sábado, 27 de agosto de 2011

Cuando el disco duro se muere...


Darth Vader


Michael Jackson


Traumatologia semiologia rodilla parte 1

Exploración de la rodilla

5º CAFD-Sevilla Vendaje Esguince LLI rodilla

KT TAPE PERU / Dolor de rodilla

KINESIOTERAPIA PROPIOCEPTIVA

Rehabilitacion Propioceptiva Rodilla Lic. Claudio Carrizo

que es geriatria

FISIOTERAPIA EN LA PREVENCIÓN Y TRATAMIENTO DEL SÍNDROME DE CAÍDAS

FISIOTERAPIA EN LA PREVENCIÓN Y TRATAMIENTO DEL SÍNDROME DE CAÍDAS:

'via Blog this'

Mano Biomecanica

5 Mano


5 Mano
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Anatomía de la muñeca

Exploración De Muñeca

Revisión bibliográfica del síndrome del piramidal

Revisión bibliográfica del síndrome del piramidal

Pelvis ósea y pelvis blanda

Biomecanica cadera, pruebas funcionales y ortopedicas

Anatomia De Pelvis Y Pelvimetria

411

SíNdrome De Distrofia

Dsr


Dsr
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Ejercicios para personas con Sd. de Hombro Doloroso

Target Tape - Hombro congelado

Hombro Doloroso, Sindrome De Duplay

Hombro Doloroso

Manguito de los rotadores

Primera demanda en EE UU contra las imágenes en las cajetillas


Primera demanda en EE UU contra las imágenes en las cajetillas

Cuatro tabacaleras llevan al Gobierno ante la justicia por violar su libertad de expresión - "No estamos obligados a hacerle la campaña contra el tabaquismo"

DAVID ALANDETE - Washington - 18/08/2011
Vota
Resultado Sin interésPoco interesanteDe interésMuy interesanteImprescindible 4 votos
Imprimir Enviar
Imágenes en las cajetillas de EE UU
Primer embate contra las escabrosas y polémicas imágenes que algunos Gobiernos, como el español, obligan a imprimir en las cajetillas para combatir el tabaquismo. Cuatro firmas del sector -entre ellas la segunda mayor de EE UU, R. J. Reynolds- han llevado al Ejecutivo norteamericano ante una corte federal en Washington por entender que atenta contra su libertad de expresión.
    Estados Unidos

    Estados Unidos

    A FONDO

    Capital:
    Washington.
    Gobierno:
    República Federal.
    Población:
    303,824,640 (est. 2008)

