, compassionate and friendly demeanor which is demonstrated on a daily basis with every patient. A great percentage of our patients are repeat customers and we hear over and over again how they only want to come here for their procedures! It is an honor for me to be associated with a surgery center that provides exceptional patient care for the surgical patient.”

Jan Marsh, RN, says she appreciates the center’s dynamic environment. “Having worked in a hospital setting for most of my professional career, transferring to the ambulatory setting was a new experience for me. I truly enjoy the atmosphere at the ASC, which is professional yet patient friendly. The doctors and nurses work together as a team to deliver the best possible patient care for every individual.”

One of the center’s orthopedic surgeons, Clifford A. Botwin, DO, observes, “I don’t ever remember any institution receiving the accolades and satisfaction from patients, families and staff that have been attributed the ASC of Union County. Led by an outstanding administrator, Marcy Sasso, and staff this facility although relatively small has been in the forefront of community health and relations in our area.”

The center believes that participating in philanthropic efforts is a worthy way to give back to the community.

“Marcy organized and brought in more than 3,000 brand new toys for the local police holiday drive, and had more than 10 pallets of medical and child care items sent to Louisiana for Hurricane Katrina-related needs,” says Davison.

The local community in central New Jersey also benefited from the center’s generosity through its free health fair held last year.

“Our physicians came out in full support of this endeavor, with more than 15 doctors representing various specialties were available for the over 350 attendees,” says Mary E. Koch, RN, BSN, CNOR, the center’s OR supervisor. “In light of our current healthcare situation, there are many people who have no access to healthcare. This provided a unique opportunity for the public to speak with a physician. This is one of the many wonderful ways we care for our community, from Toys for Tots, Katrina relief supplies, Walk for Autism, and breast cancer awareness. I am proud to work in a surgery center that gives so much to the community in addition to the exemplary care we provide for our patients.”

“At our community health fair we saved and changed more lives in that one day than any of us ever expected,” Sasso says. “I believe you get what you give, so giving back was our motive for the health fair. The local hospital used to put on a health fair and since they closed several years ago the community was no longer afforded that special day. It seemed like the perfect opportunity to market our ASC and give back at the same time. It took just two days to get a commitment from our 15 owners, and we had six weeks to organize the fair. I called every one of our vendors, every local non-profit group, the blood bank, physical therapy, imaging centers, and the local chamber of commerce. The ‘give back’ message took hold with them and we had an overwhelming response. We had our 15 doctors on site talking to the public about their specialties — orthopedics, GI, general surgery, bariatric, pain management, podiatry, gynecology and chiropractic — as well as body fat screenings and all the give-aways a visitor would hope to find at a fair. We had 350-plus guests, gave away four glucomoters, took 185 blood pressure readings, and had 11 blood donors. Giving is so contagious, you can’t help it sometimes. That fair was one of the greatest achievements in my career.”

To read more about the ASC of Union County’s involvement in ASC advocacy and politics, don’t miss the January 2010 issue of SurgiStrategies.

Q&A with Marcy Sasso

What can other ASCs do to emulate the success of your center?

If ASCs strive to continually evaluate their actions and decisions in light of patients’ best care and treatment, they will automatically discover the path to success. Make safety your No. 1 priority, and put it on the agenda for every committee meeting. Monitor your patient surveys closely, as they will be valuable assessment tool; share them with all of your staff and physicians. Our surveys have been outstanding with some wonderful comments regarding our exceptional staff and comfort of our ASC, and 100 percent of our patients have indicated that they would return should the need arise. When we saw a comment about discharge instructions, we immediately held a brainstorming meeting and made a change as to when and to whom instructions were given. If an employee has drive and ambition, take a look at how they can bring additional value to the center. For example, Lauren, our OR tech, mentioned that it would be great to be an OR nurse and really admired our RNs. Mary is now her mentor while she is going to nursing school in the evenings. Our staff attends conferences and we encourage them to share their knowledge. Look inside your team, as you may find the next surgeon just waiting to be mentored!

How do you stay current in the industry?

I read at least nine trade publications weekly, and I have signed up for every “alert” there is. I attend the annual ASC conference and send many of my staff to specialty courses. I forward at least three or four “FYI” e-mails to my center’s owners on a weekly basis to be sure that they are kept up to date in the ASC world.

