winter 2013 • Volume 16 Number 4

Children’s Hospital & Medical Center Omaha, NE

Laura J. Redoutey, FACHE President Working with you for a healthy Nebraska

nebraskablue.com Blue Cross and Blue Shield of Nebraska is an Independent Licensee of the Blue Cross and Blue Shield Association. Healthier Nebraska winter 2013

» A magazine for and about Nebraska community hospitals and health systems

CHAIRMAN, 2013 NHA BOARD OF DIRECTORS Ronald Cork in this issue Avera St. Anthony’s Hospital, O’Neill

2013 NHA BOARD OF DIRECTORS Cindy Alloway Children’s Hospital & Medical Center reduces pediatric Alegent Creighton Health Lakeside Hospital, Omaha Paulette Davidson, FACHE radiation exposure 4 Bellevue Medical Center, Bellevue Marty Fattig, ACHE Nemaha County Hospital, Auburn Glenn Fosdick, FACHE Kearney County Health Services’ facility updates The Nebraska Medical Center, Omaha Carol Friesen improve comfort, care and safety 8 Bryan Health, Lincoln Jim Hansel Garden County Health Service, Oshkosh Michael Hansen, FACHE State speeches will provide insight into 2014 Columbus Community Hospital, Columbus Harold Krueger priorities for health care 10 Chadron Community Hospital & Health Services, Chadron Victor Lee, FACHE Boone County Health Center, Albion Leslie Marsh NHA Leadership Institute 2014 Class XI Lexington Regional Health Center, Lexington 12 Daniel McElligott, FACHE Saint Francis Medical Center, Grand Island Gregory Nielsen Great Plains Regional Medical Center, North Platte Laws and regulations don’t always put the patient first 14 Roger Reamer Memorial Health Care Systems, Seward Laura Redoutey, FACHE - Ex-Officio Nebraska Hospital Association, Lincoln Quest for Excellence focuses on quality 16 Kimberly Russel, FACHE Bryan Health, Lincoln James Ulrich Community Hospital, McCook NHA volunteers at Food Bank of Lincoln Victor Witkowicz 18 Madonna Rehabilitation Hospital, Lincoln NHA STAFF Laura J. Redoutey, FACHE, president The environment of health 20 Jon Borton, vice president, educational services Lori Brandl, executive assistant Heather Bullock, member services & events manager David Burd, vice president, finance Texting protected health information 22 Meghan Chaffee, staff attorney Kevin Conway, vice president, health information Timoree Klingler, advocacy specialist Barbara Jablonski, accounting specialist Al Klaasmeyer, vice president, NHA subsidiaries Kim Larson, director of marketing Vicky Pfeiffer, administrative assistant Bruce Rieker, vice president, advocacy Adrian Sanchez, director of communications Monica Seeland, vice president, quality initiatives Cindy Vossler, director of health data Maria Witkowicz, director of accounting EDITOR Adrian Sanchez, director of communications [email protected]

Healthier Nebraska is published quarterly by the Nebraska Hospital Association, 3255 Salt Creek Circle, Ste. 100, Lincoln, NE 68504, (402) 742-8140, www.nhanet.org. All rights reserved. pcipublishing.com Created by Publishing Concepts, Inc. DISTRIBUTION David Brown, President • [email protected] Healthier Nebraska is distributed quarterly throughout hospitals For Advertising info contact in Nebraska. It reaches all hospital department heads including Deborah Merritt • 1-800-561-4686 ext. 109 administrators, hospital physicians, managers, trustees, state [email protected] legislators, the Congressional delegation and other friends of Nebraska hospitals. Edition 67

A magazine for and about Nebraska hospitals and health systems. 3 Children’s Hospital & Medical Center reduces pediatric radiation exposure

A Graduate Program for Nurse Leaders College of Nursing University of Nebraska Medical Center

4 A magazine for and about Nebraska hospitals and health systems. Vibrant decals act as a distraction technique for children undergoing scans in the Radiology Department at Children’s Hospital & Medical Center, further promoting a child-friendly environment and safer imaging.

Twisted metal. Shattered glass. A 10-year-old is rushed from the scene of a fierce automobile collision to the Emergency Department at Children’s Hospital & Medical Center. He says his tummy hurts. His breathing sounds abnormal and he is vomiting. The ER team suspects blunt trauma year in “The Lancet” that children to the boy’s torso and orders a and young adults who had multiple computer tomography (CT) scan. CTs have a small increased risk of Consumed with worry, his parents leukemia and brain tumors in the can rest easier on one front – their decade after their first scan. child will not be exposed to any “We know radiation exposure more radiation than is absolutely is a key concern for parents and necessary. received the Quest for Excellence Award we’ve been very proactive in addressing “Whenever radiation is involved in a from the Nebraska Hospital Association for that concern,” said Nicole Hardin, Children’s procedure at Children’s, we take every a continuous quality improvement project radiology manager. precaution to ensure that the amount focused on reducing the radiation dose in The CT dosing project, she said, of radiation used is the bare minimum CT scans, a diagnostic tool that delivers supports Children’s strategic goal of being necessary to achieve an accurate result,” significantly more radiation than X-rays. the unparalleled leader for pediatric care in said Sandra Allbery, M.D., a pediatric About 68 million CT scans are the Heartland. The impetus for the initiative radiologist at Children’s Hospital & Medical performed in the U.S. each year, about 10 was four-fold: Center. percent of them in children, according to Children’s efforts have earned it fresh the American College of Radiology. National accolades. The organization recently Cancer Institute researchers reported last continued on next page

A magazine for and about Nebraska hospitals and health systems. 5 continued from last page

• A trend of young patients often receiving very high radiation doses, often equaling adult dosing parameters, was discovered after reviewing CT images completed at ouside facilities. • A commitment to support the Image Gently campaign sponsored by the Alliance for Radiation Safety in Pediatric Imaging, an initiative that aims to promote radiation protection in the imaging of children. • The ongoing evolution of the patient population at Children’s. • A desire to reduce radiation exposure by utilizing non-radiation imaging techniques such as ultrasound and magnetic resonance imaging whenever possible. An underwater theme welcomes families to Children’s radiology department. Customized wraps and sea life decals contribute to a more soothing, child-friendly atmosphere. “Approximately 40 percent of children seen in our organization have chronic standardization of the process, while Hardin adds, “Radiology staff education health conditions. These conditions preserving the quality of the images. We was essential to the success of this project. increase the risk of repeated exposures to also wanted to educate referring physicians All radiology technicians and radiology CT scans,” Dr. Allbery said. about the appropriateness and efficacy of physicians completed the Image Gently “Our project aim was to decrease CT as a diagnostic exam for children,” she provider training course on reducing CT patient radiation dosage through explained. radiation exposure.”

