Are hospital quality/safety metrics used by payers & accrediting organizations getting ahead of the science of q/s measurement? (I)

Back in the day one of our system’s community hospitals achieved the top rating for obstetrics from one of the for-profit hospital rating companies and then, before it could be stopped, bought an obstetrics marketing package from the company. This was cherry-picking since the hospital did not receive marketable ratings on the company’s other clinical categories.

ASSIGNMENTS:

Look at the web sites of the three hospitals nearest to you and compare how they post hospital safety and quality report card information.

Find additional models of patient safety/ quality not based mostly on available Medicare data.

PREQUEL: Hospital web site archeology. http://doctordidyouwashyourhands.com/2016/05/hospital-web-site-archeology/

“It sure seems like there’s been a lot of bad news for and about hospitals — specifically, about their protections for patients’ safety.

Driving the news:

•             A WebMD/Georgia Health News investigation found a third of the country’s hospitals have violated basic federal rules for providing emergency care.

•             Baylor St. Luke’s Medical Center is now drawing scrutiny for poor outcomes with its liver and lung transplants, after ProPublica and the Houston Chronicle highlighted failures with heart transplants.

•             Kids at the Johns Hopkins children’s hospital in Florida are dying “at an alarming rate,” the Tampa Bay Times recently reported.

•             The federal government is threatening to end Medicare and Medicaid funding at Vanderbilt University Medical Center after a patient died from getting the wrong medication.

•             A large Detroit hospital faces the same threat due to dirty surgical equipment.

What they’re saying: “We are unnecessarily killing thousands of people every year because hospital quality is not what it should be,” says Leah Binder, CEO of the Leapfrog Group, an organization that grades hospital care.

•             “There’s lots of ratings that will say, ‘This is the No. 1 hospital, this is the great hospital list.’ But what we also need are ratings on where not to go,” Binder says. “But there’s some risk to exposing and embarrassing any part of that.”” (A)

Physician Licensing

“In Louisiana, Larry Mitchell Isaacs, MD, gave up his medical license in the face of discipline, after he removed an allegedly healthy kidney during what was supposed to be colon surgery.

In California, he mistakenly removed a woman’s fallopian tube. According to medical board records, he thought it was her appendix — which already was gone. More surgeries on the woman followed, including one in which he allegedly left her intestine unconnected.

Facing state sanctions, he surrendered his license there, too.

In New York, where regulators were moving to take action based on his California problems, he also agreed to give up his license.

But in Ohio, he has found a home.

There, his medical license remains unblemished, allowing Isaacs to work at an urgent care clinic in the Cincinnati area.” (B)

“Look up the Wisconsin medical license for John Kidd, MD.

All that is posted is a document that says he gave up his Wisconsin license in 2012 because he had moved to New York and didn’t plan to practice again in the state.

Look up Kidd’s license in New York and there is no indication of any allegations of poor care or wrongdoing against him there — or anywhere else in the country.

But, documents obtained by the Milwaukee Journal Sentinel, USA Today, and MedPage Today offer a different picture.

They show Kidd was terminated in 2010 by his employer, a business that provides anesthesiology services for Theda Clark Regional Medical Center in Neenah, Wis., after a series of alleged incidents earlier that year:

When a patient had trouble breathing, Kidd would not help a nurse and doctor who had rushed to the patient’s aid.

When a patient who was having a limb amputated complained of pain and discomfort, Kidd was on his cellphone and did not respond promptly.

A nurse thought he was once impaired at work and smelled of alcohol…

Kidd, 53, is one of more than 250 doctors who surrendered their medical license since 2012, but who were still able to practice in another state, an investigation by the news organizations found.” (C)


“The Medical Board of California has begun monitoring warning letters sent by the FDA to physicians engaged in potentially harmful practices, following a Milwaukee Journal Sentinel/MedPage Today report earlier this year about the failure of states to act on allegations raised in the letters.

That investigation found that 73 physicians around the country with active medical licenses had been the subject of FDA warning letters alleging serious problems over a five-year period, but only one had been disciplined.

The warnings involved fertility clinics that didn’t test donors of eggs and sperm for communicable diseases; researchers who didn’t follow rules designed to protect patients who volunteer for trials of drugs and devices; physicians who pushed dubious treatments and supplements to unwitting customers; and a mammography clinic faulted for inadequate quality control testing…

“The Board reviews the letters and if they contain information regarding physicians licensed by the Board, the Board looks into the matter,” he said in a recent email. The practice began in June, but only now is being confirmed…” (D)

“When it comes to improving the nation’s broken system of physician discipline, many advocates say the starting point should be fixing something that was created to do the job in the first place.

In 1986, Congress created the National Practitioner Data Bank (NPDB), pledging it would improve healthcare and reduce fraud and abuse. The data bank records all sorts of things: malpractice payments, disciplinary action, restrictions of hospital privileges, and other transgressions.

There are just three problems:

The system can be gamed, so not all problem physicians appear on the list.

State medical boards don’t always check the data bank.

And, the information is off limits to those who are most at risk: patients….

Here is a look at five other ways to improve the system:

1. The Problem: Uneven discipline. A physician who holds licenses in multiple states can lose a license in one, but get lesser or no discipline in another…

2. The Problem: Dead letters. When the FDA performs investigations and sends warning letters to physicians — a rare step that indicates serious matters — the letters typically go only to the physician. Copies are rarely sent to medical boards in the states where the physicians are licensed…

3. The Problem: Cryptic surrenders. In some cases, a physician facing discipline agrees to surrender his or her license prior to a hearing or formal charge. That can keep potential problems out of the public eye…

4. The Problem: Inconsistent data. State medical boards vary dramatically when it comes to the information they include on their websites about a physician’s background…

5. The Problem: Medicare payments. Physicians who lose their licenses in one state, or who are banned from a state Medicaid program due to problems such as fraud or putting patients in harm’s way, can still collect money from the taxpayer-financed Medicare program.” (E)

The Joint Commission

“Facts about the National Patient Safety Goals

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

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, including as a NPSG. 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.” (F)

“The Joint Commission (TJC) requires compliance with standards that will result in continuous improvement in support of safe, high quality care. Accreditation surveys, mid-cycle performance reviews, self-assessments, and plans for corrective action all drive your organization to achieving continuously higher levels of quality of care and patient safety.

QPS consultants can guide your organizations through the intricacies of TJC accreditation process as well as the CMS survey. We are subject matter experts in the accreditation process for organizations that provide behavioral health care and substance abuse treatment.  We have substantial professional experience with accreditation and regulatory surveys for organizations that provide behavioral health care and an in-depth knowledge of the standards being reviewed. QPS consultants can partner with your organization to achieve or maintain your honored status of accreditation.” (G)

“The Trump administration is weighing whether to continue approving hospital and health-accreditation groups that also have consulting arms, following potential conflicts of interest raised in an article in The Wall Street Journal.

The disclosure came in an announcement by the Centers for Medicare and Medicaid Services that it is seeking input on possible conflicts of interest.” (H)

Quality Measures Linked to Physician Reimbursement

“Physician reimbursement increasingly depends upon measures of healthcare quality. Physicians who fall short on quality measures now face financial penalties. But it might be quality measures, themselves, that are falling short, according to a study conducted by the American College of Physicians.

The study involved a panel of people with expertise in evidence-based medicine. Panelists were asked to evaluate the validity of quality measures being used by either Medicare, the National Committee for Quality Assurance, or the National Quality Forum. It is typically measures from these three groups that are used to determine physician quality report cards, and Medicare plans to use its measures to influence reimbursement for individual clinicians…

How do quality measures from these three groups stack up? The experts reviewed each measure and determined whether it was valid, uncertain, or invalid. They looked at 86 quality measures that Medicare will use as part of its MIPS program (an acronym for Merit-based Incentive Payment System). Barely more than a third of these measures were valid. The measures from NCQA and NQF came out better, with 60% and half being judged valid, respectively. But that still leaves a huge number of quality measures that are either uncertain or out and out invalid…

Their results strongly suggest that the use of quality measures, by payers and accrediting organizations, has gotten ahead of the science of quality measurement.” (I)

Electronic Medical Record Algorithms

“Several patients seen in our practice recently were significantly and dramatically transformed by the electronic health record (EHR). And not in a good way.

Take, for instance, the patient whose outside chart was reviewed when she showed up in our office for a follow-up appointment after an emergency department visit.

The notes from the emergency department providers, including a scribe and the attending physician, described her in the following way:

“This 67-year-old woman with morphine sulfate presented after a fall with injury to her head.”

Throughout the documentation, they kept referring to her as a patient with morphine sulfate.

For a while, as I read through it, my eyes skimmed over this, and it didn’t really register as something I needed to pay attention to.

Perhaps they were taking note of the fact that she had morphine sulfate with her when she arrived, had taken morphine sulfate before the fall, or was requesting morphine sulfate to ease her pain.

Only after diving deeper into her past medical history in our own chart did I realize that someone must’ve typed “MS”, and the computer auto-corrected and somehow turned that into morphine sulfate, instead of multiple sclerosis.

I’m not sure how their system works, but most of the functionality of EHRs that has been created to prevent medical confusion from abbreviations offers you a choice of what it thinks you’re looking for, the most obvious or most common diagnoses usually typed by physicians.

So maybe the system saw “MS” and offered up morphine sulfate, multiple sclerosis, mitral stenosis, myasthenic syndrome, magnesium sulfate. Pick one.

Or maybe their system just turned “MS” into morphine sulfate without giving them any choice.” (J)

“Patients often struggle to have errors in their medical records corrected, according to a recent CNBC report.

About 70 percent of patient records have wrong information, sociologist Ross Koppel, PhD, told CNBC.

For one patient — 20-year-old Morgan Gleason — the errors in her medical record claimed she had twice given birth and was diabetic. But she’s never been pregnant, nor been diagnosed with diabetes, she told CNBC.

When Ms. Gleason tried to have her records corrected, the hospital insisted she was wrong, she said. In fact, the hospital told Ms. Gleason that if she hadn’t given her physician the information, it wouldn’t have been in her chart in the first place. It wasn’t until Ms. Gleason made a written request for a correction of her record that changes were made.” (K)

“When Liz Tidyman’s elderly parents moved across the country to be closer to their children and grandchildren years ago, they carried their medical records with them in a couple of brown cardboard folders tied with string.

Two days after their arrival, Tidyman’s father fell, which hadn’t happened before, and went to a hospital for an evaluation.

In the waiting room, Tidyman opened the folder. “Very soon I saw that there were pages and pages of notes that referred to a different person with the same name — a person whose medical conditions were much more complicated and numerous than my father’s,” she said.

Tidyman pulled out sheets with mistaken information and made a mental note to always check records in the future. “That was a wake-up call,” she said…

In the worst-case scenario, an incorrect diagnosis, scan or lab result may have been inserted into a record, raising the possibility of inappropriate medical evaluation or treatment. This, too, is something that Tidyman’s father encountered soon after moving from Massachusetts to Washington. (Her parents have since passed away.)

When both his new primary care physician and cardiologist asked about kidney cancer — a condition he didn’t have — Tidyman reviewed materials from her father’s emergency room visit. There, she saw that “renal cell carcinoma” (kidney cancer) was listed instead of “basal cell carcinoma” (skin cancer) — an illness her father had mentioned while describing his medical history.

“It was a transcription error; something we clearly had to fix,” Tidyman said.”  (L)

“Health systems use numerous methods to exchange patient medical records, but providers continue to rely heavily on the old-fashioned approach of mail or fax, according to new federal data on interoperability.

Nearly three-quarters of non-federal acute care hospitals routinely use fax or mail to receive summary of care records from providers outside their system, according to new data released by the Office of the National Coordinator for Health IT. Two-thirds of health systems use fax or mail to send records…

But hospitals also employ a wide variety of methods to exchange records. Nearly 80% of hospitals used more than one electronic method to send records in 2017. However, a quarter of hospitals are not receiving records electronically at all…

The number of methods used is a detriment to health systems, ONC concluded, adding that its Trusted Exchange Framework could help streamline those options.

“The number of exchange methods hospitals need to ensure that they have information electronically available and subsequently used, contributes to the complexity and costs of exchange,” the agency wrote. “These complexities and increased costs are often cited as barriers to interoperability. Efforts, such as the Trusted Exchange Framework, might help to simplify the exchange of health information through the use of health information networks.”” (M)

Hospital Report Cards

“Consumers are getting “mixed messages” from the CMS Hospital Compare website and penalties levied by the Hospital Readmissions Reduction Program, undermining their ability to shop for quality care, according to a study in The American Journal of Managed Care.

The researchers compared hospital grades posted on Hospital Compare for heart failure and acute myocardial infarction readmissions with the HF and AMI scores for excess readmissions used to set penalties under HRRP. They also looked at how often hospitals were penalized for just one or two of the five HRRP conditions, since the penalty program affects a hospital’s sum Medicare payments.

Of 2,956 hospitals, 92% were deemed “no different” than the national HF readmissions rate on Hospital Compare, yet nearly half (49%) scored high for HF readmissions under HRRP and 87% received an overall readmissions penalty.” (N)

Emergency Medicine Physicians/ Sleep Deprivation

 “Sleep deprivation and fatigue have plagued emergency room physicians for decades but apparent widespread use of sleeping aid medications entails risks.

A recent study found more than half of ER physicians reported actively using a sleeping aid medication. Sleeping aid medications pose risks to physician wellbeing such as rebound insomnia. Negative cognitive effects of sleeping aid medications can last hours after awakening. Use of sleeping aid medication among emergency department physicians is likely far more common than previously reported, recent research shows. Fatigue has been linked to cognitive impairment among ER physicians but sleeping aid medication is a problematic solution. Sleeping aid medication fails to induce normal sleep stages and their progression to natural sleep, and health concerns have implications for physician wellbeing such as rebound insomnia after discontinuance of medications…. The most commonly used medication was a nonbenzodiazepine hypnotic such as Ambien…

ER physicians need the same kind of duty-hour restrictions that were established for medicine residents by the accrediting agency for graduate education,.. (O)

Stethoscopes Carry Bacteria

“DNA from an abundance of bacteria linked to healthcare-associated infections, including Staphylococcus, was found on stethoscopes carried by healthcare professionals in the ICU, and cleaning only led to a modest reduction, researchers found.

On a set of 40 stethoscopes in use in an ICU, all 40 had a high abundance of Staphylococcus DNA, with “definitive” S. aureus DNA present on 24 of 40 stethoscopes tested, reported Ronald G. Collman, MD, of the University of Pennsylvania (UPenn) Perelman School of Medicine in Philadelphia, and colleagues.

Moreover, while cleaning the stethoscopes reduced the amount of bacterial DNA, it did not completely bring all stethoscopes in use in the ICU to the level of “clean,” the authors wrote in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America…

The CDC, in its guidelines for disinfection, state that “medical equipment surfaces” such as stethoscopes should be disinfected with an EPA-registered low- or intermediate-level disinfectant, with these guidelines adding that “use of a disinfectant will provide antimicrobial activity that is likely to be achieved with minimal additional cost or work.”  (P)

eICUs

“In 2009, Steve Burrows’ mom, Judie, went in for hip replacement surgery. She came out with brain damage and mobility issues after a weeks-long coma that would change her and her family’s life…

What happened to Judie is complicated, but it essentially began with massive blood loss.

“In the end, that’s really how this whole thing started,” Burrows says in an interview with NPR’s Lulu Garcia-Navarro. “She lost over half the blood in her body.”

After her surgery, she was put into recovery and left alone with what’s called an electronic intensive care unit, or eICU.

With a series of monitoring tools that usually include microphones, video cameras and alarms, eICUs are meant to provide the 24-hour monitoring that many patients require after a major medical emergency.

“This [eICU] didn’t notice my mom was in a coma for at least a day and a half and I wanted to talk to the ICU doctor who was there that night,” Burrows says. “We were told there was no doctor there. I said ‘Well that’s insane, what do you mean?’ ”

He says there were doctors monitoring the cameras out by the airport in Milwaukee and they were supposed to be the safety net for his mother.

