Shhh!
Medical Center Introduces New "Silent Hospital" Program
Under a new program called Silent Hospitals Help Healing (SHHH), Montefiore Medical Center in New York City is addressing one of the biggest complaints patients have about hospitals: that they are too noisy.

Elodia Mercier, RN, the administrative nurse manager who implemented the SHHH program, found sources of noise everywhere - squeaky cart wheels, ringing telephones, blaring TVs, hospital alarms, beeping pagers and intercom announcements. The glucometer carts were so loud, she says, they sounded like the D train.

"All the sound creates what is called a ?cocktail hour' effect, where there's so much background noise you can't hear yourself, so you have to talk louder than the other person to be heard," says Ms. Mercier. Not only were the staffers talking loudly, she says, they would sometimes shout down the hall to each other.

Ms. Mercier sent out the squeaky carts and loud equipment for lubrication, repairs or other service that would make them quieter. Among the other changes she implemented:

• conversations had to be quiet;
• pagers had to be set to vibrate;
• staffers had to wear soft-soled shoes; and
• instead of shouting, staffers should either walk down the hallway or use the low-volume intercom.

To get her staff's cooperation, Ms. Mercier enlisted their help in creating the program and getting it ready for a public kickoff event. Her coworkers came up with the name Silent Hospitals Help Healing (SHHH) and developed the program's symbol: a nurse with a finger to her lips. "When you get the staff to buy into something, they are more apt to do it," says Ms. Mercier.

Staffers wore buttons with the SHHH symbol (above left) and put up posters with information about the program for anyone visiting the floor. Although patients and their families are educated about the protocols so they can contribute to the quiet atmosphere, Ms Mercier says she has encountered problems such as a patient who refused to turn the television down. To overcome this, the staffers role-played the situation to show the patient how the volume was affecting others, then asked his permission to turn down the volume.

"People like to feel empowered and like they're helping," says Ms. Mercier. "The key is not to tell them what to do but ask them for their help."

Sound meters were used in patient care areas, including on medical floors, in surgical units and in the adult emergency department, to record ambient noise levels at different times, such as during shift change at midday and in the evening. Decibel levels fell significantly. On Ms. Mercier's unit, for instance, noise levels had been as high as 78 decibels. They dropped to 50 to 60 decibels, a level more typical of libraries. When shifts changed, noise levels used to range from 62 to 70 decibels. After SHHH was implemented, noise levels were 55 to 60.

- Nathan Hall

Hospital-Physician JV Model Endangered
CMS Proposes Elimination of "Under Arrangements" Joint Ventures
Proposed changes to the federal Stark regulations would eliminate hospital-physician "under arrangements" joint ventures, those oft-criticized models in which a hospital pays an ASC a per-procedure fee for the facility component of ambulatory surgery and then bills payors under its own provider and tax identification number. Payors reimburse hospitals about 40 percent more per surgical case than ASCs, so the joint venture and its investors get richer quicker.

CMS says "there appears to be no legitimate reason" for certain hospital-physician joint ventures "other than to allow referring physicians an opportunity to make money on referrals for separately payable services" that "were previously furnished directly by the hospitals, and in most cases, could continue to be furnished directly by the hospitals."

To undermine under arrangements, CMS proposes to change the definition of entities that are prohibited from receiving referrals from physician-owners to include not just the hospital that bills Medicare for the services provided under arrangement but also the entity that performs the services under arrangement to the hospital.

In previous Stark rulemakings, CMS expressed concern that these joint ventures could be abused, but declined to prohibit them. CMS has viewed under arrangements between hospitals and physician-owned entities as "compensation and not ownership relationships," and therefore permissible so long as "an appropriate compensation exception" could be met, which many under arrangements are structured to do, says Mark Manigan, a healthcare lawyer at WolfBlock Brach Eichler in Roseland, N.J.

"The proposed changes, however, appear to collapse the physician-owned entity into the hospital outpatient department such that any referral to the hospital outpatient department would be an impermissible self-referral under Stark," says Mr. Manigan.

- Dan O'Connor

Get Accredited or Else
N.Y. Requires Accreditation for Office-based Surgery
Within the next two years, every office-based surgery center in New York must be accredited or face penalties from the state medical board. Under a law passed last month, operating in an un-accredited setting would constitute professional medical misconduct. The law takes effect in six months. It also requires doctors to report bad outcomes within one business day to the state Department of Health. Currently, surgeries performed in doctor's offices aren't regulated in New York state and practitioners aren't bound by the same credentialing and safety requirements as hospitals and ambulatory surgical centers. Though nobody knows for certain how many office-based facilities there are in New York - published reports list the number as high as 2,000, but some industry observers say there are considerably fewer than that - only a few more than 200 are accredited. The American Association for Accreditation of Ambulatory Surgery Facilities says it accredits 127 office-based facilities in New York, the Joint Commission says it accredits 60 and the Accreditation Association for Ambulatory Health Care says it accredits 26.

