I love it when others write my posts! Here is an article in which we were featured in one of our trade magazines.
Physician engagement is critical for success in the health reform era.
By Christine Stead and Tom Enders March 29, 2011
Several health providers are seen as positioned for success in health reform. While some claim that they have been operating as accountable care organizations, those that truly are positioned for success have been preparing for ACOs for a long time. They’ve done this not to comply with a law that didn’t yet exist, but to do the right thing. One of those institutions is the Greenville (S.C.) Hospital System, an integrated health system comprising a tertiary academic medical center, 11 specialty hospitals, more than 120 practice sites (including the University Medical Group), skilled nursing care and extensive subacute facilities.
Greenville’s journey toward physician engagement began approximately 10 years ago with a small group of employed physicians, including Angelo Sinopoli, M.D., now the CMO. That group gradually gained a stronger foothold in various administrative roles, supported by a willing administrative team and willing physicians. Over time, the system made key physician administrative appointments, including that of Jerry Youkey, M.D., from Geisinger Health System, as vice president of medical affairs.
In 2006, Greenville selected a new CEO—Michael Riordan, former CEO at the University of Chicago Hospitals. That appointment formalized the board’s commitment to a more academic vision and to a leader who could execute the structure required to engage physicians and integrate clinical services.
Leading by Example:
Under Riordan’s leadership, Greenville enhanced physician engagement and integrated clinical services according to its vision of accountable care and community commitment. It made several organizational changes to cement a new, physician-led clinical structure:
It launched an initiative to recruit affiliated physicians into employment. The employed physician group has grown in the last five years from 220 to almost 600 today, allowing for tighter clinical integration and physician engagement.
It rewrote bylaws and created a structure in which chairmen and vice chairmen align physicians with quality initiatives; the chairmen drive Joint Commission compliance, while the vice chairmen work with multidisciplinary quality improvement teams.
It restructured board committees to accommodate more physicians who address quality and academics.
It established an operations council to drive care delivery at Greenville and to improve quality performance. The council is a multidisciplinary team of department chairs and support staff who review each clinical area, assess plans for improving performance, then implement those changes.
It expanded the president’s council to include the chief medical officer and the chief academic officer. As the critical decision-making body, the council now is better able to reinforce the importance of physician leadership to all organizational constituents.
Greenville has transformed itself from a hospital with affiliated practices to an integrated, quasi-clinic model health system that incorporates teaching and academic medicine. The system’s objectives, illustrated in Fig. 1, form the basis for its evolution into an ACO. This degree of organizational change necessitated a firm hand from Greenville leaders as well as board support, because tension emerged between those supporting the new model and those holding on to the past. Physician leaders and employed physicians gave their support at a critical time and helped build momentum.
Short-Term Results and Long-Term Planning
Structural leadership changes have yielded significant benefits. Greenville now represents best practice in its market area, and its financial performance has improved. Fifteen months ago, prior to establishing the operations council, the finance department and the University Medical Group still were separated into distinct silos. With guidance from the operations council, Greenville integrated those silos and reported good financial performance for 2010, despite the recession and its impact on patients, employers and providers.
About two years ago, Greenville began planning for what it believed health care would look like in 2020. A clinically integrated team helped develop the 2020 plan. The outcome included five goals that have refocused Greenville’s strategic plan:
A Note of Caution
Donald Berwick, M.D., administrator of the Centers for Medicare & Medicaid Services, recently stated that “cloaking the status quo is not authentic” during a keynote address at the National Committee for Quality Assurance’s policy conference in Washington D.C. (Read “Some Claim ACO Status without Truly Changing,” by Sandra Yin, in the Dec. 4, 2010, issue of FierceHealthcare. The statement was part of a discussion on how several institutions are suddenly finding that they always have been an ACO.
Berwick’s point is that success in health reform is greater than meeting a set of requirements. It will need to be demonstrated in many ways across the clinical enterprise. Institutions focused on achieving a set of criteria are at risk for missing the greater opportunity of broad clinical care coordination.
