John Z. Kukral, President and CEO of Blackstone Real Estate Advisors, was the evening’s honoree as he received the National Jewish Medical and Research Center 2004 Humanitarian Award on December 11, during the Real Estate and Construction Industries’ Winter’s Eve Gala at the Grand Hyatt New York. Owen D. Thomas of Morgan Stanley presented the award to Mr. Kukral. Also during the event, Michael E. Pralle, President and CEO of GE Real Estate and last year’s Humanitarian Award honoree, was inducted into the Council of National Trustees.

The event, which raised a record $2,563,900, established the Dr. Albert J. Kukral Memorial Fund for Respiratory Infections at National Jewish Medical and Research Center, ranked the nation’s number one respiratory hospital for the seventh consecutive year by U.S. News & World Report.
Le Clique provided the evening’s hot Latin entertainment to go with the South Beach theme. Trustee Wendy Siegel’s exceptional leadership again produced an energetic, fun, must-attend event for the movers and shakers in the real estate industry.

The dinner leadership reflected the broad support that National Jewish has enjoyed for decades from the real estate community. Thomas M. Flexner, with Bear, Stearns and Co., Inc., served as dinner chairman, assisted by James D. Kuhn, Newmark & Company Real Estate, Inc.; Bruce E. Mosler, Cushman & Wakefield, Inc.; Peter G. Riguardi, Jones Lang LaSalle; and Stephen B. Siegel,

Caption: John I. Kukral (center, holding plaque), President & CEO of Blackstone Real Estate Advisors, was the honoree at the record-setting “Winter’s Eve Gala” benefiting National Jewish Medical and Research Center. Pictured above (l-r) are: Michael E. Pralle, Thomas M. Flexner, Karin and John Kukral, Owen D. Thomas and Dr. Lynn Taussig, the president of the hospital.

Laying off 90 workers may not be as drastic a move as filing for bankruptcy protection. But the decision by Long Beach Memorial Medical Center cut jobs last month, only weeks after Henry Mayo Newhall Memorial Hospital sought Chapter 11 protection, is another sign of the stresses facing area hospitals.

Administrators at Long Beach and its sibling hospital, Miller Children’s Hospital, said they were forced to lay off the workers after their financial performance took a rapid turn for the worse in the third quarter.

The two hospitals, operated by Memorial Health Services, posted a net loss of $120,000 in the quarter ended Oct. 31, after recording a $2.8 million profit in the prior three months.
The layoffs will result in the closure of a wound care center and two pharmacies, a cutback in hours at an urgent care center, and the sale of an off-site clinic. Hospital chief executive Byron Schweigert said the goal was to avoid cutting bedside personnel.

THE stalemated labor dispute at Garfield Medical Center is heating up.

The Service Employees International Union and Tenet Healthcare Corp. have been fighting for two years over the union’s efforts to organize and negotiate a contract for the hospital’s 450 registered nurses.

The nurses voted 201 to 154 a year ago to form a union, but the two sides have yet to reach a contract. In fact, they have yet to sit down and talk.

Hospital administrators object to the inclusion of so-called “charge,” or supervisory nurses in the bargaining unit and challenged the union’s certification. The National Labor Relations Board rejected that challenge in August, but hospital officials still won’t come to bargaining table.
“They won’t even say they won’t negotiate,” said Jim Moreau, an organizer for the union, which has negotiated RN contracts at other local Tenet hospitals.

The hospital says it disagrees with the NLRB decision. But under the complexities of federal labor law, the case cannot be heard by a U.S. Appeals Court unless the union formally alleges an unfair labor practice for failing to negotiate.

“The courts are the place to settle this dispute,” said Eric Jian, the hospital’s director of marketing.

Moreau says the union won’t make such a formal allegation, because that would play directly into Tenet’s strategy, which he believes is to tie the matter up in the courts and wear the nurses down.

What’s ahead?
The union has the support of state Sen. Gloria Romero, D-Los Angeles, who said she would seek hearings to see what could be done to bring Tenet to the table (even though federal law supercedes state law in the case).

And after complaints by the union, the NLRB has alleged other unfair labor practice charges against Tenet that are to be heard at an April 1 hearing. Those include Tenet allegedly firing an employee for union activity.

No matter if you are in an executive or a management role at an academic center or a private practice hospital, as a physician leader you want your medical staff to not only understand the principles and theories of the quality and safety movements, but also to put them into practice.

