Top Performing Healthcare Organizations Do's and

Don'ts

Session Code: TU03

Time: 8:00 a.m. – 9:30 a.m.

Total CE Credits: 1.5

Presenter: Jonathan Burroughs, MD, MBA, FACHE,

FACPE

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“What Top Performing Organizations Do and Don’t Do”Jon Burroughs, MD, MBA, FACHE, FACPEPresident and CEO, The Burroughs Healthcare Consulting Network, Inc.October 6, 2015

How do you define “High

Performance”?

• Economic (volume, margin, core measures,

outcomes, HCAHPS)?

• Thomson Reuters (outcomes, safety,

mortality/morbidity, core measures, ALOS,

cost per adjusted discharge, margin) ?

• Baldrige (leadership, planning, customer,

measurement, workforce, operations, results)

• Your strategic criteria?

• Your customers’ criteria?

I. Focus on Culture!

• Culture drives everything and either limits or

expands strategic possibilities

• Jim Collins’ “Great by Choice: Uncertainty,

Chaos, and Luck-Why Some Thrive Despite

them All”(2011)

Hill Country Memorial Hospital, Fredericksburg,

Texas “Remarkable Values”

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RVs #1: Others First

Anticipate and exceed expectations to serve others (internal and external)

Listen empathetically at all timesTeamworkEmbrace and honor diversityRecognize the contribution of othersRespect one another at all times

RVs #2: Compassion

Consistently treat others with courtesy, respect, kindness, and patience

Show genuine interest in what is important to othersDisplay a helpful and friendly attitudeSupport and encourage always

RVs #3: Innovation

Embrace evidence based practicesLearn from experience and share with othersCreate unique ways to provide remarkable careIncorporate technology to improve patient and team

member experience/outcomesAlways think beyond the box

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RVs #4: Accountability

Provide safe careLead by example at all timesBe open and honest about successes and failuresTake initiative for personal growth and developmentMake appropriate decisions in difficult situations

RVs #5: Stewardship

Demonstrate ownership of continuous improvementActively participate in financial success by optimizing

resourcesMake a positive contribution to our communityNote: Everyone in the organization is obligated to sign off on these values annually

Results:

Increased Medicare CMI from 1.3 to 1.7 (significant impact on net margin)

Press Ganey ‘Mentoring Hospital’ (99%tile)Top 10%tile for all core/safety measures“Chasing 0” safety program (eliminate the

denominator)Texas Quality AwardAble to attract top national talent2014 Baldrige Award for HealthcareOne of the Top Small Hospitals in the US

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II. Commit to Leadership Training and

Roles at all Levels of the Organization

• Leadership academies

• Certified Physician Executive (CPE) program

• MBA, MMM, MHA programs

• 10/17 US News and World Report Top US

Hospitals overseen by physician leaders

Baylor Healthcare, Dallas, Texas: Mandatory

physician leadership boot camp and executive

MBA program for committed physician leaders

2015 MSLD Curriculum

Session 3April 3, 2015

Driving

Performance

Improvement

(Dr. Burroughs/Allina

Legal & others

• OPPE & FPPE, Joint

Commission

Requirements

• Making Peer Review

Effective

• Quality Improvement

– tools and best

practices

• How to Create a

Culture of Safety &

Service

• Allina’s Culture of

Patient Safety and

Performance

Improvement (Napier,

O’Hare, Dickie?)

• Crucial Conversations

Overview/Best

Practices

Session 4May 8, 2015

Healthcare Law(Allina Legal)

• Anti-Trust Basics

• Fraud & Abuse

• Patient Privacy

• EMTALA

• Legal protections for Peer

Review

• Medical Staff

Investigation, Corrective

Action, Fair Hearing

• Working with Allina Legal

Session 2March 6, 2015

Credentialing &

Privileging:

Defining our

Culture(Dr. Burroughs/Dr. Martin)

• Strategic Medical Staff

Development Planning –

Defining your Criteria

• Credentialing and

Privileging

• Privileging Challenges

• Managing Performance

Issues

• Addressing Disruptive

Physician Behavior

• Avoiding the Biggest

Legal Mistakes

• Adaptive Leadership (Dr.

