Connected Thinking Blog - NACHRI Conferences

How to Forge Successful Alignments

Herman Gray, MD, president of Children Hospital of Michigan, presented with Gregory Maddrey, principal of The Chartis Group, on Forging Successful Alignments With Physicians, Faculty and Pediatric Specialists.

Children's Hospital of Michigan has had many challenges the past few years -- most notably the recession's impact on the Detroit economy -- but simultaneously they've been challenged to improve their alignment with their local physicians, faculty and pediatric specialists to ensure they have sustainable staffing relationships in place to continue to care for children.

Children's Hospital of Michigan has a complex governance and partnership structure. Children's Hospital is a subsidiary of Detroit Medical Center, and works with independent physician groups, primarily with Wayne State School of Medicine. The relationship between the Detroit Medical Center and Wayne State University rapidly deteriorated a few years ago, and the result of the fallout is that University Physician Group (UPG) no longer has an exclusive relationship with DMC, but now simultaneously works with several competitors. Parts of the residency program also left DMC to other hospitals in the area.

At the hospital, unionized faculty operate under a complex faculty model with University Physician Group as a separate, not-for-profit pediatric organization. Pediatric surgeons, radiologists and anesthesiologists are separate as well in their own organizations. Children's Hospital employs some surgical specialists (CV, ortho, urology) while others are part of UPG or other private groups.

Margins in the market for both groups -- Children's Hospital and UPG -- have begun to erode, especially in light of the challenged Detroit economy. Competition has increased both locally and regionally -- especially in the affluent suburbs. Children's Hospital has opened almost a dozen ambulatory clinics throughout the area to enhance its competitive position and ensure care needs are met.

To add one more variable to the mix, an investor-owned health care system, Vanguard Health System, is in the process of purchasing Detroit Medical Center, and that transaction is expected to be finished by the end of the year.

That's the context. So where to go from here? This is where cooperation with The Chartis Group came into play. The Chartis Group offered a framework for alignment, and started by looking at these key questions:

• Are partners strategically aligned; are school, hospital and practice plans coordinated together?
• Are government and management structures in place to align boards and committees around collective objectives?
• Are methodologies aligned to support strategic economic performance?
• Are management processes and stuctures in place to align organizations around goals and performance?
• Does each organization understand the overlap in your respective missions and visions?
• Are there trusted and productive relationships in place? This is essential, because without trust the process is simply mechanical and problems will not be engaged and solved.

Think about how these questions might affect aligned relationships at your organization. For a detailed look at the specific alignment challenges identified for Children's Hospital of Michigan and at strategic recommendations for alignment, check out the PowerPoint from the presentation.

The presenters offer these lessons learned:

• Process matters – Engage leaders from both the hospital and physician group to develop models
• Don't shortcut the timeline – This is emotional and taxing work, make sure your timeline is sufficient to complete the work and test the models before implementation
• Don’t focus exclusively on the economic model – If the process is not grounded in establishing a more productive relationship, then it will devolve into a fight about money
• Use good data – The effort will fall apart if the underlying data is flawed or misused
• Share progress and interim deliverables openly with hospital and physician leadership – This is complicated, allow leadership the time to absorb and reflect on the models
• Drive targets and goals down to the division and, if possible, the faculty level – It is vitally important that the faculty understand how payments work and what’s being measured
• Build staff capabilities – Verify that staff have the capabilities and the tools to manage in a more collaborative and data intensive environment

Public/Private Sector Emergency Care Partnership

After lunch, Children's National Medical Center staff led off the afternoon sessions with a look at "Right-sizing Pediatric Emergency Care Through Public-private Sector Partnership."

In 2001, a longstanding Washington institution, DC General public hospital, closed its doors after 200 years of service. The hospital had become unable to financially sustain itself, and filling the gap had become too great a drain on government resources. Under private ownership, It was reopened in 2003 as an emergency clinic. The void left by the closure of DC General resulted in significant increases in ED visits at other area hospitals, including Children's National Medical Center. The increased ED visits placed other hospitals at financial risk as well. From a Rand study looking at health care in the community, it became obvious that the areas with the highest rates of chronic conditions and high ED utilization were also the areas least accessible to any hospital.

To look specifically at the pediatric needs of the community, Children's National Medical Center undertook a comprehensive community needs assessment through Rand Corporation, the first comprehensive look at pediatric health care needs in the District of Columbia's history. Community needs is a roadmap for approaching community benefit as an institution. A solid community needs assessment is key to meeting IRS community benefit requirements, but more importantly, is key to meeting the needs of children.

