Enloe Hospital

There’s something Enloe Medical Center CEO Debi Yancer wants everyone to know: While the negative marks Medicare and the state Department of Health Services gave the hospital following its April survey look bad, in fact the evaluation has been good for Enloe.

Recent news that Medicare had put the hospital on official probation because of deficiencies found during the surveys was expected, Yancer said during a recent interview in her office, and in fact Enloe already had implemented a compliance plan to address the deficiencies.

A critical evaluation from the Medicare program is never pleasant—doubly so when it comes, as it did in Enloe’s case, on top of other crises, such as the 2006 death on the operating table of a man undergoing routine outpatient surgery and a year-long staffing crisis in anesthesiology.

But the good news, Yancer said, is that Medicare’s involvement has given her the leverage she needs to take firm control of operations. In part because the Medicare evaluation threatens the hospital’s funding, she’s been able to convince the Board of Trustees, the doctors and everybody else working at Enloe that they must adhere to the strict regulatory standards Medicare requires or face disciplinary action, including the possible loss of job or privileges.

“It’s not just Debi Yancer saying [the hospital needs to improve], it’s Medicare,” she explained. “The hospital can’t function without Medicare—that’s half our business.”

The probation means that Enloe has lost its “deemed status” and now must remain under the supervision of the state Department of Health Services in order to bill Medicare. It will be surveyed again in coming months and must show signs of significant improvement or face the possible loss of Medicare funding.

In recent days, Yancer said, she’s been meeting with the Board of Trustees, the Medical Executive Committee and other hospital stakeholders to make sure she has the authority to implement firm standards and that everyone understands what’s expected.

On June 18 the board passed resolutions stating its “absolute and unwavering commitment” to achieving full regulatory compliance and giving Yancer complete authority—and a blank check—to implement whatever measures she deems necessary.

The next evening, Yancer met with 127 of Enloe’s affiliated physicians and outlined the new regimen to them. All of the doctors will be expected not only to attend training and information sessions, but also to train their staffs.

All employees are being asked to sign off on a “compliance code of conduct” that commits them not only to participating in the compliance program, but also to fulfilling obligations related to laws and regulations, timely and accurate communications, provision of high-quality care, patient privacy protection, and duty to report violations.

The code stipulates that questions be addressed to the chief compliance officer, Cris Navarro, and that Enloe will take “corrective and/or disciplinary action” against anyone who doesn’t comply with the plan.

“It’s OK if they don’t want to commit to [the code],” Yancer said. “They just can’t be here.”

The board also authorized Yancer to hire two outside companies—Chicago-based law firm Shonnenschein Nath & Rosenthal, and Mercer Health & Benefits, a consulting firm—to assist in implementation of the compliance plan.

That plan will include a strong training and information component that will be offered to all employees, including doctors.

Medicare’s April survey found several problems at Enloe. Some patient histories were incompletely and inconsistently documented. Documentation of patient education on blood transfusion options was “inconsistent.” Some medicines were stored incorrectly. There was no quality-assurance program to address specific, high-risk drugs. And so forth.

All can be corrected, Yancer said, but only if all employees are dedicated to compliance. The problem is that people get used to doing things in a certain way, and it’s hard to change, she said. “Standards can be annoying,” she said, “because they slow you down. But we have to have them.”

Medicare and the DHS don’t want Enloe to fail, Yancer said, and will be doing all they can to assist the hospital to become ship-shape.

“I’m very confident about the future of this hospital,” she said. “There are a lot of good people here who have wanted change, and now it’s happening. We can be the best hospital in Northern California if we get on a path of excellence.”