by Jason A. Wolf

Since my last blog post where I stressed the need for our continued commitment to push the patient experience movement forward I have had a positive, life-changing experience.

Early on Friday, April 19, as we were wrapping up Patient Experience Conference 2013, my wife called to let me know she was having contractions. "Nothing imminent," she calmly told me.

It is not often you spend three intense conference days stressing the critical importance of patient experience--of people and process, patient perspective, strategic imperative--only to turn around and be that patient or family member yourself. But those three days were followed by three days admitted to the hospital--experiencing labor and delivery (L & D), post-partum care and watching everything our caregivers did to provide for my wife, our new son and me.

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It reinforced the point I often stress--that we will all be patients and family members some day.

As I switched roles to the receiver of care, I keenly observed all I could in the hospital setting--the incredibly calming and intent support we received from the individual in admissions as she carefully but purposefully pushed my wife up to L & D.

As we went through the process of labor, delivery and our following two nights as inpatients, I saw all the things I know great organizations do--effective use of communication boards, purposeful hourly rounding, tent cards from housekeeping on the importance of cleanliness (including a seat band saying "Clean for You" around the toilet in the bathroom when we arrived in both our L & D and post-partum rooms), posters noting the importance of creating a quiet and healing environment, room service menus, and much more.

I realized those are nice things to do, the tactics or the "what." And while not always expected, they are emerging as central to patient experience efforts. Living in the patient experience world, I was aware of those whats, but as a patient/family member they were not explained to me, their purpose was not revealed, and so their impact, while still impressive, was not significant.

What stood out to me and what made my familys experience, was something much simpler, yet more significant. It was the "how" of our care--how our experience, service, quality and safety were handled made the impression on us.

From that admissions experience when Patricia calmly led us up to L & D to our L & D nurse Kristin who communicated clearly and set expectations (even when not easy to communicate) and from our anesthesiologist who followed up on my wifes procedure to the day and night nurses who rounded with care and gave their time to answer questions, provide a helping hand and support for new parents who were sleepless, overjoyed and overwhelmed.

It was the food service workers who took our order knowing my wifes allergies and asking to speak with me personally to make sure they could best take my dinner order. It was Sandra the housekeeper who in the midst of ensuring the unit sparkled, took the time to explain the family break room, help with extra needs for our room and check in time to time just to see how we were doing.

This is not a secret formula or a quick checklist of to-dos. Rather it reinforces all thats central to the definition of patient experience, that experience is the sum of all interactions, shaped by an organizations culture, that influence patient perceptions across the continuum of care.

What moved me most as a new father, and what caught my attention as a champion for positive patient experience, was that I saw these central ideas come to life. It was the interactions, it was the culture--the people who cared for us each day--that ultimately drove our perceptions and made our experience so great.

I do not wish to suggest tactics are not important or strategies for patient experience execution and improvement are not critical--they are. But it is truly the how in delivering experience that can have the biggest impact. In healthcare we are fundamentally no more than people taking care of people. Our family experience reinforced this more than anything. It was how it was done that made all the difference to us.

_Jason A. Wolf, Ph.D., is president of The Beryl Institute, where he specializes in organizational effectiveness, service excellence and high performance in healthcare. Follow Jason @jasonawolf and The Beryl Institute @berylinstitute on Twitter._

by Alan Sager

In 1960, 42 acute care hospitals with 8,000 beds served Detroits 1.7 million residents. But only four hospitals with 2,700 beds survived to serve 700,000 residents in 2010.

All of the survivors are costly major teaching hospitals. Especially in winter, ambulances are sometimes challenged to provide rapid response to the people of a 139-square-mile city whose residential side streets rarely see snow plows.

Detroit is not alone. Hospital "deserts" are conspicuous--and growing--in broad expanses of St. Louis, Cleveland, Washington, Atlanta, several Texas cities, New York Citys boroughs, and elsewhere.

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These findings stem from a study of changes in some 1,200 acute care hospitals in 52 cities over the past 75 years. Of the 774 hospitals open in these 52 cities in 1960, 484 (over three-fifths) had closed by 2010.

What are the characteristics of the hospitals that survive? Decade after decade, hospitals are more likely to remain open if they are larger teaching hospitals, have more accumulated wealth relative to their size, and are located in neighborhoods that are heavily caucasian. Unexpectedly, hospital efficiency--either alone or after controlling for other factors--has had no value in predicting which hospitals survive.

But arent these changes just one part of a steady, desirable, and money-saving shift of healthcare from inpatient to outpatient services? Why should we worry or do anything about them?

To learn more, READ THE FULL GUEST COMMENTARY AT _FIERCEHEALTHFINANCE_.

by Alicia Caramenico, _FierceHealthcare_

With critics around the country increasingly questioning whether nonprofit hospitals are providing enough charity care to justify their tax-exempt status, the pressure is on for nonprofits to demonstrate their charitable duties and put their financial assistance programs to work. FierceHealthFinance talked to George Semko (pictured), vice president of Revenue Cycle at Meritus Health System in Maryland, about how the organization is serving financially disadvantaged patients in a post-reform healthcare landscape.

