Talk to hospitals around the country, and you'll hear about the same problems: crowded halls, provider shortages and sloppy patient hand-off. Mina Ubbing, president and CEO of Fairfield Medical Center in Lancaster, Ohio, and chair of the board of trustees at the Ohio Hospital Association, discusses five common dilemmas facing U.S. hospitals and some suggestions to combat them that worked for her hospital.
1. Problem: Too many avoidable patient days.
Suggestions: When Ms. Ubbing brought in an outside group to look at her hospital's inefficiencies, the group found that the number one opportunity for cost-cutting was in avoidable patient days. Patient days can add up quickly if providers aren't focused on moving patients to other facilities or their homes once appropriate. She says the hospital took several approaches to decrease patient days. They worked with nursing homes and extended care facilities to make sure patients could be transferred on weekends, to avoid keeping a patient in the hospital until Monday when they were ready to be moved on Saturday. The hospital also worked with physicians on length of stay and showed data that demonstrated how each physician stacked up compared to his or her peers.
Ms. Ubbing says the hospital's nurse leaders also introduced a concept called "full capacity protocol." A hospital might be at "full capacity" for various reasons: Perhaps so many patients are in isolation that second beds in semi-private rooms are unavailable, or perhaps all the beds in the hospital are actually full. Sometimes a patient waiting for discharge will occupy a bed when there is no medical necessity — simply because it's easier to stay in the bed than to go home. "What we do is we move the patient awaiting discharge to a hall bed, and we put the sicker patient in the room to begin care there," she says. "It's pretty amazing how soon that patient awaiting discharge finds a way home."
2. Problem: Desire for physician integration but very few employed physicians.
Suggestions: Ms. Ubbing's hospital employs around 10 percent of its physicians, meaning the vast majority of the facility's providers are independent. This echoes the traditional model of physician practice, but it can mean hospitals struggle to integrate physicians in order to take advantage of bundled payments. Ms. Ubbing says the hospital may eventually move toward a greater percentage of employed physicians, but for now, she uses co-management of hospital service lines to involve her independent physicians in hospital operations. The hospital first implemented co-management of the orthopedics service line and then moved to the cardiovascular and thoracic service line.
When structuring the co-management of the cardiovascular line, Ms. Ubbing says the hospital brought together diagnostic and interventional cardiologists, thoracic surgeons and radiologists — but also primary care physicians and nephrologists, two groups that might seem out of place. "If you step back and think about it and look at 30-day readmissions, the care between hospitalizations rests in those [primary care] offices, not in the hospital," she says. "That's where primary care comes in, and that's where nephrology comes in with vascular cases."
She says the hospital placed its trust in the independent physicians by saying, "If you want to run how clinical care is delivered in our hospital, come on down." Co-management helps integrate physicians with the system, she says. "Unlike the independent physician, who's doing his care for his patients the way he wants to, he [now] has the opportunity to be part of an institute where the incentives are for the whole group to perform at the highest level," she says.
3. Problem: Unhealthy community.
Suggestions: Under the healthcare reform law, FMC is required as a non-profit hospital to perform an annual healthcare needs assessment of its community. "One of our big issues is around healthy lifestyles, and more specifically, obesity and the disease stream it leads to," she says. Even as the insurance coverage expands, she says community members still have to make the effort to visit a physician and keep themselves healthy. In 2010, the hospital targeted drug and opiate addiction in the community, and in 2011, the hospital plans to target obesity. To fight drug addiction issues, the hospital required every employed physician to register with the Ohio Automated Rx Reporting System, an Ohio database that shows physicians a patient's prescription drug history. "There are some pretty persuasive stories that show you don't know what you don't know," Ms. Ubbing says. "One surgeon got a referral from a primary care physician for surgery, and when [he looked up the patient in OARRS], he found the patient didn't have one doctor — he had two. He was getting identical prescriptions from both." The hospital also dedicated a newsletter to issues around drug abuse and provided copies to anyone who wanted them.
In 2011, the hospital will focus on obesity, a huge problem for many communities in the United States. The community has raised money to sponsor local residents to ride their bicycles at designated events where the courses run from 5-100 miles. Because the hospital is located in a farming area, administration is trying to bring more local, fresh produce to community members and ensure nutritionally balanced meals in the hospital cafeteria. Ms. Ubbing has been amazed by the willingness of community members to participate in these initiatives: "People have come forward and said, 'I want to be part of this,'" she says.
