Saturday, January 27, 2007

Stop me if I say something you don't understand

I used to work with a physician who dictated office notes in front of his patients. After explaining his findings, he would ask the patient to listen while he dictated his findings. “Stop me if I say something you don’t understand or think is inaccurate,” he would say. When he finished, he would ask the patient (again) if there was something she did not understand. This process assured three opportunities for patient understanding – after the exam, during dictation, and after dictation.

As a medical student, the doctor had lived with his wife’s parents and often heard his mother-in-law discussing her interactions with the medical community. She was clear about what she did and did not like, and he incorporated into his own practice the lessons he learned from her medical interactions.

This physician heard the voice of the “consumer” in his mother-in-law’s stories. She became a stand-in for his future patients, a role model of the “health care consumer,” long before that term entered the health care world. Today we understand that communications are important, not just for patient satisfaction, but for reasons of patient safety.

When patients feel comfortable asking questions, volunteering information, and voicing concerns, they are more likely to understand and cooperate with their treatment. They are also more likely to speak up if something seems wrong, and this can be an important warning sign. Effective communications with patients can reduce the opportunity for mistakes, such as medication errors, identification mix-ups, and wrong-side procedures.

Two of my relatives were hospitalized in the last two months, and their experiences reminded me how different is the hospital world a patient experiences from the hospital world we see every day as caregivers.[1] What is obvious or routine to us may be invisible or incomprehensible to patients. They don’t understand our language. They don’t share our mental map that readily understands the relationships among attending and consulting doctors, charge nurses and discharge planners, therapists, and service staff.

Even knowledgeable people experience the hospital differently when they become patients. A surgeon once told me about his experience as a patient. “I was on a gurney,” he said, describing his trip to the OR. “As the transporter waited for an elevator, I was surrounded by equipment, IV poles, mobile x-ray units, food carts. I suddenly realized I was no longer a patient. I was a piece of cargo competing for elevator space.” The hospital world that was known to this experienced surgeon became a different place when he was a patient – he felt both isolated (“surrounded by equipment”) and alienated (“a piece of cargo”).

My recent experiences at two out-of-town hospitals reminded me how important it is to make patients feel secure and comfortable in our world. Recognizing the puzzlement in a patient’s eyes is a signal for us to explain what we just said – again – in different words. Recognizing that a smiling face does not always mean the patient understands what was just said should prompt us to take a moment to use new words or ask the question in a different way. These are basic skills in human communications, and in the hospital world they not only help patients feel more secure, they help us keep patients safe as well.

[1] My recent experience at the other hospitals prompted me to adapt this letter from one I wrote several years ago in a somewhat different form (January 3, 2004).

Saturday, January 20, 2007

Q&A on CGH & Van Duyn

I have written two recent posts about the Berger Commission,[1] and I thought that was enough on the subject, at least for a while. But I am often asked about the Commission so here are my answers to frequent questions.

Is the Berger Commission really “the law?”
Yes. Its recommendations became law on January 1, 2007 because there was no vote to overturn them by the State Legislature in 2006.

What exactly did the Commission say about CGH?
The Commission had two requirements for CGH. The first was that the Van Duyn Home & Hospital (526 beds) and CGH's sixth floor skilled nursing facility (50 beds) should be “joined under a single unified governance structure under the control of Community General."[2] That means that CGH will become legally responsible for all long term care beds on this campus. The second requirement is that the size of the combined CGH-Van Duyn nursing facility become smaller by “approximately 75"[3] beds. In other words, the total number of nursing home beds on campus would go from 576 to about 500.

When does all this happen?
I don’t know. The Commission report says only that Onondaga County[4] and CGH have to develop an agreement by the end of 2007. And, as yet, there are no specific plans about how to accomplish it, how long it make take to do so, or how much it might cost to do so. What the Commission asked for is quite complicated and will require time and funds to accomplish.

Does the Berger Commission want CGH to become a nursing home?
No. The Commission recommended that we “create an integrated continuum of care on campus.”[5] That means developing a health care campus that encompasses various care alternatives – acute hospital care, nursing home care, and perhaps other care levels as well. The Berger Commission did not take away any or CGH’s certified hospital beds. It effectively added 500 nursing home beds to our 306 hospital beds.

How will this affect employees?
The Berger Commission gave us one year to develop a plan with Onondaga County, subject to the state’s approval. After the plan is developed, it will take some time to implement it. I believe that at the end of this process there will be more opportunities for CGH employees, not fewer opportunities.