That point is not lost on Greenville. Delivering care in a way that improves patients’ health requires a paradigm shift in leadership, organizational structure and care delivery. Greenville’s commitment to clinical integration and physician leadership is an example of the change required for success as an ACO.
Although Greenville’s physician integration efforts are pervasive, they are not a guarantee of future performance. Better results will require constant work and dedication to a common set of strategic goals that are reinforced in the daily work of the institution.
Greenville continues to pursue its strategic objectives amid many challenges and much change. A next step for Greenville is realigning the rewards system so that quality and effective care delivery are supported with the right incentives. Funding will pose a significant challenge for Greenville and other institutions in the coming years, including potential reductions in Medicaid reimbursement at the state level. Many other challenges lie ahead as well, such as uncertainty in PPACA regulations, and even whether some aspects of the legislation will be underfunded or modified by the new Congress.
Despite the uncertainty, Greenville is in a position to succeed with a strong leadership team, including its physician managers. This guidance is critical to providing a clinically integrated academic health system for Greenville’s community and for the state in which it operates.
Christine Stead is a principal and Tom Enders is the managing director of CSC, headquartered in Falls Church, Va.
The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.
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I knew something was going to be special about the presentation when I saw Dr. Kevin Gilroy, leader of our hospitalists, show up wearing a long, rather than his usual short sleeve shirt. And, for me, it was special. I have written before about the importance of having physicians engaged and leading GHS. Could you imagine the engineers at BMW not being aligned? Let’s work on quality issues at Ford today, Nissan tomorrow and BMW the next day – I don’t think that makes sense. Our physicians are the leaders, engineers, architects, scientists, and teachers at GHS. With them in front, we can “Transform Healthcare for the Benefit of the People and Communities we Serve.”
I have attached Dr. Gilroy’s presentation and I welcome your feedback. If you cannot see the PowerPoint below, feel free to CLICK HERE to download a PDF of the presentation.
We have approximately 140 leadership team members in the organization – this group consists of Department Directors up through the Vice Presidents. Communication and interaction with this group is a high priority for me and the Corporate Chief of Staff, Tod Tappert. I often refer to the Leadership Team as “my group.” I believe they have the most difficult and important leadership job in the organization. They have to operationalize the strategy and decisions that come down from corporate and get things done. I once heard a consultant say if you want to move an organization, you need the square root of the population – we have slightly more than 10,000 employees, the easy math on that is 100, I think we are covered.
Our monthly meetings are 2 hours and contain typical corporate agenda items – Finance, Quality, Goals, Strategy, etc., but we also create a space to dig a little deeper. At the end of this post are the slides and a video on the deeper dive we took at our last meeting – perhaps not typical stuff, but I think it is invaluable to moving this organization and the leaders forward. I believe it is our job as leaders to shift ourselves first, then our employees and finally, the organization from the “To Me” mindset, where things are happening to us, to the “By Me” mindset, where things are happening because of us. The path is though authenticity and responsibility and one of the gateways is vulnerability.
Below is the PowerPoint on Vulnerability and a video from TED.com by Brene Brown: The power of vulnerability. If you cannot read the PowerPoint, CLICK HERE to download the presentation. If you cannot see or watch the video by Brene Brown in this post, CLICK HERE to watch it on the TED.com website.
This past Friday I went to the Funeral Service for the mother of a colleague. The service was meaningful and powerful. I have an alertness at funerals that I often do not bring with me on a regular Sunday. I was also struck by several things while in the Church:
- A strong show of support by other hospital employees that attended the service. A sacrifice of time and an openness for some to attend a Catholic Mass which may be quite different than their tradition. A show of respect and honor to their colleague, boss, or peer by standing, with others, in the family’s presence during a time of grief and celebration.
- The gift of technology. In the Eulogy, the priest talked about getting text messages from a family member at crucial moments towards the end of her life – he arrived in time to administer the Sacrament of Last Rights and earlier he presented her with Ashes on Ash Wednesday. I had a strong appreciation for how technology keeps us connected and present.
