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Wednesday, 25 February 2009 19:23

Back from the brink: A year later, turn around for HRMC is on the horizon

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Last February, a crisis landed on the doorstep of Haywood Regional Medical Center.

After failing federal inspections, the hospital lost its Medicare and Medicaid status, followed by an exodus of private insurance companies. The hospital effectively shut its doors aside from delivering babies and treating dire emergencies.

The community was scared, confused and angry, confronted with the very real scenario of losing their only local hospital. The future looked bleak and the road ahead a long one.

But a year later, the hospital has bootstrapped itself back into solvency.

Patient count is approaching pre-crisis levels. The hospital employs only 20 fewer people today than a year ago with the equivalent of 748 full-time staff. And after nine months of financial losses, the hospital is not only breaking even but slowly putting money back in the bank.

The hospital’s cash reserves plunged so low during the past year that it had less than a month of operating revenue left. Another few weeks, and the hospital wouldn’t have been able to keep the lights on or make payroll.

“I don’t think people realize how close to the brink this hospital was,” said Mike Poore, the hospital’s new CEO. “We had no backup plan. Our reserves had been depleted. There was absolutely no margin of error. Any bump in the road could be bad. We could have tripped and fell.”

While the hospital’s Medicare status was restored in the nick of time, it was an amazingly fast turnaround.

“That was a huge thing to address the issues and correct them and get it back so quickly,” said Dr. Chris Catterson, an orthopedist. “To my knowledge we are the fastest to ever turn that around.”

The medical community has mixed feelings on whether the hospital is better off today because of what it went through. For critics of the former CEO David Rice, the crisis seems like the only way to shake the hospital free of his hold. Rice had co-opted the hospital board and intimidated the medical community. He had amassed an untouchable level of power over the hospital.

“If you’d tried to get rid of David Rice a couple weeks before the crisis, there would have been a firestorm,” said County Commissioner Kevin Ensley.

The crisis awakened the hospital board and county commissioners to the problems within the administration, said Dr. Luis Munoz.

“It is sad it had to go through that, but I think quite honestly no change would have occurred if we had not been decertified,” Munoz said. “I think the road we were heading down before 12 months ago was not a road most of us wanted to travel. I believe we are headed in much better direction now.”

But whether it was worth the financial hit the hospital took in the process remains to be seen, Munoz said.

Like many doctors, Munoz was depressed last year. The hospital they’d invested their careers around, the community their families had grown to love, the patients they dedicated their waking hours to — all of these were thrown into turmoil and jeopardy. Today, the future is a far rosier place.

“We aren’t in debt and we are generating a profit and are a very viable entity and are getting busier on a monthly basis. I would like to think that is a trend,” Munoz said. “If that’s the case, we may not be out of the woods but we are sure headed in that direction.”

Many doctors believe the hospital will come out better.

“The hospital has become an even stronger entity,” said Dr. Charles Thomas, a cancer doctor and the hospital chief of staff. “I do think we have become a bit of the band of brothers, as Shakespeare said. I think there is the mentality that we came through this together. We have a lot of camaraderie and a very tight team relationship.”

As hospitals struggle under the economy, the crisis suffered by Haywood Regional might actually position it to weather the storm better than most, said Dr. Shannon Hunter, an ear, nose and throat specialist.

“I think what makes us stronger is a sense of pride and ownership in our community hospital,” Hunter said.

Many argue that the hospital pulled through the crisis thanks to the doctors who stuck by it. Only four left, all with bona fide excuses like moving closer to family, going back to school or pursuing a fellowship.

“The fact that we lost so few during the crisis is a testament to our desire to serve this community,” Hunter said.

Munoz agreed.

“We really struggled last year to figure out ways we could keep going, but it is a testimony to the support the medical staff has with each other that we weathered the storm and didn’t bail out,” Munoz said.

It wasn’t easy, however.

“Certainly the first half of the past year was pretty rough, trying to scramble for a place to do surgery and a place to take care of Haywood County citizens,” said Dr. Al Mina, a surgeon.

In an amazing show of generosity, neighboring hospitals like WestCare and Mission opened their doors to Haywood doctors, giving them somewhere to treat their patients.

“It is funny how you find out who your friends are when you have a crisis,” said Dr. Henry Nathan, a gastroenterologist who was put on the hospital board after the crisis.

