In place of my standard Board report, this month I would like to provide the Board with a review of our achievements over the past year, as well as highlight some of what we expect to accomplish in the year ahead. There is an abbreviated written report for the month in your packet which, as customary, we also post to our internet site for the public’s benefit.
We can look back on the past year with considerable pride. A great deal has been accomplished on many fronts. As always, each of our facilities can point to its own impressive accomplishments that reflect our long-standing tradition of responsiveness to local community need. I won’t attempt to catalogue those many noteworthy initiatives because that would be a very long list.
Bellevue WTC Environmental Health Center
But let me mention one. Earlier this month we formally opened the new WTC Environmental Health Center at Bellevue. This new center, which expands upon a joint Bellevue/NYU program established shortly after the events of 9/11, will evaluate and treat any New Yorker who suffers symptoms associated with exposure to the WTC disaster or its aftermath.
Led by Dr. Joan Reibman, the new WTC health center – which has been funded by the City — arises from the collaborative work that Bellevue has done with the Beyond Ground Zero Coalition and other community-based organizations over the last couple of years. That partnership has thus far identified hundreds of patients, especially uninsured lower Manhattan residents and new immigrant day laborers, who suffer health consequences from their exposure to the fumes and/or dust of the WTC site, but who were ineligible to receive services from existing WTC-related evaluation and treatment programs funded by the federal government.
This coming year the expanded new center of excellence will have more than double its prior capacity and will work to ensure that no New Yorker suffering from post-9/11 illness lacks access to expert evaluation and care.
As this Bellevue initiative demonstrates, and there are many other comparable facility-specific examples from this past year, we often best meet the needs of our patients when we partner with other organizations with a common mission and deep roots in our communities.
Before turning to some of this past year’s system-wide accomplishments, let me express my deep appreciation to our Network Senior Vice Presidents, our senior staff here in central office, our Community Advisory Board members, and each and every HHC employee who brings passion, dedication and creativity to the fulfillment of our mission. Every day our clinical, administrative and support staff make a difference as we provide essential care to 1.3 million New Yorkers across the City.
Prevention and Screening
Now let me highlight some specifics. One prime example of our commitment to preventive care is found in our ongoing extensive smoking cessation programs. We have enrolled more than 70,000 smokers over the course of the past four years and have distributed nicotine replacement therapy to greatly increase the odds of success. Last year we helped thousands of our patients to quit smoking, and live healthier and longer lives.
Other prevention, screening and early detection efforts narrow the gap of ethnic and racial healthcare disparities. Cervical, breast and colon cancer are three areas where death rates are higher for poor patients of color, largely due to access barriers to early detection of these cancers. We continued to step up our cancer screening efforts in each of these areas, performing more than 150,000 cervical cancer screenings and more than 80,000 mammograms. And last year we performed nearly three times the number of screening colonoscopies that we provided just four years ago.
As a result, we are diagnosing significantly more cancers at an earlier stage when treatment is more effective and prognosis much more hopeful. That is saving lives. This year we will make the new HPV vaccine available to adolescents and young women to lower their risk of cervical cancer. And we will launch a broad education and awareness campaign to get more patients vaccinated.
We also mounted a new campaign to combat the disease with the greatest ethnic and racial disparate impact of all – AIDS and HIV infection. Nearly 85% of the roughly 1500 AIDS-related deaths in NYC during 2005 were among African-American and Hispanic New Yorkers. And many of the communities of color served by our hospitals and health centers have HIV infection prevalence rates that are more than double the City average.
As you know, every one of our hospitals is a Designated AIDS Center with deep expertise in the treatment of HIV infection and AIDS. We stepped up the fight against the continuing epidemic, and last year expanded our HIV testing dramatically. Our strategy was to increasingly adopt rapid testing methods and reach patients in a broad range of care settings.
By the end of the year, through extraordinary and often innovative efforts, we tested more than 100,000 patients, a 65% increase over the year before. We identified more than 1500 patients who were HIV positive and did not know it, and we linked those patients to care.
