PHYSICIAN EXECUTIVE MBA

 

Organizational Action Projects

During their Organizational Action Project (OAP) PEMBA participants design a project that will improve both patient and organizational outcomes. They work with a faculty advisor and their own corporate team to implement it, with deliverables scheduled throughout the program year.

Similar to a thesis, the project is graded independently of all other assignments, and our students report significant impact to efficiency and patient care through through their OAPs.

Charting a Future Course for a Regional Family Clinic

Michelle Steele Rebelsky, MD, Physician Executive MBA, Class of 2017


CHALLENGE: A family practice located in a small, south central Iowa town was formed in 2011 as a Virtual Private Practice (VPP) within a larger health care system. Since the practice’s primary mission is meeting the total health needs—including preventive, acute, chronic medical care, and obstetrics—of the underserved, the VPP model was an ideal way to quickly get the clinic up and running. A VPP outsources the business side of the practice, freeing clinicians to do what they do best: provide personalized patient care. Faced with the realities of the ever-evolving local, state, and national health care industry landscape, however, it quickly became clear to the family practice clinicians that the VPP model wasn’t sustainable. Handling the volume and complexity of increasing regulations while continuing to provide the same level of patient care, would require a solid administrative structure and a new, financially viable model.

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Charting a Future Course for a Regional Family Clinic

Michelle Steele Rebelsky, MD, Physician Executive MBA, Class of 2017


CHALLENGE: A family practice located in a small, south central Iowa town was formed in 2011 as a Virtual Private Practice (VPP) within a larger health care system. Since the practice’s primary mission is meeting the total health needs—including preventive, acute, chronic medical care, and obstetrics—of the underserved, the VPP model was an ideal way to quickly get the clinic up and running. A VPP outsources the business side of the practice, freeing clinicians to do what they do best: provide personalized patient care. Faced with the realities of the ever-evolving local, state, and national health care industry landscape, however, it quickly became clear to the family practice clinicians that the VPP model wasn’t sustainable. Handling the volume and complexity of increasing regulations while continuing to provide the same level of patient care, would require a solid administrative structure and a new, financially viable model.

PROJECT: Board-certified family medicine physician Michelle Rebelsky used her PEMBA experience to devise a solid and sustainable path forward for the clinic. While the practice dissolved the VPP and joined the larger health care system’s tax identification (Tax ID) number (meaning the physicians billed using the hospital’s Tax ID) in 2015, Rebelsky and her fellow clinicians realized that the current system wasn’t the most efficient or cost-effective. Even though the hospital had taken over a larger role in maintaining the clinic (including retaining final control over operational and financial decisions), the practice financials remained on an Excel spreadsheet and the compensation structure still was based on the original VPP model. Using the tools learned through her PEMBA coursework, and with the guidance and executive coaching of the PEMBA team (especially professor Dr. Ray Husband, academic program manager Tom Brown, and Haslam College of Business Associate Dean for Graduate and Executive Education Dr. Bruce Behn), Rebelsky charted and enacted the steps needed to transition the family practice clinic from the VPP model to the more sustainable Advanced Payment Model-Accountable Care Organization (APM-ACO).

PROCESS: Rebelsky tackled the challenge using the ExperiencePoint “Lakeview” change management simulation. A modification of John Kotter’s popular “8-Step Process of Leading Change,” Lakeview is a scenario and case based on using Lean as a strategy to improve patient flow in a hospital. Here’s a quick overview of how the Rebelsky employed the Lakeview approach to develop a new administrative structure for the family practice:

1. Understand the need for change. Rebelsky focused on the top three change drivers: competition from new specialists, a new health care network affiliation, and the Medicare Access and CHIP Reauthorization Act (MACRA).

Until October of 2016, the larger health system had an affiliation agreement with an even larger health care network. The family practice had a prominent role in the network’s Accountable Care Organization (ACO). The network and the ACO helped fill the gaps in administrative leadership and outpatient expertise that was missing at the local level. With this affiliation, the family practice was on track to join the network’s APM-ACO for 2017. Being part of the APM-ACO would enable the family practice to participate in MACRA without the Merit-based Incentive Payments System (MIPS) component. MACRA, bipartisan legislation signed into law in 2015, created the Quality Payment Program that:

  • Repeals the Sustainable Growth Rate formula
  • Changes the way that Medicare rewards clinicians for value over volume
  • Streamlines multiple quality programs under MIPS
  • Gives bonus payments for participation in eligible alternative payment models (APMs).

