NUTR-4240 Chapter Notes - Chapter 10: Medical Nutrition Therapy, Reverse Dns Lookup, Electronic Health Record
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The CEO of St. Sebastian Health System, a moderate-sized hospital system in a mid-sized, Midwest city has hired you to help turn things around. The CFO is projecting a $3.7 million operating loss this year, which will be more than offset by non-operating income. However, the board has made it clear that the situation must improve. If the system cannot produce a positive operating margin in 2017, someone else is going to be the CEO. The CEO and CFO have asked you to recommend strategic approaches to sell their services in the community that will help turn the financial ship around.
Your Health System
St. Sebastian is a community-based health system. The senior management team has an average tenure of 17 years. The exception is the Chief Medical Officer (CMO). She has been in her position for two years and is the fourth CMO in that role in the past ten years. The CEO and COO have each been in their current roles for ten years. The system is comprised of the following:
Two large, acute care hospitals
Two long term care facilities
Two skilled nursing facilities
One long-term acute-care hospital (LTAC)
Four geographically distributed outpatient centers
Four Urgent Care Centers
Two free-standing ambulatory surgery centers (ASCs)
A 400 member employed physician group that includes 180 Primary Care Providers (PCPs). All 28
PCP practices are certified Level III Patient-Centered Medical Homes by NCQA.
The remainder of the 1,000 members medical staff is generally comprised of large, independent groups who have varying degrees of loyalty to the system. The Radiology and Emergency groups, for example, do 100% of their work at St. Sebastian and have no ownership of any outside facilities. The Gastroenterology Group, on the other hand, does work at the hospital but also owns its own, freestanding endoscopy center. The orthopedic group does 75% of their work at St. Sebastian but maintains privileges at other facilities. They do not own their own ASC.
In the current year, St. Sebastian is projecting 220,000 patient visits (combined IP and OP) with an average cost per visit of $1,727. They have an average charge per visit of $4,545.
Over the past ten years, St. Sebastian has been active in pursuing many different strategic projects including:
They have established clinical institutes in cardiovascular, orthopedic, oncology, maternity, and neurologic care. Each of these has been built through a co-management agreement between the system and the internal or external physician group who would be most logical. Each institute is led by a dyad of an administrator and medical director.
Five years ago, they consolidated maternity programs to one facility, a move that justified investing in a Level III Neonatal Intensive Care Unit (NICU)
They have established a research division in the hopes of working with national pharmaceutical companies and/or tertiary care hospitals in the Midwest.
They have established a Physician Hospital Organization (PHO) and intend to become an Accountable Care Organization (ACO) that can participate in the Medicare Shared Savings
Program (MSSP) and/or enter into global risk contracts with third-party payers. The PHO is currently evaluating whether or not they should purchase an insurance license so that they could offer commercial, Medicare Advantage, and Managed Medicaid insurance products.
5. They have established a Business Health division to service the corporate health needs of the employers in the region. This would include things like EAP programs, on-site wellness, drug screening, on-site clinics, etc. This division also recently built two large, full-service fitness centers.
The competition The community is currently served by three other major health providers:
Mercy is the competitor acute care system in town and has two hospitals and various outpatient centers. They have not been active in physician employment they employ a group of 60 PCPs, but no specialists. Similarly, they have not been engaged in branching out with different strategic initiatives, preferring instead to focus on cost-efficient care. They do not have clinical institutes, research divisions, a PHO, or a Business Health division. They have 230,000 visits per year, with an average cost of $1,435 per visit and an average charge of $4,348.
General Pediatric is a pediatric teaching hospital. Five years ago, they signed an affiliation agreement with Johns Hopkins to gain access to clinical and research capabilities that would have been beyond their reach, given their size. The employee essentially all of the pediatric subspecialists and have a PHO, which includes 75% of the region's primary care pediatricians. They will have 200,000 visits this year, with an average cost of $2,100 per visit and an average charge of $5,000 per visit.
General University is an adult teaching hospital affiliated with the local university's medical school. They staff the region's free-care clinics and historically, have been the region's hospital for indigent/uninsured patients. They are the region's Level I trauma center and are well regarded for intensive services like trauma, stroke, and cancer care. However, their location and reputation for taking indigent patients mean that they are not preferred for normal medical care by commercially insured or Medicare patients. Besides the community health centers, they own an inpatient rehab hospital, but no other facilities. They have explored affiliations with national leaders in academic medicine, but so far have not signed any such agreements. They see 180,000 visits per year with an average cost of $1,833 and an average charge of $5,556 per visit.
