The outpouring of fan grief and media interest following Michael Jackson's death June 25 reverberated in the Los Angeles hospital where Jackson's body arrived, all of which provides interesting lessons for CEOs.
Ronald Reagan UCLA Medical Center went into lockdown after hundreds of people began gathering outside the building awaiting further word about Jackson's passing, says Vernon Goodwin, director of security for UCLA Health System.
As part of the lockdown's immediate steps, UCLA "manned all entrances with security personnel and administrative staff, and screened everyone who requested access," Goodwin says.
Such efforts can be monumental in a large hospital, says Steven MacArthur, a safety consultant with The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.
"In a place like UCLA Medical Center, how many doors do they have?" MacArthur says.
The point is that during a lockdown, organizations likely won't have enough security officers to cover all entrances, which leads to what UCLA undertook: Using nonsecurity employees to assist.
Doing so will help a hospital avoid draining its security resources for the fairly routine task of monitoring doors, MacArthur says.
Even smaller hospitals that only have 15 entrances will still be taxed by trying to staff those doors during a lockdown, so regardless of your facility's size, verify that your security policies or incident command system account for alternate staff to bolster security efforts, he says.
From a financial perspective, hospitals also need to ensure that lockdowns don't curb medical services and admissions.
At UCLA, the "biggest challenge was in terms of effectively locking down the facility in a timely manner without disrupting normal operations," Goodwin says.
Lockdown policies should take into account the following considerations:
Conduct a hazard vulnerability analysis, which is a process by which a facility identifies risks and then weighs those threats against the likelihood of them occurring. Such assessments are required by The Joint Commission for emergency operations plans, but they are also useful for other safety and security efforts. UCLA likely has a greater chance of high-profile celebrities coming to the hospital than many medical centers, but other sites should consider the ramifications of treating people like local sports stars or even the president if he makes a stop in the area, MacArthur says.
Reach out to community resources, such as police departments and the National Guard, that could help you with manpower during a lockdown. The chances of securing outside forces will be better if a lockdown isn't the result of a regional emergency.
Establish a series of perimeters to control with a lockdown. The property line is the big perimeter, but the healthcare building itself can be a secondary boundary, and there may be the need for another border within the building. For example, in Jackson's death, it may have been necessary to secure the area where his body lie. Doing so would thwart attempts by hospital employees tempted to shoot a photograph of the corpse, MacArthur says. As evidenced by healthcare workers at UCLA sifting through Britney Spears medical records in March 2008, the lure of celebrities can be strong.
Practice lockdown plans with drills because it is the only way to determine whether staff members understand how to react. MacArthur espouses the idea of having a normal-looking drill volunteer attempt to enter a locked down facility to see where any potential gaps in monitoring exist.
The National Quality Forum included in its Safe Practices for Better Healthcare—2009 Update modifications to the medication management chapter. By combining four existing practices into one, the NQF has called for increased leadership and accountability on the part of hospital pharmacists.
Medication management has been a part of the NQF's Safe Practices since they were released in 2003. Currently, Safe Practices 17 and 18 concern medication safety.
"I can't think of one area that is more complicated to try and hit the right balance of," said Peter B. Angood, MD, FRCS(C), FACS, FCCM, senior advisor to the NQF in patient safety and former vice president and chief patient safety officer for The Joint Commission. Angood spoke during a recent NQF and Texas Medical Institute of Technology Webinar called "Medication Safety: Complex Issues for All."
"The difficulty comes with the fact that these are common problems, but highly complex in terms of finding solutions." Many organizations struggle with crafting policies that encourage change in the medication management process, he said.
Increased leadership by pharmacists
Pharmacists should have a larger presence on the leadership team to help navigate the increasingly complicated world of medication management, said Mary Andrawis, PharmD, MPH, director, clinical guidelines and quality improvement for the American Society of Health-System Pharmacists during the Webinar. To ensure that the existing practices to prevent medication errors as well as development of new practices continue, pharmacists will be an important piece of the puzzle.
