Working Together for UMMC

Working Together for

SPRING 2013

UMMC

P UBLISHED I N C ON JUN C T I ON W I TH TH E E MP L O Y E E C O MM U N I C A TI O N F O R U M S A T TH E UNI VERSI T Y O F M ARY LAND M ED I CAL CENT ER

Dear Col l ea g u e,

T

he waves of change to the health care industry are

starting to crash on “our” beach, with bigger waves expected over the next five years. These reforms will require more attention to innovative delivery of better care for less money. How to do more with less. When it isn’t possible to do more, we look for how to do things differently, and that’s where we have to focus. We can’t continue to expect that what has worked for us in the past will continue to work for us in the future. What has made us great will not be the only ingredient needed in the future to keep us on top.

Through it all, we have to stay focused on our most important value – doing what’s best for our patients, never compromising on patient safety, the quality of care and the need for compassion as we provide that care. These are our values that the UMMC staff has built and advocated for with great passion, and they’re here to stay.

But like it or not, we’ll have to find ways to deliver this kind of care to patients in the most efficient way possible. It’s a challenge that requires everyone’s participation, and we need your ideas – we want them. If our discussion at the employee forum has sparked an idea you want to share, please send them to communications@umm.edu or share them with your manager.

In addition to the ideas from our own staff, we are bringing more partners than ever into our strategic planning process to determine planning for the next five years. Our greatest strengths include that we are part of a strong medical system and that we are surrounded by the professional schools of the University of Maryland, Baltimore. We can benefit from a statewide network and tap into a wealth of knowledge and perspective, as well as the health care workforce of the future – their students.

This partnership allows UMMC access to some of the most accomplished professionals in their respective fields to best plan how to meet the needs of our community and our nation in the future.

Sincerely,

JEFFREY A. RIVEST President & Chief Executive Officer

MAXIMIZING SPACE, STAFFING AND THE PATIENT EXPERIENCE

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ive years ago, when the Emergency Department physicians, nurses and other staff began working with the Facilities Department to plan the new space they would occupy in the ground floor of the Shock Trauma Critical Care Tower, they were excited about getting more square footage. They thought space would be the answer to many of the issues they were dealing with.

In the meantime, in their smaller, old space, they re-engineered their processes and developed some strategies to move patients through more efficiently.

Staying in their smaller space while the new one was designed forced them to think differently about their work processes. And it became clear to them that by designing the new Emergency Department around the improved process, they could really maximize the new space in a way that got patients treated sooner and made better use of staff time and energy.

On the very first day that the new ED opened to patients, they treated a social work graduate student who later wrote a letter to UMMC leaders to praise the exceptional care.

“ In the first 24 hours after the new Adult ED opened, we had nearly every category of medical emergency,” said Thomas Crusse, MS, RN, CEN, nurse manager for emergency services. “We passed the test with aplomb, thanks to years of planning that led up to the new layout and system for treating patients.”

The wide room with a row of reclining chairs separated by moveable curtains takes up just a few hundred square feet in the new UMMC Adult Emergency Department. But this new room, called the patient intake area, is integral to making the whole ED run smoother.

In this patient intake area, physicians, nurse practitioners, nurses and patient care technicians work together to evaluate patients’ needs, get them comfortable and order lab work or imaging. By the time the patient moves to a bed in the ED and sees a physician, most of the necessary lab work or imaging is available for the physician to see. continued on page 2

Inside: ALSO SEE

w Bedside Meal Selection

w An Informed Strategy for Change w Systemwide Changes w Celebrating

Service and Awards

Deborah Schofield, DNP, CRNP, (center), clinical program manager for the Adult ED and a nurse practitioner, and Nicole Fletcher BSN, RN, CEN, tend to a patient in the patient intake area.

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NEW ADULT ED MAXIMIZES SPACE, STAFFING

AND THE PATIENT EXPERIENCE

“Nurse practitioners have become essential to the provision of care in the ED and throughout UMMC,” said Deborah Schofield, DNP, CRNP, nurse practitioner program manager for specialty areas. “In the Emergency Department, together with physician colleagues, they are vital providers, ensuring excellent quality of care and efficient throughput for all patients presenting to the Ambulatory Zone,

valuing change

Triage area and the Observation Unit.”