4. Problem: Poor communication between providers.
Suggestions: Fairfield Medical Center recently added a new role to its facility: clinical nurse leader. "A clinical nurse leader is the first new role in nursing in 40 years, and this is a post-masters trained nurse who is on track like an advanced practice nurse, except their training puts them in the hospital at the bedside," Ms. Ubbing says. She says the hospital has assigned a clinical nurse leader to micro-units of around 12 beds throughout the hospital, where the CNL acts as a liaison between physicians and patients and mentors other nurses. "[We think] this will reduce length of stay, eliminate some rework and get better information flowing faster for decisions to be made," she says. By installing a nurse leader to increase communication between providers, she thinks patients will have a better healthcare experience with fewer redundancies, and physicians will have a better understanding of what happens to a patient when another provider takes over.
5. Problem: Physician and nurse shortages.
Suggestions: Hospitals across the country are preparing themselves for predicted provider shortages. To offset physician and nurse shortages in southeastern Ohio, Fairfield Medical Center has partnered with Mount Carmel Health System in Columbus, Ohio, to bring a satellite college of nursing campus to the Fairfield facility. "[Mount Carmel] has a college of nursing that rewards a BSN degree, among others, and they ran out of bricks and mortar space. The cost of that is expensive," Ms. Ubbing says. "They came to us because of the vast majority of their students outside Columbus come from here — Fairfield County." Together, the hospitals installed a branch campus of Mount Carmel's nursing school at FMC.
About two miles away from FMC, Ohio University runs a branch campus — Ohio University Lancaster. Ms. Ubbing says the nursing students from Mount Carmel do their first year of classroom work at OU Lancaster and spend the next three years doing clinical work at FMC. "There are up to 24 allowed in the class, and we're on our third class this year," she says. "We have the benefit of developing more nurses, and we have a three-year relationship with those nurses [by the time they graduate]." The project benefits everyone: Mount Carmel doesn't have to build more space, Fairfield County students avoid a 50-mile drive and FMC has the opportunity to "grow their own" nurses.
The hospital has employed a similar tactic to "grow" future physicians. The hospital currently has a family practice residency program and is hoping to build an internal residency program as well.
Read more about the Ohio Hospital Association and Fairfield Medical Center.
1. Problem: Too many avoidable patient days.
Suggestions: When Ms. Ubbing brought in an outside group to look at her hospital's inefficiencies, the group found that the number one opportunity for cost-cutting was in avoidable patient days. Patient days can add up quickly if providers aren't focused on moving patients to other facilities or their homes once appropriate. She says the hospital took several approaches to decrease patient days. They worked with nursing homes and extended care facilities to make sure patients could be transferred on weekends, to avoid keeping a patient in the hospital until Monday when they were ready to be moved on Saturday. The hospital also worked with physicians on length of stay and showed data that demonstrated how each physician stacked up compared to his or her peers.
Ms. Ubbing says the hospital's nurse leaders also introduced a concept called "full capacity protocol." A hospital might be at "full capacity" for various reasons: Perhaps so many patients are in isolation that second beds in semi-private rooms are unavailable, or perhaps all the beds in the hospital are actually full. Sometimes a patient waiting for discharge will occupy a bed when there is no medical necessity — simply because it's easier to stay in the bed than to go home. "What we do is we move the patient awaiting discharge to a hall bed, and we put the sicker patient in the room to begin care there," she says. "It's pretty amazing how soon that patient awaiting discharge finds a way home."
2. Problem: Desire for physician integration but very few employed physicians.
Suggestions: Ms. Ubbing's hospital employs around 10 percent of its physicians, meaning the vast majority of the facility's providers are independent. This echoes the traditional model of physician practice, but it can mean hospitals struggle to integrate physicians in order to take advantage of bundled payments. Ms. Ubbing says the hospital may eventually move toward a greater percentage of employed physicians, but for now, she uses co-management of hospital service lines to involve her independent physicians in hospital operations. The hospital first implemented co-management of the orthopedics service line and then moved to the cardiovascular and thoracic service line.
