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EXCHANGE

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Real Issues : Real Solutions

APR/MAY 2010

KAISER PERMANENTE Key to the future HEALTHCARE EXECUTIVE EXCHANGE MAGAZINE | www.hcemag.com

Real Issues : Real Solutions

CONTENTS

04 Kaiser Permanente

In-focus stories 08 Hospital Physician Partners 11 OakBend Medical Center 14 Adventist Health System 18 Sisters of Charity Health System 22 Visiting Nurse Association of Ohio 25 West Jefferson Medical Center 28 Garden City Hospital 33 Takoma Regional Hospital 38 St. Maryâ&#x20AC;&#x2122;s Medical Center 43 Iraan General Hospital 46

Yakima Valley Farm Workers Clinic

52 Global Surgical Partners, Inc 55 Bay Regional Medical Center

Insight features 36 SHEILA D. WALCOFF AND PAUL W. RADENSKY M.D., MCDERMOTT WILL & EMERY, LLP Health Care Reform: Comparative Effectiveness Research

HCE EXCHANGE

APR/MAY

2010

Kaiser Permanente The roots of Kaiser Permanente date back to the depression era when a pre-payment system for hospital services was developed for workers on the aqueduct project in the Mojave Desert, California. Today the organization is a care delivery and care financing entity covering about 8.6 million people. The group operates hundreds of care sites and employees more than 160,000 people. “We look at the situation very much like a country looks at healthcare because we are both financing and delivering care. Most of our competitors either deliver care or sell insurance. We do both,” says George C. Halvorson, Chairman and CEO, Kaiser Permanente.

More Than Putting Medical Information into a Computer

Kaiser Permanente has developed their IT system with information flow in mind. First they looked at details such as where should the information be stored, who should have access to it, and what should that access look like. The next step in the process of building an efficient IT system was to look at how the data should be sorted for optimal benefit. “We have the computer

Kaiser Permanente maintains the largest civilian

sorting through the database for the patients for a

medical records database in the world. “The paper

given physician so that we can give a physician advice

medical record is heavily flawed by the fact that each

and counsel about how to optimize things for their

piece of data is isolated by the paper,” says Halvorson.

patient population,” says Halvorson.

The problem with electronic medical records is

“The using process is a science and art form

that they often suffer from that same isolation.

and skill set all by itself, and that’s a process we’re

Connectivity is Kaiser Permanente’s key.

embarking on,” says Halvorson. “We’re extracting

“It’s a step that a lot of people who are looking for

the data from the computer and figuring how to use

electronic medical information skip,” Halvorson says.

it.” The organization has had programs where the

“They forget the ergonomics. They forget the fact that

death rate from heart disease has been cut more

if this information is not available in an easy to use

than 70 percent through optimal use of the data in the

way, it won’t be used. It’s like designing a GPS for your

computer and linking that data to the caregivers who

car and locating it in the trunk.”

are, in turn, linked to the patients.

HCE EXCHANGE MAGAZINE

Kaiser Permanente is expanding within its existing

Halvorson says universal coverage is the end goal

geographic locations. “We’re building another half

and it is only by covering everyone that we will begin

dozen hospitals and we’re building probably a couple

to see healthcare costs fall. “If the kids don’t have

dozen other care sites,” says Halvorson “The likelihood

the ability to use the care delivery system—if no

of us jumping into an entirely new area is less likely

one is reminding them what needs to be done and

just because it makes less logistical sense. There are

if no one is tracking what is or isn’t being done,

enough people living in proximity to where we are now

then the likelihood of care improvement shrinks

that those are more than adequate markets.”

immeasurably. We need kids covered so we can

Physicians at Kaiser Permanente are salaried. “If

provide better care for kids. Once we provide better

you look at the great care systems of America—the

care for kids, the cost of care for those kids will go

ones where the providers function as teams—most

down and that will make universal coverage more

of them have salary- based physicians. That’s a good

affordable,” he says.

model because it takes out of play the decision making

“We need care improvement in America. We spend

at the point-of-care that happens just to increase

twice as much per capita as any other country in the

caregiver revenue,” Halvorson says. He believes the

world and we still have 40 million people uninsured.

care support model and tool kit now in place at Kaiser

In many areas, we have care outcomes that aren’t as

Permanente will improve physician performance in

good as the outcomes in other countries. We need to

“fee for service” models, as well.

do better and we are only going to do better if we do that systematically.”

Technology as Key to Reduce System Costs “The best care costs less,” says Halvorson. “If you have half as many heart attacks, half as many asthma crisis … that’s better for the patients and costs less. The rest of health care is setting no goals and doing absolutely nothing in any systematic way in terms of preventive care.” Halvorson cites asthma as the number one growing condition for kids in America, a top cause of death, and a high expense to our healthcare system. He promotes use of the electronic database to reduce the number of asthma related health problems. “You need to identify every single kid with asthma. You need to have connectivity so that the data about those kids who have an asthma attack flows from the hospital back to the primary caregiver.” Through provider education, you can use the current database and create a process that creates

a more systematic diagnosis. Then you have to add

Growing Healthcare Coverage for All

by T.M. Simmons

the mechanisms to transport the data. The structural advantage of electronic medical records is minimal unless the connectivity issue is addressed. “You start creating the data flows between caregivers and you start creating the mechanisms because they have a purpose. Once they are in place for the first purpose, they can be multi-purposed and used for other functionality. Just connecting for the sake of connecting wouldn’t happen in any other industry in the world, but connecting for the sake of improving something happens all the time. So if we connect for the purpose of improving something [for instance, reduced asthma attacks in children] that gives us a connectivity template that we can extend to the next issue, the next problem, the next medical condition,” says Halvorson.

Kaiser Permanente’s Outlook HCE EXCHANGE MAGAZINE

Real Issues : Real Solutions

02 | Hospital Physician Partners

Operational Excellence Equals Local Presence The Clinical Operations team members and Medical

have previously provided for their communities. That’s part of the function of the entire healthcare system,” says Schillinger. “Our company spends essentially its entire capital

Directors who work with Hospital Physician Partners

budget in information technology. Unlike a hospital,

are not just there in an advisory capacity. They are

we have no physical plant to maintain. Our challenge

clinically active physicians working regular shifts in

is trying to integrate our technology with our clients

the hospitals they manage.

in order to allow for an orderly flow of data (medical

“So if we have someone who is a Regional Medical Director supervising operations at 10 or 15 hospitals, that physician is working, through the course of the

and otherwise).”

Performance Improvement

year, a number of shifts at each one of those hospitals so that he or she can be intimately familiar with

“We maintain a performance improvement depart-

the issues that need to be addressed in that client’s

ment which is staffed by an analytics team which is

operation,” says Schillinger.

continually mining data,” says Shillinger. “They are

“From a clinical standpoint, true management and operational excellence has to start from the ground

analyzing our departmental and physician metrics

floor and it has to start from a local presence,” he

and looking for patient outcomes that need further

says. “For the 2,000 plus physicians that work with

review.”

Hospital Physician Partners nationwide, our clinical

contract; goals and benchmarks are established

90% of those folks by first names.”

collaboratively by the client and Hospital Physician

Schillinger lists the shortage of qualified physicians as one of the company’s top challenges. A second challenge is the lack of uniformity in information technology across hospitals. “This necessitates a cus-

Hospital Physician Partners is a privately held company that provides Emergency Medicine and Hospitalist Medicine management. The company currently contracts through its various divisions with approximately 130 hospitals and healthcare organizations nationwide. Their team of more than 2,000 physicians and mid-level providers treat more than 2,000,000 patients per year. “We don’t necessarily look at ourselves as a contract management company, even though that’s the category we are in,” says Jeffrey Schillinger, Chief Executive Officer. “We really are a physician organization at the end of the day. Our focus is on improving the patient experience. The thing that differentiates us from our competitors is that we have a disproportionately high number of corporate or management clinicians who actively practice medicine at our client hospitals. We make physical contact with our client hospitals more often than many of our competitors. We are hands on, working at a clinical level to resolve issues that affect patient flow and the patient experience both in the emergency department and in the hospital from an in-patient perspective.”

Schillinger says that prior to the start of a new

operations team members probably know more than

Three Areas of Challenge

Hospital Physician Partners

reviewing charts and records from the hospitals,

tomized or individualized approach to each individual hospital or hospital system,” he says. “This adds layers of cost to the hospital system.”

Partners with an emphasis on individual physician performance as well as departmental performance. “We look at all aspects of criteria which determine Emergency Department performance; patient throughput, left without being seen, time to provider, length of stay, etc. This data is discussed with hospital administration in regular meetings and is also accessible through a dedicated performance dashboard customized for each hospital.”

“There are still hospitals out there that do not have the funds to develop the capability to join the information age electronically and get us information in that manner. They are still, probably to the shock of many people, photocopying records and mailing them to us for processing. That is a process that is a little antiquated at this point and I see it as one of our greater challenges.” Another challenge Shillinger sees his company addressing is the fact that rural and unaffiliated hospitals in this country are facing such huge financial difficulties, making it very difficult for them to provide localized healthcare services. “We have to negotiate contracts with these hospitals that they can actually afford without having to cut other services that they

HCE EXCHANGE MAGAZINE Real Issues : Real Solutions

03 | OakBend Medical Center

Hospital Physician Partners maintains an ongoing physician education program, providing both internal and external opportunities for performance training, specifically as it applies to patient satisfaction. “Patient satisfaction, of course, is the cornerstone in any

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Documentation and customer service training is also a key component of the company’s ongoing education program. “Our goal is to hire physicians who not only are dedicated to clinical excellence and a great patient experience, but understand the importance of accurate documentation. As with hospitals, individual performance results are shared with physicians as part of Hospital Physician Partners ongoing performance improvement program. That’s a staple of our process,” stated Schillinger.”

