|Brooklyn Annual Public Meeting
Dr. Susan Smith McKinney Nursing & Rehabilitation Center
Monday, November 10, 2008, 6:00pm
Remarks by Alan D. Aviles
President, NYC Health and Hospitals Corporation
Good evening. I am Alan Aviles, President of the New York City Health and Hospitals Corporation (HHC). Thank you all for coming tonight. I want to thank our hosts Peola Small, Executive Director of Susan Smith McKinney, and Jean Leon, Senior Vice President of the Central Brooklyn Family Health Network and Executive Director of Kings County Hospital Center.
I want to especially acknowledge the support that HHC enjoys from the Mayor, our elected officials, community boards and patients. Without this support, our system would not have been able to accomplish many of the things I will highlight this evening; and would not be able to successfully overcome the challenges on the horizon.
Finally, I want to thank Charlynn Goins who recently stepped down as HHC Board Chair after four years of extraordinary leadership. We are fortunate to have as the new Chairman of the Board, Dr. Michael A. Stocker, a family practice physician, healthcare policy expert, and senior health plan executive, who was appointed by Mayor Bloomberg in September.
Before we hear from tonight's speakers, I would like to provide an overview of some of HHC's accomplishments over the past year and, more specifically, highlight our Brooklyn facilities and their achievements this year.
However, I cannot begin my review without mentioning the tragic death of one of our patients in the Kings County Hospital Center Comprehensive Psychiatric Emergency Program in July, and briefly informing you of the steps we have taken since then to ensure that such an event never occurs again. We have and are continuing to take decisive action to ensure that the delivery of behavioral health services at Kings County conforms to HHC's long-standing commitment to provide compassionate and patient-centered care.
We are reorganizing Kings County's psychiatric services to enable leadership and staff to deliver more effective care, involve patients and their families more directly in the design of care, and establish more comprehensive community supports for patients once they have been discharged.
We have also significantly increased staffing in psychiatric services at Kings County. We are confident that these investments and fundamental changes, coupled with the imminent relocation of all behavioral services to a newly constructed $153 million pavilion in January 2009, will enable us to transform Kings County's psychiatric services into a model patient-driven rehabilitation and recovery-focused program.
THE CURRENT FISCAL ENVIRONMENT
Let me address one more important preliminary matter. In light of the financial turmoil and uncertainty widely reported in the news media, I want to summarize what we know about the effect the unfolding economic crisis has had on the state and city budgets and the potential impact on HHC.
Because of the loss of jobs and tax revenues stemming largely from the meltdown on Wall Street, the Governor has asked the Legislature to develop plans to cut $2 billion from the state budget for the current fiscal year, which ends in March 2009, to bring spending in line with projected revenues. The state budget gap for next fiscal year is estimated to be $12.5 billion. It is anticipated that one way the state will seek to achieve the necessary reductions will be to reduce Medicaid funding, the major source of funding for HHC's hospitals, health centers and nursing homes.
Another area of concern for HHC is the city budget, which is dependent on income tax revenues that will be significantly reduced. HHC has already received a targeted reduction of $2.4 million for the current year; and $4.7 million in reduced funding for next fiscal year. These cuts are likely the first installment of reductions in city funding, given the fiscal challenges that the City will have to address.
In an increasingly uncertain financial climate, our initiatives to reduce expenses and improve efficiency are more critical than ever. Over the past few years, HHC has successfully undertaken multiple initiatives to improve our supply chain efficiency - ensuring that we leverage our size to purchase high-quality products, in a timely way, at the lowest possible cost. We will also continue to take a hard look at the way we operate day-to-day, to develop ways to be more efficient and reduce waste without sacrificing patient care quality.
High performance and public accountability are essential to remaining competitive during fiscally challenging times. Our commitment to data transparency to drive performance improvement is evidenced by our Quality Transparency Initiative. Last year HHC became the first hospital system in New York to disclose publicly a wide range of quality and patient safety performance measures on our public website.
The information includes data reported to the federal government on how often HHC facilities follow best clinical practices in treating heart attacks, heart failure and pneumonia, and in preventing surgical site infection; how well HHC nursing homes are doing in providing quality care, including preventing falls; and how HHC hospitals and nursing homes fare against established state and national benchmarks.
We also release data to the public on our efforts around prevention and early detection of disease, as well as data on how well we are doing in helping our patients better manage their chronic diseases such as diabetes and asthma.
On our web site, www.nyc.gov/hhc , you can see that our hospitals and nursing homes compare well to state, regional, and national standards on a number of important quality measures. I encourage you to visit our web site and view HHC's quality and performance data. Here are some noteworthy examples:
- Coney Island Hospital's Medical-Surgical Unit went 6 months without a central line blood steam infection last year, which was longer than the HHC average of 5.2 months.
