“The Iowa Hospital Association is the organization that represents Iowa hospitals and supports them in achieving their missions and goals.” 

That is IHA’s mission statement, and it’s a good one. Basically, IHA helps hospitals do what they need to do to meet the expectations of their communities by educating hospital staff, collecting data that helps hospitals plan and representing Iowa hospitals in Des Moines and Washington, D.C. 

That last part means IHA is a lobbying organization, not unlike other lobbying organizations that work on behalf of farmers, builders, school teachers, school boards, restaurants, grocers, insurance companies, lawyers, newspapers and dozens of other industries and organizations, including many non-profits, from Boys and Girls Clubs to Ducks Unlimited to Easter Seals. 

Some people don’t like lobbyists; one of those people may well be Dean Lerner. Which would be more than a little ironic, since the Department of Inspections and Appeals, the state agency Lerner used to run, has its own lobbyist. 

Certainly Lerner dislikes IHA, leaving one to wonder if he doesn’t feel the same way about the hospitals that make up IHA’s membership and drive the Association’s lobbying priorities. For the record, that would be every hospital in the state. 

It’s a little hard to tell just what Lerner’s mission is, even after several reads of his 650-word opinion in Sunday’s Des Moines Register.  Well, maybe it’s not that hard, as Lerner concludes early on that “hospitals…have come to reflect the values of Wall Street,” though he doesn’t bother to explain what that means or how it has affected one of the highest quality, most efficient health care systems in the country. 

But it is obvious Lerner doesn’t like that there are hospitals in West Des Moines (a city of nearly 60,000 people located in the fastest-growing region in the state that Lerner, nonetheless, describes as “nowhere”) even though these hospitals see nearly 2,000 patients each month – in just their emergency rooms. 

He doesn’t like Iowa’s smallest hospitals, either, because the federal government has the temerity to pay these hospitals 1 percent more than their cost of care. Lerner doesn’t seem to mind at all that these hospitals are almost completely dependent on Medicare and Medicaid dollars for their survival and that, without the Critical Access Hospital Program, their buildings would remain best suited for medicine as it was practiced 50 years ago. 

Maybe Lerner doesn’t realize that Iowa hospitals, particularly in smaller counties, are often the largest employer and always an economic cornerstone for a state desperate to attract and keep young, well-educated workers and their growing families. His position seems to be that these hospitals, and the communities they serve, should just get it over with and die. 

He also apparently believes hospitals should not be tax-exempt, though, once again, does not say why. He doesn’t think Medicaid losses by hospitals should count as a community benefit, though it’s difficult to imagine a greater benefit to taxpayers than the $196 million hit Iowa hospitals take each year to keep the program afloat (not to mention $63 million lost to Medicare).  

He doesn’t think a half billion dollars in charity care and another $67 million in additional health care services are enough. He doesn’t think $344 million lost to people who simply decide not to pay their hospital bills is enough. And he apparently has ready replacements for hospitals and the millions they expend supporting and improving the health of their communities through education, counseling, sponsorships and research that extend above and beyond day-to-day patient care. 

If he does have a different idea, rest assured that it will come at the expense of the communities that hospitals serve, the same communities filled with Iowans who each year donate millions of dollars and thousands of volunteer hours to their hospitals. It is those communities and their representatives that drive each hospital’s mission – the mission that IHA represents and supports. 

Because there is one thing Lerner does manage to make clear – he is still the dedicated former bureaucrat who would gladly add more layers of legislation, regulation and expense to health care, ultimately making nurses and physicians more accountable to the government than to their patients and communities. 

That’s a mission Iowa’s hospitals will not support, and neither should the people of Iowa.

“I think the focus needs to be on what staff, physicians and leaders can do to improve the patient experience instead of the ‘throw up your hands’ approach and blaming patients for being more difficult,” said David Brandon, CEO of The Finley Hospital in Dubuque.  “You cannot have an ‘opt-out’ culture if you’re going to succeed in creating an exceptional patient environment.” 

Both Sioux City and Dubuque are in multi-county hospital referral regions (HRRs) that rank in the top 20 nationwide for patient satisfaction.  The HRR around Mason City ranks at the top.  Meanwhile, out of nearly 300 HRRs, Manhattan is dead last and Cleveland is 237^th. 

“Where many CEOs fall down is they see this as a fluff kind of thing,” said Greg Paris, CEO at Monroe County Hospital in Albia, who received IHA’s hospital leadership award in 2007 in part for his work to pull that hospital’s patient satisfaction scores out of the basement.  “What they don’t realize is that satisfaction is directly related to quality outcomes, financial results and employee engagement.”

But, he added, “Smiles and singing don’t drive satisfaction.” 

Paris talks about how using key words reduces patient anxiety, which improves compliance with care plans and leads to better outcomes.  Hourly rounding (“I hear large hospitals gasping,” Paris laughed) reduces patient falls by 50 percent.  Checklists reduce errors.  Discharge calls save lives because one in six patients has an adverse health event after they go home.  Lower employee turnover means fewer mistakes and less harm to patients. 

