Skills Needed to Lead the Hospital of the Future (Complete credit for authorship is given to Sita Ananth for this most interesting article published in H&HN Daily 11/29/12 and presented to doctoral students for reading & discussion. R. E. Hoye, Ph.D.)
By Sita Ananth	November 29, 2012
A hospital that integrates complementary and alternative medicine, focuses on the patient, delivers value, and functions in the accountable care world requires a CEO who has a strong vision, assembles a highly skilled leadership team and engages the community.

The Complementary and Alternative Medicine Survey of Hospitals I conducted in 2010 revealed some encouraging data about the role of hospital leaders in championing and supporting these initiatives. A high number of respondents (39 percent) said that hospital administrators were responsible for launching the complementary and alternative medicine program, and 33 percent stated that the administrators continued to be champions for the program.
"Hospitals are recognizing that many of their patients see CAM as an integral part of managing their health, illness and recovery. Smart hospital leaders will figure out how to integrate these services to broaden their appeal to a growing segment of patients who truly value these services (and are often prepared to pay out of pocket to secure them)," says Ian Morrison, author, consultant and futurist.
This brings up an important question. What are the skills required by hospital CEOs to lead the organization of the future — one that is patient-centered, delivers value rather than volume and operates in an era of accountable care organizations? I posed this question to a few leaders, consultants and leadership experts, and some key themes emerged.
Vision. Leaders, particularly CEOs, need to adhere to a vision of their organization as one that is truly committed to compassionate care and healing. "We are seeing a trend now where CEOs are required to have a clinical background so they can evaluate and understand the operational impact of these initiatives," says Laurie Eberst, senior vice president of Dignity Health, who has led the cultural turnaround of two Dignity Health hospitals in Oxnard, Calif., and has been tapped to do the same in Northridge, Calif. Eberst was responsible for building Mercy Gilbert (Ariz.) Medical Center from the ground up and creating an award-winning "healing hospital."
Building a senior team with the right skills. With patient satisfaction and theHospital Consumer Assessment of Healthcare Providers and Systemssurvey becoming a key determinant of reimbursement, organizations are creating a culture of compassion, healing and patient-centered care. To make that happen, says Eberst, CEOs must surround themselves with people with the right skill set who will support, consistently "enforce" and monitor this cultural change. The courage to lead these efforts in the  face of conflicting demands is crucial.
Modeling behaviors. Organizational culture begins with healthy leadership. It is expressed through vision, modeled by leaders, and defined by clear behaviors and rewards for healing interactions that extend from the bedside to the boardroom. It requires compassion, trust, communication, teamwork and an ongoing framework for honest evaluation and learning, says Mary Hassett, president and principal at Integrations Inc., a strategic consultancy in Greenville, S.C. Many CEOs — in spite of their understanding and good intentions — fail. They fail because they tend to neglect their own self-care and health. The result of their imbalance takes its toll in many ways. It is evident to all when the leader is not modeling what the organization espouses to be and commits to deliver, she says.
Leader as educator. "Hospital CEOs will lead in educating their teams in what CAM is all about — what is evidence-based, what works, what the community wants," says Kathryn Johnson, retired CEO of Health Forum. They need to convince their team (and their physician leaders) that CAM not only is the right thing to do, but it also shows that the hospital is responding to the needs of its community.
Engaging the community and CAM providers. Engaging the community and bringing its members into the conversation is also key, says Johnson. Understanding community needs demonstrates a commitment to community benefit and can help the hospital ensure that its services are responsive to those needs. Using the CAM providers in the community as extenders is another way not only to build a referral network, but also to improve the hospital s reputation in the community.
"We are educating the next generation of change agents," says Meg Jordan, Ph.D., R.N., C.W.P., chair of the integrative health studies department at the California Institute of Integral Studies, "and to do that these leaders need to transform themselves, celebrating diversity not merely in thought, and be advocates of true sustainability, not merely ecological but of cultural well-being."
It s a tall order, but one it appears they are ready to take on.
Sita Ananth, M.H.A., is a writer and content expert on complementary and alternative medicine based in Napa, Calif. She is also a regular contributor to H&HN Daily.

The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.

Ethics, Confidence, and Training as Predictors of Decision-Making by Nurses During Disasters

I am pleased to present the ABSTRACT of the Ph.D. Dissertation prepared in May, 2012, by Dr. Joan Bold to Walden University.

