This is Section 2 of Leadership's Collaborating for Results report.
Return to the full report.
''It is like they speak a foreign language," is a common refrain from finance leaders, materials managers, and other healthcare professionals who are working closely together to improve patient care or reduce costs. One side might talk of par levels, per diem rates, and P&L statements. While the other speaks in care models, comorbidities, and CTs.
A dictionary or a Google search can help, of course. But this is not just about defining lingo and acronyms. As they search for better approaches to patient care delivery, healthcare leaders need to step out of their comfort zones. For instance, clinicians are finding they need to grasp financial concepts and priorities, and business leaders are leaving offices to find out what drives patient safety, quality, and costs in the ICU or in an OR suite.
Early in her career, Kelli Holt, mistakenly thought that the hospital could cover her daily salary as an X-ray technologist with the amount it charged for a single chest X-ray.
"That's how naive I was," says Holt who is now director of diagnostic imaging and cardiology services at CHRISTUS St. John Hospital in Nassau Bay, Texas. "Once I started learning about the financial side of health care, I found out what happens when you charge a patient for services. The amount that is actually reimbursed is so vastly different than what is present on your chargemaster. I now realize that it would take several X-rays to cover an X-ray technologist's salary for a day."
Demystifying managed care. A few years ago, the finance and managed care departments at 178-bed St. John began providing clinical directors with training about how managed care contracts impact the hospital revenue stream.
"I have a matrix that lists our major managed care contracts in terms of how payments are calculated for certain clinical business lines," says Anita Fluharty, regional managed care manager for CHRISTUS Heath system. "We walk through this matrix with the clinical directors, explaining how a patient's plan can affect authorization requirements or change whether we get paid for an implant on a carve-out basis. We also show how reimbursement changes based on a per diem rate versus a diagnosis-related group rate, etc."
"A lot of this is trying to understand the different languages everybody uses," says David Witt, CFO at St. John. "When we talk 'carve outs,' that does not translate down to the OR directors who are putting in $20,000 hip implants. To them an implant is an implant, and to us it's a carve out," he says.
Ensuring the appropriate setting. Learning about managed care contracts has not changed Holt's priorities as a clinician. "First and foremost you have to make sure that your patients are getting the care they really need. And you cannot make those decisions based on what the payment is going to be."
However, the training has caused Holt and other clinical directors to become more assertive about questioning tests and procedures that may not be medically necessary.
"Clinical directors are redirecting physicians when appropriate," says Witt, who believes in the power of clinicians persuading fellow clinicians. "Telling a physician that it's inappropriate to order an inpatient CT is much better coming from a clinical director than from the CFO."
Holt has taught radiology staff to ask some additional questions. "Clinicians are taught to make sure they have the right patient before conducting a test by checking the patient's date of birth and other identifiers," says Holt. "We built on that and trained staff to also check the patient's admitting diagnosis against the diagnosis for doing the procedure. When there's not a valid correlation, the radiology technologist needs to clarify whether the test is absolutely necessary."
She gives the example of a patient who is admitted to the hospital for hypertension, and is brought down to radiology for a foot X-ray. "That should prompt some questioning," says Holt. "The facility should call the case manager and question the physician's order."
There may be a valid medical reason for the X-ray, she says. But it could be the physician ordered the inpatient test at the patient's request or out of convenience-in which case, the hospital would not likely be reimbursed under a managed care plan. Some services may be more appropriately provided in an outpatient setting; other services may not be needed at all.
In recent years, St. John has seen out-of-control denials decrease to 0.51 percent of net patient revenue. Witt attributes the improvement, in part, to the finance training that clinical directors are receiving. "We've seen a decline in the number of procedures that are outside the scope of the admitting diagnosis," he says.
Stephen Shapiro, MD, had an epiphany several years back. As chairman of surgery at Gundersen Lutheran Health System, Shapiro realized that he needed to adjust his leadership style to different personalities.
"We surgeons are used to making quick decisions," says Shapiro. "But a lot of people we work with think in very different ways. When doing administrative and leadership work, it was important to realize not everyone thinks like surgeons think."
This insight came during an education session he attended. After taking a Meyers-Briggs personality test, Shapiro and other physician leaders at Gundersen Lutheran discussed the challenges of leading different personalities.
"Few new physician leaders have management experience outside direct patient care," says Shapiro. "We know what we want to get done as leaders, but the hard part is to slow down and go through the stepwise progression of getting your colleagues to understand why they need to change and in what direction they need to change."
Training physicians to lead. About 10 years ago, Gundersen Lutheran recognized it needed to provide leadership training to physicians. "Structurally, our organization will always be led by the medical staff," says Mary Ellen McCartney, chief learning officer. "So we asked, 'How can we get full performance from our physician leaders and ensure a future pipeline of outstanding leaders?"
The first step: Writing job descriptions and core competencies. "When we started, we didn't even have a medical director job description. We needed to get to the point where physicians understood what their responsibilities were."
The health system then invested in providing targeted training and support to physician leaders (see the sidebar).
In the first several years, the health system paid outside experts to provide much of the training. However, over time, experienced physician leaders- the CEO and medical vice presidents-have taken over most of the teaching. McCartney helps the physicians design curriculum on strategic planning, performance evaluations, and other issues. But the physician leaders typically deliver the training themselves.
The program runs on a shoestring staffing budget of about 0.2 FTE, which includes McCartney's and her assistant's time. "The real money in this is the physician's time in the classroom," says McCartney.
Recognizing the cost of pulling physicians away from daily duties, McCartney makes sure that all classroom sessions give physicians practical skills they can apply-right away. "What physicians really want is practical knowledge," she says. "Give them a tool, and they'll use it and use it." For example, a recent session on clarifying performance expectations gave physicians sample scripts to use when faced with difficult situations.