Though there may not yet be a burning national safety platform, for the best organizations the train has truly left the station. For leaders of health care organizations, it is not a question of if, but how to facilitate improvement in patient safety among medical staff. Changing people’s behavior is difficult and education alone is not enough.
In 1999, Children’s Hospitals and Clinics of Minnesota began a journey to improve patient safety. Our CEO at the time, Brock Nelson, had an epiphany that year that changed our organization and how we operate.

Nelson had been advised by our attorney not to disclose to a family that our pathologists made an error in a diagnosis. Nelson went against the advice and further decided that Children’s would always disclose the full truth. In addition, Children’s hired a world expert in patient safety–Julie Morath–as our chief operating officer. With these two key events, Children’s of Minnesota had begun the effort to change our culture.

We then developed a specific agenda that included readiness, accountability, infrastructure changes, empowerment of all employees and staff, high reliability training, and new safety technology.
Children’s medical staff not only concurred with the agenda but also took leadership roles in its development, through the vice president of medical affairs, the elected chief of staff, the chiefs of divisions, and by adding a new position, medical director of patient safety.

Over the past seven years, we have continually updated and revised our patient safety agenda to expand and enhance its effectiveness.

One recent enhancement is a relatively unusual commitment made by our medical staff: All members who are appointed (and at reappointment) will continue to have to meet traditional conditions such as maintaining their licenses, getting continuing medical education credits, showing competencies in their fields, and being good citizens.

In addition, each member must also pass a test that demonstrates understanding of safety and quality principles. At appointment, staff is now given a package of critical communication components to absorb, followed by a test of 10 questions. The medical leadership of Children’s of Minnesota took this step in order to raise the bar on safety. Medical staff members will not be appointed or reappointed without passing this test.

How we did it

In 2004, as Children’s vice president of medical affairs and chief medical officer, I recommended to the professional executive committee that we commit to an expectation of patient safety knowledge before allowing appointment to our medical staff.

The recommendation further stated that upon staff members’ application for reappointment every two years, Children’s would offer updated information and knowledge about patient safety, and members must renew their commitment by taking a test again.

The recommendation was supported by the leadership of the professional staff, including the chief of staff, division chiefs, community physicians and Children’s boards of directors.

With the guidance of our director of patient safety, Children’s created a package of critical communications that focused on nine areas of patient safety:

1. Stop the line policies

2. Chain of command

3. SBAR communications

4. “Do not use” abbreviations

5. Verbal order read backs

6. Rapid response teams

7. Medical accident reporting

8. Universal protocol

9. Disclosures

These recommendations were instituted in 2006. The new process began with all of Children’s employed physicians, followed by all of the private-practice (community) physicians and advance practice nurses who apply for appointment on a two-year cycle.

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The requirement can be fulfilled electronically or on paper. We have also created a CD-ROM with the information available for individuals to review the necessary communication skills.

Here’s a look at the test:

Children’s Professional Staff Patient Safety Training Questionnaire

Please circle the correct choice.

1. If someone invokes the “Stop-the-Line” rule:

A. All participants will immediately stop and respond to the request by re-assessing the patient’s safety.

B. Assistance by any means most expedient shall be sought.

C. Emergency interventions may be initiated without prior express physician order.

D. They are acting in a manner sanctioned and supported by Children’s professional staff.

E. All of the above.

2. The chain of command policy is a Children’s policy that describes how an employee or professional staff member is expected to escalate an issue of concern depending upon the patient’s acuity.

A. True

B. False

3. The obligation to provide disclosure does not require that harm has occurred.

Torrance Memorial Medical Center has hired Tracy Weintraub as vice president of nursing services. Weintraub was associate chief nurse of medical-surgical nursing at the VA Greater Los Angeles Healthcare System.

North Adams Regional Hospital administrators wanted to automate the hospital’s medication delivery process to enhance clinical operations and reduce the potential for medication errors, especially at the point of care. The hospital provides primary care services, specialty physician services, and diagnostic and treatment services to citizens in northern Berkshire County, Mass., and southern Vermont. Each year, North Adams performs more than 2,200 surgeries, and its emergency department treats more than 20,000 patients.

To help meet its medication delivery goals, the hospital chose Deerfield, Ill-based Baxter Healthcare’s Patient Care System, an integrated medication management system that uses bar code scanning technology and personal digital assistants (PDAs).
Before automation, North Adams’ nurses relied on a traditional hospital unit-dose system with a 24-hour cart exchange. Automated dispensing from electronic medication carts on the nursing unit now provides the nurse with immediate access to new medications as soon as the order is entered in the pharmacy system. This improves patient care by eliminating the delivery time involved in 24-hour cart dispensing. In addition, pharmacy staff can view the exact time when a medication is administered compared to the scheduled time.

