phha 430 final
You are meeting a group of new associates joining your well-managed HCO. You show them the mission on the HCO's website and say, "Our mission is very real to us. It's..."
"...a public declaration of intentions—why we're here."
You are staffing a PIT studying cardiology lab costs, and one member asks if the accounting department can estimate the cost of the individual processes the lab performs. "Good idea," you reply. "Our accounting people use activity-based costing (ABC). Even if they can only allocate cost to aggregates of similar tests, the estimates will help the PIT..."
"...compare our internal processes to outside vendors' bids."
You are on the team preparing for the board's annual retreat. The intern asks you why the HCO uses "five forces" to structure strategic OFIs, instead of SWOT. You reply, "That's a question that we've thought about with some care. We've chosen five forces because..."
"...the detail—customers, technology, resources, competitors, and potential changes—helps review all stakeholder concerns."
At the annual retreat, a board member says, "You keep talking about a community health strategy, broadening our services to meet more health needs. But why should we expand our mission? Our HCO is making good headway with excellence in care. Why shouldn't we stick with it?" You reply: "We will stick with it. We shouldn't attempt population health if it means lower quality and satisfaction scores for inpatient care. But..."
"...the move could reduce community healthcare costs and improve community health. It also helps our clinicians; we can plan future needs better. If our competitors move and we don't, we might lose market share."
You're the fellow, invited to sit in with the team preparing the strategic review for the board retreat. The VP marketing/strategy is chairing. During a break, she asks you if you can evaluate the HCO's risk posture. "No," you say, being candid, "but I did learn a framework for understanding risk—analyzers, prospectors, defenders, and reactors." Choose your best next comment:
"Analyzers deliberately balance innovation with excellence, looking for tested, low-risk change. Some research supports analyzers as the best posture for NFP HCOs."
A new member of the PIC asks, "The OFI we're talking about will use patient data on outcomes and satisfaction to evaluate new functional protocols. Are we allowed to do that under HIPAA rules? Do we need IRB approval?" As internal consulting (IC) staff to the PIC, you answer:
"For HIPAA, we deidentify the patients. For IRB, HHS has established an explicit right for HCOs to use data for process improvement without IRB approval."
PT has come in with a solid forecast of increased demand. Moving Social Service and expanding PT will meet their needs. If they get the new space, they are committed to making substantial gains in patient satisfaction and improvements in some patient outcomes. The orthopedics surgery service passed a resolution that expansion is a must. Social Service must move to a location on the second floor, and farther from the main entrance. Social Service is very upset. "Our patients need easy access, too," the chief says. "You're just giving it to PT because they make money and we don't. Our HCO's value of compassion is being ignored!" You reply:
"I understand. Let's ask the senior management team to review the decision. Kate Strate, in internal consulting, works on space planning. She can help you prepare your case.
On rounds, a service line manager tells the COO, "Internal consulting told us that our new equipment proposal wasn't good enough. The IC staff said it was 'hopeless,' so we dropped it. I still think it would have improved outcomes and patient satisfaction." What should the COO do and say?
"I will ask Jenny J., the IC manager, to meet with you. We'll work together to implement best practice."
Some of the surgeons in the service line you manage would like to acquire a new piece of equipment offered at $250,000. What do you say?
"I'll prepare a draft capital request for you to review. We'll need to rank-order requests within our service line first."
One of your responsibilities is linen service. It is supplied by an outside contractor on a three-year contract with 14 months to go. You receive a solicitation from a competing supplier, which claims it can cut laundry costs by 20 percent. "Thank you," you reply. "Our current supplier has a contract through more than a year from now." You continue:
"I'll see that your company is notified when we solicit bids for the next contract. You should understand that we will rate service as the prime objective—no shortages, no late deliveries, no wrong items. We will only consider bidders with a substantial record of excellent service."
At a training session for new nurse managers, one says, "I understand about our open communication and the blame-free approach. I'm ready to hear any of my staff's issues. But there are some limits. What about telling tales, criticizing coworkers, making fun of the values, saying we don't believe in the mission—that kind of thing? How do I handle that?" You reply, "Great question. That's a real test of your skill." You add:
"If it's questionable, ask for clarification. Your question is a message in itself. For a clear violation of values or mission, take the individual aside, explain, and warn. Repeated violation calls for stronger action. Get a consult from HR."
One of your first-line nursing managers is new. She's taken the HR budgeting course, using a software tool that allows her to track implications of changing staff and supply costs, but she says to her supervisor, "Why change? We don't need more people, and we'd be pressed with fewer." The supervisor should reply:
"If your cost per case is close to benchmark, and you are sure you can you make your quality and satisfaction goals, you can propose to stay the same as this year."
The chief of orthopedics drops by your office. "I hear you chair our HCO's space management program," he says. "Ortho is growing steadily. Our PTs do a good job, but the space is crowded, not as comfortable for patients as our biggest competitor, City-Wide PT. I note that the Social Service Department space next to PT isn't used all that much. Could you relocate them and give us their space?" "We can certainly look into it," you reply. You continue:
"Internal consulting can help PT plan the space, prepare a formal proposal, and also forecast the impact on the unit scorecard. I'll ask Sarah Smart, the leader there, to meet with you. The space committee will review the proposal. We have a good record of working out solutions."
The external audit report suggests that the auditing firm sells software that is "bullet-proof" on upcoding but maximizes income. The finance committee receives and discusses the report. The most recently appointed member says, "I move we ask the CFO to install the software." As CEO, you say:
"Let's investigate it a step further. I'd like the CFO to check for competing products. She can report next month."
In your internship at Sutter Health, the VP for environment asks you how you would evaluate their materials management. You reply:
"Materials management should have its own unit scorecard. I'd look for benchmarks and OFIs."
The orthopedic surgeons are worried. They think they are losing market share to a competing HCO. The chief of surgery tells the COO, "I think we should do something about it." The COO replies:
"Our marketing director and I will meet with them. Thanks for telling me."
