Monthly Archives: May 2014

FDA Notice Regarding Eszopiclone (Lunesta)

While we generally discourage the usage of sleep medications in our LivingCenters, we felt it important to notify you that the FDA has decreased the starting dosage of eszopiclone  (Lunesta), so that if you were considering usage of this medication in a clinically appropriate patient,  that the initial dose should be 1 mg instead of 2 mg.

Please see the FDA communication below:

Eszopiclone Containing Sleep Aids: Drug Safety Communication – Can Cause Next-Day Impairment

Including Lunesta and generics

AUDIENCE: Pharmacy, Primary Care Medicine

ISSUE: FDA has notified health professionals and their medical care organizations of a new warning that the insomnia drug Lunesta (eszopiclone) can cause next-day impairment of driving and other activities that require alertness. FDA recommends a decreased starting dose of Lunesta to 1 mg at bedtime. Women and men are equally susceptible to impairment from Lunesta, so the recommended starting dose of 1 mg is the same for both. FDA approved changes to the Lunesta prescribing information and the patient Medication Guide to include these new recommendations. The drug labels for generic eszopiclone products will also be updated to include these changes.

BACKGROUND: A study of Lunesta found that the previously recommended dose of 3 mg can cause impairment to driving skills, memory, and coordination that can last more than 11 hours after receiving an evening dose (see Data Summary). Despite these driving and other problems, patients were often unaware they were impaired.  The new lower recommended starting dose of 1 mg at bedtime will result in less drug in the blood the next day.

RECOMMENDATION: Health care professionals should follow the new dosing recommendations when starting patients on Lunesta. Patients should continue taking their prescribed dose of Lunesta and contact their health care professionals to ask about the most appropriate dose for them. FDA is continuing to evaluate the risk of impaired mental alertness with the entire class of sleep aid drugs, including over-the-counter drugs available without a prescription, and will update the public as new information becomes available.

Read the MedWatch safety alert, including a link to the press release.



Doctors As Team Players? You Bet!


While the doctor often may be the quarterback of the team, seasoned football fans know that it takes 10 other players to execute the play along with a whole cast of coaches and scouts to make the offense run. In today’s more collaborative medical environment, doctors can become much more effective when they adopt an attitude of every patient being their patient and realize that while they may not be singularly responsible for a patient’s treatment plan, they can offer greater value when they see themselves as contributors to all patients’ treatment plans.

Dr. Stephen Grossman, Medical Director for Clovis & Country View

The recipient of one of Golden Living’s Medical Director of the Year Awards earlier this year, Dr. Stephen Grossman based in Fresno, Calif. shared some key insights on how medical directors and other attending physicians can be even more integral to the success of a facility beyond their traditional medical approach.

Whatever It Takes

When doing rounds, doctors can get into a “zone” where they will go to their patients and handle those specific issues then leave. Grossman encourages doctors to ask staff how else they could contribute while they are in a facility.

“Before I leave a facility, I’ll ask the nursing staff what else I can do while I’m there,” offered Dr. Grossman. “Sometimes they might need help with pre-discharge of a patient or a prescription written. Usually they are things that might just take another five or 10 minutes, but they can help alleviate a bottleneck for the team.”

Putting on the Other Shoe

Often it can be helpful to put yourself in the other party’s shoes. One exercise Dr. Grossman conducts with his teams is to assume the role of an upset family .

“If I’m the family, I’m going to ask the medical team why my relative looks worse than when he came to the facility,” said Dr. Grossman. “Did you turn him frequently enough? What about the sores on his skin? How did that happen?”

Dr. Grossman suggested that playing devil’s advocate with the team can help them offer better care to their patients while also helping them empathize and develop plausible and caring reasons to defend a treatment plan.

“Sometimes this might be a hospice patient,” Dr. Grossman continued. “And what the family sees happening is a natural process of the body shutting down. The team needs to be able to explain this in a caring and sensitive manner.”

Often a family will not remember the major issues that happened with their relative but all the things that can seem very tiny. Above all, they will remember the sensitivity of the medical team or how quickly issues were resolved.

Banish “LBI”

Customer service is number one in Dr. Grossman’s book. He noted that often doctors will be sitting at the nurse’s station and a family member, patient or resident will come up for a request. He encourages everyone on the team not to be limited by their job description but to take pride in providing the best customer service regardless of the request.

“Ask if there is anything you can do to help,” suggests Dr. Grossman.

Dr. Grossman also encourages a medical team to banish what he lovingly terms “LBI” or “Lazy Butt-Itis.”

“Often a patient is told that ‘we are waiting on the doctor’ when asking about the next step of a treatment plan,” Dr. Grossman shared. “This can be very frustrating to the patient.”

Empowering staff to be able to provide good care and banish LBI are crucial success factors.

