MetroHealth fires CEO over more than $1.9M in unreported bonuses

The board of trustees at Cleveland-based MetroHealth System has fired President and CEO Akram Boutros, MD.

Dr. Boutros was fired Nov. 21 after the board received findings of a probe into compensation issues involving more than $1.9 million in supplemental bonuses, Vanessa Whiting, chair of the board, said in a statement posted on the health system’s website. The probe found that between 2018 and 2022, Dr. Boutros authorized the compensation for himself, without disclosure to the board.

“We have taken these actions mindfully and deliberately but with sadness and disappointment,” Ms. Whiting said. “We all recognize the wonderful things Dr. Boutros has done for our hospital and for the community. However, we know of no organization permitting its CEO to self-evaluate and determine their entitlement to an additional bonus and at what amount, as Dr. Boutros has done.”

Dr. Boutros took the helm of MetroHealth in 2013. Last year, Dr. Boutros announced his plans to retire at the end of 2022. In September, MetroHealth named Airica Steed, EdD, RN, its next president and CEO. Dr. Steed, who is executive vice president and system COO of Sinai Chicago Health System, will take the helm of MetroHealth Dec. 5, according to Ms. Whiting’s statement. Meanwhile, Nabil Chehade, MD, executive vice president and chief clinical transformation officer at MetroHealth, will assume the CEO’s duties on an interim basis.

Ms. Whiting said MetroHealth discovered the compensation issues related to Dr. Boutros while preparing for the CEO transition, and an internal investigation took place, led by the Tucker Ellis law firm.

She said Dr. Boutros admitted to conducting self-assessments of his performance under specific metrics he established and authorizing payment to himself of more than $1.9 million in supplemental bonuses between 2018 and 2022.

According to Ms. Whiting, Dr. Boutros repaid more than $2.1 million in October, representing the supplemental bonus money paid without board approval for performance in calendar years 2017 through 2021, plus more than $124,000 in interest.

She said the board has also implemented immediate CEO spending and hiring limitations through Dec. 31, 2022, and Dr. Boutros has self-reported to the Ohio Ethics Commission.

MetroHealth’s internal investigation is ongoing.

Among Dr. Boutros’ accomplishments at MetroHealth were helping annual revenue increase from $785 million to more than $1.5 billion; growing the health system’s workforce from 6,200 to nearly 8,000 while seeing employee minimum wage increase to $15 per hour; and developing Ohio’s only Ebola treatment center.

The Other Machiavelli: Finding lessons for leaders in a lesser-known work by the Florentine political philosopher

However cynical it may seem, Machiavelli’s The Prince has long been recognized as a source of insights for anyone trying run a business or gain power in one. A ferocious little treatise of under 100 pages, The Prince was aimed at Lorenzo de’ Medici, the iron-handed Florentine ruler, by an author hoping to regain the proximity to power that he formerly enjoyed.

But modern corporations aren’t principalities ruled by autocrats. They are, in fact, more like republics, their leaders dependent on the support of directors, employees, customers, investors, and one another. That is why, in turning to Machiavelli for management wisdom, we would be well served to leave aside The Prince in favor of another of his works, one that is less known but perhaps more to the point. Don’t be fooled by the academic-sounding title; Discourses on Livy has a great deal to teach us about leadership in any organization resembling a republic. Chances are, that includes your business.

Published posthumously in 1531, Discourses draws on the ancient Roman historian (among others) to analyze the nature of power in public life. Like The Prince, this is not a handbook for saints. But the author was a brilliant student of human nature, and not one to underestimate the potential of a determined individual. In Discourses, he firmly asserts the importance of an individual founder in establishing or renovating a republic—and by extension, for our purposes, a business. A prudent founder, he writes, “must strive to assume sole authority.”

Yet a single person cannot sustain an enterprise in the long run. That is only possible if the founder’s vision and talents result in an institution supported by stakeholders who can carry the venture into the future. “Kingdoms which depend only upon the exceptional ability of a single man are not long enduring,” Machiavelli writes, “because such talent disappears with the life of the man, and rarely does it happen to be restored in his successor.”

Besides, princes have no monopoly on wisdom. Despite the notorious unpredictability of the mob, the author acknowledged the wisdom of crowds when he asserted that “the multitude is wiser and more constant than a prince.” Machiavelli was also insightful about succession: “After an excellent prince, a weak prince can maintain himself,” he observed with admirable economy in one chapter’s epigraph, “but after a weak prince, no kingdom can be maintained with another weak one.”

