HOSPICE PROGRAM FOR CHILDREN.(Spotlight on Health & Fitness) - Rocky Mountain News (Denver, CO)

Byline: Jenny Deam News Staff Writer

While there is probably nothing to lift a family's burden when a child is dying, a new hospice program may help to ease the load.

Children's Hospital Home Care, in connection with Centura Porter Hospice, has launched a new program designed for terminally ill children and their families.

It is called The Butterfly Program, borrowing from the symbolism of transition. In this case it is the transition into the final stages of life.

When a child is gravely ill, experts say, the family most often simply wants him or her to be comfortable and in familiar surroundings. That means home. But because of the child's condition as well as the emotional stress on all involved, families need help.

That's where The Butterfly Program comes in, said Dee Mueller, a spokeswoman for Centura Home Care and Hospice. Included in the hospice program are pediatric nursing services, therapy - both physical and emotional - and respite care for parents and siblings of the ill child. That can include anything from sitting at the child's bedside so parents can get some sleep to running errands and playing with other children in the family, who often feel neglected.

The program also provides bereavement counseling for the family after the child dies.

MOM'S MENTAL HEALTH KEY IN MURDER CASE WOMAN ACCUSED OF KILLING HER TWO CHILDREN HAD BEEN TREATED FOR POSTPARTUM DEPRESSION.(Local) - Rocky Mountain News (Denver, CO)

Byline: Kevin Vaughan Rocky Mountain News Staff Writer

JEFFERSON COUNTY -- A mother accused of killing her two children goes to court Monday, beginning a legal proceeding that experts said will hinge on her mental health.

Bethe Feltman remained under police guard Friday at Centura Health Porter Hospital in Denver, where she is undergoing a psychological evaluation. She has been charged with two counts of first-degree murder in the April 9 slayings of Ben, 3, and Moriah, 3 months.

``Unlike most cases, where some hedging of the bets is appropriate, I would say there's a 100-percent, take-it-to-the-bank guarantee that the sole defense at any trial will be mental status,'' said Denver attorney Scott Robinson.

Robinson said his belief is rooted in what he knows about the case.

According to court documents, Bethe Feltman had struggled with postpartum depression since the Moriah's birth New Year's Day.

Her husband, Wade, had come home April 9 to find both children dead and Bethe incoherent in the couple's Jefferson County home.

Coroner's investigators concluded that both children were given drugs, and that Ben was strangled and Moriah suffocated.

Bethe Feltman had spent time in the hospital in the week before the children were killed and was scheduled to see a doctor again the next day, according to court documents.

She is scheduled to appear in court at 1:30 p.m. Monday. There, her mental competency is expected to be raised. A judge will be asked to determine whether she is able to understand the proceedings and assist her lawyer, Craig Truman, in her defense.

Truman declined to discuss the details of the case.

If the court determines Feltman is not competent, the proceedings would be on hold until her competency is restored.

A separate issue would be her sanity when the killings occurred. If she were to plead not guilty by reason of insanity, she would likely undergo an extensive psychiatric evaluation.

``If she's ruled sane, the chances are great the defense will ask for a second opinion - 100 percent,'' Robinson said. ``But if she's ruled insane, it's not inconceivable that the district attorney . . . might accept that.''

In that case, Feltman would be sent to the state mental hospital until she could demonstrate she wasn't a threat.

HEALTH AND FITNESS BRIEFS.(Lifestyles/Spotlight) - Rocky Mountain News (Denver, CO)

Byline: Compiled by Debra Melani

Magazine ranks Denver 6th fittest city in U.S.

Denver ranked as the nation's sixth fittest city in Men's Fitness magazine's ``America's Fattest Cities'' report, escaping the dreaded ``fattest'' list.

That designation - fattest city in America - went to Houston, followed by Detroit, Philadelphia, New Orleans and Columbus, Ohio, in that order.

Bumping Denver down to sixth place on the ``fittest city'' list were San Diego at No. 1, followed by a tie for the No. 2 spot with Honolulu and San Francisco. Seattle made the fourth spot, followed by Minneapolis at No. 5.

Men's Fitness found some key factors, such as the amount of open space and parks, commute time, availability of junk food and the quality of air and water, made a difference in a city's fitness level.

Health care systems join forces to help needy

Metro-area community programs in need of wheelchairs, beds and other medical supplies soon will have some headed their way, thanks to a medical partnership announced recently by Centura Health, Exempla Healthcare and HealthONE.

The three major health care systems each expect to donate about $100,000 worth of surplus items a year through the initiative called ``Hospital Attic.'' Providers' Resource Clearinghouse, a local nonprofit, will provide transportation, storage and distribution of donated goods and will act as a central referring point. Colorado nonprofits with 501(c)(3) status can contact the clearinghouse at (303) 296-8580.

Carbon monoxide poisoning increases in winter

What seems like the flu might be a deadlier poison making people sick this time of year, according to the American College of Emergency Physicians.

Carbon-monoxide poisonings increase during the winter months, when houses are sealed tightly and heaters, stoves and furnaces are continually in use. The gas is invisible and odorless and can kill quickly.

Symptoms of poisoning can mimic the flu, including headache, fatigue, nausea, dizziness, confusion and irritability. Continued exposure can lead to vomiting, weakness, miscarriage, brain damage, heart attack, breathing problems and death.

The ACEP offered the following precautions:

* Have fuel-burning appliances professionally checked annually.

* Choose appliances that vent fumes outside.

* Make sure appliances are properly installed, following proper venting directions.

* Never use a gas oven to heat your home.

A TURN FOR THE BETTER SYMPOSIUM AIMS TO HELP WOMEN TAKE CHARGE OF CHANGE.(Spotlight on Health & Fitness) - Rocky Mountain News (Denver, CO)

Byline: Leslie A. Young Rocky Mountain News Staff Writer

Change is one of life's few certainties.

At 31, Tracey Brummett of Denver knows that all too well.

For months she's been organizing Embracing Transitions: A Women's Health Symposium. During that time she's become the woman for whom she designed the conference.

In short, she and her husband have just hit a wall in their plans to have children.

``Intellectually, I thought I was prepared, but emotionally, I found it hit me really hard,'' she says.

Throughout the turmoil, Brummett has worked to maintain control. One thing that's helped is an emotional-fitness test designed by Susan Heitler, a Denver clinical psychologist.

Heitler will be the keynote speaker at the health symposium, to be held March 14 on the Auraria campus. The conference focuses on inevitable health crossroads women face and their options.

The conference goal is ``to raise women's consciousness about change and the fact that they have choices and they can help affect the changes in their lives,'' Brummett says. ``It doesn't just have to happen to them.''

Empowering women to face change represents a shift in psychotherapy, Heitler says.

``Initially, the field of psychotherapy looked at people who were emotionally injured and how to help them heal,'' she says. ``Emotional fitness looks at how people can prevent injuries.''

Heitler's test has 10 questions. A high score reflects a resilience that's like money in the bank for the challenges around the bend, she says. The woman probably possesses useful tools: a positive attitude toward herself; an openness not only to her own feelings but to the feelings of others; a talent for saying what's on her mind in a tactful way; an ability to take care of herself physically.

If your score indicates you're emotionally weak, that means you're susceptible to emotional injuries that ``show up as depression, anxiety disorders, excessive anger, angry outbursts or irritability,'' Heitler says.

The test isn't highly scientific, she says. ``It's more like a quick little checklist to get a very quick overview of where you stand emotionally at this point in your life.''

Brummett took the test during the symposium's initial planning phase, then again after her crisis.

``My score is lower right now,'' she says. ``I'm in a more emotionally brittle state.''

This self-understanding isn't trivial, Heitler says, because emotions are like traffic signals: ``Emotional fitness involves the abiliy to accurit from emn street ce up in orhere. Soment is happening here.' ''

Heitler sashe also us the ``RTD system'': R means gs, T is to think abtably, humhree level, she says. Recognizing feelings can be difficult. For some, it's easy to ignore them, but ``there's enormous power in being able to put a label on something.''

And if you don't think through your feelings, ``you're at risk for letting feelings go straight from your gut to your mouth,'' Heitler says.

The ``doing'' applies to yourself, she emphasizes. It's easy to decide what someone else should do, she says, but taking responsibility for your actions is empowering.

In sorting through her crisis, Brummett doesn't need traffic signals to tell her she's in pain, but she says the emotional-fitness test has helped her understand how she handles problems, and most important, it's helped her identify her support systems.

INFOBOX

IF YOU GO:

Embracing Transitions: A Women's Health Symposium, 11 a.m. to 5:30 p.m. March 14, University of Colorado at Denver, North Building. The conference is sponsored by Bea Romer's Colorado Women's Health Campaign, American WholeHealth, Colorado Parent and Centura Health. Cost: $35, with proceeds donated to the Colorado Women's Health Campaign. On-site parking: $2. Registration: 320-1000.

Questions from the Emotional Fitness Test:

* I feel irritated at home, at work or on the road: (1) pretty much every day, (2) from once to a few times a week, (3) rarely

* I find that I smile warmly, talk openly and express affection to people close to me: (1) less than once a week, (2) several times a week, (3) pretty much every day.

* I think negative thoughts about myself (thoughts like, ``That was dumb!''): (1) often, (2) sometimes, (3) rarely.

- By Susan Heitler, Ph.D.

CAPTION(S):

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HEALTH WORKERS FACE SMALLPOX DECISION; 1ST SHOTS ON FRIDAY.(NATION/WORLD) - The Capital Times

Byline: Associated Press

Across the country, doctors, nurses and public health officials are making some hard choices about whether to get the smallpox shot for the good of the country.

