Infection rates & more

Maybe you saw the story in last Sunday’s Post-Standard ¹ about the annual report card on New York State hospitals that was issued by the Niagara Health Quality Coalition² The Coalition reports on mortality rates, blood clots after surgery, and hospital infections, using a risk-adjustment technique that makes for fair comparisons among hospitals, despite differences in the mix of patients they care for.

From the Coalition’s website, I collected comparison data on hospital infections for the four Syracuse hospitals and placed them in the accompanying chart. This shows hospital 2005 infection rates per 1,000 patients for infections occurring due to medical care (that is, primarily intravenous (IV) lines and catheters) and for postoperative sepsis (a bloodstream infection caused by toxin-producing bacteria occurring after surgery).

Naturally I was proud to see that CGH’s infection rates were below the state average and below the rates of other hospitals. In some cases our infection rates were one-half those of others. As the Coalition reports on its website: “Hospitals following the appropriate procedures, such as washing hands before working with a patient…should show a lower level of infections due to medical care³

May 2 was “Hand Hygiene Day” at CGH, and at the start of each shift hospital managers stood at each entrance to greet employees, volunteers, and physicians. They handed out more than 1,000 pocket-size bottles of Purell® that were donated to CGH by the company – to reinforce awareness about the importance of safe-hand practices here.

A number of people wore buttons reading, “Ask me if I washed my hands.” That is part of a campaign to encourage patients to be aware of (and to speak up about) hospital hand-washing practices and to discourage caregivers from being defensive when patients ask about hand-washing. As I wrote in last week’s letter,⁴ medical professionals have been more than a tad defensive about hand cleanliness for 150 years or so.

When a patient or family members asks, “Did you wash your hands,” the correct response is: “Thank you for asking. Yes, I did!” Or, “I am going to do that right now! Thank you for asking.”

And patients are speaking up. I recently received a letter from a patient who said, “I hate to beat a dead horse, but the only person I saw washing his hands was my attending physician (…kudos to him!) I think I saw my nurse do it, and I never once saw an aide do it. Now perhaps they did it down the hall or something, but…I want to make sure they have not touched anything (including and especially door handles) between the act of hand washing and doing anything to me (original emphasis).”

That’s Dennis Trepanier, Vice President – Operations, with volunteer Grace Easton and a supply of hand sanitizers on Hand Hygiene Day, May 2. Another patient wrote me to say she doesn’t trust hospitals so she brought to CGH her own supply of Clorox® wipes. During her stay she asked to speak with the Environmental Services management, and because of her concerns, a supervisor visited her several times during her stay, which she appreciated. The woman wrote me a very kind and complimentary letter about the staff who kept her room clean – but she did not hesitate to offer several pointed comments and observations about how we could improve our cleanliness.

Our patients are speaking up, and – with reports like that of the Niagara Coalition – more are likely to do so. Let’s encourage them to ask us about hand washing and infection control, and let’s be as responsive and as supportive as possible about cleanliness.

Thanks to the “green volunteers” who collected dozens of bags of litter from the CGH campus on Earth Day, May 3.From microorganisms to the environment, it’s been clean-up week at CGH. The day after Hand Hygiene Day, about 20 CGH “green volunteers” celebrated CGH’s own “Earth Day, May 3” by spreading out on the campus and picking up a season’s collection of discards and debris. It’s amazing what was found in parking lots, at the curbside, and along the tree line. The green volunteers filled dozens of trash bags with litter – cigarette butts, drinking cups, candy wrapper, old sneakers, glass and plastic bottles, plastic bags, car parts, and other detritus.

Thanks, everyone, for your ongoing help in keeping CGH clean – and safe.

__
[1] “Hospital Report Card: Heart attack death rate high at University,” Post-Standard, April 29, 2007. For a copy of the story, go to: http://www.syracuse.com/poststandard/stories/index.ssf?/base/business-8/1177835843214811.xml&coll=1

[2] To see the report of the Niagara Coalition, go to: http://www.myhealthfinder.com/
(Click on “New York State Hospital Report Card” to find the area where you can compare hospital scores on 33 different measures.)