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hospital experience,” says Schillinger.

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The company experienced record growth in 2009 with the addition of 26 new contracts. “While our company continues to grow with operations in 23 states, we’re still small enough to be responsive and address the needs of our clients on a one-on-one basis,” says Schillinger. “We may not solve every problem, but we will address every problem, whether an external or internal issue,” says Schillinger. “Our ability to move quickly and efficiently and to influence change when

OakBend Medical Center

it matters is very powerful. The larger you grow as a company, the greater that challenge becomes. That’s something we’ve got to be able to hold on to, to keep setting us apart from the competition. We have to keep the ability to respond at a local level with real answers.”

The largest full service healthcare facility in Fort Bend County, Texas, opened its doors on January 15, 1950 as the Polly Ryon Memorial Hospital. It is now OakBend Medical Center, a two hospital system with a combined total of 250 beds and a full range of medical services.

by T.M. Simmons

“We have been in this community for almost 60 years and have watched our community grow from a population less than 100,000 to 530,000 residents,” says Joe Freudenberger, CEO. “We are one of the fastest growing counties in the United States—third largest, last I checked—and we have tremendous opportunities. We’ve seen a huge increase in the level of interest in Fort Bend County in the last ten years and have three competing acute care facilities in our area.” The hospital has 250 physicians on staff and 600 employees. They have approximately 2,000 emergency room visits and 550 to 600 admissions per month. The hospital provides a full range of specialty services, including cardiac, and is the only level III trauma center in the county. They also have a dedicated pediatric unit and level II nursery.

Real Issues : Real Solutions

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Directors at OakBend are involved in monthly exercises including discussions of literature on leadership concepts—training, counseling, hiring, firing, and getting feedback. “Every other month we integrate the entirety of our leadership team, including our managerial/charge nurse team—a 60 person group—and we go through concepts that are applicable at all levels,” Freudenberger says. “The managerial/charge nurse teams are the ones dealing with the staff most on the floor. If they are integrated into the process and they are using the tools that we’re developing for ourselves in terms of leadership skills, then we are going to accomplish our goals.” “Sometimes [improvements] are prompted by an issue that has arisen, but other times it’s an opportunity, an idea of how can we do better,” Freudenberger says. “How can we generate a better turn around time or how can we bring in more business and what will it take. The staff often knows better than anybody else.

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Visibility, accessibility, and openness to new ideas are

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keys to the process.”

Connecting Senior Management and Staff

Capital Direction “If you are approved by all those people, then you will be interviewed by the chief nursing officer,” says

As a smaller hospital, Freudenberger believes his

Freudenberger. “We are very careful that we get the

organization benefits from enhanced connection

right person and we spend a lot of time training our

between management and staff members. “I advocate

directors and our staff on how to interview effectively.”

loudly and frequently that our management team

When a new hire doesn’t work out, they dedicate

As is typical in healthcare, capital dollars at OakBend are being funneled toward IT improvements that will result in electronic medical records, bar code medication administration, and online documentation throughout the facilities. They also have a major campaign underway to

be available to talk with staff. Our employees have

time to analyzing the indicators that caused them to

great ideas, but if we are never on the floor listening

hire the person so that they do a better job the

to their ideas, soliciting their ideas, allowing them to

next time.

joint venture arrangement with a group of orthopedic

Developing Leaders

the community. “We need to be a fairly comprehensive

IThe second component of OakBend’s employee re-

us and sees that we can’t treat what is a normal con-

be comfortable sharing their ideas with us, then we’ll never farm those ideas and never realize the benefits of those ideas,” he says. Hiring begins with interviews at multiple levels of the organization. A potential employee does not get

tention program is about leadership. It’s not enough to

in to see the nursing director until he or she has been

make the best nurse a manager. “We strive to actively

vetted by those who will be co-workers. A nurse can-

develop leaders,” Freudenberger says. “We provide

didate will be interviewed, for instance, by a nurse’s

settings and situations and training that are directly

aide, a department secretary, an LPN, and a fellow

related to the leadership skills development that

nurse, as well as the director of the department for

we need.”

build a heart hospital within the hospital, as well as a surgeons to develop an orthopedic surgery center in operation,” Freudenberger says. “If a patient looks at dition, like cancer or cardiac, they aren’t going to want

Serving the Community The founders of the original hospital were focused on the needs of the community, and today’s OakBend continues to approach hiring and operations with community service in mind. In short, “if you are not capable of bringing the very best to the table every day then you don’t belong here,” says Freudenberger. “We don’t have the latitude to have a bad day here, because a patient’s life is always in your hands.” by T.M. Simmons

to come to us for an orthopedic injury, for instance.” The next program the hospital is looking to fully develop is neurosurgery. They already have a neurosurgeon on board and look for this program to complement existing programs.

which the candidate is being considered.

HCE EXCHANGE MAGAZINE Real Issues : Real Solutions

04 | Adventist Health System

Advancing Operations at the Point of Delivery

These efforts have helped them buck the financial trends in hospital operations. “Our balance sheet has actually strengthened significantly over the last

“I spend personally about 100 man hours per year

couple of years, which is unusual, and I think that’s

sitting face-to-face across the table with my CEOs,

because of the systems we have built,” says Jernigan.

discussing every aspect of the operation from the back

Within two years, every facility in the Adventist

office and the finances to the patient care and patient

Health System will be clinically automated. “We have

experience. I spend an intense amount of time,”

spent millions of dollars building in evidence based

says Jernigan.

medicine into the order suites so that the physicians

At this size, many healthcare systems become

have it at their disposal,” says Jernigan. “This doesn’t

mere holding companies, but Adventist continues to

mean they can’t opt out, but they have all of that disci-

focus on improving operations for all of their hos-

pline, all of that science, right at their fingertips.”

pitals. Thirty-five years in business means that the

“But we really put the focus on the local community,

organization has standardized a number of processes

the local hospital CEO, because frankly, the individual

that are directly tailored to and benefit the hospitals in

patient that walks into a hospital in Georgia only cares

their system. They’ve spent the years building a very

about what happens in Georgia. The system is only

good, automated supply chain system and a strong

good as its strength in Georgia. What happens in a

risk management program.

corporate office isn’t really the most important thing,”

Adventist Health System The Seventh Day Adventists founded Adventist Health System in 1973 to support their growing number of healthcare organizations. The group is now one of the largest not-for-profit systems in the United States, supporting 37 hospitals, 17 long-term care centers and 21 home health agencies in 12 states. The system employs a total of 50,000 individuals. “We estimate, through one form or another, that we take care of approximately 4 million people per year,” says Donald Jernigan, President and CEO. Jernigan has been with the system for the expanse of his 28-year healthcare career. He became the CEO three years ago. “We are a faith-based organization, honed and sponsored by the Seventh Day Adventist Church. Our stated mission is to extend the healing ministry of Christ and we work very hard in cultivating what we see as the Christian values into our culture, our organization,” Jernigan says. “We put a higher priority on the actual patient care process itself, but that’s what we view as unique, our ownership and our sponsorship.”

HCE EXCHANGE MAGAZINE Real Issues : Real Solutions

says Jernigan. “A system shouldn’t exist unless it makes a local hospital a lot stronger than it would be without the system.”

Preparing for the Healthcare World of Tomorrow In the last decade, Adventist has put many of its capital dollars toward increasing the bed capacity at its hospitals. They’ve seen a strong growth in admissions in the last year which Jernigan attributes, at least in part, to capacity. “We try to stay on the cutting edge of technology, as well,” he says. “In the central Florida market we are a leader in robotics surgery and in non-invasive surgery. We’ve spent the money on technology to get to that place in leadership.” Jernigan believes that clinical automation and having easy access to evidence based medicine is going to be crucial to tomorrow’s services. “You can use technology to produce a safer system of care, a more efficient system of care, that utilizes fewer and fewer resources,” he says.

His focus is on eliminating unnecessary admissions and working on programs that bundle care. Hospitalists programs are ideal, he says, and Adventist is working to make sure hospitalist programs in each hospital are being used to maximize benefit. “We have to make sure the relationship between the community care physician and the hospitalist doing the in-patient care, or the intensivist doing the inpatient care, is really optimized so that you eliminate waste and the inappropriate use of specialists. We believe that is the world [of healthcare] that’s coming. You must have aligned physicians and automation.” “If we’re going to have our national economy in order, we have to have a better health care system,” says Jernigan. “Our goal is to be a leader in that.” by T.M. Simmons

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“You can use technology to produce a safer system of care, a more efficient system of care, that utilizes fewer and fewer resources.”

HCE EXCHANGE MAGAZINE Real Issues : Real Solutions

05 | Sisters of Charity Health System

DEFINING CATHOLIC HEALTHCARE The five hospitals of the Sisters of Charity Health System are located in Canton and Cleveland, Ohio, and in Columbia, South Carolina. These hospitals carry forward the healing ministry of Jesus to serve the many needs of the community. Those community needs are not just material, but also can be spiritual or physical in nature, says Sister Karam. In many ways, Catholic healthcare is countercultural to the market-driven healthcare model, balancing the need to improve and increase access to those who are underserved or who cannot pay in a time of diminished reimbursement. “It is mandated that we operate this mission-driven ministry using sound business acumen. On the other hand, we have an ideal opportunity to serve God’s people at a precious moment in their lives,” she says. Healthcare and the delivery of that care are everchanging. And yet the Sisters of Charity Health System is committed to delivering the best quality of care, regardless of a person’s ability to pay. “This year is pretty challenging. We are facing everything from decreased reimbursement to a state hospital franchise fee in Ohio as the state works to

Sisters of Charity Health System

Catholic healthcare has strong roots in Northeast Ohio. The Sisters of Charity Health System can trace those roots back to 1851 when four Sisters of Charity of St. Augustine arrived in Cleveland, Ohio, from France to become the city’s first public health nurses. Established in 1982, the Sisters of Charity Health System now operates five acute-care hospitals with a total of 1,480 licensed beds. The organization also has three residential care facilities, three community physician practices, and three grant-making foundations. Other ministries include transitional housing for homeless men, a fatherhood initiative, early childhood program and a statewide program that provides medical care, psychological care, and glasses to children who would not quality for state support, but their families do not have enough resources to have access to healthcare.

