ALAN D. AVILES
TRAGEDY AT KINGS COUNTY HOSPITAL CENTER
HHC PRESIDENT AND CHIEF EXECUTIVE
REPORT TO THE BOARD OF DIRECTORS
July 24, 2008
As everyone here knows, this has been a difficult month at HHC. The tragic death of Esmin Green on June 19 in the Psychiatric Emergency Department at Kings County Hospital Center is a source of profound sorrow for her family and a sad and painful event for all of us associated with the public hospital system, especially for our colleagues at Kings County. Either Dr. Raju or I reached out to each of the Board members when we first learned of this appalling incident, and I have spoken with many of you about this event since that time.
Nonetheless, I want to reiterate some of the basic facts about our response to the tragedy. After learning of Esmin Green’s death on the morning of June 19, the facility’s Medical Director, Dr. Kathie Rones, immediately asked to view the surveillance video footage covering the Psychiatric Emergency Department waiting area where the death occurred. Dr. Rones contacted us at Central Office later that same day to convey what she had witnessed in that footage and the fact that certain nursing notes in the patient’s medical chart appeared to be fabricated. We immediately notified HHC’s Inspector General who sent technical staff to the hospital to secure the digital surveillance equipment.
I also asked that a copy of the relevant video footage be brought to my office at 7 a.m. the next day, June 20, at which time I viewed the footage with our Executive Vice President, our General Counsel, and the Inspector General. Immediately afterward, I asked the Inspector General to report the incident to the Kings County District Attorney’s office, and I personally called the Commissioner of the New York State Department of Health and the Commissioner of the New York State Office of Mental Health to alert each of them that we were in the process of submitting written notification of the circumstances of the patient’s death to their respective agencies. I described to them what the surveillance footage revealed to me as well as the fact of the apparently false medical chart documentation by one of the involved nurses. Other regulatory authorities, including the Office of Professional Misconduct and the Office of Professional Discipline, also were notified by the facility.
Five staff members directly involved in the incident – two security officers, two nurses and one psychiatrist – were either suspended pending mandated disciplinary hearings or terminated. In addition, after consultation with the Executive Director of Kings County Hospital, two senior managers, the Director of Hospital Security and the Deputy Executive Director of Behavioral Health Services, also were terminated. On June 24, an additional member of the staff was suspended. The investigation into this incident is ongoing.
Later in the day on June 20, we issued a press statement describing the incident, the immediate disciplinary action taken, and the fact that the incident had been reported to various regulatory agencies and law enforcement.
On June 20, I also appointed Dr. Ann Sullivan, Senior Vice President of our Queens Health Network and the former Director of Psychiatry at Elmhurst Hospital Center, as the interim administrator of all psychiatry services at Kings County Hospital Center, reporting directly to me. Dr. Sullivan will continue in this role on a full-time basis for several months while we conduct a search for a new permanent administrator.
On June 23, we turned over a copy of the surveillance video to Mental Hygiene Legal Service, plaintiff in the litigation filed against Kings County Hospital Center in 2007. Later that same week, we agreed to place ourselves under a consent order that requires, among other things, that we make best efforts to reduce overcrowding in the Psychiatric ED by requesting ambulance diversions whenever the census reaches 20 patients, and that we reduce the average length of stay in the Psychiatric ED and the Extended Observation Bed Unit to well below the statutory maximums of 24 hours and 72 hours, respectively. We also agreed to have each patient in the Psychiatric ED checked every 15 minutes by assigned staff to identify any patient in need of immediate assistance, and to document that safety precaution in detail.
The consent order was submitted to the court on July 2, and plaintiff released the surveillance videotape to the media later that same day. We are presently cooperating with multiple federal and state regulatory reviews related to this incident, as well as responding to document requests from the District Attorney’s office and the New York City Department of Investigation.
Beginning earlier this year, we had been implementing a number of changes across psychiatric inpatient and ED services at Kings County. These changes, including program and service delivery redesign, as well as the hiring of about 80 additional staff, were undertaken to improve care and to prepare psychiatric services for relocation to a newly constructed behavioral health pavilion in January 2009. Following Ms. Green’s death, we have committed to move beyond these improvements. Going forward, based on plans that are still in formation, we will transform psychiatric services at Kings County into a highly innovative, patient-centered and patient-driven model program.
