Recently, MSNBC reported that a Rhode Island doctor is facing a $500 fine and must take a continuing education course after inadvertently revealing a patient's identity during a Facebook post meant to outline some of her clinical experiences. According to the article, the doctor did not directly identify the patient, but described his or her injuries in a fashion that allowed a third party to figure out the patient's identity.

In some ways, this is the perfect cautionary tale for hospitals and docs who, like everyone else, now reach their customers via tweets and status updates. Unlike some HIPAA breaches I've heard about—stories of medical students posting patient photos on Facebook abound—the doctor in question appears to have had no intent of making light of her patient's condition or exposing their identity. And my assumption is that the lightness of the penalty, doled out by Rhode Island's medical licensing board, reflects that lack of intent—although at least one of the hospitals where she has clinical privileges terminated those privileges following the incident.

But it does raise some concerns as hospitals and doctors increasingly market themselves on Twitter, Facebook and other social media vehicles, instead of through more traditional media and community relations outlets. Hospitals don't have much choice in the matter—every business is migrating from face-to-face interactions and exposure through newspapers and TV to real-time social media encounters with the general public, but I think some caution about the extent of exposure, and social media guidelines for staff, are imperative, especially as more hospitals use clinical encounters as a chance to promote their services via Twitter and live webcasts.

My sense is that we're still in a period of unsettled chaos with Twitter, Facebook and other social media forms, and that eventually, informal and legal boundaries will begin to self-police what is still a young form of communication. Until then, tweet with caution.

Can HIPAA and other privacy protections remain meaningful—and enforceable—in an era where every action is tweeted and where we're all encouraged to share every detail of our professional and private lives? And does your hospital have a Facebook or Twitter policy to handle the pitfalls of social media? E-mail your thoughts to hbush@healthforum.com.

You could get very dizzy watching all those revolving doors—the ones spinning people in and out of hospital executive suites these days.

Though the turnover rate of hospital CEOs dropped slightly in 2010—to 16 percent, from a 10-year high of 18 percent in 2009, according to the American College of Healthcare Executives—that's still a hectic pace, and it's bound to pick up as baby boomers stampede into retirement. Some 60 percent of hospital CEOs are over 55 and by some estimates, a jaw-dropping 75 percent of health care organization CEOs will retire in the next 10 years.

And don't expect the doors to suddenly stop revolving once the boomers are gone. Those Gen Xers now eyeing the corner office over the tops of their Facebook pages "do not seek jobs for life or the gold-watch or silver-tray trappings of longevity," warns a white paper from executive services firm B.E. Smith. As for Generation Y? They "tend to think that a good job lasts three to five years."

In other words, the days of the CEO-for-life are vanishing, if they really ever existed. Back in 2006, an ACHE survey found that only a tiny fraction—3.4 percent—had served at the same institution as CEO for more than 20 years. The median tenure of a hospital CEO was just 43 months.

If, as expected, that "churn" intensifies, it will be very hard on hospitals. "The loss of a CEO can cost a health care organization $1.5 million in severance, recruitment expenses and the new CEO's salary," write B.E. Smith's Zachary N. Beesher and Christine Ricci. Moreover, it often prompts others on the executive team to leave, and it delays construction projects, new equipment purchases, physician recruitment programs and new service development.

That's not all: If there's a whiff of instability at the top, staff morale and public perception suffer, and competitors might take advantage of the situation by trying to poach members of the medical staff.

All of which ought to be motivation enough for CEOs and board members now in place to keep a sharp eye out for young staffers or job candidates with leadership potential. They should also get very familiar with what those up-and-comers expect in their careers. The expectations are, to put it mildly, "nontraditional," a fact that might stick in some boomers' craws. But it's essential for the long-term viability of an organization to understand them, adapt accordingly and build a reputation as an attractive place for Gen Xers and Yers to work.

Here are some characteristics of younger professionals identified in the B.E. Smith report:

• Because they don't plan to stay with one organization forever, they "prefer benefits loaded on the front end or a flat salary out of which they can fund their own benefits."
• They respond well to 15-25 percent management or productivity incentives and bonuses.
• They will not work the long hours their predecessors put in, and they want flexible schedules to allow a balanced work-home life.
• They need "constant feedback on performance and one-on-one time with supervisors."
• They "relish prompt recognition, even if it involves a simple card, thank you or token of appreciation."
• They "quickly grasp new concepts and are avid users of technology."
• Coaching is advisable, preferably "a formalized process that uses professional coaches to achieve specific, measurable outcomes, holds both coach and student accountable and focuses not only on organizational goals, but also on personal development."

By the way, several recent surveys have found that far too few CEOs are paying any attention at all to leadership succession plans. That can't be good.

How is your hospital preparing for the next generation of leadership? Or is it? Let me know at bsantamour@healthforum.com. And look for my column every Tuesday in this space.

In the month since the 429-page proposed rule for Medicare's Accountable Care Organization program has gone public, and with a little more than 8 months remaining until the program starts in earnest in 2012, concerns from observers and interested parties have unsurprisingly piled up, a natural response to a major initiative hailed by its supporters as one of the keys to reducing long-term health care costs at the same time it improves overall health care outcomes.

The newest addition to the chorus of skeptics entered my inbox Friday—a new study out from the George Washington University School of Public Health warns that ACOs may not fully serve Medicare beneficiaries in underserved communities. The report points out that federally qualified health care centers, which currently serve 1.4 million Medicare beneficiaries among their 19 million low-income patients, are not allowed to form ACOs. In addition, the report argues that ACOs will be discouraged from even including health centers in their organization, "because of its prohibition of the assignment of FQHC Medicare patients to ACOs for shared savings purposes." 

The report notes some incentives designed to bolster FQHC participation in ACOs—including an increase in shared savings if an ACO includes an FQHC, and an exemption from some of the requirements related to shared savings thresholds if patients have at least one encounter with a health center. But it concludes that the impact of the rule will "exclude the poorest beneficiaries with the highest health risks," and will discourage hospitals from affiliating more closely with health centers.

Of course, this is the stage in any regulatory process—as CMS solicits feedback to the proposed rule before it finalizes it—when concerns by interested parties are meant to be raised, and hopefully addressed by CMS in some form or another. Texas-based VHA, a network of not-for profit health care providers, for instance, argued in a recent New England Journal of Medicine article that participating providers in ACOs may be underwhelmed by immediate financial results. The American Medical Association, meanwhile, is worried that not all physicians who want to join an ACO will be able to participate.

It's also a good time for would-be ACO players to get up to speed on what those 429 pages will mean for their particular institution, and tomorrow, the American Hospital Association is hosting a members-only town hall where hospitals can can hear from federal regulators and AHA experts on barriers to ACO participation and possible remedies—click here for more information.

In the meantime, I'd like to hear from you, the reader. Email your issue, concern or, pray tell, your unabashed enthusiasm for the proposed ACO rule to hbush@healthforum.com, and I'll feature some of the responses in an upcoming column, along with other feedback I've recently received on ACOs.

A new report from the Dartmouth Atlas finds that chronically ill Medicare patients are logging fewer hospital days and receiving more hospice care in the last six months of life, leading to a decline in the percentage of chronically ill patients who died in a hospital from 32.2 percent in 2003 to 28.1 percent in 2007. The report also found that chronically ill Medicare patients who are admitted to hospitals are spending more time in intensive care and receiving more visits from physicians.

Among the other key findings:

• The average patient logged 10.9 hospital days in the last six months of life in 2007, down from 11.3 days in 2003.


• 36.1 percent of chronically ill patients were treated by 10 or more doctors in 2007, up from 30.8 percent in 2003.


• Among 35 academic medical centers surveyed, 22 reported increases in the number of patients seeing 10 or more doctors in the last six months of life from 2003-2007.


• In 2007, chronically ill patients in Manhattan averaged 20.6 days in the hospital in their last six months of life, nearly four times higher than in Ogden, Utah, where those patients averaged 5.2 hospital days.

Read the full report here.

Tucked away in the Affordable Care Act is a provision that may give some rural hospitals a little bit of—and much needed—financial breathing room. The law expands the Rural Community Hospital Demonstration Project, which tests what happens when so-called tweener hospitals are paid on cost-based reimbursement. Tweeners are too big to be a critical access hospital, and thus are ineligible for cost-plus reimbursement, but too small to thrive under traditional Medicare PPS. The demonstration actually started in 2004 and was slated to fade into the sunset, but it was given an extra life thanks to the ACA.