Be Kind

Being focused in one’s own world and on task is understandable, but Dr. Grossman encourages doctors to go a step beyond.

“Treat everyone professionally and walk around with a smile,” he offers.

Each team member also has a unique vantage point that can help fill out an entire picture of a patient’s treatment plan. The CNA, for example, is the first line of defense.  They will notice a change in condition before anyone, and if utilized optimally, can be your eyes and ears in the LivingCenter. The physical therapist knows how things are going with the rehabilitation and may have suggestions which significantly could decrease pain or improve speed of recovery.

Dr. Grossman talks about the concept of not worrying about who gets the credit but instead believes that it is everyone’s job to watch after all the patients no matter how large or small their request or need might be.

In the end, medical directors and attending physicians can play an essential role in the camaraderie of the medical team. In today’s progressively collaborative medical environment, doctors have the opportunity to treat every team like it is their own, even if they aren’t the one calling all the shots.

Understanding the SNF Survey Process

175974557By Melissa Purvis, National Director of Clinical Practice

Medical Directors and Attending Providers: Do you understand how the Long Term Care (LTC) Survey process works? Do you know the difference between a “D” tag and a “G” tag? Do you understand the impact the number and severity of deficiencies cited can have on YOUR living center?

The LTC Survey is one component of the CMS Five Star Initiative, which was put in place as an easy guide and gauge for consumers to measure the quality of skilled nursing facilities. The Five Star system actually consists of three components: survey performance, RN staffing ratios and Quality Measure (QM) performance. While many of you may be familiar with QM performance due to discussion around trends and improvements in your QAPI meetings, many of you may not understand the survey “grading” process.

We all know that the survey team arrives and typically visits for 3-5 days for a standard survey. They are present to observe quality of life and quality of care that our residents experience on a daily basis in their home living environment. This includes not only clinical outcomes but issues such as self-determination, choices, center efforts towards resident-centered care, perception of life in the center, experiences of pain or depression and many other measures. The process includes:  individual resident, family and staff interviews; resident group interview[s]; observations of daily living, quality of care, medication passes, treatments, infection control practices, meal preparation and environmental factors.

There are many types of surveys beyond the standard annual survey: abbreviated (often referred to as a complaint visit); revisits; extended surveys; federal follow through or tag-along; and even desk reviews.

Once completed, the survey team and field office review findings and issue a report of deficiencies known as the 2567. This report is critical in the regulatory success or challenges of a center. There is no limit to the number of deficiencies a center can receive, and some surveys result in zero deficiencies or deficiency-free.

Each deficiency is assigned a scope and severity rating. Each rating has a corresponding “point grade” assigned to it. Your aggregate score for all surveys, over the preceding three years, results in your total facility score. Facilities whose aggregate scores fall within the top 10 percent for performance in their state are assigned five stars for survey performance. Facilities which fall into the lowest 20 percent receive one star for survey performance and all others fall between two and four stars.

Below is the scope and severity matrix, depicting the “grade” each cited deficiency is assigned.


It is important to note that the survey rating is the base score and your total score can rise depending on your performance in QMs and RN Staffing. You can receive no more than one additional star each for RN Staffing and QMs, which means even with solid outcomes in those two areas, you score cannot rise more than two stars from your base survey score. If you are a two star for survey performance, you cannot be more than a four star overall. The only outlier to this rule is that if you are a one star for survey performance you may not rise more than 1 more star combined for staffing and QMs so the most you can be is a two star overall.

Due to its significance in the Five Star Rating scale, survey performance is a key metric for all centers. Not only is this information often viewed on its own merit by consumers, it is the basis for the overall center score.

It is important that medical directors and attending providers have a basic understanding of the system used to “grade” our centers so that they can partner with the center leadership teams in survey preparation, management, and response.

Your ED will be able to obtain a copy of the Long Term Care Survey Manual, often referred to as the watermelon book, which details the regulations and the guidance around understanding and meeting the intent of these regulations. Your engagement in the survey preparation and management processes is vital in the success of your center. If you have any questions regarding survey management, please do not hesitate to contact me, Dr. Yao or your regional medical director.

How customer oriented is your LivingCenter?

Rental Experience

This week, I was on a business trip and had a snag when renting my car. The rental agent did not have a car available at 6 p.m. when I was scheduled to pick up a car and told me that the car had been arranged for pickup at 9 p.m. Instead of accommodating the change in schedule, the agent argued with me on the validity of my reservation time – to the point of flipping her computer screen to show me that her system said that I was the one in error. It was more important for her to be right about me being wrong than just to provide the service of renting me a car and taking my money.