We will continue to normalize testing – making it available to more patients as part of routine care, not just patients perceived to be at a high risk. This coming year we will expand our testing efforts even further and expect to test at least 150,000 patients for HIV. Our program will reach more outpatient clinics, connect with more adolescents, and focus on the growing population of HIV-infected seniors. By reaching HIV-infected patients who would not otherwise be reached, we will get more individuals into care early when the disease can best be managed, and we will help reduce the transmission rate even as we lessen the stigma of HIV.
Managing Chronic Disease
There are other epidemics beyond HIV/AIDS where we have stepped up our efforts with promising results. We continue to focus on the twin epidemics of asthma and diabetes.
Both diseases disproportionately affect African-American and Hispanic communities. In some of our communities more than 8% of adults and more than 18% of children suffer from asthma, and more than 10% of adults have diabetes. Asthma is the single greatest health-related cause for missed school days among our children.
The incidence of diabetes city-wide has more than doubled over the past ten years, and roughly 8% of all New Yorkers have diabetes. Diabetes remains the leading cause of kidney failure, adult blindness, and lower extremity amputation, and it is a prime contributor to heart disease and stroke.
This past year we continued to use our advanced clinical information technology to improve our care of asthmatic and diabetic patients. By embedding asthma action plans in our electronic medical records and ensuring that we are prescribing the most appropriate medications for children with persistent asthma, we again reduced related emergency room visits and hospital admissions. In fact, our asthma-related pediatric emergency re-visits declined by 24% and our hospital admissions dropped by 30% during the past two years.
Last year we also moved to build on the promising results of work in our Queens Health Network which piloted an electronic diabetes registry fed from our electronic medical record. Using the e-registry as a tool to focus attention on the diabetic patients who needed it most, both of our hospitals in Queens have demonstrated that over a 30-month period they were able to more than double their number of diabetic patients with well-controlled blood sugar levels.
Under the leadership of Francis Pandolfi and Dr. Lou Capponi, we developed an electronic registry that is now available over our intranet at every one of our facilities. We are now tracking the health status of nearly 50,000 adult diabetics across our system, with the goal of replicating over the next two years the success demonstrated in our Queens network.
We will look by the end of 2008 to double the number of our patients system-wide whose diabetes is well-controlled. This would effectively mean bringing more than 10,000 diabetics under good control and lessening their risk of life-threatening complications.
We are using our electronic medical record (EMR) to address another chronic disease – one that often impedes our efforts to engage patients in the management of their own care – depression. During the past year, we embedded an evidence-based screening tool for depression into our EMR at every facility to help identify undiagnosed depression in our primary care settings. We screened more than 20,000 patients during the year, and were forced to confront the reality that the prevalence of depression among our patients outstrips the capacity of our outpatient mental health resources.
We therefore have undertaken, with the help of the city Department of Health and Mental Hygiene, a system-wide training effort to equip our primary care providers to treat mild and moderate depression in their patients. Over the course of the next year we will treat more patients for depression than ever before, and many of these patients will be treated in our primary care clinics as we continue to take a more holistic clinical approach in that setting.
To help coordinate all of this complex work around the more effective management of chronic disease, we have begun to hire and will have in place at each of our facilities a dedicated chronic disease coordinator. Each chronic disease coordinator will devote his or her full-time efforts to support collaboration among our clinical teams as they continue to develop best clinical practices, and to help both with the spread of what works and the monitoring of data that reflects our progress.
We also will enlist our health and home care division and our health plan, MetroPlus, in the more effective management of chronic disease. Our home health care operation will ramp up its deployment of telehealth technology to monitor remotely the status of an increasing number of homebound patients with serious chronic disease.
Metroplus, for its part, will expand its care management activities and continue to refine its “pay for performance” incentives to HHC facilities and community physicians focused on the attainment of better outcomes for patients with asthma and diabetes.
