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Health Care

Taking Important Steps

By Mark Morris

Dr. Christopher Peteros prepares a patient for laser therapy.

Dr. Christopher Peteros prepares a patient for laser therapy.

Spring weather in New England is a great time to shake off winter’s cabin fever and head outside to take a walk, go for a run, or play a sport. Spring also means an increase in foot injuries from people being too active, too soon.

While overdoing it can cause aches and pains in many areas of the body, it’s easy to overlook our feet, which support everything else and are key to overall quality of life. Those who specialize in this realm of care have a simple word of advice: don’t.

They stress the importance of taking care of one’s feet, listening to them when they are sore and need attention, and fully understanding how it’s not unusual for foot pain to be the cause or the result of other pain in the body.

“Sometimes foot pain causes knee, hip, or back issues, and by the same token, if someone has pain in their knees or back, it puts the foot in an awkward position, resulting in foot pain,” said Dr. Christopher Peteros, a podiatrist with New England Foot Specialists in Longmeadow, who stressed the importance of paying attention to pain, calling it our body’s early-warning system.

“If you feel pain in your foot, knee, or ankle, it’s telling you to stop what you’re doing,” he told BusinessWest. “It’s like the ‘check engine’ light in your car.”

When we walk or run, the foot’s natural movement is known as pronation (the inward roll of the foot) and supination (the outward roll of the foot), both of which move us forward while providing support, cushioning, and balance. Too much or too little of either pronation or supination can cause pain in the feet and other parts of the body.

“I’m not telling people to go walk in the middle of the street, but if you know of a neighborhood with a cul-de-sac or a circular street, those are better choices than sidewalks, which are a harder force on our bodies.”

Terrance McKeon, a physical therapist with Cooley Dickinson Health Care’s Rehabilitation Services in South Deerfield, refers to the foot as the ‘victim,’ because it’s often the one in pain while the culprits can be nearby or as far away as the hip or pelvis. To carry the analogy further, McKeon said that, when investigating the cause of foot pain, the calf muscle is often a prime suspect, because when the calf muscles are tight, the body adjusts by collapsing the foot.

“Your foot tries to maintain balance by unnaturally scrunching the toes,” he explained. “Then the fascia gets stretched, the Achilles tendon gets overstretched, and you may even wiggle your pelvis, all because your calf muscles aren’t letting you get over your foot.” 

Brianna Butcher, a physical therapist at Select Physical Therapy in Enfield, agreed. “When someone walks in with foot issues, the first thing I check is their hips,” she said, adding that, since the glute muscles tend to be weak in many people, it causes more strain to be put on the leg and foot to compensate and maintain balance.

For this issue, we take an in-depth look at what causes foot pain and discomfort and how to prepare your feet for activity.

Walking the Walk

Those who spoke with BusinessWest there are a number of factors that contribute to one’s overall foot health — or lack thereof. These include everything from the level of exercise to the type and condition of the shoes being worn, to the surface that people walk or run on.

Terrence McKeon demonstrates an orthotic insert for a patient.

Terrence McKeon demonstrates an orthotic insert for a patient.

People should be thinking about all of them and making smart decisions, said Butcher, who noted, for example, that serious runners opt for an asphalt road instead of a concrete sidewalk, because the asphalt surface is slightly less harsh on our bodies than concrete.

“I’m not telling people to go walk in the middle of the street, but if you know of a neighborhood with a cul-de-sac or a circular street, those are better choices than sidewalks, which are a harder force on our bodies,” she said, adding that, for those who live near a track, that’s an even better option than walking on the street.

While sidewalks can be too hard on our feet, Peteros said treadmills can create the opposite problem and result in repetitive-motion injuries.

“Some treadmills can be too soft, so as your foot sinks in, it creates an abnormal amount of repeated pronation while the person is walking, which can lead to tendinitis or plantar fasciitis.”

One of the most common causes of foot pain, plantar fasciitis affects the band of tissue that runs along the bottom of the foot from heel to toe. The plantar fascia acts like a shock absorber to support the arch of the foot. Too much strain on it leads to a stabbing pain in the heel.

Many factors can contribute to plantar fasciitis, but it often results from a change in activity levels that puts more stress on the heel. Peteros said likely candidates for plantar fasciitis include the person who hasn’t run in years and then decides to pursue it again, as well as the person who goes on vacation and does more walking than normal while wearing flimsy shoes.

Peteros said a person with plantar fasciitis tends to experience severe pain in the morning after just waking up. The pain subsides a little after moving around, and then, by the end of the day, it increases. He said the pain can move into a cycle that won’t easily go away.

“It’s a very difficult thing to treat in some cases,” he said, “because you’re using that sore foot for every other step you take, unlike a sore hand where you can just carry it around.”  

The first remedy Peteros suggests for plantar fasciitis and other foot injuries is the easy-to-remember acronym RICE: rest, ice, compression, and elevation. People can do this on their own, and in many cases RICE along with good, supportive shoes is enough to solve the problem. If that doesn’t work, he has a variety of treatments to further care for plantar fasciitis.

Anti-inflammatory medicines or cortisone shots are two possible treatment options. While cortisone can be effective for some, Peteros said, he cautions against its overuse because the shots can create ruptures in the plantar fascia instead of healing it.

For several years, he has used laser therapy to treat plantar fasciitis. As an alternative to anti-inflammatory medications, laser therapy uses a beam of light so it’s painless for the patient, works to reduce inflammation, and allows for faster healing. He said the success rate for healing injuries by laser therapy is about 80%.

“Depending on the injury, most patients will need between five and 10 treatments, which take about 10 minutes each. It may not always lead to a cure, but it speeds up the process,” he said.

For chronic foot issues, Peteros also uses shock-wave therapy, which treats plantar fasciitis with sound waves. He said it functions much like the technology that uses sound waves to break up kidney stones, adding that the same company makes the two machines.

When taken care of quickly, he said most people will get great results and no longer need treatment for their plantar fasciitis.

“Some patients may get an occasional flare-up, usually because they did something they shouldn’t have done. The key is to be aware of it, protect yourself, and stop as soon as you feel any pain.”

Getting to the Bottom of Things

That bit of advice applies to all aspects of foot care, said McKeon, who told BusinessWest that, overall, it’s best to best to be proactive and avoid the energetic enthusiasm of taking too much advantage of a nice spring day.

“Your brain says, ‘I used to run five miles a day,’ but when you’ve gone all winter without running even one or two miles, that’s breaking the 10% rule,” he said, explaining that the best way to prevent injury when approaching spring activities is to take it easy in the beginning and gradually increase activity levels no more than 10% a week.

Physical therapists have used the 10% rule for years, and recent studies have supported the idea that the body can react and get stronger from a 10% increase each week for nearly any activity.

“If you can obey the rule, especially for weight-bearing activities like walking and running, you’ll be fine,” said McKeon.

Brianna Butcher inspects a patient’s foot for injury.

Brianna Butcher inspects a patient’s foot for injury.

This can require some pre-planning, he added, noting that simple heel-raising exercises for the calf muscles are a good way to get ready for a walking or jogging routine.

“Strengthening calf muscles is easy because you just go up and down on your toes. Go up on your toes to hit full height, then back down, and do them until you get tired,” he said, adding that the yoga position downward-facing dog is an effective exercise for tight calf muscles. He then stressed that the 10% rule also applies to the stretches.

As essential as good conditioning is to prevent foot injury, these proactive steps can easily be undone by cheap or worn-out shoes — or the wrong kind. McKeon said serious runners should consider new shoes every six months because the foam in the shoe that absorbs the energy of running will lose its ability to bounce back with heavy use.

Peteros also emphasized the importance of protecting the feet with good hygiene and proper shoes. “Whether you are a runner, walker, or any type of athlete, good, supportive shoes are the foundation of healthy feet.”

Peteros recommends shoes designed for the specific activity in mind, with a stiff sole. “If you can bend the shoe in half, it’s not offering support.”

One of the best examples of warm-weather shoes that provide no support are the ever-popular flip-flops. Peteros did not condemn them, necessarily, but referred to them as “purpose-built.”

“If you’re sitting around the pool, or at the beach, or even on your back deck with an iced tea, they’re perfectly fine to wear,” he said, adding that problems arise when people continually wear flip-flops around town, because the feet have to work hard just to keep them on. “Your toes are scrunching as they’re trying to grip the flip-flop, and there’s just no support; they’re actually more trouble than they’re worth.” 

Peteros also mentioned the dangerous practice of people who wear flip-flops to mow the lawn, adding that yardwork is another place where good, supportive shoes matter.

“A lot of people retire their old, beat-up sneakers to wear in the yard, but when you’re doing yardwork, you’re often on uneven ground, when your feet need support the most.”  

A work boot or hiking boot is a great choice for yardwork, he said, because they are lightweight and supportive. Meanwhile, high-top or low-cut shoes are both fine, he noted, stressing that these shoes should be kept just for yardwork; don’t retire them to the yard only after they’ve worn out.

Because every foot is different, people with overly high arches or flat feet often need additional support from custom orthotic inserts. Peteros admits that some people can get good results with over-the-counter insoles and advised that, when shopping for inserts, firmer is better. When a custom orthotic insert is needed, he said the old methods to make them have given way to 3-D digital imaging that results in an orthotic that fits the exact contours of the person’s foot.

“We used to make casts and molds and have people step in foam. I haven’t done those things in at least nine years; it’s all digital now.” 

McKeon said finding the right footwear for those at one extreme or another can be tricky, while people whose feet are more in the middle range may be able to slowly build up strength in their feet and avoid using an insert.

“I tell people that, if they gradually increase their activity levels following the 10% rule, they can improve the strength in their foot,” he explained. “This works well with athletes who don’t like wearing orthotic inserts.”

So, before taking on outdoor activities this spring, remember supportive shoes, the 10% rule, and RICE. You’ll prevent injury to your feet and better enjoy the spring weather.

Health Care

Leveling the Playing Field

Spiros Hatiras

Spiros Hatiras says the Massachusetts Value Alliance has created what he called a “virtual system” for the state’s independent hospitals.