[3] http://www.myhealthfinder.com/newyork07/psi-full.php?table=07#REG

[4] “Weird, glowing substances,” April 28, 2007

Weird, glowing substances

There's an episode of Scrubs¹ that shows the incidental passing of an infectious agent from medical personnel to patients and visitors and back to medical personnel. The infectious agent is represented by a green, glowing substance that illuminates the hand or mouth or nose as it is transferred by touch from person to person. Of course, Scrubs is a television program played for laughs.

If infectious diseases were actually weird, glowing substances, it might be easier to prevent their inadvertent transmission. We would all see exactly what we’re dealing with. OK, I’m back to one of my favorite subjects² – hand washing, one of the most important things we can do to prevent harm to our patients.

Getting medical professionals to wash their hands was a struggle 150 years ago. Before the germ theory of medicine was understood, a Hungarian physician by the name of Ignaz Philipp Semmelweis speculated that the unwashed hands of physicians and medical students contributed to the significant infection rates of maternity patients. Puerperal fever (childbed fever) was common in mid-19th-century hospitals and mortality rates ranged from 10% to 35%.

Dr. Semmelweis observed that the mortality of patients who were cared for by physicians and students was up to three times higher than that of patients cared for in midwife wards. When a friend of his died after cutting his finger in a post mortem, Dr. Semmelweis speculated that the source of the disease that killed his colleague was the same as that killing maternity patients. He insisted that medical personnel wash their hands in a chlorine solution before each maternal examination. The result? The death rates of women in Dr. Semmelweis’ hospital dropped from 12% to 1%.³

You would think that Dr. Semmelweis’ dramatic results of the early 1850’s would have prompted widespread hand washing throughout Europe, but hand washing was resisted by the medical establishment. This was in part because Dr. Semmelweis did an inconsistent job of explaining and promoting the practice of hand washing. But it was also because the medical people of that day had a hard time acknowledging their hands were “dirty” and because it would be a decade before Louis Pasteur definitively demonstrated germ theory (and even then, the theory was not immediately accepted).

Today – many generations and many medical advances later – we understand the importance of hand washing. So why is national compliance with hand washing protocols so poor in hospitals across the country?

Last year hand washing compliance at CGH averaged 94.5%. That is excellent, compared with the 50-60% compliance rates reported for hospitals generally.⁴ But what does it say about the 5.5% of CGH people who do not comply?⁵ What additional risk does a failure to follow hand washing policy pose for patients, for visitors, for fellow workers – or for our families when we greet them after work?

That is why next Wednesday, May 2, is Hand Hygiene Day at CGH.

At the start of each shift on May 2, members of senior management and I will join Sue Chamberlain, Director of the Infection Control Program, in distributing free hand sanitizers to each employee (and to anyone else!) who enters CGH. It’s a way to promote the importance of hand washing for everyone – no exceptions!

Special thanks to the manufacturer of Purell® for providing CGH with the free supply of product for Hand Hygiene Day.

Because of Drs. Semmelweis, Pasteur, and the other pioneers of medicine, we know how to prevent the spread of infection. Thanks to hand sanitizers, it is easier than ever to do so.

Let’s use Hand Hygiene Day to reach 100% compliance – and stay there.


_________________________
[1] Scrubs is a half-hour comedy on NBC-TV that focuses on the surreal experiences of a medical resident surrounded by bizarre characters.

[2] I have written before about the importance of hand washing and infection control: “All fish swim in the same water,” March 5, 2005; “Why the obsession about hand washing?” March 19, 2005; “A culture of safety,” July 3, 2005; “Not Halloween masks,” October 29, 2005; “Lowest infection rate in Syracuse,” June 24, 2006; and “A tipping point,” March 18, 2006. I have re-posed excerpts from these letters on the CGH website: www.cgh.org. Click on “CGH Family Letter” and look for “Excerpts – Letters about Infection Control.”

[3] The sources for this information are: Emerging Infectious Diseases, Vol. 7, No. 2, Mar–Apr 2001, published by the Centers for Disease Control (http://www.cdc.gov/ncidod/eid/vol7no2/cover.htm) and Answerws.com (http://www.answers.com/topic/ignaz-semmelweis)

[4] On April 13, 2007, Paul Levy, CEO of Beth Israel Deaconess Medical Center in Boston, MA, disclosed in his blog that “[a]fter months of intensive effort…our compliance with hand hygiene has risen from 52% on medical-surgical floors to 57%....And some floors remain at or below 40%...The results of one particularly noncompliant floor have prompted one of our Chiefs to write to his physicians: THIS IS ABSOLUTELY INTOLERABLE! It is bad patient care…” (original emphasis) To see Mr. Levy’s blog entry, go to: http://runningahospital.blogspot.com/2007/04/i-want-to-be-proud-but-i-am-not.html

[5] CGH hand washing compliance is tracked monthly by staff who make unannounced observations.

