My astonished husband first told me about Central Vermont Medical Center's then-new CEO and President. Judy Tartaglia welcomed the domestic violence training he was there to offer to medical staff as prevention educator for Circle, Washington County's organization for such services. She gave the impression that she thought her job was to enable all hospital staff to better serve patients. Imagine. Tartaglia had even moved her offices down from a windowed top view into humbler basement space, he said. Now CEOs often talk fine principals on special occasions, but more rarely put them into action. With most multi-million-dollar enterprises, an inaccessible office on the most luxurious top floor will denote the person in charge. I told Tartaglia of my husband's report when I met her for an interview in her small windowless office. Had she been aware of the symbolic importance of her move to the basement? Tartaglia is a tall woman with a firm handshake and stately countenance. Her gracious demeanor says she is comfortable with being in charge. "Yes," she nodded and smiled. "When I first came to the hospital, they were about to remodel the second floor for administrative offices. There were patients on that floor, and I said, I am not about to sacrifice patient beds for offices." Her community relations V.P., Susan Kruthers, was there at the beginning of the interview, and couldn't resist commenting, "There were a lot of windows up there, too," implying that this had not been accomplished easily.
Photo courtesy of CVMC
Central Vermont Medical Center President and CEO Judy Tartaglia has served the central Vermont community for six years.

Patients First

Tartaglia had asserted patients' importance in a local front page story the same morning of the interview; CVMC, like hospitals across the country, was facing "sequestration cuts" in Medicare in 2013. Congressional thunderheads, long rumbling on the horizon, had finally arrived to deliver the promised $2 million in cuts for Medicare reimbursements, without any expectation of a reduction in services.

"We've known this was coming," Tartaglia said matter of factly. "We just had a management team meeting this morning, and we're going to tighten our belts. We need to preserve an operating margin, which means we need $2-3 million to maintain the operation. Our raters and the banks like to know that we can take care of our capital needs, replacing equipment or whatever is needed."

The Times-Argus report had assured the community that CVMC was not sequestering jobs. The hospital's economic impact on Vermont in 2009 amounts to about $93.5 million, according to VAHHS (Vermont Agency of Health and Human Services). Its gross patient revenue last year was well over $265 million and their net operating costs were considerably less than net revenue, a sign of close management.

Tartaglia told The Times Argus reporter that in the final analysis, "my job is to make sure the cuts don't hurt the patients." Staff cuts could result in gaps in needed healthcare services. "Last year's margin of $3.7 million was a good year," she explained. "And we have a really great team here. My first commitment is to patient care; that has to be the first commitment."

Although Congress effectively reversed its sequester cuts for air traffic controllers, meat inspectors and traffic controllers, health care for the elderly had not been restored. Medicare cuts of $11 billion nationally began to go into effect April 1, implemented by the Centers for Medicare & Medicaid Services. Yet CVMC's $2 million reduction, and that of all hospitals in the state and the country, sets a new standard for care that, surprisingly, should be to Vermont's benefit.

Why? As CVMC's CFO, Cheyenne Holland, put it in that day's news story, Vermont hospitals are "low-cost providers in general, and provide a good value to Medicare. As a result, Medicare may give us back some of the cuts."

I asked Tartaglia to explain why that was.

A Moving Target

She answered, "Not everyone will agree with me, but I think Obamacare has made some helpful changes already. Extending children's coverage to age 26 has made a big difference; and so has making sure that people with pre-existing conditions cannot be denied insurance; that is important. And also the new Affordable Care Organizations. I think the underlying premise for these is very hopeful.

And what exactly is that premise? I asked.

"In the past, if Judy Tartaglia needed a hip operation," she answered, using herself as an example, "the insurance company would pay each of her service providers; it would pay a hospital for its fees; it would pay radiology for their work; it would pay a lab for tests; and anesthesiologists, and the surgeon, and each of them would be paid separately.