La noticia en otros webs

El fabricante de Camel, Winston y Lucky Strike lidera el proceso
Obama aprobó el primer cambio del etiquetado de los paquetes en 25 años
Las autoridades del país han aprobado una normativa que les obligará desde septiembre de 2012 a suministrar cajetillas con duras advertencias visuales: un cadáver tras una autopsia, con el pecho cosido con grapas; una garganta perforada; un pulmón ennegrecido; una boca destrozada por el cáncer, y un bebé enfermo en una incubadora. "Esas regulaciones violan la primera enmienda de la Constitución", asegura Floyd Abrams, abogado de la firma Cahill Gordon & Reindel, que representa a Lorillard, una de las compañías demandantes. "La idea de que el Gobierno pueda exigir a aquellos que fabrican un producto legal que estampen en medio de su empaquetado imágenes y frases destinadas para disuadir al público de que compre ese producto no es acorde con la Constitución", sostiene el letrado.
Lorillard es la tercera tabacalera de EE UU en volumen de negocio, y la principal fabricante de mentolados. Estos suponen un 90% de su negocio.
Este año, además, la Agencia del Medicamento (FDA, por sus siglas en inglés) ha abierto un proceso de evaluación del mentol usado en esos cigarrillos, por considerarlo adictivo. Esos productos son los únicos que han aumentado ventas dentro del sector tabacalero en los últimos años, sobre todo entre la población negra y de menos recursos, según un estudio del Comité de Asesoramiento Científico de Productos de Tabaco.
A Lorillard se le han unido en esta demanda otras tres tabaqueras. La más importante, por volumen de ventas, es R. J. Reynolds Tobacco, la segunda fabricante del país, que comercializa marcas como Camel, Winston y Lucky Strike. También se ha sumado Commonwealth Brands, que pertenece al grupo Imperial, dueño, en España, de Altadis. La cuarta tabaquera en sumarse es Liggett Group LLC. Phillip Morris, la principal fabricante norteamericana, no está en este proceso.
La primera enmienda de la Constitución, que citan los abogados en la demanda, es la que protege la libertad de expresión. Es una provisión con mucha fuerza y mucho alcance, que impide que en EE UU existan delitos tipificados como el de apología del terrorismo. En una sentencia de enero de 2010, el Tribunal Supremo norteamericano ratificó que las empresas también están protegidas por esa provisión.
"El Gobierno puede hacer tanto activismo contra el tabaco como crea necesario, en los términos que desee y con las imágenes que quiera; pero no puede obligar a los que venden tabaco de forma lícita al público a que asuman también ese tipo de mensaje, esas mismas palabras y esas mismas imágenes", añade el letrado Abrams. La FDA rechazó comentar la demanda.
Es la primera vez en 25 años en que el Gobierno aprueba el cambio en el empaquetado del tabaco. Lo ha hecho gracias a una orden ejecutiva (decreto) del presidente Barack Obama de 2009, en la que le concedía a la FDA la potestad de regular la fabricación y comercialización del tabaco.
La FDA consideró 36 imágenes, puso a prueba su efectividad en un estudio entre 18.000 personas, y eligió nueve de ellas, que hizo públicas el 21 de junio. Deberán ocupar el 50% de la superficie frontal y trasera del paquete de tabaco. En los anuncios de cigarrillos que se exhiban en las tiendas, la superficie ocupada deberá ser del 20%.

Los estragos del tabaco

Fumadores. Unos 1.300 millones de personas (casi el 20% del total) fuman en el mundo. El consumo de tabaco causa alrededor de seis millones de muertes al año, según la Organización Mundial de la Salud (OMS). En España consume pitillos alrededor del 28% de la población y fallecen unas 55.000 personas por esta causa al año.
Fumadores pasivos. Unas 600.000 personas mueren al año en el mundo por estar expuestas al humo del tabaco que fuman otros. La cifra en España ronda las 1.500.
Protección. Solo el 11% de la población mundial vive en países donde se restringe el uso del tabaco en todos los espacios públicos. La mitad de los niños están expuestos al humo de los cigarrillos.
Composición. En un cigarrillo hay alrededor de 4.000 compuestos. De ellos, al menos en 250 casos se ha comprobado que son carcinogénicos. Muchas de estas sustancias son añadidas por la industria para hacer el producto más agradable o para aumentar su capacidad adictiva. En España está previsto obligar a las tabacaleras a indicar la composición de su producto (está en la última ley pero no ha entrado en vigor).
Imágenes. Canadá y Brasil fueron los primeros Estados en obligar a incorporar fotografías de los estragos del tabaco a las cajetillas. En la UE son ya 11 países: España y Bélgica, Francia, Letonia, Lituania, Malta, Noruega, Polonia, Rumanía, Suiza y Reino Unido. En total unos mil millones de personas viven ya en naciones donde estas imágenes son obligatorias. También lo son en Uruguay, Venezuela, India, Nepal, Tailandia, Georgia, Macedonia y Turquía, según datos de la OMS.
Carteles. Si se incluyen en las medidas de protección de la población, los carteles afectan a más de mil millones de personas.
http://www.elpais.com/articulo/sociedad/Primera/demanda/EE/UU/imagenes/cajetillas/elpepusoc/20110818elpepisoc_3/Tes