- Kings County Hospital outperformed the majority of hospitals in New York City and in the nation in following best clinical practices in the treatment and the prevention of heart attack.
- Woodhull Hospital administered the pneumonia vaccine to 92% of its at-risk patients last year, far above the national average (73%) and the average of all New York City hospitals (76%).
- At McKinney, 3% of the short-stay nursing home residents reported moderate or extreme pain within 7 days of admission, a decrease from the 7% recorded in the previous measured period. McKinney's rate was equal to the New York State average of 3%, and below the national average of 4%.
Across our entire system, we are working to provide safer care that prevents unnecessary harm to our patients, to provide effective care that better manages chronic disease, and to provide preventive care that averts disease or that diagnoses disease at an early stage. Our success on these fronts - which has increasingly received both local and national recognition -- speaks to the commitment of our staff at all levels to our mission and to our patients.
Patient safety is HHC's highest priority. Our goal is to make HHC one of the safest healthcare systems in the nation by the year 2010, and I am pleased to say that we have made steady progress toward that goal.
Our patient safety initiatives have contributed to a steady reduction in patient harm and preventable deaths, even as the number of patients we serve has increased over the past years.
This year, we started two important programs to reduce medical errors. The first is the use of surgical safety checklists in our operating rooms to reduce the risks of complications and death in surgery. Before major surgical procedures, circulating nurses will get a verbal confirmation and document more than a dozen safety checks. HHC is the first hospital system in New York City and among the first in the nation to implement a surgical safety checklist based on the recommendations of the World Health Organization.
We have also implemented the Colors of Safety program in our hospitals and long-term care facilities, which uses standardized color-coded wristbands to quickly communicate patients' high-alert medical conditions and help prevent medication errors, allergic reactions, and falls.
HHC facilities have aggressively reduced hospital-acquired infections. Our critical care teams have taken steps to sharply reduce ventilator-associated pneumonia and central line-associated blood stream infections. Both types of infection increase the risk of death for fragile ICU patients. Since 2005, we have achieved a 55 percent reduction in the rate of central line bloodstream infections and a 78 percent reduction in the rate of ventilator-associated pneumonia among adult patients in our intensive care units.
In addition to the progress in preventing hospital-acquired infections, the 2007 data posted on HHC's web site show that its system-wide mortality rate continued to stay below relevant national benchmarks. Overall, the system-wide mortality rate for HHC hospitals decreased by 11 percent from 2003-2007, resulting in roughly 1350 fewer patient deaths over that period of time.
The prevention of medication errors has been another area of focus. Kings County Hospital recently implemented a computerized Bar-Code Medication Administration system. Less than 10% of hospitals nationwide have this important patient safety technology. Having this additional layer of safety helps to confirm the five “rights” of medication administration, ensuring that the right patient receives the right drug in the right dose through the right route, and at the right time.
Pressure ulcers are a particular concern for our patients in our long-term care facilities. This facility, Susan Smith McKinney, has received a $50,000 grant from the New York State Health Department to provide partial funding for a technology initiative to prevent pressure ulcers in residents. The new system, which includes the installation of 16 touch screen monitors throughout the facility, will replace paper patient care records with a digital system that flags known risk factors and prompts care planning teams to address vulnerabilities. The technology is scheduled to be fully implemented by January of 2009, and will provide staff with detailed reports on care data collected from all 320 facility residents on a weekly or even daily basis.
SMOKING CESSATION, COLON CANCER SCREENING, AND
EXPANDED HIV TESTING
Our system-wide efforts to promote smoking cessation, colon cancer screening, and expanded HIV testing have produced significant and measurable benefits for our patients. Last year, we increased participation in our smoking cessation program for the third year in a row, enrolling roughly 23,000 patients.
Over the past three years, we have helped more than 25,000 patients to quit smoking successfully. Research suggests that at least one-third of these patients, or about 8,000 former smokers, will avoid smoking-related disease and premature death as a result. We expect to enroll about 23,000 smokers in cessation programs again this year.
We also continue to focus heavily on cancer screening, performing more than 90,000 mammograms and 165,000 cervical cancer screenings last year. Last year, for the third year in a row, we also performed more than 20,000 colonoscopies, considerably more than twice the number performed just four years ago. As a result, we are more often detecting colon cancer at an earlier stage when the prognosis is better. Equally important, we have removed pre-cancerous polyps from nearly 14,000 patients over the past five years and we know many of these patients would have gone on to develop colon cancer.
New York remains the epicenter of the HIV/AIDS epidemic in the United States, with the highest number of AIDS diagnoses in country. Among people under 65, HIV is the third leading cause of death in NYC.
