According to the home page the UMC mission is to serve the community by providing patient-centered care in a fiscally responsible and learning focused environment. The UMC vision is to be the premier academic health center. Also the UMC values include compassion, accountability, integrity, and respect (University Medical Center of Southern Nevada, 2014).
Also, in August 2010 UMC was honored by the American Heart Association/American Stoke Association. The award was for the use of evidence-based guidelines in the provision of exemplary patient care. UMC partnerships include the University of Nevada School of Medicine, the Department of Pharmaceutical Specialties residency program, Touro Medical School, and the College of Southern Nevada (UMC - 18th Largest Public Hospital in the United States, 2010) .
UMC plans to produce high-quality health care services in a consistent and regular manner. This will occur through the use of cutting edge treatment techniques and technology. As such UMC has been identified as a state-designated Level 1 Trauma Center for Southern Nevada (University Medical Center of Southern Nevada, 2014). Another service distinction is that UMC is the only advanced location to provide a specialized medical team, 24 hours per day. The Lions Burn Care Center represents Nevada’s only burn care facility. Finally, there are units that are specifically focused on physical medicine and rehabilitation (University Medical Center of Southern Nevada, 2014).
Specific services that are offered by UMC include a wide-range of both general and specialty services. This includes adult specialties like pulmonology, orthopedics, cancer, geriatrics, and gynecology. Other adult specialties are neurology, neurosurgery, diabetes, endocrinology, gastroenterology and GI surgery. There are a total of 541 beds that enable UMC to provide premier healthcare and also operate as a teaching hospital (US News and World Report, 2015).
According to 2014’s data there were approximately 123, 485 patients who matriculated through the emergency room. Also, there were approximately 30,746 general admissions, (8,576) inpatient and (9,517) outpatient surgeries performed by physicians (US News and World Report, 2015). These statistics would indicate that the organizations target market is the general population in local communities. Additionally as a University hospital UMC also targets medical students that benefit from teaching curriculum and activities. Goal displacement is defined as the use of resources for a purpose other than the organizations original intent. This reallocation of resources often happens based on a change in organizational focus. In researching the UMC hospital there are adverse issues identified in several hospital reports. This would by its very nature indicate probable goal displacement.
According to a 2009 Annual Hospitals Report there were several identified areas requiring improvement. Two mentioned areas were hospital throughput and infection control. The expedient realignment of these areas is necessary to ensure the quality of patient care and safety remained centric to the organizational goals. One stated goal is to move patients more proficiently through the ED (Emergency Department). There is also a focus on enhancing the continuity of care from UMC Quick Care Clinics (Department of Health and Human Services-Nevada Division of Public and Behavioral Health, 2015).
As part of a response to the 2009 report, UMC determined that short-term improvement plans also needed to be in place. This included the modification of staffing in the Emergency Department to improve the speed of patient assessments. UMC also committed to extending physician coverage for rapid medical assessment. This theoretically would ensure patients receive care by a physician in a more efficient manner (Department of Health and Human Services-Nevada Division of Public and Behavioral Health, 2015).
In terms of Long-Term improvement, UMC received funding that would enable them to redesign the ED department. This was the strategy they determined would enable more efficient patient flow. The measurement of their short and long-term improvement plan according to leadership is throughput. By continually evaluating metrics as displayed on a dashboard of overall patient wait times, roadblocks to optimal patient flow are easily identified. Additionally, UMC planned to provide Infection Control continued education. This strategy was viewed as an aggressive prevention measurement. Also, the stated intention was the establishment of policies and monitoring mechanisms that would ensure best practice implementation (Department of Health and Human Services-Nevada Division of Public and Behavioral Health, 2015).
UMC also has implemented the Institute for Healthcare Improvement as part of their short term improvement efforts. These are standardized central line kits that enable doctors to carefully follow infection control guidelines. There are also infection control staff that carefully monitor implemented infection control practices. Further, UMC’s Director of Infection control is actively engaged with the (CDC) Center for Disease Control and Prevention. This national association enables UMC to benchmark infection control metrics comparative to other facilities (Department of Health and Human Services-Nevada Division of Public and Behavioral Health, 2015).