Reporting from this system will provide North Adams with very discrete data regarding medication administration times and any problems that might arise. Pharmacy technicians can now restock the electronic medication carts based on inventory data in the pharmacy since they no longer fill 24-hour medication carts. Pharmacist time is saved, since checking medication carts is no longer necessary.
North Adams installed the pharmacy system in April 2003 and began deployment of medication carts and bedside bar-coded medication verification the following December. The hospital is working unit by unit, and the next golive is scheduled for this spring. The manual system is still in place on units that have not yet implemented the Baxter system. Pharmacy Manager Mark Kester expects that nurses on all hospital units will use the new program by late summer or early fall.

Bedside Bar Codes

Upon admission, every patient receives a bar-coded bracelet. New medication orders are electronically entered into the system, and nurses and pharmacists can immediately view the information. The pharmacist then checks all orders electronically for drug interactions, allergies, duplicate therapy and dosage errors. Next, the pharmacist prepares unit-dose prescriptions, which are packaged, bar-coded and sent to the nursing floor. There, the doses are stored in a wireless mobile medication cart.

Before she begins her rounds, the nurse reviews a to-do list from a handheld PDA or the nurse workstation. She accesses the medication for each patient from the medication cart and pulls up the patient’s electronic medication administration record on a handheld scanner or touchscreen computer on the mobile cart. Only medications requiring administration at that time are shown, and the nurse is directed to the correct drawer, bin and medication within the mobile cart.

She then scans the bar-coded medication to confirm the right medication and dose, and the patient’s bar-coded bracelet to ensure that the right patient is receiving the right dose of the right medication at the right time via the right administration route. The medication is administered, the patient profile is automatically updated and then it is tracked to the patient’s electronic medical record. Information is also tracked by the pharmacy and updated in the hospital’s inventory and patient billing records.

Seamless Integration

Clinicians were hesitant to integrate a medication management system with North Adams’ legacy healthcare information system architecture. North Adams’ has relied on its MEDITECH HIS for 12 years, so the new pharmacy system had to integrate with the existing network. “When we replaced the pharmacy system, we had to make sure the new system would integrate with our current billing application, the application for transferring and admitting patients, and the laboratory information system,” Kester says. Patient Care System interfaced seamlessly with ADT (admissions, discharge, transfer) and the billing applications, and the hospital currently is testing the laboratory interface.

Change management has also played a key role. Baxter provided client service representatives to aid the North Adams team in building the database, training the staff and helping to work through the change management process that’s needed to successfully implement the system. Baxter also worked with North Adams’ IT organization to ensure that all interfaces were seamless.

North Adams experienced few training issues with its pharmacy system, but training nurses was “a more intense situation. A bar code system presents a very different practice environment for nurses that required a lot of practice change and workflow examinations,” Kester says. “In pharmacy, we have to be much more cognizant of the nurses, because what we do affects them in real time. If we don’t have the order entered by the time they want to give it, they’re looking for the order.” The biggest challenge, he adds, was helping the nurses become more familiar with the handheld computers they use to verify medication at the bedside.

Purpose-To develop and implement a billing process that fully integrates all activities of a pediatric nephrology and transplant program, by facilitating and coordinating data from patients, physicians, hospitals, and third-party billing services to maximize revenues.

Methods-Financial operations were analyzed via a randomized audit of patient charts that focused on office procedures and revenue collection. Results based on monthly reports documenting revenue received and outstanding, procedures billed, and patient registration accuracy.
Results-The combination of improvements in patient registration, chart documentation, new billing sheets with procedure and diagnosis codes, physician in-service education, upgraded charges, and the recredentialing of all practice physicians realized an increase in revenue collections from 18% in 2000 to 89% in 2001.

