We often think of ourselves as employees and workers at a hospital. However, it is important to remember what sets our University Hospital apart from others.  First, and foremost, we are a university.  The hospital, while it exists for patient care in the region, also exists as the teaching classroom for our students.  The hospital is the classroom and laboratory where young and impressionable minds, are turned into doctors, nurses, and other health providers over time.  The graduation ceremony is an important rite of passage for these individuals as they leave medical school and enter residency training, or as they finish their education and enter the workforce.

The pomp and circumstance of a graduation is important to recognize their efforts and dedication.  It is an important time for families to celebrate.

It is probably also a good time for all of us to stand back and reflect on the role that each of us has in the education of physicians and healthcare workforce of the future.  On a daily basis, all of us have the opportunity to interact with students.  The way we interact, the examples we set, the qualities of caring and empathy that we display, all are important components of how and what our students learn.  Each of us has a role in helping to model our future workforce.

While each student and their family can be proud as they walk across the stage on Sunday to receive their diploma, each and every employee at University Hospital can also be proud for the contribution that they have made.  Each or our graduates owes you a thanks your efforts.

Congratulations to all of our students, and thank you to all of the employees of University Hospital, each of whom is “teacher” in some way to our students.

This week the federal government released data showing that the charge for the “same” medical procedure in different hospitals around the country varies considerably.  This is true both from region to region and even within the same location among different hospitals.  The full set of data can be seen at:

Medicare Provider Charge Data on CMS.gov

In today’s world of instantaneous news, rapid online publication, and the need to reduce the most complex topics to a simple sound bite, a  headline that reads “costs vary for the same procedure seven fold across the country at different hospitals” was an inviting opportunity.  As such this study has made local and national news, and continues to play out in radio and TV talk shows today.

In Syracuse, the Post Standard ran two brief and factually correct articles about some of the differences in Central New York.  The story also appeared in the print version of the Post Standard today.

Upstate CEO: Higher charges reflect specialized services like burn unit and labor costs

Hospital bills for same service vary dramatically in Central New York, federal data shows

From the perspective of someone immersed in these issues on a regular basis, I can tell you this is not a simple topic.   Any of you who have read the recent Time magazine issue (March 4, 2013): “Why medical bills are killing us” will understand the complexity of this topic.  I would recommend this issue to everyone.  It is a more in depth conversation of the topic than can be had in internet sites or in the newspaper.

Let me provide a few of my own observations with respect to the recent report and flurry of interest that it has created.

• There is an important distinction between charges, costs, and payments, they ate not the same. What an individual patient pays for the same service, even in the same hospital can vary widely.  Hospitals rarely if ever get paid their charges for a service that is provided.
• What a hospital charges for a service, just like in any other business, is related to what it costs for the hospital to provide that service.  The cost for a service is influenced by many things including:
  • Equipment and supply costs
  • The kinds of patients that are treated
  • Labor costs
  • Utility expenses
  • Amount of service provided for which no reimbursement can be collected
• As a general rule, academic medical centers have higher costs than other hospitals.  This is due to a number of factors:
  • Complexity of care in these institutions
  • Costs associated with training physicians and medical students
  • Specialized services that require additional staffing (i.e. trauma services which require onsite presence of numerous physicians and other providers on a 24 hour a day basis ready to respond at a moment’s notice)
• In any analysis of costs, labor must be a discussion since it represents the largest portion of all hospitals expenses.  However, it is not just about the costs of an individual employee in an institution, it is also about the number of employees in the institution must maintain in order to maintain vital services, safety net services for a community, and mission critical services.  Again, academic medical centers tend to employ more individuals for all of these reasons.
• The assumption that charges are therefore related to waste may be erroneous.
• The idea that charges relate somehow to quality in a singular way is unfounded

Finally, it needs to be remembered that other costs are rolled up into the average total payment, including the reimbursement from the federal government for education and training of physicians.  The vast majority of physicians practicing in the Central New York community have had some relationship to Upstate Medical University either as a medical students or as residents in training.  Without the academic institution and its associated education costs, the workforce in Central New York would be vastly different.