Workflow modification will also include the standardization of doctors’ orders, combined with ongoing education. There will also be the employment of a full-time Infection Control Physician (ICP). This ICP will provide patient consultation and education regarding infection control procedures. UMC will also measure and review patient cultures and analyze dashboards of infection rates on a monthly basis. From a macro perspective UMC will provide additional public transparency through self-reporting and education. The primary platform will be the company website umcsn.com. As a note of distinction and according to the 2009 report, UMC is the only healthcare organization committed to complete disclosure of patient quality and safety metrics (Department of Health and Human Services-Nevada Division of Public and Behavioral Health, 2015).
According to a recent article there are notable improvements at UMC, and yet there remains areas of necessary improvement. The Leapfrog Group (LG), is an employer-backed nonprofit organization that provides metrics related to patient safety. Recently LG gave UMC the lowest grade possible (an F) on patient safety. This unheralded distinction placed UMC in a group of only 22 hospitals receiving such a grade. The safety metric is measured based on infection control metrics, medical errors, and mortality rates. The Leapfrog report evaluates leadership and infrastructure necessary for patient safety, resources utilized in patient care, and overall outcomes (Harasim, 2014).
According to Dr. Joan Brookhyser (UMC chief medical officer) UMC was fiscally unable to hire staff, designated for the data compilation. Therefore, according to Leapfrog CEO Leah Binder, if an organization does not voluntarily compile the data then Leapfrog utilizes public information. This public information primarily includes the data that the healthcare organization is required to report to the Centers for Medicare and Medicaid Services. That information is subsequently compiled into a composite score that is converted to a letter grade (Harasim, 2014).
The article further stated that UMC failed for example to abide by the measure requiring the administering of a patient antibiotic within one hour prior to surgical incision. In contrast Desert Springs Hospital and St. Rose Dominican Hospital received letter grades of an A. The leadership of those hospitals attributed their success as the result of collaborative efforts by hospital staff. Implicit within this statement is a realization that UMC lacks in collaborative efforts by all staff (Harasim, 2014). According to Dr. Jerry Reeves (VP of HealthInsight) UMC currently still lacks the appropriate safety structure. Reeves acknowledges the positive indicators such as UMC’s outstanding trauma surgeons, but bemoans indicators such as employees washing their hands in a timely manner. He recommends that UMC focus on more defensive and preventive strategies, as opposed to relying on star individual medical staff (Harasim, 2014).
Brookyser acknowledged that UMC still has areas that are critical to organizational success. This includes the implementation of a computerized physician order entry system. Such an investment according to experts mitigates medication errors which adversely affected UMC’s Leapfrog score. This system according to researchers minimizes handwriting issues, reduces dosage errors, thereby minimizing potential medication interactions with other medications. Further, UMC just recently completed staffing for intensivists, who are critical in the reduction of mortaility rates (Harasim, 2014).
One of the organizations that has a significant impact on regulatory compliance is the Center for Disease Control (CDC). According to the CDC mission the objective is to protect America from health, safety, and security threats. This is a global commitment that includes addressing issues (chronic, acute, curable, or preventable) domestically and internationally. The primary strategies for the accomplishment of CDC goals include critical science and the provision of valuable health information. This is a multi-faceted process that also includes leadership development, training the public health workforce, and disease detection (Center for Disease Control, 2015).
The above graph illustrates an organizational flow chart for the Nevada Hospital Association (NHA). UMC Las Vegas is one of the 2015 members listed on the chart. Although the NHA is likely not a governing body they are undoubtedly instrumental in the development of policies and procedures that UMC follows. According to the NHA main website they are a not-for-profit statewide trade association (National Hospital Association, 2015).
Any (acute, psychiatric, rehabilitation, or specialty hospital) within the State of Nevada is part of the NHA. They are also part of the American Hospital association. Incorporated in 1971 the NHA is a platform for healthcare organizations to address critical areas such as reimbursement, worker’s compensation, professional liability, and continuing education. The NHA is a vital resource especially given the healthcare system challenges including limited funding, labor shortages, and government payment policies (National Hospital Association, 2015).