Las Tics en la formación docente



Prevención mecánica de tromboembolismo


Medias con compresión gradual para prevenir tromboembolismo en el hospital.
Graduated compression stockings to prevent venous thromboembolism in hospital: evidence from patients with acute stroke.
Kearon C, O'Donnell M.
Department of Medicine, McMaster University, Ontario, Canada.kearonc@mcmaster.ca
Pol Arch Med Wewn. 2011 Jan-Feb;121(1-2):40-3.
Abstract
Pulmonary embolism is the most common preventable cause of death in hospital patients and prevention of venous thromboembolism (VTE) is cost-saving in high-risk patients. Low-dose anticoagulation is very effective at preventing VTE but increases bleeding. Graduated compression stockings and intermittent pneumatic compression devices are also used to prevent VTE and do not increase bleeding, which makes their use appealing in patients who cannot tolerate bleeding, such as patients with acute stroke. Studies that evaluated mechanical methods of preventing VTE were small and mainly used asymptomatic deep vein thrombosis (DVT), detected using screening tests, as the study outcome. The recently published CLOTS Trial 1 (Clots in Legs Or sTockings after Stroke) compared thigh-level compression stockings with no stockings in about 2500 patients with stroke and immobility, and found that thigh-level stockings were not effective. Indirectly, the findings of this study question the ability of stockings to prevent VTE in other patient groups, including those after surgery. CLOTS 1 compared thigh-level and below-knee stockings in about 3000 patients with acute stroke. Given that thigh-level stockings were ineffective in CLOTS 1, it is surprising that they were more effective than below-knee stockings in CLOTS Trial 2. A possible explanation is that below-knee stockings increase DVT, although this seems unlikely. CLOTS 1 and CLOTS 2 question whether graduated compression stockings prevent VTE and suggest the need for further trials evaluating their efficacy in medical and surgical patients.

http://tip.org.pl/pamw/issue/article/516.html 
 
Trombopropilaxis en prostatectomía radical retropúbica: eficacia y conformidad de los pacientes con una modalidad dual.
Thromboprophylaxis in radical retropubic prostatectomy: efficacy and patient compliance of a dual modality.
Cindolo L, Salzano L, Mirone V, Imbimbo C, Longo N, Kakkos SK, Reddy DJ.
Urology Unit, G Rummo Hospital, Benevento, Italy. lucacindolo@virgilio.it
Urol Int. 2009;83(1):12-8. Epub 2009 Jul 27.

Abstract
OBJECTIVES: The risk of developing venous thromboembolism (VTE) in urologic patients undergoing major surgery without thromboprophylaxis is high (up to 40%). The aims were to study the acceptability rate of and overall patient satisfaction with an automatic sequential leg compression system and the short-term effectiveness of a combined VTE prevention modality. METHODS: One-hundred and eighty-four consecutive patients undergoing radical retropubic prostatectomy were postoperatively treated with enoxaparine and intermittent pneumatic compression of the thigh. By completing a questionnaire, the patients were prospectively studied to evaluate the comfort and tolerability of a compression device (SCD Response Compression System; Covidien, Gosport, UK). The patients were monitored for complications and development of VTE for up to 4 weeks postoperatively. The device used ensures customized and effective compression therapy matching the patient's individual vascular refill by sequential, gradient, circumferential microprocessor-controlled compression cycles. RESULTS: No clinically evident VTE, critical bleeding or postoperative death occurred during the study period. Drain output was associated with transfusion requirement (p < 0.001), obesity (p < 0.02) and longer operation duration (p < 0.001). The sequential compression devices were well tolerated by 63% of the patients, in that the sleeves were judged as being pleasant (72%) and nonoppressive (79%). Patients reported bothersome insomnia (23%) and noise (44%), and early removal was required in 3%. CONCLUSIONS: Combined mechanical and pharmacological thromboprophylaxis was highly effective, well tolerated, and safe. The device tested showed a high comfort and tolerability profile. The use of combined modalities for VTE prophylaxis is justified in patients at very high risk of VTE, such as those undergoing radical retropubic prostatectomy.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2790802/pdf/uin0083-0012.pdf 
  