Spiros Hatiras was asked about the Massachusetts Value Alliance and, more specifically, how it improves the buying power of its members, including the one he serves as president and CEO — Holyoke Medical Center (HMC).

He handled the assignment by referencing the hospital’s ongoing work to implement a new electronic medical record (EMR) system, and with an analogy that puts this concept in its proper perspective.

“Let’s say you went to Ford and asked them to build you a car, but told them that, instead of putting the power-switch buttons on the window side, you wanted them on the center console — the cost to customize the car the way you wanted it would be enormous,” he explained. “It’s the same with EMR; what hospitals used to do, and still do, is go to an EMR vendor and ask them to come in and build and install a system for that hospital.”

The Massachusetts Value Alliance, or MVA, as it’s called, is a coalition that is enabling its members to depart from that expensive scenario.

Indeed, several members of the alliance, which now includes 14 community hospitals, have come together to order an EMR system that will be customized for a group — with minor tweaks for each specific facility — and not one hospital. The savings will be substantial — in fact, Hatiras pegs the cost at roughly $5 million for HMC, close to half of what the cost might have been.

“Instead of us individually customizing, we get three hospitals to come together and say, ‘what are the features that make sense for all of us, and let’s build it one time and implement it in three locations.’”

“Our patients are not that different; in fact, they’re not different at all from the other hospitals, and the processes that we use are very similar — the order set, the treatment protocols, are all very similar,” he told BusinessWest. “So, instead of us individually customizing, we get three hospitals to come together and say, ‘what are the features that make sense for all of us, and let’s build it one time and implement it in three locations.’”

This is the very essence of the MVA, which was formed three years ago by founding members Emerson Hospital in Concord, Sturdy Memorial Hospital in Attleboro, and South Shore Health in South Weymouth. It has added new members steadily since then, and the alliance now also includes HMC, Berkshire Medical System, Harington Healthcare System, Heywood Healthcare, Lawrence General Hospital, Signature Healthcare, and Southcoast Health.

These are smaller, independent hospitals that enjoy the benefits of being independent and the ability that gives them to be focused on the needs of their respective communities, said Dr. Gene Green, president of the MVA board of trustees and president and CEO of South Shore Health. But they don’t enjoy the buying power and other cost-saving benefits of being in a larger healthcare system.

Dr. Gene Green

Dr. Gene Green says the MVA gives its members a very potent commodity in these challenging times — buying power.

The MVA, operating under the slogan “Health Care Is Better When We Work Together,” was created to level the playing field in at least some ways.

“There’s always greater bargaining power with numbers,” Green explained, adding that the MVA has helped its members reduce the cost of everything from laboratory services for their patients to health insurance for their employees. “Although a lot of people do group purchasing on common things, there are other things, especially within hospitals and healthcare systems, that are specialized, and so the question was, ‘how do we help each other bring our numbers together and help each have more bargaining power with third-party vendors?’”

The MVA was the answer to the question. It was in many ways inspired by a similar system in Connecticut called the Value Care Alliance (VCA), said Green, and today, the two alliances are collaborating to create additional economies of scale.

For this issue, BusinessWest takes an in-depth look at the Massachusetts Value Alliance and at how it is benefiting its members across the state during what remains a very challenging time for all hospitals, but especially the smaller, independent institutions.

Group Rates

Hatiras told BusinessWest that he was approached by the president of Sturdy Memorial not long after the MVA was created and encouraged to become part of the new group.

As he recalls the conversations, it wasn’t a very hard sell.

That’s because the value — yes, you’ll be reading that word a lot during this discussion — was readily apparent. And value is something these hospitals certainly need.

“We were quick to join — we’ve been a member almost from the beginning,” said Hatiras. “This is something we ought to be doing because, as independent hospitals, our resources are much more limited.

“This was a way to bring these hospitals together and join forces in terms of acquiring resources without merging assets or governance,” he went on, recounting two of the obvious downsides to becoming part of a large healthcare system. “We’re creating an almost virtual system.”

And within this virtual system, there exists that all-important commodity of businesses of all kinds, but especially hospitals that purchase a seemingly endless array of products and services — buying power. The alliance uses it with everything from laboratory services — there’s a contract with Quest Diagnostics — to elevator services, Green explained.

“The question was, ‘how do we help each other bring our numbers together and help each have more bargaining power with third-party vendors?’”

“It was a way for us to help each other find cost reductions and efficiencies to help drive down the cost of care, hopefully — unfortunately, revenues are declining at the same time we’re doing the cost cutting — and serve our communities.”

Hatiras agreed.

“We don’t have the benefits of a, quote-unquote, system,” he said, referring to the independent hospitals in the MVA. “But we replicated a lot of the those benefits with this alliance.

“We don’t have a mothership that can come to the rescue if one of its members isn’t doing so well — we don’t have that backup,” he went on. “But aside from that, all the other benefits of a system are there — the sharing of information, the sharing of best practices, collaboration, shared negotiation on resources, and more.”

And the alliance enables its members to enjoy greater buying power while also remaining independent, meaning decisions are made locally, a quality these hospitals covet.

“As independents, we’re very focused on our communities, and we’re very proud of that,” said Green. “That’s one of the reasons we came together — to see how we could help one another through cost-effective measures to be able to carry on our missions. We all have the same mission and focus on patient care, patient experience, and high quality.

“All of us are good at partnering with people in our own communities,” he went on, “which made us naturals to be able to partner with one another.”

Green said the group will collectively decide where opportunities to collaborate may exist, and then individual members have the opportunity to opt in or not, an operating mindset that provides members with a good deal of flexibility.

“We didn’t want to force anyone into doing something,” he explained. “If you had a contract that was good for five years, when that expires — and we have one — you can opt in, or you can stay with your own, depending on the relationship.

Which brings us back to that example of EMR that Hatiras mentioned. It’s a perfect example of just how and why the alliance works.

This is a project that involves HMC, Harrington Healthcare System, and Heywood Healthcare, all working with EMR-system designer Meditech.

“This allows to take advantage of tremendous economies of scale because we work on a common build and share common resources, which allows to do this build at a significantly lower cost than if we did it alone,” said Hatiras, adding that HMC will go first, with the other hospitals to follow, with an August 2020 ‘go live’ date for the system.

Bottom Line

Green told BusinessWest that, as reimbursement rates for care decrease, or hold steady, and as the price of technology and everything else hospitals buy continues to increase — the savings generated by the MVA are even more important.

“They enable us to stay afloat,” he said in a voice that clearly conveyed just how challenging these times are for all hospitals, but especially those who have chosen to remain independent.

That choice has left them without a safety net, if you will, but in the MVA, they have something that replicates a system in so many ways.

As that chosen slogan suggests, healthcare is better when people work together.

George O’Brien can be reached at [email protected]

Health Care

Implanted Thoughts

Dr. David Hirsh

Dr. David Hirsh says mini dental implants can hold a bridge or crowns in place without requiring surgery and months of recovery.

Early in his career, Dr. David Hirsh used to perform dental work for the then-Springfield Indians, and even back then, there was a clear generational divide among hockey players — one measured by how many teeth they had.

“Everybody used to talk about hockey players having no teeth,” he told BusinessWest. “But the young players grew up with helmets, facemasks, and mouthguards, and they came to the office here, and they had beautiful teeth. Their older counterparts would smile, and there would be nothing there.

“It was a matter of education,” he went on, comparing it to how today’s athletes have a better understanding of concussions for the same reason.

But that focus on education holds true among all dental patients, Hirsh added, not just athletes. Simply put, dentists are seeing people make it past their childhood and young adulthood with healthier teeth than in decades past. “We see a tremendous difference in the younger population, which is very satisfying.”

Since launching his practice in downtown Springfield in 1981 — he has expanded the Bridge Street office four times since then — Hirsh has seen plenty of change in the way care is delivered, particularly in the realm of implants, especially the mini implants he has become known for regionally (more on that later). But some of that change has to do with improving habits.

“We’re here to restore teeth and fix teeth and help patients smile and look good. But we would much rather get these people when they’re younger — meaning children or young adults — and guide them and help them to maintain their teeth,” he explained.

“There’s no fun in making someone a denture,” he went on. “There’s no fun in having to restore a full arch with implants. We do it because there’s a need. But that’s not the goal of dentistry. The goal of dentistry is clearly prevention. My goal has always been having a strong hygiene program, a strong prevention program, and helping guide people — and helping parents guide their children — to better oral health so they won’t have to be in a situation where they need a root canal, bridges, partials, dentures. Those things aren’t the goal. That’s not what we want.”

“There’s nothing more satisfying to me than to have a patient come in missing teeth, and they leave here with a beautiful smile, and they have tears in their eyes.”

But because there will always be a need for restorative dentistry, Hirsh — who practices with Dr. Kelly Soares under the umbrella of PeoplesDental — has taken advantage of plenty of innovations in the world of implants, with the goal of restoring not only teeth, but quality of life to patients with less recovery time than ever before.

Tooth of the Matter

When implants first came on the scene a half-century ago, Hirsh said, they were designed differently, and didn’t exclusively use titanium as they do today, so a membrane would form between the metal and the bone, causing the implants to loosen up.

“Today, every implant system is based on titanium technology — all of them,” he explained. “Titanium is the only metal that fuses directly to bone without forming a membrane around it.”

Implants are typically a surgical procedure, placed into exposed bone after the gums are opened up. “A hole is drilled, the implant is tapped in or screwed in very gently, and then the gums are sutured closed, and you have to wait anywhere from six to eight months in the lower jaw — four to six months in the upper — for that titanium implant to fuse with the bone.”

While traditional implants do a good job of anchoring crowns, bridges, and other structures over the long term, mini dental implants, or MDIs, have been a game changer for Hirsh’s practice.

MDIs are solid, one-piece, titanium-coated screws that take the place of a tooth root. They are much thinner than traditional dental implants and were originally designed to hold dentures in place. However, they have other benefits, including the fact that they stimulate and maintain the jawbone, which prevents bone loss and helps to maintain facial features. In addition, they are stronger and more durable than crowns and bridges that have been cemented into place.

They were first used in the ’90s and have been approved by the U.S. Food and Drug Administration for long-term use for fixed crowns and bridges and removable upper and lower dentures.

