Remarks by Alan D. Aviles
President, NYC Health and Hospitals Corporation
December 12, 2012
Good evening, I am Alan Aviles, President of the New York City Health and Hospitals Corporation, our City’s public hospital system. Thank you for being with us tonight for our Manhattan annual public meeting, the fourth of five borough-specific meetings we convene each year. As always, I am eager to hear what HHC’s communities have to say about our performance, especially during what continues to be a challenging time in healthcare generally and for HHC specifically.
First, let me recognize HHC’s Manhattan senior executives. Our host is Harlem Hospital Center Executive Director Denise Soares. Also in attendance are Iris Jimenez-Hernandez, Senior Vice President of the Generations + Northern Manhattan Network, Lynda Curtis, Senior Vice President of the South Manhattan Network, Robert Hughes, Executive Director of Coler Goldwater Specialty Hospital and Nursing Facility, Mendel Hagler, Executive Director of Gouverneur Healthcare Services, Meryl Weinberg, Executive Director of Metropolitan Hospital Center and other senior leaders from our Manhattan facilities. I thank them for the excellent work they and their teams do every day to render the best possible care to Manhattan residents.
I also want to acknowledge the support and guidance of our Board of Directors, under the leadership of Dr. Michael Stocker. My special thanks to Board members who are here tonight and to the Community Advisory Board members from Bellevue, Harlem, Metropolitan, Coler, Goldwater, Gouverneur and Renaissance Diagnostic and Treatment Center, who advocate on behalf of our public system and help keep us grounded and responsive to the needs of our patients and communities.
Let me begin by speaking briefly about Hurricane Sandy and its dramatic and wide-ranging effects on HHC. First, let me say that in the face of this unprecedented event, it was the diligent planning, hard work, bravery and selfless dedication of thousands of HHC staff that protected our patients from harm, and helped relieve their discomfort and anxiety during the storm and in its immediate aftermath. Many staff, often despite their own concerns for family and home, worked tirelessly over multiple shifts with a determined focus on ensuring the wellbeing of our patients.
Before the storm, HHC Central Office Emergency Management and local facility leadership activated Emergency Response Plans; emergency generators were tested and fully fueled; and extra supplies and food were secured. Disaster staffing patterns were set in motion, and preparations were made for staff to sleep over at their facilities. Eight Special Medical Needs Shelters were opened, and staffed round the clock with the help of HHC personnel who worked extended shifts caring for some of the City’s most fragile residents, who were displaced by the storm.
Many of our employees suffered storm-related effects, some experienced personal hardships and others found it difficult to get to work because of transportation disruptions and fuel shortages. Despite these challenges, HHC’s Manhattan facilities did superb work during and after the storm.
As you know, Bellevue Hospital in Manhattan and Coney Island Hospital in Brooklyn were severely damaged by the extraordinary storm surge and both had to be evacuated. I was in the emergency command center at Coney Island Hospital on the night of the storm and witnessed the exemplary performance of the hospital staff who reassured and protected patients as the rising waters flooded the basement and eventually washed through the first floor of the hospital.
Hospital evacuations present a significant risk to patients, even when performed under the most optimal conditions and this is why a decision to evacuate before a forecasted storm is not made lightly.
It is a testament to the skill and commitment of our staff at both Bellevue and Coney Island that nearly 1,000 patients, including many critically ill patients, were evacuated safely. All of these patients were transferred without incident into the hands of caregivers at sister HHC facilities, and to non-HHC hospitals. Transfer information was made available to families as quickly as possible.
Extensive clean up, repair and restoration work is under way at these two hospitals. Coney Island Hospital re-opened a portion of its primary care services just two days after the storm and is now preparing to open more of its specialty outpatient services. On November 30th, Coney began offering urgent care services around the clock, but has not yet re-opened full emergency services. Bellevue Hospital Center has also resumed providing ambulatory care services and just this Monday re-opened its Child and Adolescent Comprehensive Psychiatric Emergency Program, or CPEP, as well as its Medical Emergency Department for non-ambulance transported patients. We expect that Coney will resume full emergency department and inpatient operations by January and Bellevue to do the same by February.