The NHA as part of their transparency measures provides individual hospital quality performance metrics. They utilize three primary resources which include (CMS) The Centers for Medicare and Medicaid Services, (AHRQ) the federal Agency for Healthcare Quality and Research, and The Nevada State Health Division. These three primary reporting agencies subsequently influence the policies and procedures of UMC.
Below are metrics that are gleaned from the three primary resources. The numbers and columns represent a performance report card for UMC in key areas. For example, in categories like accidental punctures or blood clots UMC should have 0’s or less than 1%. Postop Hemorrhage or Post-Op Respiratory Failure are areas where the patient is at enhanced risk, after the surgery which is unacceptable.
Although the organization is funded by many sources they have also been fortunate to receive financial gifts. For example, during a recent meeting by the Governing Board (February 25, 2015) they discussed a gift of $50,000 by the late Beverly & Jim Rogers. They allotted those financial resources for the securing of forty-six reclining chairs for patient rooms. This reinforces the UMC mission of providing patient-centered care (University Medical Center, 2015). There are additional funds that are provided by the City of Las Vegas. This is part of Las Vegas’ Medical District Plan. That plan which is facilitated by the SmithGroup seeks to expand healthcare institutions throughout the city (University Medical Center, 2015).
Source: (Nevada Hospital Association, 2015)
UMC reaches out to the community through various outreach programs. Those programs include the Pedestrian Safety Task Force (PSTF) and the Safe Kids Clark Country (SKCC). The PSTF was established as a response to the growing number of auto-pedestrian crashes. Pedestrian safety is promoted through various venues including schools and health fairs. This program is in partnership with safe communities, metro PD, School Police, legislators, and parents (University Medical Center, 2014).
Another program is the Every 15 Minutes program. This is a two day program that targets high school juniors and seniors. The goal is to provide educational information about drinking and driving. The program derived its name from statistics indicating alcohol-related mortality rates occurred every 15 minutes in the United States. This program is in partnership with Clark County, Las Vegas Fire Dept. UMC, Clark County Coroner’s Office, and a number of agencies (University Medical Center, 2014).
Source: (University Medical Center, 2014)
In terms of the degree of formality UMC appears to have a very inclusive culture. Although this has not been explicitly stated it is implicit. For example the UMC Board of Trustees has meetings that are held every 1st and 3rd Tuesday of each month at 9:15 am. The information about the meetings is provided on the UMC website as well as the location. Further, the meetings are open to the public (University Medical Center, 2014). However, based on the above organizational chart there are components (i.e. Senior Leadership Team) that are more formalized groups and positions.
In terms of patterns of coordination they can be evaluated at least in part based on agenda transcripts. For example one Board of Trustees meeting described instructions for how a member from the community could speak on an agenda item. There is a Public Comment Interest Card which can be filled out in advance. Otherwise there is a Comments by the General Public period at the end of the meeting (University Medical Center, 2013). At the same time based on the transcript of a meeting, there were six business items addressed. The majority of the items required approval, adoption, authorization, or report out’s. This would indicate that the proposals, resolutions, and subsequent actions are decided on based on a transparent process (University Medical Center, 2013).
The degree of centralization of power is relative to the functional role and responsibility. In other words, there are various governing bodies that have varying degrees of operational authority. For example the CDC is a governing body over healthcare and disease control, however it is viewed as an umbrella organization. The NHA is a networking and compliance organization but it can only provide compliance education and information (University Medical Center, 2014).
The Senior Leadership group which is illustrated in the above organizational chart has functional authority based on their positions. Then there is the Board of Governors. This Board of Governors is a prolific group of leaders who have successful careers and positions within the healthcare industry. They are selected by the Clark County Commission to provide vital oversight of the University Medical Center (University Medical Center, 2014). Other critical positions related to hiring and analyzing personnel are listed in the organizational chart below. The below chart also represents the individuals who would handle any employee complaints or personnel issues.