Burrows says that when he asked whether the camera was on, the head of the ICU told him it wasn’t because of patient privacy issues…. (Q)

Assuming blame for a medical error may help patients and families heal.

Dr Tigard admits that not all medical errors are preventable. He uses the example of a nurse in an oncology unit responsible for the care of 5 patients because of understaffing at the hospital. In this scenario, 2 patients suddenly need life-saving interventions at the same time. The nurse is able to save only one patient, while the other dies. Although she may be tempted to blame the system, Dr Tigard contends that the nurse should apologize to the family, as it offers the best chance of healing…

“That means medical errors are now the third-leading cause of death in the country — yes, the third-leading cause of death of all people. The number of lives that are lost each day to a medical error, a preventable error, is equivalent to a 747 going down daily,”

Arnold’s work is focused on reducing those errors, particularly in medical emergency situations involving children. The simulation center, which moved into a new, $95-million, 225,000-sq.-ft. Johns Hopkins All Children’s Research and Education Building this fall, features 15 simulation rooms, a dozen hightech mannequins and education space for medical personnel to test their skills in simulated emergencies and learn from the experiences.

 “The technology here, all the computers to run the mannequins, that’s just the tool,” Arnold says. “What it all provides is an opportunity for our providers to become really experts, to hone their skills, not only their clinical skills and their procedural skills, but most importantly their behavioral and communication skills.””  (R)

Let Hospital Patients Sleep!

 “If part of a hospital stay is to recover from a procedure or illness, why is it so hard to get any rest?

There is more noise and light than is conducive for sleep. And nurses and others visit frequently to give medications, take vitals, draw blood or perform tests and checkups — in many cases waking patients to do so…

Peter Ubel understands the problem as both a physician and patient. When he spent a night in the hospital recovering from surgery in 2013, he was interrupted multiple times by blood draws, vital sign checks, other lab tests, as well as by the beeping of machines. “Not an hour went by without some kind of disruption,” said Dr. Ubel, a physician with Duke University. “It’s a terrible way to start recovery.”

It’s more than annoying — such disruptions can harm patients. Short sleep durations are associated with reduced immune function, delirium, hypertension and mood disorders. Hospital conditions, including sleep disruptions, may contribute to “posthospital syndrome” — the period of vulnerability to a host of health problems after hospitalization that are not related to the reason for that hospitalization…

Solutions aren’t hard to fathom. Dr. Ubel listed some in 2013. Hospital workers could coordinate so that one disruption serves multiple needs: a blood draw and a vitals check at the same time instead of two hours apart. Or they could allow patients’ needs to guide schedules. If a patient is at low risk and can go six or eight hours without a vitals check, for example, perhaps don’t do that check once every four hours…”  (S)

Are physicians aware of how much they don’t know?

His epiphany on the subject came in 1984, when he was a resident at Washington University’s Barnes Hospital in St. Louis, Mo. “We had a difficult case, and it was clear doctors had little understanding of [a particular] test result” dealing with prothrombin time, said Laposata, who now chairs the pathology department at the University of Texas Medical Branch at Galveston. As a result, they ended up needlessly giving blood to an 8-year-old boy who was getting a tonsillectomy; the blood turned out to be contaminated with HIV — a disease that was still a mystery at the time. The boy developed HIV and later died.

Upon finishing his residency, Laposata went to work at the University of Pennsylvania, where he became director of the coagulation lab there. “I said, ‘We’re not going to just send [test] results; we’re going to put an interpretative paragraph underneath the numbers,'” he explained. “We did it for 3 months and then I got a surprise visit from the chief of hematology, [who] comes to me and says, ‘Stop doing that.’ I said, ‘Why?’ and he said, ‘Hematology fellows are not seeing cases because you’re giving the diagnosis too soon.'”

When Laposata suggested that a quicker diagnosis was a good thing, the hematology chief replied, “Not for me, because without fellows, we don’t have research projects.” “I said, ‘I thought the patient comes first,’ but he said ‘No,'” said Laposata. “That was a shocker.”

He then went to work at Massachusetts General Hospital, where he became director of a lab. “I thought, ‘I’m going to go for it,'” Laposata said. “We have to change the paradigm for making diagnoses. We should have only experts providing opinions about different areas.”

So he started a diagnosis management team (DMT) for coagulation disorders, in which physicians who treated patients worked with lab experts to figure out the right tests to administer and to properly interpret the test results…”  (T)

Radiology

“There are plenty of places in the diagnostic process where things can go wrong. But radiology is a frequent source of medical error that is ripe for reform, according to a new report.

Coverys, a Boston-based medical liability insurer, reviewed more than 10,600 malpractice claims from between 2013 and 2017 and found that nearly 600 named a radiologist explicitly. These cases often related to significant patient harm and delayed diagnosis of serious conditions, according to the group’s report…

 “Radiology has done a lot over the last several years to try and see if they can become a safer discipline,” Hanscom said. “They need to continue to press on a number of fronts—they are still finding themselves very much connected to these poor outcomes.”

The report identifies several ways that radiology teams can address the risk of medical errors, including:

•             Using clinical decision support • Having a clear protocol for bringing in a second opinion on a reading •                Building templates for reports and using clear language in them •             Ensuring that incidental findings worthy of follow-up are highlighted so they aren’t missed

Peer review is a key strategy, Hanscom said, especially since the interpretation stage is the riskiest. Getting a second opinion can ensure that nothing on a test result is missed and can prevent communication gaps, such as getting crucial information to the physician that can best use it.”  (U)

National Licensure

“National licensure of nurses, physicians and other healthcare professionals is an idea whose time has come. But it’s coming pretty slowly through painstaking state-by-state approval of interstate compacts.

The underlying issue is basic: Whether you’re in Maine or Arizona, Florida or Oregon, all patients deserve the same high quality of healthcare. That means quality standards for professionals who deliver patient care should be consistent no matter where you live.

There’s no evidence that healthcare professionals in one state are better or worse than in other states. Yet, in most parts of the country, healthcare professionals who can commute to several states in an hour or two must have separate licenses to work in each state.

There’s an important reason for national licensure: flexibility. Clinical workforce shortages don’t follow any geographic rules. Some rural areas have severe physician or nurse shortages, but others don’t. Some cities have an adequate supply of highly skilled nurses, while others face a near crisis. Specialties like OB-GYNs, telemetry nurses, pediatric physical therapists or family nurse practitioners can be sufficient or sparse in different parts of the same region. Healthcare professionals need to be able to go where they are needed quickly and efficiently.

Another reason for national licensure is telemedicine. The immense value of telemedicine in improving patient care is widely acknowledged. Yet, invisible barriers to telemedicine arise at state lines. We need to knock down those barriers.

One argument against national licensure has come from state proponents who say they need to protect patients from problem clinicians who might move from state to state to escape their records of misconduct. But, a national system, where each healthcare professional has only one record, would, in fact, make it easier to catch offenders and protect the patient…”  (V)

Competency Of Aging Physicians

“A set of guiding principles from an American Medical Association council on assessing the competency of senior/late career physicians failed to gain adoption at the AMA’s interim meeting here.

In a floor vote of 281-222 on Tuesday, delegates sent the report back to the Council on Medical Education, which issued the guiding principles. Some hospitals and health systems already require competency testing by older physicians, but there are currently no standards for these tests.

There are currently more than 120,000 practicing physicians 65 and older in the U.S., according to the council. Chairperson Carol Berkowitz, MD, stressed that the report does not mandate age-based competency testing. Instead, it sets out guidelines for any organization or hospital that decides to put in place a testing process to ensure it is “fair, evidence-based, and equitable.”.. (W)

Monitoring EMRs For Patient Safety

Scientists at a patient safety organization developed a way of monitoring EHRs to detect safety risks to hospitalized patients in real time, a method they described in Health Affairs on Monday.

The paper, published in a journal issue dedicated to patient safety, was based on a three-year pilot of a safety management system developed by the organization, Pascal Metrics.

Pascal says it is the first organization to apply machine learning to a dataset of EHR-based adverse event outcomes. The system, which Pascal tested at two community hospitals, can detect patient harm from real-time data and fires triggers that result in patient safety monitoring.

“This appears to be a genuine pivot away from retrospective reviews of patient safety incidents to real-time analysis,” said Jeff Smith, vice president for public policy at the American Medical Informatics Association.

While the study demonstrates the potential for use of real-time data, there were many false positives triggered by the system, noted Dean Sittig, a professor of bioinformatics at the University of Texas Health Sciences Center in Houston.

Until EHR systems become capable of limiting these false alarms, “systems like these will be untenable for all but the highest-staffed facilities,” Sittig said.

Hardeep Singh, a health IT expert at the Baylor College of Medicine, said that while the prototype in the article was good, the portfolio of triggers it used would be limited in detecting the various types of harm seen in hospitals. In addition, few hospitals have the bandwidth to work with sophisticated algorithms to detect or prevent patient harm, he said.” (X)

Preventing Patient Harm – The Conversational Nurse Model

“Imagine an 82-year-old patient – we’ll call him Mr. A — with severe congestive heart failure, bouncing in and out of the hospital with increased frailty. During one hospital admission, Mr. A’s cardiologist consults the palliative care team for symptom management and clarification of goals of care. Mr. A tells the palliative care team that what matters most to him is to return home to be with his wife. He does not want to be placed on a ventilator, nor does he want aggressive measures taken. He agrees to go to a skilled nursing facility (SNF) for strengthening but says that if his heart failure worsens, he wants to return home.

The palliative care consult notes are filed in the medical record, along with a form stating that Mr. A does not want aggressive measures taken. However, this form and the consult notes are lost during transfer to the SNF. Mr. A tells the SNF team that his goal is to get stronger, which is interpreted as wanting all measures taken. Two weeks later, Mr. A develops shortness of breath and confusion and is transferred to the hospital. Records from the SNF indicated that he wants all measures taken. He is put on a ventilator in the emergency department and dies a week later in the intensive care unit…

To address this in our own health system, Care New England in Rhode Island developed the Conversation Nurse model: a program for training nurses in conversational skills to conduct discussions with patients about serious illness and their goals for their care. Our Conversation Nurses meet with patients across the entire health care continuum and talk with them about their understanding of their illnesses and their goals for care as their diseases worsen. We have used this model to increase the workforce trained in serious illness care and have demonstrated the following outcomes: 1) Increased volume of palliative care consults in inpatient settings, 2) Increased documentation of advance directives in the home care agency population, 3) Decreased readmissions and increased hospice consults in skilled nursing facilities, and 4) Broad training of Accountable Care Organization (ACO) interprofessional teams. The model, which started in the inpatient setting and expanded into the community, has proven useful both in increasing the workforce trained in having conversations about serious illness and in optimizing use of finite physician resources.” (Y)

Preventing Patient Harm – The PST Model

That effort takes form in the PST model—primary, secondary and tertiary responses to adverse events that encompass both a proactive and a reactive approach, leaders at the system said at a session at the Institute for Healthcare Improvement’s National Forum on Quality Improvement in Healthcare.

A safety mindset allowed the system to develop a series of interventions to prevent harms and to effectively address them should a safety lapse occur. Steps at the earliest level include adjusting hiring to bring in the best team members and offering training to enhance their skills in safety as needed.

Other proactive steps MedStar took include making safety central to the culture of its hospitals, tracking patient satisfaction to identify risks and offering standardized work processes.

To plan for “secondary” prevention, MedStar expanded its definition of harm from “serious safety event” to “serious unanticipated outcome.” Doing so allowed the system to monitor harms that may not be caused directly by providers, said Seth Krevat, M.D., assistant vice president for safety at MedStar.

That definition switch led the number of reports to increase significantly, providing a greater database for new initiatives, Krevat said. For example, in 2018 so far, 239 unanticipated outcomes have been reported, compared to 41 scenarios that would be considered “serious safety events.”

Further secondary steps taken by the hospital include diving deeper into claims data and patient surveys to flag issues and identify near misses. (Z)

Preventing Patient Harm – the Piedmont Healthcare model

“For one hospital in particular, a poor Leapfrog Hospital Safety Grade rating in 2014 became a launching pad for improved quality and safety.”When we got a ‘D’ from Leapfrog, that was our wake-up call. We had done good patient safety work before, but it wasn’t the fanatic level that we have now,” says Leigh Hamby, MD, MHA, executive vice president and chief medical officer at Piedmont Healthcare, an integrated healthcare system with 11 hospitals and almost 100 physician and specialist offices throughout Atlanta and North Georgia

Since launching systematic initiatives to improve quality and safety in 2014, the health system has posted gains.In November 2018, six of Piedmont’s 11 hospitals received “A” grades in The Leapfrog Group’s Fall 2018 Hospital Safety Grade ratings

 From July 2016 to June 2018, Piedmont reduced hospital-acquired infections 40%

One Piedmont hospital has not reported a hospital-acquired infection for more than a yearHamby says there are four ways Piedmont implemented better quality and safety at the healthcare organization and boosted its rankings.” (AA)

Postscript on Hospital Ratings

“Many organizations have started publishing hospital performance measures and report cards in recent years, growing out of the movement for improved quality and patient satisfaction, lower costs, and greater accountability and transparency. Among the organizations publishing these ratings and measures are government agencies, news organizations, healthcare accreditation and quality groups, and companies and not-for-profits focused on transparency. The emergence of these reviews has put pressure on hospital leaders to do what’s necessary to improve their scores.

But the various reports use significantly different methodologies and have different areas of focus, often producing sharply different ratings for the same hospitals during the same time period. Some hospital leaders say this makes it more difficult to know which areas to prioritize to improve their quality of care and rankings….

Reasonable people disagree on what measures are most important to include, which makes for significant differences in the various ratings, Jha said. One problem with that, though, is that hospitals can cherry-pick favorable ratings for marketing purposes, whether or not those ratings have much validity. “Anyone who wants to dodge accountability can hang their hat on some obscure rating that was good,” he said…

Some groups use a star rating system, some use a 1 to 100 percentage scale, and others use an academic-style A to F grading range. The groups also vary on how frequently they publish ratings, with some issuing reports annually and others offering more frequent updates.

The raters rely on data sets from the government, such as the Medicare Provider Analysis and Review and the Hospital Consumer Assessment of Healthcare Providers and Systems. Some create their own surveys and solicit voluntary responses from the hospitals. Others use diagnostic and procedure coding for specific diseases, conditions and services. But not all groups disclose how they weight the various quality measures in producing their final scores. “They have to create a distinct product,” Daugherty said.” (BB)

Did This Health Care Policy Do Harm?

“No patient leaves the hospital hoping to return soon. But a decade ago, one in five Medicare patients who were hospitalized for common conditions ended up back in the hospital within 30 days. Because roughly half of those cases were thought to be preventable, reducing hospital readmissions was seen by policymakers as a rare opportunity to improve the quality of care while reducing costs.

In 2010, the federal agency that oversees Medicare, the Centers for Medicare and Medicaid Services, established the Hospital Readmissions Reduction Program under the Affordable Care Act. Two years later, the program began imposing financial penalties on hospitals with high rates of readmission within 30 days of a hospitalization for pneumonia, heart attack or heart failure, a chronic condition in which the heart has difficulty pumping blood to the body.

At first, the reduction program seemed like the win-win that policymakers had hoped for. Readmission rates declined nationwide for target conditions. Medicare saved an estimated $10 billion because of the reduction in hospital admissions. Based on those results, many policymakers have called for expanding the program.

But a deeper look at the Hospital Readmissions Reduction Program reveals a few troubling trends. First, since the policy has been in place, patients returning to a hospital are more likely to be cared for in emergency rooms and observation units. This has raised concern that some hospitals may be avoiding readmissions, even for patients who would benefit most from inpatient care.

Second, safety-net hospitals with limited resources have been disproportionately punished by the program because they tend to care for more low-income patients who are at much higher risk of readmission. Financially penalizing these resource-poor hospitals may impede their ability to deliver good care.

