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David’s Refuge, Pierre Morrisseau, and the Pineview Run Celebrity Challenge

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By Christine Corbett, Director of Philanthropy, David’s Refuge

David’s Refuge is a growing local non-profit with a unique mission to provide respite, resources and support to parents and guardians of children with special needs or life-threatening illnesses in an effort to combat caregiver burnout.  They do this through an array of Respite, Wellness and Community programs which remind caregivers they are not alone, what they do matters, and that God and this community loves them.

In 2021, when planning for a unique event at Pineview Run & Country Club, Pierre Morrisseau, CEO of OneGroup wanted to include a charity component, and reached out to the team at David’s Refuge to explore the idea. When asked where the idea came from Pierre shared “I joined Pineview and realized quickly how great it is to have this right in our backyard.  The club really focuses on family fun and I think more people need to enjoy the sport of driving on a track. I’ve supported David’s Refuge for a long time and knew David personally.  It’s an organization that is focused on supporting families, so I thought why not put the two together?”

At that point, The Pineview Run Celebrity Challenge was born, with local friends signing up to be trained on driving the 1.1-mile racetrack, with a light-hearted race day scheduled for 1 month later.  During that month, drivers would raise at least $1,000 to support the mission of David’s Refuge.  As a competitive advantage, for every $1,000 that drivers raise, one tenth of a second is taken off their final track time. This means that the slowest drivers still have a great chance of winning the race and claiming bragging rights for the year.

Pierre is not just the brainchild of this event, but he is also a celebrity driver.  When asked why he chose to drive in the Pineview Run Celebrity Challenge, Pierre shared “It is a tremendous organization.  I have witnessed firsthand the relief, joy and satisfaction this mission brings to caregivers.  The rejuvenation it gives so that parents can bring that energy back to those they care for. It’s a gift that’s so important to give.” Pierre has succeeded in raising more than $14,000 for his races, all while introducing new friends to the mission of David’s Refuge.

The last two years have featured 24 amazing local “celebrities” in total and generated more than $75,000 in support of caregivers.

The 2023 Pineview Run Celebrity Challenge will take place in the Spring, if you are interested in joining as a celebrity driver, please contact Christine Corbett, Director of Philanthropy at David’s Refuge, at christinecorbett@davidsrefuge.org. 

Who Advocates for the Construction Industry?

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Earl R. Hall, Executive Director – Syracuse Builders Exchange

Politicians.  Lobbyists.  Elected officials.  Legislation.  Laws.  Regulations.  Do those words generate a positive or negative connotation?  While answers will vary depending on individual circumstances or experiences, one thing is for sure:  They all impact how the construction industry functions and influence decisions of construction industry employers. The Syracuse Builders Exchange chooses to advocate and educate in an effort to support a position which is most advantageous to the industry.

Advocacy efforts happen every day, either by special interest groups, lobbyists or the general public, in an effort to influence politicians or policy makers.  But who is representing the interest of the construction industry in both Washington, D.C. and in Albany?  The answer depends on the position of subject matter and how much money one has to hire lobbyists to deliver a persuasive argument as to why legislation should be supported or opposed. 

Although some construction industry Associations have lobbyists, many local construction industry Associations and state-wide Associations do not.  In both cases, however, there is a coalition of industry Associations which generally work collaboratively in an effort to identify items of mutual importance to the industry, and then develop a strategy to advocate a position that the various organizations can agree with. 

Examples of advocacy provided by construction industry Associations may include:

  • Meeting with local and state elected officials in an effort to directly deliver a position of support or opposition, (example – Assemblyman Al Stirpe in central New York).
  • Meeting with appointed officials to mitigate or resolve issues impacting employers and/or the industry (example – Shaun McCready, NYS Department of Labor Director of Public Work).
  • Collaborating with like-minded Associations to deliver a “strength in numbers” campaign, supporting or opposing pending legislation, or urging the Governor to veto potential legislation (example – Associated General Contractors of NYS, Builders Exchange of Buffalo & Western NY, Eastern Contractors Association, Building Industry Employers of NYS, etc.).
  • Working with lobbyists to create positions of strength in an effort to effectuate change or educate (example -Hill, Gosdeck & McGraw, LLC).
  • Working with staff of elected officials to resolve industry issues or advocate for a position (example – Senator Charles Schumer).

While the Syracuse Builders Exchange does not have a lobbyist, nor do we pay for lobbying services, the Association does advocate for construction industry employers and the industry in general.  Representing the interests of the industry is critical in defending our industry from poor legislation, governance or regulations derived in Washington, D.C. or Albany.  And while many Associations do not have the financial resources to compete with special interest groups, the Syracuse Builders Exchange will continue to partner with like-minded construction industries Associations in an effort to educate elected officials on issues of importance and to advocate for our employers and the industry in general.

Nappi Wellness Institute: Improving Healthcare Outcomes for Vulnerable Populations in an Accessible, Supportive Environment

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By Daniel K. Brantley

Tuesday, October 25, 2022

Upstate University Hospital’s soon-to-open Nappi Wellness Institute introduces a new era of health care with a suite of patient-centered ambulatory services and provider benefits in one location.

The area shown under construction will transform into a light and bright reception area.

An increasing amount of data indicates an imperative need to improve healthcare equity for vulnerable patient populations — an issue that’s been evident for years — and hospital systems across the country are attempting to level the field. With a $70 million grant from the New York Department of Health, a $75 million bonding opportunity to match funds, and an $8 million naming gift, Upstate University Hospital has been working on a solution, and that work is about to come to fruition.

Scheduled to open in early 2023, the Upstate Nappi Wellness Institute is a five-story, 200,000-square-foot outpatient facility that will integrate multiple primary and specialty health services and a bevy of unique amenities under one roof. The new Institute is expected to remove many of the barriers that send patients to the hospital instead of getting timely, appropriate care in the lowest acuity setting.

As the new Institute gets underway, Upstate University Hospital anticipates fewer unnecessary emergency visits and inpatient stays, ultimately leading to more cost-effective healthcare delivery and improved quality of life for vulnerable community residents. Combined, the benefits offered meet the qualifications of the state’s Delivery System Reform Incentive Payment (DSRIP) program, an initiative aimed at restructuring Medicaid’s healthcare delivery system and reducing unnecessary hospital use by 25% over five years.

“The COVID-19 pandemic catalyzed a transformation in health care that was talked about for a long time but only dabbled in,” says Amy Tucker, MD, MHCM, Chief Medical Officer at Upstate University Hospital. “Fortunately, we’re ahead of the curve with the Institute, which introduces a new model of care focused on wellness.”