“I really believe there is a strong need for Catholic healthcare in the United States,” says Sister Judith Ann Karam, CSA, President and CEO of the health system since 1998. “I think the complexity of the healthcare environment today, requires that we have an excellent team that is the best as far as running the business, and that we run the business in a framework of service to the people. If we do not have that service to people aspect of it, there’s no need for the Sisters of Charity Health System to be in the business.” As a nearly billion-dollar enterprise, the Sisters of Charity Health System follows the Catholic social teaching model in all of its organizations. “Catholic social teaching helps us understand our priorities. We are operating multi-million dollar businesses, but at the same time we are operating a ministry and a mission, so we have a matrix that we use as we’re making decisions. It might be a compelling business decision that we’re making, but we want to make sure that we pause and reflect on what it means to our mission and who we are,” says Sister Karam.

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balance its budget. Many of our communities are

a mission,” says Karam. “To that end, each of our

response to the demands of managed care and to rap-

really seeing the effects of the down economy. Any

hospitals has a strategic plan in place that focuses

idly improve hospital information technology systems.

one of those areas alone can impact our bottom line,

on top-line revenue growth. Our newly established

Early efforts made growth difficult. But that initial

especially when individuals question whether or not

project management office has developed tools for

joint venture did result in some positives. “It brought

to have an elective procedure. The charge at all of our

tracking the tactics that are going to ensure our goals

us our foundations that are doing a lot of wonderful

hospitals is to get the word out to our patients and our

and objectives are met in real-time. Because we are

work and are really trying to impact the lives of the

communities that we are devoted to providing care

tracking so closely, we are in a position to discover the

materially poor,” says Karam.

that combines the best in clinical excellence and hu-

obstacles and adjust based on the data.”

man compassion.”

BUILDING A VISION FOR THE FUTURE “We are living in challenging times. The economy

Reduce sharps injuries

In 1999, the Sisters of Charity Health System cre-

“We also know we have to modernize our facili-

ated a joint venture with Cleveland-based University

ties,” says Sister Karam, who also serves as presi-

Hospitals. It provided a local alliance with a respon-

dent and CEO of St. Vincent Charity Medical Center in

sive community partner that enabled the two health

Cleveland. At that urban campus, the health system

system to leverage services in a manner that was

is looking to create all private rooms and enhance

beneficial to both.

access to its campus through improved parking. It

However, as the healthcare environment contin-

has forced us all to make hard decisions about our

recently renovated its medical and psychiatric emer-

ued to change and as the economic downturn required

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operations and our support of worthy initiatives,”

gency departments, cath lab and hyperbaric medicine

more nimble organizations in order to respond to the

Can’t be accessed when locked

says Sister Karam. “While we are doing our best to

center. Three buildings dating from the early 1900s

unique needs of each market, the Sisters of Char-

weather the economic storm, we also are on the cusp

are slated for demolition in May in order to make

ity Health System and University Hospitals made the

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room for close-in parking and, eventually, a new

decision to restructure their relationship. Under that

We have been working toward a vision of the future

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restructuring, which was completed on Dec. 31, 2009,

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that enables the Sisters of Charity Health System to

At Mercy Medical Center in Canton, plans are un-

better leverage its collective strength in the areas of

derway to expand the emergency department. “Busi-

ownership of Mercy Medical Center and St. Vincent

health care, social services, advocacy and elder care

ness is booming as far as our emergency

Charity Medical Center. It was already sole owner of

services.”

department in Canton is concerned, and it is not built

Providence and Providence Northeast.

the Sisters of Charity Health System returned to sole

To that end, the health system is making signifi-

for the volume that we are receiving,” says Karam.

cant investments at all of its hospitals. These strategic

“We’ve just collected bids on a new emergency de-

served by St. John Medical Center, both organizations

capital investments totaling more than $350 million

partment that is large enough to handle the patients

determined that it made sense to continue the 50:50

over the next five years are designed to improve facili-

in that community.”

joint venture, but with the exception of streamlin-

ties and strengthen key service lines. “Beyond these

At Providence Hospital and Providence Northeast

For the suburban market west of Cleveland

ing the decision-making process by giving University

strategic investments, our hospitals are maximizing

in Columbia, South Carolina, plans are underway

Hospitals responsibility for day-to-day management of

efficiencies by working together on a range of services

to modernize the downtown hospital by converting

the hospital. Strategic and capital plans of up to $100

such as information technology, supply chain, fund

to private rooms and modernizing surgery and the

million are also in the works for that campus.

development, business development, physician align-

emergency department. The suburban Northeast

ment and palliative care.”

facility has embarked on a major expansion to add 40

ership and management was how we could further

additional patient beds and four new operating rooms

our mission and improve the manner and speed in

to better meet the needs of the community.

which decisions can be made to best serve these indi-

In the past 12 months, the health system has added several key leaders in the areas of finance, business development, physician alignment, project management, IT, construction services and fund development to support these critical initiatives

Partnering for Better Service

“At the very core of the restructuring of our own-

vidual communities,” says Sister Karam. by T.M. Simmons

designed to strengthen and grow Catholic healthcare in the communities it serves.

The organization has done some experimenting

“One of the primary areas of Catholic social teach-

with joint ventures in the past. Those joint ventures

ing is to care for the poor and increase access to care.

and strategic alliances, which were so prevalent in

But we also know that without dollars, we don’t have

the 1990s, provided opportunities that reflected a

HCE EXCHANGE MAGAZINE Real Issues : Real Solutions

06 | Visiting Nurse Association of Ohio

Referral Network

technology will help the VNA work more closely with

Networking with local healthcare facilities has gone a

neighboring healthcare providers.

long way toward helping the VNA provide services as well as receive patient referrals. “It has only been in the last five years that we have

Competition According to Zangerle, competition for patients in the

actually had competition for our business,” Zangerle

Cleveland healthcare arena is significant, particularly

said. “So, we’re working on building relationships with

from corporate-based for-profit entities with deep

our referral sources.”

pockets that are headquartered outside the state but

Part of that effort to create better relationships

Who’s caring for your needs?

operate branch offices in the area. Other competi-

with referring parties includes enhancing the VNA’s

tion comes from organizations that provide only one

information technology. Staying current with the latest

service, such as home healthcare or hospice.

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The future of medicine could be as close as home, no matter where home may be. At least that’s what Claire M. Zangerle, MSN, MBA, RN, President and CEO of VNA of Ohio believes. She sees home healthcare as an unrecognized growing part of what lies ahead for the medical profession.

Toll-Free: 1-866-970-7500 www.hospiscript.com

“If caregivers on the acute care side were more in tune with how home care is a benefit to their patients, they would see less re-hospitalizations, greater patient self-management and a reduction in overall healthcare costs,” she said. Formerly the Chief Nursing Officer at the Cleveland Clinic, Zangerle has been at VNA since July, 2008. In making the switch from acute to post-acute care, she saw this as an opportunity to take a relevant business to the next level and be a part of the future of the healthcare industry across regions. “When people think of us the VNA, they think all we provide is care to the inner-city residents,” she said. “However, we are not unilaterally focused – we care for the insured, the under insured and the uninsured, whether they live in the inner city or the suburbs. We don’t turn anybody away.” The more than 100-year-old VNA of Ohio, the largest home healthcare agency in the greater Cleveland area, is based in the city but serves 19 surrounding counties. The VNA offers services including home healthcare, rehab, mental health care, in-home hospice and a 14-bed hospice unit. The organization also operates a private duty entity called Home Assist™ as well as a visiting physician program – HouseCalls. One of the VNA’s biggest secrets its staff of 32 mental health nurses. Zangerle said VNA of Ohio is the only home healthcare company that has a mental health staff that large. Overall, the VNA handles about 14,000 admissions per year with close to 800 employees, recording an estimated $1.5 million in uncompensated care on a $55 million budget.

“You would think that being a full-service provider

us in the future in both saving healthcare dollars and

would differentiate us but it seems like consum-

delivering better care to the patient.”

ers are picking and choosing the services they want

Still more competition comes from small health-

from different companies,” she said. “That means

care companies that simply hang out a shingle and

you need to coordinate your care.”

begin offering services, without accreditation and

An emerging area of competition for home

certified nursing. Zangerle works to differentiate the

healthcare providers comes from traditional acute

VNA from these types of organizations by stressing

care facilities. In an effort to ensure that their pa-

the importance of using healthcare providers that do

tients don’t make return trips to emergency rooms

things like meet regulatory requirements and perform

and doctors’ offices, hospitals are establishing their

security checks on employees.

own home healthcare entities. However, Zangerle doesn’t think that’s necessarily the most effective

Management Strategies

use of hospital resources.

Based on her experience at the Cleveland Clinic,

“Hospitals are not in the business of post-acute

Zangerle’s management goal is to lead the VNA of

care,” she said. “So, having them stay in the busi-

Ohio in the journey toward the American Nurses

ness of acute care and partnering with somebody

Credentialing Center’s MAGNET designation. This

who is well versed in and has a process established

designation will not only attract excellent employees,

already for post-acute care is what’s going to help

but increase patient referrals as well.

