Healthcare Review

Rich Van Loan, CRPC(c)

By Rich Van Loan CFP(r), CRPC(c)

It was easier to teach children the value of a dollar when cash was a more tangible commodity. Credit, stored value and gift cards have made money invisible – creating an extra challenging environment for instilling financial discipline in your kids. But don’t despair; despite the challenges, there are still ways to pass on your financial wisdom. Here are some practical tips for teaching your children about the realities of hard-earned cash:

Start early.  Let’s face it; your kids are much more likely to heed your advice when they are young than during those years when they seem to think they know everything. It’s important to communicate your values about money during the formative years. Take advantage of opportunities to teach the difference between needs and wants. This will prepare them for making good financial decisions in the future.

Make allowance count. Correlate allowance with responsibilities like feeding pets, taking out trash or other household chores. The level of responsibility and the amount of the allowance should be appropriate for the child’s age and your own financial means.

You may also want to dole out allowances in denominations that encourage saving.  If the amount is five dollars, give five one dollar bills and suggest that at least one dollar be set aside for savings.

Encourage financial goal-setting. Work with your kids to create a list of things they want to save for-big and small. Then help to prioritize the list. Nearly every item children ask for regularly can become the object of a goal-setting session. It’s an activity that establishes discipline and helps children grow into financially responsible adults.

Allow participation during banking transactions.  Being involved in the process of depositing and withdrawing money will teach children how banking works.  It’s important that you don’t repeatedly refuse them when they want to withdraw their savings for a purchase. If they think the money is off limits, it may discourage them from saving at all. However, it’s a good time remind them about the goals they’ve set and to think about whether the desired purchase will derail their priorities.

Alert about the hazards of borrowing.  One sure way to teach kids about the perils of debt is to actually charge them interest on small amounts you lend them. If they run out of money before their next allowance is due, loan them the cash, but make sure they know the loan comes at a cost. Agree upon an interest rate and work with them to determine the payback amount. They will quickly learn how expensive it is to use someone else’s money.

Educate about credit card use.  Kids should learn that every time the plastic is used, it creates a bill that must be paid each month. When making a credit card transaction, take the opportunity to explain how the process works, how to make sure the charges are accurate, and how to be protected from credit card fraud.

Teach investment basics sooner than later. The first step for young investors is to understand the concept of risk versus reward. Before putting real money on the line, your child can test his or her stock selection skills by choosing two or three stocks and then following their performance.  You’ll generate more excitement if your child is allowed to choose a company that he or she is familiar with.

If you jointly decide it’s time to graduate to an actual purchase of stock, you’ll have to set up a custodial account since minors can’t own stocks or open brokerage accounts in their own name.

Don’t expect that you’ll have all the answers to raising financially responsible children right away. Resources are readily available online or through a financial advisor. Just remember that your determination and patience will be rewarded as you watch your kids blossom into money-smart adults.

Rich Van Loan is a Financial Advisor, CERTIFIED FINANCIAL PLANNER(tm) Professional and Chartered Retirement Planning Counselor SM with Ameriprise Financial Services, Inc. He can be reached at 617-337-3233 or via email at Richard.r.vanloan@ampf.com.

Gary Daniels

By Gary Daniels

• We will review out Strategic Plan goals and objective to ensure we are addressing the most critical issues before our institution:
• Operate at costs that decreased reimbursement, particularly Medicare, can sustain
• Meet patient and payer quality expectations, best practices, support care coordination
• Anticipate new payment models such a bundled payment
• Prepare for increased coordination across providers – working within a medical home model, participation in an Accountable Care Organization
• Implement information systems that will support the above.
• We will inventory the skills and characteristics of our Board, identifying skills the Board needs to support our strategy and then recruiting members with those skills.
• We will conduct our annual Board Assessment early in the year, identifying areas for improvement, implementing appropriate changes.
• We will develop a Board education program that responds to the Board assessment and supports the Board strategy with education sessions at Board meetings, readings and attendance at outside education programs.
• We will review our Board orientation program to ensure new Board members are well prepared – we will ask recent new members to the Board how we could improve orientation.
• We will implement a voluntary mentoring program for new Board members, providing new members with support during the first year on the Board.
• We will streamline our Board meetings ensure that we are addressing the important strategic issues and are not rehashing work done by our committees.
• We will not micro-manage.
• We will review our CEO evaluation process to ensure that it is thorough, incorporates the strategic goals and meets IRS requirements. All Board members will be aware of the results of the evaluation, the CEO salary and how that salary compares to other CEOs in comparable hospitals in the region.
• We will ensure that there is a CEO succession plan.
• We will evaluate new opportunities for revenue through philanthropy.
• We will regularly take time to celebrate the successes of the institution’s management, providers, staff and our Board.