Abstract

 Ethics, Confidence, and Training as Predictors of Decision-Making by Nurses During Disasters 

by

Joan A. Bold

MEd, University of West Florida, 1983

BSN, University of San Diego, 1981

Dissertation Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Philosophy

Health Services

Walden University

May 2012

Abstract

The American Nurses Association (ANA) 2008 Code of Ethics and Adapting Standards of Care Under Extreme Conditions describes how nurses are placed in the forefront of all phases of disaster relief, from planning to recovery efforts.  A 20-question quantitative instrument was developed and tested for feasibility in the field using ethics theory and Dillman’s tailored design method. The tool was assessed by an expert panel of 5 and then administered to 26 nurses from the public and community health departments. Research questions addressed (a) the ability of nurses familiar with the 2008 ANA Code of Ethics to verbalize knowledge of their professional responsibilities, (b) nurses ability to make confident decisions, assume leadership roles, and treat patients fairly, (c) ethics training beyond the basic nursing coursework. Data analysis technique included 6 ANOVA tests for the hypotheses. The result of the analyses supports 2 of 3 hypotheses (a) confidence in ethical decisions-making, (b) training during all-hazard situations. Both are associated with decision-making for entire group years licensed (11-40 years) and years worked (10-35 years) p= .01 respectively. Two other ANOVA test failed to accept or reject the null for confidence p= .91 and training p= .80. The results failed to reject the null hypothesis for (a) professional responsibility for years licensed (11-15 years) and years worked (11-15 years), nurses had moderate ethical concerns for decision-making p= 1.90, (b) professional responsibility (self-determination) also revealed nurses had difficulty placing their needs before their patient’s needs p= 1.19 regardless of years licensed (11-40 years) or years worked (10-35 years).  Implications for positive social change include better ethical decision making which can lead to higher quality of care for victims of disasters and improved medical outcomes.

Experiences of Accessing Medical Care by African American Men with Hypertension

I am pleased to present the ABSTRACT of  the Ph.D. Dissertation prepared and presented by Dr. Sandra Grosvenor to Walden University, September, 2012.

Abstract

Experiences of Accessing Medical Care by African American Men with Hypertension

by

Sandra Grosvenor

M.H.S.A., University of St. Francis, 2004

B.S., University of St. Francis, 2000

Dissertation Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Philosophy

Health Services

Walden University

August 2012

Abstract

The challenges and barriers that African American men with hypertension experience when accessing medical care on the Gulf Coast of Florida was the focus of this qualitative study. More than 50 million African Americans are affected by hypertension or high blood pressure. Still, many African American men may not understand the relationships between their social habits and their medical condition or how treatments such as receiving medical care for high blood pressure and eating certain foods could help improve their overall health. This descriptive qualitative study explored the lived experiences of working poor and indigent African American men between the ages of 25 and 55 with hypertension. Becker’s health belief model and Bracht’s health promotion model were used as conceptual frameworks to guide the research. Research questions were: What are the experiences of African American men when they access medical care for high blood pressure? How are African American men managing their blood pressure? What are some culturally acceptable ways to reach and competently treat African American men with high blood pressure? Four sources of data were analyzed and included questionnaires, surveys, interviews, and field notes.  A community center where African Americans frequent daily was utilized for the study. Findings showed that many African American men were not managing their high blood pressure, and had some challenges getting health care. The implications for  social change are that the health beliefs and perceptions of individuals,  have the potential to reduce the high incidences of hypertension through effective health services directly at the community level.   

Divided Government: Fiscal Cliff & Future of Reform

Credit for this article goes to author Haydn Bush, 11/9/2012 Health & Health Networks/ For use in Doctoral Research Forum.REH