Many of the epigraphs are bull’s-eyes of this kind. Take this one, for example: “Whoever wishes to reform a long-established state in a free city should retain at least the appearance of its ancient ways.” This is worth doing even if you make massive changes, because, Machiavelli notes, “men in general live as much by appearances as by realities; indeed, they are often moved more by things as they appear than by things as they really are.”

Honesty may be the best policy, but that is not a maxim ever attributed to Machiavelli. In keeping with the notion that people attend largely to appearances, he says leaders compelled to do something by necessity should consider pretending their course of action was undertaken out of generosity. In another chapter, he argues, “Cunning and deceit will serve a man better than force to rise from a base condition to great fortune.”

Machiavelli, of course, took a hard-headed view of humanity, believing that people act largely out of self-interest, whether to gratify their egos or sate their desire for material wealth, and that, for better or worse, actions tend to be judged by their consequences. Indeed, he was very much what philosophers call a consequentialist, arguing that, in some contexts, bad things must be done to achieve good ends achievable in no other way. This is not to say that law-breaking or other unethical acts are justified—even some of Machiavelli’s contemporaries considered such advice controversial—but every business leader knows that hard decisions must be made, be it the closing of a venerable division or taking a company in a risky new direction, for the long-term good of the enterprise.

Even when advocating something like mercy, Machiavelli did so with consequences in mind. He argued, for example, that failure should not be harshly punished, especially if it arises from ignorance rather than malice. Roman generals, he notes, had difficult and dangerous jobs, and Rome understood that if military leaders had to worry about “examples of Roman commanders who had been crucified or otherwise put to death when they had lost a day’s battles, it would be impossible for that commander, beset by so many suspicions, to make courageous decisions.”

If punishment should not be meted out lightly, neither should rewards be delayed. If you don’t cultivate loyalty and support from others in good times through open-handedness, Machiavelli says, those people certainly won’t have your back when things get rough. Doling out rewards only in the face of tough competition or harsh circumstances will lead subordinates to believe “that they gained this favour not from you but from your adversaries, and since they must fear that after the danger has passed you will take back from them what you have been forced to give them, they will feel no obligation to you whatsoever.”

Republics, in his view, have no choice but to grow, for “it is impossible for a republic to succeed in standing still.” Companies are the same. But acquisitions—whether in battle or by purchase—must be carried out with care, for “conquests made by republics which are not well organized, and which do not proceed according to Roman standards of excellence, bring about their ruin rather than their glorification.”

Finally, Machiavelli was well aware of the risks of advice-giving, so much so that he gave one chapter the title “Of the danger of being prominent in counselling any enterprise, and how that danger increases with the importance of such enterprise.” Consultants, take note. Just don’t let the clients catch you reading Machiavelli.

The less-discussed consequence of healthcare’s labor shortage

How Could You Be Affected by the Healthcare Labor Shortage? - Right Way  Medical

The healthcare industry’s staffing shortage crisis has had clear consequences for care delivery and efficiency, forcing some health systems to pause nonemergency surgeries or temporarily close facilities. Less understood is how these shortages are affecting care quality and patient safety. 

A mix of high COVID-19 patient volume and staff departures amid the pandemic has put hospitals at the heart of a national staffing shortage, but there is little national data available to quantify the shortages’ effects on patient care. 

The first hint came last month from a CDC report that found healthcare-associated infections increased significantly in 2020 after years of steady decline. Researchers attributed the increase to challenges related to the pandemic, including staffing shortages and high patient volumes, which limited hospitals’ ability to follow standard infection control practices. 

“That’s probably one of the first real pieces of data — from a large scale dataset — that we’ve seen that gives us some sense of direction of where we’ve been headed with the impact of patient outcomes as a result of the pandemic,” Patricia McGaffigan, RN, vice president of safety programs for the Institute for Healthcare Improvement, told Becker’s. “I think we’re still trying to absorb much of what’s really happening with the impact on patients and families.”

An opaque view into national safety trends

Because of lags in data reporting and analysis, the healthcare industry lacks clear insights into the pandemic’s effect on national safety trends.

National data on safety and quality — such as surveys of patient safety culture from the Agency for Healthcare Research and Quality — can often lag by several quarters to a year, according to Ms. McGaffigan. 

“There [have been] some declines in some of those scores more recently, but it does take a little while to be able to capture those changes and be able to put those changes in perspective,” she said. “One number higher or lower doesn’t necessarily indicate a trend, but it is worth really evaluating really closely.”