PeoplesDental in Springfield is now certified among a group known as Mini Dental Implants Centers of America — the only one, in fact, in a region that stretches from the Berkshires to Worcester, and from Vermont to Hartford. The organization is associated with the Shatkin Institute, the largest training center in America for MDIs.

“For reasons I don’t understand, mini implants in this area in New England are not widely utilized,” Hirsh told BusinessWest. “I think we’re a little slower than other areas of the country to experiment and do new things. When we have something that works, we don’t like to change. When traditional implants began in the late 1960s, early ’70s, the biggest negative voices were from dentists themselves — ‘you can’t put metal in somebody’s bone.’ Then, all of a sudden, by seeing what could be done, they came around.”

The same may soon happen with MDIs, he went on. “More people around the country are learning that minis are a very, very good alternative to traditional implants. The mini implants are not shorter, they’re just narrower; the largest minis today are equivalent to the thinnest traditional implants. The difference is basically the placement of them and what’s involved from a patient perspective.”

Most notably, no surgery is involved. Rather, the dentist makes a small hole through the gum tissue and into the bone, and screws the implant in.

“It gets its retention from the screwing effect, so you don’t have to wait six to eight months,” Hirsh explained. “That very day, you take an impression and make your final crown or bridge or whatever you’ll use it for.”

He likened the procedure to drilling a thin screw into a piece of wood. “You drill a pilot hole first, then put a screw in that’s a little bigger than the hole, so it bites into the wood. The same thing happens here, except it bites into the bone. It’s about half the cost, it’s less invasive, and there’s less chance of infection and the many types of sensitivity and soreness afterward because that usually comes from the cutting and the stitching.”

Quality of Life

More important, however, is the impact of mini implants on patients’ quality of life, Hirsh said, particularly for those wearing lower dentures.

“Lower dentures float all over the place. Nobody’s ever happy with their lower denture. It sits on a ridge like a horseshoe, and their tongue hits it and lifts it up, and they use pastes and powders that are uncomfortable and taste bad. And at restaurants, they can only eat what their teeth permit them to eat.”

With mini implants, however, a dentist can place four implants into the arch and corresponding attachments into their denture, and the denture can snap into place that same day. When they are used to stabilize upper dentures, the palate portion of the denture can be cut away, which makes it more comfortable and improves the taste of food.

“They can take it out to clean it, but it’s not going to move around,” he said. “There’s no paste or powder, it’s cost-effective, and it changes their life. I’ve done commercials with patients who bite into apples or corn with dentures, and they feel it’s rock solid.”

That’s gratifying for someone who has spent nearly 40 years helping people find solutions to dental issues that stem from genetics, accidents, environmental factors, and plain old bad habits.

In his earlier days, he explained, before dental insurance became more widely accessible, it was more common than today for families to avoid the dentist because of cost — or, if a tooth went bad, just opt for an extraction over a root canal.

“They were in a bad financial situation, or they weren’t educated to take care of their teeth, or a combination of both,” he told BusinessWest. “One tooth goes bad, and they need a root canal to save it, but they don’t want to spend the money, or don’t see the value in it. So they have that tooth extracted, and a year later, another one hurts, and it’s the same thing. All of a sudden, you’re looking at half a mouth of teeth, and half a mouth can’t do the work of a full mouth.”

Sometimes it’s a long process — decades, perhaps — to get to that point, or perhaps something happened suddenly, like a car accident or being struck in the teeth, but without insurance, it can be a challenge for families to get the work they need, at a time when procedures have become less invasive, in many cases, and more cutting-edge.

That’s changing, he said, not just on the insurance front, but as the result of decades of education and advertising the benefits of healthy oral habits. “When I see today’s young people, I don’t think, in the future, we’re going to see the amount of restorative need we see today.”

Until then, Hirsh aims to continue fixing what he can and helping young people forge a path to a future without implants. He’s scaled back to three days a week as he approaches retirement, but says the leisure activities of those coming years may not make him as happy as his current work does.

“There’s nothing more satisfying to me than to have a patient come in missing teeth, and they leave here with a beautiful smile, and they have tears in their eyes,” he said. “I’m not a golfer, but I fully understand hitting a great golf shot is very satisfying — but no one can convince me it’s as satisfying as doing something like that for a patient.”

Joseph Bednar can be reached at [email protected]

Health Care

On the Front Lines

VA Hospital in Leeds, Mass.

Early aerial photo of the VA Hospital in Leeds, Mass.

Gordon Tatro enjoys telling the story about how the sprawling Veterans Administration facility in Leeds came to be built there.
The prevailing theory, said Tatro, who worked in Engineering at what is now the VA Central Western Massachusetts Healthcare System for 20 years and currently serves as its unofficial historian, is that the site on a hilltop in rural Leeds was chosen because it would offer an ideal setting for treatment and recuperation for those suffering from tuberculosis — one of its main missions, along with treatment for what was then called shell shock and other mental disorders.

And while some of that may be true, politics probably had a lot more to do with the decision than topography.

“President Warren G. Harding came out and said, ‘stop looking for places … we’re going to put it in Northampton,’” said Tatro, acknowledging that he was no doubt paraphrasing the commander in chief, “‘because Calvin Coolidge is my vice president and he lives in Florence, and we want it to be in or around Florence.’”

Nearly 95 years later — May 12 is the official anniversary date — it is still there. The specific assignment has changed somewhat — indeed, tuberculosis is certainly no longer one of the primary functions — but the basic mission has not: to provide important healthcare services to veterans.

Overall, there has been an ongoing transformation from mostly inpatient care to a mix of inpatient and outpatient, with a continued focus on behavioral-health services.

“We’re more of a managed-care facility now,” said Andrew McMahon, associate director of the facility, adding that the hospital provides services ranging from gerontology to extended care and rehabilitation; from behavioral-health services to primary care; from pharmacy to nutrition and food services. Individual programs range from MOVE!, a weight-management program for veterans, to services designed specifically for women veterans, including reproductive services and comprehensive primary care.

Andrew McMahon says the VA facility in Leeds is undergoing a massive renovation

Andrew McMahon says the VA facility in Leeds is undergoing a massive renovation and modernization initiative scheduled to be completed by the 100th anniversary in 2024.

“When this facility was established, the mission of the VA was much different than it is today,” McMahon told BusinessWest. “We were a stand-alone campus in a rural part of the state that had 1,000 beds and where veterans went for the rest of their lives.

“Now, we are one facility within a network of eight serving Central and Western Massachusetts. We have this beautiful, 100-year-old campus, but the needs of today’s veterans are changing — they need convenience, primary care, and specialty care, and we’re trying to establish those services in the areas where the veterans live, primarily Worcester and Springfield.”

Elaborating, he said that, as the 100th anniversary of the Leeds facility in 2024 approaches, the hospital is in the midst of a large, multi-faceted expansion and renovation project designed to maximize its existing facilities and enable it to continue in its role as a “place of mental-health excellence for all of New England,” as McMahon put it, and also a center for geriatric care and administration of the broad VA Central Western Massachusetts Healthcare System.

By the 100th-birthday celebration, more than $100 million will have been invested in the campus, known colloquially as ‘the Hill,’ or Bear Hill (yes, black bears can be seen wandering the grounds now and then), said McMahon, adding that an ongoing evolution of the campus will continue into the next century.

“President Warren G. Harding came out and said, ‘stop looking for places … we’re going to put it in Northampton, because Calvin Coolidge is my vice president and he lives in Florence, and we want it to be in or around Florence.’”

Round-number anniversaries — and those not quite so round, like this year’s 95th — provide an opportunity to pause, reflect, look back, and also look ahead. And for this issue, BusinessWest asked McMahon and Tatro to do just that.

History Lessons

Tatro told BusinessWest that, with the centennial looming, administrators at the hospital have issued a call for memorabilia related to the facility’s first 100 years of operation. The request, in the form of a flyer mailed to a host of constituencies, coincides with plans to convert one of the old residential buildings erected on the complex (specifically the one that the hospital directors lived in) into a museum.

The flyer states that, in addition to old photographs, those conducting this search are looking for some specific objects, such as items from the old VA marching band, including uniforms and instruments; anything to do with the VA baseball team, known, appropriately enough, as the Hilltoppers, who played on a diamond in the center of the campus visible in aerial photos of the hospital; any of the eight ornate lanterns that graced the grounds; toys made by the veterans who lived and were cared for at the facility; copies of the different newspapers printed at the site, including the first one, the Summit Observer; and more.

Collectively, these requested items speak to how the VA hospital was — and still is — more than a cluster of buildings at the top of a hill; it was and is a community.

The oval at the VA complex

The oval at the VA complex has seen a good deal of change over the years. Current initiatives involve bringing more specialty care facilities to that cluster of buildings, bringing additional convenience to veterans.

“It was like a town or a city,” said Tatro, noting that the original campus was nearly three times as large as it is now, and many administrators not only worked there but lived there as well. “There was a pig farm, veterans grew their own food, there were minstrel shows, a marching band, a radio station … it really was a community.

“In that era, everyone had a baseball team, and we played all those teams,” he said, noting that the squad was comprised of employees. “The silk mill (in Northampton) had one, other companies had them; I’ve found hundreds of articles about the baseball team.”

This ‘community’ look and feel has prevailed, by and large, since the facility opened to considerable fanfare that May day in 1924. Calvin Coolidge, who by then was president (Harding died in office in 1923) was not in attendance, but many luminaries were, including Gen. Frank Hines, director of the U.S. Veterans Bureau.

He set the tone for the decades to come with comments recorded by the Daily Hampshire Gazette and found during one of Gordon’s countless trips to Forbes Library on the campus of Smith College. “President Coolidge has well stated that there is no duty imposed upon us of greater importance than prompt and adequate care of our disabled. And every reasonable effort will be made in that direction. I consider it the duty of those in charge of the veterans’ bureau hospitals to bring about a management and an administration of professional ability in such a manner as to recover many of those whose care is entrusted to them.”

“It was like a town or a city. There was a pig farm, veterans grew their own food, there were minstrel shows, a marching band, a radio station … it really was a community.”