HCE EXCHANGE MAGAZINE Real Issues : Real Solutions

07 | West Jefferson Medical Center

“I believe that every organization that has nurses

Clinical staff development has been enhanced as well

should be MAGNET designated because it is cer-

within the quality department. Training is another

tainly a demonstration of nursing excellence, not

area of focus, with a goal to have all home health

just clinically but as a process and collaboration,”

aides become state-tested nursing assistants and for

she said.

certification for med-surg nurses. There is already

In the VNA’s move toward a MAGNET journey, one of things the CEO needs to accomplish is to teach the workforce about shared governance. It’s

a requirement for the behavioral health and hospice nurses to be certified. “Currently, anyone can come off the street to any

not just about complying with the guidelines, but

home health agency and go straight from a fst food

it’s a choice the organization makes to demonstrate

restaurant to caring for somebody in their home,”

excellent nursing practices.

Zangerle said. “To me, that just doesn’t work.”

“We don’t just have nurses here, so we have to have everyone buy in,” she said. “It’s not just nursing

Capital Expenditures

practices but it’s a whole collaboration.”

The VNA has taken its community service to the

Part of the transition to a MAGNET program in-

streets, participating in the revitalization of the

volves changing the company’s organizational struc-

neighborhood in which the organization’s corporate

ture. Zangerle describes the now evolving structure

headquarters is located. Funds have been designated

at the VNA as “old-school” with the CEO calling all

for street improvements and other exterior renova-

the shots from the top.

tions in the VNA’s inner-city neighborhood.

“I’m trying to turn that upside down,” she said. “I

“We’re part of the revitalization efforts in collabo-

don’t know what’s going on in the field all the time,

ration with others in our neighborhood – a hospital,

so I want the people who are doing the work in the

a community college, a university and other local

field and the people who are supporting them to be

businesses to see how we can all work together to

the decision makers.”

make this a destination where people want to work,” she said.

Human Resource Challenges

West Jefferson Medical Center

By Kathy Knaub-Hardy

The biggest challenge Zangerle faces is learning the logistics of working with a unionized registered nurse workforce. “It takes an incredible amount of energy and time to make sure that I’m meeting the expectations of their contract,” she said.

On August 29, 2005, Hurricane Katrina immeasurably changed not only the landscape of New Orleans, La., but the lives of the city’s residents. To assist in recovery efforts, communities from around the country came to the aid of Louisiana’s largest city, offering housing to evacuated residents and eventually sending carpenters and other helping hands to help rebuild the city.

To ensure progressive staff development, human resources hired an individual to execute a program.

“It’s not just nursing practices but it’s a whole collaboration.”

Filling the void left with the closing of several medical facilities is neighboring West Jefferson Medical Center, located in Marrero, La., just across the Mississippi River from New Orleans in Jefferson Parish. West Jefferson, a 451-bed non-profit, full-service medical facility, was not affected by the flooding after Katrina. “There have been some difficult times in New Orleans since Katrina and as such, we have become a bigger factor in the community’s health care,” said Alfred Abaunza, M.D., chief medical officer of West Jefferson. “The community hospital that was serving many of the indigent no longer exists and the VA hospital is no longer functioning. So, we had to ramp up our services during difficult financial times.” West Jefferson, founded in 1956, offers a full spectrum of services, including emergency services, an aeromedical helicopter flight program, heart and vascular care, neuroscience, orthopedics, radiation therapy and a cancer program. In addition to his role as chief medical officer, Abaunza also serves as the medical center’s compliance officer.

Real Issues : Real Solutions

Congratulations Alfred Abaunza! Since 2005, SCI has provided service excellence in minimally invasive services and products to West Jefferson’s operating rooms.

were being trained were destroyed by Katrina. That

ferson recently added one program from the Ameri-

left no hospitals in New Orleans where they could

can College of Surgeons (ACS) to review general

train. Now we have residents from both medical

surgery, as well as a program called Crimson, from

schools training here.”

The Advisory Board Company, to conduct quality

New Leadership West Jefferson has undergone internal changes, the biggest of which was the welcoming of a new CEO, Nancy R. Cassagne. According to Abaunza, the new CEO has changed the culture of the entire executive group, establishing a vision using persuasive skills to

Service, Savings, Satisfying Results

get everyone to follow her in that direction. “We have much more teamwork and cooperation,” he said. “We all have a clear understanding of what we’re trying to do.” Abaunza said that her intention was to improve the quality of care at West Jefferson and to make sure all services are provided cost-effectively. Decreasing costs and improving the quality of care “has been a

CONTACT: craig@scisurgical.com

dramatic change for all of us,” he said. “The interaction between the staff management and physicians is much more open now, with more transparent transactions,” he said. “With open communication, there’s a lot more cooperation.”

Congratulations Alfred Abaunza! Since 2005, SCI has provided service excellence in minimally invasive services and products to West Jefferson’s operating rooms.

Evolving Roles In the 10 years since Abaunza came to West Jeffer-

Service, Savings, Satisfying Results

son, the chief medical officer’s role has evolved from

Contact: craig@scisurgical.com

one where he focused on the medical staff and direct medical staff activities to accepting line responsibilities such as the hospital’s pharmacy. He believes this

Physician Directed

is a natural assumption of responsibility.

In addition to filling a void among medical providers,

role, just to control both the supply of drugs com-

West Jefferson saw that area medical schools were

ing into the hospital and the utilization of the drugs

in need of places for their residents to practice. In

ordered by the physicians,” he said.

“It helps to have a physician in that management

studies on the medical staff as a whole. Crimson is a physician management data analysis platform that generates detailed physician profiles that encompass quality performances, adherence to pre-defined order sets and resource utilization. “We intend to collect more data, analyze it, and then give feedback to the physicians and improve the quality of care with delivery,” he said. When it comes to measuring performance, West Jefferson has used consultants in the past. However, Abaunza said it’s easier for them to cooperate with organizations like the ACS than to create their own performance product. “If we conduct our performance review with the

ing very difficult to find physicians who are willing

our data gives us the ability to benchmark against

to take more Medicaid patients and we recognize

other hospitals doing the exact same thing,” he said.

that the charity system in this town is not going to be

Capital Expenditures Looking at IT equipment, West Jefferson recently added a new Varian Medical Systems RapidArc™ linear accelerator for its radiation therapy department. The medical center also has the only CyberKnife in the area. In addition, they’re working toward a conversion of emergency room charting from paper to electronic, as well as a CPOE, so that physicians can electronically enter patients’ orders. McKesson Corp. handles the majority of the medical center’s IT

Health Care Challenges On a national level, Abaunza expressed concerns

Also, chief medical officers are branching out

about what’s going to happen with heath care fund-

Louisiana State University (LSU) and Tulane, and

ing. Locally, decreases in Medicaid reimbursement

now residents from those two institutions train at

contracting, handling joint ventures with the medical

are hitting the community hard.

West Jefferson. In addition, those residents are help-

staff and managing a number of physician agreements

“Many physicians do not want to accept the

ing to re-populate the center’s medical staff.

that traditionally have not been part of the chief medi-

Medicaid-level of payment and reducing it further is

cal officer’s role.

going to reduce the number of physicians who are

“We reached this point through cooperation among all the hospitals,” Abaunza said. “We recognize that the major facilities where the residents

functional for a long period. Finding physicians who can treat these patients is a constant challenge.” Managing day-to-day challenges is nothing new to a medical center that serves a community still recovering from one of the nation’s largest natural disasters. With new leadership and constant monitoring of physician and nursing performance, Abaunza sees West Jefferson continuing to move in a direction that is beneficial for both the medical center and the community. By Kathy Knaub-Hardy

needs, Abaunza said.

more from just medical staff activities to medical staff

the days following Katrina, Abaunza reached out to

willing to treat those patients,” he said. “It’s becom-

American College of Surgeons and submit our data,

“We all have a clear understanding of what we’re trying to do.”

One of Abaunza’s more traditional responsibilities involves overseeing quality control efforts. West Jef-

HCE EXCHANGE MAGAZINE Real Issues : Real Solutions

08 | Garden City Hospital

patient satisfaction are at the top of Garden City’s agenda

Efficiency in Operation Length of stay, clinical quality, patient safety, and patient satisfaction are at the top of Garden City’s agenda. “We are very committed to making sure the patient experience is excellent,” says Moorman. The hospital has tracked hundreds of issues related to patient safety in the past year and a half, for instance, and the majority of these issues have been resolved. “Some of them take time and capital dollars,” says Moorman. “We try to stay very sensitive and fix the small things quickly. We are making an impact. We’ve completed an annual culture of safety survey of our employee group and have seen, year over year, improvements.” The hospital has recently developed a Board level quality committee, which includes Board and physician members and the elected chief of the medical staff. They participate with the Leapfrog Group for patient safety, as well as the Michigan Health and Hospital Association’s Keystone Program, which has been on the forefront of addressing quality initiatives for a number of years now. “There’s been a statewide Keystone initiative

Garden City Hospital

related to intensive care unit standardization for caring for patients and decreasing complications. We’ve been very active in that process,” says Moorman. “We also have a central line infection

The community hospital of Garden City, Michigan can trace its origins to 1947 and the current facility opened its doors in 1960. It is a 323-bed hospital with about 375 physicians on staff. Services offered run the full spectrum of care, and include an inpatient/outpatient surgery center, hyperbaric wound care services, and a rehabilitation unit.

prevention process improvement program in which

“We are an independent hospital, not part of a large system,” says Dr. Gary L. Moorman, Vice President and Chief Medical Officer of Garden City Hospital. “We have a friendly culture at the administrative level and at the service level, and I think we do a great job, overall, with patient care and patient safety.”

project, and a project related to emergency

we’ve been participating with excellent outcomes.” Three new Keystone projects include a surgical care improvement project designed to standardize and double check all information prior to a patient undergoing surgery, an obstetrics improvement department care.

