Redesigning a PHM Program: Challenges, Opportunities, and Growth Management

1. Redesigning a PHM Program: Challenges,Opportunities, and Growth Management Craig H. Gosdin, MD, MSHA Associate Director, Generalist Inpatient Service Director, Liberty Campus Inpatient Unit Cincinnati Children’s Hospital Medical Center May 12, 2010

2. Why Redesign? • PHM Programs tend to grow and add service lines prn • Growth is often not strategically planned • Meeting short-term institutional and financial needs v. longer-term, farther ranging goals • Can result in: • Unorganized growth • Poorly defined scope of service • Potential growth opportunities might be missed

3. Hospital Medicine at CCHMC • Generalist Inpatient Service (GIS), c. 1998 • 4 Resident Teams • GIS-Liberty Campus, c. 2008 • Satellite facility-12 inpatient beds • Attending Only • Senior Residents starting 7/10 • Surgical Hospitalist Service, c. 2009 • Neurosurgery Service • Pediatric Consult Service (PCS), c. 2005

4. Hospital Medicine at CCHMC • Currently 25 Hospitalists, approx. 13 FTE’s • 4500+ admissions/year • Formed Hospitalist Medicine Group (HMU) 2009 • Business Unit within Division of Gen Peds • Leadership Group • HMU Director • Team Leaders • Business Director

5. Opportunity for Redesign • Multiple Major changes over last 24 months • New service lines • Reasonable stability in required FTE’s • GIS cares for >85% of general pediatric inpatients • Majority of Hospitalists < 5 years experience • Need for career planning, long term goals • Institutional Support for redesign • Understanding of the value hospitalists bring to the institution

6. Again-Why Redesign? • We want to excel in all 4 areas of responsibility • Clinical • Educational • Research • Organizational (QI, Safety) • We want to better define our goals and lay the foundation for the future: • Develop HMU Mission and Vision Statements • Selecting Specific Initiatives • Lead to creation of HMU Dashboard

7. Redesign Process • First needed to realize that this is a “process” • Will (and should) take a long time (years) • Evolve and change over time • Leadership Group researched and discussed different methods and processes • Decided to: • Start with group surveys (The HMU should be...?) • Set multiple large group meetings over several weeks • Use SWOT Analysis to critically assess our current situation

8. SWOT Analysis • Strengths, Weaknesses, Opportunities, Threats • Most commonly used tool in strategic analysis • Purpose is to isolate key issues that are expected to drive strategy choice • Allows for the perception of the good, the bad, and the potential of the group Luke, R.D., Walston S.L., and Plummer, P.M. 2004. Healthcare Strategy. Chicago: Health Administration Press

9. SWOT Analysis • Strengths (internal) – what are our distinctive resources and capabilities? • If customers or competitors were asked - what do they see as our strengths? • Weaknesses (internal) – what causes failures, complaints, problems? • What resources and capabilities do we need? • What distinctive resources and capabilities do our competitors have? Luke, R.D., Walston S.L., and Plummer, P.M. 2004. Healthcare Strategy. Chicago: Health Administration Press

10. SWOT Analysis • Opportunities (external) – What opportunities are available to us? • Are there neglected market positions? • Are there any trends in hospital medicine (local, regional, national) on which we might capitalize? • Threats (external) – What are the most serious obstacles we face? • Are there specific threats to us? • Do we have the resources necessary to carry out future responsibilities? Luke, R.D., Walston S.L., and Plummer, P.M. 2004. Healthcare Strategy. Chicago: Health Administration Press

11. SWOT Analysis • Need experienced Facilitator (?external) • Uncritical, positive, enthusiastic environment • Personnel from all aspects of organization • Business Director • Adolescent Med • Residency Leadership • Nursing Leaders • Record all ideas, blackboard

12. SWOT Analysis • We split into 4 groups • Each worked on one element of SWOT • Then regrouped and presented to each other • Others added thoughts throughout • Built consensus on themes • Finally ranked themes in each section • Large group met several times • Smaller groups assigned to write mission and vision statements