The facility was one of 19 built in the years after World War I to care for the veterans injured, physically or mentally, by that conflict, said Gordon, adding that the need for such hospitals was acute.

“There was a drive in Congress to get the veterans returning from World War I off the streets,” he said. “They were literally hanging around; they had no place else to go. Public health-service hospitals couldn’t handle it, and the Bureau of War Risk Insurance couldn’t handle the cost, and I guess Congress just got pushed to the point where it had to do something.”

That ‘something’ was the Langley bill — actually, there were two Langley bills — that appropriated funds to build hospitals across the country and absorb the public health-service hospitals into the Veterans Bureau Assoc.

The site in Leeds was one of many considered for a facility to serve this region, including a tissue-making mill in Becket, said Tatro, but, as he mentioned, the birthplace of the sitting vice president ultimately played a large role in where the steam shovels were sent. And those shovels eventually took roughly 12 feet off the top of the top of the hill and pushed it over the side, he told BusinessWest.

As noted earlier, the facility specialized in treating veterans suffering from tuberculosis and mental disorders, especially shell shock, or what is now known as post-traumatic stress disorder (PTSD). In the early years, there were 300 to 500 veterans essentially living in the wards of the hospital, with those numbers climbing to well over 1,000 just after World War II, said Tatro.

Gordon Tatro, the unofficial historian at the VA hospital

Gordon Tatro, the unofficial historian at the VA hospital, says the facility is not merely a collection of buildings on a hill, but a community.

With tuberculosis patients, those providing care tried to keep their patients active and moving with a range of sports and games ranging from bowling to swimming to fishing in ponds stocked by a local sportsman’s club, or so Tatro has learned through his research.

As for those with mental-health disorders, Tatro said, in the decades just after the hospital was built, little was known about how to treat those with conditions such as shell shock, depression, and schizophrenia, and thus there was research, experimentation, and learning.

This added up to what would have to be considered, in retrospect, one of the darker periods in the facility’s history, when pre-frontal lobotomies and electric-shock therapy was used to help treat veterans, a practice that was halted in the late ’40s or early ’50s, he said, adding that this is one period he is still researching.

Battle Tested

Over the past several decades, there has been a slow and ongoing shift from inpatient care to outpatient care, said McMahon, who, in his role as associate director, is chief of all operations. He added that there are still inpatient wards at the hospital, and it retains its role as the primary regional provider of mental-health services for veterans.

But there is now a much broader array of services provided at the facility, and for a constituency that includes a few World War II and Korean War veterans, but is now dominated by Vietnam-era vets and those who served in both Gulf wars.

Overall, more than 28,000 individuals receive care through the system, which, as noted, includes both Central and Western Mass. and eight clinics across that broad area. The system measures ‘encounters’ — individual visits to a clinic — and there were more than 350,000 encounters last year.

The reasons for such visits varied, but collectively they speak to how the hospital in Leeds has evolved over the years while remaining true to its original mission, said McMahon.

“We haven’t really downshifted in our inpatient mental health — that’s an area of strength for the VA, and we continue to invest in that area,” he explained. “But in geriatrics, we’re looking to expand our nursing-home footprint, and hopefully double the size of those facilities by the time the 100th comes around — we have 30 beds now, and we’re looking to add maybe 30 more.”

McMahon, an Air Force veteran, said he’s been with the VA hospital for more than seven years now after a stint at Northampton-based defense contractor Kollmorgen. He saw it is a chance to take his career in a different, more meaningful direction.

“To get over into this area and serve the veterans … it’s a job that has a mission behind it,” he told BusinessWest. “It’s more than a paycheck.”

That mission has always been to provide quality care to those who have served, and today, as noted, the mission is evolving. So is the campus itself, he said, adding that ongoing work is aimed at maximizing resources and modernizing facilities, but also preserving the original look of the campus.

Current projects include renovation of what’s known as Building 9, vacant for roughly 15 years, into a new inpatient PTSD facility, with those services being moved from Building 8, an initiative started more than two years ago and now nearing its conclusion.

The new facility will be larger and will enable the VA hospital to extend PTSD care to women through the creation of a dedicated ward for that constituency.

Meanwhile, another ongoing project involves renovation of a portion of Building 4. That initiative includes creation of a new specialty-care floor, a $6 million project that will include optometry clinics, podiatry services, cardiology, and more.

Set to move off the drawing board is another major initiative, a $15 million project to renovate long-vacant Building 20 and move a host of administrative offices into that facility, leaving essentially the entire ‘Hill’ complex for patient care and mental-health services.

“We’re going to get HR, engineering, and other administrative offices down to Building 20 and expand our mental-health facilities around the oval,” McMahon said, referring to the cluster of buildings in the center of the campus. “There’s $40 million in construction going on at present, and by the end the this year, we expect that number to be closer to $60 million.

“There’s a lot of construction going on right now,” he went on. “But things will look good for the 100th.”

That includes the planned museum. The search goes on for items to be displayed in that facility, said Tatro, adding that he and others are working to assemble a collection that will tell the whole story of this remarkable medical facility that became a community.

Branches of Service

Tatro told BusinessWest he’s been doing extensive research on the history of the Hill since he retired several years ago. He’s put together thick binders of photographs and newspaper clippings — there’s one with stories just from the Gazette that’s half a foot thick — as well as some smaller booklets on individual subjects and personalities.

Including one Cedric (Sandy) Bevis.

There’s a memorial stone erected to him in what’s known as Overlook Park, created with the help of that 12 feet of earth scraped off the top of the hill. Tatro found it while out on one of his many walks over the grounds, and commenced trying to find out who Bevis was (he died in 1981) and why there was a stone erected in his honor.

But no one seemed to know.

So Tatro commenced digging and found out that Bevis was a Marine officer who served in Vietnam as a helicopter pilot. He had been shot down more than once but survived. After attaining the rank of lieutenant colonel, he left the service in June 1971, married, and settled in the Florence area. As a Marine Reservist, he got involved with a Vietnam veterans organization called ComVets (short for Combat Veterans) at the VA Hospital and was elected its first president.

“He was honored for his impact on other Marines who were part of ComVets, and they initiated and obtained a plaque for him,” said Tatro, adding that the saga of Sandy Bevis is one of thousands of individual stories written over the past 95 years. And those at the VA facility are going about the process of writing thousands more.

The last line on Bevis’ plaque reads, “He served when called.” So did all those all others who have come to the Hill since the gates opened in 1924. That’s why it was built, and that’s why it’s readying itself for a second century of service.

George O’Brien can be reached at [email protected]

Health Care

Combating ‘Hair Interruption’

By Mark Morris

Joan Quinn, coordinator of the Wig Boutique at the Cancer House of Hope in West Springfield.

Joan Quinn, coordinator of the Wig Boutique at the Cancer House of Hope in West Springfield.

When a cancer patient goes through chemotherapy treatment, feelings of nausea, fatigue, and hair loss are all common physical reactions. For women, loss of hair often adds an emotional element of humiliation and shame.

“I don’t call it hair loss; I call it hair interruption,” said Joan Quinn, coordinator for the Wig Boutique at the Cancer House of Hope (CHH) in West Springfield, who sees her mission as helping women look good and feel better about themselves while their hair grows back.

And she is passionate about her work, as will become abundantly clear.

The Center for Human Development (CHD) runs the Cancer House of Hope as a free community resource to provide comfort and support in a home-like atmosphere for anyone going through cancer treatment. Yoga classes and Reiki massage are among the many services offered there.

As for wigs … Joseph Kane, former director of the Cancer House of Hope (he left that position for another opportunity earlier this month), admits that, while they’ve always been available, they were often treated as an afterthought.

“If someone asked for a wig, we’d pull one out of a plastic tub, and it usually looked like it had bed head; it wasn’t ideal,” he said, adding that this important service has come a long way in recent years thanks to Quinn, who not only provided the drive to create and stock a boutique where there was none, but also staff it with volunteers, maintain a steady inventory, and raise needed funding to keep the operation thriving.

Our story begins with a visit to CHH by one of Quinn’s neighbors, who left her tour thinking that the wig service, such as it was, needed serious help, and that Quinn, a cosmetology-field veteran of more than 50 years who spent 26 years teaching the subject at Springfield Technical Community College, was just the person to provide that help.

“If someone asked for a wig, we’d pull one out of a plastic tub, and it usually looked like it had bed head; it wasn’t ideal.”

“My neighbor said, ‘oh, Joan, I know your standards, and this doesn’t meet them. You should stop in and see them.’”

She did, and this was, coincidentally, after an answered prayer left her looking for a way to give back — and in a big way.

Indeed, a few years earlier, Quinn’s son suffered from a heart condition that required a transplant. As he was living in Iowa City, Quinn flew there to help. “During that time, I prayed that he would receive a heart transplant and promised God that, if he lived, I’d give back tenfold.”

Her son did receive a transplant and is healthy today.

Feeling that she now had to deliver on her promise, Quinn had no idea how she could help the American Heart Assoc. But when the need for a better wig situation presented itself at CHH, she knew immediately she could make a difference.

And she has. Now in operation for more than three years, the Wig Boutique is currently booking appointments five days a week with three volunteer consultants. Quinn estimates the facility has provided more than 300 wigs for cancer patients since opening.

For this issue and its focus on healthcare, BusinessWest explores how the Wig Boutique came to be and why the services it provides are so important to women battling cancer.

Root of the Problem

As she retold the story of how the boutique was launched, Quinn noted that, under some health-insurance plans, cancer patients can purchase a wig and get reimbursed after the fact. In order to be covered under MassHealth, cancer patients must travel to its contracted wig provider located in Worcester.

When Kane learned that three wig providers in the area went out of business, the thought of a dedicated wig program began to sound like a viable idea.

“When I met Joan, she had a vision to make the wig boutique feel like a higher-end service,” Kane said. Likewise, Quinn credits Kane for what she called his “blind faith” that she could convert one of the rooms in the Cancer House of Hope into a boutique on a zero budget.

Volunteer Jan D’Orazio in the Wig Boutique.

Volunteer Jan D’Orazio in the Wig Boutique.