"This has been in place for forty years, whether it's commercial insurance or government insurance. There was a perverse incentive to perform more services and order tests because more services resulted in more fees. But with the Obamacare model, the ACO connects all the separate players into a single organization, which then gets paid a single fee for Judy Tartaglia's overall health care for the year."

So Medicare insurance will pay Vermont's ACO without knowing that Judy needs a hip replacement?

"Yes, exactly," she said. "There will be adjustments in the fee that Medicare pays per person, depending on age and other factors, but suddenly it becomes more important to try to keep Judy from having that surgery. The incentive changes. If her doctor can get her to lose weight, to exercise and change her diet or do some physical therapy, then maybe we can prevent or postpone that surgery. In concept, if you multiply that enough times, by enough patients, this approach could result in significant savings. No one has done it yet, it's new; but I'm hopeful."

Vermont is well situated to test the theory soon, given the state's legislated goal of developing a single-payer system by 2017. The state's ACO, one of the first to be organized in the country, is headed by Fletcher Allen Health Care in Burlington and Dartmouth-Hitchcock Medical Center. It will participate in Obama's Medicare Shared Savings Program, described by Tartaglia's example. She anticipates $1 million from that source.

Tartaglia also expects that CVMC's partnership with Fletcher Allen Health Care, approved by their board of trustees in 2010, will add leverage to reduce shared purchasing costs of another $1 million. Clearly, she's prepared to meet financial challenges in the coming year's health care climate changes. (See our Spring article on ACOs at Vermont Woman's website).

Field in Flux

The most recent study of gender among American College of Healthcare Executives (ACHE) was part of a study by Dr. Paula Lantz, chair of the Dept. of Health Management and Policy at Univ. of Michigan in 2008. She found a dismal and stuck proportion of not quite 11 percent female hospital CEOs in the period from 1990-2006. Self-reported information on salary suggested women healthcare executives earn significantly lower salaries, with male CEOs consistently reporting 18 percent more for the same periods. In 2006 nearly a third, or 29 percent of women executives said they did not receive fair compensation because of gender, compared to only 1 percent of men.

In another study Lantz drew on, The Univ. of Michigan looked at gender in hospitals considered to be leading institutions (Solucient 100 Top Hospitals). Of 474 chief administrators of these cutting-edge hospitals, 24 percent, more than double the rate of the broader ACHE study, were women.

While women remain the underdogs in healthcare leadership, Tartaglia said their participation in hospital administration has changed dramatically in the last 30 years. "When I first became CEO at Miles Memorial Hospital in Maine, I was one of only two women in the state who headed hospitals. Sister Mary Norberta was the other one. She was an important influence on me."

Sister Mary Norberta CEO of Bangor's St. Joseph Hospital was recently named one of the top 52 women leaders in the nation by the ACHE. Today there are 13 women CEOs heading Maine's hospitals, 26 percent. Among the 16 hospitals in the Vermont Assoc. of Hospitals & Health Systems, 31 percent of CEOs were women; five in total, though two of these five were "interim CEOs."

"It used to be that women most often entered administration through the clinical path," said Tartaglia. "I began as a Chief Financial Officer and have financial training in my background. I understand what credits and debits are and my accountants appreciate that. It's served me well, and there are more administrators entering the field now with business backgrounds and financial backgrounds."

Tartaglia's promotion from CFO to CEO at Miles Memorial in 1993 came with an agreement to earn a required Master's degree. She found a distance education program in Health Services Administration at St. Joseph's College in Standish, Maine, and for three years, not only balanced her family life with a new and demanding job, but completed her graduate degree. After 13 years as CEO at Miles Memorial hospital, which includes a long-term care facility, she began teaching at St. Joseph's in her "spare time."

When away from the hospital, Judy Tarr nee Tartaglia said in an article written about her in St. Joseph's alumni magazine that her "first love" is oil painting. One of the most striking things you will notice whenever you have a reason to enter CVMC is its entry way art gallery with in-depth displays of accomplished local artists. The paintings and photographs are always strikingly displayed to demand your attention, close enough to the eye that their textures can be fully appreciated.