But shouldn’t getting the highly touted care at Cleveland Clinic or NYU be enough?  The better question – the one really being asked through HCACHPS and Hospital Compare – is why not expect high-quality care and a first-class patient experience?  Anyone who has made use of the Iowa Healthcare Collaborative’s “Iowa Report” will see Iowa hospitals are uniformly committed to both. 

“Yes, we need to have the right facilities and evidence-based strategies in place, but more than anything else it is the never-ending commitment to create a culture that holds service in the highest regard,” said Brandon.  “Without the right culture, the strategies and facilities alone will not allow you to meet the expectations of your patients.” 

And because of the growing amount of publicly available data, hospitals cannot depend on just their word-of-mouth reputations or referrals.  “The next generation will pick their hospital based on outcomes and experience, not just by where their doctor sends them,” noted Paris.

Eighty-four communities in Iowa have submitted a “statement of interest” to become one of 10 demonstration sites for the state’s Blue Zones Project.  Submission of the statement of interest is the first step of the application process for the Blue Zones Project.  About three-fourths of the 84 communities are home to at least one hospital – and hospitals have taken leadership roles to bring Blue Zones home. 

The Blue Zones Project is based upon findings from an eight-year worldwide longevity study to identify common elements of the world’s longest-lived cultures.  Blue Zones uses third-party research and direct studies to identify the world’s best practices in longevity and well-being. Working in collaboration with the University of Minnesota School of Public Health, it uses this research to develop lifestyle management tools.  In 2009, Blue Zones led a 10-month pilot project in Albert Lea, Minnesota, where residents increased their projected life expectancy by 2.9 years.  In addition, employers in that city reported a decline in health care claims cost and a drop in absenteeism. 

“Iowans have sent a clear signal that they are eager to improve their well-being,” said Justin Smith, co-leader of the Blue Zones Project.  “During the road shows, we were impressed by the passion shown by communities throughout Iowa and we look forward to the next stage in this exciting journey together.” 

Blue Zones is tracking community interest in the project and one of the leaders from the start has been Grundy Center. There, Grundy County Memorial Hospital has been a highly active Blue Zones supporter and leader.  “For us, this is a very mission-driven project,” said hospital CEO Pam Delagardelle.  “The path to becoming a Blue Zones community aligns perfectly with our hospital’s mission of ‘improving the health of the communities we serve.’”  

“It’s a perfect time for our hospital to drive this initiative for our community – we have the local infrastructure in place with strategic partners like public health, the school district, and local businesses all actively involved in community health implementation.  The prospect of transforming our community’s well-being is exciting and energizing and our stakeholders are prepared to align efforts to accomplish the transformation.” 

Algona is another place that has received significant community support for its Blue Zones application and Kossuth Regional Health Center (KRHC) has led the way with several staff members joining in the community-wide effort.  “We know that lifestyle choices make a big impact on people’s overall health and see great value in investing in wellness opportunities for the community and on behalf of our own employees,” said KRHC CEO Scott Curtis.  

“We have encouraged staff from all areas of the hospital to get involved and have engaged physicians, public health nurses, business health staff and others in this effort so far.  In addition to working on plans and ideas for the overall community, at KRHC we have also started introducing Blue Zones concepts to our employees.” 

After the statements of interest are reviewed, select communities will be asked to submit a formal, detailed application to become one of 10 demonstration sites to receive assistance in developing and implementing a blueprint for making permanent environmental, policy and social network changes that transition people into healthier behaviors.  These communities will share their learnings with other communities in Iowa. 

The invitations to submit formal applications will be extended to communities by November 23, and the applications must be submitted by January 4, 2012.  Upon assessment of these applications, a group of finalist communities will then be selected to host a site visit between February 27, 2012 and March 16, 2012.  This process will culminate with the selection of the first group of lead communities in May of next year. 

Well-being improvement in the participating communities will be measured using the Gallup-Healthways Well-Being Index, the first-ever daily assessment of U.S. residents health and well-being.  Well-Being Index data reveals a significant opportunity in Iowa for improvement, particularly among healthy behaviors and work environments.  Iowa currently ranks 19^th on the index; the Iowa Healthiest State Initiative, of which the Blue Zones Project is a centerpiece, aims to pull Iowa to the top of the index  by helping employers and communities achieve greater well-being, which should lead to lower health care costs, higher productivity and increased economic viability.

Imagine a chart with the hospital represented in the middle and then each layer of regulatory authority circling around it, from city councils and county supervisors to state legislators, agencies, boards and inspectors to the federal government, including everything from the fairly obvious like Human Services, CDC, FDA and, of course, Congress, but also the IRS, FCC, FAA, Homeland Security, OSHA, DEA, FTC and EPA, among others.  There is, quite literally, a universe of regulation surrounding a hospital and for nearly every employee on each day, there is interaction with that universe. 

