Health Care Organizations Analysis Presentation

Health Care Organizations Analysis Presentation Order Description Note. The background and explanation may only be 2 slides at maximum: Identify the health care delivery model. Explain the structure of the organization in the case study. Analyze the communication patterns identified throughout the process in the case study. Discuss the negotiation strategies applied as well as opportunities for relationship building across departments. Describe how the organization's performance changed as a result of the initiative. Identify laws, regulations, accrediting bodies, and practice standards that should have been considered as part of the initiative in the case study. Cite a minimum of 5 peer-reviewed resources. NAME OF THE ARTICLE IS: TRANSFORMING HEALTH CARE LEADERSHIP A Systems Guide to Improve Patient Care, Decrease Costs, and Improve Population Health MICHAEL MACCOBY CLIFFORD L. NORMAN C. JANE NORMAN 232 Chapter ??: Three Case Studies: Mastering Change CASE STUDY C: BUILDING A LEARNING ORGANIZATION AT OCHIN, PORTLAND, OREGON, UNITED STATES Background The original CEO of a payer organization demonstrated foresight when she proposed and submitted a grant to the United States Federal government in 1999 to coordinate and provide electronic medical records to their member clinics in order to reduce costs in processing claims while creating a database which would be used to improve patient care and community health. In 2000, she received a small grant to plan and begin implementation of this idea. The leadership team formed the Oregon Community Healthcare Information Network (OCHIN) with their community clinic partners to evaluate, choose, configure, and install electronic medical record software. The partner collaborative selected EPIC as the software solution that would best fit their needs for the present and the future. It is interesting to note that EPIC was the first software to be certified in 2010 by the U.S. federal government agency (Office of the National Chairman [ONC]), charged to define and provide Incentives for health care entities to install electronic medical records under the Obama Affordable Care Act. In 2005, the current executive group divested their information technology network and OCHIN became an independent organization. Strategic Intelligence As OCHIN embarked as an independent entity, the leadership group defined their purpose as ?providing technology information and solutions to the medically undeserved.? Their core work was to configure and install EPIC systems to nonprofit community clinics. OCHIN eventually was given the license to configure and host EPIC software for the unique billing and local reporting requirements for community clinics throughout the United States allowing them to expand their network of members outside of Oregon. Soon OCHIN expanded to Oregon, Washington, and California and was receiving inquiries from communities in Midwestern and Eastern states. As their membership base expanded beyond Oregon, they redefined OCHIN as ?Our? Community Healthcare Information Network. Three Case Studies: Mastering Change 233 The original funding for OCHIN came from Health Resources and Services Administration (HRSA) federal grants to research, install and host EPIC. As OCHIN grew, they continued in a traditional manner to expand the business in software support. For example, many clinics have limited resources to hire billing expertise to resolve claim and billing issues. As a result, OCHIN began contracting with members to manage claims and accounts receivable. OCHIN routinely partners with state and community entities. These parties encouraged OCHIN to apply to the federal government for a Regional Extension Center for Oregon. For CEO Abby Sears (OCHIN?s first employee), this direction would move OCHIN closer to the foresight of the original CEO who formed OCHIN not just to install and support electronic medical records but to reduce costs in processing claims while creating a database which would be used to improve patient care and community health. OCHIN was ready to move beyond being an EPIC hosting, confi guration, installation, and support organization. As the EPIC host, they had the database, and members who joined OCHIN shared EPIC software solutions. The OCHIN membership permeated Oregon with an existing learning network and trust relationship that could be used to improve patient care and community health. Soon all members in seven states were able to see medical records of any patient in the system if they moved or were in an emergency situation. OCHIN was already working with members to utilize the database for better care of patients with a product called Solutions that data-mined health care data in a usable format for health care professionals to impanel and provide better patient care. The objective of the Federal Regional Extension Centers was in total alignment to the existing networking structure at OCHIN. It seemed logical for OCHIN to submit a Regional Extension Center grant proposal, which would serve not only OCHIN?s existing nonprofit community clinics but also for-profit clinics, small hospitals with less than ten beds, and small private practices with less than ten doctors. Purpose In preparation for the future, OCHIN began a major effort to examine its purpose and vision by reexamining its products, services, delivery system, and personnel by focusing on creating a learning environment. During the journey that will be described