Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2017 Rates; Quality Reporting Requirements for Specific Providers; Graduate Medical Education; Hospital Notification Procedures Applicable to Beneficiaries Receiving Observation Services; Technical Changes Relating to Costs to Organizations and Medicare Cost Reports; Finalization of Interim Final Rules With Comment Period on LTCH PPS Payments for Severe Wounds, Modifications of Limitations on Redesignation by the Medicare Geographic Classification Review Board, and Extensions of Payments to MDHs and Low-Volume Hospitals. Final rule.

We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2017. Some of these changes will implement certain statutory provisions contained in the Pathway for Sustainable Growth Reform Act of 2013, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Notice of Observation Treatment and Implications for Care Eligibility Act of 2015, and other legislation. We also are providing the estimated market basket update to apply to the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2017. We are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2017. In addition, we are making changes relating to direct graduate medical education (GME) and indirect medical education payments; establishing new requirements or revising existing requirements for quality reporting by specific Medicare providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities), including related provisions for eligible hospitals and critical access hospitals (CAHs) participating in the Electronic Health Record Incentive Program; updating policies relating to the Hospital Value-Based Purchasing Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition Reduction Program; implementing statutory provisions that require hospitals and CAHs to furnish notification to Medicare beneficiaries, including Medicare Advantage enrollees, when the beneficiaries receive outpatient observation services for more than 24 hours; announcing the implementation of the Frontier Community Health Integration Project Demonstration; and making technical corrections and changes to regulations relating to costs to related organizations and Medicare cost reports; we are providing notice of the closure of three teaching hospitals and the opportunity to apply for available GME resident slots under section 5506 of the Affordable Care Act. We are finalizing the provisions of interim final rules with comment period that relate to a temporary exception for certain wound care discharges from the application of the site neutral payment rate under the LTCH PPS for certain LTCHs; application of two judicial decisions relating to modifications of limitations on redesignation by the Medicare Geographic Classification Review Board; and legislative extensions of the Medicare-dependent, small rural hospital program and changes to the payment adjustment for low-volume hospitals.

[Investigation of the air microbiota in the Saint Petersburg].

UNLABELLED: Microbiological tests of air in hospitals are the very important constituent element in prophylaxis of health care-associated infections. The aim of the study is to assess air in hospitals accordingly to the microbiological standards. The results were analyzed for 1993-2011. There were 0.2-4.2% of the samples that did not meet the standard. The maximum amount of microorganisms was found while SanPiN 2.1.3.1375-03 was effective within validity period SanPiN 2.1.3.2630-10 didn't normalize fungus, resulting in the minimal amount of mold. The frequency of sampling did not affect the result. DISCUSSION: Moulds are the causative agents of invasive fungal infections. Fungi can cause nosocomial infections. There is description of method to isolate fungi in the guidelines for control MUK 4.2.2942-11. CONCLUSION: It is necessary to use a new procedure when assessing the air in hospitals.

Impact of nurse staffing mandates on safety-net hospitals: lessons from California.

CONTEXT: California is the first and only state to implement a patient-to-nurse ratio mandate for hospitals. Increasing nurse staffing is an important organizational intervention for improving patient outcomes. Evidence suggests that staffing improved in California hospitals after the mandate was enacted, but the outcome for hospitals bearing a disproportionate share of uncompensated care-safety-net hospitals-remains unclear. One concern was that California's mandate would burden safety-net hospitals without improving staffing or that hospitals would reduce their skill mix, that is, the proportion of registered nurses of all nursing staff. We examined the differential effect of California's staffing mandate on safety-net and non-safety-net hospitals. METHODS: We used a time-series design with Annual Hospital Disclosure data files from the California Office of Statewide Health Planning and Development (OSHPD) for the years 1998 to 2007 to assess differences in the effect of California's mandate on staffing outcomes in safety-net and non-safety-net hospitals. FINDINGS: The mandate resulted in significant staffing improvements, on average nearly a full patient per nurse fewer (-0.98) for all California hospitals. The greatest effect was in those hospitals with the lowest staffing levels at the outset, both safety-net and non-safety-net hospitals, as the legislation intended. The mandate led to significantly improved staffing levels for safety-net hospitals, although there was a small but significant difference in the effect on staffing levels of safety-net and non-safety-net hospitals. Regarding skill mix, a marginally higher proportion of registered nurses was seen in non-safety-net hospitals following the mandate, while the skill mix remained essentially unchanged for safety-net hospitals. The difference between the two groups of hospitals was not significant. CONCLUSIONS: California's mandate improved staffing for all hospitals, including safety-net hospitals. Furthermore, improvement did not come at the cost of a reduced skill mix, as was feared. Alternative and more targeted designs, however, might yield further improvement for safety-net hospitals and reduce potential disparities in the staffing and skill mix of safety-net and non-safety-net hospitals.

