When I was growing up in Queens in the late mid-1950s the two “go-to” hospitals were Long Island Jewish and Booth Memorial.

In the early 1970’s the hospital system in the NYC metropolitan area was anchored and dominated by internationally renowned academic medical centers (then defined as a medical school and its primary teaching hospital on the same campus) – e.g., Columbia Presbyterian, Mount Sinai, NYU and Cornell. Academic affiliations were in place with area hospitals for teaching medical students and training residents.

Probably triggered by the North Shore/ LIJ merger in 1997 (North Shore was already a regional system with 10 hospitals) we have seen a rapidly accelerating merger trajectory from regional hospital systems focusing on becoming integrated health care delivery systems, to mega systems focusing on geographic reach, to super-size systems which have started or taken over medical schools, functioning almost like insurance companies and investment banks.

Some examples of the scale of super size systems:
North Shore, recently rebranded itself as Northwell Health, has annual revenue of $7.0 billion.  The LIJ name is history. http://medicine.hofstra.edu/about/history/history_nslij.html
The Mount Sinai Health System * has 3,535 beds on 7 hospital campuses.http://www.mountsinaihealth.org/about-the-health-system/facts-and-figures
New York Presbyterian includes two medical schools. Booth Memorial is now NYP Queens. http://www.nyp.org/about-us
RWJBarnabas Health, created by the merger of two mega systems, serves a geographic area that covers 5 million people, or more than half of New Jersey’s population. http://www.mycentraljersey.com/story/money/business/consumer/2016/03/31/robert-wood-johnson-barnabas-health/82489800/
Followed by the merger of Hackensack and Meridian https://www.meridianhealth.com/media/press-releases/2016/hackensack-university-health-network-and-meridian-health-announce-board-members.aspx
Geisinger, the powerhouse in central, south-central and northeast Pennsylvania now includes AtlantiCare in New Jersey http://www.geisinger.org/pages/about-geisinger/index.html  A number of New Jersey hospitals have academic and programmatic affiliations with NYC and Philadelphia medical schools.

All of the super-size systems are not-for-profits.

The NFP corporate veil has been weakened by the Atlantic Health System, owners of the Morristown Medical Center, agreeing to pay the town $15.5 million over the next 10 years in a property tax settlement based on its for-profit subsidiary profits. http://www.nj.com/morris/index.ssf/2015/11/atlantic_health_to_pay_morristown_155m_to_settle_t.html This is a template for all NFP hospitals in New Jersey and nationwide.

In New Jersey for-profit systems have been created or bought previously NFP hospitals. While “prohibited” in New York, recently there was talk of allowing for-profits demonstration projects particularly focused on rebuilding the hospital system with “other people’s money.”

In April, 2016 “The Federal Reserve and the Federal Deposit Insurance Corporation said that five of the nation’s eight largest banks — including JPMorgan Chase and Bank of America — did not have “credible” plans for how they would wind themselves down in a crisis without sowing panic.” http://www.nytimes.com/2016/04/14/business/dealbook/living-wills-of-5-banks-fail-to-pass-muster.html

Are NFP super size hospital systems structured to handle a “bubble”? Are we ready for some to become “for-profits” to have access to capital?

The FTC opposed the 1997 North Shore/ LIJ merger, which was “approved” through litigation. Now in New Jersey and New York Certificates of Need for super-size mergers are awarded in a few months time.

Maybe it’s time for STRESS TESTS!

UPDATE
Northwell* Health said in a statement that it will wind down its four-year-old CareConnect Insurance Co. business over the next year, after it suffered financial losses linked to a program designed to steady the exchanges where consumers can buy coverage.
https://www.bloomberg.com/news/articles/2017-08-24/new-york-hospital-system-shuts-obamacare-unit-after-losses

* North Shore is now Northwell

The OPIOD CRISIS developed under-the-radar into a large scale national epidemic. This calamity was created, not by a virus, but by the over-production of very profitable prescription pain medication, and over-prescribing due in part to “pain management” goals and patient demand.

And in the recent past ZIKA spread on an unpredictable trajectory followed by a confirmed link between ZIKA and microcephaly.

