Health Care Organizations Analysis Presentation
Note. The background and explanation may only be 2 slides at maximum:Identify the health care delivery model.Explain the structure of the organization in the case study.Analyze the communication patterns identified throughout the process in the case study.Discuss the negotiation strategies applied as well as opportunities for relationship building across departments.Describe how the organization’s performance changed as a result of the initiative.Identify laws, regulations, accrediting bodies, and practice standards that should have been considered as part of the initiative in the case study.Cite a minimum of 5 peer-reviewed resources.
NAME OF THE ARTICLE IS:TRANSFORMINGHEALTH CARELEADERSHIPA Systems Guide to ImprovePatient Care, Decrease Costs,and Improve Population HealthMICHAEL MACCOBYCLIFFORD L. NORMANC. JANE NORMAN
232 Chapter ??: Three Case Studies: Mastering ChangeCASE STUDY C: BUILDING A LEARNING ORGANIZATIONAT OCHIN, PORTLAND, OREGON,UNITED STATESBackgroundThe original CEO of a payer organization demonstrated foresightwhen she proposed and submitted a grant to the United StatesFederal government in 1999 to coordinate and provide electronicmedical records to their member clinics in order to reduce costs inprocessing claims while creating a database which would be used toimprove patient care and community health. In 2000, she received asmall grant to plan and begin implementation of this idea.The leadership team formed the Oregon Community HealthcareInformation Network (OCHIN) with their community clinic partnersto evaluate, choose, configure, and install electronic medical recordsoftware. The partner collaborative selected EPIC as the softwaresolution that would best fit their needs for the present and thefuture. It is interesting to note that EPIC was the first software tobe certified in 2010 by the U.S. federal government agency (Officeof the National Chairman [ONC]), charged to define and provideIncentives for health care entities to install electronic medicalrecords under the Obama Affordable Care Act. In 2005, the currentexecutive group divested their information technology network andOCHIN became an independent organization.Strategic IntelligenceAs OCHIN embarked as an independent entity, the leadershipgroup defined their purpose as ?providing technology informationand solutions to the medically undeserved.? Their core work was toconfigure and install EPIC systems to nonprofit community clinics.OCHIN eventually was given the license to configure and host EPICsoftware for the unique billing and local reporting requirementsfor community clinics throughout the United States allowing themto expand their network of members outside of Oregon. Soon OCHINexpanded to Oregon, Washington, and California and was receivinginquiries from communities in Midwestern and Eastern states. Astheir membership base expanded beyond Oregon, they redefinedOCHIN as ?Our? Community Healthcare Information Network.Three Case Studies: Mastering Change 233The original funding for OCHIN came from Health Resources andServices Administration (HRSA) federal grants to research, install andhost EPIC. As OCHIN grew, they continued in a traditional manner toexpand the business in software support. For example, many clinicshave limited resources to hire billing expertise to resolve claim andbilling issues. As a result, OCHIN began contracting with members tomanage claims and accounts receivable.OCHIN routinely partners with state and community entities.These parties encouraged OCHIN to apply to the federal governmentfor a Regional Extension Center for Oregon. For CEO AbbySears (OCHIN?s first employee), this direction would move OCHINcloser to the foresight of the original CEO who formed OCHIN notjust to install and support electronic medical records but to reducecosts in processing claims while creating a database which wouldbe used to improve patient care and community health.OCHIN was ready to move beyond being an EPIC hosting, configuration, installation, and support organization. As the EPIC host,they had the database, and members who joined OCHIN sharedEPIC software solutions. The OCHIN membership permeatedOregon with an existing learning network and trust relationship thatcould be used to improve patient care and community health. Soonall members in seven states were able to see medical records of anypatient in the system if they moved or were in an emergency situation.OCHIN was already working with members to utilize the databasefor better care of patients with a product called Solutions thatdata-mined health care data in a usable format for health care professionalsto impanel and provide better patient care. The objectiveof the Federal Regional Extension Centers was in total alignmentto the existing networking structure at OCHIN. It seemed logicalfor OCHIN to submit a Regional Extension Center grant proposal,which would serve not only OCHIN?s existing nonprofit communityclinics but