Finally, and most concerning, there is growing evidence that while readmission rates are falling, death rates may be rising.” (CC)

Physician Burnout

“Studies have shown that medical errors are common in the United States healthcare system, representing a major source of inpatient deaths. Evidence indicates that physician burnout, characterized by exhaustion and cynicism, is associated with medical errors. Safety grades provide a summary reflection of the patient safety practices within a patient care setting (or “work unit”) intended to reduce these errors. However, the interactions among these patient safety practices, physician burnout, and medical errors have remained unknown.” (DD)

Physician Stress

“Surgeons under stress are far more likely to make mistakes on patients in the operating room, even if the stress is caused by a trivial source and lasts briefly, a Columbia University study finds.

The research shows that all it takes is a negative thought or a loud noise in the room to trigger moments of short-term stress for doctors, according to lead author Peter Dupont Grantcharov, a master’s student at the Data Science Institute at Columbia.

For the study, Grantcharov had Dr. Homero Rivas, Associate Professor of Surgery at Stanford Medical Center, wear a high-tech “smart shirt” under his scrubs during 25 surgical procedures, most of which were gastric bypasses… (EE)

NIH: antibiotic-resistant bacteria living in the plumbing

“Patients were infected with antibiotic-resistant bacteria living in the plumbing of the National Institutes of Health’s hospital in Bethesda, Md., contributing to at least three deaths in 2016.

A study published Wednesday in the New England Journal of Medicine found that, from 2006 to 2016, at least 12 patients at the NIH Clinical Center, which provides experimental therapies and hosts research trials, were infected with Sphingomonas koreensis, an uncommon bacteria. The paper, written by NIH researchers, suggests that the infections came from contaminated water pipes, where the bacteria may have been living since as early as 2004, soon after construction of a new clinical center building.” (FF)

“There could be a whole post dedicated to medical inaccuracies on Grey’s Anatomy or political impossibilities on Scandal, but we’re about to explore so much more than just technical knowledge (although, there will be some of that too). Even some of the most eagle-eyed fans missed these mistakes in Shondaland’s most beloved shows, from huge mistake in birthdates to tiny mistakes in continuity. Because we’ll be talking about many seasons of many shows, beware of spoilers, especially if you’re not caught up on Grey’s Anatomy and How To Get Away With Murder.

Here are the 20 Mistakes Fans Completely Missed In Shondaland Shows.” (GG)

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“…what would it look like if Amazon CEO Jeff Bezos took the helm of a major integrated (health care) delivery system?”

“Big Silicon Valley companies have often competed for talent with specialized skills, like expertise in artificial intelligence or trendy new programming languages.

Now they’re competing for heart doctors.

Apple hired Dr. Alexis Beatty, a cardiologist, to its growing health team in July, according to a LinkedIn search. Amazon hired Dr. Maulik Majmudar, also a cardiologist, the following month. Alphabet’s life sciences company Verily named Dr. Jessica Mega as its chief medical officer almost three years ago. Mega, of course, is a cardiologist…

Apple’s smartwatch now includes an electrocardiogram, which can detect heart rhythm irregularities. Verily’s study watch, which is designed for clinical trial research, also tracks heart rate and heart rhythm, and it’s doing a lot of work in chronic disease management. Another Alphabet team, Google Fit, worked closely with the American Heart Association for its design revamp. Amazon’s plans in cardiology are less clear, but the company does have a secretive research and development team that is working on a variety of health projects under the leadership of an electrical engineer — former Google X employee Babak Parviz.

So the more likely explanation is that tech companies are interested in health care, and they have all come to the conclusion that cardiology should be an early (if not initial) target.

Here’s why….” (A)

“…. The question now is how far will Amazon, the master disrupter, take this?”

The answer: very far, it’s safe to assume. Anyone who continues to think of Amazon as just a very big digital retailer needs to think again. The company has repeatedly shown that it has the capabilities, the patience and the deep pockets to disrupt industry after industry. Healthcare is no exception. There are at least three reasons to believe Amazon is has a good shot. First, as one of the largest private employers in the United States, Amazon would reap huge financial benefits from lowering the high cost of healthcare in this country. Second, the numerous inefficiencies of the healthcare system present enticing avenues for Amazon to explore, and as CEO Jeff Bezos has famously stated, “Your margin is my opportunity.” Finally, healthcare is just the kind of big, complex problem that Bezos likes to sink his teeth into. An unabashed “Star Trek” fan with a utopian view of the future, Bezos has always aspired “to boldly go where no one has gone before.” Bezos strongly believes that Amazon has a role to play in making things better.

As Amazon turns its focus to healthcare, we believe there are four potential points of entry, with increasing levels of complexity from simple product distribution. Durable medical equipment and medical supplies. Mail-order and retail pharmacy. Pharmacy benefit manager. AI powered telemedicine, diagnostics or in-home healthcare.  (B)

“To get to their next trillion dollars, Apple and Amazon are realizing that they can’t ignore opportunities in the health sector. But to get that right, they need to focus on the things they’re good at.

Amazon is focusing on its area of expertise: the supply chain. The company bought PillPack, an internet pharmacy, and it has a grocery delivery business through Whole Foods. It is also working with two other employers, J.P. Morgan and Berkshire Hathaway, on an initiative to reduce health care costs…

But these are just the things that we know about. Undoubtedly, Apple and Amazon, which both have a strong focus on research and development, are thinking about new health-focused hardware and software products for the next decade. And where better to try them out than by talking to their doctors and garnering feedback from real patients (incidentally, their own workers)? It makes a lot of sense, health experts say, especially for tech companies that are notoriously obsessed with secrecy.

“If Amazon and Apple had considered these clinics for internal use only, they would have likely outsourced to any of the number of clinics that offer on-site clinic services,” said Nikhil Krishnan, a health-focused analyst with CB Insights, a market research firm. “The fact that Apple and Amazon are testing it in-house means they want to test the model with employees, iterate, and eventually release this product to their respective customers.”

Weinberg from the Bay Area Council Economic Institute has seen tech companies try and fail to get into health care, if they assume there’s a simple tech solution.

Health care is “devilishly complicated,” he says. In his experience, those that do succeed will be richly rewarded, while having an opportunity to make a difference. And one of the best ways to get there, says Weinberg, is to get into the business of both patient care and population health management, which includes tools to keep a population of patients as healthy as possible.” (C)

“The healthcare initiative formed by Amazon.com Inc. (AMZN – Get Report) , Berkshire Hathaway Inc. (BRK.A – Get Report) and JPMorgan Chase & Co. (JPM – Get Report) made a “bold statement” with its appointment of Comcast Corp. (CMCSA – Get Report) alum Jack Stoddard as chief operating officer, according to Leerink Partners LLC analyst Ana Gupte.

The venture is “reaffirming its commitment to upending the way consumers access healthcare in an increasing digital ecosystem,” Gupte wrote in a Wednesday, Sept. 5, note. “We believe the Stoddard hire clearly shows that [the venture] is looking to own the digital front door to healthcare.”

Stoddard, who was most recently general manager of digital health at Comcast, started his new role this month, according to his LinkedIn profile. CNBC first reported on Stoddard’s appointment on Tuesday.

The news follows the hiring of Atul Gawande, a surgeon, public health researcher and a staff writer for The New Yorker, as CEO of the healthcare initiative effective July 9. Amazon, Berkshire and JPMorgan unveiled their partnership in January, saying they’ve banded together to address healthcare for their U.S. workers…

Comcast could offer a blueprint for what Stoddard might aim to do at the Amazon-Berkshire-JPMorgan venture, Gupte wrote.

“As noted in a recent New York Times article, Comcast has been at the forefront of health insurance innovation,” she wrote. “Instead of pushing the financial burden to employees via high-deductible health plans (as nearly 50% of large employers have), Comcast has focused on lowering costs by partnering with innovative tech-enabled companies to improve employee engagement (Accolade), care management (Grand Rounds which provides second opinions) and telehealth (Dr. On Demand).””  (D)

“Amazon’s increased presence in healthcare has caught the attention of many hospital and health system leaders who are vested in a healthcare model that is at risk of being disrupted. So far the company has considered a number of patient-centered initiatives, but what would it look like if Amazon CEO Jeff Bezos took the helm of a major integrated delivery system?..

Healthcare leaders stand to learn a lot by examining Mr. Bezos’ approach toward processes. A good process serves the provider so they can serve the customer, but one of the most dangerous epidemics gripping our industry is that we have stopped focusing on the outcomes of our processes. Mr. Bezos refers to this fallacy as “managing by proxy.” If patients complain about an undesirable outcome, the first thing many clinical leaders do is defend the process that drove the outcome, so long as they followed protocol. Instead of swearing by adherence to protocol, we should examine the process itself to see if it can be improved. Do we own the process or does it own us? If Mr. Bezos ran my health system, he would be constantly reevaluating our processes not by cost optimization or operational efficiency, but by the true value that they bring directly to our patients and members…

Anyone familiar with the number of individuals and organizations that orchestrate the payment and delivery of care knows that misalignment is a troubling reality within our industry. Healthcare is extremely siloed, but Mr. Bezos has made his fortune by streamlining efficiency among numerous players to deliver the best product as quickly as possible. I believe Mr. Bezos would take innovative steps to challenge healthcare’s misalignment and integrate the model to create efficiency and savings for our patients and members.  His long-term view of success would drive Sentara’s development into a system fully aligned to maximize the value to our consumers.  Under his watch, Sentara would rapidly become the first, most convenient choice for our patients and members for all their healthcare needs.”  (E)

“Out of all the technology giants with ambitions in healthcare, hospital executives have overwhelmingly put their faith in Amazon, according to a new survey.

A full 59% of executives say Amazon will have the biggest impact, according to the survey by Reaction Data. Respondents cited resources available to the retail and technology behemoth…

 “Amazon has a huge market they can use to distribute materials. They are already a household name and the users are not specific to Apple or Android,” one CEO said.

About 80% of survey respondents were from the C-suite, including chief nursing officers, chief financial officers and chief information officers.

While Amazon alone may be generating significant excitement in boardrooms, a previous survey by HealthEdge shows consumers are largely skeptical about Amazon’s partnership with JPMorgan and Berkshire Hathaway.

Amazon’s push into healthcare “has been a shot across the bow for the entire industry,” Rita Numerof, Ph.D., president of Numerof & Associates told FierceHealthcare. The company’s consistent and deliberate investments indicate they are serious about making substantial changes within the industry.

“Amazon is known for its relentless focus on the consumer and its ability to use data systematically to identify and meet unmet needs in an accessible manner,” she said. “Unfortunately, access, consumer engagement, and segmentation haven’t been the hallmark of healthcare delivery.” (F)

“Amazon, JPMorgan and Berkshire Hathaway’s buzzy partnership over their employee healthcare announced in January caught plenty of other large employers’ attention.

Sure, it could just end up being just another purchasing coalition.

But if it actually takes advantage of the breadth of Amazon’s connection with consumers? That could stand to truly—pardon the overused term—”disrupt” healthcare for employers, said National Business Group on Health President and CEO Brian Marcotte.

“If they begin to leverage Amazon’s footprint within the home, their relationship with the consumer, their customer obsession … the customer loyalty they have, and begin to leverage their ability,” Marcotte said, it could change everything.

“One of the challenges in healthcare is employees don’t touch the system with enough frequency in order for it to be routine, in order for them to be sophisticated consumers,” added Marcotte. Amazon and other online shopping platforms are routine, he said.

“When I look at this coming together, the opportunity is how do you leverage their platform to reach people in a more natural way, in a more frequent way then we reach them today,” he said.”  (G)

“Former Cleveland Clinic CEO Toby Cosgrove said healthcare’s potential innovators need to have one key trait—persistence.

The industry is resistant to change, he said, so new ideas aren’t likely to be met with a warm reception. Instead, expect colleagues to push back.

“Don’t expect everyone to love [your ideas]—they’ll hate it,” he said. “Don’t get discouraged when your ideas aren’t immediately embraced.” ..

While the innovative examples provided by Cosgrove himself are on the clinical side, he said what keeps him up at night, and where there’s the greatest room for future growth, is cost and new tech.

“We are under tremendous pressure in the United States…about the cost of healthcare,” he said.

In innovation, cost and technology are likely to go hand-in-hand, he said. Cleveland Clinic, for example, has 2,000 employees involved in revenue cycle management, he said. Artificial intelligence could streamline that process significantly, cutting costs and improving efficiency.

Another area ripe for future innovation is leadership development. Healthcare needs administrators and often has to train people internally for top roles. Cosgrove said he didn’t really have a grasp on what a CEO does at the time he took over the Cleveland Clinic.

But strong leadership, once it’s built, can serve as a catalyst for further innovation in the ranks and sets the tone that trying new things is valued, he said.

“It’s amazing how leadership…just cascades down through the rest of the organization,” Cosgrove said. (H)

Jeff Bezos gave a master class on life and business onstage in Washington last night, with this keeper advice: “All of my best decisions in business and in life have been made with heart, intuition, guts, … not analysis.”

“If you can make a decision with analysis, you should do so. But it turns out in life that your most important decisions are always made with instinct and intuition.”

“Everything I have ever done has started small,” Bezos added, drawing laughter at the 32nd anniversary dinner of the Economic Club of Washington, D.C.:

“Amazon [now with 500,000 employees] … started with five people.”

“It’s hard to remember for you guys, but for me it’s like yesterday I was driving the packages to the post office myself, and hoping one day we could afford a forklift.”..

Turning to business best practices, Bezos said he sets his first meeting at 10 a.m.:

“I go to bed early and I get up early. I like to putter in the morning. So I like to read the newspaper. I like to have coffee. I like have breakfast with my kids before they go to school.”

“I do my high-IQ meetings before lunch. Like anything that’s going to be really mentally challenging, that’s a 10 o’clock meeting. And by 5 p.m., I’m like, ‘I can’t think about that today. Let’s try this again tomorrow at 10 a.m.'”

Bezos said he gets eight hours of sleep:

“I prioritize it. … I think better. I have more energy. My mood is better.”

“As a senior executive, you get paid to make a small number of high-quality decisions. Your job is not to make thousands of decisions every day.”

“Is that really worth it if the quality of those decisions might be lower because you’re tired or grouchy?”

“All of our senior executives operate the same way I do. They work in the future, they live in the future.”

“Right now, I’m working on a quarter that’s going to reveal itself in 2021 sometime.”

“If I make, like, three good decisions a day, that’s enough.”

“Warren Buffett says he’s good if he makes three good decisions a year.” [Laughter]. (I)

“Online retail giant Amazon is set to sell medical devices straight to consumers in a partnership with Arcadia Group, a consultancy with a history of partnering with big brand retailers such as Walmart Pharmacy to sell exclusive medical devices.” (J)

“CVS Health CEO Larry Merlo doesn’t want to leave any room for Amazon to disrupt the pharmacy benefits industry, according to CNBC.

Mr. Merlo, whose company won Justice Department approval to move forward with its $69 billion acquisition of Aetna Oct. 10, said he is more concerned with meeting customer needs than fearful off disruptors.

“So that’s what we focus on as an organization, with the goal being: Don’t leave any white space for Amazon to disrupt,” Mr. Merlo said.” (K)

“But Amazon has yet to provide any indication it’s entering the business of providing face-to-face healthcare to patients, which is increasingly the strategy being pursued by traditional drugstore chains.

Walgreens, which operates 9,800 drugstores in all 50 U.S. states, is testing myriad healthcare partnerships and this summer launched a digital marketplace that links its customers to medical care providers and their prices beyond services inside the drugstores. And CVS Health is touting its relationships with medical care providers and the potential to add more healthcare services once its acquisition of the health insurance giant Aetna is completed in coming weeks.

The strategies unfolding at CVS, Walgreens and Walmart are designed to stress the patient connection beyond the ability to order something online and have it delivered overnight or within hours. Though they don’t mention Amazon when they discuss their strategies, it’s clear they want to fill their emptying retail space with healthcare services and don’t see Amazon as a threat.” (L)

“Netflix co-founder and California resident Marc Randolph says Dallas is his favorite place in the world.

Randolph’s emotional connection to the city stems from a meeting he had with Blockbuster executives in its downtown Renaissance Tower when they were Goliaths of the video industry, and Netflix a lowly David.