Conclusion-The need to integrate and coordinate information is vital for both billing accuracy and revenue collections. Integration of clinical services and billing procedures has maximized performance, profitability, and accuracy while decreasing administrative time and costs.
When Saint Barnabas Medical Center made the decision in 1996 to initiate a pediatric nephrology and transplant program (PNTP), the mission was to expand the scope of pediatric specialty services offered within the medical center, as well as fill a vital need for renal care for the children of our community. The PNTP was initially established as a subspecialty under the Department of Pediatrics, and was subsequently reassigned to the Transplant Division in 2001 for administrative purposes. The program, which consists of 2 pediatric nephrologists, 1 pediatric nurse specialist, 1 pediatric social worker, and 1 secretary, grew more rapidly than the hospital had anticipated-even expanding consultative services to 3 other affiliate hospitals throughout the state. In 1996, the PNTP provided services for approximately 600 patient procedures and visits, and performed 1 pediatric transplantation; in 2001, however, the PNTP performed more than 1500 patient procedures and visits, and accomplished 5 pediatric transplantations-without any increase in staffing. Over time, the PNTP developed ad hoc policies and procedures so that patient services were provided adequately, but these policies and procedures were largely inefficient. Although the PNTP’s growth and success were a tremendous accomplishment, the program lacked a critical administrative infrastructure, which gradually created organizational issues. For example, charts were disorganized, incomplete, and difficult to locate; billing sheets were deficient, lacking proper codes and diagnoses, which prohibited claims collection; and the physicians were not participating in many large-area insurance networks. Additionally, program growth initiated an increase in requests for materials and manpower, which prompted financial review by the hospital’s fiscal administration. Salaries for the 5 staff members comprised the majority of the program’s expenses. Revenues for the program are generated by the services provided by the 2 pediatric nephrologists, and are billed and collected by a third-party biller. Surprisingly, the financial analysis showed that despite dramatic growth, revenues had actually decreased. Even with this depressed financial picture, the hospital was committed to maintaining this extraordinary subspecialty service. Inadequate revenues were considered to be the result of either the complicated nature of dialysis and transplant finances, payer mix, and/or problems due to improper billing and collection. Because the Transplant Division had a history of demonstrated fiscal accountability, the hospital’s administration subsequently decided to have the Transplant Division oversee the PNTP administration and finances, while maintaining PNTP clinical ties to the Department of Pediatrics.

The Transplant Division at Saint Barnabas Medical Center consists of pretransplant, transplant research, transplant short stay, and posttransplant departments, and performs approximately 190 transplantations annually. The division utilizes a multidisciplinary approach to finance, which integrates clinical, financial, and contracting components, and deals with the technical component of charges. Despite limited experience with physician reimbursement-the transplant physicians are in private group practice and are not hospital employees-the Transplant Division lent its administrative support and assistance to the struggling PNTP. To begin, a review of office practices and procedures for the PNTP was performed, which revealed the absence of any defined or coordinated operational process. An additional benefit of this analysis was that financial concerns with respect to billing and reimbursements were uncovered, as well as issues involving medical record documentation. A project that began as an update of the PNTP billing sheet quickly evolved into an in-depth analysis of the PNTP. The results showed an obvious need for the development and implementation of a billing process that fully integrated all activities of the PNTP by facilitating and coordinating data from patients, physicians, hospitals, and the third-party billing service to maximize revenues. The creation of an operational system was necessary to allow for efficient, effective, and profitable performance, as well as to allow for the PNTP to accomplish the delivery of excellent pediatric patient care services. Research and inquiries also revealed that this pattern was prevalent in many other physician practices. The disjointed and duplicative processes that were in place added another level of complexity. The clinical and financial information had to be consolidated for operational efficacy.

In just a few years, consumer-directed health care has moved from the shadows of healthcare policy to the center stage of healthcare reform. Employers, the purchasers of health insurance for most working Americans, are rapidly moving toward these mechanisms to give workers and their families more choices (something consumers have been demanding for a long time) and to rein in spending by transferring the up-front costs and more overall financial responsibility to their employees.
Although employers and developers of consumer-directed health plans are marketing them as pathways to progress through consumerism in health care, no one knows for sure whether these plans will actually produce the promised improvements. Many industry observers and policy experts see significant gaps between the theory of informed, satisfied consumers and a potential reality of confused, frustrated patients. The sudden rise of CDHPs does not necessarily mean that they are a good idea or viable solution to the vexing problems of paying for health care.

However, CDHPs and their funding mechanisms–health savings accounts, medical spending accounts, and other health reimbursement arrangements–are ushering in a critical era for finance departments in hospitals and medical groups. Providers will increasingly be drawn into personal healthcare financing for consumers on multiple fronts. For better or for worse, the emergence of new financial realities for healthcare consumers creates serious and unprecedented challenges for leaders in healthcare finance.
Developing Consumer-Friendly Pricing

Consider a fundamental aspect of CDHPs: the belief that consumers will use a wealth of data to make informed healthcare decisions. With millions of consumers now covered by plans built on this premise, hospitals and medical groups will need to adapt quickly to the new world of consumer-directed health care. First, providers need to develop information systems that produce the quality and cost data being demanded by employers, consumers, and public and private payers. Second, providers need to be directly involved in developing the mechanisms that will be used to define value from the purchasers’ points of view.