As we deal more effectively with disease, we are simultaneously moving to help those who come to us as the victims of violence. Over the past year, we effectively incorporated screening for domestic violence into our routine health assessments, and we trained more than 1,200 of our staff on how to more effectively screen for signs of child abuse. This past year, we also assembled Sexual Assault Response Teams at Metropolitan Hospital and Elmhurst Hospital to ensure that victims of sexual assault in both boroughs will receive expeditious medical care and counseling support, as well as expert forensic preservation of evidence for prosecuting their attackers. HHC now supplies Sexual Assault Response Teams, 24 hours a day, 7 days a week in four boroughs. We have been working with the City’s Criminal Justice Coordinator who is in discussion with the providers on Staten Island to address that borough’s residents’ needs.
Speaking of Staten Island, this past year we provided financial and logistical support to establish a new community health center on the Island’s North Shore, a primary care-deprived area with a large low-income population that includes many uninsured individuals and many new immigrants. The Port Richmond Health Center opened its doors this past summer and we are financing the expansion of its physical space to increase its capacity and allow it to provide a full range of primary care services for children and adults.
As Staten Island is a borough of growing need where we have a limited presence, we are committed to ensuring the success, as well as the further expansion, of the Port Richmond Health Center. A search is underway for a second site for the health center. Meanwhile, we continue to support and fund a temporary means of providing additional affordable primary care capacity for uninsured low-income residents on Staten Island through the Staten Island Health Access program (or SIHA). More than 2,500 Staten Island residents have participated in SIHA and participants receive HHC-subsidized care from community-based physicians located on the North Shore.
Increasing access to needed healthcare services for those who otherwise could not afford it, as we are trying to do on Staten Island, is central to our mission. Under the new charity care law that went into effect last month, hospitals are now required to offer a sliding fee scale to patients up to 300% of the federal poverty level. Nearly two years ago, through its HHC Options Program, HHC raised its sliding fee scale to 400% of the federal poverty level to broaden affordable access to even more New Yorkers. At the same time, we have partnered with community-based organizations to ensure that individuals in our low-income communities understand our reduced fee policies and our fundamental commitment to never turn a patient away because of an inability to pay.
With the help of our City’s Commissioner of Immigrant Affairs, and free promotion from a wide range of ethnic media, we communicated our commitment to access and confidentiality for new immigrants. We extended the message in eleven languages to let new New Yorkers know that our public hospitals welcomed them, would care for them, and would keep their personal information, including their immigration status, confidential. And City Council Speaker Christine Quinn joined us to persuade new immigrant families to secure a primary care home for their children at one of our community-based Child Health Centers, rather than endure the long waits and fragmented care of an emergency room.
As we continue to fulfill our traditional role as the primary safety net provider to the new immigrant communities of our city, we also continue to strengthen our ability to provide culturally responsive services to our extraordinarily diverse spectrum of patients. With the funding provided by the City Council, we have expanded our capacity to provide our remote simultaneous translation service beyond its points of origin at Bellevue and Gouverneur to Kings County Hospital. Later this year we will expand it to the East New York Diagnostic and Treatment Center.
Ambulatory Care Redesign
Our focus on cultural responsiveness is a prime example of patient-centered care. Another is our continuing work on ambulatory care redesign to keep our average primary care visit time down to our goal of 60 minutes or less, even as we focus on a second phase of redesign to make appointments more readily available when patients want them. We call this second phase of redesign patient-centered scheduling.
Moving away from our longstanding, but deeply flawed, approach to the scheduling of patient appointments is not easy. This redesign challenge is intrinsically difficult in our ambulatory care operations which are invariably high volume and too often resident-driven, and there are other hurdles as well.
With scheduled appointment no-show rates averaging 30% or higher and large numbers of unscheduled walk-in patients, our present system is inefficient, stressful for patients and staff, and insufficiently conducive to the continuity of care essential to our work around patient engagement in the more effective management of chronic disease.
To support this difficult but essential redesign, we have convened a workgroup to re-examine our affiliate contract productivity model to come up with an alternative approach that aligns contract incentives with our initiatives around patient-centered care. Although it will be a struggle to achieve the goals of patient-centered scheduling, we know the goal is attainable.