The energetic Quinn began by figuring out how many wigs CHH had and how to get them into presentable shape. Tapping into her network, she convinced her former teaching colleagues at STCC to open their cosmetology classrooms during summer break and made arrangements to have 110 wigs washed. “We even brought in people who didn’t know how to wash wigs, but we taught them.”

Now with a starting inventory, Quinn needed to purchase shelving material and clean lighting for the room. “It had to be organized, and it had to be cheerful,” she explained. “I could not envision people coming in to look through a tub of wigs.”

Before she even had shelves, Quinn approached local businesses and asked them to sponsor $20 shelf tags to be placed in front of each displayed wig. In a short time, she raised enough to pay for the building materials.

While planning the design of the room at the Home Depot, Quinn lamented that she had enough money for materials but not enough to cover labor. The Home Depot associate told her about a program the store sponsors where it would pay for the labor as a donation, a big step toward executing Quinn’s vision.

The finished room resembles a true boutique, displaying 59 wigs under clean lighting with a fitting chair and a full-length mirror. Kane said the boutique provides a unique experience for cancer patients.

“It gives someone who is losing her hair a chance to come in, meet with a professional, and leave with something that does not look like a wig — all for free,” he told BusinessWest. “It’s really powerful.”

When women first come in for a consultation, Quinn said, they are often reliving the horror of having cancer and confronting the reality of their hair falling out.

“Many of the women we see are depressed and fearful of taking off their head covering,” Quinn said. “While we can’t take away their fear, we reassure them that we work with many people in their situation and that this is a safe place.”

She added that the dozens of wigs displayed in the room help to shift the women’s focus away from themselves and onto which style of wig they might want.

“Current wig styles change quickly, so we’re always looking for new styles and quality wigs,” she noted, adding that she approached Sally’s Beauty Supply in West Springfield and left her name on a piece of paper to call if they ever had wigs they wanted to donate. The manager of Sally’s happened to pin Quinn’s contact information on a bulletin board, and one day, when the company discontinued its line of high-end wigs, Quinn got the call and filled two shopping carts with donated wigs. In addition to local donations, CHH receives wig and accessory donations from as far away as North Carolina and California.

Quinn told BusinessWest she is grateful for her network of volunteers and professionals, whom she refers to as her “angels.” She works with many salons in the area whose owners are often former students.

Quinn approached salons with a fundraising idea for the Wig Boutique called “Hang Cancer Out to Dry,” consisting of a small, desk-sized clothesline where customers can attach cash donations with miniature clothespins.

“In its first 17 months, this effort has raised more than $10,000,” Quinn said, adding that it’s not unusual for a salon owner to raise $300 from customer donations and then match it with a $300 donation of their own.

While Quinn pursues donations with great drive and enthusiasm, she also goes after volunteers the same way. Jan D’Orazio was shopping for Christmas decorations at Michael’s when Quinn approached her and asked if she was a hairdresser. D’Orazio replied that many years ago she was, but hadn’t done it in a long time.

“I must have been having a good hair day, because the next thing I knew, Joan was showing me pictures of the boutique on her iPad and encouraging me to join her,” said D’Orazio. “By the time I got to my car, I said, ‘what did I just agree to do?’”

Quinn freely admits she chased down D’Orazio and is glad she did. “Jan is very calm, and she makes people feel comfortable.”

Joni Provost also works with D’Orazio and Quinn as a volunteer coordinator for the Wig Boutique. The three women provide consulting services on selecting wigs. They do not cut or style the wigs, but encourage having that done at a hairdresser. Quinn said sometimes a woman brings along her hairdresser to the boutique. “We want people to feel this could be their hair and their length.”

A Cut Above

D’Orazio said one of the most rewarding parts of working at the Wig Boutique is seeing her clients change in demeanor.

She said many women who come in are feeling down and have what she described as a “cancer look.” The consultation helps to brighten their day and change their whole outlook.

“Last week, a lady came in who is fighting her third bout with breast cancer. When she was getting ready to leave, she was so happy and told me, ‘I feel like Cinderella; I don’t look like I have cancer anymore.’”

Those sentiments speak to how the boutique is providing not only hair and a certain look, but a chance for women to feel better about themselves as they confront perhaps the most difficult time in their lives.

Thus, it’s changing lives in a profound way.

Health Care

Under Pressure

A changing healthcare landscape has doctors feeling stressed, unsatisfied, and burned out like never before — and that could have dire effects on patient care. That’s why the industry is focused on diagnosing the problem and prescribing remedies.

Every day, patients rely on doctors to tackle their chronic health and wellness issues and make them feel better.

But what if it’s the doctors feeling miserable? Or stressed-out, anxious, and overwhelmed? Unfortunately, that’s happening constantly.

Burnout among physicians has become so pervasive that a new paper recently published by the Harvard T.H. Chan School of Public Health, the Harvard Global Health Institute, the Mass. Medical Society, and the Mass. Health and Hospital Assoc. deems the situation no less than a public health crisis.

“A Crisis in Health Care: A Call to Action on Physician Burnout,” as the document is titled, includes a number of strategies aimed at curbing the prevalence of burnout among physicians and other care providers, including improvements to the efficiency of electronic health records (EHRs), proactive mental-health treatment and support for caregivers experiencing burnout, and the appointment of an executive-level chief wellness officer at every major healthcare organization (much more on all of these later).

But the report also details just how extensive the problem is, and why it should be a concern for patients. In a 2018 survey conducted by Merritt-Hawkins, 78% of physicians said they experience some symptoms of professional burnout — loosely described in the survey as feelings of emotional exhaustion, depersonalization, and/or diminished sense of personal accomplishment.

Physicians experiencing burnout are more likely than their peers to reduce their work hours or exit their profession. And that’s concerning in itself; the U.S. Department of Health and Human Services predicts a coming nationwide shortage of nearly 90,000 physicians, many driven out of practice due to burnout.

“The issue of burnout is something we take incredibly seriously because physician well-being is linked to providing quality care and favorable outcomes for our patients,” said Dr. Alain Chaoui, a practicing family physician and president of the Massachusetts Medical Society. “We need our healthcare institutions to recognize burnout at the highest level, and to take active steps to survey physicians for burnout and then identify and implement solutions. We need to take better care of our doctors and all caregivers so that they can continue to take the best care of us.”

Dr. Alain Chaoui

Dr. Alain Chaoui

 “We need to take better care of our doctors and all caregivers so that they can continue to take the best care of us.”

While some have pointed to the passage of the Affordable Care Act (ACA) in 2010 — the most significant recent change in the American healthcare landscape — as a stressor, the roots of the crisis date further back, the report notes. For example, EHRs, mandated as part of the 2009 Reinvestment and Recovery Act, have dramatically changed the way doctors allot time to their jobs. And the 1999 publication of the Institute of Medicine’s “To Err is Human” report, highlighting the prevalence of medical errors, directed new attention to the need for quality improvement, physician reporting, and accountability — and brought heightened pressure.

In the past, the report notes, some have proposed ‘self-care strategies’ — such as mindfulness or yoga — as a response to burnout and presented some evidence of limited success with such approaches. However, physicians typically don’t have time to fit such coping strategies into their routine. They also don’t really address root problems.

“Such an approach inaccurately suggests that the experience and consequences of burnout are the responsibility of individual physicians,” it continues. “This is akin to asking drivers to avoid car accidents without investing in repairing and improving hazardous roads. Simply asking physicians to work harder to manage their own burnout will not work.”

Digital Dilemma

As the report noted, a broad consensus has formed that a major contributor to physician burnout is dissatisfaction and frustration with EHRs, which have become ubiquitous in recent years. While the goal of transitioning to electronic records has been to improve quality of care and patient communication, the results have been mixed at best.

“The growth in poorly designed digital health records and quality metrics has required that physicians spend more and more time on tasks that don’t directly benefit patients, contributing to a growing epidemic of physician burnout,” said Dr. Ashish Jha, a VA physician and Harvard faculty member. “There is simply no way to achieve the goal of improving healthcare while those on the front lines — our physicians — are experiencing an epidemic of burnout due to the conflicting demands of their work. We need to identify and share innovative best practices to support doctors in fulfilling their mission to care for patients.”

As Dr. Atul Gawande, a Massachusetts surgeon, writer, researcher, and CEO of the nonprofit healthcare venture formed by Amazon, Berkshire Hathaway, and JP Morgan Chase, recently described it, “a system that promised to increase physicians’ mastery over their work has, instead, increased their work’s mastery over them.”

That’s because the patient encounter is now dominated by the demands of the EHR, undermining the crucial face-to-face interaction that has long been at the core of a satisfying doctor-patient encounter, the report notes, adding that, “for many physicians, EHRs impose a frustrating and non-intuitive workflow that makes excessive cognitive demands and detracts from, rather than reinforces, the goals of good patient care.”

Dr. Ashish Jha

Dr. Ashish Jha

 “The growth in poorly designed digital health records and quality metrics has required that physicians spend more and more time on tasks that don’t directly benefit patients.”

In addition, the quantity of mandatory documentation imposed by EHRs — due to regulatory and payer requirements — means physicians typically spend two hours doing computer work for every hour spent face to face with a patient, including numerous hours after work. And they’re frustrated by spending so much time on administrative tasks they feel have little to do with actual patient care.

One promising solution, according to the report, would be to encourage software developers to develop a range of apps that can operate with most, if not all, certified EHR systems.

Improved EHR usability is, in fact, required by law. The 21st Century Cures Act of 2016 mandates the use of open health care APIs (application programming interfaces), which standardize programming interactions, allowing third parties to develop apps that can work with any EHR. This would allow physicians, clinics, and hospitals to customize their workflow and interfaces according to their needs and preferences, promoting rapid innovation and improvements in design.

Another promising but less-developed approach to reducing the HER burden on physicians, the report notes, is the development of artificial intelligence (AI) technologies to support clinical documentation and quality measurements.

Mind Matters

The report spends plenty of time on mental health, and for good reason.

“It is clear that one can’t have a high-performing healthcare system if physicians working within it are not well,” it notes. “Therefore, the true impact of burnout is the impact it will have on the health and well-being of the American public.”