 Divided Government, Fiscal Cliff and the Future of Reform By Haydn Bush H&HN Senior Online Editor November 07, 2012 The focus in Washington moves from the election to the fiscal cliff and the implementation of reform. What will that mean for hospitals? The grueling, seemingly endless presidential campaign is now a memory, and with no changes to control of the White House, Senate and House of Representatives, attention now shifts in earnest to the looming Fiscal Cliff. To be sure, there will be some time for celebration by the Obama camp and soul searching by the GOP, but those are bound to be short-lived. Even before we all sit down to gobble up turkey, stuffing and pumpkin pie in a couple of weeks, lawmakers are sure to stake out positions on the contentious issue of sequester and the 2 percent cuts in Medicare reimbursements that are slated to take hold next year. Oh, and hospitals, physicians and insurers eagerly await a slew of expected rules on the Affordable Care Act that were essentially put on hold during the last weeks of the campaign. "The election has been decided and the time for politics is over," says AHA President and CEO Rich Umbdenstock. "It is now time for governance. We must address the serious issues facing our country and have conversations that address real reform to improve the nation's health care system for patients and communities. Cuts to hospital care are not real reform. It is now clear that implementation of the ACA will move forward and we will continue to improve and build on it to advance quality of care and reduce cost." In a statement, Jeremy Lazarus, M.D., president of the American Medical Association, congratulated the president while focusing squarely on the projected cuts to physician payment scheduled to take effect next year. "The AMA is also committed to working with Congress and the administration to stop the nearly 27 percent cut scheduled to hit physicians who care for Medicare patients on January 1," Lazarus stated. "It is time to transition to a plan that will move Medicare away from this broken physician payment system and toward a Medicare program that rewards physicians for providing well-coordinated, efficient, high-quality patient care while reducing health care costs." Many experts, however, believe that in the short-term, the president and Congress will delay action on these issues well into next year. "My gut tells me that they punt the tax rates, the sequester and the debt ceilings," says Christopher Condeluci, who served as tax and benefits counsel to the Senate Finance Committee during the crafting of the Affordable Care Act and now is an attorney with the Washington, D.C.-based law firm Venable. While it's unclear at what point the federal debt limit would have to be raised — forcing action to alleviate a default — Condeluci guesses that action to move those conversations into February or March could occur, creating a new deadline of the August 2013 Congressional recess to make meaningful progress on a grand bargain around federal spending and taxes. Reform Moves Ahead In the meantime, the president's reelection means that implementation of key provisions of the ACA will continue. Most notably, open enrollment in health insurance exchanges is slated to begin Oct. 1, 2013, to prepare for coverage under the exchanges at the start of 2014. And while the final rules on the exchanges are out, Condeluci says there are a slew of other insurance market reform issues that still need to be resolved. "There will be an onslaught of regulations issued by the end of the month, and the end of the year," Condeluci says. Allowing time for the public comment process, he says, the rules could be in place by February, giving health insurance carriers eight months to prepare for open enrollment. From a longer-term perspective, of course, that means hospitals will need to continue preparations to care for the estimated 32 million Americans who are anticipated to have new access to health coverage. That means hospitals will have to carefully anticipate shifts in utilization and the impact on ED use, says Steve Valentine, president of the health care consulting firm Camden Group. One potential scenario: the potential growth in primary care offered by federally qualified health centers could contribute to a reduction in hospital utilization, he says, adding, "Inpatient use will get squeezed." And while it will take years, if not decades, to sort out all of the impacts of reform, Valentine says that in the short term participation in the Centers for Medicare & Medicaid experiments around cost containment and quality improvement, including its bundled payment and shared savings ACO programs, may not be high enough to hit the expected cost savings associated with those programs. Ultimately, the success or failure of those initiatives will trickle out to providers, he adds. "The goals of the Obama administration are not being met in terms of people in bundled payment [programs] and ACOs," Valentine says. "He's overestimated the savings, so taxes will have to go up or payment will have to go down. That's a wake-up call." 'Hospitals Will Double Down' Beyond the Beltway, of course, the health care industry is already in the midst of a major internal transformation outside of government reimbursement and oversight, from consolidation of hospitals and physician groups to the advent of insurance innovations like "narrow networks," or health plans linked to services offered by a single or handful of providers. Both Condeluci and Valentine expect these trends to pick up speed, with Condeluci predicting continued movement in the private market to embrace narrow networks, even if the plans may not initially pass muster for inclusion in the health insurance exchanges. And regardless of how federal changes to health care spending and ACA implementation shakes out, Valentine says the movement in recent years to aggressive cost containment — an issue we've covered extensively in our Fiscal Fitness series — will continue no matter what happens in Washington. Ultimately, Valentine says, that means more scrutiny for all nonclinical positions, the reevaluation of operations as they relate to the hospital's mission and a renewed focus on fundraising. "Hospitals will double down on squeezing more expense out," Valentine says. "There is no getting around this." The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.

