October 13, 2010 4:30 – 5:30 pm New Hospital–Physician Structures for Quality and Fiscal Accountability David Brooks, Chief Executive Officer, Providence Regional Medical Center Everett Al Fisk, MD, Chief Medical Officer, The Everett Clinic Lead Sponsor Sound Physicians Supporting Sponsor Clark/Kjos Architects
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October 13, 2010 4:30 – 5:30 pm New Hospital–Physician Structures for Quality and Fiscal Accountability David Brooks, Chief Executive Officer, Providence.
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October 13, 20104:30 – 5:30 pm
New Hospital–Physician Structures for Quality and Fiscal Accountability
David Brooks, Chief Executive Officer, Providence Regional Medical Center Everett
Al Fisk, MD, Chief Medical Officer, The Everett Clinic
Lead SponsorSound Physicians
Supporting SponsorClark/Kjos Architects
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New Hospital-Physician Structures for Quality and
Fiscal Accountability
WSHA 78th Annual Meeting
October, 2010
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The Everett Clinic Core Values
We do what is right for each patient
We provide an enriching and supportive workplace
Our team focuses on value: service, quality and cost
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Respect Compassion Justice Excellence Stewardship
As people of Providence, we reveal God’s love for all, especially the poor and vulnerable through our compassionate service.
VISION: Our ministry will be a transformational force for our communities by advancing health care excellence and access for all.
Results
Results
Results
Results
Responsibility: Health Care ExcellenceEach person we serve receives the best possible outcome and has an exceptional experience.
Responsibility: Access for All Every person within our community
easily gets the care they need.
Clinical OutcomesStrategies
Compassionate Care
Strategies
Mission Inspired People Centered Service OrientedQuality Focused Financially Responsible Growing to Serve
Affordability
Strategies
Coordinated Care
Strategies
Providence Mission and Vision
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The Community Snohomish County
– 705,000 with rapid growth– 65+ age cohort increasing rapidly
46% Medicare/Medicaid and Self Pay/Charity– PRMCE 68%
Several large employers: Boeing, Naval Station, Premera, Tulalip Tribes, and Providence (Microsoft a regional force)
Historical out-migration (39%) for specialty care One tertiary hospital (PRMCE) and three district community
hospitals (one recently became Swedish) Low physician ratios; shortage of primary and specialty care
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Providence Regional Medical Center Everett (PRMCE)
372 beds (468 effective June 2011) Community Hospital and Regional Referral Center Faith-based, Catholic, Not-for-Profit Dedicated to Mission – 105 years in Everett Single major tertiary hospital in county Progressive attitudes of physicians 2nd largest private employer in county
Providence Regional Cancer Partnership (TEC Co-Manages) Medical and radiation oncologists, all support
services including integration of alternative therapies
Recruitment of fellowship trained oncologic surgeons to community
Multidisciplinary cancer conferences review nearly every patient’s care
Innovated and complex economic alignments Governance by cancer executive committee with
all partners represented
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Linked Electronic Health Records
TEC and Group Health on Epic Providence initially on multiple different
platforms Hospital consideration for TEC Epic PH&S determines value in entire System
moving to Epic Epic trusted partner to link TEC, PRMCE,
GHC…
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Medical Hospitalist Team Inception in 2002 Management contract with TEC Currently 34 FTE’s (TEC physicians) Multiple teams including “nocturnalists” Manage 90% of all medical patients Manage/Co-manage 60% of all patients Extraordinarily cooperative/innovative Standardization and continuous improvement
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Intensivist Team Inception in 2004 Response to Leapfrog 2006 became 24/7 in-house Expansion to 7+ FTE’s Management contract with WWMG
– Half of physicians from TEC, half WWMG Innovative/collaborative/ACT grants
– Sepsis – Delirium
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General Surgery Hospitalist Inception in 2008 Management contract with TEC 24/7 in-house coverage Recognition of acuity of surgical patients 4.5 FTE’s plus daytime PA’s Standardization and continuous improvement
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And the rest…..
Pediatric Hospitalist
24/7 In-house
Neonatologist/NNP
24/7 In-house
Laborist
24/7 In-house
Orthopedic Hospitalist
Daytime only
Neurohositalists
Daytime only
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Why the “ists” Primary care provider office productivity
burden Requests for ED call stipends Recognition of performance deterioration
with sleep deprivation Recognition of ever-increasing acuity of
inpatients Management from “our bed” is not optimal
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…..and the Outcomes
Timely, expert care Collaboration and standardization Recruitment and retention Greater integration with physician partners Better rested physicians
Worth the investment!
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The PRMCE Experience Elected Chairs/Chiefs
– Short tenure, inexperienced– Little commitment to the organization– Provincial
Medical Directors– Operationally oriented, prime movers– Engaged, compensated
But…..– Viewed as “suits” by the Medical Staff
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Unified Leadership Model
Simple solution…unify these into single positions - Division Chiefs (4)
Ability to serve for extended time periods Accountability and responsibility for
operations and Medical Staff issues Serve in dyad model
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Unified Leadership Model
Medical Staff Officers elected Division Chiefs selected and ratified Medical Executive Committee includes both Mirror the model with Section Medical
Directors (24) (GI, ED, Radiology, etc)
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The Outcome
Medical staff leadership– Operationally educated– Dedicated to the position– Stability and continuity – Organizational thinking – Appropriately compensated
The structure embeds and integrates the physicians into the very fabric of the organization!!
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13 12
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3529
6266.2 68.2
72 74.9 73.6
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40
50
60
70
80
90
2003 2004 2005 2006 2007 2008
PercentileMean
Likelihood of Recommending
Medical Staff Survey
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Joint Monthly Meetings
Senior leadership of TEC and PRMCE meet for dialogue
Major issues early identification We don’t always agree but we do have
honest conversations Key factor in our respectful and healthy
working relationship
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Physician Engagement and Leadership Development TEC is physician owned and directed PRMCE has put physicians into key
leadership positions Investment in physician leadership and
training; TEC 1.5% of revenue, PRMCE 2.2% of net revenue
We develop physician leaders in multiple ways from master’s programs to mentoring of new leaders
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Results…
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Where did it get us? HealthGrades Distinguished Hospital for
Clinical Excellence™
– Critical Care, Stroke Care, Cardiac and General Surgery
Thomson 100 Top Hospitals
Thomson 100 Top Cardiovascular Hospitals
Thomson 100 Top Hospitals Performance Improvement Leader
One of 4 Hospitals in US to have all three in 2008
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Areas of Concern
Entry of competition into the market– “
The Arms Race”
Financial sustainability
Failure to reform the payment system
Misaligned incentives
Legal and regulatory barriers
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The Ultimate Goal
Institute of Medicine -- STEEEP
Universal access
Long term financial sustainability
A healthier community
Greater value for our healthcare dollars
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Lessons Learned
Everything defaults to the patient! Innovate from the ground up Engage and train physician leaders Competition for “market share” doesn’t help the
community Be advocates for systems of delivery Never forget…..It’s the Mission and Core