With Netflix struggling to stay financially viable, Randolph and co-founder Reed Hastings tried to set up a meeting with Blockbuster executives to see whether there was any interest in buying their company.

But Netflix, at a little more than 2 years old, had less than 100 employees while Blockbuster had 60,000, so getting a meeting at all had been like pulling teeth, Randolph recalls.

“We sent emails, we tried calling, and not a peep — nothing,” he said.

Finally, Randolph and Hastings were invited to Blockbuster headquarters at Renaissance Tower. Underdressed because of the short notice, and seemingly without much leverage, the men offered to sell Netflix for $50 million.

“The meeting went downhill very quickly after that,” Randolph said.

The men returned to California without a deal — and as determined as ever to best Blockbuster.

A “miraculous” combination of no late fees, personalized rental queues automatically ordering the next DVD for customers, and a new subscription revenue model ultimately turned the company around, Randolph said, and Netflix never looked back, even as its success began to depend more and more on video streaming. It now has 130 million paying customers.

Meanwhile, Blockbuster has one remaining store in the United States, in Bend, Oregon.” (M)

“Here are seven ways Google is tackling healthcare today: HIPAA compliance; Online search; Clinical documentation; AI; Genomics research; Application Programming Interfaces; Consumer health.” (N)

“Google, Amazon, insurers and credit card companies have long been able to tell whether you vote, own a dog, spent time in prison or drive a rusty 1997 Chevrolet. Now, that type of information is starting to pop up in front of doctors when you walk into their examination rooms.

A small but fast-growing number of technology companies, including data brokers LexisNexis and Acxiom, sell health care providers detailed analyses of their patients, incorporating criminal records, online purchasing histories, retail loyalty programs and voter registration data…

The medical profession increasingly recognizes that it needs to be aware of how socioeconomic context — the buzz phrase is “social determinants of health” — is vital to a patient’s whole health. The flip side of benevolent concern, however, could be pigeonholing or invasions of privacy.

There are few safeguards on how such outside information can be used within the health system. The algorithms that companies use to classify some patients as “high risk” are rarely made public, so patients may not know their purchasing history or lifestyle could catapult them into a higher-risk strata. For every health plan that uses algorithms to predict substance abuse and help patients get treatment, there could be one that turns patients away when it learns they have.” (O)

“Geisinger President and CEO David Feinberg will reportedly lead health strategy at Google. The move comes after he turned down a high-profile job earlier this year leading the Amazon-Berkshire Hathaway-J.P. Morgan healthcare venture.

Feinberg will be tasked with pulling together and coordinating health initiatives across Google’s properties such as Google Brain, Nest home automation and Google Fit, according to CNBC. He’ll report to Google’s artificial intelligence head Jeff Dean but will work closely with CEO Sundar Pichai…

Feinberg will have a lot to work with. Google, through parent company Alphabet and life sciences arm Verily, has been relatively secretive about explicit healthcare ambitions, but there’s clear interest in the space. The tech giant has invested in methods to help stop the spread of infectious diseases, voice technology to help doctors as well as patients and numerous AI projects. Google-owned connected home device company Nest has also shown health sector ambitions.” (P)

“Sean Parker, the tech billionaire and cancer research philanthropist, may be a product of a Silicon Valley tech giant — but he’s skeptical about the impact those companies will have as they increasingly make a play in medicine.

“I just don’t think the innovations that are going to drive this revolution in health care and discovery are going to come out of Amazon or Google,”…

While coders face their own formidable challenges, Parker said, “tech people coming from tech to biology so dramatically underestimate the complexity of the human body. It’s not designed by us. It doesn’t work in ways that make sense.”” (Q)

“HERE COMES AMAZON: The tech giants keep on trampling into medicine. Seattle tech giant Amazon announced Wednesday it’s got a new machine learning service — called Amazon Comprehend Medical — intended to help the health care sector understand free text contained in medical records.

Amazon says the information will be useful for clinical decision support, revenue cycle management, clinical trials, and population health, and will potentially save lots of clerical work stemming from the need to tag or structure prose.

“We’re able to completely, automatically look inside medical language and identify patient details,” including diagnoses, treatments, dosage and strengths, “with incredibly high accuracy,” Amazon exec Matt Wood told the Wall Street Journal.” (R)

“Amazon Web Services, the company’s cloud business, announced last week that three of its most popular services — Amazon Translate, Amazon Comprehend and Amazon Transcribe — are now HIPAA-eligible. That brings to six the number of HIPAA-eligible AWS machine learning services in its catalog of offerings. The other three are Amazon Polly, Amazon SageMaker and Amazon Rekognition.” (S)

“Technology is rapidly changing the healthcare industry: surgeries are microscopic, patients have virtual appointments, doctors offer 3D visualizations on medical scans and more. But while these advancements in patient care are happening on the front lines, there seems to be a gridlock in the healthcare supply chain industry behind the scenes. Hours are wasted each day on ordering supplies and inventory is not always in stock, which leads to delayed procedures, higher costs, and ultimately, a negative impact on patients…

Imagine the scenario: on one side of the hospital, doctors perform surgeries with robots, while on the other side — either the loading dock or a supply room — procurement teams manually check spreadsheets to ensure their inventory is in stock. As budgets get smaller and executives face more pressure to bring costs down, the need to reduce both the time and money spent on outdated inventory management processes is more pressing than ever.

And while change can be complicated, there is no denying that there are a number of ways healthcare leaders — whether at a hospital or doctor’s office — can spend less time on procurement and more time on care.” (T)

“Amazon’s potential foray into healthcare has already caused players in the space to scramble and reevaluate their core competencies.” (U))

“…Dr. David Feinberg, the Geisinger CEO turned Google healthcare leader..

Because Geisinger also insures the patients it serves, there’s a built-in financial incentive to keep people healthy and out of the hospital. Dr. Feinberg took that notion one step further in his opening remarks: “I run a health system and we have about 13 or so hospitals, and I think my job is to close every one of them.”

The alternative? As he told it, bring healthcare to the people instead of bringing people to care providers.

“I think a lot of patients could be managed better at home,” he said. “We look at our highest utilizers, our sickest patients (and) we show up at their house in two cars, because we can’t all fit in one car. We got a nurse, a palliative care nurse, a community health worker, a pharmacist, a doc. We say, hi sir or ma’am, we’re here to take care of you, and our goal is that you never go in the hospital again and we know you’ve been hospitalized 12 times in the last year. Let’s clean out the medicine cabinet. Let’s make sure the house is safe. Oh, you have a bunch of appointments that are hard for you to get to? We’ll do them through telemedicine right now at the kitchen table. We just completely eliminate the need for those folks to ever go in the hospital again.”” (V)

“Amazon made headlines this year — especially as it leaped further into the healthcare arena. While there has been speculation about Amazon’s entry into the industry for years, announcements by the e-commerce giant in 2018 make it clear that it’s planning to make a big splash in healthcare. 

Here’s a breakdown of Amazon’s healthcare ventures, acquisitions, hiring trends and product developments reported by Becker’s Hospital Review.” (W)

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“If you don’t have a seat at the table, you’re probably on the menu.”


“Most everyone is undoubtedly familiar with the term “having a seat at the table.”

Often reserved for those who are considered to have both the influence and power to make decisions and effect change, the table has become a symbol of power, negotiation and credibility through which one can forward their career, generate a sale or plot a course for enterprise success.

In other words, when one is provided with a seat at the table, it represents an opportunity to be heard and to make a difference.” (A)

When I was appointed President and CEO of Jersey City Medical Center (JCMC) in 1989, we had a Certificate of Need (CN) for a total replacement hospital on a new site but the project had stalled. I was advised to quickly develop political support for the project. The goal: to become a “player” in Trenton to have “a seat at the table”.

The strategy was to join every local board, committee and task force as a pathway for doing the same in Trenton.

So I helped form the new Hudson County Perinatal Consortium and became Chairman, and served on the Boards of the Hudson County Chamber of Commerce, the Hudson County AIDS consortium and the United Way of Hudson County. I then organized and became the first Chairman of the new Local Health Planning Board which gave me an ex-officio seat on the State Health Planning Board (Trenton!).

Early on at the SHPB a Trenton hospital applied for a CN to start open heart surgery, a proposal strongly opposed by Department of Health Staff. Since we aspired to have OHS at JCMC, this was an opportunity to set the stage for our application down the road, so under-the-radar I rounded up the votes to get the Trenton hospital CN approved. (years later we too got OHS!)

In the ways of Trenton this led to my becoming a member of Governor-elect Whitman’s health care transition team. I then served on the Governor’s Advisory Commission on Hospitals, the Task Force on Affordability and Accessibility of Health Care in New Jersey, the Governor’s Advisory Council on AIDS, and the Department of Human Services HMO-Hospital Workgroup.

When I started at JCMC, The University of Medicine and Dentistry of New Jersey (UMDNJ) had a medical education monopoly in New Jersey with three public medical schools under its umbrella. They were the only medical schools in New Jersey.

In our quest for a medical school affiliation our first stop was UMDNJ’s medical school in northern NJ, in Newark. The Dean was in favor but the relationship was vetoed by the President who was focused on developing a community hospital network which was to include all our Hudson County competitors (it never happened).

Our next stop was UMDNJ’s medical school in central NJ, in New Brunswick. The Dean was in favor, but the relationship was vetoed by the President who, we found out, had established each medical school’s “territory” and we were not in the central NJ region.

So we wound up becoming a major teaching hospital affiliate of Mount Sinai in New York City, having to overcome the UMDNJ President’s political (Trenton) efforts to stop this out-of-state relationship as a threat to his monopoly.

While working on Jersey City planning and zoning approvals for our new hospital, we ran into obstacles in one key department. Meeting after meeting the issues were not resolved. So I asked Lynn Schundler, a leader on our board, who was also the Mayor’s wife, if she would come to the next meeting for a cup of coffee. When asked what she should do at the meeting I said “enjoy the cup of coffee.” The meeting took five minutes and everything was approved.

The Board of the New Jersey Hospital Association was comprised of member hospital CEOs, and controlled by suburban hospital CEOs who wanted the state’s Charity Care funding changed from supporting safety-net hospitals like JCMC to every hospital getting its share based on charity care spending. JCMC was 75% Medicaid and Charity Care while their hospitals were 10% or less.  

Becoming Chairman of the NJHA Board was a four year project starting with Secretary, then Treasurer, then Chairman-elect, then Chairman. No safety-net hospital CEO had every made it to Chairman (and no woman CEO either). For years I did everything necessary but was never nominated to be Secretary. So some of us resigned our hospitals from NJHA and started a “renegade” safety-net hospital group. That got their attention and I negotiated our way back into NJHA with the understanding I would get the initial officer nomination. I was the first two year Secretary before becoming Treasurer, and there was a failed effort to throw me under the bus when it was my turn to be Chairman. My year as Chairman was torture but was worth the effort since it enhanced my visibility and “seat at the table” in Trenton for the rest of my career.

Since JCMC was (and still is) a safety-net hospital, we needed FHA financing (bond guarantee) to get started. Then Congressman (now Senator) Menendez was the project’s “champion.” But a glitch developed when we didn’t get FHA approval in the final days of the Clinton administration. Congressman Menendez got the approval early days in the Bush 43 administration, putting the NHP before having discussions on Cuba policy. The Menendez connection was via a senior Board member who served three governors in various capacities, and sat at many tables!

When Jim McGreevey was elected Governor (Jersey City guy, born at JCMC), I was appointed to his health care transition team at the requests of the Assembly Speaker and Senate Majority Leader, both members of our new parent board, LibertyHealth. By then we also had a member of the Assembly on each of our three hospital Boards (JCMC, Greenville Hospital, Meadowlands Hospital).  When we finally had the groundbreaking we honored Governor McGreevey, making him the honorary first newborn at the new hospital.

The New Hospital project finally got started but near the finish line we ran out of money – $5,000,000 short. Governor McGreevey provided the funding to establish the Port Authority of New York and New Jersey Trauma Center (JCMC is right near the Holland Tunnel and a stone’s throw from the Lincoln Tunnel). The key connection was again the same senior Board member.

Developing relationships with legislators is an ongoing CEO responsibility. One told me he was annoyed when a hospital CEO walked in for the first with a problem, having never previously dropped by to say hello. Fortunately I had done that! And when I once came in with three problems he said “Jon, in back of you are ten other constituents with Trenton problems. So which one of yours is most important, and if and when we resolve that, come by with the next request.”

I once asked the Senate Majority leader why his name was on a bill inimical to us. He said “Jon, sometimes I have discretion and other times I have orders from the Senate President. It’s knowing which is which that enables me to help you when appropriate”

For any request always leave a “one-pager” summarizing the topic

(One of the biggest skills a hospital CEO has is helping legislators with the health care, particularly when they or a family member need quaternary care not available nearby. But they need to consider you a friend before they will ask. My relationship with Mount Sinai in NYC paid dividends.)

I once drove an hour and a half to an 8AM Healthcare Facilities Financing Board meeting (table) in Trenton to show “respect” since it was considering an item for our new hospital project. It was the first item and took 3 minutes; we were not introduced or asked to speak. Many CEOs delegate this kind of stuff to subordinates. I never did, ever.

And it’s really important to be at legislative committee hearings and mark-up sessions (another table) when a bill that affect your hospital is on the agenda. Once it was one in the morning when some bill language was unresolved so they asked me and my CFO what to do. We were the only two people in the gallery.

“If they don’t give you a seat at the table, bring a folding chair.”  Shirley Chisholm

An area Assemblyman became Assembly Speaker in 2001. Soon after I was leading a group of hospital governmental affairs VPs from across the state and when we got to the Speaker’s office his assistant announced that the Speaker wanted to see me alone. Turned out it was about a small Hudson County matter that took one minute to discuss but we then chatted for fifteen more, and if I recall correctly mostly about baseball. I said nothing when I came out with a look of gravitas but my reputation as an “insider” was burnished.

My political credibility was further enhanced when a picture of me with President Clinton appeared on the front page of the front page of the New York Times (August 2, 1994), at a reelection rally in Liberty State Park.  Another stroke of luck where I just happened to be sitting in the first row and President Clinton sat down next to me! (Actually I was sitting in the last row of the stage when then Senator Torricelli came in with Bianca Jagger, who sat down next to me while the Senator worked the VIPs. He kept waving Bianca down a few rows at a time, and I followed. We were sitting in the front row when President Clinton came in and sat down next to me, to the dismay of area hospital CEOs who were standing in the crowd.)

In 2004, with all this political assistance we opened the new Hospital and in December of 2004 the open heart surgery/ interventional cardiology program was started only a few months before the CN expired which would have precluded another opportunity for many years, if ever.

 “If you’ve been playing poker for half an hour and you still don’t know who the patsy is, you’re the patsy.” ― Warren Buffett

When Senator Jon Corzine decide to run for Governor in 2005 after Governor McGreevey resigned, I looked for ways to become part of his “team”. First I showed up at an economic summit he held and offered one comment (long forgotten) which he used in his press briefing (long remembered). At that meeting I met his key campaign staff and started an ongoing discussion on health care policy. Soon after I was asked if they could film a health care related campaign ad at our new hospital on a Sunday afternoon. Coincidentally I happened to be there “making rounds” when Senator Corzine arrived for the shoot.

When Corzine ran into some bad news stories about his personal life, I was one of six people asked to participate in a Trenton press conference on his six position papers. One newspaper article called us “surrogates” for Corzine, another said “Attacks Dogs” for Corzine. After the polls closed I waited for Corzine’s last campaign event at the Elks Club in Hoboken for 4 hours to be there when Corzine arrived.

Sticking my neck out led to my appointment as one of four co-chairmen of Governor-elect Corzine’s health care transition team. I was often asked if I was close to Governor Corzine, since he lived in Hoboken where I live. I always said “Yup, see him all the time in Starbucks.” Rumors started that I was on the short list to be Commissioner of Health. The sitting Commissioner who wanted to stay on called me to ask about it.

