Better Care, Lower Cost - Atul Gawande in the New Yorker. This article interested me because it is exactly what I hope for in pushing for a restructuring the Healthcare District (not the specific technique described here, but the concept that better outcomes are possible while saving money.)
I used to teach economics 101 and one of the first concepts that is covered is the production possibility frontier. The idea is that a rational economy will produce goods and services so that no more of any one good can be produced without sacrificing production in another area (ofter referred to as guns or butter). In economics 101, the modern capitalist economy always produces on the ppf and never inside the ppf because if production was inside the ppf then free lunch would be a reality and TINSTAAFL is an axiom for many economists. Well, in US healthcare, there are a lot of free lunches because the system is so dysfunctional; here is just one example called "hotspotting".
Monday, January 31, 2011
Thursday, January 27, 2011
This is Uncivil?
I had some questions about the financial packets. I just fired them off to the person I thought could best answer them. The message below was viewed far and wide by Hospital staff as being rude and belittling. If that is the case, then I need to recalibrate because although I would say it was short and direct, it was not meant to be rude or belittling, I was just trying to understand the fortunate turnaround in the trajectory of the Hospital's income. I can see some umbrage about the survival question, but since I am fiercely interested in public health policy and a hot topic of debate in that arena is the cost of futile end-of-life care, I just added it on because I was curious and not with any agenda or underlying attitude.
So it looked like ICU days in those two months totaled somewhere around 100 days over budget. Is that correct? What was the contribution of those to the good results in those two months? What is the unit contribution margin of an ICU day? Is there any chance that the 3rd party payers (I assume that these were not private pay) may challenge the medical necessity of the ICU days or is that unheard of? Qualitatively are we looking at a general surge in ICU usage or one or two patients who had extraordinarily long stays? If it is the latter, I guess I have to ask if they survived? How much variance, in general, is there in the ADC in the ICU. Is this two month period the best (worst?) ADC for the ICU vs. budget in the last year, the last 5 years, the last 10 years?
Thanks,
Elliott
Wednesday, January 26, 2011
My Views on the Board Majority (and Hospital Management)
It may seem unusual that I, the newest member of the Hospital Board, do not trust the judgment of those who have served longer. Another thing that should cause me pause in the great deal of confidence I have in my views is the fact that I am in the distinct minority of those who have a say (not necessarily of Alamedans). There is a reason that I do not give much currency to these opposing views. In most of the circumstances where I have bothered to pay attention, the Board and Management have been wrong.
1. The Board and Management were objectively wrong about their chance of retaining the Kaiser contract. Kaiser was clear upon entering into the agreement that they planned to take back those services when the contract term ended. Throughout the term of the contract, they pursued a program of building and renovation at Kaiser Oakland that supported the goal of taking back those services. Kaiser's policy and practice has always been to retain services in-house where possible. What possible hope did the Board and management think they had to extend or renew the Kaiser contract? I can only assume that they felt it was inappropriate to tell the truth about the prospects of retention until the last possible moment. That misrepresentation of what anyone who paid attention could easily conclude either speaks to a lack of awareness or a lack of transparency (or some fantastic, last-minute change of mind by Kaiser - first in considering staying at the Hospital in contravention to every public indication that they would not and then a reversal to leave after all).
2. The Board and Management were objectively wrong about care for acute stroke. When the situation was first brought to the attention of the public by Denise Lai, both Debbi Stebbins and Jordan Battani strenuously defended the Hospital and argued for a continuation of a dangerous policy. It took less than 60 days and only one meeting for Alameda County to change the EMS manual. Anyone familiar with the pace that these changes are generally made will understand that this change was done emergently because the current policy was simply indefensible. Yet every member of the Board endorsed the view that the exception policy should have continued. This shows a real lack of good sense as well as a lack of concern for the health of Alamedans.
3. The Board and Management have been objectively wrong about the Hospital's financial capacity. That is most important in the context of meeting the state mandated seismic retrofit requirements. I still am not sure why the OSHPD has decided not to enforce the clearly stated 1/1/2002 deadline for NPC-2 or higher certification, but it is clear that Alameda Hospital is in technical violation of the law and, theoretically, is subject to being shut down at any moment. Regardless, the Hospital will not be able to meet the 1/1/2013 requirement without obtaining financing which they have finally admitted is not likely to materialize. Over a million dollars has already been spent on this plan while it was obvious that financing was not a viable option to anyone who was paying attention. Technically, in its recent report to the state where the Hospital acknowledged its inability to meet the 2013 deadline, it created a default condition on any extensions offered to the original 1/1/2008 deadline. In other words, the Hospital is in double jeopardy of being shut down for being non-compliant with clearly written regulations. Only the forbearance of the State of California keeps the doors open and it is questionable whether that forbearance is, in itself, a violation of the law. It seems wrong to me for me to trust those who have maintained faith in what I consider a misguided plan for so long.
