Preparing for Biological Disasters

I have blogged before about the CHRISTUS Health experience with hurricanes multiple times. As many of our facilities are located on the Gulf Coast, we learned first-hand the importance of having a clear disaster response strategy in place.

This commitment to a disaster response strategy extends beyond just hurricanes, though. The world’s experience with H1N1 flu last year reminded all of us how important it is to be prepared to offer an immediate, well-coordinated response to pandemic and biological disasters as well.

At the end of March, the CHRISTUS Health Pandemic Committee conducted a system-wide drill after several months of development and revisions of its influenza/biological pandemic plan. The mock scenario was an outbreak of unusually severe illness; specifically, a particular strain of H1N1 influenza that had been identified by the Centers for Disease Control as Phase 6 (widespread) in many states including Texas, Missouri, Louisiana, Arkansas, Georgia and Utah – all regions in which CHRISTUS Health operates.

The exercise, was launched by the system Senior Leadership Team in the corporate command center in Dallas, and we immediately began assigning and prioritizing incident response activities.

Team members quickly solidified our roles and began responding to approximately 35 mock requests for assistance that were being phoned in or made via e-mail directly to the command center from across our regions and facilities. Regional emergency preparedness coordinators from the CHRISTUS Health Southeast Texas, Southwestern Louisiana, Central Louisiana and Ark-La-Tex regions, as well as CHRISTUS Spohn, CHRISTUS Medical Group, CHRISTUS St. Vincent, CHRISTUS Santa Rosa, CHRISTUS Health Utah, Infection Control and Risk Management were among those participating in the drill.

Through this exercise, we aimed to build system-wide competency and familiarization of the revised CHRISTUS Health influenza/biological pandemic plan; provide an opportunity to exercise system pandemic reporting applications (EMResource, CHRISTUS Health emergency Website resources) with participating CHRISTUS facilities and the corporate command center; and practice emergency communications protocols by relaying vital information between responding entities.

The exercise lasted approximately three hours, including a debriefing and “after-action” review to identify what went well, opportunities for improvement, gaps in our emergency preparedness planning, and policies that will be addressed. We’re also investigating how to build social media tools into our existing disaster response communication plans, realizing the need for additional communication tools in our arsenal that can be quickly updated and are easily accessible by displaced Associates via home computers or mobile devices.

ACOs: A common goal, various models

It is abundantly clear that a significant portion of the cost savings predicted by the CBO as a result of health care reform depends on the successful implementation of a myriad of accountable care organizations within the U.S. health care delivery system. Although the models for an ACO may vary in different geographical locations (depending on the service sites available and the degree of integration in place among them presently), all ACOs will share a common coal for success. This goal simply must be the re-engineering of a transformation from a productivity orientation driven by our fee-for-service transactional payment system to a clinical-oriented outcome process driven by a payment system that rewards risk-adjusted high quality and low costs. As we have articulated in prior posts, CHRISTUS Health believes the only health care systems in the U.S. that will survive and thrive long-term will be those that have hardwired high quality and low cost health and wellness services into their delivery systems. This is not an easy task, and will require an intense effort by health care leaders to eliminate the barriers to ACOs that I discussed in last week’s post.

With a common goal, why then will there be different models? The best definition of an ACO I have found thus far was part of a recent brochure that crossed my desk, announcing the first National Accountable Care Organization Summit to be held this summer.

ACOs are provider collaborations that support the integration of groups of physicians, hospitals, and other providers in different ways around the opportunity to receive additional payments by achieving continually advancing patient-focused quality targets and demonstrating real reductions in overall spending growth for their defined patient population. The ACO model is highly flexible and can be organized in a number of ways—ranging from fully integrated delivery systems to networked models within which physicians in small office practices can work effectively together to improve quality, coordinate care and reduce costs. They can also feature different payment incentives ranging from “one-sided” shared savings within a fee-for-service environment, to a range of limited or substantial capitation arrangements with quality bonuses.

It is the hope of the U.S. government, in order to halt the growth of our health care costs, that ACOs will provide a transition from our fee-for-service mentality—paying for volume and intensity—to rewarding providers for enhancing value, which requires improving quality while simultaneously reducing costs.