Happy New Year!

Gary Daniels, FACHE
Gary Daniels Consulting, LLC
PO Box 200
Newbury, NH 03255
(603) 763-4875
(603) 505-1110 Cell
danielsconsulting@myfairpoint.net

By Rich Van Loan, CRCP

Rich Van Loan, CRPC(c)

In the face of the skyrocketing costs of health care services and insurance coverage, one benefit that can give households some relief is access to a Health Care Flexible Spending Account (FSA). If your family is taking advantage of an FSA, this might be the season when you have to decide how much money to defer from each paycheck toward your FSA. As you make your plans, keep in mind that rules about FSAs are undergoing changes as part of the recently enacted Affordable Care Act.

FSAs allow individuals to set aside pre-tax dollars from their paychecks into an account that reimburses them for qualifying out-of-pocket medical expenses. You can reduce taxable income by using this account for everything from co-pays or deductibles on doctor visits and prescription medicines to LASIK eye surgery and major dental work. The ability to use pre-tax dollars for these expenses is a way to stretch the value of your salary to help you cope with out-of-pocket medical expenses.

A new restriction for 2011
If you participate in an FSA, you should be aware of an important change that became effective on January 1, 2011. You can’t use FSA dollars to offset the costs of over-the-counter drugs unless they are purchased with the authority of a doctor’s prescription (there is an exception for insulin). This means you must submit a prescription along with a receipt for the purchase to your FSA provider to be reimbursed for the purchase of over-the-counter medications.

If you are having thoughts about trying to work around this new restriction on the use of FSA dollars, think again. If you use FSA money to purchase non-qualifying medical products or services, the amount will be included in your gross income and you could be subject to an additional penalty tax of 20 percent.

More flexibility for children
The Affordable Care Act requires employers who offer dependent health care coverage to cover adult children up to age 26. Recently, many employers have started providing more flexibility with FSAs, too. In the past, most employers restricted the use of FSA dollars to costs for dependent children. But now many employers allow the money to be used for an individual’s children who will not turn 27 before the end of the year.

Changes in the future
Since there is no regulatory limit, many employers allow you to make contributions of up to $5,000 to your Health Care Flexible Spending Account. If you have major out-of-pocket expenses to deal with, such as a child’s braces or a specialized surgery that is not covered under your medical plan, you might want to try to schedule them to occur before 2013.

Starting that year, the annual maximum limit you will be able to contribute into your FSA will be $2,500. That will reduce your options on how much pre-tax money will be available to pay for large medical expenses.

The specifics of a plan can vary by employer so be sure to find out how your FSA option works.

Rich Van Loan is a Financial Advisor, CERTIFIED FINANCIAL PLANNER(tm) Professional and Chartered Retirement Planning Counselor SM with Ameriprise Financial Services, Inc. He can be reached at 617-337-3233 or via email at Richard.r.vanloan@ampf.com.

Gary Daniels

By Gary Daniels, FACHE

Yes, Santa may leave you a bundle under your Christmas tree. But not a bundle of toys or a bundle of cash, but rather bundled payments, the proposed new reimbursement methodology by Medicare.

What is a bundled payment? CMS defines a bundled payment as a “means that rather than paying separately for each item or service, a single payment is made for a defined group of services. The bundled payment may cover services furnished by a single entity (hospital or other provider) or it may be used to pay for items and services furnished by several providers in multiple care delivery settings.”

Typically bundled payments cover an episode of care, such as a hip replacement. Bundled payments shift the financial risk from the payor to the providers.

