ALAN D. AVILES
HHC PRESIDENT AND CHIEF EXECUTIVE
REPORT TO THE BOARD OF DIRECTORS
JUNE 17, 2010

The National Association of Public Hospitals and Health Systems has given Safety Net Awards for two of HHC's initiatives to improve patient safety.

HHC Behavioral Health has won the Safety Net Award for its initiative, "Reducing the Use of Seclusion and Restraint in Psychiatric Emergency and Adult Inpatient Services." The use of seclusion and restraint is associated with high rates of patient and staff injuries, and it is seen by patients and their families as potentially traumatizing. By training staff in effective crisis intervention and de-escalation techniques, by focusing the culture of psychiatric services on rehabilitation and recovery, and by making data on the project transparent, HHC psychiatric departments were able to significantly reduce both the frequency and duration of the use of seclusion and restraint.

NAPH has also given a Safety Net Award to Kings County Hospital Center in the Health Information Technology category for its "Targeting Zero in the ICU Using H.I.T.," acknowledging the hospital's effective use of Health IT to reduce the incidence of hospital-acquired infections in its surgical ICU and target their eventual elimination. By using its clinical information system to consistently document and monitor compliance with evidence-based practices, the hospital dramatically reduced the incidence of these infections.

Congratulations to our dedicated staff for these well-deserved recognitions from NAPH. The awards will be presented at the NAPH Annual Conference, held later this month.

On June 10, 250 participants attended HHC's eighth annual behavioral health conference, "Juggling Priorities and Improving Quality in Behavioral Health Care." The program included a keynote by Dr. Dennis Morrison of the Centerstone Research Institute, an internationally recognized expert on the use of electronic health records in mental healthcare. His presentation focused on how data can inform and drive complex service delivery decisions while balancing issues related to cost, quality and patient-centered care. Workshops covered topics such as trauma-informed care for children/adolescents, improving patients' perception of care, co-occurring disorders, and behavioral health clinic restructuring. The conference highlighted experiences of three facilities' use of Breakthrough to transform care and two facilities' best clinical practices. The program also featured the presentation of best practice awards to behavioral health teams in thirteen HHC hospitals and diagnostic and treatment centers. Awards recognized achievements in wide-ranging areas such as peer counseling, mobile crisis units, adolescent treatment methods, and improving linkages to medical care for psychiatric patients.

Woodhull Medical and Mental Health Center has been selected to receive the U.S. Environmental Protection Agency's (EPA) 2010 National Environmental Leadership Award in Asthma Management for their exemplary efforts to deliver high-quality asthma care that includes environmental controls. Woodhull is one of only five programs in the country to receive the prestigious award this year. Award winners are recognized for demonstrating that comprehensive asthma care with a strong environmental component can dramatically improve health outcomes for people with asthma. As part of the evidence-based asthma care program at Woodhull, caregivers identify environmental risks and triggers that asthma patients are subject to and work with asthma patients and their families to address these environmental effects. Grant funding has been obtained from the New York City Council to provide Community Health Care Worker visits and care coordination to children suffering with the highest asthma severity. The Woodhull North Brooklyn Health Network began its comprehensive asthma management program 12 years ago in response to high asthma rates in North Brooklyn. Dr. Edward Fishkin, Medical Director of Woodhull, convened the first Asthma Summit, bringing together local stakeholders to determine the best ways to address the problem and to ensure community support. Subsequently, New York State funding was obtained and a local coalition, called the North Brooklyn Asthma Action Alliance (NBAAA), was formed. The Woodhull Asthma Program has grown to be a community force in health care, and I offer the outstanding asthma team in the North Brooklyn network my heartiest congratulations.

