From A-B-C to C-A-B

by Tiffany Lauria

‘Look, Listen and Feel’ is a thing of the past….

After years of drilling ‘Look, Listen and Feel’ into first responders heads as step one of the basic CPR process, the American Heart Association has released their 2010 guidelines which changes the sequence of CPR steps from Airway-Breathing-Chest Compressions (ABC) to Chest Compressions-Airway-Breathing (CAB)[1] to emphasize the importance of minimizing delay in starting the chest compressions component of care. Included among the other 2010 recommendations is the total elimination of ‘Look, Listen and Feel’ from the steps. Interestingly, the AHA states that rescuers often find it difficult to open the airway and begin delivering breaths, so the change in sequence is expected to encourage more people to begin CPR immediately without hesitation.

This is actually quite a big change, considering the scope of re-training that needs to be accomplished across a spectrum of populations. From babysitters and school teachers to flight attendants and lifeguards, numerous people in varying professions will now need to be educated and certified on the 2010 changes.  Most importantly, of course, are the healthcare providers that perform this procedure, or stand ready to perform this procedure, routinely as part of their daily tasks. And don’t just think doctors and nurses, there are midwives and radiology technicians and physical therapists, etc. The list goes on.

The American Heart Association has always done a great job in reaching the public to broadcast a message of the importance of CPR training for lay people as well as healthcare workers. Everyone- moms, waitresses, bank tellers, construction workers- everyone may at one point be faced with a life or death crisis that affords them the opportunity to try and help. Still, most people today have never been educated on CPR outside of possibly a high school health class (where the thought of giving mouth-to-mouth to the dorky kid next to you was not much of an enticement to learning). The number of professions that are now requiring CPR training, and the numerous regulations regarding the presence of Automatic External Defibrillators, is an encouraging sign that the AHA is reaching the right sectors with timely information and vital instruction.

There are two steps that you and your facility should take now to prepare for the implementation of the new CPR recommendations.

Step one: Make sure your staff have heard of the changes

Believe it or not, as busy as healthcare workers are on the job, they are just as busy in their personal lives! Many of your staff may have not had a chance in the last week or two to jump online for a news fix or to read a newspaper or journal that updates on important industry topics. But, what they don’t know can hurt them and their patients, so include information on the updated regulations in your next facility newsletter or scheduled staff meeting. Also, be sure to assign department heads or managers the responsibility of informing all staff that changes have occurred and that they will need to be re-trained and certified. You may want to include information on the scientific rationale behind the new recommendations, adjusted for use by clinical, administrative or ancillary staff.

Step two: Construct your training plan to implement the new recommendations

This step is actually a staircase that encompasses-

  • Working with human resources to determine which departments and staff require certification and training and the dates when all personnel are due for training based on their past certifications (The AHA has not released guidelines or recommendations yet on whether previous certifications will be revoked early)
  • Working with your facility’s education department, local Red Cross or other corporate instructional agency to determine training options, such as on-site or off-site training, scheduling and learning materials
  • Project a reasonable budget, allowing for staff overtime and any scheduling changes that will be needed to allow staff to participate in training, and any program and material costs
  • Begin cycling all needed personnel through the selected training programs, updating their personnel files accordingly to reflect up-to-date certification. Prioritize training according to need- clinical staff, then administrative, and so on
  • It may be necessary to revise facility or practice clinical protocols or other protocols related to emergency procedures. Always keep your practice, facility and department Operating Procedures and Clinical Protocols up-to-date


How can you assist in the efforts to inform the public about the importance of CPR training while making it worthwhile to your practice? Keep current brochures from the local Red Cross or continuing education providers handy in your office and share them with patients and parents and caregivers of patients, especially caregivers of young children and older patients. During routine well exams or care appointments for chronic conditions, make it routine to ask if anyone in the household has been CPR certified and talk to them about the importance of CPR education in their personal lives. Consider reaching out to community instructors and offer them use of your waiting room or conference area for holding classes. This allows you to advertise the courses to the public, maximizing your exposure while bringing in potential patients into the practice.

The AHA has scheduled instructor training sessions for November 2010, so while instructors are gearing up to teach the new recommendations to the masses, use your time wisely and start planning now on how to best educate and train your staff in an organized and efficient way.

[1] The sequence has not changed for newborns. To review the full 2010 recommendations, visit:

Hospital Gone Mad?

by Tiffany Lauria

In a recent court document[1] , filed against Dimensions Health Corporation, Joseph and Felicia Ann Wheeler allege that while recovering from auto accident injuries at Prince George’s Hospital Center, Mr. Wheeler was misidentified as a female cancer patient 13 years his junior that was scheduled for chest tumor surgery. In the disturbing events that ensued, Mr. Wheeler’s complaint includes physical assault and battery, false imprisonment and infliction of emotional distress.

