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

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The Everett Clinic (TEC) 280,000 patients 420 providers Diagnostic imaging, lab,

ambulatory surgery Physician owned and

directed, professionally managed

Source of one third of all admissions to Providence

Group Health 27,000 patients 14 providers Primary care on site Visiting specialists plus use

of TEC and WWMG specialists

Implementation of medical home model

Multi-specialty medical group linked to health plan

Organized Medical Community

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Organized Medical CommunityWestern Washington

Medical Group (WWMG) 60 physicians High quality Entrepreneurial Long standing relationship

with ProvPG Loose federation of “care

centers” Increasing development of

competing ancillaries

Providence Physician Group (ProvPG)

90 physicians Primary care based Slowly expanding specialty

arm Highly efficient and cost

effective Quickly developing

infrastructure and population health culture

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Balanced Scorecards

Providence Service oriented Quality focused Financially responsible People centered Mission inspired Growing to serve

The Everett Clinic Patient satisfaction Quality and patient safety Cost effectiveness Financial viability Staff and physician

satisfaction

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PRMCE and TEC Common Goal

Adding Value in Patient Care

Reducing unnecessary ED visits and admissions (Kaisen efforts)

Reducing readmissions (transition coach, palliative care, CHF readmissions)

Developing community cancer center Linked EMRs

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Community Kaisen Summary Reviewed entire value stream from decision to

admit to post hospital visit Removing waste, improving quality and service

at every step of the way Two year improvement process with engaged

patients, physicians, staff Strong support by PRMCE and TEC leadership

with fully aligned goals

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Reducing Readmissions

TEC development of hospital coach role for Medicare demonstration project

Providence Hospice and TEC collocate palliative care RNs in primary care offices; inpatient palliative care team

Baseline Jan-Nov 2009

1q10 2q10 3q10 Jul-Aug0%

5%

10%

15%

20%

25%

16.6% 16.9%

18.8%

12.0%

22.2% 21.4% 21.4%

Providence Regional Medical Center EverettHeart Failure Readmission Rate

Baseline compared to Quarterly and Target Per-formance

Observed Readmission Rate Expected Readmission Rate

3q10 data is raw ob-served only

Dec

embe

r 200

9 is

not

incl

uded

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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

81

0

10

20

30

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

Values!