In the coming weeks, health care workers will be deciding whether to volunteer to be vaccinated so they can be ready to respond to a smallpox bioterrorist attack. The first shots will be given Friday in Connecticut, the first state ready with the vaccine.

Nebraska, Vermont and Los Angeles County also had received vaccine shipments by Wednesday but were waiting at least until next week to begin vaccinating.

Worries about the vaccine's fierce side effects and the threat that it may even sicken people near those vaccinated have prompted a number of nurses to refuse.

As an emergency room nurse in Milwaukee, Lisa Hass-Peters knows she is a prime candidate for a smallpox response team.

But her husband, Jeff, has had two liver transplants, leaving his immune system weakened. That means the smallpox vaccine - made from a live virus related to smallpox - could make him sick. He could be infected from the scab on her arm caused by the vaccine.

'I didn't hesitate to decline,' said Hass-Peters, who works at Milwaukee's Froedtert Memorial Lutheran Hospital. 'If I truly was exposed, I guess I would be weighing my options again. But I don't feel a threat at this particular moment.'

In a recent survey, 63 percent of 2,600 nurses responding said they would get the smallpox shot, 13 percent said they wouldn't and 24 percent were undecided, according to the National Network for Immunization Information, a coalition of several health trade groups.

Ultimately, the government plans to vaccinate nearly 500,000 health workers. But even some major hospitals are refusing the vaccine, including Colorado's largest chain, Centura Health with 10 hospitals; and Grady Memorial Hospital in Atlanta, home of the Centers for Disease Control and Prevention, which is shipping vaccine to the states.

The risk of a smallpox attack is unknown, and the chance that any given person will be exposed is small, an advisory panel for the Institute of Medicine said recently.

But the risks of the vaccine are well-known. Some people may have sore arms and fever or feel sick enough to miss work. As many as 40 people out of every million vaccinated for the first time will face life-threatening reactions, and one or two will die.

The vaccine is not recommended for people with skin problems, such as eczema, or those with weak immune systems, such as HIV, transplant or cancer patients.

Memorial Health Systems in Colorado Springs looking at ways to expand market share - Colorado Springs Business Journal

Memorial Health Systems has an opportunity to expand its marketshare through expanding to other parts of Colorado -- even toKansas.

The hospital system is beginning to reinvent itself as a regionalcenter, and is building the infrastructure to compete, said MikeScialdone, CFO for the system at Memorial's monthly update to thecity council.

After spending the last two years recouping form a devastatingfinancial hit in 2008, Memorial is ready to begin spending oninfrastructure and reorganization, he said.

'We've lost a great number of outpatient visits for imaging andradiology,' he said. 'Insurance companies are sending more people tothe freestanding centers, and not the hospital. We're reorganizingthe department -- to be more competitive and more efficient.'

That's just one way the hospital plans to compete in a complexhealth care environment. It needs to stop thinking of itself as a'hospital,' only, said CEO Larry McEvoy.

'We need to move away from thinking of ourselves as a bricks-and-mortar building and move toward thinking of ourselves as a networkof physicians who are providing regional care.'

Currently, 87 percent of Memorial's patients come from itsprimary area -- El Paso County. There's an opportunity to expand tothe secondary and tertiary markets, which include counties on theeastern plains, western slope and even into Kansas.

The way to do that is to provide those communities with expertisethey don't already have, he said.

'Then, when they have a deep-water issue -- like heart surgery orcancer -- they'll come to us,' he said. 'We don't want to do this ina predatory way, but we do want to be good neighbors.'

The move to focus regionally makes sense locally, McEvoy said.

'If we grow our business regionally, then it brings resourceshome to take care of people here,' he said. 'It's what hospitals aredoing now.'

It's a switch from past thinking about the health care industry,he said. Hospitals used to only think about the local market.

'But we don't want to grow by hurting Penrose (St. Francis HealthServices),' he said. 'We view them as a partner. But we do want togrow, and this is the way to do it.'

It's also an opportunity Penrose doesn't have. It's part ofCentura Health, which already has hospitals in Canon City andPueblo.

'They don't have as much room to expand as we do,' Scialdonesaid. 'It's another reason this makes sense.'

Scialdone and McEvoy made their pitch to council as they alsogave them number from 2010 and April 2011. Those numbers showdeclining inpatient volumes and fewer outpatient visits.

In 2010, the hospital saw an 8 percent decrease in admissions forinpatient admissions, and a 6.6 decrease in outpatient visits. Thebright areas of the financial picture: emergency room visits were up4.2 percent and the net income margin grew to 5.8 percent, showing ahealthy hospital environment.

'Our days of cash on hand and our overall net income increased,'Scialdone said. 'That was due to the health of our investments in2010. The markets were strong, so we did well.'

Net revenues were down for the year, from the anticipated $574million to $536 million, he said.

The monthly snapshot for April 2011 was a little brighter.Admissions were down 9.4 percent from what the hospital budgeted and8.8 percent for the same month in 2010.

Outpatient visits for April were up 1.1 percent from budget and4.2 percent from April 2010.

Overall, net patient revenue for the month was $180 million, downfrom the $198 million budgeted by 8.7 percent, but up from the sametime last year by 1.9 percent. April 2010 saw net patient revenuesof $177.5 million.

'These numbers show we can't put off changes,' Scialdone said.'We have to invest now, and we have to invest in the right places.That's what we're doing in 2011 to prepare for the future.'

If the hospital hopes to expand to other markets outside ColoradoSprings, it will have to be free of city control. As a municipallyowned system, city law prohibits expansion beyond El Paso County.

Health workers weigh vaccine - The Columbian (Vancouver, WA)

The needle that delivers smallpox vaccine is only about 3 incheslong, with two tiny prongs at one end. But for legions of healthcare workers nationwide, it symbolizes a complex personal choice.

These doctors, nurses and public health officials must decidewhether to volunteer for the vaccine some as early as Friday sothey could treat patients in a bioterrorist smallpox attack. But thevaccine itself can cause fierce side effects and even sicken othersclose to those vaccinated.

As an emergency-room nurse in Milwaukee, Lisa Hass-Peters knowsshe is a prime candidate for a smallpox response team.

But her husband, Jeff, has had two liver transplants, leaving hisimmune system weakened. That means the smallpox vaccine made from alive virus related to smallpox could make him sick. He could beinfected from the scab on her arm caused by the vaccine.

'I didn't hesitate to decline,' said Hass-Peters, who works atMilwaukee's Froedtert Memorial Lutheran Hospital. 'If I truly wasexposed, I guess I would be weighing my options again. But I don'tfeel a threat at this particular moment.'

The government plans to vaccinate nearly 500,000 health workers.So far, only Connecticut said it was ready to begin vaccinations onFriday, the day a law protecting those giving the shots fromlawsuits takes effect. Los Angeles County, Vermont and Nebraska arethe only other locations that had received the vaccine shipmentsWednesday.

Strictly voluntary, the vaccine is aimed at creating smallpoxresponse teams for treating patients in an attack. But some healthcare workers and hospitals are refusing because of the risks fromthe vaccine itself.

Though in the minority, major hospitals refusing to vaccinatetheir workers range from Colorado's largest chain, Centura Healthwith 10 hospitals, to Grady Memorial Hospital in Atlanta, home ofthe Centers for Disease Control and Prevention, which is shippingvaccine to the states.

The risk of a smallpox attack is unknown, and the chance that anygiven person will be exposed is small, an advisory panel for theInstitute of Medicine said recently in urging the government to goslower with the vaccinations.

But the risks of the vaccine are well-known. Some people may havesore arms and fever or feel sick enough to miss work. As many as 40people out of every million vaccinated for the first time will facelife-threatening reactions, and one or two will die.

The vaccine is not recommended for people with skin problems,such as eczema, or those with weak immune systems, such as HIV,transplant or cancer patients. The government says even people withfamily members in those categories should be screened out.

Health care unions have criticized the Bush administration,accusing it of cutting corners on screening and training. They alsoworry that people who have side effects or miss work may not befully compensated; the government says it is working on a plan.

ON THE WEB

Vaccine facts:

Even people with insurance having trouble paying for health care. - Knight Ridder/Tribune Business News

By Jean P. Fisher, The News & Observer, Raleigh, N.C. Knight Ridder/Tribune Business News

Jul. 11--Eighty percent off sounds like a great deal. But if the starting price is high enough, even 20 percent can be too much to part with. Alfred Smith of Zebulon doesn't have much choice.

Smith, 57, suffers from kidney failure. He's on the transplant list at Duke University Health System, and he hopes to have his worn-out organs replaced with a healthy donated kidney as soon as one becomes available.

Because he is disabled, Smith qualifies for Medicare, which will pay for 80 percent of the $100,000 operation. It's never clear exactly how much the patient will owe because of the complexities of medical billing and coverage, but Smith figures he should be prepared to be responsible for as much as $20,000.

It's an amount that Smith says he isn't even close to being able to pay. He was forced to quit his job as a wastewater treatment operator at a Knightdale manufacturing plant three years ago when he began dialysis treatments.

The surgery would take place regardless, but Smith is trying pull together at least some of the money by asking for donations. He's got some time to work on it. Smith said he likely will have to wait at least two more years before a kidney becomes available from an anonymous donor. The transplant would come sooner if a living donor volunteers to give him a kidney.

'There is no way I can do this on my own,' said Smith, who gets by on monthly disability benefits of just over $1,300. 'I'm living paycheck to paycheck.'

Smith's case is an extreme one.

But paying medical bills is a struggle for millions of Americans -- including people who have health coverage through Medicare or private insurance. And it's probably going to get worse as health-care costs soar and budget-conscious employers shift more of the financial responsibility to workers.