The pitfalls of emergency rooms are common to most hospitals, to the point that there are two main statistics used to determine the success of an ED: • The average time between the patient’s arrival and when he or she gets to see a doctor or nurse practitioner – called the “door-to-provider time.”

• The percentage of patients who get so frustrated waiting that they just leave without being seen by a clinician – called the “left without being seen” rate.

At UMMC, the new patient intake area has reduced average “door-to-provider time” from about three hours to less than 30 minutes. And the “left without being

CONT.

seen” rate dropped from 14 percent to 6 percent.

“By decreasing the door-to-provider time, we’re evaluating patients sooner and decreasing the length of stay for patients who will be discharged from the emergency department,” said Michael Winters, MD, associate professor of emergency medicine and medical director of the Adult ED. “For patients who will be admitted, there might still be some delay based on the availability of an appropriate bed upstairs in a unit,” Winters said.

In any large academic medical center located in a metropolitan area where many patients use the ED as their primary source of medical care, emergency room wait times are an issue.

Brian Browne, MD, chairman of the Department of Emergency Medicine, has emerged as a thought leader nationally in creating a process for managing staff time and improving the experience and outcomes for patients. He and the physicians in his department provide management consulting or fully manage and staff the EDs at several hospitals in Maryland and beyond, including in China, the Netherlands, the Middle East and Africa.

1 Nina Hardy, BSN, RN

2 Thomas Crusse, MS, RN, CEN;

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Laura Ferguson-Weigman, BSN, RN, CEN; Brian Browne, MD; Michael Winters, MD.

3 The patient intake area means patients are quickly seen and assessed by clinicians, who can also start the process of getting lab work and X-rays.

4 Left to right, Stephen Lewis, BSN, RN, Alondra Sills, PCT and student nurse, and Michael Abraham, MD, assistant medical director of the ED and clinical assistant professor of emergency medicine.

5 Kendell Anderson, unit support aide, makes sure the patient care areas are stocked.

6 Lewis and Sills care for a patient in one of the treatment areas of the new Adult ED.

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without changing our values

BEDSIDE MEAL SELECTION SERVES PATIENTS, SAVES STAFF TIME AND REDUCES WASTE The Food and Hospitality Services staff delivers about 1,500 bedside tray meals each day to patients at UMMC. Until March 24, they were using an outdated process that wasted food and staff time – both costly to our hospital.

I

t was also no picnic for patients, who didn’t get to make any selections for the first several meals they got, because of the time it took for paper menus to make it to the patient, be filled out by the patient, and make it back to the kitchen.

And if the menu didn’t get lost during that time – as it often did – it was very likely that the meal wasn’t even what the patient ordered. In the 36 hours since they filled out a paper menu, their conditions might have changed, leading their doctors to order a different diet.

“We were promising the patient a selected meal, but we rarely delivered that, which led to frustration for patients and staff,” said Mark Washenko, director of Food and Hospitality Services.

Under the old system, the kitchen staff was producing more trays than necessary, because re-orders were duplicated. Food was wasted.

Now, most UMMC patients order their next meal shortly before they receive it – so it can meet their current needs. And the best part: Patients select their meal with help from a meal attendant who comes to their bedside.

The meal attendant’s computer – a workplaceon-wheels, called a WOW – is equipped with new software that interfaces with the patient’s electronic medical record, with access to the patient’s current food order.

Kitchen associates who work the “tray line” receive the order on a ticket and begin to assemble the tray with the patient’s selections.

The same meal attendant who took the patient’s order will be the one to deliver the food to the patient – leading to built-in ownership, accountability and rapport with the patient, and therefore an improved patient experience.

Meal attendants – some of whom were skeptical about change, needing to master the computer and interacting with patients – have embraced the new process. The attendants now enjoy being empowered to work with patients to bring them a meal that they look forward to and enjoy.