Judy still does oil paintings and inspired the idea; a hospital committee chooses the artists from the community and their graphic designer Maureen O'Connor Burgess installs them.

Diversity Matters

The Lantz study of gender in hospital administration cited the importance of having a diverse board for success. CVMC's board of trustees includes 11 men and 7 women, a more equitable mix than many. The gender survey also discussed the importance and mentoring and thinking about leadership succession. Tartaglia's management team is made up of 6 women and three men. Had she set out to accomplish this mix?

"Really I'm gender blind," she answered. "I go after talent. If I am looking to get a particular job done and I find someone who can do that job, whether that talent is outside, or in my own middle-management, I go for that. I don't think gender matters. I do think you look for people who aren't like you. You want people who are going to give you a different perspective, who are smart enough and bold enough to ask questions or disagree with you.

"A diverse board and staff is important, and by that I mean that we also have a number of people in management who are younger; we have people on our board and staff who are in their 60s. Our trustees are very diverse in age also. We have industry executives from National Life and Rock of Ages, a retired judge, a CPA, some business owners.

"Do you think that diversity among your decision-making groups has changed the hospital culture?" I asked her.

"I think it has changed; but then I have these little rules, like, if you pass someone in the hall, whether it's a coworker or a patient or a visitor, you acknowledge them. You smile, or you nod your head, or you say hello, or ask if there's a way you can help them.

"If we're going to have a good image in our community, then every time someone comes to our hospital, they have to have a good experience. And they have to have a good experience every time they come, for whatever reason. That is how you build a good reputation in the community.

"And escorting. That's a pet peeve of mine. I used to work in a large hospital and I would hear someone tell a patient how to get to another part of the hospital, through all these hallways and through three departments in the building about two miles away, and I'd think, they'll be lucky if they find it. There's no reason for that; take a minute, and escort that person to where they need to go."

Her tone emphasizes how basic good manners and kindness seems to her. About the hospital's culture, Kruthers said this, "I can tell you that Judy has really changed the culture here. She did that with two tools. First, she held people accountable; and that means accountable for good results, as well as for needing improvement. Secondly, she instituted CSI, the Customer Services Initiative." This program provides training in "those little rules" that make a difference.

My husband had a short stay in the intensive care unit of CVMC last year, and we were both impressed by how friendly the doctors and nurses were, how competent and attentive both to patients and family. I asked some staff what they thought of their woman CEO. "Judy?" they'd say. "Oh, she's great. Morale here is very good." It felt that way to us.

"I like to visit nursing stations and departments every week," Tartaglia said about this. "Not the same station every time, but just dropping in and asking people how things are going. I enjoy talking to staff; I get some good information that way." Tartaglia obviously takes pride, telling me their Environmental Services team had recently won a national Innovation Award and Director Rachel Tuthill was flying to Orlando to accept it; their MRI team had met "highest standards of excellence," and so had Woodbridge, their nursing and rehabilitation facility.

Safety Details

The top issues for the 1200 community hospitals that ACHE surveyed this past year were finances, health care reform and hospital safety. Finances and health care reform were emphatically on Tartaglia's radar, but what about patient safety?

The April/May issue of AARP magazine (Am. Assoc. of Retired Persons), called attention to a dismal national record of hospital dangers. A 2010 study from the U.S. Dept. of Health and Human Services estimated 180,000 deaths each year from accidents or poor practices; they range from egregious surgeries on the wrong limb to secondary infections.

CVMC has been recognized for their superior safety rating, Tartaglia said: "Last year, Consumer Reports rated CVMC #1 in New England, and #4 in the nation. Consumer Reports is very objective, so it felt really good."

Tartaglia herself has received the American College of Healthcare Executives' Regent Award, recognizing her leadership, and has received other outstanding service awards for leadership in Maine and Vermont.