4. The Board and Management on several occasions played fast and loose with Brown Act notice requirements. They continue to offer, in my opinion, too little information about closed session agenda items in the short description. On several occasions, verifiably untrue statements were made to me by CEO Stebbins. Others are free to interpret this as unintentional, but I am of the opinion that there was more to it than that and would have to label those statements as lies. In addition, the failure to attempt to avoid violation of at least the spirit if not the letter of the Brown Act (which they may have been able to do since I never actually called for formal correction of the issues I raised) seems to me to be another reason it is good policy to be weary of placing trust in my fellow Board members and Hospital management.
5. Finally, I have to mention the most compelling argument, for me personally, against trusting the majority of my fellow Board members and that is their support of Leah Williams. They chose her to be appointed in 2009. They endorsed her in the November, 2010 election. And they said nothing when she acted so detestably after the election - not even private sympathy, much less any kind of condemnation of her personal attacks on me. They continue to say nothing when someone, in the course of a discussion about changing the tone, actually resurrects and endorses those claims (although Lauren Do would have handled it differently? doubtful given how loathsomely she acted when she took offense at being called out for simply being termed cliquish). I certainly cannot trust people (Leah Williams) who declare through their actions that their aim is to destroy me and I will be very weary of those who stand silent in the face of such actions.
I think there are positive things a healthcare district can offer Alameda, but I have not seen evidence to my satisfaction that the current Board majority and management have the skills to chart that course. So it may seem arrogant to many that I maintain my own counsel versus deferring to the more experienced majority, but I think it would be foolish to trust the collective judgment of the Board/management given the above.
1. The Board and Management were objectively wrong about their chance of retaining the Kaiser contract. Kaiser was clear upon entering into the agreement that they planned to take back those services when the contract term ended. Throughout the term of the contract, they pursued a program of building and renovation at Kaiser Oakland that supported the goal of taking back those services. Kaiser's policy and practice has always been to retain services in-house where possible. What possible hope did the Board and management think they had to extend or renew the Kaiser contract? I can only assume that they felt it was inappropriate to tell the truth about the prospects of retention until the last possible moment. That misrepresentation of what anyone who paid attention could easily conclude either speaks to a lack of awareness or a lack of transparency (or some fantastic, last-minute change of mind by Kaiser - first in considering staying at the Hospital in contravention to every public indication that they would not and then a reversal to leave after all).
2. The Board and Management were objectively wrong about care for acute stroke. When the situation was first brought to the attention of the public by Denise Lai, both Debbi Stebbins and Jordan Battani strenuously defended the Hospital and argued for a continuation of a dangerous policy. It took less than 60 days and only one meeting for Alameda County to change the EMS manual. Anyone familiar with the pace that these changes are generally made will understand that this change was done emergently because the current policy was simply indefensible. Yet every member of the Board endorsed the view that the exception policy should have continued. This shows a real lack of good sense as well as a lack of concern for the health of Alamedans.
3. The Board and Management have been objectively wrong about the Hospital's financial capacity. That is most important in the context of meeting the state mandated seismic retrofit requirements. I still am not sure why the OSHPD has decided not to enforce the clearly stated 1/1/2002 deadline for NPC-2 or higher certification, but it is clear that Alameda Hospital is in technical violation of the law and, theoretically, is subject to being shut down at any moment. Regardless, the Hospital will not be able to meet the 1/1/2013 requirement without obtaining financing which they have finally admitted is not likely to materialize. Over a million dollars has already been spent on this plan while it was obvious that financing was not a viable option to anyone who was paying attention. Technically, in its recent report to the state where the Hospital acknowledged its inability to meet the 2013 deadline, it created a default condition on any extensions offered to the original 1/1/2008 deadline. In other words, the Hospital is in double jeopardy of being shut down for being non-compliant with clearly written regulations. Only the forbearance of the State of California keeps the doors open and it is questionable whether that forbearance is, in itself, a violation of the law. It seems wrong to me for me to trust those who have maintained faith in what I consider a misguided plan for so long.
4. The Board and Management on several occasions played fast and loose with Brown Act notice requirements. They continue to offer, in my opinion, too little information about closed session agenda items in the short description. On several occasions, verifiably untrue statements were made to me by CEO Stebbins. Others are free to interpret this as unintentional, but I am of the opinion that there was more to it than that and would have to label those statements as lies. In addition, the failure to attempt to avoid violation of at least the spirit if not the letter of the Brown Act (which they may have been able to do since I never actually called for formal correction of the issues I raised) seems to me to be another reason it is good policy to be weary of placing trust in my fellow Board members and Hospital management.
5. Finally, I have to mention the most compelling argument, for me personally, against trusting the majority of my fellow Board members and that is their support of Leah Williams. They chose her to be appointed in 2009. They endorsed her in the November, 2010 election. And they said nothing when she acted so detestably after the election - not even private sympathy, much less any kind of condemnation of her personal attacks on me. They continue to say nothing when someone, in the course of a discussion about changing the tone, actually resurrects and endorses those claims (although Lauren Do would have handled it differently? doubtful given how loathsomely she acted when she took offense at being called out for simply being termed cliquish). I certainly cannot trust people (Leah Williams) who declare through their actions that their aim is to destroy me and I will be very weary of those who stand silent in the face of such actions.