Relevance is also critical, says McCartney. "We focus training around our key strategies. We consider what competencies and skills physician leaders need to develop over the next three to five years to meet our strategic plan, and what specifically they need to know in 2010."
Splitting duties. More and more physicians are expressing interest in taking on leadership and administrative roles at Gundersen Lutheran.
McCartney credits the level of support Gundersen Lutheran gives physician leaders. Training is just one part of this support. As described in Section 1 (page 11), all physician leaders are paired up with an administrative partner.
Shapiro has two partners to help him lead the sizable surgery division. The administrative leader is Matt Kabliska, an MBA who oversees the budget, compliance, and other business-related issues. Roxanne Potts, RN, is the clinical manager, whose responsibilities include staffing/scheduling and patient flow.
Dividing up the management responsibilities helps ensure that Shapiro can continue to practice surgery. His administrative duties-which take up about 20 percent of his time-include managing and recruiting all physicians, physician assistants, and nurse practitioners. He also leads department meetings and is involved in strategic planning.
The partnership helps maintain the right balance between quality and cost, says Shapiro. "On his own, an administrative leader may look at ways to save money without considering how that change will affect patient care. He may be prone to make a smart short-term decision that turns out to be a bad long-term decision."
"Vice versa, the administrative leader has forced me to be more cost accountable," says Shapiro. "I might say, 'I think this will work.' Then he says, 'Well, here's the business plan, and this will only work if X, Y, and Z occur."
It took just one e-mail to all the facilities in St. John Providence Health System, and Jack Carr knew the organization could easily pull together cross-continuum teams to reduce hospital readmissions.
"The response back was huge," says Carr, project manager, Clinical Transformation, at St. John, which is based in Warren, Mich. "This told us that everyone inside and outside the inpatient world sees the value in studying readmissions."
Setting the structure. St. John is one of 53 organizations participating in STate Action on Avoidable Rehospitalizations Initiative (STAAR), which was launched by the Institute of Healthcare Improvement (IHI) in May 2009.
The STAAR goal is to reduce the 30-day, all-cause readmissions rate by 30 percent among all participants by this coming October. St. John also hopes to reduce readmissions related to congestive heart failure by 30 percent, as well as improve patient and family satisfaction.
Ten months into the initiative, St. John has eight teams actively working to decrease readmission rates: a system-level team, four hospital teams, a home care team, a senior services team, and a medical home team.
Oversight and structure is provided at the system level by Carr and Judy Avie, vice president of process improvement and care design. Carr holds weekly phone meetings with each team to assess progress, review readmission data, and provide coaching. Carr also coordinates the sharing of successes and data with all the teams and with IHI. "One of the roles I play is sharing the tools the teams are creating so others don't have to recreate the wheel," he says.
"It helps the teams to know there is support for the initiative," says Avie. She points to an immediate support need that arose: The difficulty of identifying patients' primary care physicians-which interfered with the ability to coordinate post acute care. "We immediately found a place on the front-page banner of our electronic health record to include the primary care physician's name alongside the attending physician's name. As a result, staff can now send reports to the primary care physician on admission and on discharge."
Pinpointing strategies. Each St. John team is piloting specific strategies that IHI has identified for reducing readmissions. For instance, the home care team is currently piloting the patient teach-back tool, says Loraine Cusumano, RN, BSN, MA, director, St. John Home Care. "The home care and hospital teams determined what key information we want to teach the patient. We ask the patient to repeat back our teachings in their own words."
Gathering data on the causes of readmissions helps teams match strategies to specific patient populations. For instance, recently diagnosed heart failure patients who live at home make up the majority of readmissions at one St. John hospital. Many of these readmissions might be prevented by teaching patients how to better manage their illness.
In contrast, a St. John skilled nursing facility is using different approaches to better manage older patients with heart failure. A weight management team now closely monitors patients for weight and respiratory changes. Nurses then use the SBAR (Situation, Background, Assessment, and Recommendation) communication tool to discuss the patient's case with physicians. As a result of these changes, the facility saw readmissions drop by 50 percent in three months.
Reaching across the state. As part of STAAR, St. John is also collaborating with other Michigan hospitals to improve the statewide readmission rate. Both Carr and Cusumano sit on a statewide team that aims to improve patient transfers between settings (for example, from hospital to home care, from skilled nursing facility to hospital).
The team is putting the finishing touches on a tool that will encourage better communication among Michigan providers: a one-page form that lists all the information that should be exchanged when transitioning a patient from one setting to another. The tool sums up what key data hospitals, home care agencies, physician offices, and skilled nursing facilities need from each other.
A project such as this-which involved getting disparate stake-holders to boil down their needs on a one-page form-seems like it would be fraught with frustration. But Carr and Cusumano describe team discussions as collaborative and collegial.
"It has actually gone very seamlessly," says Cusumano, who believes the project's mission created a collegial bond. "When you are there to improve quality for the patient, healthcare providers pull up their sleeves and get to work."
The team structure also provided a healthy platform for give and take. Subteams were formed to represent each stakeholder: hospitals, insurers, home care, physician offices, and skilled nursing facilities. These subteams met separately to determine key information needs, and then came together to hash out what got listed on the form.
"There were some 'a ha' moments," says Carr. "Everyone wanted their perspective on the form. When we had the opportunity to speak together as a group, we got to see how each side sees things differently. Then we realized that we had to bring all of these perspectives together and come up with a common form."
By electronically linking all healthcare players, electronic health records promise to encourage and enable collaboration. Go to Section 3, Developing a Meaningful EHR.
Or return to the full Leadership report, Collaborating for Results.
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