The OPIOD CRISIS, like ZIKA, is a complex problem where participants have to reach agreement on goals while simultaneously evaluating options, in the context of “unknown unknowns.” Previous experience, even with Ebola, were not necessarily templates for ZIKA and the many existing and emerging mosquito-borne viruses. There is no real existing template for the OPIOD CRISIS.

The OPIOD CRISIS and the ZIKA EPIDEMIC led me to reflect on my professional hospital administrator experience with “disasters”.

My first experience was in 1975; I was 30 years old, the Mount Sinai Administrator at Elmhurst Hospital. “A powerful bomb ripped through a baggage area crowded with holiday travelers at LaGuardia Airport….. killing 12 persons and injuring at least 75 others.” (2) The most seriously injured were transported to nearby EH, a trauma center. I manned a security post keeping family members and press out of the E.R., observed much but learned little.

The first World Trade Center bombing was in 1993, four years into my tenure as President and CEO of Jersey City Medical Center. (3) As the nearby EMS service we sent all our ambulances through the Holland Tunnel into Manhattan. They got caught in the gridlock, were useless, and we didn’t get them back for three days and had to rely on Mutual Assist to cover our home turf.

In the mid 1990’s we had a 4-alarm arson fire in the hospital. The extraordinary efforts of the JCFD saved the day and 400 patients as we were evacuating the smoke-filled hospital, hampered by archaic elevators and narrow, dark stairways.

My focus on LESSONS LEARNED started on September 11th, 2001 when as President and CEO of Jersey City Medical Center we were a lead responder to the World Trade Center attacks. A confidential LESSONS LEARNED memorandum to the New Jersey Commissioner of Health became public when the Mayor of Jersey, who was out of the country on Sept 11th and was planning a run for governor, leaked the report “Schundler Assails New Jersey’s Response to Terrorist Attack.” (4) The Governor’s Office was not happy.

In 2004 I was visited by a Secret Service agent who told me that JCMC had been one of two hospitals designated as the primary back-up facilities for the Republican National Convention in Madison Square Garden and that we had to be fully staffed during the week before Labor Day, one of the slowest weeks of the year – and I couldn’t tell anyone why.

In 2009 I suggested to the new Acting Mayor of Hoboken that the Swine Flu maps showed it pointing to the NYC/ Hoboken metropolitan area. This led to ““Hoboken Creates Swine Flu Task Force.” (5) Interestingly Swine Flu did not reach epidemic proportions most probably due to “herd” immunity (6) from the prior year’s sub-clinical outbreak.
I monitored the Ebola outbreak starting in 2014 and advocated for the designation of regional centers as even as community hospitals “marketed” their preparedness. (7)

While I was not involved in Super Storm Sandy in 2015, the new Jersey City Medical Center opened in 2004 was hard hit even though it had been built to withstand the “100 year flood plain.” The hospitals in Hoboken and nearby North Bergen were totally evacuated.

While it may be true that “no battle plan ever survives the first encounter with the enemy” (8), plans for “New” types of emergencies are always needed as a starting point.

I taught an MBA/ MPA/ MPHA course “Project Management. The hardest part about getting started……is getting started.” The public needs confidence that OPIOD CRISIS planning is underway.

POSTSCRIPT
Bronx-Lebanon Hospital Siege Offers Counterterrorism Lessons (9)

1. Donald Rumsfeld. “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.”
2. http://www.nydailynews.com/new-york/queens/laguardia-airport-bombing-kills-10-1975-article-1.2454144
3. http://news.bbc.co.uk/onthisday/hi/dates/stories/february/26/newsid_2516000/2516469.stm
4. http://www.nytimes.com/2001/09/22/nyregion/schundler-assails-new-jersey-s-response-to-terrorist-attack.html
5. http://www.nj.com/hobokennow/index.ssf/2009/08/hoboken_creates_swine_flu_task.html
6. http://www.vaccinestoday.eu/vaccines/what-is-herd-immunity/
7. http://hudsonreporter.com/view/full_story/25983889/article-Ebola–Local-medical-professional-releases-paper-on-what-to-do
8. http://www.lexician.com/lexblog/2010/11/no-battle-plan-survives-contact-with-the-enemy/
9. https://www.nytimes.com/2017/08/24/nyregion/bronx-lebanon-hospital-siege-counterterrorism-nypd.html?smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=0

She was triaged and escorted to a treatment room. Then sat there for 45 minutes because the desk never told the doctor she was waiting, even though the ER had a computerized patient tracking system. A COMMUNICATIONS FAILURE.