For starters, providers will need to make sure their billing statements are clearly understandable to patients. Successful organizations will need to learn how to work with consumers who engage in price-based comparison shopping. Consumers paying the first few thousand dollars of care with their own money (not to mention coinsurance beyond the new, higher deductibles) will want to know prices in advance. Because payment has never been consumer-centric, however, pricing medical services remains one of the least transparent elements in our opaque healthcare system. Providing a comprehensible and accurate answer will not be easy, but neither will it be avoidable as rising consumer responsibility for health services becomes fact.

CFOs will need to analyze the true costs of every service that patients want to buy, whether it’s a gall bladder operation, hip replacement, or normal childbirth. “It depends” will no longer be an acceptable answer to the question, “How much does it cost?” for price-conscious, value-seeking CDHP patients who are shopping for elective care. Open-ended pricing will be acceptable only in the case of unpreventable complications and life-saving emergency care. Indeed, CDHPs may be the development that finally forces providers to standardize care (i.e., to eliminate avoidable deviations from acceptable practice) according to the imperatives of patient safety, error reduction, and evidence-based medicine.

In a sense, CDHPs will force providers to do for consumers what the prospective payment system forced upon hospitals with diagnosis-related groups in the 1980s and upon physician practices with resource-based relative value scales in the 1990s. Much like Medicare announcing it would henceforth pay only standard, predetermined prices for comparable services, consumers enrolled in CDHPs will oblige providers to offer consistent pricing across all categories of basic care. In short, transparent, up-front consumer pricing will be to the first decade of the 21st century what prospective payment was in the last two decades of the 20th.

Very important, hospitals will be pressured to develop bundled pricing for the majority of their services. There will always be exceptions–unusual procedures for which it will be impossible to estimate costs in advance. But exceptions will represent a tiny percentage of all services. As a general rule, a growing number of consumers with CDHP-style coverage will expect to be quoted a reasonable base price for a needed health service. Many price-conscious health consumers will also want to know the price of “extras,” such as 24-hour nursing care or a private room, in much the same way they would consider adding a bigger engine, more memory, or a first-class cabin once they know the base price of a ear, a computer, or a vacation cruise. Like their retail counterparts, healthcare providers will need to learn how to make profits from the add-ons, not the basic products.

A-Life Medical, Inc., the leading provider of Natural Language Processing (NLP) for the healthcare industry, announced the release of Fusion3, the first practice management system that utilizes patented NLP technology for medical billing.

Fusion3 integrates documentation management, patented NLP coding, billing, collections, denial management, and auditing into a Windows®-based platform, providing the most advanced technology available today. A-Life Medical’s Fusion3 was designed to effectively streamline the code to collection process.
Fusion3 streamlines coding and billing office operations and expedites reimbursement. A-Life Medical’s advanced practice management system can code medical records, and submits charge data on the same date of service. The denial management module automatically tracks denials, sends appeal letters, and generates secondary filings without user involvement.

Fusion3 integrates a complete electronic document management system. Users have instant access to ABNs, transcriptions, insurance cards, EOBs, CMS-1500 forms, or any scanned document. The Fusion3 document management system improves the flow of information, reduces paperwork and inventory costs.

Fusion3 is a unique solution, providing coding and billing audit functionality. Fusion3 identifies a statistically representative sample of claims data and pulls electronic records from a centralized database. Detailed audit reports are automatically created to assist in the auditing process
“Fusion3 is the first end-to-end practice management system of its kind. We’ve combined our patented NLP technology with billing to effectively streamline the code to collection process. In addition, Fusion3 allows our users to automatically perform random, statistical audits on coding, charge data, and payer information. Combining documentation management, patented NLP coding, billing and auditing into one system is unlike any other offering in the market today,” stated David Byrd, A-Life Medical’s Vice President of Sales and Marketing.

About A-Life Medical, Inc.

A-Life Medical is the leading provider of Natural Language Processing (NLP)-based solutions for the healthcare industry. A-Life Medical’s products extract meaning from unstructured free text and automate tedious, complicated and labor intensive tasks. A-Life Medical’s mission is to provide world-class solutions to streamline and computerize the code to collection process and to fundamentally advance the way the healthcare industry gathers, applies and reports on patient information