Left to right: Amy Tucker, MD, MHCM, Marylin Galimi, Chief Operations Officer, Marisa Desimone, MD, Nancy Daoust, EdD, FACHE, LNHA

“The remodeling of care to focus on wellness is not just promoted at the Institute — it’s embraced. Everything about the building and the services offered centers around helping people stay well, vibrant and functional.”
— Amy Tucker, MD, MHCM, Chief Medical Officer, Upstate University Hospital

Built for Optimal Health

An integrated model of care guided the design and construction of the Nappi Wellness Institute. And following the WELL Building Standard, the Institute’s design and layout will promote the good health of patients, visitors, clinicians and staff alike.

“We wanted to change what people perceive as health care to be proactive and focused on wellness,” says Marylin Galimi, Chief Operations Officer at Upstate University Hospital. “We didn’t want another facility with clinics where you simply come in and wait for an appointment. We wanted to build something that represented the idea of caring for your body and your family.”

WELL Building Standards include the following:

  • Air: The Institute features filters that circulate 100% of outside air throughout the building.
  • Comfort: Convenient break and lactation rooms allow providers to decompress or tend to personal matters in spaces designed with an intentional lack of work-related furniture or equipment.
  • Fitness: The interior of the building has a walking loop that includes stairs, so team members can get some exercise without leaving the grounds.
  • Light: Large windows bring ample natural lighting into waiting areas, which line the perimeter of the Institute. For patient privacy, patient rooms are inside the pathway, and staff members can control the light in these and other interior rooms.
  • Mind: Calming, digital art on walls and earth-tone colors serve to provide a calming environment for all patients. Outdoor seating surrounded by trees and lush gardens, and a meditation labyrinth provide additional on-site havens.
  • Nourishment: Family-style break rooms with large-capacity refrigerators and a café bathed in natural lighting offer patients and staff members wholesome meals featuring fruits, vegetables, lean proteins and whole grains.
  • Water: Hospital-quality water filtration ensures all water sources are properly filtrated. Handwashing stations throughout the Institute allow easy access within and outside of clinical spaces.

As a LEED-certified building, the planet’s health was also considered during its planning and construction. The energy-efficient space encourages recycling all eligible materials and appropriate disposal of debris. Supplies will be purchased locally or regionally when available and appropriate.

Upstate Nappi Longevity Institute Groundbreaking

Easier Access to Primary and Specialty Care Services

The Institute will be home to a variety of primary and specialty care experts that can reach further than any single clinician or specialty could. Before the Institute was established, Upstate University Hospital healthcare services were provided in numerous locations spread throughout the area, each with its own medical directors, nursing and business leadership in place. These healthcare professionals will still retain their governance while working at the Institute, though some will share clinical space. Everyone will work together to provide more efficient, comprehensive patient care.

Patients who visit the Nappi Wellness Institute will have access to:

  • Adult and pediatric medicine
  • Alzheimer’s disease care and research, which is a special focus of the facility (see sidebar)
  • Center for International Health
  • Connect Care/Upstate After Hours
  • Endocrinology
  • Family medicine
  • Geriatric medicine
  • Inclusive health services
  • Integrated care
  • Internal medicine
  • Joslin Diabetes Center
  • Laboratory
  • Osteoporosis care
  • Nutrition counseling
  • Outpatient pharmacy
  • Palliative care
  • Radiology
  • Social work

Should hospitalization or emergency services be necessary, a pedestrian bridge gives immediate access to Upstate University Hospital. The bridge also allows Institute clinicians to follow up with hospitalized patients in a timely manner.

“We want to be of service to the community and I think we can do that with this facility — not just with the building, which is special, but with all of our services coming together in a cohesive, comprehensive way.”
— Nancy Daoust, EdD, FACHE, LNHA, Chief Ambulatory Officer at Upstate University Hospital

Services for Behavioral and Social Well-Being

Behavioral health services will also be available on-site. In the event patients present with behavioral healthcare needs, they can visit each clinic’s on-site behavioral health professional — a valued and much needed development for clinicians. For example, the Joslin Diabetes Center, the largest clinic within the Nappi Wellness Institute, is housed on the fifth floor, and behavioral health is likely to be an important part of care.

“Diabetes is often a chronic, lifelong condition that carries a heavy mental health burden for many patients,” says Marisa Desimone, MD, Associate Medical Director of the Joslin Diabetes Center. “Beyond diabetes, lots of people are struggling after spending two and a half years facing the worldwide stressors of the pandemic and other issues.”

The Institute also will provide educational spaces for well-being classes, nutrition counseling, cooking lessons, community lectures and other health and wellness learning opportunities. As equity in health care takes center stage, social determinants of health have become a major focus. According to Dr. Tucker, population health factors guided the creation of the Institute and its services, including drop-off, valet parking and covered bus stops across the street. Upstate Ambassadors will personally greet patients at the door and arrange for an escort to take them to appointments if needed.

“Those touches are a big deal,” Dr. Tucker says. “For vulnerable patients, these can make the difference between coming to a healthcare appointment and not being able to do so.”

Sam and Carol Nappi are joined by family members as well as by Upstate University Hospital President Mantosh Dewan, MD; Eileen Pezzi, MPH, Upstate Foundation; and David Amberg, PhD, Upstate Research, as they paid a recent visit to tour the building while it’s under construction. The gift from Sam and Carol Nappi — the largest ever received by the Upstate Foundation and Upstate Medical University — will be used to expand the building’s services related to neurosciences, including a focus on Alzheimer’s disease. The Nappi Longevity Institute is named in recognition of the couple’s philanthropy.

Feedback Matters

Though population health inspired the Institute, those who will be working there played major roles in ensuring it also met provider needs. Hundreds of individuals assisted in the development of the Institute, including a physician advisory committee which worked alongside nurses, business and marketing executives, hospital administration, security personnel, and more.

The physician advisory committee’s influence is evident in the exam rooms. When physician leaders examined the desks designed for exam rooms, they agreed they were aesthetically pleasing but immediately recognized they weren’t functional. That physician feedback helped the architects create an updated plan featuring large, half-moon-shaped desks that allow clinicians to face patients while talking to them. Additionally, computer screens mounted on the desks move easily to meet the specific ergonomic needs of different providers.

In the geriatric clinic, physicians recommended table height adjustments to make it easy for wheelchairs to fit underneath. Plans to develop mobile workstations in the pediatric area changed when providers noted the potential risk for children climbing on and damaging them.

“Patient care comes first — 100% — always will. [You] can’t go into health care without that outlook. It has to come first.”
— Marisa Desimone, MD, Associate Medical Director, Joslin Diabetes Center at the Nappi Wellness Institute

Technology Upgrades

To ensure continuum of care between providers at the Nappi Wellness Institute and other Upstate locations, all services tie into the Epic electronic medical record system. In place for years, this connectivity allows providers to communicate seamlessly with one another and grants patients access to their health information and appointments via MyChart.

The Institute plans to leverage additional Epic functionality to benefit all users.