On March 19th, 2004 the Newark Star Ledger had an article “Now in aisle 6: the governor, living city life -Corzine strolls streets of Hoboken.” “At Starbucks, Jonathan Metsch, wearing a baseball cap and a Hoboken sweatshirt, struck up a conversation about the Nets game the night before. Then he segued into state funding for hospitals; in addition to being Corzine’s neighbor, Metsch is CEO of LibertyHealth, which operates Jersey City Medical Center. Shamelessly lobbying, like everybody else,” Corzine joked.”

When Jon Corzine became Governor he instructed all NJ legislators on various hospital boards across the State to resign. They did.

While serving as President and CEO of LibertyHealth/ Jersey City Medical Center from 1989-2006, Jersey City Medical Center: was State designated as a Regional Perinatal Center, Level II Trauma Center, Teaching Hospital Cancer Program, a Children’s Hospital, and a Medical Coordination Center (for statewide disaster preparedness); started cardiac surgery/ interventional cardiology; and became a major teaching affiliate of Mount Sinai School of Medicine. Many tables involved!

When I left Jersey City Medical Center all my chairs immediately disappeared.

“Don’t just get involved.  Fight for your seat at the table.  Better yet, fight for a seat at the head of the table.”  President Obama, 2012, Barnard College

Revised: December 24, 2018 000000

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PUBLIC HEALTH administrators can transform monumental unique challenges to “rapid response” opportunities. Think: Hurricanes Florence and Michael, the California wildfires, the mysterious polio-like illness, the opioid epidemic, mass shootings, and immigrant family separation.


You are the head of the Department of Public Health Sciences, The University of Texas at El Paso and have been “volunteered” to develop a Rapid Response “shadow” licensing program for the Tornillo, Texas detention camp housing 2300 teens.

INTRODUCTION
Statement from the American Public Health Association and Trust for America’s Health
“As public health professionals we know that children living without their parents face immediate and long-term health consequences. Risks include the acute mental trauma of separation, the loss of critical health information that only parents would know about their children’s health status, and in the case of breastfeeding children, the significant loss of maternal child bonding essential for normal development. Parents’ health would also be affected by this unjust separation.
“More alarming is the interruption of these children’s chance at achieving a stable childhood. Decades of public health research have shown that family structure, stability and environment are key social determinants of a child’s and a community’s health.
“Furthermore, this practice places children at heightened risk of experiencing adverse childhood events and trauma, which research has definitively linked to poorer long-term health. Negative outcomes associated with adverse childhood events include some of society’s most intractable health issues: alcoholism, substance misuse, depression, suicide, poor physical health and obesity.” (A)

“Our field recognizes the importance of avoiding Adverse Childhood Experiences for the healthy growth and development of children. Trauma early in life contributes to a broad range of serious health outcomes, including social impairment, disease and disability, and early death. The harsh treatment of children at the border will affect their health and their lives for many years to come. The trauma to their parents is also devastating, and the lasting consequences to thousands of families will be profound.” (B)

“We also know that as each hour of separation goes by, children’s bodies continue to be flooded with stress hormones, thus creating long-term, disastrous injury and trauma for both the children and families who are separated.
Decades of research tells us that traumatic and forced parent-child separation immediately and permanently affects children’s brain development, educational attainment, mental health functioning, and long-term health outcomes – detailed in this Washington Post story. We also know that families seeking asylum are already traumatized from the circumstances that led to the migration and are exhausted by the journey to reach our borders…” (C)

“There is a significant body of evidence-based research detailing the vast public health implications of adverse childhood experiences. According to the Centers for Disease Control and Prevention, children exposed to adverse childhood experiences suffer from disrupted neurodevelopment; social, emotional, and cognitive impairment; are more likely to adopt health-risk behaviors; are at greater risk of developing chronic diseases, disabilities and social problems; and are susceptible to early death. Family stability is a key social determinant of health, and it’s imperative that we not disrupt these children’s chance at a healthy life.” (D)

“After the United States Department of Justice announced the “Zero Tolerance Policy for Criminal Illegal Entry,” Immigration and Custom Enforcement (ICE — an arm of the Department of Homeland Security) separated approximately 2,000 children from their parents in April and May 2018 as they approached the U.S. border. Children and parents were placed in separate facilities as they were being processed and were not told when or how they would be reunited. This policy and its consequences have raised significant concerns among researchers, child welfare advocates, policy makers, and the public, given the overwhelming scientific evidence that separation between children and parents, except in cases where there is evidence of maltreatment, is harmful to the development of children, families, and communities. Family separations occurring in the presence of other stressors, such as detention or natural disaster, only adds to their negative effects.” (E)

“The policy may have changed, but there’s still a concern over detention. Under the most recent policy change, the administration can still hold children in a confined space with their parents, and there’s a sense that they’re planning large-scale detention. We’ve ended for the moment, family separation, but now we have large-scale detention” (F)

“Reports from the National Academies of Sciences, Engineering, and Medicine contain an extensive body of evidence on the factors that affect the welfare of children – evidence that points to the danger of current immigration enforcement actions that separate children from their parents. Research indicates that these family separations jeopardize the short- and long-term health and well-being of the children involved.” (G)

“Detention, for even brief periods, has short- and long-term negative effects on the health of parents and children. Studies show high levels of psychiatric distress, including depression and post-traumatic stress, among detained asylum seekers, even after short detention periods, and that symptoms worsen over time. Global studies also show significant effects for children held in detention, including depression, post-traumatic stress, suicidal thoughts and behaviors, developmental delays, and behavioral issues. In a policy statement, the AAP notes that research documents negative physical and emotional symptoms among detained children and adults and also shows negative impacts on the parent-child relationship.
In the short term, toxic stress can increase the risk and frequency of infections in children as high levels of stress hormones suppress the body’s immune system. It can also result in developmental issues due to reduced neural connections to important areas of the brain. Toxic stress is associated with damage to areas of the brain responsible for learning and memory.
Over the long term, toxic stress may manifest as poor coping skills and stress management, unhealthy lifestyles, adoption of risky health behaviors, and mental health issues, such as depression. Toxic stress is also associated with increased rates of physical conditions into adulthood, including chronic obstructive pulmonary disease, obesity, ischemic heart disease, diabetes, asthma, cancer, and post-traumatic stress disorder.” (H)

BACKGROUND
“A top Health and Human Services official told Congress on Tuesday that he and others repeatedly warned the Trump administration that its policy of separating immigrant families apprehended at the U.S.-Mexico border would not be in “the best interest of the child.”
“During the deliberative process over the previous year, we raised a number of concerns in the (Office of Refugee Resettlement) program about any policy which would result in family separation due to concerns we had about the best interest of the child as well as about whether that would be operationally supportable with the bed capacity that we have,” Jonathan White, with the Public Health Service Commissioned Corps, told lawmakers at a Senate Judiciary Committee hearing”.… (I)

“The Department of Homeland Security was not ready to carry out the Trump administration’s family separation policy, and some of the government’s practices made the problem worse, according to a report issued Tuesday by the department’s inspector general…
“DHS was not fully prepared to implement the administration’s zero-tolerance policy or to deal with some of its after-effects,” said John Kelly, the acting inspector general.
Tuesday’s report said Customs and Border Protection held children for long periods in facilities intended to be used for only short terms, lacked the ability to reliably track children separated from their parents, and in some cases failed to adequately inform parents about the separation policy…
Computer systems used by CBP and Immigration and Customs Enforcement lacked the ability to share data about parents whose children were separated from them. And those systems were not integrated with the resettlement agency…
In a separate DHS inspector general report dated September 27, the Adelanto ICE Processing Center, a detention center housing up to 1,940 ICE detainees in California, was cited for serious violations including nooses found hanging in detainee cells, “improper and overly restrictive segregation,” and “untimely and inadequate medical care.” “ (J)

DISCUSSION
“In shelters from Kansas to New York, hundreds of migrant children have been roused in the middle of the night in recent weeks and loaded onto buses with backpacks and snacks for a cross-country journey to their new home: a barren tent city on a sprawling patch of desert in West Texas.
Until now, most undocumented children being held by federal immigration authorities had been housed in private foster homes or shelters, sleeping two or three to a room. They received formal schooling and regular visits with legal representatives assigned to their immigration cases…
But in the rows of sand-colored tents in Tornillo, Tex., children in groups of 20, separated by gender, sleep lined up in bunks. There is no school: The children are given workbooks that they have no obligation to complete. Access to legal services is limited…
The camp in Tornillo operates like a small, pop-up city, about 35 miles southeast of El Paso on the Mexico border, complete with portable toilets. Air-conditioned tents that vary in size are used for housing, recreation and medical care. Originally opened in June for 30 days with a capacity of 400, it expanded in September to be able to house 3,800, and is now expected to remain open at least through the end of the year.” …
The roughly 100 shelters that have, until now, been the main location for housing detained migrant children are licensed and monitored by state child welfare authorities, who impose requirements on safety and education as well as staff hiring and training.
The tent city in Tornillo, on the other hand, is unregulated, except for guidelines created by the Department of Health and Human Services. For example, schooling is not required there, as it is in regular migrant children shelters…” (K)

“Thousands of foster children may be getting powerful psychiatric drugs prescribed to them without basic safeguards, says a federal watchdog agency that found a failure to care for youngsters whose lives have already been disrupted.
A report released Monday by the Health and Human Services inspector general’s office found that about 1 in 3 foster kids from a sample of states were prescribed psychiatric drugs without treatment plans or follow-up, standard steps in sound medical care.
Kids getting mood-altering drugs they don’t need is only part of the problem. Investigators also said children who need medication to help them function at school or get along in social settings may be going untreated.
The drugs include medications for attention deficit disorder, anxiety, PTSD, depression, bipolar disorder and schizophrenia. Foster kids are much more likely to get psychiatric drugs than children overall.
“We are worried about the gap in compliance because it has an immediate, real-world impact on children’s lives,” said Ann Maxwell, an assistant inspector general.” (L)

“Traditionally, most sponsors have been undocumented themselves, and therefore are wary of risking deportation by stepping forward to claim sponsorship of a child. Even those who are willing to become sponsors have had to wait months to be fingerprinted and otherwise reviewed.
Federal officials say their vetting procedures are designed to safeguard the children in their care.
“Children who enter the country illegally are at high risk for exploitation by traffickers and smugglers,” Ms. Stauffer said in her statement.
But the longer children are detained, the more anxious and depressed they are likely to become, according to Mr. Greenberg, who oversaw the program under Mr. Obama. When that happens, children may try to harm themselves or escape, and can become violent with the staff and with one another, he said.
Stories of such behavior have emerged through reporting in recent months as the shelter system has faced intense criticism by members of Congress and the public…
The separated children injected a new degree of chaos into the facilities, according to several shelter operators, who spoke anonymously because they are barred by the government from speaking to the news media. The children were younger and more traumatized than those the shelters were used to dealing with, and they arrived without a plan for when they could be released or to whom.” (M)

“Deep within the fine print of a newly proposed federal rule change is an admission of its disastrous health consequences. The Department of Homeland Security’s plan would deny legal immigrants permanent residency status if they accept government assistance to which they are entitled, allegedly an effort to “promote immigrant self-sufficiency” and ensure “they are not likely to become burdens on American taxpayers” or “public charges.”
But the certain collateral damage of this misguided policy, which greatly expands an existing principle to make its application downright punitive, reveals it’s not about promoting self-sufficiency at all.
In describing the impact of this effort, the Department of Homeland Security states, “Disenrollment or foregoing enrollment…by aliens otherwise eligible for these programs could lead to:
“Worse health outcomes, including prevalence of obesity and malnutrition, especially for pregnant or breastfeeding women, infants or children…
“Increased use of emergency rooms and emergency care as a method of primary health care due to delayed treatment
“Increased prevalence of communicable diseases, including among members of the U.S. citizen population who are not vaccinated.”..
The rule change, if implemented, will cause legal immigrants, their spouses and children, including U.S. citizens, to withdraw from government assistance programs out of fear that it would endanger the chances for a family member to obtain a green card and become a legal permanent resident. Washington will, in effect, force individuals to choose between their welfare and a family member’s legal residency status…
Some children will not receive necessary vaccines, making them susceptible to preventable diseases, such as measles, mumps, Hepatitis A and B, and polio. Illnesses will not be addressed when they are easily treatable. Without proper prenatal and perinatal care, there will be an increase in birth complications.” (N)

“Complicating matters, the administration has decreed that reunifications must take place in the family’s country of origin. Which means that, once contacted, parents face an excruciating choice: give up their children’s asylum claims and have them returned home, or leave the children in the United States to try to navigate the asylum process on their own.” (O)

“The Trump administration wants to change how the government defines who is or is likely to become a “public charge.” The Department of Homeland Security released a draft regulation on Sept. 22, in which it proposed that any immigrant who is likely to use or who has already used Medicaid, public housing or a rent voucher, cash assistance or food stamps could be barred from the country or kept from getting permanent resident status.
“….The administration would remake the idea of self-sufficiency, admitting only those who never need to turn to the public safety net, but instead rely solely on “their own capabilities” or the resources of their families and private charity. It even asserts that people who use public programs “in a relatively small amount or for a relatively short duration” are still considered dependent on the welfare state.
This redefinition of self-sufficiency ignores the way that most people use these programs. Even people with jobs often cycle on and off assistance as work comes and goes, or to plug the gaps when it just doesn’t pay enough. These programs allow people to remain healthy and solvent — supporting their independence. This rule therefore hurts everyone, not just immigrants, by stigmatizing the safety net funded by all of us to help people survive when they fall on hard times.” (P)

The Trump administration has put the safety of thousands of teens at a migrant detention camp at risk by waiving FBI fingerprint checks for their caregivers and short-staffing mental health workers, according to an Associated Press investigation and a new federal watchdog report.
None of the 2,100 staffers at a tent city holding more than 2,300 teens in the remote Texas desert are going through rigorous FBI fingerprint background checks, according to a Health and Human Services inspector general memo published Tuesday.
“Instead, Tornillo is using checks conducted by a private contractor that has access to less comprehensive data, thereby heightening the risk that an individual with a criminal history could have direct access to children,” the memo says.
In addition, the federal government is allowing the nonprofit running the facility — BCFS Health and Human Services — to sidestep mental health care requirements. Under federal policy, migrant youth shelters generally must have one mental health clinician for every 12 kids, but the federal agency’s contract with BCFS allows it to staff Tornillo with just one clinician for every 100 children. That’s not enough to provide adequate mental health care, the inspector general office said in the memo…
Because the detention camp is on federal property — part of a large U.S. Customs and Border facility — it is not subject to state licensing requirements…
Federal officials have said repeatedly that only children without special needs were being sent to Tornillo. But facility administrators recently acknowledged that the Tornillo detainees included children with serious mental health issues who needed to be transferred out to facilities in El Paso, according to a person with knowledge of the discussion…(Q)

“The deportation and forced separation of immigrants has negative effects that extend beyond individuals and families to entire communities in the United States, according to a division of the American Psychological Association, which has issued a policy statement calling for changes to U.S. policy.
Based on a review of the effects of three decades of U.S. immigration policy, the policy statement details the psychosocial and economic impacts of deportation on children and families, as well as broader community consequences that unfold as immigrants fearful of being targeted withdraw from civic engagement…
Studies reveal that children who lose a parent to sudden, forced deportation experience anxiety, anger, aggression, withdrawal, a heightened sense of fear, eating and sleeping disturbances, isolation, trauma, and depression.
Children also experience housing instability, academic withdrawal, and family dissolution; older children often need to take on jobs to help support the family.
Ten percent of U.S. families with children have at least one family member who lacks citizenship.
5.9 million children have at least one caregiver who lacks authorization to live in the country.” (R)