below, the need to 234 Chapter ??: Three Case Studies: Mastering Change revise their organizational purpose became evident as they expanded both their member base and their products and services. In 2011, the board approved a revised mission to expand and align to the newly designed system and members. OCHIN Mission (purpose in our context) 2009?Providing technology information and solutions to the medically undeserved 2011?Partnering with communities to create the knowledge and information solutions to promote access to high-quality and affordable health care for all The Journey In December of 2009, the executive leadership team, senior leadership team, and employee representatives used the Quality as a Business Strategy (QBS) evaluation grid (basis for the evaluation grid?strategic intelligence and Four Ps in Chapter 11) to identify gaps and opportunities during a strategic retreat. As a result, OCHIN began a transformation to a learning organization, by focusing on the gap analysis and methods provided by the original Quality as a Business Strategy evaluation grid. Their journey started in earnest in 2010 by focusing on the alignment of their purpose and vision to the system. Aligning Purpose and Vision to the System Because they were redesigning the mainstay or delivery system, OCHIN initially utilized their existing mission (purpose in our context) to begin redesigning their system using the system map. However, work had been done to create a system map of how work was currently done. Here is the original conceptual framework of the OCHIN delivery system with two primary subsystems (see Figure 10.13): The natural inclination was to simplify and standardize the subsystem that included most of OCHIN?s resources: configuration and installation of EPIC software. But Sears recognized the system map was incomplete. Refining the installation processes would not fulfill the needs of the existing members. Sears needed a way to help people see the new OCHIN and membership in a different light. Delivery System (Mainstay) Configure and Install Software Provide Billing Support Solicit, Receive, and Respond to Requests for Quotes Define Product Deliverable Plan Configure Software Design New Interfaces or Products Manage Billing Issues Manage Accounts Receivable Manage Centralize Billing Set Up Centralized Billing Solicit, Receive, and Respond to Requests for Quotes Conduct Training Install Software on Host Platform Troubleshoot and Resolve Issues Members Figure 10.13 Original Conceptual Framework of the OCHIN Delivery System with Two Subsystems 236 Chapter ??: Three Case Studies: Mastering Change Vision Sears described her vision for OCHIN explicitly as a collaborative learning organization which encompasses the whole system, assisting health care providers with data analysis and tools for effective and efficient patient and community care once any electronic health care record system was installed. She acknowledged that resources were being sucked up by the installation process and focus on new members. The constraints of the past were to be put aside to design new and redesign old processes that would leverage strengths and knowledge within the ranks. Figure 10.14 shows the mainstay framework that was initially created from the dialogue that ensued, expanding from two subsystems to five to allow additional products and services. Redesigning the System In January 2010, OCHIN was named the Regional Extension Center for Oregon by the newly defined ONC which was charged to defi ne and act as the officiating group for the new Affordable Care Act?s Center for Medicare & Medicaid Services (CMS). The objective was to install electronic medical records throughout the nation by giving physicians financial incentives to not only install but also use the data for improvement of care to patients. They coined the term meaningful use of health care data with a complex Provide Knowledge and Information to New and Existing Members Coordinate Support for Members Provide Billing Management Services Develop and Test New Health Care Technology Products and Services Configure and Install Software Delivery System (Mainstay) Members Figure 10.14 2009 OCHIN Integrated Conceptual System Map: First Draft Three Case Studies: Mastering Change 237 tier. Funding would be dependent on the number of qualifying members with signed agreements with each Regional Extension Center. Although Regional Extension Center grants were awarded in January, the document for defining and qualifying members, incentives, and structural guidelines was not defined by the government until late summer. At least 25 percent of members originally defined when the grants were written were disqualified by late summer of 2010. OCHIN was renamed the Oregon Regional Extension Center O-HITEC. There was no government model to . follow; only expected results to deliver. OCHIN was ready for the transformation since the new conceptual delivery system defined how work would fl ow and the interdependencies. All of these subsystems would be necessary for O-HITEC. While other Regional Extension Centers were focused primarily on the installation of electronic medical record programs and trying to sell them, O-HITEC was looking at developing an integrated system. Five subsystems were integrated into the delivery system, with three new subsystems to focus their execution: 1. Providing knowledge and information to new and existing membership (which expanded beyond EPIC requests for quotes) 2. Coordinating member