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6 A magazine for and about Nebraska hospitals and health systems. The CT dosing The results of the project project team, which are tangible and substantive, included a radiology but there is more work to be fellow, the radiology done. patient care manager, “We have reduced the radiology technicians radiation dose administered and the performance as much as we can while improvement using our current technology,” manager, met six Dr. Allbery said. “Our next times over a five steps include moving to new month period. Their technology to continue to work resulted in reduce radiation dose.” the implementation The Quest for Excellence of several major award is designed to processes, including: recognize Nebraska hospitals • Developing for their outstanding quality and applying Nicole Hardin, Radiology Manager, Children’s Dr. Sandra Allbery, pediatric radiologist, improvement activities. It a method to Hospital & Medical Center Children’s Hospital & Medical Center is jointly sponsored by the calculate the Nebraska Hospital Association, minimum other concerns such as a significant CIMRO of Nebraska, the necessary radiation dose for previous radiation exposure, and if Nebraska Association of Healthcare Quality, each patient based on a series of alternatives need to be considered. and the Nebraska Department of Health conversion factors for age, size and & Human Services System Office of Public type of CT exam. “By developing a process to Health. • Requiring a standard review consistently use these conversion factors, “It is truly an honor to receive this award,” of every CT exam scheduled we were able to standardize practice and Hardin said. “It supports what everyone here to determine if CT is the most decrease the mean radiation dose for CT knows in their hearts – that Children’s is appropriate way to assess the exams by more than one millisievert,” Dr. committed to providing the highest quality in patient’s condition, if there are Allbery said. patient care and patient safety.” HN

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A magazine for and about Nebraska hospitals and health systems. 7 Kearney County Health Services’ facility updates improve comfort, care and safety

MINDEN — Kearney County Health Services’ (KCHS) new and updated facilities will improve comfort, care and safety for patients, enhance efficiency for medical staff and enable KCHS to better utilize the updated technology. KCHS held a grand opening in September to showcase the new $10 million construction and remodeling project. The improvement project on the 56 year old facility began two years ago when Kearney County voters approved the bonds to renovate the existing building and construct a new patient room wing. The 8,600-square-foot expansion added 10 new in-patient private rooms, I am aware of was nine and we average Before (the remodel) we had to wheel a new reception and admissions area three or four a day.” in a large machine to purify the air.” and a new entrance. Each of the new rooms has several The 7,900-square-foot former acute One of the most notable and dramatic amenities and technologies designed care wing was renovated and converted changes is the new hospital entrance to improve the care and comfort of into a new, larger two-bay emergency located at the southwest corner of the patients. Each room is fitted with a room with waiting area, four outpatient hospital. The new covered driveway patient lift system designed to help exam rooms with two outpatient will help shield patients from inclement medical staff get patients in and out of physician offices, a pharmacy area, a weather during pick-up and drop-off. bed, enhancing safety for both patients new nurses’ station and a procedure Inside the new entrance, visitors are and staff. room. greeted at the reception area and will Medical charts are now maintained The former ER room was expanded find a spacious waiting room. A nearby in a secured database. The new acute into the new emergency care area. The private meeting room can be used for wing has computers for medical charting side-by-side emergency bays provide hospital admissions and for consultation both inside the rooms and in the hallway medical staff quick and easy access to with medical staff. so nurses have options for recording both rooms while providing privacy to “Our new entrance is much more information. patients. accessible and more welcoming than While bathrooms aren’t typically a Both emergency bays are equipped what we had before,” Fred Meis, KCHS space one touts, the bathrooms in the with updated technology including administrator, said. “When people came new rooms are dramatic improvements a teletrauma system, which allows in the old entrance there wasn’t a visible over the old rooms according to Meis. local doctors to communicate with reception area and people weren’t sure “You could barely turn around in our old a trauma center at another hospital where to go. Now our reception area is bathrooms, let alone get a couple nurses for consultation, questions, arrange the first thing they will see when they in there to assist a patient.” transport, discuss the patient’s statistics walk in the door.” The new spacious restrooms are fully and more, without ever leaving the Out of the entire project, Meis accessible and one of the patient rooms patient’s bedside. indicated he takes the greatest pride in is even equipped with a patient lift that A new emergency waiting area the new acute care rooms. goes from the bed into the restroom. provides a comfortable place for “Our patients have a much better One of the new patient rooms is families or others who bring patients for environment to get better in. People are designed as an isolation room. The emergency care. going to be impressed at how nice these heating, ventilation and air conditioning “This area gives families a place to new rooms are.” system for that room is separate from the gather that does not impede our trauma The new acute wing includes 10 rest of the hospital and air from the room team. It also provides a space where private patient rooms. While the hospital is circulated through a special HEPA filter. medical staff can consult with families,” is licensed for 25 beds that capacity has “If we get a TB (tuberculosis) patient, Meis said. never been reached, Meis said. “The this room is self-contained and we are A procedure room was also most beds we have had filled ever that ready to treat them. constructed for diagnostics such as