Atentamente
Anestesiología y Medicina del Dolor

El cerebro humano tarda en madurar

Las espinas dendríticas son las protuberancias membranosas que se observan a ambos lados de la dendrita
Las espinas dendríticas son las protuberancias membranosas que se observan a ambos lados de la dendrita
Los seres humanos tardamos mucho tiempo en consolidar las conexiones sinápticas que articulan la organización neuronal del cerebro adulto. Se trata de un aspecto importante de la neurofisiología humana, dado que nuestra capacidad de aprendizaje, -intelectual y emocional-, es máxima durante el periodo vital en que ocurre ese proceso de establecimiento y consolidación de conexiones sinápticas, y se cree que existe una estrecha relación entre ambos fenómenos.
Hace tiempo me referí aquí al libro “El cerebro accidental” de David Linden, para explicar que el cerebro humano, en las primeras etapas de la vida, establece numerosísimas conexiones sinápticas, pero que conforme pasan los años muchas de esas conexiones van desapareciendo. Al parecer, tanto las conexiones sinápticas que se forman como las que desaparecen están muy relacionadas con la maduración cerebral y el aprendizaje. Se trata de un complejo proceso, que tiene que ver con el hecho de que no sea posible codificar genéticamente la disposición concreta de todas las conexiones sinápticas que acaba teniendo un encéfalo humano y, seguramente, con la conveniencia de que sea suficientemente flexible.
La multitud de conexiones que se van estableciendo durante las fases iniciales del desarrollo encefálico humano son como una especie de gran ventana abierta al aprendizaje y al conocimiento, pero conforme se van adquiriendo y desarrollando capacidades cognitivas y conocimientos, muchas de esas conexiones van desapareciendo, seguramente las que hubiesen correspondido a otros conocimientos y habilidades que no se adquieren. Esa es la razón por la que las primeras etapas de la vida de las personas son tan importantes para el desarrollo intelectual y emocional, ya que las conexiones que queden establecidas tras esos primeros años son las que, en cierta medida, van a prefigurar nuestra personalidad y capacidades. Como puede fácilmente deducirse de esto, este mecanismo explica muy bien la razón por la que el desarrollo neurocognitivo tiene una doble dependencia, de los factores genéticos por un lado y del entorno por el otro.
Cuando se propuso por primera vez ese mecanismo de sobreproducción de conexiones sinápticas y posterior eliminación de una parte de las mismas, se consideró que el proceso concluye, aproximadamente, al finalizar la adolescencia. Sin embargo, una serie de investigaciones neuroanatómicas y neurofisiológicas habían sugerido que se prolonga durante más tiempo. Y al parecer, efectivamente, el final de la adolescencia no marca la conclusión de ese proceso de eliminación de conexiones sinápticas “supernumerarias”.
En la micrografía, la dendrita está teñida de amarillo y una espina dendrítica recibe una conexión sináptica
En la micrografía, la dendrita está teñida de amarillo y una espina dendrítica recibe una conexión sináptica
Un estudio que se acaba de publicar ha puesto de manifiesto que el proceso de establecimiento y posterior eliminación de conexiones sinápticas no concluye hasta superada la edad de treinta años. En el estudio en cuestión se ha medido la densidad de espinas dendríticas en distintos tipos neuronales de la corteza prefrontal humana en individuos de múltiples edades (entre 0 y 90 años).
Las neuronas reciben las señales de otras neuronas o de células sensoriales a través de las dendritas, que son proyecciones del cuerpo neuronal con las que aquellas establecen conexiones sinápticas. Las dendritas de algunas neuronas del encéfalo cuentan con lo que se denominan espinas dendríticas, pequeñas protrusiones membranosas que son las que, de forma característica, reciben un terminal presináptico de un axón de otra neurona. Por ello, las espinas dendríticas juegan un papel fundamental en la transmisión de información entre neuronas y en la memoria. Esa es la razón por la que la densidad de tales espinas es un parámetro clave en estos estudios, ya que de ella depende la actividad sináptica, así como los procesos asociados a ella. La reducción de la densidad de espinas dendríticas es la consecuencia lógica de la eliminación de sinapsis supernumerarias, y se cree que la reorganización de los circuitos neuronales a que conduce tal eliminación es esencial para la adquisición de las funciones cerebrales superiores en los humanos, tanto de orden intelectivo como emocional.
La investigación a la que he hecho mención ha encontrado que la densidad máxima de espinas dendríticas se alcanza a edades algo anteriores a los cinco años y, a partir de ahí, desciende de forma paulatina, sobre todo tras la pubertad, hasta llegar a valores estables a partir de la tercera década de vida, aproximadamente. Es muy llamativo el hecho de que los valores máximos de densidad de espinas tripliquen, en la niñez, los valores característicos de la edad adulta.
Me llama la atención el hecho de que toda esa reorganización neuronal relacionada con el aprendizaje, la consolidación de conocimientos, pautas emocionales, y otras funciones de base neurocognitiva, finalice entre los treinta y los cuarenta años. Si repasamos la historia de la humanidad, veremos que solo muy recientemente la vida de los seres humanos se ha prolongado más allá de esas edades, porque durante casi todo nuestro periplo como especie, fueron pocos los que consiguieron vivir más años.
Por último, quiero recordar también que en los ámbitos intelectuales en los que la creatividad juega un papel importante, como algunas disciplinas artísticas o científicas, las aportaciones geniales, los grandes descubrimientos o las obras que han marcado cambios de rumbo, han sido producidas por creadores jóvenes, casi siempre de menos de treinta años de edad. Sospecho, -aunque esto no es más que una mera suposición-, que la máxima creatividad se alcanza precisamente cuando aún no se han acabado de consolidar todos nuestros circuitos neuronales, pero una vez han sido definitivamente eliminadas las sinapsis supernumerarias, la creatividad, la originalidad intelectual o artística, empieza a dejar paso a la experiencia y a la visión que esa experiencia otorga. No sé cuál sería la relación causal en términos precisos, pero intuyo que tal relación existe.
Fuente: Z. Petanjek, M. Judas, G. Simic, M. R. Rasin, H. B. M. Uylings, P. Rakic e I. Kostovic (2011): “Extraordinary neoteny of synaptic spines in the human prefrontal cortex” PNAS 108: 13281-13286