We are willing to have the essential elements of a mutually agreed-upon action plan for achieving transformative programmatic and service delivery improvements incorporated into a legally binding settlement document, if agreement can be reached by the parties to resolve the pending litigation on that basis. I also have committed HHC to putting the full measure of its resources behind the implementation of the proposed transformation plan.
As indicated by our Board Chair, we will convene in executive session at the conclusion of our public session so that I may brief the Board more fully on matters related to the potential settlement of pending litigation and respond to your questions.
JOINT COMMISSION COMPLETES SUCCESSFUL SURVEY AT
NORTH CENTRAL BRONX HOSPITAL
Last week, from July 15 through July 18, The Joint Commission conducted its unannounced survey of North Central Bronx Hospital. Consistent with the performance of the other four hospitals surveyed by The Joint Commission this year, NCB achieved successful survey results and unconditional accreditation. I commend Network Senior Vice President Bill Walsh, NCB Executive Director Arthur Wagner and all of their medical staff and employees for an excellent outcome on this test of quality and safety.
The Joint Commission survey of Coler-Goldwater Hospital and Nursing Facility began this Monday and will end tomorrow. We will report on the facility's survey outcome at our September meeting.
PATIENT SAFETY CAMPAIGN FOCUSES ON
PREVENTING MEDICATION ERRORS
This month we embarked on the fourth and final part of this year's 12-month Patient Safety Awareness Campaign, "HHC & You: Partnering for Safer Care," which was designed to engage and educate our employees, patients, and visitors about specific ways that we can work together to improve patient safety.
The current part of the campaign is well-expressed in its slogan "Check Meds Every Time: Name, Strength, Dose," emphasizing the most significant factors that promote medication safety.
During this phase of our awareness campaign, we are distributing materials and tips to our staff about how to prevent medication errors, including information about prescribing, dispensing, or administering "look-alike" and "sound-alike" drugs.
We are also providing our facilities with materials they can give to patients that can help patients understand the importance of medication safety and how they can partner with their providers to ensure that mistakes do not happen. The materials will be available in a variety of the languages most commonly spoken by our diverse patient population.
I am very proud that HHC has already accomplished much to reduce medication errors significantly, most notably through our electronic systems for medication ordering and administration. These have ensured we have in place multiple checks before a medication reaches a patient. By putting these safeguards in place, educating our staff and our patients, and continuing to recognize and eliminate circumstances and events that can lead to errors, we are significantly reducing the risk of medication errors.
FEDERAL LEGISLATORS ACT TO PROTECT HEALTH FUNDING
The President signed the Fiscal Year 2008 Iraq War Supplemental Appropriations legislation on June 30, 2008. This bill included moratoria on the implementation of six Medicaid regulations proposed or finalized by the Centers for Medicare and Medicaid Services until April 1, 2009. The moratoria of particular interest to HHC in this law are those on the Medicaid public provider cost limit and the elimination of Medicaid payments for Graduate Medical Education rules. Those two rules could have cost HHC $200 million each, or $400 million total, per year. The final bill passed the Senate by a vote of 92-6 on June 26th and by a vote of 416-12 on June 19th in the House of Representatives.
Unfortunately, in a last minute concession to the Administration, an outpatient rule limiting supplemental Medicaid payments, through use of “upper payment limit” reimbursement rates, was not included in the final version of the bill. This rule, when finalized, will likely result in more than $100 million in lost revenue to HHC. We are exploring various options to mitigate potential losses.
In separate legislation, on Tuesday, June 24th, the House of Representatives passed a bill whose primary purpose is to prevent a 10.6% cut in Medicare physician payments that was slated to take effect on July 1. The bill would instead provide a 1.1% increase to doctors until December 31, 2009.
On July 15, as expected, President Bush vetoed the bill. The President said that he favored canceling the physician pay cut, but the legislation would reduce funding for Medicare's managed care program, Medicare Advantage, and would undermine Medicare's prescription drug program by allowing the expansion of "protected classes" of drugs.
That same day both the House and Senate overrode the veto by a two-thirds vote in each chamber. Republicans joined with Democrats in overwhelming numbers to ensure the bill becomes law.