CMS earlier this month started naming the 20 hospitals that will participate in the program, including Grinnell Regional Medical Center and four hospitals in Maine. Only time will tell how effective the program is in addressing the financial strain facing rural hospitals, a strain that is very likely to grow in the coming years. A new TrendWatch report released earlier this week by the American Hospital Association peers into the unique challenges facing rural hospitals in a post-recession, post-reform era. "The recent economic downturn put additional pressure on rural hospitals as they already operate with modest balance sheets," the report states, noting that rural Americans are more likely to be uninsured and have lower incomes than those in the city. While the ACA expands coverage to 32 million people, "many rural hospitals will have to make upfront investments in order to handle the influx of new patients." The report goes on to point out that "limited financial and workforce resources present significant ACA implementation challenges for rural hospitals. As more rural Americans gain access to health coverage through Medicaid and the commercial markets, rural hospitals will experience greater patient demand that may strain already limited staff and capital resources."

It's not all doom and gloom though. The TrendWatch points out that the ACA boosts aid and services to rural communities. For instance, $1.5 billion for the National Health Services Corp for scholarships and loan repayment for primary care practitioners who work in health professional shortage areas. The law also extends outpatient hold harmless provisions for rurals. Still, there's ample concern that rurals will not be able to fully participate in some of the law's most substantial delivery system reforms, including accountable care organizations and value-based purchasing.

I'd encourage you to take a look at the TrendWatch. It is an enlightening read about one of the nation's most critical safety nets.

Email your thoughts to mweinstock@healthforum.com.

After two years of buzz and hype, this week marks the beginning of attestation for CMS's Meaningful Use EHR incentive program for hospitals, doctors and other providers, and the health care blogosphere is full of discussion on how hospitals can meet at least 19 of the 24 meaningful use objectives for hospitals and, if all goes right, start receiving additional reimbursements later this year.

In my interviews and informal conversations this year, meaningful use is second only to ACOs in frequency as a topic—and in the breadth of opinions I've received from both boosters and skeptics. Unscientifically, I would say a majority of the folks I've talked to take the general view of William Bria, M.D., CMIO of Shriner's Hospitals for Children, who sees meaningful use as a once-in-a-lifetime opportunity for hospitals and docs to invest in IT in a way that will lead to real clinical changes.

"It's a clear signal that there's been enough discussion…that the practice of medicine and the use of information technology should be integrated," Bria told me in a recent interview.

That's the ideal result, of course, and having written about many a tricky or initially unsuccessful IT rollout, I know hospitals will have plenty of challenges to navigate with doctors, vendors and staff as they aim for meaningful use. And that's why, for at least the initial round of attestation that starts this week, many prominent health care systems are opting to wait on applying for meaningful use funding until they're confident of meeting the requirements.

Part of the reason for the caution that I've been hearing lately is the requirement that applicants demonstrate compliance for 365 days. In practice, that means that hospitals and systems seeking to enter the program this year have to be perfect from Oct. 1, 2011, to Oct. 1, 2012. Hospitals are also concerned about meeting Stage II meaningful use requirements, which CMS released in draft form earlier this year and will take effect for 2013 and 2014.

John Frownfelter, M.D., CMIO of inpatient services for Henry Ford Health System in Michigan, told me in a recent interview that concerns about complying for a full year starting in October led to Henry Ford's wait-and-see approach.

"If we were to attest this year and start with a 90-day period this year, which is what's required, the next fiscal year requires we're perfect for 365 days, and that begins Oct. 1," Frownfelter said. By waiting a year, Henry Ford and other systems that decide to wait remain in the program's grace period, and will still qualify for full meaningful use payments.

"Starting this year, it doesn't bring inherent value, as long as we're on a long-term track that's safe," Frownfelter said.

Of course, waiting on a large infusion of federal cash isn't something that all hospitals are in a position to do.

"Mid-market facilities…are really depending on that money to show up in order to fund the technology initiatives they're going after," Spencer Hamons, corporate project manager for the Yukon-Kuskokwim Health Corporation in Alaska and formerly a CIO at San Luis Valley Medical Center in Colorado, told me in a recent interview. Is your hospital system moving ahead with attestation this week, or have has a decision been made to hold off until 2012? Email your thoughts to hbush@healthforum.com.

Kids say the darnedest things. So do certain management types, though precociousness is not nearly as endearing in people who ought to know better. That's evident in some of the responses I got to my question about what health care leaders can do to overcome friction among staff members of different generations. Clearly, for many the first step is to take a close look in a well-lighted mirror. A few cases in point:

• "I've heard leaders in a group of people say, ‘Turn up your hearing aid, Barbara,' when a woman in her 60s asked that a question be repeated. And, ‘Let's hire the young one—young people will work harder. He's just waiting for Medicare to kick in so he can retire.'"

•"When I suggested to our CEO that we move the supplies closer to the patient rooms, he told me to ask the young people to get them if my legs couldn't handle it anymore."

•"In a board retreat, the younger generation of physicians and employees were criticized for not being as committed and not working as long hours—a bit disheartening to the two gen Xers in the room (me and our CFO), who consistently put in very long hours to ensure the success of our organizations."

•"Another supervisor was planning an after-work get-together for our staff and I overheard her tell one of the new nurses she didn't need to come because she must have better things to do with her young friends."

• "He's clueless," one executive said of a C-suite colleague with a chronic case of foot-in-mouth disease. "And then he's surprised when some of these incidents end up in HR."

The good news is that there are authentic leaders out there conscientiously trying to bridge the generational divide. And there's plenty of advice to go around for the rest:

•"Managers need to lead by example and examine their own prejudices."

•"Leaders need to recognize that they have biases like everyone else and not be afraid to put them on the table for discussion, using respect and pursuit of perfection principles."

•"Talk about it. Acknowledging that generational differences exist is the first step in bridging the gap."

•"They need to build off our common commitment to patient care so we can all see we're on the same team, we just play different positions."

•"They need to stop telling staff what to do and start encouraging staff to take ownership of how we work together."

•"Environments need to be created that foster and encourage partnership and collegiality."

•"Managers need to identify key leaders (younger and more mature staff) and have them model a behavior of partnership."

•"Communication should be adjusted to be maximally effective. A generation that texts and tweets will not want to read an article or listen to a lengthy discussion about a new change."

•Conversely, "Managers can't communicate with their workers through social media alone. Older workers might not be as conversant in it, and it isolates the manager from his staff and the staff from their colleagues. I've designated two e-mail- and Facebook-free days every month because face-to-face interaction and encouraging everybody to honestly participate in a conversation promotes trust, camaraderie and teamwork."

Encouragingly, writers from a number of different hospitals described panels of executives, middle managers, physicians and staff who have come together to first understand and then work to overcome the generational divide in their own units, departments and across whole organizations.

"Our employee diversity committee has begun a series of lunch and learn opportunities to build awareness and dialogue on issues of equity, inclusion, fairness and respect," one writer related. "One of our first topics, scheduled for May, is embracing generational differences."

Like the pizza for peace summit one reader shared a couple of weeks ago, a diversity committee sounds to me like a simple step in the right direction. Do you agree?

My column, touching directly or indirectly on generational issues affecting American health care, appears in this space every Tuesday. I appreciate hearing from readers about these or any topics of interest to folks who work in hospitals. Send your thoughts to bsantamour@healthforum.com.

Today, in what will become a regular H&HN Daily feature, I'm handing the blog over to my readers and their thoughts on recent blogs, articles, podcasts and videos:

Robert Sigmond responds to Emily Friedman's recent piece on the 25th anniversary of EMTALA and its long-term impact:

"When I started working with hospitals in the 1940's on the Pennsylvania Hill-Burton plan, none of the hospitals that I remember ever charged for service in the Emergency Department. When I took my wife to the Emergency Department at the hospital of the University of Pennsylvania in the middle of the night with a terrible toothache back then, there was no way that I could pay for the care. The staff explained that they were not allowed to take tips! By the 1950's, Hill Burton requirements and the rapid growth of prepayment plans and the early insurance offerings had started to change all that, even before Medicare and Medicaid in the 1960's."

Debra Gerardi, R.N., writes in response to How to Build an Effective Accountable Care Organization, written by Abe Levy, M.D., Aric Sharp and Scott Hayworth, M.D.:

"Adopting a proactive approach to conflict management and improving conflict competency among leaders will be a necessary component of any successful ACO. In addition, the Joint Commission has required this as a component of accreditation and as such it is an invitation to leaders to think of conflict management strategically as a core component of achieving overall safety and high quality care for patients."

On Don't Use That Kind of Language Here, a blog I wrote about the importance of clearly written signage, pamphlets and forms for patient communication, Cheryl Allen, R.N. writes:

"I've been an R.N. for 30 years, and sometimes when I go to the doctor I have no idea what they're asking. The form says have you ever had any of the following...Rash, well who hasn't had a rash? Do they want me to put yes—even though it only lasted three days or do they want me to put no because it wasn't significant?"