About 20 million U.S. families had problems paying medical bills in 2003, according to a national survey of 25,400 families recently released by the Center for Studying Health System Change. More than two-thirds of families that said they struggled had health insurance.

The center didn't indicate the survey's margin of sampling error. Nor did the survey define what it means to have difficulty paying medical bills.

But families reported situations such as being contacted by collection agencies, postponing a major household purchase such as a car or borrowing money to pay health-care bills. Consumers also said they had to forgo doctor's visits or leave prescriptions unfilled because they had no money to pay or feared racking up additional medical bills.

A similar survey of 4,052 people released in March by the Commonwealth Fund found that 71 million working-age adults had trouble paying medical bills. This survey also did not define 'trouble,' and it did not report its margin of sampling error.

But it found that 44 percent of people who said they struggled used all or most of their savings to pay medical bills, and 20 percent incurred large credit-card debt or had to take a loan against their home to cover health expenses. Just over a fourth of people who had problems paying said they had been unable to pay for basic necessities such as food, heat or rent because of medical bills.

Smith says he already spends a good chunk of his income on medical care. About $300 a month goes to pay for medicine alone. Smith takes pills for high blood pressure and diabetes, a disease that contributes to his kidney problems.

The Raleigh dialysis clinic that treats him accepts Medicare's reimbursement as payment in full, so Smith doesn't face out-of-pocket expenses for the four-hour treatments he must have three times a week. Dialysis flushes waste materials from his bloodstream -- normally the kidneys' job.

Smith recently learned he might qualify for a discount program Duke established in January for people with limited incomes. Based on Smith's annual income, the Duke program could waive its right to collect any of the cost of the transplant from him. Smith plans to show the health system proof of his income by submitting a copy of his disability check stub and other financial documents to see whether he qualifies.

But Smith still fears he won't be able to pay for anti-rejection medicine after his surgery. He hopes people will be willing to donate money to help him pay for the $300-a-month drugs, which he will have to take for the rest of his life. Smith has siblings in Zebulon but said they aren't in a position to help financially.

So Smith set up an account at a Centura bank branch to receive donations, an idea he got after checking out a few organizations for kidney patients. Then he prepared fliers explaining his plight, requesting that donations be mailed directly to the bank. So far, his church has donated $100.

'I've worked in sales, so I'm not shy about asking people for money,' said Smith, who sold cars for a time after leaving his wastewater treatment job. Ultimately, he said it became clear that working was too hard on his health.

Medical inflation and a trend toward higher out-of-pocket costs for consumers are making it harder for all patients to keep up with medical bills. Costs for physician and hospital care, medical technology and medicines have been rising by 10 percent or more for at least the past four years and show few signs of slowing.

Medicare members such as Smith are particularly exposed because there is no cap on what they can be asked to pay out of pocket, unlike most private insurance plans. The lack of a limit on out-of-pocket costs is considered by health insurance experts to be one of the most serious flaws in the federal insurance program.

Employers, who pay for most private health insurance, have been sharing the pain by increasing deductibles, co-payments and other out-of-pocket costs.

'For many people, maybe those increases do not take a big bite, but if you need a lot of health care, it adds up fast,' said Peter Cunningham, a senior health researcher at the Center for Studying Health System Change and co-author of the medical debt study.

According to the survey, about 23 percent of families with out-of-pocket expenses of between $801 and $2,000 said they had trouble paying those bills. And when such costs were more than $2,000 a year, nearly 35 percent of people said they had difficulty paying.

Most industry watchers expect out-of-pocket costs to continue rising. Employers still see passing costs on to workers as the best way to trim soaring increases in health insurance costs, said Steve Graybill, a senior health-care consultant in the Charlotte offices of Mercer Human Resources Consulting.

People who buy their own health insurance are gravitating to higher-deductible plans to save on premiums. That means more money out of consumers' pockets before coverage kicks in.

'What's happening here is that everything is pushing more responsibility to the consumer,' Graybill said. 'It's a hard message.'

PAYMENT TIPS

KNOW YOUR COVERAGE: Review the summary of benefits that describes exactly what is covered by private health insurance. This can be a good starting point to determine eligible care and out-of-pocket expenses. Many health plans also make summaries of benefits available on their Internet sites.

ASK ABOUT HELP: Most hospitals and doctor's offices have professionals on staff to route patients with limited income into programs that may pay for their health care, see whether they qualify for charity care or get them a discounted price. To qualify for such programs, patients usually must submit proof of their income, including copies of check stubs and tax documents. Getting signed up before treatment can reduce a qualified patient's risk of racking up debt.

CHECK FOR ERRORS: Patients can ask for itemized medical bills. After expensive or complex medical care, check billing statements for double billing or charges for care that was not delivered.

SET UP AND USE AN INSTALLMENT PLAN: Most health-care providers say they allow patients to pay large balances over time. Usually, if patients make a reasonable effort to pay, providers will not send them to collections. Failing to pay medical bills can result in a blemish on your credit report.

USE OTHER PROGRAMS: If your company offers flexible spending accounts, you can use one to reduce taxes by setting aside pretax income for many health-care expenses. If you can afford supplemental insurance to cover out-of-pocket medical expenses, think about buying it, especially if you expect to need care.

To see more of The News & Observer, or to subscribe to the newspaper, go to http://www.newsobserver.com.

HEALTH CARE.(foodservice market)(Brief Article)(Statistical Data Included) - Restaurants & Institutions

Flexibility and entrepreneurial thinking are musts for self-operated health-care foodservice operators.

In addition to the economic vagaries with which all of foodservice wrestles, self-operated health-care foodservice operators have been contending with HMO-imposed revenue constraints. The segment's entrepreneurial responses have been numerous, ranging from expansion of room service, point-of-service carts and food-court dining arrangements to establishing shared-service agreements among facilities and converting to centralized food preparation.

Rather than cut services to meet the reduced budgets, many who work within health-care foodservice instead opt to develop new business strategies. Shared-service agreements with sister facilities, offering room service and upgrading menus to boost participation are among the changes operators are making.

Properly managed, the massive production capabilities of a central kitchen cook up plenty of opportunities. At Continuum Health Partners in New York, a consortium of 10 medical facilities, a central kitchen prepares the 12,000 meals served daily.

Extra capacity allows Continuum Director of Foodservice Barry Schlossberg to provide foodservice to hospitals outside the Continuum umbrella. The latest to sign on is Manhattan's North General Hospital. Continuum gains management income and leadership opportunities for managers; North General says it has realized a 15% drop in foodservice costs while its patients get broader menu choices. 'Delivering meals in bulk is what we do best,' says Schlossberg.

Many foodservice operators find that properly organized room-service operations can reduce costs, food waste and inventor, while pleasing staff and patients. Via Christi Health System, a 2,400-bed system in Wichita, Kan., is integrating room-service operations with its oncology and pediatrics departments and already has seen patient-satisfaction scores rise. Covenant Hospital in Saginaw, Mich., and St. Anthony Hospital-Centura Health in Denver have completed the transition to room service.

Improving food quality and variety top the must-do lists for many operators. At Bergen Regional Medical Center, a 1,172-bed facility in Paramus, N.J., Executive Chef Anthony Mongiello and his team survey patients and medical staff and conduct regular resident council meetings to gather menu feedback. Findings are incorporated into a main four-week-cycle menu that includes such favorites as crab cakes, tuna fajita wraps, honey-mustard chicken and pasta primavera.

'We're taking a unit-by-unit approach,' says Barry Kriesberg, Bergen's vice president of facilities and support services. 'The psychiatric ward alone has five different menus. A year ago [before the hospital became self-operated], all patients [selected from] the same menu.

Behind-the-scenes efficiencies keep costs down. Trayline assembly times were cut by 40 minutes per meal period after time studies identified key people to work critical points. Ensuring all food was in place before starting assembly eliminated missing components that used to cause line stoppages.

Bergen's menus are used by eight nursing-home facilities, operated by the same parent company, iCare Management in Englewood, Col.

CAPSULE: HEALTH CARE

* 2001 segment sales [1]: $12.437 billion

* Nominal growth ('00-'01) [1]: 0.7%

* Share of total foodservice market [1]: 3%

* Share of noncommercial market [1]: 13%

* Business trends: Centralized food production; stronger retail focus; room service; carryout; online purchasing.

* Key issues: Hospital mergers; multidepartment management; labor shortages; budget cutbacks; growing long-term-care population.

Christus crawling toward profitability.(Christus Health)(Brief Article)(Statistical Data Included) - Modern Healthcare

Christus Health hasn't climbed all the way out of its financial hole, but at least the 33-hospital Irving, Texas-based system has stopped digging.

After losing $146.1 million on operations in fiscal 1999, which ended June 30 of that year, Christus slowed its operating losses to $65.4 million in fiscal 2000, or enough to show a total profit

of $74 million when investment income is included.

In 2001, the company expects its operations to be in the black, with an estimated operating profit of $10.8 million, with total profits expected to be $66.2 million.

``We have been on a very diligent and focused course,'' said Thomas Royer, M.D., Christus Health's president and chief executive officer. ``At no time have we gone into what I consider a crisis mode.''

Like Philadelphia-based University of Pennsylvania Health System and Englewood, Colo.-based Centura Health, Christus used a combination of selling or closing money-losing businesses and improving central-office procedures to effect the turnaround.

The task was all the more difficult because Christus Health is a combination of Sisters of Charity Healthcare System, Houston, and Incarnate Word Health System, San Antonio, that began combined operations Feb. 1, 1999.

Christus sold its interest in Memorial/Sisters of Charity Health Network, an HMO joint venture with Memorial Hermann Healthcare System, Houston, to Louisville, Ky.-based Humana. Christus also shut down a physician contracting network, the Northern Louisiana Physician Hospital Organization.