10 Best Practices for Increasing Hospital Profitability


10 Best Practices for Increasing Hospital Profitability

Hospitals today face many challenges including an economic recession, increases in uninsured care and growing competition for outpatient services. However, there are still many steps hospitals can take to increase their profitability amid these economic conditions.


Industry experts say that hospitals wishing to increase their profitability can focus on two key areas — reducing costs and increasing reimbursement.  Here are 10 best practices for increasing hospital profitability by reducing costs and increasing revenue and reimbursement.

1. Reduce staffing costs by using data to drive staffing decisions. Because labor is the largest single expense for hospitals, it is critical that hospitals are not over- or under- staffing their facilities.

Hospitals leaders can cosider the use of flexible staffing, such as part-time or hourly employees, and adjust staffing based on patient census data. Leaders should also monitor the efficiency of this staffing by continuously reviewing benchmarking data such as hours worked per case.

Amy Floria, CFO of Goshen (Ind.) Health System, says that her facility monitors patient volume on a daily basis and adjusts staffing accordingly. "We adjust our nursing staffing every eight hours after looking at our inpatient volume and expected discharges and admits," she says.

Kevin Burchill, a director at Beacon Partners, a healthcare management consulting firm, agrees that staffing must be adjusted daily. "The easiest thing that a hospital can do to improve profitability is for the senior management team to assume responsibility for the day-to-day performance of an organization and look at the organization's performance in real time," he says. "You must shift to an emphasis on the day-to-day, not pay-period to pay-period or month-to-month."

It is important that concerns regarding efficient staffing are communicated throughout the organization and that hospital leaders work in collaboration with physicians. Donna Worsham, COO of National Surgical Hospitals, suggests that hospital leaders share staffing efficiency benchmarking data with unit managers and provide feedback regarding the productivity of the unit.

Flexible staffing is especially useful for OR nursing staff. OR managers should review clock-in times versus surgery-start times and determine if their staff is consistently arriving before a surgery actually begins. If this is the case, mangers can utilize flexible staffing to allow nursing staff to arrive later so that when surgeries run over, no overtime expenses are incurred, says Ms. Worsham.

Other facilities are saving in staffing costs by reducing benefits for full-time staff. Goshen Health System, for example, deferred merit increases, reduced paid vacation time and suspended its retirement matching program in response to the current economy, according to Goshen's CEO, Jim Dague. Goshen reduced employee dissatisfaction in response to these cuts by soliciting employee feedback on which benefits to reduce, thereby building organizational support for the changes. In addition, Goshen's executives took a voluntary 20 percent cut in order to help sustain the system through the recession.