8 A magazine for and about Nebraska hospitals and health systems. scopes and can also be used as an providing easy access for visiting spacious patient rooms, the new paging overflow emergency care area. physicians to conduct stress tests and system for nurses has been well-received Meis said that the new hospital layout observe patient progress. This area by patients and staff. The system allows maximizes efficiency. “There were so is double the size of the old cardiac nurses to respond to patient pages many things about the old layout that rehabilitation area and includes some quicker and also to communicate directly created more work for our staff. We new equipment in a sunny room with with the patient through the paging were just use to it.” plenty of windows. system itself. Through the new system, Moving patients and medical staff While not as glamorous as the administration can collect and track data from one area of care to on the timeliness of patient another area is part of the care and better address designed improvements. problems that may arise. Before the improvement Perhaps no one will be as project, there was no happy for the completion interior connection of the project as the staff between the clinic and the at the hospital. hospital. “The entire staff was “Our staff had to take fantastic. Doing the project patients the long way in phases helped, but through the hospital the staff still had to work waiting area if they needed around the transition,” an x-ray or lab work.” Meis commented. The renovation included “Everybody is excited to a hallway connecting the see the end. Everyone is clinic to the hospital. really positive about the Medical staff along with changes, our doctors will patients can easily move be happy.” HN between the two care areas now. The laboratory, which provides services for both the clinic and the hospital, was also renewed. The location of the new nurses’ Get to Know Us station was another feature that improved efficiency, according to Meis. “We strategically placed that station between the two halls and the new pharmacy is right there at the nurses’ BEFORE station. Before, our nurses had to run down the hall to pick up medicine for patients in the hospital.” You Need Us Part of the old acute wing was also renovated to create the new outpatient area. The Nebraska Hospital Association works together with Two new offices in the outpatient Western Agricultural Insurance Company* and LaMair-Mulock-Condon Co. area for visiting physicians provide space to make Workers Compensation coverage available to its members. for the doctors to work in. The offices To learn more about the coverage, and the education and can utilize the telemedicine systems that loss prevention services available, call 402-742-8162. allow physicians in different locations to consult over a teleconferencing system. Another busy part of outpatient services at KCHS is cardiology. Three cardiologists hold clinics at Kearney County Hospital, often conducting follow-up visits with their patients. The new cardiac rehabilitation room was part of the hospital addition. It sits adjacent to the outpatient area *Company provider of Farm Bureau Financial Services WC008 (1-13)

A magazine for and about Nebraska hospitals and health systems. 9 By Bruce Rieker, J.D. vice president, advocacy State speeches will provide insight into 2014 priorites for health care

At the beginning of each year, the Charity care results from a hospital’s serve as the safety net of the health care president gives the country a State of policy to offer health care services system and must provide many services the Union address. Likewise, Nebraska’s free of charge or on a discounted fee regardless of an individual’s ability or governor delivers a state of the state schedule to individuals who meet willingness to pay. In contrast, other address. In light of those two important predetermined financial criteria. As the industries can refuse to provide a service speeches, it may be worthwhile to number of uninsured and underinsured or product. examine how the State of the Union and grows, so does the need for charity care. With rising numbers of uninsured, the State of the State addresses affect the Because of the high costs of health care double-digit increases in health insurance state of health care. and insurance, hospitals are bearing premiums and greater use of plans with There are more than 1.8 million people a significant portion of the financial high deductibles and copayments, bad living in Nebraska; slightly more than burden imposed by this population — debt is the fastest growing segment of one-half of one percent of our country’s $106 million in 2011 — and that amount uncompensated care for hospitals. Due population of 318 million. The United continues to grow each year. Recognizing to the uncertainty of many variables States has 5,724 hospitals of which this increasing need, Nebraska hospitals associated with the implementation of the 1,328 are classified as critical access have established financial aid policies to Patient Protection and Affordable Care Act hospitals (CAHs) — hospitals limited to assist patients who cannot afford hospital (ACA), the majority of Nebraska’s hospitals 25 beds or less and deemed necessary care. In addition, hospitals routinely have more than doubled their budgets for to ensure access to care. Nebraska has provide assistance to patients applying for bad debt in 2014. 90 community hospitals, of which 65 are government program benefits. On the subject of budgets, Congress CAHs, and collectively those institutions Health care services provided to and the president face a financial dilemma employ 42,000 people and provide care to low-income and special needs populations of gigantic proportion and one of the more than 11,000 patients each day. through government programs such as biggest fiscal challenges is growth in Hospitals contribute significantly to Medicare and Medicaid produce hospital spending on federal health care programs. the goal of improving the overall health revenue shortfalls – $514 million in 2011 Our national debt is $16.7 trillion, or of Nebraskans, all-the-while focusing – because the payments received are nearly $53,000 per citizen. Congress on aiding the less fortunate as part of less than the cost of providing care. In has failed to pass a budget for the last their mission and purpose. Nearly all of many instances, Medicare and Medicaid four years, opting to run the federal Nebraska’s hospitals are nonprofit. In payments are based on outdated government on continuing resolutions, exchange for the benefits of nonprofit information that does not accurately increases in the debt ceiling and other status, hospitals are required to fulfill a reflect the changing nature of health short-term funding methods. Annual unique role in their communities. That role services, such as new equipment, new revenues are $2.2 trillion while spending has three parts: technologies and the rising costs of is more than $3.8 trillion per year. Our 1. to reinvest the assets of the supplies. Despite the fact that Medicare country’s debt and budget problems will organization in a way that expands and Medicaid do not pay hospitals enough dominate the rhetoric on Capitol Hill and and improves access to health care to cover the cost incurred by the hospitals across the country; however, history gives for the community; caring for patients, hospitals welcome us little hope that anything will get done in 2. to invest their resources to educate Medicare and Medicaid patients and Washington, D.C., during an election year. and train health care professionals; provide the same quality care they do for Congress and the president need to and, all patients. come together on a spending plan that 3. to provide care to the poor Hospitals shoulder another burden works for America. However, before they regardless of their ability to pay. known as bad debt when patients are impose more reductions in payments to In 2011, Nebraska’s nonprofit unable or unwilling to pay their bills and community hospitals, they should take hospitals spent more than $1.1 decline to apply for charity care. In 2011, notice of the cuts made since health billion – 22.4 percent of their net bad debt incurred by hospitals exceeded care reform was enacted. As part of the revenues – in support of those $239 million — 45 percent more than the payment, the president and Congress cut three efforts. $165 million absorbed in 2008. Hospitals hospital Medicare reimbursements by