At your fellowship interview at Memorial Hermann, your interviewer says, "With 26,000 employees and 5,500 physicians, Memorial Hermann has a big recruitment problem. What are the fundamentals to handle it?" You think for a moment, and then list the fundamental strategies:
"Retention comes first. It should be over 90 percent in every job category. Keep pay competitive. You need formal promotion; even with good retention, Hermann will need 3,000 new hires a year. Use satisfied colleagues; let them tell the story for you."
As CEO, you're concerned with some of the results on the accounting/finance (A/F) scorecard (exhibit 13.8). The cost and quality scores are excellent, but A/F worker satisfaction is low, and customer (both patients and other HCO units) satisfaction is worse. You've arranged a meeting with the CFO. What is key the "takeaway" you want convey?
"The A/F team needs to set and meet realistic improvement goals for next year on both associate and customer satisfaction."
Your HCO has a number of vendors providing various products and services. A member of the PIC asks how we treat vendor employees. "Are they treated the same as our associates? Do we have the same expectations? What should be our policy?" "Our goal should be to make them full partners," you respond. You add:
"They're empowered, and they follow our protocols. We should treat them as we do employed associates."
You're staffing the quality committee for the pediatrics service line. The committee concludes that rapid and complete team communication is essential for many inpatients. Changes in condition, parents' responses, and difficulties with treatments can be identified by any member of the care team. They need to be communicated quickly across large teams. Discussing the committee's concern with the pediatric leaders, you suggest:
"We could increase emphasis on teamwork in our training. It can be stressed for new hires, and first-line supervisors can be taught to encourage teamwork."
At a budget planning meeting, a senior leader from finance says, "We spend a ton on training. Do we have any concrete idea of what we get for the money?" "Interesting question," you respond...
"We get high scores on our measures of associates' satisfaction and engagement. Our units routinely make their improvement goals."
The environmental assessment documents steady progress toward benchmark on quality, cost, and patient satisfaction, but the forecasts show a substantial decline in total revenue, driven by reduced ED usage and fewer admissions for chronic diseases that are being managed with fewer hospitalizations. There is much emotional response. The CMO says the forecasts must be wrong. The CFO says the revenue losses endanger the borrowing covenants. The CEO says, "We'd better think about it overnight, but I want to meet tomorrow to pursue it." What should the VP planning say when the team reconvenes?
"We need fundamental restructuring—changed services or a revised merger or acquisition strategy."
You are the fellow at an HCO like Sharp HealthCare, in a city like San Diego, and your HCO is promoting its ACO. It wants to attract as many healthy and moderately ill patients as possible to balance those with chronic disease. The marketing VP tests you by asking, "What do we need to think about with this campaign?" You say:
"We should advertise at sites where people tend to be healthy. Maybe health and fitness clubs, churches, and senior citizen activities."
After your speech about the HCO's expansion plans at the public library, in the Q&A, a lady asks, "We read about these disasters that occur with poisonous or dangerous materials. I know there are a lot of dangerous things in hospitals. Can we be sure we're protected?" You reply:
"We train all our associates on safety, and we meet federal and state standards for various hazards. Our overall safety record is excellent."
Your CEO asks you how to evaluate progress of the local community health group. You say that an effective group should...
...establish quantitative goals for incidence and prevalence of preventable disease
Taking over as the new COO, you're checking out media relations. Meeting with the marketing director, you want to hear that her team...
...has a record of widely read releases, including social networking and crisis communications plans for negative events, and calls on the COO frequently for quotations.
One of the board finance committee's key jobs is establishing the appropriate level of debt. Listening to the committee's discussions as an observer, you know that long-term debt...
...increases financial risk and should be tested against worst-case scenarios.
The training program for first-line managers should demonstrate that they have learned that marketing/strategy...
...is available for consultation when questions arise, can help design new patient services, and help promote associate support of mission, vision, and values.
As COO, you know that internal consulting manages the epidemiologic planning model and that the applications drive scorecards and a great many decisions. You decide to review model application procedures with IC staff. You want to be sure that the statistical model incorporates multiple variables contributing to the demand for care and...
...is supported by experts and is regularly updated.
Briefing new first-line managers on the capital budget procedure (exhibit 14.9), you explain that the board finance committee must approve all capital projects. It...
...pays special attention to larger projects and those near the expected cut-off and can "drill down" to any level of detail on specific projects if it needs more information.
At a PIC meeting, a service line with fewer patients than their capacity asks that the HCO do more general advertising, "getting our name out in front of people, on billboards, TV, internet ads." As VP of marketing/strategy, you recognize the request as seeking a branding campaign. It's your job to make clear that branding...
...should be backed by high performance on quality and satisfaction.
Your HCO has an excellence-in-care mission. It began adopting the principles in chapters 1-3 three years ago. Outcomes, patient satisfaction, and associate satisfaction have all risen to the top 20 percent, many measures to the top 10 percent. Market share has risen, and profit has increased. Without plant expansion, the HCO will soon reach capacity. In the meantime, your two competitors have lost market share. One, which invested unwisely in new construction, may be financially challenged. Your senior management team is considering the following list of strategic options for the board retreat. 1—Begin discussions to acquire the faltering competitor. 2—Begin discussion to merge with the other, healthier competitor. 3—Use your demonstrated superiority to lure away a few of the best physicians still working at the faltering HCO. 4—Expand and strengthen your relationship with primary care providers, and plan to start an ACO. 5—Develop preliminary plans to expand plant capacity. 6—Begin discussions to move to a population health mission. What are the three options that the board should consider most carefully?
1, 2, and 5
The CFO reports that negotiations with private insurers are going badly. "Inflation has driven up purchase prices, and new care guidelines are more costly than earlier ones. Our largest payer is saying, 'No more.' They claim our competitors can live with it, and we should, too." Senior leadership rank-orders the following responses. Which of the responses do you argue is the most important?
Adjust the LRFP to the insurer's best offer, and report the results to the board finance committee with a recommendation to pursue both a and b.