Corey Martin)

Session 1February 20, 2015

Medical Staff

Governance

(Dr. Burroughs)

• Program Overview

• The Imperative for Physician

Leadership in Healthcare

Transformation

• Roles & Responsibilities of

the Board, Medical Staff and

Management

• Moving from an Effective

Clinician to Leader

• How to Manage an Effective

Meeting

• Medical Staff Bylaws &

Arrangements (Allina Legal)

• How to Manage Leadership

Conflicts & Conflicts of

Interest

• How to Lead an ACO

Medical Staff Leadership Development Program

• To provide a common development framework for Medical Staff leaders

• Ensuring the knowledge, skills and balance perspective to fulfill

the breadth of their responsibilities.Session 5

May 22 or June 5,

2015

Healthcare

Finance

(Gordon, Wheeler,

Gallagher, Wieland,

Bent, Rice?)

• Allina’s Response to

Healthcare Reform &

ACO

• Healthcare Finance

Basics

• Clinical Service Lines

Overview (Chris Bent)

• AIM Network (Brian

Rice)

• Adaptive Leadership &

Work/Life balance and

Managing of Self

• Cohort Celebration

Leadership Compensation

• Must be based upon fair market value in a not for

profit 501(c)(3) entity per IRS and state attorney

general’s office (anti-kickback, personal inurement)

• Incentives should be based upon negotiated and

aligned organizational strategic goals/objectives

• Compensation should be proportional to

accountability

• Metrics derive from overarching dimensions

(performance excellence commitments)

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Example of a management contract (ED):

• 50% base pay (5%tile MGMA compensation)

• 10% quality program and performance (2% bonus for every

20% departmental compliance with agreed upon quality

targets)

• 10% patient satisfaction (2% for each 10%tile above 30%tile

PRC departmental scores)

• 10% physician loyalty (2% for each 10%tile above 40%tile for

hospital survey of physicians)

• 10% corporate compliance (e.g. medical records) (2% for

every 10% compliance over 50%tile)

• 10% evaluation by President MS and CEO (top potential pay –

(95%tile MGMA compensation)

III. Optimize quality/safety through

Standardized Practices (EBM)

• Gawande’s “The Checklist Manifesto” (WHO

Safe Surgery Checklist)

Memorial Hermann Physician Integrated Group,

Houston, Texas: Over two hundred clinical

practice committees (CPCs) to standardize all

high volume/risk clinical and procedural

approaches

Is there a difference in performance when physicians

and staff work together?

Measurement MHMD CI Physicians

Crimson-All Hospitals

LOS 4.52 (5%) 4.74

HAIs 0.68% (91%) 7.56%

General Complications

1.24% (66%) 2.82%

30 DayReadmissions

5.92% (43%) 10.38%

Mortality 1.95% (23%) 2.52%

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Third party payers are moving forward

What AETNA did when it saw this data:

1. Requested to negotiate a new contract with MHMD

2. Offered a 8% increase in FFS payment with a

guarantee of 3% next year minimum

3. With 10% movement of ‘share’ to the system, committed

$7.5 million to physician pool and $8.0 million to system

pool in bonuses

4. Committed to invest in a comprehensive marketing

program to compete with United and BCBS

IV. Continuous Focus on Customer

Service and Loyalty

• Internal AND external customers!

• “Satisfaction is fool’s gold”

• What is the leading indicator for patient

loyalty?

Mercy Medical Center, Baltimore, Maryland:

Physician Centric Business Plan (patient

centered and physician led)

It turns out that patient loyalty is the

greatest driver of….

Compliance with recommended

treatment and follow up (up to 400%)

Reduced medical negligence claims (the

critical 3%)

Enhanced reputation and market share

(think Apple/Harley-Davidson)

Measurable quality outcomes (due to

compliance)

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Cost Side: Lower Satisfaction Scores lead to

greater turnover and lower quality/safety

Relationship Between Employee Turnover and Patient Outcomes

Blue Bar: Mortality Index = Clinical QualityYellow Bar: LOS = Operational Efficiency

Y-axis: Employee Turnover = Service Excellence

.78

3.81

5.02

1.09

28% greater mortality24% longer stay

IV. Continuous Focus on Customer

Service and Loyalty

• Internal AND external customers!

• “Satisfaction is fool’s gold”

• What is the leading indicator for patient

loyalty?

Mercy Medical Center, Baltimore, Maryland:

Physician Centric Business Plan (patient

centered and physician led)

V. Work with Management to

Continually Reduce Operating Costs

• What is the impact on your organization to

reduce LOS by 0.1 day? Reduce cost per

adjusted discharge? Increase CMI by 0.1?