also for-profit clinics, small hospitals with less than tenbeds, and small private practices with less than ten doctors.PurposeIn preparation for the future, OCHIN began a major effort to examineits purpose and vision by reexamining its products, services, deliverysystem, and personnel by focusing on creating a learning environment.During the journey that will be described below, the need to234 Chapter ??: Three Case Studies: Mastering Changerevise their organizational purpose became evident as they expandedboth their member base and their products and services. In 2011, theboard approved a revised mission to expand and align to the newlydesigned system and members.OCHIN Mission (purpose in our context)2009?Providing technology information and solutions to the medicallyundeserved2011?Partnering with communities to create the knowledge and informationsolutions to promote access to high-quality and affordablehealth care for allThe JourneyIn December of 2009, the executive leadership team, senior leadershipteam, and employee representatives used the Quality as aBusiness Strategy (QBS) evaluation grid (basis for the evaluationgrid?strategic intelligence and Four Ps in Chapter 11) to identifygaps and opportunities during a strategic retreat. As a result, OCHINbegan a transformation to a learning organization, by focusing onthe gap analysis and methods provided by the original Quality as aBusiness Strategy evaluation grid. Their journey started in earnestin 2010 by focusing on the alignment of their purpose and vision tothe system.Aligning Purpose and Vision to the SystemBecause they were redesigning the mainstay or delivery system,OCHIN initially utilized their existing mission (purpose in our context)to begin redesigning their system using the system map.However, work had been done to create a system map of how workwas currently done. Here is the original conceptual frameworkof the OCHIN delivery system with two primary subsystems (seeFigure 10.13):The natural inclination was to simplify and standardize the subsystemthat included most of OCHIN?s resources: configuration andinstallation of EPIC software. But Sears recognized the system mapwas incomplete. Refining the installation processes would not fulfillthe needs of the existing members. Sears needed a way to helppeople see the new OCHIN and membership in a different light.Delivery System (Mainstay)Configure and Install SoftwareProvide Billing SupportSolicit, Receive, andRespond to Requestsfor QuotesDefine ProductDeliverable PlanConfigure SoftwareDesign NewInterfaces orProductsManage Billing IssuesManage AccountsReceivableManage CentralizeBillingSet Up CentralizedBillingSolicit, Receive, andRespond to Requestsfor QuotesConduct TrainingInstall Softwareon Host PlatformTroubleshootandResolve IssuesMembersFigure 10.13 Original Conceptual Framework of the OCHIN Delivery System with Two Subsystems236 Chapter ??: Three Case Studies: Mastering ChangeVisionSears described her vision for OCHIN explicitly as a collaborativelearning organization which encompasses the whole system,assisting health care providers with data analysis and tools foreffective and efficient patient and community care once any electronichealth care record system was installed. She acknowledgedthat resources were being sucked up by the installation process andfocus on new members. The constraints of the past were to be putaside to design new and redesign old processes that would leveragestrengths and knowledge within the ranks. Figure 10.14 showsthe mainstay framework that was initially created from the dialoguethat ensued, expanding from two subsystems to five to allow additionalproducts and services.Redesigning the SystemIn January 2010, OCHIN was named the Regional ExtensionCenter for Oregon by the newly defined ONC which was chargedto defi ne and act as the officiating group for the new AffordableCare Act?s Center for Medicare & Medicaid Services (CMS). Theobjective was to install electronic medical records throughout thenation by giving physicians financial incentives to not only installbut also use the data for improvement of care to patients. Theycoined the term meaningful use of health care data with a complexProvideKnowledge andInformation toNew and ExistingMembersCoordinateSupport forMembers Provide Billing Management ServicesDevelop and Test New Health CareTechnology Products and ServicesConfigure and Install SoftwareDelivery System (Mainstay)MembersFigure 10.14 2009 OCHIN Integrated ConceptualSystem Map: First DraftThree Case Studies: Mastering Change 237tier. Funding would be dependent on the number of qualifyingmembers with signed agreements with each Regional ExtensionCenter. Although Regional Extension Center grants were awardedin January, the document for defining and qualifying members,incentives, and structural guidelines was not defined by the governmentuntil late summer. At least 25 percent of members originally defined when the grants were written were disqualified bylate summer