Delegation within municipal health care.

AIM: To describe how registered nurses (RNs) perceive delegation to unlicensed personnel (UP) in a municipal healthcare context in Sweden. BACKGROUND: Within municipal health care RNs often delegate tasks to UP. The latter have practical training, but lack formal competence. METHOD: Twelve RNs were interviewed and the material was analysed using a phenomenographic approach. RESULTS: Owing to a shortage of RNs, delegation is seen as a prerequisite for a functioning organization. This necessity also involves a number of perceived contradictions in three areas: (1) the work situation of RNs - facilitation and relief vs. lack of control, powerlessness, vagueness regarding responsibility, and resignation; (2) the relationship with unlicensed personnel - stimulation, possibility for mentoring, use of UP competence and the creation of fairness vs. questioning UP competence; and (3) The patients - increase in continuity, quicker treatment, and increased security vs. insecurity (with respect to, for example, the handling of medicine). CONCLUSION: Registered nurses perceptions of delegation within municipal healthcare involve their own work situation, the UP and the patients. IMPLICATIONS FOR NURSING MANAGEMENT: Registered nurses who delegate to UP must be given time for mentoring such that the nursing care is safe care of high quality.

Ifema hospital model. Implementation and start-up of the Pharmacy Department.

On the 20th of March 2020, triggered by the public health emergency declared,  the Health Authorities in Madrid reported a legal instruction (Orden 371/2020)  indicating the organization of a provisional hospital to admit patients with  COVID-19 at the Trade Fair Institution (IFEMA). Several pharmacists working in  the Pharmacy and Medical Devices Department of the Madrid Regional Health  Service were called to manage the Pharmacy Department of the  abovementioned hospital. Required permissions to set up a PD were here  authorized urgently. Tackling human and material resources, and computer  systems for drug purchase and electronic prescription, were some of the initial  issues that hindered the pharmaceutical provision required for patients from the  very day one. Once the purchase was assured, mainly by direct purchase from suppliers, drug dispensing up to 1,250 hospitalized patients (25 nursing units) and 8 ICU patients was taken on. Dispensing was carried out  through either drug stocks in the nursing units or individual patient dispensing  for certain drugs. Moreover, safety issues related to prescription were  considered, and as the electronic prescription was implemented we attained  100% prescriptions review and validation. The constitution of a multidisciplinary  Pharmacy and Therapeutics Committee let agree to a pharmacotherapy guide,  pres cription protocols, therapeutic equivalences, interactions, and drug  dispensing circuits. The Pharmacy Department strategy was to ensure a very  quick response to basic tasks keeping the aim to offer a pharmaceutical care of  the highest quality whenever possible. Working under a health emergency  situation, with many uncertainties and continuous pressure was a plight.  However, the spirit of collaboration in and out of the Pharmacy Department was  aligned with the whole hospital motivation to offer the highest quality of  healthcare. These were possibly the keys to allow caring for almost 4,000  patients during the 42 days that the hospital lasted.

El día 20 de marzo de 2020 la Consejería de Sanidad publicó una Orden  (371/2020) para la apertura de un centro hospitalario provisional para atender a  pacientes COVID-19 en la Institución Ferial de Madrid (IFEMA), por razón de  emergencia sanitaria. Se dispuso un equipo de farmacéuticos de la Subdirección  General de Farmacia y Productos Sanitarios para la apertura de un Servicio de  Farmacia, que obtuvo la autorización correspondiente por el órgano competente, con carácter de urgencia. La gestión de recursos humanos,  materiales y de herramientas informáticas para la adquisición y prescripción  electrónica fueron unas de las primeras dificultades que se solaparon con el  primer reto de garantizar la prestación farmacéutica a los pacientes que atendía  el hospital desde el mismo día uno. Asegurada la adquisición, fundamentalmente  mediante la compra directa a proveedores, se planteó la  dispensación para un máximo de 1.250 pacientes de hospitalización (25  controles de enfermería) y una Unidad de Cuidados Intensivos de 8 pacientes;  se establecieron botiquines en las unidades de enfermería y circuitos  individualizados de dispensación para determinados medicamentos. A su vez,  desde el primer momento se trabajó en la seguridad en la prescripción, llegando  a la revisión y validación del 100% de los tratamientos, una vez instaurada la  prescripción electrónica. La creación de una  Comisión de Farmacia y Terapéutica multidisciplinar permitió consensuar la guía farmacoterapéutica, protocolos de  prescripción, equivalencias terapéuticas, interacciones y circuitos de  dispensación de medicamentos. La estrategia del Servicio de Farmacia se basó  en asegurar una respuesta rápida en las funciones básicas, sin perder la visión  de incorporar una atención farmacéutica de la máxima calidad posible a medida  que iba siendo factible. A pesar de un escenario adverso, de incertidumbre y  presión continuas por la emergencia sanitaria, se ha mantenido un espíritu de  colaboración y contribución dentro y fuera del Servicio de Farmacia, alineado con un objetivo común de trabajo en equipo para brindar una atención sanitaria rápida y de la mayor calidad posible. Posiblemente éstas han sido las claves del  éxito que han permitido atender a casi 4.000 pacientes en los 42 días de vida  del hospital.

