Wednesday, January 28, 2009

Balancing Community and Institutional Interests

Recently, I had the opportunity to participate in a panel discussion held at the University of Texas School of Public Health. The topic was “Health Care Leadership Challenges: Balancing Community and Institutional Interests.” Although this topic was chosen probably a year in advance, its relevance has escalated because of the current economic crisis that is significantly affecting all global economies and having a uniquely negative effect on health care, an industry that was previously considered to be recession-proof.

To present our view on this topic, I could quickly utilize our balanced scorecard approach, which we have discussed before, and have fully committed to on our Journey to Excellence. This balanced scorecard, as you recall, permits us to simultaneously monitor our improvements in clinical quality, service delivery and community value as well as the business literacy of our ministry. This approach has permitted us to focus on the very question that this panel discussed on a continuous basis within CHRISTUS Health.

It has been against the backdrop of this balance of all 4 of our directions that we have made very difficult decisions to exit several of our regions as well as sell St. Joseph Hospital in Houston, one of the first hospitals in the Sisters of Charity Health System (one component of CHRSITUS), which was begun over 140 years ago and was at one time the largest hospital in Houston.

Clearly, this case study brought forward the realities of the question “How does a CEO balance the community need for health care with the institutional need to be fiscally sound?” very vividly. Unfortunately, because of the economic crisis in which we are presently journeying, it is predicted that there will be a potential bankruptcy of over 1,000 hospitals in America during 2009.

Again, this means that this question will be asked over and over again as the year progresses. In the last month, numerous hospitals have been closed in New Jersey, one was shuttered and consolidated into another hospital in Florida, and we continue to deal with a fourth hospital in our various regions that is on the brink of bankruptcy.

Therefore, recognizing that this is a critical question that will be asked more frequently, what are the steps that one takes to seek a reasonable answer?

1. Make sure that community assessments are updated on a continuous basis to verify that the community services that are being provided are essential. We know that quality is impeded on many occasions because of the over-use of services rather than the failure to provide necessary services. This is driven by an overabundance of facilities and medical services in a community. We know that by doing careful needs assessments, we have the opportunity to provide in the information in educational forums that would support closing a service which was not financially stable because the services could be provided by other providers.

2. Study and develop alternative models for delivering the same or similar care that is no longer sustainable from a fiscal standpoint in the model that is presently used. A key example of this would be the need to close a financially unstable hospital in a community that was within 10 or 20 miles of another facility, to which the patients and their families could easily drive. However, it may be that this community needs urgent or emergency care with a closer proximity. Therfore, the alternative might be to open an urgent care center or a convenient clinic, which would be much more cost-effective and permit the more expensive care to be rendered in the nearby hospital.

3. Look for partners in the community who could help support the financial burden of the model which is presently not working for the health system. Certainly, we all know that the financial crisis has exaggerated the number of under- or uninsured people who we are serving in our facilities. The initial impact is often that we see the volume of people in our Emergency Departments rapidly rising, which of course causes the least expensive illnesses to be cared for in the most expensive environment. One workable solution is to form a community collaborative to support and develop a Federally Qualified Health Center that is run by a community board and sustained by community support.

Clearly, the tension between community needs and health care delivery system interests has always been present. But it is clear that the economic crisis we are facing today has only accelerated this tension and has caused this question to be at the forefront of the challenges facing health care leaders. By recognizing that this is an important issue, keeping it high on the agenda of the leadership team and board meetings and by formulating potential other pathways to take to address this tension and minimize it, we have the opportunity to be more successful in creating a strongly supported solution than if we do not face the reality of the question as early as possible.

Wednesday, January 21, 2009

Health Care Reform: Ensure That Health Care is Patient-Centered

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I have repeatedly stressed that for CHRISTUS Health, keeping a picture of a patient in our minds as we make decisions is a must. In the same way, I believe that those who come to the table to enact health care reform must balance the many voices that will fight to be heard, but ultimately keep the same picture in mind as the ultimate voice as they design a new plan for the U.S. going forward.

Monday, January 19, 2009

Health Care Reform: Mandate Coverage for All

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One of the things we’d like to see in the Obama health care plan as it is reviewed is a mandate of coverage for all. As it was presented during the primaries, Obama’s plan only requires that children have health care coverage. I find it hard to believe that adults, and especially parents, who serve as role models for their children, could benefit from a plan of this design. Therefore, I’d like to encourage those on Obama’s health care team to consider adapting the plan to include a mandate of coverage for all.

Sunday, January 18, 2009

Health Care Reform: Physician Alignment

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Physician alignment is not only a very important priority for hospitals and health care systems, but vitally important to every person in the U.S. who seeks care. If health care reform is to succeed, it will require that all health care providers work together.