The hospital has been recognized several times as one of the best places to work in the Detroit area. It is ranked as a top-100 teaching hospital, nationwide, for hospitals with more than 200 acute care beds. HCE EXCHANGE MAGAZINE

Capital Dollars Spending for a Small Hospital $PHULFDQ %DURPHGLFDO &RUSRUDWLRQ LV D QDWLRQDO ZRXQG

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upkeep and renovation, include an inpatient/

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for implementing electronic medical records so

replaced, as well. They are working on the process

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take up a significant portion of capital spending in

Moorman looks for the health records upgrades to

coming years.

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he doesn’t imagine they are any better or worse off

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than their competition. “It’s been a general challenge

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with our human resources department, have put

On the human resources side, Moorman says

in that area. Our nursing leadership, in conjunction

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nal programs that have helped to decrease outside

helped us,” he says. “We have created some inter-

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HCE EXCHANGE MAGAZINE

09 | Takoma Regional Hospital

down a fair amount, which continues to create staffing

efficient and actually improve, ultimately, the care that

issues, but we are certainly trying to manage those on

patients get, and make it safer while maintaining and

a proactive basis.”

improving the quality of care that each

Opportunity for the Healthcare of Tomorrow “I think that in healthcare today—especially in southeast Michigan—there are challenges. We, as an organization, are up to facing those challenges and we have an opportunity to make significant changes in a number of processes as we go through the implementation of an electronic medical record,” says Moorman. “We have the opportunity, as well as the

patient receives.”

Takoma Regional Hospital

by T.M. Simmons

One of Tennessee’s top-rated hospitals for patient safety got its start as a sanitarium in 1928. According to the most recent Leapfrog Report, Takoma Regional Hospital joins Vanderbilt and Children’s Hospital at Vanderbilt as only three hospitals in Tennessee to achieve the highest possible patient safety ratings in three areas including “Prevent Medication Errors.”

challenge, as we continue to adopt and implement information technology systems into the hospital to closely examine the work flow and process.” “I believe that we have efficiencies to gain using some of this technology and it will require a lot of time, effort and innovative ideas. It will make us more

Real Issues : Real Solutions

The 100-bed hospital serves Greeneville and Greene County in the foothills of the Appalachian Mountains. The hospital is a partnership between Wellmont Health System, the premier healthcare provider in the Tri-State region of northeast Tennessee, southwest Virginia and southeast Kentucky and Adventist Health System, its managing partner. The staff includes 120 physicians and 450 nurses, technicians, and support staff members.

“We really look for associates that share our goals,understand our mission and realize that we must work together to excel in patient care. “ Better Healthcare through Teamwork

Advantages to Being a Part of a Big System

ciated with either joint venture partner to implement

At the very core of the team is the Takoma Regional

Takoma Regional is a joint venture between two large

Computerized Physician Order Entry (CPOE).

medical staff. “We want to ensure that our physicians

health systems. Adventist manages the hospital. “Cer-

succeed as the hospital succeeds,” Wolcott said. “We

tainly, the strength that Adventist brings to the table

Wolcott said. “A change of this magnitude is never

are continually looking at ways to enhance the physi-

is the depth of understanding in healthcare and the

easy, but at this point most of our providers and asso-

cian practice.”

technology and expertise surrounding purchasing and

Embracing Technology

Clinical Pharmacy Services Inc. has dispensed radiopharmaceuticals for nuclear medicine departments in East Tennessee and Southwest Virginia for twenty years. We are dedicated to providing the region with cutting edge technology and excellent service.

Takoma Regional Hospital was the first hospital asso-

“We have certainly had our share of challenges,”

ciates are fully on board.” Indeed, Takoma is realizing the benefits of being an early adopter.

“Healthcare is a very person dependent, individual dependent industry. It’s important that each associ-

productivity,” says Wolcott. “What Wellmont Health System brings to the table

One benefit has been in the area of diabetes man-

ate, each medical staff member, each volunteer, each

is name recognition in our local community. It gives

agement. “We’re able to better control blood glucose

board member—have a stake in our organization and

us a sense of being a part of something bigger than

levels, for instance,” says Wolcott. “The credit here

understands where we’re headed. We really look for

one little hospital in one little town in one little corner

goes to our hospitalists, nurses and pharmacists as

associates that share our goals, understand our mis-

of Tennessee. Wellmont brings a tremendous amount

they utilize enhancements in the computer system

sion and realize that we must work together to excel

to the table in terms of local power and leverage, our

to monitor and manage blood glucose more closely,

in patient care. Teamwork, compassion

ability to negotiate managed care contracts, and our

enabling our patients to get better faster.”

and their Christian mission are the focus of an exten-

ability to work together with our medical staff to cre-

sive orientation.

ate a continuity of care for our patients.”

CPOE has also helped reduce delays in treatment and provides decision support to the physician directly

Takoma’s goal of being the best place to work,

“We’re proud to be able to serve this community,”

at the point of care. This means that physicians are

practice medicine and receive care appears to have

says Wolcott. “We’re a not-for-profit hospital and we

able to cross-reference for drug interactions and

taken root as they have won their local newspaper’s

think our Christian mission provides us with an extra

potential drug allergies, giving them the opportunity to

People’s Choice award for Best Hospital, Best Place to

special level of compassion, expectation of care, and

alter their plan of care accordingly.

Work and Most Community Involved Business for two

quality that is important to our associates, our medi-

years running.

cal staff, and our community.”

Takoma Regional continues to maintain results that are well above the national Leapfrog Group stan-

by T.M. Simmons

dards for CPOE.

HCE EXCHANGE MAGAZINE Real Issues : Real Solutions

Insight features 1

HEALTH CARE REFORM: COMPARATIVE EFFECTIVENESS RESEARCH STAKEHOLDERS SHOULD UNDERSTAND AND MONITOR DEVELOPMENTS IN COMPARATIVE RESEARCH PRIORITIES, METHODOLOGIES AND COMMUNICATION OF RESEARCH FINDINGS. BY SHEILA D. WALCOFF AND PAUL W. RADENSKY M.D., MCDERMOTT WILL & EMERY, LLP The recently enacted Patient Protection and Affordable Care Act (PPACA) built on federal efforts to support and direct research comparing patient treatments. Drug manufacturers, diagnostics companies, medical device manufacturers and health services providers should carefully monitor and selectively engage in the formal and informal processes that will shape the development of the Patient Centered Outcomes Research Institute, conduct of research and communication of research findings. Background Section 6301 of the PPACA amends Title XI of the Social Security Act (42 USC 1301 et seq.) to add a new Part D on comparative clinical effectiveness research. Under the PPACA, comparative clinical effectiveness research means research that evaluates and compares the patient health outcomes and benefits of two or more medical treatments or services. Such treatment and services are defined broadly to include protocols for treatment, care management and delivery; procedures; diagnostic tools; medical devices; therapeutics;

and any other strategies used to treat, diagnose or prevent illness or injury. (See 42 U.S.C. 1181(a)(2)(A)-(B)). The PPACA establishes a new Patient Centered Outcomes Research Institute (PCORI) responsible for the identification, prioritization and execution of such comparative effectiveness research. The PCORI will be structured as a tax-exempt independent government corporation overseen by a board of governors that includes the directors of the Agency for Health Care Research and Quality (AHRQ) and the National Institutes of Health (NIH), plus 17 members appointed by the Comptroller General (U.S. Government Accountability Office). The PPACA requires three industry representatives on the board. The PCORI is responsible for setting national clinical comparative effectiveness research priorities and is directed to enter into contracts to manage the funding and conduct of research, with preference given to AHRQ and NIH. The PCORI will be responsible for establishing a standing research methodologies committee (comprising up to 15 members, each of whom is appointed by the Comptroller General) to develop standards for clinical comparative effectiveness, but the PCORI will conduct no research itself. Nevertheless, the PCORI is required to appoint advisory panels that are expert in carrying out randomized clinical trials under the PCORIâ&#x20AC;&#x2122;s research project agenda and to appoint an expert advisory panel for purposes of assisting in the design of research studies and in determining the value and feasibility of conducting research studies for rare diseases.

ABOUT THE AUTHOR Paul W. Radensky, M.D. and Sheila D. Walcoff are partners in the law firm of McDermott Will & Emery LLP. Dr. Radensky is a recognized authority on the full range of legal, regulatory and reimbursement issues pertaining to pharmaceutical, biotechnology, medical device, and clinical laboratory development and marketing. Ms. Walcoff focuses her practice on personalized medicine and other federal regulatory and science policy matters, counseling a broad range of clients on policy, government affairs advocacy, business strategy and communications. They can be reached at pradensky@ mwe.com or swalcoff@mwe.com.