 

Restoring confidence

A big challenge facing the hospital was restoring confidence in the community. Doctors had braced themselves for the worst, wondering how long it would take for patients to trust HRMC again and whether they would go out of business in the meantime. The hospital dug in for a long tough slog to restore confidence.

“I think it is a little bit at a time. I am a realist to know you can’t just flip a switch and everyone change their opinion,” Poore said. “It is one patient at a time.”

The return of patients to the hospital has been better than most doctors or the administration could have hoped.

“I think that has turned out as good or better than I thought it might,” Nathan said. “It could have been that we had a hard time to get our patients to come back and use our hospital, but it doesn’t seem to have been too difficult.”

Nathan said the community has shown it values a local hospital and prefers to get their care close to home.

A nearly clean sweep of upper level management has helped the public perception of a makeover. The former administration bore the brunt of blame for the hospital crisis. They were lambasted by consultants hired to remake the hospital. The media, the public and medical community quickly followed suit.

With nearly a dozen new vice presidents and department heads already hired or in the process, the public perceives major change. There was a similar sweep of the hospital board, with only three of the 10 board members held over from the old administration.

Some in the community never lost confidence or doubted the quality of care provided at HRMC, Mina said. Those who did are coming around.

“I think they are getting more comfortable with it but not completely restored,” Munoz said.

But in some ways, the job of instilling confidence will never be finished.

“When you have a bigger institution within 30 minutes from here, you always have something to prove, so that might be part and parcel of what we have to do,” Mina said.

Residents of Haywood County enjoy a high percentage of doctors trained in the United States. The percentage of doctors here that graduated from American medical schools rather than abroad is among the highest ratio in the country.

Another factor is the strong referrals from family doctors to specialists practicing at HRMC, whether for gall bladder surgery or hip replacement, Nathan said. Patients will typically take the referral advice from their primary care doctors.

 

Patient numbers

Inpatient numbers — those admitted to the hospital overnight — hovered around 70 per day this month. It’s on par for February of last year before the crisis hit, but that month had been a slow one and makes for a less than ideal comparison. It will take a consistent census of 75 to 80 patients to truly claim a return to pre-crisis numbers.

There’s another factor skewing the numbers. Of the 70 admitted patients Haywood Regional had as of Monday, a dozen were registered to a new mental health wing. That wing wasn’t here last year, flawing the comparison. Remove the mental health patients from the equation and the hospital hasn’t fully rebounded.

A testimony to the low numbers: an entire wing of the fifth floor remains closed. Even prior to the crisis, however, patient count would ebb and flow, prompting the closure of a floor.

The hospital is outfitted to handle 137 patients — that’s with every crib in the nursery filled, every labor and delivery room and every bed in ICU.

Meanwhile, outpatient surgery is still off by about 15 percent over this time last year, as are emergency room visits. Of course, hospitals everywhere are seeing a similar trend due to the economy as people put off care they can’t afford.

Poore has been grappling with how to weigh the numbers.

“One, are we measuring the same thing as was measured last year? Two, how much is a hangover from decertification? And three, how much is the economy?” Poore said. “The difficult thing with stats like this, is you don’t know what you don’t know. You are trying to prove a negative — you are trying to prove who’s not coming to you.”

 

Building a better way

Doctors are united in a feeling that the decertification a year ago was overly harsh and undeserved.

“For whatever reason, it seemed extreme,” said Dr. Chris Catterson, an orthopedist. “If I thought HRMC was a bad hospital or I weren’t happy with the way my patients were treated, I wouldn’t be here.”

Thomas, HRMC’s chief of staff, believes the hospital was penalized for picky things.

“The quality of patient care, the commitment and compassion has never been a question and has always been a priority and always been well done,” Thomas said.

Despite the hard feelings over the situation, doctors are proud of how quickly the hospital turned things around. They overhauled patient procedures, hired a new slate of administrators, appointed a new hospital board, put nurses through rigorous training, and passed new inspections.

“It is pretty miraculous,” Nathan said.

Doctors unanimously cited improvements in the system of checks and balances that govern patient care as one of the top accomplishments of the past year.

“Over the last several months I have noticed a huge improvement overall in the morale of employees and nurses, and in putting together systems for patients being our number one goal,” said Mina.

Thomas said there is universal intolerance among nurses and doctors for anyone who doesn’t follow procedures.

