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M iddleboro Community Hospital (MCH) was founded as a short-term, general acute- care nonprofit hospital in 1890. Originally built with a 40-bed capacity, it has slowly grown to its present 272-bed size and has added a significant number of outpa-
tient services. MCH is licensed by the state, incorporated as a 501(c)3 nonprofit corporation, accredited by The Joint Commission, approved by the American College of Surgeons (cancer program), approved for Blue Cross participation, certified by the US Department of Health and Human Services for participation in Medicare, and accepts Medicaid patients. The Joint Commission recently granted a five-year accreditation based on periodic surveys. Current ser- vices, as indicated on the most recent survey by the American Hospital Association, include the following:
C A s e 5
m i D D l e B o r o C o m m u n i t y h o s P i ta l
• Airborne infection isolation room
• Auxiliary organization • Bariatric/weight control
services • Birthing room, LDR room,
LDRP Room • Cardiac intensive care • Cardiac rehabilitation
• Extracorporeal shock wave lithotripter
• Health fair • Community health
education • Health screening • Health research • Hemodialysis • HIV/AIDS services
• Multislice spiral computed tomography, <64-slice CT
• Multislice spiral computed tomography, 64+ slice CT
• Positron emission tomography
• Positron emission tomography/CT
• Ultrasound
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Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Healthcare strategy and operations. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2020-06-04 21:43:51.
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hI s t o ry a n d ph y s I C a l st r U C t U r e Since its construction, MCH has been a model of hospital engineering and community interest. The hospital replaced three area homes used for the care of the sick. Today, the hospital is a fully air-conditioned, five-floor brick facility on a 68-acre campus. Ample parking is provided. Over the years increasing service demands required additions to the original structure. Each time these additions were built, existing facilities were modern- ized. Fund-raising campaigns raised the majority of resources for additions completed in 1924 and 1946. Federal Hill-Burton funds were used to partially finance the 1952 and 1966 additions. The 2002 building program relied on retained earnings, community phi- lanthropy, and long-term borrowing.
In 1919, this hospital founded a school of nursing to train area personnel. This three-year diploma school was one of the largest in the state and trained many of the nurses
• Adult interventional cardiac catheterization
• Case management • Chaplaincy/pastoral care • Chemotherapy • Children’s wellness
program • Community health
reporting • Community health status
assessment • Community health status–
based service planning • Community outreach • Complementary and
alternative medicine • Emergency department • Enabling services • Palliative care program • Optical colonoscopy • Endoscopic ultrasound • Ablation of Barrett’s
esophagus • Endoscopic retrograde • Enrollment assistance
services • Electron beam computed
tomography
• Hospital-based outpatient care center services
• Immunization program • Medical–surgical intensive
care services • Neurological services • Nutritional programs • Obstetrics • Occupational health
services • Oncology services • Orthopedic services • Other special care • Outpatient surgery • Patient controlled
analgesia • Patient education center • Physical rehabilitation
inpatient services • Physical rehabilitation
outpatient services • Prosthetic and orthotic
services • CT scanner • Diagnostic radioisotope
facility • Magnetic resonance
imaging
• Image-guided radiation therapy
• Intensity-modulated radiation therapy
• Shaped beam radiation system
• Genetic testing/ counseling
• Robotic surgery • Sleep center • Social work services • Sports medicine • Support groups • Tobacco treatment/
cessation program • Transportation to health
services • Urgent care center • Virtual colonoscopy • Volunteer services
department • Women’s health center/
services • Wound management
services
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C a s e 5 : M i d d l e b o r o C o m m u n i t y H o s p i t a l 1 6 1
currently working at the hospital. In 1985 however, the increasing costs of the school, the declining interest of local residents, and the increasing popularity of collegiate nursing pro- grams led the board of trustees to close the school officially in 1987. In 1988, the hospital established a clinical affiliation with the State University that continues today to provide clinical rotations for third- and fourth-year student nurses.
In 1970 the hospital, in cooperation with the Middleboro Trust Company, built Medical Office Park on land adjacent to the hospital’s campus. This three-story medical office building was established as a condominium restricted to physicians with active medi- cal staff privileges at MCH. To begin the enterprise the hospital leased sufficient land for the building and adjacent parking for 50 years to the condominium association and then constructed the medical office building on the leased land. Once all condominiums were sold, the hospital relinquished all title to the building, but it remains the leaseholder of the land. The Middleboro Trust Company holds mortgages for each condominium. Today, the building is totally owned and managed by the condominium association of physicians, a for-profit corporation. The hospital provides no services to Medical Office Park except for snow removal and general landscaping services at cost. Unless the hospital agrees to furnish additional land, Medical Office Park cannot be expanded. Currently all 30 offices are occu- pied. Each office has approximately 6,000 square feet. Its current assessed valuation for local tax purposes, done under a special provision in the local tax code, is $375,670 with a cap of 2 percent increase per tax year. Real estate appraisers have repeatedly stated that given its “limited and restricted use” they are unable to provide a fair market value. The current facility meets all current building codes. Over the years, individual condominiums have been sold to other members of MCH’s active medical staff. The last sale in 2010 was estimated to be for $300,250.
Although tranquil in nature, this hospital has experienced volatile periods in its his- tory. Since 1930, major disagreements between area physicians (MDs and DOs) created two independent systems in the community. Physicians trained in osteopathic medicine, for example, still continue to refer patients to other osteopathic physicians, often located in Capital City, even though local allopathic physicians (i.e., MDs) could manage the case.
Six years ago the board dismissed the president of MCH, who had served in this capacity for 31 years. The board of trustees cited no formal reasons, although it is known that the board refused to honor his request for a multiyear contract. The medical staff fully supported the termination of this individual. Five years ago James Higgens was appointed president.
The hospital has also experienced frequent staff changes in certain management positions. “Conflict with administration” is the most frequently cited reason for these resignations. Over the past 12 years no chief nursing officer has served for more than four years. Conflict with the medical staff involving patient care practices and administration concerning nurse scheduling and staffing levels, recently led to the resignation of Mary
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Nurse, RN, after three years’ service in this position. Nurse had worked for the hospital for 18 years at the time of her resignation. The vice president for nursing position is currently vacant. The director of education, Janet Martin, RN, is currently acting director of nurs- ing. The administration accepted Nurse’s resignation in stride and has told the board that she could not effectively manage the nursing department and communicate administra- tion’s policies to the nursing staff. Nurse did not support the decision to lower the staffing levels in nursing and the hiring of licensed practical nurses (LPNs) to replace registered nurses. While Nurse understood the need to reduce hospital expenses, she recommended that the hospital reorganize using small nursing units, each with a manager and support team. This plan was dismissed by the senior management team as too costly. The medical staff took no position on Nurse’s resignation.
Nurse had been hired shortly before the nurses voted on unionization in 2010. In 2010, the petition to be recognized as a bargaining unit failed by the vote of 43 percent to 57 percent. Shortly before her resignation, however, Nurse had warned Higgens that another petition for another election was being discussed by nurses because of implica- tions associated with downsizing the inpatient capacity of the hospital. Management’s position for staff termination ignored seniority and emphasized “competency and job performance.” On at least three occasions, terminated employees wrote to the local paper complaining that the hospital was looking to retain “only those workers who would work for less.”
While members of the board were surprised by Nurse’s resignation, all have expressed support for the current administration.
go v e r n a n C e a n d or g a n I z at I o n The board of trustees is composed of 14 members, each elected for a four-year term. Elec- tions are held at the annual meeting of the corporation. Nominees for trustees-at-large and trustee officers are chosen by the board nominating committee and presented to all hospital incorporators for consideration. Staggered terms of office ensure that no more than four new members are elected annually. The hospital’s bylaws reserve two positions on the board for physicians nominated by the medical staff, but the rules specifically state that no physician nominated by the medical staff can be an elected officer of the board. Board members may succeed themselves. There are no limitations on the number of terms an individual can serve as a member of the board of trustees. Current board officers are as follows:
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C a s e 5 : M i d d l e b o r o C o m m u n i t y H o s p i t a l 1 6 3
Name Board Position Occupation Residence
Michael Rich (2)* Chairman President, Middleboro Trust Co. Mifflenville
Peter Steel (1) Vice chairman President, River Industries Middleboro
Mary Drew (3) Secretary Attorney, Giles, Giles, and Drew, PA
Boalsburg
Carl Meadows (4) Treasurer Accountant, Meadows and Associates
Middleboro
Peter Paul MD (4) At-large Physician Middleboro
Ed Tracer MD (2) At-large Physician Middleboro
Harry Water (3) At-large Owner, Water Hardware Middleboro
Melvin Seed (1) At-large Owner, Mid-State Oil Company Jasper
Kevin Land (4) At-large Real estate agent, Land Sales, Inc.
