September 19, 2003
Volume 47, Issue 38
WHA Pursues Systemic Hospital Survey Reform
WHA is undertaking an initiative to address the shortcomings of the existing hospital survey and certification process. Members have long expressed concerns about the process, including delays in having plans reviewed, varying interpretation of rules and lack of responsiveness by reviewers, lack of provider input into the process, and an overall sense that the process does not reflect today’s health care delivery system.
Rather than dealing with these issues separately, WHA is taking a fresh, comprehensive approach to reform the process in its entirety. This will require collaboration with the Department of Health and Family Services and the Centers for Medicare and Medicaid Services (CMS), which sets policy for the Medicare and Medicaid programs.
WHA will work with DHFS and CMS to gain a mutual understanding of each others needs and concerns along with current policies and procedures, and then work towards a redesign that addresses those concerns and maintains the important oversight role in the survey and certification process.
To start the initiative, WHA staff members Steve Brenton, Laura Leitch, and George Quinn together with Tim Size of the Rural Wisconsin Health Cooperative will meet with DHFS Secretary Helene Nelson in early October. Later in October, the same group will meet with individuals from CMS Region V to better understand what CMS requires from states as part of their delegation of review responsibilities.
WHA is energized about this new initiative, and is hopeful that the survey process will successfully be streamlined and modernized in the process. If you have questions regarding this initiative, contact George Quinn 608-274-1820 or gquinn@wha.org .
Quality Steering Committee Endorses Safety Goal Measuring Methodology
Approves Branding Package—Quality and Safety "CheckPoint"
The Wisconsin Quality Steering Committee met September 15 in Madison. Steering Committee Chair Chuck Shabino reviewed the mission of the committee, which is to develop a consumer-focused quality reporting initiative that is valid and reliable. He noted that embedded in the mission statement is the ability to measure quality and present it in such a way that it facilitates the hospital selection process as well as improvement within the hospitals.
Dana Richardson, WHA vice president of quality, said nearly 100 Wisconsin hospitals have either pledged or enrolled in the quality program.
Eric Stanchfield from the Wisconsin Employee Trust Fund, noted that they recently added language in their health plan contracts that requires the health plans to encourage participation in the WHA program, similar to the requirement for Leapfrog. In fact, he said, several plans benefited during the bidding process because of their exemplary efforts in patient safety. Stanchfield said it is their goal to "be on the same page as the hospital association, and we feel we are there."
Mary Kay Grasmick, vice president, communications, presented the branding package for the public reporting initiative. Tagged, "CheckPoint," she pointed out that the name lends itself to adding the words "Quality" and "Safety" to CheckPoint, until it becomes familiar enough to the public and providers that they know it refers to a source for quality and safety information about hospitals.
Terri Potter, chair of the Communications and Education Team (CET), which is charged with developing a communications plan for the CheckPoint program, provided an overview of the first CET meeting. Potter said the communication plan must clearly articulate the kind of data that is inside the box and what is outside.
Pat Schroeder, chair of the Measures Team, presented that group’s work to date. She said the Measures Team weighed two factors in their decisions: the need to provide useful information to the public that would allow apples-to-apples comparisons and the need to create a process that would not be so burdensome to hospitals that they would find it impossible to participate. Schroeder thanked Richardson for her work, stating that developing measures is not easy.
Schroeder described four components that will constitute each goal’s measure. They are:
For the goal to eliminate dangerous abbreviations, acronyms and symbols, the group recommended that hospitals chose their three improvement areas from the Institute of Safe Medication Practices list.
WHA President Steve Brenton noted that unlike the evidence-based clinical measures that were developed nationally, the safety measures are an unchartered area. He called the work of the measures team "admirable."
The group discussed what could be coming in the future as far as public reporting, and Brenton pointed out that Wisconsin hospitals will need to be aware of the drive for patient-centered reporting, and "stay in front" of reporting mechanisms like that as they are becoming a dominate theme in the IOM reports. The group agreed that using the IOM six aims of quality would serve as a broad framework for CheckPoint.
The Steering Committee will meet again in January 2004, when they will review the work of the Measures Team and the progress of the Communications and Education Team.
