October 13, 2010
4:30 – 5:30 pm
New Hospital–Physician Structures for
Quality and Fiscal Accountability
David Brooks, Chief Executive Officer,
Providence Regional Medical Center Everett
Al Fisk, MD, Chief Medical Officer, The Everett Clinic
Lead Sponsor
Sound Physicians
Supporting Sponsor
Clark/Kjos Architects
New Hospital-Physician
Structures for Quality and
Fiscal Accountability
WSHA 78th Annual Meeting
October, 2010
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The Everett Clinic Core Values
 We do what is right for each patient
 We provide an enriching and supportive
workplace
 Our team focuses on value: service, quality
and cost
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Providence Mission and Vision
As people of Providence, we reveal God’s love for all,
especially the poor and vulnerable through our compassionate service.
Respect  Compassion  Justice  Excellence  Stewardship
VISION: Our ministry will be a transformational force for our
communities by advancing health care excellence and access for all.
Responsibility: Health Care Excellence
Each person we serve receives
the best possible outcome and
has an exceptional experience.
Results
Results
Compassionate
Care
Results
Affordability
Strategies
Coordinated
Care
Strategies
Results
Clinical
Outcomes
Strategies
Responsibility: Access for All
Every person within our community
easily gets the care they need.
Strategies
Mission Inspired  People Centered  Service Oriented
Quality Focused  Financially Responsible  Growing to Serve
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The Community
 Snohomish County
– 705,000 with rapid growth
– 65+ age cohort increasing rapidly
 46% Medicare/Medicaid and Self Pay/Charity
– PRMCE 68%
 Several large employers: Boeing, Naval Station, Premera,
Tulalip Tribes, and Providence (Microsoft a regional force)
 Historical out-migration (39%) for specialty care
 One tertiary hospital (PRMCE) and three district
community hospitals (one recently became Swedish)
 Low physician ratios; shortage of primary and specialty
care
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Providence Regional Medical Center
Everett (PRMCE)
 372 beds (468 effective June 2011)
 Community Hospital and Regional Referral
Center
 Faith-based, Catholic, Not-for-Profit
 Dedicated to Mission – 105 years in Everett
 Single major tertiary hospital in county
 Progressive attitudes of physicians
 2nd largest private employer in county
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Organized Medical Community
The Everett Clinic (TEC)
 280,000 patients
 420 providers
 Diagnostic imaging, lab,
ambulatory surgery
 Physician owned and
directed, professionally
managed
 Source of one third of all
admissions to Providence
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Group Health
27,000 patients
14 providers
Primary care on site
Visiting specialists plus
use of TEC and WWMG
specialists
Implementation of medical
home model
Multi-specialty medical
group linked to health plan
Organized Medical Community
Western Washington
Medical Group (WWMG)
 60 physicians
 High quality
 Entrepreneurial
 Long standing
relationship with ProvPG
 Loose federation of “care
centers”
 Increasing development
of competing ancillaries
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Providence Physician
Group (ProvPG)
 90 physicians
 Primary care based
 Slowly expanding
specialty arm
 Highly efficient and cost
effective
 Quickly developing
infrastructure and
population health culture
Balanced Scorecards
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Providence
Service oriented
Quality focused
Financially responsible
People centered
Mission inspired
Growing to serve
The Everett Clinic
 Patient satisfaction
 Quality and patient safety
 Cost effectiveness
 Financial viability
 Staff and physician
satisfaction
PRMCE and TEC Common Goal
Adding Value in Patient Care
 Reducing unnecessary ED visits and
admissions (Kaisen efforts)
 Reducing readmissions (transition coach,
palliative care, CHF readmissions)
 Developing community cancer center
 Linked EMRs
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Community Kaisen Summary
 Reviewed entire value stream from decision
to admit to post hospital visit
 Removing waste, improving quality and
service at every step of the way
 Two year improvement process with engaged
patients, physicians, staff
 Strong support by PRMCE and TEC
leadership with fully aligned goals
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Reducing Readmissions
 TEC development of hospital coach role
for Medicare demonstration project
 Providence Hospice and TEC collocate
palliative care RNs in primary care
offices; inpatient palliative care team
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Providence Regional Medical Center Everett
Heart Failure Readmission Rate
Baseline compared to Quarterly and Target Performance
Observed Readmission Rate
Expected Readmission Rate
25%
22.2%
15%
10%
5%
16.6%
21.4%
December 2009 is not included
20%
21.4%
18.8%
16.9%
3q10 data is raw
observed only
12.0%
0%
Baseline Jan-Nov
2009
1q10
2q10
3q10 Jul-Aug
Providence Regional Cancer
Partnership (TEC Co-Manages)
 Medical and radiation oncologists, all support
services including integration of alternative
therapies
 Recruitment of fellowship trained oncologic
surgeons to community
 Multidisciplinary cancer conferences review
nearly every patient’s care
 Innovated and complex economic alignments
 Governance by cancer executive committee with
all partners represented
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Linked Electronic Health Records
 TEC and Group Health on Epic
 Providence initially on multiple different
platforms
 Hospital consideration for TEC Epic
 PH&S determines value in entire System
moving to Epic
 Epic trusted partner to link TEC, PRMCE,
GHC…
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Medical Hospitalist Team
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Inception in 2002
Management contract with TEC
Currently 34 FTE’s (TEC physicians)
Multiple teams including “nocturnalists”
Manage 90% of all medical patients
Manage/Co-manage 60% of all patients
Extraordinarily cooperative/innovative
Standardization and continuous improvement
Intensivist Team
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Inception in 2004
Response to Leapfrog
2006 became 24/7 in-house
Expansion to 7+ FTE’s
Management contract with WWMG
– Half of physicians from TEC, half WWMG
 Innovative/collaborative/ACT grants
– Sepsis
– Delirium
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General Surgery Hospitalist
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Inception in 2008
Management contract with TEC
24/7 in-house coverage
Recognition of acuity of surgical patients
4.5 FTE’s plus daytime PA’s
Standardization and continuous improvement
And the rest…..