Green initiatives growing among healthcare facilities

From Recycling and waste management programs to nontoxic paint and permeable pavement, hospitals across the country are implementing green initiatives to produce healthier environments for patients and staff, which they say saves not only energy, but money.

Among several provider facilities going green is Stony Brook University Hospital, in Stony Book, N.Y., which recently signed an agreement with the U.S. Environmental Protection Agency (EPA). The agreement outlines energy and water conservation, waste management and the use of environmentally friendly products, and the hospital is currently auditing areas to reduce energy consumption.

“A hospital is unique in that it’s a structure that operates 24/7,” says Andrew Bellina, EPA program coordinator, “So, there are opportunities for powering down in many areas of the hospital that do not impact the people that are working or the care of the patients.”

He says the EPA is helping Stony Brook through the audit as part of its Energy Star program, which strives to reduce energy by 10%.

In addition, the hospital is taking on a number of initiatives designed to reuse materials and reduce material waste. For example, staff has eliminated the blue, disposable wrapping used for sanitary operating tools, says Bellina. Tools now arrive in reusable containers.

However, he notes, the hospital has to evaluate recycling from a practical standpoint while also maintaining strict accreditation standards. Even so, recycling at the hospital increased by about 420 tons in 2007 and 2008, and it is expected to be higher this year.

“It significantly affects your carbon footprint when you recycle waste instead of just throwing it out, because you don’t go through the actual mining, the treatment, the procurement, the manufacturing and the transportation,” he says. “You’re cutting all that out.”

Water conservation is another important aspect of the agreement struck with the EPA. Bellina notes water supply costs recently increased 20% in New York City. He predicts water shortages in as many as 36 states in the next three to five years.

The hospital is looking to conserve water in two ways. First, captured storm water can be reused for non-contact functions, such as watering lawns and landscaping. Second, he says, it will be important to reduce demand for water. The hospital is monitoring water use with equipment that limits water flow and reduces total use.

Going green will definitely show a return on investment in the long run, and in most cases, produce immediate savings, Bellina says.

“Five years ago it [going green] would have cost you money, and the payback would be seven, 10 or 12 years, but now there are immediate cost savings. For example, recycling is an immediate cost saver,” he says, “And you reap the economic benefits through the lifetime of the structure after that.”

Determining effects on the quality of care is not as easy, he says, but he postulates that once the hospital’s energy audits are complete and the air handling is upgraded to a more efficient mix of outdoor and indoor air, the quality of air will improve within the hospital. Better air means better health, especially for those who need respiratory care.

EAST CAROLINA HEART INSTITUTE

The East Carolina Heart Institute, which is attached to the Pitt County Memorial Hospital in North Carolina, has implemented both green and general health ideas into its structure, including ergonomic equipment, natural light and an energy efficient utility plant.

The structure has only been open for a year, but was built with energy efficiency in mind, according to Brian Floyd, executive director of the Heart Institute. It also contains recycled materials in the carpet as well as in bathroom, kitchen and ceiling tile.

Natural lighting is one feature that overlaps in the green movement and healthy hospital movement. An effort was made to light the Institute with large windows in patient rooms, physician work areas, waiting rooms, lobbies and cafes.

“Many studies show that people recover faster when they have access to sunlight, and we want to make people as comfortable as possible and acclimate them to the day and night cycles so they can heal faster,” Floyd says.

It also requires less energy to light the facility during the day. With the help of sensors, artificial lighting turns on only when someone is in the room and dims when natural light levels are adequate.

The utility plant powering the Institute operates on energy efficient air conditioning chillers, high-efficiency electric motors and variable-speed pumping and air flow systems, according to Floyd.

The monthly electricity expenses at the Heart Institute have averaged 30 cents per square foot, or $142,000 per month, since opening in January 2009, according to James Ryals, Media Specialist for the Heart Institute and Pitt County Memorial Hospital. To compare, over the same period, monthly electricity expenses in the main hospital have averaged 45 cents per square foot, or $533,000 per month. The main hospital was built in 1977, and is twice as big as the Heart Institute, says Ryals.

“The per-square-foot figures are a better basis for comparison than the monthly totals,” he says. “It’s safe to say that, with the efficiency measures we’ve taken, our power expenses at the Heart Institute are roughly 33% lower than the main hospital.”

Certain intangible cost savings, such as worker productivity, are harder to define, says Floyd, but he has noticed that retention of staff is higher and length of patient stays are shorter.