Mifflenville
Bret Crop (3) At-large Farmer Minortown
Jill Wheat (2) At-large Vice president, Wheat Farming Supplies
Statesville
Steve Corn (1) At-large Farmer Carterville
Elton Giles (2) At-large Attorney, Giles, Giles and Drew, PA
Middleboro
Janet Simon (4) At-large Homemaker Harris City
(* = number of years remaining in current term. Note that 1 = 1 year or less)
Rich has been board chairman for the past 12 years and has more than 16 years of service on the hospital board. His term will end next year. Steel has been vice chairman for 11 years and has more than 18 years of service on the board. His term will end this year. All other board members except Elton Giles have previously served at least one complete term as a trustee. Seed has recently informed the board that, given his business interests, he will be unable to serve another term.
The hospital’s president (James Higgens) and the president of the medical staff (Frederick Mask, MD) are ex-officio members of the board of trustees. Standing commit- tee of the board include the following:
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T h e M i d d l e b o r o C a s e b o o k1 6 4
Executive Committee All board officers
Long-Range Planning Steel (Chair), Paul, Land, and Simon
Finance Meadows (Chair), Water, Corn, and Giles
Quality Assurance Tracer (Chair), Seed, Wheat, and Mask
Nominating Seed (Chair), Crop, and Rich
The board of trustees meets monthly. Prior to the annual meeting in March, a two- day retreat is held to review progress and update corporate plans. The executive committee meets with Higgens weekly and tours the hospital. Once every two years, each board mem- ber is sponsored by the hospital to participate in a continuing education program offered by either the American Hospital Association or the State Hospital Association.
A special ad hoc subcommittee of the board, staffed by John O’Hara, the hospital’s chief financial officer, is examining its options for responding to physician requests for “more good inexpensive office space close to the hospital.”
The board is currently considering a change in its bylaws to reduce the size of the board from 14 to 8 and increase the term of appointment to six years.
se n I o r Ma n a g e M e n t te a M p r e s I d e n t
James Higgens holds an undergraduate degree in sociology and master’s degree in hospital administration from a major midwestern university. Prior to becoming administrator, he completed a two-year postgraduate residency at Lake Shore Hospital (450 beds) in Chi- cago and was the chief operating officer at Capital City General Hospital in Capital City (365 beds) for many years. He served two years with the US Army Medical Service Corps in Europe.
A Fellow in the American College of Healthcare Executives (ACHE), Higgens is vice chairman of the board of directors of the State Hospital Association. He has authored several professional papers on hospital management and is noted for his ability to interact with the medical staff and his understanding of hospital operations.
When asked what he considers to be the major issues facing the hospital, he men- tioned continued financial strength, long-range planning, cooperative ventures with the medical staff, increased worker productivity, and possible affiliation with another hospital or national chain of voluntary hospitals. He indicated that Webster Hospital, given its size, was no real threat to MCH. He also said that he has every confidence in the national search
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firm he has retained to fill the director of nursing position. When asked to describe the potential for union activities in the hospital, he stated, “Any movement in this direction should be curtailed when I find the right person to head up nursing.”
When asked to describe MCH’s primary strength, Higgens said there were two— the medical staff and the board. In contrast, when asked to list the primary threats, he indicated that less of the area’s population appears to have adequate hospital insurance and that rates paid by the state for Medicaid and the federal government under Medicare were making it difficult to prosper. When asked his strategy to cope with these rates, he said, “It’s simple. We will continue to strive for good inpatient occupancy and lower our operational costs throughout the hospital. Although the board has required that I bring all plans to them, they have generally approved everything.” Although he was concerned that a national for-profit firm has recently purchased a hospital just east of Capital City, he sees no local consequences associated with this decision.
Quotes from his recent interview include “Our hospital wants to be the low-cost, high-quality provider in the area. We need to reduce our inpatient capacity in the future and be much more creative than we have been concerning physician recruitment and retention.” When asked about the financial health of the hospital, Higgens said, “We are very conservative; we don’t like to carry too much debt. While our building is getting old it is still modern, and we have the most up-to-date technology for patient and medical care.”
s e n I o r v I C e p r e s I d e n t f o r f I n a n C e a n d C h I e f f I n a n C I a l o f f I C e r
John O’Hara has been employed in this position for nine years. His education includes an undergraduate degree in accounting from State University and a master’s in business administration from an eastern university. He is a certified public accountant and an active member of the Healthcare Financial Management Association (HFMA). Previous positions include being vice president for finance for Seneca Hospital (NY) and assistant controller at two hospitals in New England. He has more than 25 years of professional experience.
Since arriving at the hospital, O’Hara has revised and updated many financial practices. On six different occasions he has received special commendations for excellence from the board, most recently for upgrading telecommunication services in the hospital at a reduced cost. When asked about future plans and priorities, he mentioned that the hospital needed a better financial information system that could link financial and patient care data; he is preparing a request for proposal for the management team to review and take to the board. He also mentioned that he believed that the hospital’s relationship with Regional Blue Cross as well as other insurance companies would remain as harmonious as it has been in the past. O’Hara negotiates all contracts with physician professional associations (e.g., radiology) having a contractual relationship with the hospital. He has
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led hospital efforts to employ hospitalists beginning in 2012 and the selective purchase of medical practices by Medical Practices Subsidiary (MPS), Inc.
O’Hara recently reported that the most recent Centers for Medicare & Medicaid Services (CMS) calculated case mix index for the hospital was 1.5250. He indicated that MCH is following the pattern of most hospitals nationwide with this index increasing slightly over the past five years. He also mentioned the need for a budgetary process that was based on budgeted units of services in contrast to full-time equivalent (FTE) employ- ees. O’Hara does not appear to be well liked by employees in the hospital. He has been responsible for the implementation of the hospital’s plan to downsize its inpatient acute care capacity. Often he has been blamed by current and former employees for decisions to terminate or reassign staff in keeping with this plan, a plan he contributed to but that was designed and approved by Higgens and the board.
He is currently chairing a special management and medical staff committee to examine a hospital managed care plan (HMO or PPO) and different approaches to meet expectations established by recent federal legislation, including accountable care organiza- tions. A report is expected in three months.
O’Hara serves as the chief financial officer for the hospital and reports to Higgens. He has responsibility for the hospital admitting department and the business office. He is also CEO of MPS, Inc., which owns and manages select medical practices of affiliated physicians. MPS is owned as a for-profit subsidiary of the hospital with its own board of directors.
O’Hara regularly attends all MCH board meetings.
s e n I o r v I C e p r e s I d e n t f o r I n f o r M at I o n s y s t e M s a n d C h I e f I n f o r M at I o n o f f I C e r
Mabel Watkins was appointed to this position four years ago and is charged with imple- menting the new electronic medical records system. This system includes the hospital and all owned medical practices. Prior to joining the management team, Watkins was deputy CIO for a major medical center in a midwestern city. She was born in Jasper and earned her undergraduate degree in computer science at state university and MBA at a private eastern university. She has approximately 15 years’ experience in hospital IT and is a member of the College of Healthcare Information Management Executives (CHIME). She manages all aspects of the internal information technology (IT) infrastructure and is also responsible for IT system security. She also co-chairs the hospital’s task force on meaningful use.
When interviewed, Watkins stated, “Our electronic health record system is one of the reasons we have qualified for the maximum financial award every year since 2012 under the federal meaningful use criteria. Our system is changing how and what information we capture as well as our clinical and medical practice. Given the significant investment
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Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Healthcare strategy and operations. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2020-06-04 21:43:51.
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we made in acquiring and implementing the system it has to lower our operational costs. I believe it is beginning to show progress.” Every year the hospital has participated in the federal meaningful use program, it has qualified for the maximum financial award. Watkins also indicated that some of her most difficult challenges include the number and types of vendor and service contracts her office manages, assessing the value of new technologies, and staying in compliance with regulations and best practices for securing protected health information (PHI). Direct reports include the department of medical records and the offices of IT systems services, IT grants and contracts, IT system security, and telecommunications.
v I C e p r e s I d e n t f o r p r o f e s s I o n a l s e r v I C e s
Rob Stewart has held this position for 15 years. He had previously been assistant admin- istrator for professional services for seven years. Stewart holds both an undergraduate and graduate degree in health administration from a southern university and is an active member of ACHE. He also served six years in the US Air Force Reserve (Medical Service Corps).
Stewart first came to MCH as part of his administrative residency requirement for his graduate degree. He has held a number of management positions in the hospital. Dur- ing an interview, Stewart indicated that he had recently presented a plan to Higgens for the adoption of a formal guest relations program. He reports to Higgens and is responsible for the following departments:
◆ Dietary
◆ Pharmacy
◆ Physical therapy
◆ Occupational therapy
◆ Recreation therapy
◆ Speech therapy
◆ Social services
◆ All outpatient departments and services, including the emergency department.
He is also chairman of the hospital disaster planning committee and serves on com- mittees of the State Hospital Association.