As a system, Christus worked on supply issues. Christus reviewed its vendor contracts to ensure that the system was taking full advantage of them and worked to set lower inventory levels to save on purchasing costs.

Employees in the billing department were retrained and new workers were hired to make the system's bills more accurate as part of an effort to speed average payment time, Royer said.

Christus also is looking to hire its first ``director of the revenue cycle'' to work with each of the 14 regional systems that make up Christus Health on payment issues, Royer said.

Each of the regions also reviewed all of its businesses and many trimmed services such as home health and psychiatric care or outsourced functions such as food and laundry services, Royer said.

Mostly through attrition, Christus also has trimmed its workforce by about 1,000 full-time equivalents to about 24,000 FTEs systemwide. About 800 FTEs were trimmed in two of the system's most troubled markets, the San Antonio area

and northern Louisiana, Royer said.

Royer said he considers almost all of these moves as one form of growth or another, along the lines of what economists call ``creative destruction,'' in which new, better ideas force out the old ways of doing business.

``In some instances, (growth) means new and more. In some instances, it means less, `garage-saling' some things that we don't think we need to be doing anymore,'' Royer said. ``That is not an easy thing to do,'' but careful planning and good communications with customers and partners smoothed out the process, he added.

The changes have impressed Standard & Poor's, a New York-based credit-rating agency. Christus Health has stabilized and has retained its investment grade, or A, bond rating, said Martin Arrick, a healthcare analyst for Standard & Poor's.

Health-care workers find jobs with no trouble at all - The Gazette (Colorado Springs, CO)

Local retail sales are down, manufacturing is slow and the high-tech sector has laid off some 600 people this year, but you can landa job tomorrow - if you're a qualified nurse or medical technician.

Penrose-St. Francis Health Services has about 250 job openingslisted on the company's Web site, www.centura.org, everything fromcouriers to nurses and lab technicians. Memorial Hospital's Web site,www.memorialhospital.com, lists about 110 openings.

Fort Carson recently advertised a pharmacist position with astarting salary of $60,000 a year, and four nursing homes are waving$2,000 signing bonuses for any nurse who will hire on.

'There are a lot of positions and not enough qualified people,'says Lynn Hunter, who helps finds health-care jobs for clients of thePikes Peak Workforce Center. 'We have a lot of job seekers who gotlaid off in other industries now looking to train into the health-care field.'

Where the jobs are

Laurie Kennedy, human resources director for Penrose-St. Francis,can't remember when there weren't at least 100 openings at hercompany's hospitals and other clinical facilities.

Almost 800 of Penrose-St. Francis' 2,900 employees are registerednurses (RNs). Most units are staffed around the clock and the demandfor nurses follows the hospital's fluctuating patient count, or'census.'

The nursing shortage is critical, and Kennedy has one full-timerecruiter working to find qualified candidates. The average salaryfor nurses at Penrose is $22 an hour, which is comparable to nurses'salaries at Memorial.

Part of the problem is demographic - women, who once flocked tonursing as their main entree to the medical profession, are findingbetter-paying jobs elsewhere. Kennedy says the nursing shortage willonly get worse as RNs now in their 50s and 60s leave the professionover the next decade.

'Every hospital has the same problem - there are fewer candidatesfor the jobs,' she said. 'And then Colorado Springs has its ownproblem with housing costs. It's getting expensive to live here.'

Memorial Hospital is also constantly recruiting nurses, but hasjust as many openings for medical technicians. There are now about 40tech openings on the hospital's staff of 3,400. Medical techniciansperform a variety of jobs, from assisting surgeons to running MRIs.

Memorial's Human Resources Director Gordon Riegel saystechnological advances in medical treatment are changing asfrequently as the hospital's patient census. New jobs in vasculartechnology, radiography and sonography (ultrasound) are being createdall the time as new procedures, machines and protocols are invented.

Memorial is offering $12 to $20 an hour for surgical technologistsand radiographers. The top dollar for sonographers at Memorial is $28an hour.

Riegel says the health-care industry faces the demographicchallenge of aging baby boomers retiring and requiring increasedmedical attention.

'The shortage is only beginning and it's going to get worse,' hesaid. 'We are anticipating greater shortages in radiation therapists,sonographers and surgical techs.'

Competing with hospitals for job candidates are numerous nursinghomes, doctors' offices, specialty clinics and temporary-medical-staffing agencies in town.

Traveling Nurses of Colorado Springs, for example, provides bothlocal hospital systems with nurses on a temporary basis.

Traveling Nurses, founded in the Springs by Jon and CarrollSmallegan 25 years ago, actually spun off a second company, Per DiemMedical Staffing Inc., last month. Per Diem allows nurses to pick andchoose shifts on a day-to-day basis; Traveling Nurses places them in13-week contracts across the country.

Colorado Springs Health Partners PC, the area's largest doctors'group, employs almost 500 people in 11 area clinics. CSHP presentlyhas openings for nine doctors and 21 support staff, such as medicalassistants and receptionists.

Although doctors used to hire nurses for their office practices,they now rely on medical assistants to draw blood, take bloodpressure and give injections, said CSHP Human Resources Manager LindaSommervold.

Training and certification

Health-care occupations usually require training - one to fouryears for nursing or technical certificates, less time to be anurse's aid or medical assistant.

Those with training can walk into a job. Those without trainingcan get it locally.

The Beth-El College of Nursing and Health Sciences at theUniversity of Colorado at Colorado Springs offers four-year degreesin a variety of health fields, including nursing, emergency healthservices and radiology.

Pikes Peak Community College has a Health Occupations Departmentoffering programs in nursing, pharmacy, medical assisting andemergency medical work. The RN program takes two years, the licensedpractical nurse (LPN) track takes three semesters and the certifiednurse assistant (CNA) takes just over seven weeks.

Pharmacy techs, who assist pharmacists in filling prescriptions,stocking and billing, can be certified in three semesters. Acertificate in medical office technology takes one year.

A basic emergency medical technician (EMT) certificate at PikesPeak Community College takes one semester, but there are more jobopenings for EMT-paramedics, which require three semesters oftraining.

All the college's health-care classes are held at the RampartRange campus, located almost directly across Interstate 25 from theAir Force Academy football stadium. Classes cost $60 a credit hour.

Memorial Hospital runs its own radiology school. The two-yearprogram begins every June and tuition runs $3,000. Private schoolssuch as IntelliTec Medical Institute and Blair College offer programsin medical assisting and lab work as well as certificates in medicaltranscription and coding.

Federal funds are available for laid-off workers in need ofretraining, said Hunter of the Pikes Peak Workforce Center.

Health Digest - The Pantagraph Bloomington, IL

ANNOUNCEMENTS

Komen grants

BLOOMINGTON - The McLean County Affiliate of Susan G. Komen forthe Cure, among 100 Komen affiliates nationwide dedicated to puttingan end to breast cancer, has announced the availability of grantsfor the coming year. Applications are due by Dec. 1 and areavailable at www.komenmcleanco.org.

Komen McLean County events, such as the recent Dance for theCure, allows the organization to fund activities such as cancersurvivor nutrition programs, screening for women who areunderinsured, a professional to help guide women newly diagnosedwith breast cancer, and community education workshops. More than$62,000 in community grants were awarded in 2008.

Medicare Part D

LACON - Central Illinois Agency on Aging has scheduled sessionswhere individuals may get the latest information on Medicare Part Dplans for 2009.

Among the sessions will be 1 to 3:30 p.m. Thursday at Nan's inLacon, 10 a.m. to noon Nov. 13 at Minonk Library, 11 a.m. to 1 p.m.Nov. 20 at Metamora Library, 1 to 3:30 p.m. Nov. 20 at Nan's inLacon, and 1 to 3:30 p.m. Dec. 18 at Nan's in Lacon. For moreinformation, call (309) 674-2071.

Foundation grant

BLOOMINGTON - Children's Home + Aid Children's Foundation hasreceived a $10,000 grant from Ronald McDonald House Charities ofCentral Illinois to equip a new classroom for preschool children.

The grant will allow Children's Foundation's Scott Early LearningCenter to respond to the increasing need for quality early childhoodcare and education services in McLean County by opening anadditional preschool classroom for about 20 children. Lisa Pieper,Children's Foundation regional vice president, credited the McDonaldHouse Charities and Bob and Julie Dobski, local McDonald Restaurantowners, for their support of the project.

State Farm Classic

BLOOMINGTON - The LPGA State Farm Classic set an event record forcharitable contributions. Because of money raised at the recent 2008tournament, $377,600 will be distributed to 11 schools andorganizations, many of which are health-related.

The amount was $32,000 more than was raised last year and bringsto nearly $3 million the amount of money raised at the classic since1980.

APPOINTMENTS

St. Mary's CEO

STREATOR - Joanne Fenton, a registered nurse and health careexecutive with experience in hospital management, has been namedpresident and chief executive officer of St. Mary's Hospital inStreator. Fenton, 55, replaces Richard Carlson, who had been interimCEO.

Fenton joins the Hospital Sisters of St. Francis after 10 yearswith Banner Health, most recently as interim CEO at Banner LassenMedical Center in Susanville, Calif. Before that, she served atNorth Colorado Medical Center in Greeley, Colo.; Tucson HeartHospital in Tucson, Ariz.; and Centura-St. Anthony Hospitals inDenver. She has a bachelor's degree in nursing from the Universityof Florida in Gainesville and a master's degree in businessadministration from the University of Phoenix in Denver.

Health Alliance

URBANA - Health Alliance Medical Plans - which has more than310,000 members in Iowa and Illinois, including in McLean County -has named Dr. Robert C. Parker as chief medical officer. In January,the existing chief medical officer, Dr. Robert Scully, will stepdown but will remain with Health Alliance part-time.