People's reaction to disaster planning is usually a form of denial: "It can't happen here, so why should I take the disaster procedures seriously?" As a representative of management, you need several good answers on the tip of your tongue. They include:
All of the above
The local chapter of the Human Rights Campaign has asked for a speaker to describe how the HCO meets the association's members' needs. The HRC website rates HCOs according to its "Core Four" criteria: Patient Non-Discrimination, Equal Visitation, Employment Non-Discrimination, and Training in LGBT Patient-Centered Care. Your HCO, like many, is not rated, but the description says, "We did not find an LGBTQ-inclusive patient nondiscrimination policy." The cause seems to be that your patient information addresses only "sexual orientation," without adding "gender identity." You start an amendment process, but it will require committee reviews lasting at least six months. What else do you do to prepare?
All of the above
You're staffing a PIT to review internal consulting (IC) services. At the first meeting, you explain that a sound plan for the PIT should include which of the following
Answer c, plus an effort to identify best practices of similar, noncompeting HCOs
As a management intern, you are a little late one morning, but you see an elderly couple ahead of you in the parking lot. She's helping him; he seems to be having trouble walking. There's at least 100 yards to go, just to the clinic door. What do you do?
Ask them, "Would you like me to get you a wheelchair?" Get it, even if they decline, wheel them to a reception station, and make sure the receptionist can help them reach their clinic.
The SEIU has filed paperwork for an organizing drive at your HCO. It will focus on your clinical technician associates. Counsel suggests that management's response emphasize positives, avoiding threats. "You can probably convince most workers that union dues are not worth the money." You'll want counsel to review any statement, but what are the basic points against unionization?
Competitive pay, empowerment, training and promotion opportunities, high retention and worker satisfaction
You are staffing a PIT making sure that the HCO utilities (power, water, sewage, fuel) are best practice. Your mental checklist includes which of the following?
Compliance with code, very low failure rate, dual or triple sources, disaster drills and failure simulations, plans for catastrophic or extended failures
The VP for planning and continuous improvement always participates in the training of new first-line managers. She wants the new leaders to take away a few key concepts. She emphasizes that her team can do which of the following?
Help a lot with process improvement, capital budget requests, and 90-day plans
There's an undercurrent of dissatisfaction with the nursing scheduling system. Senior leadership decides it's an OFI. You will staff a PIT. What's your plan?
Identify by unit the number of shifts where staffing was below standard, at standard, and above standard, and recover comments about scheduling in nursing personnel satisfaction surveys. Review this with the PIT's chair before the first meeting.
You meet a colleague at a bar after an ACHE meeting. The colleague says, "I'm scared of this incentive pay that all the Baldrige winners are using. Incentive pay has a long history, a lot of it bad. We might be walking into real trouble." You don't have to reply, but you think about it. He's right about the history. Yet the approach seems to be working at your HCO and many others. What are the factors that have made it a success?
It is outcomes driven, with negotiated goals supported by tested process changes, training, and 90-day plans for recovery.
In several questions in this quiz, a nurse manager encounters realistic situations and can make some serious errors. How does an excellent HCO make sure he answers correctly?
It trains him, gives him a coach with more seniority, and rounds so that he and his staff can approach senior management directly.
In a PIT reviewing procedures for using external consultants, you are prepared to argue that the following step helps ensure high value for dollars spent:
Outside consultants should be hired through and supervised by internal consultants.
A religious leader on your governing board suggests that low income is an important cause of disease and preventable use of HCO services. She proposes that the HCO lead the community by raising pay levels for its lowest earners by about 50 percent, and require its contractors to do the same. "Getting everybody in our community a living wage is a first step to health," she says. Senior leadership is asked to report on the proposal.
Prepare a report documenting the impact on the HCO. Recommend that the HCO promote a community-wide program to increase income of low-wage workers, noting that the concept has promise, but also complexity and risk.
You're on the team at step 4 of exhibit 14.9: "Senior leadership and medical staff rank the lists from all service lines and activities." You notice that two proposals from two different units are synergistic; if done together, they will generate bigger improvements and be significantly cheaper than the individual proposals claim. But these are not units that report to you; if their proposals move up, funding chances for your units go down. What should you do?
Raise your hand, and explain your idea.
You meet weekly with the COO, who seems to be preparing you for promotion. One day she says, "We buy most environment of care services from outside vendors, but we have a few services that we make. Why should we make those? What are the criteria that determine whether we make or buy a specific service?" You reply, "Well, of course we want low cost, but just low cost could get us into trouble. Let me think about it till next week." Which approach should you use at your next meeting?
Supplier change (either way) is an OFI if there's a substantial price advantage or a reliability advantage, or if we are far from benchmark costs."
Senior leadership learns that several first-line managers are complaining about the goal-setting process. They say that the budget office isn't helpful—recalculation for changes is slow, the budget office doesn't explain changes, and one says, "The budget office is snarky." What next?
The COO and CFO round to the budget office. They solicit and listen to comments from the team on how the work is going. The COO speaks briefly on why prompt, responsive service is essential, and suggests that the finance team form a PIT to make sure its internal customers are satisfied.
At the senior leadership team meeting, the CFO remarks, "I'd like to move to transfer pricing for specific services wherever we can." "Good idea," the CEO says. "Why don't we ask our fellow to work on a plan for transition? How could we move smoothly from what we have to a transfer pricing approach?" You, the fellow, think, "I'd better get some concepts in mind, or the CFO will eat me for lunch." You check exhibit 12.8. There are three advantages listed, and two of them (benchmarking and bidding) relate solely to the service provider, not the user. You decide to suggest which of the following?
We will need to educate managers in the change and its implications. Let's form a PIT to do some trials."
Describing the HCO's audit and compliance program to a new board member, you want to mention that it...
all of the above
You're staffing a PIT that is evaluating improvements to a work process. An outside vendor proposes to provide the process, meeting your quality and service specifications for a unit cost that is lower than the activity-based costing (ABC) unit cost of doing it in house. The vendor is fully qualified; there's no reason to think it would not produce effectively on a contract at that price. A member of the PIT says, "I guess that settles it. We should accept the vendor's proposal." You say:
both b and c
A trustee says, "We're asked to invest big sums of money based on forecasts of demand. How do we know those forecasts are accurate?" You reply, "That's a great question. We use a sophisticated planning model that..." What's your strongest point?
