Letter to the editor - Caswell Messenger
May 16, 2007
To the editor:
A little over a year ago I wrote a letter to the editor asking this community to work together in an effort to constructively address issues related to our hospital. I defined our community as both citizens, employees, physicians and LifePoint representatives. I am disappointed to say that I have seen little progress and am deeply concerned that we are still worried about who is to blame and who's responsibility it is to "repair the damage."
It is everyone's responsibility. The issues we are facing are multi-faceted and can not be placed solely on the shoulders of LifePoint executives. Our community and our biggest asset; our hospital are facing the same issues found throughout the United States. Shortages of qualified professional staff, reimbursement issues, regulatory issues and uninsured populations lacking primary care solutions all challenge healthcare throughout our country. I ask all involved which includes everyone who uses or has the potential to use the services at Danville Regional Medical Center to begin to look outside the anger, hate, political motivations and manipulations dominating this discussion to examine the true issues of healthcare in our community.
I agree, we do have problems in Danville. I see it from all sides. I am an employee at the hospital. I am a citizen of this city. My children go to its schools. My husband has chosen this city as the home for his business. I have had and will in the future have family members treated at my local hospital. I am concerned that the present pattern of attacking, bashing, speaking without knowing the facts and pre-judgement on both sides will lead to not only the destruction of this hospital but the destruction of this community.
Do you not see how dysfunctional this entire issue has become?
Acknowledgement of problems and issues is important but the next step, the one I have not seen attempted, is to begin an effort to pull resources from all sides to work toward the common good. I keep hearing the question what is LifePoint going to do about this? I challenge the community in saying what are you doing to assist LifePoint? I challenge the employees to speak up and communicate to all the work you are doing to provide the best care possible. I challenge politicians to stop worrying about making your name be heard but to make your name be known for your honest efforts to work toward the common good. And I challenge all to constructively offer solutions not just more of the mud that is being flung from every angle.
Laurie
Danville
(NOTE: This letter also appeared in the Star Tribune)
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89 comments:
Another interesting letter in the Star Tribune:
Hospital puts 'spin' on accreditation
Wednesday, May 16, 2007 9:05 AM EDT
Art Doloresco, who is Lifepoint's manager of the moment at Danville Regional Medical Center, has complained that a letter in your paper misrepresented the accreditation status of our hospital, now that it has fallen into the hands of out-of-town profit-makers.
In doing so, Mr. Doloresco shows us his feeble talents as a spin-master.
If you look at the Joint Commission website, you will find that the degraded status of Danville Regional Medical Center to that of "Preliminary Denial of Accreditation" is the next-to-worst rating a hospital can get.
The next one is a flat "Denial of Accreditation," which could lead to shutting the doors.
Website: www.jointcommission.org/GeneralPublic/Decisions.htm]
In revoking Danville Regional Medical Center 's status of "Accreditation," the Joint Commission did not give it the next status-level down, which is "Provisional Accreditation."
It did not even assign Danville Regional Medical Center the status-level worse than that, "Conditional Accreditation."
The Joint Commission gave Danville Regional Medical Center the lowest possible status short of outright denial: "Preliminary Denial of Accreditation."
Mr. Doloresco, you may recall, is the person who told the Danville newspaper that the reasons for this atrocious rating were none of the public's business, thus denying us from knowing which services were the worst.
It is unconscionable for Mr. Doloresco to write your paper and try to use words to dress up the mess Lifepoint has created with our great hospital.
It established what we all know: Doloresco and his Lifepoint colleagues are into spin instead of substance.
V.A.W.
Chatham
No coverage of the Yanceyville forum????
Well Laurie,
Lifepoint has had 2 years to do something productive. Citizens are pretty much powerless to do anything. Heck even the physicians of Danville have been unable to do anything and some are even leaving Danville. The first step was the citizens commission, but even they have admitted they are powerless except for the ability to make suggestions. The citizens and employees were called on to attend meetings and make comments about what was wrong and what was right about the hospital. The fact that the vast majority of the comments were negative should speak volumes to you.
The "present pattern of attacking, bashing, speaking without knowing the facts and pre-judgement" comes from Lifepoints decision to be condescending and secretive about their take on the issues as well as their pattern of lying about what they were doing and planning to do. In fact they came to town with a lie they have been caught in. "No staffing changes or lay--offs for 2 years". When investors already knew that the initial plan for our hospital was to reduce staff immediately.
You state "I challenge the community in saying what are you doing to assist LifePoint?" I ask you, has there been any indication Lifepoint would want our help, or listen if we offered it?
I imagine the only help they want is our $ as patients.
While I appreciate the tone and premise of your letter, I notice you seem to be at as big a loss as I am about a constructive solution. The only option at this point is to openly expose problems so citizens can make an informed decision about the hospital. I assure you if the citizens and employees quit pointing out the problems, Lifepoint surely won't.
Gosh, Laurie, Did you hear that Doloresco refused to tell us why DRMC got the next to worst rating from the Joint Commission? Did you hear that Bob Ashby, the chief step-and-fetchit for the boys at the bank, said in the newspaper that it did not matter what was going on at the hospital? Have you read the agonizing, terrible accounts from people about what happened to their loved ones at DRMC? It goes on and on.
Through no fault of the community, LifePoint has self-destructed--even to the point that its CEO delivered in public the ultimate slur by calling us "low-hanging fruit."
It's certainly your right to love LifePoint, to forgive them, to believe that their next promises will be kept. However, most of us who live in the real world cannot do that. We know that people like this can never be trusted after what they have done to this community. They have nothing but comtempt for Dumbville as the place where they grabbed some low-hanging fruit.
Your world must be nice, Laurie. Wish my extended family and I could live in such a place.
Sorry, but I just don't see Lifepoint as a local "community" asset anymore ... and since it is a private business I see no reason to assist with it's profits anymore than I would American National Bank or Davenport Energy. The time when DRMC was a community asset deserving of volunteered time and donations is past. Sorry, but I'll take my healthcare business elsewhere.
I don't think Laurie is off the mark at all....kudos for writing a letter and issuing the challenge. The only problem is that LPNT must...MUST...be willing to admit that there are problems that need to be corrected. Until that happens, all of the effort on the part of readers of this blog, members of the commission, and well-intentioned letter writers like Laurie are for naught.
I think I could have written a letter like Laurie's eight or nine months ago. Unfortunately, I've seen the conditions slip to the point that we have a serious problem on our hands. Through it all, the one constant is that LPNT does not admit there are problems and, therefore, feels no obligation to do anything about it.
Kudos to you Laurie. I'm afraid that your message is one we can believe in, but that many of us have gotten tainted by the way things really appear to be.
No matter how much goodwill you feel, how can anyone believe anything these people say? That's the question. We gave them the benefit of the doubt and they destroyed it, trampled our trust under their quest for profits. It wopuld be different if this was one of the fly-by-night deals we have around here, but these people are dealing with the lives of our children, grandchildren, grandparents, etc.
No one can afford to use their loved ones to test the waters with people like this. They have defined themselves loud and clear, and they have failed every test for community service.
Laurie, did you get kudos from Art for writing this since you work for him?
I too believe it is too late for LPNT to make a comeback in this community.
Things were handled entirely wrong from both sides from the beginning of the business relationships. Just too much water under the bridge.
Whats so special about her letter? She offers zero in the way of solutions and the idea of everyone working together applies to every problem we encounter daily.
"Shortages of qualified professional staff, reimbursement issues, regulatory issues and uninsured populations lacking primary care"
1) "staffing shortage" was created by Lifepoint with their pool, lay-offs, and treatment of employees.
2) "reimbursement issues" exasorbated by failure to attain accredidation.
3) Lifepoint failed to be "regulated".
4)"uninsured population" Lifepoint was well aware of before buying (they knew Dan River was in bankruptcy and Dimon was closed) Even the investors questioned why with 2 major employers closing, Lifepoint would continue with its plan to purchase....their idea was they could reduce staff and services enough to compensate.
So you see Laurie, Lifepoint was responsible for 3 of the 4 issues you raised and the community had no hand in any of it.
I am sure were the hospital still community owned, the community would once again rise to the occassion and help out. As would City Council and Pitt. County Board of Supervisors. Now none of the above are interested in giving time or money to line the pockets of "o"'s throughout the country.
Another point....if the community is such a critical part in the solution, why hasn't Art chosen to be a part of this community? That sends a strong message in itself.
Last Healthy Hospital Standing
David Whelan 04.21.07, 1:00 AM ET
It’s getting hard to pick stocks in the hospital industry. There are only five sizable publicly traded hospitals left, after two of the biggest said "adios" to the public markets.
First HCA (nyse: HCA - news - people ) went private in a $33 billion deal led by Kohlberg Kravis Roberts. Then Triad Hospitals (nyse: TRI - news - people ), an old HCA spin-off, disappeared into a $7 billion cloud of smoke after shunning a private equity bid for a richer but controversial counterbid from rural hospital operator Community Health (nyse: CYH - news - people ). Tenet (nyse: THC - news - people ) is a shadow of its former self after repeated run-ins with regulators and prosecutors. It could be a future target--if it can locate a buyer with nerves of steel. Lifepoint (nasdaq: LPNT - news - people ) has a small, steady business running rural hospitals. Not much buyout action there.
Hospitals are the perfect buyout targets because they throw off lots of cash that should keep coming in because people will always get sick. As a result, they can be loaded up with debt. Health Management Associates (nyse: HMA - news - people ) in Naples, Fla., did its own weird take on a management buyout, borrowing $3 billion to pay a $10 per share dividend to lavish on shareholders (and managers).
So what’s left to invest in? The best company remaining is probably Universal Health Services (nyse: UHS - news - people ). And it’s not going anywhere. The King of Prussia, Pa., firm owns hospitals mainly throughout the Sun Belt--those warm states with few competing academic medical centers, sprawling, growing populations and hordes of retirees. It also has a psychiatric hospital business that’s lately been building facilities for troubled teens. Its operating margins hover around 8%, higher than the 6% industry average. UHS has also seen admissions rise 1% or 2% the last couple quarters, compared to flat or declining admissions elsewhere.
I know it's a lot to read through but it does a great job of explaining some of the issues dealing with for-profit hospitals. With non-profits the focus can be on turning profits into expanded services, staff retintion, and facilities upgrades. The issues with for-profits is those things have to be trimmed to keep investors happy and pay bonuses to the operating officers. Rather than improved services and patient care, their focus is more on avoiding areas with competition and only dealing with cash customers if possible.
(quoting from the article) "Hospitals are the perfect buyout targets because they throw off lots of cash that should keep coming in because people will always get sick." and "states with few competing academic medical centers".
We may have to resign ourselves to the fact that we are now part of corporate America. Much like Goodyear, Dimon, and Dan River. We are a slave to the economy and profits take precident over community. Fewer folks will have to do more with less. Hopefully with the good Dr.'s and Nurses help lives won't hang in the balance, but we will see fewer extra services and more dirt. Now instead of watching our money build new floors, buy state of the art equipment, and add new services, we can watch it go to NY, Arizona, and Tennesse.
Tank you boys. (Ed Sullivan)
OK Laurie, "How about some constructive solutions?"
You offered none, yet challenged local politicians of "to stop worrying about making your name be heard"
From the lack of solutions offered by you, it appears you were just trying to "make your name be heard" by your superiors.
I am glad that Laurie can still maintain a positive outlook concerning the LifePoint situation. My husband who has been a doctor in the area for 20 years feels the problems won't improve until LifePoint is out the picture. Normally a very positive guy, his frustrations with Art D. and LifePoint increase on a daily basis. For example, when he makes patient rounds and sees 24 patients on a floor with only 3 nurses he cringes. A ratio of 1 nurse/8 patients is unacceptable. Ideally it should be 1 nurse/3-4 patients. That is a terrible work situation for the nurses. They cannot do the proper patient care under these circumstances.
Many doctors now have privileges at other local hospitals. They are prepared to admit their patients elsewhere (i.e. South Boston, Reidsville, Greensboro) if current problems at DRMC do not improve. Some of the surgeons are now doing outpatient procedures in these other hospitals. Also, some of the doctors have given up staff privileges at DRMC and will only see patients in their offices. They maintain consultative privileges but if they have to admit patients to DRMC they are taken care of by the hospitalists. There would be a real crisis if the majority of doctors did this. The hospitalist staff can barely handle their current patient count.