I think there are positive things a healthcare district can offer Alameda, but I have not seen evidence to my satisfaction that the current Board majority and management have the skills to chart that course. So it may seem arrogant to many that I maintain my own counsel versus deferring to the more experienced majority, but I think it would be foolish to trust the collective judgment of the Board/management given the above.
Sunday, January 23, 2011
My View of the Healthcare District
I have been following the Hospital since I first applied to be appointed to the original Board in 2002. At that time, the Hospital was losing significant amounts, but had a strong balance sheet and almost no debt. I was somewhat ambivalent about the District, but persuaded by the arguments regarding the isolation of the Island along with a (mistaken) belief that the subsidy was intended to be a short term fix so that the long-term structural problems could be addressed. At the time, the supporters of the Hospital estimated that seismic retrofit would cost about $1 million.
At the first meeting in 2002, it was surprising to find the Hospital was in much better shape financially than the voters had been led to believe. Nonetheless, the Board voted to impose the full amount of the parcel tax. (I spoke at that first meeting asking them to evaluate the needs of the Hospital rather than just imposing the maximum tax.) This approach continued for the next 8 years. No non-incumbent was ever publicly elected to the Board. In 2008, the number of candidates running were equal to the number of seats so the race did not even appear on the ballot (and some new blood was added in the person of Mr. McCormick, but Mr. McCormick is intimately tied to the political power structure in Alameda so it's unclear how new his perspective was). To my knowledge, no vote until after my election to the Board has ever been by anything but consensus and if anyone wants to correct me, I'd love to hear about whatever issue actually caused any kind of controversy.
The appointment process during this time was just as sclerotic (thank you Steve Rogers for that word). Jordan Battani talks about how that process was a transparently open and robust debate, but I have a different opinion. For example, within 2 minutes of hearing Leah Williams begin her presentation back in 2009, I knew that she had been pre-selected to be the appointee. James Oddie was sitting right next to me; I think I wrote a note to him that indicated who I thought would be selected. I felt sorry for Mr. Oddie because he had been induced to apply by Rob Bonta, and I think he thought he had a chance, but the cards were stacked against him. I had no illusions and was simply being quixotic when I applied. Stewart Chen, the only person who had pulled paperwork before the Board decided to extend the deadline, had no chance to be appointed at that time. He, along with me, are now both sitting members.
The major issues facing the Hospital have not changed since 2002 and I have detailed them in previous posts. The things that have changed most remarkably are three things. Standards of care consistently move forward requiring new resources of both the financial and human variety to keep pace (which the hospital is in no position to accomplish easily). The financial picture of the Hospital has deteriorated significantly as evidenced by the fact that there was only $72,000 in cash at one point this year. The seismic requirements have not been met and, it appears, cannot be met by the legally mandated deadlines.
Based on the above, there is no way that I would vote to form the Healthcare District today. Whether I was deliberately misled by the campaign in 2002 or history just took an unfortunate course, circumstances have changed radically. The majority of the Board (and several previous Board members) have suggested that great deference is due the 2002 vote, but given what has happened over the last eight years and the misrepresentations (perhaps unintentional) made in the original campaign, I think that is mostly an argument that is simply used to justify their prejudice.
If you have read this far, then perhaps you are interested in an actual discussion rather than loathsome personal attacks. I welcome alternative viewpoints in the comments.
At the first meeting in 2002, it was surprising to find the Hospital was in much better shape financially than the voters had been led to believe. Nonetheless, the Board voted to impose the full amount of the parcel tax. (I spoke at that first meeting asking them to evaluate the needs of the Hospital rather than just imposing the maximum tax.) This approach continued for the next 8 years. No non-incumbent was ever publicly elected to the Board. In 2008, the number of candidates running were equal to the number of seats so the race did not even appear on the ballot (and some new blood was added in the person of Mr. McCormick, but Mr. McCormick is intimately tied to the political power structure in Alameda so it's unclear how new his perspective was). To my knowledge, no vote until after my election to the Board has ever been by anything but consensus and if anyone wants to correct me, I'd love to hear about whatever issue actually caused any kind of controversy.
The appointment process during this time was just as sclerotic (thank you Steve Rogers for that word). Jordan Battani talks about how that process was a transparently open and robust debate, but I have a different opinion. For example, within 2 minutes of hearing Leah Williams begin her presentation back in 2009, I knew that she had been pre-selected to be the appointee. James Oddie was sitting right next to me; I think I wrote a note to him that indicated who I thought would be selected. I felt sorry for Mr. Oddie because he had been induced to apply by Rob Bonta, and I think he thought he had a chance, but the cards were stacked against him. I had no illusions and was simply being quixotic when I applied. Stewart Chen, the only person who had pulled paperwork before the Board decided to extend the deadline, had no chance to be appointed at that time. He, along with me, are now both sitting members.
