knowlton knotes

knowlton knotes

Recently I witnessed firsthand the kind of leadership that saves lives. It was, perhaps, a simple decision — one that might have gone unnoticed. But it reflects the kind of leadership we need to create a true culture of safety in our nation’s hospitals.

I am on the Quality Committee of the Board of CHE Trinity Health, the $13 billion Catholic health system with 82 hospitals in 20 states, as well as many hospice and continuing care programs.

We were reviewing a case before the committee. A patient in the operating room at one hospital improperly received nitrous oxide — used as an anesthetic and lethal in heavy doses — instead of oxygen. The mistake was noticed quickly and the patient was not harmed.

Nonetheless, it was a close call that we needed to investigate. We had many questions. We learned that a warming blanket covered the two tanks, oxygen and nitrous oxide, obscuring their different colors. But we also knew the oxygen tubing should not have been able to connect to the nitrous oxide tank. This safety feature is designed to compensate for the inevitable human error.

So what went wrong? The safety valve, we learned, is attached to the tanks after the tanks are delivered to hospitals. A member of the hospital staff attaches the correct safety valve to the correct tank. But after hundreds and hundreds of attachments throughout the years someone, one time, attached the oxygen safety valve to the nitrous oxide tank.

Richard J. Gilfillan, MD, President and Chief Executive Officer of Trinity CHE, listened as people on the committee discussed ways to prevent another occurrence. Should a second hospital staff member review the installation of the safety valve? Could some other round of checks and double checks be required? We learned that the vendor of the nitrous oxide tanks could not deliver the tanks with the safety valves already installed.

Then Dr. Gilfillan spoke.

“Get another vendor,” he said.

It was a simple statement. Dr. Gilfillan made this clear: No oxygen or nitrous oxide tanks would enter any Trinity CHE hospital without a safety valve already attached. Dr. Gilfillan did not ask about the cost or about hospital or vendor politics. He did not entertain other options.

He made a simple declaration that patient safety comes first.

We know that to err is human. Dr. Gilfillan’s decision was supported by Dr. P. Terrence O’Rourke, CHE Trinity Health’s EVP of Clinical Transformation. They both know that we cannot completely prevent humans from making errors. Instead we must create fail-safe systems that will prevent the human error from becoming a human tragedy.

The last thing hospital officials ever want to talk publicly about is error. But Dr. Gilfillan has allowed me to write about this experience because he knows that we must talk about safety. We need good systems, technological advances, and education to reduce medical errors.

But the most critical component is courage and leadership.

From Beth Fitzgerald, NJBIZ

If you’ve been looking for the hospital bill that illustrates the difference between in-network and out-of-network costs — and the fight between hospitals and insurers that goes with it — we’ve found it.

That’s what happened when reports of an $8,775 bill from Bayonne Medical Center to bandage a cut finger in the emergency room surfaced.

And while all parties involved admit the cost is out of line, how to fix it — and who is at fault for it — is not so easily agreed upon.

The bill, the result of an emergency room visit from a Bayonne man in 2013, has reignited calls for Trenton to clamp down on excessive “out-of network” ER costs that can result when patients show up to a hospital that’s not in their health insurance company’s network.

But the passionate response from health care stakeholders — with hospitals questioning whether insurers pay them a fair rate, and insurers contending some hospitals abuse out-of-network charges to shore up revenue — suggests it could be just as tough to find a consensus now as it was in 2010, when lawmakers tried and failed to regulate out-of-network hospital bills.

State Sen. Joseph F. Vitale (D-Woodbridge) said he’s ready to try again.

Vitale said in the Bayonne case, insurer UnitedHealthcare “was slammed for thousands of dollars for taking care of what was essentially a booboo. And that is absurd.”

He noted that under state law, a patient who gets emergency care at an out-of-network hospital is supposed to encounter the same billing terms as if that hospital were in-network. The insurance company, however, may have to pay hospital “charges” — prices that hospitals post but then routinely negotiate downward when they join an insurance company network.

And here’s the problem with that: When insurers pay high out-of-network charges, those costs get baked into the health insurance premiums that everyone pays.

To read the full article, click here.

James J. Florio

James J. Florio


You’ve probably heard me talk about our impressive board of directors, leaders who bring talent and skill and passion to our mission. So I am never surprised when others recognize them as well.

Recently Governor James Florio was inducted into the New Jersey Hall of Fame. Jim has been a board member of the Quality Institute since our earliest days. He is a champion for the environment, for quality health care, and for sensible gun legislation.

He’ll join other recent inductees from the worlds of music, government, art and literature — all with ties to New Jersey. The other new inductees include “Sopranos” star James Gandolfini; Dorothy Parker, the acerbic writer and Long Branch native; and pioneering suffragette Elizabeth Cady Stanton, who lived in Tenafly while battling for women’s rights.

Jim, you probably know, served as the 49th Governor of New Jersey from 1990 to 1994. He also represented New Jersey’s First Congressional District in congress from 1975 to 1990.

Jim understands the connection between our health and our environment. In Congress, he was a leader in the creation of Superfund legislation to clean up the most polluted sites in the country. His work on the Safe Drinking Water Act, and the Federal Resource Conservation and Recovery Act — which provided for the safe disposal of waste — have made our environment cleaner today.

Jim was critical to efforts to protect the New Jersey Pinelands National Reserve, and when my wife and I kayak through the Pine Barrens we try to remember to shout out our thanks to Gov. Florio.

I could continue, but instead I will give you some examples of Jim’s own words. You will see he also is an eloquent and thoughtful speaker. Please join me in congratulating Gov. Florio on this well-deserved honor and please spend a few minutes reading my favorite Jim Florio quotes:

  • I believe that doing what’s right can’t be wrong.
  • I look forward to a day — when public servants who follow the dictates of their conscience are regarded not as heroes worthy of awards, but simply as men and women worthy of the offices to which they are entrusted.
  • Having principles is important and sticking to them is even more important.
  • I don’t believe in carrying those who can walk; neither do I believe in refusing a hand to those who stumble.
  • I believe instead that all of us must accept responsibility — for our families, our communities, and ourselves. And if we are fortunate enough to be chosen for public office, we must accept the responsibility of making difficult decisions.
  • We don’t get to choose the times in which we live, but we do get the chance to determine how we respond to those times.
  • We can consign our children to inadequate schools, or we can choose to make our schools better.
  • We can stand by and watch our economy slowly crumble, or we can choose to invest again in our people and their potential.
  • We can cower at the threats of powerful special interest groups who would put the deadliest weapons into the hands of criminals, or we can dare to break their grip and take back our democracy.
  • It’s up to us.
  • The first thing I learned as Governor is that you can’t please everybody. The second thing I learned is, some days, you can’t please anybody.
  • So be it. Conflict is inevitable. It’s the price we pay for change in a democracy.