The Importance of Advocacy

As I mentioned in a previous post, the Future Task Force I (FTF I) recommendations solidified our strategic focus on our four directions to excellence, but also indicated that if declining reimbursement and the rapid introduction of non-invasive technology were going to be the major drivers for the first decade of CHRISTUS Health, philanthropy and advocacy needed to be added as strong strategic initiatives. Consequently, we have been focusing on both, with clearly defined staff, business plans and operational tactics.

With regard to advocacy, we have attempted to minimize our interactions with state and federal governmental representatives that focus on requesting additional funding, which is the primary message they generally hear from any health care leadership team that visits them in Washington or their state capitals.

We recognized that an approach that only and repeatedly requested funding would not be successful, for one of the scenarios predicted in the FTF I process was that a national disaster would occur, as well as a war in a foreign country, causing great amounts of U.S. governmental funding to be removed from education and health care and reallocated to these efforts.

Our predictions came to pass, and unfortunately the results were as negative as we expected. With the occurrence of 9/11 and the Iraq war, both state and federal governments have been working feverishly to do whatever it takes to reduce reimbursement for Medicaid and Medicare for health care institutions as well as physicians and other health care providers.

Therefore, we have focused on educating elected government officials as well as members of regulatory agencies on the causes of the rapidly rising numbers of uninsured as well as pilot projects we have undertaken to more effectively and more cost-effectively care for this population of people.

In addition to this educational process, we have also indicated—particularly to the regulators who could possibly be in their present jobs even with the change of administration in January of 2009—that because of our innovative work in creating the pilots mentioned above, we would hope to be invited to participate when the next president chooses to put together a task force to make an attempt to design a new health care system that will be more affordable and provide basic health care to all.

Last year, we made a trip to Washington, D.C. and met with the top leadership of key regulatory agencies to give them both our educational message and redesign inclusion request. They appeared very receptive, and asked us to provide as much data to them as possible which would indicate that our pilots are actually raising the quality of health care while reducing the cost for the uninsured. We are in the process of collecting and refining this data now.

The majority of our discussions regarding these pilot projects focused on two which we are currently undertaking.

First, in Mexico, in each community where we are asked to establish a “for-profit hospital,” we also commit to opening and operating a clinic, complete with x-ray and lab capabilities as well as 10 short-stay beds to care for the poor. We now have six of these in operation and will have three more opened by December of 2008.

In our process of developing these clinics, we first identify the geographical location where we will have the greatest potential to serve the largest number of poor people. However, we often find that the government has already placed a health care clinic in this area, but so often these clinics are under-funded, poorly staffed and rarely see more than 5 to 10 patients a day. Therefore, on numerous occasions, we have successfully asked the Mexican government to give us this clinic, which they are more than happy to do. Upon receipt, we renovate the clinic, add air conditioning and begin services which not only include health care, but also other social services such as day care, craft classes, literacy classes and even grooming and beauty salons.

As you will recall, in a previous post regarding a Future Task Force II trip to Canada, I re-emphasized that health status is determined by seven factors, only two of which are clinics and hospitals, with the remaining five being connected to social services such as housing, food, clothing and employment. Our clinics for the poor try to provide educational opportunities to enhance or improve the skills and outcomes in these five other areas as well.

One interesting outcome of our clinics in Mexico is that we are seeing, on average, 300 people in each 24-hour period for at least the first 18 months after opening. Then, we see about a 10 percent reduction in the number of patients who come for treatment each day. On researching why that is occurring in areas where the populations are stable or growing--which would indicate that our clinic visits should increase--we discovered that many of our prior patients were saying that what we were doing for them was keeping them well, and therefore they did not need to come back for subsequent visits.

Again, this is really proof that if you provide good health care in all seven determinants, eventually the over-users of health care will become appropriate users of health care, and therefore improve the region’s overall health care status as well as reduce the cost for individuals. This is the kind of information that people must have in order to redesign health care so they can direct resources to where they will be most beneficial.

