Heal Thyself?

Fines point to woes at state's hospitals

by Liese Klein
In their most recent checkups, Connecticut hospitals have been showing signs of stress: The state's Department of Public Health (DPH) has announced six regulatory actions by the agency in the first two months of this year, compared with 12 such actions in all of 2007.

But is the surge in actions a reflection of financial pressures on overburdened hospitals or tougher standards? Hospitals say they are under more scrutiny as the state deals with the mess at Haven Health Care, a regional nursing home chain that collapsed in the wake of financial irregularities and patient-care complaints.

Regulators say the actions reflect the state's tough rules and political priorities as the Connecticut's population ages. Patient advocates point to hospital management issues even as CEO salaries swell.

"I really think that hospitals need to focus on improving the quality of care and saving money that way," says Jean Rexford, executive director of the Connecticut Center for Patient Safety.

"We're just not doing a good enough job," Rexford says, adding that national surveys have found that only 30 percent of hospitals follow basic hand-washing protocols.

"It's all of us that ultimately pay," Rexford says.

Whatever the cause, the recent surge in state regulatory actions is hitting close to home: The Hospital of Saint Raphael, Milford Hospital and Waterbury Hospital have all been singled out by the DPH thus far in 2008.

Waterbury Hospital was named in a January 17 consent order after state workers found violations during inspections there last spring. The state fined the hospital $8,000 and ordered managers to hire a wound-care specialist and tighten up infection-control procedures, recordkeeping and maintenance.

New Haven's Saint Raphael's was fined $12,000 on January 4 related to two nonfatal patient overdoses and violations of wound-care protocols were found in inspections in June and July last year. Milford Hospital was named in a consent agreement released on January 3 relating to violations of medication and wound procedures in inspections dating to mid-2006.

The most serious action was announced on February 8, when the DPH placed Hartford Hospital on probation after four patients died under questionable circumstances. Following up on dozens of complaints, the state found violations of basic medical care including wound and medication procedures and supervision of suicidal patients. The hospital was ordered to hire consultants to review operations and could lose its license if care is not improved.

Locally, the Saint Raphael's case has attracted the most attention, with the most recent action coming after a 2006 consent order in which the hospital was blamed for a patient's death.

The new consent order prompted a strongly worded editorial in the New Haven Register. "The state Department of Public Health should keep paying unannounced inspections at the Hospital of Saint Raphael, which is compiling a growing record of disregard for its patients' safety," the Register editorial asserted.

But Yale-New Haven Hospital Chief of Staff Peter Herbert wrote to the paper to defend Saint Raphael's and assert that the consent order reflects progress in patient care and reporting of medical errors.

"Connecticut hospitals are more knowledgeable of what can go wrong and more effective in preventing accidental injury than at any time in the last half-century," Herbert wrote. "Saint Raphael's physicians and nurses provide excellent care. There are absolutely no objective data showing its patients are less safe than those in any other Connecticut hospital," he concluded.

"Many of the actions called for in the newly signed consent agreement are part of corrective action plans already implemented by Saint Raphael's and approved by the state last year," the hospital said in a statement. "Saint Raphael's goal is to always be in compliance with or exceed the many hundreds of standards that [regulatory agencies] have."

The recent actions reflect the state's ongoing commitment to monitoring hospital care, says DPH spokesperson William Gerrish.

"We're regarded by the federal government as one of the top regulators in the country," Gerrish says, adding that Connecticut recently helped pilot a quality-improvement program for nursing homes. Inspectors visit all of the state's hospitals at least four times a year and assign registered nurses instead of non-specialist staff members to assess care.

The recent Haven Health Care scandal has also prompted Gov. M. Jodi Rell to propose adding another ten inspectors to examine day-care centers, nursing homes and other health facilities.

"We're committed to ensuring quality care for hospitals," Gerrish says. "We're in hospitals often."

Connecticut was also one of the first states to implement "adverse event reporting," which requires hospital to disclose medical errors in specific categories.

New regulations have also been added as fears about drug-resistant infections in hospitals increase. Attorney General Richard Blumenthal in January called for new legislation to track cases of MRSA (methicillin-resistant staphylococcus aureus) at the state's hospitals and screen all ICU patients for the infection.

"Hospitals have a moral obligation to screen and report MRSA infections, but we must make it a binding legal duty," Blumenthal said at the time.

The tougher standards come as hospitals find themselves under increasing financial strain as Medicaid reimbursements lag behind costs. The 31 hospitals in the state absorb about $250 million a year in uncompensated care because Medicaid and state programs pay 70 cents on the dollar, according to the Connecticut Hospital Association.

Lower federal grants and reimbursements are squeezing all of the state's hospitals even as demand for charity care grows. A report last year by the state's Office of Health Care Access found that many state hospitals were showing drops in operating margins, cash on hand, uncompensated care costs and equity financing ratios.

"Hospitals face an increasingly unpredictable level of net revenues to cover rising operating expenses," the report stated. Several facilities, including Waterbury Hospital, may not be financially viable in the long term, the report added.

Yale-New Haven Hospital CEO Marna P. Borgstrom warned last year that her facility's "earnings per patient" ratio was nearing zero and that health-care costs were outpacing society's willingness to pay.

Most recently, UConn's Health Center reported a $10.3 million deficit in January and administrators announced they had hired PriceWaterhouseCoopers to draft a financial turnaround plan

But the hospital's industry's complaints come amid ballooning paychecks for top administrators: A governor's task force recently found that executive salaries rose 95 percent from 2002 to 2006 at the state's hospitals. Costs for fringe benefits rose more than 200 percent over the same period.

Locally, three Yale-New Haven Hospital administrators make more than $1 million each and Saint Raphael's CEO David Benfer made $721,656 in 2006, according to the hospital's most recent tax return.

"Where are their board of directors?" ask Rexford of the Connecticut Center for Patient Safety. "I don't know what they're basing their evaluations of the CEOs on."

The state's on the right track by holding hospitals to even higher standards of care and transparency, Rexford says, but efforts are still falling short. More than 42,000 people contracted infections in Connecticut hospitals last year, she says, many of them preventable.

"We don't have any real way of finding out what happens in our hospitals," Rexford says. Statistics on infection rates at hospitals should be available to health-care consumers to inform their choices, she adds.

In the meantime, individual patients should bring "medical fact sheets" with them to the hospital with the names of their physicians, specific ailments and drug dosages clearly listed to prevent errors, Rexford says. Patients should also complain to the state if they feel they have been treated in error.

"People have to begin to assume responsibility," Rexford says. "I'm really feeling a great deal of impatience about the hand-wringing - and not the hand-washing that should be taking place in our hospitals."