Unfortunately, my husband becomes more weary each day as he encounters continued difficulties in doing patient care at DRMC. Thanks to LifePoint and its "slash and burn" mentality, DRMC is no longer the fine hospital it used to be. While he is not currently planning to leave Danville, he is very close to telling his patients not to go to DRMC.
Is that an elephant I see standing in the room? I do believe it is!
The only hope for the mess created by Lifepoint is to get rid of them--one way or the other. They have destroyed everything they have touched. The bankers who did this to ouR community should step forward with our money and start to help us make the right things happen.
As always, WHERE IS ANY LEADERSHIP?
Can you even imagine the feeling the staff, physicians and community would have if the news came out DRMC was once again OUR hospital and was to be operated as a non-profit? I can see folks now rolling up their sleeves and digging in to make things right.
It would be like Gerald Ford's first public words when Nixon resigned: "Our long national nightmare is over."
I think what this person who wrote this letter is saying that we need to work together and stop fighting...why the anger? It is time to be constructive.
The hospital is an important asset to this commuity whether owned by LifePoint or non-profit. Without it this community will lack the ability to attract other businesses, higher paying positions etc. Economically this community needs this hospital to survive.
LifePoint did make some serious errors in judgement but be fair people...the DRMC of pre-lifepoint years had many of the same quality issues it has now. If you can not objectively look at the situation you can not expect to influence positive change.
Many of the issues leading to the preliminary denial of joint accreditation were years in the making. Instead of pointing fingers...join hands.
Not so sure I believe the problems were "years in the making". Accredidation happens every 3 years and our last 2 jcaho surveys were fine. Don't forget DRMC had a person who kept up with accredidation issues and with her team prepared for it. There was also a person who maintained physician and nurse compliance. (As I understand it that was an accredidation issue). Lfpt decided these were unneccesary positions and teams. These folks were put in the pool and reassigned or left. So for 2 years they had NO ONE preparing as had been done in the past. Now you would think if lil' 'ole Danville could figure this out years ago a company running 50 hospitals could..oh wait, they have accredidation problems elsewhere too, so maybe they haven't figured it out yet.
I think the bigger issue is people aren't willing to "settle" for the lifepoint way. They aren't coming together to "rescue" lifepoint because the hope is we can go back to where we were.
Physicians, nurses, staff, and the community would rather go elsewhere and hope something can be figured out to get rid of lifepoint, rather than stick around and "settle" for what we would have even if lfpt figures out how to regain accredidation. They know what we were and what we can be and aren't willing to be happy with something much less than that.
We wouldn't condsider sub-par operation of our schools, police, fire, or utilities without crying out in protest and doing everything possible to better it, why should we with what used to be our hospital?
As I see it, we may one day have to give in and admit Lifepoint isn't going away.Then we can "settle" and make the best of a bad situation, until then we need to take advantage of every opportunity to try to get back the level of care and sense of pride we are accustomed to.
Instead of settling try working together. Yes there were better systems in place to prepare for accreditation but I also know the process of accreditation has changed... numerous hospitals who never had problems are now having problems.
And please everyone stop clinging to the past....Danville must start looking to future or it will always have the same problems. The past always looks so much better in hindsite. But the many of the very same people complaining aobut the present state as compared to the "perfect" past were the same ones complaining 5 and 10 years ago about the hospitals problems.
Get over it and move on.
anonymous wrote: Whats so special about her letter? She offers zero in the way of solutions and the idea of everyone working together applies to every problem we encounter daily.
I wish to reply...
For those who think the author of this letter has done nothing constructive to solve the problem you are not aware of the many efforts Laurie has put forth both within her work environoment and the community to improve the efforts at DRMC. She consistently speaks to standards of practice, professional growth and committment to the patient in the bed. she has led many efforts by example and often sheer determination. She started this effort when she moved to this community a number of years ago.
She objectively speaks to both sides of the issue to employees and LifePoint Administration. She speaks to bring improvement to the organization and is trying from the inside to influence change. She is not shy no matter the person (LifePoint or not) to honestly speak to the issues and it is evident in the emotions she shares that she cares deeply for the success of this hospital.
I have seen her both pumped up and positive and beaten down and discouraged yet she continues to keep trying. I do wonder how we will maintain individuals like Laurie as the obstacles raised from both LifePoint decision makers and DRMC employees alike can discourage one beyond repair.
Why be critical of person who is trying to imporve the situation...are you afraid of change?
Agreed, but explain "working together". From Lifepoints perspective "working together" means "shut up and don't make any suggestions, we aren't listening and we know better than you anyway"
We are "looking to the future", and in most cases your future should be better than your past. Sure there were problems in the past as well as people comlaining about them. The difference was, in the past complaining brought actions or at the very least answers. As a previous poster pointed out, in the past you could point out problems, find out nothing could be done, and move on at least feeling like someone heard you and cared and valued your opinion.
"Get over it and move on" is exactly what is happening only not the way you mean it. Read a few posts up. A 20+ year physician "becomes more weary each day as he encounters continued difficulties in doing patient care at DRMC." "he makes patient rounds and sees 24 patients on a floor with only 3 nurses he cringes"
How about "Many doctors now have privileges at other local hospitals. They are prepared to admit their patients elsewhere (i.e. South Boston, Reidsville, Greensboro) if current problems at DRMC do not improve. Some of the surgeons are now doing outpatient procedures in these other hospitals. Also, some of the doctors have given up staff privileges at DRMC and will only see patients in their offices. They maintain consultative privileges but if they have to admit patients to DRMC they are taken care of by the hospitalists."
Are those the kind of things you want us to "Get over"?
Laurie has been extremely instrumental in supporting change in our enviornment since her employeement with us.
We often wondered why she was not given the opportunity to fill the position of CNO since she holds a key role in the hospital.
Maybe now's the time since she is not afraid to speak out and is not considered to be part of the "management groupies".
To the post defending Laurie:
I am glad she is championing the cause and my post regarding her letter was not directed at her, just the letter. Unfortunately the letter merely said "someone should come up with something". It appeared to be a swipe at people who were pointing out issues. For most of us, that is all we can do, point out what we see.
In all fairness it appears she is doing more than most and that is a good thing. But to print a letter saying others should be constructive without offering anything constructive yourself seemed a little redundant.
My apologies to anyone who thought I was questioning her personally.
So you ask what is the point give us something constructive but then you right..." For most of us, that is all we can do, point out what we see."
Why is this person who is saying lets work together constructuvely offering less of a solution then the endlesscomplaints and pointing out issues. If you are going to point out an issue make a suggestion. WE ALL have that responsibility. Can't you see that is what this person is saying?
Would the "Managment Groupies" be those directors with the perpetual cups of starbucks in their hands?
You are right she is above that and engages with all staff not just the Starbucks lady and the other groupies.
But somehow the others seem to be the recognized and in crowd. Lets recognize knowledge, skill, talent, hard work and committment and experience versus those who just say the right thing and lie through their coffee stained teeth.
Well it's nice to know that others see the same groupies as we do.
Now the truth is coming out!!!
anonymous said: "Why is this person who is saying lets work together constructuvely offering less of a solution then the endlesscomplaints and pointing out issues. If you are going to point out an issue make a suggestion. WE ALL have that responsibility. Can't you see that is what this person is saying?"
If I point out we are short staffed do I need to follow that with "suggestion: add more staff"
If I point out lfpt refuses to admit where we failed is it necessary to say "tell us where we failed"
Do I need to say "listen to the physicians and address their concerns" after pointing out that Dr's are taking their prodecures elsewhere?
To point out a concern or problem like these is offering a constructive criticism. So far lfpt has failed to come forward to staff or the community and say "this is your concern and this is what we are doing to address it" or even "this is your concern and because of x,y,or z we cannot change it."
Remember the City council was concerned enough to form a commission and the attorney general was concerned enough to appoint a rep.
Then the community and employees were ASKED to bring forth their concerns good and bad.
To simply say "we all need to work together" (and I do believe we do) isn't a solution to any of the problems that have been pointed out. I think that is what the poster was trying to say. They even posted later an apology if it appeared the statements were directed at the letter writer (Laurie) when their intention was to direct the comments at the letter itself.
Not to beat a dead horse, but I believe her letter was on target. It just appeared to be saying those outside of lfpt who were bringing up issues were wrong to do so unless they had solutions. For the community at large their only action can be to point out problems. It is incumbant upon Lifepoint to address those problems if they want to keep customers. So far the only thing the community knows about lfpt is...they cut staff, they don't appear to think much of the citizens of Danville, they don't want to talk about what's wrong, and they failed to get accredited.
The citizens commission was formed because Lfpt chose not to address the issues with the community.
This blog has gotten to the point that it no longer serves as an inteligent forum on this issue. Please become part of the solution instead of the problem.
hmmmm another problem pointed out without a solution attached....
Get real. Since the newspaper does not cover the hospital mess seriously, the only avenue we have for learning anything is through this blog. Thank goodness for whoever handles this blog. Without you, the community would not have a flicker of hope.
Be constructive about Lifepoint? That's like demanding that people be constructive when they talk about the Wreck of Old 97.
How silly can you get?
Only Lifepoint toadies would make such a ridiculous suggestion.
Laurie, we talk often and I appreciate all your efforts on our behalf.
Danville, please, let's get on with the business at hand....social and economic improvement in ALL areas, not just at 142 S Main St.
Oh, by the way, textiles and tobacco and one room schoolhouses are a thing of the past.Be visionary.
From a Lifepoint Investors Conference call: Oct. 2005
http://library.corporate-ir.net/library/88/880/88004/items/172567/LPNT-Transcript-2005-10-27T18-00.pdf
Sheryl Skolnick - Fulcrum - Analyst
Most important question, Danville. Now, you guys have owned that since July 1. I think
we're probably expecting an awful lot out of that hospital. I'm not sure we really understood just what, to be nice, an opportunity
it is. One of the things -- so we've talked about their bad debt, we've talked about their supply costs. We haven't talked about
their man hours, which you were kind enough to tell us seemed to be 150 per adjusted admission versus your 83 or so. How
long is it going to take you and what are you going to need to do and how socially/politically sensitive is it for you to be able
to turn it around? Because it's not an insignificant piece of your business at this point in time, and so it sounds like it's something
you need to be doing. So I guess the other way to ask the question is how long should we expect it for margins to begin to
improve at Danville?
Ken Donahey - LifePoint Hospitals, Inc. - Chairman, President, CEO
Sheryl, this is Ken. We had a lot of discussions when we were negotiating that transaction. We walked into our first visit, we
noticed an administrative area as large as our corporate office. And knew there was a lot of opportunity. We've got a plan
together to offer some early retirement there, and basically a transition plan to get it back down to normal run rates over the
next, well, now it would be 18 to 24 months, but our commitment to the community was to try to do it over a two-year period
of time. So it obviously is a great opportunity on the salary side and our goal is to get man hours per adjusted admission in that
facility down about a third from where it is now. Going from 150 down to just north of 100.
The last post is an interesting conversation but please think that we did have a great deal of overhead. What needs to be done is design systems and porcesses that are more efficient then those present.This will assist in man hour reduction without influencing patient quality of care. the problem LifePoint executives had from the start (and let us remember those decision makers are no longer present) was that manhours were dropped before systems were in place to allow for that drop. To remain a viable institution proft or not for profit requires competitive man hours per patient day. DRMC has always been way over the averages. More staff does not alwqays equate to better quality.
I won't begin to question the manhours issue (since I'm not an employee). I did notice the analyst appeared to be delicately saying "we paid a lot for that hospital and expect a lot out of it, is that possible?"
I am also concerned by a CEO (allbeit former) who replies "we noticed an administrative area as large as our corporate office. And knew there was a lot of opportunity".