“Children tend to respond to separation from their caregiver in three fluid phases. First, children enter an acute phase of protest characterized by fear, distress, crying and urgent seeking of their caregiver that may last from a few hours to days. As the length of separation continues, children enter a phase of despair during which crying weakens, movement lessens and children reject the approach of alternative adults. With prolonged parental absence, children may become passively compliant with care staff, giving the appearance of having ‘settled in’ to their new environment. Disturbingly, this can signify that the child has detached from the parents and is now living in a perceived state of ‘fear without resolution’. Children reunited while they are in the early separation protest phase usually fare well. Children in despair may respond to the reappearance of their parent with hostility or ambivalence, taking many weeks to rebuild their bond. Children who have detached from their parents may reject their approaches or treat them as strangers. Additionally, when children interpret themselves as ‘abandoned’ by parents, they may develop a profound sense that they have done something wrong to cause their caregiver to leave, igniting shame and complex emotions that can damage the lifelong relationships with themselves and others.”(S)

“When children are reunited with parents, the reintegration process is sometimes difficult. Widespread videos of families being reunified have shown emotionless children, some even avoiding their parent’s embrace. A number of children do not even recognize their parents upon return, which speaks to the intense trauma that these children have experienced. “We think that we’ve made the family whole again by simply bringing them back together and letting them go on with their lives, when the reality is that there’s a lot of work that still needs to be done,” said Vivek Sankaran, a clinical professor of law at the University of Michigan Law School. After becoming reunited, the families affected by separation need continuing support in order to reestablish their relationships and routines.” (T)

“It is clear, then, that the families affected by the current administration’s separation policy need services to help them cope with the trauma that has occurred. It is possible for the individuals and the family units to find some healing, given the opportunity, resources, and tools to do so.
Griffith says that a key to working through such a trauma is bringing the families back together as quickly as possible. “If the core family unit can stay intact, that accomplishes a lot. [There’s a feeling of] ‘As long as we’re together, we can be okay, regardless of how harsh the circumstances,'” he says. However, the reunification process thus far has been plodding and uncoordinated. It appears that far too many families will remain separated long term.
In addition to reunification and in the face of indefinite separation, family members should have access to psychosocial services to help them cope. Unfortunately, it is unclear what services are currently available to the children still separated from their parents. “We don’t have access to those facilities,” Lusk says.” (U)

“The Trump administration did not tell key government agencies about its “zero tolerance” immigration policy before publicly announcing it in April, leaving the officials responsible for carrying it out unprepared to handle the resulting separations of thousands of children from their families, according to a government report released on Wednesday.
The Department of Homeland Security, which apprehends border crossers, and the Department of Health and Human Services, which cares for separated migrant children, were both caught off guard when Attorney General Jeff Sessions announced plans to criminally prosecute anyone who crossed the border illegally, the report said…
Because they did not know about the “zero tolerance” policy in advance, officials at the Department of Homeland Security said, they did not take steps to prepare for the resulting family separations. Staff members at the Department of Health and Human Services said their leaders told them not to prepare for an increase in children separated from their families because homeland security officials claimed that they did not have an official policy of separating parents and children, according to the report, which was prepared by the Government Accountability Office, Congress’s nonpartisan investigative arm.” (V)

In just six months, the Trump administration has built a detention camp for migrant kids in the Texas desert that is larger than 203 of the 204 U.S. federal prisons.
Driving the news: The Tornillo camp now holds 2,324 boys and girls, most from Central America, between the ages of 13-17, the AP reports.
Why it matters: “Confining and caring for so many children is a challenge. By day, minders walk the teen detainees to their meals, showers and recreation on the arid plot of land guarded by multiple levels of security. At night the area around the camp, that’s grown from a few dozen to more than 150 tents, is secured and lit up by flood lights.”
Between the lines: Among the list of issues at Tornillo discovered by an AP investigation:
1. Security: The 2,100 staffers haven’t done FBI fingerprint background checks.
2. Costs: “What began as an emergency, 30-day shelter has transformed into a vast tent city that could cost taxpayers more than $430 million.”
3. Rules: “Under federal policy, migrant youth shelters generally must have one mental health clinician for every 12 kids, but shelter officials have indicated that Tornillo can staff just one clinician for every 100 children…”..
The bottom line: There are more than 14,000 migrant children in U.S. detention, most from central America. Figuring out what to do with these kids is a challenge that doesn’t seem to be going away.” (W)

“”Aid workers and humanitarian organizations [are sounding the alarm on] unsanitary conditions at the sports complex in Tijuana where more than 6,000 Central American migrants are packed into a space adequate for half that many people,” AP reports.
Lice infestations and respiratory infections are rampant, and Mexico’s National Human Rights Commission reports four cases of chicken pox.” (X)

“The founder of Southwest Key made millions from housing migrant children..
Southwest Key has collected $1.7 billion in federal grants in the past decade, including $626 million in the past year alone. But as it has grown, tripling its revenue in three years, the organization has left a record of sloppy management and possible financial improprieties, according to dozens of interviews and an examination of documents. It has stockpiled tens of millions of taxpayer dollars with little government oversight and possibly engaged in self-dealing with top executives…
Shortly after, the federal government temporarily shuttered a third Arizona shelter, in Youngtown, after Southwest Key staff members were accused of physically abusing three children. In a recent agreement with Arizona officials, Southwest Key was fined $73,000 and agreed to close that facility and another troubled shelter in Phoenix. Mr. Weber, the government spokesman, said there were “numerous red flags and licensure problems” with the two shelters.” (Y)

(A) BUSSW Dean Statement on Migrant Family Separation Crisis, , Jorge Delva, https://www.bu.edu/ssw/bussw-dean-statement-on-migrant-family-separation-crisis/
(B) Sign-on letter: Public health implications of family separation at the border, http://www.phi.org/news-events/1452/sign-on-letter-public-health-implications-of-family-separation-at-the-border
(C) The Science is Clear: Separating Families has Long-term Damaging Psychological and Health Consequences for Children, Families, and Communities, https://www.srcd.org/policy-media/statements-evidence/separating-families
(D) Jacqueline Bhabha speaks to the human rights of children detained at the U.S.-Mexico border., Professor of the Practice of Health and Human Rights at the Harvard T.H. Chan School of Public Health https://www.hks.harvard.edu/research-insights/policy-topics/human-rights-justice/human-rights-impact-family-separation
(E) Statement on Harmful Consequences of Separating Families at the U.S. Border, http://www.publicnow.com/view/01C73956A92A17674EA5913A13F14F325310FFE6
(F) Separating parents and children at US border is inhumane and sets the stage for a public health crisis, https://www.apha.org/news-and-media/news-releases/apha-news-releases/2018/parent-child-separation
(G) Key Health Implications of Separation of Families at the Border (as of June 27, 2018), https://www.kff.org/disparities-policy/fact-sheet/key-health-implications-of-separation-of-families-at-the-border/
(H) Top HHS official warned Trump administration against separating immigrant families, by Eliza Collins, Alan Gomez, https://www.usatoday.com/story/news/politics/2018/07/31/trump-administration-official-warned-family-separations/874963002/
(I) DHS not prepared for family separations under Trump zero tolerance policy, watchdog finds, by Pete Williams and Jacob Soboroff, https://www.nbcnews.com/politics/politics-news/dhs-not-prepared-family-separations-under-trump-zero-tolerance-policy-n915916(
(J) Migrant Children Moved Under Cover of Darkness to a Texas Tent City, by Caitlin Dickerson, https://www.nytimes.com/2018/09/30/us/migrant-children-tent-city-texas.html
(K) Thousands of foster children may be getting psychiatric drugs without safeguards, watchdog agency says, by Ricardo Alonso-Zaldivar, https://www.statnews.com/2018/09/17/thousands-of-foster-children-may-be-getting-psychiatric-drugs-without-safeguards-watchdog-agency-says/?utm_source=STAT+Newsletters&utm_campaign=fab0f6340f-MR_COPY_12&utm_medium=email&utm_term=0_8cab1d7961-fab0f6340f-149527969
(L) Detention of Migrant Children Has Skyrocketed to Highest Levels Ever, by Mike Blake, https://www.nytimes.com/2018/09/12/us/migrant-children-detention.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosam&stream=top
(M) One sick immigration rule: The ‘public charge’ regulation will make America less healthy, by KENNETH L. DAVIS, http://www.nydailynews.com/opinion/ny-oped-one-sick-immigration-rule-20181009-story.html
(N) The Continuing Tragedy of the Separated Children, https://www.nytimes.com/2018/08/30/opinion/family-separation-trump-zero-tolerance.html
(O) Trump Wants to Turn the Safety Net Into a Trap, by By Bryce Covert, https://www.nytimes.com/2018/10/01/opinion/trump-wants-to-turn-the-safety-net-into-a-trap.html
(P) Separating Families at U.S. Borders is a Public Health Issue, Ellen J. MacKenzie, https://www.jhsph.edu/about/dean-mackenzie/news/separating-families-at-us-borders-is-a-public-health-issue.html
(Q) US waived FBI checks on staff at growing teen migrant camp, by GARANCE BURKE AND MARTHA MENDOZA, https://www.apnews.com/0c62b088c27147b0a6055d1e8394a3af?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiospm&stream=top
(R) Deportation and family separation impact entire communities, researchers say, by Jennifer McNulty, https://www.sciencedaily.com/releases/2018/08/180801131554.htm
(S) Impact of punitive immigration policies, parent-child separation and child detention on the mental health and development of children, by Laura C N Wood, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6173255/
(T) The Impact of Parent-Child Separation at the Border, by Hurley Riley, https://sph.umich.edu/pursuit/2018posts/family-separation-US-border.html
(U) Children and Families Forum: The Impact of Immigrant Family Separation, by Sue Coyle, https://www.socialworktoday.com/archive/SO18p8.shtml
(V) ‘Zero Tolerance’ Immigration Policy Surprised Agencies, Report Finds, by Ron Nixon, https://www.nytimes.com/2018/10/24/us/politics/immigration-family-separation-zero-tolerance.html
(W) Axios PM: Trump’s detention camp for migrant teens; November 27, 2018
(X) Axios AM, November 30, 2018
(Y) He’s Built an Empire, With Detained Migrant Children as the Bricks, Tamir Kalifa for The New York Times, by Kim Barker, Nicholas Kulish and Rebecca R. Ruiz, https://www.nytimes.com/2018/12/02/us/southwest-key-migrant-children.html
(Z)

Prequels
..The HHS needs to review thousands of case files by hand for clues to which children were taken from their parents…

“Most immigrants facing deportation wouldn’t climb onto a table during their court hearings. But then again, most 3-year-olds don’t go to court without parents or lawyers.

“President Trump has moved on from caring about the migrant children in cages

“Only a dead heart is unstirred by the intentional infliction of suffering on children and babies as a weapon of deterrence.”

“In 6 Days, Trump Admin Reunited Only 6 Immigrant Children With Their Families”, http://doctordidyouwashyourhands.com/2018/06/in-6-days-trump-admin-reunited-only-6-immigrant-children-with-their-families/

“…the only way parents can quickly be reunited with their children is to drop their claims for asylum… and agree to be deported.”

White House Press Secretary Sarah Huckabee Sanders said the government was starting to
“run out of space” to house people apprehended crossing the border

Trump’s policy “could be creating thousands of immigrant orphans in the U.S.”, http://doctordidyouwashyourhands.com/2018/06/trumps-policy-could-be-creating-thousands-of-immigrant-orphans-in-the-u-s/

Tender-Age Immigrant Children. “They need bilingual workers. Some kids speak indigenous languages, so that’s an issue as well. http://doctordidyouwashyourhands.com/2018/06/tender-age-immigrant-children-they-need-bilingual-workers-some-kids-speak-indigenous-languages-so-thats-an-issue-as-well/

“The idea of pulling a child out of a parent’s arms, or identifying a parent but still keeping them separate—it isn’t right.”

“The business of housing, transporting and watching over migrant children detained along the southwest border is not a multimillion-dollar business. It’s a billion-dollar one…

“If it could happen to them…why can’t it happen to us?”…separating children from their parents,

“…Trump’s (family separation) policy amounts to “government-sanctioned child abuse.””,

“The Trump administration’s policy of separating parents and children at the U.S.-Mexico border will have a dire impact on their health, both now and into the future.” (C)

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“…really targeting the depth of the opioid epidemic would require an infusion of federal dollars on par with the more than $20 billion a year spent on HIV/AIDs.”


“Subdued and on-script, President Donald Trump struck a bipartisan tone as he signed sweeping legislation Wednesday to combat the opioid epidemic, an issue that has animated his effort to support Republican midterm candidates.
Discussing a crisis affecting urban centers as well as rural communities that supported his election, Trump touted the measure as a bipartisan response to a problem rarely cited as a top issue for voters that nevertheless touches millions of them personally.
“We are going to end it or we are going to at least make an extremely big dent in this terrible, terrible problem.” Trump said during an East Room event that drew members of both parties. “We have mobilized the entire federal government to address this crisis.”..
Speaking at a rally in Nevada this past weekend, Trump touted the “bold action” and “historic effort” he said his administration embarked on to address the problem. His administration’s response has fallen into two categories, he has said: Stepped up enforcement and more funding for states to expand treatment.
“We obtained $6 billion to fight the opioid epidemic,” Trump said during his most recent stop in Houston this week, referencing a funding bill approved by Congress in March.
The new legislation that Congress approved Oct. 3, makes it easier to intercept drugs being shipped into the country, authorizes new funding for more comprehensive treatment, speeds up research on non-addictive painkillers and clears Medicare and Medicaid regulations that advocates have said can stand in the way of treatment. “ (A)

“Addiction treatment advocates say two provisions — one that would allow Medicaid, the federal-state health insurance plan for the poor, to pay for residential treatment in large facilities and another that would allow Medicare, the federal health plan for people 65 and older, to pay for methadone treatment — will substantially improve access to treatment.
The legislation, approved last month by the House and Wednesday by the Senate, also would pay for research into opioid alternatives, support greater use of non-opioid pain management and invest in new law enforcement efforts to curb illicit drugs.
Some critics say the legislation, which calls for roughly $8 billion in federal investment over five years, doesn’t go far enough given the magnitude of the drug overdose crisis.
In an epidemic that killed more than 72,000 people in 2017, the federal government should commit to spending far more money on treatment, prevention and access to the life-saving drug naloxone, advocacy groups have argued. The groups, including the Harm Reduction Coalition, recommended $100 billion more in federal spending, similar to the Ryan White HIV/AIDS Program.
Still, treatment advocates say that Medicaid coverage of residential treatment and Medicare coverage of methadone would go a long way to boosting treatment quality and capacity, as well as people’s ability to pay.
The residential treatment provision would lift a 53-year-old ban in the federal Medicaid statute that prohibits coverage of mental health and addiction treatment services in facilities with more than 16 beds. Called the “institutions for mental disease” or IMD exclusion, the rule was intended to prevent states from using federal dollars to warehouse people with addiction and mental disorders.” (B)

“While very broad in scope, the final legislation contains a number of provisions related to Medicaid’s role in helping states provide coverage and services to people who need substance use disorder (SUD) treatment, particularly those needing opioid use disorder (OUD) treatment.
Services. The most controversial measure in the bill amends the long-standing prohibition against the use of federal Medicaid funds for services in “institutions for mental disease” (IMDs) for nonelderly adults by creating a state option from 10/1/19 to 9/30/23 to cover those services up to 30 days in a year for individuals with a substance use disorder. To be eligible to receive federal matching funds, states must meet maintenance of effort and other requirements..
The SUPPORT Act also requires state Medicaid programs to cover medication-assisted treatment (MAT), including all FDA-approved drugs, counseling services, and behavioral therapy, from October 2020 through September 2025, unless a state certifies to the Secretary’s satisfaction that statewide implementation is infeasible due to provider shortages…
Demonstrations. Prescription Drug Oversight. The SUPPORT Act requires states to have drug utilization review safety edits in place for opioid refills, monitor concurrent prescribing of opioids and other drugs, and monitor antipsychotic prescribing for children” (C)