Key findings of the CNMC/Rand study:

• High rates of hospital use among those publically insured
• Majority of children have health insurance, however they reported no usual source of care
• Lack of access of primary and speciality care in non-hospital settings

CNMC made the business decision to open a satellite site located within the high need, underserved, low-income area south of the Anacostia River. The forecast was for a caseload of 45-50 emergency department visits a day, significantly lightening the load of the main hospital. One of the initial challenges was to demonstrate to the District that the emergency department is one of the most appropriate places for families to receive information about the importance of primary care. The CNMC satellite clinic set up follow-up visits with patients -- particularly for ashtma -- to conduct education on the need for a primary care medical home. The challenge for the community was not a lack of primary care options, but a lack of primary care utilization.

Factors Contributing to Project Success

• Development of synergistic partnerships with the government and with the community hospital to capitalize on health care resources at the neighborhood level
• Leveraging municipal relaitonships for start up capital and operational funding
• Planned incorporation of on-site community health education as an integral component of ED operations

In the three weeks the clinic has been open, it has shown an immediate success in achieving expected patient loads and reducing the burden on the main hospital, while increasing community access to needed services.

Technology to Bridge the Divide Between Inpatients and the Outside World

A pair from Arkansas Children's Hospital -- David Higginson, chief information technology officer, and Penny Ward, nursing director for adolescent and general medicine units -- presented on their work designing a technology solution implemented throughout the hospital to help streamline patient education, communication and entertainment. The process has had particular impact on improving the experience of chronically ill patients, especially CF patients, who spend extended periods of time -- often weeks -- at the hospital.

The goal of the project was to "connect patients to the electronic consciousness at the hospital." Social network is increasingly electronic, and is central to the life of most children, especially adolescents. Bringing an electronically connected component to the hospital helps keep patients and families from suddenly feeling disconnected when they come into the hospital. Systems needed to be on-demand, self sufficient, and provide education both in the hospital and at home. The system also needed to help patients stay connected with the hospital after discharge.

System Components

After looking at options,  hospital decided on using off-the-shelf components and bridging available products to create a highly flexible, easily modifiable and upgradable system. Component-wise, the sytem involves a PC, a touchscreen flatpanel on a swing arm, a wall-mounted plasma, a silicone keyboard, and an XBox, with a software package and streamlined interface to allow the touchscreen to control all parts of the system.

System from an entertainment perspective provides TV and TiVO' age/language specific, on-demand options; gaming; and media support for photos and audio online. There is a survey component set up as part of discharge so that patients can rate and improve the system.

Education Component

All education material is digital and on-demand and available for nurses to help patients and families understand what needs to happen. Ensures key information is received, curriculum is tracked, and is also available to patients from home. Education is a forced function -- families have to watch the required educational material before they can use the other functions of the system.

Benefits for Nurses

1. Reduced time nurses spent entertaining, so less frivilous pages to nurses
2. Infection control was made much simpler because nurses no longer had to spend a lot of time cleaning equipment coming in and out of rooms.
3. Nurses learned new technology, which became a collaborative effort with the patients teaching the nurses, building relationships.
4. Collaborative effort -- nurses needed IT and IT couldn't have done it as well without nurse input.

Connection Pieces

One of the most challenging parts of the intended system was to allow patients to communicate with one another in house. There is a patient chatroom where all patients can chat in a public space with one another. The hospital openly monitors the system, but it has not deterred patients from engaging one another, supporting one another, and establishing friendships. Private chat lines with outside family members are also permitted.

To help patients feel more connected with the outside world, the hospital also put web cams in various places throughout the hospital that patients can log into and control, giving them views of the helipad, cafeteria and other areas.

E-mail and internet are also used on the system, but parents are in control of the system. They can set the system to turn on and off at specific times -- or to turn on or off certain components are certain times. Parents and hospital staff can also pull up full lists of everything the patient has done on the system to know how their time is being spent. Parents can even log in to the CareHub portal from home if they are not at the hospital and access all the same reports and settings.

Staying Connected After Discharge

Care plans, instructional videos, discharge notes, visit history, upcoming appointments, billing information, selected medical records, and other features are available remotely so that patients and families can stay connected from home. Families can encourage extended family and friends to sign up, where they can also communicate with the patient and access patient educational materials to better understand the particular care being delivered and ongoing needs of the patient. The portal helps establish an ongoing relationship with patients and families. To keep patients coming back and keep providing new content, new functions in the works involve real time appointment rescheduling, enhanced medical record access, custom meal planning and ordering, and access to patient treatment schedules.

The bottom line has been that this is not meant to reduce the nurse-patient relationship, or to reduce the human component of care. The project has met with incredible patient and family feedback and is being used to support and improve the patient experience.

Opening Keynote: Analytics at Work

The Breakaway-themed conference was launched by Thomas Davenport, Ph.D., who gave the opening keynote, "Analytics at Work in Children's Hospitals," about the human side of analytics, and how it might affect the children's hospital mission.