support 3. Developing and testing new health care products and services Manpower was immediately added to the first subsystem to develop and execute processes to provide knowledge and information to new and existing members. This group designed educational sessions, a new website, and solicited information from potential new members into the O-HITEC incentive system to help identify their needs. An installed certified EMS was the base requirement of the incentive system. EPIC was predicted to be one of the certifi ed systems. Therefore, physicians in the OCHIN membership would automatically qualify for the first year?s incentive, but that was not sufficient to meet the first year?s quota for O-HITEC. Small private practices and small hospitals that had a defined percentage of Medicare/Medicaid patient populations were the qualifying group. The cost of EPIC was prohibitive for most small practices 238 Chapter ??: Three Case Studies: Mastering Change and OCHIN was not authorized to install EPIC in small hospitals. O-HITEC would leverage OCHIN?s strength, configuring and installing electronic health record (EHR). But they needed to assess other products and get feedback from potential members. Currently installation capabilities have expanded to include All scripts EHR, eClinicalWorks EHR, addition authorization for EPIC applications in hospitals with fewer than ten beds, and recently Greenway?s PrimeSuite EHR. All products include secure health information exchange capabilities and web-based patient portals that let patients and doctors communicate easily, safely, and securely over the Internet. All products offered by OCHIN are geared to enable members and clients to implement and achieve meaningful use of their EHR as required to secure federal incentive payments and support provider and practice efforts to advance clinical, financial, and operational goals?the preconditions for clinical transformation. The intent of installing electronic health records goes beyond input of a patient?s data by the health care provider. Expanding from an internal system?s view to responding to the needs of clinics, health care professionals, and all users and potential patients has enabled OCHIN to expand services to include 1. Business Services provides multitier support designed to create operational efficiencies and drive savings directly into OCHIN-supported practices. 2. Data Services provides the capability to aggregate data from any number of vendor sources enabling users to interface with, and build on, existing clinical, financial, and operational tools already in place for reporting and improving health outcomes. OCHIN?s data warehouse is tailored to a health care environment and uses an innovative proprietary data aggregation architecture that makes the accurate measurement of clinical and operational variables straightforward, thus making it possible to compare metrics easily across different organizations without the need for complicated audits. All data exchange is governed by agreements that are compliant with applicable laws and regulations governing protected health information. Three Case Studies: Mastering Change 239 3. Health Information Exchange (HIE) connects all OCHIN network members via Epic Care Everywhere network that connects hospitals nationally and through the emerging Nationwide Health Information Network (NwHIN) exchange. OCHIN is also building a national HIE capability that utilizes the rules and guidelines for how computer systems should exchange information defined by Health Level Seven International (HL7) with the international Integrating the Healthcare Enterprise (IHE) initiative for health care?specifi c data. These solutions enable OCHIN to seamlessly integrate multiple systems including hospital registration systems, laboratory systems, immunization registries, and, via the NwHI, to support information exchange with federal agencies. Using OCHIN, administrative and clinical staff can coordinate patient care across multiple states and unrelated health care entities, giving care providers the knowledge to improve patient outcomes regardless of where patient treatment took place. 4. Practice-Based Research Network (PBRN) operates as an independent business unit within OCHIN for the purpose of encouraging practice based research that advances understanding of the health of underserved populations, increases health equity, improves quality of care, and informs health policy. The OCHIN PBRN is unique among other practice-based research networks because it has no formal affiliation with a particular academic health center and is comprised almost exclusively of federally qualified health centers (FQHCs) and rural health centers (RHCs). The evolution of the OCHIN system map has expanded to show these important subsystems and their integration to achieve the organization?s purpose. Systems thinking continues to drive the organization to solicit and assess member and patient needs. PDSA symbols have been added to the OCHIN system map to reflect where internal prioritized Accelerated Model for Improvement projects (Ami? charters) are targeted. In addition, OCHIN is using their system map as part of their analysis, prioritization, resource allocation, and communication of joint improvement projects initiated by members? requests to address growing member and patient documentation and analysis needs (see Figure 10.15). Figure 10.15 2012 OCHIN Conceptual System Map with Internal and Member Ami? Improvement Projects Three Case