Just look at the Queens Hospital Center medicine clinic and the Kings County pediatric clinic where the appointment templates have been re-worked, where the clinics no longer resort to the automatic scheduling of patient re-visits far into the future, where patients generally can now access appointments when they need them, and where, as a result, the no-show rates have dropped by approximately 50%. Over the next year, more of our primary care clinics will follow this lead.
The Choice of More Patients
And I am glad to say that, as we transform our system to be more efficient, effective and patient-centered, more patients are choosing to obtain their care at our facilities. This is in stark contrast to the ‘90s when so many of our facilities seemed to be in free fall, with sharp drops in outpatient clinic use and year after year of declining hospital admissions.
This past year, the total number of patients served by our outpatient clinics was up again for the fifth time in the last six years. And for the first seven months of our current fiscal year which began on July 1st, the number of inpatient discharges across all our acute care hospitals is up by more than 4%. Assuming that trend continues, we will provide care to roughly an additional 8,000 inpatients this year. At the present time, even with the addition of some 40 beds over the past two years to meet community need, our total system’s inpatient occupancy rate is above 90%. What a difference a decade can make.
The transformation of our public hospitals was strikingly validated by the work of the Berger Commission as it targeted hospitals across the city and state for closing and reconfiguration. The Commission recommended not that our public hospitals shed beds, but rather that the State approve 40 additional beds for Queens Hospital Center.
Rebuilding Our Infrastructure
We are not only transforming the way that we are providing care. We are transforming our environments of care with the largest hospital capital construction program in the City’s history. At the same time, we have made priority investments in health information technology and cutting-edge medical equipment to link modern efficient space with modern medicine.
Our massive rebuilding of our infrastructure will ensure that our public hospital system is positioned to serve future generations of New Yorkers. This past year we completed work on the ambulatory care pavilions at Kings County and Queens Hospital Center. We began or continued construction on several other major projects, including the new Harlem Hospital Center, the new Kings County Behavioral Health Center, the new ambulatory care pavilion at Jacobi, and the expansion of the Emergency Department at Lincoln.
And our capital dollars have been invested beyond our acute care hospitals. The planned modernization of the Gouverneur diagnostic and treatment center and skilled nursing facility has now been approved and funded and we are in the design phase of that project. We completed the construction of the impressive new home for our Bedford Stuyvesant Alcoholism Treatment Program, and we have upgraded the physical plants of some of our community-based health centers, including the Junction Boulevard Family Health Center in Queens. We will soon complete the new and expanded home for HHC’s Mariners Harbor Child Health Clinic in Staten Island.
As part of our commitment to earlier diagnosis and treatment of cardiovascular disease, we have continued our upgrade and expansion of cardiac catheterization centers. New units opened last year at Bellevue and Jacobi, and one at Kings County will be completed later this year. In all, we will have new or renovated cath labs at six of our hospitals.
With three new labor, delivery and recovery units completed in 2006 at Coney Island, Kings County and Lincoln Hospitals, all eleven of our hospitals can boast state-of-the-art maternity suites. Nearly 22,000 babies were delivered across our system last year with one facility – Woodhull Hospital — experiencing a remarkable 20% increase in deliveries over the last two years.
Following the lead of our Regional Perinatal Center at Bellevue, our other Regional Perinatal Center at Jacobi and our seven Level 3 NICUs will undergo retrofitting this year, partly funded through the HHC Foundation. These targeted renovations will lower lighting and noise levels and achieve certain other environmental modifications that have been shown to improve the outcomes of fragile babies – some of whom are born weighing little more than 2 lbs.
We continue to invest not simply in modern therapeutic space, but also in modern diagnostic equipment, such as 64 slice CT-scanners at Lincoln and Queens Hospitals, digital mammography units at North Central Bronx, Elmhurst and Lincoln Hospitals, and a new state-of-the-art MRI suite at Bellevue that we acquired this past year.