The antiquated paper-menu system was implemented before computers and the myriad changes in health care. Nurses and other unit staff often had to call the kitchen for patients whose meals were inaccurate, or for newly arrived patients.

Often, the nurses would call multiple times, and the

Sharene Jones, left, delivers a meal to patient Bob Bryan on 10 West.

At the bedside, Lorraine Luster, right, enters a patient’s selections in a workplace-on-wheels.

IN THE ROOM

kitchen would interpret each as a new call, meaning several trays might eventually be delivered to one patient’s room.

Paper menus might still be used on a few units for certain patient populations. But even these patients and units will benefit from the new system because it streamlines Food Services inpatient meal processes.

Eva-Lynn Stevens, MS, RD, LDN, assistant director of Food and Hospitality Services, and Ellen Loreck, MS, RD, director of Clinical Nutrition Services, also updated the list of diet types physicians use to categorize what type of food a patient can order, to reflect the most current evidence-based practices.

The new bedside menu selection system is part of a department-wide streamlining of Food Services, all designed to remove unnecessary steps and work, and increase the quality of the meals and service, said Stephen Mack, executive chef and food production manager.

The recipes were developed so that more foods can be served to more patients. For example, more menu items will qualify as “low sodium” or “low fat,” and be among the regular selections that all patients can get. In other words, the barbecued pork will be lean enough for those on low-fat diets, but taste good enough for anyone.

Each day, UMMC’s executive chef, Stephen Mack, will have a featured menu for each meal.

To be more efficient, meal attendants will start by offering the patient that menu, making changes as needed to accommodate the patient’s medical needs and food preferences.

Meal attendants went through training to take orders in a patient room, following hand hygiene and other safety procedures.

They will ask: “Tonight at dinner, our featured item is baked chicken. It comes with mashed potatoes, gravy and green beans. Does that sound OK?” If the patient doesn’t like baked chicken, the attendant will offer an alternative until the patient can decide on something. Then, they might ask: “Would you like a salad or soup with that?”

“How does sherbet sound for dessert?”

HOW BEDSIDE MEAL SELECTION WILL SAVE TIME, MONEY AND FOOD • P atients will select food much closer to the actual meal time.

• Patients will receive the food they want.

• Less food will need to be thrown out.

• Less staff time is wasted as fewer duplicate meals will be created.

• Nurses and other unit staff will spend less time intervening on behalf of patients, because of the better coordination of meals and diet orders.

PROJECTED SAVINGS With the new bedside meal selection, the hospital expects to save more than $300,000 Eva-Lynn Stevens, assistant director of Food and Hospitality Services and Mark Weshenko, director of Food Each day, UMMC’s executive chef, Stephen Mack, has a featured menu for each meal.

and Hospitality Services.

a year by reducing the amount of food, supplies and staff time wasted producing a meal the patient didn’t want or couldn’t eat.

This number will be much higher if savings in nursing and other unit staff time are included.

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TEAM TAKES A FRESH LOOK AT

H

Health Insurer Payment Denials, $

RECOVERING MILLIONS

ealth care insurers sometimes refuse to pay for care that a hospital has already provided, if the insurer determines that the care wasn’t necessary.

In hospital finance, this is called a “denial.” It happens often, and hospitals had become resigned to it. But in an era when all health costs are under scrutiny, UMMC has taken a fresh look at “denials management.”

“Our goal is to make sure that insurers understand that a particular lab test, or CT scan, or extra day in the hospital was really necessary, and why the physician in charge of the patient’s care determined this,” said Jonathan Gottlieb, MD, senior vice president and chief medical officer at UMMC. “When we’re caring for a patient, we need to make decisions based on the best medicine and an individual patient’s needs. That will never change,” Gottlieb said. “What can change, however, is an improvement in the communication between our staff and the payer about what the patient’s condition requires, and in our meticulous attention to documentation.”

Earlier this year, UMMC formed a crossdepartmental Denials Management Team to deconstruct the process and develop new strategies.