Columbia University Medical School and HHC this week completed reading a backlog of 7,000 echocardiograms dating to 2005 that were either reviewed by technicians but not officially read by the Columbia physicians at Harlem Hospital Center or were read and not properly signed off by the physicians. All the tests were reviewed by a team of more than 60 appropriately credentialed cardiologists who worked around the clock to eliminate the backlog. Nearly ten percent of unread echo tests prompted an immediate review of the patient's medical record to determine whether the patient's current treatment plan was consistent with the test results. Fortunately, the great majority of those medical records confirmed that the patient's care was consistent with the findings of the official echocardiogram report just completed. In fact, only 14 patients whose medical records were flagged for urgent review needed to be called in for follow up care.

In the next couple of weeks, we'll begin to contact all other patients whose echocardiograms were involved in the backlog. They will receive a letter confirming the reading of their test and will be offered an opportunity to speak to their physician or a hospital representative if they have any additional questions or concerns. In the meantime, we have 311 as well as a toll free call center available to take calls from patients who have questions or concerns about their tests.

The 7,000 echocardiograms read included 5,000 test that were performed by technicians but not read by physicians, and another 2,000 tests that were read by Columbia cardiologists at Harlem, noted in the medical records, but not completed with the required signature. We decided to review these additional 2,000 as an extra precaution.

As you know, under an affiliation contract with Harlem Hospital, Columbia Medical School provides all physician services and is responsible for hiring and supervising medical personnel. Columbia Medical School officials identified the backlog of echocardiograms while undergoing a routine review of patient medical records and informed HHC officials about the backlog on May 20. The appropriate regulatory agencies were immediately notified, including the State Department of Health and the Office of Professional Medical Conduct.

To prevent a situation like this from occurring in the future, Columbia and HHC revised the hospital practices to ensure that all echocardiograms are reviewed and reported to the appropriate physician within one day for inpatients and two working days for outpatients. In addition, there will be regular reporting of the timeliness of the reporting to the Harlem management team as well as the appropriate Columbia supervising physicians at Harlem Hospital.

Although this entire matter is still under investigation and the full facts are not known, our findings suggest that there was very often informal communication between the patient's treating physician and either the technicians performing the tests or cardiologists who viewed the images but did not render a formal report for the record. This appears to account for the finding that the treatment plans for the vast majority of the patients aligns with the official echocardiogram report. But the lack of any discernable adverse impact so far on the many patients placed at potential risk does not fundamentally alter the reality that what happened here is inexcusable. We will get to the bottom of how this occurred and ensure that it can never happen again.

As mentioned at last month's meeting, a priority for HHC is enactment of a six month extension of the enhanced Federal Medical Assistance Percentage (FMAP) provisions originally enacted through the American Recovery and Reinvestment Act (ARRA), which provided $87 billion to state Medicaid programs. That initial increase is currently set to expire on December 31, 2010. Extending this enhanced rate for six months, from January 1, 2011 through June 30, 2011 would cost $24 billion. The provision is worth $609 million to New York City and $2.2 billion -- half in the current state fiscal year -- to New York State. It should be noted that over 30 states, including New York, have already included the enhanced FMAP funds in their proposed budgets for this year.

On May 28, however, the House passed a version of H.R. 4213, The American Jobs and Closing Tax Loopholes Act of 2010, commonly called the Jobs Bill, in which the FMAP extension provisions were dropped.

Senate majority leader Harry Reid and Finance Chairman Max Baucus have included FMAP in the revised Managers Amendment to the Jobs bill, which greatly reduced spending in the bill in the hope of attracting the 60 votes necessary for passage.

As you probably have read, over the past two weeks, the Governor had submitted budget extender bills to the Legislature that contained modified portions of his Executive Budget proposals. Since the Legislature cannot modify the language in a budget bill, this maneuver has forced them to choose between shutting down state government or approving program cuts. Most of the healthcare cuts that were proposed in the Executive Budget released in January were included in the budget extender that passed the Legislature on June 7th.

The statewide savings were estimated at $775 million and include Medicaid funding cuts and increased fraud and abuse savings targets. The estimated impact to HHC is approximately $45 - $50 million and could grow based on further analysis. The provisions include:

1. the elimination of the trend factor for hospitals, nursing homes and home care agencies;
2. a nursing home rate appeal and bed hold payment reduction;
3. a 1.7% managed care rate reduction affecting MetroPlus; and
4. a readmissions penalty with a behavioral health carve-out.