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During a recent interview he expressed hope that the medical staff would become more realistic in their view of administration, and he felt that the hospital should seriously consider providing certain services off campus. While he indicated that he was disap- pointed that the hospital has elected not to provide contractual therapy services to area nursing homes—a plan he worked on for more than a year—he understood that “other priorities need attention first.” He also indicated that “that past five years have been the most difficult” of his career and that too often “good employees had to be dismissed or reassigned because of the changes in the hospital sector.” When asked to describe exactly what he does in the hospital, he said he spends most of his time working with department heads “in their offices,” and he looks forward to his new project of establishing a more effective quality assurance/total quality management program.
a s s o C I at e v I C e p r e s I d e n t f o r o p e r at I o n s
Ted Beck joined MCH as a billing clerk when he graduated from high school 24 years ago. Since that time he has held positions as accounts receivable manager, director of purchasing, and most recently, director of the business office. He recently completed his undergraduate degree in health administration at State University. After the retirement of Hank Wrench last year, Beck was appointed assistant administrator for operations and pro- moted to associate administrator six months ago. Beck is a member of ACHE and plans to complete his certification exam within two years. For the past three years, employees have voted Beck the “Outstanding Supervisor.” He is currently developing a plan for shared laundry services with area nursing homes.
He reports to Higgens and has responsibility for the following departments:
◆ Parking and security
◆ Engineering and maintenance
◆ Housekeeping
◆ Laundry
◆ Purchasing, materials management, and supply chain management
◆ Human resources
When interviewed, Beck indicated that he had just completed the plan and new job description for the director of human resources position, vacant since the recent resigna- tion of Sally Simmons. Under his plan the new hire will be called the assistant adminis- trator for human resources and will report directly to Higgens. Beck also indicated that, given the range of his current duties and associated details, he has just about enough time
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to check that each of his departments is running smoothly. Although he is busy, as acting director of human resources he does all exit interviews. When asked to characterize the nursing department, he expressed confidence that a new director in that department could solve any problems and that LPN substitution for RNs who resign has been an effective policy in curtailing financial increases.
Beck indicated that Simmons really resigned as director of human resources over the issue of outplacement services not being provided to terminated employees. Although Beck said that Simmons had a valid point regarding the hospital’s responsibility to loyal employees, he supported O’Hara’s position that MCH could not afford to spend money on employees it no longer needed. Beck also said human resources was a complex area that he did not fully understand, and he was looking forward to hiring a qualified replacement quickly.
It should also be noted that Beck has strongly urged MCH to affiliate with a national voluntary chain of hospitals to access joint purchasing services. His recent analysis shows that the hospital could save up to 8 percent on medical supplies if it were to change its purchasing affiliation to a large national chain. A consultant noted that the develop- ment of a state-of-the-art supply chain management program could lower inventory costs by 11 percent and reduce warehouse space by 25 percent. According to Beck, “Supply chain management needs to become a major priority.”
a s s I s ta n t v I C e p r e s I d e n t f o r h U M a n r e s o U r C e s
This newly created position is currently vacant. A regional search and consulting firm has been retained to identify qualified candidates. The hospital has indicated that it would consider changing this position to a vice president with direct report to Higgens. Sufficient funds have been budgeted to support this position and a small staff.
v I C e p r e s I d e n t f o r n U r s I n g
This position is currently vacant. A recruitment firm has been retained to identify qualified candidates. In addition to having a high degree of professional nursing experience, can- didates must have demonstrated administrative talents. To date, no internal applications have been received. Two candidates identified by the recruitment firm were recently inter- viewed. One candidate withdrew before any decision could be made. The other was not retained based on her limited management experience. On recent consultation with the recruitment firm, Higgens informed the board that this position probably would remain vacant for at least another six months.
This position reports to the administrator and has responsibility for all in-patient nursing services in the hospital, including ICU/CCU and pediatrics, maternity, general medical–surgical services, and central surgical supply as well as the department of education.
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T h e M i d d l e b o r o C a s e b o o k1 7 0
Janet Martin, RN, director of education, is currently acting director of nursing. Martin has held her position as director of education for the past 20 years. She is a graduate of the Middleboro Community Hospital School of Nursing and holds an undergraduate degree in nursing and a master’s degree in nursing education from State University. Com- bining 36 years’ experience between nursing and education, Martin has held a variety of nursing positions at MCH, including staff nurse, charge nurse, evening nursing supervisor, and night nursing supervisor. On three different occasions, she has been acting director of nursing.
Martin knows every nurse in the hospital. She is very well liked and known to listen to her department heads, charge nurses, and head nurses. She indicated, however, that she still feels very uncomfortable with administration. While all department heads in nursing were relieved when Martin (again) agreed to become acting director, some indicated that Martin really was not qualified for the position on a permanent basis. One even stated, “She really doesn’t have the ability to present our position. She just implements what administration tells her to do.”
Martin recently informed Higgens that she would retire in six months. The director of education is responsible for ensuring that all nurses remain pro-
ficient in professional practice. In-hospital seminars and workshops are provided. The director also serves as the liaison official with the nursing department and their student nurses from State University. In the past Martin has declined the opportunity to apply for the director of nursing position. When interviewed, she indicated that the hospital needs to listen to its nurses, attract a “good” director of nursing, and provide staff nurses more opportunity to influence patient care practices. Martin also said she “believes that team nursing, in contrast to primary nursing, was being forced on the hospital by the availability of qualified and experienced registered nurses and economics.” She also indicated that she felt obligated to (again) become acting director of nursing to help the hospital.
The vice president for nursing reports to Higgens and supervises the following services:
◆ Pediatrics
◆ Maternity and nursery service
◆ All medical and surgical units
◆ ICU/CCU
◆ Nursing education and staff development
◆ Nursing quality assurance
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◆ Case management services
◆ Central sterile supply
◆ Operating rooms
Until 2010, the vice president for nursing also managed all outpatient clinics and the emergency department. As part of the plan to downsize the inpatient capacity of the hospital and adjust to an increase in the demand for outpatient services, responsibility for these units was transferred to the associate administrator for professional services.
The vice president for nursing and the hospital’s medical director, Dr. Fred Limpey, regularly convene the hospital’s CMS Core Measures Working Group. Other members of the committee include Hazel Webster, RN, director of quality programs, and Candace Mathews, RN, director of case management. This group examines all CMS quality data furnished to the hospital by the area Quality Improvement Organization and institutes appropriate actions. This group also measures and monitors other specific quality mea- sures. Eighteen months ago this group, working with a consultant, implemented a formal quality improvement program to prevent:
◆ Ventilator-associated pneumonia (VAP)
◆ Central line–associated bloodstream infection (CLABSI)
◆ Surgical wound infection (SWI)
Each program involved a specific bundle of services, policies, and procedures that constitute an evidence-based standard of care. For example, studies indicate that 5.3 CLABSIs occur in ICU per 1,000 catheter days and that approximately 18 percent of CLABSIs result in death. Studies indicate that VAP occurs in up to 15 percent of patients receiving mechanical ventilation. Whenever the bundle of required services, policies, and procedures is not fully implemented, the Core Measures Working Group determines the facts surrounding the case and reports its recommendations to the administrator for implementation. Frequently it must determine whether the problem is with a system or with a specific nurse or physician adhering to clinical protocols. Since implementing the standards, the occurrence of VAP, CLABSI, and SWI has declined by at least 65 percent.
s p e C I a l a s s I s ta n t f o r p r o f e s s I o n a l s e r v I C e s
Marie Calley is a recent graduate of the health and hospital administration program (MBA) at a private eastern university. She has held this position for six months, having
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T h e M i d d l e b o r o C a s e b o o k1 7 2
moved back to Middleboro nine months ago when her husband accepted a position with the law firm of Giles, Giles, and Drew. She reports directly to Higgens. Calley also holds an undergraduate degree in English. While in graduate school, she studied with one of the leading academic experts in hospital strategic planning. Her previous professional experi- ence is limited to a two-year residency at Coastal Medical Center (450 beds) in a major western city. Calley recently applied for membership in ACHE.
Calley is responsible for the operation of three departments: radiology, laboratory, and anesthesiology. Based on a recent positive evaluation, Higgens has taken her off proba- tion, a condition for any new employee. When interviewed, she indicated that she hopes to learn more about her departments and ensure that budgets are adhered to. Medical terminology and requests for new equipment she “really does not understand” have often sent her “back to the books,” and she still seeks help from Higgens. She feels the hospital needs to develop a formal marketing program and says the physicians she deals with are clearly committed to the goals of the hospital.
Calley believes that other women employees perceive her as the “young professional woman role model” in the hospital, a status she says she is somewhat uncomfortable with. She feels she made the right decision to refer a group of concerned employees to Beck as acting director of human resources to share their views about the need for a day care program for dependents of hospital employees. She is a graduate of the local high school. When asked to characterize the hospital, she said it resembles a textbook case, “a ‘good’ hospital beginning to run itself as a ‘good’ business.” While she understands the distress many employees feel about the recent changes in this hospital, she said that “most just do not understand, we have to adjust to changing demands and work cooperatively with our medical staff if we are to remain a viable hospital in the future.”
d I r e C t o r o f v o l U n t e e r s e r v I C e s /p U B l I C r e l at I o n s
Janet Stock has held this position for the last four years. She holds an undergraduate degree from State University and has previously served as director of volunteer efforts at the American Red Cross Chapter in Capital City. Stock is known for her ability to attract and retain volunteers from all facets of the community. Under her direction the hospital volunteer and auxiliary programs have been expanding.