"Literature shows that when pharmacists are involved in care, the result is improved patient care, fewer adverse events, and reduced costs," said Andrawis, speaking about Safe Practice 18. "But, in order for that full benefit to be realized, it's really important that those pharmacists be given appropriate authority, and consequently that they continue to take accountability for patient outcomes."
Greater integration of pharmacists with the healthcare team is a benefit not only to the organization by way of more efficient care, but more importantly to the patient, as his or her care will become safer with a pharmacist around at all time to be involved in the decision-making associated with care, said Andrawis.
She presented some actions that facilities can do take to realize an effect on medication safety:
Open the lines of communication between the leadership team and the hospital's pharmacists. Pharmacists want to have a greater role in decision making, said Andrawis. They can also best explain how medication management can lower the facility's costs. She gave the example of a new service opening up within the hospital. "It's really the pharmacy leader that can best anticipate any disruptions or changes that might result on the medication use system from other decisions that are made.”
Create a medication safety committee. Led by a pharmacist, this committee can be tasked with reviewing errors, performing root cause analyses related to medication errors, and brainstorming how to plug gaps in the medication system. This group should also be involved in any Walkrounds that take place, said Andrawis.
Make sure pharmacists are involved in technology planning and implementation. Today, many types of technology are used to manage medications in the hospital. Examples include smart pumps, bar coding, and computer physician order entry. "I really believe the results could just be catastrophic if the technology is not planned for adequately and implemented safely," said Andrawis.
Include a pharmacist on the clinical team. Instead of referring to pharmacists at certain stages of the process, Andrawis encouraged hospitals to consider making the pharmacist another part of the team, much like the nurse, doctor, and any specialists. Doing so will eliminate delays in care, promote collaboration, and better decision-making for each patient's care, and encourage a sense of shared responsibility for each patient, said Andrawis.
Bridges to Excellence, which now recognizes and financially rewards 15,000 selected physicians for providing quality care nationwide, announced it will now be assessing the diagnosis, treatment, and management of new five chronic conditions: asthma, congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease, and hypertension.
The new programs--combined with an existing focus on diabetes, ischemic vascular disease, back pain, and depression--are expected to cover the majority of conditions accounting for healthcare costs in the system today and the bulk of patients that many providers are seeing in their practices.
The Bridges to Excellence programs have been designed to provide incentives to reward physicians and practices for adopting better systems of care. At the inception of the program, emphasis had been placed on encouraging the adoption of systems of care--such as electronic medical records--along with using those systems in delivering good results in patient management. BTE works with large employers, health plans, providers, and other organizations that have a shared goal to improve quality and patient outcomes.
Now, the emphasis is being placed on results of patient management, specifically with chronic conditions. Physicians who demonstrate excellent performance can earn recognition and also qualify for incentives from participating employers and health plans.
Work at Bridges to Excellence has shown that significant avoidable costs exist with the management of these conditions, says Francois de Brantes, the Bridges to Excellence CEO. "By reducing preventable complications incurred by most patients with these chronic conditions, we could significantly improve the health of employees and save employers billions of dollars."
Bridges to Excellence uses "continuous scoring" meaning that physicians can get points that are calculated upon exactly how many patients they get into compliance, says Edison Machado, MD, Bridges to Excellence medical director and programs manager.
And to promote continuous quality improvement, the Bridges To Excellence physicians are monitored by using three levels or tiers of recognition. The levels are designed to recognize improvements in performance--from successfully managing the patients at the highest risk of hospitalization to optimally managing the majority of patients--while controlling for patient selection bias.
The levels are:
Level I: Focuses on a "physician centric view" of measurement, with an emphasis placed on reducing the number of patients in "poor control" as assessed by intermediate outcome measures.
Level II: Focuses on a combination of physician and patient centric measurements, which look at the defect rate of care delivery across the "poor control" measures on a per patient basis.