"...has a good track record, not just here but among other clients."
Orienting a group of new patient care assistants, you explain that functional protocols or "standard work"...
"...help us guard against errors and omissions. You can always access the protocol, and sometimes a video, on our computers."
As you start your internship at North Mississippi Health Services (NMHS), you know that they emphasize "service excellence" (see exhibit 2.2). Your preceptor asks, "Do you know why this is important?" Your best reply is, "It's because..."
"...it shows that, if all the parts of NMHS support each other, we will thrive."
The CIO comments in a senior leadership meeting, "We're implementing best practice from Memorial Sugar Land (see exhibit 10.5). It does not address disaster planning, though. I'd like to form a PIT to consider implications of long-term power loss, protection of data against theft, how to coordinate transfer of data if patients must be moved and our system is down, and issues like that." The COO says, "Sure, but..."
"...maybe we should dedicate a senior leadership meeting to thinking through the charge."
You're recruiting a physician to join your HCO. She says, "The story you tell, of what you call empowerment and continuous improvement, sounds good, and I contacted some people I know on your clinical staff. They say very complimentary things, that your HCO delivers, and they like practicing there. My concern is this: I'm making basically a lifetime commitment. How do I know the HCO will continue to be cutting-edge?" You begin, "Well, nobody can foresee the future, but..." What's the best way to complete the sentence?
"...our record is our best argument. We've got growing market share, delighted patients, and enthusiastic associates."
You want to describe evidence-based management (EBM) to a group of civic leaders. Which of the following would you start with?
"EBM replaces authority and opinion with fact."
A few days after the systemwide planning retreat (May-Aug., #4, in exhibit 3.7), a first-line manager says to a rounding senior manager, "The PIC did not fund any of our OFIs. I don't think we can improve any scorecard goals next year." What is the best response?
"I'm sorry. Can you and I meet with your manager, to plan what to do?"
You're on the search committee to replace the CIO at a high-performing HCO. The leading candidate asks you, "How can I be sure that your HCO will provide adequate capital investment funds?" You reply:
"The board's policy is (state what the policy is—so much per year earmarked for IT or to judge IT requests with all capital needs). Here's our record in recent years."
A new member of the board quality committee wants to know more about "standard work"—that is, functional protocols. You say, "They are guidelines for clinical procedures, like hand-washing and catheterization." You continue:
"They standardize practice to ensure consistent safety and effectiveness."
The chief of your new and highly successful ACO says, "Prescription drug costs for some of our outpatients can bankrupt them. They don't fill their scrips, and then they turn up in the ED, where we either get Medicaid or write it off. Can we set up a PIT to find the best solution?" "Sure, doctor," you reply...
"What's your thinking about membership? It sounds like pharmacy, social service, and accounting should be involved."
All of the following statements about empowerment are true. Select the one most important to convey to associates.
Empowerment gives an associate the ability to control his or her work situation in ways consistent with the mission and values.
Your lunch friends—young nurses and doctors—complain steadily about the EHR. "Takes forever" and "can't find" are common threads. You should:
Find out if there are EHR OFIs about speed and search, and report back to your friends.
Your ACO is going well, but the primary care chief, who provides critical leadership, decides to retire. The replacement in your succession plan, Dr. A., will be interim chief, but she declines the permanent post, saying she needs to get her kids out of high school, another two years. The senior management team is debating what to do next. What do you recommend?
Meet with the current chief, and Dr. A., to see how to make the job manageable for Dr. A.
Reviewing the scorecards of the clinical support services (CSS) you manage, you know they have several opportunities to increase appropriate demand. Which of the following would you not recommend as a way to increase volume and cut unit cost?
Offering a discount to patients of high-volume attendings
Your membership checklist for a population health advocacy group includes the following: • Local and state health departments • Competing HCOs and the county medical society • K-12 schools, police, and social services departments • United Way, chamber of commerce, and local business groups • Local religious leaders • Disease-specific support groups, such as the cancer society and arthritis foundation The COO says it's unmanageably long. Now what?
Suggest that the HCO start by building support with the health departments, competitors, and the medical society, with plans to expand around that core.
At a PIT discussing improving hospital-initiated infection rates, somebody says, "We have the right protocols. What are the tools we have to improve compliance?" Your reply should address which of the following?
Training, reward, reminders
Pursuing the nurse's complaint in the previous question, you look up the lab's patient waiting time results and goals on its scorecard. It's not there, but patient satisfaction is lower than nursing or most other CSS. You talk to the lab manager, who says that delays happen sometimes, and they're not avoidable. He adds that the EHR records arrival and service times by patient.
You complete the actions described in option b and thank the nurse manager for identifying an OFI.
You're the nonclinical service line administrator for a group of nursing units. You monitor the clinical results by scanning the scorecards for goal achievement in outcomes quality, HCAHPS, NDNQI, cost, turnover, and associate satisfaction.
You review the whole scorecard with the nurse managers of each unit.
Why is a values statement important? Like the mission, many associates will assume that it's window dressing. What does leadership need to say? "We're serious about our values, and they are important because..."
all of the above
You're an intern at a high-performing HCO with a community health mission. Your preceptor says, "We're about to start our annual review process. We need to put together the book for the board retreat. Here's last year's. Look it over. It was organized into 'Customers/Market,' 'Med Staff and Associates,' 'Insurance Trends,' and 'Financials.' I wonder if we can organize it better?" You think about it and look back at exhibit 3.2. It's clear this isn't an amateur effort, so you'll start with something like, "Last year's arrangement was certainly strong. Do you think we should add a section about..."
"...community health needs?"
You're starting a campaign to "brand" your ACO, population health mission, and community health coalition. A professional promotional firm will help you. They ask you for a central theme statement. Which of the following is best? "Our new ACO will..."