Parker is returning to Champaign-Urbana, where he was chiefexecutive officer of Carle Clinic Association and president ofHealth Alliance from 1995 to 1999. Parker has been CEO of MountSinai Medical Group and chief medical officer of Sinai HealthSystem, Chicago.

'We're very happy to have Dr. Parker returning to HealthAlliance,' said Health Alliance CEO Jeff Ingrum.

AWARDS

Poulter recertified

BLOOMINGTON - The plastic surgery operative suite of Dr. JeffreyPoulter has been recertified by the American Association forAccreditation of Ambulatory Surgical Facilities following a recentinspection. Poulter has achieved accreditation during each three-year cycle since opening The Center for Cosmetic and Laser Surgeryin 1998.

Poulter, a board-certified plastic surgeon, has cared for morethan 15,000 patients in his 16 years of practice in Bloomington.

Accredited facilities must comply with all local, state andfederal regulations; adhere to OSHA standards and the Americans withDisabilities Act; use advanced instruments and monitoring devices;have surgeries performed only by qualified surgeons with hospitalprivileges; and provide for safe anesthesia by certifiedanesthesiologists.

Fundraisers

EAST PEORIA - The Central Illinois Chapter of the Association ofFund Raising Professionals has announced its 2008 Philanthropy DayAward Winners.

Among them are Dave and Karen Magers of Bloomington, co-winnersof the Lewis J. Burger Outstanding Volunteer Fund Raisers; and theIllinois State and Illinois Wesleyan universities Habitat forHumanity Campus Chapter, winners of the Outstanding Youth inPhilanthropy for Ages 18 to 23.

Winners will be honored with an awards program and luncheon onNov. 12 at the Embassy Suites, East Peoria. More information is atwww.afpcentralillinois.org.

Nurses honored

PEORIA - The Saint Francis Medical Center College of Nursinghonored four alumni during a recent homecoming celebration. Thealumni were nominated by their peers for outstanding contributionsto the profession of nursing and for being outstanding nurses.

The winners were Deborah Scudder Richardson of Metamora, class of1972, the Ruby Cealey Distinguished Alumni Award; Norma SpanglerKelly of Morton, class of 1959, Outstanding Alumni Excellence inLeadership; Wendy Mann Woith of Normal, class of 1976, OutstandingAlumni Excellence in Education; and Arlene Sparling Onken of Morton,class of 1954, the Alumni Heart of the Class.

Submit Health Digest items to Paul Swiech atpswiech@pantagraph.com.

Puebloans craft health plan for working poor: Using a Michigan plan as its model, Pueblo business and medical leaders suggest three-way cost sharing to cover employees. - The Pueblo Chieftain (Pueblo, Colorado)

Byline: James Amos

Jan. 29--It would be the Holy Grail of health-care coverage -- a health benefits plan for the working poor that they can actually afford -- and Pueblo officials said they think they can bring it here. The plan is based on a successful Michigan program in which employees, business owners and the community each pay one-third of the cost for coverage for each employee. The cost has been less than $50 a year for employees, and the entire community chooses which services are covered and to what extent. The community's share was paid with federal funds that come to area hospitals when they provide uncompensated care. Philanthropic foundations also contributed to start the program.

The program could easily be used here in Pueblo, and there are thousands of working adults with no health-care coverage who need it, according to Len Gregory of St. Mary-Corwin Medical Center. Both St. Mary-Corwin and Parkview medical centers support creating a similar plan in Pueblo, Gregory said, with backing from the Greater Pueblo Chamber of Commerce, United Way of Pueblo County, Pueblo Medical Society and several other local groups. Pueblo has at least 13,000 working residents who have no health insurance, Gregory said. The Michigan plan, first started in Muskegon, Mich., in 1994, is designed to provide coverage to those who work in businesses that can't afford to provide health insurance, typically companies with 25 or fewer workers. Pueblo business and medical leaders started talking about the plan last year after being approached by members of a statewide task force of Centura Health, St. Mary-Corwin's parent company. The task force had heard about the success of the Michigan program and, hoping to start a pilot program here in Colorado, was told that Pueblo would be a good candidate. Muskegon, like Pueblo, is an industrial city of about 100,000 people that suffered when the steel and auto-making industries collapsed in the 1980s, Gregory said. The two cities each are home to a high number of uninsured working residents with a desire to do something about it. Muskegon officials put the program together with the help of the W. K. Kellogg Foundation and chose a board-game style format for choosing which benefits the program would provide with its limited funds. The exercise, available under the 'try a demo' function at http://healthmedia.umich.edu/cgi-bin/WebObjects/chat.woa/wa/login, shows people how they must budget their health-care resources when choosing plan benefits. The benefits selected in the Michigan program were chosen by everyone who participated and do not vary by person.

Cindy Lau of the Pueblo Step-Up agency has been conducting the benefits exercise with groups of employees at Pueblo businesses in order to help decide what Pueblo's plan would look like. Participants in the exercise use a fixed number of stickers to chose which levels of coverage will be in the plan. Workers can get more stickers, and therefore more coverage, if they agree to several health-maintenance and improvements programs, like taking classes to quit smoking or better manage chronic diseases. Lau said she has made the presentation and conducted benefits-choice exercise to a small number of Pueblo businesses and their workers. The reaction from initial business owners and their employees has been overwhelmingly positive, she said.

'They all wanted to sign up today.' Pueblo's plan isn't finished and won't be for about a year, according to Lau and Gregory. The Pueblo group trying to start the plan must make sure there aren't legal problems, work out the benefits package with workers and the community and set up contractual agreements with health-care providers. Gregory said the group has met with a number of Pueblo doctors, and nearly all of them said they'd be interested in participating. The Michigan plan pays doctors and other health-care providers the amount they would get from Medicare plus 10 percent, so providers don't have to discount their services more than that. The Michigan plan also uses case managers to spot usage and efficiency problems, such as workers using the emergency room for common colds. They then talk with workers to steer them to the correct type of care. The plans doesn't cover families, since the children of many of the people who qualify for the plan already qualify for government programs. It also steers workers to other health and wellness programs that can help them. Rod Slyhoff, president of the Greater Pueblo Chamber of Commerce, said the business community has liked what it has seen of the plan so far. 'We're excited about it,' he said. 'The chamber's number one legislative priority has been trying to get a handle on the cost of health care in Pueblo County. And while we've not had a lot of luck on that, this is an opportunity to at least put a Band-Aid on that and help some folks.' He said employers stand to benefit from the plan by having healthier workers, and workers who are not worried about large medical costs taking away their finances and even their homes. 'People with financial problems aren't good employees,' he said. 'Their minds are on other things.'

The Michigan program can provide a decent basic level of coverage, with other benefits, because it costs much less than private health-care insurance. The Michigan program is run by a community nonprofit agency and has low overhead. Gregory said the community share of premiums for the Pueblo plan could come from grants, federal matching funds for the hospitals and even the hospitals. Leaders at both Pueblo hospitals have said they think Pueblo needs the plan and have pledged to help, he said. The Michigan program is not the same as health insurance, a fact everyone involved has taken great pains to emphasize.

'This is not an insurance product,' Gregory said. 'And this is not competition for insurance products. We don't want to threaten the insurance industry.' Chris Adams, a consultant helping the Pueblo group bring the plan to fruition, said Michigan's experience has shown that the plan doesn't keep people from buying regular health insurance.

Instead, because most poor workers has never had private insurance before, the plan actually trains them to use and pay for it, Adams said. Later, when they move on to better-paying work, they are accustomed to buying health insurance and using it wisely. The Pueblo plan would not provide benefits outside of Pueblo or Pueblo County, depending on how it is configured, Gregory said. But the Pueblo pilot plan could become an example for the entire state, its backers said. 'The whole reason that this will work is that there is this whole community behind it,' Lau said. 'People have really been excited by the idea.' For more information, or to schedule a presentation of the plan and its benefits-decision exercise, call 560-5886. ------ HEALTH COVERAGE CHOICES EXCERCISE Inspired by a health care plan for the working poor in Michigan, Pueblo business and medical leaders are working to craft a low-cost health benefits plan for working people who cannot afford private health insurance. Participating employers and their workers will decide what benefits the system will offer, using the circle graph below and a certain number of 'dots' to determine how much of each service to buy in the coverage plan. Rings farther inside the circle provide more services, but cost more. A working demonstration of the Michigan program's exercise is available at: http://healthmedia.umich.edu/cgi-bin/WebObjects/chat.woa/wa/login

Copyright (c) 2007, The Pueblo Chieftain, Colo.

Distributed by McClatchy-Tribune Business

News.

Integration's best performers-seven habits of successful health care systems. (Integrated Systems).(Statistical Data Included) - Healthcare Strategic Management

Over the past 10 years there has been a rapid consolidation of health care providers in many markets throughout the country and the related development of integrated health care delivery systems. In an effort to measure the evolution of these health care systems, Arista Associates Inc, Fairfax, Va.,. in cooperation with Modern Healthcare magazine, has surveyed system CEOs for the past six years. There were 144 respondents to the 2001 Integrated Delivery System Survey, which included questions relating to:

* System characteristics and performance

* Physician organization/integration

* Clinical integration

* Disintegration activities, and

* Overall experiences.

Although many are predicting the demise of these systems and, in fact, more than a few have already unraveled, some systems are succeeding. We can all agree that a key measurement of success is financial performance. Of the survey respondents, 21 organizations (17%) reported operating margins of 4% or more. When analyzed, it appears that these best performing organizations found the following seven secrets to success:

* Focus on core competencies

* Bigger is not necessarily better

* Success has not bred complacency

* Execution, execution, execution

* Quality versus quantity of physician integration

* Reduce duplication of services

* Controlled future growth.