MIPS was designed to tie payments to quality and cost efficient care, drive improvement in care processes and health outcomes, increase the use of healthcare information, and reduce the cost of care. Since Medicare is approximately 30 percent of the family practice clinic’s revenue, a guaranteed five percent increase in payment as part of the APM-ACO would be much better for the clinic than gaining or losing four percent under MIPS.

In late October 2016, the larger health care system ended its seven-year affiliation with the health care network and started working with two other entities in a joint venture. This joint venture still was in the planning stages as Rebelsky proceeded with her project, requiring her to deal with many moving parts as the project—and the transition from VPP model to a more sustainable model—unfolded.

2. Enlist a core team. Rebelsky assembled a strong Change Staff made up of the family practice providers and clinic supervisor, and the health care system’s vice president of finance, who helped served as a liaison between the pro-change clinic staff and the change-resistant hospital leadership. Satellite team members included “helpers,” such as the information technology (IT) and billing departments and PEMBA faculty.

3. Develop a vision and strategy. The initial vision called for the family practice to be part of an APM-ACO for 2018 using the following strategies:

  • Finish establishing a Patient-Centered Medical Home (PCMH) model encompassing five functions and attributes: comprehensive care, patient-centered, coordinated care, accessible services, and quality and safety.
  • Get financials in order. 

  • Develop a new compensation model. 

  • Review staff concerns about changes that were happening.
  • Investigate the requirements for joining the joint venture’s ACO. 

  • Investigate a local Clinically Integrated Network (CIN), a legal entity where physicians and hospitals partner to provide high quality and cost-effective patient-centered care.
  • Consider independent options.

4. Motivate by creating a sense of urgency. Since May 2017 was the Centers for Medicare & Medicaid (CMS) deadline for joining an APM-ACO and several discrepancies in the financials needed to be reconciled before the merger, the urgency was clear.

5. Communicate the Vision: Rebelsky and her team conveyed the vision in multiple meetings and huddles, and through visuals.

6. Act: Here’s a quick overview of the actions steps, all of which involved some repetition of steps 1-5. Rebelsky and her team:

  • met with the leadership of the joint venture and the ACO
  • attended multiple health care system taskforce meetings
  • spent months reconciling financials
  • rejected local CIN and independent options due to staff concerns.

7. Consolidate gains. To maintain the momentum for change (and to avoid reverting to the clinic’s old way of doing things), Rebelsky celebrated the achievement of three short-term objectives before setting tougher goals.

The three big wins were:

  1. Attaining PCMH Level 3 recognition from the National Committee for Quality Assurance in February 2018
  2. Approval in September 2017 for the ACO in 2018
  3. Negotiating a new physician compensation model.

RESULTS: In January 2018, the larger health care system was acquired by the joint venture and renamed. The gains achieved through Rebelsky’s PEMBA OAP allowed for a new clinic structure, which is the transition plan for 2018 and 2019.

“My initial proposal was to develop a new administrative structure for GRFP,” Rebelsky says. “The Virtual Private Practice model would not be financially sustainable when the joint venture acquired the hospital and clinic in January 2018. With the newly developed and implemented administrative structure, we have had a smooth transition into the new health care system and the ACO.”


Post-Anesthesia Care Unit Process Improvement to Increase Patient Throughput

Pankaj Kumar, MD, Physician Executive MBA, Class of 2017


CHALLENGE: The high-stress environment of post-anesthesia care units, or PACUs, commonly leads to staff burnout and dissatisfaction. Stress levels are particularly high on days when a PACU reaches the point of over-capacity, known as a “surge” in patient census. Having a surge plan in place can help mitigate problems (such as staffing shortages), however, frequent surging can lead to surge “fatigue” or “numbness” among staff. While working in a PACU is inherently stressful, process improvements could increase patient throughput (the cycling of patients through the department), resulting in higher patient and staff satisfaction. As processes become more complex, however, individual hospital departments—including PACUs—tend to display the Fiefdom Syndrome, which is tendency of groups to isolate from the larger organization to protect their own turf and preserve the status quo.