Why is CMS interested in bundled payments?

Simply put, CMS believes bundled payment may be the most feasible way to reduce costs while maintaining or improving quality. Their assumption was at least partially supported by a 2009 article in the New England Journal of Medicine where savings in national (all payors) health care spending could be reduced as much as 5.4% during the ten year period 2010-2019.

The estimate was based upon “optimistic scenarios” in the Prometheus bundled care project, recognizing the past difficulty of implementation of reimbursement changes. Recent studies by the Rand Corporation have substantiated that difficulty – “there is a tremendous amount of interest in this type of payment reform, but we found that transferring it into practice is extremely difficult,”

Why the interest now?

In August, CMS released the Bundled Payments for Care Initiative which intends to

• “Support and encourage providers who are interested in continuously reengineering care to achieve ‘better health, better care, and lower costs through continuous improvement’
• Create a positively reinforcing cycle that leads to decreasing the cost of an acute episode of care and the associated post-acute care while fostering quality improvement.
• Develop and test payment models that create extended accountability for three-part aim outcomes for acute and post-acute medical care.
• Shorten the cycle time for adoption of evidence-based care.
• Create environments that stimulate rapid development of new evidence-based knowledge.”

Will this impact my hospital?

Maybe. It is a voluntary program that will provide opportunities to study the implementation and impact of bundled payments; in other words a study but with real reimbursement impact on those involved. Cost reimbursed hospitals, CAHs, are not eligible to participate alone, but may partner with the primary target hospitals – those that are paid solely under the Inpatient Prospective Payment System.

What does this mean to my Board?

• Education – All Board members should be familiar with bundled payments and studies such as the Bundled Payments for Care Initiative where alternative models are being evaluated. Invite knowledgeable speakers on the subject, such as reimbursement specialists from you auditor, hospital association staff, CMS representatives or other hospitals that are participating in studies.
• Strategy – Include consideration of bundled payments in your strategic planning. Of particular importance are
• What collaboration could be required such as physicians, both primary and specialists, and post-acute care? How can we achieve that collaboration?
• What infrastructure will be required such as protocols for care across providers, technology to measure cost and care and administrative capacity to allocate payments?
• What advantage is there to participate early?
• Physician relationships – Physicians will be increasingly important to implement evidence-based care, to measure quality and to help reduce costs under any method of payment, bundled payments make such collaboration even more vital and urgent.
• Quality – Payors emphasize their intent to utilize the new methodologies to improve quality. That may well be true, but it is reasonable to assume their primary intent is to reduce cost. While with increasing health insurance premiums and the impact of Medicare and Medicaid on national finances we may agree, it is still a fundamental responsibility of the Board to assure the quality and safety of care throughout the organization. This responsibility is even more important with bundled payments.

With the 2012 election before us, the rhetoric about the health care reform is in the news every day. Payment reform under Medicare will happen, with or without the Affordable Care Act. Your board should be aware of what is happening so you can make the most advantageous decisions for your hospital and your community.

1. “Bundled Payments for Care Improvement Initiative, Frequently Asked Questions, August 23, 2011
2. “Controlling U.S. Health Care Spending – Separating Promising from Unpromising Approaches” Peter S. Hussey, Ph.D., Christine Eibner, Ph.D., M. Susan Ridgely, J.D., and Elizabeth A. McGlynn, Ph.D.N Engl J Med 2009; 361:2109-2111 <http://www.nejm.org/toc/nejm/361/22/>November 26, 2009
3. “Bundling Payments to Curb Health Care Costs Proves Difficult to Realize”, Rand Corporation, November 7, 2011

Gary Daniels, FACHE
Gary Daniels Consulting, LLC
PO Box 200
Newbury, NH 03255
(603) 763-4875
(603) 505-1110 Cell
danielsconsulting@myfairpoint.net

“Health care is the most difficult, chaotic and complex industry to manage today.”