It also seems that to bring Danville in line with their other hospitals will require a reduction from 150 manhours to 83 manhours per admission anyway you cut it thats a 45% reduction...I hope for your sake the systems are capable of making up for those kinds of cuts. I noticed an earlier post that quoted a 3 nurse to 24 patient floor (8 to 1) when it should be more like (3-4) to 1. Could those ratios be part of the accredidation failure?
All of this begs the question "WHY couldn't our board of directors have accomplished this themselves?"
If all it took was reducing manhours and putting systems in place to accomplish this to maintain viability, why didn't we do it ourselves, remain a non-profit, and turn the new profits back into ourselves? We could have kept expanding services (instead of losing them), maintained our affiliation with Duke, kept the physicians happy, and not be sending that money to other cities in the former of bonuses and stock dividends.
And why couldn't we have discussed all of these options before any decision to sell was made?
Many questions should have been addressed prior to the sale but those issues need to be addressed by that board. We can't blame Lifepoint for buying the hospital. We might be albe to blame them for some decisions made after.
As for the size of administration...prior to the sale there were many people holding high paying positions that it was common knowledge did little for the actual function of the facility. I will not mention names but we who worked there through this transition do know of whom I am speaking. These people were some of the first to go. And this was a good thing. Sadly, we lost others who we would have been smart to keep.
Keep in mind nurse patient ratios can not just be about numbers. What is the patient acuity? What other ancilliary help is available? What is the turnover of patients etc. This all contributes. You can not speak to nurse patient ratios without asking many other questions.
The state of california invoked such ratios and is now finding that hospitals are closing because they can not possibly meet the criteria. Nurses are finding this is not what it is cracked up to be because now they have lost ancilliary help such as CNAs and secretarial support.
Nothing is black and white and when people jump to conclusions solely on numbers they are misinformed.
At last, after long last, I am reading some very reaalistic observations and admissions......all prior to LifePoint.
And your point is?
Like most who have drank the kool-aid his point is....If it was a problem before Lifepoint got here it doesn't count and shouldn't be talked about. Just because lifepoint made certain situations worse they shouldn't be held accountable to fix those problems that might have been here before they got here.
Funny thing is BEFORE lifepoint we WERE accredited, clicking along and in spite of our problems were NOT being investigated by a citizens commission and attorney general.
The Ratios mandated in california and the 9 other states preparing to pass legislation are a good thing. Conversations with colleagues in some of those states do not denote failure of any kind and more states are jumping onto this before the government eventually ends up making this mandatory due to corporate greed in the US. As for "manhours per day"
24 hours is 24 hours we have to treat patients 24 hours per day not a preset hours to make a CEO COO etc a HUGE bonus. "Oh I'm sorry MR. A-Z I missed your insulin due to the manhours being arbitrary, your not that sick anyway" We never close
24x365.33x each patient recalculated everyday.
Solution :
Repurchase DRMC at no-profit status
this eliminates most of the taxes on the facility and it eliminates
huge bonuses for multiple people and it eliminates the multiple people that produce nothing
which in turn reduces operating costs and increases revenue.
Also continues/increases flow of repayment for the types of patients most likely to use DRMC.
Reduces the patients costs and reduces default.
Computer systems system wide that are fast and inclusive for the hospital, eliminating wasted paper on faxing things 1 or two floors away and speeding up transfers.
also reduces redundant recopying of information.
Re-affiliate with a teaching hospital, this increases name recognition reintroduces clout and credibility, also affiliate DRMC school of nursing with :either one of the local colleges or the affiliated teaching hospital for increased education opportunities for the grads ,this equals constsnt PROgression and more clout. Setup a voted on by the community board with no autonomous sale power, make it a community voice. Maintain a CPA on retainer for periodic evaluation of cashflow and strategy.Ther are so many more but first there must be a downfall of the present tragedy and a City that is willing to go back to the future instead of the present outdated mess we are in.
And then we need a city council that will say " we don't care about a few wealthy dictators that the City has bowed down to for decades we want many vibrant families and contributors"
Only then will Danville progress.
What was going on prior to LifePoint makes no difference at all. It's irrelevant. This is not a blame game.
We are talking about the lives of people in this community. What we are seeing with these nonsensical references to conditions prior to Lifepoint is a retrograde pr effort by the Lambert pitifuls to turn the tide.
They don't realize that you cannot spin a mess like this--but you can sure bill hours fopr pretending to.
Dry Fork
You can say that the "past makes no difference" but.. The only measure available is an organizational review,
The TRUTH and the FACTS are
DRMC was for DECADES functional and profitable.
The measurement is the Joint Commission .The Hospital ownership/leadership is all that has changed other than Lifepoint threatening firings actually firing people and layoffs ,that weren't going to happen (according to Lifepoint)The hospital was consistently accredited , now it is not and it will take a minimum of 2 years just to catch up to where LIFEPOINT HAS DRIVEN IT.
The past is relevant.Just as much as the future is .
The employees cannot fix this, we
HAVE been, and are constantly threatened with "corrective " action and firing.
Kind of hard to correct a woe that we didn't create.
Joint commission seems to have singled out Lifepoint as they have a disproportionate level of accreditation problems for the industry "read their own literature and business releases" Arizona Florida etc..You had better remember the past or you will end up settling for the present and in the future "the Boys will have another 200 million of you and your families money to play with. Right now artie and his gang are stimulating the economy of Tenn and Arizona with your money and health, the benefits that were for the employees and the community are now paying artie's jet fuel bill, how are you handling $3.10 a gallon gas? Live in ignorance and it will ruin you.
I think what the poster means about its being irrelevant what DRMC USED to be like is that it doesn't matter what used to be wrong. Yes, certainly what used to be RIGHT is very important because it allows us to measure the destruction caused by Lifepoint. And that's the whole point. But yakking about what USED to be wrong at DRMC is just a silly pr tactic Lifepoint is using in trying to make this all a blame game.
Message for Laurie: Your gripe about mud being thrown reminds me of a quote I heard recently concerning politics, adapted here for you:
That's not mud being slung around. That's LifePoint's record of service to this community since grabbing off our hospital as low-hanging fruit.
ONE QUESTION:
I don't know whose fault anything is, but I MUST have an answer to something I'm ashamed to ask the nurses at the hospital. Is vomit considered a bodily fluid the same as blood? When my loved one vomits, we try to clean it up because it takes so long to get a nurse and the poor things surely have higher priorities than to clean vomit off a patient's face and bedclothes. But is it dangerous for us to have some of the vomit touch us? Should we take rubber gloves?
Thank you so much for answering.
Scared.
Vomit is considered a bodily fluid. Yes the nurses should be helping you. Certainly we clean such fluids up for our loved ones at home and gloves are not usually required but if your family member does possess an infectious disease gloves will help prevent you from contracting it.
Always wash your hands thoroughly after cleaning such a mess with or without gloves. There should be gloves in a box within your family member's room. If you wish help ask for it.
The first step in fixing the problems is understanding them. start to educate yourself and others...we can not simply speak to raitos we need to understand th eissues and the need for more research in this area. Read below:
www.nursingmanagement.com April 2006 Nursing Management staffing plans and ratios
What’s the latest U.S. perspective?
By Kathleen M. White, RN, CNAA,BC, PhD
The current movement to solve the nursing shortage and staffing problems within U.S. hospitals
is to mandate minimum nurse to-
patient ratios. This complex issue,
debated for the past decade, has centered on issues that really haven’t yet been addressed.
Proponents of mandated minimum
ratios base their opinions on patient safety and care quality.
Opponents cite the lack of solid data to determine ratios, and the need for critical thinking and realtime nursing judgment to
determine acuity needs. They also point out the well-accepted adage, “A nurse is not a nurse is not a nurse.”
But countless, legitimate questions
remain: Where will the nurses come from once ratios are set? How will hospitals increase staff to
meet the ratios in the midst of the nursing shortage? How will those ratios ensure that the same level of care will be provided just because the numbers
are the same? Where does nursing
judgment and professional control over practice fit in? How will hospitals remain accountable for maintaining the ratios once they’re set? Will these ratios
become the ceiling for staffing?
On the national front
Senate Bill 71, Registered Nurse Safe Staffing Act of 2005—introduced by Daniel Inouye (D-HI-1) over a year ago (January 24, 2005)— has been read
twice and was referred to the Senate sits. The bill amends Part D of Title XVIII (Medicare) of the Social Security Act to: 1) require each participating hospital to adopt and implement a staffing system that guarantees a number
of registered nurses (RNs) on
each shift and in each unit of
the hospital to ensure appropriate
staffing levels for patient
care; 2) provide for the public
reporting of certain staffing
information, including a daily
posting for each shift in the
hospital of the current number of
licensed and unlicensed nursing staff
directly responsible for patient care; 3)
prescribe record keeping, data collection,
and evaluation requirements for
participating hospitals; 4) specify civil
monetary penalties for violations of
such requirements; and 5) provide
whistleblower protections.
The requirements of this bill are
a condition of participation in
Medicare. The legislation takes into
account contextual issues affecting
staffing and care delivery, including
architecture, geography of the environment,
and available technology;
the level of preparation and experience
of those providing care; ancillary
staffing level effectiveness or
deficiencies related to certified
nurse assistants (CNAs), licensed
practical nurses (LPNs), and others;
and staffing levels recommended by
specialty nursing organizations. The
bill also states that an RN may not
be assigned to work in a particular
unit without first having established
the ability to provide professional
care in that unit.
The companion bill to Senate Bill
71 is House Bill 1372. The Quality
Nursing Care Act of 2005 was introduced
by Representative Lois Capps
(D-CA-23), an RN, and Representative
Rob Simmons (R-CT-02). This
House version has 13 co-sponsors,
including Robert Brady (D-PA-01),
Maurice Hinchey (D-NY-22), Eddie
Johnson (D-TX-30), Carolyn
McCarthy (D-NY-04), Frank Pallone
(D-NJ-06), Donald Payne (D-NJ-10),
Lucille Roybal-Allard (D-CA-34),
John Salazar (D-CO-03), Janice Schakowsky
(D-IL-09), Allyson Schwartz
(D-PA-13), Fortney Stark (D-CA-13),
Edolphus Towns (D-NY-10), and
Albert Wynn (D-MD-04). The bill
was introduced into the House on
March 17, 2005 and referred to the
Committee on Energy and Commerce
and its Subcommittee on
Health, and to the House Committee
onWays and Means.
Both of these bills would require
hospitals to develop staffing systems
with the input of direct care
RNs, and provide whistleblower
protection for RNs who speak out
about patient care issues.
State-side
Over the last several years, states
across the country have approached
the problem of patient safety and
care quality in several ways. The
first approach is to mandate specific
minimum nurse-to-patient ratios.
The second approach is to mandate
the development and implementation
of nurse staffing plans, usually
requiring appropriate input from
the direct care RNs. A third
approach is to require an institution
to publicly post nurse-to-patient
staffing ratios in order to increase
public awareness of the staffing levels
while not mandating the levels.
Finally, several states have used
combinations of these approaches
to attempt to solve the problem.
¨ Mandated minimum ratios. In 1999,
California became the first state to
enact legislation that required the
development and implementation
of unit-specific nurse-to-patient
ratios for all California hospitals.
The ratios were developed by the
California Department of Health.
The initial set of ratios was implemented
in January 2004. In January
2005, hospitals were required to
meet a 1:5 nurse-to-patient ratio in
all medical-surgical units.
Massachusetts may become the
second state to enact legislation
requiring minimum nurse-topatient
staffing ratios. The state has
developed the Coalition to Protect
Massachusetts Patients, which
includes 106 sponsors to the bill
and 94 healthcare organizations
advocating for the legislation. The
legislation, HB 2663 and SB 1260,
known as An Act Ensuring Patient
Safety, will require hospitals to
adhere to Massachusetts Department
of Public Health–enforced
minimum RN-to-patient ratios as a
condition of licensure.
The legislation would establish
minimum ratios on all hospital
units and in all departments. The
ratios, one nurse to two patients for
intensive care units (ICUs) and one
nurse to four patients in medicalsurgical
units, would be the same
for all three shifts. The legislation
allows for flexibility to improve the
ratios based on patient acuity and
the educational level of the nurse.
