Volume 5 (2020-21)

Each volume of Management in Healthcare consists of four quarterly 100-page issues.

The Articles published in Volume 5 include:

Volume 5 Number 4

Editorial
Simon Beckett
Case Studies
Change management: A framework for measuring and implementing organisational change
Christa Y. Leung, Senior Principal Health Systems Engineer, Mayo Clinic, et al.

In 2018, Mayo Clinic completed the largest transformational project in its 150-year history. Mayo Clinic was prepared to take on the implementation of new software systems (Epic Systems Corp) as an integrated electronic health record (EHR) and revenue cycle management (RCM) system across all sites of the enterprise. Three foundational teams were launched for this project: leadership, project management and change management. In a project such as this, a common pitfall is to focus completely on the system and lose sight of the end users. For Mayo Clinic, the people side of change was at the forefront of the project. A robust change management team was budgeted, staffed and engaged with an experienced outside consulting partner. A goal for the change management team centred on the best way to measure the change management impact and the degree to which it was making a positive contribution in driving successful adoption of the new EHR and RCM system. With literature lacking in this area, the team moved forward with courage and quickly learned that the easy part was the development of a survey with questions mapped to the six components of the change management strategy and the phases of the awareness, desire, knowledge, ability, reinforcement (ADKAR) Model (Prosci Inc). The hard part was building the infrastructure to visually display millions of rows of data that needed to be positioned, filtered and analysed for all affected locations. The authors share the methods to measure change and explain the importance of developing a comprehensive and robust means of gathering and displaying large volumes of change management data at the project onset. This paper prepares the reader to confidently develop an organisational framework to measure and report the effectiveness of a change management strategy.
Keywords: change management, data, measure, survey
Strengthening community hospital/university partnerships through establishment of a virtual library to support clinical practice, research and education
Russell J. Buzalko, Director of the Office of Education, Children's Hospital & Medical Center, Teresa L. Hartman, Associate Professor, University of Nebraska Medical Center at McGoogan Health Sciences Library and Alison M. Bobal, Head of Collection Development and Metadata at University of Nebraska Medical Center, McGoogan Health Sciences Library

During a time when many hospitals were eliminating library services, a clinical and an academic organisation worked together to develop a new dedicated paediatric hospital virtual library. This paper describes the strengthening of existing partnerships and use of experts during the change management process and well into the early sustainment phase. The new healthcare service library offered additional resources and services and provided informational equity to those who previously had limited access in their support roles. With a relatively modest increase in spending, the hospital saw a 700-per cent increase in downloads of papers and received expert research support not readily available during previous library arrangements. The use of experts in various functional areas and formal change management practices were crucial to the positive results garnered by both organisations. The implementation team largely avoided major impediments and commonly expected issues through the leveraging of existing partnerships. Minor barriers, however, related to communication, time constraints, vendor negotiations and overcoming preconceived notions based on past experiences associated with inferior products were easily managed during the course of this project. This paper offers a non-traditional model for organisations to consider while redesigning library services with the intent to improve support for medical education, research and clinical outcomes.
Keywords: library, partnerships, experts, change management, administration
Achieving speed, spread, scalability and sustainability in life plan communities: Two case studies
Ray Johnson, Managing Principal, Caldwell Butler & Associates, Bruce Chittenden, Chief Financial Officer, John Knox Village and Stephen P. Fetyko, President and CEO, United Methodist Retirement Communities

The aim of this paper is to show how a focused 100-day workout will develop middle managers to become more accountable in achieving margin improvement of 0.5–1 per cent or greater. The reader will take away strategic questions that can be asked of the executive team.
Keywords: margin improvement, leader development, change management
Practice paper
Disruption and opportunity: Harnessing technology to address health disparities and achieve equity
Ginger L. Pilgrim, Principal of Health Industries Advisory and Kiesha McCurtis, Director, Health Industries Advisory, PwC

As the COVID-19 pandemic continues unabated, it is reshaping the fabric of the US health-care system and shifting the ways in which consumers and patients seek care and treatment. The ongoing public health crisis has laid bare fault lines in the healthcare system and highlighted socioeconomic and racial divides that have been prevalent but ignored by many for decades. As with many crises, the pandemic presents both disruption and opportunity. This paper outlines opportunities for health-care leaders to leverage technology to create robust platforms for virtual care, take tangible action steps to advance virtual care for a more inclusive patient experience and tackle the drivers of health disparities by revitalising organisational diversity, equity and inclusion efforts.
Keywords: COVID-19, health equity, health disparities, virtual care
Research papers
Organizational support of physician well-being: A survey of healthcare executives
Ted Hamilton, Chief Mission Integration Officer, Senior Vice President, AdventHealth and Chair, Executive Committee, Coalition for Physician Well-Being, et al.