The degree to which ACOs will be successful yet remains to be seen. But clearly, their goals to incent integration and coordination of care and minimize fragmentation of care are absolutely the right ones and must be achieved if health care reform has any chance of success.

The Barriers to an Accountable Care Organization

In multiple health care-related journals over the last several weeks, readers viewed numerous articles as well as invitations to attend conferences to learn more about “accountable care organizations” or “creating high-performing care organizations.”

This new terminology, Accountable Care Organization, or ACO, is one of the critical efforts in the recent health care reform law that is proposed to reduce the cost of health care in the U.S. It is predicated on the belief that well-coordinated, integrated care will be more likely to increase quality of the outcomes while reducing costs in comparison to the often-fragmented care which is experienced by our patients today. This clearly makes sense to providers of care, and yet it is not the norm in medical practices today. What are the barriers that keep well-coordinated, high-quality, cost-effective treatment plans from being implemented across he care continuum? What barriers will CHRISTUS Health face in building its aggregator model, one of our five strategic directions on its continuing Journey to Excellence?

The first, and perhaps most, significant barrier is our current fee-for-service payment system. This system has unfortunately incented most providers to perform as many procedures and treatments as possible, repeating studies and tests that have been done elsewhere which, if results were obtained, would not need to be repeated.

The second barrier is that coordinating care which is personal, safe, accessible, reliable and efficient often takes time. To connect the dots between multiple points and providers rendering services to a patient on a health care journey requires phone calls, immediate completion of records so a patient can carry them from point A to point B and timely transfer of treatment plans to the next provider so studies/tests are not duplicated.

A third barrier is the educational experience of most providers, which has focused on individuals rather than a population health management model. The former focus often provides individual treatment plans with variability in quality and costs, while the latter focuses on more consistent processes which minimize duplication and rework, and maximize repeated learnings which encourage rapid-cycle improvement.

Yes, the logic behind ACOs make sense, but to make them successful, strategies must be put in place to knock down the barriers which are real and visible in U.S. health care today.

Opportunities to look forward to

I am excited about attending the 2010 World Health Executive forum in Montreal in early November, so wanted to share some information with you about it now! I will absolutely share more learnings and information after I return.

The theme of the forum is “Paving the Way toward Healthcare Sustainability,” and will be attended by a select group of international ministers, senators, permanent secretaries and CEOs who will participate in unique roundtable discussions with professional moderators. The intellectual power brought together will allow dialogue and interaction to guarantee a maximum transfer of ideas and experiences!

This forum has been called because some European countries and American states are virtually bankrupt. In the majority of these countries, health care costs are the biggest drivers of the deficit. Even in times of prosperity, costs were extremely hard to contain, with an upward spiral of 3 percent to 6 percent each year for the past decade.

However, we all know it is the end of an era. Many of those attending will be from countries faced with not only health care budget freezes, but also cutbacks ranging from 5 to 20 percent. The way each attendee looks at sustainability will be different, and it is critical for all to understand what works, what doesn’t and what simply doesn’t make sense. The goal of this authoritative meeting is to share strategic intelligence in top priority issues, determining the most efficient way to face the unprecedented changes – contingency plans and difficult choices – to address the present and new risks that are forthcoming. This incredible experience should be of great value to CHRISTUS Health and our advocacy program initiatives.

Eight drivers will be examined and discussed in detail during the intense, three-day forum. These include:
1. Reconciling political and Transformational Agendas
2. Priorities of Contingency Plans
3. Seizing “Out of Control” Costs
4. Next Wave of Regional Delivery
5. Next Wave of Integrated Delivery Systems
6. A Population-Based Model is Not Enough
7. The Role of Information Technology
8. International Collaborative Framework

It is the hope that the learnings from this forum, based on an intense discussion of each of these drivers, should keep key health care decision makers design the best future of our health care systems, and I can’t wait to share the results of these discussions with you!

Thoughts for Holy Week

As Holy Week approaches, leading to the crucifixion on Good Friday and the resurrection on Easter, I am reminded of the inherent message of eternal hope that the season brings. As CHRISTUS continues our Journey to Excellence, we have, and will continue to have, many challenges which may seem insurmountable. However, we all know that with time, effort and focus, potential solutions will be identified and the pathway to success will appear far less daunting.