Why we’re in this business

I'd like to share an e-mail I recently received from Lois Sperling, a social worker on our sixth floor. She wrote me on April 12, and it will be obvious why I consider her message important enough to share. I use this message with her permission.

I became an employee of Community General Hospital at the end of December 2006 as the Social Worker for the RHCF [residential health care facility].

In my position, I hear the good and the bad. There are often issues surrounding patient’s care and experiences but most of the input I have been receiving has been positive which is why I am writing to you.

On Wednesday…I heard from three different residents and/or their family about the care on this unit. They used expressions like “wonderful experience”, “very compassionate staff”, and being admitted on the 6th floor as something that was meant to be.

Today I witnessed two aides holding the hands of a dying resident with tears running down their faces. The daughter told them they were like family. The resident has only been here three weeks.

As I sit at my desk typing this email, I hear a resident’s spouse as he passes my office say to a male aide that he makes life worth living! I can’t help smiling almost in disbelief at the impact any of us can have on someone at any given time. That aide was simply being himself and not doing anything out of the ordinary for this person.

I have had very positive experiences in the past at this hospital as a patient and as a family member. Now I am proud to be a part of Community General Hospital and the team that serves the residents on the 6th floor.

Here is my response of April 13

What a wonderful message to receive. Thank you for sharing these thoughts. Life is often difficult for us, for those we love, for those we know. What a privilege it is to make life better, even a little bit, for others. And how thoughtful you are to share this with me.

The senator and the budget

In December 2002 State Senator John DeFrancisco invited a couple of us to his Albany office to meet with officials of the State Department of Health. The subject was CGH’s application for the Physical Medicine and Rehabilitation Unit (PM and R), which had been stalled in the state’s approval process for a year or longer. The Senator thumped the desk. He looked each official in the eye. He said it was time to call the question, to get moving, to make a decision.

That meeting broke a logjam, and several months later the state officially approved the PM and R unit for CGH. In December 2003 Senator DeFrancisco helped us cut the ribbon at the PM and R opening on 4 East. I have a picture of that event in my office. He arrived here a few minutes before ribbon-cutting and asked me about CGH plans. I told him about the cardiac catheterization laboratory being developed in partnership with St. Joseph’s Hospital Health Center. In his typical way, the Senator asked several blunt questions, then said simply, “I’ll support it.”

Fast forward to the opening of the cardiac cath lab on February 14, 2006. The Senator had not only endorsed the project to the state, he had obtained $500,000 in state funds for it. A plaque outside the cath lab commemorates his assistance in securing that funding.

Two weeks ago the Legislature passed the 2007 state budget after a particularly difficult budget season.[1] As proposed by the Governor, the budget would have cost CGH some $940,000 a year. In the end, some of the proposed cuts were reversed by the Legislature. The new state budget will cost CGH about $440,000 a year. That is a significant reduction in revenue, but it is about a $500,000 improvement over the budget’s starting point.[2]

Two days after budget passage, Senator DeFrancisco called me. He said he had been able to secure in the final budget $200,000 in capital funds for CGH. “I know you can use it,” he said. Needless to say, I expressed appreciation for his assistance.

This was a difficult budget year and, despite the relative improvement for CGH – that is, fewer budget cuts than first proposed – the budget is a problem. All hospitals should have a bottom line of two or three percent a year so they can fund the necessary upgrades in equipment and physical plant.

CGH has been fortunate to have had a positive bottom line in each of the last four years, but in every case it is less than one percent. Enough to get by. But not what we should be earning as we make the longer term investments in patient care. The new state budget does nothing to help. It merely hurts us less than it could have.

In this difficult environment, CGH has had a constant friend in Senator DeFrancisco. He is interested in what we do, he has expressed support when needed, and he has secured additional state funds when it helps.

