Health Care Management 1

BHA 3002, Health Care Management 1

Course Learning Outcomes for Unit II Upon completion of this unit, students should be able to:

6. Analyze the finance system in a healthcare organization. 6.1 Examine key differences between for-profit, not-for-profit, and public healthcare facilities. 6.2 Explain the process of creating and balancing a healthcare facility budget.

8. Evaluate ways to improve the quality and economy of patient care.

8.1 Describe the process of quality review and privileging for physicians. 8.2 Discuss the importance of quality initiatives, quality equipment and supplies, and quality

regulations. 8.3 Identify a management problem in a healthcare organization.

Course/Unit Learning Outcomes

Learning Activity

6.1 Chapter 3 Reading Unit Assessment

6.2 Chapter 3 Reading Unit Assessment

8.1 Unit Lesson Chapter 4 Reading Unit Assessment

8.2 Unit Lesson Chapter 4 Reading Unit Assessment

8.3 Unit Lesson Chapter 4 Reading Unit II Project Topic

Reading Assignment Chapter 3: Financing the Provision of Care Chapter 4: Quality of Care

Unit Lesson Evidence-Based Performance Measures One of the hottest topics in healthcare administration today is evidence-based performance, and you certainly need a solid understanding of this process in order to function effectively as a healthcare leader moving into the future. American health care needs to improve. There is no doubt about that. Americans deserve more bang for the buck that they spend on medical services. One of the most important initiatives to make that happen is a move to more evidence-based practice. What evidence-based performance is truly all about, first and foremost, is the patient (UT Health, 2015). In particular, it is all about making sure that the patient receives care based upon the best and latest research that is available for the patient’s own particular health problem or set of health problems. It is about giving the right care, every time, for every patient. Other benefits of a solid evidence-based medicine program include the ability to assure your own community that your hospital provides high quality care and that you are doing your own quality review studies to make sure of this. Finally, evidence-based medicine makes sense because

UNIT II STUDY GUIDE

Financing and Quality for Health Care

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the Centers for Medicare Services (CMS) demands it of us. They will actually pay us more for our services if we meet evidence-based performance criteria and goals, and they will financially penalize us if we do not meet evidence-based goals. In short, there are many good reasons to implement evidence-based medicine in your own medical facility. Currently, there are several national focus areas for evidence-based medicine programs. These are heart failure (HF), acute myocardial infarction (AMI), pneumonia (PN), and the surgical care improvement project (SCIP). Let’s consider these four very important projects here separately. Heart Failure Congestive heart failure accounts for more than 700,000 hospitalizations each year in America (UT Health, 2015). It is one of the most common reasons people over the age of 65 are hospitalized each year (UT Health, 2015). The reason that so many people are showing up at the hospital with congestive heart failure today is actually pretty easy to understand. We are simply living longer in this country, and more people are now living long enough to encounter chronic illnesses such as heart failure. Additionally, the American lifestyle and diet make us susceptible to heart problems as we age. So, taking excellent care of heart failure patients and keeping them well to avoid readmissions, becomes an important part of our role in community hospitals. Acute Myocardial Infarction Acute myocardial infarction, heart attack, is also a major reason for admission to hospitals in our nation. As you probably know, cardiovascular disease is the single leading killer in America today (Centers for Disease Control and Prevention [CDC], 2015a). Each year in America, a little over one million people have heart attacks, and almost two-thirds of them do not make a complete recovery from the heart attack (UT Health, 2015). We need and want to do better for heart attack victims in this country, and there are some very specific steps that doctors and hospitals can take to make that a reality with better outcomes for our patients. We will discuss those steps below. Pneumonia Also very important as a quality-focus measure is pneumonia. Even with modern antibiotics, vaccines, and high technology respiratory therapy, pneumonia and influenza continue to be among the leading causes of death in patients over age 65 (UT Health, 2015). Pneumonia generally does not kill younger patients, but in patients over age 65, the risk is very real. About 90% of pneumonia deaths are in patients over 65 years of age (Cassiere, 1998). Surgical Care Improvement Surgical care improvement is also a major goal for medical care in the United States. According to UT Health, the most alarming current statistic is that 22% of preventable deaths in U.S. health care are due to postoperative complications (2015). Patients who develop surgical site infections have about twice the mortality rate of those who avoid them after surgery (UT Health, 2015). Additionally, patients who develop postoperative infections are about 60% more likely to spend time in the intensive care unit during their admissions (UT Health, 2015). UT Health (2015) states that these patients are about five times more likely to be readmitted to the hospital after discharge. In short, there is plenty of reason for us to work hard and avoid postoperative complications. Surgical patients are also much more likely than other patients to experience deep venous thrombosis (DVT), and sometimes pulmonary embolism (PE), which is an immediately life- threatening complication (UT Health, 2015). PE and DVT result in 60,000 to 100,000 hospital deaths per year (CDC, 2015b). It is generally considered to be the most serious type of postoperative complication. Key Performance Measures So, the information presented above should make it clear that these are health problems worth studying and worth working to improve. Let us share the actual measures for these major health problems. Heart Failure Measures

 Complete discharge instructions must be provided.

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 Left ventricular function assessment must be performed.

 An ACE inhibitor or ARB medication must be prescribed at discharge.

 Smoking cessation instruction counseling must be provided (UT Health, 2015). Acute Myocardial Infarction Measures

 Aspirin must be given at time of arrival.

 Aspirin must be prescribed at time of discharge.

 ACE inhibitor or ARB medication must be prescribed at discharge.

 Smoking cessation instruction counseling must be provided.

 Beta blockers must be given at time of arrival.

 Beta blockers must be prescribed at time of discharge.

 Thrombolysis (clot busters) must be given within 30 minutes of arrival.