It also prohibits the reduction of
ancillary staff, including aides, technicians,
and LPNs, because of the
RN-to-patient ratios. The bill prohibits
mandatory overtime, mandatory
on-call, and floating without
proper orientation. It also requires
the collection and reporting of
nurse-sensitive patient outcome
data to evaluate the patient care
and nurse staffing. Finally, it provides
for some specific consumer
protections, such as the patient’s
right to know the staffing ratio of
each unit and to demand safe
ratios. It also creates a hotline
where inadequate RN staffing can
be reported to the Department of
Public Health. These requirements
are stronger than those enacted in
California and would be the most
stringent in the nation. Opponents
of the legislation say that preliminary
cost estimates of implementing
the proposal would range from
$250 million to $450 million.
The Maine legislature had enacted
minimum nurse-to-patient
staffing requirements, with a
required increase of nurses based
on patient acuity. But in 2004, prior
to implementation, Maine enacted
legislation that removed this legislative
requirement and required the
Maine Quality Forum Advisory
Council to make a recommendation
to the Maine legislature in 2005
about the need for staffing ratios.
In 2005 the Quality Forum reported
that there was no reliable scientific
evidence that showed that
mandated nurse-to-patient ratios
guaranteed quality and safety of
patient care in hospitals, and concluded
that staffing effectiveness
should be achieved by standardization
of staffing plans. At this time,
20 Nursing Management April 2006 www.nursingmanagement.com
S T A F F I N G P L A N S A N D R A T I O S
22 Nursing Management April 2006 www.nursingmanagement.com
S T A F F I N G P L A N S A N D R A T I O S
mandated nurse-to-patient ratios
won’t be implemented in Maine.
¨ Mandated staffing plans. This type
of requirement has been enacted in
eight states: California (regulations),
Florida, Kentucky, Nevada (regulations),
Oregon, Rhode Island, Texas
(regulations), and Virginia.
In 2002, Texas adopted regulations
mandating hospitals to adopt,
implement, and enforce a written
staffing plan. These regulations—
supported by the Texas Nurses
Association, the Texas Hospital
Association, and the State Health
Department—require that the
staffing plan fall under the authority
of a chief nurse officer and an
advisory committee of nurse members,
and be consistent with standards
set by the Texas nurse licensing
boards and the nursing profession’s
Code of Ethics. In addition,
the regulations require evaluation
of nurse-sensitive patient outcomes
to determine the adequacy of the
staffing plan.
Oregon enacted legislation in
2002 that required hospitals to
develop and implement hospitalwide
nurse staffing plans and establish
an internal review process. In
2005, the Oregon legislature
strengthened the law by requiring
that the staffing plans be developed
by formal committees with equal
representation from hospital managers
and direct care RNs.
The new bill also required that
specialty nursing standards be used
in the development of staffing plans
for labor and delivery, the emergency
department (ED), the
ICU/CCU, the operating room
(OR), and the neonatal ICU. With
this approach, the profession basically
determines the staffing plan.
In 2005, Rhode Island enacted
legislation that requires hospitals to
submit a core-staffing plan annually
in January to its Department of
Health. The plan must specify the
average daily census for each unit
and the number of RNs, LPNs, and
CNAs who are a part of each unit’s
staffing plan for that census.
In 2002, Florida passed
legislation that established
minimum staffing standards
and quality requirements
for subacute pediatric
transition care centers.
Nevada passed a bill
in 2003 requiring its
Legislative Committee on
Health Care to conduct an
interim study on nurse
staffing, including reviewing
measures to ensure
quality and safe patient
care and the evidence on
the usefulness of nurse-topatient
ratios. Nevada
already had regulations for
acuity-based staffing in
place for the OR, intensive
coronary care unit, ED,
and obstetrics unit.
Virginia has used the
guidelines from the
Association of Women’s Health,
Obstetric and Neonatal Nurses to
establish regulations for perinatal
nurse-to-patient ratios. New York
requires 1:1 or 1:2 for the ICU, 1:3
or 1:4 for intermediate care, and 1:4
for antenatal care units. The state
also requires 1:10 for unscheduled
ED visits. Arizona requires a minimum
ratio of 1:3 in the ICU.
¨ Public disclosure/posted ratios. In
January 2005, the New Jersey governor
signed into law a requirement
that New Jersey hospitals make
daily public disclosures of the ratio
of patients to the healthcare workers
on duty, including RNs, LPNs,
CNAs, and other licensed professionals
providing direct care.
Illinois is the only other state with a
staffing level disclosure law, but it
requires disclosure upon request,
not public posting of the ratio.
¨ Combined approach. In 2005,
Michigan introduced companion
legislation, HB 4101 and SB 169,
known as the Safe Patient Care
Legislation. These bills would
Reprinted with permission from the American Nurses Association
24 Nursing Management April 2006 www.nursingmanagement.com
C A R R Y H E A D
require hospitals to develop staffing
plans, implement minimum nurseto-
patient ratios, and limit mandatory
overtime for nurses. Legislators
are hopeful that the proposal
will pass this spring.
According to the American
Nurses Association, legislation or
regulation calling for identified
ratios, staffing plans, public disclosure
of staffing, or some combination
of the three was introduced in
2005 in 18 states. (See map.)
Additional factors
The Joint Commission on
Accreditation of Healthcare
Organizations (JCAHO) released
staffing effectiveness standards in
2002, defining them as the number,
skill mix, and competency of staff
related to the provision of services.
The staffing effectiveness standards
require healthcare organizations to
monitor a minimum of four indicators,
including two human resource
indicators—such as overtime use—
and two clinical indicators—such as
patient falls—and to determine the
effect of the indicators on patient
outcomes.
JCAHO has 21 indicators from
which healthcare organizations can
choose. The healthcare organization
must then analyze the collected
data with regard to staffing effectiveness
and adjust staffing levels
based on the analysis.
Last summer at the International
Council of Nurses (ICN), several
member countries called on the ICN
to develop and recommend minimum
nurse-to-patient ratios worldwide.
Nurses from the Bahamas,
the Dominican Republic, and several
African nations asked the ICN to
make a statement about effective
levels of nurses. This issue has also
been hotly debated by nurses in the
United Kingdom, Australia, and
Ireland.
Several national research studies
have demonstrated that an increase
in the number of nurses is associated
with fewer deaths, shorter hospital
stays, and lower rates of complications
such as pneumonia, shock,
and cardiac arrest. Despite these
results, there’s no consensus among
healthcare experts that mandating
the number of RNs is the best
course of action.
Shortly after California passed its
legislation in 1999, Joanne Spetz, an
economist with the Public Policy
Institute of California, analyzed the
effects of staffing proposals by three
prominent organizations: the California
Hospital Association, the
California Nurses Association, and
the Service Employees International
Union. She said, “As California
implements its minimum staffing
legislation, it is more important
than ever that researchers continue
to examine the relationship between
RN staffing and quality of care. It is
no longer adequate to conclude
that ‘more RN staffing is better.’
Policymakers and hospital administrators
need to learn whether there
are thresholds below which quality
of care is abysmal or above which
there can be little improvement.
After the minimum staffing ratios
are established in California,
researchers need to examine the
extent to which hospitals change
actual RN staffing and adjust their
costs. Finally, the effect of this legislation
on the quality of care should
be evaluated after minimum
staffing ratios are implemented, as
other states may make their decisions
about mandating nurse
staffing ratios based on the
California experience.”1
Last year, experts attempted to
determine the cost effectiveness of
various nurse staffing ratios.2 They
found that nurse-to-patient ratios of
1:4 are a reasonably cost-effective
patient safety intervention. They
also concluded that the number and
skill of staff nurses play a critical
role in patient outcomes across a
range of conditions in the hospital
setting; however, research hasn’t yet
shown, and may be unable to show,
the optimal nurse-to-patient ratio.
Also last year, another group of
researchers presented the first
analysis of the impact of mandated
minimum staffing ratios on nursing
care hours and skill mix in adult
medical-surgical and definitive
observation units in a convenience
sample of 68 acute care hospitals
participating in the California
Nursing Outcomes Coalition
Project.3 The results showed no significant
changes in the incidence of
patient falls and the prevalence of
pressure ulcers, despite previous
research linking these indicators to
nurse staffing.
The idea of requiring more nurses
at the bedside won’t necessarily
make them go there. The issue is
much more complex than that. If
we do get nurses to the bedside, we
need to keep them there by providing
the appropriate resources, such
as staff and technology, so that
working conditions best support
their daily needs. NM
REFERENCES
1. Spetz J. What should we expect from
California’s minimum nurse staffing legislation?
JONA. 2001;31(3):132-140.
2. Rothberg M, Abraham I, Lindenauer P, Rose
D. Improving nurse-to-patient staffing
ratios as a cost-effective safety intervention.
Med Care. 2005;43(8):785-791.
3. Donaldson N, Bolton L, Aydin C, et al.
Impact of California’s licensed nursepatient
ratios on unit-level nurse staffing
and patient outcomes. Policy, Politics and
Nursing Practice. 2005;6(3):198-210.
ABOUT THE AUTHOR
Kathleen M. White is an associate professor
and director of faculty practice at Johns
Hopkins University School of Nursing,
Baltimore, Md. She’s also an editorial advisory
board member of Nursing Management.
S T A F F I N G P L A N S A N D R A T I O S
This article is quite interesting. I thank the last person who posted in providing this to us. I believe it is showing us that the issues in Danville are very much the same issues effecting other hospitals throughout the United States. sadly, we are not special in these problems. We must also be aware this situation will only grow worse nationally as we are lacking numbers and enrollments of many different types of healthcare professionals, doctors, nurses, rad techs, phycial therapists, CRNAs, pharmacists etc. etc.
We all must become politically aware of the issues and the latest research to speak in a united educated voice. Sadly, I do not see such a presentation in the majority of posts within this blog.
Thanks for great info on nursing staffing!
Great piece.
Sadly we were in the top group as far as staffing .
Now, we are in the lowest.
We should certainly respect the sensibilities of the poster who is saddened over the lack of sophistication in some of the comments on this blog.
But issues in hospitals are exceedingly democratic in their application to people of all educational and economic stations. I, for one, salute the fact that this forum has continued to welcome commentators from all areas to express their fears and concerns at multiple levels.
If DRMC is ever to regain the trust of this community, it must address the problems in terms of all of us. It is doubtful that can ever be done with the current cast of characters, but we must struggle on with the effort, each in terms of his own concerns.
Just today, in reading the posts, I see the very articulate and thoughtful analysis on staffing, right alongside a heartfelt query on whether people should treat vomit as a dangerous bodily fluid in the absence of nurses on duty to clean it up.
Without this forum we would have absolutely nothing. We would be at the mercy of LifePoint in combination with our thoroughly incompetent community newspaper--both owned by out-of-towners with no connections to our area.
Thank you.
I wondered whose butt Mrs. Prescott had been kissing since Grossman has been gone, seems obvious now.
Thank you, someone, so much for informing us about the vomit as a bodily fluid. We will ask for the rubber gloves. Bless you. It means so much to be able to ask without people thinking you're stupid.
Praise the Lord! Someone has nailed Mrs. Prescott's butt. About time.
One down ,several to go.
Brown nosing squad beware.
to the poster suggesting Ms. Prescott should be considered for a CNO candidate. Although she comes across as being articulate, she at key times becomes very emotional (cries at the drop of a hat). I don't think she has the emotional maturity to be CNO.
Look for someone on the outside. Someone with absolutely no history with our hospital. And please, do it fast so we can get the mother of all deceit out, Ruth McDaniel.
Can someone confirm whether of not LPNT plans for Arts departure by the end of summer. This rumor has been circulating among the management level. Allegedly, it is being discussed frequently by them (managers and Ruth). If so, maybe there is a ray of hope in our future.
The "brown-nosers" are getting a little defensive. Maybe they are beginning to get the picture.
They should have bailed with some of their previous so called "buddies".
Ummmm, maybe the Starbucks sells might diminish soon.
Give Laurie a break, she hasn't a clue about what she's doing. Just trying to save her position and keep her husband's business thriving. Can't say as I blame her.
But she "ain't a CNO" type of gal.