Joe Freudenberger, CEO of OakBend Regional Medical Center in Richmond, Texas, agrees that staff must buy in to any reductions in hours and shifts worked that will personally affect them in order for the hospital to remain successful. He says that hospital leaders must communicate the reasoning for these changes to the staff before making them. "If we call off staff, they see it as personally hurting their income when we need to help them understand that it is actually preserving their income by maintaining the financial viability of the hospital," he says. "It may be obvious to us that we're calling them off because we have a significant reduction in patient volume, but we need to communicate that to them for them to understand the financial realties we face."

Although some staffing cuts may be necessary, hospitals should be careful not to take a blanket approach to layoffs or cuts in services. Hospital leaders must take a close look at their business before making cuts.

"Don't make the same mistake everyone else does — don’t look at bottom line, determine that you need to cut $1 million, for example, and then cut 10 percent across the board. Doing so will trim some fat but will cut meat and bone in other areas," says Mr. Burchill. 

He suggests that hospitals assess each program individually and determine which ones are what are winners and losers. "You do not want to cut areas that you should be doing more of or that are already profitable," says Mr. Burchill.

2. Reduce supply costs by better managing vendors. Hospital leaders can reduce supply costs by working with vendors to improve contracts and encouraging physicians to make fiscally responsible supply decisions.

"When it comes to supply costs, you must drive this expense or the vendor will drive it for you," says Ms. Worsham.

Hospital leaders should not shy away from approaching vendors for discounts. Goshen's IT director recently requested a discount on the health system's contract for IT maintenance due to current economic conditions and successfully received a discount that saved the hospital 15 percent on this contract, according to Ms. Floria.

Hospitals can also reduce supply costs be reducing the number of vendors. Goshen, for example, is in the process of reducing the number of vendors in its surgical suite and aims to eventually scale the vendors down to 4-6 companies. "This action is expected to save us at least a million dollars in supply costs," says Mr. Dague.

Another way in which hospitals may reduce supply costs is by requiring vendors to submit purchase orders for any equipment or implants that are not included in a negotiated, written agreement with the facility. "All of our vendors sign agreements that any purchase orders must be submitted at least 24 hours before a procedure and must be approved by the materials manager or the CEO, or it's free," says Ms. Worsham. "If you don't require this, vendors will drop off the invoice for a pricey piece of equipment or implant after the procedure has already taken place and walk out the back door, which can greatly hurt your profitability."

3. Ensure that your OR is utilized by physicians efficiently. All hospitals can benefit from tightening up the efficiency of their operating rooms, but it is especially critical that less busy facilities ensure that their ORs are used as efficiently as possible.

"Hospitals need to review block time utilization," says Ms. Worsham. "Physicians who are assigned more time than they are using are hurting your profitability."

Ms. Worsham suggests that hospital OR managers work directly with physicians to make OR utilization more efficient.

"When physicians' schedules create gaps in the OR schedule, it effects a hospital's ability to staff effectively, which can create significant labor costs for the hospital," says Ms. Worsham.

4. Involve physicians in cost reduction efforts. Hospitals should work to encourage physicians to become more concerned about the costs of supplies and other activities, such as unnecessary tests and inefficient coding processes that may drive up hospital costs.

"Hospitals today have a unique opportunity to leverage physicians' interest in having hospitals help to stabilize their incomes with the hospitals' needs to involve physicians in cutting costs and improving quality," says Nathan Kaufman, managing director of Kaufman Strategic Advisors, a hospital consulting firm.

Hospitals can encourage the use of products from vendors that are cost-effective, but still high quality, especially in areas such as orthopedic implants, which can be considerably costly for hospitals. In addition, experts say the use of protocol-based care can reduce costs associated with unnecessary tests or treatments.

