Jewish Hospital (KY) CEO abruptly resigns

Ben Amirault, September 19, 2011

Marty Bonick, president/CEO of Jewish Hospital Medical Campus, abruptly resigned Friday, as the hospital's parent company and two other Kentucky hospitals work on merging. "He resigned today and left," said Barbara Mackovic, a spokeswoman for Jewish Hospital & St. Mary's HealthCare, adding that she could not make him available for comment. Bonick has been president and CEO of the campus since February 2008, joining the organization after serving as CEO of Oklahoma State University Medical Center in Tulsa. He is the second hospital CEO within the Jewish & St. Mary's system to leave in about three months. Mackovic said she had no information on whether his departure was related to the planned merger of Jewish Hospital & St. Mary's HealthCare, University Hospital and Lexington-based St. Joseph Health System, which is owned by Catholic Health Initiatives of Denver.

Parkland expects CMS report by Sept. 15

Ben Amirault, September 7, 2011

The chairwoman of the board that oversees Parkland Memorial Hospital said Tuesday that she remains hopeful the facility will retain its ability to receive government healthcare reimbursements, but she offered no assurances. The Dallas County hospital's Board of Managers met in executive session Tuesday evening for a briefing about a follow-up inspection by the Centers for Medicare & Medicaid Services. No official action was taken. "I'm hoping and I'm optimistic that (Parkland will pass the re-inspection)," Lauren McDonald, MD, chairwoman of the Parkland Board of Managers, said after the two-hour closed-door session. "But I'm not putting all my eggs in one basket." Jay Shannon, MD, CMO, said hospital administrators expect a report from CMS by Sept. 15. The hospital's Medicare and Medicaid funding could be cut off effective Sept. 30 if the hospital has not remedied problems found in an earlier inspection.

Opinion: Leverage HIT to Improve Care Management

Ben Amirault, August 5, 2011

The ever-increasing number of publicly reported measures of some aspect of quality or patient safety is one of the most concrete signs of the rising expectations of the public, employers, and payers. These provide a large set of targets for improving care, and much of the same patient information is required to measure performance as to deliver safe, high-quality care consistently.

Luckily, the pace of progress on the electronic health record—long envisioned by the Institute of Medicine and others as key infrastructure for provider organizations in the journey toward safer, higher quality care—has picked up considerably thanks to the HITECH incentive program. More and more patient data is being captured electronically and providers are reaching the stage that electronic support can become part of the toolset for clinicians at the point of care.

But putting the EHR to work to improve clinical performance at the bedside requires breaking down some of the traditional silos in our approaches to using HIT in the hospital.

The key to harnessing the value of clinical data and HIT in the interest of improving clinical performance is bringing quality reporting from the background (and after the fact) to the bedside, delivering actionable information about risks of care deficiencies or potentially poor outcomes to the clinicians caring for the patients in time for them to intervene. It also involves a focus on capturing key information needed for care management and quality reporting that still resides for the most part in paper documentation, free-text electronic notes, or in separate databases that capture documentation in the emergency room, surgical suite, or intensive care unit.

When the often similar logic of measurement and clinical decision support can be applied to this integrated patient information in real-time and clinicians at the bedside notified when action is likely warranted, it becomes possible for deficiencies in care to be identified in time to address them. In some cases, medical evidence and clinical experience are also sufficient to develop more complex logic to identify patients at risk of future, avoidable adverse events.

One of the highest priority targets for leveraging the EHR to enable better care management, sepsis, provides an excellent example of how this should work because hours, even minutes, matter in preventing or ameliorating resulting major organ dysfunction in at-risk patients. Sepsis is the biggest cause of death in hospital ICUs and many cases are preventable.

Efforts such as the Surviving Sepsis Campaign provide the basis for algorithms that can be used for early identification of at-risk patients and to check for consistent use of protocols for prevention and treatment.

Next-generation care management will require the coordinated action of different participants, each supported by the EHR according to their role, as described below for sepsis.

*May be led by hospitalist or Infectious Disease team

+Or other individual or staff responsible for patient tracking and quality reporting.

In many high-risk situations in hospital care (as in the example involving sepsis), there are many factors to be considered in detection and treatment, new information becomes available every few minutes, and quick recognition and intervention is critical to the best possible outcome for the patient. This type of situation with a large and constantly updated data set, complex logic, and the need to continually reevaluate is where computers excel.

Put to work in this way, the EHR will enable next-generation quality management at the bedside.