- Finally, the wisdom of someone facing death. There came a point in the conversation where she told the priest, “I am ready.” What a wonderful thing to say and feel. I wondered what it would be like if I came to work each day and approached my role as a leader with the confidence and openness to allow whatever is meant to be, to be.
I am grateful to have been instructed in the way of leading by the mother of a friend.
A visual update on how things are going with regards to the University of South Carolina School of Medicine – Greenville expansion to a 4 year campus.
While I was at Emory, the University of Chicago Hospitals and now here at GHS, I have been asked for my view on Hospital rankings. Often, the question is whether or not I think they are credible? My answer, like more and more things in my life, is both and it depends. On a recent trip, I saw a bill board touting the local hospital (not in SC) as one of the top rated hospitals in the country. I couldn’t determine the source of their claim, but I imagine it was based on a credible survey. I pointed it out to my wife and said if something happens to me, keep driving. There are numerous methodologies for calculating these scores and some of them are suspect. There is also a big business around these rankings. Lots of magazines get sold when Hospitals or Colleges are ranked. In addition, local and national companies have stepped in to provide more information about hospitals and will charge consumers, businesses and providers to access the information. Some of these companies do not verify the information and depend on self-reported data as well as some publicly available data. There can be significant variability in the results.
As you can see from the banner on this blog, we advertise the US News & World Report Rankings. I have ambivalent thoughts about it, just as many other Academic Medical Centers and Colleges and Universities have mixed reactions. I like that it compares us to our peer Teaching Hospitals and Academic Medical Centers throughout the country. I like knowing how we compare against Mayo, Duke, Emory, Chicago, etc.. I really like it when we do well. What is the downside? I was at a breakfast this morning at Furman and the president, Rod Smolla, discussed this issue in Academia. With so much emphasis on SAT scores, his concern is Furman may exclude students that excel at many things, but fall outside the top percentile in terms of standardized testing. He joked about the students who go to the preparation courses to raise their scores – are they smarter than two months ago before the test or did they do the equivalent of taking performance enhancing drugs? Now the question for me is, what are the unintended consequences for GHS? What is the balance between informing patients about how well we score versus how well we do? More on that later, but for now, I give the USN&WR rankings a grade of A+ for marketing to the public and a B- for informing the public.
So, where is a patient to go? I asked Dr. Tom Diller, VP Quality and Clinical Effectiveness at GHS to give me his suggestions:
- The South Carolina Hospital Association (SCHA) has an excellent site, www.myschospital.org, that posts core measures, mortality rates, some utilization and volume reports, and HCAHPS (Patient Survey Results).
- The South Carolina Department of Health and Environmental Control (DHEC) publishes hospital acquired infection rates at, www.scdhec.gov/health/disease/hai/reports.htm.
- The Center for Medicaid and Medicare Services (CMS) quality site is Hospital Compare at, www.hospitalcompare.hhs.gov. It posts core measures, mortality rates, readmission rates, HCAHPS, some new measures for selected radiology test utilization, and median payments and annual volumes for several diseases and procedures.
- The Joint Commission quality site is Quality Check at, www.qualitycheck.org. It posts core measures, HCAHPS, and mortality rates. It also provides accreditation decisions, advanced certification programs, and special quality awards.
If you take the time to look at some of the public sites I mentioned above, you will find that the upstate is blessed with a lot of high-performing hospitals. But remember, not every hospital has the same breadth of services and capabilities or same severity of illness with their patients. This is evident if you look at the campuses at GHS, you will see some great scores and results, but differences between Patewood, North Greenville, Hillcrest, Greer, and Greenville Memorial. I once had a teacher say, “two things that are not alike are different.” Same is true for hospitals.
The following email was sent out by Thornton Kirby, President of the South Carolina Hospital Association, to membership. I believe Thornton sends these updates out to about 1,000 people. I think that is an example of his integrity and transparency. He really is the best hospital association executive that I have seen in my 25 years.