One recent example that comes to mind is our task force on Haitian Relief, which worked tirelessly over a period of several weeks to coordinate CHRISTUS’ response to the devastating earth quake that struck Haiti on Jan. 12. The task force finalized plans to send a 20-member team, together with ample medical supplies to Port-au-Prince to provide medical care and spiritual assistance from Feb. 20-27 in partnership with the University of Miami Miller School of Medicine. In all, our CHRISTUS team performed 85 surgeries, hundreds of procedures and outpatient visits and delivered nine babies.

Over the course of one week, as challenges and obstacles of all varieties were faced and overcome on a daily (and sometimes hourly) basis, the mission that had seemed overwhelming upon our arrival in Haiti become a miracle in and of itself.

In answering the call for help as the Sisters from France did so many years ago, the CHRISTUS family left the hospital in Port-au-Prince a better place. Our CHRISTUS missionaries will always remain astounded at the incomprehensible resilience of the Haitian people. In the spirit of the Easter season, the Haitian community is slowly and incrementally transforming tragedy into hope.

As we experience Holy Week and the resurrection, I am again reminded of our foundation in Incarnational Spirituality, and the honor and privilege we have each day as members of the CHRISTUS Family, to carry out the healing ministry of Jesus. May we also especially this Easter remember the people in Haiti that touched in Haiti and that we continue to heal in CHRISTUS Santa Rosa Children’s Hospital. So may each of us, in our own way, call upon our spirituality, and reflect on this prayer.

How We Are Seen
An Expression of our Incarnational Spirituality

Wherever our feet walk
We leave footprints
On the ground in Haiti,
on the grass at the Sisters Park
In the floors of our homes
And where we work
Wherever our live travel takes us each day
We leave our identity.

Wherever our hands touch
We leave fingerprints
On our patients and families
Both in Haiti
And those we touch daily in all of our ministries
On the walls, on the furniture
On doorknobs, dishes, books
As we touch them, we leave our identity.

O God, where we go
On our Journey to Excellence today
Help us to also leave heartprints
Heartprints of compassion
Of understanding and love
Heartprints of kindness
And genuine concern.

May our hearts touch
The Haitian children now at Santa Rosa
The concerned family members of our patients
The residents in our senior centers
Those seeking relief in our clinics
And all of those who turn their most precious gift – their lives
Over to us each day.

Lord, send us out today
To leave heartprints on all of these people
And if one of them should say
“I felt your touch”
May that person sense our commitment
To Your healing ministry.
This is our identity.
We are CHRISTUS Health.
Amen.

What Nursing Shortage?

Healthcare Finance News recently published an article about a new study by the Health Resources and Services Administration, which found that the nursing workforce is growing and diversifying.

The study reported that the number of licensed registered nurses in the U.S. grew to a new high of 3.1 million between 2004 and 2008, an increase of more than 5 percent. The study also found a 4.6 percent increase from 2004 to 2008 in the percent of nurses who are Asian, Black/African/American, American Indian/Alaska Native and/or Hispanic.

This further supports my previous assertions that it is possible the nursing shortage has been overstated. When we have “nursing shortages” in a patient care delivery setting, we are able to find a contract nurse to fill the slot. I think that if all the nurses filling more lucrative contracted positions would take permanent employment, the perceived shortage would quickly diminish.

In addition, because of recent layoffs in many other industries due to the global economic crisis, more students are applying to nursing schools. When trained, having put forth the money and time, they will not leave a profession where there is much greater job stability.

In fact, the White House/Congressional Leadership Reconciliation Bill [Health Care and Education Reconciliation Act of 2010 (H.R. 4872)] which was just passed by the House and signed by President Obama yesterday, includes additional investments to improve health care workforce training and development, some of which focus on nursing specifically. For instance, the bill aims to address the projected shortage of nurses and retention of nurses by increasing the capacity for education, supporting training programs, providing loan repayment and retention grants, and creating a career ladder to nursing. (Initial appropriation in fiscal year 2010.) It also provides grants for up to three years to employ and provide training to family nurse practitioners who provide primary care in federally qualified health centers and nurse-managed health clinics. (Funds appropriated for five years beginning in fiscal year 2011.)