University of Pittsburgh Medical Center-Hamot,

Erie, Pennsylvania clinical documentation

improvement (CDI) program

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Case Mix Index is all about

documentation!

Today’s ICD-9 codes for congestive heart failure (#1

inpatient diagnosis):

DRG number WeightPayment

DRG 127(pre-2009) 1.0490 $5,561.29

MS-DRG 291 1.4850 $7,923.02

MS-DRG 292 1.0216 $5,450.61

MS-DRG 293 0.7317 $3,903.89

Get ready for ICD-10 (10/15) with

132,500 new DRGS!

• Number of DRGs for CHF goes from 3 to 25

• The difference between the lowest and highest

payment will increase

• How many of you know all 300-800 clinical modifiers

in your respective specialties?

• Reimbursement for hospitals and physicians is

decreasing (PPACA

• What is the solution?

Collaborative Clinical Documentation

Improvement (CDI) initiatives

• Clinical documentation experts or software (e.g.

CMORx) to support physician and nursing

performance with a return on investment (ROI)

Case in point: UPMC Hamot, Erie, PA-robust

documentation program (BCE) with five coaches on

site 24/7 to ‘blue note’ inpatient charts to optimize

documentation.

Results: CMI 1.45 to 2.21 (how much would that be

worth to your organization?) and $1 million net

increase per quarter

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VI. Expand Focus to Disease

Management and Population Health

• In a reimbursement world moving from FFS to

capitation with incentives, which makes more

sense: expand high margin or high quality/low

cost services?

Sutter Davis Hospital, Davis California with

outstanding indigent care program

(readmission rate top 5%tile performance)

What do you think was the impact on operating

margin?

Stage the Transition from FFS to Risk

Based Contracting:1. Align with all key facilities and providers before

everything

2. Build the integrated network together (all solutions

must make clinical and operational sense)

3. Focus on opportunities to lower cost structure first

(labor, supply chain, palliative care, inpatient disease

management) (MUST HAVE ANALYTICS!)

4. Grow new sources of revenue second (e-health

solutions, contracts for domestic/international medical

tourism, focused factories (VAPs), solution shops etc.)

5. Grow the ambulatory population health infrastructure

third as you move into risk based contracting (e.g.

post-acute care, ambulatory disease management,

retail medicine, home health, etc.)

6. Exit fee for service last and focus completely on

health optimization and prevention of disease

VII. Become HIM Adept and Literate

• Chief Information Officer (CIO)-fastest growing

member of executive team

• Necessity to build a HIN with seamless health

information exchange (HIE)

• Disruptive innovation will largely replace

routine care (Stanford Hospital’s e-care,

American Wells ‘virtual visits’)

Sarasota Memorial Hospital, Sarasota, Florida’s

Allscripts/Ellipsis EHR X 15 years

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Healthcare System Apps (UCLA

Health app by Mobile Smith):

1. General Information: map, directions, accepted insurance, phone numbers (tap to call)

2. Services: directory of services and providers (tap to call/e-mail)

3. Virtual Tour: 360 degree tour of rooms, maps and access information, times of operation

4. ER Wait Times: dynamic wait times for all facilities

5. Interactive gallery, events, and social media: streaming content and interactivity

Healthcare Provider Apps: The

Four Most Common Potential

Benefits

1. Free providers from offices and work stations (e.g. Epic’s Haiku, Allscripts, MedPlus’ QuestCare 360 mobile etc.)

2. Access to lab results and medical imaging (e.g. Mobile MIM for images, Normal/Pocket Lab Values etc.)

3. Convert a smart phone into a medical device (e.g. ECG Guide, MIM, MindWave etc.)

4. Practice Management Tools (e.g. Hospital Rounds, E/M Code Check etc.)

Social Media Rules!

Worldwide Users: Facebook: 1.4 B, Twitter: 0.5 B,

Linked in: 0.25 B (2013)

>70% of healthcare organizations actively utilize

social media (97% facebook, 66% twitter, 54%

youtube, < 20% google+, linkedin, blogs)

90% of text messages read within 3 minutes!

Children’s Hospital (LA) and BIDMC (Boston) have

raised millions in additional revenues VIA

Facebook!