To that end, it calls on hospitals and other healthcare organizations to improve access to, and expand, health services for physicians, including mental-health services — while reaching out to doctors and encouraging them to take advantage of such services in order to prevent and manage the symptoms of burnout.

That’s easier said than done, of course, as a stigma still exists around seeking help for mental-health issues.

“Physician institutions — including physician associations, hospitals, and licensing bodies — should take deliberate steps to facilitate appropriate treatment and support without stigma or unnecessary constraints on physicians’ ability to practice,” the report argues.

Last year, the Federation of State Medical Boards (FSMB) adopted a policy reconsidering ‘probing questions’ about a physician’s mental health, addiction, or substance use on applications for medical licensure or renewal, as the existence of such questions may discourage physicians from seeking treatment. “To the extent that such questions are included,” the report says, “those questions should focus on the presence or absence of current impairments that impact physician practice and competence, in the same manner as questions about physical health.”

The FSMB is also calling for state medical boards to offer ‘safe-haven’ non-reporting to applicants for licensure who are receiving appropriate treatment for mental health or substance use. Such non-reporting would be based on monitoring and good standing with the recommendations of the state physician health program (PHP).

Speaking of which, Physician Health Services Inc. (PHS) — a charitable subsidiary of the Massachusetts Medical Society that serves as the PHP for Massachusetts physicians — intends to reach out in a broader way to physicians and hospitals to encourage doctors dealing with burnout and behavioral-health issues to seek appropriate and confidential care.

“Many PHPs in other states have expanded their outreach,” the report notes. “Hospitals and other healthcare institutions should complement and support this effort by acknowledging physicians’ concerns with seeking mental healthcare and clearly identifying avenues and opportunities to receive confidential care, particularly for residents and trainees, who are at a vulnerable stage of their careers.

Finally, the report calls for the appointment of executive-level chief wellness officers (CWOs) at all healthcare organizations. “CWOs must be tasked with studying and assessing physician burnout at their institutions, and with consulting physicians to design, implement, and continually improve interventions to reduce burnout.”

“Patients do not like being cared for by physicians who are experiencing symptoms of burnout, which is significantly correlated with reduced patient satisfaction in the primary-care context. Evidence further suggests that burnout is associated with increasing medical errors.”

The key responsibilities of the chief wellness officer, in addition to acting as an advocate and organizational focal point, may include studying the scope and severity of burnout across the institution; reporting findings on wellness and physician satisfaction as part of institutional quality-improvement goals; presenting findings, trends, and strategies to CEOs and boards of directors; and exploring technological and staffing interventions like scribes, voice-recognition technology, workflow improvements, and EHR customization to reduce the administrative burden on doctors, just to name a few.

CWOs could benefit physicians not just in hospitals, the report continues, but across health systems, and in affiliated practices. “Departments, units, and practices can survey for burnout, begin to identify their areas of focus and barriers to success, and collectively develop solutions. The CWO can help lead this process and provide best practices and other supports.”

Lives in the Balance

In the end, physician burnout is a problem with many triggers, which is why the authors of “A Crisis in Health Care” encourage a multi-pronged approach to counter it. But it’s also an issue with many potential consequences, not just for doctors and their employers.

“Patients do not like being cared for by physicians who are experiencing symptoms of burnout, which is significantly correlated with reduced patient satisfaction in the primary-care context,” the report notes. “Evidence further suggests that burnout is associated with increasing medical errors.”

Dr. Steven Defossez, a practicing radiologist and vice president for Clinical Integration at the Massachusetts Health and Hospital Assoc., said hospitals in the Commonwealth place a high priority on the safety and well-being of patients, so combating burnout will continue to be an area of focus.

“In particular, we recognize the need to further empower healthcare providers and support their emotional, physical, social, and intellectual health,” he said. “This report and its recommendations offer an important advance toward ensuring that physicians are able to bring their best selves to their life-saving work.”

Joseph Bednar can be reached at [email protected]

Health Care

Progressive Course

Laura Hanratty

Laura Hanratty says the number of BCBA students has probably doubled since 2012, a clear sign of growing need for such trained individuals.

In many cases, Alyssa Clark says, progress — in whatever way it is measured — comes slowly.

But in most all cases, it does come, and when it does, it quickly reminds her why she chose this career path — not that she ever really forgets.

Clark was talking about her work as a board-certified behavior analyst, or BCBA, as those with the requisite credentials are called. She works in a few area elementary schools with students in grades K-4. Some are on the autism spectrum, but all of them are defined with an industry term of sorts: social/emotional, which means they have behavioral issues, usually brought on by trauma in their backgrounds — poverty, divorce, or being in foster care, for example.

“Sometimes, progress is slow in coming, but even the little things you see … kids might have that one good day after several bad ones,” she told BusinessWest. “And to be able to see that and know that you could make a difference in that kid’s life and help them…”

She didn’t actually finish the sentence, because she didn’t have to. The satisfaction that comes with such work is clearly apparent. And it is one of many reasons why applied behavior analysis (ABA) is becoming an increasingly popular career path within the broad spectrum of healthcare, and also why programs such as the master’s in ABA program at Elms College in Chicopee, which Clark graduated from recently, were created and continue to see growth in enrollment.

“Every kid that we work with should go through an analysis to determine why problem behaviors are occurring, and then treatment based on that analysis helps address those behavioral concerns.”

But the biggest factor is growing need within the community, said Laura Hanratty, assistant professor and director of both the ABA and ASD (autism spectrum disorders) programs at Elms.

“It’s definitely a growing field,” she said, noting that, when she sat for the certification exam in 2012, there were roughly 10,000 BCBAs in this country; now, there are perhaps twice that number.

Why? The ever-growing number of people diagnosed with autism is a big factor, she said, adding that there are many theories surrounding this surge, but the prevailing one is that there is simply more awareness of the condition and, therefore, more early diagnosis.

But the nature of applied behavior analysis, and the tremendous rewards, as Clark described, are also a factor in the growing popularity of this profession.

When asked to elaborate, Hanratty said there is a good deal of science, some of it rigid in nature, in this field. But there are also large amounts of creativity, and this blend of ingredients appeals to many people looking to enter the broad realm of healthcare.

“What we try to teach our students to do is become a scientist practitioner,” she went on, adding that there is much that goes into that phrase. “Every kid that we work with should go through an analysis to determine why problem behaviors are occurring, and then treatment based on that analysis helps address those behavioral concerns.

“We know that attention and rewards help increase behaviors,” she went on. “So what our students do is take that science side, but then then get really creative and personalize with our kids.”

This ability to be creative is what appeals to Rachel Reyes, currently enrolled in the Elms master’s degree program and working part-time with young people through a company called Positive Behavior Supports Corp. (PBS). She has one client, a 4-year-old with autism she sees three times a week.

“I’m working one-on-one with a child a lot, and that’s what I love most about this work,” she said, adding that she aspires to become a BCBA. “I get to see them grow, I get to see their progress, and I get to know them; I build a relationship with them first so they they’ll trust me.”

For this issue and its focus on healthcare, BusinessWest takes an in-depth look at the ABA offering at Elms. In the course of doing so, we’ll explain why the program, and the careers it can lead to, have attracted people like Clark, Reyes, and many others.

Down to a Science

When asked how she got onto the path to becoming a BCBA, Clark said a single course on applied behavior analysis she was taking during her undergraduate work at the Elms opened her eyes and changed her career focus.

Alyssa Clark

Alyssa Clark, seen here at the Applied Behavior Analysis International Conference in San Diego earlier this year, says there are many rewards from her work as a BCBA.

“I was in the speech language pathology program,” she recalled. “They mentioned applied behavior analysis; that one class really stuck with me. I knew I always wanted to work with this population of kids, whether it was kids on the autism spectrum or kids with disabilities. So I looked into it more and I saw the behavior side of things, and I loved it.”

Reyes tells a somewhat similar story. She was doing undergraduate work at Westfield State University, studying special education. She had come to the conclusion that she didn’t want to teach and took an introductory course in ABA.

“Prior to creation of this program, there was a master’s in autism spectrum disorders, which was also behavior-analytics-focused, but a little more broad. What we found is that most people who are coming into the program are really interested in the behavior-analysis side, so that’s where most of our students are now.”

“The professor was great — when she would teach, everything was amazing,” she recalled. “I thought about things some more, went to her office, and asked if there were any graduate programs in the field, because I realized that this is what I wanted to do. She told me about Elms.”

Hanratty said many of the students now in the ABA program arrive via a somewhat similar experience, and this helps explain the creation of the master’s program, which accepted its first cohort in 2017.

“Prior to creation of this program, there was a master’s in autism spectrum disorders, which was also behavior-analytics-focused, but a little more broad,” she explained. “What we found is that most people who are coming into the program are really interested in the behavior-analysis side, so that’s where most of our students are now.”

Rachel Reyes, a student in the Elms ABA program

Rachel Reyes, a student in the Elms ABA program, says she enjoys working one-on-one with children.

Students enter the program with a wide diversity of backgrounds, she went on, adding that there are many with a psychology or communications sciences background, who took their undergraduate focus on speech disorders and shifted it to behavioral analysis.

But there are others with backgrounds in education, sociology, social work, and other fields.

“We also get some students who earned their bachelor’s degree in … whatever, and then found a passion for working with kids with autism,” she went on, adding that enrollment in the master’s program fluctuates, but it averages about 17. The smaller size of the cohorts — and the classes themselves — appeal to many students because of the one-to-one support from faculty members.

As she mentioned earlier, ABA is a blend of science and creativity that addresses a range of recognized behavioral issues in people of all ages.

“ABA is based on basic science principles,” Hanratty explained. “We take the basic principles of behavior and apply them to promote changes in behavior among children with autism or behavior concerns. Our students get to take that science and apply it.”

Practitioners use reinforcement — giving some kind or reward or positive contingency — for appropriate behaviors, as well as strategies for reducing inappropriate behaviors.

When asked for an example, she cited a research project she worked on with several of her students, including Clark. Together, they gave a presentation on their work at the Applied Behavior Analysis International Conference in San Diego earlier this year, and also at the Berkshire Conference for Behavioral Analysis.