"...expand our award-winning, high-quality, patient-sensitive care. We're proud to be part of a community-wide effort toward good health."
You're on a team of senior managers preparing the annual planning data for the board retreat, step 1 of exhibit 3.7. One of the team members says, "Our quality and satisfaction will look good, but our costs don't. I think we should say that the cost benchmarks are not realistic for places like us." Pick the single best reply.
"I think we're obligated to report all the facts, maybe especially the unpleasant ones."
Newcomers are often impressed at the complexity of the measurement system for individual work teams (see exhibits 3.3, 3.4, and 3.5). Explaining the measures to them, which of the following statements is least useful?
"Many of the measures are reported by Medicare."
Rounding in the doctors' lounge, you hear Sam, an older physician, say, "I don't understand this Magnet nursing stuff. I guess it's just a recruitment gimmick." A younger doctor, Jane, replies, "Well, nursing has a big role." She's interrupted by George, who says, "Nursing's got too big for itself. There's no such thing as a nursing diagnosis." You might just let them ventilate, but if you join in, what is your best line?
"Nursing makes a proven contribution to shorter stays, better recovery, and better patient satisfaction."
The board is considering changing from an excellence-in-care mission to a population health mission. One member says, "Why should we do this? We will be jack of all trades, master of none." The CEO should say: "Our scorecard shows we are masters of acute care..."
"Population health will help control health insurance costs. We think we can move toward it without endangering our care."
You're part of the strategy team at a small NFP HCO with a strong patient-care mission. The question of joining are large system comes up. One of the senior managers asks you, "Just in general, why might we do that?" You reply, "I think the most important reason might be..."
"The system will help us do a better job of supporting patient care."
You're on a PIT that's charged to improve your HCO's strategic scorecard (exhibits 3.3 and 3.5), and a number of additions and deletions have been suggested. It's clear that the PIT will need some criteria for deciding what to include. What will you emphasize when you explain the charge to them?
"The underlying criterion is the sense of importance to mission."
A clinical staff member says he thinks a guideline should be changed. The nurse manager should reply:
"Why? You'll have to explain why to the service line chief, but maybe I can help."
You're explaining your HCO's approach to a new attending physician. You want to be sure she understands that...
...the attending physician leads the care team that applies evidence-based guidelines to each patient's needs.
Your HCO has several clinical services, and a record of improvement on quality, patient satisfaction, and associate satisfaction in most of them. One service is lagging. Guidelines are not routinely used, and the clinicians argue over guidelines. Outcomes quality and patient satisfaction are the lowest in the HCO, although still better than national medians. Senior leadership debates, and decides...
...to form a PIT of clinicians in the service, chaired by the chief of a similar service with top or near top scores on all the unit scorecard dimensions.
A couple years after your fellowship at a high-performing HCO, you are offered a seat on the knowledge management planning committee. You accept, knowing that it's a growth opportunity for you personally because the committee...
All of the above
A new board member asks, "How do we know that the board is doing a good job?" You reply, "Good question! The answer isn't easy, but there are several important indicators..."
All of the above
A promising young associate, just promoted to first-line leadership, asks you, "Can you list a few skills I should think about and work on to become a really good transformational leader?" You begin your reply, "I think these are what you should emphasize." Which skills do you include in your list?
All of the above
A trustee says, "You have said that the right diagnosis is critical. How does the HCO help its clinicians make good diagnoses?" You reply, "Our HCO does several things to support reaching the right diagnosis quickly on every patient, including..."
All of the above
As an administrative resident at a Baldrige-winning healthcare system, you report to the COO. She says, "Let's improve improvement. Where do we look for OFIs in our goal-setting and continuous improvement programs?" You reply, "Well, we could..."
All of the above
At your interview to get employed as a manager at Atlanticare, the interviewer presses you. "You've said you admire Atlanticare's worker empowerment. What do our leaders need to do to make sure worker enthusiasm actually improves mission achievement?" You answer: "Leaders need to make sure..."
All of the above
After several years of strenuous effort, nurse retention is now 90 percent across every unit, and 95 percent in two units. Senior leadership debates what to do about it. Several ideas are proposed, and the CEO asks you which you think should be pursued. You choose:
Both b and c
You staff your HCO's credentialing committee. At a meeting, you hear one older member grumble to another, "Credentialing these nurse practitioners is stupid. They are not as good as doctors, and they cut into our income." What is your response?
Discuss the comment with the chair, encouraging the chair to take a few minutes to reinforce why the HCO needs and credentials nurse practitioners and other nonphysician LIPs.
As fellow, you take your regular rotation on call for senior leadership. One evening, a trustee calls, very upset. He's in your emergency department. His elderly mother has been in the ED for two hours, and nothing seems to be happening. He'd like your help to get her admitted. You go to ED, where the physician managing her case reports that she's been examined and diagnosed, and will be admitted. She's waiting for an appropriate inpatient bed. You thank the emergency physician, and together you explain to the trustee. You call the CEO to alert her. What else should you do?
Go to the floor where the patient will be admitted. Ask the floor charge nurse what the plan is and when a room will be available. Report that back to the trustee.
You are part of the staff of the large PIT that has just begun a deliberate effort to reduce readmissions. Checking IHI.org, you note that they have a number of documents on the subject (www.ihi.org/explore/Readmissions/Pages/default.aspx). After reading the supporting documents, how should you proceed?
Talk with the PIT chair about the IHI work and how to use it.
Orienting a group of new associates on the HCO's values, you want them to take away all of the following points. Which one should you start with?
The values make the HCO a great place to give care.
Attending a meeting of your HCO's primary care physicians, you hear a lot of complaints. "The EHR's a pain"; "I can't spend the time I should with patients"; "You have to check every box, 'No, this man is not pregnant. Yes, this 80 year old has arthritis. It's a waste of time.'" You decide:
To ask the practitioners if they would serve on a PIT to make the EHR less obtrusive
Your preceptor says, "When I started out, it was 'command and control.' Somebody, usually a doctor, gave an order, and everybody was supposed to jump. Now it's 'encourage, reward, and celebrate.' Does that work as well?" You respond:
"Actually, when it's combined with benchmarks and continuous improvement, it works better than command and control."