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Post-Anesthesia Care Unit Process Improvement to Increase Patient Throughput

Pankaj Kumar, MD, Physician Executive MBA, Class of 2017


CHALLENGE: The high-stress environment of post-anesthesia care units, or PACUs, commonly leads to staff burnout and dissatisfaction. Stress levels are particularly high on days when a PACU reaches the point of over-capacity, known as a “surge” in patient census. Having a surge plan in place can help mitigate problems (such as staffing shortages), however, frequent surging can lead to surge “fatigue” or “numbness” among staff. While working in a PACU is inherently stressful, process improvements could increase patient throughput (the cycling of patients through the department), resulting in higher patient and staff satisfaction. As processes become more complex, however, individual hospital departments—including PACUs—tend to display the Fiefdom Syndrome, which is tendency of groups to isolate from the larger organization to protect their own turf and preserve the status quo.

PROJECT: Dr. Pankaj Kumar, a board-certified hospital medicine physician and Medical Director of QI/QS, Hospital Medicine at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, recognized that analytics and mathematical modeling could help improve processes in the PACU model, which demonstrates significant variability. Under the guidance of his PEMBA advisors Dr. Don Lighter and Dr. Amy Cathey, Kumar designed a project implementing Lean Six Sigma (LSS) principles to make the PACU more efficient, reliable, and responsive. The top objectives of the project were increasing patient throughput and, eventually, improving patient and employee satisfaction.

As Kumar stated in making the case for the LSS combination: “Lean is a methodology allowing hospitals to improve quality of patients’ care by reducing errors and waiting times, and by ensuring that every activity and process step adds value to the end service. Lean can be complemented by Six Sigma, which is a more sophisticated, structured, and statistical approach to problem solving.”

PROCESS: Kumar decided to pursue a DMAIC (Define-Measure-Analyze-Improve-Control) approach to problem-solving. Specific project goals included:

  • Increasing throughput in PACU by decreasing PACU boarding and overnight stays
  • Removing inefficiencies by enhancing workflow in PACU via Lean methodology
  • Decreasing nurses’ patient bedside documentation by removing redundant paperwork
  • Decreasing PACU operational variation by creating a standard work document.

Serving as the backbone of the project was the model outlined in John Kotter’s popular “8-Step Process of Leading Change.” Here’s a quick overview of how Kumar and the Wake Forest Baptist Health team employed Kotter’s approach to address the challenge and make PACU process improvements:

  1. Increase urgency. Common purpose was established and trips to the Gemba were made to explain the sense of change and urgency to the frontline staff. [In Gemba Kaizen, a Japanese concept of continuous improvement for enhancing processes and reducing waste, Gemba refers to the location where value is created and Kaizen relates to improvements.] The sense of urgency was well-received by PACU staff and the project was communicated to leadership. Good progress was made during the define and measure phase, however, progress slowed with a change in PACU leadership.
  2. Build the guiding team. A LSS team was created with a LSS champion and executive sponsor for the project. Due to increasing momentum, another executive sponsor was added to project.
  3. Get the vision right. The vision was carefully formulated, initial thoughts were given to increase patient throughput, but later achieving high employee and patient satisfaction was also added.
  4. Communicate to build buy-in. This project was jointly conceived by the project champion and the Associate CMO, meaning executive leadership was present from start. Frontline employees were receptive to the project despite being overwhelmed by day-to-day duties. Areas for improvement included interdisciplinary communication.
  5. Empower action. There was strong frontline staff involvement in employee surveys and process mapping during the define and measure phase. A mentioned above, a change in leadership slowed momentum. Areas of improvement include frontline staff involvement by PACU leadership.
  6. Create short-term wins. To create a sense of urgency, the project initially was presented in several institutional committees. The greatest achievement was having the process mapping findings presented in an institutional patient throughput meeting attended by a Wake Forest Baptist Medical Center Vice President.
  7. Don’t let up. As the project evolved, Kumar realized that wave after wave of changes will be required to fulfill the vision.
  8. Make change stick. Once the project steps are implemented, Kumar says he understands that expecting and demanding strict adherence to the new processes is needed to succeed in the face of traction and turnover of change leaders.

RESULTS: Based on the initial progress made, Kumar reports that several anesthesiology providers have volunteered to join the project.

For Kumar, the top four lessons learned from his OAP experience were:

  1. Interdisciplinary team dynamics is key in the PACU. Since multiple teams work collaboratively, communicating goals and achievements to all stakeholders helps strengthen team dynamics
  2. The change in PACU leadership resulted in better understanding of current PACU deficiencies
  3. While local culture and status-quo can be serious barriers to change, taking steps early on to involve frontline workers can lead to success.
  4. Although the use of LSS tools at Wake Forest Baptist Medical Center mainly are restricted to Performance Improvement and Quality Improvement teams, the results of this project demonstrate promise for more widespread application.