Cutting-Edge Information Technology
And we are investing additional resources in our advanced clinical information systems. We launched two major pilots this year, a customized EMR module in Elmhurst Hospital’s busy emergency department and another custom EMR module in Coney Island’s outpatient and inpatient behavioral health services. Both installations will be completed this year and, assuming we are satisfied with the results, we will begin rolling both applications out to our other facilities. Other than the VA, we are likely the only multi-hospital system with a comprehensive, integrated EMR that will soon extend to both emergency departments and behavioral health services.
Apart from these major extensions of EMR functionality, we continue to augment our EMR system to enhance patient safety.
To lower the risk of deep vein thrombosis, our clinicians can now calculate an inpatient’s risk of deep vein thrombosis directly in our electronic medical record and embedded decision support will recommend the most appropriate preventive treatment.
To lower the risk of medication error, we have extended EMR-linked robotics to more of our outpatient pharmacies with built-in safety check features. And, in conformity with one of the national patient safety goals emphasized by the hospital accrediting organization, we have extended electronic medication administration reconciliation to the bedside in all but one of our networks. In doing so, we have provided our nurses with the electronic support they need to ensure that the right patient receives the right medication in the right dose at the right time. E-medication administration will be installed in the last of our seven networks this year.
All of these continuing innovative efforts have kept us at the forefront of healthcare systems that are improving care through the leveraging of clinical information technology.
While our IT achievements are not necessarily well-known by the public, they are not lost on our own industry. This past year, for the second time in the last five years, one of our networks won the national Nicholas E. Davies award for excellence in the use of an EMR to improve patient care. Only two other health systems in the country – Kaiser Permanente and the VA – have received that recognition twice.
As you know, I have made patient safety one of our highest priorities and I have challenged our organization to become one of the safest hospital systems in the nation by the end of this decade. I remain absolutely convinced that we can achieve this daunting goal and our progress over the last year in the area of critical care has moved us toward that goal in a powerful way.
Hospital-acquired infections in critical care units are among the most dangerous preventable events in our acute care facilities. Both ventilator associated pneumonia and central line associated blood stream infections greatly increase the risk of death for fragile ICU patients.
This past year critical care teams from across our system implemented evidenced-based practices that reduce both types of infection and the majority of our hospitals went several months in a row without a case of ventilator-associated pneumonia or a central line infection in their ICUs. I want to particularly acknowledge Dr. Jose Mejia and his team members at Woodhull Hospital where there was only one instance of hospital associated pneumonia in that hospital’s ICU all year. That one case broke a streak of 18 straight months without a single instance of ventilator-associated pneumonia.
And at Bellevue Hospital, which runs 40 ICU beds, I salute Dr. David Chong and his critical care team for their impressive work. Bellevue’s Medical ICU went all year without a single case of ventilator-associated pneumonia and now has gone nine months and counting without a case of a central line blood stream infection.
In addition to their work in reducing hospital-acquired infection, each of our facilities has now implemented rapid response teams to bring critical care resources to the bedside of patients outside the ICU when patients show telltale signs that elevate their risk of a cardiac arrest. Again Bellevue has led the way as the first of our facilities to implement rapid response teams hospital-wide during this past year. As a result, the number of out-of-ICU cardiac arrests is down significantly at Bellevue for the year. Several of our other facilities are beginning to see the same results.
I can report excellent results on yet another patient safety front — surgical site infection prevention. Our system as a whole continued to outperform national and state average scores for adherence to the federal quality indicators related to the prevention of surgical site infection. Five of the top six scoring NYC-based hospitals in this category, according to the State Department of Health, are HHC facilities. It is no surprise then that our clinicians from Lincoln and Bellevue Hospitals were featured in a training film on the prevention of surgical site infection produced by the Healthcare Association of New York State.
All of these patient safety efforts and others have helped to reduce our system-wide mortality rates again this past year. In fact, this was the fourth year in a row where we have seen a decline in our system-wide mortality rate. That means that 460 fewer patient deaths occurred this past year across our system than in calendar year 2003. Make no mistake about it; this work around patient safety is saving lives.