Scott Mason responded to Dan Beckham's article CEOs Under Scrutiny, about the changing expectations hospital boards have for their CEOs:

"Rather than punt to a health system in the absence of a thoughtful strategy or simply put off succession planning, progressive boards may be required to embrace non-traditional models in the selection of their future leaders. It has long been the model in healthcare for CEOs to come up through operations. This has worked to a point. But it is my observation that operations has very little to do with strategy; there is almost no crossover. Future CEOs in healthcare, as Dan noted, must be strategic. And to the extent that operations is important, it may be more a need for familiarity with physician practice and freestanding ambulatory operations (growing) rather than just hospital operations (shrinking). At the same time, we should not forget that ‘culture eats strategy for lunch.'"

And finally, Daniel Fell, from Chattanooga, T.N., responded to How CIOs Can Stay Relevant, a podcast interview with Spencer Hamons, corporate project manager for the Yukon Kuskokwim Health Corporation in Alaska, on the importance of CIOs in smaller markets:

"I think one way CIO's can break out of the IT silo is to collaborate with departments like marketing who have a shared interest in IT solutions. Marketing also brings a broad market and customer perspective that can help IT to be more successful in its planning and implementation efforts."

Send your thoughts on any item to hbush@healthforum.com.

In today's Data Snapshot, we're highlighting a CDC report out this week finding that 52 percent of Americans used at least one dietary supplement on a regular basis between 2003 and 2006, up from 42 percent between 1988 and 1994. The report tracked U.S. use of dietary supplements by gender as well as ethnic and age groups. Among the other key findings:

• Roughly 39 percent of Americans reported taking either multivitamins and multiminerals, up from 30 percent in the previous study and the most common dietary supplement reported taken.
  

• The number of Americans taking supplements with vitamin D increased for men and woman in nearly all age groups.

• Overall 60 percent of women over 60 report taking a dietary supplement containing calcium.

• Non-Hispanic white women were approximately twice as likely to take one or more dietary supplements containing folic acid than non-Hispanic black and Mexican-American women.

Read the full report here.

Would you be more likely to put down that French fry and pick up a carrot stick if you knew that your health insurance policy didn't have a deductible? Would you hit the gym more often if your insurance premium were waived? And what if you didn't have to pay for smoking cessation classes? Would you be more likely to snuff out the habit?

Federal health officials are hoping the answers to all of those questions are a deafening "Yes" from Medicaid beneficiaries. CMS earlier this month started accepting applications from states for $100 million in grants to reward Medicaid beneficiaries who quit smoking, lose weight, exercise, keep their blood pressure or cholesterol under control, and more. The Medicaid Incentives for Prevention of Chronic Diseases Program was mandated by the Affordable Care Act. In announcing the grant application period, which ends May 2, CMS said the goal is to "test and evaluate the effectiveness" of providing "financial and non-financial incentives to Medicaid beneficiaries of all ages who participate in prevention programs and demonstrate changes in health risk and outcomes, including adoption of healthy behaviors."

A guidance document put together for CMS by Thomson Reuters says the program should not be about giving people money. Rather, it should include incentives such as waiving premiums, deductibles and coinsurance payments. States could provide points that could be used to buy medications. Beneficiaries could be reimbursed for taking smoking cessation classes or Weight Watchers. The guide also discourages the use of penalties, calling them counterproductive.

"Penalizing beneficiaries for not participating in health improvement programs or achieving certain health outcomes will instill resentment and likely negatively impact the most vulnerable beneficiary populations," the guide states.

That's not necessarily how Arizona Gov. Jan Brewer sees things. She's taking the stick approach. The Republican governor proposed a $50 annual fee for adults who smoke. Similar penalties would apply to obese or diabetic beneficiaries who fail to follow a physician's treatment plan.

Importantly for providers, the CMS guidance suggests that state activities be done in conjunction with existing care coordination projects, including patient-centered medical homes and ACOs. To be clear though, the financial incentives are for beneficiaries, not providers.

The jury is still out on how effective incentive programs are in getting people to adopt healthful lifestyles and/or better manage their chronic conditions. But with Medicaid at the center of the budget debate boiling over in D.C., it's clear that health professionals need to utilize any and every tool at their disposal. That cost curve isn't going to bend all by itself. Treating diabetes alone accounts for $174 billion in direct and indirect health care costs. Multiple that by other chronic conditions such as congestive heart failure or high blood pressure and, well, you see where I'm headed.

It'll be interesting to see what kind of programs states bring forward. And isn't it kind of refreshing to think about a government health program spending money in the hopes of making people more healthy, rather than solely focusing on Medicare and Medicaid's looming billion dollar diet?

I'll continue to explore issues of wellness and prevention in upcoming blogs and certainly welcome you take on how we can bend the cost curve. Send me your thoughts at mweinstock@healthforum.com.

(Editor's note: H&HN Daily Regular Contributor Emily Friedman is guest blogging today.)

AMSTERDAM—Last week, I had the privilege of speaking at the International Forum on Quality and Safety in Healthcare in Amsterdam, Netherlands, cosponsored by the Institute for Healthcare Improvement and the British Medical Journal (BMJ) Group. There were nearly 3,000 attendees from 86 countries; several thousand more watched via satellite.

Rein Willems, the retired president of Shell Netherlands, now a member of the Dutch Senate, in his keynote address spoke of "blame-free error reporting"—systems that allow or require reporting of all adverse events, without blame or penalty—and asked why health care systems are so reluctant to adopt this approach when it is used widely in other sectors. Americans might say that the reluctance is due to potential malpractice litigation, but it's a problem in health systems around the world, including those where lawsuits aren't much of an issue.

Two compelling sessions focused on disaster. Afghan physicians spoke of progress made despite years of Taliban oppression and war. Dr. Nadera Hayat Burhani, deputy minister of health, emphasized culture change: "We need to break learned helplessness on the part of [hospital] staff." She also reported that Afghanistan has gone from relatively few midwives to 2,000 (critically important in a country with the second highest maternal mortality rate in the world), and that 22,000 community health workers have been trained. The most moving moment came when Dr. Nasrine Oryakhail, director of Malalai Hospital in Kabul, marveled that ten years ago, she could not leave her home without permission, and now she was addressing an international audience.

A Skype broadcast of two physicians in Fukushima Prefecture, Japan—the center of earthquake, tsunami, and nuclear power plant damage—was riveting. Dr. Ryuki Kassai, a community physician and professor, and Professor Shigeatsu Hashimoto of Fukushima Medical University Hospital (FMUH) said that the hospital did not suffer structural damage, but its water and electric supplies are severely limited.

Five hospitals were destroyed by the quake and tsunami; their patients were transferred to FMUH, as were patients from a hospital near the power plant. FMUH is screening transferred patients, local residents, and plant workers for radiation exposure. About 500 have been screened; 10 were decontaminated, and two nuclear plant workers who suffered burns from highly radioactive water were treated. FMUH also brought in an expert on radiation risk from the Nagasaki University School of Medicine to educate staff and counteract rumors.

Dr. Kassai and Dr. Hashimoto expressed their thanks for words of support and prayers from around the world, which, they said, encouraged them and their colleagues to persevere.

"Please think of us," Dr. Kassai said.

The BMJ has made the broadcast from Japan available on its web site.

Emily Friedman

Independent Health Policy and Ethics Analyst

WASHINGTON, D.C.—The toolbox is full. The science is ready. All we need to do now is decide to do it.

That was the message CMS Administrator Don Berwick delivered yesterday when he and HHS Secretary Kathleen Sebelius made a last-minute appearance together at the American Hospital Association's annual membership meeting in Washington, D.C. They came to ballyhoo the Partnership for Patients: Better Care, Lower Costs initiative launched with great fanfare earlier in the day.

Spearheaded by HHS, the public-private Partnership aims to improve patient safety by widely sharing real-world examples of how organizations have reduced errors and encourage others to adopt those best practices.

"We know safety can be improved because hospitals are already doing it," Sebelius told AHA members gathered in the Washington Hilton. "Unfortunately, many of the proven methods have been slow to spread."

The Partnership sets two goals to be reached by the end of 2013: reduce preventable hospital-acquired conditions by 40 percent and reduce avoidable readmissions by 20 percent. Up to $1 billion in Affordable Care Act funds will support the program.

Achieving the goals will not only save lives and prevent injuries to millions of Americans, Sebelius told AHA members, it could also save up to $35 billion dollars across the health care system, including up to $10 billion in Medicare savings, over the next three years. During the next 10 years, it could reduce costs to Medicare by about $50 billion and result in billions more in Medicaid savings.

AHA President and CEO Rich Umbdenstock reassured the audience that the Partnership is a voluntary effort. "It's not changing the dates or penalties of the Affordable Care Act," he said.

"There's no down side," Umbdenstock stressed, noting that the AHA and five other national hospital associations were among the first to sign on, jointly pledging themselves to help the Partnership achieve its goals. Sebelius said 500 hospitals across the country had already pledged to participate as of yesterday afternoon.