Evaluating the Potential Benefits of Acquiring a Skilled Nursing Care Facility

Richard Harp, MD, Physician Executive MBA, Class of 2017


CHALLENGE: In the world of skilled nursing and rehabilitation facilities, a one-star rating from the Centers for Medicare & Medicaid Services (CMS) is akin to a scathing Yelp review. CMS created the Five-Star Quality Rating System to help consumers, their families, and caregivers to easily compare nursing homes (also known as skilled-care facilities) and come up with questions—and things to look for—when touring a facility. Nursing homes with five stars are considered to exceed expectations for above average quality, while facilities with one star are deemed to have quality much below average. Such was the case at one-star Woodruff Manor, a privately owned, 88-bed skilled nursing and rehabilitation facility serving the Woodruff, South Carolina, community since 1987. Elevating Woodruff Manor from a one-star to three- or four-star facility would require significant upgrades and additional staffing. For the non-profit Spartanburg Regional Health System (SRHS), acquiring Woodruff Manor presented the possibility of increasing net income—if the due diligence process proved the acquisition to be financially and strategically sound.

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Evaluating the Potential Benefits of Acquiring a Skilled Nursing Care Facility

Richard Harp, MD, Physician Executive MBA, Class of 2017


CHALLENGE: In the world of skilled nursing and rehabilitation facilities, a one-star rating from the Centers for Medicare & Medicaid Services (CMS) is akin to a scathing Yelp review. CMS created the Five-Star Quality Rating System to help consumers, their families, and caregivers to easily compare nursing homes (also known as skilled-care facilities) and come up with questions—and things to look for—when touring a facility. Nursing homes with five stars are considered to exceed expectations for above average quality, while facilities with one star are deemed to have quality much below average. Such was the case at one-star Woodruff Manor, a privately owned, 88-bed skilled nursing and rehabilitation facility serving the Woodruff, South Carolina, community since 1987. Elevating Woodruff Manor from a one-star to three- or four-star facility would require significant upgrades and additional staffing. For the non-profit Spartanburg Regional Health System (SRHS), acquiring Woodruff Manor presented the possibility of increasing net income—if the due diligence process proved the acquisition to be financially and strategically sound.

PROJECT: For Dr. Richard Harp, interventional radiologist and system vice-president of the SRHS medical staff, the PEMBA program offered the unique opportunity to complete the due diligence process while also earning an MBA and continuing to work fulltime. A significant portion of the due diligence process—and, thus, of Harp’s OAP—was focused on developing a credible revenue and profitability forecast, or pro-forma, for Woodruff Manor if the facility were to be acquired by SRHS. Using the results of this pro-forma, SRHS would be positioned to make an informed decision about whether to move forward with the acquisition.

PROCESS: Completing the due diligence process required wading through the complex laws and regulations governing hospitals and nursing homes. Harp used the tools, mentoring, and peer and faculty input and support gained through his PEMBA experience to take a deep dive into one of the most poorly understood federal health care industry laws: Upper Payment Limit (UPL). Basically, the UPL is a supplemental payment program designed to increase Medicaid reimbursements to facilities. The result of this program is that certain facilities, if they meet the criteria set by CMS and by state regulations, can charge additional fees (often exceeding the actual cost of medical services to Medicaid beneficiaries), provided the total doesn’t exceed the UPL.

The UPL program only applies to non-profit, government hospitals and nursing homes, not privately owned facilities like Woodruff Manor. Since SRHS is a self-funded entity of the state of South Carolina and does not receive tax dollars from the community, however, the hospital system could take advantage of the law. As a result, SRHS potentially could realize a reasonable profit by acquiring and operating Woodruff Manor as a non-profit, while also funding needed facility and staffing upgrades. For Woodruff Manor residents, Harp determined, the acquisition—and infusion of UPL funds—could result in improved quality, care, and safety.