Guilty in Rhode Island. Conviction of hospital executives in Roger Williams case strengthens the argument that stronger oversight needed.

The conviction of two former Roger Williams Medical Center executives in Rhode Island is sure to keep up the heat for more vigorous oversight of hospitals. Robert Urciuoli and Frances Driscoll were both convicted of fraud. "It's not to say that directors should be running these organizations," says attorney Patrick Coffey, left. "But it is their function to hire qualified people (who) won't ever tarnish the reputation of their institution".

Informed proxy consent: communication between pediatric surgeons and surrogates about surgery.

OBJECTIVE: Informed consent for surgical procedures requires that the procedures are explained and that the patient understands the procedures and risks and agrees to undergo them. Proxy consent occurs when an individual is provided with the legal right to make decisions on behalf of another. This study was conducted to determine how surgeons communicate information to obtain an informed proxy consent, and to investigate how that information is received and processed by surrogates responsible for providing such consent. STUDY DESIGN: Twenty English-speaking parents or legal guardians and 5 surgeons in an urban pediatric hospital were interviewed before, and 2 to 4 weeks after, the surgical procedure. In addition, the interview between the surgeon and surrogate, when consent was obtained, was audiotaped and subsequently analyzed. Semistructured interviews were used to elicit the motivations and influences on the surrogates to consent to the procedure. The same methodology was used to elicit the corresponding impressions of the surgeons. The data were analyzed using descriptive statistics and crosstabulations. RESULTS: Demographic data did not influence the results. Although there was concordance between the surrogate's understanding of the procedure and the surgeon's impression of this understanding, only 3 of 17 surrogates could recall any specifics of the explained procedure. Contrary to the stated belief of surgeons, surrogates consulted with a variety of others, including medical and paramedical professionals, family members, and spiritual leaders. CONCLUSIONS: Communication plays an important role within the surrogate-surgeon dyad. Psychologic variables such as expectations, and the perception of both the surrogates and the surgeons, influence the amount of information that is proffered and the manner in which it is received. Improved communication may be achieved by use of visual aids, discussion of anesthesia and the postoperative course, recognition of the circumstances around the discussion, such as timing and location of the discussion, and personalization of the discussion.

Out of the frying pan: New York City hospitals in an age of deregulation.

For several decades New York City hospitals had been distinguished by their tightly regulated environment, chronically weak finances, high occupancy rates, teaching intensity, dependency on public payers, low managed care penetration, and minimal merger activity. Then in the late 1990s a rapid convergence of forces--the Balanced Budget Act, managed care growth, state deregulation of commercial rates, escalating costs, and plunging hospital occupancy rates--threw the city's hospital industry into turmoil. In this paper we describe this period of turbulent change that has left most of the city's safety-net and small community hospitals near bankruptcy.

Competition versus regulation: its effect on hospitals.

While factors other than competition and regulation influence hospital's behavior, these two strategies have dominated the health policy debate. To examine the impact of these two competing strategies on patients and hospitals, the authors examine experiences in Baltimore, which has followed a regulatory strategy since the early 1970s, and Minneapolis/St. Paul, which has pursued a competitive strategy during the same time frame. Compared with the national average, both strategies had only a minor impact on containing hospital costs per capita, but they influenced hospital productivity, cost per discharge, and utilization in different ways.

Improving access to the underserved through Medicaid managed care.

New York City's Harlem community faces extraordinary health care needs that a failing economy has made more urgent. In an attempt to open lines of access to health care, the New York City Health and Hospitals Corporation has implemented a managed care program for Medicaid participants. The program is a team approach to link each Medicaid patient with a primary care physician responsible for coordinating medical services for the patient. We hope the managed care program will help us conserve our dwindling resources while better managing patients' services and improving access to care.