The major issues facing the Hospital have not changed since 2002 and I have detailed them in previous posts. The things that have changed most remarkably are three things. Standards of care consistently move forward requiring new resources of both the financial and human variety to keep pace (which the hospital is in no position to accomplish easily). The financial picture of the Hospital has deteriorated significantly as evidenced by the fact that there was only $72,000 in cash at one point this year. The seismic requirements have not been met and, it appears, cannot be met by the legally mandated deadlines.
Based on the above, there is no way that I would vote to form the Healthcare District today. Whether I was deliberately misled by the campaign in 2002 or history just took an unfortunate course, circumstances have changed radically. The majority of the Board (and several previous Board members) have suggested that great deference is due the 2002 vote, but given what has happened over the last eight years and the misrepresentations (perhaps unintentional) made in the original campaign, I think that is mostly an argument that is simply used to justify their prejudice.
If you have read this far, then perhaps you are interested in an actual discussion rather than loathsome personal attacks. I welcome alternative viewpoints in the comments.
Friday, January 21, 2011
Community Relations and Finance Committee Next Week
Agendas posted on website. The packet for the Community Relations meeting is available and Finance should be on Monday. I will be interested in the financials of course. Stebbins already reported that November had positive income (after parcel tax subsidy) and I expect the same will be true for December given the fact that Stebbins also reported census numbers up for December. I will be interested in cash flows as well as income. The CFO's and CEO's report have some interesting items. No closed session (I can't recall how frequently the finance committee goes into closed session).
EDITED to add: One thing I want to look at also is to see if there is any chance there might be a problem or a need for special planning to make sure the Hospital has the funds to send to the state for the Medi-Cal intergovernmental transfer (IGT) that comes back with matching funds. It is a "free" money for the Hospital, but it would be good to know if there is any chance of a cash flow problem so that can be planned for appropriately. I think somewhere around 2.5 million is needed to be available for 30 - 60 days, but I'm sure the CFO will be able to answer definitively.
EDITED to add: One thing I want to look at also is to see if there is any chance there might be a problem or a need for special planning to make sure the Hospital has the funds to send to the state for the Medi-Cal intergovernmental transfer (IGT) that comes back with matching funds. It is a "free" money for the Hospital, but it would be good to know if there is any chance of a cash flow problem so that can be planned for appropriately. I think somewhere around 2.5 million is needed to be available for 30 - 60 days, but I'm sure the CFO will be able to answer definitively.
What's Important
It would be easy to get into a back and forth with people acting loathsomely, but fruitless.
The top things about the Hospital to keep in mind:
1. The Hospital is on tenuous legal ground. There was a January 1, 2002 deadline for certain seismic improvements that was never met. There has been no extension or waiver of that deadline. OSHPD has declined to enforce.
2. Care is subpar. What numbers are publicly available demonstrate this. I urge you to check them out. The difference between Alameda Hospital's stroke mortality and the currently stroke certified hospitals represents real lives. In general, volume = better quality in healthcare and Alameda is too small to generate enough volumes to provide anything other than subpar care.
3. The Hospital operates at a loss. Whether the level of that loss is above or below the parcel tax subsidy varies, but it loses money every month.
4. The Hospital cannot get financing for the state mandated improvements because of its financial position. In addition, the ability of the Hospital to finance any new service (such as wound care) or care initiative (such as PACS) is hampered by the terrible financial position.
So look past my personal issue with some people, who by their actions seem to me to be detestable, and examine whether the Hospital is accomplishing its mission since Alamedans are the owners of the Hospital and each parcel pays $298 per year to keep the doors open.
The top things about the Hospital to keep in mind:
1. The Hospital is on tenuous legal ground. There was a January 1, 2002 deadline for certain seismic improvements that was never met. There has been no extension or waiver of that deadline. OSHPD has declined to enforce.
2. Care is subpar. What numbers are publicly available demonstrate this. I urge you to check them out. The difference between Alameda Hospital's stroke mortality and the currently stroke certified hospitals represents real lives. In general, volume = better quality in healthcare and Alameda is too small to generate enough volumes to provide anything other than subpar care.
3. The Hospital operates at a loss. Whether the level of that loss is above or below the parcel tax subsidy varies, but it loses money every month.
4. The Hospital cannot get financing for the state mandated improvements because of its financial position. In addition, the ability of the Hospital to finance any new service (such as wound care) or care initiative (such as PACS) is hampered by the terrible financial position.
So look past my personal issue with some people, who by their actions seem to me to be detestable, and examine whether the Hospital is accomplishing its mission since Alamedans are the owners of the Hospital and each parcel pays $298 per year to keep the doors open.