WHA Foundation Announces Global Vision Award Recipients
The WHA Foundation selected three programs for the 2003 Global Vision Community Partnership Award. The award was established in 1995 to recognize community partnership programs that meet the documented health needs of a community through creativity, innovation, and community collaboration. "I am constantly impressed with the quality of the projects that are submitted for this annual award," said Steve Young, WHA Foundation president. "Our hospitals do a great job of working to meet community health needs outside their doors, and this award is one way we acknowledge and celebrate these efforts," said Young.
Award winners will be recognized at a luncheon during the WHA Convention and will receive a commemorative plaque and an unrestricted grant of $2,000 to support the program. Selection criteria for the award includes: nomination by a WHA member; the program has been in existence for two years; addresses a documented community health need; constitutes a creative or innovative approach to meeting the need, includes a collaborative or partnership approach in the development and implementation; and produces measurable results. The award winning programs are:
Award Winner: Waukesha Hispanic Health Initiative
Nominator: ProHealth Care/Waukesha Memorial Hospital
Beginning in 1999, the Waukesha Hispanic Health Initiative is the result of collaborative partnerships among Waukesha Memorial Hospital, Waukesha Family Practice Program, and the Center for Healthy Communities of the Medical College of Wisconsin and La Casa de Esperanza to address primary care and behavioral health needs of the growing Hispanic community in Waukesha County. The project’s objectives include providing comprehensive, culturally appropriate care, linking the Hispanic population with primary care physicians, developing an Hispanic community health resource center and developing an Hispanic collaborative network.
Award Winner: IMPACT Child Development Screening Program
Nominator: Columbia St. Mary’s
This 10-year-old program was developed to identify children with hidden delays and medical problems and facilitate early treatment and intervention. The partners in the program include Children’s Outing Association, YMCA Family Center, Bay View Community Center, Milwaukee Health Department, Birth to Three Program and the Milwaukee Public Schools. A medical team composed of a physician, nurse, and speech, physical and occupational therapists provide assessments. Host sites promote the program availability, coordinate consents and provide space and privacy. In 2002-2003, IMPACT served 102 children at eight host sites.
Award Winner: Infinite Boundaries
Nominators: Affinity Health System and Franciscan Skemp Healthcare-Mayo Health System, La Crosse
Infinite Boundaries retreats are designed to help women heal emotionally, spiritually and physically from breast cancer. A program of the Breast Cancer Recovery Foundation since 1999, the retreats for breast cancer survivors serve to meet a gap, identified by the National Cancer Institute as "…surviving cancer can leave a host of problems in its wake. Physical, emotional and financial hardships often persist for years…" The retreats were created by Ann Haney, foundation founder, to assure that breast cancer survivors, in addition to receiving state of the art medical care, receive added support that family, friends and support groups cannot always provide. Affinity Health System and Franciscan Skemp have identified patients who would benefit from attending a retreat, provided scholarships and have served as retreat staff. Additional partners include Aurora Sinai Medical Center, SSM Healthcare of Wisconsin, Froedtert Memorial Lutheran Hospital and the Rural Wisconsin Health Cooperative. This program has positively impacted hundreds of cancer survivors across the state.
President’s Column -- Washington DC Issue Update
Here are a few thoughts and impressions that are the byproduct of meetings last week with members of the Wisconsin Congressional Delegation, as well as opinions expressed by others intimately involved "inside the Washington beltway."
Steve Brenton, President
Registration Deadlines Approach for State Bioterrorism Exercises
The registration deadlines are approaching for the First Annual Bioterrorism Preparedness Tabletop Exercises. Registration forms and instructions can be found on the PHIN (www.han.wisc.edu) in the "Bioterrorism>Hospitals (HRSA Grant)" topic area under "Wisconsin Regional Bioterrorism Preparedness Exercises."