The Coler campus of the Coler-Goldwater Specialty Hospital and Nursing Facility, one of our long-term care facilities which serves some of the City’s physically fragile and chronically disabled individuals, lost power and heat after the storm. This made it necessary to transfer 104 medically fragile patients to Goldwater. More than 500 patients remained at Coler, diligently cared for by Coler’s stellar employees. The facility now has power and heat. However, there is significant work to be done to permanently repair damaged electrical and heating systems at this essential long-term care facility.
Finally, some of our Central Office locations sustained damage from the storm. More than 1,200 staff members working in key areas such as the Finance Department, Home Care, the IT Department, and MetroPlusHealth Health Plan have been displaced from 160 Water Street. Despite being deployed among several sites across the City, these resilient and dedicated employees have kept our core functions operational. We are hoping that the 160 Water Street building management will have the space ready for re-occupancy by the end of February.
There were so many HHC superstars during the storm. It would take the entire evening to talk about all of them, so I will highlight the efforts of only a few.
Bellevue Hospital safely evacuated 492 patients in just under two days, each carried from one of the hospital’s 21 floors since the elevators were not working. Three days later, after diligent effort, one elevator was brought back into service enabling the safe transport of two remaining patients, including a young man in his late thirties with a serious heart condition. Before the storm, Bellevue cardiologists had inserted a temporary device to correct a life-threatening heart blockage. This device had to be removed and his chest closed-up before he could be safely transferred. The rest of the story is one for the history books, involving the heroic efforts of a large team of doctors, nurses and Operating Room staff. The team set to work creating a pristine operating theater for Bellevue surgeons Abe Deanda and Leora Balsam. The operation was not only a success, but the expert post-operative care facilitated a seamless transfer of the patient to Columbia-Presbyterian for ongoing care. The patient’s family was on-site throughout the operation and transfer.
Metropolitan accepted 59 patients transferred from Bellevue during the first wave of evacuations. The hospital reopened two previously closed inpatient units to make almost 50 additional beds available for medical, surgical, and psychiatric patients from Bellevue; and treated up to 300 patients per day in a special Walk-In Center opened to accommodate Bellevue patients seeking outpatient care. Metropolitan also welcomed 235 medical staff and 1,000 other professionals from Bellevue and other areas of HHC. Some of these staff have since returned to their facilities.
In addition, Metropolitan served as a special fuel distribution center during the gasoline shortage that followed the storm. A tanker from Texas provided 8,400 gallons of gasoline to local hospital, nursing home, and home care employees. The Department of Defense, the Department of Homeland Security and FEMA provided the fuel and Metropolitan staff dispensed it.
Let me touch on a couple of quick examples of how individual staff rose to the challenge of the storm. Denise Jones, Head Nurse in OB/GYN at Harlem Hospital Center showed up for work the morning before the storm with a packed bag and ended up staying at Harlem Hospital for three straight days. And when she learned that her staff nurses were eager to report to work, but couldn’t make it in because public transportation had been suspended, Ms. Jones got in her car. Driving as far as the Bronx and New Jersey through high winds and rain, she picked up her colleagues on three separate occasions. To ensure that her nurses didn’t get completely worn out during the week post-Sandy, Ms. Jones set up rooms where they could rest at the hospital. She also personally provided RN coverage on both the hospital’s Labor and Delivery and Post Partum units.
Chak-Sin Wong arrived at his hospital police post at Gouverneur on October 28th and stayed at the facility until November 5th. As the only Chinese-speaking security officer present, Mr. Wong was indispensable, keeping Gouverneur’s reception area running smoothly during and after the storm. When Bellevue Hospital Center closed, many outpatients went to Gouverneur, where Mr. Wong’s knowledge of the facility and warm demeanor proved instrumental in helping the facility manage the additional patient volume. His ability to communicate with Chinese patients, some of whom previously had been served at Bellevue, made it easier for them to get connected to the right services within the facility.