Peter Drucker on Hospital Management

Gary Daniels

You probably have heard the above quote from Drucker, if not before you joined the hospital Board, then certainly soon after.  His comment is never truer than today. In just the past few weeks we have seen local headlines describing

• Layoffs of hospital employeesá
• Early retirement programs
• Reduction in services to Medicaid patients
• Reactions to cost-shifting by insurers financially incenting patients to seek care outside their traditional service communities.

It is not the position of this writer to comment whether these decisions are right or wrong.  Rather it is more appropriate here to acknowledge the circumstances hospitals are now facing that have prompted these actions and the challenges faced by governing Boards in approving them.

When facing immediate and substantial financial impact hospital Boards are asked to make difficult choices, such as the following described in the Policy Blog NH;

• hospitals can lower their costs by providing the same level of care more cost effectively;
• they can shift the costs to private insurance premiums;
• they could do nothing and absorb the loss with existing operating margins or funds from endowments and hospital foundations;
• or they can reduce the community benefit they provide, for example, to local clinics.”

In the short term the impact is most often on what can be done most quickly – reducing labor costs and eliminating or modifying services. Shifting costs to private insurers is less and less feasible. Absorbing losses from existing margins or other sources is likely also not feasible for most because most operating margins are less than 2% with many, particularly those serving the most Medicaid and Medicare patients, are negative.

Where do you go from here?
The financial problems will not go away…they are only temporized with short term actions. Furthermore, some form of health care reform has joined death and taxes as inevitable. It will not be enough to be financially strong. No money, no mission is still true, but the mission and the vision for your organization are paramount or in more personal terms, your patients are the ultimate concern.

You have spent much of your Board’s time making difficult, nearly impossible, decisions. How much time have you spent looking into the future, addressing the first action mentioned above from the Policy Blog -”lower their costs by providing the same level of care more cost effectively.” Day-to-day issues are much easier for the Board, management and providers to address. And such discussions often become strategy by extrapolating the present into the future. That may have worked well, or at least was good enough, in the past. The environment is too unstable for that tactic to continue.

Strategic thinking
Strategic thinking does not ignore the present. Rather, it considers the current environment, internal and external, in combination with the expected future environment identifying what must change for the organization to continue to succeed and achieve its mission. Strategic thinking encourages thoughtful and creative approaches to identify future a direction that builds upon organizational strengths and best utilizes increasingly limited resources.

For example, strategic planning for hospitals, large and small, has typically focused on acute care. While such care will always be important, other parts of the continuum of healthcare (community-based care and recovery and rehab care) will take a larger, if not dominate role, particularly for most community hospitals. Strategic thinking will lead governing Boards to establish organizational direction consistent with these anticipated changes.

What does your Board need to think strategically?

• Time – make sure your Board and your Board committees make the time to devote to strategy
• Talent -The right people involved, particularly those who can place the patient experience, in whatever continuum of care, first
• Treasure, i.e. information – learn what is be considered in your state and nationally, go meetings, read journals, invite speakers
• Strategic thinking is the relentless focus on the future and how your organization can best achieve its mission (which, of course, may be redefined) – don’t fall back to the day-to-day orientation. Strategic thinking is also the recognition that you will never again have a neat plan for the next five years. Instead you will constantly be looking at your plan adapting it to the changing environment.

I will end with another comment from Drucker … “The hospital is altogether the most complex human organization ever devised.” And it is getting more complex each day.

Gary Daniels, FACHE
Gary Daniels Consulting, LLC
PO Box 200
Newbury, NH 03255
(603) 763-4875
(603) 505-1110 Cell
danielsconsulting@myfairpoint.net

By Rich Van Loan CFP(r), CRCP(c)

Rich Van Loan, CRPC(c)

As if our financial system hasn’t suffered enough – or caused enough suffering – economists worry that more difficulties lie ahead in the student lending sector. Students, parents and lenders alike are stressed by rising tuition costs, mounting debt and a weak job market. Will the student loan bubble burst under the pressure?

For recent college graduates who borrowed heavily, these issues may hit very close to home. Federal loan repayment kicks in a mere six to nine months after graduation. Loan default, which can damage your credit report, makes it difficult to purchase a home, get a job or even find affordable insurance, is a very real possibility for many young people. If you’re a new college grad and facing your first loan repayment deadline — or have a child in this situation — here are some strategies that can help, even in tough times like these.