Mr. Freudenberger says that one of the biggest mistakes hospitals make is not engaging medical staff in profitability. "Physicians have a huge role in maintaining hospital profitability, but unless you give them a reason to be concerned with a hospital's profitability, they will make choices in what and to whom they refer services that will not consider the implications to the hospital," says Mr. Freudenberger. "Hospital leaders should work to help medical staff understand the connection of their referrals to the hospital's viability so that their referral decisions reflect the value they place on the hospital."

5. Consider outsourcing the management of some services. During tough economic times, some hospitals may benefit from outsourcing or partnering with other organizations for certain services, such as food and laundry services, and even, in some cases, clinical services.

"Some hospitals see these economic times as an opportunity to outsource unprofitable services," says Mr. Burchill.

By outsourcing certain services to more efficient providers, hospitals can share the savings with the service provider. However, hospitals must be sure to select truly efficient providers.

"Outsourcing is clearly a smart thing to do if an organization can gain greater efficiency through finding a larger-scale operation; however the provider must be more efficient than the hospital," says Kevin Haeberle, executive vice president, HR capital, for Integrated Healthcare Strategies.

Oftentimes, hospitals outsource services such as laundry, food and nutrition, information technology or human resources because they do not have the capital to invest in the equipment upgrades or training that is needed to increase the efficiency of their internal service. In these cases, the decision to outsource may not directly be related to profitability but instead the "lacking of funds for the investment required to make current services viable," says Mr. Haeberle. However, this decision can improve profitability in the long-run by allowing hospitals to use funds for more profitable services.

Some hospitals have also begun to outsource clinical services such as emergency room staffing and anesthesiology in an attempt to become more efficient. Because these staffing groups employ a large number of specialty physicians, they may be able to provide more efficient services, especially in clinical areas that require around-the-clock coverage where the demand for services is high.

Mike Mikhail, MD, vice president of client services for Emergency Physicians Medical Group, says that hiring an emergency department management company can help to improve the profitability of hospitals whose demand for emergency services exceeds its emergency treatment capabilities. "An emergency management group can help make the emergency department more efficient by introducing management oversight and best practices, allowing more patients to be seen and keeping others from leaving to find another hospital," he says. "Because a majority of hospital admits come from emergency walk-ins, driving more patients through an ER will create more admits, and therefore more profit for the hospital."

6. Consider partnering with local physicians to reduce competition for outpatient cases. An increasing number of hospitals are joint venturing with local physicians and surgery center management companies to offer outpatient services through the development of a surgery center.

According to Clete Walker, vice president of development for Surgical Care Affiliates, hospitals are beginning to focus on the need for a comprehensive outpatient strategy and recognizing the need to partner with doctors to effectively execute on this strategy. Mr. Walker reports that he has seen an increased interest from hospitals in joint venture arrangements for outpatient services.

"More and more hospitals are realizing that their core competency is providing inpatient care; their outpatient cases are more costly per case and take up more of the physician's and patient's time than they do at an ASC," he says. "As a result, hospitals are competing with physicians for outpatient cases. Hospitals with joint-venture agreements, however, do not have to compete with the physicians."

Hospitals can leverage their standing in the community to partner with local physicians to share the revenue generated by efficient outpatient cases.

"We are in lean times, and lean times call for us to rethink our strategies," says Mr. Walker. "It's better for physicians, hospitals and other groups to work together to provide an efficient delivery system for patient care than for the groups to compete."

7. Grow case volume by attracting new physicians to your facility.
 Identifying and attracting additional physicians to bring cases to your hospital is another way that hospital leaders can increase profits. Physician-owned hospitals can bring in additional physicians as partners, while other types of facilities can recruit new physicians who are willing to perform cases at their hospitals.

"New physicians will bring in more cases and grow your profits," says Ms. Worsham.

Ms. Worsham suggests polling your medical staff for names of local physicians to target and inviting them into the facility. During the visit, Ms. Worsham recommends that hospitals work to "wow" the target physician. "We work tirelessly to promote the services we can offer them," she says.

When a new physician begins performing cases at one of Ms. Worsham's facilities, that physician is assigned a concierge. "We have strong internal programs in place for this first day. A concierge is assigned to each new physician who provides them with a tour facility and walks them through every aspect of their day," says Ms. Worsham.