After our Coler long-term care facility on Roosevelt Island lost power and hear, Coler-Goldwater staff worked tirelessly over a 14-hour period on October 30th and 31st to safely evacuate fragile residents to the Goldwater campus. Guided by the Coler-Goldwater evacuation team of Monserrate Martinez, Associate Director of Hospitals, and Jenny Rosario, Director of Patient Relations, and with the aid of FEMA and EMS paramedics, nursing and numerous other Coler-Goldwater staff, 104 residents were transferred to waiting ambulances and safely delivered to Goldwater Specialty Hospital. Ms. Gladys Dixon, Chair of the Coler Community Advisory Board and Ms. Judy Berdy, Coler CAB member were on hand to assist residents upon their arrival at Goldwater. And not surprisingly, the namesake for HHC’s soon-to-be new healthcare facility in Harlem, Henry J. Carter, helped residents and staff throughout the night.
Mayor Bloomberg and the City Council have set aside $300 million to help our public hospitals to repair the extensive storm-related damage to our facilities. These city-appropriated funds will go toward structural restorations, new boilers, new mechanical and electrical systems, roof repairs, flood remediation and more. In addition, we have begun the process of applying to FEMA for funds to repair facilities and replace equipment. None of these funds will cover lost revenue from Bellevue and Coney Island, which amounts to $15 million a week, and we estimate that total operating losses may approach $200 million before we get both hospitals back to full operation.
HHC has faced adversity before, and we have come out of it stronger. We expect the same to be true in this instance, though the physical and financial damage to our facilities is significant, and will strain our budget and make it even more challenging to implement the strategic initiatives planned for the coming year. Nonetheless, I have full confidence in our ability to rebuild primarily because of the incredible staff both at our facilities and in our central offices, who work tirelessly to ensure that we sustain our mission in serving all of the patients who need us.
Let me now focus on the very significant financial challenges HHC faced before the storm — challenges that will continue to intensify.
At the City level, as a result of a forecasted $2.5 billion budget gap for the fiscal year beginning July 1, 2013, City agencies have been required to submit spending reduction proposals. For HHC, this means a 5.4% reduction to our baseline City funding, or a $4 million cut. This will increase to an 8% reduction, or a $5.1 million cut in 2014 and beyond.
We also face diminishing state and federal funding. Under the Budget Control Act of 2011, an across the board cut totaling $1.2 trillion over ten years will begin in January 2013—you may have heard this called the “fiscal cliff”. This massive cut will take place unless Congress adopts an alternative approach by the end of December 2012. An across the board 2% cut in Medicare – as currently planned — would result in HHC losing nearly $10 million in Medicare reimbursement in 2013 and more than $83 million from 2013 to 2021.
Beyond these looming reimbursement cuts, we are increasingly in an environment where we will be expected to deliver better care, with better patient outcomes at lower costs. More and more of our reimbursement will be tied to our ability to accomplish these three things.
Healthcare providers throughout the country are also dealing with these same expectations; however the challenges for HHC are greater because we provide care for so many uninsured patients, yet continue to receive less and less funding for that work.
And under the federal health reform law, upheld by the Supreme Court in June, beginning in 2014 the federal government will make significant reductions to supplemental Medicaid and Medicare funding that supports public hospitals and other safety net institutions. Ultimately, these cuts could reduce HHC’s federal funding by more than $325 million annually. There is very little prospect of Congress re-visiting the wisdom of these looming, devastating cuts.
We continue to grapple with a daunting budget gap, and we are in the third year of a four-year cost containment and restructuring plan projected to yield $600 million in new revenue and cost savings. We remain on target with this plan, and our efforts to date have closed the budget gap by roughly $400 million. Our workforce has 3,000 fewer full-time employees than three years ago. Most of this workforce reduction has not involved direct patient care positions and, to the credit of our dedicated employees, we have maintained virtually the same service capacity across all care settings.
It is important that our stakeholders understand what we are up against and why we have resorted to measures such as workforce reductions through attrition and targeted layoffs, as well as the consolidation or outsourcing of certain services to lower our expenses. HHC’s senior leadership team is fully committed to keeping our financial plan on track while continuing to provide high quality, safe care to our patients. For example, one of our cost-containment initiatives is a new contract for dialysis services that will enable us to increase our dialysis capacity by 35% over the next three years while saving an estimated $100 million over a nine-year contract period. We will continue to guarantee access to dialysis services for all patients without regard to insurance or immigration status, and no HHC staff member will lose employment as a result of this contract.