Deadlines for registration are as follows:
Region 1: September 30, 2003, Turtleback Conference Center, Rice Lake -- Deadline: Sept. 15
Region 2: October 23, 2003, Westwood Center, Wausau -- Deadline: Oct. 1
Region 3: October 22, 2003, Comfort Suites, Green Bay -- Deadline: Oct. 1
Region 4: September 26, 2003, La Crosse Center, North Hall, La Crosse -- Deadline: Sept. 15
Region 5: November 7, 2003, Alliant Energy Center, Madison -- Deadline: Oct. 15
Region 6: October 14, 2003, Sunnyview Expo Center, Oshkosh -- Deadline: Oct. 1
Region 7: November 6, 2003, Washington Co. Fairgrounds, West Bend -- Deadline: Oct. 15
The HIPAA TCS Deadline is October 16
By Sarah Coyne, Attorney, Quarles & Brady LLC
The deadline for compliance with the HIPAA Transactions and Code Sets Standards (TCS) is October 16, 2003, less than one month away. All covered entities are required to test now, and be up and running by then. Providers probably have the most to lose if the system is faulty because claims may be rejected and payment delayed.
Here are some practical tips on TCS testing recommended by various industry experts:
In sum, to minimize delays in payment, maintain your organization’s cash flow and assure HIPAA compliance, get your testing on track now if you have not done so already. HIPAA does not allow any covered entity to accept or submit noncompliant transactions after October 16, 2003. For more information about HIPAA, contact Sarah Coyne at 608-283-2435 or your Quarles & Brady attorney.
A Special Thank You to Annual Convention Exhibitors
WHA wishes to thank the 42 exhibitors of the 2003 Annual Convention who graciously plan to contribute their time and resources to the convention. Stop by and visit with these exhibitors on Thursday, September 25, during meals and session breaks.
ACUTE CARE, INC.The Speaker’s Task Force on the Wisconsin Technical College System (WTCS) took its first step toward formulating recommendations during a September 16 session facilitated by UW Colleges Associate Vice Chancellor Greg Lampe. Members debated three previously identified issues: transfer of credits between the University of Wisconsin System and WTCS, course duplication, and state and local board accountability. A fourth issue - funding mix – was not addressed due to time constraints. The task force recognized other topics, such as WTCS governance structure, accessibility for students, and state educational and economic development priorities, which may require discussion as well.
Credit Transfer: Task force members stressed students’ need for a consistent, predictable and efficient credit transfer system. Members pointed to current efforts to establish a standardized nursing curriculum across WTCS and to collaborate with the UW system on the transfer of nursing credits as an example of how this can be done. This ongoing dialogue between the two systems was hailed as a model for other degree programs.
Duplication: Task force members agreed institutions should remain true to their missions, and discussed three potential areas of duplication; facilities, programs and geography. Members cited shared programs and facilities in some WTCS districts as evidence that duplication can be avoided. However, other members were concerned that these partnerships depend on working relationships that do not exist in all districts.
Accountability: Task force members struggled with the question of whether technical college district board members should be elected or appointed. Some members argued that elected officials are more accountable, while others said increasing the complexity of participation could limit those willing to serve. No consensus was reached. Still, members generally agreed review and possible revision of rules governing local board makeup is necessary.
The task force will continue its discussion on October 7. Co-chairs Reps. Suzanne Jeskewitz (R- Menomonee Falls) and Gary Bies (R-Sister Bay) hope to finalize recommendations to Assembly Speaker John Gard (R-Peshtigo) by the end of October. The 15-member task force includes Tomah Memorial Hospital CEO Phillip Stuart. For more information, contact Jodi Jensen or Judy Warmuth at 608-274-1820 or jjensen@wha.org or jwarmuth@wha.org .
Register Now for October 14 Seminar: Understanding Government Enforcement Actions
"Effective Self-Disclosure and Avoiding Fraud & Abuse Investigations"
Avoiding potential serious government enforcement action is the focus of a WHA seminar "The Power and Art of Self-Disclosure and What To Do When The Feds Come Calling At Your Hospital." The seminar will be October 14 at the Stevens Point Holiday Inn from 10 to 3.