An estimated 25,000 New Yorkers-one in four people living with HIV-do not know they are infected. We have aggressively pushed for HIV testing to be a more routine part of care across our emergency departments, inpatient units, and many outpatient clinics. In Fiscal Year 2008 we tested more than 160,000 people for HIV, a 20% percent increase from the previous year's total. Kings County tested more than 16,000 people, the most patients tested in any of HHC's acute care facilities and a 13% increase over FY 2007. East New York and Cumberland Diagnostic and Treatment Centers each tested more than 2,300 people.
Over the past four years, the city hospital system has tested nearly 450,000 people. HHC's 11 acute care hospitals are Designated AIDS Centers and offer specialized HIV care to all New Yorkers, regardless of ability to pay or immigration status. Our facilities treat 19,000 HIV/AIDS patients-20% of the nearly 100,000 people known to be living with HIV/AIDS in New York City.
BEHAVIORAL HEALTH / CHRONIC DISEASE MANAGEMENT
HHC facilities provide a very significant portion of hospital-based inpatient and outpatient mental health services in this city. In fact, 40 percent of the city's inpatient psychiatric care is administered by HHC's facilities. Because we run the majority of our City's psychiatric emergency departments, we also care for a large percentage of New Yorkers with serious and persistent mental illness as well as people with substance abuse problems arising from the use of alcohol and drugs, both illegal and legal, who often suffer mental disorders as well.
The performance indicators that measure how well we serve the people who came to us with substance abuse problems demonstrate impressive progress, and as substance abuse is a continuing concern in New York City as well as in Brooklyn, I will share several facts about our citywide progress:
- The percentage of patients completing detox treatment increased to 78% last year. In FY99 that number was 30%.
- The percentage of patients referred for aftercare was 80% and of those patients, 77% actually arrived at aftercare as compared with the New York State median of only 38%.
- The percentage of HHC outpatients who discontinued substance use in FY08 was 68%, as compared with 44% of outpatients in 1998.
- 49% of clinic patients improved their employment status in FY08, compared with the FY98 number of 27%.
People with substance abuse problems and mental illness often suffer from chronic diseases such as diabetes, hypertension, and congestive heart failure. Therefore it is important that we better coordinate the delivery of care between our mental health and primary care services.
For this reason, depression screening is now a routine part of our primary care services and we screened 72,000 patients across our system in 2007. We will look to increase that number by 50% this year and to screen virtually all of our patients in primary care who have diabetes. We know that untreated depression can be a significant impediment to our engaging patients in the management of their diabetes and other chronic diseases.
All chronic diseases, such as asthma, diabetes, congestive heart failure, and depression, disproportionately impact the low-income communities served primarily by HHC. In light of this, HHC collaborative learning teams have spent the past three years working to develop and implement best practices to help our patients manage their chronic disease more effectively.
The incidence of diabetes in New York City has doubled over the past ten years and is growing, and HHC has nearly 50,000 patients with diabetes who are receiving primary care at our facilities. The medical and financial implications of poorly controlled diabetes for these patients and their families are enormous. Diabetes is the leading cause of end-stage renal failure, adult blindness, as well as amputation of extremities. It also is a major contributor to heart disease and stroke. Our recent significant reduction in prescription medication fees for very low-income patients should help to reduce an obvious barrier to medication compliance for patients with diabetes who generally take several prescription medications each month.
HHC OPTIONS PROGRAM
Our efforts to reduce health disparities through clinical initiatives would be futile if we did not also ensure that patients have access to care regardless of their ability to pay. This past year, revisions to the eligibility standards of our HHC Options program made healthcare and medications more affordable, accessible, and inclusive for very-low-income New Yorkers. Among other actions, we eliminated all outpatient fees for pregnant women and children of families with incomes below 250% of the federal poverty level, even as we maintained heavily discounted fees for families with incomes up to four times the federal poverty level. For patients at the lowest income levels, we have reduced our already modest prescription drug fees - to a mere $2 - to further lower barriers to medication compliance. We are promoting our HHC Options Program broadly with communication material that has been translated into the twelve languages most commonly spoken by our patients.
DEVELOPMENTAL CARE AND BREASTFEEDING
HHC's 11 hospitals delivered more than 23,000 babies in 2007. We treat a disproportionate number of the City's high-risk pregnancies and, last year, nearly 24% or more than 5,500 babies were born prematurely or critically ill and required treatment in our neonatal intensive care units (NICUs). In these units, we are reengineering the environment to minimize stress factors and maximize comfort and developmental support, evidence-based measures that have been shown to improve survivability and outcomes for fragile infants born very prematurely.
We are improving the delivery of neonatal care as well. In fiscal year, all NICU staff were trained to use nurturing developmental care protocols. We will soon complete the final phase of implementation, including making capital improvements to modify the NICU physical environment to reduce noise levels and lighting intensity.