READ THE FULL INTERVIEW AT _FIERCEHEALTHFINANCE_.

by Kent Bottles

The 91-7 confirmation by the U.S. Senate of Marilyn B. Tavenner as administrator of the Centers for Medicare & Medicaid Services means we now have a permanent CMS leader for the first time since Mark B. McClellan, M.D., left the post in October 2006.

Republicans refused to allow a vote on Obamas first choice, Donald M. Berwick, M.D.; he served as acting administrator for 18 months under a recess appointment.

Does this bipartisan Senate vote mean we have finally accepted that the Affordable Care Act is the law of the land? Will all Americans now work together to ensure the new law will be fully implemented as smoothly as possible?

In a word, the answer to those questions is no.

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For example, one of the senators voting against Tavenner was the Republican Minority Leader Mitch McConnell who issued the following statement to _Politico_:

"By giving the CMS administrator the primary role in implementing Obamacare, with the responsibility for issuing and enforcing thousands of pages of new regulations, rules and requirements, the Obama administration has changed the central focus of this job. The new administrators time and focus will be diverted on what my Democratic colleagues have called an impending train wreck, rather than strengthening Medicare and Medicaid at a time when they face enormous challenges."

Democratic Sen.Tom Harkin of Iowa delayed the Tavenner confirmation vote to protest the raid of ACAs prevention and public health fund to pay for implementation costs.

In the same week that Tavenner won confirmation, the GOP dominated House of Representatives voted for the 37th time to repeal the ACA even though there is not a chance the Senate will agree or that President Obama would sign such a law.

The American public also is confused about the ACA. The Kaiser Family Foundations April poll found that four in ten Americans are unaware that the ACA is still the law of the land. Among groups specifically helped by the health care law, the findings are even more worrisome: six in ten households earning less than $30,000 a year and less than half of young people are unaware that the ACA has not been repealed.

These findings led a _New York Times_ columnist to conclude, "A clueless electorate is a corruptible one, and one that seems ill poised to make the smartest, best call about something as sweeping as Obamacare and how it gets tweaked or not down the line. Maybe well blink our way to the right decisions. Or maybe well just stumble around with our eyes closed."

Does all of this mean implementation of the ACA will be a total failure? Probably not. It will work in some states; it will be messy in some other states.

As I mentioned in my _Hospital Impact_ blog post right after the presidential election, most of the action has shifted from Washington, D.C., to the states, where much of the implementation must occur. I discussed Oregons ambitious coordinated care organization approach to Medicaid and South Carolinas close collaboration with private companies.

Another unique state approach to the ACA has surfaced in Utah, where Gov. Gary Herbert and U.S. Department of Health & Human Services Secretary Kathleen Sebelius have agreed to have a preexisting state unit become the exchange for employers with 50 or fewer employees and the federal government will set up an exchange for individuals.

Maryland has been a states that enthusiastically embraced the ACA from the beginning, and with its recent announcement of a sophisticated public relations connector campaign it likely will have a smooth implementation process. Another state that has proactively embraced the ACA is Vermont, where Act 48 established the Vermont Health Benefit Exchange and where exchange insurance premiums have come in lower than predicted by many experts.

In contrast to states like Oregon, Utah, Maryland and Vermont, where citizens may encounter well organized approaches to ACA implementation, Texans may well experience more difficulties because Gov. Rick Perry has consistently opposed state-run exchanges and the expansion of Medicaid.

On Perrys website, he states, "If anyone was in doubt, we in Texas have no intention to implement so-called state exchanges or to expand Medicaid under Obamacare, I will not be party to socializing healthcare and bankrupting my state in direct contradiction to our Constitution and our founding principles of limited government." The Washington Post recently published a fascinating summary of articles from 1966, when Medicare was first introduced:

"What will happen then, on that summer day when the federally insured system of paying hospital bills becomes reality?" Nona Brown, a _New York Times_ reporter, wondered in a story published April 23, 1966. "Will there be lines of old folks at hospital doors, with no rooms to put them in, too few doctors and nurses and technicians to care for them?"

Most of the articles, like those written today about the ACA, emphasize the difficulties of enacting Medicare because it represented such a sweeping change. Today 47 years later, anyone who wants to change Medicare is met with stiff opposition from the public who largely feel entitled to their Medicare benefits.

Tavenners confirmation as CMS administrator is a welcome bipartisan episode that seems to be out of step with most of the reaction to the ACA. The American peoples experience of the ACA will be mostly decided by where they live. There will be some places where I predict it will be a smooth transition. There will be other places where it will most likely be a rocky time.