Focus on core competencies

While they are diversified, the best performing systems tend not to stray as far from hospital core competencies than all respondents as a whole. Fewer best performers have investments in health plans, physician practices, and specialty hospitals. On the other hand, the best performers had a greater investment in their core competencies areas such as ambulatory care and surgery. Amy Nyberg, Director of Planning at Centura Health in Englewood, Colo., said: 'Given the complexity of the acute care business, systems must focus on their core business to succeed.' Centura Health's operating margin has gone from losses in 1998 to 8% in 2001. The turnaround was accomplished by going back to basics and unraveling acquisitions that were not benefiting the system.

Further, there appears to be a level of investment in senior care and end-of-life care in the form of hospice, chronic disease treatment, and residential care. Nyberg indicated that Centura has a significant mission-driven investment in home care and hospice that are also profitable service lines.

Bigger is not necessarily better

The best performing systems were generally smaller than all respondents as a whole, both in net revenue and number of units by type. The vast majority of the best performing systems (80%) had net revenues in the range of $100 million to $500 million, while only 52% of all respondents fell into that size range. As we previously mentioned, the best performers are diversified; however, their holdings are more limited. The following table compares the system holdings by type of unit for the best performers and all respondents. Of particular interest is the significantly lower median and maximum number of employed physicians in the best performing systems.

Success has not bred complacency

With operating margins above 4%, the best performing systems achieved a respectable financial outcome by today's market standards. Furthermore, over 70% of the best performers indicated at least a modest rise in operating margin over last year as compared to only 47% of all respondents. In addition, over 80% of the best performers indicated at least a modest rise in net revenues over last year as compared to 66% of all respondents. At the same time, 10% of the best performers -- double the percentage for all respondents--indicated a decline in market share.

This combination of data implies a controlled and strategic market approach that may include targeting selected patient populations and payors coupled with improved contracting performance, while controlling expenses at the operating level. According to Frank Sacco, CEO of Memorial Healthcare System in Hollywood, Fla., their financial success was achieved by going back to basics--including watching collections and making sure the managed care companies pay reasonable rates in a timely fashion.

Execution, execution, execution

The best performers determine what is important to their success and then execute--far better than survey respondents as a whole. As the comparison below illustrates, the best performers outperform all respondents in all initiatives (on a 1-9 scale). The most successful initiatives focus primarily in two areas: enhanced positioning for contracting and bottom line performance.

According to Mr. Sacco, Memorial's success was not only attributable to expert implementation of a strong strategic plan, but also included 'placing high performing executives in key positions to execute the plan.' Lowell Krause, president and CEO of Heartland Health in St. Joseph, Mo., said: 'Heartland's success stems from a high level board commitment to being the best. A benefit we have realized from this commitment is the ability to attract and retain top performers to help build and manage the organization.'

Quality versus quantity of physician integration

Most would agree that physician integration is a critical success factor for integrated delivery systems. Furthermore, a large percentage of systems that employ physicians also lose money on system-owned practices. What distinguishes the best performing systems is the fact that as a group they utilize fewer physician integration models. This is particularly true of the employed physician with incentives model, with 67% of the best performers as opposed to 82% of all respondents indicating use of this integration model. However, there is less consensus among the best performers as to the most and least effective models.

With respect to system-owned physician practices, the best performers fare much better financially. The percentage of best performers and all respondents that lost money on owned practices was 57% and 83%, respectively. Also, of those that lost money, the best performers did a better job of minimizing their losses, with 36% of those that lost money losing less than $25,000 per physician (as compared to only 25% for all respondents).

Nyberg of Centura said, 'It is important to get beyond the mistakes of the past and we need to focus on quality and efficiency in the future.' In the past 2 years, Centura has divested itself of 120 physician practices.

Reduce duplication of services

Reduced duplication of services throughout the system translates into reduced expense structure. Eliminating services from selected locations should not negatively impact volume if it is strategically coordinated and marketed with patient convenience and satisfaction in mind. The best performers assigned a higher level of importance to reducing duplication of services. The strategic importance of reducing duplication translated into higher levels of implementation success for the best performers compared to all respondents (6.4 versus 5.7).

The focus on reduced duplication of services can be seen in the area of clinical integration. A slightly higher percentage of best performers indicated introduction or expansion of a case manager program (78% versus 71%), which through better coordination of patient services reduces duplicate procedures. Consolidating procedures to one site requires a willingness to make some tough and politically charged decisions. The best performers have shown such a willingness. Of the best performers, 56% indicated consolidation of procedures at one site versus only 46% of all respondents.

Nyberg says Centura continues to work on finding the right balance between reduced duplication and decentralization and efficiency and responsiveness to stakeholders.

Controlled future growth

It appears that best performing systems have grown more slowly, and as a result, maybe more carefully. This was indicated by the smaller median size of the best performing organizations. Just as important, the best performers appear to have experienced less disintegration activity, 33% versus 41% of all respondents. Those that experienced disintegration focused on divesting primarily two things--health plans and physician practices.

HEALTH CARE GIANT GETS TOUGH COLUMBIA TELLS HMOS IT WON'T DEAL WITH THEM IF THEY DEAL WITH DOCS WHO LEFT CONGLOMERATE.(Business) - Rocky Mountain News (Denver, CO)

Byline: Michele Conklin Rocky Mountain News Staff Writer

Columbia/HealthOne is playing hardball with a group of physicians that broke off from its Rose Medical Center last year.

Columbia officials have been telling local HMOs that if they contract with Precedent Health Center - a hospital being opened in May by the physicians - the managed-care plans will not be allowed to contract with Columbia / HealthOne's six Denver-area hospitals, according to Precedent officials and other industry insiders.

Columbia's chief financial officer, Richard Shallcross, would not comment on whether Columbia has issued the ultimatum, saying it was ``not an appropriate time to discuss that.'' He also declined to comment on Columbia's ``strategic initiatives.''

``We'd like the health plans to respect the relationship we've had in the past where we've been their primary downtown provider,'' Shallcross said. ``We have not said, nor have payers said, there's a need for more hospital beds downtown. From our standpoint, this spreads the same patients over more bricks and mortar, more payroll, more costs. . . . We think it will add costs that will flow back to anyone who pays for health care.''

Columbia / HealthOne owns Rose, Presyterian / St. Luke's, Swedish, North Suburban and the two Aurora hospitals. Nashville-based Columbia / HCA, half-owner of Colorado's system, is the nation's largest for-profit hospital chain operating 342 hospitals, 150 surgery centers and 570 home health services in 37 states.

Precedent Health Partners is a group of about 100 prominent physicians who broke off from Rose last summer and announced plans to reopen the former Mercy Hospital. The hospital, renamed Precedent Health Center, is meant to specialize in procedures that can be done on an outpatient basis or require less than a three-day hospital stay. The physicians have insisted all along that they would continue to use Rose for their more critical and long-term patients, such as those needing major surgery or intensive care.

``We've tried in every way possible to work with Rose and Columbia, but they've clearly declared war,'' said Dr. Jeffrey Mishell, president of Precedent. ``We didn't declare war, but we'll be happy to compete with them.''

Several HMO officials said Columbia has not issued a direct ultimatum but rather voiced concerns about the presence of Precedent.

``We are in discussions with Columbia and they are very concerned about Precedent,'' said Chris Miller, president of One Health Plan of Colorado. ``We've had conversations about this, but we have not received anything official.''

One Health reportedly had decided against contracting with Precedent, but Miller said no such decision has been made.

QualMed also reportedly will not contract with Precedent. Officials there declined to comment.

Columbia also has discussed the Precedent issue with Pacificare, said Val Dean, chief operating officer for the health-maintenance organization.

``It's very problematic for Columbia,'' Dean said. ``We've had conversations about the pros and cons of Precedent, but no one has directly threatened me. It wouldn't make any sense to me that they would. We have 300 and some odd thousand patients in metro Denver that split 50-50 between Columbia and Centura (Health). It makes no sense for Columbia to cut off its nose to spite its face.''

Centura Health, another local hospital system and former owner of Mercy, is Precedent's financial partner in the health center. Officials there said they have heard about the threat.

HIPAA compliance readiness assessment: A case study. (Integrated Delivery Systems).(Health Insurance Portability and Accountability Act of 1996) - Healthcare Financial Management

Centura Health, a faith-based, not-for-profit IDS headquartered in Denver, Colorado, recently undertook a rapid assessment to determine its readiness to comply with the standards mandated by the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The assessment process consisted of a business-impact assessment, compilation of results, a gap analysis, and a preliminary business case. The business-impact assessment involved a series of interviews.

For the business case, results of the business-impact assessment were compared with the related HIPAA standard to determine the current level of compliance and develop an action plan, for approval by the project steering committee, to correct deficiencies. The HIPAA readiness assessment uncovered numerous areas in which Centura needed to implement changes, particularly with respect to ensuring the security and privacy of patients' paper records.

Denver-based Centura Health recently completed a rapid assessment to determine its readiness to comply with regulations promulgated under the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (a) Centura Health is a faith-based, not-for-profit integrated delivery system (IDS) sponsored by Catholic Health Initiatives and Adventist Health System. Centura is the largest IDS in Colorado, comprising 10 acute care hospitals located throughout central Colorado, four full-service medical/surgical centers, 10 long-term care facilities, and a statewide home care and hospice division.

Centura's leaders decided that a HIPAA readiness assessment should be performed as quickly as possible. Unlike a stand-alone hospital, Centura would require considerable time and effort to analyze the impact of HIPAA on each component of its delivery system, present HIPAA remediation proposals for multiple facilities to its board for funding approval, and implement a statewide HIPAA training program for all IDS staff.