Physician burnout has reached epidemic proportions in the United States, and COVID-19 has only exacerbated the strain on the physician workforce. To gather data on organisation-level support for physician burnout prevention initiatives, the American Hospital Association, AdventHealth, and the Coalition for Physician Well-Being collected responses from more than 500 top-level executives from healthcare systems across the United States, documenting the current state of organisation-level interventions to support physician well-being. This paper discusses the findings, which revealed that organisational initiatives to curb physician burnout vary in scope and degree, but the need for organisation-level interventions appears to be widely recognised.
Keywords: physician burnout, healthcare administrators, survey, organisational initiatives
Impact of chronic disease integration strategies on healthcare outcomes and costs in Canada: A scoping review
Grace Liu, PhD Candidate, Peter Tsasis, Associate Professor of Management and Christo El Morr, Associate Professor of Health Informatics, Faculty of Health, York University and Research Scientist, North York General Hospital

There has been a growing body of evidence suggesting that chronic care integration strategies can improve healthcare outcomes and decrease costs. In fact, according to the World Health Organization (2002), there is an opportunity to improve health care for chronic conditions and to curtail the growth in healthcare expenditures through integration and coordination. The purpose of this scoping review is to evaluate the impact of chronic disease integration strategies on healthcare outcomes and costs in Canada. For the purpose of this study, the words chronic disease, healthcare costs, integration and Canada were searched for in five peer-reviewed databases. The inclusion criteria included papers published from 2006 to 2020 in English. The results showed 37 papers that met the inclusion criteria, 51 per cent of which were published from 2006 to 2015 and 49 per cent from 2016 to 2020. The papers were critically appraised for quality (5 per cent strong, 11 per cent moderate, 16 per cent weak and 68 per cent not applicable); 35 per cent, however, were protocols and did not provide evidence. Only two papers demonstrated improved healthcare outcomes and decreased utilisation. Although there was insufficient evidence, this review contributes by highlighting the need to further implement chronic disease integration strategies to demonstrate healthcare outcomes and costs. This review identifies research gaps and provides directions for researchers and implications for healthcare managers and policymakers.
Keywords: chronic disease, health systems integration, health outcomes, health service utilisation, health policy, Canada

Volume 5 Number 3 - Special Issue: COVID-19

Editorial
Simon Beckett
Case Studies
Rapid healthcare innovation during the COVID-19 pandemic
Steven D. Crowley, Senior Health Systems Engineer, Jammie M. Henson, Senior Health Systems Engineer, Jesse D. Andrist, Health Systems Engineer, Sandra J. Elsen, Health Systems Engineer, Jeff R. Ziegler, Senior Health Systems Engineer and Julie M. Doppler, Senior Principal Health Systems Engineer, Mayo Clinic

The COVID-19 pandemic challenged healthcare organisations in safely providing healthcare to patients while protecting employees and reducing the spread of the virus. This paper shows how the Mayo Clinic responded by implementing innovations, including screening, testing and tracing patients for COVID-19; expanding telehealth services; adjusting surgical and procedural operations and reallocating staffing and supplies. These changes were operationalised rapidly through the coordinated response from its leadership, partnership of experts across the organisation, prompt decision-making driven by data, redistribution of resources and expedited training. These innovations and methods of rapid implementation enabled Mayo Clinic to safely continue its mission of providing healing and hope to its patients worldwide, and quickly return to financial sustainability.
Keywords: rapid innovation, pandemic response, COVID-19
Banner Health supply chain’s strategic pivot in 2020
Darcy Aafedt, Supply Chain IS Program Director of Supply Chain Services, Banner Health

Supply Chain’s job is to ensure that critical personal protective equipment (PPE) supplies remain available for their caregivers. COVID-19 has made running out of those supplies a real possibility. Business as usual is not an option; pivoting is strategic and crucial. Banner Health Supply Chain’s collaboration and education throughout the organisation on supply chain services and cost, quality and outcomes as core competencies enabled rapid mobilisation and permanent strategic pivots in response to COVID-19. It collaboratively teamed with clinical practice to assess the situation and implement solutions in an environment that presented numerous barriers. Managing disruption and understanding the changing supply chain, while not new practices, calls for faster turnaround, flexibility and resilience. Continued work to digitally enable the supply chain allowing for more visibility will support these efforts. This paper provides an overview of supply chain services at Banner Health and the team’s strategic responses to COVID-19. It also looks ahead to a future supply chain post COVID-19.
Keywords: Healthcare Supply Chain, personal protective equipment, Supply Chain planning, reusable isolation gowns, COVID-19
Managing the COVID-19 pandemic: Five lessons learned from a Georgia healthcare system
Lily Jung Henson, Chief Executive Officer, Piedmont Henry Hospital, Mariana V. Gattegno Quality and Safety Program Manager and Leigh S. Hamby, Chief Medical Officer, Piedmont Healthcare