In turn, the improved Woodruff Manor could attract higher paying residents. The historical payer mix for Woodruff Manor is unfavorable, with a bias toward the lower reimbursing payers such as Medicaid. While this is to be expected for a one-star CMS-rating facility, Harp concluded that raising the rating to three or four stars would result in a more favorable payer mix. At the outset of Harp’s PEMBA project, Medicaid accounted for approximately 83 percent of Woodruff Manor’s reimbursing payers. Based on his projections, Medicare and private insurance would comprise a larger share of the resident pool at an improved and SRHS-operated Woodruff Manor, with Medicaid dropping to 64 percent—the industry norm.

Harp’s pro-forma was calculated using a very conservative Hurdle Rate of 15 percent and a more realistic rate of eight percent. In addition, the Net Present Value (NPV) was calculated incorporating the Horizon value, as this represents all future cash flows. The pro-forma was based upon historical payer mix, which, as mentioned above, was unfavorable.

RESULTS: Harp’s pro-forma indicated that the purchase should move forward. Applying UPL to Woodruff Manor’s 88 licensed Medicaid beds would add an additional $1.9 million to yearly revenue. Additional long term revenue would be achieved by elevating the CMS star rating. Harp concluded that the acquisition not only would provide an additional revenue stream for SRHS, but also would enhance quality of life at Woodruff Manor—benefitting residents, their families, and Spartanburg County.


Leading Change in Emergency Department Chest Pain Care

CHALLENGE: Chest pain is a common reason people seek emergency medical care, resulting in about eight million emergency department (ED) visits in the United States each year. Many of those patients are hospitalized for comprehensive—and expensive—testing, even if they are at very low risk for life-threatening acute coronary syndrome (ACS) based on their history, electrocardiogram (ECG) findings, and cardiac biomarkers. Over-testing of ED patients with chest pain can lead to hospital crowding and inefficiency, while harming patient outcomes.

PROJECT: Leon Adelman, emergency medicine physician and director of clinical operations at the Inova Alexandria (Va.) Hospital (IAH) Emergency Department recognized that a standard, evidence-based approach to chest pain evaluation was needed to accurately determine whether a patient was at very low risk for acute coronary syndrome (and thus, safely could be discharged without further cardiac testing). Using the modeling tools learned in the PEMBA program—and the input and guidance of his UT PEMBA mentor and advisor Jody Crane—Adelman focused his Organizational Action Project on designing and implementing a ED Low Risk Chest Pain Initiative (LRCP) at IAH. He led an IAH LRCP team charged with improving the quality, consistency, and efficiency of the process for chest pain evaluation at the hospital.

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Leading Change in Emergency Department Chest Pain Care

CHALLENGE: Chest pain is a common reason people seek emergency medical care, resulting in about eight million emergency department (ED) visits in the United States each year. Many of those patients are hospitalized for comprehensive—and expensive—testing, even if they are at very low risk for life-threatening acute coronary syndrome (ACS) based on their history, electrocardiogram (ECG) findings, and cardiac biomarkers. Over-testing of ED patients with chest pain can lead to hospital crowding and inefficiency, while harming patient outcomes.

PROJECT: Leon Adelman, emergency medicine physician and director of clinical operations at the Inova Alexandria (Va.) Hospital (IAH) Emergency Department recognized that a standard, evidence-based approach to chest pain evaluation was needed to accurately determine whether a patient was at very low risk for acute coronary syndrome (and thus, safely could be discharged without further cardiac testing). Using the modeling tools learned in the PEMBA program—and the input and guidance of his UT PEMBA mentor and advisor Jody Crane—Adelman focused his Organizational Action Project on designing and implementing a ED Low Risk Chest Pain Initiative (LRCP) at IAH. He led an IAH LRCP team charged with improving the quality, consistency, and efficiency of the process for chest pain evaluation at the hospital.

PROCESS: The IAH LRCP team followed the model outlined in John Kotter’s popular “8-Step Process of Leading Change.” Here’s a quick overview of how the team employed Kotter’s approach to address the challenge and create a low-risk chest pain pathway.

1. Create a sense of urgency. Adelman and his team used existing research to illustrate how improvements in laboratory testing and clinical decision-making algorithms for chest pain have outpaced changes in practice, leading to excessive admission rates and variation. They also conducted a thorough review of journal articles, best practices currently used by leading medical institutions, and American Heart Association guidelines, as well as discussions with national chest pain experts, to make a compelling case for how consistently adhering to best-evidence practice can improve chest pain care quality, safety, and efficiency, while decreasing costs.