Gather the facts
To meet your debt obligations, you need to know how much you owe and when it’s due. Open your mail and read your loan agreements. While the numbers may be intimidating, they can also inspire action. Armed with concrete information, you can determine how much income you need to meet your monthly bills and focus your energies on tackling the challenge. If you have questions or have missed a deadline, contact your lender immediately.

Explore your repayment options
Before your grace period ends, familiarize yourself with the repayment plans offered on your federal student loans. With a standard repayment plan, you are expected to repay your loans with equal monthly payments over a 10-year period. Under special circumstances, you may qualify to extend the repayment period up to 25 years or make payments that increase over time as your income increases. Income-based repayment is a newer option that caps your payment based on your income and family size. Under this plan, you may pay less than 10 percent of your income, and if you still owe after making payments for 25 years, your balance may be wiped clean.

Keep it simple
When you set up your repayment plan, opt for automated monthly loan payments. It’s a convenient service – you can be confident your payments will be made on time and avoid the temptation of spending the money elsewhere. Most importantly, you may be eligible for an interest rate reduction when you sign up for automatic debit. Ask your lender about automatic debit benefits.

Get a job ASAP
Though it may be easier said than done in a struggling economy, be realistic about making income now that you’re a college graduate. Backpacking your way across Europe after may sound like fun, but think ahead to how it will affect your job prospects and your wallet as your loans come due. Polish both your resume and interviewing skills. If necessary, take a job outside of your field to generate income as you search for something better. Even part time work can help pay the bills.

Delay repayment, if you must
If you simply cannot manage your student debt, talk to your lender immediately to determine if your case warrants special accommodation. You may also consider other ways to postpone repayment, as appropriate to your situation. For instance, if another degree or more course work will improve your job prospects and future income potential, you can defer student loan repayment by continuing your education. Take this course of action with care, as the last thing you want to do is incur more debt simply to delay repayment. Another way to postpone student loan repayment is to join a community service organization such as AmeriCorps or Teach for America. These programs provide valuable work experience and a modest stipend in exchange for your talents and an automatic extension of your student loan grace period.

Tap a financial expert
As any college student knows, information is power. Seek the expertise of a financial advisor who can help you sort out your financial goals and responsibilities and create a plan of action. If you’re considering a consolidation loan, an independent eye can help you evaluate lenders and weigh the feasibility of payments.

Your hard work will pay off – eventually
It takes time and effort to eliminate debt. Fortunately, when you’re young, you have time on your side and energy to spare.  Take advantage of the resources offered by your alma mater, your lender and your community as you face your responsibilities. With hard work, discipline and a bit of luck, you can make good on your loans and capitalize on the education you received from your school – and from the valuable experience of overcoming a financial hurdle.

Rich Van Loan is a Financial Advisor, CERTIFIED FINANCIAL PLANNER(tm) Professional and Chartered Retirement Planning Counselor SM with Ameriprise Financial Services, Inc. He can be reached at 617-337-3233 or via email at Richard.r.vanloan@ampf.com.

A Massachusetts hospital – $ 1 million settlement re potential HIPPA violation over lost outpatient records

A Connecticut health insurer – $250,000 fine after loss of a hard drive containing health information

By Gary Daniels, FACHE

Gary Daniels

All Board members are aware of the term meaningful use – the rules and regulations your hospital must meet to qualify for federal incentives under the ARRA (American Recovery and Reinvestment Act of 2009). Incentive payments are substantial, potentially involving millions of dollars over several years. Also part of ARRA are expanded responsibilities for HIPPA (Health Information and Protection Act) which if not followed can result in the penalties described above.