Patient safety is not a workforce issue, Berwick said, "it's a property of a system," that may, for instance, be too complex, too fragmented or that uses poor technology. Improving it depends on leadership—from the board of trustees to the C-suite to clinical executives.

The Partnership "takes excellence to scale," Berwick said, in order "to make the best care, normal care."

Sebelius said the initial targets are just the start. "Our ultimate goal in health care should not be to reduce errors by 10 percent or 20 percent or 30 percent," she said. "It should be to eliminate errors."

For more information, click here.

WASHINGTON, D.C.—"Of all the introductions I've received, that was the most recent," former Sen. Alan Simpson remarked as he took the podium Monday at the American Hospital Association's annual membership meeting. Simpson gave a wry, often laugh-out-loud review of his work on the National Commission on Fiscal Responsibility and Reform, a nonpartisan panel appointed by President Obama to come up with a strategy to reduce the nation's debt.

Simpson, a Republican, led the panel along with Democrat Erskine Bowles. Their plan was unveiled in December and immediately set off a fury of condemnation from all points along the political spectrum. It recommends, among other things, significant changes to entitlement programs as well as a three-tiered income tax and tweaks to corporate taxes. The White House response up to now has been muted to say the least, but speculation here in Washington this morning is that the Simpson-Bowles proposal will, in fact, be the basis of the deficit reduction strategy the president is slated to unveil tomorrow.

Of all the government spending issues his commission tackled, Simpson said, "We found health care to be an absolute monster. It's the biggest fiscal challenge that our nation will ever see." If Americans are serious about getting the federal budget under control, "you can't get there without cutting Medicare, Medicaid and Social Security," he declared. "Anyone who tells you otherwise is a fraud."

Criticism of Medicare and Social Security reform is "bilious babble," Simpson said, noting that 10,000 baby boomers retire every day, the average life expectancy has climbed from 63 to 78 since Social Security was introduced, and as of May 2010, Social Security paid out more than the amount put into the program.

But balancing the budget can't happen by cutting alone, he said. "Ronald Reagan raised taxes 11 times. Why do you think he did that? To keep the government running."

Simpson said his commission's plan was "written for the American public" in plain English and is just 67 pages long. You can read it here.

I've heard a lot of interesting speakers and had conversations with a lot of attendees from hospitals around the country during the AHA annual meeting. Many of the issues discussed revolve around generational issues, including aging patients, physicians, nurses and hospital leaders. I'll share some of what I've heard in that regard on upcoming Tuesdays in this space.

Last Friday, HHS released a five point action plan to address racial and ethnic disparities, the latest sign that hospitals, the federal government and other health industry leaders are making a strong push in this critical area. The HHS report calls for, among other things, expanded insurance coverage, new service delivery sites to better serve patients and the increased use of patient-centered medical homes. The report comes as the Joint Commission is on the verge of implementing its own standards around patient-centered communication—a key element of disparities reduction efforts—next year.

My sense is that as efforts intensify nationally to control health care costs, health care leaders are beginning to see disparities work not just in the context of delivering equitable, high-quality care to all patients, but as a key prong in the overall battle to reduce the high costs associated with patients with multiple chronic conditions. The HHS disparities plan, for instance, specifically notes the presence of disparities in care in cardiovascular disease, childhood obesity and tobacco-related diseases, and recommends targeted efforts in these diseases as part of its overall approach.

That approach—viewing disparities not so much as an isolated area of focus but as a critical component of an integrated quality strategy—was championed by the subject of today’s HHN Daily video interview, Joseph Betancourt, M.D., director of the Disparities Solutions Center who also works as a primary care physician at Massachusetts General Hospital in Boston. Betancourt talked up a Mass General program in Chelsea, Mass., that employed a bilingual health coach to improve adherence to diabetes treatment regimens and, ultimately, patient control of the disease. The presence of the coach helped reduce disparities in care for Hispanic patients, but also improved diabetes outcomes for all patients in the program regardless of race or ethnicity, all of whom benefited from the coach’s instruction.

Reducing disparities can be daunting work, of course, and requires a great deal of detailed information. When I interviewed Maulik Joshi, president of the AHA's Health Research Educational Trust, last week to discuss HRET’s new report, Improving Health Equity Through Data Collection and Use, he stressed the importance of engaging all staff around the critical first step of acquiring patient data around ethnicity and language, which, given its sensitive nature, can pose a major hurdle.

In the years to come, directives from the Joint Commission and HHS on disparities reduction will force providers to get in the game. And with the innovative work already going on in the field as inspiration, I'm increasingly optimistic that disparities reduction work is moving from an isolated area of hospital operations to a central component of overall patient care strategy.

A report this week in Health Affairs finds that adverse events occur in 33.2 percent of hospital admissions, or 91 events per 1,000 patient days. Those rates are considerably higher than previously suspected, the authors argue.

The researchers, funded by the Robert Wood Johnson Foundation, used the Institute for Healthcare Improvement's Global Trigger Tool as a guideline for discovering adverse events. According to the report, traditional event detection methods, including AHRQ's Patient Safety Indicators and voluntary reporting, may miss up to 90 percent of adverse events.

In a statement, AHA President and CEO Rich Umbdenstock said hospitals are dedicated to improving patient quality and safety to prevent adverse events. "Hospitals are actively engaged in quality improvement efforts and are eager to identify and use strategies and tools that can further improve patient safety," he said.

On average, patients experiencing adverse events were older, had greater hospital length of stay and a higher case-mix index than the norm, the study also found. Read the full report here.

I never thought that I would actually say this, but a spokesman for McDonald's is right.

The other day, a New York City councilman introduced legislation that would prohibit handing out toys or games with any meal that doesn't meet certain nutritional guidelines. Fines would range from $200 to $500 for the first offense. Similar bills have been proposed nationwide. San Francisco lawmakers enacted just such an ordinance last year.

Mason Smoot, vice president and general manager for McDonald's New York region, issued a statement saying that taking toys out of Happy Meals won't solve the childhood obesity epidemic. He noted that kids eat the majority of their meals away from fast food restaurants. "That adds up to a larger discussion than toys," he said.

Smoot is right. Toys are not the issue. Don't get me wrong, I am not one to defend McDonald's and its impact on America's ever-growing waistline, but as I've written in the past, banning toys from Happy Meals is hardly a long-term solution to our penchant for unhealthy eating. Now I know that the big news this week isn't the debate over putting a plastic Superman in with your kid's chicken nuggets. CMS' proposed ACO regulations and the budget showdown that threatens to shut down the government are top of mind, and rightfully so. But, a larger, more thoughtful and reasoned discussion about attacking the nation's obesity epidemic is absolutely something we should have as we test new ways to deliver care and attempt to curtail runaway deficits.

The Centers for Disease Control & Prevention in 2009 issued a report showing that the increased prevalence of obesity added $40 billion in medical costs between 1998 and 2006, including $7 billion in Medicare prescription drug costs. Obesity was responsible for 9.1 percent of annual medical spending, compared to 6.5 percent in 1998. CDC went on to predict that total annual costs for treating obesity would climb to $147 billion by 2008, up from $78.5 billion in 1998. The National Bureau of Economic Research in 2010 pegged the number at $168.4 billion or 16.5 percent of medical costs.

From other CDC data, we know that 6.5 percent of children aged 6 to 11 were obese in 1980. In 2008, it was 19.6 percent. Among teens, the percentage soared from 5 percent to 18 percent. Obese youths are more likely to develop risk factors for cardiovascular disease and diabetes. They are at greater risk for bone and joint problems, as well as sleep apnea and psychological problems.

The problem is so much more complex than Happy Meals. It crosses almost all socioeconomic issues—education, jobs and the economy, economic development. Hospitals can't control many of the leading causes of obesity. Instead, they have to deal with the effects. Until we take a holistic approach to addressing the obesity epidemic, there will be little bend in that cost curve they are talking about in Washington, D.C.

In the year since the passage of the Affordable Care Act, Medicare's Accountable Care Organization program, or partnerships between providers designed to improve cost and quality in exchange for shared savings, has been one of the most-talked about components of the bill, especially within the industry. The fever pitch to join an ACO has even been parodied on YouTube, a telltale modern sign of the idea's popularity and reach.

After months of waiting—and with the Jan. 1, 2012, start of the ACO program looming, CMS finally released the 429-page proposed ACO rule last week. Among the big takeaways: CMS estimates that 75 to 150 ACOs will be formed, serving between 1.5 million to 4 million Medicare beneficiaries over the first three years of the program. Simultaneously, the FTC and DOJ released a proposed statement on antitrust enforcement policy as it relates to ACOs.

