Getting It Done: Experienced Healthcare Leaders Reveal Field-Tested Strategies for Clinical and Financial Success

By Kenneth Cohn

Regardless of the outcome of national healthcare reform legislation, pressure is mounting on healthcare professionals to provide more cost-effective, coordinated care.

Nothing is more valuable than experience. Overcoming a challenge builds skills, knowledge, and confidence.

This book shares the hard-earned lessons of healthcare leaders who removed roadblocks to clinical and financial excellence. Each chapter describes a real-life dilemma, distills the lessons learned, and provides step-by-step guidance. Use the strategies presented in this book to tackle similar challenges in your organization with greater speed, confidence, and success.

Physician engagement and collaboration are the common themes of these stories. Administrators, physicians, and nurses provide firsthand accounts of how they worked together to overcome obstacles and transform care for their communities.

Tap the wisdom and experience of healthcare leaders who:

Accelerated physician adoption of electronic health records Cut mortality from sepsis Transformed the culture of the operating room Developed a successful ED-call pay program Cut costs using strategic supply cost management

• Language: English
• Publisher: Health Administration Press
• Release date: Jun 25, 2011
• ISBN: 9781567934540

Book preview

Sometimes it feels like we still live in a wild-west habitat of hospital—physician relations. This book showcases stories and insights that can help any healthcare organization depersonalize differences to improve care. Each chapter offers key insights that help us move closer to relationships that best help those we serve—our patients and families.

–Ruth W Brinkley, FACHE, President/CEO Carondelet Health Network, and West Ministry Market Leader, Ascension Health

"This book has the best chance of any for improving how hospitals operate. For the first time, physicians and hospital leaders have a collaborative, evidence-based approach to delivering greater care at lower cost. From the administrative level to the way care is delivered, this book enables hospitals to make a huge cultural shift toward consistently better care. The authors have created and tested actionable clinical and administrative strategies and procedures drawn directly from the experience research of medical and healthcare leaders from across the country. As a former Wall Street Journal reporter who covered healthcare and who has spent the past eight years researching and crafting collaborative strategies and communication, I believe the book is so practical and well researched that it can unite hospitals around a common vision and, more important, collective action."

–Kare Anderson, Leader, Collaborative Strategies, Center for the Edge, Deloitte

"Actions speak louder than words, and Getting It Done is all about taking action. Cohn and Fellows demonstrate impact through action by providing thought-provoking, real-life examples of what our health system could be if we effectively collaborated and aligned stakeholder incentives to meet our shared goals. With the noise level on health reform rapidly on the rise, this book could not have been timelier."

–Gautam Gulati, MD, MBA, MPH, founder and chief idea experimenter, Gulati Group; adjunct professor of medical innovation and entrepreneurship, Johns Hopkins Carey Business School; Senior Vice President, Science and Medicine, Digitas Health

Improving documentation often makes physicians angry and defensive. The authors make a compelling case for why improving documentation impacts patient care, quality, and safety and enhances revenue for physicians and hospitals.

–Jennifer Daley, MD, Executive Vice President and Chief Operating Officer, UMass Memorial Medical Center

"Chapter 14 is a very successful story in a situation most seasoned healthcare administrators have been a part of in their careers. The distinguishing characteristic that makes this chapter different from other books on this subject is that the sidebars read like well-thought-out ‘recipes for success’ and allow the reader immediate access to these tools and techniques for their own situations. The stakes are very high when the knowledge and skills of all team members are not optimal, and fortunately, this situation had a ‘burning platform’ that did not cause harm to the patients. The information in this chapter about the cost of staff and physician turnover and the correlation between quality and staff turnover is well written."

–Erin Yale Horwitz, FACHE, Administrator for Diagnostic Imaging and Professional Services, Children's Hospital of Wisconsin

"The practical insights in Getting It Done from healthcare leaders on the frontlines are quite instructive. As the landscape continues to shift, this guide will be a key part of many a healthcare executive's toolkit."

–David Harlow, JD, MPH, Principal, The Harlow Group LLC

"To improve performance and safety is a goal shared by all teams in all hospitals. However, the human element is often the elephant in the room, which is invisible despite being in plain sight of all involved in dysfunctional hospital units. Dysfunction may start from a single individual, but it spreads faster than C. difficile, rapidly crippling the normal function and risking patient well-being and safety. A model intervention, developed by an experienced team, that can be rapidly implemented is a boon to hospital care, administration, and most important, patient safety."

–Jimmie C. Holland, MD, Wayne E. Chapman Chair in Psychiatric Oncology and attending psychiatrist, Memorial Sloan-Kettering Cancer Center

"Getting It Done provides some applicable real-world scenarios of what happens on the frontlines. While technology may help advance the capability of providing healthcare, it does not negate the use of old-fashioned but affirmative positive communication and collaboration."