10 A magazine for and about Nebraska hospitals and health systems. six percent. Since then there have been programs, bundled payments, accountable six-year terms. Every two years one-third coding adjustments and sequestration care organizations, population health and of the United States Senate is up for cuts. Together, Nebraska’s hospitals meaningful use of health information reelection unless a senator chooses to have been forced to absorb a reduction technology and electronic medical records. retire or resign, as is the case in Nebraska in Medicare payments of $1.3 billion ­­­— Many ACA mandates take effect Jan. where we will elect a new senator due to eight percent — over a 10 year period 1, 2014. Subsidies and tax credits will the retirement of U.S. Sen. Mike Johanns. and Congress is currently considering be available for individuals eligible to Because of the two-year terms in the additional cuts of more than $600 million purchase health care coverage through United States House of Representatives, over that same period. the insurance marketplace. People all 435 House members are up for There are many areas that Congress without qualified health coverage will re-election unless the incumbent is retiring could tackle to address our nation’s have to pay penalties. Employers with or there are vacancies. The House of growing debt and budget issues. None more than 50 employees must provide Representatives has 232 Republicans, of those changes would be easy but qualified coverage or face future fines and 200 Democrats and three vacant seats. they include: slowing the growth of the penalties. Essential health benefits of all All three of Nebraska’s members of the federal contributions to the Federal qualified plans must include: emergency House — Reps. Jeff Fortenberry, Lee Terry Employee Health Benefits Program services; hospitalization; ambulatory and Adrian Smith — are all running for (FEHBP), introducing cost sharing patient services; prescription drugs; reelection. Two have opponents; however, responsibilities to TRICARE beneficiaries, maternity and newborn care; mental we will not know all of the names on the basing Social Security cost of living health, substance abuse and behavioral ballot until after the March 3, 2014 filing adjustments and other entitlements on health treatment; laboratory services; deadline. the CPI-U index, placing dual eligible rehabilitative and habilitative services and At the state level, Nebraska will see Medicare and Medicaid beneficiaries devices; preventive, wellness and chronic the largest change in political leadership in Medicaid managed care, reforming disease management; and pediatric dental since 2006, when legislative term limits medical liability, reducing Medicare costs and vision care. went into effect. In 2014, Nebraska will by changing cost-sharing structures for Significant changes are in store for elect a new governor and at least 17 Medicare Parts A and B, raising the age of hospitals as they continue to see declines new members to the legislature because Medicare eligibility to 67 and reforming in volumes and revenue growth. New of term limits. Seven more senators are pharmaceutical pricing. business models will be developed to running for re-election and another seat In contrast to our federal budget accommodate the transition from a fee- will be up for grabs due to a resignation. deficit, Nebraska has a balanced budget. for-service model to a payment structure With a minimum of 17 new senators, For the current biennium, fiscal years based on quality and outcomes. Insurance at least 35 percent of the 49 member 2013-2015, our state’s budget is $7.88 plans may limit hospital and provider legislature will be new when it convenes in billion with $627 million in our cash choices. Less capital will be available for January 2015. reserve. During the 2014 legislative replacements and new technology. Some There is room for hope. Elections session, senators will be faced with hospitals and other providers will form can bring the key ingredient of success several significant issues, including networks to improve outcomes and lower — leadership. They can also present an taxes and Medicaid eligibility expansion. costs. Concerns about access to high opportunity, and a challenge, to educate The governor and several senators are quality care and an adequate workforce newly elected representatives on the determined to reform Nebraska’s tax will continue to abound. Hospitals issues facing hospitals, providers and the structure before their time in office expires will wrestle with how to handle the health care industry. and there will be extensive debate in three unprofitable, but critical and necessary, Escalating costs of health care, reform areas — property taxes, individual and needs of their communities. and economic challenges may add up to corporate income taxes and sales and use Hospitals are highly vulnerable to the catalyst that transforms the delivery taxes. Likewise, there are many senators changes in public policy and payment of care into a system focused on value determined to strengthen Medicaid and inadequacies. The majority of hospital instead of volume. Insurance marketplaces improve the health of Nebraskans by stays are paid for by government programs should bring more consumerism. Better expanding eligibility to individuals earning such as Medicare and Medicaid and nearly data and transparency will help consumers up to 138 percent of the federal poverty everything hospitals do is regulated by the make more informed decisions. New level — $14,856 for an individual and state and federal government. Every other models of care such as patient centered $30,675 for a family of four. year the winds of change sweep across medical homes focused on population Implementation of health care our country with elections at the state and health may be the new norm. More reform will continue to dominate debate federal levels. Elections bring new faces providers may work together with similar between policy makers. It will also have with new agendas and sometimes the goals and incentives. the constant attention of hospital leaders balance of power shifts from one party to The journey will be challenging; and other health care providers as they the other. however, it is one we must take. navigate their way through the unknowns The United States Senate is comprised Bruce Rieker, vice president, advocacy, of delivery system changes, insurance of 53 Democrats, 45 Republicans and can be reached at [email protected]. HN marketplaces, value-based purchasing two independents; all serving staggered