Saturday, January 17, 2009

Health Care Reform: Sharing Our Learnings from our Futures Planning

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Our experience in futures planning with Futures Task Force I and the recent completion of Futures Task Force II has also helped us prepare to meet tomorrow’s challenges.

Futures Task Force I employed scenario planning, which resulted in a selection of scenarios that the team expected could happen within the following 10 years—many of which were accurate. (For instance, the task force projected a possible terrorist attack that would divert resources away from health care as well as a global economic recession). As a result of this scenario planning, the task force determined that the two most significant drivers taking us into the first decade of this century would be declining reimbursement, particularly on the inpatient side, and the rapid introduction of new technology which would give us the ability to move more inpatient treatment to the outpatient arena.

Futures Task Force II employed “learning journeys” that allowed us the opportunity to observe first-hand some processes and systems very different than those we are familiar with and the opportunity to experience what may be the trends of tomorrow.

We believe our work in futures planning has positioned us to prepare for and better face the opportunities and potential hardships we might experience in the next 10 years. It is this planning that I believe would be invaluable for those redesigning the U.S. health care system.

Friday, January 16, 2009

Health Care Reform: Sharing Our Learnings from our Experiences in Mexico

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Not only have we learned from our experiences in providing health care in the U.S., but we have also gained much knowledge from our experiences in Mexico. CHRISTUS Health partnered with a Mexican health care group in 2001 called Grupo Muguerza, and that partnership has since grown to include seven hospitals in 6 Mexican states as well as four short-stay hospitals for the poor.

Because the Mexican health care system is structured somewhat differently than what we are familiar with in the U.S., our partnership has given us a chance to explore other ways of providing care and evaluate their effectiveness. For instance, care in Mexico is what I call segmented, which means they provide the same quality health care in different settings and with different amenities according to the patient’s or family’s ability to pay for such amenities. I think segmented health care may be something we need to explore in the U.S. as we search for ways to make health care in our country more affordable.

Thursday, January 15, 2009

Health Care Reform: Sharing Our Learnings from our Experiences in American Health Care

Clearly, CHRISTUS Health has many years of experience in providing health care in the U.S. The CHRISTUS system is 10 years old, but we have a rich legacy of providing care in the U.S. that dates back 140 years. As a result, we feel we have much knowledge regarding how cost-effective care in the U.S. may be structured and provided. We would love to share this knowledge with any team tasked with redesigning health care in the U.S.

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Wednesday, January 14, 2009

Health Care Reform: Health Care is Moving to the Outpatient Arena

I have a few more thoughts on health care reform that I would like to share before the inauguration next Tuesday. Therefore, I will be posting a video blog every day until then. Please stay tuned, and let’s be sure to continue the conversation on this very important topic!

It is clear to us that much of the health care once provided within the walls of hospitals is now provided in the outpatient arena (which includes facilities such as ambulatory surgery centers). This shift is largely made possible by new technology, and we expect this trend to continue. This is one of many reasons we are working to modify CHRISTUS’ portfolio to include one-third non-acute care.

This shift is important in health care reform because it seems that many suggested changes to the reimbursement structures of Medicare and Medicaid largely focus on how hospitals and physicians are paid. These discussions will soon be rendered unimportant, since care is rapidly moving to other delivery models. Therefore, funding and reimbursement discussions should center around innovative ways to not only deliver care but also keep people healthier.

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Wednesday, January 7, 2009

A Message for the New Year: At This Moment in Time

I recently distributed a message about the coming year to all our CHRISTUS Associates. I believe it may be helpful to other health care leaders who are also facing these tough economic times and are reflecting on the most effective methods to achieve excellence in all areas this year.

Below are some excerpts from that message. My video blogs will resume next week.


As each of us enters 2009 as part of the CHRISTUS Family and travels toward the 10th Anniversary of our ministry on February 1, 2009, it seems most appropriate for me to share some important information and reflections as we continue our Journey to Excellence which we, together, began nearly a decade ago. At this significant and historical moment in time it is crucial for us to reflect on and honor our past history and accomplishments, to implement the performance improvement plans necessary for our present success, and to envision and invest in the future of CHRISTUS Health, striving continuously to be one of the best health systems in the world.

Answering the Call for Another Decade

Responding to the call of Bishop Dubuis over 140 years ago which indicated that “a multitude of sick and infirmed of every kind seek relief at your hands,” the two Congregations of the Sisters of Charity of the Incarnate Word in Houston and San Antonio established two health care systems which merged in 1999 to become CHRISTUS Health. We have been driven by our Mission – to extend the healing ministry of Jesus Christ; guided by our Values – dignity, integrity, excellence, compassion, and stewardship; and directed by our Vision – to be a leader and advocate in creating exemplary health care services, processes, and structures that improve the health of individuals and of local and global communities so all may experience God’s healing presence and love.