We also committed to improving the health of the babies born in our facilities by promoting breastfeeding of newborns, through educating expectant mothers about the health benefits of breastfeeding, and actively supporting successful breastfeeding post-delivery. We have discontinued the formerly routine practice of distributing free formula samples and formula marketing materials to all mothers. We do, of course, make formula available to mothers who cannot or who choose not to breastfeed. The percentage of new mothers who are discharged exclusively breastfeeding their well infants rose to 34% during this past fiscal year, and it is our goal to reach 50% by the end of this fiscal year.
Even as we address how to better meet the needs of our patients and families as a new life begins, we are also grappling with doing a better job toward life's end. Over the course of the last year, we have allocated dedicated funding to support the deployment or strengthening of palliative care services at every one of our hospitals. Now that our patients and providers have increasing access to expert palliative care as an option for end of life (and chronic pain) situations, fewer patients are spending their last days in an intensive care unit and are opting instead for closure with family and friends in greater comfort and with less trauma. This past year, about 1,500 patients received palliative care services across HHC. This coming year we expect that number to increase as our palliative care services, supplemented by contracted home hospice services, mature further.
To ensure that HHC is positioned to meet the needs of the next generation of New Yorkers, we have continued our ambitious capital program that has systematically rebuilt most of our aging infrastructure. In doing so, we created therapeutic environments that better support the practice of modern medicine and enable the use of technology to realize better outcomes for our patients. Over the past three years, we have completed construction on major modernization projects totaling more than $700 million on the campuses of six facilities.
For example, Coney Island Hospital installed a new 1,100 square-foot Computer Tomography Suite and replaced its anesthesia and ultrasound system for vascular surgery. Kings County has newly renovated Urology and Surgery clinics and a 64-slice computerized tomography suite. At East New York, the pediatric clinic and lobby have been renovated, and Woodhull acquired a digital mammography unit and fluoroscopy system. We have also invested $173.5 million in capital projects in Brooklyn that will be completed by the end of this fiscal year; and another $56.1 million for projects to be completed in FY 2010 or later.
JOINT COMMISSION SURVEY RESULTS
The Joint Commission is a national organization that surveys, accredits, and certifies more than 15,000 health care organizations and programs in the United States, and weighs these organizations' commitment to meeting nationally established standards on organizational quality, safety-of-care issues, and the safety of the environment in which care is provided.
In calendar year 2008, The Joint Commission conducted accreditation surveys of six HHC facilities -- Bellevue Hospital Center; Coler-Goldwater Specialty Hospital and Nursing Facility; Harlem Hospital Center; North Central Bronx Hospital; Queens Hospital Center and Woodhull Medical and Mental Health Center - all of which achieved successful survey results and unconditional accreditation.
Coney Island, Kings County and Lincoln Hospitals, and Sea View Rehabilitation Center and Home will be surveyed by The Joint Commission in 2009. I am confident that all will do well.
Just last month, the Joint Commission and National Quality Forum, honoring our work to make quality and safety data transparent to the public, presented the John M. Eisenberg Patient Safety and Quality Innovation Award to HHC. In a public statement of congratulations, Mayor Bloomberg said, “I am proud of the extensive transformation our public hospital system has achieved. This recognition validates HHC's growing role as a national model of quality, affordable, and accessible healthcare."
Our Brooklyn hospitals also received recognition for the quality of their services. For example, Woodhull Medical and Mental Health Center received the Gold Award from both the American Heart Association and the American Stroke Association for quality management of both Coronary Artery Disease and Heart Failure - the only hospital in New York City to receive the Gold Award in both categories. The American Society of Health System Pharmacists also acknowledged Woodhull for the accomplishments of its Anesthesiology Department.
In October, the Commonwealth Fund, the national private foundation that advocates for a high performance healthcare system, published a comprehensive case study about HHC that praises the improvement initiatives we have undertaken. The report recognizes that HHC is becoming a "provider of choice" and is achieving higher levels of performance through our clinical information systems, our work to improve chronic disease management, our effective clinical collaboratives, our efforts to secure our financial health, and our continued commitment to expand access and create a patient-centered healthcare system.
HHC is a better organization than it was just a year ago. We are better at providing access to the people who need us; better at rendering evidence-based care to patients in comfortable, technologically advanced settings; better at keeping patients free from harm in our facilities; better at informing the public about our quality of care and where we need to improve. We are also better at providing linguistically and culturally competent care; better at helping patients become partners in the maintenance of their own health. And, we are better at preparing to face our challenges next year and in the years to come.
The achievements that I have mentioned this evening would not have been possible without the generous guidance and advocacy provided by our Community Advisory Boards and our labor partners; the contributions of our volunteers and auxiliaries; the steadfast support of Mayor Bloomberg and our elected officials; and, of course, the compassion, creativity, and commitment, of the men and women who staff our health centers, nursing homes, and hospitals in Brooklyn and throughout our city.
Thank you for your attention and your support of our public hospital system. I look forward to hearing your comments.