She is also responsible for media relations and the preparation of the hospital’s annual report. She reports to Higgens and has said if he reassigns her to report to anyone else, she will resign. When interviewed, she indicated that hospital volunteers were get- ting harder to find. She also noted that hospital advertising has limited her ability to place hospital stories in the local newspaper. The mayor of Middleboro recently awarded her a community citation for her demonstrated effort involving the Middleboro Hospital Baby Car Seat Program.
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th e Me d I C a l sta f f a n d Me d I C a l re s o U r C e s The active medical staff has 172 physicians, and the general medical staff has 9 hospitalists. Physicians with “consulting” status on the medical staff must maintain “active” status at Capital City General Hospital, University Hospital in University Town, or another hospi- tal. Appointment to the medical staff requires that the physician be board certified, unless granted a formal waiver based on 20 or more years of affiliation with MCH.
a n e s t h e s I o l o g y
The hospital maintains a contractual relationship with Anesthesiology Associates of Mid- dleboro (PA) to provide all needed services. Dr. Frederick Mask is president of this profes- sional association and chairperson of MCH’s anesthesiology department.
e M e r g e n C y M e d I C I n e
The hospital maintains a contractual relationship with Emergency Medical Associates of Middleboro (PA) to provide all needed services. Dr. Simi Hines is president of this profes- sional association and chairperson of this department.
d e pa r t M e n t o f f a M I ly p r a C t I C e
This department includes physicians in private practice. Dr. Joe Apple is chairperson of this department.
d e pa r t M e n t o f I n t e r n a l M e d I C I n e
This department includes physicians in private practice in various specialties, including general internal medicine, pediatrics, allergy and immunology, cardiology, gastroenterol- ogy, ENT, psychiatry, oncology, and hematology. Dr. Godfrey Hurt is chairperson of this department.
d e pa r t M e n t o f p at h o l o g y
The hospital maintains a contractual relationship with Pathology Associates of Middleboro (PA) for all needed services. Dr. Douglas Mushroom is the president of this association and the chairperson of this department.
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T h e M i d d l e b o r o C a s e b o o k1 7 4
d e pa r t M e n t o f r a d I o l o g y
The hospital maintains a contractual relationship with Radiology Associates of Middle- boro (PA) for all needed services. Dr. Adam Picture is president of this association and the chairperson of this department.
d e pa r t M e n t o f s U r g e r y
This department includes physicians in private practice in various specialties. Dr. Limpey is the chairperson of this department.
d e pa r t M e n t o f h o s p I ta l M e d I C I n e
The hospital currently employs nine physicians trained in internal medicine to provide in-house 24-hour care and services as hospitalists. Although hospitalists are members of the general medical staff and eligible for committee appointment, based on the medical staff bylaws hospitalists cannot admit nor vote on medical staff resolutions. Hospitalists are scheduled by the medical staff coordinator.
M e d I C a l s ta f f o r g a n I z at I o n
Dr. Mask (department of anesthesiology) is president of the medical staff, a position he has held for the last two years. The president is elected every two years. No additional compensation is received for service as an elected officer of the medical staff. Dr. Carlos Leatros (department of pathology) is vice chair. At the last meeting of the medical staff, physicians currently located in the medical office building presented a letter asking that “the medical staff recommend to the hospital that the hospital work with the physician owners to upgrade and expand facilities and that the building be enlarged to accommodate even more members of the medical staff.” After discussion it was decided that this issue was not a medical staff issue and that the current residents of the medical office building should directly communicate their request to Higgens.
Dr. Limpey (department of surgery) is employed part-time by the hospital as the medical director and chief medical officer. He provides staff support to all medical staff committees and assists the administrator on special projects. For example, he chairs the monthly meeting of the CMS Core Measures Working Group.
Standing committees of the medical staff include:
◆ Bylaws Committee
◆ Cancer Committee
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C a s e 5 : M i d d l e b o r o C o m m u n i t y H o s p i t a l 1 7 5
◆ Credentials Committee
◆ Critical Care Committee
◆ Education Committee
◆ Emergency Services Committee
◆ Executive Committee
◆ Hospitalist Practice Committee
◆ Medical Records Committee
◆ Pharmacy and Therapeutics Committee
◆ Quality Assurance Committee
◆ Tissue/Transfusion Committee
◆ Utilization Review Committee
The executive committee of the medical staff meets monthly or as needed. Other committees meet monthly. The entire medical staff meets quarterly. Recredentialing is done at the annual meeting of the medical staff.
Dr. Raymond Samuels (pediatrics) has recently written to the medical staff indicat- ing that he would like to be considered for election as president. Without criticizing the performance of the incumbent, Samuels wrote that the interests of the medical staff would be better represented by a physician in private practice, not a physician in a hospital-based practice such as anesthesiology.
ot h e r In f o r M at I o n e M e r g e n C y d e pa r t M e n t s p e C I a l s t U d y
The hospital has just received a report from the Department of Health Services Manage- ment at State University that included the following information on the MCH emergency department.
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Emergency Department Demand by Day of Week Percent
Sunday 22.3
Monday 13.2
Tuesday 9.2
Wednesday 7.2
Thursday 9.0
Friday 12.8
Saturday 26.3
Demand by Time of Day
12:00–2:00 a.m. 12.5
2:00–4:00 a.m. 9.8
4:00–6:00 a.m. 5.9
6:00–8:00 a.m. 9.6
8:00–10:00 a.m. 3.7
10:00 a.m.–12:00 p.m. 2.3
12:00–2:00 p.m. 3.5
2:00–4:00 p.m. 4.2
4:00–6:00 p.m. 7.6
6:00–8:00 p.m. 9.5
8:00–10:00 p.m. 12.6
10:00 p.m.–12:00 a.m. 18.8
Source: Three-month study, 12/31/CY
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C a s e 5 : M i d d l e b o r o C o m m u n i t y H o s p i t a l 1 7 7
Type of ED Care % 3:00 p.m.–11:00 p.m. 11:00 p.m.–7:00 a.m. 7:00 a.m.–3:00 p.m.
Emergency 3.1 12.5 4.4
Urgent 32.6 36.2 48.3
Nonurgent 64.3 51.3 47.3
Total 100 100 100
Emergency Department Patients by Age (%) Male Female
Under 15 14.4 10.4
15–24 11.4 7.8
25–44 19.6 14.0
45–64 6.4 6.4
65–74 1.7 2.3
75 and older 1.5 4.1
Total 55 45
Source: Three-month study, 12/31/CY
This study also documented the growing problem associated with psychotic patients and other patients in need of acute mental health services. Frequently these patients must wait in the emergency department for extended periods of time before they can be trans- ferred to appropriate service providers. The state hospital in Capital City is the closest facil- ity that accepts involuntary emergency admissions. Local services only provide outpatient services. The report documents that within the past year, four patients waited more than three days in the emergency department before transfer and on five days, mental health patients awaiting transfer occupied 12 of the emergency department’s 27 beds.
This information was collected as part of a pilot study to determine appropriate emergency services in communities served by two or more emergency departments. This study suggests that current operational costs in the emergency department are approxi- mately 18 percent above costs incurred in similar hospitals with similar utilization. Dur- ing 2014, approximately 12 percent of emergency department visits resulted in a hospital admission.
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T h e M i d d l e b o r o C a s e b o o k1 7 8
re s U lt s o f t h e Bo a r d re t r e at Approximately six weeks ago, the board and senior management team gathered for a spe- cial two-day strategic review of the hospital. Strategic Visions, Inc., facilitated the retreat sessions. The retreat was organized after board chair Michael Rich and vice chair Peter Steel each attended a national meeting of the American Hospital Association on strate- gic options for community hospitals. Both Rich and Steel returned from this meeting with specific questions regarding whether the hospital should develop off-campus services, acquire and operate additional medical practices, and affiliate with other service providers, including the possibility of an asset merger or sale to a for-profit corporation. Given the nature of topics discussed, the board has agreed not to publicly discuss these topics until the full board has had the opportunity “to better understand and address the strategic options it faces.” The board has asked that management continue to assess the implications of the Sarbanes-Oxley Act and other relevant laws and regulations on hospital governance.
The board, meeting without senior managers, also discussed whether the compensa- tion package for the president should include financial incentives linked to financial and quality measures. The board agreed to continue this discussion and has asked the state hospital association for examples of contracts used at other similar hospitals. The retreat served to convey to the entire board the significance of these issues as well as other issues it faced, including the following:
C h a n g e I n C e r t I f I C at e o f n e e d l aw
Harry Water, a trustee and an elected member of the state legislature, has been asked by the governor to introduce legislation that would deregulate the healthcare system and allow the current Certificate of Need (CON) law to lapse at the end of 2016. Water has shared with the board that he feels that, with the governor’s endorsement, this legislation would be successful. He is concerned, however, that the demise of this legislation would allow hospitals and other currently regulated healthcare providers to move into new mar- kets, such as Jasper. Water also shared with the board that he feels the governor could be convinced to delay the demise of the CON law until the end of at least 2018 if he were furnished with compelling reasons.
The leadership of the hospitals in Capital City and other major cities in the state strongly support the demise of the current CON laws and the community hospitals in suburban and rural areas generally want the law retained.