For example, 569 sentinel events were reported to the Joint Commission in the first six months of 2021, compared to 437 for the first six months of 2020. However, meaningful conclusions about the events’ frequency and long-term trends cannot be drawn from the dataset, as fewer than 2 percent of all sentinel events are reported to the Joint Commission, the organization estimates.

“We may never have as much data as we want,” said Leah Binder, president and CEO of the Leapfrog Group. She said a main area of concern is CMS withholding certain data amid the pandemic. Previously, the agency has suppressed data for individual hospitals during local crises, but never on such a wide scale, according to Ms. Binder.  

CMS collects and publishes quality data for more than 4,000 hospitals nationwide. The data is refreshed quarterly, with the next update scheduled for October. This update will include additional data for the fourth quarter of 2020.

“It is important to note that CMS provided a blanket extraordinary circumstances exception for Q1 and Q2 2020 data due to the COVID-19 pandemic where data was not required nor reported,” a CMS spokesperson told Becker’s. “In addition, some current hospital data will not be publicly available until about July 2022, while other data will not be available until January 2023 due to data exceptions, different measure reporting periods and the way in which CMS posts data.”

Hospitals that closely monitor their own datasets in more near-term windows may have a better grasp of patient safety trends at a local level. However, their ability to monitor, analyze and interpret that data largely depends on the resources available, Ms. McGaffigan said. The pandemic may have sidelined some of that work for hospitals, as clinical or safety leaders had to shift their priorities and day-to-day activities. 

“There are many other things besides COVID-19 that can harm patients,” Ms. Binder told Becker’s. “Health systems know this well, but given the pandemic, have taken their attention off these issues. Infection control and quality issues are not attended to at the level of seriousness we need them to be.”

What health systems should keep an eye on 

While the industry is still waiting for definitive answers on how staffing shortages have affected patient safety, Ms. Binder and Ms. McGaffigan highlighted a few areas of concern they are watching closely. 

The first is the effect limited visitation policies have had on families — and more than just the emotional toll. Family members and caregivers are a critical player missing in healthcare safety, according to Ms. Binder. 

When hospitals don’t allow visitors, loved ones aren’t able to contribute to care, such as ensuring proper medication administration or communication. Many nurses have said they previously relied a lot on family support and vigilance. The lack of extra monitoring may contribute to the increasing stress healthcare providers are facing and open the door for more medical errors.

Which leads Ms. Binder to her second concern — a culture that doesn’t always respect and prioritize nurses. The pandemic has underscored how vital nurses are, as they are present at every step of the care journey, she continued. 

To promote optimal care, hospitals “need a vibrant, engaged and safe nurse workforce,” Ms. Binder said. “We don’t have that. We don’t have a culture that respects nurses.” 

Diagnostic accuracy is another important area to watch, Ms. McGaffigan said. Diagnostic errors — such as missed or delayed diagnoses, or diagnoses that are not effectively communicated to the patient — were already one of the most sizable care quality challenges hospitals were facing prior to the pandemic. 

“It’s a little bit hard to play out what that crystal ball is going to show, but it is in particular an area that I think would be very, very important to watch,” she said.

Another area to monitor closely is delayed care and its potential consequences for patient outcomes, according to Ms. McGaffigan. Many Americans haven’t kept up with preventive care or have had delays in accessing care. Such delays could not only worsen patients’ health conditions, but also disengage them and prevent them from seeking care when it is available. 

Reinvigorating safety work: Where to start

Ms. McGaffigan suggests healthcare organizations looking to reinvigorate their safety work go back to the basics. Leaders should ensure they have a clear understanding of what their organization’s baseline safety metrics are and how their safety reports have been trending over the past year and a half.

“Look at the foundational aspects of what makes care safe and high-quality,” she said. “Those are very much linked to a lot of the systems, behaviors and practices that need to be prioritized by leaders and effectively translated within and across organizations and care teams.”

She recommended healthcare organizations take a total systems approach to their safety work, by focusing on the following four, interconnected pillars:

  • Culture, leadership and governance
  • Patient and family engagement
  • Learning systems
  • Workforce safety

For example, evidence shows workforce safety is an integral part of patient safety, but it’s not an area that’s systematically measured or evaluated, according to Ms. McGaffigan. Leaders should be aware of this connection and consider whether their patient safety reporting systems address workforce safety concerns or, instead, add on extra work and stress for their staff. 

Safety performance can slip when team members get busy or burdensome work is added to their plates, according to Ms. McGaffigan. She said leaders should be able to identify and prioritize the essential value-added work that must go on at an organization to ensure patients and families will have safe passage through the healthcare system and that care teams are able to operate in the safest and healthiest work environments.