When structuring the co-management of the cardiovascular line, Ms. Ubbing says the hospital brought together diagnostic and interventional cardiologists, thoracic surgeons and radiologists — but also primary care physicians and nephrologists, two groups that might seem out of place. "If you step back and think about it and look at 30-day readmissions, the care between hospitalizations rests in those [primary care] offices, not in the hospital," she says. "That's where primary care comes in, and that's where nephrology comes in with vascular cases."
She says the hospital placed its trust in the independent physicians by saying, "If you want to run how clinical care is delivered in our hospital, come on down." Co-management helps integrate physicians with the system, she says. "Unlike the independent physician, who's doing his care for his patients the way he wants to, he [now] has the opportunity to be part of an institute where the incentives are for the whole group to perform at the highest level," she says.
3. Problem: Unhealthy community.
Suggestions: Under the healthcare reform law, FMC is required as a non-profit hospital to perform an annual healthcare needs assessment of its community. "One of our big issues is around healthy lifestyles, and more specifically, obesity and the disease stream it leads to," she says. Even as the insurance coverage expands, she says community members still have to make the effort to visit a physician and keep themselves healthy. In 2010, the hospital targeted drug and opiate addiction in the community, and in 2011, the hospital plans to target obesity. To fight drug addiction issues, the hospital required every employed physician to register with the Ohio Automated Rx Reporting System, an Ohio database that shows physicians a patient's prescription drug history. "There are some pretty persuasive stories that show you don't know what you don't know," Ms. Ubbing says. "One surgeon got a referral from a primary care physician for surgery, and when [he looked up the patient in OARRS], he found the patient didn't have one doctor — he had two. He was getting identical prescriptions from both." The hospital also dedicated a newsletter to issues around drug abuse and provided copies to anyone who wanted them.
In 2011, the hospital will focus on obesity, a huge problem for many communities in the United States. The community has raised money to sponsor local residents to ride their bicycles at designated events where the courses run from 5-100 miles. Because the hospital is located in a farming area, administration is trying to bring more local, fresh produce to community members and ensure nutritionally balanced meals in the hospital cafeteria. Ms. Ubbing has been amazed by the willingness of community members to participate in these initiatives: "People have come forward and said, 'I want to be part of this,'" she says.
4. Problem: Poor communication between providers.
Suggestions: Fairfield Medical Center recently added a new role to its facility: clinical nurse leader. "A clinical nurse leader is the first new role in nursing in 40 years, and this is a post-masters trained nurse who is on track like an advanced practice nurse, except their training puts them in the hospital at the bedside," Ms. Ubbing says. She says the hospital has assigned a clinical nurse leader to micro-units of around 12 beds throughout the hospital, where the CNL acts as a liaison between physicians and patients and mentors other nurses. "[We think] this will reduce length of stay, eliminate some rework and get better information flowing faster for decisions to be made," she says. By installing a nurse leader to increase communication between providers, she thinks patients will have a better healthcare experience with fewer redundancies, and physicians will have a better understanding of what happens to a patient when another provider takes over.
5. Problem: Physician and nurse shortages.
Suggestions: Hospitals across the country are preparing themselves for predicted provider shortages. To offset physician and nurse shortages in southeastern Ohio, Fairfield Medical Center has partnered with Mount Carmel Health System in Columbus, Ohio, to bring a satellite college of nursing campus to the Fairfield facility. "[Mount Carmel] has a college of nursing that rewards a BSN degree, among others, and they ran out of bricks and mortar space. The cost of that is expensive," Ms. Ubbing says. "They came to us because of the vast majority of their students outside Columbus come from here — Fairfield County." Together, the hospitals installed a branch campus of Mount Carmel's nursing school at FMC.
About two miles away from FMC, Ohio University runs a branch campus — Ohio University Lancaster. Ms. Ubbing says the nursing students from Mount Carmel do their first year of classroom work at OU Lancaster and spend the next three years doing clinical work at FMC. "There are up to 24 allowed in the class, and we're on our third class this year," she says. "We have the benefit of developing more nurses, and we have a three-year relationship with those nurses [by the time they graduate]." The project benefits everyone: Mount Carmel doesn't have to build more space, Fairfield County students avoid a 50-mile drive and FMC has the opportunity to "grow their own" nurses.
The hospital has employed a similar tactic to "grow" future physicians. The hospital currently has a family practice residency program and is hoping to build an internal residency program as well.
Read more about the Ohio Hospital Association and Fairfield Medical Center.