Members included staff from Case Management, Patient Financial Services, Performance Innovation and Clinical Decision Support. Physician advisors included internists Mangla Gulati, MD, Barry Reicher, MD, and Ada Offurum, MD. “This was my favorite project ever,” said Mary Nanson, MS, RN, director of case management.“We had tried to do this in the past without great success.

This project worked well because we utilized the Lean process combined with the right team membership.

We were able to identify communication roadblocks and work for solutions. We reorganized the flow of information to all stakeholders, allowing us to identify potential denials quickly and then to work efficiently to resolve them.”

The strategies they developed involved a lot of improved communication and documentation, including direct communication between the patient’s

physician and the physician advisor to the insurer.

The result – a projected $14 million in stop-loss, meaning the team stopped $14 million worth of care from going unpaid.

The team concentrated its efforts where the hospital was losing the most money: medical care of patients (as opposed to surgery or other specialty care). And one insurer, a managed care organization called Maryland Physicians Care (MPC), had a particularly high rate of denial of payment.

In FY 2011, MPC denied 16 percent of all charges UMMC submitted, amounting to $4 million it withheld from paying UMMC for care already provided to patients. Combined losses from denials by all payers – Medicare, Medicaid, Carefirst, HMOs and other commercial insurers – for FY 2011 were $26 million.

So far, the new processes developed by the Denials Management Team have resulted in fewer denials.

For MPC, the payer that had the highest percentage of denials at 16 percent, denials were down to 11 percent in the current fiscal year.

Gulati said the project was so successful that it has now become the new practice.

“The success lies in a multidisciplinary approach with case managers, physician advisors, clinical decision support, active executive involvement from our CMO [chief medical officer] and CFO [chief financial officer Keith Persinger] and the expert facilitation from our performance improvement team,” Gulati said. “What was begun as a project has now become the standard way we do our work, addressing denials at the Medical Center with significant and sustaining outcomes.”

Mary Nanson, MS, RN, director of case management, and case managers Lynette Richardson, RN, BSN, CCM, and Yvonne Sheppard, RN, ensure that patients have a safe and effective discharge at the end of their stay in the hospital. They worked with a team that included internist Mangla Gulati, MD, and Joshuha Ayres in Management Engineering to make sure that insurers understand what patients need and that they reimburse UMMC for the care.

“ When we’re caring for a patient, we need to make decisions based on the best medicine and an individual patient’s needs. That will never change. What can change, however, is an improvement in the communication between our staff and the payer about what the patient’s condition requires, and in our meticulous

STRATEGIES THE UMMC DENIALS MANAGEMENT TEAM USED INCLUDE:

• A series of meetings with the staff of MPC to form a collegial relationship so that denials can be discussed objectively.

• A new documentation template for cases in which the payer is denying payment.

• Peer-to-peer conversations between the UMMC physician caring for the patient and the physician-advisor to the payer.

• Case managers, who work for UMMC and who communicate with the payers about patient care, are alerted earlier when there is a potential for payment to be denied.

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attention to documentation.”

JONATHAN GOTTLIEB, MD

IMAGINE THAT UMMC PAID STAFF IN THE SAME WAY INSURERS PAY UMMC (This is just for illustration purposes – no one at UMMC is suggesting we do this!)

• On the Thursday before every payday, an auditor would review all the work you did in the previous two weeks and decide whether all of it was really necessary and whether every hour was used appropriately.

• Better electronic communication and documentation more effectively identify which cases the payer is denying.

• If the auditor determines that some of your work was not necessary, your paycheck would be reduced accordingly. Even though you already did the work and put in the time. And even though your work was of high quality.

• Regular reports to monitor the difference between what is billed to insurers and what they deny payment for.

• If the auditor determines you could have done the necessary work less expensively, your paycheck would be reduced further, for the difference.