There are no other hospitals currently operating, though there are 23 skilled nursing facilities (SNFs) and 3 inpatient rehab facilities throughout the region. They are independent actors and for the most part, are struggling to stay profitable. Several single-specialty physician groups operate ambulatory surgery centers and one chain of independent diagnostic treatment facilities (IDTFs). Three years ago, there was a significant change in the state government, and that resulted in the long-time Certificate of Need (CON) program is all but scrapped (Skilled Nursing Facilities are still heavily regulated). Several for-profit hospital companies have recently done some analysis around entering your market, but have not done so yet.
The community is a Midwest city and surrounding suburbs in the midst of a transition from a manufacturing employment base, which unfortunately accelerated with the 2008 economic downturn. The hospitals have seen this over the past several years in a tightening of benefits offered by local employers. Benefits continue to be offered, but increasingly are likely to have a significant deductible associated with them. Unemployment has been above the national average and is projected
to remain that way. This means that the average wage in the region is actually below where it was in 2008 when the last recession hit. The number of Medicare-age residents is projected to rise over the next 10-20 years while working-age patients are projected to stay flat or fall slightly. Similarly, birth rates are expected to fall slightly over the coming decade.
The community is 60 miles south, 45 miles east, and 50 miles north of other, similarly-sized cities. Until 20 years ago, that made this city effectively an island unto itself. Increasingly, however, the suburbs of each of these communities have become very close to each other. As that has happened, providers in each community have followed and established practice sites and free-standing outpatient centers.
The community has a normal looking mix of Commercial, Medicare, and Medicaid patients. Because the state's governor was fiercely against the Affordable Care Act, the Medicaid expansion that happened in other states hasn't happened here. Thus, the community also has a sizable population without insurance today. As you'd expect, different hospitals see a different mix of these patients. The local health council was able to provide you with the most recent years payer mix by hospital below:
|
Patient visits |
Commercial |
Medicare |
Medicaid |
Uninsured/Self-pay |
|
Mercy |
80,500 |
105,800 |
23,000 |
20,700 |
|
St. Sebastian |
99,000 |
101,200 |
11,000 |
8,800 |
|
Gen. Pediatric |
70,000 |
4,000 |
110,000 |
16,000 |
|
Gen. University |
63,000 |
45,000 |
45,000 |
27,000 |
|
Community Total |
312,500 |
256,000 |
189,000 |
72,500 |
Reimbursement the CFO was able to supply you with their best estimate for what various payers are reimbursing for services. In general, the commercial plans are paying 50% of charges, regardless of location, except at General Pediatric. There, the monopoly on pediatric services has allowed them to negotiate rates of 80% of charge, but only for the commercial plans. Medicare currently pays 30% of charges at all hospitals, and Medicaid pays 25% of charges everywhere. Uninsured patients are generally paying 2% of charges.
refer back to St. Sebastian and the facts laid out in the background reading and Case #1and consider:
What products are in this industry vs. part of another distinct group?
What is the geographic scope of competition?
Identify the participants and segment them. Who are,
The buyers and buyer groups?
Suppliers and supplier groups?
The competitors?
The substitutes?
The potential entrants?
Which of these forces is strong/weak and why?
If possible, analyze the industry structure.
Why is the level of profitability what it is?
Which are the controlling forces for profitability?
What are the recent and likely future changes in each force, both positive and negative?
New technologies to enhance nursing practice
Ramundo, Debby MSIT, BSN, RN
Author Information
Debby Ramundo is senior technology consultant at Sparling, Inc., in Seattle, Wash.