Level III: Focuses on a patient centric view of measurement, with the defect rate strategy expanded to apply to "superior control" as well as "poor control" measures on a per patient basis.
While a public insurance plan option simultaneously has been one of the most hotly contested healthcare reform proposals, a recent report noted that a public plan as part of a comprehensive healthcare reform approach could slow healthcare cost increases more quickly over a 10-year period.
This cost decrease is not so much related to more people joining a public plan, but to increased competition that would make healthcare insurance more competitive, says Stuart Guterman, an assistant vice president with The Commonwealth Fund.
Guterman is co-author of a new study released last week that found the potential savings for families, businesses, and the federal government will vary depending on whether or not a public insurance plan option is included. This is illustrated under three different scenarios:
A public plan option in which healthcare providers are paid at rates falling between current Medicare rates and private plan rates
Another one that includes a public plan option that relates payments more closely to Medicare rates
An option that relies exclusively on private plans and includes no public plan.
The cumulative health system savings between 2010 and 2020—compared with projected trends for that period—would range from:
$3 trillion under the scenario that includes a public plan paying providers at Medicare rates in competition with private plans
$2 trillion for a public plan paying providers at rates halfway between current Medicare and private plan rates
$1.2 trillion in the private plan scenario
All three approaches would make affordable coverage available to everyone.
Each of the scenarios includes a national health insurance exchange that provides consumers with a choice of insurance plans, along with federal assistance to make coverage affordable. Other than reforms related to the public plan, the cost estimates for all three options include the same payment, system, and insurance reforms.
"In all of these proposals, more people would end up with coverage, and most of that coverage would be through their employers—as it is now," Guterman says.
Offering a choice of a public plan would make it possible for payment reform to spread somewhat more quickly at the current time. A public plan also would provide a way to lower administrative costs—operating with no or low administrative costs and no costs of underwriting. Public plans would serve as a "catalyst" for competing private plans to make their operations more efficient, according to the study, "Fork in the Road: Alternative Paths to a High Performance U.S. Health System."
"You're able to keep insurance premiums down. There's competition between public plans and private plans," he says. "And all of the innovations that are built into our payment and system reform proposals would be spread more widely because the public plan adopts those policies as well."
In the long run, this forces more competition as far as insurance premiums. "And of course, if premiums are lower, that` means that employers' costs are lower because in the end, employers who cover their employees still would cover their employees—they would just cover them through the exchange," he says.
The report also showed that:
With all three scenarios, near-universal coverage would be achieved. If reforms started in 2010, for instance, the number of uninsured would decline to 4 million by 2012 (or 1% the population) and remain low. Without reform, the number of uninsured could rise to 61 million by 2020.
By providing a cheaper base for expanding insurance coverage, federal costs would be lower in the scenarios with a public plan choice. With savings offsetting the costs of expansion, the 11 year net increase in federal budget costs from 2010 to 2020 is expected to be $112 billion with a public plan with Medicare payment rates option, $232 billion under a public plan with intermediate payment rates, and $360 billion under private plans.
Hospital and physician revenues could grow under all three scenarios—but at a slower rate. Reforms that insured everyone and raised Medicaid's payment rates to Medicare's would "infuse new revenues" and "eliminate the need for cross subsidies built into the current charges to private insurers," the report noted.
Overall, the bulk of savings would benefit individuals and families because of the slower growth in premiums and out of pocket costs, the report said. By 2020, the annual savings per household would range from $1,600 in the private plans and the public plan (with intermediate payment rates) to more than $2,200 in the public plan (with Medicare rates). These benefits would accrue across income groups.