SYSTEMWIDE BRANDING STRENGTHENS CONNECTION TO UMMC

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s the flagship hospital of the University of Maryland Medical System (UMMS), UMMC will benefit from the changes and growth of UMMS and its member hospitals. Over the next few months, several hospitals in the system will change their names, putting the “University of Maryland” at the beginning of their names to strengthen their brand and their connection to UMMC. “Across the country, the leading medical systems that include an academic medical center all have a high level of brand recognition among the general public and the doctors who practice there and refer patients for specialized care,” said Alison Brown, MPH, senior vice president for business development, marketing and system strategy at UMMC and UMMS. “We want to establish the connection between our well-known and highly regarded UMMC brand and our system’s community hospitals across Maryland,” Brown said.

The first step in this new approach to naming our system hospitals came when UMMS acquired its newest member in December 2012 – University of Maryland St. Joseph Medical Center.

A new family of consumer health magazines was also just mailed to homes across the state, tailored by each of the community hospitals that are part of UMMS. The magazine is called Maryland’s Health Matters, and it replaces the magazines that each hospital has done in the past. The magazine is filled with health and lifestyle advice and articles about the local hospital’s services, as well as at least one story highlighting specialty care at UMMC. The goal is to emphasize the benefit to patients in the UMMS community hospitals with access to the highly specialized care at UMMC.

HERE’S WHAT ELSE IS COMING: UMMC MIDTOWN CAMPUS DEBUTS IN JUNE

UMMC will become a two-campus organization starting July 1 when Maryland General Hospital merges with the Medical Center to become University of Maryland Medical Center Midtown Campus, or UMMC Midtown for short.

The change will allow UMMC to expand some services and patients to the Midtown campus for better use of staff and resources. In order to continue caring for the sickest patients at UMMC, certain clinical programs delivering less complex and more general care will move to Midtown. Over the last several months, many University of Maryland faculty physicians have been performing outpatient surgery at Maryland General – approximately 50 percent of all surgeries performed at the hospital. The UMMC Emergency Department has also started transferring appropriate patients who need to be admitted to Maryland General – soon to be UMMC Midtown. Ambulatory services are planned for expansion in the near future. Further communication will be provided to staff at both campuses throughout the summer as teams begin to work together more closely.

AN INFORMED STRATEGY FOR CHANGE

T

he changes coming in the next few years in health care reform bring more attention to patient safety, better patient outcomes and better health in the community – all at a lower cost to insurers and patients. Those who provide care face the challenge of working together more closely to make it all happen.

Because none of it can happen without purposeful planning, leadership and staff from throughout UMMC and Maryland General Hospital have been participating in the development of a new five-year strategic plan to guide UMMC through the challenging times ahead.

This is the last year of the current UMMC Strategic Plan for 2008-2013, whose theme is “Raising Our National Profile.”

“Our 2008-2013 strategic plan focused on growth in clinical services and national prominence. We’ve had wonderful success thanks to the entire staff striving for excellence,” said Jeffrey A. Rivest, president and chief executive officer of UMMC. “Thanks to that success, the Medical Center can now plan for what the next five years will bring. It will be very different because the health care environment is changing quickly,” Rivest said.

Medical Center leaders have enlisted staff across the organization, including at Maryland General Hospital, which will become a campus of UMMC in June (see article at left), in an effort to seek broad input into a new strategic plan.

The planning staff also is involving faculty at the University of Maryland, Baltimore (UMB), as well as community leaders and the UMMC Patient and Family Partnership Council.

“We’re formulating strategies that will position us for continued success,” said Dana Farrakhan, vice president for strategy and system program development.

A work group has been assigned to each of the five core elements of the plan: ambulatory care, regional referrals of patients to UMMC, medical informatics, care innovation and the education of health professionals.

“Our partners at UMB, for example, are educating tomorrow’s health professionals and can inform the planning process with their experience, research and perspective,” Farrakhan said.

With better alignment between UMMC and UMB, the students graduating as physicians, nurses, physical therapists, pharmacists, social workers and dentists will be better prepared for the realities of patient care, reducing the orientation time. Internships can further align UMMC and these graduate professional schools.

The UMMC 2014-2018 Strategic Plan will be completed this summer and will be shared across the organization and throughout the community.

In the meantime, any staff members may contribute by e-mailing Communications@umm.edu or their managers.