While standing at the treatment room door, trying to remind the staff she was there, she overheard doctors talking about other patients’ clinical information. A HIPPA (CONFIDENTIALITY) VIOLATION.

A tetanus shot was ordered by the doctor, but it took another 45 minutes for the nurse to show up. A SYSTEMS PROBLEM.

When asked if she had washed her hand, the nurse said she always washed her hands after each patient, and then proceeded to wash her hands. Really? A PATIENT SAFETY ISSUE.

I sent an email to the CEO and got a “form letter” response addressed to the wrong last name. A PUBLIC RELATIONS PROBLEM.

Two weeks later when she touched the punctured area a splinter popped out. When this information was emailed to the ER the email response was “A splinter?! After reading the note and talking to the physician, I was under the impression that the wound was from a “barbeque skewer”. I guess it was not really clarified in the note whether it was metal or wood. I suppose I was just thinking that it was metal.” A CHARTING OMMISSION & A MEDICAL ERROR. AND A DUMB STATEMENT TO PUT IN WRITING!

If this happened to you, what would you have done? Most people just ignore these situations. That is how systems breakdowns become permanent operating procedures.

Doing that required being a risk taker, not being risk averse. So here are vignettes about some risks taken over 17 years, some with success, some with failure, and some with mixed results. These examples are from my experience. Recognizing the new health care industry algorithm is more complicated, being a risk-taker is still essential for organizational and professional success.

“A ship in harbor is safe, but that is not what ships are built for.” John Augustus Shedd.

Jersey City Medical Center provides EMS services to Jersey City and paramedic services to Hudson County. In the early 1990’s portable, almost self-operating defibrillators became available so our EMS Director (Mary Beth Ray Simone) proposed that we train our EMTs and paramedics and put defibrillators in each of our EMS trucks. This raised eyebrows at the State Department of Health and litigation by the county’s many volunteer ambulance corps. We persisted and now, of course, defibrillators are pervasive in train and bus stations, sports stadiums and arenas, college campuses….everywhere.

“Only those who dare to fail greatly can ever achieve greatly. “ Robert F. Kennedy

In 1989 Jersey City Medical Center was a second-tier, unaffiliated teaching hospital. The University of Medicine and Dentistry of New Jersey (UMDNJ) had a medical education monopoly in New Jersey with two allopathic and one osteopathic medical schools. There were no other medical schools in the state. The President of UMDNJ (now Rutgers) refused to consider JCMC as an affiliate, rather trying to build a network of referring community hospitals, including the half dozen in Hudson County.
So JCMC became the first hospital in New Jersey with an out-of-state medical school affiliation and became a major teaching affiliate of Mount Sinai School of Medicine. The medical staffs at all three of our hospitals were against it and most Board members underestimated the importance of a first class medical school affiliation to the success of our new hospital.
We had a choice with Mount Sinai of our residency training programs in medicine, pediatrics and obs/gyn being free-standing, affiliated, or sponsored. Sponsored meant the most oversight and control from Mount Sinai and that’s what we chose with every residency program director opposed.
The biggest success story with Mount Sinai was a totally integrated Emergency Room when we opened the new hospital enabling the recruitment of a terrific cadre of Emergency Medicine trained physicians.

“What you have to do and the way you have to do it is incredibly simple. Whether you are willing to do it is another matter.” Peter Drucker

At our two community hospitals being a department chair or division chief was much sought after. Both had a history of the positions going to the “next in line” but to my dismay allowed non board certified physicians to garner these roles. When it was proposed that a system wide standard of board certification be put in place it was successfully opposed by lobbying Board members against it; of course the physicians had leverage as the board members doctors.