8. Consider adding profitable service lines. Hospitals may also be able to grow case volume and profits by adding new service lines. However, hospitals need to be careful to do their homework on the expected profitability and ROI for any new lines added, especially in a market where access to the funds required to invest in new service lines may be tight.

"You have to look at what the market needs are and where you're going to get the referrals from," says Ms. Worsham. "Meet with local physicians and interview them about their needs and the number of cases they see that could utilize a new service."

Hospitals should also be sure to examine the competitive landscape for any new service line.

Ms. Worsham reports that her facilities have had great success from adding a hyperbaric service line because few competitor hospitals were offering this service.

9. Consider hiring hospitalists to manage inpatient care. Hospitals that use hospitalists to care for patients can benefit from the more efficient care and better documentation that specialized hospitalists can potentially provide.

"A protocol-based hospitalist program can increase efficiency and help to reduce the length of stay for patients, which can increase case volume without the need for additional beds," says Mr. Kaufman.

Hospitals should consider employing these specialists as a means to improving care and enhancing their bottom lines, according to Mr. Kaufman.

Stephen Houff, MD, president and CEO of Hospitalists Management Group, says that hospitalist groups can provide effective care to patients and possibly increase reimbursement. "Hospitalists may be the most reliable and cost-effective means available for hospital leaders to transform medical delivery in their health system," he says. "Through shared vision, an effective hospitalist team partners with hospital leadership to improve patient safety and access, streamline care, improve patient and family satisfaction, enhance reimbursement via improved clinical documentation and provide seamless transition to post-discharge care."

10. Renegotiate managed care contracts. One of the most important ways that hospitals can improve their profitability is by continually evaluating and renegotiating their managed care contracts.

"Hospitals must demand their fair share of premiums from third-party payors in order to subsidize the underpayment of Medicare and Medicaid," says Mr. Kaufman. "Hospitals need to focus on reducing their cost structure as much as possible to approach breaking even with Medicare reimbursement rates, but that only goes so far."

Mr. Kaufman recommends that hospitals only agree to contracts that reimburse at 130-140 percent of cost. "If a facility is not big enough or strong enough to get these rates, then they should look at merging with a larger facility," says Mr. Kaufman.

Ms. Worsham suggests that hospitals perform a profitability analysis by payor and by procedure in order to determine where a facility is losing money and identify any trends. She also suggests that hospitals evaluate older contracts due to changes in severity-based DRGs and carve out the reimbursement of implants in order to ensure they are reimbursed appropriately for the costs associated with these.

Ms. Worsham also suggests that hospitals evaluate contracts on a quarterly basis, even if the contract is not near expiring. She suggests that hospital leaders examine the contracts with the following questions in mind: 

•    Is revenue where we thought it would be given reimbursement rates and volume of policy holders?
•    Are we being paid as agreed upon in the contract?
•    Are we being paid in a timely manner?

Contracts that are determined to be "high risk" should be renegotiated. Make sure your contracts contains a material harm clause, which will allow you to readdress terms of contracts that have become financially harmful to the facility, according to Ms. Worsham. Renegotiating contracts can be very valuable — one hospital Ms. Worsham advises will gain $500,000 this year due to renegotiations.
Looking forward
Hospitals that focus on enacting these best practices are likely to see improvements in their profitability; however, hospitals can also benefit by using today's economic conditions as an opportunity to improve their overarching approach to business, creating a more sustainable organization in the future.

"When profits were high, hospitals had the luxury of being sloppy in some areas; now we must run a tighter ship," says Ms. Floria. "This will benefit the industry in the long-run."

Hospitals can also use this opportunity to find creative solutions to problems that plague their facilities.

Goshen Health System, for example, recently enacted a program in which the hospital pays the premium required to sustain Cobra benefits for recently laid-off patients seeking care. "We are willing to be creative with our patients," says Ms. Floria. "We pay for benefits when certain patients cannot. The revenue we receive from caring for these patients recoups this cost and provides us with additional cash flows that likely would have been uncollected or written off to charity care or bad debt."

This idea, which was enacted during lean times to improve profitability, will continue to benefit the hospital's bottom line, even when profitable times return.

Contact Lindsey Dunn at lindsey@beckersasc.com .