“The Institute represents the clinic of the future,” says Nancy Daoust, EdD, FACHE, LNHA, Chief Ambulatory Officer at Upstate University Hospital. “We’ve had great talks with Epic, and we hope to be a beta test site for them to test upcoming Epic functionalities.”

In addition to Epic, real-time location scheduling (RTLS) technology will remedy any scheduling and patient-flow issues. With RTLS, clinicians on one floor can identify available equipment and exam space on another to make use of them as needed. These and other high-tech functionalities will enhance the physical proximity providers experience at the Institute.

“Being in the same building will facilitate even closer collaboration when we pass one another in the hallway, garage or elevator,” Dr. Desimone says. This opens the door for clinicians to “strike up a conversation and brainstorm how to meet a patient’s needs.”

Prepared for Growth

The Nappi Wellness Institute is presently large enough to meet a variety of health needs in the community, but Upstate administrators also had the foresight to plan for growth. The Institute currently has five floors but can accommodate an additional three stories if clinicians, administrators and other team members see a need.

“We want to decant all ambulatory services out of the hospital, which is cramped for space,” Dr. Daoust says. “Doing this presents us the rare opportunity to scope out incoming practice needs and ensure they have more space that allows them to grow further in the future. Think about the impact we can have on a real-time basis instead of a patient having to wait in the ED.”

To ensure the appropriate allocation of areas within the hospital and stand-alone clinics, Dr. Daoust and others are closely monitoring department communications so they can successfully meet future requirements and build on their success.

“By making services accessible and convenient, co-located in a one-stop shop and affordable, we’re positioned to move the needle on our community’s health,” Dr. Tucker says. “The services we offer will be robust, in addition to a very nice experience for patients who go to the Institute, and for the clinicians and staff who practice there. We’ll have a model that is welcoming and easy for referring providers as well.”

A Naming Gift of Lasting Impact

The naming gift from Sam and Carol Nappi will be used to provide services related to the neurosciences inside the new Nappi Wellness Institute, including a special focus on Alzheimer’s disease. The Nappi Wellness Institute is named in recognition of the couple’s philanthropy.

“The Nappi’s support, with its focus on Alzheimer’s disease and brain health, is a down payment on creating healthy futures for all of us as we age,” says Sharon Brangman, MD, Distinguished Service Professor and Chair of Geriatric Medicine at Upstate University Hospital, and a former president of the American Geriatrics Society.

“Sam and I want to continue our commitment to Central New York in both deed and funding,” Carol Nappi says. “We will work with Upstate Medical University to build a world-class facility, assemble a renowned medical team and fund groundbreaking research.”

“We’re encouraged and excited about the 21st century vision the team at Upstate Medical University and the Upstate Foundation have shown in their commitment to medical research and proactive medical care,” Sam Nappi says. “Carol and I look forward to working with them.”

The Nappis have a long history of supporting local causes, focusing much of their philanthropic initiatives on medical research and community medical care. Sam Nappi is founder and chairman of Alliance Energy. Carol Nappi, a former psychiatric therapist at Community General Hospital, now Upstate Community Hospital, is active with numerous local and national charitable organizations. She is a 2000 Jefferson Award winner, a national recognition honoring community and public volunteerism.

Visit upstate.edu/nappi-wellness-institute to learn more about the groundbreaking approach to care at the Nappi Wellness Institute.

Comprehensive Breast Care at Oneida Health

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By Becca Taurisano
Tuesday, October 25, 2022

Breast surgeon Mary Ellen Greco, MD, FACS, and Physician Assistant Kristen McNeil bring expertise and a personal touch to Oneida Health’s new breast care subspecialty.

Mary Ellen Greco, MD, FACS, and Kristen McNeil, PA-C joined Oneida Health in February after working together for the last five years in Syracuse. Their arrival launched the new Oneida Health Breast Care service line.

Both from Central New York, the pair says it was a natural next step for them to bring high-quality, comprehensive breast care to a community setting.

Together, Dr. Greco and McNeil provide the complete spectrum of breast care including abnormal imaging findings, known diagnoses of breast cancer, screening for patients with a strong family history of breast cancer, patient-related complaints of a self-detected lump, in-office ultrasound-guided biopsies, surgery, genetic counseling and testing, and benign conditions of the breast.

Built on Experience

A graduate of the SUNY Science Center at Syracuse and fellowship trained in trauma and surgical critical care at the University of Maryland Medical System, Dr. Greco brings over 20 years of medical and surgical breast care experience to Oneida Health. She says at the time she finished her surgical training, there was no breast care specialty.

“As the only female surgeon in the practice, I ended up seeing our breast patients because the patients felt more comfortable with me,” she says. The end result was a career with a sole focus on breast care which Dr. Greco calls both exciting and rewarding.

McNeil spent two years in urgent care and 12 years in family medicine before working with Dr. Greco at her Syracuse office.

“Breast care is a subspecialty that became very important to me,” says McNeil, having lost a close friend to metastatic breast cancer at 31 years old. “It’s my goal to provide patients the piece that [my friend] felt was missing from her care.”

Personalized Care

Patients from Oneida and Rome were being referred to their practice in Syracuse, so it made sense to bring care closer to them.

“Here at Oneida, we have all of the technology and pieces of the puzzle to provide the highest quality of personalized care to our patients,” Dr. Greco says.

Plus, many patients prefer going to Oneida because of the convenience or proximity to family members who can provide support. Continuity of care is the key, says Dr. Greco, noting that she has had some patients for 20 years no matter where her practice is located.

Other members of Dr. Greco’s staff have been with her for 10 years or more and that consistency is important for patients.

Mary Ellen Greco, MD, FACS

“A lot of what we do isn’t surgical — it’s care, education, follow-up and reassurance,” Dr. Greco says. “It makes patients very happy to have consistent people be a part of their health care.”

An essential part of providing personalized care is Oneida Health’s certified nurse navigator, Linda Lyon, CN-BN.

“With a breast cancer diagnosis, we are just one pillar of a patient’s complete care,” McNeil says. “The nurse navigator is critical in holding a patient’s hand every step of the way.”

Lyon helps patients get the necessary support they need, whether it’s financial assistance, transportation, access to social workers or supplemental care. “The nurse navigator is the key to keeping the whole system moving effectively,” Dr. Greco says.

Network of Support

When surgery is required, Dr. Greco’s patients have the advantage of receiving all pre- and post-operative care from Roswell Park, an awarding-winning hospital in Oneida. When other treatment options are needed, patients don’t have to go far.

As a member of the Roswell Park Care Network, Oneida Health Breast Care patients have access to the latest developments in cancer treatment if they require medical or radiation oncology.

“We are very happy to be affiliated with Roswell Park and to collaborate with them in caring for our patients,” Dr. Greco says.

Roswell Park’s expertise can be accessed by Oneida patients quickly and easily, either by on-site providers or by using telemedicine if necessary, eliminating the need to travel to Buffalo in nearly all cases.