 Percutaneous coronary artery intervention (cardiac catheterization with angioplasty) must be done within 90 minutes of arrival (UT Health, 2015).

Pneumonia Measures

 Oxygenation assessment must be performed.

 Blood cultures must be performed within 24 hours of arrival.

 Blood cultures must be performed before the first dose of antibiotic is given in the hospital.

 Smoking cessation instruction counseling must be provided.

 Antibiotics must be started within six hours of arrival.

 An appropriate antibiotic must be selected for the patient.

 Influenza vaccination must be provided before discharge.

 Pneumococcal vaccination must be provided before discharge (UT Health, 2015). Surgical Care Improvement Conclusion The interesting thing about these measures is that none of them are particularly difficult to achieve, and most of them are not very expensive. However, our track record in making certain that these simple steps are taken for all patients has not been very good. There have been significant gaps and significant delays in treatment for many patients in U.S. hospitals. What all American hospitals are working toward today is a system of care in which every patient receives these fundamental diagnostics and therapeutics and has the best possible chance for survival and full recovery from these serious medical problems. Notes As you know, by the end of Unit VIII you will need to submit a management action plan (MAP) for grading. The MAP does comprise a significant portion of your overall course grade and deserves considerable planning and effort on your part. As you advance in your healthcare administration career, creating MAPs will be an important part of your work. Your CEO may ask you to prepare a MAP, or you may identify a problem in your own department that needs to be addressed. The MAP is simply a way of clearly stating a problem or opportunity for improvement (OFI), setting goals, brainstorming possible actions, and then synthesizing the best possible actions into a cohesive plan. Very important in this process is determining accountability (who will own various parts of the MAP) and establishing, in advance, how the success of the MAP will be measured. Healthcare administrators approach the MAP as a way of organizing their thoughts and their work, assuring accountability and accurate measurement of improvement. First, we need to be sure that we very clearly understand what the problem or OFI really is. That involves talking to the people who understand the problem best. Depending on the specific problem, those people may be patients, staff members, managers, and/or doctors. Let’s take the example of emergency room (ER) wait times—a common source of patient dissatisfaction with hospitals. In clarifying the problem, we will want to consider patient complaints, feedback from staff members, data provided by the ER director, and input from doctors and physician’s assistants

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(PAs) who work in the ER. Gathering input from all of these people allows us to clearly state the problem or OFI. Next, we try to set goals for problem solving that are realistic. For example, if our current average ER wait time is 50 minutes, we might set a goal of reducing the average wait time to 30 minutes with the goal being that we will achieve this 90 days from the start of our project. Patient satisfaction will be much better when the wait time is reduced to 30 minutes from 50 minutes. Next, we bring together all key players and brainstorm possible solutions. Often, that involves flowcharting the process and looking for bottlenecks. Is the problem with registration? Are there delays in nursing assessment? Does the holdup take place after the nursing assessment while the patient waits for a doctor? Maybe the problem is actually the number of ER rooms that we have available. Brainstorming is non- judgmental. We should simply brainstorm all possible solutions and put those on a whiteboard for discussion. Then, we focus on realistic options for making the needed improvements. Some possible solutions might seem beneficial, but they are unrealistic in terms of cost. For example, we might solve our ER wait time issue by staffing the ER at all times with three ER physicians instead of one ER physician and one PA. Patients would love that, but it is an $800,000 annual solution. We probably cannot afford to do that. Doubling the bed capacity of our ER might help, but that is a $20 million solution. We would need to be sure that capacity is the true problem before spending $20 million. Other solutions do not seem to address what we have identified as the real problem, so we focus on actions that are likely to help that we can fund and implement. The sequencing of our selected actions is also important. Accountability is next. It is so important to make key players in our organization accountable for the various steps in the MAP. A particular member of our leadership team needs to own each step and commit to a timeline for that step. Certainly the ER director, medical director, and chief nursing officer will have key accountabilities in our ER waiting time example. Finally, we must agree on how improvement will be measured. In our ER example, average waiting time is the likely measure, which is something that we track routinely anyway. We might also set parameters for the upper limit of wait times during peak periods, and we might set parameters for wait times in certain key diagnoses such as chest pain and acute abdominal pain. It is useful to put data points for these key measures on a graph displayed in the ER director’s office and the ER breakroom so that everyone can track our progress. The MAP is a very important part of this course. After the course ends, you will want to retain a copy of your MAP. It is an excellent way to demonstrate for potential employers that you have this skill set in hand as you join the organization. Click here to view an example of a completed MAP. In the example, you will see some strikethrough text. This is meant to represent ideas and strategies that you first considered when you were brainstorming ideas for the MAP, but then you decided not to include in the final MAP. You can leave those ideas in the MAP with an explanation of why you decided not to use them, or you can simply remove them before submitting your final version. Either option is fine. In this unit, you will need to select your MAP topic. In the assignment for this unit, you will either present an actual management problem from your own organization for instructor approval, or you will choose your topic from the list given to you in the Unit II Project Topic assignment.

References Cassiere, H. A. (1998). Severe pneumonia in the elderly: Risks, treatment, and preventions. Retrieved from

http://www.medscape.com/viewarticle/722306_1 Centers for Disease Control and Prevention. (2015a). Heart disease. Retrieved from

http://www.cdc.gov/heartdisease/facts.htm Centers for Disease Control and Prevention. (2015b). Venous thromboembolism (blood clots). Retrieved from

http://www.cdc.gov/ncbddd/dvt/data.html

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UT Health. (2015). CMS core measures: Evidence-based performance measurement. Retrieved from http://uthealth.utoledo.edu/depts/quality/docs/CMS%20Core%20Measures-%20basic.pdf