An orthopedist on staff says, "My residency hospital in the Intermountain system used some patient recovery measures that aren't on my unit's scorecard. They were helpful, because they focused on improving function." You reply:
"Can you explain them to me? I'll check the literature and draft a proposal for your review. It will have to be reviewed by orthopedics and the KM planning committee."
You've been working for two years at an HCO that works hard at maintaining an environment where all associates are empowered and motivated to meet their customers' needs. A woman you knew in college moves to town. She's now an experienced baccalaureate-prepared nurse, and she asks if she should apply to your HCO or a competitor. You say:
"Come here. It's a great place to give care. I can introduce you to several nurses I know you'll like."
A colleague at the HCO where you are a manager says, "Rounding takes a lot of time. I wonder why the senior leadership team wants us to spend five hours a week at it." You think before you answer, and conclude that your strongest response is:
"Rounding encourages workers and first-line managers to raise questions and get answers."
Your internship preceptor asks, "I want to know if we have everything we need in our knowledge management system. Do you think you could start a review? You reply:
"Sure, I'd start with the Poudre Valley summary in my textbook from class."
On rounds with the nursing supervisor, a nurse manager says, "We've had a lot of problems with laundry. Deliveries are coming too late for our bed changing, and it's complicating our day." What's your best response?
"Tell me more about that. Is this a recent problem? What time does the linen arrive, and what time do you need it?"
A nurse manager complains to a rounding senior leader: "My mom had to wait an hour in the lab yesterday to get her blood drawn, and I could have done it for her. The lab is always behind. Why can't they keep up?" The senior leader might reply, "Gee, I'm sorry to hear that..."
"That sounds like an OFI. I'll look into it and keep you posted. How is your mom now?"
In your internship, one of the younger people on the senior leadership team reflects, "You know that, when you're a leader, any associate or patient comment should get a constructive response. When I started, I had a lot of trouble understanding what 'constructive response' means. What do you think that term means?" You reply, "I think it means..."
"...solving the problem raised if you can and accepting it as an OFI if you can't."
A curious associate asks, "Who owns our HCO?" It's a nonreligious not-for-profit that is a subsidiary of a larger system with many HCOs (like Sharp, Henry Ford, or Sutter Health). You respond, "The individual HCOs are owned by..."
"...the communities they serve."
The therapist in the previous question continues: "What if I think an order for a patient might be wrong—not harmful, but incomplete, or a little off base? What should I do?" You reply: "If it's harmful, of course, never do it. If it's not..."
"...you should try to reach the attending to revise the order. If you can't, you decide what's best for the patient. You might check with your manager."
The board is reviewing the recommendations of the Clinical Staff Executive Committee, which has advised that a certain internist not be reappointed. Ms. Jones, a trustee, says, "Gee, he's my physician!" A physician trustee says, "We have followed procedures in the bylaws related to impairment (substance abuse), and we have an obligation to protect our patients." The CEO looks at the chair, who looks stunned. The CEO says:
"Gee, that's unfortunate. Ms. Jones may need to recuse herself from the discussion and vote. We all need to remember that these discussions are strictly confidential."
In your HCO fellowship, you meet on a biweekly basis with the CEO. Today, she says, "I'm off to a meeting of the board nominating/governance committee. It will be a while before you get to go to one; they are very confidential. But tell me what I should be looking for at the meeting. How do I monitor the committee's functioning?" You reply:
"I think I'd work off exhibit 4.3. Could we make a checklist of how well the board is doing on the ten items and use it as a survey?"
On rounds, the OR supervisor motions you into her office and closes the door. "Yesterday, Dr. Smith showed up late for his afternoon case. I don't know how to put it. The operation went okay, but he dropped some instruments on the floor, and the assistant did a lot of the work. But afterwards, the scrub nurse said she smelled alcohol on his breath." You reply: "Thanks for bringing this up. I know it's tough..."
"I think the chair of the Department of Surgery needs to be notified as soon as possible. Let's call her right now."
A registered nurse on the HCO's staff says, "The patient care assistant, Mary Smith, doesn't seem to know what she's doing. She takes forever. Yesterday, she took 30 minutes to change an empty bed." The nurse's immediate supervisor should reply:
"I will observe her and see if we can get some better results. Keep me posted."
Your interview at Memorial Hermann has gone well. As the day draws to a close, a member of the search committee asks, "What are you looking for from us? What do you think Hermann can offer you?" You respond:
"I'd like a chance to learn by doing, with guidance from people who know best practice. I hope I can win promotion. I'd like a plan for my personal development. If my partner can get a position where we live, Hermann is my first choice."
A young patient care assistant, Sally Jones, tells her nurse manager, "Dr. Baker asked me to meet him for a drink in his office after work. When I said no, he said, "I can make life a lot better for you." The nurse manager should reply:
"I'll call Human Resources for you. They will want you to meet with a counselor. What you say will be confidential, and it won't be used against you."
At many excellent HCOs, the CEO reviews the mission with all new hires. When you're hired as a young manager, you attend with all the other hires. At the coffee break, you hear one new hire say, "The boss really put emphasis on the mission and stuff. I wonder if he really means it." What is your best comment?
"I'm pretty sure he does. You could ask coworkers on your team."
Your aunt Sarah, who lives in another city, is selecting a care provider. She says, "I've looked up two cardiologists in my insurance panel. Each is privileged at a different hospital. Does the hospital make any difference?" You reply: "It might make a difference. I'll look up the record of each on WhyNotTheBest.org..."
"If you go to one that takes quality seriously, you'll know not only that your cardiologist is competent but also that other specialists you might need are competent."
Meeting with a small group of newly hired therapists, you tell them the HCO is committed to excellence and gets there through continuous improvement, with measures, benchmarks, OFIs, PITs, and goals. One of the therapists asks, "What does that mean for therapists?" You reply:
"It means doing your best job with every patient, helping meet your team's scorecard goals, following protocols, and speaking up when you see an OFI."