CITY BUDGET SET FOR FISCAL YEAR 2009
As many of you may have heard, the FY 09 City Budget agreement that was adopted on June 29th contained significant reductions to Council-funded initiatives and discretionary member items. In light of multi-billion dollar out-year gaps in Fiscal Years 2010, 2011, and 2012 and an uncertain economic forecast, cuts of nearly $300 million were made to practically all City agencies that had received funding from the Council, with the exception of the Department of Education. Specifically for HHC, the Council only partially restored $5 million of nearly $6.5 million in funding for Child Health Clinics and $2 million for rapid HIV testing, a decrease of $1 million. The Council did not restore any of the $6.2 million in funding for many outpatient substance abuse and chemical dependency programs that they had historically supported. Funding of $1 million was not restored for the TEMIS simultaneous translation program operating in South Manhattan network and Central Brooklyn, and $2.4 million was not restored for HHC's outpatient pharmacies.
MAYOR ANNOUNCES NEW PROTOCOLS AND TOOLS TO ENHANCE PATIENT CARE PROVIDED BY SEXUAL ASSAULT RESPONSE TEAMS IN HHC HOSPITALS
I joined Mayor Bloomberg at a press conference held this month at North Central Bronx Hospital where he announced that new Suspect Evidence Collection Kits will be used to collect physical evidence in New York City sexual assault and rape investigations. The new suspect kits, which will require the consent of the suspect or a court order, will make the collection of critical and time-sensitive evidence from suspects more routine.
The Mayor also announced that under a new ambulance routing protocol, a sexual assault victim now has the choice of being transported to a hospital with special care and counseling, including any of our 11 public hospitals, or to one of eight voluntary hospitals with an equivalent sexual assault treatment program.
The latest announcement is built on the success of the Sexual Assault Response Team (SART) program, launched at North Central Hospital in 2005. That program, which was expanded to every HHC hospital, ensures that every sexual assault victim receives care from a specially trained forensic examiner and a rape crisis advocate within one hour of arriving at a hospital. That one-hour response time minimizes the risk that critical evidence will be lost, damaged, or overlooked. Since the SART program was established in HHC hospitals, more than 1,800 sexual assault victims have received this heightened level of care.
HIV TREATMENT ENHANCED BY ADDED FEATURE IN
HHC COMPUTERIZED MEDICAL CASE MANAGEMENT SYSTEM
HHC hospitals are adding an electronic HIV treatment module to their automated medical record system to support comprehensive HIV care for patients and to comply with HIV-QUAL guidelines for optimal standards of care. The HIV modules are currently live at five HHC hospitals, and will be incorporated by the remaining six hospitals over the next several months. In the next phase, staff will be able to use the modular design to automate components for HIV-QUAL reporting of measures such as timely screening for tuberculosis, regular assessments of immune function, and appropriate medication regimens.
As we continue our ambitious $1.3 billion 5-year capital campaign to upgrade the public hospitals, throughout the city there are several celebrations scheduled for openings of newly built or renovated facilities this summer.
PROPOSED NINE-YEAR CONTRACT WITH MEDICAL-SURGICAL PRIME VENDOR TO SAVE $194 MILLION
- Elmhurst Hospital Center will host a ribbon-cutting ceremony in the next few weeks to celebrate the opening of the facility’s new Cancer Care Center and World Trade Center clinic. The six-story facility will include a mammography center, a cancer care clinic, and a chemotherapy clinic. A daycare center will be located on the first floor. The facility will also be opening its new WTC Environmental Health Center on the fourth floor of the Cancer Care Center building. The WTC Environment Health Center provides free treatment to people with 9/11-related illnesses, and will be available to anyone who lived, worked or went to school in lower Manhattan and part of Brooklyn, or who helped in the WTC cleanup process. Funding for this new building and the World Trade Center Clinic were generously provided by the Mayor and the City Council.
- The new 130,000 square-foot Ambulatory Care Pavilion at Jacobi Medical Center is completed and open for business. The new four-story facility will provide outpatient services, including general medicine, surgical sub-specialties, and women’s health services. A ribbon-cutting celebration will be scheduled in the near future.
- Woodhull Hospital of the North Brooklyn Health Network will be hosting an opening celebration and tour for the new school-based health center at the ACORN High School for Social Justice on August 5. The Health Care Team of the Center will be on hand to meet community members and students of the school who will receive healthcare services when the new school year begins.
On our agenda today for your review and approval is a contract for a Medical-Surgical Prime Vendor. As you may know, the Corporation is currently facing rising costs for medical supplies and products and, especially, product freight costs which are rising substantially due to fuel price increases. Inventory management is also becoming increasingly difficult and costly due to the lack of an electronic monitoring system. Additionally, the lack of standardization of the Corporation’s medical supplies and products also aggravates the current inflationary environment, adding an exponential factor to the spiraling costs for both freight and product.