As we define patient safety to include everything that we can do to avert unnecessary harm to our patients, we have turned our focus on the unnecessary suffering and anguish that too often accompanies the last weeks and days of life for terminally ill patients in our ICUs. Many patients facing certain and imminent death want high-tech interventions continued to the very end, no matter how invasive or futile, and that is their right. Others, however, would choose differently if given the choice.
Two of our hospitals have established palliative care teams to ensure that our patients have the option, if they so choose, to spend the very end of their lives in an environment that emphasizes comfort and affords an opportunity for lucid closure with family and friends. As evidenced by the roughly 800 patients and family members served by the palliative care team at Coney Island over the past two years, many want that option.
Over the course of this year, more of our hospitals will fully implement palliative care teams.
All of our work to provide safer care that prevents unnecessary harm to our patients, to provide more effective care that better manages chronic disease, and to provide more preventive care that averts disease or that diagnoses disease at an early stage, speaks to the commitment of our staff at all levels to our mission and to our patients.
This coming year we will demonstrate that commitment in yet another way. Today we have launched a newly designed website to replace our current internet site – it is accessible at nychhc.org/hhc.
Our new website – which we will continue to refine during the year – is intended to provide more useful information to our patients, community physicians and the public. The site contains a new section titled “Safety and Quality”. In that section, we have begun to post quality data that we think our patients and the public have a right to know.
Most, but not all, of the data that we post starting today is already in the public domain, if someone knows where to look for it. We have made it easy by posting this data in as clear and direct a way as possible for each of our facilities on our website. We invite our patients and other members of the public to compare our quality data to others where that is possible. We challenge other hospitals in our communities to be as transparent with their quality data so those comparisons can be made more readily.
Later this year we will begin posting more quality data that is not yet available to the public in this state, but we think should be. We will post our rates of hospital-acquired infections, the rates of catheter-related urinary infections, unadjusted and risk-adjusted mortality rates, the aggregate health indicators – like blood sugar, blood pressure and cholesterol levels — that reflect the health status of our diabetics, and more.
All of this data relates to our performance improvement efforts to protect our patients from unnecessary harm or to better their health status through more effective care. We believe that making our data transparent to the public will help drive the improvements to which we are committed. And we are willing to be held accountable for how well we are accomplishing what we have set out to do for our patients’ benefit.
That is an overview of the year past and a preview of some of what we expect to accomplish in the coming year. All is not rosy, of course, and there are some dark clouds on the horizon. I have asked Marlene Zurack and LaRay Brown to provide you with a synopsis of the budget challenges that face us on the state and, most dauntingly, on the federal level.
But we continue to move forward aggressively to fulfill our mission. We view that mission as not merely affording access to the most vulnerable among us, but doing our best to provide our patients with the most efficient, effective and safe patient-centered care possible. And as we look to the future, we hope that the growing drumbeat about the need for universal healthcare coverage actually takes us in that direction. Until we get there, however, HHC – the public’s hospital system – continues to be the next best thing…. and we are going to continue making it even better.
On February 16th HHC provided a Corporate Orientation for Mary Ellen Janda, the 2007 Joint Commission Survey Team Leader. Joint Commission surveys are now unannounced, and five of our facilities will be surveyed at some time during this year. Elmhurst, Metropolitan, Jacobi , McKinney and Gouverneur may be surveyed at any time between February 19 and December 31. The facilities are well prepared for the surveys and we are anticipating favorable survey outcomes. I will inform you of the survey outcomes as they occur.
On January 29 I authorized a deviation from Operating Procedure 100-5 to allow Jacobi Medical Center to pay a consultant, Joint Commission Resources, Inc. (“JCR”), which it had retained through a professional services agreement, a total $67,200. Exceeding a $50,000 cap would normally require Board approval. JCR was engaged to conduct an unannounced mock survey deemed essential for Jacobi, which will be having an unscheduled actual Joint Commission survey sometime in calendar year 2007. The consultant’s only available dates to conduct the mock survey were from January 29th through February 1st.