Thursday, January 20, 2011
Navel Gazing
Begin
So because I am requesting an apology from Lauren Do because she has acted loathesomely, because I find that Lena Tam should have been ashamed (and the people of Alameda should have been ashamed of her) in using bcc to cozy up to, what I consider, an inappropriate political ally at SunCal, because I think that it is ridiculous to pay a tax to keep an underpreforming hospital open, because I think that when an announcement of a closed session action is a surprise to many that is sort of, a priori (a favorite phrase of mine), an indication that notice was insufficient, and because I find the cliquishness of the CADC to be damaging, I think that many may have made some assumptions about my political leanings that are inaccurate. To clear the air:
1. I think the Hospital should be closed. It's bad for Alameda.
2. I am generally in favor of development. Unfortunately, the development is going to be overseen by people who want Alameda Hospital to stay open and who proclaim it a success. That's a sign of incompetence right there so I mistrust those people. Also, unfortunately, the set of people who are of the same opinion as me - anti Alameda Hospital and pro development is either very small or (more likely) smart enough to not get involved in politics.
3. I favor measure A. This is self-interest because I own a home and have 2 kids, but it is also a political philosophy that borders on socialism. I think there should be free public education up to and including university (with heavy income taxes to pay for it). Ditto for healthcare. We briefly went the private school route in the past and have considered homeschooling. I'm pretty sure there is no single answer that works for everyone, but I think starving our schools of resources in the hopes of cutting out inefficiency is a really bad mistake. I don't think teachers are generally overpaid although I think that there are a lot of less than stellar ones, but in what organization is that not true?
4. I don't really have an opinion about the pay of police and firemen except to say that there is no way that they are underpaid and I think that the current structure (including overtime, pension, and healthcare benefits) is likely to bankrupt Alameda and almost every other city in California. Someone will have to take the unpopular position in opposition; that is unlikely to happen and, if it does, I think it likely will be by someone whose other political positions I am unlikely to support so that is a quandary for me.
5. As to state and national issues, you can pretty much assume I am to your left.
End
I will try to keep the non-hospital stuff to a minimum.
So because I am requesting an apology from Lauren Do because she has acted loathesomely, because I find that Lena Tam should have been ashamed (and the people of Alameda should have been ashamed of her) in using bcc to cozy up to, what I consider, an inappropriate political ally at SunCal, because I think that it is ridiculous to pay a tax to keep an underpreforming hospital open, because I think that when an announcement of a closed session action is a surprise to many that is sort of, a priori (a favorite phrase of mine), an indication that notice was insufficient, and because I find the cliquishness of the CADC to be damaging, I think that many may have made some assumptions about my political leanings that are inaccurate. To clear the air:
1. I think the Hospital should be closed. It's bad for Alameda.
2. I am generally in favor of development. Unfortunately, the development is going to be overseen by people who want Alameda Hospital to stay open and who proclaim it a success. That's a sign of incompetence right there so I mistrust those people. Also, unfortunately, the set of people who are of the same opinion as me - anti Alameda Hospital and pro development is either very small or (more likely) smart enough to not get involved in politics.
3. I favor measure A. This is self-interest because I own a home and have 2 kids, but it is also a political philosophy that borders on socialism. I think there should be free public education up to and including university (with heavy income taxes to pay for it). Ditto for healthcare. We briefly went the private school route in the past and have considered homeschooling. I'm pretty sure there is no single answer that works for everyone, but I think starving our schools of resources in the hopes of cutting out inefficiency is a really bad mistake. I don't think teachers are generally overpaid although I think that there are a lot of less than stellar ones, but in what organization is that not true?
4. I don't really have an opinion about the pay of police and firemen except to say that there is no way that they are underpaid and I think that the current structure (including overtime, pension, and healthcare benefits) is likely to bankrupt Alameda and almost every other city in California. Someone will have to take the unpopular position in opposition; that is unlikely to happen and, if it does, I think it likely will be by someone whose other political positions I am unlikely to support so that is a quandary for me.
5. As to state and national issues, you can pretty much assume I am to your left.
End
I will try to keep the non-hospital stuff to a minimum.
Wednesday, January 19, 2011
Just an Observation
I'm proud to say that I was the only person who defeated a City of Alameda Democratic Club endorsed candidate in the November, 2010 election.
The endorsement list:
Mayor - Gilmore (check)
City Council - Bonta, Tam (check, check)
BART - Raeburn (check)
School Board - McMahon, Sheratt (check, check)
AC Transit - Ortiz, Young (check, check)
Healthcare District Board - Chen, Williams (check, ----)
Now I am an evidence driven kind of person. That looks like good evidence to me.
The endorsement list:
Mayor - Gilmore (check)
City Council - Bonta, Tam (check, check)
BART - Raeburn (check)
School Board - McMahon, Sheratt (check, check)
AC Transit - Ortiz, Young (check, check)
Healthcare District Board - Chen, Williams (check, ----)
Now I am an evidence driven kind of person. That looks like good evidence to me.