Studies: Mastering Change 241 Using Personality Intelligence in a Changing Environment Early in 2009, OCHIN began using the Strength Deployment Inventory (SDI) from Personal Strengths Publishing as a means to educate and develop personality intelligence throughout OCHIN. Assessment of the 2009 delivery processes using the new system maps revealed some interesting issues. First, the billing subsystem had only one manager, Phil Skiba. He was an experienced manager who had executive experience at larger companies with a strong personality to get things done and a willingness to make changes, while routinely treating risk as a challenge. Skiba was also aware that his strong personality had to be held back when working with more analytic and nurturing personalities, which was the predominant cultural norm. He used his SDI learning to modify his communication methods to improve relationships and communications. In a relatively short time, he had taken the small subsystem over and grown it with more clients, delivering excellent results for these billing customers. In contrast, the install subsystem was composed of six managers. Five of them had been promoted from within, with no management experience nor any management or leadership training. They were in a high-stress environment and were constantly adapting and making changes to make things work. But some changes were not aligned with strategic plans, which forced them to make additional changes. This only created more stress and confusion. Their flexible adaptive personality profiles explained this behavior. In a rapidly growing and changing organization, management needs alignment and experienced leadership. By the end of 2009, the decision was made to begin the transition to test the revised delivery system. Within weeks, OCHIN was officially informed that they had been selected as the Oregon Regional Extension Center, renamed O-HITEC. Realigning resources to move toward the new integrated delivery system was critical for success. Five managers were moved back into the organization for added delivery resources. Experienced leaders within the organization were reassigned. The previous COO, Clayton Gillett, now became the designated leader of the O-HITEC group and was assigned to develop and integrate the processes to provide knowledge and information to new and existing members. The existing quality assurance director was moved to coordinating support for members. Skiba (a certified project manager) retained billing but was allowed to hire a billing manager so that he could 242 Chapter ??: Three Case Studies: Mastering Change also manage the project managers for the installation processes. The new COO, Jane Norman, managed personnel for EPIC confi guration and development of new products and services. OCHIN began a series of communication sessions with their associates, many of whom had been with the organization from the beginning. Initially, the leadership team delegated communication to the COO, who conducted weekly meetings. Later the executive leadership team took ownership. Leadership predicted weekly meetings and openness in these meetings would help the associates make the transition. With the announcement of O-HITEC, the new delivery system was unveiled. The first stage reallocated leadership responsibilities. These were shared using the revised delivery system map with leaders? names noted in the next stage. Demand in the subsystems was assessed to begin a transition of people for dedicated resources. Roles had not been determined, but would be shortly. In order to do this without disrupting the installation process, OCHIN?s primary financial resource, some programmers would work in two Subsystems for the first few months. In an effort to dispel anxiety that changes were permanent, leadership stated that the delivery system was like Jell-O?as we mold it, we will review it. Changes that were not working would be abandoned and a new mold would be created from what was learned. The leadership team was committed to learning from experience and making necessary changes. Skepticism that the delivery system would never be more than an installation effort fl owed from side conversations spreading skepticism to others who had been optimistic. Communication and transparency was essential. As Mark Twain once noted, ?A lie can travel halfway around the world while the truth is still putting on its shoes.? In addition, the COO learned at the second communication session that the Jell-O analogy was causing anxiety. She was a flexible-adaptive personality who was comfortable with uncertainty and learning from changes. But for the analytic and nurturing programmers, Jell-O communicated uncertainty. They needed specific direction. They wanted to be told what to do and that the plan was solid. The Jell-O analogy was abandoned. The COO replaced it with another analogy of ?building the bridge as we walk on it? and stated that the framework of most of the bridge was already in place. O-HITEC would take the response to quotes, defi ne additional Three Case Studies: Mastering Change 243 processes, and integrate into subsystem 1. Subsystem 2 was putting new processes in place for the informal help desk. Subsystem 3 was dedicating more resources to new products like Solutions, which was already in place. More resources for O-HITEC and the delivery system would be added. Developing processes and roles were the next hurdles. Throughout the transition everyone was responsible for learning and sharing