Together we have experienced 10 years of challenges and changes, while creating significant and measurable progress. During these 10 years, CHRISTUS Health has grown from 23,000 to 30,000 full, part-time, and per diem Associates, from 5,500 to 6,800 physicians and from 1,000 to 1,500 volunteers who serve our ministries in eight states in the United States and nine states in Mexico. Although we have grown and accomplished much, we will still continue to face challenges and will be required to make more changes in the future. As we begin our second decade as the CHRISTUS Family, we also must again reaffirm our commitment to answer the call since there are still a multitude of sick and infirm who seek relief at our hands.

A “Perfect Storm” Sets the Stage for 2009

As we enter 2009, external forces are buffeting the health care industry, forcing all delivery systems, including CHRISTUS Health, to react to and prepare for new financial realities, regulations, and new technologies. Chief among these forces will be the effects, both short- and long-term, of the global economic crisis, a new President, a different Congress, and significant declines in state treasuries. Like the “perfect storm,” we recently experienced in Hurricane Ike, several problematic fronts have been and will continue to brew simultaneously on the U.S. health care horizon, connecting, converging, and challenging hospitals and health care systems to do more with less. The economic crisis, which has affected the entire world, also mandates the same for our international ministries in Mexico.

The realities of rapidly surging health care costs, flattening Medicare and Medicaid reimbursements, the rising tide of an aging population, evaporating of federal and state funding for education and housing – two critical components for creating and maintaining “wellness” – the new wave of the uninsured and underinsured, soaring insurance premiums, and a health care labor shortage are forcibly coming together, leaving providers like us with no easy solutions for surviving the torrential storms. In fact, there is growing evidence that current health care systems of nations around the world will be unsustainable if unchanged in the next 15 years. Five competitor hospitals in our regions have already closed or declared bankruptcy, a number which is rapidly growing in the U.S., which some predict may affect 1,200 of the 5,500 hospitals serving the American people.

At present, hospitals have closed from impoverished Newark, NJ to wealthy Beverly Hills, CA. In addition, other health care systems have implemented layoffs, other cost-cutting action plans, and scrapping or delaying building projects. It is inevitable that more hospitals will close. Most endangered are rural hospitals and urban ones with excess hospital beds and a lot of poor, uninsured patients.

In addition, donations and investment returns are down, patient visits are flat, and profitable diagnostic procedures and elective surgeries have declined as people with inadequate insurance are delaying care. Unfortunately, many of these people are turning up later in our emergency departments seriously ill. And finally, patients and insurers have been paying bills, not only more slowly, but in some cases not at all, thereby increasing our bad debt.

It is in the midst of this storm that we stand at this moment in time. It is in the midst of this storm that we begin our Journey to Excellence for the next decade of the CHRSISTUS Health ministry.

Our Response to the Storm – Enhanced Focus on our 4 Directions to Excellence

The key for us who serve in CHRISTUS Health so as to not only survive but also thrive in the future is to further improve cost management and efficiencies, the major focus of our performance improvement plans throughout 2008. In addition, we must continue, with even more energy, our Journey to Excellence which we have said so often in these last 10 years is a necessity, not a luxury, because each day thousands of people continue to seek CHRISTUS services in our acute, non-acute, and international locations to improve their lives or the lives of their loved ones. These interactions and relationships have been, are, and will always be an awesome and sacred responsibility.

In addition, further quality and service delivery improvements must continue to move toward the goals we have set for these critical Directions to Excellence as part of our Balanced Scorecard which we defined and implemented in 2000. We must also continue our commitment to transparency, reaffirming our belief that the only way we can chart our course to excellence is through open and honest communication of our performance metrics, reported regularly on our web page for all 4 of our Directions –Clinical Quality, Service Delivery, Business Literacy, and Community Value.

Collectively We can Help Create Success in our Second Decade

What can each of us do to collectively make CHRISTUS Health stronger as we begin our second decade?

With our Mission, Vision, and Values always before us, we first and foremost must manage and reduce labor and non-labor costs. This will involve being more accepting of flexible scheduling and monitoring each position to determine its value before immediately filling it. Supply costs, as we all know, are the second largest health system expense. Clearly, being more compliant to our standards, working more closely with physicians after giving them as much cost data as possible, and negotiating reduced costs from pharmaceutical companies and other vendors will continue to be most helpful.