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Pediatric Hospitalist
Neonatologist/NNP
Laborist
Orthopedic Hospitalist
Neurohositalists
24/7 In-house
24/7 In-house
24/7 In-house
Daytime only
Daytime only
Why the “ists”
 Primary care provider office productivity
burden
 Requests for ED call stipends
 Recognition of performance deterioration
with sleep deprivation
 Recognition of ever-increasing acuity of
inpatients
 Management from “our bed” is not optimal
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…..and the Outcomes
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Timely, expert care
Collaboration and standardization
Recruitment and retention
Greater integration with physician partners
Better rested physicians
Worth the investment!
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The PRMCE Experience
 Elected Chairs/Chiefs
– Short tenure, inexperienced
– Little commitment to the organization
– Provincial
 Medical Directors
– Operationally oriented, prime movers
– Engaged, compensated
But…..
– Viewed as “suits” by the Medical Staff
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Unified Leadership Model
 Simple solution…unify these into single
positions - Division Chiefs (4)
 Ability to serve for extended time periods
 Accountability and responsibility for
operations and Medical Staff issues
 Serve in dyad model
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Unified Leadership Model
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Medical Staff Officers elected
Division Chiefs selected and ratified
Medical Executive Committee includes both
Mirror the model with Section Medical
Directors (24) (GI, ED, Radiology, etc)
The Outcome
 Medical staff leadership
– Operationally educated
– Dedicated to the position
– Stability and continuity
– Organizational thinking
– Appropriately compensated
 The structure embeds and integrates the
physicians into the very fabric of the organization!!
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Medical Staff Survey
Likelihood of Recommending
90
81
80
70
66.2
68.2
72
74.9
73.6
62
60
50
40
35
30
29
25
20
10
13
Percentile
Mean
12
0
2003
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2004
2005
2006
2007
2008
Joint Monthly Meetings
 Senior leadership of TEC and PRMCE
meet for dialogue
 Major issues early identification
 We don’t always agree but we do have
honest conversations
 Key factor in our respectful and healthy
working relationship
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Physician Engagement and
Leadership Development
 TEC is physician owned and directed
 PRMCE has put physicians into key
leadership positions
 Investment in physician leadership and
training; TEC 1.5% of revenue, PRMCE 2.2%
of net revenue
 We develop physician leaders in multiple
ways from master’s programs to mentoring of
new leaders
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Results…
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Where did it get us?
 HealthGrades Distinguished Hospital
for Clinical Excellence™
–
Critical Care, Stroke Care, Cardiac and General Surgery
 Thomson 100 Top Hospitals
 Thomson 100 Top Cardiovascular
Hospitals
 Thomson 100 Top Hospitals
Performance Improvement Leader
 One of 4 Hospitals in US to have all
three in 2008
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Areas of Concern
 Entry of competition into the market
– “The Arms Race”
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Financial sustainability
Failure to reform the payment system
Misaligned incentives
Legal and regulatory barriers
The Ultimate Goal
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Institute of Medicine -- STEEEP
Universal access
Long term financial sustainability
A healthier community
Greater value for our healthcare dollars
Lessons Learned
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Everything defaults to the patient!
Innovate from the ground up
Engage and train physician leaders
Competition for “market share” doesn’t help
the community
 Be advocates for systems of delivery
 Never forget…..It’s the Mission and Core
Values!
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