The Act provides a tiered system for assessing the level and penalty of each violation. CMS, which enforces the HIPAA Security Rule, and the Office for Civil Rights, which enforces the HIPAA Privacy Rule, can supersede the following limits, but with a cap of $50,000 per violation and $1.5 million for the calendar year for the same type of violation. The different tiers are:
Tier A is for cases in which offenders didn't realize they violated the Act and would have handled the matter differently if they had
Minimum per violation: $100
Maximum per calendar year: $25,000
Tier B is for violations "due to reasonable cause, and not to willful neglect," though HHS still must define "reasonable cause"
Minimum per violation: $1,000
Maximum per calendar year: $50,000
Tier C is for infringements that the organization corrected, but were due to willful neglect
Minimum per violation: $10,000
Maximum per calendar year: $250,000
Tier D is for violations due to willful neglect that the organization did not correct
Minimum per violation: $50,000
Maximum per calendar year: $1.5 million
How does the sanction structure look at your facility? HIPAA requires covered entities to have a structured sanction policy in place.
AHIMA proposes two sanctioning models that demonstrate categories and mitigating factors:
Categories of privacy incidents: The organization creates categories defining the significance and impact of the privacy or security incident to help guide corrective action and remediation steps.
Multifactor model: The organization takes corrective action and bases remediation on the highest level of category indicated.
Privacy and security experts agree facilities should take a look at their internal sanctions.
"I would look at the wording in your policies and remove any examples of different violations," says Dena Boggan, CPC, CMC, CCP, who is HIPAA Privacy/Security Officer at St. Dominic Jackson Memorial Hospital in Jackson, MS. "We're focusing on the tiers and if things were unintentional or intentional. (HHS) did a pretty good job at explaining what the tiers were."
Some of the other highlights from the revamped internal sanctions policy at St. Dominic, a 500-bed, 3,500 employee system, is:
Tier setup. Much like HITECH, St. Dominic rewrote sanctions to reflect a tier system. It established a level of breach–such as intentional, unintentional, malicious intent, or personal gain.
Internal process. St. Dominic documents in its policy the steps it takes when it knows an employee accessed information inappropriately. "The worst thing to do is to not let them know how you're handling the process," Boggan says.
Use of "generally." Lawyers at St. Dominic suggested using "generally" when documenting what a sanction may be. "We wanted to give ourselves leeway," Boggan says. So instead of limiting themselves to a concrete fine, the word "generally" opens the door. For example, the offender is "generally" subject to disciplinary actions.
Sign them up. St. Dominic gets its employees to sign a nondisclosure form stating they will not inappropriately access PHI, and if they do there may be disciplinary actions.
Supporters say prevention will save the nation billions in averted long-term healthcare costs, and recent studies show that Americans support investing in prevention. But questions persist—most notably from the Congressional Budget Office.
Prevention has been mentioned as an important piece of healthcare reform. In its health reform draft proposal, The House Committees on Ways and Means, Energy and Commerce, and Education and Labor shed some light on where the prevention dollars would flow:
Expand community health centers
Waive cost-sharing for preventive services in benefit packages
Create community-based programs to deliver prevention and wellness services
Target community-based programs and new data collection efforts to better identify and address racial, ethnic, and other health disparities
Strengthen state, local, tribal, and territorial public health department programs
This proposed package of prevention programs in the healthcare reform debate would go beyond provider-based healthcare with supporters hoping to create a better wellness culture in the country. But will the government be more successful than doctors, employers, health plans, and population health companies who have struggled to get people more active and eat right? Then, there's the question whether prevention programs actually save money.
Employers and the population health industry have been discussing the issue of prevention and ROI for years. Groups, such as the Trust for America's Health, suggest the U.S. could save $16 billion annually within five years and experience a 5.6:1 ROI by simply investing $10 per person annually in community-based programs to increase physical activity.
Another study, funded by Pittsburgh-based health insurer Highmark Inc., found a modest 1:64:1 ROI in a four-year review of the insurer's employee wellness program, which includes employer health risk assessments, online programs in nutrition, weight, and stress management, tobacco-cessation programs, on-site nutrition and stress classes, biometric screening, and health coaching.