Although we need to collect more data, our initial findings in Mexico seem to suggest that if we open more of these clinic and short-stay hospitals for the poor, we could build fewer hospitals in the future.

A second pilot is our investment in Community Health Workers (CHWs), who help clients access health resources at the appropriate level of care, find medical homes impact the client’s health status and specifically prevent and manage chronic illnesses.

Our Associates who serve as CHWs generally do not have a background in health care, but we provide them with training and then assign them to 9 or 10 chronically ill, uninsured people.

The CHWs really become navigators for these people, to get them as expeditiously through the health care system as possible, but also provide them with resources that permit them to monitor their health care status at home, hoping that they will require less costly health care services as they continue life’s journey.

Our initial data from studying these patients cared for by CHWs show that their ED visits have been reduced drastically, the medications they have taken could be eliminated or reduced also, and their activities of daily living are enhanced.

Like our programs in Mexico, we will continue to develop and study the outcomes of these CHWs and present this data to governmental regulators as they are refined, so hopefully CHWs will become reimbursed in the future.

The growth of these pilots will depend on funding, but again, we are not advocating more money for these programs, for we realize that there is none available. However, by presenting the knowledge from these pilots and educating both elected officials and regulators as to the importance of them and the positive outcomes they have created, we are hoping that they will pass legislation and implement regulations that will take money from present inpatient funding and reallocate it to these programs that we are sure would prove to be successful in reducing the number of uninsured and keep patients out of very expensive hospital settings.

We have learned that advocacy is and will always be important, but is no longer a trip to the state capitol or Washington D.C. for more—it rather must become a trip to educate those who will listen regarding support for the health care strategies which will make a sustainable difference in the future.

Does CHRISTUS Health Possess Some of “The Secrets of Enduring Greatness”?

Built on the foundation laid by three Sisters more than 140 years ago, CHRISTUS Health has, for nearly a decade, been intensely focused on a Journey to Excellence, striving to create a future that will be sustainable and value-added for all the people we serve. Driven by our mission, vision and values, we have utilized a balanced scorecard approach, striving for the best performance possible in our four Directions to Excellence, Advocacy and Philanthropy.

During the nearly 10 years since the combining of the Sisters of Charity and Incarnate Word Health Systems, CHRISTUS Health has grown its assets from $33 billion to $44 billion and its operating revenue from $1.9 billion to $ 3.0 billion, improving significantly our clinical quality and service delivery metrics, while maintaining our ministry’s leadership position on providing charity care to the most vulnerable.

Clearly, CHRISTUS Health, like all health care delivery systems in the U.S., has business literacy challenges, enhanced recently by the volatility in the bond market and the growing numbers of uninsured. As the FY09 budget is reviewed, supporting a year of intense operational focus with only selective growth to further enhance our one-third, one-third, one-third strategies, perhaps it would be worthwhile pausing to read and reflect on an article I found helpful.

Written by Jim Collins, the author of Good to Great several years ago, the article, entitled "The Secret of Enduring Greatness,” reviews the characteristics of companies which have eventually succeeded in sustaining greatness. Utilizing case studies, the article specifically reviews four types of organizations:
• Companies that were once great who are no longer in existence;
• Companies that fell from greatness but then regained their footing, standing defiant against the forces of creative destruction;
• Companies who have enduring greatness;
• Companies that overcame oppressive mediocrity or worse to achieve sustained success.

The learnings from these case studies, although few, are critical for sustained success:
• The cause of failure cannot simply be attributed entirely to change in the environment;
• Success, to a large degree, depends on what you do to yourself;
• Throughout history, the greatest companies have used adverse times to their advantage;
• A great company never surrenders to the forces of mediocrity and succumbs to irrelevance;
• Great companies are built on values and a purpose beyond making money, building a culture that makes a distinctive contribution while striving to deliver exceptional results.