Water has asked the board for its views on this law and has asked Higgens to furnish the entire board with a legal opinion on whether federal antitrust laws and regulations would constrain other hospitals from attempting to serve Jasper and other communities traditionally served by MCH. Higgens has asked the hospital counsel—Giles, Giles, and Drew—to furnish this opinion within 60 days. The state hospital association has reserved
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C a s e 5 : M i d d l e b o r o C o m m u n i t y H o s p i t a l 1 7 9
any judgment on the CON law until “after the specific legislation has been introduced.” Higgens reported that he felt that this association will be unable to present a unified posi- tion given the split sentiments of its constituents on this statute.
s I n g l e -o C C U pa n C y I n pat I e n t r o o M s
Higgens has suggested the hospital hire a consulting firm to assess whether single- occupancy inpatient rooms are possible and desirable. He feels that it would give the hospital an advantage over its competition without any significant changes in staffing or expenses if the hospital implemented such a plan over a five- to seven-year period. When he presented this idea to the board he indicated that inpatient hospital admissions rates were continuing to drop and average length of stay also was stable or dropping, indicat- ing that a larger number of hospital rooms could be configured for single occupancy. The board wants to consider this idea. Note that current double-occupancy rooms dedicated to maternity services can be modernized for $100,000 each, regardless of whether they are to be single or double occupancy. Current medical surgical rooms can be converted to single- or double-occupancy birthing rooms for $115,000.
s t r at e g I C v I s I o n s ’ r e C o M M e n d at I o n
Strategic Visions, Inc., recommended that the hospital consider developing a 25-bed criti- cal access hospital and rural health center in Harris City to serve Harris City, Minortown, and Carterville. Such a facility could meet the federal requirements of the Medicare Rural Hospital Flexibility Program. The 25 beds would be dual-licensed as acute swing beds. The adjacent rural health clinic could house primary care physicians directly employed by the hospital. Higgens has not yet taken this suggestion to the board.
M e d I C a l o f f I C e B U I l d I n g o p t I o n s
The attorney managing the estate of the landowner (who originally leased the land to the hospital) has recently informed the hospital that this land will be bequeathed to the hospi- tal as a result of the owner’s death last month. This move creates a series of options, as the land and structures could be exempt from local taxes once they are owned by the hospital. O’Hara is currently developing a series of options to be considered.
Irs 990 d I s C l o s U r e s
The recent release of the IRS Form 990 indicates that the 2014 salaries for the ten highest paid hospital employees are as follows:
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T h e M i d d l e b o r o C a s e b o o k1 8 0
James Higgens President $659,600
John O’Hara Senior vice president for finance/CFO 313,000
Mabel Watkins Senior vice president for information systems/CIO 303,450
Janet Martin Director, nursing—acting 181,500
Dr. Martin Shine Hospitalist 212,445
Dr. William Lewis Hospitalist 198,445
Dr. Mega Gupta Hospitalist 178,320
Dr. Cathy Frost Hospitalist 177,540
Dr. Fred Limpey Chief medical officer 155,000
Martha Limpey Director, medical records 113,140
Compensation also includes benefits that average 34 percent above salary. Note that emergency services, radiology, pathology, and anesthesiology are provided by contract. Currently the hospital does not directly employ any physicians in these specialties.
The hospital has ownership interests in 25 physician practices. MCH Medical Prac- tices Subsidiary, Inc., a wholly owned for-profit subsidiary of the hospital, employs all physicians and staff used in these practices.
Additional information regarding MCH’s staffing, utilization, payer mix, financial status, and patient demographics may be found in the following tables.
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C a s e 5 : M i d d l e b o r o C o m m u n i t y H o s p i t a l 1 8 1
taBle 5.1 Medical Staff Information as of December 2014
Name Notes Office Age Specialty 2014 Patient Days
Family Practice: Active Staff
F. Player 5 70 General Practice 235
G. Banero 8 55 General Practice 319
J. Apple 6 59 General Practice 174
S. Fistru 7 58 General Practice 260
S. Mix 2 64 General Practice 130
Family Practice: Consulting Staff
C. Berrnally 3 38 General Practice* 101
D. Mathews 3 45 General Practice* 48
H. Cavenero 3 55 General Practice* 57
H. Wang 3 40 General Practice 79
J. Yates 3 44 General Practice 51
N. Chamerberlin 3 47 General Practice 118
S. Mathews 3 42 General Practice 18
Internal Medicine
A. Barton MA 1 45 Internal Medicine 812
B. Crush 3 63 Internal Medicine 380
C. Douglas MA 1 41 Internal Medicine 800
D. Justin 1 67 Internal Medicine 310
D. Meow 1 60 Internal Medicine 280
D. Michael 4 45 Internal Medicine* 250
E. Frost MA 3 41 Internal Medicine 490
F. Grist 3 50 Internal Medicine 140
G. Filly 1 58 Internal Medicine 240
G. Hurt 8 55 Internal Medicine* 172
(continued)
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T h e M i d d l e b o r o C a s e b o o k1 8 2
taBle 5.1 Medical Staff
Information as of December 2014
(continued)
Name Notes Office Age Specialty 2014 Patient Days
H. Hippster 1 56 Internal Medicine 250
J. Justin 4 59 Internal Medicine* 84
J. Vogel 5 55 Internal Medicine 103
K. Kessler MA 1 34 Internal Medicine 658
L. Lesko MA 1 38 Internal Medicine 560
L. Nask 5 56 Internal Medicine 203
M. Horse 1 68 Internal Medicine* 544
M. Mast 2 41 Internal Medicine 877
M. Master MA 1 40 Internal Medicine 472
N. Nostrom 2 57 Internal Medicine 112
O. Ogg 2 39 Internal Medicine 572
P. Xiao 2 50 Internal Medicine 126
P. Trip 6 52 Internal Medicine 263
Q. Quinn 6 63 Internal Medicine 156
S. Jessey 7 60 Internal Medicine 177
S. Knach 8 67 Internal Medicine* 63
S. Steel 3 50 Internal Medicine 416
S. Stocapy 3 57 Internal Medicine 150
T. Beata 3 60 Internal Medicine 80
T. Cushing 3 62 Internal Medicine 87
T. Davis 3 58 Internal Medicine 203
T. Figher 3 54 Internal Medicine 306
T. King 3 63 Internal Medicine 64
Pediatrics
A. Sloan 1 54 Pediatrics* 56
B. Bickford 1 50 Pediatrics 92
G. Gavin 1 44 Pediatrics 44
(continued)
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C a s e 5 : M i d d l e b o r o C o m m u n i t y H o s p i t a l 1 8 3
taBle 5.1 Medical Staff Information as of December 2014 (continued)
Name Notes Office Age Specialty 2014 Patient Days
M. Miller MA 3 40 Pediatrics 103
M. Bill 3 59 Pediatrics 52
N. Otter MA 3 37 Pediatrics 105
O. Pushy 1 50 Pediatrics 120
P. Kettel 3 57 Pediatrics 70
P. Quester MA 3 40 Pediatrics 280
Q. Reaper MA 1 59 Pediatrics 81
R. Samuels MA 1 47 Pediatrics 114
S. St. James MA 1 40 Pediatrics 120
T. Turtle 1 58 Pediatrics* 240
U. Unvey MA 3 56 Pediatrics 234
V. Vesh 1 52 Pediatrics* 92
W. Warren 1 56 Pediatrics* 84
W. Washed 3 64 Pediatrics 48
Allergy and Immunology
S. Sleek 1 49 Allergy/Immunology 448
T. Gustave 1 53 Allergy/Immunology 207
T. Hampshire 3 58 Allergy/Immunology 204
Cardiology
D. Eastman 1 56 Cardiology* 384
G. Hurst 1 60 Cardiology* 234