–Colleen Stukenberg, MSN, RN, CMSRN, CCDS, Clinical Documentation Management Professional, FHN Memorial Hospital

The dance of the blind reflex prevents participants from seeing the enabling role they play in the conditions they deplore. With their carefully edited cases and analyses, Dr. Cohn and Mr. Fellows have skillfully addressed the elephant in the room—subjects that every-one else tiptoes around. I look forward to making their book available to my second-year graduate students in my capstone course.

–Leonard H. Friedman, PhD, FACHE, Professor and Director, Department of Health Services, Management, and Leadership, The George Washington University

Finally, a book that tells the truth about how the lack of collaboration undermines our nation's medical centers and how true collaboration, as opposed to disguised control, can save us time, expense, and needless lives lost. Implementing just one of the strategies described in this book can make a tremendous difference for physicians, facilities, and most important, patients.

–Mark F. Weiss, healthcare attorney, Advisory Law Group

ACHE Management Series Editorial Board

Joseph J. Gilene, FACHE, Chairman

Quorum Health Resources

Mark C. Brown, FACHE

Lake City Medical Center-Mayo Health System

Robin B. Brown Jr., FACHE

Scripps Green Hospital

Frank A. Corvino, FACHE

Greenwich Hospital

Terence T. Cunningham III, FACHE

Shriners Hospital for Children

David A. Disbrow, FACHE

Ohio Cardiac Thoracic and Vascular Surgeons

Kent R. Helwig, FACHE

UT Southwestern Medical Center

Natalie D. Lamberton

Rio Rancho Medical Center

Trudy L. Land, FACHE

Executive Health Services

Greg Napps, FACHE

Bon Secours St. Mary's Hospital

James J. Sapienza, FACHE

MultiCare Health System

Arthur S. Shorr, FACHE

Arthur S. Shorr & Associates Inc.

Leticia W. Towns, FACHE

Regional Medical Center at Memphis

KENNETH H. COHN | Editor

        STEVEN A. FELLOWS | Editor

GETTING IT

DONE

Experienced Healthcare

Leaders Reveal

Field-Tested Strategies for

Clinical and Financial

Success

Your board, staff, or clients may also benefit from this book's insight. For more information on quantity discounts, contact the Health Administration Press Marketing Manager at [phone].

This publication is intended to provide accurate and authoritative information in regard to the subject matter covered. It is sold, or otherwise provided, with the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

The statements and opinions contained in this book are strictly those of the authors and do not represent the official positions of the American College of Healthcare Executives or of the Foundation of the American College of Healthcare Executives.

Copyright © 2011 by the Foundation of the American College of Healthcare Executives. Printed in the United States of America. All rights reserved. This book or parts thereof may not be reproduced in any form without written permission of the publisher.

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Library of Congress Cataloging-in-Publication Data

Getting it done : experienced healthcare leaders reveal field-tested strategies for clinical and financial success / Kenneth H. Cohn, editor, Steven A. Fellows, editor.

   p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-56793-414-4 (alk. paper)

1. Hospitals—Administration. 2. Hospitals—United States—Administration. I. Cohn, Kenneth H. II. Fellows, Steven A.

[DNLM: 1. Hospital Administration—United States. 2. Hospital-Physician Relations—United States. 3. Organizational Case Studies—United States. 4. Quality Improvement—United States. WX 150 AA1]

RA971.G475 2011

362.11068—dc23                                                                          2011016534

™

Found an error or typo? We want to know! Please email it to [e-mail], and put Book Error in the subject line.

For phocopyopying and copyright information, please contact Copyright Clearance Center at www.copyright.com or [phone].

Project manager: Jennifer Seibert; Acquisitions editor: Janet Davis; Cover designer: Gloria Chantell; Layout: Putman Productions

Health Administration Press

A division of the Foundation

of the American College of

Healthcare Executives

One North Franklin Street

Suite 1700

Chicago, IL 60606

[phone]

Kenneth H. Cohn dedicates this book to his father, George A. Cohn, MD, a reluctantly elected medical staff president who nevertheless showed up and got it done.