To address all of these concerns, the Corporation issued a Request for Proposal (RFP) in January 2008 to enter into a long term contract with a medical and surgical prime vendor distributor.
As a result, the Corporation received four bids and of the three responsive bids, Cardinal Health 200, Inc. was the highest rated vendor. Cardinal Health’s proposal offered a nine-year contract with flexible payment terms of 30/60/90 days with the lowest markups (2.89%, 3.65%, and 4.61% respectively) of any of the proposers. Cardinal Health’s proposal also offered the best package of new technologies for supply chain management, inventory management, and a Low Unit of Measure option at hospitals of our choice.
We estimate that implementation of the Cardinal Health contract for medical and surgical products will result in projected cumulative savings exceeding $194 million over the nine-year contract term. I urge your support.
MEDIA PLANNING AND BUYING CONTRACT FOR PROMOTION OF
WTC ENVIRONMENTAL HEALTH CENTER AND
OTHER COMMUNITY HEALTH INITIATIVES
Also on our agenda is a contract to provide strategic media planning and media buying services that will enable HHC to bring targeted health promotion and disease prevention messages to the diverse communities we serve through a variety of media outlets, such as television, radio, newspapers, bus shelters, bus sides, and subway cars and platforms.
To acquire the professional services of a media planning and buying agency that would be compensated at the lowest possible media commission rate, HHC issued a Request for Bid (RFB). Milton Samuels Advertising Agency, Inc. (MSA) submitted a responsive bid that was 10% of the Gross Media Budget, which is significantly lower than the industry standard rate of 15%. The proposed contract is for a term of thirty-six (36) months to be funded in the first year for an amount not to exceed $3,565,000. Approximately $2,300,000 of this amount is funded by discrete appropriations from the City of New York to promote the healthcare services available at the WTC Environmental Health Center and at HHC Child Health Centers.
HHC IN THE NEWS HIGHLIGHTS
- June 26 – Jacobi Medical Center’s Emergency Room Rapid HIV Testing Project was featured in multiple television, radio and newspaper stories, discussing the City Health Department’s three-year effort to test every adult Bronx resident. Dr. Yvette Calderon, Director, Urgent Care Services, Jacobi Medical Center, noted Jacobi has been able to test a majority of their ER patients by using an innovative computer-based bi-lingual counseling program that supplements the work of the health educators/HIV counselors working in the Emergency Room.
- July 2 – The New York Amsterdam News, along with several community newspapers, reported on Harlem Hospital Center’s celebration of its designation as the first hospital in New York City to receive the coveted “Baby Friendly” certification granted by Baby-Friendly USA, part of a global initiative sponsored by the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF). Dr. John Palmer, Executive Director, thanked the Harlem staff and noted that this prestigious international designation confirms Harlem’s commitment to supporting a mother's decision to breastfeed.
- July 15 – During Major League Baseball’s All-Star Week, officials from Major League Baseball and the New York Yankees teamed up with Starlight Children’s Foundation to donate a Fun Center to Lincoln Hospital’s child life program. In addition to the donation, several baseball team mascots visited children in Lincoln’s pediatric unit - a moment captured by the New York Daily News.
- July 20 - The New York Times reported on the rise in the number of New Yorkers seeking help to quit smoking because of the recent tax increase on cigarettes. Lourdes Robles, Quit Smoking Program Coordinating Manager, Woodhull Medical and Mental Health Center, noted that the number of enrollees doubled over the past two fiscal years, and price is only one of many factors smokers consider when deciding to quit. James Horton, a Woodhull Quit Smoking Program participant, also offered that he had smoked for 38 years and quit only when he needed heart surgery.
- July 23 – CNN’s special series “Blacks in America” featured Dr. Icilma Fergus, Chief of Cardiology, Harlem Hospital Center, in the health segment of “The Black Woman & Family” report. Dr. Fergus noted the importance of having outreach events in the community to educate Black women and families given that Black communities across the country disproportionately suffer from obesity, diabetes, heart disease, HIV/AIDS and other chronic diseases as compared to other communities. Sabra Abdullah, a Harlem Hospital cardiovascular patient, noted the difficulty in obtaining fresh fruits and vegetables in the Harlem community.