On 9 March 2020, Piedmont Healthcare diagnosed its first case of COVID-19. Piedmont is committed to the operating company model with a focus on the value of ‘systemness’ at our facilities. We dealt with the COVID-19 pandemic using a system approach but allowed for local management to modify as context required. This paper is an attempt to capture the learnings of our system by balancing these system and local dynamics. In view of the urgency of the pandemic, system and local incident command centres were set up in less than 12 hours. Piedmont used a combination of quality and process improvement methodology, as well as the Hospital Incident Command System (HICS) structure. Piedmont Henry Hospital — a 236-bed community hospital in Stockbridge, Georgia — set up its local incident command centre on 16 March that focused entirely on that single facility. Soon after the first case of COVID-19 arrived, a wave of many others soon followed, filling up the intensive care units (ICUs). The COVID-19 pandemic has been a challenging time for our healthcare system and our employees, but it has given us an opportunity to grow as an organisation. Most notably, we experienced the benefits of a true operating company model, with a centralised corporate structure supporting the hospitals and clinics within the system. In what follows we share five lessons we have learned at Piedmont Healthcare from this global pandemic.
Keywords: COVID-19, Hospital Incident Command Center, pandemic management, lessons learnt, systemness
Battling the COVID-19 pandemic: Intermountain’s new paradigm of emergency planning
Brent Wigington, Director of Operations Integration, Intermountain Healthcare

The aim of this paper is to highlight complications surrounding the worldwide epidemic and to provide several scripts for surviving it. The scope of this paper is to provide insights into five-dimensional survival strategies: (1) expediting, (2) product substitution, (3) conservation, (4) reconditioning and (5) innovation. Relying on all five of these strategies will increase the probability that there will be something in the clinician’s hands while caring for patients. In addition to these strategies, using a cross-functional, coordinated, daily huddle to facilitate communication and share a personal protective equipment (PPE)/Commodities dashboard will prove to build resiliency during a long-term crisis.
Keywords: COVID-19, pandemic, supply continuity, emergency preparedness, innovation
Practice papers
Hospital/healthcare financial recovery under COVID-19: Financial metrics that improve understanding and action
Steven Berger, Principal, Lumina Health Partners

The COVID-19 pandemic has tested the limits of financial executives’ dedication, skill, patience and ingenuity. For many, the first wave of the pandemic has overwhelmed available resources, while others may be battening down the financial hatches for a second (or third) wave. In this maelstrom of uncertainty, it is important for healthcare organisations to have a clear-eyed view of their current financial situation and determine a clear path forward. What complicates matters is that each organisation has its own unique needs, history and circumstance to consider. There are plethoras of unique circumstances that create small or large differences between every hospital in the country that the article will discuss. There is no ‘one size fits all’ approach to financial recovery: what works for one organisation may not work for another. The key to finding the best approach is a clear and data-driven understanding of each organisation’s unique circumstances. This paper will examine the specific financial metrics healthcare financial leaders should monitor during COVID-19 that provide actionable advice, on the basis of Lumina’s depth of expertise, on precisely how healthcare organisations can use these metrics to chart their own customised path to financial recovery.
Keywords: hospital financial measurement goals, key hospital financial performance indicators, strategy for hospital financial leaders, finance and operations, healthcare organisation financial position, COVID; financial recovery; healthcare financial executives; balance sheet; income statement
Smoothing variability in patient flow to improve the value of care delivery during the COVID-19 pandemic
Ellis Knight, retired internist/hospitalist

The effective management of variability in patient flow can be applied to overburdened hospitals, especially now during the COVID-19 pandemic. The methodology outlined in this paper has been successfully applied in many hospitals throughout the United States and internationally. It is endorsed by prominent hospitals and healthcare systems, regulatory and safety promotion organisations, and esteemed clinical and administrative thought leaders throughout the healthcare industry. Unfortunately, it has not been widely adopted and should be reconsidered now in the midst of the many financial, safety, quality and patient/staff satisfaction challenges facing hospitals today.
Keywords: artificial and natural variability, patient flow, healthcare operation management, process improvement, COVID-19, value in healthcare delivery
Redefining value in post-COVID-19 healthcare: A perspective
Harold Tan, Director of Population Health Finance, National Healthcare Group