Thursday, January 13, 2011
More Complete Notes
Agenda and materials
1. Quality issues are only covered in Closed Session. This is allowed by the Brown Act but certainly not required. I have requested an agenda item for a public summary of Quality metrics that the Hospital reports and which ones are accessible to the public (and where). This would also include a discussion of why the Hospital has chosen not to participate in the California Healthcare Foundation reporting.
(February may be too full for this discussion.)
2. Nothing of note in the consent calendar.
3. I am the Secretary of the District which makes me Keeper of the Seal.
4. The meeting dates were approved.
5. I will be on the Board Quality Committee. I won't be able to say much without running up the Hospital's legal bill by constantly asking Mr. Driscoll for clearance so I probably will choose to say almost nothing. I find the current Quality reporting difficult to work with, but that might be my own limitation, newness to the Board, and the fact that more in depth analysis will happen within the Committee. The Brown Act is so comprehensive that it is even hard for me to write that without being wary.
6. The Primary Stroke Certification discussion was not pretty. See my notes below and Denise Lai's summary. Dr. Deutsch brought up his father again who at the Cardinal Point candidate's forum had had a stroke and at the Board meeting it seemed like it was just symptoms of a stroke. I'm not sure anymore and I don't know what it has to do with the discussion. I really mean that. First, one incident is hardly a basis for a decision. You don't ask the lottery winner if playing the lottery is a good idea or (when mandatory seat belt laws were being debated everyone had a friend of a friend who this happened to ) the guy safely thrown free of a car wreck if he should have worn a seat belt. Also, do you really think the quality of care, the diligence, the speed at which orders are written, labs done and imaging completed are going to be the same for your average Alamedan vs. Dr. Deutsch's father? I'll say it again. I think the evidence is lacking to consider Alameda Hospital a good choice for stroke care. I think the logical inference of the studies I am aware of is that there are better alternatives even if they require a longer trip to get to (and the OSHPD mortality numbers would imply the same).
7. Compensation survey. Well, the Board is spending money to come to the conclusion that Debi Stebbins is underpaid, but that we simply can't afford to raise her compensation to the market rate so we will give her none or a nominal raise (and nominal here would still mean thousands of dollars). That's why you hire consultants - to tell you what you want to hear - and the Board and Ms. Stebbins wants to hear that. My answers when interviewed will probably be outliers. I wonder if anyone of my fellow Board members will be clever enough to suggest that she should get MORE money because she has to deal with me.
8. Electronic devices. No outside communication on Board business and we should all pay rapt attention. When I am on the computer during the meeting, I am usually gathering data. During the stroke discussion I was searching PubMed for articles relevant to the discussion, but noone actually wanted to discuss real evidence.
9. CEO reported on how great the stroke certification process is and how careful the JC is in issuing stroke certification. I will just excerpt something I wrote to someone who actually cares about healthcare outcomes, "Common sense suggests that if every organization is capable of meeting a standard then it is simply a minimum rather than any measure of quality."
10. More sick people = better financial performance. The November interim results were plus 72,000 and the ytd loss of the hospital is only 189,000 although I think that is astill bout a half million below budget and, even in the best month so far this year, not enough to support financing for the seismic retrofit. I also want to see cahs flow numbers since the hospital is capitalizing retrofit work, but that still costs dollars.
11. Too much money contributed to Debi Stebbins pension plan. Hospital gets about 25k back to defer the negative actuarial balance currently in the plan and reduce the amount of future contributions.
12. The Hospital is operating illegally. Noone cares. Other hospitals throughout the state are also in the same boat. OSHPD has not responded to my request for more information on this issue.
In short, the Hospital is still a mess and the Board cannot conceive of the only rational course of action which is to plan for a radical change.
1. Quality issues are only covered in Closed Session. This is allowed by the Brown Act but certainly not required. I have requested an agenda item for a public summary of Quality metrics that the Hospital reports and which ones are accessible to the public (and where). This would also include a discussion of why the Hospital has chosen not to participate in the California Healthcare Foundation reporting.
(February may be too full for this discussion.)
2. Nothing of note in the consent calendar.
3. I am the Secretary of the District which makes me Keeper of the Seal.
4. The meeting dates were approved.
5. I will be on the Board Quality Committee. I won't be able to say much without running up the Hospital's legal bill by constantly asking Mr. Driscoll for clearance so I probably will choose to say almost nothing. I find the current Quality reporting difficult to work with, but that might be my own limitation, newness to the Board, and the fact that more in depth analysis will happen within the Committee. The Brown Act is so comprehensive that it is even hard for me to write that without being wary.
6. The Primary Stroke Certification discussion was not pretty. See my notes below and Denise Lai's summary. Dr. Deutsch brought up his father again who at the Cardinal Point candidate's forum had had a stroke and at the Board meeting it seemed like it was just symptoms of a stroke. I'm not sure anymore and I don't know what it has to do with the discussion. I really mean that. First, one incident is hardly a basis for a decision. You don't ask the lottery winner if playing the lottery is a good idea or (when mandatory seat belt laws were being debated everyone had a friend of a friend who this happened to ) the guy safely thrown free of a car wreck if he should have worn a seat belt. Also, do you really think the quality of care, the diligence, the speed at which orders are written, labs done and imaging completed are going to be the same for your average Alamedan vs. Dr. Deutsch's father? I'll say it again. I think the evidence is lacking to consider Alameda Hospital a good choice for stroke care. I think the logical inference of the studies I am aware of is that there are better alternatives even if they require a longer trip to get to (and the OSHPD mortality numbers would imply the same).