2. Build a guiding coalition. The LRCP initiative was incorporated into the Alexandria-Springfield Emergency Physicians (ASE) Clinical Operations Council, which provided key support to the project. Council member Darren Morris, emergency physician and assistant director of the Virginia Hospital Center in Arlington, Va., served as project co-leader with Adelman.

3. Form a strategic vision and initiatives. The LRCP team crafted a vision based on the premise that using an algorithmic approach to chest pain would help IAH clinicians better protect patients from missed myocardial infarctions, or heart attacks; help protect providers from litigation; increase efficiency; and decrease costs. After a literature and best practice review, the team created a new evidence-based ED chest pain pathway based on the HEART (history, electrocardiogram results, age, risk factors, and troponin) Score. The guidelines are designed as single-page graphic pathways to walk a provider through the steps of evaluation and treatment.

4. Enlist a Volunteer Army: Involving key stakeholders—such as IAH ED providers, cardiologists, administrators, hospitalists, and nurses—early in the process helped build buy-in. The team educated stakeholders about the issue, answered questions, and provided multiple avenues for feedback. In addition, the IAH ED providers and cardiologists participated in drafting the new evidence-based chest pain pathway.

5. Enable action by removing barriers. Educational tools—including pocket cards that providers can carry with them during a shift, mandatory online learning modules, informational posters in the ED, and staff meeting presentations—helped build the knowledge and consensus needed for full integration of the new pathway. In addition, cardiologists agreed to see all insured LRCP referrals within 3 days and a new 24/7 voicemail-based ED cardiology referral system was created.

6. Generate short term wins. When compared with the six months prior to the LRCP Initiative, the first three months’ post-pathway launch showed improvements in key metrics.

7. Sustain acceleration. The subsequent three-month period showed mixed results, likely due to incomplete integration of the pathway into provider workflow and challenges in obtaining process measures integral to driving continuous improvement.

8. Institute change. Based on the initial improvements, the team partnered with Inova’s Quality and Informatics Departments to better integrate the LRCP Pathway into ED clinician workflow via the Epic EMR (electronic medical record) system. Epic data will drive a continuous improvement process based on individualized transparent performance feedback.

RESULTS: The IAH ED LRCP Pathway was adopted in November 2016 by all EDs in the Inova Health System, a network of hospitals and other health care facilities located throughout Northern Virginia and the Washington, D.C. metro area. Patient data collected during the first several months of implementation clearly demonstrated that the new evidence-based ED chest pain pathway improved safety, quality, and efficiency of IAH ED chest pain evaluations. From Sept. 2016 to June 2017, for example, the percentage of Inova patients presenting with chest pain who received a HEART score increased from 1.1 percent to 32.4 percent. During that same period, the percentage of patients with a primary diagnosis of chest pain who returned to the emergency department within 30 days decreased from 9.1 percent to 4.4 percent. Next steps include EMR optimization, implementing data-driven improvement strategies, and application of the LRCP model to other common ED conditions.


Restructuring a Growing OB/GYN Practice

CHALLENGE: Expanding any medical practice involves more than a few growing pains. While the addition of new physicians typically produces long-term benefits—such as lightening patient loads for current providers—short-term challenges can sabotage success. For Women’s Specialty Care (WSC), a Knoxville, Tennessee, obstetrics/gynecology practice located at the main University of Tennessee Medical Center campus, the decision to add four new physicians in 2015 was made, in part, to adopt a variation of the laborist, or obstetrics hospitalist, model.

The OB/GYN hospitalist approach ensures that a fully trained OB/GYN will be physically available—with no assigned tasks or responsibilities elsewhere—to manage patients who present to labor and delivery. Since WSC is aligned with a teaching hospital (the University of Tennessee Graduate School of Medicine) the laborist-like model also made it possible for four physicians in the practice to incorporate academic goals with the Department of Obstetrics and Gynecology.

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Restructuring a Growing OB/GYN Practice

CHALLENGE: Expanding any medical practice involves more than a few growing pains. While the addition of new physicians typically produces long-term benefits—such as lightening patient loads for current providers—short-term challenges can sabotage success. For Women’s Specialty Care (WSC), a Knoxville, Tennessee, obstetrics/gynecology practice located at the main University of Tennessee Medical Center campus, the decision to add four new physicians in 2015 was made, in part, to adopt a variation of the laborist, or obstetrics hospitalist, model.