knowledge. The new analogy and explanation of the new delivery system, ?building the bridge,? soon became a common theme. And leadership learned more about personality intelligence and the communication needs of the organization. Using Role Descriptions to Integrate People into the Learning Organization Starting in 2007, OCHIN doubled its members and the number of visits hosted yearly. When OCHIN had under twenty people, it was easy to learn from one another. But in 2009, with sixty-two people, it became harder to facilitate learning. Once the revised delivery system was in place, the organization was flattened with existing and new resources allocated to the five major interdependent subsystems of the delivery system. The initial restructuring of existing resources in the fi ve subsystems exposed other weaknesses in the system, specifi cally personnel with underdeveloped skills and those who were doing more than their share of work to make up for the inadequacies of others. What skills did individuals need to be successful? How could OCHIN leverage and utilize individuals? strengths and knowledge? In 2009, approximately one-third of the staff were application specialists whose skills were critical for the success of support, installation, and new products, or 60 percent of the delivery subsystems. These skills were developed in three main categories: basic structure, clinical, and billing. There was no master skill list for training or assessing application specialist?s knowledge or skills. Leadership worked with subject matter experts to defi ne 100 skills for each of the three skill categories. Skills were self-assessed by each of the application specialists using a similar format to the portion of the form below. This helped defi ne what an application specialist knew. The list has since been refined to 122 skills in seventeen areas. In addition, 53 skills for training members in EPIC functions have been defined in five areas to assess and develop application trainers? skill levels. Figure 10.16 describes the Skills Assessment Tools Format. Figure 10.16 Skills Assessment Tools Format Three Case Studies: Mastering Change 245 Based on the results, each application specialist was classified by skills in one of four categories: basic structure, clinical, billing, or training. For each category a technical lead (who had demonstrated the highest knowledge) was identified. The leads were charged with conducting learning sessions and utilizing the skills inventory to build the skills of their technical group. Fridays were declared learning days to support the time needed to develop the skills. As application specialists mastered and demonstrated new skills, salaries were adjusted. The skills inventories also became a tool for hiring experienced individuals. Candidates self-assessed their skills, and if they passed the previous screening interviews, a technical lead interviewed them to verify their skill levels. Additional technical leads were identified throughout the organization and Friday learning days were used for sharing learning during the week. Helping the technical leads learn the difference between telling or managing people and leading and developing people was a challenge. A three-day leadership workshop at Gettysburg was conducted by Austin API, Inc., with follow-up sessions for learning. Primarily the executive leadership team attended. Attendees used the experience to learn, reflect with one another, and become better leaders. A key lesson from experience is courage, which was discussed in Chapter 8. On the battlefield a leader must display physical courage. In business, the effective leader must display moral courage and be prepared to move beyond the second level of ethics and morality discussed in Chapter 4 to a third level, where the leader and team might have to sacrifice for the overall system. The following year, a second group of technical leads and additional managers attended the three-day Gettysburg leadership experience. These learning sessions were building leaders at all levels within OCHIN and creating a learning environment with a shared understanding of the three levels of ethics and morality necessary to support the practical values of OCHIN. The skills inventory (including training) for different levels of application specialists requires understanding the processes a role performs and the knowledge needed to be effective. Traditional job descriptions focus on reporting structure, pay scales, qualifications and generalized skills. Formal role descriptions are a critical tool to align individuals and develop them within a learning organization. 246 Chapter ??: Three Case Studies: Mastering Change Role descriptions have been developed for all associates and have replaced job descriptions. They are currently used for yearly individual development plans. Processes and the skills required were used to defi ne the role descriptions, so that organizational pay grades were matched with market levels, but also demonstrated expertise. In addition to traditional job description information the role description explicitly states the following additions (see Role Description Template in Exhibit 10.2): 1. How the role contributes to the purpose of the organization 2. The processes in which the individual is expected to execute 3. Measures of the process to detect when an individual needs help or when the process needs to be redesigned 4. Rules of conduct that are aligned with the organization?s practical values 