| Technology has continued to change healthcare since the stethoscope was invented in 1816. As with contemporary technology, the device didn't replace the work of clinicians, but rather enhanced and expanded their capabilities. Digital thermometers, advanced wound care supplies, ECGs, and electric patient lifts are just a few of the technologies that have enhanced and expanded clinical practice |
| As the healthcare industry faces the challenges of skyrocketing costs, decreasing reimbursement, nursing shortages, and increased patient acuity, technology may be able to help us meet our patients' needs and optimize the work that we do. |
| Integrating technology into nursing practice doesn't change the fundamental elements of nursing practiceâassessment, planning, intervention, evaluation, education, support, documentation, and communication. For example, the University of Pittsburgh Medical Center is working with Welch Allyn to develop a machine that automatically obtains and downloads vital signs into the patient's electronic medical record (EMR). This machine can be integrated with a nurse call system, sending an alert if the reading falls outside established parameters, but the machine can't interpret the meaning of an elevated BP, for example. The nurse is the one who determines if the patient's BP is elevated because of pain, an argument with a family member, or fluid overload. Yet, the automated technology saves the nurse time and effort, by not alerting the nurse until critical thinking is needed. In the meantime, the nurse can spend time with another patient. By collecting the information, the technology lets nurses do the work exclusive to the nursing processâassessing and interpreting vital signs. Now let's look at four ways technology is improving nursing practice. |
| Distributing EMRs |
| We want to spend more direct time with our patients and less time on tasks such as running around looking for equipment or making phone calls to discharge a patient. A study conducted by architectural firm HKS, Inc., demonstrated that on average, a nurse walked a distance of 6.43 miles in a 12-hour shift.1 This was on a unit that had a typical central nursing station for all charting, phone calls, supplies, medication, and nutrition. |
| In a typical two-bed patient room, each patient has about 80 square feet of space each, not including the bathroom. Many healthcare organizations are building new facilities with all single-bed patient rooms that provide 200 to 250 square feet per patient. Assuming the same number of patients, this makes for a bigger unit and more walking for the staff. |
| HKS tested two unit models with different types of nursing stations and measured walking distance in those scenarios. The first scenario was a unit that had two smaller nursing stations; this reduced walking distance 26.8% (compared to a unit with a single central nursing station) and provided an additional 61 minutes per nurse per 12-hour shift to spend with patients.1 |
| HKS's second scenario had charting available at each room (either a computer in the room, tablet computer, or a charting station outside the room); two small nursing stations; phone, medications, supplies, and linens at the bedside; and equipment in four locations on the unit. In this scenario, the nurses' walking time decreased 67.9%, providing an additional 154 minutes per nurse per 12-hour shift to spend providing direct care to patients. |
| This second scenario is made possible when the unit has EMRs, and computers can be placed in or outside of each patient room. Paper records can't be kept in the patient room due to privacy requirements. Even if the EMR took more time to document than paper charts, nurses would still have significantly more time to spend with patients because they wouldn't have to duplicate documentation. |
| Real time locating systems |
| All too often, when a patient needs an infusion pump or a wheelchair, the nurse must walk from room to room or floor to floor to find an available one, only to be unsure if the equipment is clean or if the infusion pump is up to date on its maintenance. Real time locating systems (RTLS) use technology such as radiofrequency identification tags, ultrasound, or infrared technology to tag and track equipment (see âUsing RFID to solve problems in healthcare deliveryâ in the January issue of Nursing2012 Critical Care). |
| Once items are tagged, staff members can look on a computer screen on their unit to locate the nearest wheelchair. The clinical engineering staff would be able to track equipment maintenance and locate infusion pumps that were due for service. A study conducted by Indiana University-Purdue University Indianapolis found that using an RTLS system to track medical equipment reduced the time spent by staff in searching for medical equipment by 96%.2 |
| This same locator technology can help with patient flow and bed management. A sensor bracelet or clip-on tag is placed on a patient, and used to track the patient's location and time in that location. Pacific Medical Center's Canyon Park Clinic in Bothell, Wash., uses this type of system. The patient is given an RTLS tag on check-in. When the patient enters the exam room, the RTLS system changes the color of the room on the computer screens that are placed around the clinic. Different colors represent various statusesâpatient in exam room, nurse in room with patient, patient ready to be seen by healthcare provider, and room ready for cleaning. A nurse who goes into an exam room only to find that the patient isn't there could use the nearest map screen to locate the patient (for example, in computed tomography) and see how long that patient has been in that location. |
| The system also can be set up with alerts, for example, to alert the staff that the patient has been waiting for more than 15 minutes (if the facility's goal is to see patients within 15 minutes of arrival). Because everyone on staff can see these screens, nurses no longer have to locate other staff and tell them the status of the patient or the room. This frees more nursing time for direct patient care. |
| Patient logistics |
| Typically, when you discharge a patient, you must call the transportation department to come pick the patient up. You must then wait and continuously check to see when the patient has actually left. Then you must call Environmental Services to come clean the room, and you may or may not be notified when the room is clean and ready. When the room is ready, you have to call the central office to let them know they have a bed available. |
