Depending upon how well they are organized, board meetings can provide vital monthly or quarterly face-to-face time among the decision-makers to keep your physician practice running smoothly.
Or, they can devolve into a cat rodeo; a huge waste of time and energy, where very well educated, very opinionated, highly trained professionals find themselves arguing over the everyday and trivial issues that should be solved on the middle-management level.
At Radiological Associates of Sacramento (RAS), the monthly practice board meeting is a model of efficiency. It is no small feat to get the 64 physician-owners of the practice to sit down for some two to four-and-a-half hours every month to review critical governance issues. But the efficiencies built into the meetings, which might seem effortless to the casual observer, are actually the result of constant streamlining and review, says Fred Gaschen, executive vice president at RAS.
"I'm proud of the way they have organized this," Gaschen says. "I've been here more than 13 years and I inherited a good structure. But I'd like to think that in that time we have streamlined and improved the structure."
RAS has been around since 1917, and Gaschen says the physicians in the practice know enough to let the business people they've hired to run the business, run the business. The business side takes care of the minutia, and helps the physicians organize the subcommittee and board meetings.
"We support the decision-making process by the physicians at the board level through our infrastructure," Gaschen says.
This all seems perfectly logical and simple. Don't waste everybody's time squabbling for hours about lower-level management issues that prolong meetings, force you to skim through more important issues, and leave practice partners irritated by the sense that important issues are not being addressed. But it's surprising how many physician practices run their meetings exactly that way, says Ken Hertz, principal, MGMA HealthCare Consulting Group, based in Monroe, LA.
What's on the agenda?
"I don't think you want to spend a half-hour at a board meeting deciding what kind of chairs you are going to put in the reception area. I don't think you want to spend a half hour at the board meeting or partner meeting deciding whether Dr. Jones' nurse Mary should get a bigger raise than the other nurses, because she has been here longer and, after all, she does three times the work everybody else does," Hertz says.
Instead, he says, the board should focus on governance. "We are talking about strategic issues—mergers, acquisitions, integration, recruitment, strategic decisions to develop a marketing plan," Hertz says. "Sitting at the board meeting is not where you read the copy for the ads and Dr. Jones says 'I don't like the way that paragraph is written.' It is your right to question, but there are certain things you need to entrust to a manager or a subcommittee."
To run an efficient meeting, Gaschen says, what is not on the agenda is almost as important as what is on the agenda.
"Small operational issues are not discussed at the board level. The board is responsible for overseeing corporation setting policy and directions. That is their role," he says. "The day-to-day operations are handled by the respective administrative staff hired in the divisions and each division."
For example, RAS has several subcommittees that meet weekly to vet and prepare issues for the larger board to act upon.
"It is at the divisional level they will look at new offices, new equipment, new services, or new medical ways of doing things, and there will be a lot more debate at the division level and the sub-groupings that happen between the monthly board meetings," Gaschen says.
"So the division will arrive at a consensus within its membership and that division will take it forward to the executive committee for informational purposes and the board of directors for final approval. By the time it gets to the board of directors, it has been vetted in multiple stages along the way. Rarely do we bring something up to the board level and there is a big brouhaha."
Meeting parameters
The agenda, the structure, the frequency, and length of the meeting may vary from practice to practice, depending on what works for the practice, Hertz says, but there are also some fundamental, common sense rules that should apply, regardless of whether you've got two or 200 physicians in your practice.
"Meetings need to start and end on time," Hertz says. "The people who show up on time shouldn't be penalized for the people who don't. It's disrespectful not to start on time and end on time. The more you don't start on time, the more people say 'why should I show up on time?' and then it becomes a downward spiral."
Meetings need to have a structured agenda and a facilitator to ensure that the agenda advances. "What we really want is the meeting to move forward. I've sat through many meetings where nobody moves. Somebody introduces a topic and it just meanders. There has to be some leadership," Hertz says. In most physician practices, the president of the board or a managing partner should lead the meeting. "I've seen a lot of practices where the administrator or manager chairs the meeting, but I'm not a big fan of that," Hertz says. "They are an employee. It's your practice. You're the governance. The manager can meet with the chair or the president, review the agenda and the material, point out any landmines or other things they need to be aware of, but, ultimately, a board needs to do the board's work."