The Oneida Health Gorman Imaging Center is essential to breast care in Oneida as well. Patients have access to robust imaging right on campus, such as 3D tomosynthesis, screening sonogram, 3 Tesla MRI, and an advanced PET CT. Dr. Greco and McNeil coordinate biopsies with the Gorman Imaging Center, if it is not something they can do in the office.

According to McNeil, providing convenient access to regular screenings is an essential part of providing comprehensive care.

Kristen A. McNeil, PA-C

“Having convenient access to a facility like Gorman Imaging is really important, so patients can easily get their annual mammograms,” she says.

Dr. Greco agrees and adds, “There are people who are motivated now to get their care because they can go to Oneida. All patients want to have their care close to home.”

A Rapidly Changing Field

Collaborating with other physicians and staying up to date with the latest techniques is essential to providing patients with the best possible care. Breast care is one of the most rapidly changing subspecialties of surgery and medicine, which Dr. Greco finds exciting.

“More than ever, women are very invested in their own health care,” she says. “They come pre-educated with questions and have discussed options with their friends and family. Our team takes great pride in not only discussing their concerns but sharing with them the advanced treatment options, many available right here in Oneida.”

Dr. Greco uses advanced surgical practices such as oncoplastic closure for more cosmetic healing, and sentinel lymph node biopsy after neoadjuvant chemotherapy, to help reduce lymphedema complications. She is hoping to soon have plastic surgery available at Oneida Health to do simultaneous mastectomies and reconstruction, eliminating the need for patients to travel.

New Developments

“In order to be a specialist, you have to stay on top of all of those changes and be aware of the most current recommendations and standards of care,” Dr. Greco says.

She and McNeil work closely with medical oncology and radiation oncology to for treatment planning, as chemotherapy and radiation therapy indications continue to change and evolve.

Determining which patients qualify for genetic testing is changing too. Anyone with a history of breast cancer is now eligible for genetic testing, a change from what was recommended three years ago.

“We are happy to see those patients, counsel them and test them,” Dr. Greco says.

Oneida Health Breast Care Staff: Jayme Lohr, Dawn Leduc LPN, Karisa Zuke, Linda Lyon RN, Kim Sabatino LPN, Mary Ellen Greco, MD, FACS, and Kristen McNeil, PA-C

Gun Violence in Central New York

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By Kathryn Ruscitto

Tuesday, October 25, 2022

It’s time to focus on solutions.

Every morning, as I read the news, there’s more and more reported gun violence. I’ve been reading — but not acting — for far too long, and I have to ask myself why. Gun violence is getting worse and more violent, and everyone involved suffers from this epidemic: the shooter, the victim, the families and the community members lost to death or incarceration.

In August, Syracuse police reported a 35% increase in those injured or killed by gunfire over the last year, from 81 individuals to 110. 

Many of these deaths were among teenagers, and nationally, gun violence is now the leading cause of childhood death. The issue — which has become a political football — is clearly based on fact: Guns are causing deaths.

What are we going to do to reverse this trend? Many other public health threats, from smoking to driving under the influence to COVID-19, have prompted research and program interventions. They may have taken time, but slowly, progress was made and public health improved.

Many experts are concluding, similar to how infant mortality rates are viewed, that we have a deep societal problem on our hands, one that requires us to look closely at the social determinants feeding this crisis. Inherent racism in our systems, a proliferation and lack of controls on firearms, poverty, and lack of programming and resources for children are certainly factors.

Standing Up To Do Something

This epidemic needs a different kind of partnership to break through to faster results. Engaging the communities and the leaders closest to the problems, and listening to their recommendations for investment, often referred to as place-based decision-making, would help.

What is somewhat hopeful is the call to action building across the healthcare community with research, funding and best practice innovations.

Michael Dowling, CEO of Northwell Health, launched an initiative this summer called The Gun Violence Prevention Learning Collaborative for Health Systems and Hospitals, and 1,000 healthcare organizations and clinicians have joined the effort.

“This is about protecting people’s health. This is about protecting kids’ lives,” Dowling says. “Have some courage. Stand up and do something. Put the interest of the community in the center of what you think about each and every day.”

We each can contribute in ways that move the conversation forward. Discuss the issue with your family and social and professional organizations. Support funding for research and programming that keep children engaged and safe. Understand the social determinants and attitudes we can change in health care.

This issue won’t get better with hope alone. It requires outrage and action, as Dowling reminds the healthcare community.

“Our job is to save lives and protect people from illness and death,” he says. “Gun violence is not an issue on the outside — it’s a central public health issue for us. Every single hospital leader in the United States should be standing up and screaming about what an abomination this is.”

Kathryn Ruscitto, Advisor, can be reached at linkedin.com/in/kathrynruscitto or at krusct@gmail.com.

Resources

  1. Gun Violence Collaborative (youtube.com/watch?v=GUJG0CuPWCY)
  2. Every Town, Community Safety Fund (everytownsupportfund.org/how-everytowns-community-safety-fund-grantees-prevent-gun-violence/)
  3. Syracuse Cure Violence (smnfswcc.org/programs/snug/)

Leading the Way in Robotic-Assisted Surgery

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By Becca Taurisano
Tuesday, October 25, 2022

Crouse Hospital’s robotic-assisted surgery program is the largest and most successful in Central New York, thanks to the collective expertise and support of the surgeons participating in the program.

Kenneth Cooper, DO, (right) and Jeffrey DeSimone, MD, with the da Vinci Robot
 

Since it started in 2008, the robotic-assisted surgery program at Crouse Hospital has grown to include seven robotic platforms, with six da Vinci XI systems and the latest addition of a da Vinci Single Port (SP) system, the only one in Central New York. The program’s surgeons have completed over 14,000 procedures in the areas of general, bariatric, colorectal, thoracic surgery, GYN oncology, gynecology, and urology. Crouse’s commitment to the success of the program ensures the region’s largest multispecialty robotics surgery program will continue to flourish, enhancing the patient experience and benefiting the community as a whole.

Kenneth Cooper, DO, and Jeffrey DeSimone, MD, use the robotic platform to perform gastric bypass and sleeve gastrectomy bariatric surgery. When the da Vinci XI, a four-arm robotics system, was released in 2014, Dr. Cooper says it was a game changer compared to laparoscopic surgeries.

“There are a lot of options in this community for surgery of all kinds, including bariatric, but Crouse is clearly the leader in Central New York in robotic cases and that makes the difference.”
— Kenneth Cooper, DO

“The robotic-assisted technology provided patients with a less invasive surgical experience, and made it more comfortable for surgeons,” Dr. Cooper says, citing the physical challenges surgeons have when working on patients with an elevated body mass index (BMI). The da Vinci XI allows Drs. Cooper and DeSimone to perform bariatric procedures in ways they could not do laparoscopically.

