DON’T DEPEND ON ANYONE ELSE TO BRING THE COFFEE! & other Lessons Learned as a junior hospital CEO back in the day….
“It is fine to celebrate success, but it is more important to heed the lessons of failure.” – Bill Gates
One summer Friday early afternoon I was in my car heading off for the weekend when the New Jersey Commissioner of Health called and told me he was closing the Jersey City Medical Center Trauma Center for failure to get renewed State approval.
Our new Trauma Service Director had told me that we were at risk for non-approval so we should have an American College of Surgeons consultation visit before the ACS certificationvisit, a prerequisite for State approval. But apparently he did not know that State approval had an absolute re-approval date of three years no matter what preparatory steps we chose to take.
The call was on the re-approval deadline date so the Commissioner shut the TC down but the radio stations said the ER was shut down, making the matter even worse.
To make a long story short, we got approval to reopen the TC on Monday after an early morning compliance visit by the State, and three months to get re-approval. Which we did with no contingencies, conditions or recommendations.
And what would you do about the Trauma Service Director?
“Failure is only the opportunity to begin again, only this time more wisely.” – Henry Ford
Bariatric Surgery was the rage and our new Chairman of Surgery said we had to be in the game. So he recruited a team of bariatric surgeons to branch out to Jersey City Medical Center, and spent time at their home base training to be an Assistant Bariatric Surgeon (and thus able to bill for this role).
We staffed up, lots of prospective patients came to orientations, but no cases were ever done. Why? The prospective patients were mostly our own employees who “chose”, we were told, to have the surgery at the team’s home base for “privacy concerns.” So we not only paid for the programs fixed costs but also for the insurance impact when our employees had the surgery elsewhere.
“There are no secrets to success. It is the result of preparation, hard work and learning from failure.” – Colin Powell
Each of our three hospitals had different protocols to avoid “wrong site/ wrong side” surgery (e.g., a wrong kidney removal actually happened). Some surgeons operated at 2 or 3 of our hospitals (as well as at other non-system hospitals) and thus had to navigate the different protocols. We called a meeting to establish one standard protocol for our system, to be approved by each hospital’s medical staff.
Only to find out months later that our two community hospital medical staffs amended the protocol rather than simply adopt it. So as CEO of all three hospitals I mandated the standard protocol, it rose to the level of the Boards of Trustees, but common sense prevailed.
“A person who never made a mistake never tried anything new.” – Albert Einstein
Three full time Chairmen told me they were in the final stages of building a free-standing surgi-center a half mile away from the hospital, and that the previous President had promised to buy it. Nothing in writing. I demurred. So they partnered with two competing hospitals. One Wednesday morning I went to a Chamber of Commerce showcase event only to find the three Chairman at their surgi-center booth. All three ran residency training programs and Wednesday was Grand Rounds for all three. They told me they were using vacation time. I said that was not appropriate. They said it was none of my business. I told each of them they had a choice, either sell their shares of the surgi-center or be fired. Two sold, one “left” and took his residents with him to one of the competing hospitals.
The Mystery of the Hospital CLAUSTROPHOBIA CLUSTER
Recently a friend was told by his doctor he needed an MRI and said that he could get it at the hospital on the campus where the doctor’s office was located, or at a private imaging center two blocks away.
This reminded me of the mystery of the Claustrophobia Cluster about twenty-five years ago, in Greenville Hospital, a member hospital of LibertyHealth.
Our Teaching Hospital, Jersey City Medical Center had just acquired a new state-of-the-art MRI, GH was only a little over a mile away, there was an MRI transfer protocol in place, and we ran a robust county-wide EMS transport system.
But almost every insured patient at GH who needed an MRI was referred to a “private” free-standing Imaging Center due to CLAUSTROPHOBIA. Somehow, also mysteriously, Medicaid patients and the uninsured made it to JCMC.
The problem was compounded by the fact that we were under a DRG reimbursement system where we got reimbursed an all-inclusive rate for every diagnosis, and had to pay for “outside” MRIs out of that bundled payment. These very expensive outside MRIs often meant that GH and the system lost money on many of these patients.
Whichever entity provides the service tacks on a Facilities Fee to the professional fee charged, for example, by a radiologist.
This raises the question of whether self-referral is a purely clinical recommendation or might “ownership” and the Facilities Fee be an influence.
We never solved the CLAUSTROPHOBIA CLUSTER mystery, because the outside MRI was buried in a myriad of corporations, although we felt somewhere this was the case of physicians referring patients to a facility they owned.
But it ended as mysteriously as it started when we started tracking referrals.
The DOH issued a CN “call” for inpatient rehabilitation beds. This was an excellent opportunity for Meadowlands Hospital with all single bedded rooms and flagging admissions.
The Meadowlands medical staff wanted a patient care model where any physician could admit to the rehab unit and the physiatrist was a consultant. The best practice at academic medical centers as well as rehab hospitals in New Jersey was a “closed unit” where the physiatrist managed the patients and other physicians could consult on other medical conditions such as COPD, UTI, and coronary disease.