The OB/GYN hospitalist approach ensures that a fully trained OB/GYN will be physically available—with no assigned tasks or responsibilities elsewhere—to manage patients who present to labor and delivery. Since WSC is aligned with a teaching hospital (the University of Tennessee Graduate School of Medicine) the laborist-like model also made it possible for four physicians in the practice to incorporate academic goals with the Department of Obstetrics and Gynecology.

While the new model produced immediate benefits (such as consistent coverage in labor and delivery), it also presented challenges in five areas:

  • Location: There was an initial concern that more space would be needed to accommodate the new providers at the practice’s main office on the UT Medical Center campus. WSC physicians also provide care at four satellite locations.
  • Technology: Reliance on outdated processes and computers—which, already was causing delays and frustrations—increased with the addition of more providers.
  • Furnishings and Flow: The office furnishings and work flow—both essentially the same as when the practice was founded in 2004—needed updating to keep pace with the growth.
  • Schedules: Negotiations were needed to determine a balanced coverage schedule.
  • Marketing: An updated marketing strategy was needed to attract new patients.

PROJECT: To meet the current challenges—and position the practice for future growth—WSC obstetrician/gynecologist and Medical Director Jaclyn van Nes created workable solutions using lean methodologies and marketing techniques. Her Organizational Action Project systematically addressed each challenge facing the growing practice.

PROCESS: First, van Nes used a sticky note board to map out a workable daily schedule, incorporating all five locations staffed by WSC providers. Since all provider contract requirements could be met within the schedule and the existing space, she determined there was no immediate need for additional space.

Next, van Nes performed a lean manufacturing workflow analysis to identify inefficiencies (such as using paper encounter forms before entering information into electronic medical records, or EMR) and find ways to minimize or eliminate any “double work” currently performed in the practice. Van Nes presented her findings to the office staff, information technology department, and hospital administration. As a result, the office team leader developed a much faster and essentially paperless check-in process, decreasing check-in times from 2 to 5 minutes per patient to approximately 15 seconds. In addition, patient forms were added to the practice website, saving time by allowing patients to fill out required forms in advance of their visit. The office also was equipped with more user-friendly laptops. Finally, due to the workflow analysis results and technology upgrades, more than half of the providers now use digital—not paper—documentation, significantly reducing the workload for the nursing staff.

Van Nes then conducted a patient flow analysis (PFA) at the practice’s main office to help identify inefficiencies and improve care delivery processes. Using the PFA results and the office floor plan, the office layout was redesigned to improve efficiency and accommodate additional physicians and patients. In addition, a portable lab kit was prepared to allow for lab draws in patient rooms and the storage closet was organized for better inventory management. Finally, new signs, office flooring, and furnishings were installed.

The final two challenges were addressed by creating a rotating call and clinic schedule (agreed upon by all providers) and by making research-driven marketing decisions (including updates to the WSC website and a new campaign promoting labor and delivery).

RESULTS: The practice restructuring project resulted in better quality of life for the physicians, the ability to see more patients more efficiently, and overall work and patient flow improvement at WSC. In addition, the practice is well positioned for future growth and is attracting new patients through its retooled and research-based marketing efforts.


Connecting rural community hospitals to advanced critical care expertise.

CHALLENGE: Small community hospitals in rural South Carolina offer personalized, close-to-home care, yet commonly don’t have specialists on staff to meet the needs of critically ill patients. Physician specialists, such as intensivists (board-certified physicians who provide special care for critically ill patients) and pulmonologists, primarily are located in the state’s larger suburban and urban population centers. Lack of local access to critical care expertise often means that patients requiring intensive care-level treatment have to be transported to hospitals outside of their communities. The distance between home and hospital creates an extra financial burden (due to factors such as transportation and lodging expenses and lost work days) for patient families and can be stressful for patients who are receiving treatment in unfamiliar surroundings.

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Connecting rural community hospitals to advanced critical care expertise.

CHALLENGE: Small community hospitals in rural South Carolina offer personalized, close-to-home care, yet commonly don’t have specialists on staff to meet the needs of critically ill patients. Physician specialists, such as intensivists (board-certified physicians who provide special care for critically ill patients) and pulmonologists, primarily are located in the state’s larger suburban and urban population centers. Lack of local access to critical care expertise often means that patients requiring intensive care-level treatment have to be transported to hospitals outside of their communities. The distance between home and hospital creates an extra financial burden (due to factors such as transportation and lodging expenses and lost work days) for patient families and can be stressful for patients who are receiving treatment in unfamiliar surroundings.

