The New Science of Medicine & Management: A Comprehensive, Case-Based Guide for Clinical Leaders

Foreword I
Foreword II
Preface
	Part I
	Part II
	Part III
	Part IV
	Summary
Acknowledgments
Contents
List of Contributors
1: Introduction to the New Science of Medicine
	Difficulty Involving Physicians in Health Care Performance Improvements
	Quality as Ambiguous Versus the Value Revolution in Health Care
	The Importance of Training Physicians in Management
	The Science of Medicine and Management
	The Clinical Side of Medical Organizations Are Led by Medical Practitioners Trained in the Bio-Medical Sciences
	Impact of Physician Leadership on Health Care Performance
	The Difficult Transition from Clinical Staff Member to Clinical Manager
	The Early Frontiers of Medicine and Management
		Organizational Learning and the Case of Minimally Invasive Cardiac Surgery
		Lesson
		Explaining Variations in Risk-Standardized Mortality
		Lesson
		In-Hospital Cardiac Arrest
		Lesson
		Adoption of LEAN Management Is Not Implementation
		Lesson
	Managing for Medical Results at Intermountain Healthcare: Putting Medicine and Management Science to Work
	A Few More Lessons about Medicine and Management
	The Way Forward
	References
Part I: The Well-Managed Health Care Organization: Building Implementation into Strategic Thinking
	2: Shouldice Hospital from Interviews and Observations: The Well Managed Organization
		Introduction: The Well-Managed Health Care Organization
		Literature Review
			The First Stream: The Evolution of Hernia Surgery & the Search for an Optimal Hernia Repair
			The Second Stream: Comparing Shouldice with Other Techniques
			The Third Stream: Focused Factories and Well-Managed Organizations
		Research Methodology
			The Current Hernia Repair Landscape: How Attractive Is this Service Line?
		Shouldice Hospital: Analysis from Interviews and Observations
			History: The Early Years of Shouldice
			The Care Program: A Vision that Reconstructed the Boundaries for Hernia Surgery
			Anesthesia and Conscious Sedation
			Post-Operative Care: Immediate and Continuous Ambulation
			Hyper-Focused Clinic and a Very High Volume of Cases
			The Front Stage and the Key Clinical Activities
			An Admission in Two Visits: Pre-Admission and Investigation
				Day One: Admission and Investigation Prior to Surgery
				Day Two: Surgery and Therapy
				Days Three and Four: Post-Surgery Recovery, Follow-Up, and Discharge
			Patient Echoes and Frontstage Voices: The Patient Value Proposition
			The Back Stage at Shouldice
			Targeted Patient Segments
			Shouldice Service Concept
			Operating Strategy: Focused on Productive Efficiency and Quality
			The Method and the Operating Rooms: Focused on Quality and Efficiency
			A System and Culture of Patient-Centered Accountability
			Well-Designed Service Delivery System
				Organization Structure and People Management
				People and Job Design
				Human Resource Investment in Training
				A Patient-Centered Facility
			Caregiver and Staff Echoes and Voices: Value Creation for Employees
			End Results and Performance at Shouldice
				Financial Aspects
			Incidence of Recurrent Hernias: Shouldice Versus Mesh
			Chronic Post-Operative Pain and Complications
			Social Impact of High-Performance Care at Shouldice: Value Creation
			Challenges for the Coming Years
			Future Demand for Hernia Repairs
			The Four Tiers of Shouldice Patients
				Tier Zero Patients
				Tier One Patients
				Tier Two Patients
				Tier Three Patients
		Discussion and Conclusions
			Positioning and the Strategy Landscape
			Leveraging Value to Patients and Employees over the Cost of Care
			Standardization in the Backstage and Customization on the Frontstage
			Managing Patient Demand and Coordinating Patient Flow
			Optimizing Patient-Caregiver Co-production
			A Loyal Patient Base: The Lifetime Value of Shouldice Patient
			An Integrating Culture
			Patient-Centered Focus
				Managing Patient Expectations
			Team-Based and Patient-Centered Culture
			Value Innovation at Shouldice
		Conclusions: Lessons from Shouldice
			Lessons for Health Care Organizations
				Lesson One
				Lesson Two
				Lesson Three
				Lesson Four
				Lesson Five
		References
	3: Improving Leadership and Business Structures in a Rural Emergency Department
		Background
		Overview of BWEP Engagement & Methodology
		Emergency Department Structure and Equipment
			Staffing & Finance
			Quality Work
			Relational/Cultural/Political