This was not a battle over best patient care but a battle over money. We adopted the “closed unit” model but the major Meadowlands attending staff members punished Liberty by never referring patients to Jersey City Medical Center, the closest tertiary care hospital, again unless they were uninsured.
Parenthetically two MH urologists covered the Urology Clinic at JCMC. Patients with insurance were transferred to MH for surgery while those without insurance were treated medically at JCMC. When the urologists were fired MH/ JCMC animosity increased.
Jersey City Medical Center had “free-standing” residency training programs in medicine, obs/gyn, and pediatrics. After JCMC became a teaching affiliate of the Mount Sinai School of Medicine the programs could be either be affiliated, sponsored, or integrated. “Affiliated” was a euphemism for “free-standing”, “sponsored” meant over sight by the Mount Sinai Dean for Graduate Medical Education, and “integrated” was the “gold standard” or one set of residents rotating between Mount Sinai, JCMC and other Mount Sinai affiliated hospitals.
Our chiefs wanted “affiliated” so no one would be looking over their shoulders but I mandated “sponsored” as a step toward “integrated.”
In the early 1990’s Jersey City Medical Center was the only hospital in Hudson County to have a diagnostic cardiac catheterization lab. Interventional cardiac catheterization was highly regulated with on-site cardiac surgery back-up required, so there were no interventional labs in the County.
When I was a member of the State Health Planning Board, DOH staff were against a hospital in Trenton getting a CN for open heart surgery, and just assumed the Board would agree. Under-the-radar we garnered support for the application and to the amazement of the DOH staff, it was approved – setting the stage for JCMC in the future.
Then the New Jersey Department of Health issued a Certificate of Need “call’ for a demonstration project allowing a handful of community hospitals to have cath labs for primary angioplasty without cardiac back up, but each applicant had to have a transfer agreement for elective angioplasties. Nearby Bayonne Hospital put in an application including an agreement with JCMC for patient transfers, so we provided a letter of support and together we lobbied the DOH. We were trying to position JCMC as a referral center so we could apply for cardiac surgery, anticipating a “call” down the road. Bayonne got its cath lab and then immediately sign a new transfer agreement with a hospital in Newark.
Later the DOH essentially deregulated primary cath labs and in a period of about one year over 20 new cath labs opened across the State, including three in Hudson County, one being at Meadowlands Hospital. I was against the MH lab but the parent Liberty Board supported the MH Board. Most of the new labs closed within a few years, including all three in Hudson County.
In 1999 JCMC had the opportunity to apply for a CN to start a cardiac surgery program. Everyone on the senior staff was against it except for the CMO. The CFO may and end run to the Board, and the Board chairman told me it was my decision but my “job was on the line.”
We were in the process of building a total replacement hospital on a new site. It was impossible to become a Top Tier New Jersey Hospital without cardiac surgery/ interventional cardiology.
The payer mix at the old hospital was 70% Medicaid/ Charity Care/ self-pay.
We opened the cardiac surgery program at the new JCMC just two months before the CN expired.
Several factors helped the program and saved my job. The American College of Cardiology protocol channeled many insured patients to JCMC mostly those candidates for stenting within the one hour “golden” hour (only JCMC did stenting then). The cardiac surgery payer mix eventually becoming 75% insured, 25% Medicaid, uninsured.
“Cardiac department at Jersey City Medical Center reaches milestone with 503rd open-heart surgery, looks to future expansion.” Saturday, April 09, 2011 By RHEA MAHBUBANI, JOURNAL STAFF WRITER
“Although each surgery costs between $30,000 and $50,000, there has been a constant demand for both elective and emergency operations. On most days, the cardiac surgery team can expect one such four-to-five hour procedure, while some days bring none and others, two or three.
The first 500 operations were representative of the efforts being made to establish a high-quality program, which could serve as a backbone for the Hudson community, they said.
Having reached nearly 550 surgeries by late-March, the team is no longer focused on simply the basic, daily functioning of their department. “Now its time to start expanding,” “
Three baseball umpires are at a continuing education program on Barbados, the subject “What’s a ball, and what’s a strike?” The rookie umpire says “There are balls, and there are strikes and I call them as they are.” The mid-career umpire says: “There are balls, and there are strikes and I call them as I see them.” The veteran umpire, about to retires, says” “There are balls, and there are strikes and they ain’t nothing ‘til I call them.” (source unknown)
There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don’t know. But there are also unknown unknowns. There are things we don’t know we don’t know. (Donald Rumsfeld)
“Don’t depend on anyone else to bring the coffee! There’s nothing worse than starting the day at a meeting where they don’t provide coffee. It’s better to have two cups than none.”
I started every new course with this “early morning meeting” aphorism. But students took this as something much more “strategic” and started using it in presentations, papers etc. as a metaphor.
What do you think they were thinking?
“I made a lot of mistakes in my time but didn’t waste any time making them.”
(attributed to Gustave Levy, Goldman Sachs)
“TRUST, BUT VERIFY.” (Ronald Reagan)
“If Columbus had an advisory committee he would probably still be at the dock.” (Arthur Goldberg)
“Never, never, never give up.” (Winston Churchill)