Thank you, Senator DeFrancisco.


_________________________________________
[1] I wrote about the “The worrisome state and federal budgets” in my family letter of March 10, 2007. For a copy, go to www.cgh.org/cghfamily

[2] In the weeks since budget passage, there has been a lot of talk in government and health care circles about who won and who lost the budget battle. Health care spending was particularly contentious this year with statewide advertising by SEIU 1199 and Greater New York Hospital Association, as well as advertising by the Governor himself. According to Crain’s Health Pulse, April 12, 2007, the Governor’s campaign manager said the budget includes $1 billion in health care cuts of the $1.3 billion initially proposed, or 77%. The Governor’s office considers the budget battle “a success.”

The doctor as STAR

Yesterday was “doctor’s day” at CGH, and members of the medical staff stopped in the cafeteria for a free pancake breakfast – and a chance to socialize with their medical colleagues. In today’s fast-paced, high-tech world, a pancake breakfast is a low-tech opportunity for doctors simply to say “hi” and take a moment to catch up with one another.

Physicians have faster access to information, such as the Digital Passport,[1] but they may actually see one another less frequently than in the past. With hospitalist services available to patients, many physicians spend more time in their offices and less time at CGH. With more outpatient care, the hospital is not the sole focus of physicians’ busy lives. So CGH’s “famous pancake breakfasts” are an opportunity for doctors stay in touch on a personal level, not just professionally.

Yesterday, the doctors’ pancake breakfast added a new dimension, thanks to Dr. Andrew Merritt, the Marcellus family physician who is serving as CGH’s interim Chief Medical Officer, or CMO. Dr. Merritt has started a “physician STAR award” to recognize doctors with star qualities – that is Sensitivity, Thoughtfulness, Appreciation, and Respect (STAR).[2]

I was pleased to join Dr. Merritt yesterday in presenting CGH’s first STAR award to Dr. Joseph Barry of Preventive Medicine Associates, PLLC in Camillus, NY. Dr. Barry, who also serves as medical director of CGH’s skilled nursing facility (sixth floor), “on a routine basis sets aside time to play chess with multiple residents on 6 West,” in the words of one nomination form.

Dr. Barry’s “genuine humor and lighthearted challenge to residents has created a splash of excitement,” on the sixth floor, and his “thoughtfulness extends to the rest of the residents who…come to watch the ‘the chess match’…” During the match, Dr. Barry talks with the residents “on a casual, loving level,” and he is “always generous to provide pizza as a prize if he loses…”

Another nominator called Dr. Barry “a man of the people, always approachable,” and “someone who totally immerses himself in an medical problems from the patient’s perspective.”

The STAR award comes with a certificate for the physician, dinner for two at a local restaurant, and a special visit (next week) with treats for the doctor’s office staff – all courtesy of the Auxiliary to Community General Hospital.

Medicine may be more fast-paced than ever. Physicians may communicate less in person and more over the internet. But the STAR award reassures us that physicians, as busy as they may be, continue to make a difference on the human level.

Thank you, Dr. Barry.


[1] The Digital Passport is CGH’s name for several electronic information initiatives that started in 2005 and will continue to roll-out over the next two years. They are SCM Clinical Manager, Computerized Physician Order Entry (CPOE), and the Surgery Information System (SiS).

[2] Anyone can nominate a CGH physician for a STAR award. On any CGH computer, go to CGHNet and move the cursor to “Point Here” to find the drop-down menu. On the menu find “Forms” and click on “Physician STAR Award.” This brings you to the STAR nominating form. After completing the form, return it to Trudy Orr or Joan Russell in the Medical Affairs Office.

What the CEO said...

I wrote my first family letter on October 20, 2002 (my third week as CEO), and with a few exceptions I’ve been writing my thoughts every Saturday since, e-mailing these letters to departments and posting them on the CGH website. They remain on the website for about six weeks, and anyone can write to me by return mail from the website.

I’ve recently become aware of a hospital CEO who puts these humble letters to shame. He’s Paul Levy, the President & CEO of Beth Israel Deaconess Medical Center in Boston, and he writes a blog.[1]

If nothing else, Mr. Levy’s blog is impressive by its sheer scale. The blog contains about 55,000 words. This letter, for example, is 590 words in length. If I write four such letters a month, it will take me almost 24 months to equal the length of Mr. Levy’s blog – and he’s been writing only since last August! How does he find the time to do it?