| Lehigh Valley Hospital and Health Network in Allentown, Pa., has found a better way. The hospital's patient logistics software program tracks not only the patient's location but also the status of the patient's room. The hospital's bed turnaround timeâthe time from discharge until a room is clean and ready for the next patientâwent from 240 minutes to 60 minutes at the Cedar Crest location, 45 minutes at the 17th and Chew Street location, and 37 minutes at the Bethlehem location.3 |
| This software can be coupled with a workflow panel from the nurse call system that makes patient discharge a smooth and efficient process. When you determine that the patient's ready to be discharged, you can push a button on the workflow panel. This sends an alert through the nurse call system to a pager or wireless phone, notifying the transportation department to come to the patient's room. After picking up the patient, the transportation worker pushes another button on the workflow panel, alerting Environmental Services to clean the room. When the room is clean, the Environmental Services worker pushes another button, alerting the patient logistics center that the room is clean and ready for a new patient. |
| This has all happened automatically without any further actions on the nurse's part. At each step of the way, the software changes the appearance of the room on the computer screen, indicating the stage of the turnaround process. This system can help avoid delays in notification, improve patient flow and bed management, and conserve nursing time for direct patient care. |
| Patient education |
| Imagine a system that provides a personalized website for a preadmission patient, filled with education about why the patient is coming to the hospital, a reminder to bring a list of all medications, and directions to the proper area of the hospital. Also imagine that same system picking up the diagnosis codes when the patient is admitted, automatically selecting and sending the appropriate patient education video to the patient's TV, and notifying the patient that these videos have been recommended by their nurse. |
| These features are available in some patient entertainment and education systems. The systems provide TV, movies, music, video gaming, Internet, e-mail, and a wide range of patient education materials. Patients also can use the systems to order food from dietary services, see their schedule for the day, answer surveys, and receive reminders about activities they need to complete before discharge. The hospital can post welcoming information, introductions to the staff, and directions to other parts of the hospital. |
| After the patient watches the educational video, the patient entertainment and education system asks if the patient watched and understood the video. If the patient answers âyes,â the system sends appropriate documentation to the EMR. If the patient responds âno,â the system alerts the nurse via wireless phone, so the nurse knows to follow up with the patient and reinforce the teaching. |
| Once the patient is ready to go home, discharge instructions and appropriate patient education can be provided on the patient's personalized, secure section of the hospital's website, which the patient can access from a computer at home. The information on this site reinforces the discharge instructions that the nurse reviewed with the patient before leaving. |
| Available at a hospital near you |
| These are but a few of the technologies available to hospitals. Other technologies include robots delivering pharmaceuticals, lab specimens, and supplies to the different areas of the hospital; smart beds that register and record vital signs and patient weight; and tablet computers that convert handwriting on the screen to typewritten medical record entries. These technologies are all used at hospitals around the country. |
| Embrace the change |
| In our personal lives, we've adopted many new technologies, such as ATMs for banking and e-mail for communication. Embracing new technologies in healthcare can help reduce our physical workload and put needed resources in the proper locations. New tools can improve communication between nurses and patients, with other providers, and with families. Patient safety can be improved by having the patient's medical information available at every site in the hospital. |
| By identifying how technology can improve our work and the service we provide, we'll be able to spend more time in direct patient care. Facts about the National Patient Safety Goals December 2, 2015 In 2002, The Joint Commission established its National Patient Safety Goals (NPSGs) program; the first set of NPSGs was effective January 1, 2003. The NPSGs were established to help accredited organizations address specific areas of concern in regard to patient safety. Development of the Goals A panel of widely recognized patient safety experts advise The Joint Commission on the development and updating of NPSGs. This panel, called the Patient Safety Advisory Group, is composed of nurses, physicians, pharmacists, risk managers, clinical engineers and other professionals who have hands-on experience in addressing patient safety issues in a wide variety of health care settings. The Patient Safety Advisory Group works with Joint Commission staff to identify emerging patient safety issues, and advises The Joint Commission on how to address those issues in NPSGs, Sentinel Event Alerts, standards and survey processes, performance measures, educational materials, and Center for Transforming Healthcare projects. Following a solicitation of input from practitioners, provider organizations, purchasers, consumer groups and other stakeholders, The Joint Commission determines the highest priority patient safety issues and how best to address them. The Joint Commission also determines whether a goal is applicable to a specific accreditation program and, if so, tailors the goal to be program-specific. Changes Effective for 2016 For 2016, there are no new National Patient Safety Goals. However, NPSG.06.01.01 elements of performance 3 (establish policies and procedures for managing the alarms identified in EP 2) and 4 (educate staff and licensed independent practitioners about alarm systems) are effective as of Jan. 1, 2016 for the hospital and critical access hospital accreditation programs. Questions: 1) List three (3) new technologies and describe how each technology listed impacts nursing practice. 2) Describe how each technology you chose can help to meet a National Patient Safety Goal identified by The Joint Commission for a practice setting where you have worked. |