All this week, I've been surveying reaction to the rules, and the consensus seems to be that there were no major surprises in the rule that weren't apparent from reading the relevant portions of the ACA last year. Still, there are plenty of differing opinions out there to digest, and I've compiled a few of them that caught my notice:

• Fiercehealthcare.com surveyed the health care industry and labeled the general reaction to the rule as one of "cautious enthusiasm."
  

• In an interview with Health Leaders, Paul Keckley, executive director of the Deloitte Center for Health Solutions, said the main idea emanating from the guidelines is the promotion of physician-hospital alignment. "…You step back and see they are compelled by the vision of integrated systems," Keckley said. "That to me is the big cake here."


• Over at The Health Care Blog, Vince Kuraitis, principal and founder of Better Health Technologies, concluded that the rule was "surprisingly aggressive and well-reasoned." Kuraitis called the Antitrust Enforcement Policy notice a sign that "concerns over maintaining competition and avoiding antitrust are being taken seriously." Kuraitis also had words of caution for organizations thinking of applying that may not be entirely ready to participate. "The bar has been set high…very high. Tire kickers need not apply."

• Paul Levy, former CEO of Beth Israel Deaconess Medical Center, and author of the now Not Running a Hospital blog (formerly Running a Hospital), took issue with the fact that providers cannot require beneficiaries to obtain services from other providers. "How can you be held accountable, as a provider group, if you cannot control the management of care of your patients?" Levy wrote.

• Jeremy Lazarus, M.D., speaker of the AMA House of Delegates, told American Medical News that all physicians who wish to participate should have the opportunity to do so. "ACOs offer great promise for improving care coordination and quality while reducing cost, but only if all physicians who wish to are able to lead and participate in them," Lazarus said. That will certainly be an issue; as I wrote earlier this week, some observers believe not all ACOs will have the capacity to absorb all interested parties.

• And finally, Eweek.com reported that the legislation poses a challenge for IT vendors who will need to create systems that can distribute shared savings and share data among providers.

Send your take on the Proposed ACO Rule to hbush@healthforum.com.

One of these Tuesdays, I'll report back on the responses to my question about what hospital leaders can do to overcome friction between staff members of different generations. First up, I wanted to share this example from a senior executive at a small hospital in the South.

"I was made aware of hard feelings between two baby boomer staff nurses and two recent hires just out of nursing school," she told me. "I decided to meet them in a neutral location so we could clear the air."

She chose the pizza place across the highway from the hospital. The nurses arrived separately in pairs according to age, and the two pairs slipped into opposite sides of the booth. The executive pulled a chair up to the end of the table.

She asked what they wanted on the pizza. One of the boomer nurses said she liked pepperoni. One of the Generation Y nurses said she was a vegetarian and asked for mushrooms. The other older nurse said mushrooms upset her stomach and if pepperoni was out, they should just get a plain cheese pizza. The other younger nurse said she was on a diet anyway and would just have the house salad.

Listening to the back-and-forth and trying her darnedest to hold it in, the executive finally burst out laughing. Nonplussed, the four nurses drew back in their seats and exchanged wary glances. Then, one by one, they joined in.

"We sat there like lunatics laughing helplessly for five minutes," the executive recalled. "The poor waiter was afraid to come over to take our order. When he did get up the nerve, I asked for two medium pizzas—one with pepperoni, one with mushrooms—and house salads all around." As soon as everyone had regained her composure, the executive leaned forward and said, "OK, now that we've settled the Pizza War, what can we do about work?"

And so began a 45-minute discussion, sometimes heated, but mostly not, about everything from scheduling of shifts to job assignments to office etiquette and behavior toward colleagues. "When we got to the topic of actually dealing with the patients, I was a little nervous," the executive admitted. "I thought it would be between ‘this is the new way we were taught in school' and ‘we've always done it this way here and it works just fine.' "

Instead, a younger nurse confessed that she sometimes felt overwhelmed by the workload and didn't know if she'd ever be able to juggle so many different tasks. An older nurse sheepishly acknowledged that she'd felt the same way her first year or so on a patient floor.

"That was the turning point," the executive said. "The ice was broken." Soon enough, the younger nurses were asking the baby boomers if they had any tips for sorting out the work a little more efficiently, and the boomers were asking if their co-workers could help make sense of some of the new technology.

"Let's face it, these nurses will never be the closest of colleagues," the executive said. "But the defensiveness and anger are pretty much gone."

What do you think? Can the generational conflicts at your hospital be tempered with a little pizza diplomacy? Tell me at bsantamour@healthforum.com.

By the way, I'll be in D.C. for the American Hospital Association Annual Membership Meeting starting this weekend. If you're around, look for my name tag and introduce yourself. I'd like to meet you and hear some of your real-life experiences working in a hospital—whether they relate to generational issues or not.

MIDWAY, UTAH—During last week's CMS announcement of the proposed rules for accountable care organizations, or ACOs, I was, appropriately enough, in Utah's Rocky Mountains at the Intermountain Healthcare Clinical Quality and Accountable Care Seminar. Intermountain, with its own insurance plan and medical group, is designed to deliver clinical best practices in every patient encounter and is often held up as one of the models for ACOs. The seminar was billed as a chance for other hospitals to learn how all the pieces fit together.

But while Intermountain leaders were happy to discuss their efforts to root out variation, partner with physicians and manage population health initiatives, they were generally cautious about the comparisons between the ACO program and their system, which has evolved gradually since it was created in 1975 as a non-for-profit organization inheriting 15 hospitals previously run by the Church of Jesus Christ of Latter-day Saints.

When I talked to Intermountain CEO Charles Sorenson, M.D, he took pains to point out that many of Intermountain's key assets—an EMR that gives doctors best-practice information at the point of care; its in-house insurance plan, Select Health; and its close relationships with doctors—took years of fine-tuning and negotiations to get right. And Linda Leckman, M.D. CEO of Intermountain's Medical Group, had words of caution about the ACO model's emphasis on clinical integration, during a session on alignment between the medical group and individual physicians. Sometimes, hospitals simply don't have the capacity to hire or affiliate with every physician who would like to join, Leckman pointed out.

"Nationally, speakers are telling physicians that in the next three years, you need to be tied to an ACO," Leckman said. "In our community, there are physicians who want to be a part of us, but it doesn't always work for us. The more clinicians you have, the more your infrastructure gets stretched."

On the final day of the seminar, Greg Poulsen, senior vice president of strategy for Intermountain, drove home the importance of the work that ACOs and independent care coordination efforts, like those at Intermountain, will have to deliver in the years to come. Poulsen briefly surveyed the current political machinations around the ACA, and then argued that regardless of how national reform plays out, the challenge of bending the ever-rising health care cost curve will remain. Poulsen noted that future, unfunded obligations to Medicare are estimated by the GAO at roughly $37.9 trillion—dwarfing unfunded obligations to the national debt and Social Security.

"This is a big problem if the growth rate continues," Poulsen said.

Despite that grim forecast—backed up by a flurry of statistics on variations in health care outcomes and utilization—Poulsen sounded a somewhat upbeat call to the hospital leaders and doctors who trekked out to Utah to look for solutions.

"Can we change the health care cost structure to make things better?" Poulsen asked the audience.

I went to a Chicago Bulls game a couple of weeks ago with my friend Phil and during a 40-point rout of the hapless Sacramento Kings, we started talking about health care. Sad, I know. But with a 20-point lead at halftime and Da Bulls' superstar point guard Derrick Rose resting on the bench, it was hard to stay focused on the game. Plus, Phil and I are both in our 40s, so after touching base on the kids' schools, the start of t-ball and Little League practice, home repairs and Libya, what was left?

I asked Phil, who's been in health care communications for more than a decade, if he likes his primary care doctor. I happen to be in the market for one. True confession: I haven't seen my primary care doctor for at least two years. True confession II: I falsely claimed I would schedule an annual physical just to get a prescription renewed. I've grown less enamored with the practice over the years for a variety of reasons and have been using retail clinics for routine illnesses and a specialist for a chronic condition. As an aside, my allergy-asthma doctor would not renew a prescription without actually seeing me for my annual appointment. She was wise to my crafty ways of avoiding doctors.

Phil has a doc he likes, but astutely noted, "I have nothing to really judge him against, or a solid basis for that opinion." In a Yelp-like review, Phil rattled off some positive attributes: the doctor takes time to explain things, he listens, it's relatively easy to get an appointment, and so on. As Da Bulls' bench players widened the score, we had a deeper conversation about how and why patients choose a provider.

To be sure, highly educated health care consumers can look up quality indicators on Hospital Compare or at the Joint Commission's website, or on any of a dozen other public databases. But we also know that many, if not most patients rely on recommendations from friends and family. As we've reported in H&HN over the past year or so, that conversation is now extending to Facebook and Twitter. Reviews are also being posted on such sites as Angie's List, Yelp and even Zagat. Often the recommendations are based on, shall we say, softer measures, rather than concrete quality metrics.