But his blog is more than mere words. Mr. Levy discusses everything from his hospital’s infection rates (“We saved one person's life. Can we keep it going?” February 16, 2007) to questions about expensive new technology (“daVinci Uncoded…” February 20, 2007). He’s written about the SEIU union organizing campaign at Beth Israel Deaconess (“Union Issues,” August 25, 2006) and even about his own income (“Do I get paid too much?,” January 28, 2007).

According to the Boston Globe:

There are some things that Boston hospital executives generally believe are best kept quiet. Gripes about competitors are one. The rates of hospital-acquired infections among patients are another, at least at this point.

Then came Paul Levy's blog.

In August, Levy…began writing an Internet blog called ‘Running a Hospital,’ about the inner workings of an academic medical center. Since then, he's broken a few unwritten rules.[2]

Last week another Boston hospital was in the news, again because of something its CEO wrote. Dr. Paul Slavin, CEO of Massachusetts General Hospital (and a competitor of Bet Israel Deaconess), wrote a memo about that hospital’s recent unannounced survey by the Joint Commission.[3] He didn’t post his memo on the web, but when it came to the attention of a newspaper, it was news because Dr. Slavin talked about deficiencies in Mass General’s hand washing (one of my favorite subjects), medical records documentation, pain management, and medication reconciliation.

That memo prompted the Globe to editorialize. “But how does this renowned institution [Mass General] compare with other hospitals?” [4] The paper continued: “Paul Levy, president of Beth Israel-Deaconess, courted controversy on his blog ‘Running a Hospital’ last December when he listed the rate of infections for a common procedure at his hospital. He challenged others, including MGH, to do the same. They haven't done so yet.”[5]

Meanwhile, a blog by the Wall Street Journal (yes, another blog) asked the following question: “What’s your take on Levy’s blog? Self-indulgence? Or a welcome experiment in accountability in health care?”[6] The responses from readers have been generally positive. Some readers pointed out that Mr. Levy’s blog seeks a public relations advantage, others gave Mr. Levy credit for being “transparent” about hospital quality measures, and others said “time will tell.”

In past letters, I’ve written about the many changes affecting doctors and hospitals, about the financial pressures from state and federal budgets, and about the relentless movement toward public reporting of hospital outcomes.

It’s time to add CEO memo writing and blogging to our record of “these changing times.”



[1] Paul Levy’s blog address is: http://runningahospital.blogspot.com/ Blogs are an on-line diary or journal in which an individual provides daily commentary on a particular subjects, such as news events or a job or a hobby. The word “blog” is a blend of the words “web log.”
[2] “Blog tests hospital leaders' patience,” Boston Globe, February 23, 2007.
[3] CGH is expecting its own unannounced survey by the Joint Commission any time this year. It could be as early as next month – or next week.

[4] “Improvement time at MGH,” Boston Globe, March 20, 2007.
[5] Ibid.
[6] “Paul Levy, Online CEO,” Wall Street Journal Health Blog, March 16, 2007. The blog entry is available at: http://blogs.wsj.com/health/2007/03/16/paul-levy-online-ceo/

Trust but verify

On March 13, 2007 at an early morning Board of Directors committee meeting, the Directors (that is, my bosses) excused me from the room to meet in confidence with Deb Kurtz, Director of Corporate Compliance.

Deb had just completed her semi-annual report to the Board Corporate Compliance Committee where she documented and discussed activities used to monitor and investigate CGH business practices. “Corporate compliance” means that CGH follows ethical and legal business practices. In other words, we do not issue fraudulent bills, and we do not engage in illegal practices with vendors or doctors.

In her report Deb briefed the Board about calls she gets on the “corporate compliance hotline.”[1] Such calls may come from many sources, but they are typically from employees asking if it is appropriate to accept a gift from a patient or wondering if a vendor might be using unfair influence with CGH. Each call has to be taken seriously because any one of them could be a warning that something is not as it should be. Corporate compliance is something the Board wants to know about, up to and including any potential unethical behavior involving senior management.