As efforts to implement the EHR move forward in every hospital, leadership should take note of the following four steps; each step provides an opportunity to make progress on next-generation care management.

  1. Formally link all strategies and plans for EHR roll-out with quality goals (the examples above, plus at least a subset of all measures required by the Joint Commission and CMS provide a starting point).
  2. Involve all of the key roles in planning, design, and implementation support. Next-generation care management will require not just physicians and nurses, but also case managers, quality nurses, and data management and analysis specialists, all working as a team.
  3. Ensure that EHR roll-out and quality management initiatives are making progress in parallel and that meaningful use of each increment of EHR implementation ensures that added capabilities (more data for patient identification and tracking, new uses of clinical decision support) are put to work.
  4. Build real-time data analytics into the IT infrastructure and ensure that the necessary searchable data store is appropriately structured and searchable. This may require influencing the product development plans of the major EHR vendor partner or implementing one or more additional applications.
It's time to look forward instead of in the rearview mirror.

Jane Metzger and David Classen are with CSC. They can be reached at jmetzger2@csc.com and dclassen@csc.com, respectively.

Freestanding EDs Can Make Providers Healthy

Ben Amirault, July 30, 2010

You’ve heard the horror stories. A California man with a blood disorder dies after more than seven hours of waiting in a hospital emergency department. A pregnant 25-year-old Las Vegas woman with abdominal pains languishes in the local ED for more than six hours without being seen by a physician, returns home in frustration and loses her baby. A 63-year-old Philadelphia man with breathing problems dies in a hospital waiting room after being diverted from the overcrowded ED.

Sadly, these tragic stories are all true, ripped from newspaper headlines during the past year.

Clearly, these sensational tales are rare exceptions to the routinely high level of care delivered by most EDs. Yet they draw attention to the fact that emergency care providers face a mounting set of challenges. The most pressing include overcrowding, growing patient wait times, inadequate facilities, limited capital, and deteriorating work environments for physicians and staff.

There’s no magic bullet that can fully address the difficult issues confronting today’s EDs. But there is a concept that appears to be a step in the right direction. It’s called a freestanding ED, and it is an idea that is gaining credence nationwide.

Trouble in the ED

Historically, providers have delivered emergency care on their campuses in dedicated EDs attached to an acute care hospital. But traditional methods of emergency care face numerous challenges.

An “ED paradox” has arisen during the past 20 years. The demand for emergency care has increased by more than 30%, yet the number of ED beds has decreased by 20% and the number of inpatient beds has decreased by more than 20,000, according to the American Academy of Emergency Medicine.

More recently, from 1996 through 2006 (the most recent year for which data is available), the annual number of ED visits increased to 119.2 million from 90.3 million?a 32% jump. That’s according to a 2008 report from the Centers for Disease Control and Prevention.

It is also reasonable to assume that ED patient volumes have continued to increase—and perhaps even accelerate—since that 2008 study. The proportion of ED patients without health insurance was rising even before the recession. So as unemployment increased and laid-off workers eventually lost their health insurance, it is plausible to suspect that even more patients have been forced to turn to EDs for routine healthcare.

Although it is anticipated that healthcare reform will reduce the ranks of the uninsured, that will probably only slow?not stop?the pace of future ED volume increases. Granted, it is anticipated that 32 million additional Americans will obtain medical insurance by 2014, which will presumably reduce their reliance on EDs for routine healthcare. But the overall population will continue to grow, which will probably result in a corresponding increase in non-routine ED visits.

Anyone with a basic understanding of economic theory might also reasonably conclude that increased demand and decreased supply have combined to put significant stress on the emergency care system, and they would be right.

Most visibly, patient wait times have increased. As noted, the dramatic examples cited above are in the extreme. But there’s no denying that ED patients are waiting longer for care. The mean (average) wait time for ED patients steadily increased from about 38 minutes in 1996 to about 47 minutes in 2004 to nearly 56 minutes in 2006, the CDC study found.

Those results were skewed by some very long waits, the CDC report points out. But the median wait time was still 31 minutes in 2006 (meaning half of patients waited less than 31 minutes and half waited longer). Meanwhile, access to care has declined. The number of hospital EDs decreased to 3,833 in 2006 compared to 4,109 in 1996, the CDC reported.

Hospital EDs have also become increasingly crowded. A 2009 analysis by the advisory services firm Avelere Health found that 47% were “at capacity” or “over capacity.” The heaviest load was found at teaching hospitals, where 73% reported that they were at or over capacity. Urban hospitals were at 65%, non-teaching hospitals 42% and rural hospitals 31%. The analysis was based on 2007 American Hospital Association data.