The project involved one young person exhibiting problem behaviors, said Hanratty. “We did an analysis and found that kids were engaging in severe problem behavior usually to gain some control over their environment — they want to take a break from adult-led activities and just have time to do their preferred activities.

“We taught the kids to ask for control, and then we would reward that, with them being able to have ‘their-way’ time,” she went on. “We gradually started saying, ‘you can’t have your way right now; it’s adult time, and you need to do X,Y, and Z.”

Eventually, the students would come to understand that they can’t always have ‘their-way’ time when they asked for it, and would acquiesce to adult-led activities without immediate reward or reinforcement.

Such progress was noteworthy, because these were students who were engaging in severe problem behaviors, said Hanratty, adding that they would (note the past tense), when asked to do an instruction, aggress toward adults and engage in self-injurious behaviors.

“We were making really impactful outcomes for families,” she told BusinessWest. “It was very rewarding work.”

And just one example of how to blend science and creativity, she went on, adding those attracted to this work now have a number of attractive career options.

These include work in school systems and specifically in special-education classrooms, but also, and increasingly, in the home, working with both children and their families. Others open their own private practices or conduct research. With a doctorate, which some go on to attain, they can teach in the field.

Meanwhile, many students, like Reyes, are finding work in the field, or, in this case, the home, as they’re earning their master’s degree.

“I’d love to stay in the home; I love the home setting,” she said, adding that she enjoys working with not only the child, but the family as a whole.

Bottom Line

Such sentiments, such passion for this demanding yet rewarding work, help explain the growth of the ABA field and programs like the one at Elms.

As Hanratty and her students noted repeatedly, applied behavior analysis is indeed an intriguing blend of science and creativity, a rare mix that is gaining the attention of people from diverse backgrounds and putting them onto the path of becoming a BCBA.

And also opening doors to a wide mix of fulfilling careers.

Health Care

Healthy Development

Baystate Health & Wellness Center in Longmeadow held a grand-opening and ribbon-cutting ceremony on Feb. 25. The $11 million, 54,000-square-foot medical office building offers primary and specialty care, as well as services like Baystate Reference Laboratories and Baystate Radiology and Imaging.

State legislators present Baystate leaders, including President and CEO Mark Keroack (center), citations on the grand-opening occasion

State Sen. Eric Lesser and Keroack share a moment before the event

State Sen. Eric Lesser and Keroack share a moment before the event

The ribbon-cutting ceremony

The ribbon-cutting ceremony

Dr. Elizabeth Boyle chats with state Rep. Angelo Puppolo

Dr. Elizabeth Boyle chats with state Rep. Angelo Puppolo

The back entrance to the new facility at 21 Dwight Road

Health Care

Game Plan

By Mark Morris

James Ferry, certified aging life care manager at Coaching Caregivers Inc.

James Ferry, certified aging life care manager at Coaching Caregivers Inc.

Many adults take on the role of caregiver for an aging parent, but few are prepared for what’s actually involved in taking on that all-important assignment.

What starts out as a trip to the grocery store or a ride to the doctor’s office can, and very often does, become overwhelming when the parent has a medical crisis or other event where their needs suddenly change.

“It often begins with a hospitalization,” said James Ferry, who manages Coaching Caregivers Inc. in Northampton. “Let’s say your mom is admitted for a urinary-tract infection. After a short stay at a skilled-nursing facility, your family is told that she can no longer stay home alone.”

If the family is local, he went on, an adult child, usually a daughter, typically tries to be the caregiver. But as she tries to balance her mother’s care needs with holding down a job and taking care of her own family, burnout inevitably sets in.

And that, unfortunately, is the time when many families usually reach out for help.

“They come to me when they’re exasperated,” said Ferry, a certified aging life care manager with more than 25 years of experience and an advanced degree in social work. He sees his role as someone who helps navigate the complexities of elder care to relieve the family’s burden and develop a course of action that provides a quality life for the elder parent.

He’d rather get involved before people become exasperated, but human nature often precludes that from happening. Regardless of when he does get involved, the goal is the same — to come up with a care plan that works for both the elder parent and the caregiver.

It’s an art and a science, he says, that brings many rewards.

The Big Picture

In order to develop a plan, Ferry starts by doing an assessment.

“I’ll visit the elder in their home and ask them to tell me their family story,” he explained. “At the same time, I’m listening for what’s going on emotionally and with their mental processing. Then we might take a tour around the home to see how they maneuver in that environment, how safe it is, and how realistic is it for them to remain in the home.”

After the assessment, Ferry develops a care plan to best meet the elder’s needs. The plan can range from a few basic services on an as-needed basis to a more substantial plan that provides daily services.

Arranging for help with even simple tasks can provide great relief for the family, he added. “There’s a big difference between having nothing and having a person in place for grocery shopping, doctor’s appointments, or just to walk the dog.”

For more intensive needs, Ferry will often recommend a plan that functions like assisted living, but takes place in the person’s home and still allows for family to be involved.

He refers to this type of plan as a “split-shift approach” in which a caregiver arrives in the morning around 8 a.m. to help the elder client with bathing, getting dressed, and eating breakfast. Then the caregiver will make lunch, clean up after lunch, and leave. The client has the afternoon to themselves to watch TV, catch up with friends, or take a nap. The elder can be alone during this time because they will have a lifeline-type device in the event of an emergency.

A second caregiver arrives around 5 p.m. to prepare dinner, do the cleanup afterward, and help get the client get ready for bed.

“With a plan like this, you can cover the whole day with only seven or eight hours of care,” he explained. “This approach is much less expensive than an assisted-living facility and provides a much higher quality of life for the client.”

This type of plan reflects the current trend of ‘aging in place,’ where services that were once provided in a facility are now delivered in the home. In recent years, home-healthcare agencies have seen strong growth because their services can cost much less than an admission to a long-term-care facility. In addition, studies have shown that people enjoy better quality of life when they can stay in their home and follow their own schedule.

In addition to health concerns, caring for an aging parent also involves financial, legal, and other issues. During this time, family dynamics can bring out a whole new level of stress. “If a family member has a resource agenda, such as the parent’s house or some cash, they could potentially subvert a plan of care because they see it as less going to them.”

Ferry’s role in these situations, he explained, is to be a facilitator who helps the family reach common ground and remind everyone of what’s best for their parent.

Age-old Concerns

The need for the services provided by Coaching Caregivers and similar businesses is sure to increase as more people than ever before are living longer in retirement. According to the U.S. Census Bureau, a 65-year-old couple has a 50% chance of one of them living to age 93, and a 20% chance that one of them will reach age 97.

“I work with a lot of people in their 90s who need some help, but clearly do not need a nursing home,” Ferry said, noting that, 25 years ago, far fewer people lived past age 90.

When an aging parent is living a vital and independent life, it’s easy to avoid an elder-care discussion, but he said that’s the time to do it. As difficult as it is to start the conversation with a healthy parent, Ferry said it’s much easier than waiting for a crisis when significant decisions about care must be made under stress.

“When people are desperate for help, they don’t have the capacity to shop around. Instead, they listen to the first person who can offer a solution,” he noted, which may not be in the elder’s best interest.

Ferry counsels people to ask many questions before selecting a caregiver. “Try to get a sense of their reputation. Are they looking out for your parent, or are they steering you to the business they are in?”

There are many professionals who consider themselves care managers, he added, but may represent the interests of an agency or an insurance company. His advice, simply put, is to look for someone who will objectively represent the client’s interests. Once a care plan is in place, he explained, he then takes on the role of ‘consumer advocate’ for the client to make sure they get the services they were promised.

“Professionals like me have no bias for a particular course of action,” he told BusinessWest. “I have relationships with many home-care and assisted-living agencies, as well as other professionals I can recommend. My only interest is what’s best for my individual client.”

Health Care

Lean — But Not Mean

Mark Fulco in the ‘Mission Control’ room at Mercy Medical Center.

Mark Fulco in the ‘Mission Control’ room at Mercy Medical Center.

‘Lean.’ ‘Six Sigma.’ ‘Gemba walks.’ These are terms and phrases, used traditionally on manufacturing shop floors, in relation to continuous improvement initiatives and efforts to take waste out of processes. Today, they’re being heard more in the healthcare realm, and especially at Mercy Medical Center, where efforts are ongoing to improve efficiency without impacting quality of care.

The sign on the door says ‘Mission Control.’

That’s a play on words, obviously. There’s a definite nod to NASA and its famous control room, where decisions were made, and moonshots were choregraphed. But that word ‘mission’ takes on a different, higher meaning at Mercy Medical Center, part of Trinity Health Of New England. The hospital was founded more than 125 years ago by the Sisters of Providence, and its mission to care for the region’s population, and especially those who are traditionally underserved, has been paramount and in most ways more important than the bottom line.

But these days, the mission is being carried out in a different way, said Mark Fulco, president and CEO at Mercy, who recently marked a year at the helm. He noted that, in many ways, the hospital, and the Trinity system on the whole, are taking cues from the auto industry and other business sectors and taking a Six Sigma approach to healthcare — a lean approach, one that manifests itself in a number of ways.

But the major focus is on making the medical center more efficient in ways that will reduce costs without sacrificing quality.

“It’s been a watershed for us, because it has changed our work and has helped us focus on key metrics to drive efficiencies.”

“It’s been a watershed for us, because it has changed our work and has helped us focus on key metrics to drive efficiencies,” said Fulco, adding that the hospital’s efforts to become leaner are reflected in everything from reduced wait times in the ER to an increase in the number of discharges over last year by staffing up more beds; from reducing the overall cost of each discharge by roughly $1,100 to cutting back on travel by using videoconferencing technology.

Overall, Mercy and the Trinity system are eliminating waste whenever possible, creating efficiencies in every department, and constantly looking for ways to improve service without impacting quality of service.

This work extends all the way down to the medical center’s printers and copiers, the number of which has declined noticeably over the past year or so.

“We’ve gone very much paperless,” Fulco explained. “We had two big meetings this morning, and instead of printing out huge packets of information, we did it electronically and on large monitors.

“It’s unbelievable what a color copy costs these days, and when you produce lots of color copies with charts and graphs, it costs a lot of money,” he went on. “So we’ve actually taken printers away and put codes on some of our printers so departments are accounting for every color copy they make.”