Regulators demand a lot from health care providers and it does impact care for patients – but that impact is not always positive.  One study found that for every hour of patient care, there is at least 30 minutes of paperwork.  In some settings, the ratio is one-to-one: one hour of paperwork to every hour of patient care. (The Obama administration recently announced steps it was taking to reduce regulatory red tape hospitals face.)

Does this mean hospitals are against regulation?  Absolutely not.  Hospitals recognize and honor the need for consistency, guidance and accountability because, in the end, providers and regulators are seeking the same thing: the right care for every patient, every time.  As David Vellinga, CEO at Mercy Medical Center-Des Moines, recently wrote: “While these processes can be burdensome at times, we at Mercy understand they are important parts of continuously improving quality — necessary steps in the journey toward perfect care.” 

The work to comply with regulations, inspections and surveys is no less for a smaller hospital.  “At times it is difficult to look beyond the minutia of regulations to see the intent,” said Sharon Taylor, who serves as the compliance officer at Burgess Health Center in Onawa.  “However, the intent of the majority of regulations is to be sure that treatment, payment and health care operations are delivered to our patients in a safe and effective manner.” 

Another reality is that nearly every hospital employee is affected by regulations and has a role in knowing and complying with them.  To prevent infections, housekeeping staff need to know that different cleaners must be used in different rooms and situations and they need to know how to use those cleaners safely and effectively.  Plant operations staff need know where hand gel dispensers can be mounted to comply with fire regulations.  And all staff are routinely trained on patient safety and privacy regulations. 

But, despite the hard work of staff, mistakes do happen.  “Employees come to work to do a good job, they don’t come with the intention of making a mistake or breaking a regulation,” Taylor said.  “Sometimes it is the processes that are put into place, because of regulations, that cause mistakes to happen and sometimes mistakes are just that, a mistake. While this doesn’t make it right and is certainly not an excuse, the people working in health care are after all humans.” 

More and more, hospitals – often in partnership with inspectors and surveyors – are looking closely at those processes, looking for opportunities to reduce problems and mistakes. “Over the years surveyors have changed their perspective to a more collaborative team approach,” said Michelle Burford, who manages compliance at Fort Madison Community Hospital.  “In my experience they often welcome questions.  They share suggestions they have learned from other organizations across the country.” 

Though it is enormous, the amount of regulation placed on hospitals is, for the most part, well intended. Most hospitals see its advantages and, in fact, practically all hospitals voluntarily seek other outside assessments that ultimately create more work but also improve health care.  “Mercy has proactively added to the number of survey processes by seeking and achieving accreditations and certifications for many services,” noted Vellinga.  “Mercy wants our patients and communities to understand the extensive efforts under way every day to scrutinize our facilities and services, find opportunities for improvement, and make changes to ensure we do everything right, every time, for every patient.” 

That is the goal of all health care providers – and it should be the goal of those who regulate them.  Just as hospitals examine and re-examine their processes in quest of improvement, hospital regulators should be careful as well, making sure whatever further demands they place on providers are both necessary and effective.

More than 291,000 Iowans voted with their feet in favor of the new Healthiest State Initiative by participating in Start Somewhere Walks held across Iowa last week, according to estimates by walk organizers.  The walks were a huge success in communities both large and small, from one side of the state to the other. 

“In more than 2,300 group walks and thousands of individual walks, Iowans said ‘yes’ to starting our journey to becoming the healthiest state in the nation,” said Governor Terry Branstad, who announced the Healthiest State Initiative in August. “It was a remarkable display of energy as Iowans came together to ‘start somewhere’ in reaching this ambitious goal.” 

Start Somewhere Walks, which were held in each of Iowa’s 99 counties, were hosted by several Iowa hospitals (see a slide show of photos) as providers continue to play in leading role in the initiative and its centerpiece, the Iowa Blue Zones Project. 

Blue Zones uses third party research and direct studies to identify the world’s best practices in longevity and well-being. Working in collaboration with the University of Minnesota School of Public Health, it uses this research to develop lifestyle management tools. In 2009, Blue Zones led a 10-month pilot project in Albert Lea, Minnesota, where residents increased their projected life expectancy by 2.9 years. In addition, employers in that city reported a decline in healthcare claims cost and a drop in absenteeism. 

Now, communities across Iowa have been invited to apply to become one of 10 to receive direct assistance from national experts in their quest to join Blue Zones.  Communities will be selected in multiple phases over the next five years. These communities will become demonstration sites and share their learnings with other communities in Iowa who are employing Blue Zones principles. Businesses will also take the lead by transforming their worksites, followed by government, schools and non-profit organizations. 

Dozens of Iowa cities and towns have expressed interest in becoming Blue Zones communities.  Communities wanting to find out more can send representatives to Blue Zones “road shows” being held this week.  Information is also available from a webinar that was presented last month and recorded.  To officially join the Blue Zones competition, communities must submit a statement of interest by October 28.