A magazine for and about Nebraska hospitals and health systems. 11 By Jon Borton, MS, vice president, educational services The more we NHA Leadership Institute 2014 Class XI get together, the The Nebraska Hospital Association NHA Leadership Institute success opportunity to attend the Nebraska (NHA) Foundation Leadership Institute stories Hospital Association Leadership Institute. is gearing up for the 2014 Class XI. “My experience with the Leadership The program provided a unique and Officially completing its first decade, Institute was one of the most rewarding valuable opportunity for me to build on happier and the NHA Leadership Institute proudly experiences of my management knowledge that I had previously obtained passed the 200 alumni mark. career. At the time I participated in the through work experience and formal In partnership with faculty of Institute, I was still very ‘green’ in my education by providing a varied curriculum Bellevue University, the Institute’s knowledge of the business and how I of essential leadership skills. healthier we’ll be. mission is to advance the effectiveness needed to improve my leadership skills The networking opportunities were of hospitals by providing a quality to take me to the next level in health invaluable and from the 360 degree environment of professional care. The teachers and presenters gave assessment to the coaching session, the development and support for health care leaders. Coursework focuses on the unique challenges and organizational management techniques facing hospitals. Each year, approximately 30 health care professionals from across Nebraska come together for a 10-month program designed to instruct, inspire and invigorate. Participants establish peer-to-peer connections and lifelong bonds with classmates and faculty. The NHA Leadership Institute provides up-and-coming leaders within your hospital the necessary skills to become exceptional leaders and puts them on the path to senior Arlan D. Johnson (left), CEO of Howard County Medical Center and Manuela Wolf, CEO of Harlan County Health management positions. It is important System, are both graduates of the 2010 Class VII Leadership Institute class. for current CEOs to develop the leadership pipeline to ensure effective me the knowledge and confidence to program provided me with many of the succession planning while enhancing apply for the CEO position at my facility skills I needed in my growth through the employees’ contributions to your and to be offered that job. ranks in my organization to my current organizations. I also used Bellevue University to position as CEO. Course faculty was This initiative includes a complete master’s degree in health always helpful and accessible. To this comprehensive curriculum, combining care administration. I encourage every day, I often look toward the knowledge I core leadership competency working facility to make a commitment to gained about myself, my co-workers and sessions and multiple layers of applied its employees and send them to the my organization when facing the various practice in health care. Participants in Institute, and help insure we have challenges in my day-to-day routine.” the Leadership Institute will improve strong leadership in Nebraska moving Manuela Wolf, RN, BSN, 2010 Class VII At MMIC, we believe patients get the best care when doctors, staff and their leadership skills and enhance forward.” Leadership Institute graduate administrators are humming the same tune. So we put our energy into creating their effectiveness in the health care Arlan D. Johnson, MHA, 2010 Class CEO at Harlan County Health System in risk solutions that help everyone feel confi dent and supported. Solutions field, while preserving the care and VII Leadership Institute graduate Alma. such as medical liability insurance, physician well-being, health IT support and compassion critical to quality health CEO at Howard County Medical Center patient safety consulting. It’s our own quiet way of revolutionizing health care. care delivery. in St. Paul. Questions about the NHA Leadership Institute? Contact Jon Borton, vice To join the Peace of Mind Movement, give us a call at 1.800.328.5532 president, educational services, at (402) or visit MMICgroup.com. 742-8147 or [email protected]. HN ”I am thankful that I was given the

12 A magazine for and about Nebraska hospitals and health systems. The more we get together, the happier and healthier we’ll be.

At MMIC, we believe patients get the best care when doctors, staff and administrators are humming the same tune. So we put our energy into creating risk solutions that help everyone feel confi dent and supported. Solutions such as medical liability insurance, physician well-being, health IT support and patient safety consulting. It’s our own quiet way of revolutionizing health care.

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A magazine for and about Nebraska hospitals and health systems. 13 By David Burd, FHFMA vice president, finance Laws and regulations don’t always put the patient first

Health care is a very complex The conditions of participation allow physician or non-physician practitioner industry that is heavily regulated at both a CAH to provide acute inpatient care (NPP) must be “immediately available” the state and federal levels. for a period that does not exceed, to furnish assistance and direction Hospital staff must stay up-to-date on an annual average basis, 96 hours throughout the procedure. Hospital on statutes and regulations, which are per patient. However, the conditions outpatient therapeutic services have extensive, complicated and change on a of payment require that a physician always been provided by licensed, daily basis. Limited resources make this certify that the patient may reasonably skilled professionals under the task even more challenging. However, in be expected to be discharged or overall direction of a physician. While most cases, laws and regulations seem transferred to another hospital — paid hospitals recognize the need for direct to have the best interests of the patient under the prospective payment system supervision for certain outpatient in mind and ultimately help ensure — within 96 hours after admission to services that pose a high risk or are that health care services are provided the CAH, which applies to each patient complex, CMS’ policy generally applies appropriately and safely. Therefore, individually instead of on an average to services with the lowest amount of hospitals dedicate significant resources, basis. risk. both in staff time and funding, to ensure The conditions of payment In an environment of continuing that they are in compliance with all requirement means that CAHs are not shortages of health care professionals, applicable regulations and statutes. paid for Medicare procedures and especially in rural areas, the direct Statutes and regulations should treatment that take longer than 96 supervision requirement will be always put patients first. There are hours, unless the physician expected difficult to implement for hospitals, times when that doesn’t seem to be the patient to be discharged within could ultimately reduce access to the case. While written by people that 96 hours at the time of admission. care and is clinically unnecessary. The are well-intentioned, some regulations There are many procedures that CAHs requirement would make hospitals appear to do nothing more than add are qualified to provide where clinical engage more physicians and NPPs for significant costs to the health care protocol would dictate a stay of longer direct supervisory coverage without a system, without adding any real than 96 hours. If patients are unable clear clinical need and create patient benefit to the patient. Two examples of to obtain treatment in these situations access problems if hospitals are forced requirements that don’t seem to be in at their local CAH, they could face long to discontinue or limit the hours of the best interests of the patient are the drives to another hospital, ambulance certain outpatient services. This is 96 hour requirement for critical access or helicopter fees to be transferred another example of a requirement that hospitals (CAHs) and the physician to another hospital or potentially, ultimately is not in the best interests of supervision requirement for outpatient health risks (including death) due to patients. therapeutic services. the delay in treatment. Due to this Statutes and regulations play an The Centers for Medicare and requirement, Medicare patients face important role in health care. They Medicaid Services (CMS) has established significant inconveniences at the least are necessary and improve the system conditions of participation and and potential health complications overall. They are written by individuals conditions of payment that providers at the most. Patients are prevented that are well-intentioned but also must adhere to in order to participate from receiving health care services in generally from the east coast and not in the Medicare program and to their hometown CAH only because of familiar with the unique challenges that receive payment for services provided a statute or regulation that requires it, exist in rural states such as Nebraska. It to Medicare patients. In most cases, even if it is not in their best interests. is critical that statutes and regulations provisions within the conditions of In 2009, CMS mandated a new take these differences into account. participation and the conditions of policy for direct supervision of If they do not, they drive up the costs payment are in sync with each other. outpatient therapeutic services. of health care and ultimately hurt the However, that is not always the case. An CMS characterized the change as a patient. After all, aren’t we supposed to example of where they are not in sync “restatement and clarification” of be putting the patient first? involves the length of stay for patients existing policy going back to 2001. David Burd, vice president, finance, at a CAH. Direct supervision means that a may be reached at [email protected]. HN