The patient experience will only grow in importance during the next few years. Under CMS' proposed value-based purchasing regulation, HCAHP scores will be incorporated into a hospital's overall ranking, and thus impact Medicare reimbursements. But that's not all. An article in our forthcoming April issue looks at how some hospitals are beginning to assess the patient experience across the care continuum. Officials at these hospitals understand that as health care becomes more integrated, and they are held more accountable, what happens to a patient post-discharge is extremely important. They've expanded their patient satisfaction surveys to understand how care coordination is being managed.

This isn't to minimize a provider's top priority—to provide safe, effective and quality health care. But we need to keep in mind the impact satisfaction has on a provider's reputation. I am loyal to my allergy-asthma doctor because she is responsive to my needs, she spends time explaining things to me, she's proactive in getting me to do follow-up appointments and she e-prescribes to the pharmacy. I can't say the same things about my primary care doctor's practice, which is why someone else will be getting my business. I welcome your thoughts. E-mail your thoughts and suggestions to mweinstock@healthforum.com.

The other day, I was glancing at a new report from AHRQ announcing that 75 million Americans have limited health literacy, when I stopped abruptly. Unsurprisingly, the report found that low health literacy is linked with high risk of mortality and more visits to the ED, and recommended increased communication and education for all patients. But what piqued my interest the most was a line buried at the end of the report, which describes the National Action Plan to Improve Health Literacy, developed by HHS last year.

"The plan calls for improving the jargon-filled language, dense writing, and complex explanations that often fill patient handouts, medical forms, health web sites and recommendations to the public."

It made me wonder—how much of improving health literacy comes down to producing easily understood signs and pamphlets that ordinary patients can understand and act on?

As it happens, I read the report the same day I interviewed Spencer Hamons, a corporate project manager for Yukon-Kuskokwim Health Corporation in Alaska and formerly CIO at San Luis Valley Regional Medical Center in Colorado, for a podcast running Friday on the challenges and opportunities of rural health IT. During a conversation about ACOs, Hamons argued that successful providers in the accountable care age will need to see their facilities through the eyes of an average patient—and communicate accordingly.

"The terms that we use—we take those for granted, and…they create apprehension for the patient," Hamons told me. "Think about what goes through the mind of a 75-year-old patient, who's spent his entire life as a longshoreman. He goes into a room with a sign on the door that says nuclear medicine and has warning signs plastered everywhere. We expect that patient to give up a certain amount of control while they're in the hospital, but we don't do a very good job of explaining why."

Of course, effective signage is precisely the sort of low-tech solution that good hospitals already do every day. I've been in hospitals as a patient where the signs and pamphlets are written in clean, simple language that most patients and visitors, regardless of their familiarity with the health care system, can understand—and I've been in facilities where a medical degree is seemingly necessary to decipher the myriad warnings and protocols on the walls.

I'm not discounting the difficulty of reaching patients with limited understanding of the health care field and the challenges they face when interacting with doctors, nurses and other hospital staff. But communication is a two-way street, and effective signage and reading materials can go a long way in educating patients and making an often bewildering experience a little less so.

E-mail your thoughts and suggestions to hbush@healthforum.com.

A couple of weeks ago in this column I wondered if readers had seen signs of tension between different generations of staff in their workplace. Little did I know what a hornet's nest I was stirring up.

The reaction was immediate, emphatic and unanimous. Everybody who responded said they are acutely aware of colleagues of one age group who hold colleagues from another age group in low regard. In most cases, the disdain simmers just below the surface. But several of you described contempt so extreme it occasionally erupts in front of co-workers and even patients.

"Our youngest staffer lost it last summer and yelled at the supervisor to get off her back. The supervisor shouted that she was a spoiled brat who ought to move back home with Mommy and Daddy," one e-mailer reported, adding dryly, "It went downhill from there."

Thankfully, the tension tends to be more subtle, though the attitudes are strongly held.

Gen Xers and Yers "are only interested in collecting a paycheck and doing the minimum they need to do to get by," a boomer wrote. "If it isn't required, they aren't interested"—a theme echoed by a number of other respondents in the 40-and-over age range. To wit:

"Younger employees view their jobs as jobs, not as professions or careers."

"They don't want to pay their dues by taking night shifts, etc…"

"They lack commitment to the mission. They're only committed to having fun."

"As soon as they're hired they ask, ‘When can I take time off?' That is irritating to me."

OK, so what do people in their 20s and 30s think? Well…

"I work with two people in their 50s and I can tell you, they are just coasting toward retirement."

"The tenured staff have a sense of entitlement. They don't think they should have to take call or learn the new technology."

"The baby boomers get mad when we wonder why things are done a certain way. They're defensive about their sacred cows."

"Some older staff withhold information from the younger staff to make themselves indispensable."

"My older co-workers feel threatened by me. They're scared of change and I'm not. They think I want their job and I do. If I'm better at it, why not?"

All righty, then …

Happily, nearly everybody who e-mailed me—even those who lamented most emphatically what they view as the shortcomings of their younger or older colleagues—understand how destructive generational friction can be to a work unit. A common theme in the responses: Employees, supervisors and top executives must recognize the unique strengths each generation brings to the workplace and capitalize on those traits so they complement rather than clash with each other. As one writer put it: "Respect for what each generation contributes and avoiding 'us vs. them' discussions is essential."

Though one R.N. was writing specifically about nurses, I think her comments could apply to staff wherever they work in the hospital: "Older nurses have the experience that can predict how things will occur in patient care. Younger nurses bring a sense of risk to the workplace. They're definitely not intimidated by technology and are more resourceful in finding needed solutions/answers. I view these unique practices as the yin and yang needed to move patient care into the next phase of health care services … delivering quality care for less."

Nicely put.

Lots of people had good ideas about what hospital management can do to ease generational friction. I'll share some of those next Tuesday in this space. Many thanks to everyone who responded to my questions. And as always, I enjoy hearing your thoughts about how generational shifts are impacting American health care. E-mail me at bsantamour@healthforum.com.

Employee satisfaction and engagement are intangibles every institution wants to possess, especially with the daily stresses of hospital work. But they're more than just buzzwords—the time will come when every organization has a choice between genuinely listening to their employees and merely giving lip service to terms like "inclusiveness" and "open door policy."

I was reminded of these hard choices during last week's ACHE 2011 Congress in Chicago. During her keynote address, Commonwealth Fund President Karen Davis discussed efforts to drive employee engagement at El Camino Hospital in Mountain View, Calif., which ultimately led to recognition by the Commonwealth Fund as a top-performing institution.

When I interviewed Davis later in the week, she pointed to a critical moment in the evolution of El Camino Hospital—when the hospital had to choose whether to retain a difficult physician that staff had repeatedly complained about.

The hospital chose to let the physician go—Davis said, a clear sign to staff that leadership was not only listening to employees but willing to act on their feedback. Davis, an economist by background, had expected to find that financial incentives and structures drove high performance at El Camino, but ultimately concluded that employee buy-in was the key factor in its results.

Erik Steele, CMO of Eastern Maine Health System, made a similar point to me in a interview we ran last Friday about his system's efforts to sustain its electronic medical records. Despite the difficulties of adjusting to new systems that don't always work intuitively the first time around, Steele noted that the hospital's leadership made genuine efforts over time to continually listen to doctors about their concerns and suggestions and integrate them into the platform.

"If we can find areas where it helps me as a physician achieve extraordinary outcomes in things I really want my patients to have, then I begin to feel like it's a partnership," Steele said. For Steele and the other doctors at Eastern Maine, the success of the EMR wasn't based on mastering the technical details—it was getting to feel like partners.

Getting staff to feel engaged, of course, is notoriously difficult, even for institutions that make real efforts at it. Ultimately, though, employees either feel like trusted partners in their hospital or they don't. And gaining that critical buy-in requires a bit of the courage to make the tough decisions when the moment demands it—as at El Camino—and the patience to listen to employees over time, as at Eastern Maine.

Has your hospital had to make tough choices that signal whether employee concerns are truly valued or not? E-mail your stories to hbush@healthforum.com.

One of the first things I do every morning after booting up my iMac is peruse the headlines in the gazillion e-mails I get from the bazillion news amalgamation services to which I subscribe (wait, is a gazillion bigger than a bazillion?). There are, of course, a fair number of articles about the Affordable Care Act and how it will bring about the end of the world, or prove to be the greatest achievement since man walked on the moon. Honestly, I rarely click on those links. I'm a bit tired of the Inside Baseball reporting on the daily political posturing.

No, what's really catching my eye these days are the machinations in the states. Every day, there are dozens of headlines that read something like this: State Budget Standoff Could Give Us Minority Rule, or Hospitals, Families Bear Brunt of NH Budget Cuts, or Demonstrators Across Texas Demand Fairness in Budget Cuts.