Anna Silberman, vice president of preventive health services for Highmark, says the company's prevention program stops non-healthcare users from becoming "huge users of the system." Prevention not only reduces direct medical costs, but also saves companies and the nation on work-related costs in the areas of absenteeism, work production, and presenteeism, she says.
Silberman says the healthcare system should reward physicians for educating their patients about prevention and reminding patients of recommended tests, such as mammograms and diabetes screenings. "There are so many things that we can do that often get put on the backburner because we're dealing with the acute thing that's happened as a result of not addressing them earlier in our lives," she says.
However, there are others who say prevention doesn't save much—if anything. The issue is that preventive programs are open to a wide population rather than those who could be at risk of chronic diseases, such as diabetes, heart failure, or kidney disease. So, in fact, the companies are using a wide net to help people who may never have a chronic disease or are destined for a chronic disease regardless of activation level or food choices.
One group to question the cost-effectiveness is the CBO, which suggested in December that more prevention would bring modest cost reductions over 10 years, and could actually increase costs.
Mary Jane Osmick, MD, vice president and medical director at LifeMasters, a health management company in Irvine, CA, supports wellness programs, but acknowledges there are still questions about whether wellness programs can save money.
"My guess is that there is a [positive] ROI, but I don't know that we have the methodology to say this is what it is and this is when you'll see it. I think the jury's still out on that. But I sure believe it from a physician stand point, that prevention is the absolute way to go," says Osmick.
Judith H. Hibbard, PhD, professor of health policy in the University of Oregon's Department of Planning, Public Policy and Management in Eugene, OR, who created the Patient Activation Measure, which is a questionnaire that gauges an individual's activation level in health, says whether prevention is cost-effective depends on the program. "If you mean by clinical prevention, I don't think it's going to get us that far. If you mean to really help people to avert illness or avert future declines in health, then yes, I think it could [save money]."
Hibbard says prevention programs can't merely happen in physicians' offices. Ninety percent of what determines an individual's health state is outside of the healthcare system. For prevention to be successful, the country will have to need a more encompassing wellness program.
"I think we have to take a more holistic view and get outside the system too. People live inside the community and not just look for the medical system to make that happen. They need to be part of the solution too—not divorced from it," says Hibbard about empowering the individual.
With that thought in mind, Sen. Tom Harkin, D-IA, filed legislation that would provide tax credits for employers that spark employers to participate in programs, such as health education and behavior change.
Health management company Alere also recently presented its National Health Improvement Strategy that it claims could save American businesses and health insurers "tens of billions of dollars" by focusing on preventing health risks and chronic illness. Alere CEO Ron Geraty, MD, promotes more collaboration between providers, employers, and health plans in the areas of health information technology, home monitoring services, rapid diagnostic tools, clinical outreach, and health coaching. He says these program could avoid episodic visits, procedures, and treatments. In addition to national nutrition programs, Geraty says the government needs to kick off a national healthy pregnancy campaign because healthy babies lead to healthy adults.
"We think a concerted strategy for the country is needed to say ‘we care about health, we promote health, and then when there is disease, we are actively managing the longitudinal impacts of those illnesses.' That will really change the way healthcare is delivered in the country," says Geraty.
What would need to happen?
In order to change the healthcare system to focus on prevention, industry experts pointed to a number of needed changes:
Paying healthcare providers for keeping patients well, such as reimbursing for patient education, prevention, and early detection. "I think it's important for physicians and other healthcare professionals that there be a mechanism introduced where immunizations are adequately reimbursed for," says Silberman.
Physicians need to be trained on nutrition and exercise so they can provide guidance to patients.
Incentive programs for people who are active in physical or nutrition programs, which employers have found can improve the wellness culture
Technology to make health a more compelling choice, such as portable interactive Web sites that integrate a person's personal health record and patient history. "Most people when they think of personal health records think of a place to store medical information, which I think is critically a part of it, but we think the PHR ought to be a personal healthcare planner," says Geraty.