J. Dufresne 3 60 Cardiology 180
T. Underwood MA 1 46 Cardiology 652
U. Victem 1 41 Cardiology* 471
(continued)
00_SeidelLewis (2258).indb 183 11/22/13 8:44 AM
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T h e M i d d l e b o r o C a s e b o o k1 8 4
taBle 5.1 Medical Staff
Information as of December 2014
(continued)
Name Notes Office Age Specialty 2014 Patient Days
Gastroenterology
T. Amas 1 60 Gastroenterology 120
T. Eisher 1 55 Gastroenterology 128
T. Tiger 2 59 Gastroenterology 58
T. Wingate 2 64 Gastroenterology 86
Y. Zaller 1 49 Gastroenterology 1,270
Z. Autumn MA 1 44 Gastroenterology 748
Psychiatry
A. Actor 1 42 Psychiatry 480
B. Banana 1 50 Psychiatry 432
F. Jilley 1 39 Psychiatry 360
I. Stanzl 2 61 Psychiatry 86
S. Zeus 2 40 Psychiatry 272
Other: Medicine
C. Tunsteb 1 60 ENT 80
M. White 1 63 ENT 68
M. Whittier 1 44 ENT 353
V. Weckenson MA 1 44 ENT 470
W. Xerox MA 1 42 ENT 497
X. Yalper 1 57 ENT 170
B. Divan 1 44 Oncology/Hemo 440
M. Schoen 1 39 Oncology/Hemo* 401
S. Hatcher 1 53 Oncology/Hemo* 459
T. Kwok 1 32 Oncology/Hemo 150
C. Carp 3 54 ENT 300
F. Fish 3 49 ENT 280
(continued)
00_SeidelLewis (2258).indb 184 11/22/13 8:44 AM
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C a s e 5 : M i d d l e b o r o C o m m u n i t y H o s p i t a l 1 8 5
taBle 5.1 Medical Staff Information as of December 2014 (continued)
Name Notes Office Age Specialty 2014 Patient Days
Surgery: Orthopedic
D. Jones 1 57 Orthopedic 1,376
G. Hooper 1 50 Orthopedic 1,253
K. Amberson 1 55 Orthopedic 1,540
K. Matthews 1 45 Orthopedic 1,721
K. Questrom MA 1 39 Orthopedic 1,401
L. Rex 1 57 Orthopedic 1,703
M. Dillon 1 64 Orthopedic 1,420
M. Stanley MA 1 49 Orthopedic 1,507
Surgery: General
B. Hersh MA 1 40 General 1,200
C. Isherum 1 57 General* 1,245
D. Jackson MA 1 39 General 734
F. Limpey 1 58 General* 1,300
G. Munson 1 50 General* 586
H. Never MA 1 45 General 870
I. O’Connell MA 1 49 General 416
J. Putter MA 1 62 General 601
J. Timas 1 59 General* 1,246
J. Victor 1 57 General* 980
Surgery: OB/GYN
D. Dustin MA 1 33 OB/GYN 650
E. Eberle 1 51 OB/GYN 290
F. Fraser 1 65 OB/GYN* 480
G. Gost MA 1 45 OB/GYN 720
J. Kim 1 57 OB/GYN 336
(continued)
00_SeidelLewis (2258).indb 185 11/22/13 8:44 AM
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T h e M i d d l e b o r o C a s e b o o k1 8 6
taBle 5.1 Medical Staff
Information as of December 2014
(continued)
Name Notes Office Age Specialty 2014 Patient Days
I. Japen 1 56 OB/GYN* 236
K. Lights 1 55 OB/GYN 186
M. Nester 1 59 OB/GYN* 280
Surgery: Other
B. Bernal 1 45 Neuro 329
C. Eason MA 1 56 Urology 450
D. Crow 1 50 Neuro 334
D. Fixer MA 1 43 Urology 578
F. Seimer 1 59 Neuro 444
G. Tho 1 42 Plastic 332
H. Yee 1 58 Plastic 101
J. Underside 1 55 Thoracic 921
J. Warren 1 60 Thoracic 844
J. Yellow 1 60 General 640
J. Zetias 1 66 General 225
L. Clock 1 47 Thoracic 340
L. David 1 51 Vascular 310
L. Fession 1 44 Bariatric 380
L. Frederick 1 47 Vascular 340
M. Blue 1 46 Eye 300
M. Mold 1 45 Urology 650
N. Nerve 1 51 Urology 850
Department of Medicine: Consulting Staff
W. Pokorny 9 51 Psychiatry 14
B. Rubble 3 54 Oncology 32
F. Feada 9 63 Hematology 32
(continued)
00_SeidelLewis (2258).indb 186 11/22/13 8:44 AM
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C a s e 5 : M i d d l e b o r o C o m m u n i t y H o s p i t a l 1 8 7
taBle 5.1 Medical Staff Information as of December 2014 (continued)
Name Notes Office Age Specialty 2014 Patient Days
F. Flint 9 56 Oncology 54
H. Ruth 9 42 Gastroenterology 65
J. Klock MA 3 49 OB/GYN 130
K. Kipstein MA 3 50 Cardiology 201
L. Gomez 9 44 Allergy 26
L. Mustard MA 3 39 OB/GYN 223
M. McVoy 9 37 Psychiatry 32
O. Maeer MA 3 42 Cardiology 133
P. Carles 9 60 Pulmonary Medicine 28
S. Ange 9 48 Endocrinology 84
S. Lott 9 50 Hematology 112
S. Malone 9 55 Allergy 31
S. Parish 9 48 Dermatology 16
V. Vitter 9 57 Hematology 102
Department of Surgery: Consulting Staff
A. Hamp 9 48 General 45
A. Steve MA 3 47 Thoracic 80
C. Finn MA 3 49 Thoracic 39
F. Mike 9 60 Orthopedic 28
J. Wingate 9 50 Pediatric 30
L. Picture MA 3 47 Orthopedic 76
L. Richard 9 45 Orthopedic 19
N. New 9 58 Orthopedic 24
S. Lee MA 3 40 Orthopedic 56
(continued)
00_SeidelLewis (2258).indb 187 11/22/13 8:44 AM
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T h e M i d d l e b o r o C a s e b o o k1 8 8
taBle 5.1 Medical Staff
Information as of December 2014
(continued)
Name Notes Office Age Specialty 2014 Patient Days
Department of Pathology: Active Staff
A. Mixture 1 61 Pathology
B. Nerverto 1 56 Pathology
C. Leatros 1 47 Pathology
D. Mushroom 1 42 Pathology
D. Pathos 1 56 Pathology
E. Fisher 1 54 Pathology
F. Mautz 1 64 Pathology
G. Wingate 1 63 Pathology
Department of Radiology: Active Staff
A. Picture 1 56 Radiology
B. Quadic 1 45 Radiology
C. Roetgen 1 61 Radiology
D. Sunshine 1 40 Radiology
M. Ray 1 45 Radiology
K. Hines 1 50 Radiology
W. Hines 1 39 Radiology
L. Jinks 1 45 Radiology
P. Patel 1 52 Radiology
R. Ricker 1 34 Radiology
R. El-Amin 1 44 Radiology
R. Trippe 1 49 Radiology
E. Tracer 1 49 Radiology
Department of Anesthesiology: Active Staff
A. Aaron 1 38 Anesthesiology
B. Carter 1 62 Anesthesiology
(continued)
00_SeidelLewis (2258).indb 188 11/22/13 8:44 AM
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C a s e 5 : M i d d l e b o r o C o m m u n i t y H o s p i t a l 1 8 9
taBle 5.1 Medical Staff Information as of December 2014 (continued)
Name Notes Office Age Specialty 2014 Patient Days
B. Dexter 1 66 Anesthesiology
B. Harrington 1 63 Anesthesiology
B. Nelson 1 60 Anesthesiology
B. Thomas 1 64 Anesthesiology
C. Fisher 1 54 Anesthesiology
D. Gass 1 48 Anesthesiology
E. Lister 1 61 Anesthesiology
F. Mask 1 59 Anesthesiology
Department of Emergency Medicine: Active Staff
R. Romanikova 1 29 Emergency
S. Hines 1 60 Emergency
B. Casey 1 44 Emergency
J. Smooth 1 54 Emergency
G. Goodspeed 1 70 Emergency
L. Jinks 1 45 Emergency
M. Gotlike 1 52 Emergency
J. Ishabi 1 43 Emergency
L. Cytesmith 1 60 Emergency
M. Welby 1 56 Emergency
R. Hotlick 1 58 Emergency
S. Tobias 1 51 Emergency
Department of Hospital Medicine
A. Palmer 1 32 Hospitalist
B. Carlos 1 40 Hospitalist
C. Frost 1 39 Hospitalist
F. Drudge 1 35 Hospitalist
(continued)
00_SeidelLewis (2258).indb 189 11/22/13 8:44 AM
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T h e M i d d l e b o r o C a s e b o o k1 9 0
taBle 5.2 Hospital Inpatient
Occupancy by Service,
2008–2014
Hospital Service 2014 2013 2012 2011 2010 2009 2008
Pediatrics
Beds 12 14 16 18 18 18 18
Patient days 2,249 2,245 2,224 2,270 2,546 3,260 3,150
Occupancy 51.3% 43.9% 38.1% 34.6% 38.8% 49.6% 47.9%
Maternity
Beds 26 28 28 29 29 29 29
Patient days 4,372 4,423 4,134 5,045 6,023 6,007 6,045
Occupancy 46.1% 43.3% 40.5% 47.7% 56.9% 56.8% 57.1%
Medical Surgical I
Beds 50 50 50 50 50 50 50
Patient days 13,756 13,505 13,333 13,340 12,103 12,400 12,547
Occupancy 75.4% 74.0% 73.1% 73.1% 66.3% 67.9% 68.8%
(continued)
taBle 5.1 Medical Staff
Information as of December 2014
(continued)
Name Notes Office Age Specialty 2014 Patient Days
M. Gupta 1 40 Hospitalist
M. Shine 1 43 Hospitalist
S. Ruderbacker 1 56 Hospitalist
V. Martinez 1 44 Hospitalist
W. Lewis 1 50 Hospitalist
NOTES: MA = Medical Associates Office Location: 1=Middleboro; 2=Mifflenville; 3=Jasper; 4=Harris City; 5=Statesville; 6=Carterville; 7=Boalsburg; 8=Minortown; 9=Capital City; 10=Other * = Medical practice owned by Medical Practice Subsidary (MPS), Inc.