KAISER PERMANENTE MODESTO

Kaiser Permanente’s Modesto Medical Center in California is a pilot model for green healthcare facilities aimed at improving public health, according to John Kouletsis, national director of strategy, planning and design for Kaiser. The center is equipped with everything from solar panels on the roof, rubber flooring instead of vinyl inside the hospital and permeable pavement in the parking lot.

“We’re always looking at public health,” says Kouletsis, “so, to me it’s probably the least obvious things that I think are the most dramatic and the most impressive.”

Those not-so-obvious endeavors include eliminating toxicants from paint and upholstery and eliminating polyvinyl chloride (PVC) from flooring and carpet. There is a case for patient care: When a vinyl floor is cleaned, aerosolized particles release into the air and become asthma triggers.

“It’s ironic, because [these steps are] not very sexy, they’re not very eye-catching, but they actually have a much bigger impact on keeping people healthy,” he says.

At Modesto, calculating all the sustainable strategies show a cost savings of roughly $400,000 over what would have been spent on a typical project without those sustainable elements, Kouletsis says.

“A long-term savings in terms of public health is incalculable,” he says.

Kaiser looks at sustainability through a different lens than other providers, says Kouletsis.

“Our lens has to do with patient safety and workplace safety, and what we’ve discovered is that if you look through these two lenses first, you almost always get to a sustainable product,” he says.

Encourage depression screening for all pregnant women

The Incidence Of Depression runs high, and the utilization growth of antidepressants is a testament to this common condition. Unfortunately, pregnant women who also need to manage depression present a chronic-care challenge for doctors and health plans.

Between 14% and 23% of expectant moms experience depressive symptoms, according to the American Psychiatric Association (APA) and the American College of Obstetrics and Gynecologists (ACOG). Treatment with antidepressants for pregnant women is a bit tricky, prompting discussion about whether to prescribe and whether women already taking the drugs should continue their regimen despite being pregnant.

“The Management of Depression During Pregnancy: A Report from the American Psychiatric Association and The American College of Obstetricians and Gynecologists,” published in Obstetrics & Gynecology (September 2009) andGeneral Hospital Psychiatry (September/October 2009), weighs the risk and benefits of different treatment options for depression. The new guidelines should serve as a call to obstetricians to look for signs of depression in their patients.

The organizations’ guidelines for pregnant women currently on medication for depression include:

Psychiatrically stable women who prefer to stay on medication may be able to do so after consultation between their psychiatrist and ob-gyn to discuss risks and benefits;

Women who would like to discontinue medication may attempt tapering and discontinuation if they are not experiencing symptoms, depending on psychiatric history;

Women with recurrent depression or who have symptoms despite their medication may benefit from psychotherapy;

Women with severe depression (with suicide attempts, functional incapacitation or weight loss) should remain on medication; and

If a patient refuses medication, alternative treatment and monitoring should be in place, preferably before drug discontinuation.

The study also makes recommendations for pregnant women not on medication for depression, saying risks and benefits of treatment choices should be evaluated and discussed, including factors such as stage of gestation, symptoms, history of depression and other conditions and circumstances (smoking, difficulty gaining weight, etc.).

Nishendu Vasavada, MD, clinical associate professor, Department of Psychiatry at the University of Texas Southwestern Medical Center in Dallas, says it is not unusual for women to be on antidepressants when they get pregnant but cautions against their use in the first trimester.

“It is generally safer to take antidepressants after the first trimester,” he says, recommending the lowest possible dose and the use of Class C drugs. “Women should talk with their providers and find out as much as they can about medication choices to make the best decisions.”

Rajni Lad, MD, medical director at CBHNP, a behavioral health managed care company, agrees and notes added support is beneficial.

“The therapist is able to assess a member’s condition and related issues, oversee medication regimens and communicate with the obstetrician,” he says. “We can determine if a member should remain on an antidepressant once she is pregnant and when it is safe to stop taking the drug. We generally don’t prescribe drugs for depression during a woman’s first trimester, but provide other support.”

CBHNP partnered with its sister company, AmeriHealth Mercy Health Plan, a Medicaid managed care plan in Pennsylvania, in implementing the Perinatal Depression Pilot Program in November 2008. Nurse case managers at AmeriHealth Mercy screen women for depression by phone using a validated set of questions designed for a pregnant population. Those at high-risk (15% on average) are referred to CBHNP behavioral health specialists for evaluation and appropriate interventions.