As the world continues its fight against the COVID-19 pandemic, one wonders how healthcare will change after the dust settles. In recent years, the concept of valuebased healthcare has emerged as healthcare payers and providers attempt to deliver good health outcomes at optimal costs. But as the pandemic has demonstrated, is value in healthcare simply about balancing bedside care quality and cost? There is a need to go beyond this myopic perspective of value and consider how the global reaction to COVID-19 will change stakeholders’ expectations of future healthcare, its delivery and the extent to which society is prepared to invest or trade off to prevent future such crises. This paper discusses new value norms which will emerge, post-pandemic, which go beyond the quality-cost equilibrium, as the definitions of quality and cost are redefined in the context of wider public health and its impact on society.
Keywords: value, healthcare, COVID-19, epidemic preparedness, one-Health, telehealth, payment, care prioritisation
Lessons learned from COVID-19: Best practices for building a more resilient healthcare supply chain
Jackie Nguyen McGuinn, Executive Director of Global Marketing Strategy, GHX

The COVID-19 pandemic has posed unprecedented challenges to the US healthcare industry from a clinical, operational and financial perspective. Surges in suspected and confirmed COVID-19 cases have depleted supplies, most notably personal protective equipment; overwhelmed health system and hospital order/inventory management processes and systems, particularly those that are manual, paper based; and essentially wiped out revenues, with US hospitals losing an estimated US$1m per day in cancelled or delayed elective procedures (American Hospital Association. (June 2020) ‘Hospitals and health systems continue to face unprecedented financial challenges due to COVID-19’, available at: https://www.aha.org/system/files/media/ file/2020/06/ahacovid19-financial-impact-report.pdf). In this paper, we present insights from US healthcare supply chain leaders on how COVID-19 has impacted their operations and what steps they have taken to support clinicians and maintain patient care delivery. We include recent research on the impact of COVID-19 on the supply chain and commentary from industry organisations and thought leaders on important findings. On the basis of these industry insights and our own work to support both provider and supplier organisations in delivering critical supplies during the COVID-19 pandemic, we conclude with best practices for strengthening the supply chain moving forward. Readers will gain knowledge around the following: • How COVID-19 has impacted health systems and hospitals clinically, operationally and financially, including commentary and examples from US healthcare supply chain leaders on their experiences during the pandemic • Why traditional methodologies, systems and processes for procuring products and managing inventory have failed under the sudden and sharp increase in supply demands • The impact of the pandemic on the global supply chain, including the risks of procuring products from non-traditional suppliers to meet clinical supply needs • The many ways health systems and hospitals have been financially impacted by the pandemic, including increased supply acquisition costs coupled with lower revenues and delayed cash collection • Best practice supply chain advance preparation strategies aimed at strengthening supply chain resiliency and mitigating the negative impact of future disruptions to supply availability and delivery
Keywords: COVID-19, healthcare supply chain, healthcare finance, supply chain analytics, data management, supply chain automation

Volume 5 Number 2

Editorial
Simon Beckett
Case Studies
Chipping away at the granite mountain: Challenges in transitional leadership for system change
Curtis W. Turner, Professor of General Pediatrics and Pediatric Hematology and Oncology, University of South Alabama