Let me stress that we are looking at every conceivable way to close our budget gap without adversely affecting our capacity to serve our communities, without negatively affecting access to care and without diminishing the stellar gains in safety and quality that we have made. That said, given the looming reductions in federal funding starting next year, it will be considerably harder to achieve these aims.
Another way we are meeting our financial challenges is to achieve greater efficiency through redesign of our operations using Breakthrough, our employee-driven process improvement approach. With Breakthrough, we use the experience, skill, and creativity of staff at all levels to help improve services, take out waste, and reduce cost. Since its launch in 2007, more than 7,500 employees and affiliate staff have been involved in Breakthrough activities, leading to roughly $284 million in new revenue and cost savings.
Coler-Goldwater began implementing Breakthrough in March of this year. Through early efforts, they have significantly reduced the time it takes to admit patients. In addition, the facility staff have begun using Breakthrough tools to plan for relocation to the Henry J. Carter Specialty Hospital and Nursing Facility.
At Bellevue, Breakthrough teams’ efforts have helped to decrease the average delay between surgical procedures by 68%. The results of this work included an increase in the number of procedures completed, reductions in patients’ waiting times to obtain appointments, and the generation of additional revenue.
At Harlem Hospital Center, patients needing surgery were required to go to multiple areas to complete financial clearance. Too often, this resulted in patients being delayed for surgery because the process was so complex. Through Breakthrough, by eliminating internal forms and unnecessary steps and by creating scripts for all areas to communicate to patients, 30 minutes was taken off of the waiting time for clearance and the number of patients completing financial clearance before their procedures increased by 55%.
At Metropolitan Hospital Center, 30% of patients with congestive heart failure were readmitted within 30 days of discharge from the inpatient cardiology unit. In order to help keep these patients well, the hospital used Breakthrough to create a standard process for all involved staff to provide consistent teaching to patients both before and after discharge. This work, which was a collaboration among Metropolitan, HHC’s Health and Home Care division, and our health plan, MetroPlusHealth, led to a 33% reduction in the number of congestive heart failure patients who are readmitted and a 20% reduction in their readmission rate.
As we work to make our system more efficient, and manage our ongoing financial challenges, we continue to be responsive to the needs of our communities. HHC facilities provide nearly 220,000 hospital inpatient stays, more than 1 million ED visits, and more than 5 million outpatient visits annually. In Manhattan, HHC provides 86% of all hospital-based clinic visits and 32% of all inpatient stays made by uninsured residents. And we continue to offer the communities we serve a full range of primary and preventive care services, emphasizing early detection of disease and effective management of chronic diseases such as asthma, diabetes, and hypertension.
HHC has moved forward in a number of areas that will help us transform care in a positive way for our patients. This past year, we have met new federal standards for implementing effective health information technology, including electronic medical records. As a result, we are slated to receive $82 million in federal funding to support further development of our health information technology. Payments began in June 2012 and we have already received more than $17 million of these funds.
Last year I spoke about our successful efforts to convert HHC’s primary care clinics into Patient Centered Medical Homes. Such medical homes match each patient with a dedicated team of providers who offer coordinated, comprehensive care. Medical Homes improve continuity of care for patients and earn additional reimbursement. HHC has applied for $28 million in available state funding to support the continued strengthening of the patient-centered medical homes model.
In addition to our work in developing patient-centered medical homes, HHC and our health plan, MetroPlusHealth, received New York State designation as a Health Home for Queens, Manhattan, Brooklyn and the Bronx. Health Homes are paid to be responsible for assuring that people with mental illness and multiple chronic conditions – that is, high users of healthcare services – have better access to primary care as well as improved coordination and care management. Assuming responsibility as a Health Home is a part of our effort to strengthen services for vulnerable populations, improve outcomes, decrease unnecessary Emergency Department visits, and decrease unnecessary hospital admissions.
HHC has also applied to participate in the Medicare Shared Savings Program as an Accountable Care Organization (ACO). This initiative creates a new model to offer Medicare beneficiaries higher quality care while reducing costs through increased efficiency and integration of services. To receive incentive payments, the HHC ACO will have to measurably improve the health status of patients through evidence-based clinical practices, and lower spending for the Medicare program by reducing unnecessary hospitalizations, re-admissions, and Emergency Department visits for designated Medicare patients. If approved, the HHC ACO will begin operations in January.