(University Medical Center, 2014).
To summarize the culture of UMC in one word it would be “inclusive.” According to the organizational website there is a Volunteer Services Department (VSD). The VSD works in concert with clinical and non-clinical departments to serve patients and visitors. There is a shared commitment to service attainment. There are also advertised classes, many of which are free to the community. Classes include (Senior Yoga, Breastfeeding, Infant & Child CPR, Cardiology Series, etc.). This also indicates a focus on building healthy and informed communities (University Medical Center).
Recently the Governing Board Audit and Finance Committee had a meeting. As part of that extensive meeting there was a PowerPoint about Implementation of various strategies. For example the process for vendor selection includes the identification of funds, negotiation of contracts, and obtaining of board approval (University Medical Center, 2015). The timeline for this process is approximately 16 months. In terms of a establishing an organizational strategy, key objectives include ensuring that projects have minimal impact on Revenue Cycle. Additional goals include physician satisfaction and improved integration between the Emergency Department and the main floors. Other key objectives include enhanced workflow, mobile access for physicians, and anticipated reimbursements (University Medical Center, 2015).
Consultants are responsible for identification of key objectives, and benchmarking the organizational baseline. Also consultants provide an optimal future state while keeping executives focused on change management. Finally consultants are key stakeholders in the implementation of project management objectives. The project approach and role include the following:
Source: (University Medical Center, 2015)
Examining the agency, one of the primary displaced goals is enhanced collaboration within UMC. The fact that there are public platforms, access to past (transcripts), and future meeting dates is noteworthy. However, the disconnect appears to be is in the implementation or facilitation of change management strategies. There are so many shareholders involved in the organization that they don’t always connect with vital information. The LeapFrog Report is one example of how restrictive and disconnected the organizational flow can be at times. This does not take away from the numerous accomplishments that have been achieved. However, greater efforts need to be taken to ensure that all stakeholders feel engaged at every level of the organization.
Regulatory agencies like CDC and AHRQ are influential in terms of reporting. Although UMC has a philosophy of transparency the revealed information is still vetted internally first. However the regulatory agencies provide an accountability link that ensures patient safety is maintained. Many of the preventative measures that are being implemented in organizations like UMC and other healthcare providers is based on audits and reporting. Audits and reporting subsequently leads to recommendations with deadlines. Since UMC is at least partially funded by taxpayer dollars then clients influence the practice by demanding change when services are substandard. Key decision makers are present at every level of the organization.
Therefore, it is important that leadership becomes transformative as opposed to being simply a functional role. In this sense the leaders must inspire others to operate as empowered stakeholders within the organization. If UMC is only an organization that houses superstars in key departments as opposed to developing leaders that is problematic. This is because every frontline, back-office, and auxiliary employee or contractor impacts the organization.
In terms of recommendations, they include the implementation of the strategies that have been proposed in various meetings. Especially strategies like the project approach and role. For every project there must be the establishment of key objectives and a milestone for completion. Reflecting for a moment back on the LeapFrog report there was evidence that certain goals had not been achieved. This ultimately affected the UMC LeapFrog score in an adverse and undesirable way.
Since UMC is not a new hospital then they should already be aware of the LeapFrog organization and deadlines for data submission. Although it may not be as exciting as the investment in infrastructure it is extremely important. The organizational grades are often viewed by a potential client as reflective of the whole organization. In other words they may not be able to take the time to truly get to know UMC before making an informed decision.
I would especially encourage the organization to focus on the monitoring of quality control metrics and the completion of Post-Implementation benchmarking. This will enable UMC to be more proactive in the implementation of necessary change strategies. It should never be a surprise for an organization to see safety or other quality metric indicators trending downward. Rather an organization should be able to see undesirable patterns at the early stage of a process. This will ensure that any necessary modifications are handled in an expedient manner and before the issues become too extensive to correct. It is also recommended that UMC ensure that each project is viewed as a cost related line item. As they calculate factors like (manpower hours, technical resources, etc.), they can then compare that to anticipated rewards.
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