The University of South Alabama (UoSA) has a mission to deliver health care to the underserved community and provide for the education of future paediatric healthcare providers. Previously, the UoSA paediatric residency ambulatory clinic had a large percentage of missed appointments or ‘no-shows’, which hampered the revenue cycle, patient care and education of medical students and paediatric physicians in training. UoSA has since opened the door to enhance paediatric patient flow through the implementation of ‘on demand’ or an open access scheduling system. Open access scheduling has decreased the number of missed appointments. In addition, the volume of phone calls for families attempting to schedule future appointments also decreased in a short time. The implementation of this system involved an internal analysis performed on the problems that obstructed the clinics’ performance. Under new leadership, the clinic created a new system of templates and schedules that accelerated the rate at which patients were seen and enforced individual responsibility among resident physician providers and advanced paediatric practitioners (APP). Scheduling changes included appointment templates that incorporated ‘wave’ scheduling and staggered start times. Implementation of these templates increased the number of available appointments or open access and decreased the number of no-shows. The number of incomplete charts decreased, resulting in an improved revenue cycle, as evidenced by collections. Residents were also given educational resources and visual reminders to improve the accuracy and consistency of billing and coding procedures. The educational efforts addressed the knowledge deficit about billing and coding, increasing the number of encounters that were documented as moderate complexity. The educational components consisted of reading papers and applying knowledge to billing and coding case scenarios or vignettes. In addition, billing and coding practices were reviewed in detail during patient encounters to provide instantaneous feedback. Overall, the clinic had improved access to patient care and a decreased number of missed appointments and missed billing opportunities, leading to improved collections. Some of the issues discussed in this paper include chaotic clinic scheduling, incomplete charts affecting billing and revenue cycle, large numbers of no-shows for appointments, lack of resources due to a negative budget and a need for educating residents about billing and coding.
Keywords: patient access, scheduling, revenue cycle, ambulatory clinic, redesign, education
A customer- and business-driven healthcare access model
Mark T. Fleischer, Principal Health Systems Engineer and Chris Schneider, Unit Head, Management Engineering & Internal Consulting, Terry Brandt, Regional Chair of Administration, Southwest Minnesota Region, Jill M. Robinson, Operations Manager, Scheduling Operations and Janine (Coelho) Kamath, Chair, Management Engineering & Internal Consulting, Mayo Clinic

Whether centralised or decentralised, healthcare access models provide varying degrees of benefit to customers and to the organisations they serve. Mayo Clinic Health System in Southwest Minnesota, United States, is a community-based practice of 23 clinics and 6 hospitals that has undergone an evolution of its access model. In 2010, a centralised access model was adopted, including the physical location of schedulers, which was expected to offer greater efficiency, flexibility and staff savings. However, in 2016, the region noted concerning trends of low patient and provider satisfaction with scheduling, decreasing patient access and less-than-optimal patient throughput, all subsequently contributing to declining financial performance. Early concerning trends led to further investigation of practice areas and geographical sites that had notable appointment capacity yet low patient access and throughput. Provider productivity rates, calendar management and patient access varied substantially. Performance in scheduling operations was below par because of limited connection with the practice. The combination of practice variation and a centralised access model was causing an increase in scheduling errors, consistent rework/rescheduling, less-than-optimal patient access, low provider calendar fill rates and high levels of dissatisfaction for patients and providers. Our group was tasked with analysing the problems and developing a new scheduling model. This paper describes the resulting model: a hybrid of centralised and decentralised models, which promised the benefits of both and involved transformation in clinical practice operations and access management. Standardisation for provider scheduling and template management was enhanced. Pods of scheduling personnel were embedded in practice areas. The proximity of the pods to physician, nursing and other clinical staff allowed for increased collaboration and communication. The hybrid model improved access metrics for average speed to answer, abandoned call rates, patient access and throughput, financial performance, and patient and provider satisfaction.
Keywords: centralised, decentralised, healthcare access, hybrid, provider calendar management, scheduling
Practice Papers
Leading across complex healthcare systems: Learning from an action inquiry project
Stefan Cantore, Senior University Teacher, The University of Sheffield

To focus solely on organisational management is no longer enough to be effective. Instead, healthcare managers and leaders must also pay attention to the behaviours required to shape organising within complex systems. The author, together with his collaborator, Dr Mark Gatenby, undertook research within a large UK rehabilitation unit over the course of a year. This work combined consulting with action inquiry and explored the challenges faced by healthcare managers and professionals as they grappled with the complex dynamics within their own complex hospital organisation and the wider region. A notable finding was that quite different behaviours are needed to positively impact on a complex system when compared with the behaviours that are often modelled by organisational managers and still taught in management development programmes. Ten relevant behavioural practices are shared, including purposing, empathising, conversing, leading for learning, influencing, role shaping, culturing, storying, languaging and reflecting. The ideas underlying these practices are described and the implications outlined. Suggestions are offered for action along with a few questions for individual reflection. The paper concludes that a refocussing of leadership development is required to stimulate individual interest in system behaviour. When combined with fresh approaches to commissioning management development, this is more likely to produce a new generation of healthcare system leaders.
Keywords: system leadership, behaviours, development, effectiveness
Worksheet S-10 is here to stay: Programme update and a look at MAC S-10 audits
Michael Newell, Partner and Jonathan Mason, Director, Moss Adams