“We didn’t think we could improve upon laparoscopic surgery, but the data we have collected has shown that robotic surgery is an excellent option for our patients,” Dr. Cooper says.

Incision sizes with the robot are similar to laparoscopic incisions, but patients recover faster and have shorter hospital stays. In addition, robotic-assisted surgery significantly reduces the need for postoperative narcotics among bariatric surgery patients, who are able to return to work faster with fewer incision issues requiring wound care.

“We were a Center of Excellence three times over before robotics, so we didn’t think we could improve on our excellent outcomes, but we did,” Dr. Cooper says.

Surgeons have greater control with the da Vinci XI technology, allowing them to toggle between the four arms, which include surgical instruments and a camera. “You can see detail you couldn’t see otherwise,” Dr. Cooper says. “That allows us to visualize much more clearly, especially in patients with a large amount of intra-abdominal tissue.”

The robotic instruments can be rotated like a human wrist in multiple planes, allowing surgeons to operate in tight spaces and use both hands with complete dexterity. The instruments themselves are high-tech and smaller in size, which reduces the potential for complications and bleeding. The technology allows surgeons to perform procedures faster and with more efficiency.

“Anything that is an advantage for me as a surgeon is going to translate into an improvement for our patients,” says Dr. DeSimone.

Introducing robotics technology into the operating room has changed the skill set needed for the surgical team. Every member of the team must be able to prepare for next steps before the surgeon performs them, streamlining the entire process. Dr. DeSimone refers to this process as a highly choreographed dance. Highly-skilled personnel that possess the knowledge of the robotic platform and equipment are essential to ensuring a case is completed quickly and efficiently.

 

The Robotic-Assisted Surgeons at Crouse Hospital

Bariatric
Kenneth Cooper, MD
Jeffrey DeSimone, MD
Taewan Kim, MD

Colorectal
James Berry, MD
David Nesbitt, MD
John Nicholson, MD

Cardiopulmonary Thoracic
Michael Archer, MD
Mark Crye, MD
Jason Wallen, MD

General
Akbar Ahmed, MD
Benjamin Sadowitz, MD
James Sartori, MD

Urology
David Albala, MD
Po Lam, MD
Hadley Narins, MD
Nedim Ruhotina, MD
Harvey Sauer, MD

Gynecology
Stephen Brown, MD
Nikole Bucsek, MD
Catherine Fiori, MD
Myron Luthringer, MD
Navpriya Oberoi, MD
Byuong Ryu, MD

OB/GYN Oncology
Rinki Agarwal, MD
Douglas Bunn, MD
Mary Cunningham, MD
Allison Roy, MD

“We heavily rely on other individuals to do their part so we can provide the safest care for our patients. It is truly a team approach and we are very efficient with the use of our time,” says Dr. DeSimone.

“The hospital’s commitment to robotic surgery is visionary.”
— Jeffrey DeSimone, MD

Po Lam, MD, (left) and team
 

Urology surgeon Po Lam, MD, performs prostatectomies using the da Vinci SP (Single Port) robot, which has a single arm, or port. Originally, the SP unit was mostly utilized by teaching hospitals to refine surgical techniques done with multiport systems.

“The SP platform puts Crouse in a very unique position, as it is the only system of its kind in Central New York,” Dr. Lam says.

In addition to the change from multiple ports to one port, the instrumentation with the SP system is more flexible. Dr. Lam explains that the flexibility of the instrumentation and the camera allows the surgeon to work in tight spaces they could not access before.

“It allows for an innovative way to do the same surgery in a more confined space,” says Dr. Lam. “With the availability of the SP, there’s no reason to perform prostate surgery any other way.”

For Dr. Lam’s patients, there are numerous benefits to having robotic-assisted surgery with the da Vinci SP.

“We can reduce the risk of damage to the intestines or large blood vessels and avoid scar tissue that may exist due to a patient’s prior abdominal surgeries.”

The positioning of the patient is different with the SP robot as well. During a laparoscopic prostatectomy, a patient is placed with their head down and feet up, creating potential issues to maintain proper breathing during anesthesia. By eliminating this positioning during robotic surgery, patients have fewer issues and faster recovery.

“The real impetus to do this is that it’s ultimately better for our patients,” says Dr. Lam

“The ability to enter the body through a single, small incision helps surgeons perform procedures in a less invasive way, helping to reduce trauma and discomfort to the patient.”
— Po Lam, MD

From the beginning of the robotics program in 2008, Crouse has been the regional leader in the field of robotics surgery, ensuring that their surgeons have the resources they need to be on the cutting edge.

“To their credit, Crouse leadership understood the advantages of robotic surgery early on and has done a great job of nurturing the program,” Dr. DeSimone says. Bariatric patients require special equipment and furnishings to accommodate their size and Crouse provided them with everything they need on their own floor, making an overnight stay in the hospital more comfortable. “We have never been faced with a lack of institutional support,” Dr. Cooper says.

Wilkins Mechanical: ‘I accept this challenge’

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By Tami S. Scott

When Susan Heffernan was presented with a chance for change, she grabbed it. It wasn’t part of her plan though it certainly served its purpose.

Heffernan had just enrolled at the Whitman School of Business at Syracuse University to further her education. She had been working as an accountant but felt an inner tug to do something different. Earning a master’s degree in her field was a sensible, safe route to start.

One phone call changed everything.

She learned through a friend that the owners of Wilkins Mechanical were looking to retire and sell their business. Her friend, who was aware of her current discontent, encouraged her to inquire. And so, she did.

“The broker asked if I’d ever considered owning my own business and I said ‘well, not consciously,’” Heffernan said, noting that for years she always worked hand-in-hand with business owners. “I guess you could say in a way, I’ve always been in training for this very moment, it didn’t take long for me to realize that this was the right path to take, so I gladly accepted the challenge and the process began.”

On Dec. 30, 2021, Heffernan became a business owner. For 11 months leading up to that moment, she embraced every occasion to learn from the people who built it.

“I worked alongside the previous owners for a few months with the intent of hitting the ground running a little faster upon closing,” Heffernan said. “That experience certainly helped me gain some insight on what challenges they faced and what I might expect.” 

Heffernan credits her mom and grandmother — her biggest heroes — for instilling the strength to take challenges and leaps of faith because, “if you don’t you never really know what you are capable of, and without risk, there’s no reward, right?”

Looking back, Heffernan said never once did she feel like she couldn’t do it. “I had the attitude of ‘yes, you can do this.’ The experiences I’ve gained over the years have prepared me for this.’”

Heffernan is in the process of working on obtaining her WBE certification, which she hopes to achieve by the end of 2023. “Through research, webinars, and speaking with other certified WBE business owners, I know the process is quite extensive,” she said.

Challenges and rewards

When asked what are the challenges and rewards of this new venture, Heffernan responded by saying that everything is rewarding and challenging all at once.