While the egregious complaint cannot be stated as fact until the matter is settled, a read through the actual complaint brings up multiple areas in which hospitals, indeed all facilities, could benefit by reviewing their operating procedures and more importantly, the extent that these procedures are followed. Two obvious areas of risk  highlighted by the complaint are as follows:

1. Patient Identification Protocols: From his first contact with clinical staff, right down to his interactions with hospital security, not only did staff neglect to check Mr. Wheeler’s ID bracelet, but upon checking and finding a female name, a nurse failed to exhibit common-sense and flag concern over the patient’s identity. A physician brought in to answer the patient’s questions was apparently upset over Mr. Wheeler’s ignorance of the surgical procedure and as a previous nurse did, failed to check Mr. Wheeler’s ID bracelet. The next time Mr. Wheeler states someone at the hospital checked his ID bracelet was following a period of alleged battery at the hands of hospital security.

Some things to consider when reviewing your organizational policies:

– Does your protocol contain enough checks and balances to ensure that the right identification bracelet is placed on the correct patient from the beginning?

– Are there mandatory sign off sheets or tick screens for clinical staff to mark identity checks completed with each interaction?

– Does your protocol also include physicians, obliging them to check patient identification with every patient interaction?

A proper identification protocol will include each of the aforementioned, as well as stated consequences for staff and physicians not performing up to task, the dates of training sessions completed on the importance of correct identification procedures, and proper procedures for following up on any concerns or deviations.

Remind your staff that common sense should always prevail, and the hospital would rather conduct an investigation into correct identity, than defend itself against allegations of misconduct or malpractice. Make that part of your organizational culture – safety comes first.

2. Incidence Response Protocols:

Mr. Wheeler indicates that as soon as he walked out of his exam room to leave the hospital, nursing staff began to argue with him and call for security. The two officers that responded, according to the allegations, immediately unleashed a barrage of physical abuse and verbal expletives in their attempt to hold the patient against his will in the hospital. This abuse subsequently continued through an interaction with the ranking Lieutenant, the apparent wrestling of a cell phone out of Mr. Wheeler’s hands as he attempted to call 911, and culminated in a hospital administrator begging Mr. Wheeler to stay and promising to provide Mr. Wheeler with a private room and any medications or pain killers that he requested.

One has to wonder about the sensitivity training provided to the security staff in dealing with patients, whether they are leaving against medical advice or truly combative. Regardless of whether your facility contracts out for security or hires in-house, it ultimately falls to you to ensure that all personnel have undergone extensive background checks and targeted training on dealing with your patients and their family members. At one point during the alleged physical abuse, Mrs. Wheeler was prohibited from being with her husband and told she could not enter into an elevator with her husband and the two security officers.

Incident training encompasses much more than security, however. Your Incidence Response Manual must be reviewed and updated annually, with revised versions of protocols and documentation logs, and emergency contact information for management and legal staff. A well-done manual is not only written with legal assistance, but final approval on all revisions must be approved by an attorney familiar with healthcare law. Staff training should include all clinical, administrative and ancillary personnel and it is highly recommended that drills be enacted for various situations.

Oh, and regarding the administrator offering patients any drugs or pain killers they want? One word- Don’t.

As Mr. Wheeler’s complaints play out in the judicial system, there will likely be some more points to be gleaned on how not to run hospital operations. In the end, it would benefit all facilities to take a good, hard look at what you have down on paper, and what really happens when things go awry.


Fraud & Abuse News for Your Practice

By Jason E. Lopata, Esq.

Received a take-back letter recently or had a claims audit by an RAC?  Amid the changes found with health care reform laws passed earlier this year are new fraud enforcement powers that have the potential for impacting all medical practices, big and small.  Recently, President Obama took steps to target Medicare and Medicaid fraud and cut down on wasteful healthcare spending.  On August 26, 2010, his administration outlined new federal enforcement efforts to combat healthcare fraud, stating that fraudulent conduct is costing taxpayers billions of dollars each year.  During a healthcare fraud summit in California, Attorney General Eric Holder Jr. and Health and Human Services Secretary Kathleen Sebelius said their agencies were jointly targeting fraud in the federal Medicare and Medicaid programs.

The government initiative, originally launched in May 2009, had so far produced more than 580 criminal convictions and recovered more than $2.5 billion in fraudulent proceeds.  However, while $835 million in questionable Medicare payments were identified by private contractors in 2007, the government managed to recover only $55 million (7 percent) according to a recent report from the Office of the Inspector General.  Congressional investigators found that the average investigation lasted 178 days, long enough for many cases to go cold, making it hard to identify the individuals involved or recover money owed taxpayers.  The Obama administration said it is now reorganizing contracts with private investigators and trying to help them coordinate better with claims processors and law enforcement.

