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.

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