Physicians need time to prepare for the meeting. Hertz says one of the most common complaints he hears from physicians is that they aren't given a chance to plan for the meeting. He recommends publishing agendas as far in advance as possible. "You come to the meeting and somebody gives you a 15-page report and expects you to comment on it. That is not right," Hertz says. "I also hear 'I came to the meeting and all I heard was reports and I left.' Well, then why have a meeting? Put it in writing and e-mail it to me." Hertz says some practices don't issue the agenda because they say their physicians won't bother to read it. "I say 'I don't really care.' The right thing to do is give it to the docs in advance and they read it or they don't. It's their choice, but that is the proper way to do it."
Don't rehash the same issue in meeting after meeting. "Some practices allow that. Some practices say 'We made the decision. We are moving on.' If it is a major decision that the board is going to make and the board isn't made up of all the partners in the group, it is incumbent on the part of the board to get the shareholders input before the meeting and before the decision is made."
In the end, the board can't allow itself to get bogged down on one issue. Make a decision. It all comes back to leadership.
It is common for patients 65 and older to get potentially inappropriate medications when treated in emergency departments, a new University of Michigan Health System study has found.
Nearly 19.5 million older patients, or 16.8% of eligible emergency visits from 2000-2006, received one or more potentially inappropriate medications—or PIMs. The large sample of approximately 470,000 ED and outpatient clinic visits, corresponding to a national estimate of about 1.5 billion total visits, allowed the researchers to determine the extent of the problem nationwide, according to the study published in Academic Emergency Medicine.
Researchers looked at a nationwide sample of ED visits using data from the National Hospital Ambulatory Medical Care Survey to see how many patients aged 65 and older sent home from the ED were prescribed potentially inappropriate medications. The study found that 10 medications accounted for 86.5% of PIMs in the ED.
The five most common ones were promethazine, ketorolac, propoxyphene, meperidine, and diphenhydramine; and two of these—promethazine and ketorolac—accounted for nearly 40% of PIMs.
William J. Meurer, MD, the lead author of the study, and an assistant professor at U-M’s departments of Emergency Medicine and Neurology, said doctors need more education about the suitability of certain medications for older adults. The study also found that prescribing inappropriate medications was less likely to occur if a resident or intern was involved in the treatment, probably because younger doctors have had recent training about medications.
There was substantial regional and hospital type (teaching vs. non-teaching) variability. PIMs were less likely to occur in visits to hospitals in the Northeast and twice as likely in other parts of the country. And receiving a potentially inappropriate medication was more likely to occur at for-profit hospitals.
The study did not explore the possibility of medication interactions, so it is possible that the potential harm by medications is underestimated.
Connecticut Attorney General Richard Blumenthal said this week that his office has uncovered a potentially anticompetitive practice by health insurance companies that could raise healthcare costs and lower competition.
In a letter to HHS Secretary Kathleen Sebelius, Blumenthal called for an investigation of these practices at the national level.
Blumenthal said his office has been conducting an antitrust investigation of Anthem Blue Cross and Blue Shield of Connecticut, which is owned by WellPoint, Inc., and has found contractual Anthem clauses—commonly referred to as Most Favored Nation clauses—requiring hospitals and other providers to allow Anthem to pay the lowest reimbursement rates in the industry.
Despite apparently having the best reimbursement deals, Blumenthal said Anthem won't pass on its savings to policyholders. Instead, he said the company has sought and received premium increases on Connecticut health insurance consumers, and possibly elsewhere in the country, of at least 13% to 20%.
"Our investigation remains ongoing, but federal officials deserve immediate warning about these practices—potentially having national implications and warranting federal investigation," Blumenthal said in a media release. "Small businesses, individuals—and our entire economy—have a direct and immediate stake in practices that straitjacket hospitals and raise healthcare costs."
"WellPoint and Anthem—among the most powerful players in the health insurance industry—may be exploiting its strength to force hospitals into giving them the best deal in the market. As a result of Anthem's practices, competitors are forced to pay more, hospitals are forced to accept less from Anthem—and consumers are the ones paying," Blumenthal said.
Blumenthal added that less than a year ago, Anthem received approval for premium increases between 13% and 20% on individual health insurance policies in Connecticut, even as the company acknowledged paying at least 39 executives a minimum of $1 million each.
Anthem said its premium hikes were owing to the trouble economy, because "younger, healthier policyholders who lose their job are canceling their health coverage. This means there are fewer policyholders, resulting in those who are left having to pay more."