“They feed each other,” she said. “It’s exciting to be faced with a challenge or obstacle, and finding the solution or resolution to those situations are the reward.”

Before pursuing a shift in her career, Heffernan worked in finance for almost ten years at Martin-Zombek Construction. “We were all encouraged to “think like a business owner,” “think like an entrepreneur,” she said. “At that time, it was practice; now, it’s the real deal.”

Stopping the “I’m an employee” thought process was one of Heffernan’s biggest challenges. Her background at Martin-Zombek, however, prepared her well for the new path she walks today.

“I’m grateful to have had the experience at Martin-Zombek,” she said.

Though Heffernan is the new leader of this female-owned business, she’s mindful of each team member’s purpose within the establishment.

“We all have a very important job to do here and none of us can do it [alone],” she said. “The kind of culture I’m trying to create and build off of [is] the foundation that the Wilkins’ [had] so tirelessly built. We’ve got a solid crew, in the field and in the office.”

Aside from the employee-to-employer transition, Heffernan is also conscientious of continuous learning and the value of networking. The Construction Financial Management Association (CFMA) and the Syracuse Builders Exchange (SBE) — had both served as substantial resources for her in the past. She plans to engage with each again.

“[CFMA] and [SBE] were huge for networking and were resources when I was in my previous position in construction,” she said. “I miss that education because [not only] would I learn something new, but it also validated what I knew [already]. That’s how I can be most helpful to my team, by making sure I’m continually learning and knowing  the best way to account for all the hard work my team is doing.”

Though it’s been less than a year, the rewards so far, she said, are seeing the teams come together and watching the business develop.

A little history

Wilkins Mechanical Inc. was formally incorporated in 1997 and family-owned for 41 years. That’s a history that would make anyone who succeeds the founders feel both secure in their acquisition and apprehensive about filling their shoes.

“Many people dislike change,” said Heffernan. “There are times when it’s even uncomfortable for me. So, I understood there was going to be some apprehension [and] potentially some resistance.”

Heffernan noted how oftentimes when a new owner takes over, they decide to build their business from scratch. “It makes sense that there would be some concern,” she said, “but that was definitely not my plan.”

In fact, the only changes she sees on the horizon are newer technology and more staff. For herself, Heffernan implemented an accounting software program within the first six months to keep organized in job costing and project tracking. Her next focus will be organic expansion — growing the business in a way that makes sense.

“I hope to increase employment over the next few years,” she said. “New York State has been a very good customer; we have had success in bidding OGS, DASNY and SUNY projects. ”

Heffernan looks forward to having internal conversations with employees on exploring other gainful avenues, too.

What should their customers know?

Sometimes change can shake up customers’ confidence if they’re uncertain about what to expect. At Wilkins Mechanical, Heffernan exudes a commitment to excellence.

“I carry the same values, work ethic, and pride that the former owners had,” she said. ”I respect that. I want to continue to preserve the reputation that the previous owners worked so hard to build — that’s my goal.”

Does that mean there won’t be any “oh shoot,” “oh darn,” or “I’m sorry” moments? Of course, there might be, she said, because learning curves are a natural — and healthy — part of a new process, and show humility. Heffernan advocates for customer conversations to bring her up to speed on current happenings.

“I appreciate our customers and I am thankful for their patience in our growth,” Heffernan said. Our customers have been wonderful to work with. I’ve very much enjoyed getting to know them.”

In essence, Heffernan’s view on success for everyone is about collaboration. “We’re very prideful in the work that we do because we do a knockout job. We’re welders, we’re pipefitters and nobody can weld as good as we can,” she said. At the same time, feedback is critical, too. “If our client is unhappy with a certain situation, we entertain that. We’re open to that conversation.”

“I see everything as a team,” she added. “Everybody needs support, whether it’s on a project from a project manager to the foreman to the client’s project manager — we all need to work together and that’s the kind of culture and philosophy that I’m trying to build.”

Heffernan may not have ever consciously thought about owning a business, but her experience, philosophies, and can-do attitude, together with team-building principles, appears to have put her on the path she had been seeking from the start.

Breakout Box or Sidebar

Wilkins Mechanical Apprenticeship Program

The Wilkins Mechanical Apprenticeship Program is accredited through the National Center for Construction Education & Research (NCCER), which is recognized by the New York State Department of Labor.

“We encourage anyone, at any age, to join our organization and learn the plumbing, pipefitting, and steam-fitting trade,” Heffernan said.

The typical program is five years. The work processes that an individual is trained on and the minimum required hours are set by the DOL. A newly hired individual who enters the program will “test in,” which will determine their knowledge and skills to influence their entry level.

NEW YORK STATE POISED TO ADD REGISTRATION REQUIREMENT TO PUBLIC WORKS CONTRACTING NYS Senate Bill S5994C

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By Joseph Schuler, Sheats & Bailey, PLLC

Public works contracting in NYS is subject to various statutes, rules, and regulations under Article 8 of the NY Labor Law.  The state is on the brink of adding another onerous registration requirement to the list. The requirement would apply to all contractors on public works projects in NY and is on the way to the Governor’s desk after passing the State Senate and Assembly.

The bill is a self-described attempt “to better enforce existing labor laws and regulations in the public works industry.” In reality it is a way for NYS to raise revenue and add another unnecessary layer of bureaucratic review for contractors to navigate.  The bill requires contractors to register with the DOL’s Bureau of Public Works. The registration must be renewed every two years and prior to bidding on any public work. Unregistered contractors may not bid on public contracts. Additionally, registered contractors may not use the bids of unregistered subcontractors. Proof of application is not accepted as proof of registration. All bidders must provide proof of their own registration and that of any underlying subcontractors their bid relies on when submitting their bid.

Noncompliance with any of the registration or proof of registration requirements may, after notice and a hearing, result in a fine of up to one thousand dollars.  It may be prudent for contractors to revise their current form subcontracts to include indemnification clauses specifically covering potential fines under this new law.  Also, it may be wise to add language permitting claims for lost profits if an unregistered subcontractor causes the prime contract to be terminated.  Including subcontract language that subcontractors must maintain and renew their certification at their own cost could mitigate a contractor’s risk. Furthermore, requiring proof of registration in advance of bid submission by subcontractors and developing an in-house database of registered subcontractors may reduce the chance of using a bid from a sub that is not registered.  The proof of registration terms could be included in RFPs sent to subcontractors.

Registration, in its simplest form, is completed in three parts. First, there is a registration fee of $200, which the Commissioner has the discretion to lower for M/WBEs. Second, the registrant must fill out a fairly extensive disclosure form. Finally, the company must show proof of workers’ compensation insurance coverage for all employees.