GETTING FEEDBACK FROM CO-WORKERS Employee groups participating in strategic planning so far include: the Employee Advisory Group, the Staff Nurse Council, the Patient and Family Partnership Council, the Council on Cultural Competence (formerly called the Diversity Council), as well as many department teams.

Strategic questions being asked include:

• What do you believe are the top three critical issues facing UMMC over the next five years?

• W hat should be UMMC’s role in caring for patients before and after their inpatient stay?

• H ow should the role of you and the other staff in your department adapt over the next five years to increase efficiency, enhance the patient experience and improve quality?

• H ow does our care delivery model need to change in order to deliver care more efficiently to match reimbursement changes?

SHORE HEALTH AND CHESTER RIVER HEALTH MERGE

Two groups of hospitals that joined UMMS about 6 years ago – Shore Health and Chester River Health – will merge their operations in July and be called University of Maryland Shore Regional Health.

what an organization is, what it does and why it does it.

KERNAN NAME CHANGE

THE 2014-2018 UMMC STRATEGIC PLAN WILL FOCUS ON

Kernan Orthopaedics and Rehabilitation – also known as Kernan Hospital – will become University of Maryland Rehabilitation and Orthopaedic Institute.

This change better reflects the specialty nature of the hospital and the desire to increase the hospital’s regional and national prominence in clinical rehabilitation research with the School of Medicine.

ADDRESSING FIVE CORE THEMES:

Strategic Planning is a disciplined effort to shape and guide

Ambulatory Care • Regional Referral • Education of Health Professionals • Medical Informatics • Care Innovation

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VALUING CHANGE – WITHOUT CHANGING OUR VALUES

]

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STAFF HONORED

FOR SERVICE MILESTONES Staff who celebrated a milestone year in their service to UMMC and UMMS shared services were honored this spring at two events. The employees who have given 5 or 10 years of service enjoyed a luncheon at the Baltimore Hilton on March 11. More than 400 employees were honored for their 5-year anniversary and more than 200 were recognized for 10 years.

“It is truly the privilege and pleasure of UMMC senior leadership to honor our staff who are celebrating significant service milestones. We’re grateful to the hundreds of annual service awards recipients for their commitment to UMMC, collaboration with their colleagues, and contributions to our patients and their families,” said Jeffrey A. Rivest, president and chief executive officer.

A gala April 13 honored those with 15, 20, 25, 30, 35, 40 or 45 years of dedication to UMMC/UMMS. An impressive number of 17 employees celebrated their 40th or 45th years of service during the gala.

CELEBRATING EXCELLENCE IN PATIENT CARE AND SAFETY The University of Maryland Medical Center made the Leapfrog Group list of Top Hospitals for the seventh consecutive year. The Leapfrog Group recognizes the nation’s top hospitals for quality and patient safety.

UMMC is one of only two hospitals in the country to make the list every year since it began in 2006.

STEP UP AND STEP OUT FOR A LUNCHTIME WALK The Step Up to Good Health 12-WEEK WALKING CHALLENGE began April 1, but anyone can still join the lunchtime group for a 30-minute walk every Monday, Wednesday and Friday from noon to 12:30 pm in the Weinberg Atrium, across from the Patient Resource Center

“Together, we celebrated this significant achievement

and near the fountain.

and the employees who made it possible,” said Jeffrey

The walking group continues until June 28.

A. Rivest, president and chief executive officer.

The group walks outside most days, and inside during inclement weather.

To honor this achievement, a Leapfrog party was held Jan. 9. Did you get your picture taken with “Leapfrog”? Photos of employees with the leapfrog mascot are available in a slide show on the Intranet.

THE MARKET OPENS MAY 14!

The University Farmers Market is proud to announce that this year, in addition to WIC/FVC and FMNP (Farmers Market Nutritional Program) benefits, they will now accept SNAP (Supplemental Nutritional Assistance Program) benefits, formerly known as Food Stamps.

The University of Maryland Medical Center is an equal opportunity employer and proud supporter of an environment of diversity.

This publication is printed on recycled paper.