This exchange made me think about the customer service experience.  My previous occasions with this rental car company in several locations and was typically positive. So why did this one irritate me? Maybe it was the fact that in a 50/50 error situation, that the attendant would rather argue with me than apologize for the chance that it was their fault.   Maybe it was that even though I was the customer, I was the one apologizing.  Perhaps it could have been her implication that only a reprehensible person would ever  return a car with an incompletely filled gas tank.

I then thought about what happens in our LivingCenters.  There are many occasions where misunderstandings occur and mistakes are made.  In fact, because of the amount and complexity of information exchanged, it would surprise me if some minor misunderstanding didn’t arise during each admission.  What is our approach when no one knows why something is recorded incorrectly?  Do we argue with our patients?  Does having us “prove” that it wasn’t our fault do anything to enhance the patient experience?

Why it’s important

Patient Satisfaction – Patient satisfaction obviously is important in any business, and even more so in healthcare.  Our most vulnerable population depends on us, and their emotional experience is vital to their satisfaction.  In the skilled nursing facility, we may not be able to get them back to 100 percent function, or may not be able to cure their chronic, progressive illness, but certainly we should be able to do everything we can to alleviate physical and emotional suffering. At Golden Living, we measure patient satisfaction via admission and discharge surveys using electronic tablets.  Longer stay patients also get interim satisfaction surveys.

Liability – It is a truism that “friends don’t sue friends.”  The quality of the relationships which we develop and maintain has an inverse relationship to the number of lawsuits and complaints.

Regulation – Surveyors will observe how we treat our patients. Do we knock before entering a room?  How is sensitive information conveyed when the roommate is within earshot? Are we sensitive to comfort needs?  Surveyors will interview our patients randomly and ask about how they are being treated.  F tags can be associated with care that is lacks attention to patient dignity, for example.

Quality of care – When my father was in a different skilled nursing facility, how he was treated would affect his ability to get care.  If it seemed like he was irritating someone with a request, he’d just not complain.  While this may seem to a staff as him being  a “good patient, ”  this also mean that there were potential  times when he had pain or discomfort and it was not being addressed.  It would break my heart to leave the building knowing that he totally was dependent on others for his comfort and that he was sometimes holding back his discomfort.

What would Disney do?

In his book, If Disney Ran Your Hospital, Fred Lee describes three levels of caring.  They are competence, courtesy and compassion. People are hired for their competence, and that’s a given. We train our staff to be courteous during orientation, require this as part of ‘service excellence’ and try to measure this during customer satisfaction surveys.  The third and final level is compassion. Lee describes this as an emotional level of caring.  An employee may be let go for incompetence, or repeated discourtesy, but generally not be dismissed for lack of compassion.  Compassion seems to come from within oneself.

Compassion however, makes courtesy come out naturally. Even when I was having a bad day, was behind on rounds and had a patient’s family member asking me a question I had already answered twice, it would be much easier for me to find the right words when I kept in mind my relationship with the patient, the families and how much I cared about them.

Steps to take

How is the customer service culture in your facility?  Is there something you can do about it as Medical Director?

Set the tone – as a respected, frequently the most  tenured leader in the LivingCenter, the Medical Director can set the tone.  This is done by example as well as by instruction.  A LivingCenter’s culture can change with leadership, and in particular if there is turnover in staff, the consistency that you bring can make a huge difference.

Pass on the feedback – Since Medical Directors generally are not seen as “company” personnel, it is likely that you get feedback about customer service every day from your patients.  This unique perspective gives you the opportunity to pass information on to the staff and facility leadership which they may not otherwise receive.  Giving direct feedback to staff also really is appreciated.  It is a telling sign when the patient says, ”Oh – please don’t tell anyone.  I don’t want my aide to get mad at me.” We must grow a culture that allows criticism and feedback without fear of retaliation.

Check the scores – do you know how your LivingCenter is doing on the customer satisfaction scores?  What categories are in need of improvement?  Golden Living also has done “mystery shopper” surveys. QAPI meeting is a particularly good time to discuss customer satisfaction.

RAVE about it – the Golden Living family of companies has instituted an employee recognition system.  If you notice someone in the LivingCenter doing something in an outstanding fashion, you can give them a boost by mentioning it to your ED or DNS.  They can give “RAVE points” which get posted with the nature of the reason on a site which is like social media.  This can be another way for you to reward customer satisfaction and to recognize  their attitude and efforts. Your ED can explain the RAVE system to you in more detail if you like.

Customer service is vital to our patient experience.  As leaders in our LivingCenters, you as Medical Directors can help set or maintain the tone.  When this culture exists, patient interactions with staff improve, and the mood generally is better, and everyone’s day is better. Let’s see what we can do to foster this. If you have ideas or best practices that have worked in your LivingCenter, please let me know, so I can share it in future editions of this newsletter.

For more reading:

Lee, Fred,  If Disney Ran Your Hospital, 9 ½ Things You Would Do Differently, Second River Healthcare Press, 2004.