The data and the related stories are all systematic of a very complex healthcare system that in many ways is quite sick itself.  The complexity built into to charges, bills, and payments, is a burden not found in many industries.  The amount of effort, administrative time, and personnel that are devoted to unraveling the complexities of charging, billing and collecting in the medical industry is quite simply insane, it certainly is an area that needs significant reform.  However, simply blasting out the idea the charges are higher in one place than another for the same procedure, without understanding the relationship of charges to costs or charges to payment doesn’t fix the system.  It simply casts a shadow of doubt and mistrust over institutions that day to day work to provide complicated and complex care to keep patients healthy and then are burdened with enormous work to be paid at anything close to a reasonable rate for the services that have been performed.

Something needs to change!

This week, I became aware of two important outside recognitions of the quality of our care.  It is always nice when external entities recognize us for our work and care at University Hospital.

The Commission on Cancer of the American College of Surgeons granted its Outstanding Achievement Award this week to 79 accredited cancer programs across the United States.  The cancer program at University Hospital is one of these elite programs that was recognized.  The award is granted to facilities that “demonstrate a commendation level of compliance with seven standards that represent six areas of cancer program activity: cancer committee leadership, cancer data management, clinical management, research, community outreach, and quality improvement”.  Less than one out of five cancer programs reviewed by the American College of Surgeons receives this achievement award.   Such an award puts in a category of elite facilities around the nation.  It is testimony to the excellent administrative and clinical staff that provides leading edge cancer care to patients in Central New York every day.  We all feel that this care can only continue to improve and expand with the opening of the Upstate Cancer Center in 2014.

University Hospital is also recognized this week by the American Heart Association for its outstanding work in heart failure and stroke.  We were awarded Gold Plus Achievement Awards in both of these areas.  The Gold Plus Award is given to institutions for achieving adherence to “get with the guidelines” indicators over two or more 12 months consecutive intervals.  Again, we join an elite group of institutions dedicated to improving the care patients with stroke and heart failure.  Again, this is a testimony to the high quality administrative, and clinical activity across a broad range of disciplines at University Hospital.

I offer my sincere congratulations to all of our staff involved in cancer care, heart care, and stroke care.  These are important diseases.  The care of these patients is integral to our missions.  The recognition seems most appropriate.

Clearly, this is a senseless and cowardly act.  It puts our own lives, and the lives of loved ones in a different perspective.  The idea of how one’s life can change in an instant at the hands of others, bent on destruction, is always sobering.  Obviously, our prayers and thoughts are with the survivors and their families.  As has been reported in the news, it is clear that the resilience of the American people, especially in the Boston area, will help them to recover and move on from this event.

From the medical perspective, I often wonder how we would respond were an event of this magnitude to occur in our own area.   The response in Boston is one of law enforcement on the scene, a coordinated EMS response, community volunteers, a well-run trauma system, and years of rehearsal.   I believe that all of these elements exist in the Central New York region as well.

There is little doubt that our law enforcement agencies, be they local, county, or state, would respond in a coordinated fashion.  We have seen this in past events in the Syracuse area.  We see the excellent coordination of mass event gatherings in CNY in the  many regional events such as the State Fair,  Carrier Dome gatherings, Syracuse Jazz Fest and others.  The ability to coordinate between agencies is well demonstrated in our region.

Our EMS personnel are well-trained.  Care across communities is already coordinated with mutual aid response plans.  The 911 center and county emergency response teams are well organized. Paid EMS staff exists in most of our communities.  There is good coordination of specialized service such as air medical evacuation.

All of our hospitals routinely practice for disasters.  While no actual disaster is ever exactly like the disaster drill, each disaster drill helps individuals to understand their roles, to learn team work, and to be prepared for whatever the next disaster sends our way, be it a natural disaster, chemical contamination, mass casualty incident, or terror event.