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A magazine for and about Nebraska hospitals and health systems. 15 By Monica Seeland, RHIA vice president, quality initiatives Quest for Excellence focuses on quality

The 2013 Quest for Excellence Awards were presented during the 34th Caring Kind Awards Luncheon held Oct. 25 at the Embassy Suites La Vista Conference Center in La Vista. The award winners were Memorial Community Hospital & Health System (MCH&HS) in Blair for the Critical Access Hospital (CAH) division and Children’s Hospital & Medical Center in Omaha for the non-CAH division. Each year Nebraska hospitals compete for the Quest for Excellence Award. The Quest for Excellence Award is a joint initiative of the Nebraska Hospital Association, CIMRO From left: NHA President Laura J. Redoutey poses with representatives of Memorial Community Hospital & Health of Nebraska, the Nebraska Department of System (MCH&HS) in Blair, Janice Fitchhorn, therapy services and sports medicine lead, and Laura Stawniak, chief nurse Health and Human Services and the Nebraska executive, and with NHA Board President and Avera St. Anthony’s Hospital President and CEO Ron Cork. Memorial Community Hospital & Health System received the Quest for Excellence Award, Critical Access Hospital division, on Oct. Association for Healthcare Quality, Risk and 25 during the 34th Caring Kind Awards Luncheon in La Vista. Safety. The award showcases innovative and reproducible models of patient care to the looked at their current Fall Prevention Policy The “Patient Road Map” was developed rest of the health care community. This was to determine if changes were needed and to serve as an education tool when teaching the 10th year for the award, designed to whether their practices were consistent with patients about their fall risk and what recognize and reward hospitals for their quality national standards of care. measures the Health Care Team will use to improvement achievements. The fall prevention policy was re-tooled keep patients safe. MCH&HS is comprised of a Critical Access to include clearer expectations surrounding To assist with workflow of gathering Hospital along with three rural health medical utilization of the Morse Fall Risk Model when supplies needed when a patient is deemed a clinics, a home health care program and a completing each patient’s fall risk assessment. fall risk, they planned, built and implemented hospice program. In March of 2013, an elderly An assessment for risk for injury was also a “Fall Risk Kit.” This kit contains items that patient receiving care on their medical surgical added to the policy. This secondary assessment every patient scoring 50 or greater on their (M/S) unit suffered a fall resulting in a major targets patient conditions, which if there was fall risk assessment will need implemented and permanent injury. At the direction of a fall, the patient would likely sustain injury. as a prevention measure. The kit includes executive leadership and quality, a response The policy was also streamlined in order to yellow socks, yellow arm-band, yellow star, the team was organized to carry out a root cause assure consistency with manual and electronic “Patient Road Map,” a gait belt and a green analysis (RCA). This team met and reviewed documentation of assessments and selected arm band in case the patient is determined to the timeline for the event and determined prevention measures. be a high risk for injury. immediate causal and risk factors to be Once re-tooling was complete and the Children’s Hospital & Medical Center is a mitigated. Further investigation of the fall policy approved, they developed standard 144 bed acute care hospital focusing on the itself revealed inconsistent practices around operating procedures (SOPs) for both fall special needs of children. Their project was patient fall risk assessment and the timeliness risk assessment and for the post fall huddle. identified by clinical staff in the radiology of implementing appropriate prevention These SOPs provide staff with step by step department, with input from a parent measures. instructions for completing fall risk assessment concerned with the amount of radiation Prior to the fall event described above, falls and implementation of prevention measures, received by their child. on the M/S Unit were tracked as part of the but also assures the right people come Accurate pediatric radiation dose and departmental performance improvement (PI) together if a fall occurs. Additional tools were risk from a computerized tomography (CT) activity and reported quarterly to the Quality pushed out for use during the redesign of examination are not easily interpreted. Council. Falls occurring outside of the M/S Unit their processes. A “Fall and Risk for Injury Without adjustments, the radiation risk were monitored, but without a structured PI Interventions” table was created, which is used to the pediatric population is significantly activity. The concept of completing a post fall as a trigger to define appropriate prevention underestimated. A more accurate radiation huddle had been implemented on the M/S measures for nurses to consider in order to dose can be obtained by applying conversion Unit, but the practice was inconsistent. They prevent a patient fall. factors specific to the patient’s size, age and

16 A magazine for and about Nebraska hospitals and health systems. type of exam. By developing a to the success of this project. All process to consistently use these radiology technicians and radiology conversion factors, they were physicians completed training on able to standardize practice and reducing CT radiation exposure. decrease the mean radiation dose Since the patient’s clinical treatment for CT exams. is guided by the referring physician, Their project aim was to communication and education with decrease patient radiation dosage referring physicians was crucial to the through standardization of the success of this project. process to determine the radiation A tri-fold pamphlet was created dose to be administered, while and distributed to providers, preserving the quality of the patients and families explaining images to allow the radiologists the risk of radiation, the radiology to accurately interpret exams. A From left: NHA President Laura J. Redoutey poses with representatives of Children’s dose equivalents to environmental secondary aim was to educate Hospital & Medical Center in Omaha, Cheryl Calabro, performance improvement radiation exposure and Children’s referring physicians about the nurse specialist, and Dr. Sandra Allbery, radiologist, and with NHA Board President efforts to limit patient radiation and Avera St. Anthony’s Hospital President and CEO Ron Cork. Children’s Hospital appropriateness and efficacy of CT & Medical Center received the Quest for Excellence Award, non-Critical Access exposure. Several educational as a diagnostic exam for children. Hospital division, on Oct. 25 at the 34th Caring Kind Awards Luncheon in La Vista. presentations on the topic of medical Several major process changes radiation exposure were completed, were implemented through this project. The exam and all previous CT exams completed. targeting new and referring physicians inside first was to develop and apply a prescriptive Once this information is gathered, a radiologist and outside the organization. method to calculate the minimum necessary determines if CT is the most appropriate way Go to http://www.nhanet.org/quality_ radiation dose for each patient based on a to assess the patient’s condition, or if there are patient/quest.htm to read more about these series of conversion factors for age, size and other concerns such as a significant previous projects. The Nebraska Hospital Association type of CT exam to be completed. The next radiation exposure. congratulates these facilities for their excellent process change included a new process where If the radiologist recommends a different work in quality improvement. each CT exam scheduled is reviewed by the type of exam, the ordering physician is Monica Seeland, vice president, quality radiology nurse. During this review, the nurse contacted to discuss the alternatives for the initiatives, may be reached at mseeland@ looks at the patient history, indication for patient. Radiology staff education was essential nhanet.org. HN