Finally, there is often no room for maxed-out EDs to expand. By definition, traditional hospital-based EDs are situated in hospital buildings on hospital campuses. For many “landlocked” urban campuses, that often means there is no opportunity to add capacity.

Opportunities for providers
But let’s put aside for a moment the growing array of challenges faced by ED care providers. Now let’s examine the strategic needs and opportunities many hospitals and health systems have identified in recent years.

For example, there is an attractive opportunity to provide more outpatient services. Outpatient care is the fastest-growing component of the U.S. healthcare system. It also tends to be more profitable for providers. Not surprisingly, the “outmigration” of care is seen by providers as far and away their No. 1 new business opportunity, identified by 33% of respondents in a recent Bank of America hospital survey. Cardiac care and physician joint ventures were a distant second with 15% each; followed by outpatient diagnostics and cash/retail businesses, 12% each; general imaging and general surgical, 8% each; sleep labs/disorders, 6%; and pain management, 4%.

At the same time, many urban providers seek to extend their brand and defend?or expand?their market shares in growing suburbs. Adding off-campus facilities also improves convenience and access to care for nearby patients and their families. Many providers are also looking for greater revenue diversity and growth, increased patient satisfaction, and better strategic alignment with their physicians.

Yet these needs and opportunities all come at a time when most providers are facing significant capital constraints at both the facility and system levels. Yes, the worst of the credit crunch is behind us. But capital remains more costly and difficult to obtain than it was only two to three years ago—and most providers don’t expect that to change anytime soon.

Thus many providers confront two separate challenges. On the one hand, they face the mounting difficulties associated with ED care. On the other, they must achieve their organizational objectives in an era of constrained capital. With the potential to alleviate both problems in a single stroke, is it any wonder that more and more providers are considering freestanding EDs?

EDs outside the box

Freestanding EDs, or FSEDs, are still an evolving concept. Due to the number of variables, it is difficult to define “emergency department,” let alone “freestanding emergency department.” But most providers would at least agree that freestanding EDs are healthcare facilities that deliver emergency services at a non-hospital-based (i.e., off-campus) location.

Beyond that, the characteristics vary. Although the vast majority of freestanding EDs are affiliated with hospitals or health systems, they might be treated as part of the system or as a separate legal and financial entity. In addition to emergency services, freestanding ED buildings can also include ambulatory surgery centers, laboratories, imaging centers, and primary care and specialty physicians’ offices.

The general concept of freestanding EDs has existed for decades, but its popularity has increased sharply in recent years. According to the AHA’s 2009 annual U.S. hospital trends survey, there were 191 hospital-owned freestanding EDs, not including independently owned and operated facilities. That represented an increase of almost 31% since 2005.

Why are freestanding EDs on the rise? More and more providers and private developers have begun using these facilities to directly address many of the thorny issues confronting emergency care while furthering their organizational objectives.

Although they are no panacea, freestanding EDs can:

  • Shorten ambulance and patient travel times to the ED
  • Reduce patient wait times
  • Provide greater access to care
  • Ease hospital overcrowding
  • Increase patient/customer convenience and satisfaction
  • Expand providers’ brands and market shares in growing suburbs
  • Address the “outmigration of care” trend
  • Grow and diversify revenue streams
  • Enable inpatient acute care facilities and systems to add services despite capital constraints
  • Reduce the physical cost and challenge of ED expansions and renovations
  • Support physician alignment strategies

    Case Study: St.Vincent Health

    A member of Ascension Health, the nation’s largest not-for-profit and Catholic healthcare system, St. Vincent Health is Indiana’s largest healthcare employer, with 19 facilities serving the central part of the Hoosier State.

    With existing full-service hospitals in Indianapolis and its environs, St. Vincent administrators sought to expand their presence in the city’s fast-growing northeast suburbs. Their specific objectives were to:

  • expand their presence in Hamilton and Madison counties;
  • maintain and grow market share in the rapidly expanding suburbs of Fishers, Noblesville, Carmel and Pendleton;
  • continue their strategy of locating facilities near Interstate highways;

  • achieve “first-to-market” status at Interstate 69 Exit 10;
  • develop the first freestanding ED in Indiana; and
  • maintain off-balance sheet status.