- Dan O'Connor

Send in the Clones
Robot's Making Rounds, But How's His Bedside Manner?
Many physicians wish they could be in two places at once, but Alex Gandsas, MD, division head of Bariatric and Minimally Invasive Surgery at the Sinai Hospital of Baltimore, found a way to do it. To make rounds, all Dr. Gandsas has to do is sit at his office's computer and move a joystick until the screen shows the particular patient he wants to see. Meanwhile, his laparoscopic bypass patient sees a wheeled robot roll to her bedside. This machine, the RP-7 from InTouch Medical, is 65 inches tall and topped with a flat-screen that displays Dr. Gandsas's face. All a patient has to do is tell Dr. Gandsas how she's feeling and ask any questions she may have.

"The patients love it," says Dr. Gandsas. "They forget that it's a piece of machinery. It's like being on the phone; you ignore the plastic against your ear and listen. Here, they forget about the metal and focus on the content of what they're saying."

As the patient talks, Dr. Gandsas watches another screen display her electronic medical records. He can review her X-rays or electronically stored documents as the patient talks. He can also display imaging scans on the robot's screen to show the patient what the problem is while explaining it to her.

Robotic rounds might also help patients recover more quickly. In the July issue of the Journal of the American College of Surgeons, Dr. Gandsas and his colleagues compared the results from 376 patients who underwent laparoscopic gastric bypass for morbid obesity. Of these, 284 received bedside visits during the post-operative period and the other 92 had the bedside visits plus rounds from the RP-7. They found that 77 percent of the patients who had visits from the robot were ready to be discharged one day after surgery while 77 percent of those who only received bedside rounds were discharged two days later. The mean lengths of stay were 1.26 days for patients for the robot-assisted group and 2.33 for the non-assisted group.

The RP-7 costs $4,750 per month through a four-year rental agreement.

Since he began working with the RP-7 in January 2006, Dr. Gandsas says he has found several other uses for this system. It lets other physicians visit his facility without leaving their homes, for one thing, and Dr. Gandsas has even used it to instruct a group of medical students in Argentina and consult with specialists throughout the country. "It has a lot of potential to bring experts from other facilities into our hospital," he says "They don't have to change their schedules or get on a plane to see us."

There are currently about 100 RP-7s being used in 40 healthcare systems nationwide, says Jennifer Neisse, marketing communications manager for InTouch Health in Santa Barbara, Calif. In a prepared statement, the company says that it only takes users two 30-minute sessions to learn how to use the robot. Staying in touch with it means you need a wireless network and broadband lines to retrieve information, but most hospitals already have this infrastructure in place.

Some facilities have found other ways of using their RP-7s. At Johns Hopkins University in Baltimore, an on-call translator has remote access to the RP-7 so he can assist with Spanish-speaking patients. The Nursing Institute of West Central Ohio in Fairborn is using it to allow a retired professional to teach classes from her home during a one-year trial. And, according to the manufacturer, other facilities have found this system useful for emergency consults, when the orthopedic surgeon or other specialists are oncall but unable to reach the emergency department in a timely manner.

- Nathan Hall

In the Know
New Fire Prevention Guidelines. Citing a possible increase in surgical fires over the last two decades, the American Society of Anesthesiology has announced plans to issue new practice parameters on their prevention by year's end. The group links the rising risk of OR fires to the ever-present use of electrosurgical units, lasers and other energy instruments in surgery. The proposed guidelines may recommend the use of lower concentrations of intraoperatively delivered oxygen when energies are active as well as draping and suction to avoid and remove pooled oxygen from the surgical site.

Pa. Law Pushes Facilities to Expand Infection Control. Pennsylvania hospitals, nursing homes and ambulatory surgery centers must expand infection control efforts and surveillance under a new law that offers financial incentives, starting in 2009, to healthcare facilities that curb infection rates. Under the law, signed by Pennsylvania Gov. Edward Rendell, providers must draft prevention and control plans for infections acquired in hospitals, nursing homes or surgery centers and these file plans with state health officials. Hospitals, which already report such infections to the state, must now report data to the Centers for Disease Control and Prevention. By Dec. 31, each hospital must evaluate the cost and logistics of adopting an electronic infection surveillance system and adopt such a system no later than Dec. 31, 2008. The law includes provisions for hospitals unable to meet the deadline.

AMO Takeover of B&L Fizzles. After a week of volleying offers and counteroffers, Advanced Medical Optics withdrew its bid to takeover rival Bausch & Lomb. In a pointed letter to B&L, AMO president and CEO James Mazzo was indignant over B&L's refusal to accept his company's reported $4.2 billion cash-and-stock offer that would have paid B&L stockholders holders $75 per share. B&L is now expected to finalize its pending sale to private equity firm Warburg Pincus for a reported $3.67 billion.