Related to the Grossman comment. He was a nice guy, just a push over. Remember, he too was set up by LPNT. They described him as being the "best person for the time" until they could get someone else. I think his departure was as big of a surprise to him as it was to us. His days were numbered from the beginning and he was treated very disrespectfully by a lot of people. Wish him the best in his future goals!!!
Yeah maybe, But remember the adage
"If you stand for nothing , you'll fall for anything"
Some of us want to stand up to these theives .
DRMC dirty laundry surfaces.....more, more, more.
I am not sure who's butt you think Prescott is kissing...I think she has struggled to try to do her job well with little support and huge committment to trying to better the organization. Unfortunately every time there is a change in leadership she is less involved.
As for struggling to keep her husbands business alive...what does that mean? She has nothing to do with his business and my understanding is there is no struggle there. Why must we beat up people because they have ideas and did not grow up here?
I know Laurie well and she has no interest in the CNO position. That is not where her talents lie although she has many years in management she knows this job is bigger than her. someone formt he outside is needed a new face with year sof experience and skill that can be trusted and this needs to happen sooner than later. presently nursing is in deep trouble.
Why are you shooting a person who is just asking for us all to work together?
Please name your favorite three brilliant ideas Laurie Precott has ever had.
#1 Let's all work together.
#2 We should help Lifepoint.
#3 Let's all work together.
These are all from the Department of Bright Ideas--not a solution in sight. Nothing is easier than Bright Ideas. Come up with some solutions--like getting rid of LifePoint.
OK
#1 Get rid of Lifepoint.....now previous poster, the solution would be?????
Seems to me "get rid of lifepoint" falls into the bright idea class too. Ranks right up there with "Lets all work together constructively" which is what Laurie caught so much flack over.
Most of us knows what needs to be done...get rid of lifepoint, get some or most of the former DRMC physicians, staff, nurses, and "o"'s back and go back to doing things as close to the old way as possible with our eyes more on profitability and viability for a non-profit as we look to the future. The $200 question is how?
Sure it's a do-able solution. The mayor and council need to summon, as good citizens, the bank boys and Bob Ashby to come to the table with our $200 million-Plus. LifePoint needs to be paid off to get out of town, and then money provided to create an alliance with one of the excellent community hospitals nearby, where most of us have fled anyway. Sure, you can't make the bank boys do this, but you use political pressure and the public bully pulpit to push them.
Get cracking! Call the people you know! Make it happen! That, by the way, is what a solution is.
I made the first step. The following was posted to the Citizens commission forum:
From conversations on the blog, discussions with nurses and physicians, and discussions with folks at other Lifepoint hospitals, there seems to be one definitive suggestion to remedy our problems once and for all.
There seems to be a concensus from those most intimately invovled that the best solution would come from a joint effort of City Council and The Danville Regional Foundation. Through a joint effort these two groups could provide the leadership and funds to create an alliance with one of the excellent non-profit community hospitals nearby. Most feel Lifepoint has burned too many bridges and eroded trust to a point that it cannot be recovered. I would encourage you to get feedback from physicians as to how they would receive the idea of losing lifepoint and gaining an affiliation with the likes of Moses Cone, Bapitist etc.
I would think such an arrangement would garner quick support from physicians, allow us to recover some if not most of our lost nurses, and regain the communities faith in our medical facility.
I am afraid any suggestions you make short of this will fall on deaf ears with Lifepoint. If their past is any indication, they are not really interested in what employees and citizens think, they just want us quiet so they don't have to bother with us. Even with comments from your meetings being published in the paper, more staff and nurses have resigned.
In my opinion, they are still looking to reduce employees and are just glad they are leaving without being laid off. The foundation has the money and surely they are as weary as we are of this issue. City Council would surely be interested in providing the leadership to get the negotiations started, and I'm guessing Lifepoint would be glad to move on too.
Whose next?
ALL YOU HAVE TO DO IS COME UP WITH 200+MILLION $$$$$ AND YOU TO CAN OWN DRMC. THEN LETS SEE JUST WHAT KIND OF PLACE IT WOULD BE.
SO FAR ALL YOU CAN SAY IS SOMEONE MUST COME UP WITH SOLUTIONS. OK SINCE YOU ARE SO SMART WHAT ARE THEY????
IS IT JUST AS EASY TO RUN DRMC AS IT IS A TRAILER PARK?
The post above yours appears to be a solution, have you got any? Or do you fall into the "It is what it is we may as well learn how to settle for less and live with it" crowd?
Forget about the poster talking about trailer parks.....great comment to the commission. A salute to you. Others need to speak up. Just cal;l the mayor, or any councilman you know. People must do it while enough energy is left. Lifepoint's game is to wear us all down....Again, congratulations.....I for one have let all of them know what I thnk....
This nonsense is endless.
But remember, Danville Can!
Danville Could !
uh, Danville Might!
Hmmm, Danville Doesn't Give a Flip!!! Yeh, that's it!
How about we as citizens of danville bring forth a class action lawsuit against the board that sold us?
Hey, watch those snide comments about Danville. Keep in mind we're A WORLD CLASS ORGANIZATION. That slogan simply epitomizes the stupidity of Gwaltney and the whole bunch. No wonder our city is steeped in hopelessness.
WELL I SEE ALL YOU IDIOTS ARE STILL AT IT TRASHING THE ONLY SMART PEOPLE IN THIS REGION. I HAVE BEEN IN FLORIDA FOR A NUMBER OF WEEKS AND THANK GOODNESS NOBODY DOWN THERE CARRIED THIS NONSENSE ON THE COMPUTERS. I HAD SURGERY IN FLORIDA AND I'M SURE I WOULD OF BEEN BETTER OFF AT MEMORIAL HOSPITAL. NURSES WERE FAT AND UGLY AND THE FOOD STUNK BUT I CAME OUT OKAY. WISH I HAD HAD THE WORK DONE HERE SO I COULD VBOAST ABOUT IT.
so ALL CAPS care to "vboast" about how the labotomy went? Or was it eye surgery? Nope still can't see the caps lock button.
By the way ALL CAPS where in Florida were you that hasn't yet discovered the internet?
How many want to bet he/she is a lifepoint plant who just tries to change the subject or take the direction of the blog toward mudslinging? Not a very good explanation of his/her absence, and the last we heard he/she was swearing off the blog as it was irrelevant to him/her.
Educate yourselves ont he issues versus whining and insulting people.
Nurse Staffing and Hospital Ownership in California
[ARTICLES]
Seago, Jean Ann PhD, RN; Spetz, Joanne PhD; Mitchell, Shannon PhD, MPH
Authors’ affiliations: Associate Professor (Dr Seago), Assistant Adjunct Professor (Dr Spetz), Department of Community Health Systems, School of Nursing; Senior Fellow (Dr Seago), Center for the Health Professions; Senior Fellow (Dr Seago), Assistant Director (Dr Spetz), Center for California Health Workforce Studies, University of California, San Francisco; Research Scientist (Dr Mitchell), Department of Health Policy, Yale University, New Haven, Conn.
Corresponding author: Dr Seago, University of California, San Francisco, School of Nursing, Department of Community Health Systems, 2 Koret Way, San Francisco, CA 94143-0608 (Jean.ann.seago@nursing.ucsf.edu).
Financial support was provided by the National Science Foundation, the Lynde and Harry Bradley Foundation, and the Public Policy Institute of California.
Abstract
Objective: The purpose of this study is to describe the relationship between nurse staffing and owner type or specific corporate owner in California acute care hospitals.
Background: Little empirical data exist regarding nurse staffing as it relates to owner type or specific corporate owner. With minimum staffing ratios scheduled to be implemented in January 2004, this study provides baseline data for evaluating the impact of minimum staffing ratios in California.
Methods: The study design is descriptive and cross-sectional. Data used in this study are for short-term general hospitals that reported to the California Office of Statewide Health Planning and Development database for fiscal years ending in 1997 through 1999. Six regression models were estimated using pooled data from the 3 years of data.
Results: The most consistent significant findings are: increased patient days or patient discharges predict increased registered nurse (RN) hours; lower RN wages predict increased RN hours; higher technology scores predict increased RN hours; and in 1998 there was an across-the-board decrease in RN hours. Other significant findings include that for-profit hospitals and for-profit systems had fewer RN productive hours for medical-surgical nursing, and select corporate owners, unrelated to profit status, had consistently fewer RN productive hours for medical-surgical nursing.
Conclusions/Implications: For-profit hospitals and systems behaved differently in the healthcare market environment of the late 1990s. Select nonprofit systems were also using significantly less RN staffing. Other findings support the implication that as technology sophistication increases, there will be a need for increased RN hours to manage the advanced technology. This runs counter to the argument that increasing technology will decrease the need for RN hours. Finally, as discharges go up, the need for RN hours increases.During the past decade, legislators, healthcare workers, and the public have expressed concern that for-profit companies are taking over hospitals and other healthcare organizations. 1–5 Critics of for-profit hospitals argue that the for-profit mentality forces organizations to give too little consideration to patient care, removes charitable assets from public control, and focuses too intently on the financial bottom line. 5,6 At the same time, research has demonstrated that changes in the profit status of hospitals are relatively rare, and that affiliations of hospitals with multihospital systems are increasingly common. 7,8 After several failed high-profile hospital mergers, such as that of the University of California San Francisco Medical Center and Stanford University Hospital, nursing leaders and others are questioning whether mergers of healthcare organizations and/or hospitals negatively affect the quality of healthcare. 9–11 Because staff nurse salaries are a large part of any hospital budget, hospital administrators and nurse executives have continued to try to reduce the amount spent on nurses’ salaries. 12–14 The relationship between the type of ownership of a hospital and nurse staffing has rarely been studied, however. 15–18 Throughout the 1990s, nurses protested the redesign/downsizing of the nursing workforce in the inpatient setting. 19,20 Across the United States and the world, newspapers, nursing journals, and medical journals chronicled nurses’ displeasure about staffing issues and other work place dissatisfiers, such as mandatory overtime. 19–31 In 1996 the Institute of Medicine 32–34 stated that the literature was inadequate to make a recommendation for minimum nurse staffing. Many studies have demonstrated a positive relationship between nurse staffing and patient outcomes 34–40; however, specific amounts of staffing for various patient groups is less clear. It would be helpful to know if there is a relationship between hospital ownership and nurse staffing because nurse staffing has direct implications for the quality of patient care.
Background
Concern about the change of nonprofit hospitals to for-profit ownership has risen during the past decade. Needleman et al 41 found a total of 532 owner changes between 1980 and 1990 in US hospitals, with 110 changes from nonprofits to for-profits. In California, however, Spetz and others have found that the largest number of ownership changes have occurred within like groups, which are nonprofit to nonprofit and for-profit to for-profit. 7,8 Of the 296 ownership changes between 1986 and 1996, only 13 involved changes from nonprofit to for-profit ownership. 7,42 During that same period, 12 hospitals switched from for-profit to nonprofit status, and about 80% of hospital ownership changes in California did not involve any change in the profit status of the hospital. 7,43
Most of the ownership changes between 1986 and 1996 were the result of hospital mergers. In 1995, 43 mergers and purchases were initiated in California, the highest number in the United States. 43 As a result of these consolidations, multi-hospital organizations grew significantly. At least half of all hospitals in California are now affiliated with multisite hospital corporations, and 6 organizations operate more than one third of the state’s hospitals. 7,43 These data indicate that the public debate has focused disproportionately on the activities of for-profit organizations and that it would be worthwhile if public interest also focused on the activities of nonprofit healthcare organizations and systems.