I should note at this point that CGH has a well-developed policy about such things (called the corporate compliance policy) that sets forth the do’s and don’ts of business practices for everyone who works here, whether our job is to negotiate contracts with doctors, order materials from suppliers, or work directly with patients. [2]

So why do I leave the room when Deb speaks to the Board? To assure she and they are able to speak freely about anything, including any potential matters affecting the management of the hospital. This is another safeguard against bad business practices.

Sometimes I hear from people that it must be great to be president because “you get to do whatever you want.” Well, that’s not true. I have responsibilities to the organization, the same as anyone does, and the Board, with its oversight function, has a responsibility to assure that I do my job – and in this case, to assure that I do not misuse the job in illegal or unethical ways.

Ronald Reagan had a catch phase, used repeatedly during the final days of the Cold War – “trust, but verify.” The US was willing to subject itself to verification that it had, in fact, dismantled the proper number of nuclear warheads as specified by treaty – and the Soviet Union must be willing to subject itself to the same verification. It is not enough to trust that people do what they are supposed to do – you have to verify it.

A recent article in the Wall Street Journal featured, of all things, an interview with two convicted felons.[3] The two individuals served time in prison because they defrauded the investors of their companies. Both have since been released, and both talked to the newspaper columnist about fraud. Interestingly, their message was similar to Mr. Reagan’s. They said, “Do not trust – verify." Verify what? asked the Journal’s columnist. "Everything,” the ex-convicts said. “Criminals are scared of skeptics and cynics….We are petrified when you verify our representations.”

“Criminals” is a strong word, and none of us expects a criminal to be working among us – but how do we prevent fraud except by being prudent and having in place systems that document and check? If 99% of us are trustworthy, we still need controls in place to assure that the other 1% do not harm patients or misuse hospital resources. Each of us reduces the risk of unethical or illegal behavior when we understand, cooperate with, and help enforce the corporate compliance policies.

So the Board may trust Tom Quinn when he represents that CGH is operating according to ethical principles, is complying with laws, and has in place systems to identify errors or wrongdoing and to fix them. But they also want to hear directly from Deb Kurtz – so they verify it too.




[1] CGH’s corporate compliance hotline number is 492-5965. It may be used anonymously by anyone to report a potential violation of the law.

[2] The corporate compliance policy is available in two locations on CGH computers. In Outlook, find “Public Folders” and click on “All Public Folders,” then open “Corporate Compliance.” In CGHNet, find “Manuals” in the dropdown menu, click on “Other Manuals,” and open “Corporate Compliance.” The Healthcare Fraud and Abuse Prevention, Corporate Compliance Program Handbook is available in both locations. The handbook is 32 pages long, plus two Appendices. There is also a copy of the Handbook in each department.

[3] H. Greenberg, “My Lunch With 2 Fraudsters: Food for Thought for Investors,” Wall Street Journal, March 3, 2007

The power of the initials "RN"

I want to share the following message I received from a registered nurse:

I just finished reading your letter[1] and felt compelled to write. My mother…has also been ill and entering her third week in hospital care. She had an MI[2] three weeks ago. Since then my sister and I have learned a lot. But for myself, as a medical professional and an RN, the lessons have been invaluable and worth passing on.

I learned the power of the initials "RN" that I have taken for granted for 25 years.

I learned it is important to proudly say, “I am the RN taking care of you today, and if you have any concerns or questions, I am the person you can come to today.”

This statement is a simple one, but could have saved so much time and confusion. I never knew who was who. I asked questions over and over to the wrong people, mixed with painful emotions, and the lack of slack of sleep and energy did nothing but build anxiety.

It would have been so simple to have known at the beginning of each day...who could answer our questions or at least steer us in the right direction.

We learned many other things along the way, but this I felt was the most simple and a good one to pass on to my colleagues….

We grow as professionals when we see our world through the eyes of patients and family members.

The writer gave me permission to print her letter without her name. I thank her for her personal and important message.


[1] On January 27 I wrote: “Two of my relatives were hospitalized in the last two months, and their experiences reminded me how different is the hospital world that a patient experiences from the hospital world we see every day as caregivers. What is obvious or routine to caregivers 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.” (See “Stop me if I say something you don’t understand,” January 27, 2007.)

[2] "MI" is myocardial infarction, a heart attack.

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).

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 http://www.nyhealthcarecommission.org/final_report.htm
[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.