7. Compensation survey. Well, the Board is spending money to come to the conclusion that Debi Stebbins is underpaid, but that we simply can't afford to raise her compensation to the market rate so we will give her none or a nominal raise (and nominal here would still mean thousands of dollars). That's why you hire consultants - to tell you what you want to hear - and the Board and Ms. Stebbins wants to hear that. My answers when interviewed will probably be outliers. I wonder if anyone of my fellow Board members will be clever enough to suggest that she should get MORE money because she has to deal with me.
8. Electronic devices. No outside communication on Board business and we should all pay rapt attention. When I am on the computer during the meeting, I am usually gathering data. During the stroke discussion I was searching PubMed for articles relevant to the discussion, but noone actually wanted to discuss real evidence.
9. CEO reported on how great the stroke certification process is and how careful the JC is in issuing stroke certification. I will just excerpt something I wrote to someone who actually cares about healthcare outcomes, "Common sense suggests that if every organization is capable of meeting a standard then it is simply a minimum rather than any measure of quality."
10. More sick people = better financial performance. The November interim results were plus 72,000 and the ytd loss of the hospital is only 189,000 although I think that is astill bout a half million below budget and, even in the best month so far this year, not enough to support financing for the seismic retrofit. I also want to see cahs flow numbers since the hospital is capitalizing retrofit work, but that still costs dollars.
11. Too much money contributed to Debi Stebbins pension plan. Hospital gets about 25k back to defer the negative actuarial balance currently in the plan and reduce the amount of future contributions.
12. The Hospital is operating illegally. Noone cares. Other hospitals throughout the state are also in the same boat. OSHPD has not responded to my request for more information on this issue.
In short, the Hospital is still a mess and the Board cannot conceive of the only rational course of action which is to plan for a radical change.
Tuesday, January 11, 2011
Placeholder on 1/10 Meeting Notes
I will have more to say when I have more time but the two big things to come out of last night's meeting are:
1. The Hospital and Board are fully committed to treating stroke patients at the Hospital. The thought that Alameda Hospital provides subpar care is just so foreign to them that it is impossible to contemplate. The thought that the Board might dictate clinical direction is so frustrating to Jordan Battani that she almost lost her cool. I admit it is ridiculous for it to come to this, but the Hospital is perfectly happy hurting people because they are not able to admit that they are not the greatest in the world, (nor California, nor even a 20 minute radius of Alameda). Dr. Barger of Alameda County apparently wants every single hospital in the County to obtain PSC. That's news to me and, I think, a mistake unless transfer agreements are required as a condition of initial EMS routing. Also, Stebbins doesn't understand statistics or, more likely, is deliberately misrepresenting the data (she has in the past) to argue that Alameda is just as good as any other Hospital in the County when it comes to stroke care. That is demonstrably not true; In 2009, Alameda Hospital had a higher risk adjusted mortality for stroke victims than the average for Alameda County with a p-value <0.05.
2. Alameda Hospital has no legal authority to operate and has been in violation of state law for 9 years and counting. Other hospitals in the state may be in the same situation. All hospitals were required to be NPC-2 compliant on 1/1/2002. No exceptions nor extensions have been given for this law. Any hospital not compliant with this regulation may not provide acute care services in the non-compliant buildings. Is this just the way things work with a wink and a nod? Do these regulations have no meaning? It seems to me to be, at a minimum, a mini-scandal. Also, for all the ignorant people who want to argue that Alameda Hospital is required because a catastrophic earthquake might cut the Island off. Guess what? The Hospital is going to fail long before land routes off the Island do (and that's not even considering alternate modes of transportation). In fact, based on what I know right now, Alameda Hospital may be one of the more dangerous places in Alameda to find yourself in the event of an earthquake with the potential to cause structural damage.
1. The Hospital and Board are fully committed to treating stroke patients at the Hospital. The thought that Alameda Hospital provides subpar care is just so foreign to them that it is impossible to contemplate. The thought that the Board might dictate clinical direction is so frustrating to Jordan Battani that she almost lost her cool. I admit it is ridiculous for it to come to this, but the Hospital is perfectly happy hurting people because they are not able to admit that they are not the greatest in the world, (nor California, nor even a 20 minute radius of Alameda). Dr. Barger of Alameda County apparently wants every single hospital in the County to obtain PSC. That's news to me and, I think, a mistake unless transfer agreements are required as a condition of initial EMS routing. Also, Stebbins doesn't understand statistics or, more likely, is deliberately misrepresenting the data (she has in the past) to argue that Alameda is just as good as any other Hospital in the County when it comes to stroke care. That is demonstrably not true; In 2009, Alameda Hospital had a higher risk adjusted mortality for stroke victims than the average for Alameda County with a p-value <0.05.