Contents

Foreword by C. Duane Dauner

Acknowledgments

Introduction by Steven A. Fellows and Kenneth H. Cohn

1   Saving Lives by Improving Processes of Care by Jeffrey C. Fried

2   Disaster Preparedness for Healthcare Professionals by Carl W. Taylor

3   Overcoming Rural Healthcare Challenges by Charles F. Rinker II

4  Building and Sustaining a Culture of Safety by Kenneth H. Cohn, Carol L. Sale, and Gary R. Yates

5  Launching an Innovation Revolution in Healthcare by Philip A. Newbold and Diane S. Stover

6  Engaging Physicians in Collaborative Supply Cost Management by Natalia Wilson, Anand Joshi, and Eugene S. Schneller

7    Documentation as Destiny: A Tool for Survival by Robert S. Hendler

8   Collaborative Approaches to Emergency Department Call by Drew Erra and Michael E. Hogue

9  Healthcare Leadership: Challenges and Solutions by Edward J. O'Connor, Jeremy Mann, and C. Marlena Fiol

10   Breaking Down Silos: The Successful Collaboration of Two Feuding Healthcare Partners by Ralph Jacobson

11   The Role of a Physician Executive in Facilitating Collaboration by Robert A. Reid

12   Building a Functional Operating Room Culture by Stanley R. Mandel and Susan S. Phillips

13   Innovations to Address Disruptive Physician Behavior by Susan M. Lapenta, Larry Harmon, and Mel Belding

14   Coaching Healthcare Teams to Improved Performance by Elizabeth R. Becker and Ashley Wendel

15   Engaging Physicians to Adopt and Use Electronic Health Records and Computerized Physician Order Entry by Joel C. Berman and Michael B. Green

16   Physician Integration: The SSM Vision by William P. Thompson, Robert Porter, Christopher D. Howard, R. Brent VanConia, and Lorraine Kee

Epilogue by Kenneth H. Cohn and Steven A. Fellows

References

Index

About the Contributors

About the Editors

Foreword

Legislation enacted by Congress in 2010 will have a more profound effect on healthcare financing and delivery than all previous health-related laws combined. The next five years will be the most challenging in history. Also, the half decade before us will open doors to our greatest opportunities to improve healthcare financing, delivery, quality, safety, and infrastructure.

Clearly, the time to act is now, if hospitals and physicians wish to maintain a viable private—public healthcare partnership with government. Aligning incentives, coordinating care, managing care in an integrated network, and optimizing the deployment and utilization of resources are top priorities.

Although local, regional, and state initiatives are essential to reforming healthcare, the importance of ground-zero work and relationships cannot be overstated. Healthcare is a person-to-person experience. Regardless of the technology, knowledge, and sophistication that are continuously changing, patients must be cared for individually.

Kenneth H. Cohn, MD, and Steven A. Fellows, FACHE, have compiled and edited an impressive set of insightful chapters by leading experts throughout the nation. Getting It Done: Experienced Healthcare Leaders Reveal Field-Tested Strategies for Clinical and Financial Success is a must-read for policymakers and leaders in the trenches of healthcare delivery. The authors do an excellent job of making the theoretical practical and the practical implementable.

Healthcare executives and practitioners will find the topics enlightening and informative. I highly recommend this timely and thoughtful contribution to the healthcare field.

C. Duane Dauner

President, CA Health Association

Acknowledgments

Writing and editing a book is a process about which we find it difficult to be indifferent. Writers get it done because we believe passionately in a cause in which we strive to enlist others. We have been fortunate to find chapter authors who have engaged in heroic journeys, which they share with pride in the following chapters. We thank them for putting their thoughts into a framework of introduction, case presentation, case analysis, multistep key concepts, and lessons learned so that readers can learn from their experience quickly, and hopefully painlessly.

We also thank our families, mindful that no calendar month is ideal for starting and finishing a book. For me (KHC), this book culminates a decade of work in 40 states, traveling over 800,000 miles to capture stories of tragedy and ultimate triumph that have not been published elsewhere in this type of format.

Ron Werft, President and CEO of Santa Barbara Cottage Hospital, deserves gratitude for bringing us together and exposing us to chapter authors who inspired this book.

Finally, we thank our editorial team for sticking with us and the project when at times the outcome seemed uncertain. Sharon Hogan shared her art of proposal writing. Janet Davis suggested a video summary to capture our enthusiasm for improving clinical and financial outcomes. Although the process may have seemed, like the chapters, a little like making sausage, we hope that the results are similarly spectacular.

Introduction

Never before has there been a greater need to get work done in a collaborative way than today. We stand on a precipice, with the winds of change swirling around us, as

state and federal regulations demand more of us, with public reporting of outcomes;

Medicare moves to pay for performance;

healthcare reform takes us back to the future with accountable care organizations, à la capitation, part two;

consumers are more educated and reliant on the Internet for healthcare information, whether it is accurate or not; and

the physician community struggles to take care of patients and make a living, asking their hospitals to help them survive in an era of disruptive change.

Getting It Done: Experienced Healthcare Leaders Reveal Field-Tested Strategies for Clinical and Financial Success attempts to fill the gap in this uncertain world of healthcare management. Experts who have been there and done that share their stories of success and, in some cases, failures that later turned into success, so that we practitioners of today and tomorrow do not need to reinvent the wheel and can learn from others how to effect change.