“Do one thing every day that scares you.” Eleanor Roosevelt

When we moved from our old facility to our new hospital in 2004 we made the entire campus smoking-free and mandated the smoking-free campuses for our two community hospitals as well. First this was a public health commitment so staff and visitors didn’t have to walk through the blue haze of smoke at entrances. But I had also noticed the same people smoking outside time-after-time, while their colleagues inside were working. Smokers were offered smoking cessation assistance. But the biggest negative reaction was from Board members who smoke and were now prohibited from doing so. Of course now almost all hospitals are totally smoking-free. (There was an interesting discussion about whether or not psychiatric inpatients should be allowed to smoke but that was ended as well.)

“Life is being on the wire, everything else is just waiting.” Karl Wallenda

For many years cardiac cath labs were restricted by the state’s Certificate of Need process. Then there was a “call” which would allow any hospital that met certain standards to apply to open a diagnostic cath lab (not interventional). It didn’t make sense to have a lab at one of our community hospitals but again Board members were pressured and an application was submitted.
In the next year dozens of cath labs opened in NJ, including three in Hudson County including one in our community hospital. Only one survived, not ours, because it was also part of interventional cardiology pilot program that allowed certain types of intervention without onsite cardiac surgery. (Parenthetically we helped get them into the pilot program with the proviso that JCMC would be their referral center. They reneged and sent all their referrals to Newark.)

“Trust your own instinct. Your mistakes might as well be your own, instead of someone else’s.” Billy Wilder

The lane to top tier hospital in New Jersey was cardiac surgery. We had secured a Certificate of Need for cardiac surgery while building the new hospital but it would expire one year after we moved in to the new hospital. Our patient mix 30% commercially insured and 70% Medicaid and Charity Care, not very promising from a reimbursement perspective since CS was expensive to staff and required a massive capital infusion to build the necessary specialized facilities.
Everyone except our Chief Medical Officer was against proceeding including the Chairman of the Board who said to me “Jon, I am against this project but will defer to you as President, but your job is on the line.”
We opened the unit in collaboration with Mount Sinai (there was no way we could start a program on our own) and the game changer was interventional cardiology, whereby according to American College of Cardiology guidelines certain patients had to be transported to hospitals with interventional cardiac cath labs and we had the only one in the county. This led to more cardiac surgery cases and a flip of the cardiac surgery payer mix to 70% commercially insured and 30% Medicaid and Charity Care.

Soon after I left one community hospital was closed, the other sold, and the affiliation with Mount Sinai was terminated, but the cardiac surgery and emergency medicine stayed on a very positive trajectory.

“The biggest risk is not taking any risk… In a world that changing really quickly, the only strategy that is guaranteed to fail is not taking risks.” Mark Zuckerberg

“It is fine to celebrate success, but it is more important to heed the lessons of failure.” – Bill Gates

Back in the day…
One summer Friday late afternoon I was in my car heading off for the weekend when the Commissioner of Health found me and told me he was closing the JCMC 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 certification, 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.

“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., wrong kidney removal). 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.

“You build on failure. You use it as a stepping stone. Close the door on the past. You don’t try to forget the mistakes, but you don’t dwell on it. You don’t let it have any of your energy, or any of your time, or any of your space.” Johnny Cash

The Mystery of the Hospital CLAUSTROPHOBIA CLUSTER

Our Teaching Hospital (TH) had just acquired a new state-of-the-art MRI. One of our Community Hospitals(CH) 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 CH 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 TH.

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 CH and the system lost money on many of these patients.

Since 1989 Federal Law “Prohibits a physician from making referrals for certain designated health services (DHS) payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership, investment, or compensation),…

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 but the Cluster  disappeared very quickly after we focused on it.