of 2010.OCHIN was renamed the Oregon Regional Extension CenterO-HITEC. There was no government model to .follow; only expectedresults to deliver. OCHIN was ready for the transformation sincethe new conceptual delivery system defined how work would fl owand the interdependencies. All of these subsystems would be necessaryfor O-HITEC. While other Regional Extension Centers werefocused primarily on the installation of electronic medical recordprograms and trying to sell them, O-HITEC was looking at developingan integrated system. Five subsystems were integrated intothe delivery system, with three new subsystems to focus theirexecution:1. Providing knowledge and information to new and existing membership(which expanded beyond EPIC requests for quotes)2. Coordinating member support3. Developing and testing new health care products and servicesManpower was immediately added to the first subsystem todevelop and execute processes to provide knowledge and informationto new and existing members. This group designed educationalsessions, a new website, and solicited information frompotential new members into the O-HITEC incentive system to helpidentify their needs. An installed certified EMS was the base requirementof the incentive system. EPIC was predicted to be one of thecertifi ed systems. Therefore, physicians in the OCHIN membershipwould automatically qualify for the first year?s incentive, but thatwas not sufficient to meet the first year?s quota for O-HITEC. Smallprivate practices and small hospitals that had a defined percentageof Medicare/Medicaid patient populations were the qualifyinggroup. The cost of EPIC was prohibitive for most small practices238 Chapter ??: Three Case Studies: Mastering Changeand OCHIN was not authorized to install EPIC in small hospitals.O-HITEC would leverage OCHIN?s strength, configuring and installingelectronic health record (EHR). But they needed to assess otherproducts and get feedback from potential members. Currentlyinstallation capabilities have expanded to include All scripts EHR,eClinicalWorks EHR, addition authorization for EPIC applicationsin hospitals with fewer than ten beds, and recently Greenway?sPrimeSuite EHR. All products include secure health informationexchange capabilities and web-based patient portals that letpatients and doctors communicate easily, safely, and securely overthe Internet.All products offered by OCHIN are geared to enable membersand clients to implement and achieve meaningful use of their EHRas required to secure federal incentive payments and support providerand practice efforts to advance clinical, financial, and operationalgoals?the preconditions for clinical transformation.The intent of installing electronic health records goes beyondinput of a patient?s data by the health care provider. Expandingfrom an internal system?s view to responding to the needs of clinics,health care professionals, and all users and potential patientshas enabled OCHIN to expand services to include1. Business Services provides multitier support designed to createoperational efficiencies and drive savings directly into OCHIN-supportedpractices.2. Data Services provides the capability to aggregate data from anynumber of vendor sources enabling users to interface with, andbuild on, existing clinical, financial, and operational tools alreadyin place for reporting and improving health outcomes. OCHIN?sdata warehouse is tailored to a health care environment and usesan innovative proprietary data aggregation architecture that makesthe accurate measurement of clinical and operational variablesstraightforward, thus making it possible to compare metricseasily across different organizations without the need for complicatedaudits. All data exchange is governed by agreements that arecompliant with applicable laws and regulations governing protectedhealth information.Three Case Studies: Mastering Change 2393. Health Information Exchange (HIE) connects all OCHIN networkmembers via Epic Care Everywhere network that connects hospitalsnationally and through the emerging Nationwide Health InformationNetwork (NwHIN) exchange. OCHIN is also building a national HIEcapability that utilizes the rules and guidelines for how computersystems should exchange information defined by Health LevelSeven International (HL7) with the international Integrating theHealthcare Enterprise (IHE) initiative for health care?specifi c data.These solutions enable OCHIN to seamlessly integrate multiplesystems including hospital registration systems, laboratory systems,immunization registries, and, via the NwHI, to support informationexchange with federal agencies. Using OCHIN, administrative andclinical staff can coordinate patient care across multiple states andunrelated health care entities, giving care providers the knowledgeto improve patient outcomes regardless of where patient treatmenttook place.4. Practice-Based Research Network (PBRN) operates as an independentbusiness unit within OCHIN for the purpose of