2. Alameda Hospital has no legal authority to operate and has been in violation of state law for 9 years and counting. Other hospitals in the state may be in the same situation. All hospitals were required to be NPC-2 compliant on 1/1/2002. No exceptions nor extensions have been given for this law. Any hospital not compliant with this regulation may not provide acute care services in the non-compliant buildings. Is this just the way things work with a wink and a nod? Do these regulations have no meaning? It seems to me to be, at a minimum, a mini-scandal. Also, for all the ignorant people who want to argue that Alameda Hospital is required because a catastrophic earthquake might cut the Island off. Guess what? The Hospital is going to fail long before land routes off the Island do (and that's not even considering alternate modes of transportation). In fact, based on what I know right now, Alameda Hospital may be one of the more dangerous places in Alameda to find yourself in the event of an earthquake with the potential to cause structural damage.
Saturday, January 8, 2011
Official Agenda and Attachments Posted
Near as I can tell, the Hospital should have ceased operation on January 1, 2002. I must be missing something; some change in the law or waiver granted that makes this part of Title 24 chapter 6 inapplicable:
I'll get the answer Monday night.
1.5.1 Compliance deadlines.
1. After January 1, 2002, any general acute care hospital
building which continues acute care operation must, at
a minimum, meet the nonstructural requirements of
NPC 2, as defined in Article 11, Table 11.1 or shall no
longer provide acute care services.
I'll get the answer Monday night.
Friday, January 7, 2011
My Officially Speaking Answers Are Posted
Here.
Also, check out the 2008 and 2009 quality measures just posted by OSHPD. 2008 looks wierd since only 3 deaths out of 67 but the adjusted mortality number, although better than the state average, is 9.1% so those 67 cases must have been very low risk or some other reason for the risk-adjustment to yield a mortality rate twice as high as the raw rate. I don't know if there is a typo or what?
2009, the Hospital goes back to being mediocre (point estimate less than the state average, but not "statistically significant", but check out the high quality of stroke care throughout the County! Four hospitals were statistically significantly "better" than average. The Countywide average risk adjusted mortality was 8.5% which makes Alameda Hospital's 12.6% look really bad by comparison. Only Highland had a worse result for stroke in Alameda County.
Also, check out the 2008 and 2009 quality measures just posted by OSHPD. 2008 looks wierd since only 3 deaths out of 67 but the adjusted mortality number, although better than the state average, is 9.1% so those 67 cases must have been very low risk or some other reason for the risk-adjustment to yield a mortality rate twice as high as the raw rate. I don't know if there is a typo or what?
2009, the Hospital goes back to being mediocre (point estimate less than the state average, but not "statistically significant", but check out the high quality of stroke care throughout the County! Four hospitals were statistically significantly "better" than average. The Countywide average risk adjusted mortality was 8.5% which makes Alameda Hospital's 12.6% look really bad by comparison. Only Highland had a worse result for stroke in Alameda County.
Monday, January 3, 2011
Stroke Certification Discussion Should Be On Next Meeting's Agenda
Jordan Battani has been working hard to place an item on the next meeting's agenda that will capture what I believe is important about this issue. I am not sure what form it will take, but there will be something.
To clarify, my position is:
As to whether stroke certification is a good idea in a vacuum, that is not what is on the table so it makes it impossible to have a discussion when people paint the issue as, "why would anyone be against stroke certification?" Of course, I believe that stroke certification, all things being equal, is a good thing, but if it means that stroke victims are then routed to Alameda Hospital instead of alternative facilities elsewhere in the County then the net effect is worse health outcomes for Alameda's citizens. Since I doubt that Hospital management is interested in having patients routed off-Island after stroke certification is obtained, then I believe that the rational conclusion if you want the best for Alamedan's health is to oppose stroke certification.
To clarify, my position is:
My position is that without the Hospital management demonstrating that treatment of stroke patients at the Hospital is medically beneficial then they should refrain from doing so. Full stop.
As a corollary to the above, I believe that Hospital management has been dishonest as to the benefits to having stroke victims treated at the Hospital and need to justify their position that this is beneficial to Alamedans. Making that case would require independent analysis (and the Joint Commission certification is not sufficient to answer that question).
As to whether stroke certification is a good idea in a vacuum, that is not what is on the table so it makes it impossible to have a discussion when people paint the issue as, "why would anyone be against stroke certification?" Of course, I believe that stroke certification, all things being equal, is a good thing, but if it means that stroke victims are then routed to Alameda Hospital instead of alternative facilities elsewhere in the County then the net effect is worse health outcomes for Alameda's citizens. Since I doubt that Hospital management is interested in having patients routed off-Island after stroke certification is obtained, then I believe that the rational conclusion if you want the best for Alamedan's health is to oppose stroke certification.
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