“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.” (A)

When I returned to MBA/ MPH/MPA teaching five years ago, after a 40 year intermission, this was the first LESSON LEARNED I shared with each of my classes. Students had to submit three Lessons Learned a week, and share them with the class on Blackboard, with the notion of making LLs a career-building exercise. (B)

Here are some more of my personal management LLs:
“Read the health care related newspaper headlines on your way into work. You don’t want to be surprised when you hear news in the coffee room. Especially if it’s about your organization.”
“Almost every challenge can be stated as a problem or an opportunity. It’s always better to be positive than negative.”
“Keys to success. Be consistent, persistent and innovative.”
“If you raise ten great ideas at a meeting, no one will remember any of them. Be prepared by doing your homework and raise one sensational idea at a meeting, and everyone will remember.”
“Take a risk and jump right in when you have a unique, interesting idea. How many times have you held back, only to have someone else hit the ball out of the park with your idea?”
“Don’t edit yourself out of opportunities.” (from Joe Welfeld) For example if a job ad has 7 requirements and you have four, go with those four. No one has all seven.
“Find a mentor – don’t expect a mentor to find you.”

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)

“Never, never give up.” (Winston Churchill)

And my final LL in every course:
“Character is how you behave when no one is watching.” (attributed to John Wooden and others)

“Effective meetings don’t happen by accident, the happen by design.” (author unknown)

In 1975 I was appointed Administrator of Mount Sinai Services at City Hospital at Elmhurst, a public hospital where Mount Sinai School of Medicine contractually provided professional services. We had a quarterly Dean’s Committee meeting with the Dean of the Medical School. After our first Dean’s Committee meeting I was proud of my contributions only to be chastised by our Clinical Director of Medicine who said: “Dr. Metsch, this is our meeting with the Dean not yours, you can meet with the Dean (your boss) whenever necessary, we only get to talk to him four times a year. It’s our agenda, not yours!”
A painful but important Lesson Learned which led me to constantly monitor committee work for the rest of my career.

Here are some more Committee Lessons Learned.
When I was an SVP (Office of the President) at Mount Sinai I had to remember that my role was different at every meeting. Meeting with the same people on different topics my role might range from full participant to minute taker.
Parenthetically I once had a staff member who always thought he was as important as the most important person in the room and spoke up accordingly. If he was in a meeting with the President of our organization, he acted presidential too.

I remember a meeting with a Board member who was a senior state legislator. I introduced several important issues and asked his assistance on them. He said: “Jonathan, there are ten people outside waiting to see me after our meeting. They all have important issues. So which one issue do you want me to help you with, and after we finish that please come back and raise the next most important one then.”
Parenthetically I once asked another Board member, also a senior state legislator why he had signed on to a bill that was not good for our hospital. He said: “Jonathan, I am part of the Leadership. Sometimes I can vote how I want but there are other times the Senate President directs the caucus on an issue. At the end of the day you should want me to be in the leadership group more than you are upset about one bill.”
Lesson Learned: when you are asking an influential to step in on an issue, make sure you understand the “demands” on that person and request support accordingly. Otherwise you may wind up with no gain.

If you raise ten great ideas at a meeting, no one will remember any of them. Be prepared by doing your homework and raise one sensational idea at a meeting, and everyone will remember.

I have served on numerous industry and community Boards. It is always easy to go to a few Committee meetings and quickly identify some “best practices” that would make a committee more effective. Share those ideas privately with the chairperson; never embarrass the chairperson publicly.
Parenthetically, when I was the CEO I once made a colossal mistake at a SVP/ VP staff meeting. One SVP caught it but he walked out of the meeting with the others at the end of the meeting, then circled back, explained my mistake which I quickly corrected.

Every project management committee meeting should end with scheduling the next meeting and clarifying individual assignments. Meeting notes should be produced quickly. And anyone with an assignment for the next meeting should send out reading material at least two days before the next meeting.
Parenthetically, always volunteer to write to write the Meeting Notes if the opportunity is there. This gives you a strategic role and earns you appreciation from the chairperson (particularly if the chairperson is higher up in the organization).

Never hijack someone else’s meeting because you would do things differently.

When someone makes a point that adds value never say “I was going to say that” when you didn’t speak up first.

When you chair a committee your job is to facilitate not dominate.

And at any meeting you learn more by listening than by talking. So pick your spots strategically.

“When in doubt, don’t call a meeting.” (source unknown)

“Meetings without an agenda are like a restaurant without a menu.” (Susan B. Wilson)

(A) Arthur Goldberg