The email provides a great recap of the meeting and captures what I believe was a positive tone. However, I do want to speak to one comment that Tony made that did not make into the update. Those of you that have been following the Medicaid debate know that there has been some “chirping” back and forth between the association and the governor’s office. That came up in the meeting and Tony spoke to it. I am going from memory, but it was something like this…the Governor is not saying things about the providers because she is angry, but because she thinks you can do better. I thought about that comment the entire ride back to Greenville. At first I was defensive, but as I kept thinking about the comment, I became increasingly curious. As an aside, my experience is that whenever I get defensive, somebody is on to something. Next week we have set aside several days for our annual strategic planning meeting. We will be looking at what we need to do next year and for the next several years. The idea that we can do better will be a big part of that planning.
Recap of SCHA Board’s Meeting with Tony Keck. Yesterday morning the SCHA Board held its regular meeting and invited Tony Keck to attend for an in-depth and less formal discussion of the Medicaid program. It seems odd to say a Board meeting would be less formal, but it was in the sense there were no reporters or elected officials waiting to seize on any nuance of the conversation. As a result, we covered a lot of ground and the Board members and Mr. Keck got a much better sense of each other. I want to use today’s update to share with you the highlights of yesterday’s conversation.
First of all, I would characterize Tony as forthright and open in his discussion of issues and opportunities. He was candid about the strengths and weaknesses in the system, the successes and failures of the agency and each provider group, and the urgency he feels to address them. In response to Tony’s openness, the Board members were quite open about their own assessment of the same issues. Based on the comments of Board members after his departure, the group felt Tony has a firm grasp on the Medicaid program and the policy implications surrounding it.
Rather than writing paragraphs about each topic discussed, I will share them in bullet format.
· Tony shared a lot of value-oriented comments about Medicaid, starting with this one. “We want to pay people fairly to do the right things for patients at the right time. We don’t want to pay people to deliver unnecessary care.”
· The agency built into its FY 2011-12 budget an 8% growth factor ($114M) before implementing any cuts. As part of the cost-reduction plan, the agency will take $125M out of the provider line. According to Tony, the net reduction from the provider line (taking into account the 8% growth factor) will be $82M.
· Tony does not intend to accomplish 100% of the provider line savings through rate cuts; he intends to meet with each provider group and explore opportunities to reduce unnecessary spending. The more such opportunities can be identified, the less rates will have to be cut. He gave as an example pre-term births, which cost the Medicaid program tremendous amounts of money. If the provider community can legitimately reduce pre-term deliveries, the program can achieve savings without rate cuts. Mr. Keck and his team plan to schedule meetings with provider groups in the next few weeks, and he agreed with the Board yesterday that SCHA should organize a single, representative group of hospitals instead of having the agency meet with small groups or individual hospitals to discuss the impact of rate changes. The SCHA Board strongly encouraged Tony to deal with the hospital community as a whole, not as parts; everyone agreed a transparent process would engender more confidence in the end result, and Mr. Keck agreed.
· As part of the discussion on reducing costs, several hospitals noted the frustration they feel when they reduce costs and receive lower reimbursement in return (because of the cost settlement model). Tony noted this as a fundamental barrier to effective reform of Medicaid, and he expressed his desire to move toward a pure DRG system. By that he explained he wants to establish a payment rate that is fair and that rewards hospitals for driving down costs. Under such a system a hospital that reduced its costs to below the DRG rate would be entitled to retain the difference. He noted this as one example of how the Medicaid agency has too often disconnected policy issues from the reimbursement model.
· Tony also expressed his desire to make it easier for hospitals to develop Medical Home Networks (MHNs). He wants hospitals engaged in meaningful shared savings plans, and he believes they will serve to aid the transition to ACOs.
· The MHN conversation opened a discussion about Medicaid MCOs, and several Board members expressed their concerns about the lack of any concrete evidence to show the value MCOs have brought to the Medicaid program. Tony addressed these concerns forthrightly, explaining he has shared the same questions with MCOs and already begun to cut their administrative fees. He said he did not expect the initial cuts to administrative fees would be the only such cuts, and he is reviewing the value and cost of MCOs compared to similar programs in other states.