This focus on lean practices and accountability brings us back to the room behind the door bearing the sign that says ‘Mission Control’ and its co-called ACE (achieving clinical excellence) boards that track progress in specific areas.

They are part of what is now known as the Trinity Health Management System, or lean daily management, an operating philosophy, if you will, that we’ll explore in greater detail later.

It also brings us to the large conference room, also known as the Patient Safety and Flow Room, a few hundred paces away. Here, each day at 8 a.m. (no one is typically late, because if they are, they have to walk into a room filled with people who were on time), as many as 50 people gather for what are known as ‘huddles.’

These are strategy sessions where issues are discussed, problems are identified, and solutions generated, said Fulco, who offered an example.

“We have several huddles every morning, and one of them is our ‘tier 3 huddle,’ where we bring together leaders from across the entire hospital,” he explained. “The very first thing we talk about is patient safety or problems that came up the night before, or safety catches — like if something was a near-miss — because we want to know, first and foremost, what we need to do to be better and keep patients safer.

“That’s our early-warning system,” he went on. “And at the meeting, if we have a detected infection, we report it, and then we talk about what we can do to prevent another case like that from happening.”

For this issue, BusinessWest looks at Mercy’s broad efforts to employ the principles of Six Sigma and become, in keeping with its mission, lean but certainly not mean, at least in a very literal sense.

Work in Progress

They’re calling it the ‘29-minute pledge.’

That number is significant because of its specificity, meaning it’s not the ‘30-minute pledge,’ a much rounder number to be sure.

It refers to the maximum time it will take for someone visiting Mercy’s Emergency Department to see a physician or physician’s asistant, and this pledge is due to be launched in the coming weeks and announced with billboards and other forms of advertising.

“We’re pledging a door-to-provider time, in our emergency room, of 29 minutes,” Fulco explained, adding that the program has essentially been rolled out already, but the billboards won’t be going up for another few weeks. “We chose 29 minutes because it represents an average of what we can hold out as a pledge; there are times when we’ve averaged 16 minutes.”

The 29-minute pledge is a another example of Mercy’s efforts to improve quality of service while also becoming more efficient and taking cost out of the equation, said Fulco, noting that it is one of many initiatives put in place during what has been a very intriguing and challenging (he would use that word early and quite often, and usually with at least one ‘really’ in front of it) first year at the helm — and year for all those who provide healthcare.

He would sum it all up, sort of, by saying, “I knew what I was getting into — I knew it was challenging; it’s just been more work than I expected — not in a bad way, but in a good way, because it’s been a labor of love.”

What he was getting into is a very demanding climate for not just Mercy but all healthcare providers, one in which reimbursements for services provided, especially from public payers including Medicaid and Medicare, do not really come close to covering the cost of those services.

This disparity is especially large in the broad realm of behavioral health, Fulco noted, adding quickly that, through its facilities at Providence Behavioral Health Hospital, the Trinity Health system is the region’s leading provider of such services.

And these are services that are, from a purely bottom-line perspective, losing propositions, again because the cost of care is not being met by those paying for it. And while Providence and the Trinity system have always been mission-driven, there comes a point where the losses being incurred cannot be sustained, said Fulco, adding that this reality explains why there were inevitable cutbacks at Providence, and in other departments under the Mercy/Trinity umbrella as well.

Mission Control is part of an effort to bring the principles of Six Sigma to Mercy Medical Center.

Mission Control is part of an effort to bring the principles of Six Sigma to Mercy Medical Center.

“We had to make some tough decisions — the status quo simply doesn’t work,” he explained, adding that among these decisions were staffing reductions at Providence (most employees were offered other positions within the system) and cutbacks within or elimination of some departments at Mercy, including the Hearing Center.

While the cutbacks and staff reductions garnered the largest headlines regarding the Mercy system in 2018, a considerable amount of work going on behind the scenes to make the system more efficient, more responsive, and, yes, leaner — efforts like the 29-minute pledge — were perhaps more newsworthy.

As he talked about them, Fulco said these initiatives accurately reflect a system-wide operating philosophy being implemented by Trinity Health Of New England’s recently appointed CEO, Dr. Reginald Eddy, a former emergency-room physician.

“He really gets it,” said Fulco. “He gets it from a care perspective, and he has a strong sense of urgency that he’s really instilled in us in terms of doing it right, doing it well, and doing it quick, not just from a patient perspective, but from a business sense.”

Tracking Improvement

As he talked about the Trinity Health Management System, Fulco said it is focused on quality metrics, or what he called ‘people-centered metrics,’ which are carefully monitored with an eye toward continuous improvement.

As an example, he cited the infection rate, a key issue — and major challenge — for all hospitals.

“Our infection rate has remained below target and below what’s expected for a hospital like Mercy, and is, in fact, one of the 20 lowest infection rates across all the 94 or 95 Trinity hospitals,” he said, using infections from urinary catheters as an example of how Mercy tracks issues and addresses problems.

“Our goal is to be an ‘A,’ and we’re not stopping until we get there, and then we have to stay there, which becomes progressively more difficult.”

Steps such as these have a trackable impact on quality, as measured in a number of ways and by a number of entities, said Fulco, noting that Mercy’s Leapfrog score — its rating based on surveys undertaken by the Washington, D.C.-based Leapfrog Group, improved from ‘C’ to ‘B’ in 2018.

“Our goal is to be an ‘A,’ and we’re not stopping until we get there, and then we have to stay there, which becomes progressively more difficult,” he explained. “But we’ve improved by one whole grade, which is a significant step forward.”

But while quality is certainly an important benchmark, so too is cost, said Fulco, adding that the ultimate goal is to not only improve the overall level of quality but reduce the cost of providing care as well.

“On the cost side, because we’ve been more efficient and we’ve tried to tease out unnecessary expense — and there are several buckets of expense, from labor to non-labor — we have reduced the cost per case by more than $1,100 from last November [2017] to this November,” he said. “And when you multiply that by the 1,400 or so discharges we had, that’s a savings of more than $1.5 million.”

With that, he went to his desk to retrieve the current average cost per discharge, $6,850, a number he had handy, and for a reason — it is carefully tracked, and its downward movement is a source of pride within the system.

It’s been accomplished through a number of means, he said, starting with staffing changes (none at the bedside) that result from consolidation in some areas, such as billing, that are made possible by synergies with the regional Trinity team, thus reducing overhead costs.

Further savings have been achieved on supplies, he said, returning to efforts to go paperless when possible, and also such things as travel expenses.

“We work with people; if they’re printing too much, we take steps to reduce that volume,” he said. “It doesn’t sound like much, but it adds up when you’re saving 50 cents or 75 cents on a print; it adds up over time. And it doesn’t contribute anything to patient care, so we’d rather put the money into patient care than into paper.”

As for travel, it has been cut back as well, he said, noting that meetings between the Mercy team and the system team are now staged electronically. “Instead of having our people drive to Hartford or their people drive here, we’re using technology,” he told BusinessWest.

Huddling Up

As he offered a tour of the Mission Control room, Fulco started by referencing several large charts, called A3 charts, on the wall. Each one outlines an individual’s primary strategic aims, and they are part of the hospital’s lean daily management system.

“An A3 is putting our key objectives and measures all on one page,” he said, referencing his own A3, while noting that the charts track progress toward meeting those specific aims and goals, as laid out in an action plan. “We track this every week; we look at this every week. Every member of the leadership team has one of these.”

And when problems arise at those huddles, as he noted several times, everything is measured.

That goes for efforts to address recognized problems or issues as well, he went on, referring to other charts and the four letters ‘P,’ ‘D,’ ‘C,’ and ‘A,’ which stand for ‘plan,’ ‘do,’ ‘check,’ and ‘act,’ the four stages of tackling a problem, as Fulco identified them.

“This is flowing constantly; it’s changing every day,” he said, adding that the PDCA cycle, as it’s called, was created to generate action on a specific matter and keep things moving.

From Mission Control, the tour moved to the Patient Safety and Flow Room, where there was a comparatively small huddle going on (this was late afternoon). For the 8 a.m. huddles, those assembled have an agenda and start with safety, and move on to a daily operating summary and then performance reports — how well the hospital is doing with patient satisfaction, for example. Next is a round-robin session, at which feedback is sought on problems that have been identified.

But the tier 3 huddle is actually the second step in the process, said Fulco, noting that there are huddles on the departmental level as well. Matters arising at those sessions then come before the larger group, and there is then a Gemba walk. That’s a Japanese term that translates, loosely, into going to the front lines to see what’s going on, to hear from the people involved and come to understand the problem; it is similar in many ways to the concept known as MBWA — managing by walking around.

“A Gemba walk is daily rounding — we’re not sitting in our office or around a conference-room table; where going to see things where they really happen. We’re talking to people who are doing the work, and we’re doing some accountability checks,” said Fulco. “From 8:30 to 9:30 we take that walk, and from there we go to the Mission Control room and do an accountability huddle.

“It’s about getting close to the people,” he went on, “and finding out how we, as leaders, can help them.”

To emphasize these points, he concluded the tour in the Emergency Department, where are charts similar to those in both Mission Control and the Patient Safety and Flow Room.

They track things like wait times and numbers of patients who left without being seen — presumably because the wait times were too long — said Fulco, adding that subsequent huddles and PDCA charts identified the causes of those problems and tracked the success of steps taken to address them.

Healthy Outlook

Gemba walks. PDCA cycles. Huddles. A Mission Control room. These names, acronyms, and places all help explain how, while the mission hasn’t changed at Mercy Medical Center and Trinity Health Of New England, the process of carrying out that mission certainly has.

The emphasis today is on continuous improvement and being lean — without impacting the quality of care being provided at the bedside. As Fulco said repeatedly, in this environment, everything is measured, or charted, and progress is marked daily.

There is considerable work still to be done — this process never actually ends, he said — but progress can be seen in the ER, on the bottom line, and on the charts in the Patient Safety and Flow Room.

It could be seen as paper as well — only they’re using much less of it these days. That’s just part of the process of running lean.

George O’Brien can be reached at [email protected]