“Together,” the president told grieving mothers and fathers, cabinet members, lawmakers, and representatives of local law enforcement, “we will end the scourge of drug addiction in America. We’re going to end it or at least make an extremely big dent in this terrible, terrible problem.”
Almost no one who’s studied the legislation and understands the magnitude of an epidemic in which an estimated 72,000 people died from drug overdoses in 2017 thinks it will do any such thing. The bill’s provisions to expand addiction treatment, speed up research on alternative drugs, and provide Medicaid funding to treatment centers with more than 16 inpatient beds will certainly help, as will $6 billion in funding to fight opioids, “the most money ever received in history,” Trump said. But many public-health experts, and some of Trump’s Democratic opponents in Congress, say something closer to $100 billion is needed over 10 years to end or “make an extremely big dent” in opioid addiction. Senator Elizabeth Warren cites “broken promises” by an administration that still does not have a confirmed director of its Office of National Drug Control Policy (ONDCP) after nearly two years in office.
Formed in 1988 through the Anti-Drug Abuse Act, the ONDCP is supposed to coordinate drug-control policy and funding between 16 federal departments and agencies. The director of the office is intended to be the U.S. president’s “principal advisor” on drug-control issues. The Senate has to confirm whomever the president appoints…
The office has yet to release the annual National Drug Control Strategy, which spells out how the administration will tackle drugs and how it will develop a drug-control budget. Three months after taking office, Trump chose an unorthodox approach to drug policy, establishing the President’s Commission on Combating Drug Addiction and the Opioid Crisis, appointing Governor Chris Christie, a Trump political ally, as chair. The commission, staffed and funded by ONDCP, released a report that recommended nearly 60 ways to address the crisis. The recommendations cover prevention, treatment, recovery, and more. “ (D)

“The legislation takes wide aim at the problem, including increasing scrutiny of arriving international mail that may include illegal drugs. It makes it easier for the National Institutes of Health to approve research on non-addictive painkillers and for pharmaceutical companies to conduct that research.
The Food and Drug Administration would be allowed to require drugmakers to package smaller quantities of drugs such as opioids. And there would be new federal grants for treatment centers, training emergency workers and research on prevention methods.
Karen Yost, CEO of Prestera Center, said in a statement the 70 pieces of this bill is a good start, though there is no “magic bullet” to solving the opioid crisis.
“How this legislation is implemented will be key as even good legislation implemented poorly will not be helpful,” Yost said.
“This bill is a start in the right direction, even though it does not address significant underlying issues in this epidemic, including adverse childhood experiences, extreme poverty, gainful employment, safe affordable housing, related chronic health problems and co-occurring mental health problems.”
That’s a long list, and it helps explain how this problem became so big and is so difficult to overcome.” (E)

“Yet many public health advocates and experts say it doesn’t offer the one thing truly needed: The massive amount of funding needed to fully combat a crisis that deeply affects rural and urban communities across America.
Sarah Wakeman,the medical director for Mass General Hospital’s Substance Use Disorders Initiative, said really targeting the depth of the opioid epidemic would require an infusion of federal dollars on par with the more than $20 billion a year spent on HIV/AIDs.
“We have historically not thought of addiction as a medical issue and so our health care and public health system are woefully unprepared to respond in a robust way,” she said.”..
“I hope Congress doesn’t think they can put this behind them because they passed these bills,” said Patrick Kennedy, a former Democratic congressman of Rhode Island and a mental health advocate . “It takes an urgency like we had during HIV-AIDS. That will call to mind what it takes to address a crisis, it takes political will.” (F)

“”Without real money, it’s just lip service,” said John Rosenthal, co-founder and chairman of the Police Assisted Addiction and Recovery Initiative, to CNHI’s Christian M. Wade. “This disease has been raging for more than a decade without any serious federal response. Now they’re playing catch-up.”
Sarah Wakeman, the medical director for Mass General Hospital’s Substance Use Disorders Initiative, told the Washington Post that really targeting the depth of the opioid epidemic would require an infusion of federal dollars on par with the more than $20 billion a year spent on HIV/AIDs.
Rosenthal agreed and said there are “good things” in the bill, but it needs “billions” of dollars in money — similar to the federal response to cancer and HIV/AIDS prevention and treatment.” (G)

“Governments around the globe and their citizens routinely respond to ecological disasters. Think Exxon Valdez or Love Canal in the U.S.; Chernobyl in the Soviet Union; Bhopal in India; and far too many others. The responses, though not always immediate or thorough, at least tend to be multifaceted. We are currently in the midst of a human-made ecological disaster, the opioid crisis, that isn’t recognized as such, but that can benefit from the same sorts of responses made to ecological disasters…
Treating the opioid epidemic as an ecological disaster could set important precedents for cleanup and prevention that can be particularly useful in areas where effective responses have been lagging. Such efforts are relatively easy to visualize when the disaster is a pollutant like mercury. But what does a cleanup look like when the offending substance is, for some people, a medically essential resource?..
The opioid disaster is occurring simultaneously on so many levels and affecting so many lives in ways that other disasters may not. It can be viewed through many different lenses. I see the opioid disaster as an individual living with chronic pain who depends on opioid medications to manage each day. But I also acknowledge and suffer with members of my community who are experiencing substance abuse themselves, or are in recovery from it, or who have lost family members or friends to opioid overdoses.
Even now, nearly 30 years after the Exxon Valdez struck a reef and spilled nearly 11 million gallons of crude oil into Prince William Sound, some of that oil persists in Alaskan soil and water, breaking down minutely year by year. The opioid disaster will continue to saturate our environment for the near future, but it should not need to take three decades for us to break it down.” (H)

(A) President Trump tries to project image of bipartisan action with opioid bill signing, by David Jackson and John Fritze, https://www.usatoday.com/story/news/politics/2018/10/24/donald-trump-opioids-bill-signed-into-law-weeks-midterm-election/1750400002/
(B) Opioid Bill Expands Treatment Options, by Christine Vestal, https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2018/10/04/opioid-bill-expands-treatment-options
(C) Federal Legislation to Address the Opioid Crisis: Medicaid Provisions in the SUPPORT Act, by MaryBeth Musumeci, https://www.kff.org/medicaid/issue-brief/federal-legislation-to-address-the-opioid-crisis-medicaid-provisions-in-the-support-act/
(D) Trump’s ‘Big Dent’ in the Opioid Crisis, by Lola Fadulu, https://www.theatlantic.com/politics/archive/2018/10/trumps-signs-landmark-law-fight-opioid-addiction/573850/
(E) Federal opioid law moves in right direction, http://www.reflector.com/Editorials/2018/10/02/Federal-opioid-law-moves-in-right-direction.html
(F) Senate easily passes sweeping opioids legislation, sending to President Trump, by Colby Itkowitz, https://www.washingtonpost.com/politics/2018/10/03/senate-is-poised-send-sweeping-opioids-legislation-president-trump/?utm_term=.25aa48506c2b
(G) Where’s the money? Federal opioid bill gets flack for lack of funds, by Jonathan Greene, https://www.richmondregister.com/news/politics/where-s-the-money-federal-opioid-bill-gets-flack-for/article_c7f460c6-8d37-5542-ab4a-a6b219e03cb4.html
(H) Viewing the opioid crisis as an ecological disaster could help with ‘cleanup’, by MAIA DOLPHIN-KRUTE, https://www.statnews.com/2018/11/15/opioid-crisis-ecological-disaster/

Prequels
“The U.S. is about 5% of the world’s population yet consumes about 80% of the world’s oxycodone supply.” http://doctordidyouwashyourhands.com/2018/08/the-u-s-is-about-5-of-the-worlds-population-yet-consumes-about-80-of-the-worlds-oxycodone-supply-i/

US health official reveals fentanyl almost killed his son, http://doctordidyouwashyourhands.com/2018/07/us-health-official-reveals-fentanyl-almost-killed-his-son/

“For at least six months, staffers in the Office of National Drug Control Policy — often political appointees in their 20s — (have) sat through weekly meetings of an “opioids cabinet” chaired by Kellyanne Conway., http://doctordidyouwashyourhands.com/2018/06/for-at-least-six-months-staffers-in-the-office-of-national-drug-control-policy-often-political-appointees-in-their-20s-have-sat-through-weekly-meetings-of-an-o/

“The House on Friday passed bipartisan legislation aimed at fighting the nationwide epidemic of opioid abuse, culminating months of work on the crisis…, http://doctordidyouwashyourhands.com/2018/06/the-house-on-friday-passed-bipartisan-legislation-aimed-at-fighting-the-nationwide-epidemic-of-opioid-abuse-culminating-months-of-work-on-the-crisis/

Why is there a nationwide hospital shortage of injectable opioids? – follow the money. , http://doctordidyouwashyourhands.com/2018/04/why-is-there-a-nationwide-hospital-shortage-of-injectable-opioids-follow-the-money-part-3-of-a-continuing-case-study-on-the-opioid-crisis/

“In 2016, more than 40 percent of opioid overdose deaths in the U.S. involved a prescription opioid.”, http://doctordidyouwashyourhands.com/2018/04/in-2016-more-than-40-percent-of-opioid-overdose-deaths-in-the-u-s-involved-a-prescription-opioid/

CASE STUDY ON THE OPIOID CRISIS. “We still have lacked the insight that this is a crisis, a cataclysmic crisis”, http://doctordidyouwashyourhands.com/2018/03/case-study-on-the-opioid-crisis-we-still-have-lacked-the-insight-that-this-is-a-crisis-a-cataclysmic-crisis/

Opioid commission member: Our work is a ‘sham’, http://doctordidyouwashyourhands.com/2018/01/opioid-commission-member-our-work-is-a-sham/

“White House counselor Kellyanne Conway will be the point person for the Trump administration’s opioid crisis efforts…, http://doctordidyouwashyourhands.com/2017/12/white-house-counselor-kellyanne-conway-will-be-the-point-person-for-the-trump-administrations-opioid-crisis-efforts/

Facebook users can easily find these drugs – Oxycodone, Hydrocodone, and Percocets, http://doctordidyouwashyourhands.com/2017/11/facebook-users-can-easily-find-these-drugs-oxycodone-hydrocodone-and-percocets/

“…the president.. reversed course to instead declare opioids a public health emergency, a move that releases no new funding to contend with a drug crisis….”, http://doctordidyouwashyourhands.com/2017/10/the-president-reversed-course-to-instead-declare-opioids-a-public-health-emergency-a-move-that-releases-no-new-funding-to-contend-with-a-drug-crisis/

“At a time when the United States is in the grip of an opioid epidemic, many insurers are limiting access to pain medications that carry a lower risk of addiction or dependence…..”, http://doctordidyouwashyourhands.com/2017/10/at-a-time-when-the-united-states-is-in-the-grip-of-an-opioid-epidemic-many-insurers-are-limiting-access-to-pain-medications-that-carry-a-lower-risk-of-addiction-or-dependence/

Congress blocked DEA action against drug companies suspected of flooding the country with prescription narcotics, http://doctordidyouwashyourhands.com/2017/10/congress-blocked-dea-action-against-drug-companies-suspected-of-flooding-the-country-with-prescription-narcotics/

The rise of ‘grandfamilies’: Opioid crisis requires more Hoosier grandparents to raise children.., http://doctordidyouwashyourhands.com/2017/09/the-rise-of-grandfamilies-opioid-crisis-requires-more-hoosier-grandparents-to-raise-children/

Opioid Crisis. ““We got here in part because there was a paper done in the 1980s by a well-meaning physician that said opioids are not addictive…., http://doctordidyouwashyourhands.com/2017/09/opioid-crisis-we-got-here-in-part-because-there-was-a-paper-done-in-the-1980s-by-a-well-meaning-physician-that-said-opioids-are-not-addictive/

“To manage and (eventually) reverse the opioid epidemic, state Medicaid programs should now take a deeper look at the role prescribing plays…”, http://doctordidyouwashyourhands.com/2017/08/to-manage-and-eventually-reverse-the-opioid-epidemic-state-medicaid-programs-should-now-take-a-deeper-look-at-the-role-prescribing-plays/

As Washington dawdles, the States step in on the opioid crisis, with initiatives and lawyers, http://doctordidyouwashyourhands.com/2017/08/as-washington-dawdles-the-states-step-in-on-the-opioid-crisis-with-initiatives-and-lawyers/

“We would never tolerate a situation where only one in 10 people with cancer or diabetes gets treatment, and yet we do that with substance-abuse disorders,” (A), http://doctordidyouwashyourhands.com/2017/08/we-would-never-tolerate-a-situation-where-only-one-in-10-people-with-cancer-or-diabetes-gets-treatment-and-yet-we-do-that-with-substance-abuse-disorders-a/

“For most of my surgical career, I gave out opioids like candy….” “With approximately 142 Americans dying every day”….” We need to take away the matches, not put out the fires.”, http://doctordidyouwashyourhands.com/2017/08/8224/

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“…SEXUAL HARASSMENT IN HEALTHCARE CAN ADVERSELY AFFECT EMPLOYEE HEALTH AND, BY EXTENTION, PATIENT SAFETY…”


“Google engineers and other workers at the internet giant’s offices around the world walked off the job Thursday morning to protest its lenient treatment of executives accused of sexual misconduct.
It is the latest expression of a backlash against many men’s mistreatment of female employees across the business landscape and in politics….” (A)

“The healthcare industry is not exempt from sexual harassment; in fact, over 50% of female nurses, physicians, and students report experiencing sexual harassment. Sexual harassment is unwelcome conduct, on the basis of gender, that affects a person’s ability to do his or her job (or complete studies), including unwelcome sexual advances, verbal or physical conduct of a sexual nature, and requests for sexual favors. Although most claims of sexual harassment are made by females, there have been increasing charges of sexual harassment of males.” (B)

“More than 3,000 employees at medical and surgical hospitals filed sexual harassment charges with the U.S. Equal Employment Opportunity Commission (EEOC) between 1995 and 2016, reported BuzzFeed News.
The site highlighted more than 170,000 sexual harassment claims across multiple industries.
Other sectors of healthcare also faced sexual harassment claims, including nearly 2,000 in ambulatory healthcare services, more than 1,500 in nursing care facilities and more than 380 claims in physician offices…
The claims about sexual harassment in healthcare aren’t new. Last year, a JAMA study found nearly one-third of women in academic medical faculties reported having experienced workplace sexual harassment. In that report, women also perceived and experienced more gender bias than men.” (C)

“Some of the incidents of harassment that physicians, nurses, and PAs described were rather extreme. A couple described physical assault—someone grabbing their breast. In one case, another physician held a female physician while he fondled himself. Some physicians say they were offered a promotion in exchange for sex and were threatened if they didn’t comply. Many nurses reported aggressive and distressing sexual behavior from physicians and also colleagues. Do you find it surprising that healthcare professionals would do things like this, especially at their place of work?” (D)

“In his Health Law column, Francis J. Serbaroli discusses the long and unfortunate history of sexual harassment in the health care workplace. Given the recent spate of high-profile career-ending sexual harassment charges, he urges all health care employers to have comprehensive policies and procedures for handling complaints, to educate everyone in the organization about sexual harassment, and to promote a culture of respect for all employees.
In recent months, many prominent persons have had career-ending allegations of sexual harassment brought against them. Those accused in these high-profile cases have come from media and entertainment, education, sports, government, finance, the arts, and other areas. The organizations with whom they were affiliated are scrambling to investigate these allegations, to do damage control, and to implement new policies and processes to demonstrate their zero-tolerance for such harassment. Questions are being raised as to whether the leadership of these organizations and their governing boards knew about the harassment, and if so, why appropriate action was not taken to stop it and prevent its recurrence.” (E)

““Like other aspects of a dysfunctional work culture, sexual harassment in healthcare can adversely affect employee health and, by extension, patient safety…
… there is every reason for an emphasis on training workers and implementing sexual harassment prevention programs in healthcare. The continuing revelations about nationally known figures exposed by the #MeToo movement is adding further impetus. Given the available data and anecdotal reports, it appears that a similar movement in medicine would generate a substantial number of personal accounts of sexual harassment. If nothing else, this is a teachable moment.
Though nurses have power in numbers as the predominant workforce in healthcare, they have long experienced sexual harassment from both colleagues and patients. A contributing social factor is thought to be the “sexy nurse” stereotype in pop culture and annual Halloween costumes. The author of an article on the issue concluded by urging nurses to “stop the line” and point out the behavior when it occurs.
“Report any incidents of harassment that you see occur or experience yourself,” the author concluded. “Involve your supervisors and peers in reporting. Empower all professionals to be able to say without fear, ‘No! This behavior isn’t okay,’ or ‘I feel uncomfortable with this conversation.’”…
Supervisors also can be found liable if they don’t step in when they become aware of harassment, as there is a responsibility and accountability in the hierarchy of the workplace…” (F)