    With a 31.3% share of all inpatient admissions and 40% of all ED admissions in the Exit 10 market as of 2005, St. Vincent sought to protect and expand upon that strong base with a freestanding ED. The site selection process began in January 2006. By June 2006, St. Vincent had secured 26.6 acres just southeast of the I-69/State Road 238 interchange in the Indianapolis suburb of Fishers, a site providing excellent highway visibility and access.

    After evaluating various options for the property, St. Vincent officials settled on a plan calling for a 15-bed freestanding ED. The new facility would screen and stabilize adult and pediatric patients, be staffed 24/7 by board-certified emergency medicine physicians, and provide a helipad for air medical transportation. The faith-based institution also tapped the expertise of several area ambulance providers during the design process.

    In addition to providing better, more accessible care, the freestanding ED was a key financial strategy for St. Vincent. The Fishers facility would be owned by BremnerDuke Healthcare Real Estate, which provided financing, planning, development, leasing and construction management services to St. Vincent. That decision allowed St. Vincent to avoid the risk associated with trying to lease the part of the building it would not be using. The third-party ownership structure also enabled the system to receive off-balance sheet treatment for the asset, preserving capital for other uses.

    St. Vincent to communicate its vision for the new facility to prospective physician-tenants and evaluated the level of interest to “right-size” the building. About 85,000 square feet (about 71%) of the planned 120,000 square feet of space was “pre-leased” by the health system before construction in September 2007. A fast-track design and construction process was used.

    The $31.7 million, three-story St. Vincent Medical Center Northeast opened in October 2008. It features 11 exam rooms, four observation rooms, a trauma room and a room for victims of sexual assault. It also offers an ambulatory surgery center and all-digital imaging center, and secondary uses including pediatric care, a breast center, a stress center, a sleep lab, physical therapy and a women’s boutique. Future plans for the campus include a full-service acute care hospital and a medical office building.

    What were the results of this pioneering effort in freestanding EDs?

  • It was first to market and the first system in the state to build a freestanding ED.
  • It has expanded its presence and market share in the northeast Indianapolis suburbs, as evidenced by a 67.2% increase in its ED patient volumes in the area during the first nine months after the building opened.
  • The new facility increased convenience and access to care for suburban residents, adding emergency services to existing urgent care facilities.

  • St. Vincent Medical Center Northeast almost instantly became the system’s busiest ED in the area, accounting for more than 48% of its total ED patient volume in the Exit 10 market.
  • Patient volumes eased by a total of almost 14% at the system’s four other EDs in the market, shortening wait times and reducing overcrowding?even though total ED use increased.
  • Only 13% of patient waiting times at the new freestanding ED exceeded 30 minutes ? far below the national average.
  • The freestanding ED created a new source of referrals for St. Vincent-affiliated physicians.
  • Third-party financing kept the whole project off-balance sheet, preserving the system’s capital.

    St.Vincent reaffirmed its commitment to the concept by collaborating with Witham Health Services on the development of 42,500 square foot freestanding ED in Boone County. That facility opened in October 2009.

    Another system that is actively developing a freestanding ED is TriHealth, a not-for-profit system with two hospitals and about 50 other locations in the Greater Cincinnati area.

    TriHealth’s Good Samaritan Hospital is developing Good Samaritan Medical Center at Western Ridge, a 45,000-square-foot facility in the northern portion of Cincinnati’s West Side. Plans call for primary care and specialty physician offices, imaging, lab services, and a 24-hour ED with ambulance access and a helipad. Construction is under way and the facility is scheduled to be operational by this fall. The project is envisioned as the first phase of a multi-building medical and retail development.

    A powerful strategy

    Freestanding EDs are not a cure-all for everything that ails emergency services. Some healthcare industry observers have also complained that freestanding EDs might increase costs by attracting patients with non-emergency ailments. Others worry that standalone EDs aren’t equipped to handle the most critically ill patients.

    But proper planning for hospital-affiliated facilities can mitigate those types of concerns. And as demonstrated by the experiences of St. Vincent Medical Center Northeast—and the growing number of freestanding EDs nationwide—the benefits can be considerable.

    As a financial tool, a competitive strategy, and a way to increase patient convenience and satisfaction, freestanding EDs can deliver many benefits—not the least of which might be a welcome reduction in the kind of horror stories mentioned at the start of this article.

    Keith Konkoli is a Senior Vice President with BremnerDuke Healthcare Real Estate’s midwest region. He may be reached at keith.konkoli@bremnerduke.com.