PROJECT: Dr. Tallulah Holmstrom, Chief Medical Officer of CMO of Carolina Pines Regional Medical Center in Hartsville, S.C. and KershawHealth in Camden, S.C., and her leadership team recognized that existing telehealth technologies could provide the connection needed to help patients in a rural community hospital receive critical care close to home. Using the modeling tools learned in the PEMBA program—and the input and guidance of her UT PEMBA mentor and advisor Dr. Erin Atchley—Holmstrom focused her Organizational Action Project on establishing a Tele-ICU program at KershawHealth. A Tele-ICU uses an off-site command center in which a critical care team (including intensivist physicians and critical care nurses) is connected with patients in distant intensive care units (ICUs) to exchange health information through real-time audio, visual, and electronic means. The initial goals of Holmstrom’s project included increasing successful outcomes for critically ill patients, reducing length of stay, and improving hospital financial performance.

PROCESS: Since establishing a successful and sustainable Tele-ICU program at KershawHealth would require hospital-wide buy-in and collaboration, Holmstrom and her team followed John Kotter’s eight-step Change Management Model to implement the change. Data demonstrating how critically ill patients in community hospitals benefit from having 24/7 access to an intensivist helped create a sense of urgency among the KershawHealth management team and staff.

The KershawHealth team then partnered with the Medical University of South Carolina (MUSC), a member of the South Carolina Telehealth Alliance (SCTA), and with Advanced ICU Care, a leading national provider of Tele-ICU monitoring services. Building a guiding coalition enabled KershawHealth to cost-effectively leverage state-of-the-art technology and world class clinicians to collaborate with hospital staff. Instead of “reinventing the wheel,” KershawHealth was positioned to match its unique needs with existing telehealth best practices.

The result of this collaboration was a vision for change in which KershawHealth (in partnership with MUSC Health) would provide Tele-ICU monitoring by highly trained intensivist physicians and critical care specialists 24 hours a day, 7 days a week. Patient rooms would be equipped with two-way video access to allow face-to-face consultations between the bedside and Advanced ICU Care team. Additional Tele-ICU services included continuous monitoring of patient vital signs, medications, labs and clinical status. Algorithms built into the monitoring technology serve as an early warning system, detecting potential problems and prompting intervention, if needed.

In communicating the Tele-ICU vision to key stakeholders (including critical care nurses and patient families), Holmstrom’s team made it clear that the Tele-ICU would complement—not replace—the onsite care directly provided by KershawHealth physicians and nurses. Medical staff received reassurance that Tele-Health would provide additional support and resources designed to enhance patient safety and improve outcomes, while families took comfort in knowing that critically ill patients would be monitored around the clock by an intensivist physician.

Results: In 2016, KershawHealth became the first hospital in the MUSC Health network to implement a Tele-ICU program with 24/7 intensivist monitoring. On a personal level—for both medical staff and patient families—the extra layer of care provides priceless peace of mind. KershawHealth physicians take comfort in knowing that their critically ill patients are continuously monitored by specialists. Critical care nurses appreciate the additional care and support provided by the Tele-ICU specialists and monitoring. Patient families know that any potentially problematic changes in their loved one’s condition will be detected and addressed immediately.

Now a physician can hit a button and, within a 30-second notice, have a telehealth, board-certified, real-live critical care intensivist help co-manage the patient, Holmstrom says. It’s an opportunity for the healthcare system to remove disparities in care by bringing additional expertise right into a community hospital room and deliver the same outcomes as the patient would have received at a bigger medical system elsewhere.

The measurable results of implementing the Tele-ICU protocol have been just as impressive. Tele-ICU data collected at KershawHealth through the first quarter of 2017 showed:
• The ICU length of stay was cut from a baseline of 3.8 days to 2.3 days.

• The overall length of stay was consistently less than predicted, with 2,953 total hospital days saved and 979 ICU days saved—for a total financial savings equivalent to $1.9 million.

• The ICU mortality percentage dropped from a baseline of 6.1 percent to 2.3 percent.

• Thirty total lives were saved (based on predicted mortality using APACHE scoring).

• Total benefit program costs equal $1,538,322 in year one.

• The financial benefit per patient was $2,331 in year one.

In addition, using the Tele-ICU likely will extend the practice life of some KershawHealth physicians, adds Holmstrom, thanks to the additional specialty support they are receiving.

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