The form is statutorily required to include the following criteria: (1) company name and address, (2) business entity type, (3) contact information for any individuals with company interest, (4) company tax ID number, unemployment insurance registration number, and workers compensation board employee number, (5) outstanding wage assessments in NY, (6) debarments in the last ten years in NY, (7) debarments in the last ten years outside NY, (8) past violations of NY labor or employment tax law, (9) past OSHA violations, (10) associations with apprenticeship programs, and (11) status as a M/WBE or not.

After paying the fee, filling out the form, and showing proof of workers’ compensation insurance, the Commissioner of the Bureau of public works has the broad discretionary power to determine a contractor’s fitness. The unelected Commissioner is required to “promulgate regulations to determine under what circumstances a contractor would be unfit to be registered.” A bright spot for some, past debarment is not permitted to be the sole determining factor of fitness, unless the debarment is currently still in effect under section 220-b(3) of the Labor Law (five-year debarment for two prevailing wage violations in six years) or 141-b of the Worker Compensation Law (one-year debarment for workers compensation payment violations).

If the Bureau of Public Works Commissioner finds a company unfit the company will have the opportunity to dispute the finding at a hearing. Then the Commissioner will make a final determination. Companies found to be fit at the outset or after a hearing will be issued their certificate of registration. The Bureau is required to establish an online interface for contractors to access their certificates.  

The attorneys at Sheats & Bailey, PLLC are experienced with compliance in the public works bidding process. For more information or assistance with navigating the Public Works Construction landscape contact Sheats & Bailey, PLLC.

The information provided in this article is not intended to serve as specific legal advice for any particular situation. Competent legal and experienced counsel should be consulted.

Workers’ Compensation: Changing the Experience Mod Calculation

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Paul Coderre, CSP, ARM, Vice President of Risk Management Services

What does it mean for your business?

  • It’s good and getting better / It’s bad and getting worse
  • Changes go into effect 10/1/2022
  • Intent: Incentivize companies to do better at preventing injuries
  • Withdraw from NCCI for multi-state operations

They say, “Change is good”

As you may have heard, the New York State Compensation Insurance Rating Board (NYCIRB) is changing the way they calculate your Experience Modification Factor (aka “mod”). They are also withdrawing from the National Council on Compensation Insurance (NCCI) and eliminating the “Merit Rating” system for small businesses. This would probably be interesting if you are an insurance person (Like me). If you’re not an insurance person, you probably just want to know how it’s going to affect you in insurance availability and cost.

First: How is Workers’ Compensation Premium Calculated?

Your workers’ compensation (WC) carrier calculates your organization’s premium, using data provided by you, the State of NY, and their own (approved) factors. The calculation follows a standard formula in which the underwriter uses your workers’ compensation classification codes, loss cost rates tied to those codes (set by the State) and your payrolls to calculate your manual premium, which is the first step in setting the premium for a guaranteed cost policy.

The manual premium would be the same for any two companies that do the same thing, have the same number of people, and pay their people the same in wages. It does not consider the loss performance of either company. This is where other factors, including the loss cost multiplier (LCM) and the experience modification factor (EMF) come in.

LCM: The loss cost multiplier is a factor that is developed by the WC carrier, and approved for use by the State. Carriers can have several LCM’s approved for use, and reflect the carrier’s “feeling” about how your company will perform. Loss cost multipliers can range from 1.10 to over 1.5.

EMF: The experience modification factor is calculated by NYCIRB based on your classification codes (what you do), three years of your payrolls, and three years of your losses (how well you do what you do). This is the thing that is changing as of 10/1/2022.

A key to remember about the LCM and EMF is that they are “multipliers” in the premium formula; meaning the underwriter takes that initial “manual premium” figure and multiplies it by both factors.

Manual Premium X LCM X EMF = Standard Premium

The standard premium is the important premium number. There may be other discounts introduced by the underwriter, but it is the true basis for your annual workers’ compensation premium. Needless to say, the lower either “factor” is, the lower the impact on that standard premium number. So, if you want to control your workers’ compensation premium, you need to do what you can to control the LCM and the EMF.

Control: Since the LCM is set by the underwriter, you have little control over the number itself. Your opportunity to control the LCM stems from your operations, your overall performance, consistency in performance and the presence and effectiveness of your risk management efforts.  It is really a more subjective decision by the underwriter whether you get an LCM of 1.12 or 1.45.

However, the EMF is a controllable factor. It is based on your injury costs over a three year period; if you minimize the frequency and severity of incurred losses, your modification factor will be lower, and will have a more positive impact on your premium. Unlike the LCM, the EMF can actually calculate to be less than one (<1). When the manual premium is multiplied by a modification less than one (called a Credit Mod) it actually reduces the ultimate premium figure (Yay!). So the bottom line is that in order to control your workers’ compensation premium, your best opportunity is to control your EMF.

This is why the State’s change to the EMF formula are so important to you and your business.

Second: Why is the State Changing?

New York State has been studying the performance of organizations from the standpoint of workers’ compensation injuries and costs. Those studies have revealed that companies performing very well (minimizing the frequency and severity of on-the-job accidents) are not realizing the benefit of their performance in their workers’ compensation premiums (remember, the EMF is based on performance over a three year period). The State also found that companies performing poorly in workers’ compensation outcomes are not being assessed adequately for their poor performance. (Note that the experience rating system is supposed to reward good performers and “incentivize” poor performers to do better) The bottom line is that the State felt it necessary to change the EMF formula to better affect what organizations pay in premium based on their performance.

Discontinue participation in NCCI:  The National Council on Compensation Insurance is an organization that provides EMF calculations for companies with operations in multiple states. While they do not cover all states, those companies whose operations are within a state that is a member of NCCI would have a common EMF for all such operations in all such states. Not all states participate in the NCCI system. In a case where a company has operations in both NCCI states and non-NCCI states, premiums will be calculated for NCCI States using the common NCCI mod, and for Non-NCCI states individually using the experience mod calculated for that state on its own merit. Since NY no longer calculates a mod the way that NCCI does, it needed to withdraw from the NCCI program.

Discontinue the merit rating system: Very small companies in New York (WC Premium < $5,000) have traditionally been treated differently in their workers’ compensation premium calculation than larger companies. They fell under a program called “merit rating.” With the changes made to the experience rating formula (specifically the variable split point) the State felt it was no longer necessary to have a separate means of premium calculation. Companies who previously qualified for merit rating will now be rated the same way as all other workers’ compensation risks in the state. The changes to the EMF calculation are designed to accommodate small, medium and large risks. (More on the variable split point in a moment).

What Has Changed?

Key elements of the experience rating formula have changed. It is felt by the State that those changes will result in the following:

Organizations that in the past have had a very favorable credit mod will likely see their EMF improve further. Those companies who in the past have struggled with a very poor debit mod will likely see their new mod get even worse. And those companies who have been in the middle (not great but not terrible) will see only minor changes to their newly calculated EMF. That is how the State described the expected outcome of changing the mod formula. Our early observations have shown a little more tendency for mods to move up slightly for those in the middle group.