			BlueWater Emergency Partners Internal Changes
		Results
			Finances
			Quality Work
		Discussion
		Conclusion
		Addendum
		References
Part II: Physicians Leading and Implementing Change: Improving Operating Strategy and Changing Culture While Overcoming Organizational Inertia
	4: Improving the Operating Room Efficiency through Communication and Lean Principles
		Executive Summary
		Introduction
		The Environment
		Methodology
			Problem Definition
			Preliminary Hypothesis
			Project Plan
				Process Improvement Tools
				The Project Initiation
		Data Gathering
		Results
		Discussion/Lessons Learned
		Conclusion
		References
	5: Implementing Change in Surgical Culture
		Executive Summary
		Introduction
		Methods
		Results
			Nurses as Boundary Spanners
			Policy Was Decided behind Closed Doors
			“Us” against “Them”
			Relational Mapping
			Organizational Structures Analysis
		Discussion
			Lessons Learned
			Reflections on Change Management
		Conclusion
		References
	6: Fast Track Approach Following Heart Surgery in Infancy and Early Childhood: Implementation Strategy with Outcome and Cost Analysis
		Executive Summary
		Brief Narrative of Key Values to Lead Change
		Introduction
		Methodology
			Variables
			Statistical Analysis
			Project’s Organizational Format/Participants
		Results
			Demographics
			Procedural Details
			Complications/Survival
			Early Versus Late Extubation/Determinants of Failure
			Cost Analysis
			Limitations
		Discussion
			Implications/Impact on Organization or Clinical Practice
				Preoperative Parameters
				Intraoperative Parameters
				Postoperative Parameters
			Assessment of Team Performance and Leadership: Lessons Learned
		Managing Change: Reflections
		Conclusion
		References
	7: Decreasing Variance in Care: Implementation of Protocolized Postoperative Feeding as a Proxy for Discharge
		Executive Summary
		Introduction
			A Historical Basis for Stakeholder Perspectives
			A Service Line for Pediatric Surgery
			Piloting a Quality Improvement Project
			Focus on Procedural or Nonprocedural Component of a Surgery
			The Goals and Timing of this Project
		Methods
			Assembling a Policy Team
			Analysis
		Results
		Discussion
			Change Management
			Lessons in Management
			Implementation of the Project
		Conclusion
		References
	8: Institutional and Professional Transition: The Foundations of Business Management in the First 100 Days of a Chief Medical Officer
		Introduction
		Role of the Chief Medical Officer
		Defining the Problem
		Creating a Plan
		Getting to Work
		Reflections and Results
		Conclusion
		References
Part III: Value Creation in Health Care I: Improving Technical Outcomes and Patient Experience
	9: National Surgical Quality Improvement Program (NSQIP) Improvements: A Case Study
		Executive Summary
		Introduction
			Conceptual Framework
		Methods
			Outlier Analysis
			Change Management
		Results
		Discussion
			Lessons for Changing NSQIP Ratings
			Lessons for Leadership
		Conclusion
		References
	10: Addressing America’s Opioid Crisis through Community-Based Primary Care
		Background
		Approach
		Community-Based Prevention Programs
		Pain Management Model
		Reducing Barriers to Care
		Discussion
		Conclusion
		References
	11: Team-Based Care: A Foundation for Success in Value-Based Payment Models
		Executive Summary
		Background
		The Role of Team-Based Care
		Management Methods
			Four Core Principles for Team-Based Care
			Co-Location
			Pre-Visit Planning
			The Morning Huddle
			The Four-Stage Office Visit
		The Role of Medical Assistants and Nurses
		The Role of Good Data
		Advanced Team-Based Care Implementation
			Assess Current Protocols
		Findings about the Team-Based Model of Care
			Provider Capacity
			Patient Experience
			Provider and Staff Experience
		Conclusion
		References
	12: Impacting Risk Communication: Educating Providers to Improve Informed Consent Conversations in Procedural Sedation
		Executive Summary
		Introduction
		Methods
		Results
		Discussion
		Lessons Learned
		Conclusion
		References
	13: Factors Influential in Seeking Care for Neonates with Congenital Heart Disease
		Executive Summary
		Introduction
		Methods
		Results
		Lessons Learned
		Conclusion
		References
	14: Creation of the LSU Health Shreveport Complex Cranial Surgical Center of Excellence: Needs Served, Process to Obtain, and Lessons Learned
		Executive Summary
		Introduction: Background and Problem Description
			Why Should We Develop a Neurosurgical Center of Excellence?