“While the member is on the phone, a nurse case manager arranges an appointment with a mental health provider to ensure these women receive timely attention. The nurse not only coordinates care but follows the member’s progress, recommends appropriate resources and conducts follow-ups,” says Lawrence Kay, MD, senior medical officer for the health plan. “Access for these women is the most critical issue.”

As of September, 125 women have been screened, nine referred to a behavioral health provider and two to an outpatient clinic.

SPECIAL DELIVERY

After developing a set of healthcare reform principles, King County (Washington State) incorporated them into a Maternal and Child Behavioral Health Pilot, a four-year program that identifies and treats depression in low-income, pregnant women, mothers and their young children. These populations are more likely to suffer from depression and are less likely to obtain treatment due to poverty, lack of community support and substance abuse.

New data presented by the APA illustrate that Medicaid beneficiaries are more vulnerable to depression than other populations. They are more than five times less likely than privately insured patients to attend the recommended three follow-up visits with their physician (5% vs. 29%) in the 12 weeks following diagnosis and a prescription for an antidepressant; less likely to stay on medication for more than 60 days (35% vs. 55%); and half as likely as the privately insured to have their antidepressants augmented or changed—despite equal access to antidepressants.

The pilot, operating in eight ethnically diverse King County safety-net clinics, rests on the evidence that the best way to reduce the negative impact of depression is through early diagnosis and treatment. Anne Shields, manager, community and school partnerships, Public Health, Seattle and King County, notes that screening and follow-up are rare among the low-income population with more attention being paid to children’s health rather than their mothers’.

The pilot’s primary goals are:

Improve mental health outcomes in low-income children through increased access for their mothers to depression screening and treatment;

Improve mental health treatment through the implementation of standardized treatment protocols in primary care; and

Improve primary care providers’ ability to reduce the risk of mental health problems and treat conditions suffered by mothers and children.

Shields says the pilot is guided by the five essential elements of an evidence-based model for depression care known as IMPACT: 1) A PCP works with a care manager to implement a treatment plan. 2) A depression care manager educates the patient about depression, supports medication therapy, coaches patients and monitors their symptoms. 3) The care manager and PCP gain access to a designated psychiatrist. 4) Care managers measure depressive symptoms at the beginning of and throughout treatment, using the PHQ-9 (Patient Health Questionnaire), which evaluates the presence and severity of patients’ depression symptoms. 5) Treatment is adjusted based on clinical outcomes.

“PCPs often don’t know how to screen for depression and don’t have the time, but a care coordinator can serve as an extension of the PCP with the time and skills to offer the best intervention,” Shields says. “It’s easy for a PCP to lose sight of follow-up. One of the best things about our program is access to a psychiatrist who knows how to prescribe appropriate medications for pregnant women, ensure that they are safe to use, provide oversight and change regimens if necessary.

The results are noteworthy. More than 97% of enrolled mothers have been screened at least once for depression using the PHQ-9 tool. All the clinics screen pregnant patients during their prenatal visits; some also have developed successful protocols to screen mothers during their children’s visits. Finally, 75% of women on caseload have participated in numerous follow-up activities, including phone calls, clinic visits and support groups.

CHANGING MOODS FOR MOMS

Shoshana Bennett knows only too well the risks of depression related to pregnancy. As a clinical psychologist in Bodega Bay, Calif., she has learned from her own experiences.

“Obstetricians aren’t trained in mood disorders,” she says. “Every pregnant woman should be screened at least once during the first trimester to make sure she isn’t clinically depressed. Women are most vulnerable when they are pregnant but often depression is dismissed as ‘just being pregnant.’ If a woman has trouble sleeping or has no appetite, she may have feelings of anxiousness but is afraid to say anything for fear of being prescribed an antidepressant. Or if she is already taking one, there is a chance she could experience a relapse if her doctor decides to terminate the drug.”

Bennett recommends counseling first and medications second as well as communication between the obstetrician and a mental health specialist.

“Depression can affect the fetus so if symptoms are affecting a woman’s life, she shouldn’t white knuckle it, but instead use appropriate treatment,” she says.

According to Consumer Reports Best Buy Drugs, 60% to 70% of people with depression don’t receive the treatment they need.

Mari Edlin is a frequent contributor to MHE. She is based in Sonoma, Calif.

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