(This table can also be found online at ache.org/books/Middleboro.)
00_SeidelLewis (2258).indb 190 11/22/13 8:44 AM
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C a s e 5 : M i d d l e b o r o C o m m u n i t y H o s p i t a l 1 9 1
taBle 5.2 Hospital Inpatient Occupancy by Service, 2008–2014 (continued)
Hospital Service 2014 2013 2012 2011 2010 2009 2008
Medical Surgical II
Beds 50 50 50 50 50 50 50
Patient days 13,845 13,604 13,503 12,056 12,440 10,378 10,501
Occupancy 75.9% 74.5% 74.0% 66.1% 68.2% 56.9% 57.5%
Medical Surgical III
Beds 44 50 53 55 55 53 53
Patient days 10,054 10,450 11,004 11,856 11,420 11,890 11,945
Occupancy 62.6% 57.3% 56.9% 59.1% 56.9% 61.5% 61.7%
Medical Surgical IV
Beds 40 40 45 50 50 50 50
Patient days 9,850 9,893 9,833 10,956 11,584 12,282 12,470
Occupancy 67.5% 67.8% 59.9% 60.0% 63.5% 67.3% 68.3%
ICU/CCU
Beds 18 18 18 18 18 20 20
Patient days 4,644 4,847 4,856 4,934 4,926 5,102 5,008
Occupancy 70.7% 73.8% 73.9% 75.1% 75.0% 69.9% 68.6%
Total Hospital
Beds 240 250 260 270 270 270 270
Patient days 58,770 58,967 58,887 60,457 61,042 61,319 61,666
Occupancy 67.1% 65.5% 62.9% 62.2% 62.8% 63.1% 63.4%
(This table can also be found online at ache.org/books/Middleboro.)
00_SeidelLewis (2258).indb 191 11/22/13 8:44 AM
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T h e M i d d l e b o r o C a s e b o o k1 9 2
taBle 5.3 Detailed Utilization
Statistics for 2014 and 2013
2014 Discharges Patient
Days Inpatient Surgery
Outpatient Surgery Births
ED Visits
ED Admits OPV
January 890 4,959 201 362 98 2,134 272 9,558
February 823 4,655 209 350 84 1,883 238 8,973
March 934 5,098 190 372 101 2,090 268 9,495
April 956 5,124 193 348 112 2,063 254 9,088
May 923 5,170 197 394 109 2,110 283 9,265
June 1,025 5,768 185 345 108 2,203 260 8,857
July 897 4,535 170 325 99 2,083 253 9,436
August 862 4,425 165 303 101 2,068 250 9,356
September 898 4,978 187 365 109 2,205 275 9,030
October 893 4,990 198 323 114 2,003 245 9,234
November 863 4,923 193 395 104 2,209 249 9,345
December 766 4,145 170 302 109 2,027 240 8,245
Total 10,730 58,770 2,258 4,184 1,248 25,078 3,087 109,882
2013
January 882 4,703 191 390 109 2,167 270 8,951
February 837 4,780 190 331 110 2,107 265 8,094
March 893 5,149 207 387 113 2,278 289 9,092
April 967 5,547 215 367 109 2,678 365 9,234
May 980 5,320 199 346 110 2,398 310 9,245
June 1,005 5,756 204 361 111 2,351 270 9,345
July 823 3,701 187 302 103 2,278 280 9,832
August 812 4,301 160 296 102 2,056 263 9,257
September 934 5,734 188 379 116 2,556 289 9,934
October 954 5,134 193 384 111 2,044 240 10,109
November 848 4,775 196 382 103 2,196 279 9,887
December 703 4,067 178 312 113 2,286 288 8,750
Total 10,638 58,967 2,308 4,237 1,310 27,395 3,408 111,730
NOTES: ED Visits = Total emergency department visits ED Admits = ED visits that lead to an inpatient admission OPV = Outpatient Visits, excludes ED visits
(This table can also be found online at ache.org/books/Middleboro.)
00_SeidelLewis (2258).indb 192 11/22/13 8:44 AM
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C a s e 5 : M i d d l e b o r o C o m m u n i t y H o s p i t a l 1 9 3
taBle 5.4 Statement of Revenue and Expenses for Calendar Years Ending December 31 ($)
2014 2013 2012
Revenue
Patient services revenue, total 658,351,925 650,578,354 650,829,412
Inpatient 312,565,340 315,343,506 322,465,856
Outpatient 345,786,585 335,234,848 328,363,556
Allowances and uncollectables—inpatient
200,564,989 190,282,353 185,374,561
Allowances and uncollectables—outpatient
203,464,546 200,343,595 196,294,375
Total 404,029,535 390,625,948 381,668,936
Net service revenue 254,322,390 259,952,406 269,160,476
Other operating revenue 154,229 288,354 372,343
Total operating revenue 254,476,619 260,240,760 269,532,819
Expenses
Operating expenses
Patient care services 80,373,449 78,354,002 77,343,526
Other professional services 69,363,454 68,394,262 68,001,200
General services 40,383,464 42,393,446 44,627,308
Fiscal and admin services 40,228,343 45,383,557 50,526,303
Interest 3,956,433 3,825,354 3,800,240
Depreciation 14,378,565 15,340,272 16,340,229
Community education and outreach 542,383 599,454 535,495
(continued)
00_SeidelLewis (2258).indb 193 11/22/13 8:44 AM
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T h e M i d d l e b o r o C a s e b o o k1 9 4
taBle 5.5 Balance Sheet as of December 31,
2012–2014 ($)
2014 2013 2012
Current assets
Cash 16,008,364 16,343,949 10,438,282
Short term investments 6,546,791 3,283,445 3,029,393
Accounts receivable—gross 72,564,867 71,540,304 70,283,443
Allowances for uncollectables 28,453,998 29,474,665 29,117,273
Accounts receivable—net 44,110,869 42,065,639 41,166,170
Due from third-party payers 378,559 349,228 103,450
Inventories 2,663,265 2,995,394 2,235,119
Prepaid expenses 89,020 72,343 69,372
Total current assets 69,796,868 65,109,998 57,041,786
(continued)
taBle 5.4 Statement
of Revenue and Expenses
for Calendar Years Ending
December 31 ($) (continued)
2014 2013 2012
Total operating expenses 249,226,091 254,290,347 261,174,301
Net income from operations 5,250,528 5,950,413 8,358,518
Nonoperating revenue
Unrestricted gifts and bequests 76,342 147,841 111,343
Income from investments 1,978,564 2,018,334 3,005,264
Miscellaneous nonpatient revenue 118,453 134,575 157,394
Total 2,173,359 2,166,175 3,116,607
Nonoperating expenses 1,553,675 1,494,303 1,324,556
Net nonoperating income 619,684 671,872 1,792,051
Profit (loss) 5,870,212 6,622,285 11,475,125
(This table can also be found online at ache.org/books/Middleboro.)
00_SeidelLewis (2258).indb 194 11/22/13 8:44 AM
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C a s e 5 : M i d d l e b o r o C o m m u n i t y H o s p i t a l 1 9 5
taBle 5.5 Balance Sheet as of December 31, 2012–2014 ($) (continued)
2014 2013 2012
Noncurrent assets
Property, plant, and equipment—gross 354,783,292 354,282,404 360,283,443
Less accumulated depreciation 176,453,887 171,133,779 165,242,577
Property, plant, and equipment—net 178,329,405 183,148,625 195,040,866
Other investments 39,997,354 39,105,569 34,674,187
Total assets 288,123,627 287,364,192 286,756,839
Current liabilities
Accounts payable 16,342,575 15,369,594 16,002,347
Accrued salaries and wages 10,453,274 8,259,669 7,345,002
Accrued interest 134,569 156,304 700,585
Other accrued expenses 1,393,253 1,657,330 1,435,020
Due to third-party vendors 1,205,494 1,723,657 582,491
Long-term debt due within one year 5,142,939 4,920,338 4,823,293
Total current liabilities 34,672,104 32,086,892 30,888,738
Long-term debt 67,540,223 75,330,404 82,374,337
Total liabilities 102,212,327 107,417,296 113,263,075
Net assets
Restricted 6,128,484 6,034,292 6,203,445
Unrestricted 179,782,816 179,782,816 179,782,816
Total net assets 185,911,300 185,817,108 185,986,261
Net assets + liabilities 288,123,627 293,234,404 299,249,336
(This table can also be found online at ache.org/books/Middleboro.)