5. Expectations for improvement 6. Organizational relationships (external and internal) ? EXHIBIT 10.2: ROLE DESCRIPTION TEMPLATE Role Description Template Role Statement Position Title: Department Title: Function: Supervisor: Title: Pay range: Type of position: Hours/week: (Depending upon experience and level of responsibility and market) Full-time Part-time Temp employee/Contractor Intern Exempt Nonexempt Three Case Studies: Mastering Change 247 OCHIN recognizes that people do their best work and are most satisfied when working in a healthy work environment. OCHIN seeks to nurture a healthy and productive work atmosphere that supports current members of the team and one that is eager to welcome and adapt to new members as they are added. The following values have been identify ed as essential characteristics and behaviors of OCHIN?s work environment. They establish a framework for Employee and organizational expectations about what it means to Work at OCHIN. Organization Mission OCHIN partners with communities to create the knowledge and information solutions to promote access to high-quality and affordable health care for all. Role Statement?How This Position Supports the Mission The (role name) supports the mission of OCHIN by Process and Measurement Responsibilities All work is a process. Each role has process responsibilities which are interdependent and impact the OCHIN system and network. Processes currently defined for this role have been defined below. We must be alert to defining new processes and eliminating obsolete processes as needs of our role dictate. Performance measurement measures the system and the individual together. Below are the key processes for this role and measures that have been currently defined for this position which will be presented on control charts with a weekly frequency: Process Name (#) Process Measurement Secondary Process Responsibilities (Back Up for Others) Conduct The (role name) will model behaviors consistent with the published values of OCHIN. 248 Chapter ??: Three Case Studies: Mastering Change Responsibilities for Improving the System All OCHIN employees are responsible for working together to improve the OCHIN network (internally and externally.) Friday afternoons are allocated for this purpose. When changes are considered, we will use the following questions from the Model for Improvement routinely: What changes do we want to test? What are we trying to accomplish or learn from these changes? How will we know a change is an improvement? (Use of measures will help us understand if our changes are improvements.) The (role name) is responsible for ? Documenting, communicating, sharing information and developing solutions. ? PDSA cycles are the approach to all improvement work that we undertake. ? Routinely monitoring all personal measures. Special causes will be noted, researched, documented, and action taken, if reasonable. Unacceptable system performance will be submitted for improvement projects. Time will be allocated for improvements that focus on OCHIN or member productivity, improved satisfaction, and elimination of waste. ? Troubleshooting problems independently without escalation whenever possible. ? Knowing how to find answers to questions and ask for help, when appropriate. ? Learning from mistakes and unintended consequences. ? Documenting, communicating, and suggesting solutions for ? Equipment that needs repair or replacement ? Things that go wrong and can be prevented ? Things that could be made easier or more efficient ? Equipment or supplies that are needed ? Items identified as a problem or observation ? Safety incidents or issues ? What does management need to do to make your job better and easier? Three Case Studies: Mastering Change 249 Organization Relationships ? The (role) directly reports to and is part of the team. ? The (role) shares information within the OCHIN organization. External Relationships Personal Improvement OCHIN provides $2,500 per year to employees in support for education and training outside the organization. It is the associate?s responsibility to seek approval, schedule, and participate in education or training that will prepare him or her for present and future needs. QUALIFICATIONS/ABILITIES: Using and Developing Practical Values to Guide Decisions In 2010, the leadership group developed and published the following practical values for present and future employees. These values permeate decision making as new potential candidates are considered for employment or current associates are coached and developed. Candidates and associates are challenged to verbalize actions in contrast with their values. Contradictions are acknowledged and questioned to ensure alignment for the present and future. Currently these practical values are displayed prominently on the wall of the main staircase at the entrance of the building as a reminder to their importance. Table 10.3 describes these practical values from the perspective of the individual and the OCHIN system. Initially, some members of the executive team believed that taking the time to defi ne values was a waste of time. However, within the fi rst month of publishing these values, practical applications were evident. When the values were published, all associates felt able to challenge behaviors and decisions which seemed to be in confl ict with the stated values. Issues were surfaced and resolved, using the values as the guide. Routinely, executives discuss how to model these values and take action