In our Spring 2012 issue, Vermont Woman published a C-Section Score Card for Vermont hospitals. Author Katharine Hikel, M.D., had found in state hospital data that Vermont mothers were delivering babies by surgical birth at three times the rate the World Health Organization recommended. This is a figure that matches poor national rates, but some Vermont hospitals, such as Copley Hospital in Morrisville, come significantly closer to the recommended 10 percent rate for C-sections. Copley was our top-rated Vermont hospital, while CVMC came in 11th out of 16. I asked Tartaglia about it.

"When your article came out," she said, "I called our team in here to ask what we could do to improve it, and they explained to me the difference between the total rate, and the primary rate. You have to dig down a little deeper into the numbers. When a woman once has a C-section, most often she will have to have a repeat C-section every time she has a child. And it turns out we had a good many repeat C-sections from people who had stayed in the community. So now we are working on preventing those primary C-sections and lowering that rate."

Their current rate holds at 32 percent; their primary rate is 23.5 percent.

She said, "It's very difficult to provide a full-range of birthing options, ranging from midwives who help with home births, to nurse practitioners who work with OB-GYNs, to OB-GYNs who concentrate on the difficult C-sections. It gets very complex. But that's what we're going to do. We lost some midwives, but now we have one on staff and are recruiting more. We have two new, young OB-GYNs who are very open to working with midwives."

Life Balance

Interestingly the Lantz study also found women hospital CEOs were more likely than men to make sacrifices that exist in two-career families. Vermont had just seen this trend illustrated by the recent resignation of Anya Rader Wallack, head of Vermont healthcare reform's Green Mountain Care Board, for family reasons. Wallack will serve until September.

Tartaglia nodded, saying, "I think it is a terrible loss for Vermont. She knows the industry so thoroughly, and to have someone making public policy with that level of knowledge? Well, it's a terrible loss for Shumlin. I mean, Al Gobeille, he's great too. All the members on the GMCB are—but boy, they have a tough row to hoe.

"It's very hard when you have two high-stress careers in one family; ultimately someone is going to have to make a sacrifice, that's just how it is."

I noted that the Lantz study had pointed out fully a third of male hospital CEOs has a full-time wife. Did she think that would make the job easier?

She laughed. "Oh, we say that here all the time. I need a wife! But it's gotten easier over the years. My two kids are grown now and are out on their own."

What about her employees? "Well, so long as the job gets done, I don't worry about the details. If someone has to go to daycare to pick up their kids at 4:00 p.m., I remember when I had to do it. I'm not worried. I notice that most people here love their work, and work more than 40 hours when they need to. The people we have working here might be doing an email at 9:00 p.m. from home. I think the most important thing for young families is that we give them flexibility on the job. I know I'm grateful to the people who gave me that kind of flexibility when I was younger."

Changing Tide

At a recent meeting, the GMCB had discussed high hospital prices, the subject of a Time Magazine article as well as Vermont Woman's, "An Arm and a Leg" in our Spring issue. A representative from The Hospital Association had been reported to say that hospital overcharges were nothing new; hospitals had long been saying that Medicaid patients were not covering their costs and that the money had to come from somewhere. Did she have anything to add about that?

"There's no question that some of the charges are outrageous," she admitted, whipping out a piece of chalk for the black board on her office wall, and standing up to draw me a picture. "But it's also very complicated the way medical costs are financed. No other industry has to deal with these complications. I like to explain it this way."

She sketches a bottle next to a dollar sign. "Let's say I go to the store and I buy a gallon of milk, and because I have 'commercial milk insurance,' I pay $2.00. So I feel good about that, until the person behind me comes and buys a gallon of milk, and that person has 'government milk insurance for the poor' and pays 50 cents for their gallon of milk, and then an older person is next in line, and she has 'government insurance for the elderly' and she gets that gallon for 70 cents.

"Now the real cost of producing the milk is $1.00. So what Vermont is trying to do is get that $2.00 hospital cost down," and she draws a downward arrow, "and that government reimbursement increased to meet the cost in the middle." She draws another line up to meet the first.

"We still don't know how it's actually going to work. Everyone is waiting to find out how exactly all this will work. But this is the tide of the future…."