As part of the recent efforts, The Centers for Medicare and Medicaid Services (CMS) expects to transition from some previously used private investigators to zone program integrity contractors (ZPICs) to solve many of the over-spending problems identified.  Two ZPICs became fully operational in February 2009, and all program safeguarding work will be transitioned to the remaining five by the end 0f 2010. The goal is to consolidate all Part A, B, C and D fraud-fighting activities under the ZPICs.   With the transition to more ZPIC enforcement, and the increased use of Recovery Audit Contractors (RACs), CMS is taking multiple avenues toward combating fraud and abuse.

But you’re a good doctor – not engaged in any fraudulent conduct.  How might this still affect your practice?  According to the new legislation, government overpayments must be reported and returned within 60 days of identification.  So constant monitoring for overpayment situations in your office is a must.  Further, since all government payments can be suspended by CMS pending a “credible allegation of fraud,” make certain that you are taking steps to not let the appearance of impropriety arise.  Lastly, HHS’ Office of the Interior General now has greater and broader subpoena power in the event of a government audit, where failure to timely reply to requests for information could be penalized up to $15,000 per day.  So should CMS request supporting documentation from your office in the event of an audit, take immediate measures to collect the data and submit it in a timely fashion.

Other steps your practice can take to prevent fraud include understanding and complying with all state and federal laws.  It sounds simple enough, but make sure that you are staying on top of all regulatory changes that may take place in your jurisdiction.   Also, create a culture of compliance in your office, making it a part of all partnership and staff meetings that take place, as well as employee training and education.   Part of that culture allows for the self-disclosure of any overpayments that are received from Medicare or Medicaid.  Another benefit of such an environment is that your practice does not have to fear for “whistleblowers,” since disclosure of misconduct is encouraged and addressed properly.  Practices that self-disclosure overpayments of government proceeds have more success working with CMS in resolving payment problems.

Avoiding Costly Litigation by Using Alternative Dispute Resolution

By Jason E. Lopata, Esq.

I’m always perplexed by the ease at which certain people shoot off the phrase “I’ll sue,” without thinking of the practical considerations involved in such an endeavor.  Court costs, legal fees, the amount of time, effort and attention devoted to the lawsuit – these almost always seem to have a higher price tag then most would think.  And depending in which jurisdiction you reside, the wheels of justice may not spin at a rate that seems appropriate to your current frustration or anger with another individual or entity.   But as a physician with a legitimate complaint who doesn’t want to sue – where does that leave you?

Mediation, one of the forms of alternative dispute resolution, is gaining popularity now more than ever.  Perhaps it’s because everyone is more cost conscious in these leaner economic times.  This is particularly true for the complex world of medical malpractice litigation, where if a matter proceeds through to trial, the costs can easily reach six figures for all parties involved.

Recently, New York and Connecticut have initiated new programs designed to ease the Courts’ backlog of medical malpractice cases and attempt to reduce costs associated with such litigation.   In New York City, Beth Israel Medical Center, Mount Sinai Medical Center, New York-Presbyterian Hospital, Maimonides Medical Center, and Montefiore Medical Center have agreed to participate in a pilot mediation program.  Each hospital will implement a program whereby it provides early disclosure to a patient and/or patient’s family when a medical error occurs and makes an early offer of compensation, if appropriate.   If out-of-court settlement is not initially successful, the case is sent to a mediation hearing.  If mediation is unsuccessful, only then would the case proceed to litigation.

In Connecticut, there is a new mediation requirement for all medical malpractice cases, which became effective July 1, 2010.  Requiring a “period of mediation” for 120 days before the close of pleadings (i.e. the initial written, court-filed documents required by each party), the court is hoping to reduce the number of smaller or less meritorious claims before litigation makes settlement more difficult.  Cases settled with early stage mediation involve a fraction of the time and cost, rather than taking cases through costly components of litigation such as medical records discovery and expert witness testimony.  The Connecticut Medical Society believes that mediation is one method to reduce medical malpractice insurance premiums throughout the industry.   That is also the goal of the New York hospital project, which is being funded by a $3 million grant provided by the federal government.   New York and Connecticut join states such as Maryland and Wisconsin, which have already been using mandatory alternative dispute resolution, including “early neutral evaluations,” for medical malpractice cases.