		Methodology: Developing a Center of Excellence for Complex Cranial Surgery
			Strategic Location
			Strong Referral System
			Clinical Interdependency
			Academic Excellence
			Monetary Support
			Managing the Change
		The Business Proposition
		Lessons Learned by Our Leadership
		Conclusion: Summary and Future Directions
		References
	15: Obtaining Center of Excellence Accreditation of a Robotic Program in a Safety Net Academic Hospital
		Executive Summary
			Introduction of Topic/Background Information
			Benefits of Robotic Surgery
			Environment
			Current Status of Program and Benefits
			Reason for Accreditation
		Methodology
			Stakeholders and Resources
				Stakeholders
				Executive Change Team
				Resources
			Project Plan
			Unexpected Obstacles
				Loss of Executive Champion
				Resistance to Change
				Barriers to Forward Progression
			Evaluation of the Program
				Competitive Advantage and Key Success Factors
			Relational Coordination Analysis
			Organizational Alignment
				Seven S Factor Analysis
				Sweet Spot Analysis
				Sizing Up the External Environment
					Remote Environment
					Operating Environment
		Results
			Project Deliverables and Milestones
			Results and Impact
				Metrics
				Growth
				Outcomes
		Discussion/Lessons Learned/Reflections
			Leadership Reflections
				Assessment of Leadership
				Assessment of Team Performance
		Conclusion/Summary
		References
Part IV: Value Creation in Health Care II: Improving Clinical Efficiency and Lowering Costs
	16: Vascular Diagnostic Laboratory Improvements Through Effective Data Management
		Executive Summary
		Introduction of Topic/Background Information
			Vascular Laboratory: Current System
			Vascular Laboratory: Proposed System (NewLab)
		Methodology
			Incremental Costs
			Incremental Revenues/Cost Savings
			Other Intangible Cost Savings
			Sunk Costs
			Opportunity Costs
		Articulation of Variable and Fixed Cash Outflows over the Project Term
			Existing System (OldLab)
				Variable Costs Include
				Fixed Costs Include
			Proposed System (NewLab)
				Variable Costs Include
				Fixed Costs Include
				Non-incremental Cash Outflows
		Articulation of Revenues (Cash Inflows) over the Project Term
			Cash Inflow 1: Cost Savings from Greater Efficiency
			Cash Inflow 2: Cost Savings from Direct Materials
			Cash Inflow 3: Direct Patient Service Revenue
			Discounted Cash Flow Analysis
			Final Analysis Using Net Present Value to Determine if the Proposal Is Viable Along with Sensitivity Analysis Showing Estimations of Best, Middle, and Worst-Case Scenarios
			Analysis 1: Patient Volume
			Analysis 2: Technician Costs
			Analysis 3: Cost of Capital
		Sensitivity Analysis Conclusions
		Articulation of Qualitative Factors that Require Consideration Along with the Financial Analysis
		Project Team, Process, and Evolution
		Results
		Discussion
		Conclusions
		References
	17: Use of Operations Management Tools to Improve Efficiency for Ambulatory Surgery Procedures
		Executive Summary
		Introduction
			The Hospital System
		Methods
		Results
			Supply Costs Vs. OR Time Cost
		Discussion
			Influence of Schedulers
			Building Buy-in
		Retrospective
		Conclusion
		References
	18: Physician Engagement in Population Health: A Case Study in Project Selection and Practice Variation
		Executive Summary
		Background
			The Case for Decreasing Health Care Costs
			Health Policy Focuses on Cost
			Physician Engagement
			Context of the Organization
			Choosing the Project: Stakeholder Alignment, CQI
		Methods
			Continuous Quality Improvement: Plan Do Study Act
			“Plan”
			“Do”
			“Study”
			“Act”
		Results
			Continuous Quality Improvement
			Baseline Analysis Reveals Wide Variation in Practice Patterns
			Monthly Provider Education Was Associated with Decrease in Lab Ordering
		Discussion
		Conclusion
		References
	19: Late Surgical Cancellations in a Pediatric Surgical Practice
		Executive Summary
		Introduction
		Methods
		Results
		Discussion
		Conclusion
		References
	20: Routine Post-reduction Radiographs After Closed Reduction of Pediatric Wrist and Forearm Fractures Is Unnecessary: Effecting Process Change and Eliminating Waste in the Pediatric Emergency Department
		Executive Summary
		Introduction
		Methodology
			Initial Study
		Results
			Initial Study
			Opportunity Costs
		Methods
			Follow-Up Study
			Change in Protocol
			Data Collection
			Analysis
		Results
			Follow-Up Study
		Discussion
		Lessons Learned/Principles
		Conclusions
		References
Index