Anthem issued a statement saying it is working with Blumenthal's office, but the health insurer insisted it has done nothing wrong.
"We have no reason to believe that any provision in our hospital contracts is in violation of applicable law," Anthem said. "When negotiating contracts with hospitals, Anthem makes every effort to obtain fair market reimbursement rates for our customers.
"The increases in premium costs, however, are driven by much more than the increase in hospital rates. An aging population, higher patient utilization, the increase of chronic disease, new high-cost technologies, and cost shifting from Medicare and Medicaid all contribute to rising insurance premiums."
Hospital nurses spend three hours of a typical 12-hour shift away from the patients' bedside to complete regulatory requirements, redundant paperwork, and other non-direct care, a recent online survey of more than 1,600 nurses shows.
Some of the biggest distractions and time eaters include documenting patient care information in multiple locations, and completing logs, checklists, and other "redundant" paperwork, the nurses said. They also reported wasted time trying to secure equipment and supplies.
The nationwide survey, conducted last fall for Jackson Healthcare, the Alpharetta, GA-based healthcare staffing and management company, targeted nurses, nursing managers, and CNOs. It was conducted with StatCom and Travel Nurse Solutions, and was based upon the online responses from 1,663 hospital nurses.
"Nurses are being taken away from the patient's bedside by non-patient activities. Unfortunately, due to the regulatory nature of healthcare, we know that some of these redundancies won't go away," said Jackson Healthcare CMO Bob Schlotman.
"However, the good news is methodology, in the form of process improvements, and adaptive technology now exists to help minimize and manage these frustrations for our nurses."
The survey found a number of differences between CNOs and front-line nurses. CNOs were more concerned with the coordination of patient care, whereas nurses felt overworked and in need of additional staff support, the survey showed.
The front-line nurses said ancillary staff support, hospital-wide communications technology, and reductions in redundant regulatory requirements could alleviate the distractions and time away from patient, the survey showed.
A new study found that patients admitted to full or near-full hospitals increased their risk of dying by 5.6%.
University of Michigan Health System researchers evaluated four factors that can affect hospital deaths: occupancy, nurse staffing levels, weekend admissions, and seasonal flu.
Having more nurses made patients safer, decreasing risk by 6%. But weekend admission raised the risk by 7.5% and admission during seasonal flu had the greatest impact by increasing the risk of death by 11.7%, according to the study, which was published today in Medical Care.
"The study establishes that there is indeed a connection between hospital occupancy and death rates in U.S. hospitals," said lead author Peter L. Schilling, MD, a resident in orthopedic surgery at UMHS, and Robert Wood Johnson clinical scholar. "It's important to emphasize though that this study does not identify a specific occupancy level above in which patient care suffers and deaths abruptly become more common. The key occupancy level may differ for each hospital."
The study included 166,920 adult patients admitted to 39 Michigan hospitals over three years, and can be generalized to hospitals nationwide, Schilling said.
The study—the first to compare all four factors at once—found that each factor had a significant impact even while evaluated in a model simultaneously. "The good news is that each can be modified in some way," says co-author Darrell A. Campbell Jr., MD, chief of clinical affairs at the UMHS.
For example, during peak flu season, hospitals can reinforce the importance of hand washing and covering coughs and sneezes. The impact of seasonal flu may also be diminished by improving vaccination rates in the community and among healthcare workers.
Researchers calculated the occupancy of the hospitals every day for the years 2003-2006. On average, patients in the study were admitted while hospital occupancy was 73% of full capacity. One-third of patients were admitted on high occupancy days, at average levels of 80% or more.
Study patients were admitted after being seen in the ED for heart attack, congestive heart failure, stroke, pneumonia, hip fracture or gastrointestinal bleeding.
"Hospital occupancy changes from day to day, so patients shouldn't try to choose a hospital based on its occupancy level," said co-author Matthew M. Davis, MD, co-director of the Robert Wood Johnson Foundation Clinical Scholars Program at the UMHS. "But these kinds of study findings should prompt hospitals to look at the flow of patients and processes of their care teams during high occupancy times. Those are more challenging moments when more things can go wrong."
The UMHS study also examined the impact of "access block" when a full hospital prevents ED patients from accessing an inpatient hospital bed. While a wave of accident victims to the ED is impossible to predict, hospital administrators can control occupancy by managing the number of elective surgical cases scheduled for admission.