A cut to voluntary hospital indigent care payments was also included in the budget extender along with language to essentially free up DSH room under the statewide DSH cap by paying voluntary hospitals for indigent care in a way that does not count towards the State's DSH cap. HHC has been working strenuously to attain this additional DSH room to help close our budget gap. However, our work is not over yet. The budget language that was approved tied the provision of these additional DSH funds to the period in which enhanced federal FMAP funds are available. Given that the extension of the enhanced FMAP funds appears to be very uncertain right now, the authorization for the additional DSH may expire at the end of this year.

Additionally, there are other budget actions, both revenue and policy, still on the table that could impact HHC. As part of the larger discussion on revenues, the proposal to increase the tax on hospitals, nursing homes and home care agencies is still alive. This would cost HHC an additional $16.5 million, if this is approved as proposed by the Governor in January. A decision has also not been made yet on the nursing home regional pricing proposal which could cost HHC's nursing homes $30 million when fully implemented. In the Governor's Executive Budget, the implementation of this provision was delayed to March 1, 2011. There has been a strong push, however, to eliminate this proposal outright and begin discussions anew on a new payment methodology.

In a leader's meeting in Albany yesterday, the Governor issued an ultimatum to the Legislature. He gave them until June 28th to come to agreement on the remaining items in the budget, which include the contentious issues of education funding levels, revenues and several non-fiscal policy issues by June 28th or face the prospects of his original proposals being placed in the extender budget bill that day. This would set the stage for another government shutdown if the Legislature fails to approve the extender.

Two weeks ago, I testified on HHC's Executive Budget for FY 2011 before the City Council Health, Finance and Mental Health Committees. The Council questioned us thoroughly on the budget and aspects of our restructuring plan. There were members who spoke out against our plan to close some clinics and reduce the workforce. Other members expressed support for restoring funds to Council funded programs and for programs facing PEGs. The Council's Budget Negotiating Team has begun to meet to review spending requests and funding availability. Negotiations between the Mayor's Office, the City Office of Management and Budget, and the City Council will start to increase in frequency and intensity as they move to adopt an on-time budget by the end of this month. It is our hope that the Council will again choose to provide funding to HHC to support our child health clinics, expanded HIV testing, and behavioral health programs this year.

This month, HHC is launching the second episode of Believing, our four-part multi-media series about our patient safety initiatives and achievements. Episode Two, Working Together, includes several examples of the tools, techniques, and training methods we use successfully to strengthen both teamwork and communications across departments and facilities. By focusing on these two key elements, both essential to providing high quality, safe care, we helped our staff turn believing into action. The Believing series is available on our web site, and it uses narrative, film, photograph and data to tell the story. The third and fourth episodes will be premiered at the July and September Board meetings.

On Friday, June 4, Kings County Hospital Center hosted a concert featuring the internationally acclaimed Haitian singer Emeline Michel in partnership with the Weill Music Institute at Carnegie Hall. The event was attended by more than 250 staff, patients, and community guests. The program was emceed by Dr. Herold Simon, one of the more than 60 HHC employees who have used their own funds to travel to Haiti and offer medical care to the Haitian people after the earthquake. Special guests at the event also included: NYC Councilman Mathieu Eugene, Bed-Stuy Volunteer Ambulance Corps, Yves "Fanfan" Joseph of legendary band Tabou Combo and Charles Dessalines, a descendant of revolutionary hero Jean-Jacques Dessalines. Thanks once again to Kings County Senior Vice President Antonio Martin, who has headed up the generous response of HHC employees to provide relief during the crisis. Contributions to the Haiti Relief Fund can still be made through the HHC Foundation at www.thehhcfoundation.org or to The HHC Foundation at 346 Broadway, Suite 715 West, New York, NY 10013.