Silberman says the good news is that much of healthcare costs is preventable. But to benefit from prevention, the nation will need to make major investments inside and outside of healthcare.
"There's so much potential when you think about the fact that 75% of what we cope with as a country is preventable," says Silberman.
Four very different patients underwent a CT scan at North Shore University Hospital this week. They each hail from the Middle East, are well-to-do, and, oh, died thousands of years ago.
Four ancient Egyptian mummies, dating as far back as 1188 BC, journeyed from their display at the Brooklyn Museum to the Manhasset, NY, hospital so that the museum's Egyptologists could learn more about their lives—and deaths. North Shore's 64-slice CT scan, though normally used to detect heart abnormalities, provided the scientists with detailed images of the mummies' tissues and skeletal systems without performing any potentially damaging invasive procedures.
"The Brooklyn Museum had a history of using medical technology to look at Egyptian antiquities to evaluate them and try to explore them without actually causing damage to them and going through them and opening them," says Dr. Amgad Makaryus, North Shore's director of cardiac CT and MRI. "The reason they contacted us is they knew we had this new 64-detector scanner technology that gives you high resolution images that would be helpful in exploring these mummies."
After reviewing the images, the Egyptologists made some startling discoveries. The remains of the Count of Thebes were found to have a reed-like tube in the chest area, which the scientists believe could have been placed there to keep the Count's head in a regal position for eternity. When the remains of Lady Hor were scanned, the scientists found something even more shocking—the Lady was a man.
"The museum people were a little bit amazed about that," Makaryus says. "The best part is we got all this information noninvasively. I think that's really one of the main points here—modern science meeting very old mummies and exploring them without actually having to cut them open."
But not only did these CT scans provide benefits for the museum's scientists, they also created a positive public relations opportunity for the hospital. The press coverage surrounding the mummies' medical procedure incidentally informed the public about the hospital's advanced technology, says Michelle Pinto, North Shore's director of media relations.
"Aside from the fact that we're very proud that we can offer our cardiac patients the 64 slice CAT scan, what we were proud about is that by bringing the mummies here we were able to treat them with the respect that ancient objects of art deserve," she says. "It was a great new way to use the great technology and it was a blending of art and science."
Makaryus says some curious acquaintances have even contacted him personally.
"I've had people call up and say we saw about the mummies and most people are very interested," he says. "We're using this new technology to scan very old mummies and actually learn something about them. There's definitely general interest about it."
Though the Brooklyn Museum has no immediate plans to scan any additional mummies, they may use these four mummies' CT scan images in an upcoming exhibit, Makaryus says.
"The old meeting the new, in terms of this modern day technology that we use on living human beings to actually assess mummies, really ties the whole juxtaposition of ancient mummies and modern day technology," he says.
David Axelrod, President Obama's top political adviser, declined to rule out the possibility that the White House would agree to a tax hike on health insurance plans that would hit middle-income Americans. Speaking on ABC's "This Week," Axelrod declined to repeat Obama's pledge during his campaign that families making under $250,000 would not see "any form of tax increase, not your income tax, not your payroll tax, not your capital gains taxes, not any of your taxes." Instead, Axelrod said the president has no interest in "drawing lines in the sand" on the issue of how to pay for the costly health reform plan making its way through Congress.
Congressional Republicans are objecting to Democratic healthcare proposals, illustrating the difficulty Democrats face in creating an overhaul that can attract enough Republican support to be portrayed as bipartisan. Republicans' primary objection is the Democrats' push for a public health insurance plan that would serve as an alternative to private coverage. Republicans say such a plan would cause the private insurance market to unravel.
A growing cadre of liberal activists is aiming against Democratic senators who they accuse of being insufficiently committed to the healthcare reform cause. The attacks—ranging from tart news releases to full-fledged advertising campaigns—have elicited rebuttals from lawmakers and sparked a debate inside the party over the best strategy for achieving President Obama's goal of a comprehensive health-system overhaul.