encouraging practice basedresearch that advances understanding of the health ofunderserved populations, increases health equity, improves qualityof care, and informs health policy. The OCHIN PBRN is unique amongother practice-based research networks because it has no formalaffiliation with a particular academic health center and is comprisedalmost exclusively of federally qualified health centers (FQHCs) andrural health centers (RHCs).The evolution of the OCHIN system map has expanded toshow these important subsystems and their integration to achievethe organization?s purpose. Systems thinking continues to drive theorganization to solicit and assess member and patient needs. PDSAsymbols have been added to the OCHIN system map to reflectwhere internal prioritized Accelerated Model for Improvement projects(Ami? charters) are targeted. In addition, OCHIN is using theirsystem map as part of their analysis, prioritization, resource allocation,and communication of joint improvement projects initiated bymembers? requests to address growing member and patient documentationand analysis needs (see Figure 10.15).Figure 10.15 2012 OCHIN Conceptual System Map withInternal and Member Ami? Improvement ProjectsThree Case Studies: Mastering Change 241Using Personality Intelligence in a Changing EnvironmentEarly in 2009, OCHIN began using the Strength Deployment Inventory(SDI) from Personal Strengths Publishing as a means to educate anddevelop personality intelligence throughout OCHIN. Assessment ofthe 2009 delivery processes using the new system maps revealedsome interesting issues. First, the billing subsystem had only onemanager, Phil Skiba. He was an experienced manager who had executiveexperience at larger companies with a strong personality toget things done and a willingness to make changes, while routinelytreating risk as a challenge. Skiba was also aware that his strong personalityhad to be held back when working with more analytic andnurturing personalities, which was the predominant cultural norm.He used his SDI learning to modify his communication methodsto improve relationships and communications. In a relatively shorttime, he had taken the small subsystem over and grown it with moreclients, delivering excellent results for these billing customers.In contrast, the install subsystem was composed of six managers.Five of them had been promoted from within, with no managementexperience nor any management or leadership training. They werein a high-stress environment and were constantly adapting andmaking changes to make things work. But some changes were notaligned with strategic plans, which forced them to make additionalchanges. This only created more stress and confusion. Their flexible adaptivepersonality profiles explained this behavior. In a rapidlygrowing and changing organization, management needs alignmentand experienced leadership.By the end of 2009, the decision was made to begin the transitionto test the revised delivery system. Within weeks, OCHINwas officially informed that they had been selected as theOregon Regional Extension Center, renamed O-HITEC. Realigningresources to move toward the new integrated delivery system wascritical for success. Five managers were moved back into the organizationfor added delivery resources. Experienced leaders withinthe organization were reassigned. The previous COO, ClaytonGillett, now became the designated leader of the O-HITEC groupand was assigned to develop and integrate the processes to provideknowledge and information to new and existing members.The existing quality assurance director was moved to coordinatingsupport for members. Skiba (a certified project manager) retainedbilling but was allowed to hire a billing manager so that he could242 Chapter ??: Three Case Studies: Mastering Changealso manage the project managers for the installation processes.The new COO, Jane Norman, managed personnel for EPIC configuration and development of new products and services.OCHIN began a series of communication sessions with theirassociates, many of whom had been with the organization fromthe beginning. Initially, the leadership team delegated communicationto the COO, who conducted weekly meetings. Later the executiveleadership team took ownership. Leadership predicted weeklymeetings and openness in these meetings would help the associatesmake the transition.With the announcement of O-HITEC, the new delivery systemwas unveiled. The first stage reallocated leadership responsibilities.These were shared using the revised delivery system map withleaders? names noted in the next stage. Demand in the subsystemswas assessed to begin a transition of people for dedicatedresources. Roles had not been determined, but would be shortly. Inorder to do this without disrupting the installation process, OCHIN?sprimary financial resource, some programmers would work in twoSubsystems for the first few months. In an effort to dispel anxietythat changes were permanent, leadership stated that the deliverysystem