Nurses are such a vital part of the care delivery process that what cannot be overstated is the importance of this issue. However, I believe it is possible to meet the nursing shortage we are feeling now, and am hopeful that these investments in encouraging future students to pursue nursing will further enable us to put care within reach of all those who need it.

Disaster Response: What we Learned from Haiti

As I mentioned previously, CHRISTUS’ 20-member team worked in Haiti from Feb. 20-27 and performed 85 surgeries, hundreds of procedures and outpatient visits and delivered nine babies.

We have since debriefed with team members who traveled to Haiti as well as with the task force that worked to identify and vet partner organizations in Haiti and select, organize, orient and commission the Haiti team. I believe our findings are so important that they are worth sharing. We will take these learnings with us if we pursue future trips to Haiti, and know they will also be useful when our facilities situated on the Gulf Coast face future hurricanes.

The principles of CHRISTUS’ successful mission in Haiti include:
• Command - From inception to operation (mobilization and demobilization), command of the task force and team in Haiti were clear.
• Control – Leadership established control via regular conference calls, daily operational updates and by ensuring the team was composed of the right number and type of personnel to meet the mission requirements. Span of control was maintained with appropriate number of workers to supervisors.
• Communication – Planned conference calls and regular communication before, during and after the mission facilitated information exchange and flow (up & down the organization, across functional areas and to/from external partners). This provided opportunities for real-time information to be passed on to appropriate teams so correct responses to changing needs of the mission could be anticipated and planned for and so the CHRISTUS family remained informed.
• Coordination – The coordination amongst partners on the ground in Port-au-Prince, between internal CHRISTUS departments, external government entities, and private resources was notably welcomed.

Members of the team that served in Haiti expressed an overall feeling of pride and accomplishment. They said that the team worked together flawlessly, and they were grateful for the opportunity to care for the people of Haiti. However, many also expressed angst over leaving so much undone, describing their work as a “drop in the bucket” of what would be needed throughout the city.

Almost all team members expressed interest in traveling to Haiti again, and many suggested that the task force consider sending another CHRISTUS team. It was also suggested that we consider a more long-lasting way to respond to disasters by working with CHRISTUS to identify early responders now. We are considering this suggestion and may implement an early response team to provide “intellectual capital” and care to devastated regions.

A few also expressed that one week in Haiti was not long enough, and that they were able to get into the rhythm of the work around the third day, but then had to leave 3-4 days later.

Team members expressed that CHRISTUS’ inclusion of chaplains in the team and their administration of spiritual care were central to our ministry there. “We not only operated on people, but were able to love and care for other needs,” one team member said.

While in Haiti, the wound care team started a Haiti Google group with suggestions and a list of items helpful to pack (sharpies, pens/paper, etc.). New team members emailed and posted questions regarding vaccinations, medications and what personal items to bring, and asked what they could bring to help families and what equipment was needed (connectors for wound vacs, sponges, etc.). This helped old team members keep in touch with local workers and continue the aid process from home.

Many believe that CHRISTUS’ leadership and organizational skills were pivotal to the work there. Team members unanimously expressed that the task force did a wonderful job, especially with organization and supplies.

Additional supplies they would like to have seen include:
• Postoperative needs such as wheel chairs, walkers and crutches
• Mosquito nets
• Additional walkie talkies or a way to facilitate easy communication between all caregivers and not just triage/ER staff
• More bottled water
• Foam hand wash (as there was no running water, we used antibacterial hand gel to sanitize our hands, but some team members felt it was sticky and made getting gloves on and off difficult)
• Extension cords
• Chairs
• Chux pads
• Drapes for tables
• Blue booties to use over dressings on feet
• Small autoclave
• Suction machine and canisters

Team members also mentioned that they discharged many Haitians to the streets, as they were without permanent shelter. They suggested continuing to send tents if possible.

Truly, our time in Haiti was just one more way that members of the CHRISTUS family lived out the CHRISTUS mission to extend the healing ministry of Jesus Christ around the globe. I am proud of each and every one of our CHRISTUS healers, and remain proud to be the team leader for CHRISTUS.