On May 22nd, more than 500 HHC employees from all around New York led the American Lung Association's Seventh Annual Asthma Walk in downtown Manhattan. HHC staff members marked our seventh year as a flagship sponsor of the event by turning out in force in our signature blue t-shirts. Even as the financial climate continues to be challenging, our employees, family members and Team Leaders remain among the loudest supporters and the strongest fundraisers in the fight against asthma and COPD, raising nearly $400,000 in the past four years. Thanks once again to our caring HHC employees, who do so much to help our patients and neighbors breathe easier.

This month HHC has launched websites for two more of our hospitals, Lincoln Medical and Mental Health Center in the Bronx and Woodhull Medical Center in Brooklyn. HHC has been assisting our facilities to launch individual websites, giving them an additional medium for reaching out with information that is particularly helpful to their own communities. Other websites that have been launched before this month are websites for Jacobi Medical Center, Kings County Hospital, Gouverneur Healthcare Services, and McKinney Nursing and Rehabilitation Center. Elmhurst Hospital Center will launch their website later this month. Before the end of 2010, all HHC facilities are scheduled to launch websites that are focused on their local communities and centered on the needs of their patients. Today I will show highlights of these websites and some of the features that make them easy for our patients to use.

On our agenda today, for your review and approval, is a one-year extension of the current Affiliation Agreement with New York University School of Medicine for the provision of general care and behavioral health care services at Woodhull Medical and Mental Health Center and Cumberland Diagnostic and Treatment Center. The proposed agreement will commence on July 1, 2010 and terminate on June 30, 2011, consistent with the general terms and conditions outlined in the Resolution. The contract costs over the one-year extension period totals approximately $96.4 million.

Tomorrow a ribbon-cutting ceremony will be held at Jacobi Medical Center for the Inpatient and Outpatient Oncology and Infusion Units. The inpatient Oncology Unit is a 12-bed unit, all single bedrooms, arranged in a semi circle all within direct observation of the Nurses Station. The Outpatient Oncology and Infusion Services Unit is newly renovated space that has a separate wing with 7 exam rooms, pharmacy for mixing chemotherapy drugs, Infusion Therapy room with 10 stations, registration area, waiting room for patients, staff offices and support functions.

Last week, Bellevue Hospital hosted a site visit for nine participants of U.S. Department of State's International Leadership program. The group consisted of leading healthcare professionals from Israel and the Palestinian territories. The delegation participated in a lively roundtable discussion with Bellevue's senior management team, who shared Bellevue experience as a major emergency response center of excellence. Bellevue was represented by professionals from the Emergency Medicine Department, Intensive Care Unit, and the WTC Environmental Health Center. Following the discussion, the delegation toured the Intensive Care Unit, Emergency Department and Bellevue Decontamination Unit, a prototype unit developed in consultation with the federal government.

• Dr. Olajide Williams, Harlem Hospital, Teaching Kids to Be Healthy, WNYW-TV, 6/09/10
• Artists Access Program at Woodhull Medical Center, WNYC- Radio, 06/15/10
• Men's Health Month (Bellevue, Woodhull, Metroplus), WBLS- Radio, 06/13/10
• Long Island University, HHC Partner to Offer Nursing Degree, Nursing Spectrum, 06/14/10 (Also covered by Advance for Nurses, Hospital Newspaper)
• City's Hospitals Honor Bronx Volunteers, The Bronx Times, 06/14/10
• Hospitals honor four volunteers, The Queens Courier, 05/27/10
• Elmhurst Hospital Center Receives AHA Stroke Award, The Queens Gazette, 06/09/10 (Also covered by the Queens Courier)
• Easing their pain, Modern Healthcare, 05/31/10
• Palliative care, NAPH, 06/02/10
• Haru Okuda's Balancing Act, Asian Fortune News, 06/02/10
• Sandy Ground gets heroic 'Black Angels' from Sea View's heyday to tell their stories, Staten Island Advance, 06/09/10
• Donations Get Children A Day of Fun At the Hospital, Bronx Times Reporter, 06/10/10
• More Than 150 Bikers Ride For Breast Cancer Awareness, The Queens Gazette, 06/09/10