Mayo Clinic Center for Social Media (MCCSM)

CEO blogs (St. Luke’s Health, Boise, ID)

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5. E-Health: Largest Player-

American Well, Boston, MA

Turnkey tele-health platform (lease or buy) to

organizations/health

plans/payers/employers, online care

group

Access to 100 M health plan members across

45 states

$49/visit VIA credit, debit, HSA cards

Payment processing, payer management,

advanced reporting and analytics,

dynamic pricing options, e-prescribing,

provider driven follow up tools, medical

home tools (registries)

5. E-Health: Most Common Uses

Urgent care (e.g. URI, UTI, rash, flu etc.)

Chronic medical management On demand inpatient consults (e.g.

rural areas)Emergency department case flow

(MSE)Home healthcare servicesPost discharge/surgical careBehavioral healthContribute physicians to national pool

VIII. Work in Interdisciplinary Teams

• Healthcare is now a team sport

• Crew resource management (CRM) saves

lives

• Interdisciplinary means more than ‘clinical’!

St. Elizabeth Hospital, Red Bluff, California’s

CHW foundation model and alignment in

governance, management, and all clinical

settings

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IX. Be Willing to Exclude Low

Performers or “Non-Performers”

• Performance is the ultimate manifestation of

‘culture’ and ‘values’

• Not everyone can go on the journey to

excellence

• “Non-performers” can excel in other

environments

Mayo Clinic, Rochester, Minnesota’s

membership ‘by invitation only’

University of Virginia ‘eligibility criteria’

X. Become Completely Aligned with

Physicians

• Employment and ‘pay for call’ ≠ alignment

• Cultural alignment precedes economic

alignment precedes clinical alignment

• Culture of alignment = trust + respect +

partnership

Memorial Hermann Physician Integration

Program and Baylor Healthcare alignment with

self-employed physicians

The Significant ‘Few’

Out of a medical staff of 1,435 physicians:

57% of the staff drove a profit of $34 M

43% of the staff drove a loss of $41 M

4 MDs drove $6.5 M in profit!

7 MDs drove $6.6 M in losses!

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What would Self-Employed or Employed

Physicians be interested in?

1. Enterprise partnership

2. Hospital based revenue (leveraged contracts)

3. Access to GPO (supply chain costs)

4. Access to IT (HITECH)

5. Revenue cycle management (RCM) support

6. Access to investment capital

7. Access to preferential referrals

8. Input/increasing control at the highest levels of

the organization

What are the non-negotiable quid pro

quos of such a partnership?

1. Standardize regulatory quality, safety, service

and cost effectiveness

2. Work with management to drive down

operating costs

3. Work with management to achieve strategic

goals/objectives (e.g. service culture,

population health etc.)

Key Components of ‘At Risk’ Contracts

with Physicians (Intermountain Health):

• Be willing to participate in ‘at risk’ contracts based upon

strategic goals/objectives developed and approved by

physicians and management

• Comply with clinical and business ‘best practices’ as

determined by peer group/management (and be willing to be

peer audited for exceptions)

• Agree to un-blinded transparency of all clinical and financial

data/analytics

• Be willing to comply with value analysis process

• Disclose all potential conflicts of interest and accept

determination of deliberative physician bodies

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What is the Difference between Clinical

Departments and Service Lines?:

• Independence v. collaboration (team)

• Autonomy v. consensus

• Wide variation v. narrow variation

• Clinical focus v. clinical + operational + financial focus

• Open v. semi-open or closed

• Self-employed/employed v. contractual with performance expectations

• Voluntary leadership v. dyad/triad contractual leadership

Dyad/Triad Model of Leadership:

Physician + Manager (e.g. nurse) + Executive partnership:

� Clinical quality (physicians + staff)

� Safety

� Service

� Operations (e.g. supply chain/budget)

� Financial performance

� HR

� Branding/marketing

Co-Management Agreements

• Partnering physician and managerial leaders

to oversee inpatient/outpatient services,

ancillary, multi-site specialty care (exclusives),

service lines, clinical institutes, and enterprises

for performance in:

� Quality

� Cost savings

� Service

� Safety

� Efficiency

� Marketing/branding

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Perspective from the ages….

"Excellence is never an accident. It is always the result of high intention, sincere effort, and intelligent execution; it represents the wise choice of many alternatives - choice, not chance, determines your destiny.”

--Aristotle (384-322 BC)

Jon Burroughs, MD, MBA, FACHE, FACPEjburroughs@burroughshealthcare.com;

603-733-8156

Thank You for Joining Us!

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