Across the nation, governors and legislators are grappling with severe budget crises. In some instances, the debates have played out in very public and high-stakes games of hide-and-seek. Democrats in Wisconsin and Indiana fled to Illinois to protest budget plans put forward by Republican governors. Lawmakers in other states are pushing politically unpopular proposals to drastically cut services, while some states, like Illinois, are both raising taxes and looking to cut services.

The Center of Budget and Policy Priorities last month reported that 44 states and the District of Columbia have projected budget shortfalls in FY 2012, which begins this July for most states. At least 26 states are already predicting shortfalls totaling $75 billion for FY 2013. Talk about having to bend a cost curve! Many states have a balanced budget law, which means they have to close the gaps as they did in 2009 and 2010. CBPP noted that most states instituted spending cuts, drew down on their reserves, increased taxes and deferred some very difficult decisions on pension programs.

Since it is one of the biggest line items in any state budget, Medicaid is a big target for budget cutters. This isn't necessarily anything new. Year after year, budgets get balanced on the back of Medicaid cuts, higher eligibility requirements, increased provider taxes or, often, all of the above. But the situation is slightly different now. Although the economy seems to recovering from the Great Recession, unemployment remains high. "Continued sluggish job growth will keep state income tax receipts at low levels and increase demand for Medicaid and other essential services that states provide," CBPP noted. Added to that is the fact that federal aid to the states will be severely trimmed as Congress and the Obama administration struggle to get the national debt under control. And we know what's scheduled to come starting in 2014—Medicaid expansion, assuming the Affordable Care Act isn't overturned. So, budgetary pressures on Medicaid will only grow and the impact on health care providers will certainly be dramatic. In Texas, lawmakers are considering a budget that would leave a $6 billion hole in Medicaid. Nursing home, safety net and other providers say that would force many facilities to close. Similar debates are raging across the nation, from New York to Ohio to Nevada.

One of my concerns is that we pay so much attention to news coming from D.C., that we often lose sight of events in our backyard. During the next couple of months, state lawmakers will be making very hard and very significant decisions. Health systems need to brace themselves for some serious belt tightening.

E-mail your thoughts to mweinstock@healthforum.com.

CHICAGO—During a keynote presentation at the ACHE 2011 Congress Tuesday, Joseph Betancourt, M.D., director of the Disparities Solution Center and program director for multicultural education at Massachusetts General Hospital in Boston, argued that as increasing regulatory pressure mounts to improve health care outcomes for all Americans, work to reduce disparities in health care outcomes for minorities is no longer a matter of choice.

Pointing to emerging Joint Commission standards around patient-centered communication, set to take effect next year, and federal mandates in the Affordable Care Act to reduce readmissions and improve overall outcomes—areas where major disparities gaps persist—Betancourt said the financial stakes are too high for hospitals to remain on the sidelines.

"Disparities reduction is moving from a luxury to a necessity," Betancourt said.

Betancourt, who said his first encounter with the challenges of navigating the health care system came as a 7-year-old serving as a translator for his grandmother during a visit to the doctor, noted that health care providers can reduce disparities while simultaneously improving outcomes for all patients. He pointed to the Chelsea Diabetes Disparities Program, a pilot effort launched by Mass General in Chelsea, Mass., that has reduced the gap in diabetes outcomes between Latino patients and white patients while improving overall outcomes for patient control of diabetes. Those gains were made in part with the use of a bilingual health coach working with all patients to drive home the importance of diet, exercise and medication adherence.

"Addressing disparities and quality in one fell swoop…is the way we hope the field will go," Betancourt told me afterwards.

His co-presenter, Joseph Swedish, president and CEO of Michigan-based Trinity Health, made a similar argument about the need for diversity in health care organizations, noting that minorities are expected to comprise 41 percent of the health care work force by 2030, up from 18 percent back in 1980. Hospitals must begin more aggressively recruiting minorities, Swedish argued, or miss out on cultivating the next generation of leaders.

At Trinity Health, Swedish said, all hospital CEOs are expected to also serve as chief diversity officers, a move he said underscores the significance of diversity in hiring practices.

"I wanted my associates to understand the importance of this issue," Swedish said, "and I wanted my senior leadership to be publicly accountable for these results."

E-mail your thoughts to hbush@healthforum.com.

Dan was 83 when he was admitted to the hospital with a lung condition, and the medical staff did a stellar job of treating it. In a matter of days, the condition had cleared up and Dan was discharged. But back home, he felt weak and anxious, and was occasionally disoriented. He no longer participated in the activities that had so enriched his life before he went into the hospital. His family worried that the independence Dan prized was about to end.

It didn't have to be that way. Typically, health care providers zero in on a patient's single, dominant ailment. But for Dan and the rapidly expanding cohort of elderly patients like him, other issues—physical and emotional—often complicate the picture, and the chances of robust recovery.

Far too few people working in hospitals today understand the unique needs of their elderly patients, a fact that must change as increasingly millions of Americans live far into their 80s and beyond and consume a larger share of the health care you provide. It's startling to realize that while almost every physician and nurse receives at least some education in pediatrics, only a tiny fraction get any training whatsoever for patients at the other end of the age scale.

Hospital executives are beginning to recognize the problem. "A lot of CEOs see improving geriatric care as good business," says Marie Boltz, R.N., associate director for practice at the Hartford Institute for Geriatric Nursing and an assistant professor at NYU School of Nursing. It can avoid costs due to complications, reduce readmissions, and increase patient and staff satisfaction.

Moreover, she says, "it resonates with them on a personal level because they have loved ones who are elderly."

One program that's tackling the geriatrics gap is called NICHE—Nurses Improving Care for Healthsystem Elders. Administered by Boltz's Hartford Institute, NICHE offers a series of modules that hospitals can implement to ramp up their clinicians' skills when it comes to such things as preventing falls, ensuring proper use of medications, reducing urinary tract infections, involving patients and their family members in decision-making, and preventing, diagnosing and treating delirium.

NICHE's six-week, Web-based Leadership Training Program gives a hospital the tools to conduct an internal evaluation of its strengths in geriatrics, the level of its staff's expertise and, importantly, how it might need to change policies, the environment and even its mission statement to foster improvement. "You can have a nurse with all the knowledge in the world in these areas, but if the culture doesn't support her, she can't put that knowledge to good use," Boltz says.

The results of the internal evaluation are benchmarked against other hospitals, and NICHE staff help prioritize educational and clinical initiatives. A team of at least three hospital staff members is trained to lead the effort internally and make sure improvements spread from unit to unit.

Nearly 300 hospitals have signed onto NICHE so far, representing all types and sizes. Collaboration among those participants is vital, Boltz says, with hospitals from across the continent sharing their experiences and advice with colleagues. The program is compiling data to identify best practices. And NICHE staff members mentor participants throughout the process and beyond. You can learn more at NICHE's web site.

Last Tuesday I asked readers if there was any tension among employees of different generations in their hospitals. The responses so far have been eye-opening and I'll share some of them next week. You still have time to respond by clicking on "I Can't Work With Anybody That Age." And as always, I welcome feedback and ideas about how the aging of America and other generational issues are affecting our health care system, from a patient's, clinician's and hospital executive's perspective. E-mail me at bsantamour@healthforum.com.

CHICAGO—Rulon Stacey, CEO of Poudre Valley Health System in Fort Collins, Colo., got the American College of Healthcare Executives 2011 Congress off to a rousing start this morning, asserting in his opening keynote that some health care pundits have exaggerated the risk posed by medical errors and other patient safety issues. That's led to a widespread misperception that hospitals present substantial risks to incoming patients.

Stacey, the 2011-11 ACHE Chairman, singled out "politicians looking for votes and consultants looking for clients" for suggesting that "American hospitals kill more patients than they save."

Stacey said those perceptions "have created a subculture of Americans who refuse to get needed treatment because they are afraid the system will do them more harm than good."

Despite his concerns about misinformation, Stacey called on the gathered executive audience to take the lead in improving patient safety through the adoption of best practices, noting that Poudre Valley Health System has reduced mortality by 14 percent over the last several years with an aggressive patient safety initiative. That translates into roughly 83 lives saved each year, he said.

"Somewhere, right now, a father can play catch with his son because the employees, physicians and volunteers at Poudre Valley made a high level of investment," Stacey said.

Karen Davis, CEO of the Commonwealth Fund, followed Stacey, and, after discussing several Commonwealth Fund reports on health care outcomes, lamented "unacceptable variation in patient safety."

Davis then expressed hope that the payment and delivery system provisions of the Affordable Care Act would ultimately produce more substantive changes to health care than the more highly publicized coverage provisions, arguing that accountable care organizations can produce real changes in care delivery if proper coordination occurs and if CMS gives budding ACOs enough flexibility to experiment with different structures.