The readiness assessment was conducted with two basic premises in mind. First, HIPAA compliance is not a finite undertaking like the Year 2000 compliance initiative, but rather, requires adoption of policies and procedures to facilitate ongoing compliance. Second, because the priority of the HIPAA readiness assessment is compliance, solutions need to be found within the IDS's current IT capabilities, and transformation of system capabilities should be considered only when absolutely necessary and in accordance with the organization's strategic plan.

To begin, Centura organized a steering committee of senior management from across the organization. The IDS then formed a statewide task force to perform the basic work of the assessment and to report findings to the steering committee. The task force was composed of about 40 staff members, including billing and accounts receivable personnel; medical records personnel; the chief privacy officer; the chief security officer; IT program office staff; representatives from the medical/surgical department, intensive care unit, emergency department, and other specialty lines of services; and quality, integrity and legal staff.

The HIPAA readiness assessment was piloted at one of Centura's hospitals. This phase of the assessment took about six weeks, The assessment process involved four phases:

* Business-impact assessment;

* Compilation of results;

* Gap analysis; and

* Business case.

Business-Impact Assessment

The business-impact assessment focused on the business office, IT functions, and clinical operations. Interview questions were developed to elicit information about Centura's HIPAA-compliance readiness in each of these three areas with respect to security privacy and transaction code sets. The interviews were conducted with various constituents throughout the organization. The IDS allotted three weeks for this process, whose broad goals were to:

* Identify gaps between Centura's current policies and procedures and HIPAA compliance by analyzing the impact of HIPAA on targeted systems, processes, and business-associate relationships;

* Determine the effect of HIPAA on the IDS's current strategic initiatives, including a clinical messaging project designed to provide physicians across the state with intranet access to information on patient outcomes, and a patient management project designed to facilitate patient access to the health system; and

* Identify alternative solutions to close gaps in HIPAA compliance.

The interview questions were designed by a consulting firm in a format that would enable task-force members to conduct the interviews without needing a thorough knowledge of the HIPAA regulations. The HIPAA standards were broken down into specific points, each of which could be addressed by a focused question. Because interviews were conducted face-to-face, interviewers could ask respondents follow-up questions, as necessary.

Interviews were conducted with individuals and, in some instances, small groups. The interviews on privacy and security issues took about six hours for each participant or group, and the transaction-code-set interviews took much longer, largely because many of these interviews involved vendors. All participants were asked in advance to bring an outline of their current policies and procedures to the interview.

Security. The proposed HIPAA rule on health data security was published in the August 12, 1998, Federal Register. Although the proposed security standards still are under review, and it is uncertain when the final standard will be issued, Centura determined that a readiness assessment should be conducted for this area because of the considerable time and expense that would likely be required to comply with the final standard. Important issues addressed in the interviews included:

* Administrative procedures, including employee termination policies;

* Physical safeguards, including locks and keys; and

* Technical security, including access, passwords, and encryption.

Exhibit 1 provides a sample question regarding security.

Privacy. The HIPAA final privacy rule was published in the December 28, 2000, Federal Register, with an effective date of April 14, 2003. On July 7, 2001, HHS Secretary Tommy Thompson issued a new statement regarding privacy, which relaxed some of the more stringent standards related to nonwritten communications about a patient's medical condition, use of prior consent, prescription pickup, and consultations.

To assess Centura's current state of compliance with the final rule and Secretary Thompson's revisions to it, the readiness-assessment questionnaires sought information on:

* The revenue cycle, especially whether billing personnel's access to protected information is limited to only that information required to perform their duties and whether the business-office activities are sufficiently out of public view to safeguard protected information;

* Clinical operations, including steps taken to safeguard information in the patient medical record, as well as faxed and written information;

*Administrative functions, including the positioning of computer screens and message boards and steps taken to safeguard patient lists and schedules; and

*Pastoral care providers and volunteers and the degree to which they can access protected information.

Transaction code sets. The final rule on transaction formats and code sets was published in the August 17, 2000, Federal Register with a compliance date of October 16, 2002. Centura's HIPAA readiness questionnaires focused on:

* Payment collection on patient accounts;

* Management of patient access and eligibility;

* Communications with physicians and other members of the professional community; and

* Employer information.

Exhibit 2 provides a sample of a typical question regarding code sets.

Compilation of Results

Because Centura's HIPAA readiness assessment involved multiple facilities, it was necessary to compile results into a database to facilitate comparison of findings. Data entry was time- and labor-intensive, requiring the dedication of two staff members to the task almost full-time for about 10 days. A stand-alone hospital with just one set of responses for each area evaluated may be able to skip this step. For Gentura, however, the use of the database was necessary to aggregate information regarding all results statewide, thereby allowing for easier analysis of results, businesscase preparation, and costing during the planning and implementation phase of the project.

Gap Analysis and Preliminary Business Case

The results of the pilot assessment were analyzed to identify gaps in compliance, and a preliminary business case was prepared for review and confirmation by the steering committee and task force. The preliminary business case included

results of the business-impact assessment, gaps identified, alternative solutions, a risk assessment, preliminary work plans, resource requirements, and a budget for completing the initiative.

Accountability for the business case was assigned to the HIPAA project manager, who, in turn, designated responsibility for developing reports on each focus area (ie, privacy, security, and transaction code sets) to individuals who also would be responsible for implementing changes in the business office and IT and clinical areas.

A formal review process was established to give task force members an opportunity to review the business case before it was presented to the steering committee. Following approval of the remediation plan by the steering committee, the task force met to discuss individual projects, time frames, and costs; develop an action plan; and designate the individuals who would be responsible for overseeing remediation activities. This phase of the project took about two weeks.

Project Findings

The following are representative findings for each area assessed:

Security. The task force determined that authentication and identification of all users, within or outside of Gentura's facilities, were required. One area requiring increased security was vendor screening in materials management, including the need to safeguard protected information of patients who receive prosthetics and implants.

In addition, physical security for all locations in which patient data are used or stored needed to be strengthened. The task force was surprised by the lack of sufficient physical security of paper records, finding that copies of records had proliferated across the organization's hospitals as a result of efforts to obtain rapid access to the information. Although the task force acknowledged that implementation of a systemwide electronic medical record eventually would solve this problem, immediate measures were required to eliminate these copies and secure the original records.

Privacy. The task force determined that training programs on privacy/confidentiality were required for physicians and other staff, and forms and processes for ensuring patient consent and tracking disclosure of protected health information needed to be developed and disseminated. Increasing the awareness of patient privacy standards among all medical staff was identified as a priority An unexpected finding with significant implications for capital investment was that some family conference rooms might need to be redesigned to afford patients greater privacy for discussing healthcare issues.

Transaction and code sets. The task force found that Centura's eligibility transactions were not HIPAA-compliant. The IT department therefore was charged with ensuring that all eligibility transactions involving Gentura's business partners use the prescribed ASC X12N format. Also, because the business community was not prepared to provide details regarding its HIPAA compliance efforts, continued monitoring of business partners' progress was deemed necessary

The task force also found that Centura was using local billing codes for several of its managed care contracts, whereas HIPAA regulations mandate the use of prescribed code sets. The IDS therefore has begun mapping its procedures to the national code sets.

The task force was surprised to find substantial inconsistency in code structures among Centura's payers. It became evident that the Federal requirement to standardize code sets would help the organization substantially reduce overhead costs with electronic eligibility, authorizations, and claims submissions.

HIPAA's Financial Impact

Consulting firms offer a number of tools to assist organizations in preparing a business case and a two- to three-year financial pro forma for HIPAA compliance initiatives. The financial models reviewed by the task force tended to project relatively high costs for compliance projects. Nonetheless, use of these tools helped senior management better understand the financial impact of HIPAA.

The total financial impact of Centura's HIPAA compliance measures remains uncertain, but substantial technology infrastructure changes already have been implemented to protect patients' protected medical information in electronic formats. It was determined that having the right IT infrastructure is critical to properly protect confidential electronic data and to ensure that future software systems are HIPAA-compliant.

A major technology expense for Gentura will be implementation of an electronic medical record for postdischarge information. Fortunately for a large IDS, such large-scale IT initiatives need to be implemented only once as a single, systemwide solution.

There also will be significant costs associated with training medical and administrative staff on the organization's policies and procedures and with revising paper processes at each facility to safeguard paper records. Centura acknowledged that initial and ongoing training would be required on all HIPAA issues, thus requiring integration of HIPAA training into basic employee orientation and training programs. It was estimated that HIPAA training would cost about $50 per staff member. Centura also is seeking grant funding for education of its physician partners.

Centura anticipates that the greatest privacy-related expense, in addition to staff education, will be the redesign of patient consent forms. In addition, as noted previously the IDS expects to incur some remodeling expense to ensure patient privacy in conference areas.

Next Steps

Centura currently is completing the business-impact assessment for the remainder of its hospitals and facilities, using lessons learned from the initial assessment to improve and streamline the process. Centura has estimated that it will take eight to 12 weeks to complete the assessment of all its facilities, with a targeted completion date of October 30, 2001. For each facility, the task force will develop a business case, with priorities set among recommended solutions. The final, statewide business case, including the estimated costs for HIPAA remediation, will be presented to the steering committee in December 2001.

In general, Centura is seeking standard solutions that will be applicable to all facilities (eg, with respect to transaction code sets, patient consent forms, and communication of electronic patient information). In some instances, however, the business case may be hospital specific. For example, registration areas in some of Centura's older hospitals may need to be remodeled to meet the HIPAA privacy standards, whereas those in the IDS's newest hospitals already offer patients sufficient privacy.