· When asked what hospitals should expect in terms of rate cuts July 1st, Tony said in the absence of agreed-upon opportunities to reduce unnecessary spending, hospitals should expect a rate cut of 10-11% as of July 1st. This number includes the 3% rate cut to be implemented April 1st. This information, though not unexpected, was obviously sobering to the Board. Their response was to direct SCHA to assemble a strong team to represent the hospital community in the cost-cutting discussions with Tony and his staff.
· Tony wrapped up the conversation by advising the Board he wants to build a strong partnership with any and all organizations that share the core values of reducing waste, increasing quality of care, and improving the health of South Carolina’s Medicaid population. Several Board members emphasized the hospital community’s demonstrated commitment to reengineering the delivery of care in our state, and Mr. Keck acknowledged that every interaction he has had to date reinforces that commitment. He ended the conversation by reiterating his desire to work with hospitals as the central and necessary players in the redesign of our state’s delivery system.
I hope this recap is helpful; I will share more details as the conversations around rate cuts and system redesign continue to unfold.
As always, please don’t hesitate to contact me if you have questions or comments about anything in this update.
Perhaps there have been times when you read or heard Greenville Hospital System University Medical Center and wondered what does that mean? Being a University Medical Center is all the things we do for teaching – nearly 180 Residents and Fellows, 3rd and 4th year medical students, campus for the University of South Carolina, close to 1,400 nurses, over 100 pharmacists, and many other allied health professionals. It means being a critical resource for the community hospitals in the upstate and the patients. I hope you check out UHC’s website and see the members. You will recognize many of the names of the most prestigious Academic Medical Centers in the country, including ours.
Patients Transferred to Academic Medical Centers From Community Hospitals Are Sicker Now, But Survival Rates up, According to New Data From University Healthsystem Consortium.
OAK BROOK, Ill., March 9, 2011 /PRNewswire/ — Thousands of the nation’s most at-risk patients have been saved over the last three years by advanced care at academic medical centers (AMCs). Based on data submitted by 86 university hospitals to University HealthSystem Consortium (UHC), the volume of critically ill patients transferred from community hospitals to AMCs has risen steadily over this time period. These patients receive initial treatment from community hospitals, but require more advanced, specialized care that AMCs are more equipped to provide.
“Sicker patients are being transferred to AMCs more often,” said Mark A. Keroack, MD, MPH, UHC’s Chief Medical Officer and Senior Vice President. “This is good news for patients as our data shows that AMCs have decreased the risk of death for those transferred patients by 17 percent over a three year time period.”
According to UHC data, the severity of these patients’ conditions as measured by case mix intensity and expected mortality rates has increased, however, the actual mortality rate has declined. AMCs have seen an 18 percent increase of transfers into their facilities, representing 42,392 patients, along with 13 percent increase in acuity of those transfers based on UHC risk adjusted models.
“Our member organizations have been working to strengthen their ties with community hospitals,” said Keroack. “Enhancing programs for routine care in community sites seems to result in increased AMC capacity for the challenging patients that AMCs are best equipped to care for. The result is a win-win for both types of institutions as well as for patients.”
Academic medical centers are continuously improving the quality of patient care.
“Combined with new technologies in diagnosis and treatment, patients are experiencing better chances of survival,” said Julie Cerese, RN, MSN, UHC’s Vice President for Performance Improvement. “Since 2002, UHC has worked closely with its member organizations to improve the safety and quality of care. This work is occurring across academic medicine and includes improvements in assessing pre-operative risks, reducing post-operative complications, increasing the use of safer technologies to manage illness and disease and incorporating new strategies to manage patients.”
Initiatives include practices to improve the prompt recognition and treatment of deteriorating patients, implementing evidence-based practices in the care of high risk populations (e.g., stroke, heart attack and pneumonia), improvements in the coordination of care and the supervision of residents and students.
A detailed study of UHC’s work with AMCs to reduce mortality was published in the December 2009 edition of Academic Medicine.