For physicians, mediation also has practical uses outside of the early resolution of medical malpractices claims.  It can also be a useful tool to consider for many of the disputes that arise within a practice partnership or employment setting.  Whether it is for the negotiation of a physician employee now joining the practice’s partnership or the reformation of an existing partnership agreement to reflect the current status of the practice, each physician need not hire an individual attorney at the first whiff of disagreement between parties.  Mediation can also be used for disputes with subcontractors, vendors, and independent contractors.  An impartial mediator can help facilitate a quicker resolution that has many more advantages than traditional court-based litigation.   These advantages include more party involvement in shaping the resolution, less likelihood of an all-or-nothing outcome imposed by a judge or jury, more opportunities for creative solutions (rather than just monetary judgments) and the opportunity to conduct hearings in a less formal, more relaxed setting than inside a courtroom.

So the next time you feel that urge to call your attorney and rush into the courthouse, or you’re tempted to shoot off the ever popular phrase “I’ll see you in court” – stop and think of the alternatives first.  Mediation can bring parties to the table in a less confrontational manner and hopefully help to create a resolution that is more palatable for everyone involved, all for a fraction of the time and costs involved in full scale litigation.

Retail Clinics and Your Practice- What Can You Learn?

by Tiffany Lauria

In a world where we can access up-to-the-minute information on our smartphones, purchase a car and drive off the lot that day, and cook a microwaved meal in 5 minutes flat, is it any wonder that patients are carrying over that need for ‘instant gratification’ into their interactions with physicians?

Today’s patients are demanding faster service and faster results, while still expecting quality care and affordable treatments. And that demand has lead to the explosion of retail clinics onto the healthcare scene. While growth in the number of retail clinics has generally slowed, the impact of the continuing development in this field can’t be ignored, with an estimated 1,200 clinics being formed in the US since their inception in 2000[1].

A recently released Rand Health1 report highlighted the most common reasons why patients chose to utilize a retail clinic for their healthcare needs. Since these clinics are not going away anytime soon, it is to your practice’s benefit to learn from the model and minimize the impact that a clinic can have on your practice and your patients. The issues surrounding retail clinics in the healthcare landscape are too numerous to cover here, but focusing on patient preferences is a good way to determine if you are in competition with the clinic down the block.

What are some things the retail clinics offer that draws a patient in?

  • Clinic offering: Convenience- flexible hours, immediate access, and centrally located to other needed services (such as pharmacies and shops to complete errands while patients are waiting).

How to do it: When was the last time you analyzed your schedule? Do you offer extended hours- early mornings and late afternoons and evenings to accommodate working and school age patients? Have you blocked out specific times during the day for walk-in appointments and urgent matters? And most importantly, have you advertised this fact to your patients and the community? Convenience is only convenient if you know about it!

If your office is not located within a reasonable range from a pharmacy, consider working with a vendor and implementing point-of-care dispensing in your office.

  • Clinic offering: Low Cost Care- Most retail clinics accept healthcare insurance, and their cost of care is lower than care provided by a medical office physician, which is an incentive for uninsured patients.

How to do it: Have resources at the ready and provide all of your uninsured patients with low cost state insurance options. The goal- get these patients covered and stop the exodus into retail clinics for acute care or preventive care episodes. Keep them in-house whenever possible.

As it is likely difficult enough to cover practice costs currently, it may be impossible for you to lower service costs any further. Be sure to offer flexible payment plans and provide sensitivity training for your billing staff when dealing with payment issues. Be sure that all staff know to never turn away a patient due to monetary issues, arrangements can generally be made.

On another note, increased care coordination efforts can be very useful in lowering practice costs, and in keeping your patients healthier in the long run.

Taking a look at the above items brings to mind another, more rapidly growing healthcare model- the Patient Centered Medical Home. Physician access, patient satisfaction, cost of care and the like are all components of the PCMH. So while the retail clinic down the block may be siphoning off your profits by drawing patients away, implementing some tweaks in your operations may lead to recognition as a PCMH, and the enhanced reimbursement that comes right along with it. For certain, the opportunities are there, because as the Rand report noted, only 39% of people that visited a retail clinic report having an established relationship with a primary care provider.

Reach out for improvements in your practice, because the additional 61% are still out there.

[1] Weinick, Robin M. et al. Policy Implications of the Use of Retail Clinics. Rand Health, a division of The Rand Corporation. (2010). Retrieved from:


Joining the ranks of bloggists is necessary if for no other reason than to simply record the threads that make up this messy managed care system.

There is fascinating discourse about healthcare going on in many arenas today, but much of it is occuring within individual specialties, or regions, or in specific vertical structures. It is my hope that by bringing together pieces of information from different sectors and forums, we may be able to discern a broader, more horizontal view that helps create innovative ways to think about solutions.

I look forward to a long and interactive dialogue on managing the business of managed care.