The call of Bishop Dubuis to CHRISTUS Health is as strong today as it was to those first three Sisters 140 years ago. There is still a multitude of sick and infirm of every kind who seeks relief at our hands. Our Journey to Excellence must be our continuing focus, utilizing consistently our balanced scorecard seeking improvement in all four Directions to Excellence simultaneously. We must continue, through our three-year strategic plan, future planning processes to evolve CHRISTUS Health into a delivery system that cannot only make sick people healthy, but promotes wellness and end-of-life care. The further growth and enhancement of our one-third acute, one-third non-acute, and one-third international strategy, driven by the significant decline of traditional reimbursement, the rapid introduction of non-invasive technologies and the positive aging of seniors with increasing life expectancies appears to be critical in creating a value-added future, rather than one of irrelevance.

This article clearly demonstrates that the CHRISTUS Health ministry, like all for-profit and not-for-profit companies, is on a continuous journey. But, more importantly, it does give us the ability to say we do share some of the secrets of enduring success.

Learning from a Canadian Innovation Institute

Although the challenges of health care today keep us very focused on traditional operational solutions, we have said many times it is important to take some time to look into the future and attempt to identify those innovative activities that will help us address these challenges long-term and develop the best health care for our patients and their families long into the future.

In addition to our future planning processes, which we have discussed in numerous blog posts, we are attempting to put together a virtual innovation institute within CHRISTUS Health where we will be constantly exploring potential new technologies, treatment processes, preventive health initiatives and wellness programs that will permit more and more health care to be delivered in more non-acute settings and in less invasive manners.

To add additional knowledge to this developmental activity, we visited an innovation institute in Canada on our recent Futures Task Force II learning journey. (See my previous blog posts for more information on this visit to Canada and some of our other learnings.)

Led by a physician with a strong team of clinical researchers, this institute was opened approximately a decade ago. Its primary goal is to look at technologies that are being developed which will improve the quality and safety of the health care delivery process.

To accomplish this, one floor of a medical office building has been dedicated to create large spaces in which every conceivable health care delivery process can be mocked up for careful study. The spaces have been structured in such a way that they can be quickly put together and quickly torn down with ample space in floors and ceilings for wiring that is necessary to provide as many cameras and monitoring tools as is necessary to determine what is working and not working for health care providers as they test these technologies in as close to real-life situations as possible.

Examples of the technologies under study at this time include a new infusion pump which has multiple safety factors imbedded in it as well as one screen in the room that can be utilized not only for television, but for health education, as well as a screen on which the health care providers pull up all the clinical data on the patient they are caring for.

By carefully studying these technologies through observation windows and utilizing multiple cameras as well as listening and data collection devices, these researchers can determine what is and what is not working for the health care providers. In addition, they can stop the process and go into the room to talk with the health care provider to determine what would make the process easier and what would prevent the error that hey had just made from reoccurring.

After doing these studies with a statistically significant number of individuals, this information is then fed back to the inventors and manufacturers of the proposed devices so that they can be enhanced to prevent as many of the errors as possible that were seen in the testing process from reoccurring when they are actually produced and mass marketed.

Because the researchers also agree with us that much of health care will be rendered on an outpatient basis, they are also studying innovative ways in which various health care metrics can be identified and visualized on your cell phone and then transmitted to your caregivers either in your family or to your professional medical care providers.

For instance, they have developed a blood pressure cuff that can be connected to the phone so that you can see your daily blood pressure and then transmit it to anyone else who needs this information. They have also developed a blood glucose monitoring device which is attached to the phone, can read your blood sugar level and also transmit it to the appropriate people. This eliminates a series of other devices and also connects it to a now almost universal mode of communication, a cell phone, which is often owned by even the poorest people in many countries.

Clearly, this experience has demonstrated to us that as challenging as it may be, we must continue to reserve a portion of our time in looking innovatively at what the future might be bringing us which will improve our health care delivery processes, our non-invasive technology, and ultimately our medical outcomes for the patients and families that we serve each and every day in CHRISTUS Health.