In short, leaders should ask themselves: “What is the burdensome work people are being asked to absorb and what are the essential elements that are associated with safety that you want and need people to be able to stay on top of,” she said.

To improve both staffing shortages and quality of care, health systems must bring nurses higher up in leadership and into C-suite roles, Ms. Binder said. Giving nurses more authority in hospital decisions will make everything safer. Seattle-based Virginia Mason Hospital recently redesigned its operations around nurse priorities and subsequently saw its quality and safety scores go up, according to Ms. Binder. 

“If it’s a good place for a nurse to go, it’s a good place for a patient to go,” Ms. Binder said, noting that the national nursing shortage isn’t just a numbers game; it requires a large culture shift.

Hospitals need to double down on quality improvement efforts, Ms. Binder said. “Many have done the opposite, for good reason, because they are so focused on COVID-19. Because of that, quality improvement efforts have been reduced.”

Ms. Binder urged hospitals not to cut quality improvement staff, noting that this is an extraordinarily dangerous time for patients, and hospitals need all the help they can get monitoring safety. Hospitals shouldn’t start to believe the notion that somehow withdrawing focus on quality will save money or effort.  

“It’s important that the American public knows that we are fighting for healthcare quality and safety — and we have to fight for it, we all do,” Ms. Binder concluded. “We all have to be vigilant.”

Conclusion

The true consequences of healthcare’s labor shortage on patient safety and care quality will become clear once more national data is available. If the CDC’s report on rising HAI rates is any harbinger of what’s to come, it’s clear that health systems must place renewed focus and energy on safety work — even during something as unprecedented as a pandemic. 

The irony isn’t lost on Ms. Binder: Amid a crisis driven by infectious disease, U.S. hospitals are seeing higher rates of other infections.  

“A patient dies once,” she concluded. “They can die from COVID-19 or C. diff. It isn’t enough to prevent one.”

The folly of fighting over board seats

https://mailchi.mp/3e9af44fcab8/the-weekly-gist-march-26-2021?e=d1e747d2d8

The Importance Of Board Seats During Fundraising

In our work over the years advising health systems on M&A, we’ve been struck by how often “social issues” cause deals that are otherwise strategically sound to go off the rails.

Of course, it’s an old chestnut that “culture eats strategy for breakfast”, but what’s been notable, especially recently, is how early in the process hot-button governance and leadership issues enter the discussions.

Where is the headquarters going to be? Who’s going to be the CEO of the combined entity? And most vexingly, how many board seats is each organization going to get? That last issue is particularly troublesome, as it’s often where negotiations get bogged down. But as one health system board member recently pointed out to us, getting hung up on whether board seats are split 7-6 or 8-5 is just silly—in her words, “If you’re in a position where board decisions turn on that close of a margin, you’ve got much bigger strategic problems.” 

It’s an excellent point. While boards shouldn’t just rubber stamp decisions made by management, it’s incumbent on the CEO and senior leaders to enfranchise and collaborate with the board in setting strategy, and critical decisions should rarely, if ever, come down to razor-thin vote tallies.

If a merger makes sense on its merits, and the strategic vision for the combined organization is clear, quibbling over how many seats each legacy system “gets” seems foolishNo board should go into a merger anticipating a future in which small majorities determine the outcome of big decisions.

Who Can and Can’t Get Vaccinated Right Now

Who Can and Can’t Get Vaccinated Right Now

Some countries have stockpiles. Others have nothing. Getting a vaccine means living in the right place — or knowing the right people.


A 16-year-old in Israel can get a vaccine.

So can a 16-year-old in Mississippi.

And an 18-year-old in Shanghai.

But a 70-year-old in Shanghai can’t get one. Older people are at high risk for severe illness from Covid-19. But Chinese officials have been reluctant to vaccinate seniors, citing a lack of clinical trial data. Neither can an 80-year-old in Kenya. Low vaccine supply in many countries means only health care employees and other frontline workers are eligible, not the elderly.

Nor a 90-year-old in South Korea. Koreans 75 and older are not eligible until April 1. Only health care workers and nursing-home residents and staff are currently being vaccinated. The government initially said it was awaiting assurances that the AstraZeneca vaccine was safe and effective for older groups.


Anyone in Haiti.

Anyone in Papua New Guinea.

Anyone in these 67 countries. These countries have not reported any vaccinations, according to Our World in Data. Official figures can be incomplete, but many countries are still awaiting their first doses.

It wasn’t supposed to be like this: Covax, the global vaccine-sharing initiative, was meant to prevent unequal access by negotiating vaccine deals on behalf of all participating nations. Richer nations would purchase doses through Covax, and poorer nations would receive them for free.