Magical Thinking in Health Care

Complete credit for this article is given to author Ian Morrison,11/6/2012 Health & Health Networks Daily. Magical Thinking in Health Care By Ian Morrison November 06, 2012 From numbers that don't add up to faulty assumptions about patient behavior, many in health care believe in the impossible. We all do it. Magical thinking is about engaging in causal fallacies. It is comforting. Otherwise we'd spend our entire lives going: "Say what?" But in our national political discourse (and in health care in particular) we have elevated magical thinking to our basic operating model for the future. Bad stuff will happen, then we will do something to [insert simple idea here], then magical thinking happens and the world becomes a better place. Easy. Magical Thinking in Politics Both parties have demonstrated an astonishing capacity for magical thinking in the run up to the election. Republicans confidently assert that cutting tax rates for the wealthy will simultaneously grow the economy and not add to the deficit, even though the dismal economic performance from 2000 to 2007 suggests that precise strategy failed. (It would also be nice if the closed loopholes were specified: namely, mortgage deductibility and health insurance deductibility. Instead, the loopholes are left to the imagination, and magical thinking, about how the deficit can be reduced by cutting public broadcasting and foreign aid, both minuscule shares of the budget.) Similarly, Democrats argue that raising taxes on the rich spurs middle class job growth and returns the middle class to prosperity, when in reality the forces of globalization and technology (beyond the control of even presidents) continue to widen gaps between rich and poor. Magical Thinking in Health Care In health care, we have raised magical thinking to an art form. Our legislative process creates incoherent mishmashes of unintended consequences, even when the laws are well-intentioned and directionally correct. There are too many examples of magical thinking to cover, but here are a few: Rich people happily subsidize poor people. For five years I have been arguing that the central question in health reform is: "Will rich people write a check to cover poor people?" This whole election was really about that. You will know the answer shortly. But, no matter who wins the election, America must solve the riddle that majorities support government taking action to cover the uninsured, but those same majorities are unwilling to pay the taxes to make it happen. This is what scholars call the principle-policy gap. Budget delusions. The deficit matters; national debt in excess of 100 percent of gross national product matters. We can krugman in the short run ("krugman" is a verb I just invented to mean "run big government deficits to avoid depression, as the Nobel laureate and New York Times columnist Paul Krugman advocates"); but even John Maynard Keynes recognized you can't run these deficits forever. Both sides in the budget debate are delusional. Eventually, we have to cut spending and raise taxes (on everyone), and health care has to be a big part of the new austerity — otherwise the arithmetic doesn't work (even with magical thinking). Repeal and replace. It is extremely unlikely that anything would replace Obamacare if it were repealed. And even then, the proposed solutions are magical. My personal favorite is buying insurance across state lines. Apparently, my favorite out-of-state health plan, Blue Cross Blue Shield of Tennessee, can have enormous contracting clout with my doctors at the Palo Alto Clinic. I just don't understand this. States as laboratories for bad science. As the contrast between Massachusetts and Texas demonstrates, states are very different in their politics and culture. Massachusetts' health reform took place in a small, affluent, highly educated state with very low numbers of uninsured and relatively generous Medicaid and uncompensated pools. In contrast, Texas has more than a quarter of its citizens who are uninsured, and the state seems unlikely to aggressively pursue coverage expansion even if federal money for Medicaid expansion and exchanges are available. Imagining that all states eventually will look like Massachusetts seems like magical thinking, given the Supreme Court's green light to states' rights on Medicaid expansion. Single payer. Another area of magical thinking, common on both the right and left, is the idea that eventually we will have a single-payer system because either private-based reform fails or Obamacare creeps toward a socialist takeover. A true single-payer system requires massive income transfer from rich to poor and a standardized fee schedule delivered in a global budget framework. Put that way, it seems unlikely in the current American political context. Vermont, the only state really considering this, has yet to be specific about how the money would be raised to pay for the proposed single-payer plan but, as far as I can tell, it does not involve state-based income tax increases, but rather magical thinking about flows of funds from employers and the federal government. Exchanges. The clock is ticking for the exchanges to get up and running. The vast majority of states will not have a functioning exchange up and running on the due date, even with Obamacare intact. Even the states that are ahead are figuring out quickly that it is tough to design a health plan that can simultaneously fit through the precious metal aperture of affordability specified in the ACA, and be affordable and attractive to the humans who will be mandated to purchase these plans. In my state, California, we are further ahead than almost anyone, yet leaders in the state are ruminating that no HMOs beyond Kaiser can fit through the aperture of affordability and that the default plan will be a very, narrow-network, very, high-deductible PPO offering. Folks, we may be headed to that future anyway through the widespread creation of private exchanges which have all the features providers hate about state-based exchanges (narrow networks, low effective provider reimbursement through consolidated purchasing and competitive bidding, and high deductibles and the resulting bad debt