when anyone in 250 Chapter ??: Three Case Studies: Mastering Change Table 10.3 OCHIN Practical Values for the Individual and System Practical Values Individual The System Excellence Quality Results and Service Delivery Critical thinker who is able to make appropriate decisions and fi nd solutions for each situation. Works effectively under pressure meeting deadlines and delivering superior results. Keeps the focus of the customers and striving to meet their needs at the forefront of his work. The pursuit of creating value which is defi ned as: Value = Quality/Total Cost Innovation Future Oriented Generates new and creative ideas that shape new processes, cuts costs, and improves the overall system that we are working in. OCHIN encourages creative ideas that promote organizational and individual learning. Leadership Strategic Demonstrates vision, courage, respect, and accountability. A leader is one who has followers. The OCHIN employees are responsible for ensuring constancy of purpose by providing: The will to embrace change, ideas to better serve the purpose, execution of needed changes, and support of the people that make it happen. Inclusive Engenders Diversity and Learning Thoughtfully considers and incorporates the diversity of ideas of people and customers in daily decision making through honest and productive communications. OCHIN recognizes the complexity of our environment and actively seeks out and respects the internal and external input that contributes to our purpose. Collaboration Teamwork Cooperation Unity Solves problems and works as a team player to meet member and organizational needs. Makes an effort to fi nd solutions that fi t for everyone involved. Understands the value of give and take and looks for strengths in others in order to build productive partnerships. The OCHIN system thrives when talented and skilled people work together to meet our purpose. OCHIN creates a high value for the organizations it works with and partnerships it builds. Three Case Studies: Mastering Change 251 the organization?s actions is not consistent with them. Analysis of past relationship failures have led OCHIN to now recognize value differences which were not evident before. As future members and partners are considered, their stated values are also reviewed to ensure that OCHIN is the right match. As a result, values are acknowledged by all executives as a crucial component for OCHIN?s success as a learning organization. No longer is the focus just on skills and knowledge; rather, individuals? values are their foundation for decisions. Alignment of individual or organizational values is essential in the execution of OCHIN?s collaborative learning environment. Partnering with Members to Create a Collaborative Structure When creating a collaborative environment, a primary challenge is to develop a structure where multiple, independent entities share, learn, and cooperate. Such an environment requires prioritization and decision making that cannot focus on one member?s needs more than any other. Decisions must be good for the entire system to ensure that OCHIN and the membership benefi t. The collaborative has three primary elements: ? A hosted electronic health records and practice management system ? Networking and mentoring (among members) ? Collaboration through shared direction setting and decision making Elements of the collaborative structure can be seen in Figure 10.17. Stewardship Service Integrity Nurtures a fi duciary responsibility to use the money in a conscientious manner. Has a passion for supporting and bettering the environments and communities in which they work. Exhibits trust and honesty. Everyone striving to make better use of our funds. Table 10.3 Continued 252 Chapter ??: Three Case Studies: Mastering Change The OCHIN Health Innovation Program Team is the core of the collaborative structure and integrates directly with the OCHIN delivery system and members to charter workgroups with specifi c 90- to 180-day assignments. This overall structure not only gives members a voice in the collaborative network but also integrates them into the overall delivery system. Partnering with Members to Transform Health Care A primary goal of OCHIN is to partner with members and share learning among members. As the data host for the electronic health records for independent clinics and county health departments OCHIN leadership believed this was an operational necessity. Members work collaboratively on clinical readiness, workfl ow redesign, provider and staff training, hosting, implementation, optimization, reporting, billing, and effective use of practice management and electronic health record (EHR) systems required to achieve strategic clinical, operational, and financial goals. Members also share software data interfaces and capabilities which minimizes the cost to each member to use and update the system. In 2009 OCHIN sponsored and received a small grant for fi ve members with fi fteen community clinics to improve diabetic patient ? Member-driven agenda ? Opportunities to network ? Round tables ? Mentoring workshops OCHIN Member Conference (Annual or Semiannual) OCHIN Health Innovation Program Team (MU, PCMH, ACO, CCO) OCHIN Member Advisory Council Member Workgroups ? Align OCHIN and member priorities ? Maintain member engagement ? Member conference design ? Member satisfaction survey ? Set priorities and work ? Strong focus on innovation ? Maintain program approach ? Oversee workgroups ? Specific projects ? Time bound ? Staff managed ? Deliverable/outcome focused Figure 10.17 Member Collaboration Structure Three Case Studies: Mastering Change 253 outcomes for their community health in a three-year period from HRSA in the U.S. Department of Health and Human Services. The collaborative7 agreed to the following three measures as a preliminary step in the application for the grant: 1. Percentage of patients diagnosed with diabetes with the last HbA1c reading done within the last 6 months (see Figure 10.18) 2. Percentage of patients diagnosed with diabetes with the last HbA1c reading <=8 months (see Figure 10.19) 3. Percentage of patients diagnosed with diabetes with depression screening within the last 12 months (see Figure 10.20) Starting in September 2009, members worked collaboratively on clinical readiness, workfl ow redesign, receiving provider and staff training in workfl ow redesign, quality improvement methods, variation, and personality intelligence. They used the data services program called Solutions to manage the patient care and results. The fi rst year, they worked with one clinic in each organization. By the second year, they had spread the improvements to all fi fteen clinics with the following results, one year ahead of schedule. OCHIN was recognized by HRSA for achieving the following results in record time. 100% Open Door Community Health Ctrs- Eureka Klamath Open Door- Klamath Multnomah County Health Dept- East Santa Cruz County- Watsonville Virginia Garcia Memorial HCBeaverton 95% 90% 85% 80% 75% Percentage 70% 65% 60% 55% 50% Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Figure 10.18 Percent of Patients Diagnosed with DM with HbA1c Done Within 6 Months 254 Chapter ??: Three Case Studies: Mastering Change Developing Partners?Outside of OCHIN and Its Members OCHIN recognizes the value of partnering with not only members, but with private, nonprofi t, state and federal government entities in order to achieve its purpose and deliver the best value products and services to its membership. Partnerships require foresight, tenacity, willingness, and creativity to develop relationships that will benefi t both parties. Following are some examples where OCHIN has Open Door Community Health Ctrs- Eureka Klamath Open Door-Klamath Multnomah County Health Dept-East Santa Cruz County- Watsonville Virginia Garcia Memorial HCBeaverton 85% 80% 75% Percentage 70% 65% 60% 55% 50% 45% Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Figure 10.19 Percent of Patients Diagnosed with DM Last HbA1c Reading <=8 Months 85% 90% 95% 100% Percentage 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Open Door Community Health Ctrs- Eureka Klamath Open Door-Klamath Multnomah County Health Dept-East Santa Cruz County- Watsonville Virginia Garcia Memorial HCBeaverton Figure 10.20 Percent of Adult Patients Diagnosed with Diabetes and Screened for Depression Within the Last 12 Months Three Case Studies: Mastering Change 255 reached beyond their organization?s capacity and expertise to provide additional services and products through partnerships: Products: ? Mid Rogue eHealth Services (MReHS) and OCHIN/O-HITEC announced a partnership that will advance electronic health record adoption in the state of Oregon. MReHS was founded by physicians to promote health care quality, access, and effi ciency through the effective use of information technology. They currently provide a hosted implementation of Greenway?s PrimeSuite electronic health record (EHR). O-HITEC chose Mid Rogue eHealth Services as a statewide partner to implement Greenways PrimeSuite EHR because of their solid reputation as a Greenway provider in Southern Oregon. Services: ? EasyStreet? Online Services Inc. as its data center colocation partner. ? Oregon Medical Association to conduct workshop series called ?Passport to Health IT.? The series is designed specifi cally for small and medium-sized clinics operating both with and without an EHR. The courses are intended to complement the HITECH programs, language, and organizations in Oregon. ? ORHQN to assist Oregon?s twenty-fi ve Critical Access Hospitals in reaching the federal requirement to meaningfully use an electronic health record (EHR). ? Gateway EDI, a leading health care solutions provider of electronic data interchange services to help OCHIN/OHITEC members save time and money. Summary In the twelve years of OCHIN?s existence, the last two have proven to be the most challenging. Transforming OCHIN from primarily an electronic health record installation company to a health information and technology provider and almost tripling personnel in two years is a likely formula for failure. Yet using the elements of leadership, Sears embarked on this learning journey, building an executive leadership team that was not afraid to learn and grow. 256 Chapter ??: Three Case Studies: Mastering Change Her vision pushed the bounds of their collective leadership knowledge and experience. Responding to unexpected consequences and weaknesses in the system required tenacity, trust in the vision, and methods explained in this book. But the benefi ts have far exceeded the pain along the way, and the bridge is getting stronger every day through collaborative learning from internal talent, member contributions, and outside partnerships. Of course, no one is satisfied and the work goes on to attain better patient health, better community health, and lower costs for health care. RICHARD MARGOLIES - page 232

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