14. Themes: Institutional Support Community Support Family Centered Care Commitment to community improvements Supportive institution/infrastructure • Resident involvement • Range of practices • Community buy-in • Enthusiasm/engagement *Youth and Energy of Staff • Support from hospital leadership • Support for continuing education • Strive for evidence-based clinical care • Family Centered Rounds • Physicians • Nationally recognized pediatric teaching institution • Academic resources • Reputation of CCHMC Brand • Monopoly on pediatric care • Financial Resources • Flexibility of Staff (Schedules) • Partnering with nursing units and willingness to change • Shared decision marking • Academic/Administrative leadership opportunity *QI *Clinical research *Pratt Library • Culture of innovation • Foresight to develop academic mission • Teamwork among physicians and nursing staff Strengths

15. Themes: Lack of defined career ladders/level Lack of integration of community health care system Lack of infrastructure to support growth, expansion and success Lack of sustainable financial model, which addresses outcomes • Care Coordination across system and in-house • Lack of integration with community care • LT feeling of "separateness" - lack of integration • Lack of academic mentorship • Lack of defined career ladder • No clear metrics to determine success or failure • Lack of effective, efficient communication • Fellowship training (need more robustness) • High clinical work load (especially with expanding hours) compared to other programs • Our youth, higher junior:senior facility ratio • So many QI projects, sometimes leads to poor follow-through, communication • Potential for poor retention/high turnover due to higher clinical load • Inbreeding • Lack of training to care for subspecialty patients • Financial sustainability • Inconsistency among metrics • Sustaining what we do well • Staffing Weaknesses

16. Themes: Define and Implement learner specific Hospital Medical training Becoming the leader in Pediatric Hospital Medicine Meeting the challenge of integrating Hospital Medicine into medical home Develop a model of care across services, teams, and patient populations that are integrated, standardized and sustainable. Enhancing hospital follow-up *Outpatient follow-up clinic • Standardization of care • Spread Family-Centered Care • Pediatric Hospital Medicine Leadership • Defining Hospitalist Research *Making QI research respectable • Research void within Pediatric Hospital Medicine Unit • Diverse clinical opportunities with subspecialties/different clinical environment • Expansion of Liberty campus and its integration with base • Define shape and field of hospital medicine • Global expansion • Health Care Reform • Non-GIS Hospitalist Services: Coordination vs. galactic domination • The changing cultural makeup of Cincinnati • Integration with underserved care • Technology: Telemedicine • Higher involvement/shaping of Medial Student education • Continuing communication/education of community pediatrician • Expand field within resident education Opportunities

17. Themes: Risk of "Silo-ing” External Education Restrictions Varied expectations of Subspecialties Reimbursement Recruitment/Retention • Poor Medicaid Reimbursement *Poor "commercial" reimbursement *"Reimbursement rules" • Competition with other hospitals for top candidates • Physician Retention • The Unknown • Varied expectations of subspecialties • Lack of respect from other subspecialists • Resident limitations • Private vs. Academic Compensation systems • Silo-ing *Within CCHMC *Within an integrated community health system • Communication with Hospital Medicine Unit as it expands • Physical environment/space • Structure of resident/med student *Educational system • Work hours restrictions • Hand-offs • "Dumping" ground • Being "Scut -monkey" of surgeons or other subspecialties • Buy-in from current system *Both within Gen Peds/GIS and other departments *Do other groups want to be hospitalists or is there still a place for "ward" team Threats

18. HMU Strategy Summary Draft 10-21-09 To be the leader in improving the outcomes of hospitalized children. Vision We will become the model of Pediatric Hospital Medicine through exemplary research, education, quality improvement and integrated care. Mission Strategic Goals Clinical Excellence Research Excellence Educational Excellence Organizational Excellence Strategic Initiatives Key Metrics

19. Lessons learned • Critically/honestly evaluating and assessing your situation critically is difficult • Essential to keep an open mind • Others see things differently • Constantly learn from each other clinically… • New/better ideas • Important to have a seasoned facilitator • Keeps things flowing • “Big Picture” – why we are doing this