Non-compliance is, however, not simply about fines but is more about the mission of your hospitals. That is,

• Patients entrust providers with not only providing the best care, but also with keeping that information confidential.
• Participants on the EHR, especially medical professionals, must have confidence in the security of the system to ensure their involvement.
• Other organizations with whom your hospital shares confidential data, other hospitals for example, must be assured of the security of your system or they may not be willing to link their information system with yours, thereby jeopardizing patient care.
• As a Board member your fiduciary responsibility (acting in the capacity of a “caretaker” of another’s rights, assets, and/or well-being) includes the responsibility to ensure the security of confidential patient information. This responsibility is not new, you have always had it. But the conversion of patient records to electronic health records where thousands of records can be lost on a single hard drive, where hackers can penetrate your system and obtain information on thousands of patients or where and unintended error could transmit vast amounts of patient information to an unauthorized source, raises the importance of that responsibility to a much higher level.

In “Proactive Defense Kurt Long recommends that Boards consider

• Compliance, legal and privacy, incorporating relevant laws and regulations such as expanded HIPPA requirements , policies for disclosure and disposal of information, revised business associate agreements, and reporting of security breaches.
• Information security and privacy technology – not only the basic anti-virus and firewall technology, but also policies regarding encryption and audit of applications that involve patient information.
• Training policies and procedures – supporting the organization’s commitment to secure patient information.

How can your Board address such a complex and sensitive issue?

• First, the Board can request management prepare a Board education program about security of patient information, particularly electronic information, and the responsibilities of the hospital.
• From that meeting the Board can define in broad terms its expectations for an information security policy.
• The Board can then request that management develop the appropriate policies, and practices for Board review and approval.
• Few Boards will have members with the expertise to address information security. The Board may, therefore, want to create an ad hoc committee to address the problem, a committee that includes appropriate representation from IT, clinical and operations staff as well as expertise from outside the hospital determined to be necessary. The ad hoc committee can then prepare recommendations regarding information management security strategies for Board action.

[1] Proactive Defense, by Kurt Long, Trustee Magazine, July 2011

Gary Daniels, FACHE
Gary Daniels Consulting, LLC
PO Box 200
Newbury, NH 03255
(603) 763-4875
603) 505-1110 Cell
danielsconsulting@myfairpoint.net

John T. Lovett

Healthcare faces a new union organizing challenge. Right before Labor Day, the National Labor Relations Board (NLRB) dramatically multiplied union organizing opportunities within all non-acute healthcare facilities. Prudence requires understanding of what has happened, and what to do about it.

Specialty Healthcare Decision
The NLRB multiplied the opportunities unions have to form new “bargaining units” by giving them unprecedented new power to carve up a workforce for purposes of union organizing.  The NLRB now empowers unions to select any “readily identifiable” group in a healthcare facility for the purpose of starting a union. Only members of the union’s selected group will have a vote on unionization.

In the past, a union could not segregate CNAs from other employees who shared much in common with them. All employees who shared a “community of interest” in the healthcare facility would have a say in whether to give up their rights to a union. All this now changes with the NLRB’s decision in Specialty Healthcare and Rehabilitation Center.

The NLRB’s new standard for “units appropriate for collective bargaining” grows out of a United Steelworkers effort to form a union at a Mobile, Alabama nursing home, Specialty Healthcare and Rehabilitation Center. Only the certified nursing assistants (CNAs) at Specialty Healthcare showed an interest in supporting the union. The union would not have received the required majority support if other employees had a vote on unionization. Accordingly, the Steelworkers asked the NLRB to hold an election among only the CNAs. Going against decades of its own decisions, the NLRB gave the union what it wanted.

What Does This Mean for Employers?
Employers Face “Overwhelming” Burden. Unions may now choose employees “based on job classifications, departments, functions, work locations, skills or similar factors.” They may exclude from their chosen group co-workers who share much in common with those the union picks. To add additional voters, an employer must prove those excluded are “almost completely” alike the group the union wants. They must share an “overwhelming community of interest” with the union’s group. Otherwise, a union is free to pick any group it wants to hold a vote only among the members of that group.

Unions Will Choose So Employers Will Lose. The Specialty Healthcare decision reinvents union organizing. In practice, an organizing union will attempt to secure as much employee support as it can. The union will then ask for a vote only among sub-sets of employees who support it. Such “bargaining units” are sometimes called “micro-unions.”