The authors said restricting these profitable procedures can cost hospitals money since they've become increasingly important to hospital finances in recent years. "However if access block is a true phenomenon, a hospital full of elective surgical admissions may be limited in its ability to safely handle an influx of urgent admissions through the ED," Schilling said.
Healthcare network VHA Inc. has signed a five-year strategic agreement with Omnicare Inc. subsidiary Tidewater GPO, a group purchasing organization for long-term care providers.
The agreement gives Covington, KY-based Tidewater's approximately 4,000 members access to VHA's non-acute care portfolio for food and food distribution services with U.S. Foodservice.
"With the power of VHA's key contracts, Tidewater enhances its ability to bring significant value to its membership in a highly competitive and reimbursement sensitive marketplace, while remaining independent and committed exclusively to serving our senior care providers," said Tom Ludeke, president of Tidewater GPO, in a media release.
The agreement expands Irving, TX-based VHA's reach into the non-acute market of non-hospital healthcare providers, such as surgery centers, physician practices, home health agencies, and cancer centers.
VHA now serves more than 1,400 nonprofit hospitals and more than 28,000 non-acute care organizations nationwide.
VHA's contracting company, Novation, manages more than $35 billion in contract purchasing annually, including purchases through its agreement with U.S. Foodservice.
"Tidewater has a deep understanding of the long-term care market, which is growing rapidly as the baby boom generation approaches retirement age," said Amy Anthony, senior vice president of Supply Chain Programs for VHA, in a media release.
News that Martin Memorial Medical Center in Stuart, FL, disciplined several employees for taking cell phone pictures of the victim of a Feb. 3 shark attack who later died has generated a lot of interest on our HealthLeaders Media Web site.
The Martin Memorial incident was a clear violation of HIPAA privacy laws. What happens, though, when the shutterbug is not an employee, but a relative or a friend of the patient or even someone walking through the emergency department who otherwise has no connection with the patient or the hospital?
Digital cameras are standard equipment on most cell phones. This could make anyone walking into your hospital a potential photojournalist.
An emergency clinician—who is not connected to Martin Memorial or the shark attack incident—sent me an email asking that question. He writes:
"I am a provider working in the ER and have often had a case where either family or friends are taking pictures of the patient that is getting a splint after breaking something or in the process of getting stitched up. I often don't know this is happening until the cameral flash is going off and next thing you know, I am on someone's Facebook page stitching up their friend in the ER (my patient)."
"I realize we can't stop the interest of family and friends and their uncontrolled urges to capture every moment with the advances of technology and a camera on everyone's phone. The question that I raise is how does this work with HIPAA? Should we be banning camera phones in the ER/hospitals/clinics? Good luck with that one. Are the medical providers or the facilities at risk for violations?"
"Obviously a provider or other medical employee would face violation if these were taken and released, but what about something coming back to us that originated from a non-medical providers phone camera and the patient that agreed to have the picture taken due to peer pressure only to regret it later?"
I asked the Department of Health and Human Services' Office of Civil Rights about it. They replied: "Entities subject to the HIPAA Privacy and Security Rules are covered entities: health plans, healthcare providers, and healthcare clearinghouses. Generally speaking, a covered entity would not be responsible for the actions by a patient's friends or family."
So it appears that you and your hospital are off the hook if family or friends are taking the pictures. We live in a very litigious society, however. Can a patient sue his hospital for failing to protect his privacy when a stranger–someone not connected to the provider or the patient—takes a quick cell phone photo of the patient waiting in a hallway, or lying on a gurney?
John C. Parmigiani, president of John C. Parmigiani & Associates, LLC, says hospitals should post signs at the entrance to the ED or near ED examining rooms stating that picture taking is not permitted. That way, if a visitor ignores the rules, takes a picture and posts it online, the hospital can at least demonstrate that it was exercising reasonable measures to protect patient privacy. "To me, the posting prohibiting picture taking would represent another example/level of ‘due diligence' on the part of the hospital," Parmigiani says.
Kate Borten, CISSP, CISM, president of The Marblehead Group, says HIPAA expects healthcare providers to take "reasonable" measures to protect patient privacy, but also "accepts situations such as waiting rooms where patients can be seen by the public or a family member accompanying a patient to a bed in the ER. As long as the hospital wasn't doing something out of the norm, then it shouldn't have any liability when a member of the public snaps a picture."