problems). It's Obamacare without the subsidies. Low-income folk will sign up. Massachusetts had an aggressive social marketing campaign to explain to the uninsured that they should avail themselves of coverage. It worked well. But it takes some magical thinking to assume that 15 million-plus newly eligible citizens will sign up in every state across the country, especially when in many states there is no aggressive outreach, no social stigma to forgoing coverage, and no state leadership behind coverage expansion. Block grants. When you hear the phrase "block grant," it is code for "less money." Few people propose block grants with more money. It defeats the purpose. One battle to watch for after the election is reframing block grant proposals for Medicaid as self-imposed per capita caps on Medicaid spending (states would agree to a cap on federal contribution). This sounds sensible to me, but it may be magical thinking to assume that conservative politicians will take that deal if spending increases as enrollment in Medicaid increases. Spending the Medicaid managed care dividend before you've earned it. Across the country, states are converting their Medicaid programs to managed care. Others, like California, are aggressively pursuing waivers to expand managed care to special needs populations, the disabled and dual eligibles. While I applaud the move, many states (including California) seem to be banking the expected savings before they actually earn them. As one CEO of a local Medicaid plan in California told me last month: "I'll eventually get the 30 percent savings, but it may take three years to get all the care coordination, medical home and population health infrastructure in place for these patients." Dual eligibles present a special opportunity (and challenge). Many commercial players (including health plans and at-risk provider groups who thrive on Medicare Advantage) are salivating at the prospect of managing these dual eligibles. Plans and providers can deliver better care at lower costs and benefit financially in the process. But the magical thinking comes when you have to deal with all the segments of the dual-eligible population. The target population of dual eligibles for these commercial interests is what one local plan CEO dubbed "the nice old," namely the little old ladies with chronic conditions that can be managed much better in a coordinated care platform. The commercial players are less interested in the disabled, the institutionalized, the seriously mentally ill, and those with serious substance abuse issues, which represent significant subsegments of the dual eligibles. The recent transfer of special needs populations into managed care as part of California's Medicaid waiver provides a small window on this problem nationally. Players in the field estimate that costs for caring for the population were 10 to 15 percent higher than anticipated by their actuaries. The Smith conundrum. My friend Mark Smith, M.D., M.B.A., CEO of the California HealthCare Foundation, has identified a key conundrum in American health policy. The paragons of delivery excellence for value, whether it be Kaiser or at-risk medical groups, cannot make money on the Medicaid level of reimbursement. So the question becomes: What is the delivery model for the bottom third of the income distribution when Kaiser and other high-value delivery models to which we aspire lose $100 per member per month on these patients, and no one is volunteering to make up the difference in taxes? Reimbursement reform. Everyone in Wonk World agrees that changing the reimbursement system to align incentives is the key to system transformation. However, Harris Interactive surveys of physicians and hospital leaders consistently show extremely low levels of enthusiasm for new payment models such as bundled payment, global budgets and capitation. Let's face it. Fee for service is like crack — it's tough to get off it. Accountable care organizations. Hospitals and doctors are huddling together for warmth as they face the new future, many under an ACO umbrella. But reality is dawning on these fledgling new organizations, in particular, that structure doesn't automatically confer performance. Just because you are legally a clinical integration organization doesn't mean you are integrated clinically. That actually requires hard work … or magical thinking. Shared savings. Much of the transition from the first curve to the second curve, from volume to value, is enabled through shared savings models. What happens if there are no shared savings, only shared losses? What if a combination of budget cuts at the federal and state levels, organizational intransigence, and poor management fail to yield savings? If that's the case, where is the fuel for transformation? Right now, the principal fuel for much of this is provider-based reimbursement (you pay a cardiologist more in facility fees when the practice is owned by a hospital), which seems to me to be a policy accident waiting to happen. Patient-centered medical homes. We all should have a medical home with a highly integrated team of caring professionals hovering over our medical record, ready to pounce on any deviation from health. Well, that is magical thinking. Even the fathers of the movement concede that really what PCMHs are about is creating the mother of all triage systems, where you identify and concentrate resources on the heavy users to improve care, while automating the primary care and wellness initiatives so that the nagging to maintain health is done by your iPhone, not by the entire cast of Grey's Anatomy. It's all about segmentation and focus. Migrating the Business Model All these examples point to the critical challenge we keep cycling back to in recent columns, and that is migrating the business model. It needs to be done systematically but urgently, with compassion for those we serve and commitment from those who deliver care. We need to make the system work better and we need to be clearheaded about this transformation. And not just succumb to magical thinking. Ian Morrison, Ph.D., is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Daily and a member of Speakers Express. The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.