Hopefully, the nation can learn from what works and what does not work in making changes to this vital industry that represents one fifth of the U.S. economy.

_Kent Bottles, M.D, is a Senior Fellow at the Thomas Jefferson University School of Population Health._

by Jonathan H. Burroughs

That was a question a physician asked me at dinner last week and I answered simply, "World-class quality, safety and service at half the price."

Healthcare reform/transformation is a problem in the guise of a political conflict. What the two political parties argue over is who has the legal right to control and regulate the healthcare market: the federal government, state governments or private industry.

This is a war that has been waged since we began as a nation and it shows no sign of slowing.

Unfortunately, while corporate lobbyists spend hundreds of millions of dollars to defend their entrenched positions, our country is losing the increasingly global competition to provide high-quality, low-cost healthcare services.

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Medical tourism is the fastest growing healthcare sector. In 2006, it was a $25 billion industry; today it is a $125 billion industry that is projected to double every two to three years. Why did almost 1 million Americans go abroad last year for healthcare services? They could not find what they were looking for anywhere in this country.

Consider the typical story of a Dallas business executive who could not find anyone to do a repair of his knee meniscus under epidural anesthesia for under $32,000. For $9,000 he and his wife flew first class to Monterey, Mexico, where he underwent surgery by an American-trained orthopedic surgeon under epidural anesthesia at a Joint Commission International-accredited hospital, received private nursing at a first-class hotel and flew home first class.

The book by Josef Woodman, "Patients beyond Borders: Everybodys Guide to Affordable World Class Medical Travel," (2013) provides hundreds of options for Americans seeking cost-effective, high-quality medical services.

Large employers are getting on board with high-quality, low-cost care. Wal-Mart, with more than $466.1 billion in revenues and 2.2 million associates has chosen six high-quality, low-cost "Centers of Excellence" for any heart, spine, or transplant surgery required by its associates. These centers include:

1. Cleveland Clinic (Ohio) 2. Geisinger Medical Center in Danville, Pa. 3. Mayo Clinic in Rochester, Minn.; Scottsdale, Ariz.; and Jacksonville, Fla. 4. Mercy Hospital Springfield (Mo.) 5. Scott and White Memorial Hospital in Temple, Texas 6. Virginia Mason Medical Center in Seattle

Wal-Mart will pay all costs for its associates to go to one of these centers and will pay a spouse or "significant other" to join them for support. If an associate chooses to go anywhere else (including the closest qualified facility to him/her), the associate is responsible for all deductibles and co-payments, as well as any cost for their significant other. Wal-Mart claims it has saved tens of millions of dollars in healthcare costs with this strategy and other major employers are taking notice.

Third-party payers are moving forward as well. When a group of highly motivated physicians formed the Memorial Hermann MD Clinical Integration Program in Houston and standardized hundreds of clinical and functional pathways to evidence-based practices through creation of clinical practice committees (CPCs), the results were remarkable. Hospital-acquired infections dropped by 91 percent, general complications dropped 66 percent, 30-day readmissions fell 43 percent, and mortality dropped 23 percent.

Aetna, one of the three major insurance carriers in the market came to the group, offered to renegotiate their contract at a higher rate (with a significant bonus to divert patients to the integrated group), and offered to market the group to compete against United and Blue Cross Blue Shield in the Houston market. Aetna realized this integrated group could increase quality, margin and return to stockholders/investors, and joined an increasing number of third-party payers to create a tiered network to preferentially incentivize patients to go to high-quality, low-cost providers and groups.

Discriminating patients are doing the same. For instance, Healthgradess website gets more than 11 million hits a month and the Centers for Medicare & Medicaid Services Hospital Compare website gets more than 14 million hits per month. This represents only 8 percent of patients; however, this group represents highly educated individuals with disposable income who want to make discriminating high-quality, low-cost healthcare choices for their loved ones.

Healthcare reform is not a political issue. We have inadvertently allowed our healthcare system to fail by reverting to a supplier-based reimbursement system that rewards organizations that perform high numbers of procedures and ancillary studies, half of which (according to the RAND Corporation) are unnecessary. Also because of a reimbursement system based upon return on investment (ROI) to stockholders, investors, and not based on healthcare outcomes, half of the services that patients need have no meaningful reimbursement (e.g., chronic disease management, particularly in the outpatient setting).

Healthcare transformation requires an overhaul of our system so we can provide world-class quality, safety and service at a cost structure below that of most of our international competitors, delivering the kind of healthcare we deserve and compelling those abroad to come to our country for high-quality, low-cost care.

_Jonathan H. Burroughs, MD, MBA, FACHE, FACPE is a certified physician executive and a fellow of the American College of Physician Executives and the American College of Healthcare Executives. He is president and CEO of The Burroughs Healthcare Consulting Network and works with some of the nations top healthcare consulting organizations to provide "best practice" solutions and training to healthcare organizations._