The PIT (from the previous question) is formed, and extensive discussions occur in and around it. Several of the radiologists now approach the HCO with a proposal to purchase equipment for advanced computer-aided mammography. (See Zhang and Xiao, "Diagnostic Value of Nineteen Different Imaging Methods for Patients with Breast Cancer: A Network Meta-Analysis," Cellular Physiology & Biochemistry 46 (5): 2041-55, 2018.) The COO asks your opinion. You reply:
"It's complicated, and probably high risk, but we ought to negotiate. "
During rounding, a recently employed nurse says he is happy to be here, but at Mass General, the nursing care plans for his service were more thorough. The nurses took several steps that his colleagues here don't always do. The CNO replies:
"It's great you worked at Mass General. Could you discuss the differences in our practice council?"
Serena Smart, a leader of the African American community, accepts nomination to your governing board. Of course, senior leadership briefs her on how the board works. "Tell me more about the governance committee," she says. "It's a concept I haven't encountered before." Your reply begins:
"It's worked well for us. It systematically monitors board activity, identifies OFIs, and applies continuous improvement to board activities."
At a senior leadership meeting, the COO says, "We need to know how to make nursing more effective. What can we do collectively to improve nursing unit scorecards?" The CNO replies, "I'm not sure what we could do collectively. I think the only way to improve our scores is to work in each service line, which we're doing." What should the COO say next?
"Let's form a small PIT to check for new options. We could look over the OFIs collectively, to see if they share any themes."
While you're lunching with a group of young nurses, one of them says, "On my unit, we seem to have had an increase in catheter-associated urinary tract infections (CAUTIs), but the rate on monthly report does not show it. My nurse manager says not to worry about it. Do you think she's right?" You respond:
"Maybe not. Do you have any idea why it's changing?"
Your HCO is part of a large not-for-profit system. You are recruiting a prominent local citizen to join the local governing board. "Let's be candid," the citizen says. "This is just an honorific post. All the real decisions are made by your corporate office." "I'm glad you brought that up," you reply. "Our system wants strong local input. The central office expects its local boards to initiate all local actions." You continue:
"Our system wants local board members who will help us achieve our mission here in this community. It's a working board, about a day a month of your time."
As a fellow in a high-performing HCO, you often take time for coffee with the house officers and younger nurses. One of them comments, "Our electronic health record (EHR) is a pain. It's too slow, too complicated." When you reply, "Really?," she says, "It's hard to find critical parts of the history. I was looking for patient advocate and advance directives yesterday, and it took forever." Which of the following should start your reply?
"That sounds like an OFI. I'll see what Info Services says and get back to you."
As an administrative fellow, you are rounding with the CMO, visiting an office of primary care practitioners. The leader of the group complains that committees take a lot of time. She'd like the HCO to pay for the time. You know that the CMO should answer:
"That's not easy to do, but I think we should set up a PIT to consider it."
Several members of your radiology group are in independent practices specializing in mammograms. As the literature reports, the 2009 recommendations of the US Preventive Services Task Force, which cut the recommended frequency of examinations in half, had virtually no impact on their practice. (The recommendations were opposed by the American Cancer Society, the American College of Radiology, and the American College of Obstetricians and Gynecologists.) Now, however, several healthcare insurers drop coverage to the USPSTF level. A radiologist friend of yours asks, "What is the HCO's obligation to help us out?" You reply:
"The HCO could set up a PIT to discuss it. We could limit recruitment of radiologists if the PIT recommends it."
Your HCO's population health strategy is just beginning, but it is going well. Dr. S., a high-volume surgeon, says, "This ACO and community health stuff is a serious mistake. It will reduce the HCO's revenue, eliminate profits, and keep us from maintaining state-of-the-art critical care, which is our real mission." His views are quickly noticed by the board, which asks senior management for a response. The response should be:
"The board reviewed our forecasts of volumes and finances with and without our ACO strategy. They showed that the HCO will continue to generate cash for new technology. We will review these with Dr. S."
As fellow at an HCO like Charleston Area Medical Center, you spend a month with the chief medical officer. She says, "There's a big rhubarb in anesthesia. The anesthesiologists limited the nurse anesthetists (CRNAs) from certain procedures, and now the CRNAs are threatening to strike. I think there are attitude problems, too; some of the older anesthesiologists are quick with the put-downs. What do you think I should do?" You respond, "Let's form a PIT." You go on:
"The charge should be addressing expressed concerns of the CRNAs."
A newly hired nurse wants to know, "What if our nursing care plan conflicts with the clinical management protocol? What if the patient needs something unique that's not in the protocol?" Which of the following do you include in your response?
"The need should be brought up during rounds and the decision entered in the IPOC. If it's recurring, bring it up at your practice council."
WMHO defines stakeholders as having "a direct interest in an organization's success." A PIT studying a not-for-profit HCO's mission wants to know, "Are some stakeholders more important than others? Can we give priority to the interests of some group of stakeholders at the expense of others shown in exhibit 1.3?" You reply:
"They all have equal rights. If their 'direct interests' are not met, any stakeholder group can close us down."
You are orienting a group of newly appointed first-line managers. The takeaway you want them to remember most is that the HCO's not-for-profit governing board...
...is legally responsible for ensuring the quality of care and must monitor quality of care to maintain accreditation.
In midyear, a first-line manager says to a rounding senior manager, "We're not making a couple of our goals for this year." What is the best response?
"We can bring in a team to help you out and make a 90-day plan for recovery. Can you and I meet with your manager, to plan what to do?"
The new urology medical director says, "The trend to fewer prostatectomies is hurting some of our doctors' income. Can we do anything about that?" You reply, "Maybe. We can use our planning model to forecast the number of urology procedures each year, by procedure." You continue:
"We can present the forecasts to the urologists and follow up with a survey of practice intentions. If it shows an oversupply, we can recommend to the board that we close the service to new members."
You are addressing a group of newly hired associates. You will mention all of the following points to help them understand the HCO's continuous improvement philosophy. What's the most critical takeaway?