In a frenzy of mergers, acquisitions, affiliations, and reorganizations, acute care hospitals have sought to control costs by improving care delivery efficiencies, improving contracts with suppliers, and maximizing relationships with physician groups and insurance groups. 18,44 The literature is mixed on the results of these ownership changes. As early as 1985, study findings indicated that system-affiliated hospitals were more profitable, with better access to capital markets. They were also more effective price setters but had higher costs per case, which was found to be related to longer lengths of stay and less productive use of physical plant and equipment in generating revenues. 45
The California Nurses Association and other bargaining unions for nurses in California feared that with the increased emphasis on profits, nurse staffing in hospitals would be reduced. 9–11 Although California has had a substantial number of owner changes in hospitals, there is some evidence to support the notion that there has been an increase in RN hours in acute care hospitals during the past decade 46; however, the evidence is mixed. 47 Several studies have found that change in profit status is not related to lower nurse staffing, but this may be because the hospitals that are converting have higher initial nurse staffing patterns. 15–18 Overall, data are scarce, and evidence is inconclusive regarding the relationship between nurse staffing and owner type or specific corporate entity. 8,48
Data and Design
The California Office of Statewide Health Planning and Development’s (OSHPD) Hospital Disclosure Report is a survey of service provision, finances, and resource utilization in a hospital’s fiscal year. It includes information about capital acquisition, labor staffing, and the provision of medical care in each revenue unit of the hospital (eg, intensive care units, laboratory services, medical-surgical units). OSHPD’s Patient Discharge Data contain abstracts of every in-patient discharge in a calendar year. The OSHPD database is one of the best sources of information about acute care hospitals because it is required annually of all California hospitals, except Kaiser Foundation and Federal hospitals. OSHPD audits survey responses for consistency, and many hospitals use accounting systems that automatically produce reports for OSHPD at the end of the fiscal year.
The data used in this study are those for short-term general hospitals that reported in the OSHPD fiscal years ending in 1997 through 1999. The “1997” data provide information for hospitals with fiscal years ending between June 30, 1996, and June 29, 1997 (Table 1). Because RN productive hours can be a function of factors other than hospital owner or owner type, we estimate 6 multivariate regression equations to control for these variables (Table 1).
Hospital ownership is categorized 2 ways. The first categorization is by type of ownership, which includes independent nonprofit, independent for-profit, system/corporate nonprofit, or system/corporate for-profit. Second, the 12 largest systems in the state were identified, along with the location of corporate headquarters and number of hospitals in California (Table 2). After we explored descriptive statistics by owner type and specific corporate owner (Tables 3 and 4;Figures 1 and 2), the variable of interest and the covariates were entered to estimate 6 regression models (Table 5).
On the basis of the conceptual grouping of variables, the regression models were estimated using pooled data from the 3 years of OSHPD data. The variable of interest is medical-surgical RN productive hours. Conceptually, Model 1 estimates medical-surgical RN productive hours, controlling for number of patient discharges, nurse wages, share of MediCal discharges, case mix index, average length of stay, the Saidin Technology index (indicates technical sophistication whereby the more rare service gets a higher score), 8,49,50 a dummy variable for each year, and a dummy variable for urban status. Model 2 adds for-profit versus nonprofit ownership; Model 3 adds for-profit/nonprofit systems; Model 4 adds for-profit/nonprofit urban systems; Model 5 includes patient days and excludes discharges (the reverse of Model 4); and Model 6 includes corporate owners and excludes type of ownership (the reverse of Model 1).
Sample Description
For owner types in California hospitals whose fiscal year ended in 1999, RN-to-patient ratios range from 1:3.2 in independent for-profits to 1:7.4 in corporate for-profit hospitals, and RN skill mix (percentage of RN hours in total nurse hours) ranges from 58% in nonprofits to 66% in independent for-profit hospitals (Table 3). Technology sophistication is greatest in nonprofits with total productive HPPDs (hours per patient day) highest in independent for-profits. Medicare case mix index and percentages of MediCal discharges are highest in independent for-profits (Table 3). Wages for RNs are relatively constant across owner types. Total HPPDs vary from 5.47 in the corporate for-profits to 11.20 in the independent for-profits (Table 3).
For specific corporate owners in California hospitals whose fiscal year ended in 1999, RN-to-patient ratios range from 1:4.2 for University of California hospitals to 1:10.3 in Tenet hospitals, and the RN skill mix ranges from 55% in Adventist hospitals to 68% in Paracelsus hospitals. University of California hospitals have the highest technology index, the highest Medicare case mix index, and the highest overall HPPD, RN HPPD, and RN wage of the various corporate owner groups (Table 4). LA County had the highest percentage of MediCal discharges (41%) and the longest average length of stay (5.54 days) (Table 4). Figures 1 and 2 illustrate graphically the differences in hours worked per patient day by employee category for corporate owner and owner type. The corporate for-profits have the lowest number of hours per patient day, and Tenet has the lowest number of hours per patient day among the specific systems.
Results
All 6 regression estimates are displayed in Table 5. The most consistent significant findings across all models are
* increased patient days or patient discharges predict increased RN hours;
* lower RN wages predict increased RN hours;
* higher technology scores predict increased RN hours; and
* in 1998 there was an across-the-board decrease in RN hours.
Other significant findings in this study are
* for-profit hospitals and for-profit systems (Models 2 and 3) had fewer RN productive hours for medical-surgical nursing; and
* select corporate owners (Unihealth, which is now part of Catholic Healthcare West and Tenet) had consistently fewer RN productive hours for medical-surgical nursing (Model 6).
A most intriguing finding is that, for all models, the number of medical-surgical RN hours worked declined significantly in 1998. The results indicate that for-profit hospitals, particularly those that are part of a multihospital system, use fewer RN hours in the provision of care in medical-surgical units (Models 2 and 3). However, when dummy variables are included to distinguish urban for-profit system hospitals from rural for-profit system hospitals, for-profit hospitals are no longer significantly different from other hospitals (Models 4 and 5).
The lower use of RNs in for-profit system hospitals appears to be driven by Tenet hospitals, as seen in Model 6. Unihealth hospitals also used significantly fewer medical-surgical RN productive hours (note bold coefficients in Model 6). Interestingly, holding all other variables constant, RN productive hours are consistently and significantly lower in fiscal year 1998 across all models (Table 5).
Not surprisingly, more discharges, more patient days, higher case mix index, and higher technology scores predict more RN productive hours. In several models (3, 4, 5) the higher nurse aid wage predicts more RN hours, and for all models, increases in RN wages are associated with fewer RN productive hours. Overall, our models explain 72% to 75% of the variation in medical-surgical RN productive hours.
Discussion
The significant finding in this study that supports conventional wisdom is that for-profit hospitals and for-profit systems have fewer RN productive hours for medical-surgical nursing. In addition, specific corporate owners, Unihealth (nonprofit) and Tenet (for-profit), had consistently fewer RN productive hours for medical-surgical nursing. As expected, hospitals with higher discharges, technology scores, and acuity scores have more productive RN hours. In addition, the demand for RNs increases as wages decline.
It is also expected that the University of California hospitals and Scripps hospitals, both academic teaching hospitals, have the highest technology scores and the highest case mix indices. This supports the contention by academic medical centers that they require more staff because they serve a population that has a higher acuity and are given more technology interventions, so they need more staff to manage the acuity and technology.
The study has several limitations. We use only 3 years of data for these analyses, and no financial data from Kaiser Permanente are available in the OSHPD databases. We are unable to distinguish rural/urban differences in the profit effect, probably because of the small number of rural hospitals in the sample. This is not a causal model so, if a hospital changes ownership, we are unable to say whether the hospital will reduce staffing based on our estimates.
These data support the notion that for-profit hospitals and for-profit systems were behaving differently in the healthcare market environment of the late 1990s; however, they also point to the issue of select nonprofit systems (Unihealth now part of Catholic Healthcare West) using significantly less RN staffing. Perhaps both Tenet and Unihealth were in difficult financial straits during this time and reduced staffing to preserve the organization. In the past, the conventional wisdom has been that nonprofits have “purer” motives than for-profits when it comes to patient care and quality. We believe that these data provide evidence for calling that notion into question and that all hospital systems, both for-profit and nonprofit, deserve closer attention and investigation.
Countering the conventional wisdom is the finding that independent for-profit hospitals have the highest total HPPD, the highest RN HPPD, the richest RN-to-patient ratio, and the richest skill mix. One possible explanation for this is that most of the independent for-profits are in rural areas. Rural hospital staffing averages may be unexpectedly high because the facility must maintain a minimum number of RN hours even if there are no patients in the facility. The independent for-profits also have the highest percentage of MediCal patients and highest Medicare case mix index, so another explanation is that they may have increased the total HPPD and RN HPPD to appropriately manage the workload.
Implications
One implication for nurse managers and executives that can be taken from these findings is that as the organization technology sophistication increases, there will be a need to plan for increasing RN hours to manage the advanced technology. This runs counter to the argument that is often used that increasing technology should/will decrease the need for RN hours. In addition, as discharges increase, the need for RN hours increases, and as RN wages decline, the need for RN hours increases. Although organizational decisions often are made without data, nurse managers may be able to use these results to justify/explain budgets and support arguments for maintaining or increasing nurse and RN hours based on changes in their organizations.
References
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We are not alone in this process...
Hospital Conversion Foundations: Issues in Creation, Operation, and Evaluation
[Article]
Baker, Constance M. RN, EdD, MA
FIGURE Constance M. Baker, RN, EdD, MA, Professor, Nursing Administration, School of Nursing, and Adjunct Professor, Center on Philanthropy, Indiana University, Indianapolis, Indiana E-mail: cbaker1@iupui.edu.
Abstract
A major healthcare transformation in the United States is the conversion of nonprofit hospitals to for-profit entities, and the creation of hospital conversion foundations for the nonprofit charitable assets, which now exceeds $9 billion. Because less than 21% of the 525 hospitals converting from nonprofit to for-profit ownership have established a hospital conversion foundation, the public's monetary losses are considerable. This article examines some of the key legal and organizational issues related to hospital conversion foundations including factors related to establishing fair value of the converting hospital, foundation mission, use of conversion revenue, governance, and evaluation.
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Managed care has created a revolution in the United States healthcare industry with all sectors competing to protect market share. During the past 6 years approximately three of every five hospitals have been involved in some type of consolidation, whether merging with a comparable type hospital, converting from nonprofit to for profit ownership, or privatizing a public hospital.1-6 While the media has spawned the notion that nonprofit hospitals are being overtaken by for-profit corporations, the facts reflect a different picture. Among the 2,800 general hospital consolidations since 1980, ownership conversions to for-profit status actually occurred in fewer than 525 hospitals, and only 109 hospital conversion foundations have been identified.7 Although these hospital conversion foundations have combined total assets of $9.3 billion, many conversions have taken place without creating foundations and diligence is needed to prevent the philanthropic monetary losses that have occurred over the past 19 years.
The purposes of this article are to: 1) assess the magnitude of US hospitals converting to for-profit status and creating hospital conversion foundations; 2) analyze stakeholders' issues surrounding the creation, operation, and evaluation of a hospital conversion foundation; 3) summarize current public policy issues and future research possibilities.
Method of Literature Review
Four approaches were used to identify relevant healthcare, legal, and philanthropic literature. A computerized search of Medline, Health Infotrack, American Business Index, and Philanthropy was conducted using the following key words: health facilities mergers, hospital conversions, and hospital foundations. The Indiana University computerized library catalog was searched using key words: healthcare and consolidations, hospital and merger, conversions and for-profit. References in scholarly and research articles also were pursued. Searching the World Wide Web and informal consultation yielded information about current policy organizations and government publications. Numerous articles and books were identified; priority is given to those published within the past 5 years. This literature informs the following consideration of hospital conversion foundations and public policy issues.
Legislative Background
Nearly 70% of the hospitals qualify for tax exemption under Section 501(c)(3) of the Internal Revenue Code because they were formed and operated solely for charitable purposes. Nonprofit hospitals provide their communities with charity care and exhibit greater "community orientation" than their for-profit counterparts.8,9 In turn, they receive many advantages including exemption from property, sales, and income taxes; perhaps prime is the community's trust.