Our learning journey and the observations outlined above have only re-emphasized for us that there are always better ways to do what we are presently doing to raise our safety and quality standards, and it is only by asking inquisitive questions and tediously studying the pros and cons that we can determine what is best for the future and what we must leave behind from the past.

Canada’s Experience With SARS

Our Futures Task Force II learning journey to Canada also provided an outstanding opportunity to meet with and hear directly from the physician who was the key spokesperson and coordinator for the SARS epidemic that occurred in Tornoto in 2003.

Based on his report, we were all re-educated in the epidemiology of an epidemic and relearned that careful attention must be given to every detail in the investigation and that all the dots must be connected in order to determine the cause of the initial outbreak and to learn the methodology of “spread” so that as quickly as possible, barriers can be put around the causes and the geographical locations so as to mitigate the future spread and expansion of the problem.

With regard to the SARS epidemic specifically, what were the learnings that can be applied to the possible rapid identification and control of a future U.S. or international pandemic?

1. A high level of suspicion should be maintained in all health care providers for patients who present in clinics, EDs or hospitals with symptoms that cannot be rapidly connected to a traditional diagnosis.
2. Concerns should be heightened when patients return on a frequent basis in less than 24 hours with worsening symptoms that, again, don’t traditionally relate to a classical diagnosis.
3. When unexpected deaths occur from what are at first thought to be simple viral illnesses, one should be concerned that something very different might be occurring.
4. When clumping of similar patients with similar symptoms begin to present themselves, either in the same or different locations throughout one geographical area, the possibility of an epidemic or pan-epidemic should be occurring to health care providers and should perhaps trigger the report to the appropriate local, state and even national health care departments.
5. When providers start to complain about the same symptoms that patients came in complaining about, indicating a high potential of an infectious disease, one should again be very concerned that an epidemic might be occurring.

Clearly, if all of these findings are seen, it is important that health officials as well as epidemiologists and infectious disease specialists be sought and brought into the investigation to review any suspicious cases and to commence the process to identify the source of their illness and better clarification of the causes of these illnesses.

All these suspicions identified above and the implementation of the team I just described occurred in Toronto’s SARS epidemic, and as a result of this rapid learning, resulted in this epidemic being isolated predominately to the Toronto area.

Let’s look at this situation more closely as a case study to emphasize the points outlined above. In essence, a husband and wife presented to an ED complaining of what appeared to be a respiratory illness. Over several days, the patients got extremely sick and both died as a result of what--at that time--appeared to be a serious and rapidly advancing pneumonia-like illness. Shortly thereafter, the children of this family became ill simultaneously with several of the staff members who were caring for the patients. In addition, an unrelated patient to this family also became ill with similar symptoms and subsequently died. Immediately, sophisticated laboratory studies were put in place to identify what virus or bacteria might be causing this illness by utilizing samples of sputum and blood from all the affected patients and caregivers.

In addition, the unrelated patient was tracked through the Emergency Department, and it was discovered that he or she was cared for in a room where the original patients who died were treated a day or two earlier. Immediately, all these facts were put together and the staff quickly declared that a pandemic was in process.

This resulted in the following immediate and required next steps:
Isolation wards were created in the hospital where more intensive infectious disease prevention techniques were implemented, including negative air flow, intense hand washing and daily decontamination/ disinfection of the rooms, beds and bedding. Toronto was closed down to tourist travel, and no one was permitted to come into hospitals where there were infected patients except critical staff.

These steps eventually caused all of the patients to be further identified and treated as quickly as possible in isolation settings. Eventually no new cases arose, and the patients who had the diseases were either recovering or, unfortunately, had expired.

It is clear that pandemics are a potential in America and in the world, with highly resistant new strains of bacteria and viruses that will be very challenging to treat. But the appropriate handling of a pandemic is based on scientific knowledge and processes which have been clearly identified in the past and have been reemphasized and studied as a result of the SARS epidemic and how it was handled successfully. It is always imperative to reacquaint ourselves with scientific principles and processes by using current case studies, and the review of the SARS epidemic on our recent learning journey gave us this real-time opportunity.