Research will be funded by the newly established Patient Centered Outcomes Research Trust Fund (PCORTF), which shall receive appropriations from private insurance based taxes. However, this funding source is time limited, and any amounts remaining in the PCORTF after September 30, 2019, will no longer be available for research and must be transferred back to the general treasury. For purposes of developing the research agenda and supporting such research, the PCORI will have access to Medicare and Medicaid data. Within 90 days of receipt of findings or the completion of the research, the PCORI must publish research findings and any limitations, as well as what further research may be needed, in a manner useful to clinicians, patients and the general public in making health care decisions. Such findings may not include practice guidelines, coverage recommendations, or payment or policy recommendations. Importantly, there is no requirement that the findings communicated to the public be consistent with U.S. Food and Drug Administration approved labeling of regulated products. Federal payors are not prohibited from using research findings to inform payment, coverage and treatment decisions. However, comparative research findings alone may not be used to deny coverage. Congress already added significant funding and direction to federally sponsored comparative effectiveness research in 2009 when it appropriated $1.1 billion for comparative effectiveness research through AHRQ; NIH; and the U.S. Department of Health and Human Services, Office of the Secretary, under the American Recovery and Reinvestment Act (the Stimulus Act). The Stimulus Act created a Federal Coordinating Council for Comparative Clinical Effectiveness Research charged with comparative effectiveness research priority setting and development of strategies to support translation and dissemination of comparative effectiveness research findings. This Council was terminated upon enactment of the PPACA provisions establishing the PCORI. Implications for Personalized Medicine The PPACA specifies that research design should account for individual differences and sub-populations, but the ability to use and misuse data will remain ever present, since research findings will be greatly influenced by the methodological standards that will be developed under the auspices

of the PCORIâ&#x20AC;&#x2122;s Methodology Committee. Measures will be developed to assess quality through comparative effectiveness, but can also assess value, which will likely include an evaluation of comparative cost and patient compliance factors, such as treatment regimen and unpleasant or harmful side effects. It is important to assess how widely a study reporting results across a population/sub-population applies to individuals or smaller sub-populations with the larger studied population. Bending the Cost Curve Comparative effectiveness research findings have the potential to identify savings in the health system and improve patient outcomes, but the most effective treatments are not necessarily the least costly treatments. The development of a balanced agenda with appropriate methodological standards, as well as identifying the appropriate context to communicate effectively such findings to all stakeholders, including clinicians, patients and payors, will be essential to those overarching objectives. In addition, it is important for those reviewing or using comparative effectiveness data to understand what the clinical findings show separate from economic outcomes. These endpoints taken together help assess value, but economic endpoints should not blur or confuse the presentation of the comparative clinical outcomes. Implications for Stakeholders Given the broad implications of the establishment of the new PCORI and its role across the research enterprise, medical products industry and health delivery system, stakeholders should understand and monitor developments in comparative research priorities, methodologies and communication of research findings. Product manufacturers and service providers, particularly in areas where regulated products or services are targeted at specific subpopulations, should consider engaging proactively in the formal and informal processes that will shape the development of the PCORI and ongoing research.

10 | St. Mary Medical Center

The Team Approach to Care The hospital’s strong service record is producing the growth to support this claim. St. Mary Medical Center’s inpatient orthopedic program has seen 2530% growth in volume since the opening of its Joint Academy in 2008. This collaborative team approach to joint replacement surgery educates and supports patients through all stages of care and rehabilitation from pre- to post-operation. “Our patient satisfaction scores are consistently in a high 90th percentile for our orthopedic unit,” says, Ryba. This successful approach to patient care and education is now being utilized in the development of a Stroke Program at St. Mary Medical Center. One of the strengths to these programs is the use of patient care coordinators who help navigate patients through their hospitalization, care and recovery. “In both the Joint Academy and our Stroke Program, we have dedicated care coordinators, whose responsibilities are to assist our patients in navigating through their continuum of care. They become the point person for those patients and their families as well as our physicians,” says Ryba. “Our coordinators build a strong level of trust with our patients and families. Physicians appreciate it because they can trust the consistency of quality care and medical protocols for each patient. It is a valuable

St. Mary Medical Center

relationship that benefits everyone and helps patients and families move through an often complex system of health care.” “Another priority for St. Mary Medical Center is proactive participation in our geographic service

St. Mary Medical Center in northwest Indiana, is located about 30 miles southeast of Chicago. As one of three not-for-profit hospitals in the Community Healthcare System, the 190-bed facility has almost 500 physicians on staff, and operates seven outpatient locations in Hobart and neighboring communities. It has been ranked in the top 5% of hospitals, nation-wide, for four years in a row based on patient safety ratings. “Healthcare is personal,” says Chief Executive Officer of St. Mary Medical Center, Janice Ryba. “That’s the philosophy here at our facility and our entire healthcare system. We’re always asking staff to approach their work with their patient’s perspective in mind. Putting the patient’s experience first guides us in making the best healthcare decisions to assure positive patient outcomes.”

areas, identifying community needs and building programs that will meet those needs,” says Ryba. This past year the hospital opened a wound/ostomy/ continence center, added an off-site ambulatory surgery center and expanded their women’s wellness programs. An innovative approach to provide exceptional mammogram services has earned the hospital and Community Healthcare System accolades as the only system in northwest Indiana offering same-day

HCE EXCHANGE MAGAZINE

results. In addition, about 60% of patient biopsy re-

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sults are provided on the same day, as well. â&#x20AC;&#x153;For women who are worried about the possibility of having breast cancer, offering walk-in appointments and producing definitive results within 24 to 48 hours avoids a great deal of needless stress and anxiety,â&#x20AC;? says Ryba.

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Current Investments The hospital and healthcare system are currently embarking on a $40 million investment in an integrative electronic medical record system, EPIC, that will function cohesively across multiple hospital programs

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and departments, as well as physician offices. â&#x20AC;&#x153;These tools will enable us to implement a fully integrative approach to healthcare,â&#x20AC;? says Ryba. â&#x20AC;&#x153;It will help us manage our utilization, and delivery of healthcare, especially for patients who see multiple specialists for a variety of medical or chronic conditions.â&#x20AC;? In October of 2009, the hospital broke ground on a new emergency department expansion and

Superior Air-Ground Ambulance Services, Inc., a family owned and operated Emergency Medical Services provider, has proudly served St. Maryâ&#x20AC;&#x2122;s

Training Practitioners and Maintaining Staff

Medical Center for 10 years. Founded fifty years ago, Superior is the second largest privately-held

St. Mary Medical Center is involved in a number of

ambulance company in the country partnering our

programs with local universities as a training site for

highly qualified and progressively trained flight

nurses, as well as for numerous ancillary services.

crew and emergency medical personnel to the

The hospital and healthcare system emphasizes a

people of Indiana and the Chicagoland area.

culture that focuses on creating strong physician partners and environments that will result in great customer service. With a focus on hiring employees committed to the hospitalâ&#x20AC;&#x2122;s culture, the human resources depart-

renovation, with a 23% increase in patient visits over

ment has modeled its orientation program, as well as

the last three years. â&#x20AC;&#x153;For many of these patients, this

its application process, with the Studer initiatives in

will be their first visit to our hospital, and at least

mind. â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;ve been successful in retaining employees

20% of those patients will be admitted through our

over time and making certain that new employees

emergency department,â&#x20AC;? says Ryba. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s important

are invited to join our healthcare team for the right

to make that experience as comfortable and efficient

reasons,â&#x20AC;? says Ryba. The hospital already maintains a

as possible.â&#x20AC;? The project, scheduled for completion in

high level of longevity with employees. Management

the fourth quarter of 2010, will nearly double the size

team members average 15 to 20 years with

of the existing department.

the organization.

HCE EXCHANGE MAGAZINE Real Issues : Real Solutions

11 | Iraan General Hospital

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same challenges as hospitals across the nation,” says

Still family owned and operated since 1959

Ryba. “We must advance our technology and continue to develop patient care service lines while at the same time attending to the uninsured and underinsured in our local communities.” Ryba theorizes that the unemployment rate has not yet peaked in this region and that the effect on healthcare will lag on the impact of what’s happening in the economy by at least a year or eighteen months.

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“We are assuming, at this point, that we will see an increase in uninsured and underinsured patients. They will most likely present themselves in the emergency department as much more critically ill than they might have presented otherwise. We’re preparing for those possibilities, while also adjusting to the new challenges and opportunities that will be unveiled with the new health care reform laws. I believe that by building on our strengths today, we are poised to continue to succeed in the face of the future’s uncertainty,” she says. by T.M. Simmons

Iraan General Hospital Imagine a 14-bed hospital so small that the CAT scan machine was located outside. Wind, rain or shine, patients had to be rolled out to the street to get imaging services. When a helicopter needed to land to take a patient to a larger hospital, staff members had to coordinate with the Baptist church congregation next door to clear the street and make room for the air ambulance to land. This was the old reality for Iraan General Hospital in Pecos County, Texas. A new facility, triple the size of the old one, has now been built on ten acres of land donated by Marathon Oil Company. Iraan General is a small, critical access hospital located in rural west Texas. It is 80 miles from Midland, Texas and 118 miles from San Angelo. It provides primary care services and is a Level IV Certified Trauma Center, open 24 hours a day, 7 days a week. The hospital began as a county hospital more than 50 years ago. In 2004, when funds were being primarily invested in a hospital on the other side of the county, the community decided to support its own hospital. “We won our independence,” says Teresa Callahan, CEO and Administrator of Iraan General. She has been with the hospital for eleven years. “Our community decided we could make decisions in healthcare for our own surrounding people.” Within two years of becoming district, the community decided to build a new facility to house its hospital.

Healthcare in Rural America

salary printed on one side and the statement of

also works as a nurse practitioner for the hospital.

needing a doctor on the other to a big medical con-

â&#x20AC;&#x153;At the old hospital we had one big ER and one tiny ER

One of the biggest obstacles to healthcare in such ru-

ference. He came back with a doctor for us, all for

and most of the time we had multiple patients in it and

ral areas of the country is attracting and maintaining

the cost of a t-shirt.â&#x20AC;?

we were caring for patients out in the hallway. Now we

upper level healthcare professionals. â&#x20AC;&#x153;Physical thera-

The three doctors at Iraan General work two

have two trauma rooms that are nice and big and we

pists, RNs, X-Ray technicians, getting those people

weeks on and two weeks off in order to keep the

can actually take very good care of

to come out to the small rural areas is a challenge,â&#x20AC;?

hospital covered at all times. In this manner, they

our patients.â&#x20AC;?

says Callahan. â&#x20AC;&#x153;Most people want to live in a town that

avoid having to use traveling ER doctors to maintain

The new hospital was also built to be entirely

has a Wal-Mart, a Sonic-- but out here in small towns

coverage. â&#x20AC;&#x153;I do not have to worry about that because

wireless, so the move involved a switch to electronic

you donâ&#x20AC;&#x2122;t have that luxury. You have to like living in a

my three doctors are able to rotate their schedules.

records, as well. It was decided to invest in new equip-

small town.â&#x20AC;?