This paper discusses the change to the Inpatient Prospective Payment System Medicare (IPPS) Disproportionate Share (DSH) programme, the introduction of Worksheet S-10 to distribute payments and the history of S-10 audits that are a result of the new methodology. The paper provides insights to help hospitals and hospital system providers understand what they can expect in S-10 audits and tips to help them prepare their organisation.
Keywords: hospital, Medicare reimbursement, Worksheet S-10, Medicare DSH, inpatient prospective payment system, uncompensated care, S-10 audits
Research papers
Healthcare quality: An empirical analysis in urgent care
L. Drew Rosen, Progress Energy/Gordon Hulbert Professor of Operations Management and Rebecca A. Scott, Assistant Professor of Supply Chain and Business Analytics, Cameron School of Business, University of North Carolina Wilmington

Today’s healthcare system is especially complex and significantly different from what it has previously been. This paper reviews the impact that health-care quality has on consumers and what needs to be done in order to successfully navigate the system and advocate for further quality improvements. The literature is replete with research relating to healthcare in hospitals and healthcare in general. There is a gap in the literature relating to service quality in urgent care facilities, in particular the important dimensions of quality that should be the focus in the urgent healthcare field. With the new Affordable Healthcare Act taking hold, we expect to see more and more consumers using urgent care facilities, versus a traditional healthcare provider, making this research very timely in uncovering the drivers of quality health care in the urgent care domain. Current research in the healthcare system is especially complex and significantly different from what has been previously discussed in the literature. The current study examines the nature of the association between service quality as perceived by patients and its service determinants. With the assessment knowledge generated by this study, we will be able to provide guidelines for operating strategies that urgent care facilities need to successfully compete in the ‘new world’ of affordable health care.
Keywords: health-care quality, service quality (SERVQUAL), urgent care facilities, quality improvement, marketing research
Supervisor’s effect on clinical workers’ job satisfaction and turnover intentions
Michon R. Revader, Instructor of Cardiopulmonary Science Program, School of Allied Health Professions, LSU Health Shreveport

Healthcare supervisors who lack proper knowledge of the profession’s standards may inadvertently put patients’ safety at risk. Clinical workers’ job satisfaction and turnover intentions potentially affect the quality of care provided to patients. Contingency Theory, Transformational Theory and Situational Theory are appropriate to underpin this study because healthcare supervisor expertise can affect job satisfaction and turnover intentions of their employees. This causal comparative study examined the relationship between clinical workers’ perceived leadership expertise of their supervisor and the turnover intentions and job satisfaction of employees of healthcare organisations in Southern Louisiana. The study included research questions regarding the following: the relationship between the responses of supervisors and clinical workers on the Leadership Practices Inventory (LPI), the relationship between clinical workers’ job satisfaction, as measured by the Job in General scale, and their perceptions of their general healthcare supervisor’s expertise, and the relationship between clinical workers’ turnover intentions, as measured by the turnover intention scale of the Michigan Organizational Assessment, and their perceptions of their general healthcare supervisor’s expertise. Utilising the analysis of variance, no statistically significant relationship was identified among the variables. The primary findings of the study, however, revealed a strong association between a supervisor’s expertise and the leadership practices of modelling the way and encouraging the heart on LPI. Although the findings were not aligned with those of previous studies, the results are valuable to healthcare leaders seeking to examine the relationship of healthcare supervisor competencies and workforce shortages.
Keywords: job satisfaction, leadership, nursing, supervisor, turnover intent
A longitudinal study of the school-to-work transition of early careerist healthcare managers
Mark J. Bonica, Assistant Professor and Cindy L. Hartman, Assistant Professor, University of New Hampshire

In this exploratory longitudinal qualitative study, we examine the lived experiences of 12 graduates from a traditional undergraduate programme in health administration over two years during the school-to-work transition (STWT). Participants were interviewed prior to graduation, quarterly during the first year and semi-annually during the second year. They were questioned about their STWT experiences, with a particular focus on the socialisation process into their organisation and career area. Grounded theory analysis found that individuals define successful STWTs using objective (ie employment, promotion) and subjective measures (career adaptability, work satisfaction). Organisational and professional industry commitment are also considered measures of success in the STWT. Factors supporting successful STWT included organisational socialisation, organisational support, proactive socialisation, work competence, coaching and mentoring. An integrated model of the successful STWT from individual and organisational perspectives is provided, and recommendations are made for healthcare organisations aiming to improve STWT outcomes.
Keywords: school-to-work transition, organisational socialisation, perceived organisational support, mentorship

Volume 5 Number 1

Editorial
Simon Beckett
Case Studies
Collapsing organisational silos in health system operations
Rhonda Stewart, Transformation Sensei, Virginia Mason Institute