Our trauma team at University Hospital is always ready. We have ample expertise from emergency medicine staff to trauma surgeons, to specialty physicians, to the nurses and ancillary medical staff.  Our ICU services are second to none in the region.  We maintain the operating room staff, equipment, diagnostic equipment, and other resources necessary to respond to large scale events.

Finally, even in this Central New York competitive healthcare environment, we have also shown the ability for hospitals and providers to work together in times of demonstrated community need.   It is not infrequent that multi-casualty incidents, albeit on a much smaller scale, have been managed in a coordinated fashion with all the hospitals in the region. We could count on everyone’s cooperation.

While we are all saddened by the events of Boston, we should all rest assured that, in this community, we would be well prepared to respond to a similar event.  While we hope we never have to use  these skills, we should all continue to practice, continue to know our roles in such an event, and be sure that the coordination and cooperation occurs, from law enforcement through to the operating rooms and the ICU, as well as among healthcare providers and between our healthcare institutions.

We can all think back to the pre-email days when communication was often through a face to face meeting, a casual conversation, a phone call, or a more formal written document.  We would often think for a little bit about what we wanted to say, compose it in a hand-written note, or a typed or dictated message.  We had the opportunity to review our thoughts once more when the document was actually produced before we put our own signature on the document.  The document then took some time to arrive to its intended audience.  In those days, I had always maintained a folder in my desk for items that had been written, that needed to mature “for a few days” before they were sent.  Many of these communications, after a few days of thoughtful review, remained in the file forever, unsent.  These days, we don’t have the same luxury with email.

We often find ourselves fiercely typing at email, instantly communicating, and then sometimes regretting what we sent.  It is all too easy to send an email message to many, many recipients.  It is all too easy to take out our anger or frustration of the moment at the keyboard.

We also spend time communicating things through email “because we can”, rather than because it is important.  How often are we carbon copied in an email on something that really doesn’t pertain to us?  How often do we banter back and forth unnecessarily with others?

For this week’s blog, I’d like to have us all consider the following:

• Everyone should have time each day where the email program is not open, where the iPad or the Smartphone is not constantly refreshed or looked at.  Wouldn’t it be interesting if we all had a two or three hour block per day where we simply didn’t look at, read, or respond to email?  Those who really needed us would be able to find us regardless.

•  Let’s commit to the following set of rules for efficient, effective, and courteous use of email. (These were given to me by folks in other leadership positions in the hospital, and I present them with my own modifications.)

Before you click “send”:

• Be sure there is a greeting and closing, the message should always be polite. (Follow-up communications may be less formal.)

•  Write using proper grammar, punctuation and spelling and make sure your message is clear.

•  Eliminate needless words and sentences—keep the message brief and to the point, this is respectful to the time of others.

•  DO NOT USE ALL CAPITALS AS THIS IS CONSIDERED SHOUTING IN AN E-MAIL.

•  Be sure that the message is appropriate for an e-mail—avoid counseling or reprimanding by e-mail, gossip or highly personal subject matter.

•  Ensure that it is not aggressive, venting, or could be perceived as offensive.

•  Be sure it’s sent only to those who need to know, and avoid blind copying.

•  Do not forward others’ emails without permission if there is sensitive information or the sender intended the message to be private.

• Don’t “reply to all” when a reply to only the sender is more appropriate.

•  Be sure it is professional and not a personal attack.

•  Be sure that you do not react to an offensive e-mail in an e-mail, ask to speak or meet. Responding in kind only escalates the problem and causes more damage.

•  Don’t say something in email that you would not be willing to say in a face to face conversation.

•  Be careful about patient specific information in email….remember HIPAA .

In a busy hospital and clinical world, where we all ought to be focused on patient care, effective family communication,  good inter-personal relationships, interdisciplinary support, wouldn’t it be nice if we were a little less distracted by email?  Perhaps we should all recommit to more attention to actual job performance, and in-person communication, and reserve email communication for, important and critical communication.