Variable Split Point: A key change to the formula has been the establishment of a “Variable Split Point.” The split point defines what portion of incurred claim costs on a specific claim will be considered primary, and what will be considered secondary. The mod formula leans heavily on costs associated with small to moderately severe claims, and discounts high severity claim costs so they don’t over skew the mod.

This was a point in which a smaller company’s mod could be overly impacted by a single claim, while a larger company may not feel the impact of several claims as intended by the State. The new method sets the split point value based on the company’s payrolls and Expected Losses. A small company may have a split point of $1,500, while a larger company’s split point may be $60,000. The result is that if each company had a single claim that totaled $65,000: the small company would have $1,500 used in the mod calculation while the larger company would have $60,000 entered into their calculation. While it seems harsh, the larger company’s higher expected losses do soften the blow of the higher split point.

Caps and Limits

First Year Cap: During the first year of applying the new calculation (experience mods effective from 10/1/2022 to 9/30/2023), a mod calculated under the new method that generates result greater than 0.30 higher than using the old calculation will be capped at the mod calculated by the old method plus (+) 0.30. This will show up on the experience rating sheet provided by the State (NYCIRB).

Claim Count Limits: There is also a limit on the experience modification for organizations having only 1, 2, 3 or 4 claims in the rating period. This is another way for the State to limit the impact of a single or a very few claims having a severe impact on a smaller company’s experience rating; and for a larger company’s mod to be limited by a calculated cap (although this cap can still be fairly high).

  • For an organization having only 1 claim, their mod cannot exceed 1.12.
  • If the organization has only 2 claims, their mod is capped at 1.40.
  • If the organization has 3 claims, the cap is 1.75, and
  • If the organization has 4 or more claims the mod is capped via formula – (2 + 0.000003 X Expected losses)

 

The Bottom Line and What Can We Do About It?

The bottom line in the changes made to the experience rating formula is that it is here and it is real. The State (NYCIRB) has begun applying it to those mods effective on 10/1/22 or after. For many, their mod will go up; some slightly, others not so slightly. For others, their mod will go down and they will realize the benefits in their next policy renewal.

What we can do is:

  • Work with OneGroup to stay ahead of the game. We can do some prospective calculations of your mod to see (approximately) where it’s going to be at renewal time. This will help in making decisions relating to carriers and programs.
  • Work with OneGroup Risk Management and Claim professionals to help minimize the occurrence and severity of workers’ compensation losses. Remember, the only real option you have in controlling your experience mod is to control the losses driving it.

What Else:

If you want to know more about the details surrounding the change to the mod formula and the potential impacts of those changes:

CASH IS KING

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Kenneth C. Gardiner, CPA, CCIFP, CDA, Dannible & McKee, LLP

With inflation at its highest since the early 1980s, contractors are required to fund higher construction costs to perform the same construction operations. The cost of materials and labor have increased significantly, and cash requirements have never been higher. It takes money to make money, and contractors need cash to mobilize projects, fund payroll and stay afloat.

Here are 10 strategies to help preserve cash flow and reduce construction costs:

  1. Negotiate and ask for material escalation provisions– Historically, escalation provisions have been limited to asphalt and a few other commodities. It is becoming much more prevalent to obtain escalation on a wide variety of construction materials and equipment. Many contractors are approaching contract owners and negotiating inflation-oriented contract increases.
  2. Manage over- and under-billings – One of the best sources of cash flow is over-billings. Manage bid and pay items to front-load as much profit as reasonably possible into early construction phases. Use the early cash flow to reduce line credit borrowing and fund project costs. Conversely, minimize under-billings; discuss pay items with project engineers to confirm when items can be billed on applications for payment. Strategically time when significant material purchases need to be paid to suppliers to when you can bill the owner for these materials and equipment.

3.Explore new sources of products and materials– Now might be the best time to research new sources of products and materials. Inflation and ownership transition in the construction materials and suppliers’ industries may create opportunities to forge new relationships with vendors hungry for new business. We have seen relationships that were once deemed taboo turn into new opportunities for better pricing and/or payment terms. The Internet also may be a great source of new supplier opportunities.

4.Teamwork– Make sure construction teams work together with purchasing personnel to obtain the best price and delivery options. Don’t let construction teams purchase goods and services in a silo. Centralize purchasing as much as possible at the home office, or at least make sure large purchases amongst projects are coordinated to maximize volume purchase pricing and related discounts.

5.Contract outside advisors– Stay connected to your outside advisors. Industry professionals such as accountants, legal counsel and construction industry associations can help identify federal, state and local programs to assist contractors with programs, such as was the case with the Paycheck Protection Program (PPP) and Employee Retention Credit (ERC), that can provide substantial government incentives to maintain your workforce and provide much-needed cash flow.

6.Billings, collections and year-end payments– Review your billing and collection policies. Consider emailing invoices, applications for payment and other communications with customers. Provide electronic payment options such as EFT and credit card options. Negotiate better payment terms with vendors. Offer wire transfer payments on a specified due date or use credit card payment services to provide additional cash flow or credit card rewards to extend cash terms or use rewards for future purchases.

7.Subcontractor and supplier buyouts– Despite having quoted prices, consider going back one more time to negotiate or obtain better pricing on significant subcontract or supply contracts. You might be able to hit on a few cost savings that could have an impact on overall job profitability.

8.Review equipment needs– For contractors with significant rolling stock and equipment operations, consider a review of equipment usage on current and future projects. Sell off idle or low-usage equipment for new purchases. Look at short- or long-term equipment lease options vs. financing purchases. The acquisition of new equipment requires a cash flow analysis, including an increase in cash for potential reductions in repairs and maintenance to replaced equipment and a decrease in cash for interest components of any long-term financing.

9.Evaluate estimated tax payment requirements– Whether you are a regular tax-paying C corporation or a pass-through entity, consider deferring estimated tax payments to assist in short-term cash needs. Most taxpayers believe you must make estimated tax payments equal to your prior-year tax. Evaluate current year profitability and determine if you can adjust estimated payments based on your current year’s quarterly taxable income.

9.Lines of credit– While most contractors have a line of credit, the best time to ask for an increase or expansion of your line is when you don’t need the money. It might seem counterintuitive, but banks may be hesitant to lend money when you need it, however, tend to be much more willing to increase or provide a line of credit when you demonstrate healthy cash flow management. With inflation and costs dramatically increasing, now might be the best time to request an increase in bank borrowing availability before it is too late.

It’s not likely the impact of materials inflation is going to reverse, and it looks like the “new” costs are here to stay. Additionally, there is no way to reverse labor inflation, so we are all going to have to manage the impact of increased costs. These are just a few suggestions to help you improve cash flow, manage costs and increase profitability.