"We deliver on our promises—that is, we set realistic goals and meet them."
At an associate forum, one associate asks if the HCO can add free parking as an employment benefit. You reply:
"We try to add benefits that are useful to a large number of employees and don't give an advantage to some employees. Many employees car-pool or use public transportation."
The new director of the orthopedics service line says, "Our post-op complications are higher than they could be—can you help me deal with these?" You reply, "Absolutely," and continue...
"We use PITs to work on problems like this. You know how it works; you've served on several."
Your community's population health council was formed as a voluntary association. It has no corporate status, but it has made significant progress, establishing a set of measurable goals and a strategy for each. One goal, "Coordinate our FQHCs, HCOs, and ACOs to provide appropriate care for all citizens," will be measured by hospitalization rates of ambulatory care-sensitive diseases and a household survey administered by the local health department. At the council meeting, the chair, who is the county public health officer, proposes that all three of the county's HCOs meet to discuss how to serve the entire city with ACOs. As the representative of one HCO, you reply:
"We welcome such a discussion. To make sure we're complying with the law, I'll ask our HCO's general counsel to confer with you."
You give a public talk on your HCO's achievements at the local community college. In the Q&A, a lady asks, "I've heard the electronic records are not really safe, but you said they were a big success. How can we be sure our information is protected?" "I understand your concern," you reply. You continue:
"Whether they are paper or electronic, patient records are subject to various risks. We meet or surpass national privacy standards. Outside auditors have given us a high score. We've met all the auditors' recommendations."
Interviewing for a position at Sharp Healthcare, you are asked, "Are you familiar with our 12 Behavior Standards? We want all our managers, even our beginners, to exemplify them. Do you think you can do that?" Which is the best response?
"Yes, of course. I studied them with my class at __________. I especially like 'All For One, One For All'" (or any other one that you remember).
A registered nurse on the HCO's staff says, "These checklists are nothing but a pain. It takes time to enter them into the record, and they almost never help the patient." His nursing manager should reply:
"Yes, they do take a few minutes, but they prevent really serious problems."
The board is reviewing the strategic scorecard, which is modeled on exhibit 3.4. A member asks, "There are three yellows—weren't they there last month?" The COO, who is a guest at the meeting, gets a nod from the chair. He says.
"Yes, we've instituted 90-day plans for all three." He then briefly summarizes progress and identifies any difficulty that might lead to year end failure.
Your HCO has offered free screening for all comers at health fairs, county fairs, and similar events, with weight and body mass index, blood pressure, diabetes, prostatic cancers, and cholesterol. The health department representative on the newly formed community population health committee says, "That's not population health; it's care promotion. It raises community health costs without noticeably impacting disease. You should redesign the program, drop several of those tests, and make the rest age and sex specific." What is your response?
"You might be right. It will take some study, but let's work out a stronger offering."
You are staffing a PIT to implement an accountable care organization. The PIT's initial list of criteria for success include team care, emphasizing clinical support service professionals; holistic care plans; community support; and an outcomes-oriented scorecard. You consider proposing...
...adding palliative and end-of-life care, because it's a critical element for many patients
In your fellowship at a high-performing HCO, the CIO asks, "Is our communication to associates what it should be? Ideally, every associate should know all the general policies related to their job. How could we identify communications OFIs? Give me your thoughts on that, to help me decide whether we should do a more extensive review." You go back to your office and start a list of ways to assess HCO-to-associate communication. Your initial thoughts include the following options: 1—Every PIT could report to KM planning on what they feel are communication OFIs.2—Add questions to the employee satisfaction survey. 3—Study unexpected-event reports to identify cases where communication failed.4—Offer all intranet users a voluntary follow-up survey, "Was this the info you needed?"5—Ask senior management to ask first-line managers on rounds, "What do associates not know but should?"6—Ask for comments in exit interviews of voluntary terminations.Now report the three best back to the CIO. Which do you choose?
1,3, and 5
You are interviewing for an HCO CEO position, and a search committee member asks, "What kinds of reports should the board receive?" You reply, "The board should receive several items at every meeting." Which of the following should be your list?
A "state of the HCO" report by the CEO; the strategic scorecard; any new accreditation, regulations, or legal actions; any changes in clinical staff appointments or bylaws
Excellence is defined as "safe, effective, patient-centered, timely, efficient, and equitable." A new associate asks you why "safe" is first. You reply:
All of the above
In a discussion about the ACO, a new trustee asks, "How do nurses impact readmissions and success measures for the ACO?" The CNO should reply, noting:
All of the above
Responsive or "servant" leadership emphasizes listening. Explain to your BFF or your mom why listening by managers at all levels is important.
All of the above
Your HCO has had a contract with a group of radiologists that expires in nine months. You prepare for negotiations by listing the five most important things to the HCO in the relationship. Safe, effective, and timely care comes first, followed by what?
Continuous improvement, patient satisfaction, credentialed practitioner satisfaction, low cost
Community health needs assessments (CHNA) are required of all 501c3 hospitals at three-year intervals under the Affordable Care Act (see www.irs.gov/charities-non-profits/charitable-organizations/new-requirements-for-501c3-hospitals-under-the-affordable-care-act). You are preparing the CHNA for your HCO. Following the spirit of the law, you assemble the HCO's demand forecasts for preventable chronic disease and post-acute services. Your assessment should also include information about:
Relations with other agencies committed to community health, and local plans to address health disparities
The senior leadership council is debating a proposal to modify the mission to include population health. The COO notes that, although quality measures are generally well above median, two small service lines have important OFIs. "Should we fix those first?" she asks. In the discussion that follows, you suggest, "We should move forward with population health." You continue:
So long as the work on population health and support for those services don't conflict."
As the intern in a large HCO, you are alone in an elevator until two patient care techs and two guests enter. The PCAs are talking about "Ms. Jones," who apparently has some complication to her surgery. As you hear them, you decide:
To tap one on the shoulder and point to a sign that says, "Do not discuss patient matters in public"