In recent employee forums, and in many other settings, I continue to speak highly of our workforce.  They are a dedicated and an exceptional group of people, working in a difficult environment, with a challenging patient population, and a complexity of medical care that exists nowhere else in the region.  Anyone who is a regular reader of this blog knows that many of the posts are dedicated to highlighting and supporting the fine employees of Upstate.

The reality of our institution is that the vast majority of our workforce is represented by public unions.  The cost of the workforce is greater than that in similar institutions both in our region and the state.  It is my firm belief that any additional costs imposed upon us through negotiated agreements by the State of New York, should be funded by the State of New York.  We have over the years worked with SUNY to demonstrate the areas where we believe we incur additional costs because of the labor processes, mandates, and restrictions that are put in place without hospital or campus input. These costs include: a fringe rate considerably higher than that of our surrounding medical centers, a ratio of worked to paid hours that is lower at University Hospital than elsewhere, a paid time off percentage which is higher than other institutions, and a pension cost that continues to skyrocket.  All told, we believe these differences add up to approximately $75M per year of additional expense.

When I raise these issues, it is not to bash the unions, or to look despairingly on any of our employees, or to complain about the negotiations that have occurred.  Simply, it is to point out that our unions and the State of New York have reached agreements through a process that excludes the direct involvement by those who are expected to generate the funds to pay the bills.  Unlike the non-hospital parts of the SUNY system, all of the salary and benefits for hospital employees are paid from hospital generated funds.  As a result, any increase in salary, anything that changes the working conditions, and anything that increases the fringe benefit must be offset by new hospital generated revenues.  In the current environment, and moving forward with healthcare reform, it has become increasingly difficult to generate the new dollars to fund these mandates.

Our public unions are doing their job, representing their members.  To the extent that this creates costs to the hospital which are not funded from the State of New York, this presents a dilemma.  I don’t view this as union bashing at all, just a statement of outcome, and a source of ongoing concern for me and hospital leadership.

As I have said in my previous blog, it’s time for those who help support and sustain public hospitals in New York State to decide if the level of support will be commensurate with the expectations that are placed upon these public hospitals, in terms of structure, labor issues, procurement rules, patient care expectations, and guarantee of availability of “safety net programs”.

To be clear one more time, I don’t have a beef with the unions, but I would like someone to be responsible for the costs that are negotiated elsewhere and given to University Hospital.

Here on our own campus, we seem to have a bit more “crankiness” than normal in recent weeks.  Stress is evident everywhere, both around issues of staffing, the tensions that go along with state budget negotiations, intermittent episodes of unprofessional behavior, typical patient circumstances, and the changes that are occurring with healthcare reform, just to name a few.

Amidst all of this, I happened to come across a recent video from the Cleveland Clinic.  To watch it will take 4 minutes out of your busy life.  However, I think it is a video that every single person involved in healthcare out to invest their time to watch.  I’d say this to all of our healthcare providers, every other employee of our hospital and campus, patients, insurers, government officials, and our elected leaders.  The video starts with a quote by Thoreau:  “Could a greater miracle take place than for us to look through each other’s eyes for an instant?”  I would hope that taking the time to watch this video would give us each a new perspective on the people we interact with, see, and pass by on a daily basis.  Particularly during these challenging times where we often remain focused on our own needs and frustrations, this video sets an important tone for all of us.

Historically, public hospitals have world class trauma and emergency care, they have been the locus of preparation for and response to the threat of terrorism, epidemics, and natural disasters.  These hospitals typically are training laboratories for medical students and residents, and thus produce many of the nation’s physicians.  In addition, they are sites of training for nurses, respiratory therapists, other allied health professionals, dentists, and a whole host of other healthcare providers.  As such, the public hospitals ensure that our communities and our nation as a whole remain healthy, strong, and prepared for the future.