A micro-union of non-essential or easily replaced employees may create little cause for concern. Often, however, unionization of even a small collection of employees can lead to big trouble. Union organizers will use micro-unions as a beachhead for unionizing others. Even a small union of key staff could bring some facilities to their knees. A real or threatened strike of specially licensed healthcare workers or similar essential staff would cripple many healthcare facilities.

For now, acute care healthcare facilities can breathe a sigh of relief. NLRB regulations prevent carving up acute care hospitals into micro-unions. Over the past year, however, the NLRB has announced it is considering other changes to its regulations. Even acute care facilities may not be safe in the future. For several reasons, including a U.S. Supreme Court decision warning against a proliferation of “bargaining units” in hospitals, however, micro-unions are unlikely to be approved for acute care hospitals soon. But, nursing homes and other non-acute healthcare organizations need to get prepared.

Preparing for Micro-Unions. To thwart union efforts to start micro-unions health care employers will have to create micro-union-free environments:

Past Areas of Union Strength.  The first place unions will look to organize micro-unions will be job categories, work functions, departments, or similar groups of healthcare workers where a union has shown signs of strength in the past. Have past union organizing efforts found pockets of support among particular groups in your facility? Watch for the union’s return now that it will likely not need the support of other employees.

Essential Groups of Employees. Healthcare managers need to be especially vigilant to protect classes of workers upon whom their facilities are especially dependant.

A Single Weak Manager. A single supervisor or department manager with poor “people skills” may not have been fatal to a facility’s union-free environment in the past. The overall strength of the management team delivered the support of a majority of the facility’s employees for remaining union free. A single poor manager may now cause a micro-union.

A Single Union Opinion Leader. Experience teaches that comparatively few employees do the thinking for everyone else whenever controversy or concern grips a healthcare organization. Now that the NLRB has endorsed micro-unions, a single opinion leader’s support for a union among his/her peers may force management to the bargaining table.

As noted above, the NLRB’s endorsement of micro-unions requires prudent healthcare executives to re-think their union risk and avoidance strategies. The rules of game have changed.

John T. Lovett is an attorney with the law firm Frost Brown Todd.  John chairs the firm’s labor and employment law practice group, he is a Charter Member of the American Employment Law Council, he is listed in The Best Lawyers in America(r) and has been named one of the “Top 100 Labor Attorneys” in the U.S. by the Labor Relations Institute.

Gary Daniels

As I sit at my desk listening to the pounding wind and rain from Hurricane Irene, only a few days after an infrequent East Coast earthquake, I think of disaster preparedness. The television commentators have warned us individually to have a plan, to have enough food for three days, to have an adequate supply of gas for our car and prescriptions for ourselves as well as having a plan for pets. But what about your hospital? Are you are aware of the hospital’s Disaster Plan…what does it cover…when was the last drill and how did it go….what is your role as a Trustee?

Disaster Prepared is a fundamental requirement for all hospitals, one supported by Joint Commission Accreditation, Medicare Conditions of Participation and state licensing. Should you as a Board member leave preparedness to regulatory oversight and the organization’s clinical staff and management? No, because such preparedness is part of your fiduciary responsibility. As a fiduciary you have agreed to act in the capacity of a caretaker of the wellbeing of members of your community as related to the services your organization provides. What then should you do?
Schedule a time at a board meeting when management and clinicians can discuss disaster preparedness. That discussion should include

• What is the plan?
• What is covered? (What could you normally expect in your community, what is unique – natural disasters, major accidents such as a plane or a bus, chemical spills, infectious disease outbreaks, as well as internal disasters such as fire or a  major computer crash)
• How often is the plan tested with a drill? What are the results of the most recent drills?
• How is the community involved in the plan and in the drills?
• How do you guarantee the necessary staff to support the hospital during the disaster – communication, transportation?
• How long could you organization operate in a disaster…similar to the advice to have three days of food in your house?
• How do you relate to other providers? What can be shared? How are transfers handled?

A part of your discussion should also include what support should the board provide. Disaster preparedness is expensive. The board should support those expenditures that are required for your organization to be ready – backup for power, communication and water systems, transportation, decontamination equipment, backup for information systems. Such expenditures should be considered as part of the annual capital and operating budgets and well as new facility plans.  The board should also encourage the participation of volunteers from the community where there assistance would be valuable, such as helping manage the potentially large influx of family and friends of the injured.
Disaster preparedness is primarily the responsibility of management and the clinical staff.  The board, however, has both an oversight responsibility as well as the ability to support planning efforts.