When one is looking to reduce death due to sepsis; to improve financial performance by engaging physicians in proper documentation, healthcare information technology, emergency department call, disaster planning, breaking down barriers, and supply chain decision making; to address disruptive behavior; and to build and sustain a culture of safety and optimal performance, none of these important outcomes will occur until we fully engage the physician community in daily operations that drive performance improvement.

We hope that you find the material in this book to be a trajectory that guides you to improve your organizations in a more rapid and effective way for the benefit of the communities you serve.

Steven A. Fellows and Kenneth H. Cohn

CHAPTER 1

Saving Lives by Improving

Processes of Care

Jeffrey C. Fried

THE NEED FOR GREATER SEPSIS RECOGNITION

At 11 pm on a typical Saturday night, the waiting room of the emergency department (ED) is full. Suddenly, four patients are brought in by ambulance. The first is Martha, a 75-year-old woman with a cough and mild confusion, whose blood pressure, heart rate, respiratory rate, and temperature are mildly abnormal. Martha doesn't look that sick, so her nurse puts her in a back room of the ED where less acute patients are evaluated. Routine blood tests and a chest X-ray are ordered.

With multiple patients to evaluate, the ED physician has to prioritize those who seem to need the most attention. While the ED physician is sedating a disruptive patient and cleaning his wound, Martha is decompensating in the back room. Her blood pressure is dropping, her heart rate is climbing, and she is becoming sleepy, but no one notices. When the ED physician goes to evaluate Martha at 2 am, she is in shock. Her blood pressure is 60/30, and she is unresponsive.

Martha had severe sepsis (an overwhelming bacterial infection) due to pneumonia, and if the severity of her condition had been recognized and rapidly treated when she first arrived in the ED at 11 pm, her chance of survival would have been 80 percent. By the time she was treated at 2 am, her chance of survival had fallen to 50 percent. Meanwhile, the other three patients had predicted survivals of greater than 95 percent on arrival, and all received attention before Martha.

This scenario plays out in EDs all over the United States every day. In 2004, I asked, Why can't we recognize and treat the sickest patients first? In that same year, the Surviving Sepsis Campaign (SSC) was launched (Dellinger et al. 2004). The campaign focused on the early recognition and rapid treatment of patients with over-whelming bacterial infections that kill more than 200,000 people in the United States annually. For many years, despite new antibiotics and other medical advances, the mortality from these diseases had not changed. However, between 2000 and 2002, several large studies targeting different aspects of sepsis treatment demonstrated significantly lower mortality from severe sepsis and septic shock (Rivers et al. 2001; Annane et al. 2002; Van den Berghe et al. 2001; ARDSNet 2000; Bernard et al. 2001). By bundling these different treatments, investigators hoped to reduce sepsis mortality by at least 25 percent.

THE JOURNEY

Paradigm Shift

I realized that the implementation of the SSC at our hospital would require multidisciplinary cooperation. I became the physician champion committed to developing a sepsis protocol. I had no experience developing and implementing such a complex protocol.

My first step was to analyze the SSC guidelines in detail and compare the requirements to the realities at our hospital. Our strengths included

a committed nursing and ancillary staff eager to improve patient quality and safety;

a physician community with high standards of care;

medical and surgical residency programs, which make physicians immediately available to treat sepsis patients (rather than on-call from home or other settings);

trauma service and cardiac catheterization programs that could serve as models for interdisciplinary cooperation; and

a not-for-profit structure and a board of directors committed to improving quality standards and clinical outcomes for the community.

The barriers to implementation of a sepsis protocol included

a busy community ED, averaging approximately 40,000 annual visits, that needed a better system of triage to incorporate the needs of sepsis patients;

lack of ED recognition of the problem and its urgency;

laboratory turnaround times that were too slow for key tests, such as lactate and complete blood count (CBC) with differential;

pharmacy delivery times that were too slow for antibiotics and other critical medications;

slow transfers from the ED to the intensive care units (ICUs), where sepsis patients receive most of their care;

a need for new technology, which would require both capital expenditures and physician and nurse training; and

a need for extensive education of medical staff, residents, ED nurses, critical care nurses, respiratory therapists, pharmacy staff, and laboratory personnel.

The Prerequisites to Change

Although multiple departments needed to collaborate, no structure existed to bring people together. Additionally, I had no support staff of my own to help with development. I decided to break down the problem into discrete parts and map out the changes we would need to make to our current practices and processes. I soon realized that a few key components needed to be put in place before the entire protocol could be implemented.

The first component included the purchase of new patient monitoring equipment—an ScvO2 catheter, which measures the balance between oxygen supply and demand, a key component of sepsis monitoring. Fortunately, at the time, the catheter had recently been developed, and the company was willing to loan us the monitors if we would purchase the disposable catheters. Thus, we were able to develop this capability without any capital equipment outlay. Our ICU nursing leadership and critical care nurse educator developed a