Do you believe the Commission’s decisions will be implemented?
I believe they will be implemented, yes, but I am not sure how or when – and I don’t know if the state will permit changes in some of the Commission decisions.

At least seven hospitals have started lawsuits against the state to stop it from implementing the Commission’s decisions. The lawsuits object to the absence of Department of Health hearings on Commission decisions and to the Commission’s alleged failure to comply with the state’s open meeting law.

Also, we do not know exactly how the new Administration in Albany is going to implement the Commission’s decisions. The Administration has been busy filling top positions in the health department – these are the positions that will oversee implementation of the Berger report. A new Commissioner of Health was appointed by Governor Spitzer only two days ago.[6]

The state has identified funding sources for the institutional changes that are expected as a result of the Commission. These are HEAL funds, which come from the state, and FSHRP (“f-sharp”) funds, which come from the federal government. It is not known how or when these funds will become available for the organizations that need to make changes.

So the timing and ability to comply with the report’s recommendations may depend on the outcome of court cases, on Administration decisions yet-to-be-made, and on the future availability of funds.

So what is CGH doing about all this?
CGH and Onondaga County had met about ways to work together even before the Commission report. We met together with the Berger Commission last summer when it was considering its recommendations. Although we did not expect the changes that the Commission ultimately recommended, both CGH and Onondaga County support the goal of an integrated continuum of care campus. Since the Commission’s report, CGH and Onondaga County have prepared for discussions with the state. We hope to learn more about the timing and flexibility we have to achieve the goals of the Berger Commission. And we need to answer a very important question: how do we obtain the funding necessary to achieve these goals?

[1] The New York State Commission on Health Care Facilities in the 21st Century was chaired by Steven Berger – so it was called the “Berger Commission” as shorthand. On November 28, 2006, the Commission recommended the closing of nine hospitals across the state, most of them in New York City. It recommended the restructuring of 48 hospitals, closing about 4,200 staffed hospital beds in all. The Commission also proposed to close seven nursing homes and to restructure 14 others, leading to a reduction of some 3,100 nursing home beds statewide. The 2005 law that established the Commission was crafted so that its recommendation became law unless they were entirely reversed by the State Assembly and the State Senate before December 31, 2006.
[2] Commission on Health Care Facilities in the 21st Century, p. 101. To see the full report, go to
[3] Commission, p. 101
[4] Onondaga County owns and operates Van Duyn, which has been a part of the County for 180 years. It began as the County Sanitarium 1827. In 1979 the Van Duyn Home & Hospital opened as newly-constructed 526-bed facility.
[5] Commission, p. 102.
[6] Richard F. Daines, M.D. was named to serve as State Commissioner of Health on January 18, 2006. Dr. Daines is the President and CEO of St. Luke's-Roosevelt Hospital Center in New York City.

Saturday, January 13, 2007

A tale of two cities

I remember going [to work] Saturday morning and I said to my husband… “I’m going to go, but I am so afraid”….I thought I was the next one to get [SARS]….’cause all our nurses were falling down.[1]

Those are the words of a nurse from Ontario Province as quoted in a report by a Canadian Commission that has examined the SARS epidemic of 2003. It is a cautionary tale for hospitals and governments about controlling the spread of infection.

The report focuses on two Canadian cities, Vancouver, British Columbia, and Toronto, Ontario. At 4:55 p.m. on March 7, 2003, an ambulance brought a 55-year old man to Vancouver General Hospital. About three hours later, at 7:45 p.m., a 43-year-old man went to Scarborough Grace Hospital in Toronto. Both patients had Severe Acute Respiratory Syndrome (SARS), but the course of SARS contagion was very different in the two cities.

Because the Vancouver hospital followed strict precautions, there was no SARS epidemic in British Columbia. In Toronto precautions were inconsistently used. As a result, 44 people died in Ontario and 375 became sick with SARS. “Of the…people who contracted SARS in Ontario,” says the report, “72 percent were infected in a health care setting….[and] 45 percent were health care workers.”[2] In Vancouver only one health care worker contracted SARS.

This “tale of two cities” demonstrates the importance of proper infection control procedures, including the use of personal protection equipment. It was a “combination of a robust worker safety and infection control culture at Vancouver General….[that] ensured…B.C. (British Columbia) was spared the devastation that befell Ontario.”[3]

I was recently at an out-of-town hospital with a relative, and I saw a very casual use of precaution gowns and virtually no enforcement of gowns for visitors. I was at a meeting this week where a lay person, who had been recently cared for at another hospital, told me stories to me about inconsistent infection control practices there. We know that health care people do not always follow standard precautions, as they should.