Gary Daniels, FACHE
Gary Daniels Consulting, LLC
PO Box 200
Newbury, NH 03255
(603) 763-4875
(603) 505-1110 Cell
danielsconsulting@myfairpoint.net

Gary Daniels

From U.S. New and World Report, “HealthDay” poster July 5, 2011

Yes, that is a recent headline appearing as the result of an article in the July 6th Journal of the American Medical Association. Researchers at the Harvard School of Public Health initiated a study “to examine the quality of care and patient outcomes of CAHs and to understand why patterns of care might differ for CAHs vs. non-CAHs.” The study included 4738 Medicare hospitals, over 2 million total patients, including about 150,000 CAH patients, discharged for acute myocardial infarction, congestive heart failure, or pneumonia in 2008-2009.

The conclusion was “compared with non-CAHs, CAHs had fewer clinical capabilities, worse measured processes of care and higher mortality rates for patients with AMI, CHF, or pneumonia.” CAHs were found to not as likely to have intensive care units, cardiac catheterization facilities, and electronic health records. In addition the CAHs were found to have care that was consistent with process of care defined by Hospital Quality Alliance.1 The study also found that the CAH patients for the three conditions studied had higher mortality rates – 7.3% higher for AMI (25.5% vs. 16.2), 2.5% for CHF and 2% higher for pneumonia.

What Should I Do As A Board Member?

Call the CEO and demand “what are we going to do?” Probably not the place to start for many reasons…the CEO may not know about the article and even if the CEO is aware, the study really needs review by a clinician experienced in public health studies.

Call the CEO and ask “what are our numbers?” This may be a more reasonable response, but don’t be surprised if the information you have is not helpful because your numbers are very small, handicapping a statistically valid conclusion.

Instead, it may be more reasonable to ask, through your Board, for your Quality Committee to review the study and promptly report back to the Board. Your charge to the committee should be:

Bring back a summary of the study the Board can understand (most are not clinicians or statisticians) verifying as possible the reasonableness of the overall conclusions.

Compare the results to your hospital as best you can. More relevant may be a comparison to CAHs in your state…your hospital association should be helpful.

Return with recommendations for care at your hospital. For example,
If you do not have an ICU, adding such a service is likely not be clinically or financially feasible, in which case you must consider the best patient options such as direct transport to a referral hospital if within a distance to be clinically appropriate, which may already be done.

Cardiac catheterization is probably even more infeasible for your hospital, so how can you ensure the decision for the procedure is more promptly made and the patient is transferred as soon as clinically appropriate.

As a Critical Access Hospital you were required to develop a Network Agreement with a referral hospital; that agreement includes:

• Arrangements for patient referral and transfers
• Development of a shared or common communication system, if feasible
• Arrangements for the transportation of emergent and non-emergent patients
• Agreements with a hospital or other entity identified in the state plan for appropriate credentialing for all medical staff and quality improvement initiatives.

Your network arrangement with the referral hospital can not only help ensure timely and appropriate transfers, but can also provide assistance in helping improve the quality of care provided in your hospital. As a Board member, identify what is being done with you network hospital encouraging their participation with your Quality Committee.

And finally, check with your CEO to be sure the hospital is prepared to respond to questions from the public and the press about the JAMA article.

The 1327 CAHs in the country provide essential care in their communities in face of some of the greatest economic challenges, both hospital and community, in the industry.  Studies such as this recent one in JAMA present an opportunity to improve that care.
[1] In December 2002, the organizations representing America’s hospitals joined with consumer representatives, physician and nursing organizations, employers and payers, oversight organizations and government agencies to launch the Hospital Quality Alliance (HQA).

Gary Daniels, FACHE
Gary Daniels Consulting, LLC
PO Box 200
Newbury, NH 03255
(603) 763-4875
(603) 505-1110 Cell
e-mail: danielsconsulting@myfairpoint.net