It helps, budget wise, as well,â&#x20AC;? says Callahan.

ment rather than continue to make do with hand-me-

Most of Iraanâ&#x20AC;&#x2122;s population either works in the oil fields, school or they are ranchers. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s not like the

Luxury in a New Facility

old days where we just came because we wanted a

down machines that did not always accommodate patient needs and assure safety. â&#x20AC;&#x153;Now weâ&#x20AC;&#x2122;re looking to see what other things we

job,â&#x20AC;? says Callahan. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s almost like we have to offer

The new hospital houses everything under one roof.

can bring in that will keep our patients from having to

them a gold mine. If you want them to come you have

A patient never has to leave the facility, not even as

travel down the road so much,â&#x20AC;? says Callahan. â&#x20AC;&#x153;Be-

to offer moving expenses, bonuses, student loan pay-

far as the street to get a CAT scan. A larger lab al-

cause of the economy and the cost of gas and people

ments, and higher salaries. Once we get an employee

lows them to do more work in-house. Physical ther-

without insuranceâ&#x20AC;&#x201D;that is a big problemâ&#x20AC;&#x201D;weâ&#x20AC;&#x2122;re just

here, they do tend to stay. Many of our employees

apy now has a space shared with cardio-pulmonary

trying to think of what we can bring in that will help

have been here greater than ten years.â&#x20AC;?

rehab, a new service the hospital is able to offer.

our community.â&#x20AC;?

Her doctors, however, do their own recruiting.

â&#x20AC;&#x153;Our rooms are bigger where you can actually

â&#x20AC;&#x153;One of my doctors actually wore a t-shirt with the

maneuver around the patient,â&#x20AC;? says Callahan, who

Down the road, Iraan General will be looking into future plans for a wellness center, nursing home or assisted living services.

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Working Together â&#x20AC;&#x153;If you set your mind to it, you can almost achieve any dream when everybody works together on it,â&#x20AC;? says Callahan. â&#x20AC;&#x153;We may be little, but our hearts are very big and healthcare is important to us all. Of course, itâ&#x20AC;&#x2122;s the last thing that you hope you have to use, but if you have a severe heart attack or a burn or something critical, time is of essence, and you hope and pray that there will be something right there for you.â&#x20AC;? â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;ve never had to close our doors in this town in all these years. I feel that weâ&#x20AC;&#x2122;ve done well getting the new hospital built and I hope that it will provide healthcare services for another 50 years just like the old hospital.â&#x20AC;? by T.M. Simmons

HCE EXCHANGE MAGAZINE

12 | Yakima Valley Farm Workers Clinic

“looked at expansion of services to meet demand.”

Expanding Services to Meet Demand Executive Director, Carlos Olivares, came to the clinic about five years after it opened. “The lack of services— medical, dental, and social services for this community—was significant,” he

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Yakima Valley Farm Workers Clinic With a small grant from the federal government, The Yakima Valley Farm Workers Clinic was founded 30 years ago to care for migrant and seasonal farm workers. The small clinic in Toppenish, Washington had one physician on staff. The Toppenish clinic today has 44 medical exam rooms and a dental clinic. It continues to serve seasonal and migrant farm workers, but also targets low income populations, the underinsured, and uninsured.

Real Issues : Real Solutions

says. “As demand for healthcare services was identified, we began to move into a different type of strategic plan that really looked at expansion of services to meet demand.” The Yakima Valle Farm Workers Clinic is now a 120 million dollar operation that relies on government funding for less than 7% of its total revenue. Last year the organization served 135,000 people and produced over a half-million face-to-face visits with a provider for medical and dental services. The group employs 1,400 people in clinics in the states of Washington

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MED3OOO improves outcomes through the integrated application of systems, operations, informatics, and expertise. Through our full circle approach to informatics, we harness the power of information collected through disparate systems, using and sharing that information to improve outcomes and achieve success across the full spectrum of healthcare delivery and financing. www.MED3000.com | www.InteGreatEHR.com 412-937-8887

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and Oregon and has a medical staff of more than 200

fifteen years and we have over 40,000 enrollees. We

physicians and 39 dental providers.

have expanded our work around other types of social

â&#x20AC;&#x153;We now provide a full complement of services

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has a budget of over $10 million and we do a lot

mary careâ&#x20AC;&#x201D;but also some specialty care built around

of educational programs with youth in the school

OB, pediatrics and internal medicine. We also have a

districts. We do a weatherization and energy assis-

pharmacy, fully automated, in most of our 17 clinics,â&#x20AC;?

tance program. We are very much moving into the full

says Olivares.

implementation of a medical home model that I hope

Yakima Valley operates the largest Women, Infants, and Children (WIC) program in the state of ton they serve more than 10,000. â&#x20AC;&#x153;We have community

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and the highest immunization rate,â&#x20AC;? says Olivares.

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will be viewed as one of the most innovative models in the country,â&#x20AC;? says Olivares.

Oregon where they serve 9,000 families. In Washing-

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services. We have a community action program that

for all of our patients starting with medical careâ&#x20AC;&#x201D;pri-

service programs associated with diabetes, asthma,

A Business Approach to the Delivery of Healthcare

â&#x20AC;&#x153;90% of our children are fully immunized.â&#x20AC;? They also own approximately a third of one of the

â&#x20AC;&#x153;A couple of things have become clear over the years,â&#x20AC;?

largest Medicaid managed care plans in the area. â&#x20AC;&#x153;We

says Olivares. â&#x20AC;&#x153;The automating functions do not

have been in the managed care world now for almost

always represent a savings in cost. Much of the time,

0HGLFDO $VVRFLDWHV RI &OLQWRQ ,RZD HCE EXCHANGE MAGAZINE

Real Issues : Real Solutions

priority. Low income and underserved people continue to be the driver of everything we do. However, we believe that you can merge that philosophy with one of responsible business strategies that allow you

“I believe that we are probably set better than most organizations for welcoming the new healthcare reform.” the investment in technology is not a short term gain, but it’s always a long term gain.” Yakima Valley already has a fully electronic medical records system, including dental, as well as a robotics system built into their pharmacies. “We have an IT intelligence program that allows us to produce information and data and, in turn, allow us to make decisions based on solid information,” Olivares says. “I believe that we are probably set better than most organizations for welcoming the new healthcare reform.” He emphasizes the importance of hiring people who are extremely competent in their fields. Most of his management team has been with him for almost 15 years. As new services are added, such as information technology, he has added experts to take care of those areas of the business. “My philosophy on

hiring managers is that you’ve got to have people who have experience and are capable of doing the work.

to be progressive, sustainable, and at the same time, continue that special commitment to the population we serve.” “There’s usually this sense that if you are a nonprofit organization, business principles are not very compatible with your mission. I think over the last 20 years we have proven that to be a wrong assessment and a wrong statement to make.” by T.M. Simmons

“to be progressive, sustainable, and at the same time, continue that special commitment to the population we serve.”

They have to be smarter than I am,” he says. “And they have to have the work ethic that I have.” “We have an incredible work force and I assure you, every one of my employees knows me. I visit all of our clinics on a regular basis. I put over 40,000 miles a year on my car because I am engaged and I demand my managers to be engaged. I think an aspect of our structure is we make decisions based on data and we make decisions based on solid information. We try to stay away from the hypothetical decisions. Those are usually not lasting.” “We function very much as a business, and as a business with a heart,” says Olivares. “It is important to keep the mission of our organization in place. Migrant and seasonal farm workers continue to be our

HCE EXCHANGE MAGAZINE Real Issues : Real Solutions

13 | Global Surgical Partners, Inc

Full-Service Development and Management â&#x20AC;&#x153;We are a turnkey company,â&#x20AC;? says Ziskind. â&#x20AC;&#x153;We donâ&#x20AC;&#x2122;t outsource very many of the things that we do to set

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up a center. Weâ&#x20AC;&#x2122;ve been very successful on all of our projects, and I think have developed a focused identity

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with regard to ensuring success.â&#x20AC;? Global exclusively develops ambulatory surgical centers that are physician owned or physician-hospital joint ventures. Ziskind feels that it is important that the physicians own as much of the equity as possible â&#x20AC;&#x153;In all cases the physicians have a significant equity stake,â&#x20AC;? says Ziskind. â&#x20AC;&#x153;We think thatâ&#x20AC;&#x2122;s helpful in terms of keeping the surgeons associated with our projects and focused as opposed to looking or testing the waters elsewhere.â&#x20AC;?