Hospital conversions occur when the assets of a nonprofit hospital come under the control of a forprofit entity. Conversions may take the form of an outright sale of assets to a for-profit hospital, a merger with a for-profit hospital, or a joint venture where a share of the assets are sold to a for-profit and some type of nonprofit control is maintained. Hospital conversions are controlled primarily by state law, although federal tax and antitrust law may be relevant. Conversion of nonprofit hospitals to for-profit could involve five sources of legal authority.10,11 The first, called "charitable trust" doctrine, imposes fiduciary duties on the nonprofit board and requires that each director exercise care in conducting the business of the nonprofit.12,13 The second, called cy pres doctrine, allows the assets to be used for purposes similar to those stated in the articles of incorporation.14 Third, the common law provides the attorney general parens patriae power to protect the public's interest in charitable assets.15 Fourth, the Internal Revenue Service may monitor the process to ensure compliance with laws governing tax-exempt organizations.11 In some states the charitable trust law requires that before the hospital either sells the assets or enters into a joint venture with a for-profit organization, the nonprofit must apply to the court to change its purpose.13 The state attorney general then becomes a party to the case and can approve or disapprove the application. If the attorney general disapproves the application and the parties proceed with a conversion, the court may impose a legal injunction and hold the nonprofit hospital directors in breach of their fiduciary duty.
When the conversion involves a tax exempt hospital in a joint venture with a for-profit organization, several requirements must be met to maintain tax-exempt status.16 The nonprofit hospital must abide by the separate entity principle and continue to operate exclusively for its charitable purposes, establish mechanisms to ensure that the nonprofit controls the venture, and operate the venture in the interest of furthering the exempt hospital's charitable purposes. Further, consistent with the classic case of Plumstead Theatre Society v. Commissioner,17 the nonprofit hospital board must be free of any conflicts of interest in relation to the for-profit organization, maintain full control over the nonprofit's operations, and is under no obligation to reimburse contributions made by the for-profit organization. Although the recent Revenue Ruling 98-15 addresses whole-hospital joint ventures, it is relevant to all joint ventures between tax-exempt hospitals and for-profit organizations and is especially timely as nonprofit hospitals build integrated delivery systems through joint ventures.18,19
The fifth source of legal authority has evolved more recently in response to the volume of health-care mergers and conversions. Legislators and attorneys general have introduced legislation to regulate the process. For example, in 1996 Nebraska legislature passed NE L1188 Nonprofit Hospital Sale Act requiring the attorney general to evaluate conversions, and the California legislature passed AB3101 Regulation of Nonprofit Mergers giving the attorney general more authority to scrutinize conversions.20 Both laws are being used as models for similar activity in numerous states; 12 states have passed laws and three other states have had their legislation vetoed by governors. In March 1997 the National Association of Attorneys General adopted Ohio's resolution on nonprofit conversions.21 Specifically required are written public notice of plans to convert, independent valuation of assets, similar use of assets, and minimum compensation of nonprofit board and executives.
There is considerable variation across the states in regulating nonprofit conversions.22 For example, California's AG halted a joint venture between Sharp Hospital Group and Columbia/HCA because it threatened the value of charity services in San Diego, Ohio's AG prevented Blue Cross Blue Shield from selling assets to Columbia/HCA to protect charitable assets in Cleveland, and similar activities have involved Attorneys General in Massachusetts, Missouri, and New Jersey. Some attorneys general seem satisfied with common law authority and others are depending on the market to shape the conversion outcomes.
Hospital Consolidations and Conversions
Hospital consolidation is a broad term used to describe any merger or acquisition between and among any ownership status. Hospital conversion is a narrower term used to describe a change in ownership from nonprofit to for-profit status. Trends in hospital consolidations between 1980 and 1993 were gleaned from an exhaustive study of American Hospital Association data and include the following:
• Most mergers occur between hospitals of similar type.
• Public hospitals accounted for 56% of all ownership changes between 1980 and 1990 and 32% between 1990 and 1993.
• Only 2% of all nonprofit hospitals changed ownership.
• Three fourths of the changes in for-profit hospitals was to nonprofit.23
• Between 1980 and 1993, 270 hospitals converted from nonprofit to for-profit ownership.24
• During 1990-93 more than half (55%) of all consolidations occurred in just four states, with each state experiencing at least five for-profit conversions without any consistent public oversight.23
Since 1994, there have been more than 1200 hospital consolidation agreements, California leads the nation with 88 and Wyoming reports one.1-6 Among these consolidations, approximately 250 1-6 hospitals converted from nonprofit to for-profit ownership. Data regarding the geographical distribution of hospital conversions from nonprofit to for-profit has not been found.
Hospital conversion foundations have been created in 31 states, with 12 states accounting for 77 (71%) of the 109 created. Table 1 shows that Ohio, California, and Virginia lead the nation with 13, 10, and 9 foundations, respectively. There are 7 in Florida, 6 in Missouri and South Carolina, and 5 in Illinois and Texas. Finally, there are 4 conversion foundations in Colorado, North Carolina, Pennsylvania, and Tennessee. Despite the limitations of this data, a positive relationship between the number of consolidations and the number of hospital conversion foundations is suggested in California, Florida, and Texas. A vigilant and active Attorney General may explain the number of conversion foundations in Ohio. In terms of assets, California's hospital conversion foundations leads the nation with more than $1 billion of the $9.3 billion currently available.7
Stakeholders' Interests
Attention is focused here on the initial stage of hospital ownership conversion and the major stakeholders: the hospitals' boards of directors and chief executive officers, the attorneys general, buyers/payers, and community groups and persons served by the hospital. Collectively, their primary interests include adhering to the laws governing charitable organizations, ensuring fair valuation for the converting hospital, protecting community rights to public disclosure and open hearing, and safeguarding community benefit.25
Fiduciary responsibilities are the primary concerns of the board of directors and the chief executive officer of the nonprofit hospital considering an ownership change. The board has the fiduciary responsibility to protect the nonprofit's assets and promote the nonprofit's mission.20 In considering a conversion, the board is obligated to represent the community's needs, protect the full value of the nonprofit, decline any personal financial interest or private inurement, and avoid any hint of impropriety.26
Boards have several "duties": the duty of care, the duty of loyalty, and the duty of obedience. The duty of care involves behaving like a prudent person in similar circumstances and performing in the best interests of the nonprofit hospital.27 The duty of loyalty involves maintaining unequivocal allegiance to the mission, putting the interests of the hospital above self interests.20 The duty of obedience involves conforming to all laws affecting the hospital.13
In 1987 the American Bar Association presented a Revised Model Nonprofit Corporation Act, but hospital directors may need more standards of conduct and closer monitoring. For example, a 1996 Michigan circuit court ruling focused on the Board's violation of their fiduciary duties and disregard for the Michigan Nonprofit Corporation Act (NCA).10 In Kelley v. Michigan Affiliated Healthcare Systems, Inc.,13 the judge ruled that a joint venture between two nonprofit hospitals and Columbia/HCA violated the NCA and that commingling of (even partial) assets was inappropriate for charitable funds.
Valuation of assets is a major issue in hospital conversions because tax monies and donations built the nonprofit hospital; however, there is little consensus about proper appraisal methods,14 the public has not been consistently informed, and it is difficult to make a monetary assessment of the community benefits.28 Yet, the assets are the basis for the conversion foundation and are used as the new for-profit entity moves from tax-exempt to the taxable sector. The nature of healthcare compromises the three appraisal methods commonly used to determine corporate value.11 The cost or asset method involves determining the costs of replacing the hospital and allowing for depreciation. The market comparison method compares similar businesses. The income method involves projecting a hospital's earnings potential. The outcomes of these methods are influenced by the quality of the facilities, geographical location, the local business environment, and the competitive managed care environment and utilization. Although combining the merits of each method may be the preferred method, it may not be relevant for a charitable hospital and the board will need to seek a third party "fairness" opinion or invite bids from prospective buyers. To pass the financial "fairness" test, the board may prefer to consider both of these sources of information.
The board's due diligence is reflected in their documented efforts to seek fair market value and consider competing bids. The importance of meeting minutes to demonstrate directors' duty of care has been reinforced by Tennessee's Attorney General's 1995 statement to the Tennessee Court of Appeals in support of the Nashville Memorial Hospital Board's decision to sell the Hospital to the for-profit Adventist Health Care Systems/Sunbelt.27
Public disclosure of the conversion exploration and valuation process are obligations of the non-profit board, but some boards have ignored the attorney general's office, avoided open discussions, and proceeded without any community involvement.20 Despite having the authority to regulate hospital conversions, there is considerable variability among the attorneys general, perhaps due to inadequate background, resources, or the will to pursue these issues.14 Table 2 lists the 11 states in which hospital conversion foundations have not been created. Questions about attorney generals' vigilance are stimulated when consideration is given to the number of consolidations and for profit hospitals, especially in New York, Mississippi, Nevada, and Utah.
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[Email Jumpstart To Image] TABLE 2 Hospital Ownership and Consolidations by States with Most Consolidations and No Conversion Foundations
Community concerns regarding nonprofit hospital conversions include accessible healthcare, source of employment, and contributions to the quality of community life.9 Many citizens expect to participate in decisions regarding nonprofit hospital mergers and conversion foundations. Some citizens, such as Milan Pavkov in Barberton, Ohio, take action to hold decision makers accountable for providing community benefits.29 Community advocates are concerned about the impact of hospital conversions on healthcare access, quality, and affordability. Some fear that when the nonprofit's non-distribution constraint is lifted patient care decisions may not benefit the patient.30 Although the technical nature of healthcare has increased information asymmetry, where one party has greater knowledge about a problem than another, recent healthcare consolidations have eroded community trust 31 and lowered the public's confidence in the quality and efficiency of nonprofit providers.32
The magnitude of hospital consolidations during the past several years, coupled with expansion and conversions of managed care programs, has received negative treatment by the media.33 Although the actual number of hospital conversions seem low, sufficient concern was expressed to stimulate a Congressional review.34 After assessing market value and selling price of 14 conversions in 6 states, mechanisms for creating nonprofit charities, and state laws covering such transactions, the US General Accounting Office report calls for greater community involvement in decision making. The community is the prime focus of the July 1997 American Hospital Association "Guidelines for hospitals/health system leaders when changing ownership or control."35
Finally, consideration must be given to the nonprofit hospital's current foundation and the various options available after the conversion.36 If the foundation is considered part of the total asset package, then the foundation might merge into the new hospital conversion foundation. If circumstances of creation and mission of the foundation do not allow merger, the foundation might continue with a revised mission or disband and distribute the endowment.
Creating a Hospital Conversion Foundation
The future of the nonprofit hospital's assets after a conversion usually is part of the terms of the conversion process. The options include establishing a new foundation, distributing the assets to existing institutions with similar purposes, or supporting a government program.37,38 The issues that surround creating a hospital conversion foundation include selecting the board, determining the tax status, establishing a governance model and accountability structure, developing a mission statement, and designing a programmatic focus.
The first board of directors is extremely important to the future evolution of the foundation because they develop and refine the mission statement, select the first executive director and staff, and create the infrastructure for operations. Although the notion of the nonprofit hospital board becoming the foundation board has been implemented in most instances,39 many authors express concern about violating inurement and private benefit rules, conflicts of interest with the new for-profit hospital, and the need for expertise in grant-making foundations rather than business-oriented hospital boards.26,40 The literature recommends new board members who are independent from the for-profit hospital and with designated terms of office. For example, Nebraska, California, Rhode Island, and a few other states now require a completely new board with broad community representation and expertise in leading a grant-making foundation.14
Tax issues confronting the hospital conversion foundation board include establishing the tax status as a private foundation or a public charity.37 These options are distinguished by federal tax rules about the sources of funding, the minimum level of charitable expenditures each year, and accountability to the public through annual reports. Because the size of the hospital conversion endowment probably prevents meeting the public support requirement of public charities, most conversions have resulted in private foundations. They are prohibited from holding more than 20% of the voting stock of a corporation, required to spend at least 5% of the value of the endowment each year and distribute an annual report of its activities.14,38
The mission statement of the hospital conversion foundation is expected by the cy pres doctrine to be similar to the nonprofit hospital; however, there are several instances of departure.41 Although most of the foundations have maintained a health focus, some have expanded their definition of "health" to include quality-of-life issues, civic and anti-discrimination efforts, and sports training.42,43 One challenge to an expanded mission came in 1996 from California's Attorney General who required the Good Samaritan Charitable Trust to adhere to the original mission of the nonprofit hospital and provide direct care.39 Whereas this case reflects adhering to the letter of the law, most foundation boards have implemented missions that reflect the spirit of the law.