00_SeidelLewis (2258).indb 195 11/22/13 8:44 AM
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T h e M i d d l e b o r o C a s e b o o k1 9 6
taBle 5.6 Top Ten DRGs,
2009–2014 Number of Discharges
DRG Name 2014 2013 2012 2011 2010 2009
Normal newborn1 1,284 1,236 1,182 1,204 992 1,075
Vaginal delivery, no complications
943 898 858 874 720 781
Atherosclerosis 770 726 674 576 401 576
Caesarean section 356 351 336 342 282 306
Major joint or reattachment of lower
extremity
301 314 327 364 287 364
Simple pneumonia and pleurisy
300 286 319 354 278 353
Chest pain 292 290 296 328 275 339
Chronic obstructive pulmonary disease
205 167 285 265 238 329
Acute myocardial infarction
195 165 197 197 236 275
Spinal fusion 139 157 165 175 230 241
Total top ten, excluding births
3,501 3,354 3,457 3,475 2,947 3,564
Total discharges 10,730 10,638 10,243 10,733 10,040 10,238
Percent top ten, excluding births
32.63% 31.53% 33.75% 32.38% 29.35% 34.81%
NOTE: 1. Counted as births, not discharges
00_SeidelLewis (2258).indb 196 11/22/13 8:44 AM
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00_SeidelLewis (2258).indb 197 11/22/13 8:44 AM
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T h e M i d d l e b o r o C a s e b o o k1 9 8
taBle 5.8 CMS Core
Measures for MCH, 2012–2014
Category CMS Core Measure State
Benchmark MCH 2014
MCH 2013
MCH 2012
Timely Heart Attack Care
Average number of minutes before outpatient with chest pain or possible heart attack who needed specialized care was transferred to another hospital
1 hr n/a n/a n/a
Timely Heart Attack Care
Average number of minutes before outpatients with chest pain or possible heart attack got an ECG
8 min 9 min n/a n/a
Timely Heart Attack Care
Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival
100% 92% 90% 81%
Timely Heart Attack Care
Heart attack patients given PCI within 90 minutes of arrival
94% 96% 94% 94%
Effective Heart Attack Care
Heart attack patients given aspirin at discharge
100% 100% 100% 100%
Effective Heart Attack Care
Heart attack patients given a prescription for a statin at discharge
97% 98% 98% 94%
Effective Heart Failure Care
Heart failure patients given discharge instructions
92% 98% 94% 94%
Effective Heart Failure Care
Heart failure patients given an evaluation of left ventricular systolic (LVS) function
97% 94% 94% 95%
Effective Heart Failure Care
Heart failure patients given ACE inhibitor or ARB for left ventricular systolic dysfunc- tion (LVSD)
97% 96% 95% 85%
(continued)
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C a s e 5 : M i d d l e b o r o C o m m u n i t y H o s p i t a l 1 9 9
taBle 5.8 CMS Core Measures for MCH, 2012–2014 (continued)
Category CMS Core Measure State
Benchmark MCH 2014
MCH 2013
MCH 2012
Effective Pneumonia Care
Pneumonia patients whose initial emergency department blood culture was performed prior to the administra- tion of the hospital dose of antibiotics
97% 98% 99% 98%
Effective Pneumonia Care
Pneumonia patients given the most appropriate initial antibiotics
96% 96% 96% 95%
Timely Surgical Care
Outpatients having surgery who got an antibiotic at the right time (within one hour before surgery)
98% 99% 99% 98%
Timely Surgical Care
Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection
98% 98% 99% 98%
Timely Surgical Care
Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)
97% 96% 97% 98%
Timely Surgical Care
Patients who got treatment at the right time (within 24 hours before or after their surgery) to help prevent blood clot after certain types of surgery.
97% 96% 95% 96%
Effective Surgical Care
Outpatients having surgery who got the right kind of antibiotic
98% 99% 100% 98%
(continued)
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T h e M i d d l e b o r o C a s e b o o k2 0 0
taBle 5.8 CMS Core
Measures for MCH, 2012–2014
(continued)
Category CMS Core Measure State
Benchmark MCH 2014
MCH 2013
MCH 2012
Effective Surgical Care
Surgery patients who were taking beta blockers before coming to the hospital, who were kept on the beta block- ers during the period just before and after the surgery.
96% 94% 93% 90%
Effective Surgical Care
Surgery patients who were given the right kind of antibi- otic to help prevent infection
98% 100% 96% 96%
Effective Surgical Care
Heart surgery patients whose blood sugar is kept under good control in the days right after surgery
95% n/a n/a n/a
Effective Surgical Care
Surgery patients whose uri- nary catheters were removed on the first or second day after surgery
94% 91% 92% 94%
Effective Surgical Care
Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal by the end of surgery
100% 100% 100% 100%
Effective Surgical Care
Surgery patients whose doc- tor ordered treatments to pre- vent blood clots after certain types of surgeries
98% 99% 98% 99%
Emergency Department (ED) Care
Average (median) time patient spent in the ED before they were admitted to the hospital as an inpatient (minutes)
Being developed
312 n/a n/a
Emergency Department (ED) Care
Average (median) time patient spent in the ED, after the doc- tor decided to admit them as an inpatient before leav- ing the ED for inpatient care (minutes)
Being developed
186 n/a n/a
(continued)
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C a s e 5 : M i d d l e b o r o C o m m u n i t y H o s p i t a l 2 0 1
taBle 5.8 CMS Core Measures for MCH, 2012–2014 (continued)
Category CMS Core Measure State
Benchmark MCH 2014
MCH 2013
MCH 2012
Emergency Department (ED) Care
Average time patients spent in the ED before being sent home (minutes)
Being developed
129 n/a n/a
Emergency Department (ED) Care
Average time patients who came to the ED with broken bones had to wait before receiving pain medication (minutes)
Being developed
45 n/a n/a
Emergency Department (ED) Care
Percentage of patients who left the ED before being seen
Being developed
5% n/a n/a
Emergency Department (ED) Care
Percentage of patients who came to the emergency department with stoke symptoms who received brain scans results within 45 minutes of arrival
Being developed
n/a n/a n/a
Preventive Care
Patients assessed and given influenza vaccination
95% 88% n/a n/a
Preventive Care
Patients assessed and given pneumonia vaccination
93% 88% n/a n/a
Readmission, Complications, and Death
Rate of readmission for heart attack
No different from US national rate
Readmission, Complications, and Death
Death rate for heart attack patients
No different from US national rate
Readmission, Complications, and Death
Rate of Readmission for heart failure patients
No different from US national rate
Readmission, Complications, and Death
Rate of readmission for pneumonia patients
No different from US national rate
(continued)
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T h e M i d d l e b o r o C a s e b o o k2 0 2
taBle 5.8 CMS Core
Measures for MCH, 2012–2014
(continued)
Category CMS Core Measure State
Benchmark MCH 2014
MCH 2013
MCH 2012
Serious Complications and Deaths
Serious complications - rate No different from US national rate
Hospital- Acquired Conditions
Hospital-acquired conditions Being developed
n/a n/a n/a
Healthcare- Associated Infections
Central line–associated bloodstream infections
No different from the US national benchmark
Use of Medical Imaging
Outpatients with low back pain who had an MRI without trying recommended treat- ments first, such as PT
32.9% 29% 28% 34%
Use of Medical Imaging
Outpatients who had a follow- up mammogram or ultra- sound within 45 days after a screening mammogram
12.4% 12% 12% 9%
Use of Medical Imaging
Outpatient CT scans of the chest that were “combina- tion” scans
0.03% Less than 1%
Less than 1%
Less than 1%
Use of Medical Imaging
Outpatient CT scans of the abdomen that were “combina- tion” scans
0.07% Less than 1%
Less than 1%
Less than 1%
Use of Medical Imaging
Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery
Being developed
8% 9% 7%
Use of Medical Imaging
Outpatients with brain CT scans who got a sinus CT scan at the same time
Being developed
5% 7% 5%
Patient Survey Results
Patients who reported that their nurses “always” commu- nicated well
84% 72% 60% 80%
Patient Survey Results
Patients who reported that their doctor “always” commu- nicated well
80% 74% 77% 71%
(continued)
00_SeidelLewis (2258).indb 202 11/22/13 8:44 AM
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C a s e 5 : M i d d l e b o r o C o m m u n i t y H o s p i t a l 2 0 3
taBle 5.8 CMS Core Measures for MCH, 2012–2014 (continued)
Category CMS Core Measure State
Benchmark MCH 2014
MCH 2013
MCH 2012
Patient Survey Results
Patients who reported they “always” received help as soon as they wanted
62% 58% 59% 60%
Patient Survey Results
Patients who reported that their pain was “always” well controlled
75% 70% 63% 70%
Patient Survey Results
Patients who reported that staff “always” explained about medicine before giving it to them
69% 74% 64% 70%
Patient Survey Results
Patients who reported that their room and bathroom were “always” clean
73% 82% 84% 80%
Patient Survey Results
Patients who reported that the area around their room was “always” quiet at night
73% 50% 52% 50%
Patient Survey Results
Patients at each hospital who reported “yes,” they were given information about what to do during their recovery at home
85% 94% 98% 93%
Patient Survey Results
Patients who gave their hos- pital a rating of 9 or 10 on a scale from 0 to 10
68% 61% 62% 60%
Patient Survey Results
Patients who reported “yes,” they would definitely recom- mend the hospital
76% 80% 75% 76%
NOTES: “n/a” means not applicable and that the data are either not available or that the number of cases is too small for a legitimate conclusion. “Being developed” means that the core measure remains under development and no standard or benchmark has yet to be published. “State” means the statewide mean score.
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