Davenport says he has put a personal focus on analytics in health care the past few years, and is doing a lot of research in that area. The frustrating part of decision-making choices is that "health care decisions are often bad." There are several key challenges:

• The body of knowledge on what works is often ignored
• Care decisions take too long, involve too many or too few
• Still way too much medical error
• Clinical decisions often not tied to financial decisions, and vice-versa

On the bright side, accountability is higher in health care environment than it is in many other areas of life. Right now, the upcoming government investment in meaningful use and electronic health records is approximately $22 billion. On the downside, better information is not directly linked to better decision making.

So What Are Analytics?

All good analytics are founded on good metrics; get good metrics in place so you have reliable information to analyze. Two general categories of analytics -- "descriptive," which is about 95 percent of what people do, and "predictive and prescriptive" analytics that looks towards the future and provides a quantitatively-based look at "what will happen next."

How Do Organizations Improve Their Analytical Processes?

Davenport recommends a DELTA model. DELTA = change:

• Data -- is the prerequisite for everything analytical; it must be accessible; and to give an advantage, it has to be unique
• Enterprise -- No more silos. Groups, systems, data and technology need to be shared across the organization.
• Leadership -- A strong leader with an understanding of analytics, and an understanding that you need data-based decision making to figure out what works. All decisions should have a control group.
• Targets -- Analytics need to involve goals, so you know what you are working toward. Make sure your targets are strategic.
• Analysts -- Analytics champions leader analytical initiatives, so analysts need personalities that can cast vision and implement change.

Lastly, make sure to systematically review your work and take the opportunity to learn from your mistakes. Health care has a historic opportunity to change the industry -- don't slow down! Use analytics tools to move ahead wisely.

For Discussion

How is your hospital using analytics to change your practices and improve care?

What challenges do you see on the horizon that could benefit from a data-driven, analytical approach?

ALC Opening Town Hall Meeting

NACHRI 2010 Annual Leadership Conference attendees were welcomed by local CEOs Alan Goldbloom, MD, Children's Hospitals and Clinics of Minnesota, and Kathie Taranto, University of Minnesota Amplatz Children's Hospital. They also  gave a quick overview of social and cultural highlights of the Twin Cities area.

NACHRI President and CEO Larry McAndrews provided his own welcome on behalf of NACHRI and introduced Chris Dawes, NACHRI chairman of the board and president and CEO of Lucile Packard Children's Hospital at Stanford, who provided attendees with a brief overview of the work in progress to bring NACHRI and Child Health Corporation of America (CHCA) closer together to provide a more unifed voice for children's health care. Dawes highlighted five key reasons for need for closer collaboration:

1. Strengthen our voice on behalf of the children we serve
2. Provide greater value for members
3. Make the best use of member support
4. Build the success of both organizations through collaboration
5. Create a board with shared governance to align strategic priorities

Dawes' overview led into brief presentations by two other key people involved in the process of bringing NACHRI and CHCA into closer alignment:

• Steve Worley, chairman of the board of CHCA and president and CEO of Children's Hospital in New Orleans, gave a quick overview of the history and strucutre of CHCA.
• Jim Shmerling, chair of the joint task force looking at the feasibility of bringing NACHRI and CHCA closer together, and president and CEO of The Children's Hospital in Aurora, CO, shared on where the task force is in its process

Q & A Session

Dawes, Worley and Shmerling candidly answered questions from the audience about the future of NACHRI and CHCA.

Q. Has the committee discussed what membership fees might be in a united organization?

A. The task force has not gone into that level of detail, but the goal is to achieve a "Win Win Win" -- for NACHRI, N.A.C.H. and CHCA and their members -- the goal is to not have an increase in dues, but to streamline strategy to do more with what we have.

Q. NACHRI membership is more disparate than CHCA membership; how will the disparate membership be integrated in a new structure?

A. The task force was given two questions to address: Is there a legal structure that allows the for-profit CHCA and non-profit NACHRI to be brought together? And if there is a viable legal framework, what options exist and which option makes the most sense? Decisions about important details like member integration can't be considered until these initial questions are addressed.

Q. If the organzations are brought together will the membership of NACHRI become simultaneous with the membership of CHCA and vice-versa?

A. These kinds of details are not yet ripe for discussion until the bigger picture options are determined. Most likely, some areas or certain programs within both organizations willl have a defined membership that is a subset of the whole, but the broader membership will be shared. But this is speculation and will be up for discussion later.

Timeline for Moving Ahead

The joint task force expects to have their two assigned questions answered in November, and the results will be disseminated to the boards of both organizations. Both boards will meet together in January, and will either move forward or push back in late January. Assuming it appears wise to move forward, the boards will go out to the broader membership in February or March for further input.