Both in New York and around the nation, the changes in our healthcare systems threaten public hospitals.  Over the years, these hospitals have moved away from being fully supported from public tax payer funds to having only a small portion of their operating revenue provided by direct public support.  These hospitals rely heavily upon federal and state supported insurance programs such as Medicare and Medicaid.  However, such payers are less profitable than the commercial insurance programs.  Often these hospitals have disproportionally high percentages of Medicaid and patients without insurance.

As direct public support for these hospitals has diminished, it has become harder and harder for the institutions to maintain their public missions.  These hospitals find themselves in the difficult dilemma of wanting to care for the uninsured, and those without other sources of care, while providing the most complex of care.  At the same time, with diminishing revenues, it becomes harder and harder to maintain a viable and sustainable business model.

Public hospitals are affected by decisions made in many different arenas that impact public hospitals much to their detriment.  For instance, a hospital such as University Hospital is impacted by state budget cuts to the SUNY campus in the education world, decreased direct support from the state to the hospital, cuts in state Medicaid reimbursement, cuts in commercial insurance payments, decreasing support for graduate medical education, and cuts from the federal government sequestration, just to name a few. It often feels like “death from a thousand paper cuts”.

In our recent trips to Albany and Washington, leadership from this institution continues to ask the question whether we as a nation want to continue to support public hospitals.  The value of these hospitals is clear: excellent care, care in complex areas like trauma, education of future physicians, and care for the most vulnerable populations in our communities.  However, in these times of very tight financial constraints, all entities, be they localities, states, or federal government, seem less inclined to continue this support for public hospitals.  It would seem prudent in each community to ask “what would our community look like without our public hospital?”  As a nation we ought to ask the same question.

So, has the time come and gone for public hospitals after 300 years?  The same needs exist, the same vulnerable populations exist.  Or perhaps, is it time to “ante up” to preserve, protect, and promote the public mission of these safety net hospitals.  No one can argue that many of the changes occurring in medicine to improve quality, to decrease costs, to improve access, are all laudable goals.  Moving from a system of fee for service to population management will have great value.  However, if these goals are met through the destruction of public hospitals throughout the state and nation, we will certainly find ourselves far worse off in the future.

This week, there were numerous news stories  about the recent spread of drug resistant bacteria.  This article highlights a report from the CDC on carbapenem resistant enterobacteriacae.  The article talks about the spread of this drug resistant bacterium, the potential for creating significant patient morbidity and mortality, and the simple procedures that all healthcare providers can undertake to help prevent the spread.  Among these is “the ruthless scrubbing of all surfaces and relentless hand washing?”

So how well do we do at washing our hands?  Well, our own data shows that we do pretty well, but not perfectly.  The graph below shows the cumulative goal for institutional hand washing throughout the last year.  While our hand hygiene is generally between 90-100%, we can easily make the case that it should be at 100% all of the time.  There are many reasons why providers don’t do this: lack of knowledge, lack of attention to detail, time constraints, ready availability of sink or hand hygiene solutions, and perhaps the sense that it isn’t as important as others would make it out to be.  While understood, none of these can be acceptable excuses in an institution like ours.

Even if you don’t want to take the time to read the New York Times article, access the CDC report, or look at and interpret the above graph, you might want to take the opportunity to view the video.

It’s hard for me to believe that anyone watching this brief video wouldn’t understand the importance of routine and “relentless” hand washing in our academic medical center.  We all need to be vigilant about this, need to encourage our co-workers to do the same, and monitor our performance.  Finally, as patients in this institution, we should accept nothing less than 100% compliance with good hand hygiene.  To do anything less violates the basic tenant of medicine to “do no harm”.

Sue Campanaro, the manager for Environmental Services, deserves much of the credit and thank-you from all of us for assembling, managing, and coordinating this fine team of Upstate employees.

I would ask that all of us stop from time to time, and thank our Environmental Services staff for the outstanding job that they do.  They do their work well, and with a good attitude.  What more could we ask for from this group?