But rich nations quickly undermined the program by securing their own deals directly with pharmaceutical companies. In many countries, they have reserved enough doses to immunize their own multiple times over.

Anyone who can afford a smartphone or an internet connection in India and is over 60 can get one. Mostly wealthy Indians are being inoculated in New Delhi and Mumbai, hospitals have reported, since vaccine appointments typically require registering online. Less than half of India’s population has access to the internet, and even fewer own smartphones.

And anyone who can pay $13,000 and travel to the U.A.E. for three weeks and is 65 or older or can prove they have a health condition.

A British travel service catering to the rich offered vaccination packages abroad, and wealthy travelers to the U.A.E. have acknowledged they were vaccinated there.


member of Congress in the United States. Friends of the mayor of Manaus, Brazil. Lawmakers in Lebanon. A top-ranking military leader in Spain. The extended family of the deputy health minister in Peru. The security detail to the president of the Philippines. Government allies with access to a so-called “V.I.P. Immunization Clinic” in Argentina. Around the world, those with power and connections have often been first in line to receive the vaccine — or have cut the line altogether.


A smoker in Illinois can get one. But not a smoker in Georgia.

A diabetic in the United Kingdom can. A diabetic in Connecticut can’t.

Countries have prioritized different underlying health conditions, with the majority focusing on illnesses that may increase the risk of severe Covid-19. In the U.S., health issues granted higher priority differ from state to state, prompting some people to travel across state borders.

A pregnant woman in New York. Not a pregnant woman in Germany. Up to two close contacts of a pregnant woman in Germany. Pregnant women were barred from participating in clinical trials, prompting many countries to exclude them from vaccine priority groups. But some experts say the risks to pregnant women from Covid-19 are greater than any theoretical harm from the vaccines.


A grocery worker in Texas, no. A grocery worker in Oklahoma, yes.

Many areas aim to stop the virus by vaccinating those working in frontline jobs, like public transit and grocery stores. But who counts as essential depends on where you live.

A police officer in the U.K. A police officer in Kenya. A postal worker in California. A postal worker in North Carolina. A teacher in Belgium. A teacher in Campeche, Mexico. Other jobs have been prioritized because of politics: Mexico’s president made all teachers in the southern state of Campeche eligible in a possible bid to gain favor with the teacher’s union.


Medical staff at jails and prisons in Colombia. A correctional officer in Tennessee. A prisoner in Tennessee. A prisoner in Florida. The virus spread rapidly through prisons and jails, which often have crowded conditions and little protective equipment. But few places have prioritized inoculating inmates.


An undocumented farm worker in Southern California. A refugee living in a shelter in Germany. An undocumented immigrant in the United Kingdom. Britain has said that everyone in the country is eligible for the vaccine, regardless of their legal status.

A Palestinian in the West Bank without a work permit. Despite leading the world in per-capita vaccinations, Israel has so far not vaccinated most Palestinians, unless they have permits to work in Israel or settlements in the occupied West Bank.


An adult in Bogotá, Colombia. An adult in the Amazonian regions of Colombia that border Brazil. In most of Colombia, the vaccine is only available to health care workers and those over 80.

But the government made all adults in Leticia, Puerto Nariño, Mitú and Inírida eligible, hoping to prevent the variant first detected in Brazil from arriving in other areas. A police officer in Mexico City. A teacher in rural Mexico.The government of populist president Andrés Manuel López Obrador has prioritized vaccinating the poor and those in rural communities, despite the country’s worst outbreaks occurring in major cities.

Native populations not federally recognized in the United States. The pandemic has been particularly deadly for Native Americans. But only tribes covered by the Indian Health Service have received vaccine doses directly, leaving about 245 tribes without a direct federal source of vaccines. Some states, including Montana, have prioritized all Native populations.

Indigenous people living on official indigenous land in Brazil.


These 43 countries, mostly high income, are on pace to be done in a year. These 148 countries, mostly low income, are on pace to take until next year or even longer. Countries like the U.S. continue to stockpile tens of millions of vaccine doses, while others await their first shipments.

“The vaccine rollout has been inequitable, unfair, and dangerous in leaving so many countries without any vaccine doses at all,” said Gavin Yamey, director of Duke University’s Center for Policy Impact in Global Health.

“It’s a situation in which I, a 52-year-old white man who can work from home and has no pre-existing medical conditions, will be vaccinated far ahead of health workers or a high-risk person in a middle- or low-income country.”