The University HealthSystem Consortium (UHC), formed in 1984, is an alliance of 112 academic medical centers and 255 of their affiliated hospitals, representing more than 90% of the nation’s nonprofit academic medical centers. UHC offers its members specific programs and services to improve clinical, operational, financial, and patient safety performance. The mission of UHC is to create knowledge, foster collaboration, and promote change to help members succeed. For more information, visit www.uhc.edu.
I have written before about my personal and professional connection to diabetes and many of you know that I have a personal, multi-year, work-goal to improve the delivery of care for diabetes in our community. A goal like that cannot be done alone – especially by an administrator. We need physician leaders to make this happen. For me, that leader is our Chief Medical Officer and Chair of Medicine, Angelo Sinopoli, MD. We also need resources and a desire to pursue improvements in a rigorous, academic fashion. The Duke Foundation provided those resources via a 2.6 million dollar Duke Innovation Grant. I have attached a copy of a recent presentation given by Angelo to our Board of Trustees. I am grateful to Dr. Sinopoli and the physicians that are making this happen….and, I am grateful to the leaders that awarded us the grant.
If you cannon view the presentation below, CLICK HERE to download the PDF.
I hope you see how initiatives like this help to transform healthcare in Greenville.
What is Conscious Leadership?
I got this definition of conscious leadership from a friend of mine Tim Peek. We belong to a forum of leaders that discuss, share and think about how to lead our organizations in very intentional, conscious ways.
“Conscious leadership is recognizing that we have the power to act at every moment. That we create the rules we live by. That we have a choice every moment to go along with what is presented to us, or to strike out on our own. Conscious leadership is taking only those actions that are in alignment with our deepest beliefs and in alignment with what is best for the whole.
Conscious leadership is choosing to act as our highest, best self. But it also is recognizing that there is something bigger out there that wants to be expressed through us, and that we can, in fact know, and be part of that bigger consciousness.”
Thanks Tim, I like that definition – especially the part about “something bigger out there that wants to be expressed through us.” When I re-read that definition, I am reminded and grateful for how the expansion of the University of South Carolina School of Medicine – Greenville came to be.
I believe Conscious Leadership and “something bigger” emerge when there is a discipline and an observed practice connected to them. On an individual level, a practice may be prayer, meditation, exercise, etc., but there is a discipline associated with the outcome. No different for an organization and we have built practices around trying to see what is seeking to emerge from us at GHS. One of those practices is that every 90 days I meet with the senior physician and administrative leaders at GHS. I call it the President’s council – about 15 of us. Last Friday we met all day in the Board Room reviewing our progress on 2011 Goals, brainstorming on 2012 Goals, discussing the curriculum for leadership development at GHS, and exploring Conscious Leadership. We have a facilitator, Jim Dethmer, who helps keep us on track and guides the conversation – especially around Conscious Leadership. I will give a mid-course update on our 2011 Goals and let your know our proposed 2012 Goals in the near future, but today I want to focus on the discussion around Conscious Leadership and Commitments.
The Commitments are the gateways to help individuals and organizations shift to the next level of responsibility. Starting with a small group like the President’s Council gives us the opportunity to practice and hold each other accountable as we learn.
I commit to:
- take full responsibility for the circumstances of my life, and my physical, emotional, mental and spiritual well-being.
- live from the belief that I have enough of everything…including time, money, energy, space, resources, etc.
- be the source of my security, control, and approval.What is Conscious Leadership?
- grow in self-awareness.
- see that the opposite of my story is as true or truer than my original story.
- see others as equals and allies who are perfectly suited to help me learn the most important things for my growth.
- fully express my potential.
- create a win for all.
- ending gossip in my life including speaking and/or listening to it.
- being the resolution or solution that is needed.
- say what is true for me and whom others can express themselves in candor.
- practice the masterful practice of integrity, including acknowledging all key feelings, expressing the unarguable truth and keeping my agreements.
- feel my feelings all the way through to completion.
- create a life of play, fun ease, improvisation, and laughter.
- live in appreciation – giving and receiving.