was like Jell-O?as we mold it, we will review it. Changesthat were not working would be abandoned and a new mold wouldbe created from what was learned.The leadership team was committed to learning from experienceand making necessary changes. Skepticism that the deliverysystem would never be more than an installation effort fl owedfrom side conversations spreading skepticism to others who hadbeen optimistic. Communication and transparency was essential.As Mark Twain once noted, ?A lie can travel halfway around theworld while the truth is still putting on its shoes.? In addition, theCOO learned at the second communication session that the Jell-Oanalogy was causing anxiety. She was a flexible-adaptive personalitywho was comfortable with uncertainty and learning fromchanges. But for the analytic and nurturing programmers, Jell-Ocommunicated uncertainty. They needed specific direction. Theywanted to be told what to do and that the plan was solid.The Jell-O analogy was abandoned. The COO replaced it withanother analogy of ?building the bridge as we walk on it? andstated that the framework of most of the bridge was already inplace. O-HITEC would take the response to quotes, defi ne additionalThree Case Studies: Mastering Change 243processes, and integrate into subsystem 1. Subsystem 2 was puttingnew processes in place for the informal help desk. Subsystem 3 wasdedicating more resources to new products like Solutions, whichwas already in place. More resources for O-HITEC and the deliverysystem would be added. Developing processes and roles were thenext hurdles. Throughout the transition everyone was responsiblefor learning and sharing knowledge. The new analogy and explanationof the new delivery system, ?building the bridge,? soon becamea common theme. And leadership learned more about personalityintelligence and the communication needs of the organization.Using Role Descriptions to Integrate People into theLearning OrganizationStarting in 2007, OCHIN doubled its members and the number ofvisits hosted yearly. When OCHIN had under twenty people, it waseasy to learn from one another. But in 2009, with sixty-two people,it became harder to facilitate learning. Once the revised delivery systemwas in place, the organization was flattened with existing andnew resources allocated to the five major interdependent subsystemsof the delivery system. The initial restructuring of existing resourcesin the fi ve subsystems exposed other weaknesses in the system, specifically personnel with underdeveloped skills and those who weredoing more than their share of work to make up for the inadequaciesof others. What skills did individuals need to be successful? How couldOCHIN leverage and utilize individuals? strengths and knowledge?In 2009, approximately one-third of the staff were applicationspecialists whose skills were critical for the success of support,installation, and new products, or 60 percent of the delivery subsystems.These skills were developed in three main categories:basic structure, clinical, and billing. There was no master skill listfor training or assessing application specialist?s knowledge or skills.Leadership worked with subject matter experts to defi ne 100 skillsfor each of the three skill categories. Skills were self-assessed byeach of the application specialists using a similar format to the portionof the form below. This helped defi ne what an application specialistknew. The list has since been refined to 122 skills in seventeenareas. In addition, 53 skills for training members in EPIC functionshave been defined in five areas to assess and develop applicationtrainers? skill levels. Figure 10.16 describes the Skills AssessmentTools Format.Figure 10.16 Skills Assessment Tools FormatThree Case Studies: Mastering Change 245Based on the results, each application specialist was classifiedby skills in one of four categories: basic structure, clinical, billing, ortraining. For each category a technical lead (who had demonstratedthe highest knowledge) was identified. The leads were charged withconducting learning sessions and utilizing the skills inventory tobuild the skills of their technical group. Fridays were declared learningdays to support the time needed to develop the skills. As applicationspecialists mastered and demonstrated new skills, salarieswere adjusted.The skills inventories also became a tool for hiring experiencedindividuals. Candidates self-assessed their skills, and if they passedthe previous screening interviews, a technical lead interviewed themto verify their skill levels.Additional technical leads were identified throughout the organizationand Friday learning days were used for sharing learningduring the week. Helping the technical leads learn the differencebetween telling or managing people and leading and developingpeople was a challenge. A three-day leadership workshop atGettysburg was conducted by Austin API, Inc., with follow-up sessionsfor learning. Primarily the executive leadership team