Second, improving patient through-put must receive even more attention. Patient flow is a constant challenge for all hospitals today, and it is one of the most common causes for low patient satisfaction scores, particularly in outpatient areas and emergency departments. Bottlenecks not only compromise access to care when patients are diverted from our emergency departments because of bed shortages, but also prevent us from accepting referrals or direct admissions from physicians. As a team, we must enhance and expand our care management programs, since delays and inefficiencies can cause increased length-of-stays, decreased quality and service, and ultimately lost revenues.

Third, we must more effectively integrate physicians into our operational improvement plans. We know that physicians have progressed well beyond being internal customers to assuming primary roles in health care management. We also know we have increasingly found ourselves in direct competition with our local physicians for patients and residents. Clearly, we must achieve a more successful balance with our physicians and physician extenders, and continue growing our plans to do so with a multitude of affiliation options for partnering that are mutually beneficial, including the physician and physician extender employment model.

Fourth, we must continue to reduce risk and enhance our focus on monitoring compliance, keys to further controlling our costs. It is imperative, with regard to the latter, that we do not lose our “moral and ethical compass” as we face the pressures associated with the challenges we articulated earlier. Fortunately, CHRISTUS Health already has strong internal audit, compliance, and risk management functions which place us, for the most part, in good position as the health care industry is being increasingly scrutinized by a myriad of federal and state regulatory agencies, along with congressional committees and state attorneys general.

And fifth, we must be willing to make additional changes, yet unknown, as we continue on our Journey to Excellence in the next decade of service. A popular bumper sticker says “change is easy – you go first!” Certainly, the pressures to address the challenges outlined earlier can create tension between senior leaders, managers, front line associates, and clinicians. However, if we can each keep a picture of a patient in our minds and hearts as we address the challenge we face at this moment in time, I am positive that, for the most part, we will do the right things which will create more Miracle Moments in our ministries, and help us reach our measurable goals in all 4 Directions to Excellence. It is clear that resistance to change significantly hinders successful execution of improvement plans and it is also clear that if change is to be better, it must be based on an understanding of why things are the way they are.

Future Thinking and Continuous Lifelong Learning: Keys to Our Success

Driven predominately by the rapid development of increasingly non-invasive technology, health care delivery processes are constantly changing. As examples, in the first decade of its existence, CHRISTUS Health has seen some old diseases cured, new diseases identified, healthier aging of seniors, and more understanding and enhanced treatments for memory disorders. Because of this rapidity of change, health systems that strive for excellence must embrace continuous life-long learning, allocate time to future thinking, and support and participate in future, long-term planning. At this moment in time, CHRISTUS Health is known for developing and enhancing these attributes as part of its brand, learning much from Futures Task Force I in 2000-2001, the 10 year Journey to Excellence, the critical Board Retreat in 2005, Dr. Royer’s Task Forces, the articulation of the Umbrella Strategy, and Futures Task Force II work begun in 2008. These important events on our journey have given us the ability to be early adapters of innovative strategies, including focused acute care expansion, growth of non-acute services, and development of an international presence, including the CHRISTUS Muguerza medical travel program. Utilizing the knowledge gained from these intense and beneficial experiences, we will have the opportunity in 2009 to review again many of our learnings and intensify and modify, if appropriate, our focus and strategic directions so we can speed our call to successful actions.

A Perfect and Prayerful Opportunity

A great philosopher once said, “pain is inevitable, but suffering is optional.” Health care’s perfect storm, accentuated by the global economic crisis, is upon us at this moment in time. Many of the external factors causing it can not be controlled. However, we do have the opportunity to control how rapidly we continue to design and implement the action plans to calm the storm. Who better than CHRISTUS Health understands the ravages of floods and hurricanes, and what must be done to bring forth the sunlight!

Calm perseverance, innovative approaches and a clear course of action has in the past, and will in the future, carry CHRISTUS Health through even the worst of conditions. As a family, and as individuals, we can do much to address the challenges in 2009, make the changes required, and thereby, create the progress necessary to not only sustain, but redesign and or grow our various ministries.

A Sincere Thanks

As we begin 2009 and our second decade as part of the CHRISTUS Health Family, it is clear we have traveled far and touched many lives on our Journey to Excellence. It is important at this moment in time that we pause to reflect on the past, present, and future of our sacred ministry. On behalf of the Senior Team, I would like to thank you for your individual and collective team efforts. As you have done so well in the past 10 years, I would ask each of you to again hear and respond to the call of Jesus Christ in the multitude of the sick and infirm of every kind who still seek relief at our hands.

As we continue to answer this call, let us pray that 2009 may be one of the very best for your families and loved ones, that all the lives we touch in CHRISTUS Health in so many different ways will be blessed, and that a more peaceful world will evolve.