In addition, Centura is implementing automated clinical and billing systems in its long-term care facilities and home health agencies. These applications are accessed through Centura's intranet to ensure appropriate safeguarding of patient information. Although the HIPAA compliance dates for home health agencies, long-term care facilities, and clinics are not until 2003, the need to eliminate duplicate paper records and implement a systemwide electronic medical record compelled Centura to develop business-impact assessments immediately for these areas as well.

Conclusion

For organizations that have not yet begun the HIPAA assessment process, the need for such a process is becoming acute. Many of the HIPAA mandates make good business sense and will have a positive effect on U.S. healthcare delivery. Some require substantial work to ensure compliance, including redesigning facilities, raising physician awareness (since their offices will not be affected until 2004), and--perhaps the greatest challenge of all--working with hospital managers to transform noncompliant practice habits.

Elaine Callas is senior vice president and CIO, and executive HIPAA sponsor, centura Health, Englewood, Colorado.

Karl Brockmeier is director, IT Program Office and HIPAA project manager, Centura Health, Englewood, Colorado

(a.) For a discussion of the HIPAA standards, see Hamby, Pat H., and McLaughlin, Mark, 'HIPAA Standards Offer More Accuracy and Eventual Cost Savings,' HEALTHCARE FINANCIAL MANAGEMENT, April 2001, pp. 58-62.

RELATED ARTICLE: EXHIIT I: SAMPLE HIPAA QUESTION/GAP ANALYSIS SECURITY

HIPAA Requirement: Security and Electronic Signature Standards

HIPAA Regulation Section: 42.308(b)(4)(i)

HIPAA Standard Description: Physical Safeguards: Policy/Guideline on Work Station Use

Question Regulation Text: Policy and Guidelines on Work Station Use require documented instructions and procedures delineating the proper functions to be performed, the manner in which those functions are to be performed, and the physical attributes of the surroundings of a specific computer terminal site or type of site, dependent upon the sensitivity of the information accessed from that site.

Question Text: Are there documented policies and procedures for storing patient-identifiable information on workstation hard drives and a means to mitigate the risk?

Priority: Medium

Department: Patient Accounting

Gap/Explanation: There are no written policies for storing protected health information on workstation or portable PC hard drives.

Implications: Unauthorized access to restricted information is possible by accessing the hard drives of the PCs.

Alternatives:

1. Forbid storage of protected health information on PC hard drives.

2. Issue thin-client workstations without hard drives.

3. Implement policies governing storage of protected health information.

Solutions: Need to implement policies governing the storage of protected health information and the security of PCs.

Comments: Removal of portable PC hard drives is not practical because it would cripple the PCs capabilities. Forbidding storage of all protected health information on PC hard drives is too restrictive; it would interfere with the ability to perform analyses and produce custom reports.

EXHIBIT 2: SAMPLE HIPAA QUESTION/GAP ANALYSIS: CODE SETS

HIPAA Requirement: Standardization of Code Sets

HIPAA Regulation Section: 62.1002

HIPAA Standard Description: HCPCS

HIPAA Regulation Text: Standardization of Code Sets: Drugs and Biologics National Drug Codes (NDC), as maintained and distributed by HHS, in collaboration with drug manufacturers, will be mandated for the following: (1) Drugs, (2) Biologics

Question Text: HCPCS Level 2 J-Codes will not be used as of October 16, 2003. Are you currently utilizing HCPCS Level 2 J-Codes for drugs and injections?

Priority: High

Department: Pharmacy

Gap/Explanation: Pharmacy is using J-codes for drugs and injections. HIPAA requires a change to NDC codes.

Implications: Cash-flow impact when bills are rejected.

Alternatives: Replace J-codes with NDC codes.

Solutions: Replace J-codes with NDC codes.

CEO of Colorado health system to step down at end of year. - Knight Ridder/Tribune Business News

By Marsha Austin, The Denver Post Knight Ridder/Tribune Business News

Nov. 11--Joseph Swedish, chief executive of Centura Health, Colorado's largest hospital system, will leave Jan. 1 to take the helm of Michigan-based Trinity Health.

Swedish pulled Centura from deepening financial losses in the late 1990s, orchestrating a turnaround that produced record profits for the hospital system and fueled one of the nation's largest hospital construction booms.

During Swedish's six-year tenure, Centura built Parker Adventist Hospital south of Denver and launched expansions at Avista, Porter and Littleton Adventist hospitals. Centura also is reportedly considering relocating its Saint Anthony Central Hospital to a new campus.

'Over the past six years, Joe has led our organization to unprecedented achievement,' said Mike Fordyce, chair of the Centura Health Board of Trustees and chief administrative officer of Catholic Health Initiatives, a Centura parent. 'Under his leadership, Centura has improved its financial stability, strengthened its voice on health-care policy issues and made enormous investments in quality, facilities and service to the community.'

But without the gains Centura also made in improving medical care and strengthening its faith-based culture, 'it would have been a hollow transformation,' Swedish said. 'What I'm most proud of is the transformation of our culture to one that is known for clinical excellence and organizational excellence.'

Swedish said Trinity Health, one of the nation's largest Catholic health-care systems, recruited him.

'I wasn't looking,' he said.

The opportunity was too good to pass up, Swedish said.

Trinity Health is one of the nation's largest Catholic health-care systems. It has operations in seven states, including 45 hospitals, 384 outpatient facilities, numerous long-term-care facilities, home health offices and hospice programs, a health-care architectural firm, a physician practice consulting company, and two health plans.

Centura Health operates 12 hospitals, eight senior living residences, medical clinics and home-care and hospice services. The nonprofit Centura provides care to more than half a million people a year and is Colorado's fourth-largest private employer with more than 11,000 associates. Centura is owned jointly by Catholic Health Initiatives and Adventist Health System.

The two organizations will begin the search for a new Centura CEO soon, officials said.

To see more of The Denver Post, or to subscribe to the newspaper, go to http://www.denverpost.com.

RBC Says Next U.S. Deal Won't Come Soon.(National/Global)(Royal Bank of Canada)(RBC Centura Banks Inc.) - American Banker

Byline: Matthew Monks

W. James Westlake knows there are second-guessers of Royal Bank of Canada's strategy to right its U.S. operations, but he says they aren't realistic.

After a speedy and ill-fated push past the Mason-Dixon Line a few years ago, Canada's largest lender is in no hurry like others to buy any more U.S. banks.

Yes, there are signs that its money-losing RBC Bank, a $33 billion-asset company in Raleigh, is finally turning the corner after being burned by bad loans to home builders. And yes, the company 'would certainly expect to be a consolidator' in the United States if and when the economy rebounds, said Westlake, Royal Bank's head of international banking.

But rushing into a deal right now could be rash, he said.

'We don't expect to be doing anything in the near future,' Westlake said in an interview Monday.

'We think that until banks are getting out of' the Troubled Asset Relief Program, 'and the capital and risk structures take shape, it will be very difficult to do a very normal market deal.'

Yet some analysts are questioning Royal Bank's strategy, saying it should take advantage of its relatively sound financial health and go on a buying spree in the United States while native banks are hobbled by the credit crisis. A Canadian banking analyst who declined to be identified because his company discourages its analysts from talking with the media said that RBC should go the other way and follow the lead of Toronto-Dominion Bank, which has made clear a desire to further penetrate the U.S. market through acquisitions and other means.

'In my opinion they are overly cautious,' the analyst said.

'This is the perfect opportunity to get out there. ... RBC has a better credit rating and more capital than [most] any other U.S. bank.'

Another says that abandoning caution now could make the bank prone to repeat mistakes.

Brad Smith, an analyst with Blackmont Capital Inc., said Royal Bank would be wise to shy away from deploying any more capital in the United States, after making seven acquisitions there since 2001.

He said Royal Bank's U.S. expansion - which began with its purchase of Centura Banks - has been plagued with missteps that culminated with a $915 million goodwill impairment charged in the fiscal second quarter.

'It's not working out,' Smith said. 'We don't think the U.S. retail banking business is a place where Canadian banks can create shareholder value.'

For his part, Westlake said Royal Bank is walking the line between those two views.

'I don't think that we should have been more aggressive recently,' he said. 'I can't speak for TD, but I haven't seen anybody buying anything that hasn't been a government-sponsored deal. I feel we have been prudent in waiting until the market sorts itself out.'

Royal Bank also has its hands full with RBC Bank, which has 430 branches in the Carolinas, Virginia, Georgia, Florida and Alabama. Though Royal Bank does not report financial results for the U.S. unit, it said RBC Bank's weak performance drove its international division to a loss of $1.03 billion loss in the quarter that ended April 30. The division, which includes U.S. and Caribbean operations, posted a profit a year earlier.

Westlake said the parent has taken a number of steps to turn things around at RBC Bank. It has limited its exposure to troubled loan segments such as commercial real estate by letting a sizable portion of such loans run off its books. He declined to be more specific, as Royal Bank doesn't disclose financial details about RBC Bank's loan portfolios, either.

The company has also addressed consumer credit issues by marketing more cards to existing customers with sound credit, rather than trying to drum up business with mass mailings to prospects, he said.

Westlake said there are signs that the worst has passed at RBC Bank. Provisions to cover U.S. loan losses may have peaked in the latest quarter, he said, after international provisions rose 45% from the prior quarter, to $264 million.

Though the company will likely have to continue building provisions, he said he expects them to rise at a lower rate.

Also, though its U.S. division's impaired loans rose in the latest quarter, they did so at a slower pace than in the prior quarter, which Westlake said was another good sign.

The unit's impaired loans rose 14% in the latest quarter, compared with a rise of 31% in the prior quarter.

'We hope that we are at or near the bottom and coming out the other side,' he said.