Robust primary care is the foundation of health reform, and as a step toward meeting the need for more primary care doctors in the future, HHC and St. George’s Medical College have collaborated on the City Doctor’s Scholarship program. Over the next five years, we will offer $11 million in tuition-based scholarships to New York City residents who attend St. George’s Medical College and commit to practice primary care medicine at an HHC hospital. Eleven scholarships were awarded this past year, and more scholarships will be awarded this coming January.
Our Work in Manhattan
Here in Manhattan, our public hospitals continue to exceed national benchmarks on many important publicly reported measures of quality and patient safety.
Harlem Hospital had no cases of ventilator-associated pneumonia infections in the past two fiscal years. Harlem also cut its rate of central line bloodstream infections in half in fiscal year 2012. Bellevue and Metropolitan lowered their rates as well. Metropolitan had only one central line bloodstream infection case in this same time period.
Metropolitan’s Women’s Imaging Center was recently surveyed and re-accredited. The Center also was designated a Breast Imaging Center of Excellence, fully accredited in Mammography, Stereotactic Breast Biopsy, Breast Ultrasound and Ultrasound-Guided Breast Biopsy.
The New York Medical College sponsored Surgery Residency Program at Metropolitan Hospital Center was newly accredited this year. This is the first new surgery residency program in New York City in about forty years.
Metropolitan opened a new state-of-the-art Pediatric Inpatient Unit in March 2012, part of the hospital’s comprehensive inpatient and outpatient services for babies, children and adolescents. The new 14-bed unit integrates the highest quality medical care for children with a beautiful, nurturing environment that fosters patient safety and healthy recovery.
Harlem Hospital opened its new mural pavilion in September with a Ribbon Cutting Ceremony and reception for more than 300 people. The new $325 million healthcare facility will expand access to preventive health services, emergency room care and specialty care and is equipped with state-of-the-art technology. The Pavilion also features restored, historic murals by African-American artists that are now on exhibit, and images from one of the murals are reproduced across the block-long glass façade of the new facility.
This past year, Bellevue received an “A” rating on the Leapfrog Group’s Hospital Safety Score. Only 15% of hospitals in New York State achieved this top grade. The Hospital Safety Score uses 26 measures of publicly available hospital safety data to produce a single score representing a hospital’s overall capacity to render safe care to patients.
The new Henry J. Carter Specialty Hospital and Nursing Facility, named for local philanthropist Henry “Hank” J. Carter, in recognition of his more than $25 million in donations to Coler-Goldwater, will be located on Madison Avenue and 122nd Street and will be the new home of the Goldwater Specialty Hospital and Nursing Facility currently located on Roosevelt Island. This Harlem-based long-term care hospital and skilled nursing facility, consisting of nearly 400,000 square feet of combined new and renovated state-of-the-art space, will be completed in late fall of 2013.
This past September, CMS awarded Coler and Goldwater Nursing Facilities an overall rating of five out of five stars, the highest score possible. CMS rates nursing homes on a scale of one to five stars, taking into account its on-site survey results, regulatory compliance, staffing data and selected measures of quality.
On the lower east side, HHC’s $200 million Gouverneur Major Modernization project continues. The project will create the Center for Community Health and Wellness and The Residence at Gouverneur Court to better meet the community’s healthcare needs in an attractive and functional setting. The modernization will expand access to needed ambulatory care services, as well as expand Gouverneur’s skilled nursing facility capacity from 210 to 285 beds.
I appreciate and am proud, especially after Hurricane Sandy, of the work that our dedicated HHC staff performs every day here in Manhattan and across our city to provide accessible, high-quality healthcare to our patients. I can assure you that the leaders across our organization, as well as our Board of Directors, are advocating at every level of government to secure resources so that HHC can continue to effectively meet the needs of our vulnerable patients and communities.
We appreciate the strong advocacy support that we receive from our partners in labor, our community advisory boards and auxiliaries, and many community-based organizations that care about our mission. Our strong connection to, and support from, the communities we serve is one of our most important assets.
Thank you for your attention and your attendance. I will now turn the program over to Mr. Russo. I look forward to hearing your comments.