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A magazine for and about Nebraska hospitals and health systems. 17 NHA volunteers at Food Bank of Lincoln

Nebraska Hospital Association staff volunteered at the Food Bank of Lincoln on Nov. 21 to help the food pantry stock shelves and make preparations for Thanksgiving. Staff who participated are, from left, Lori Brandl, Cindy Vossler, Maria Witkowicz, Vicky Pfeiffer, NHA President Laura Redoutey, Timoree Klingler, Barb Jablonski, Meghan Chaffee and Kim Larson.

18 A magazine for and about Nebraska hospitals and health systems. Work smarter and faster with service and support from Cassling. Hands-On Help With Health Care Finance Equipment Service. Supplemental 30 Years of Dedication. Experienced with revenue and general obligation Cassling customers, Services. We’ve been a trusted bonds in both public offerings and private on average, receive Our marketing/ partner to Midwest health- placements, D.A. Davidson & Co. is exceptionally support on a critical consulting services and care organizations qualified to assist healthcare institutions with down system in just educational events since 1984. infrastructure financing. Types of organizations 52 minutes. help you achieve your organizational goals. we have served include hospital systems, independent hospitals, community hospitals, critical access hospitals and senior living facilities. Call D.A. Davidson & Co., while you are in the planning stages for a no cost consultation. Dan Smith 800-394-9219 Managing Director, 402-392-7979 Public Finance Paul Grieger 800-528-5145 YEARS Senior Vice President, Public Finance Banker 402-392-7986 Cody Wickham 866-809-5596 Vice President, Public Finance Banker 402-392-7989 Andy Forney Visit www.cassling.com to download case studies on how Cassling's service Public Finance Banker 866-809-5443 and support can help your organization be more efficient. 402-392-7988

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A magazine for and about Nebraska hospitals and health systems. 19 By Adrian Sanchez, director of communications The environment of health

Educating residents on the keys to that stress. Stress leads to chronic to improve the overall health of those improving health and longevity and inflammation, associated with every communities. addressing the economic and social barriers major age-related disease. Bluford, the second keynote speaker to health through community outreach 4. 80% Rule — Stop eating when the at the convention, has led the Kansas City are critical components of improving a stomach is 80 percent full. The 20 hospital for more than 12 years, and during community’s overall health. percent gap between not being hungry that time he identified the greatest social Those were the messages provided and feeling full could be the difference determinants of health — safety, security by keynote speakers during the Nebraska between losing weight or gaining it. and permanence. Hospital Association’s (NHA) 86th annual 5. Plant Slant — Beans, including “Stress kills, poverty kills, not being able convention held Oct. 23-25 at the Embassy fava, black, soy and lentils, are the to pay the bills kills,” Bluford said. “We Suites La Vista Conference Center in La cornerstone of most centenarian diets. want to stop them from needing to come to Vista. The theme for the NHA 2013 Annual A serving size of meat, mostly pork, the hospital, by making them better. When Convention was “Healthy Communities: about the size of a deck of cards is you increase quality of life, the number of Hospitals Meeting the Challenge” The eaten on average only five times per hospital, visitations goes down.” theme embraced The World Health month. Since one of the biggest financial Organization’s (WHO) definition of a healthy 6. Wine at 5 — People in all Blue Zones, impacts on the hospital’s cost curve is community, which is “one that is continually except Adventists, drink alcohol chronic illness, Truman Medical Centers creating and improving those physical and moderately and regularly. Moderate has engaged the community to promote social environments and expanding those drinkers outlive non-drinkers. The trick healthy lifestyles in an effort to reduce community resources that enable people to is to drink 1-2 glasses per day with the numbers of preventable illnesses. mutually support each other in performing friends, food or both. A few of the projects the hospital has all the functions of life and in developing to 7. Belong — All but five of the 263 undertaken include offering a mobile fresh their maximum potential.” centenarians we interviewed belonged food store to encourage healthy eating, Few communities exemplify the WHO’s to some faith-based community, partnering with the Kansas City Chiefs to definition of a health community like regardless of denomination. Research provide routine vaccinations, health fairs, the five “Blue Zones” identified through shows that attending faith-based physicals and healthy education for youth research conducted by the convention’s services four times per month will add and putting up billboards to replace worn opening keynote speaker Dan Buettner 4-14 years of life expectancy. out tobacco and soda ads with uplifting, and his team. Blue Zones are places where 8. Loved Ones First — Successful positive messages that encourage a healthy people reach age 100 at rates up to 10 times centenarians in the Blue Zones put lifestyle. The hospital also engaged in case greater than in the United States and, with their families first. This means keeping management initiatives to help residents the research, in a sense, reverse engineered aging parents and grandparents monitor and manage their own care in an those environments of longevity. nearby or in the home, committing effort to reduce the number of emergency Buettner, an internationally recognized to a life partner and investing in their department visits with successful results. researcher, explorer, New York Times children with time and love. Bluford acknowledged those efforts bestselling author and National Geographic 9. Right Tribe — The world’s longest required a great network of support from Fellow, said the keys to longevity are to: lived people chose, or were born into, community leaders and the business 1. Move Naturally — The world’s longest- social circles that supported healthy community and that is why it is important lived people live in environments that behaviors. The social networks of long- for hospitals to remain active in the constantly nudge them into moving lived people have favorably shaped community, because “It is difficult for without thinking about it. their health behaviors. people to say no when it is the right thing 2. Purpose — Knowing your sense of to do.” purpose is worth up to seven years of While Buettner’s presentation focused “The more successful we are at this, the extra life expectancy. on the ideal communities for health, less we are utilized,” he said. 3. Down Shift — Even people in the Truman Medical Centers’ President and CEO Adrian Sanchez, director of Blue Zones experience stress. What John Bluford presented how his hospital communications, can be reached at the world’s longest-lived people have was working to re-shape the environments [email protected]. HN that we don’t are routines to shed of poor socioeconomic areas in an effort