“I think that has permeated our staff,” Thomas said. “I think there has been a marked dedication, people attending lots and lots of 7 a.m. meetings.”

Some might argue HRMC is the least likely place for a patient mishap or error — just like the safest place to stand in a lightning storm is somewhere lightning has struck before.

Since the decertification, HRMC has passed three subsequent inspections, one earlier this month.

“The surveyors were highly complimentary,” Nathan said. “We can be proud of that. It doesn’t mean you can let down. As Poore says, you have to be ready every day to get a spot inspection and not just get ready when you know they are coming.”

 

Value where it counts

A leading contributor to the crisis was overtaxed nurses who weren’t careful enough in administering medication, the main sticking point cited by inspectors. At a management level, the system of checks and balances wasn’t working. Nurses knew this, but when they took complaints to their superiors, their concerns were squelched or buried.

Add to that a large number of traveling nurses, pinch hitters in essence. There had been an exodus of nurses from HRMC blamed on an oppressive climate created by management. The hospital had turned to a greater number of outside nurses contracted to fill shifts on demand but who weren’t as familiar with the workflow procedures.

Even more nurses left during the decertification, forcing the hospital to rehire large numbers in the past six months.

There is an industry wide shortage of nurses, posing an even greater challenged. But luckily, that is Poore’s forte. Poore came from Atlanta, considered one of the most competitive markets for nurses.

“But I had waiting lists for nurses to get into our hospital,” Poore said. Poore focused on creating an environment where nurses would want to get up in the morning and come to work.

As far as that last point, wages were raised at HRMC for the experienced nurses. One problem plaguing HRMC was nurses coming there to start their career, then jumping to higher paid jobs once they got a few years experience. So that upper bracket was targeted with pay increases to keep them from jumping.

By December, HRMC was no longer contracting with agencies to supply nurses.

“That was one of the key issues,” said Munoz. “You have to rely on nursing staff that is permanent and not in constant transition. That is a big plus.”

Poore claims the hospital didn’t lower its standards to hire so many so quickly. In fact, one thing working in his favor was the high number of nurses who still lived here but had left to work at neighboring hospitals. With the old regime gone, they were willing to come back, which gave hiring numbers a boost.

There was still a fair share of new grads, so Poore created for the first time a position dedicated solely to nurse training.

Another big push was to empower nurses and make them feel valued.

“They’ve worked very hard to make the nurses able to do their job with less impediments,” Nathan said.

 

Recruiting doctors

One of the top challenges that lies ahead is recruiting new doctors to the community.

“Our challenges are like anyone else’s in the country. There is a growing demand and not enough doctors,” Poore said.

The list Poore rattled off included orthopedics, urology, general surgery, cardiology, pulmonology and family practice. The list has no particular order. The hospital is recruiting them all simultaneously.

Recruiting is endless for any hospital. Despite the obvious cloud over the hospital the past 12 months, six new doctors relocated here, from an orthopedist to a pediatrician to a family doctor.

But it would be natural for any doctor to be leery of coming here given the events of the past year, especially since so few hospitals have ever lost their certification.

“That bad rap is going to last a little bit and is going to hurt our recruitment efforts,” Munoz predicted.

Dr. Henry Nathan said the right doctors, especially those looking for somewhere to raise a family, will realize the value of making a community like Haywood County home.

“Ultimately we just need to find the physicians who want to live here,” Nathan said.

Thomas thinks every doctor should want to come here.

“We are a growing, prosperous, desirable community,” Thomas said. The hospital is in a great building, is well equipped and faces no debt.

Fresh out of school, doctors already have large debt. Setting up a new practice and building a patient base can be more than they want to bite off, making a small community like Haywood a hard sell.

“Some of these doctors come out of medical school with a debt of $200,000,” Lang said. “With their overhead they cannot afford to practice. We have to fix this and make it possible for them to practice economically.”

One draw for young physicians coming here could be stepping into an active and tight-knit medical community.

Poore has heaped accolades on the medical community since arriving at the helm in October. When asked in a recent interview about surprises he has confronted since his arrival, he cited the dedication of the medical community.

“Often times they are so busy with their practices they don’t get as involved in the hospital as this staff does,” Poore said. “I’ve never been in a hospital that had such an involved and committed medical staff.”

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