The potential for conflicts of interest with the mission of the for-profit converted hospital seems greater when the board members are the same ones who directed the nonprofit conversion. One example of conflict of interest is funding free care of uninsured patients receiving care at the for-profit converted hospital. A strategy to avoid the appearance of conflict of interest is to follow the example of the Baptist Community Ministries' Board in New Orleans who surveyed the community, visited similar foundations, and invested in a board retreat to draft a mission statement and 10 major goals for the next 15 years.40 Because the citizens' taxes contributed to the foundation's assets, community involvement in finalizing the mission statement acknowledges their contributions and enriches the outcome.
Designing a governance model and establishing an accountability system to the community are critical tasks for the success of the hospital conversion foundation.37 Bylaws can guide the foundation decision-making activity and help to prevent the perception of conflicts of interest. Considerable work in grant-making foundations is conducted in committees; consultation with experts in board governance and visits with similar foundations should be helpful.
The programmatic focus of the hospital conversion foundation will evolve from the mission statement.14 Foundations have a wide range of choices in determining how to achieve the mission.38,44 Once the board establishes strategic directions for the foundation, consultants can help formulate policies and design strategies for implementing, monitoring, and evaluating grant-making programs.
Operating a Hospital Conversion Foundation
Once the hospital conversion foundation is launched, a top priority should be ongoing education of the board and the grant-making staff. The board needs instruction in their tax status and fiduciary responsibilities, guidance in identifying ongoing community health issues suitable for grant-supported projects, assistance in working effectively with each other in overseeing the foundation work, and reflection in collaborating with other community agencies. If staff were appointed from the nonprofit hospital foundation, personnel training will be required to make the transition from fund raising and development to grant-making and supervision. "Leftover" foundation staff probably will be concerned about job security, the conversion's impact on donors, and the necessity to replace their foundation traditions with a new organizational culture and new colleagues.45 Little attention has been given to the relationship between responses to a hospital conversion and the staff's educational preparation, professional experiences, and career commitment. Early management strategies include estimating their acceptance of the conversion and their resistance to change, followed by assessing their attitudes toward governance and autonomy and identifying new priorities in grant making.
Efforts are needed to begin planning a continuous quality improvement program of all aspects of the foundation's efforts. National accreditation may not exist yet, but criteria and standards for quality operations can be introduced and used in assessing organizational effectiveness.
Early in operations a communication campaign with donors and potential stakeholders should be launched to interpret actions and answer questions.45,46 The governing board of the new for-profit hospital is interested in the quality and quantity of foundation work and all the factors that contribute to the organization's reputation. While organization policy should influence the nature of the foundation's role, community visibility will impact future collaboration. Boards and personnel in other health foundations are interested in the impact of the hospital conversion foundation on their own activity. Their potential for collaboration and cooperation is important to meeting the needs of the local communities and should be cultivated.
The media has considerable power to influence how the hospital conversion foundation is portrayed.33 Further, the media creates an image of the institution that can influence collaboration efforts, grant-funded projects, and future donors. The executives need to be alert for opportunities to showcase satisfied stakeholders and examples of outstanding project successes. Operating a new hospital conversion foundation is similar to operating any new endeavor, but there are differences related to the foundation's origins and the media climate.
Evaluating a Hospital Conversion Foundation
Assessing the effectiveness of a new hospital conversion foundation involves an internal and an external assessment of the mission and its implementation. Internal stakeholders need to be involved in evaluating the board of directors and foundation executives, governance model for decision making, staff performance, and overall operations. Attention must be given to annual income and donations and, when relevant, comparisons with pre-conversion levels. Regular evaluation of ongoing activities is required to ensure they are consistent with the mission.36 External stakeholders must be involved in assessing the grant making process, impact of the grants on the community, and overall community concerns.
These foundations are too new to be subjected to accreditation reviews, but the visionary executive would be anticipating, if not leading, efforts to establish national quality standards. Beyond the individual foundation level, evaluation research is needed at both the state and national levels to assess the outcomes of this monumental transfer of funds into healthcare philanthropy.47 Attention needs to be given to the environmental context that created these changes, the structures and resultant processes that were designed to implement the changes, the cumulative outcomes of the hospital conversion foundations, and the impact on the local, state, and national health.
Public Policy Issues
The revolution in US healthcare continues as major sectors are transformed by economics and technology, health professions are "right sized" and realigned, and the public assumes more responsibility for their health status. In this context there are many deserving recipients for the charitable assets released by hospital conversions and there are numerous public policy issues for consideration.
Public involvement is basic to a strong democratic society and an accountable healthcare delivery system. All tax-exempt organizations should be required to disclose their financial activities in a timely fashion, for example, the annual report and Form 990. Both private and public nonprofit health organizations should be accountable to their communities for their business plans and operations. The public and the board members need ongoing education regarding fiduciary responsibilities. The public needs help recognizing that the language of partnering may be quite different from the realities of joint ventures.
Valuation methods need to be established to ensure consistent and fair assessment of assets. Sufficient experience has been garnered over the past 5 years to create a standard procedure for determining the worth of a nonprofit hospital's assets. Even allowing for changes in federal reimbursements for patient care, there are acceptable methods and practices to establish a standard procedure to protect the community's charitable assets. Monitoring mechanisms are imperative for joint ventures especially because of the numerous reports of for-profits paying less than market value and retaining nonprofit assets as passive investments.
Community benefits require clarification and refinement within the context of hospital conversions.22 Does the creation of a hospital conversion foundation relieve the for-profit entity of any responsibility for uncompensated care? Some conversion agreements have specified the for-profit's responsibility to the community, both the type and duration of healthcare services. How is the community benefit definition modified and how are assets monitored when a nonprofit hospital enters into a joint venture with a for-profit entity?
Regulators' responsibility to the public needs critical examination. Authority to regulate conversions arguably exists in the common law in all states, but the majority of the attorneys general have not exercised their discretion to review the conversion of charitable hospitals. There are 771 for-profit hospitals in 44 states, seven states do not have a for-profit hospital in operation.48 There are 109 hospital conversion foundations in 33 states.7 What is suggested by the observation that 11 states have had nonprofit hospitals convert to for-profit entities but no laws are in place and no hospital conversion foundations have been created? The public's monetary losses can be documented; it is more difficult to document the public's pain and suffering because healthcare is not accessible.
Conflict of interest issues need to be addressed, preferably by outlining behavior limits in bylaws and holding individuals and organizations accountable. The speed with which the healthcare industry is being transformed necessitates some societal norms regarding acting in the public's good and accountability mechanisms. Attention is needed to ferret out the subtleties involved when nonprofit hospitals enter into joint ventures with for-profit organizations, especially assuring that the charitable assets are not lost to the public. Foundation accountability mechanisms must be developed. Operating standards and public involvement will ensure that the community receives the benefits due from the charitable assets.
Directions for Future Research
Health services scholarship needs to expand in several directions. First, continue to refine the conceptualization and empirical work on similarities and differences between and among for-profit and nonprofit healthcare facilities. Although the underlying economic and policy theory support differences by ownership, research evidence is inconclusive and suggests the need to broaden the focus of studies to include governmental regulations, geographical markets, and community benefits. Second, direct attention toward explaining geographical differences in the rate of hospital consolidations and conversions. By focusing on environment characteristics and organizational niche, organizational ecology theory may help interpret the geographical patterns of hospital conversions and the creation of hospital conversion foundations and suggest hypotheses for additional research. Third, conduct some basic organizational research on newly-formed hospital conversion foundations to compare similarities and differences in mission, structure, work design and operations, and performance. Additional research variables are suggested by organizational effectiveness theory, organizational life cycle framework, and the research on nonprofit boards. Fourth, evaluate the hospital conversion process by comparing the purchase price with the assessed value once under a new owner, assessing how the proceeds were actually distributed, and specifying the services and benefits changed with a for-profit owner. State policy makers need information to design reporting and monitoring systems and to identify legislative needs. Finally, extend outcome studies to hospital conversion foundations and document organizational outcomes and community impacts as preliminary to designing quality indicators and implementing programs for continuous quality improvement.
Summary and Conclusions
Healthcare in the United States is being transformed by economics and technology. Mergers and acquisitions have decreased the number of hospitals and advancing technologies have shortened or eliminated hospital stays. A major transformation is the conversion of nonprofit hospitals to for-profit entities and the hospital conversion foundations created with the nonprofit charitable assets. Less than 45% of the 250 hospitals converting from nonprofit to for-profit ownership between 1994 and 1999 have created a foundation for the assets. Although the combined assets of these foundations exceed $9 billion, few state attorneys general have been active in the conversion process. Key legal and organizational issues are examined in relation to nonprofit hospital conversions and the process of creating, operating, and evaluating the hospital conversion foundation. Public policy issues are summarized in relation to the public's involvement, hospital valuation methods, definition of community benefits, regulators' responsibilities, conflicts of interest, and foundation's accountability. Directions for future research focus on conceptual and practical issues.
Acknowledgment
The author thanks Professor Gilbert V. Kelling, Jr., Esq., and colleague Susan E. Ziel, RN, MPH, JD, for guidance, critique, and manuscript recommendations.
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Thats a lot to get through but a couple of things jump out:
1) All of the studies were during the 80's and 90's so while statistically some may apply in 10-15 years technology and procedures could have changed dramatically and that might have huge impacts on the numbers.
2) Funny a lot of the first posts statistics come from California which appears to be at the forefront of nursing ratio problems.
3) Many times it is noted that no two healthcare systems have the same dynamics so to apply results from any one system to another might not work.
Most interesting to our case is the second post and this jumped out at me:
" The board has the fiduciary responsibility to protect the nonprofit's assets and promote the nonprofit's mission.20 In considering a conversion, the board is obligated to represent the community's needs, protect the full value of the nonprofit, decline any personal financial interest or private inurement, and avoid any hint of impropriety."
As well as:
"Public disclosure of the conversion exploration and valuation process are obligations of the non-profit board, but some boards have ignored the attorney general's office, avoided open discussions, and proceeded without any community involvement"
Further:
"The first board of directors is extremely important to the future evolution of the foundation because they develop and refine the mission statement, select the first executive director and staff, and create the infrastructure for operations. Although the notion of the nonprofit hospital board becoming the foundation board has been implemented in most instances,39 many authors express concern about violating inurement and private benefit rules, conflicts of interest with the new for-profit hospital, and the need for expertise in grant-making foundations rather than business-oriented hospital boards.26,40 The literature recommends new board members who are independent from the for-profit hospital and with designated terms of office. For example, Nebraska, California, Rhode Island, and a few other states now require a completely new board with broad community representation and expertise in leading a grant-making foundation."
Looks like our beloved foundation should have read this article before deciding to sell our hospital without our involvement and then establish themselves as the guardians of our money.
Everyone should remember as they read the post on nurse ratios one of the opening paragraphs:
"Background: Little empirical data exist regarding nurse staffing as it relates to owner type or specific corporate owner. ..., this study provides baseline data for evaluating the impact of minimum staffing ratios in California."
While patients may be universal and method of care may be universal, businesses are operated a lot differently in California than they are here.
You are right that California in many ways is a different world but in most areas the trends that hit that state find their ways to the east coast within time. We can learn form the issues encountered and the mistakes made in California.
The problems we are experiencing in Danville are not new to healthcare. Unfortunately, the entire system within the United States needs to be fixed.
And the shortage of all types of healthcare professionals only complicates the issues even more. Who will be there to care for us boomers?
I have to laugh about the comment that DRMC's administrative area is bigger that Lifepoint's corporate office. If that is true.....how do they have room for the big, fat coiner of the term "Dumbville" who yelled at employees, called them stupid and lazy and unworthy of raises and then was promptly promoted to a position within the corporate office? I personally told Art of these comments and that as a person born and bred in Danville, I am tremendously offended in having my hometown slandered in such a way. Do any of you feel the fact that this lady who slandered our beloved community in this way has been promoted to such a high position within Lifepoint is a kick in the rump for us? I cannot work for such a corporation and am pissed that I felt I had to leave my hometown for employment elsewhere for that reason.
I am sorry I missed the dumbville term and the low hanging fruit where did these come form?
Her name: Roberta
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