attended.Attendees used the experience to learn, reflect with one another, andbecome better leaders. A key lesson from experience is courage,which was discussed in Chapter 8. On the battlefield a leader mustdisplay physical courage. In business, the effective leader must displaymoral courage and be prepared to move beyond the secondlevel of ethics and morality discussed in Chapter 4 to a third level,where the leader and team might have to sacrifice for the overallsystem. The following year, a second group of technical leads andadditional managers attended the three-day Gettysburg leadershipexperience. These learning sessions were building leaders at all levelswithin OCHIN and creating a learning environment with a sharedunderstanding of the three levels of ethics and morality necessaryto support the practical values of OCHIN.The skills inventory (including training) for different levels ofapplication specialists requires understanding the processes a roleperforms and the knowledge needed to be effective. Traditional jobdescriptions focus on reporting structure, pay scales, qualificationsand generalized skills. Formal role descriptions are a critical tool toalign individuals and develop them within a learning organization.246 Chapter ??: Three Case Studies: Mastering ChangeRole descriptions have been developed for all associates and havereplaced job descriptions. They are currently used for yearly individualdevelopment plans. Processes and the skills required wereused to defi ne the role descriptions, so that organizational paygrades were matched with market levels, but also demonstratedexpertise. In addition to traditional job description information therole description explicitly states the following additions (see RoleDescription Template in Exhibit 10.2):1. How the role contributes to the purpose of the organization2. The processes in which the individual is expected to execute3. Measures of the process to detect when an individual needs help orwhen the process needs to be redesigned4. Rules of conduct that are aligned with the organization?s practical values5. Expectations for improvement6. Organizational relationships (external and internal)? EXHIBIT 10.2: ROLE DESCRIPTION TEMPLATERole Description TemplateRole StatementPosition Title:Department Title: Function: Supervisor:Title:Pay range: Type of position: Hours/week:(Depending uponexperience and levelof responsibility andmarket)Full-timePart-timeTempemployee/ContractorInternExempt NonexemptThree Case Studies: Mastering Change 247OCHIN recognizes that people do their best work and are mostsatisfied when working in a healthy work environment. OCHINseeks to nurture a healthy and productive work atmosphere thatsupports current members of the team and one that is eager to welcomeand adapt to new members as they are added. The followingvalues have been identifyed as essential characteristics and behaviorsof OCHIN?s work environment. They establish a framework forEmployee and organizational expectations about what it means toWork at OCHIN.Organization MissionOCHIN partners with communities to create the knowledge andinformation solutions to promote access to high-quality and affordablehealth care for all.Role Statement?How This Position Supports the MissionThe (role name) supports the mission of OCHIN byProcess and Measurement ResponsibilitiesAll work is a process. Each role has process responsibilities whichare interdependent and impact the OCHIN system and network.Processes currently defined for this role have been defined below.We must be alert to defining new processes and eliminating obsoleteprocesses as needs of our role dictate. Performance measurementmeasures the system and the individual together. Below arethe key processes for this role and measures that have been currentlydefined for this position which will be presented on controlcharts with a weekly frequency:Process Name (#) Process MeasurementSecondary Process Responsibilities (Back Up for Others)ConductThe (role name) will model behaviors consistentwith the published values of OCHIN.248 Chapter ??: Three Case Studies: Mastering ChangeResponsibilities for Improving the SystemAll OCHIN employees are responsible for working together toimprove the OCHIN network (internally and externally.) Friday afternoonsare allocated for this purpose. When changes are considered,we will use the following questions from the Model for Improvementroutinely:What changes do we want to test?What are we trying to accomplish or learn from these changes?How will we know a change is an improvement?(Use of measures will help us understand if our changes areimprovements.)The (role name) is responsible for? Documenting, communicating, sharing information anddeveloping solutions.? PDSA cycles are the approach to all improvement work that weundertake.? Routinely monitoring all personal measures. Special causeswill be noted, rese
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Health Care Organizations Analysis Presentation