Interestingly, the spread of SARS in Canada was mostly within hospitals and not within the community-at-large. The report credits “bold public health efforts and stringent quarantine measures”[4] with stopping the infection in the general community.

At one point, when the epidemic subsided, the Ontario government officially lifted the emergency measures that had been imposed. Here’s what the Commission said happened next:

As soon as the precautions were relaxed…the disease surged back and spread…to patients, staff, visitors, and their families.

Stringent infection control and worker safety precautions, so recently relaxed, were imposed once more. Health care workers donned their N95 respirators and gowns and gloves again. As soon as precautions were reinstated, the disease again subsided.

The value of hospital standard precautions[6] has never been more clearly demonstrated. Vancouver’s precautions stopped an epidemic before it started. Ontario’s inconsistent prevention measures allowed an epidemic to get started and, even after it was brought under control, to start a second time.

Despite the infection control system failures in Ontario, SARS was ultimately stopped, and the report credits the heroism of health workers for this:

SARS was stopped by the front-line workers and the scientists and the specialists who stepped up and who were not afraid to take strong measures that worked in the end.[7]

The SARS report shows the need for a culture of safety, a culture where every hospital worker knows, respects, and follows standard precautions. SARS was not immediately recognized as a new and serious illness. We don’t know the diseases we might face on any given day.

That is why 100% compliance with standard precautions is the way we protect ourselves, our patients, and our families.

[1] Spring of Fear, Volume 1, Executive Summary, The Commission to Investigate the Introduction and Spread of SARS in Ontario. The nurse’s quote is from p. 9. All four volumes of the Commission’s report are available at this web address:

[2] Spring of Fear, Volume 1, p. 12.

[3] Spring of Fear, Volume 1, p. 4.

[4] Spring of Fear, Volume 1, p. 6.

[5] Spring of Fear, Volume 1, p. 6.

[6] Standard precautions are safety measures for all patients who receive care, regardless of a patient’s diagnosis or known infection status, such as hand washing, the use of gloves, masks, and eye protection, face shields, gowns, etc.

[7] Spring of Fear, Volume 1, p. 10

Saturday, January 6, 2007

Why we have a hot line

In my greeting to each class of new employees, I spend a couple minutes talking about “corporate compliance.” That is the technical term for hospital business ethics.

This month a new federal law requires hospitals and other providers[1] to “teach their employees how to ferret out fraud and report it,” according to a New York Times report.[2]

Corporate compliance policies affect all of us who work at CGH. For example, the arrangements we make with vendors and providers must be ethical and legal. None of us can negotiate or manage a contract for the hospital in a way that benefits himself personally. We cannot steer business to favored parties or people with whom we might have a personal or business interest. Our corporate compliance policies mean none of us can accept a monetary gift for providing services,[3] we cannot disclose confidential information, and we cannot use hospital equipment or supplies for personal use.

Under the new law, it is important for CGH to make sure employees know there are specific laws against Medicare or Medicaid fraud and abuse. Employees have an obligation to report a suspected illegality to their employer or to the government, and they have rights when they do so – such as no retaliation for such reporting. People who report suspected fraud to the government are sometimes called “whistleblowers,” and they have specific rights, as well.

We already have a strong corporate compliance policy, and we are updating it to comply with the new law. There will be changes in the employee handbook , as well.

When new employees join us, I am not the only one talking about corporate compliance. Deb Kurtz also addresses the subject with employees. She is CGH’s corporate compliance officer. She is the person any employee can go to about a suspect activity. Deb Kurtz even operates a “hot line” number – 492-5965 – to make it easy to contact her, anonymously, if you wish. She reports directly to the Corporate Compliance Committee of the Board of Directors.

There is a copy of the corporate compliance policy is in your department. Ask your supervisor to see it, and feel free to ask questions of your supervisor or Deb Kurtz if you think something is not right. If you think something at CGH might not comply with the law or is of questionable ethics, please speak up. Tell your supervisor or report the matter to Deb Kurtz at extension 5965.

[1] “Other health care providers” includes physicians groups, health maintenance organizations, pharmacies, medical equipment suppliers, and home care agencies.

[2] “At Hospitals, Lessons in Detection of Fraud,” New York Times, December 24, 2006.

[3] Employees may not solicit gifts from patients or others, but the Corporate Compliance Policy does permit an employee to accept an unsolicited gift of nominal value, that is, $30.00 or less. See CGH the Corporate Compliance Program Handbook, p. 13.