‘Coordinated care’ is a growing concept in healthcare, with practices like electronic health records (EHR) helping disparate providers and specialists break out of silos to complement each other’s care for a given patient. But de-siloing is also beneficial — and sorely needed — in the way health systems organise their management teams, both in clinical and business operations. Virginia Mason Institute has helped medical centres minimise errors, reduce workloads and improve morale at all levels, from front-line staff to directors, through a series of reforms focused on cross-functional collaboration. These reforms may serve as a template for other systems to follow as they seek to conserve costs, engage staff and instil a culture of teamwork and shared goals. This paper describes how Virginia Mason applied VMPS in two scenarios. These scenarios showcase how combining two broad strategies and five specific tactics can diminish silos and improve efficiency, morale and financial performance.
Keywords: lean management; efficiency; revenue cycle; waste reduction; staff engagement
Blending diverse expertise to optimise and sustain project outcomes
Janine R. Kamath, Chair of Management Engineering & Consulting, Jason E. Barclay, Senior Project Manager, Lydia A. Baude, Senior Project Manager, Jeffrey R. Ehman, Senior Health Systems Engineer, David M. O’Brien, Senior Health Systems Engineer, Bradley E. Williams, Senior Project Manager, Munawwar A. Khan, Senior Principal Health Systems Engineer and Nicole K. Hanf, Senior Health Systems Engineer, Mayo Clinic

Strategic projects in large healthcare organisations are often highly complex and dynamic, and they require a team of skilled business professionals to execute them. Examples of difficult, costly and extended project executions have been shared in the literature. Successful project execution involves many critical facets. One facet that continues to be of marked interest is effective resourcing of strategic projects. This paper focuses on describing a staffing approach used at Mayo Clinic (Rochester, Minnesota) to facilitate successful, agile and sustainable execution, with desired outcomes. In 2016, Management Engineering & Consulting (ME&C) began exploring a collaborative staffing model that partnered management engineers with project managers (PMs) to drive strategic, multisite projects. This ongoing collaboration model was evaluated from multiple perspectives, including project outcomes, timeliness, client and staff satisfaction and opportunities for innovation. Data and feedback on the model were collected with historical reports, surveys and focus groups with stakeholders, leaders, PMs and management engineers. The feedback and data indicated that the collaborative staffing strategy and model have further optimised service delivery, enabled professional staff to work at the highest level of their competency and dynamically blended knowledge, expertise and skills to achieve better and more sustainable overall project outcomes.
Keywords: best practice; collaboration; execution; optimisation; project management; systems engineering
Practice Papers
How non-value added work affects the productivity of healthcare professionals
Rene T. Domingo, Associate Professor, Asian Institute of Management, Philippines

This paper analyses how non-value added work significantly reduces the productivity of healthcare staff and the service capacity of healthcare systems worldwide. It first describes how the ageing population, manpower shortage and wastefulness in hospitals continuously increase the demand-supply gap. The paper explores the application of lean thinking practised by manufacturing industries in improving healthcare staff productivity to complement the conventional supply, demand and technology solutions. It illustrates the principles and best practices in spotting and stopping the seven lean wastes or ‘muda’, particularly in hospitals. The paper identifies several industry and institutional hurdles in improving productivity. It concludes with recommendations for policymakers, regulators and payers to enjoin healthcare institutions to adopt lean practices in order to improve their capacity, cost performance and patient care quality.
Keywords: productivity; lean; non-value added; wastes; efficiency; manpower shortage
First things first: Analysing predecessor programmes to glean insights about Medicare’s primary care first programme
Jonathan Staloff, Fellow, Value & Systems Science Lab, Leah M. Marcotte, Associate Medical Director for Population Health and Joshua M. Liao, Medical Director of Payment Strategy, UW Medicine

In 2021, the Centers for Medicare and Medicaid Services plans to launch Primary Care First (PCF), a fee-for-service population-based primary care payment model that will engage primary care practices to assume accountability for the cost and quality of care for aligned beneficiaries. In terms of programme design, PCF progresses from several proposed or implemented predecessor payment models. Organisations considering PCF participation should be aware of how PCF compares to its predecessors and the operational insights that can be drawn from important similarities and differences. This paper addresses these issues by reviewing PCF design, summarising the design and available data from PCF predecessors, and using comparisons to discuss potential implications for PCF performance, including those related to risk adjustment, care management across patient populations, acute care utilisation management, data analytics and accounting and revenue cycle management systems.
Keywords: Medicare; value-based payment; health policy; primary care; primary care reform; alternative payment models
Medication cost sharing in low-income elders with chronic disease co-morbidities: Policy implication of PPACA provisions for dual eligibles and parallel systems at national health services
S. Mantravadi, Health economist