The dual focus of the seminar allows participants to gain an understanding of the benefits of effective self-disclosure compliance strategies, and they will learn how to implement a proactive self-disclosure philosophy within the facility. Additionally, the seminar will reveal the content of federal fraud and abuse investigations, appropriate responses, and how to develop a plan of action if hospitals find themselves as a subject in an investigation.
The seminar is intended for compliance officers, risk managers, in-house counsel, chief financial officers, and executive management. The registration fee is $159. Registrations are still being accepted for this seminar, with registration materials available on the Web site at www.wha.org. On-line registration is also available for this seminar.
For more information on program content, contact Jennifer Frank at 608-274-1820 or jfrank@wha.org . For registration questions, contact Bridget Gifford at 608-274-1820 or bgifford@wha.org .
St. Mary’s Lambeau Field Gala Raises $450,000 for Hospital -- Dignitaries Include Thompson, Doyle, Sherman, Favre, and Starr
On September 5, 2003, the Lambeau Field Inaugural Ball raised $450,000 for the endowment of St. Mary’s Hospital Medical Center in Green Bay. St. Mary’s Hospital Administrator Jim Coller said the gala "was probably one of the largest fund-generating events for a hospital in the entire country."
Nearly 800 guests attended including dignitaries like U.S. Secretary of Health and Human Services and former Wisconsin Governor Tommy Thompson, Governor Jim Doyle, Packers Coach Mike Sherman, former general manager Ron Wolf, quarterback Brett Favre and former Packers quarterback and coach Bart Starr.
Fifteen Sisters of the Hospital Sisters Health System, the order that runs St. Mary’s Hospital, socialized and dined with Packers players Mark Tausher, Marco Rivera and Donald Driver, among others. Sister Mary Beth Culnan, Wisconsin regional vice president of HSHS, said the Sisters "are all so happy to have been a part of the gala and are very proud of the Packers and St. Mary’s Hospital."
Shawano Medical Center CEO John Kestly Announces His Retirement
Shawano Medical Administrator/Chief Executive Officer (CEO) John Kestly has announced his retirement after nearly 14 years in the position. His retirement takes effect October 6.
Kestly started as CEO in November 1989, and has overseen many significant improvements. He said he is especially proud of the excellent team of employees, physicians, board members, volunteers, and auxiliary members that have been assembled during his tenure. Kestly was a valued member of WHA, having served on the Rural Health Council from 1990-1995 and on the Board of Directors from 2002-2003.
"I have had a very successful run in a challenging position. The average hospital CEO usually stays at one hospital 5-7 years. I am pleased that our quality, customer service and financial benchmarks all exceed the hospital industry standards. It speaks well for the fine people that are associated with SMC," Kestly said.
Dunlop Ecker will serve as interim CEO until a permanent replacement is recruited.
Wisconsin Physician Named Patient Safety Leadership Fellow
Matthew Scanlon, MD has been named a Patient Safety Leadership Fellow by the Health Forum/AHA and The National Patient Safety Foundation. The Patient Safety Leadership Fellowship program is a yearlong intensive learning experience for senior leaders committed to advancing the science of patient safety in health care. The program provides the tools and methodologies needed to develop and implement strategies and practices to improve patient safety in health systems.
Scanlon is the program director of patient safety at Children’s Hospital of Wisconsin, serves as an assistant professor of pediatrics (critical care) at the Medical College of Wisconsin, and is on the associate faculty for the National Outcomes Center. His special interests include patient safety and the safety of medical devices and products.
Ronk Resigns from Brown County Human Services Department
Earlene Ronk, longtime administrator for the Brown County Mental Health Center, has resigned effective October 10. Beginning October 21, Ronk will be the administrator of a new Jefferson County nursing home.
Milwaukee RN Receives Award of Excellence
NurseWeek magazine recently named Beth Hammer, MSN, APNP, RN at the Clement J. Zablocki VA Medical Center a 2003 Nursing Excellence Award Winner. Hammer has spent her professional life at the VA, and praises the hospital system for being at the forefront of a number of practice settings, including telemedicine. In her interview in NurseWeek magazine, Hammer affirmed her belief in nursing by commenting, "Even on my worst days, there’s always been a patient who has somehow touched my spirit and made me feel that this is where I should be."