HIPAA makes an "absolute distinction" between the hospital's workforce (a term defined in the regulations) and everybody else. "Organizations are responsible for the actions of their workforce, but not for the rest of the world," Borten says.
Given the frivolous or groundless nature of some lawsuits, it's understandable if hospitals and their employees are skittish about patient privacy violations. In the case of the shark attack victim at Martin Memorial, they should be skittish. They screwed up. However, if you exercise common sense and simply recognize that the person you're treating deserves the same respect and confidence that you'd want for yourself or your family, you shouldn't have anything to worry about.
Note: You can sign up to receive HealthLeaders Media HR, a free weekly e-newsletter that provides up-to-date information on effective HR strategies, recruitment and compensation, physician staffing, and ongoing organizational development.
Atlanta-based Grady Memorial Hospital, on the verge of financial collapse about two years ago, has reached financial stability and improved patient care, hospital officials said. Two years ago, the hospital owed medical supply companies $40 million, owed Emory and Morehouse medical schools $60 million, and the Joint Commission had just inspected the hospital for medical care and issued a critical report that endangered its accreditation. Now, hospital officials tell the Atlanta Journal-Constitution that a turnaround has occurred.
Malpractice payments in 2009 were the lowest in inflation-adjusted dollars since 1992, according to Public Citizen, a liberal watchdog group.
The organization says its findings are consistent with a National Practitioner Data Bank update this week that showed fewer malpractice payments were made on behalf of doctors in 2009 than any year since 1990, when the data bank was created.
Public Citizen said the data contradict claims that malpractice litigation is to blame for rising healthcare costs, and that changing the liability system to the detriment of patients will not curb healthcare costs.
"Litigation accounts for a miniscule fraction of health costs, small enough to be a rounding error," said David Arkush, director of Public Citizen's Congress Watch division, in a media release. "It's ridiculous that certain members of Congress continue to obsess about this greatly exaggerated problem. They should know better, and they should focus instead on fixing real problems like the crisis of preventable medical errors."
AMA President J. James Rohack, MD, however, disputed the findings, and said Wednesday that Public Citizen "continues to rely on a flawed database as the source of its information."
"While [Public Citizen continues] to oppose improvements to our broken liability system, the AMA is focused on efforts to make it work better for patients and physicians," Rohack said.
"There are proven reforms working in California and Texas that keep doctors caring for patients and preserve patients' day in court. Today, President Obama included alternative medical liability reforms in his health system reform proposal because there is broad recognition that liability reform is needed to curb the growth in healthcare costs."
In a letter to congressional leadership this week, President Obama—under fire from the GOP for not better addressing tort reform in current healthcare legislation—called for funding alternative demonstration projects, such as health courts, for resolving medical malpractice disputes.
Public Citizen said the health courts would cost several times as much as the status quo, if administered fairly, and that the only way to save money would be to impose "draconian" compensation caps.
Public Citizen added that 2009 was the fifth straight year the number of malpractice payments has fallen and the sixth straight year in which the value of payments has fallen. In contrast, US healthcare costs have increased every year since 1965. Between 2000 and 2009, healthcare spending rose 83% while medical malpractice payments fell 8%—with both figures in unadjusted dollars. A total of 10,772 payments were made on behalf of doctors in 2009, totaling $3.5 billion. That figure equals .14% of the estimated $2.5 trillion that CMS estimated was spent on US healthcare in 2009, Public Citizen said.
The advocacy group added that numerous studies have found that injuries and deaths caused by medical errors dwarf the number of actual malpractice payments.
The healthcare sector created 12,000 new jobs in February, even as overall employment from all business sectors saw 36,000 jobs lost, according to Bureau of Labor Statistics preliminary data released this morning.
The national jobless rate remained steady at 9.7%.
Ambulatory services accounted for 6,700 payroll additions in February, and hospitals accounted for 1,300 new payroll additions. Nursing and residential care facilities reported 4,000 payroll additions in February, after reporting 4,900 reductions in January. Physicians' offices reported 900 payroll additions in February, after reporting 5,800 payroll additions in January.
The healthcare sector has been one of the few areas of job growth during the recession, and created 228,100 new jobs in 2009.
The BLS information from the last two months is considered preliminary and may be revised.