The implementation of the Patient Protection and Affordable Care Act (PPACA) is aimed at addressing patient safety, quality and insurance coverage for patients with co-morbidities in the United States. Chronic disease patients with both Medicare and Medicaid coverage, however, are further impacted, especially for prescription drug coverage. Additionally, the healthcare reform act entails specific provisions that only affect coverage benefits for low-income elders with chronic disease eligible for both Medicare and Medicaid insurance (dual eligibles). This paper will review the impacts on dual eligible beneficiaries prescription drug cost sharing, Part D plan optimisation and Medicare Advantage premiums. It will focus on the impacts of reducing the Part D doughnut hole and prescription drug cost sharing on patients having additional chronic disease co-morbidities, with reference to healthcare management theory of insurance. This paper will also analyse impacts that affect beneficiary quality of care and access. Dual eligible care for chronic disease patients will be summarised in the context of health insurance and management/economic theory. The PPACA provisions concerning dual eligibles Part D cost sharing align with the theory of demand for health insurance and health care. For dual eligibles with chronic disease, reduced medication cost sharing will increase medication adherence and reduce inpatient expenditures with reference to insurance theory.
Keywords: chronic disease; impact of cost sharing; dual eligible; national health systems
Utilisation improvement plans for avoidable hospital delays
Jose R. Masip, Consultant, DOCDUO Consulting Group

Providing optimal healthcare in the inpatient settings inevitably involves specific management strategies to keep costs at bay. While prices appear to drive the high-cost trends in the healthcare system with no feasible solution on the horizon, the overutilisation of services and goods worsens this scenario. Managing the length of stay and avoiding hospital delays are strategies essential to controlling clinical operating costs. Hospitals run software suites, specifically designed to capture and report on delays. Without departmental action plans, however, these strategies do not generate sustainable and continuous improvement. This paper complements the topic of avoidable hospital delays (AHDs) by describing the use of avoidable delay tracking systems and contributes to the body of knowledge with the development of utilisation improvement plans based on the type of trending AHDs. It also proposes splitting AHDs into clinical and non-clinical delays to better elucidate the type of action plans required to resolve these issues. The next step points to the development of clinical protocol and guidelines specific for AHDs as well as gathering indirect and direct data to quantify the weight of AHDs in hospital profits.
Keywords: avoidable hospital delays; discharge planning; hospital costs; action plans; overutilisation; length of stay; protocols; case management; continuous improvement
Research paper
Strategic leadership: A study of strategic health leadership (SHELDR) practices among former US military Surgeons General
Douglas E. Anderson, Chair of Health Work Group, West Virginia Eastern Health and Human Services Collaborative, Talbot N. Vivian, Professor, Old Dominion University, Brian J. Masterson, Senior Behavioral Health Medical Director, United Health Group/Optum, James A. Johnson, Professor, Central Michigan University and C. Bruce Green, Managing Director, Deloitte Consulting LLP

This study identifies leader development gaps and strategic health leadership (SHELDR) competencies, explores how a cohort of strategic leaders applies those competencies and makes recommendations to improve development of future leaders. The literature identifies leader development gaps and applicable strategic leadership theories leading to development of the SHELDR Model. A qualitative case study determines which competencies are most applied (or not applied) by a cohort of former Military Health System Surgeons General (SGs). An expert panel compared and contrasted the SHELDR Model, interview results and recommended how to develop future SHELDRs. Transformation, complexity and collaborative leadership theories provide the foundation for the SHELDR Model. SGs selected develops leaders, develops and promotes vision, builds trust, challenges the status quo and actively listens as competencies applied most often. Systems approach, listening, critical thinking, communication and emotional health are identified as competencies to develop. The SGs and the expert panel generally agree on the competencies. Immersive learning, assignment to strategic-level projects, critical thinking and role playing are common recommendations on development of future strategic leaders. To successfully transform complex health systems, SHELDRs need specific competencies — strategic-level leadership competencies. Aspiring and current health leaders will benefit from the insights on developing future leaders. Organisation leader development plans should use the SHELDR Model as a developmental and evaluation guide. Research on other cohorts and the SHELDR’s interrelationship with the competencies and development of more strategic-minded leaders earlier rather than later with the right methods to support health system transformation and better outcomes is required.
Keywords: strategic leadership; transformational leadership; complexity leadership; collaborative leadership; leader development; leadership competencies