“Many factors make an organization prone to sexual harassment: a hierarchical structure, a male-dominated environment, and a climate that tolerates transgressions — particularly when they are committed by those with power. Medicine has all three of these elements. And academic medicine, compared to other scientific fields, has the highest incidence of gender and sexual harassment. Thirty to seventy percent of female physicians and as many as half of female medical students report being sexually harassed…
The efforts of many healthcare organizations and medical centers tend to go little further than avoiding litigation. This needs to change. We propose a number of actions institutions must take to eliminate sexual harassment and create a safe environment that allows everyone in the health care workforce to do their best work on behalf of their patients.
Quantitative and qualitative assessment. The first step is for healthcare organizations to commit to understanding the problem. They must thoroughly and repeatedly measure the nature, prevalence, and severity of harassment and discrimination. Since this is unlikely to happen spontaneously, boards of directors and trustees should require open reporting of aggregate data, forums where employees can share ideas on how to reduce or eliminate harassment, and tying compensation of executives, deans, and chairs to outcomes…” (G)

“But the ultimate goal should be preventing harassment before it occurs. Physicians’ Practice offers three recommendations:
In meetings, make sure there’s a witness who’s the same gender as the employee. This is especially important in cases where a reprimand, discipline or termination is involved.
When possible, have a woman in the room (e.g., a nurse or medical assistant) if a male doctor is performing an exam, and vice versa. Patients may feel more comfortable if someone else is in the room, especially if the exam or treatment involves breasts or genitals. And if possible, if a patient requests a provider of a specific gender, honor that request.
Create a positive, harassment-free culture. Pay attention to comments being made in the cafeteria or break rooms, and call out employees who may be making others feel uncomfortable. If suggestive or inappropriate comments are being made, shut them down, and make it clear to others they should feel empowered to do the same.
Training employees about how to recognize sexism and sexual harassment when it occurs can also go a long way toward preventing upsetting incidents. Inappropriate jokes or conversations about sex might make others feel uncomfortable, even if that’s not the intent.” (H)

“When it comes to reporting, organizations should provide multiple avenues for those who believe they’ve been subjected to sexually harassing behavior, at least one of which is anonymous, according to Eaton.
One area of training that’s often neglected is bystander training — teaching employees who may not experience sexual harassment but witness someone else being harassed how to respond and whom to tell.
“Effective and interactive training in sexual harassment should be given to supervisors and support staff alike, including training on how bystanders may intervene when witnessing such behavior,” Eaton says. In healthcare, it’s also important to address how to respond to unwanted patient behaviors, he adds.
Healthcare workplaces need to demonstrate zero tolerance for sexual harassment.
It should be part of an organization’s culture that certain behaviors are not acceptable, according to Ballard. Senior leaders need to model acceptable behavior to create a safe and healthy workplace environment, he added.
With sexual harassment on the national radar right now, it seems a good time for organizations to revisit their policies and procedures around handling complaints and ramp up trainings to prevent abuse.
“I think we are seeing a national catharsis,” Quick wrote. “Everyone has known it’s there. Now it’s on the table and I am optimistic that we will make progress, but not straight-line linear [progress]. There will be setbacks and challenges, but this appears an inflection point.”” (I)

“What made Weinstein’s behavior so reprehensible is the aspect of the power differential associated with his actions. The women he targeted were struggling actresses who knew that success in Hollywood often comes from a lucky break and impressing powerful producers, directors, company heads.
Nurses are often in similar situations when hospital administrators value doctors and surgeons more than nurses. In 2009, Janet Bianco, a nurse from Flushing Hospital in New York was awarded $15 million after being sexually harassed by Dr. Matthew Miller for years that ultimately led to two violent attacks in 2001.
Despite complaining to her supervisors, no action was taken, even though the doctor was previously sanctioned by the state medical board for what they called, “moral unfitness to practice medicine.”
What is most disturbing about the Weinstein case is that for decades, everyone knew about it, but no one did anything about it. The same was true for Nurse Bianco. In fact, the harassing doctor tried to force his tongue down her throat as the hospital’s medical director, Dr. Peter Barra looked on.
Nurses who are sexually harassed at work face frustration, emotional consequences, and professional setbacks. Many leave the field altogether. That’s why it’s important that all of us watch out for each other, report inappropriate behavior, and make our hospitals safer places to work.” (J)

“The medical field, like popular culture, reinforces the physician-as-hero trope. Having answered their “life’s calling,” physicians are trustworthy, objective, selfless — even godlike. Doctors certainly do not rape, assault, or molest their patients.
But they do. The harrowing experiences of several hundred gymnasts who exposed Dr. Larry Nassar’s history of molestation under the guise of medical treatment demonstrates how he was able to sexually assault these young women because he was a doctor — using his trusted position and the safe confines of a doctor’s exam room.
Other doctors enabled Nassar’s predatory behavior. There was Dr. Gary Stollak, a clinical psychologist who heard about Nassar’s abuse from a former victim 14 years ago but did not report it; Dr. William Strampel, dean of the Michigan State University College of Osteopathic Medicine, who imposed protocols for Nassar — including wearing gloves and having a chaperone for sensitive exams — but failed to enforce them; and Dr. Brooke Lemmen, who resigned from Michigan State after failing to tell the university that Nassar had informed her he was under investigation by USA Gymnastics…
We must confront the culture of medicine that dissuades physicians from reporting our colleague’s “bad behavior,” including conduct much less egregious than sexual assault. We must also advocate for independence in systems that hold physicians accountable.
At the same time, we must be respectful of survivors of sexual assault by strengthening our training around caring for them and ensuring that they feel comfortable seeking care in an environment that may have previously betrayed their trust. …”(K)

“A…Perspective by Victor J. Dzau, MD, of the National Academy of Medicine in Washington, and Paula A. Johnson, MD, of Wellesley College in Wellesley, Massachusetts, called upon medical leadership to help institute these changes, including:
Aligning and embedding the values of diversity, inclusion, and respect into institutional policies
Reducing hierarchical power structures
Providing alternative reporting options
Protecting victims from retaliation
Ensuring transparency and accountability in institutional investigations”
“Sexual harassment in academic medicine is a symptom of systematic failures that prevent the medical workforce from operating at its fullest potential,” Dzau and Johnson wrote. “As leaders, we ignore this problem at our peril.”” (L)

(A) Google Walkout: Employees Protest Over Sexual Harassment Scandals, https://www.msn.com/en-us/news/local/google-walkout-employees-protest-over-sexual-harassment-scandals/ar-BBPeGMb
(B) Sexual Harassment in Healthcare, WWW.RN.ORG, www.rn.org/courses/coursematerial-236.pdf
(C) Data shows breadth of sexual harassment in healthcare, by Les Masterson, https://www.healthcaredive.com/news/data-shows-breadth-of-sexual-harassment-in-healthcare/512434/
(D) Sexual Harassment in Healthcare: Doctors and Nurses, by Leslie Kane and Susan Strauss, https://www.medscape.com/viewarticle/898027_2
(E) Sexual Harassment in the Health Care Workplace, by Sexual Harassment in the Health Care Workplace, by Francis J. Serbaroli, https://www.law.com/newyorklawjournal/2018/01/22/sexual-harassment-in-the-health-care-workplace/
(F) #MeToo in Medicine? Sexual Harassment in Healthcare, by Gary Evans, https://www.reliasmedia.com/articles/142185-metoo-in-medicine-sexual-harassment-in-healthcare
(G) Sexual Harassment Is Rampant in Health Care. Here’s How to Stop It, by Jane van Dis, Laura Stadum, Esther Choo, https://hbr.org/2018/11/sexual-harassment-is-rampant-in-health-care-heres-how-to-stop-it
(H) Is there a Weinstein in your hospital? Dealing with sexual harassment, Kelsy Ketchum, http://www.healthcarebusinesstech.com/sexual-harassment/
(I) Health industry not immune to workplace sexual harassment, by Meg Bryant, https://www.healthcaredive.com/news/from-med-school-to-practice-sexual-harassment-in-healthcare/515061/
(J) Sexual Harassment In Nursing – It’s More Common Than You Think, https://nurse.org/articles/harvey-weinstein-and-harassment-against-nurses/
(K) Larry Nassar isn’t the only doctor accused of molesting patients. We need to do more to stop it, by Altaf Saadi, https://www.statnews.com/2018/02/05/larry-nassar-doctors-sexual-assault/
(L) Treat Sexual Harassment in Medicine on a Systemic Level, by Molly Walker, https://www.medpagetoday.com/publichealthpolicy/medicaleducation/75064

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Tomorrow morning’s Emergency Preparedness meeting (just scheduled for 8AM)


October 28, 2018

FROM: CEO, Northern New Jersey Regional Medical Center
TO: SVPs
SUBJECT: Tomorrow morning’s Preparedness meeting (just scheduled for 8AM)

Over the last few days there has been a convergence of preparedness challenges. We need to set priorities, confirm assignments, allocate resources, initiate communications plan.

1. NOR’EASTER/ FLOODING.
Assessment. Review SuperStorm Sandy rapid response (A) (B) (C)

2. ACTIVE SHOOTER TRAINING
“Hospital active shooter response programs are essential for healthcare facilities to stay prepared for shootings on their campus or in their communities. Hospitals with the ability to receive patients from an active shooter attack have a responsibility to be prepared.
The new National Fire Protection Association Standard, NFPA 3000: Standard for an Active Shooter/Hostile Event Response (ASHER) Program, gives details on what that preparedness should look like.
Specifically, chapter 19 of the NFPA 3000 standard describes different aspects of an effective, scalable hospital active shooter program.
John Montes, an NFPA emergency services specialist who helped write NFPA 3000, believes active shooter response plans should be distinct from hospital officials’ general emergency plans.” (D) (E)

3. DEADLY VIRUS OUTBREAK & BACTERIAL INFECTION
“New Jersey Department of Health officials said this week that in addition to an investigation of an outbreak of adenovirus that has killed seven children at the Wanaque Center for Nursing and Rehabilitation in Passaic County, they are investigating four cases of Acinetobacter baumannii in the neonatal intensive care unit of University Hospital in Newark, following the death of a premature baby.” (F) (G)

4. POLIO-LIKE ILLNESS
“Acute flaccid myelitis, the polio-like syndrome leaving some children partially paralyzed.
The Centers for Disease Control and Prevention says it doesn’t know what’s causing a sudden rise in cases of a frightening, polio-like condition that leaves children paralyzed or with weakened limbs.
The No. 1 suspect had been a virus called enterovirus D68, or EV-D68. In 2014, a wave of cases of acute flaccid myelitis coincided with outbreaks of EV-D68 across the country.” (H)

5. SEASONAL FLU
“New York City on reported its first flu-related death of the season Thursday, and the health department urged everyone over 6 months of age to get a flu shot.” (I)
“Surge” capacity
Mandatory staff vaccinations? (J)

6. SEPSIS
“Scientists have created an artificial intelligence (AI) system that could help treat patients with sepsis by predicting the best treatment strategy.
The system developed by researchers from Imperial College London in the UK analysed the records of about 100,000 hospital patients in intensive care units and every single doctor’s decisions affecting them.
The findings, published in the journal Nature Medicine, showed the AI system made more reliable treatment decisions than human doctors.” (K)

7. EBOLA TRAINING
“Preparedness for emerging infectious diseases threats saw a marked improvement at U.S. hospitals after an Ebola outbreak scare in 2014, according to a new report from a federal watchdog agency.
The challenge now? Keeping that level of preparedness in the midst of competing priorities.
According to the HHS Office of Inspector General, 71% of hospital administrators reported their facilities were unprepared to receive Ebola patients in 2014. But after scrambling to update emergency plans, train staff to care for patients with emerging infectious diseases (EID), purchasing additional supplies and conducting drills, 86% of administrators said their facilities were prepared in 2017.” (L)

8. HALLOWEEN COVERAGE
Halloween Health and Safety Tips (M)

RESOURCES
Emergency Preparedness and Response, CDC. https://emergency.cdc.gov/planning/index.asp
Emergency Management Resources, The Joint Commission, https://www.jointcommission.org/emergency_management.aspx
Is Your Hospital Prepared? CHA. https://www.calhospitalprepare.org/
Hospital Surge Evaluation Tool https://www.phe.gov/Preparedness/planning/hpp/surge/Pages/default.aspx

(A) Five years after Superstorm Sandy, NYC hospitals may be as ready as Houston’s were for Harvey, by Rachel Z. Arndt, https://www.modernhealthcare.com/article/20170909/NEWS/170909889
(B) Hurricane Sandy: A Tale of 2 Hospitals, by Marc Lallanilla, https://www.livescience.com/40734-hurricane-sandy-shorefront-center-coney-island-hospital.html
(C) Bracing for the Worst, https://today.duke.edu/2018/09/bracing-worst
(D) What Hospital Active Shooter Response Programs Should Look Like, https://economictimes.indiatimes.com/magazines/panache/now-an-ai-system-could-help-treat-patients-with-sepsis-by-predicting-best-treatment-strategy/articleshow/66331925.cms
(E) Children’s Medical Center Dallas boosts ER preparedness with active shooter drills, by by Paige Minemyer, https://www.fiercehealthcare.com/hospitals-health-systems/children-s-health-children-s-medical-center-dallas-active-shooter-training
(F) 8th death reported at North Jersey pediatric care facility, by NICOLE LEONARD, https://www.pressofatlanticcity.com/wellness/deadly-viral-and-bacterial-cases-strike-nj-children-at-health/article_0a4912c9-820f-5890-b2ae-6bcfe558f751.html
(G) STATE TO GIVE FAST TRAINING ON INFECTION CONTROL AT THREE OTHER FACILITIES, by LILO H. STAINTON, https://www.njspotlight.com/stories/18/10/25/state-to-give-fast-training-on-infection-control-at-three-other-facilities/
(H) CDC says polio-like disease is puzzling. These doctors disagree, by Maggie Fox, https://www.theatlantic.com/health/archive/2018/10/afm-polio-like-illness-thats-paralyzing-children/573982/
(I) NYC Health Dept. Announces First Child Flu Death Of Season, https://newyork.cbslocal.com/2018/10/25/child-flu-death-nyc-department-of-health/
(J) Menu of State Hospital Influenza Vaccination Laws, https://www.cdc.gov/phlp/docs/menu-shfluvacclaws.pdf
(K) Now, an AI system could help treat patients with sepsis by predicting best treatment strategy, https://economictimes.indiatimes.com/magazines/panache/now-an-ai-system-could-help-treat-patients-with-sepsis-by-predicting-best-treatment-strategy/articleshow/66331925.cms
(L) U.S. hospitals improved infectious disease preparedness in response to Ebola threat, federal watchdog says, by Tina Reed, https://www.fiercehealthcare.com/hospitals-health-systems/u-s-hospitals-performed-well-response-to-ebola-threat-federal-watchdog
(M) https://www.cdc.gov/family/halloween/halloween_tips.pdf

PREQUELS
We don’t know what we don’t know” (1) The challenge to emergency preparedness….., http://doctordidyouwashyourhands.com/2017/08/we-dont-know-what-we-dont-know-1-the-challenge-to-emergency-preparedness/
“..in a severe (flu) pandemic, the U.S. healthcare system could be overwhelmed in just weeks., http://doctordidyouwashyourhands.com/2018/01/let-there-be-no-mistake-in-a-severe-flu-pandemic-the-u-s-healthcare-system-could-be-overwhelmed-in-just-weeks/
The new Jersey City Medical Center (2004) was constructed above the 100 year flood plain – then came Sandy, Harvey & Irma, http://doctordidyouwashyourhands.com/2017/11/the-new-jersey-city-medical-center-2004-was-constructed-above-the-100-year-flood-plain-then-came-sandy-harvey-irma/

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