New factors in the antitrust regulation of hospital mergers.

This research considers four recent hospital merger attempts in smaller urban areas where a hospital merger clearly presents antitrust concerns, as determined by the Federal Trade Commission (FTC) or Department of Justice (DOJ). These cases provide an understanding of the more compelling strategies that hospitals are using to offset federal antitrust concerns and the increased number of factors that are being used by the FTC and DOJ to analyze a merger's effect on a market. In particular, the cases illustrate how federal agencies' likelihood of contesting a merger is now based on the merging hospitals' ability to provide strong evidence of substantial savings resulting from a merger. Further, evidence indicates that states are taking on increasing authority for the oversight of hospital mergers. This federalism trend suggests that consumer protection for hospital mergers may be enhanced through a combination of federal and state oversight measures.

Searching for some answers. Mount Sinai's lawsuit against recruiter Heidrick steps into current debate on shortage of qualified replacement executives.

Heidrick & Struggles, the nation's largest executive recruiting firm and a staunch champion of the National Center for Healthcare Leadership, is fighting a lawsuit that may test the premise that the healthcare industry lacks future leaders. As far as the placement business goes, Michael Doody, left, a senior vice president at search firm Witt/Kieffer, is confident a hospital's lawsuit alleging Heidrick fell down on the job won't cause irreparable damage.

New York court refuses to block merger of Long Island hospitals.

In October 1997, a New York court rejected an attempt by the U.S. Department of Justice (DOJ) to block the merger of two New York teaching hospitals. The DOJ's case was based, in part, on the premise that the consumers in the hospitals' market were managed care organizations, which needed prestigious teaching hospitals to "anchor" their healthcare delivery networks. In rejecting the DOJ's argument, the court found, in particular, that the merging hospitals were not sufficiently distinguishable from other area hospitals to constitute a separate product market of anchor hospitals and that the merging hospitals' faced competition for about 85 percent of their services. Moreover, the court recognized other significant consumers in the market. The decision may pave the way for metropolitan-area hospitals to pursue mergers.

Implementing hospital-based communication-and-resolution programs: lessons learned in New York City.

In 2010 five New York City hospitals implemented a communication-and-resolution program (CRP) in general surgery. The program's goals were to improve reporting of serious adverse events to risk management, support clinical staff in discussing these events with patients, rapidly investigate why injuries occurred, communicate to patients what was discovered, and offer apologies and compensation when the standard of care was not met. We report the hospitals' experiences with implementing the CRP over a twenty-two-month period. We found that all five hospitals improved disclosure and surveillance of adverse events but were not able to fully implement the program's compensation component. These experiences suggest that strong support from top leadership at the hospital and insurer levels, and adequate staff resources, are critical for the success of CRPs. Hospitals considering adopting a CRP should ensure that their organizations can tolerate risk, their leaders are willing to reinforce CRP implementation, and resources are in place to educate clinical staff about how the program can benefit them.

Providers' perceptions of the factors influencing the implementation of the New York State mandatory HIV testing law in two Urban academic emergency departments.

OBJECTIVES: Of the 1.1 million people in the United States infected with human immunodeficiency virus (HIV), more than 20% are unaware of their infection. To increase early diagnosis and treatment, New York State recently passed legislation mandating that HIV testing be offered to all patients, ages 13 to 64 years, receiving health care services. Implementation of this legislation is complex, especially in the emergency department (ED). This study explores ED providers' perceptions of the factors affecting the implementation of the law. METHODS: The authors conducted six focus group sessions and three in-depth interviews with ED health care providers from two New York City teaching hospitals. Sessions were audiotaped and transcribed. Data were coded and summarized thematically through an iterative process after each session. RESULTS: A total of 49 providers participated and data saturation was achieved. Six factors were identified that predispose a provider to offer an HIV test: 1) self-efficacy, 2) behavioral intention, 3) the testing process, 4) provider knowledge of the legislation, 5) type of HIV test, and 6) follow-up procedures. Five factors were identified that enable providers to offer an HIV test: 1) resources related to time, 2) space, 3) staff, 4) type of test, and 5) timing of the offer. Improving access to HIV testing, linkage to care, and public health were all key factors in reinforcing providers' desire to offer HIV tests. Concerns regarding overall cost saving and coverage for the test were indicated as barriers that needed to be resolved to reinforce the providers to offer an HIV test. CONCLUSIONS: Understanding the factors influencing the practice of ED providers charged with carrying out this mandate is critical. Despite earlier research that indicated that offering HIV testing to ED patients is largely influenced by cost, this study found additional factors that are important to consider to effectively implementing HIV testing in the ED.