"It is my belief that the delivery and payment system reforms will go furthest in achieving the Triple Aim," Davis said.

The underlying question that Davis and Stacey ruminated on, of course, is how health care leaders can improve both patient safety and public perceptions of the health care system in the difficult years to come. Both noted the upcoming shift from fee-for-service to global payment structures, value-based purchasing and other pay-for-performance arrangements. Stacey's provocative comments got a huge reaction from the audience—some of whom gave him a loud of round of applause. But I'd like to hear from you—is misinformation about patient safety risks keeping some people from seeking needed medical care? E-mail your thoughts to hbush@healthforum.com. And read the full text of Stacey's speech at his blog.

Friday's Data Snapshot features the CDC's report this week finding that estimated life expectancy at birth in the U.S. rose in 2009 to an all-time high of 78.2 years, up from 78 in 2008. Female life expectancy rose to 80.6 years; the life expectancy for men rose slightly to 75.7.

Other interesting findings: the CDC reported that "significant decreases" in mortality occurred for children under one year of age, who saw their mortality rates drop 4.2 percent. Children aged 1-4 saw mortality drop 7.7 percent. Mortality rates for young adults between the ages of 15-24 fell 6.7 percent, and Americans between the ages of 75 and 84, who registered a 4.9 percent drop in mortality.

The report also found that heart disease remains the leading cause of death in the U.S., followed by cancer, respiratory diseases, strokes and accidents.

Read the full report here.

It's likely to become one of the lasting images of the disaster in Japan—a soldier holding a four-month old baby saved from the rubble. I don't know about you, but after watching countless clips on YouTube of the raging waters ripping houses off of their foundation, or seeing pictures of medics scanning people for radiation exposure, I needed something to lift my spirits. That picture did it. It's a reminder that amidst the devastation, there are signs of hope.

My guess is that many U.S. health care workers are already trying to figure out ways to help in the ongoing relief efforts, to be part of that hope. Some, like Kelly Kreisler, M.D., are already on their way. Kreisler is a physician at the University of Kansas Hospital and is part of a relief mission organized by Heart-to-Heart International. "I am the mom in the car pool line that you see and not some really special kind of person. Because of that, other people can do something too," she told her local news channel.

There are sure to be similar reports about clinicians, technicians and others from your community. We saw the same response to last year's devastating earthquake in Haiti. I recall talking with Andy Davidson, president and CEO of the Oregon Association of Hospitals & Health Systems, for more than an hour about his experience heading up a relief mission and serving as temporary administrator of King's Hospital in Port-Au-Prince. And early this year, at our Rural Health Leadership Conference, Paul Auerbach, M.D., spoke passionately about the herculean efforts of clinicians at University Hospital, also in Port-Au-Prince.

So often those of us in the media only highlight these heroic efforts in times of disaster. They are dramatic and compelling human-interest stories. But we know that there are many untold tales of hospital staff doing amazing things right here at home. That's why a couple of years ago H&HN started the Extra Mile column. In the pages of the magazine each month, we profile the efforts of hospital workers who go above and beyond the call of duty. Some of the stories are big, some are small, but in the end, they are all about health care workers making a difference. There's the ICU nurse who created a colorful picture book called "What's This Stuff?" to try and put children at ease before they go see a parent in the ICU. There's the midwife who travels to war-torn Afghanistan to deliver babies. And then there's the trauma registrar who awoke from a coma after an ATV accident to become a vocal proponent of rider safety.

Whether they are heading to international disasters, or responding to needs in your local community, we want to hear about staff who are doing extraordinary things.

Email your stories to me at mweinstock@healthforum.com.

It's Tuesday morning and I'm still waiting for my coffee to fully kick in. Reading through the day's news from our clipping service, I learn that the Orthopedic Institute at Swedish Medical Center in Seattle is minutes away from broadcasting a knee replacement surgery live on their website, with the opportunity for audience participation via a web chat and Twitter. The event was designed to promote the use of new robotics equipment during the surgery—all with the consent of the patient.

A little curious and a little in need of a kick to complement my coffee, I tuned in to a bird's-eye view of the surgery already in progress, with occasional cuts to the docs' computer monitors. Questions on the surgery technique, infection risks and the robotics equipment used to perform the surgery poured in from the viewers, estimated at one point at more than 1,500. The surgeon involved in the procedure occasionally added his own commentary as he removed pieces of bone with a bone-cutting burr implement, raising his voice over the din of the burr.

This isn't my first experience with the use of social media to publicize a new surgical technique. Two years ago, I traveled to Sherman Hospital in Elgin, Ill., to watch a clinical team perform a robotic hysterectomy while I jostled for space in the operating room with other journalists, including cameramen. The hospital's PR reps tweeted the proceedings, occasionally asking the surgeons questions about the procedure.

At the time, I quoted other hospital execs—including social-media savvy bloggers like former Beth Israel Deaconess CEO Paul Levy—who said they wouldn't consider it. Too many risks, Levy said. The advocates, meanwhile, pointed to the promotional benefits of getting in on the ground floor of the live-tweeted surgery industry, hastening to point out they had plans to cancel the social-media experiment if anything went awry.

Two years, of course, is a lifetime in social media, and tweeting a surgery is apparently old hat—now you need a live webcast to get noticed.

There were unexpected complications Tuesday—but not with the procedure. A problem with the live streaming web site UStream forced the docs to switch over to JustinTv, delaying the start of the broadcast. As the editor of a daily e-newsletter, my sanity dependent on cooperation from the IT systems that store our blogs and videos, it's heartening to know even live-streaming, tweeting orthopedic surgeons have to contend with the same mundane technical difficulties the rest of us do.

I'm interested in your thoughts, though. Do you think your facility should stream a live surgery to promote a new service line or technique? E-mail your thoughts to hbush@healthforum.com.

People that age feel entitled. They don't put in the hours. They won't do the hard work. They just don't get it.

I heard those comments at a roundtable last year on multi-generational staffing in hospitals. Panelists included executives, middle managers, physicians and nurses, and they ranged in age from late 20s to early 60s.

I bet you can guess which end of the spectrum that particular speaker came from. Can't you?

The fact is, I've been hearing comments like those for years, and not always from the obvious suspects. Sometimes it's a department manager lamenting the lack of a successor willing to put in the same hours he's worked for 20 years. Sometimes it's a 30-something nurse complaining that her supervisor is delegating all the most strenuous tasks to others while waiting for her own retirement to kick in. Sometimes it's fresh-faced physicians scoffing at their baby-boomer colleagues' discomfort with the latest technology—or boomer physicians shaking their heads at younger clinicians' refusal to take call or sit on any hospital committees.

The generation gap is nothing new. Way back in the ‘60s, whipper-snappers like myself weren't supposed to trust anybody over 30. Now we've been over 30 for nearly half our lives and can hardly believe we're working on the same floor with people who weren't around during the heyday of student activism or the Beatles or fondue.

The difference these days is that we're talking generation gaps. At no time before this very one have so many employees from so wide a range of ages toiled side by side in the same workplace. You know the labels—we've got the boomers, born between 1945 and 1964, and the Xers (1965-1980) and the Yers, (aka Millennials, born after 1980). We've even got the so-called Matures, men and women born before 1946 who are still out there on the front lines either because the Great Recession took a nasty bite out of their retirement accounts or because they remain energetic and engaged enough to keep doing the thing they've dedicated their lives to doing.

It all adds up to a boiling kettle of clashing values, expectations and sensitivities. And it takes a deft chef to keep the kettle from blowing its lid to kingdom come.

Hospital CEOs recognize the benefits of having a staff that reflects the world we live in. They understand that older employees bring a strong work ethic and an institutional knowledge that would be sorely missed. They understand that younger workers have a lust for innovation that will keep their hospital, and American health care, pushing the boundaries of patient care ever forward.

What they need to learn is where the generations might scrape up against each other in ways that could be hurtful to individuals and to the organization as a whole. They need to consider whether they themselves have certain built-in age-related biases. And they need to find ways to ease the tensions and harness the energy that diversity produces.

On future Tuesdays in this space, I'll offer background and guidance from experts on generational issues in the hospital workforce. In the meantime, I invite you to respond to three simple questions. You don't need to tell me your name, but please include your job title and which generational category you fall into. Have no fear: When I report back on this very informal survey, I won't include e-mail addresses or anything else that might identify respondents.

And the questions are:

1. Have you witnessed any tensions between staff of different generations in your workplace?

2. Are employees who are significantly older or younger than yourself as good at their jobs as they should be? Why not?

3. What, if anything, can management do to help the generations work together more effectively?

E-mail me your answers at bsantamour@healthforum.com. And thanks for your time.