20 A magazine for and about Nebraska hospitals and health systems. T:7”

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© 2013 Autism Speaks Inc. “Autism Speaks” and “It’s time to listen” & design are trademarks owned by Autism Speaks Inc. All rights reserved. The person depicted is a model and is used for illustrative purposes only. A magazine for and about Nebraska hospitals and health systems. 21

This advertisement was prepared by BBDO New York Filename: P35132_A_BBD_GEN_V12.indd CLIENT: BBDO Internal Proof #: 12 Path: Studio:Volumes:Studio:MECHANIC...hani- Created: 2-7-2013 4:10 PM PRODUCT: Smiles Magazine “A” cals:P35132_A_BBD_GEN_V12.indd Saved: 5-16-2013 4:54 PM JOB#: P35132A Operators: Susalis, Tracie / Wolcott, Catherine Printed: 5-17-2013 4:54 PM SPACE: Full Page 4/C Print Scale: None BLEED: None TRIM: 7” x 10” Fonts Ink Names SAFETY: None Helvetica Neue (47 Light Condensed), Archer (Semibold), Gotham Cyan GUTTER: None (Medium, Book), Minion Pro (Regular) Magenta PUBS: None Graphic Name Color Space Eff. Res. Yellow Black ISSUE: None Carnelina_Mitchell_010.psd (CMYK; 357 ppi), adcouncillogo_WHITE. TRAFFIC: Donna Mendietta psd (CMYK; 301 ppi), AS_12_FLogo_STK_cmyk_www.EPS ART BUYER: Cali Capodici ACCOUNT: Amy Brody RETOUCH: None PRODUCTION: Michael Musano ART DIRECTOR: None COPYWRITER: None Smiles By Al Klaasmeyer, vice president nha subsidiaries Texting protected health information

Texting has become a way of life for use of a technology or methodology technology incident, and improper individuals wishing to communicate specified by the Secretary in the guidance disposal of information. The source of information to other individuals in a under section 13402 (h) (2) of Public the breaches have occurred with failing short period of time. While some texting Law 111-5. The unauthorized use of to secure PHI on laptops, paper records, has been beneficial, other forms of unsecured PHI is considered a breach of desktop computers, portable electronic texting are ill-advised. Texting unsecured security. Severe penalties are assessed devices, Electronic Medical Records, Protected Health Information (PHI) is on hospitals, clinics, billing agencies and network servers and email. presumed to be a breach as defined in nursing facilities for not providing PHI NHA Services, Inc., will be unveiling a the HIPAA Omnibus Final Rule as of Sept. security that could result in a breach of solution for the breaches involved with 23, 2013. information. texting and storing of PHI information, The definition of unsecured PHI The loss of PHI takes on many partnering with Matrix Mobile Security is: “Unsecured Protected Health different types of breaches, which Solutions to eliminate the potential Information” that is not rendered include theft of information, breaches by use of mobile devices. unusable, unreadable or indecipherable unauthorized access or disclosure, loss Matrix Mobile Security Solutions uses to unauthorized persons through the of information, hacking or informational their relationships with other security vendors to ensure information and the storage of information is encrypted to provide a barrier to unauthorized YOUR OWN CUSTOMIZED persons to thwart the improper use of PHI. In the HIPAA Omnibus Final Rule HOSPITAL PATIENT GUIDE it is stated, “No breach notification is required for PHI that is encrypted in accordance with the guideline.” The technology to encrypt information is No Cost available and can provide a sense of assurance the PHI is safe and secure. The utilization of the technology for PATIENT To You. encryption is minor in comparison with INFORMATION & Fiscal restraints and budget line item cancellations the potential for fines, cost of the Breach VISITOR have hospitals cutting back in all areas. Here’s Notification and cost of notification to GUIDE help. Our Patient Guides are an excellent perceived FALL 2011 patient benefit saving your hospital time and each and every person whose PHI was money while informing and educating patients improperly obtained. Since 2008, the about your facility and their care. Best of all, penalties for Civil Monetary Penalties & there’s no effect on your bottom line, we produce Resolution Agreements have exceeded PATIENT them at absolutely no cost to you. $15.2 million. This figure is expected to INFORMATION Your full-color, glossy, Patient Guide is increase as investigations from the HHS & ➲ VISITOR completely customized for your hospital. Office of Civil Rights, State Attorneys GUIDE FALL 2011 ➲ You also get an easy-to-use ePub version to General and U.S. Department of Justice send to patients with email-also at no cost. continue their efforts to enforce this ➲ Inform and educate your patients quickly and Final Rule. efficiently. Your professional staff can now Al Klaasmeyer, vice president, spend less time answering routine questions. NHA subsidiaries, may be reached at [email protected]. HN Your hospital needs one and you can get it free. For complete, no obligation, information on how we can provide your Hospital Patient Guide, call or email today. Gary Reynolds • 1-800-561-4686 ext.115 or [email protected]

22 A magazine for and about Nebraska hospitals and health systems. A magazine for and about Nebraska hospitals and health systems. 23 Nebraska Hospital Association Presorted Standard 3255 Salt Creek Circle. Ste. 100 U.S. Postage Paid Lincoln, Nebraska 68504 Little Rock, AR Permit No. 2437

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