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â&#x20AC;&#x153;You start with a group of doctors and they think in six months they are going to have a place to happens. Thatâ&#x20AC;&#x2122;s just not the way it works,â&#x20AC;? Ziskind says. Each

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Global Surgical Partners, Inc J.A. Ziskind and Kenneth Arvin founded Global Surgical Partners in 1999. The two had practiced law together for a number of years and, building on combined backgrounds that included healthcare management and tax and financial work for healthcare entities, they first opened Manatee Surgical Center in Bradenton, Florida. The four-operating room, three-procedure room facility had 23 physician investors. â&#x20AC;&#x153;That was our first project and weâ&#x20AC;&#x2122;re still there,â&#x20AC;? says Ziskind, President and CEO. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s been one of our more successful projects, not withstanding the fact it has a large Medicare population and, of course, this is a highly prolific area in terms of managed care. Rates are probably not what they are in other areas of the country and state.â&#x20AC;? Global does not advertise and gets its projects through referral. The business has now developed six ambulatory surgery centers in the states of Florida and Mississippi and manages two additional centers. All eight sites are multi-specialty.

ambulatory surgery center Global develops meets Now Thereâ&#x20AC;&#x2122;s an Easier Path to EHR Adoption With the HITECH Act passed into law, itâ&#x20AC;&#x2122;s critical for surgical centers to make smart investments when it comes to healthcare technology. SourceMedicalâ&#x20AC;&#x2122;s Vision EHR Compliance Guarantee Program reduces the investment risk of purchasing an EHR by guaranteeing its software will meet the requirements outlined by the ONC for use of an approved EHR in an ASC. To learn more visit http://sourcemed.net/hitech-surgery/

full licensure requirements for the state it is in and meeting those requirements can take considerable time and effort. Mississippi, for instance, is a certificate of need state for multi-specialty centers. If you donâ&#x20AC;&#x2122;t have an identity with a local hospital, the chances of getting that certificate are greatly diminished. â&#x20AC;&#x153;We were fortunate we identified with local hospital systems that either had a certificate of need or were well on their way to obtaining one, so it worked out for everybody.â&#x20AC;? Ziskind also requires that all of Globalâ&#x20AC;&#x2122;s ambulatory centers be Joint Commission Accredited. â&#x20AC;&#x153;We feel that if our hospital partners are Joint Commission Accredited, we ought to stick to the same gold standard. Weâ&#x20AC;&#x2122;ve done that and all of our centers operate profitably.â&#x20AC;?

HCE EXCHANGE MAGAZINE Real Issues : Real Solutions

14 | Bay Regional Medical Center

Assuring High Quality

less infections and complications, that has already

In the years Global Surgical Partner’s centers have

payor and, most importantly, to the patient, is less.”

been in operation, Ziskind can only recall two or three minor claims Combined, the group’s centers are performing approximately 70,000 cases per year now. “We have an incredible system of peer review, bench marking, and oversight that insures that kind of quality.” “I think a lot of that success has to do with our medical staff and our physician ownership. One of the things we are very cognizant of when we start a center is associating with quality doctors. I know a lot of people give lip service to that, but our physician founders have been very selective. We don’t take every comer,” Ziskind says.

been proven. As well, the cost both to the third party Surgeons like the ambulatory center setting because it allows them greater control over their patients, over their activity, and they have a lot less down time between cases. “I can’t tell you how many doctors tell me that this is their best investment, not only financially, but also from a time perspective,” says Ziskind. “They say, ‘I am able to do six or seven surgeries and get out of the center by 1 or 1:30. If I were doing this at the local hospital, I’d be there all day.’ Doctors tend to, once they get into a block booking situation, find they have significant time available to devote to other activities.” Ziskind expects his company will stay busy in the future. “I think surgical centers will continue to be winners and there will continue to be growth. Whether

Ambulatory Centers vs. Hospital Surgeries “Surgical centers are the low cost provider in any community. They have to be by definition,” Ziskind

it’s 10 million or 30 million new people coming onto the insurance rolls, there will definitely be more people seeking services at surgery centers.” by T.M. Simmons

says. He believes that although hospitals have tra-

Bay Regional Medical Center

ditionally been opposed to physician-owned surgical centers—based on the fact that they tend to take elective surgeries, and therefore money, out of the hospitals—the growing trend is hospitals joint-venturing with physicians to build such centers.

The product of a four-hospital merger that took place in the 1970s and 1980s, Bay Regional Medical Center is now a 415-bed, full service hospital serving approximately half a million people in northeast Michigan. The hospital is arranged on several campuses and employees a staff of approximately 2,000.

“Every hospital management person involved in our Centers is proud to be associated with the physician-hospital joint-venture surgical center. They know the care is more appropriate. There are

Bay Regional Medical Center is a subsidiary of McLaren Health Care, one of the top 25 integrated health systems in the country.

HCE EXCHANGE MAGAZINE Real Issues : Real Solutions

Employee Commitment to Customer Satisfaction â&#x20AC;&#x153;We just received our employee engagement forms, and among our strongest performing areas, the perception by our employees is that we are committed to the community. We are focused on patient safety and on the needs of our customers,â&#x20AC;? says Ellen Talbott, Vice President of Patient Care Services. Talbott has overseen the clinical services for Bay Regional Medical Center for three years. She is responsible for delivery of care and the systems that go with that in areas such as nursing services, pharmacy, and radiology. â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;re always working on moving our customers through the system as quickly as we can,â&#x20AC;? says Talbott. â&#x20AC;&#x153;Customer service is always on our mind.â&#x20AC;? A number of initiatives center on this area of focus. A rapid response initiative, for instance, allows for line and clinical staff to engage a specially trained, qualified team of expert nurses to help them respond and rapidly evaluate a patient. â&#x20AC;&#x153;It allows for an immediate mobilized response to care for a patient when there is any kind of concern,â&#x20AC;? says Talbott. â&#x20AC;&#x153;We see that as an &RPSUHKHQVLYH ,210 6ROXWLRQ

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extremely valuable tool.â&#x20AC;? Bay Regional is also working on a number of medication safety initiatives. The Bedside Delivery Discharge Rx program has just completed the pilot stage. The program is designed to allow patients to have their

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medications delivered to their bedside prior to checking out of the hospital. This helps avoid delays in getting started taking medications and makes sure insurance authorizations are dealt with prior to patient discharge. The hospital has programs in place for improving the care modality for acute myocardial infarction, acute care, and pneumonia, all issues requiring very specific pathways for delivering care. â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;re particularly proud of the manner in which we provide interventional thera-

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py,â&#x20AC;? says Talbott. â&#x20AC;&#x153;From a nursing perspective, there is more and more demand for documentation of the care delivered to a patient. The challenge is to figure out the best model for care delivery.â&#x20AC;?

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Critical Equipment Needs and Improvements

in the future. â&#x20AC;&#x153;We have very robust nursing program

Talbott lists a number of critical equipment ar-

last year of nursing school and they go through a for-

eas where attention is being focused on getting

malized training program where they are working side

replacements, such as the cath lab and MRI-type

by side with various nurses. It has been very effective

machines. Cardiac procedural areas and the

for us. It gives nurses a jump start and also gives us

cardiac catheterization labs have been expanded.

opportunities to get to know that individual better

The hospital is also in the midst of renovating the

before hiring. This is a major strategy for us and prob-

emergency room department.

ably our most successful.â&#x20AC;?

â&#x20AC;&#x153;We definitely have a vision for building our in-

here,â&#x20AC;? she says. â&#x20AC;&#x153;A two year Student Nurse Extern program. We bring in people during their second or

â&#x20AC;&#x153;Bay Regional is a very strong, community based

frastructure for information technology so that we

hospital,â&#x20AC;? says Talbott. â&#x20AC;&#x153;We are very connected to the

will have a complete, comprehensive IT system,â&#x20AC;?

community and highly focused on patient safety and

says Talbott. â&#x20AC;&#x153;That would increase patient safety

quality initiatives. We are becoming well known for

features, along with other things.â&#x20AC;?

a number of services, probably the strongest being

â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;ve already brought in a lot of the digital technology, so our strategy is to go forward with more of a comprehensive clinical documentation

cardiology and cardiovascular.â&#x20AC;? â&#x20AC;&#x153;We are very proud of where we are and in our employee and patient satisfaction.â&#x20AC;?

system,â&#x20AC;? she says. by T.M. Simmons

Facing a Healthy Future Talbott says the nursing shortage has not hit hard in Michigan, but they continue to expect a shortage

HCE EXCHANGE MAGAZINE Real Issues : Real Solutions

APR/MAY

2010

Real Issues : Real Solutions

HCE Exchange Magazine EDITORIAL Editor-in-Chief Tiffany Ford Editor: In-Focus John Abraham Contributing Writers Teresa Pecoraro Jacqueline Rupp David Winterstein Meghan White Tracy Simmons Kathy Knaub-Hardy Editorial Associates Levent Nebi Deepa Bhatia Sunita Bhawani Manoj Pal ART DEPARTMENT

CUSTOM REPRINTS

Art Director Kiki Ikura

A Custom Reprint of your Cover Story or Special Feature offers cost-

Associate Art Director Devdutt

effective opportunities for your company to stand out and make a lasting

PRODUCTION DEPARTMENT

impression. Increase the value of your marketing efforts

Production Director Russell Ford

â&#x20AC;&#x201D;make the most of your article.

Production Associate Ivan Bogdanovich

BENEFITS SALES DEPARTMENT Sales Associates Guy Tarditi

HCE EXCHANGE

Peter Biddle Reprints reprints@hcemag.org Circulation circulation@hcemag.org Reuse Permissions copyright@hcemag.org Editorial Policy CopyrightÂŠ 2010 by One World Media LLC. All rights reserved. Reproduction in whole or part without permission is prohibited. The opinions expressed by the interviewees, contributors and advertisers in this issue do not necessarily coincide with those of the editor and publisher. Every reasonable effort is made to ensure that the information published is accurate, but no legal responsibility for loss occasioned by the use of such information can be accepted by the publisher.

Include reprints with sales and marketing brochures Use in a direct mail campaign Use as a public relations tool Use as an insert in local newspapers Distribute at Trade shows, Career Fairs and seminars Display in your office or other locations REPRINT SPECIFICATIONS All reprints printed on 100lb text, high gloss paper Digital reprints (High Resolution PDF) available All reprints are printed in four-color (CMYK) Available in 2, 4 and 6 page formats CUSTOMIZATION Add your company logo and contact information Add/Remove advertisements Put your company on the Cover Swap out existing photos for new photos Update text with an exclusive message For additional information, please email: reprints@hcemag.org