Health Care Organizations Analysis Presentation

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Health Care Organizations Analysis Presentation

Health Care Organizations Analysis Presentation

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Note. The background and explanation may only be 2 slides at maximum:
Identify the health care delivery model.
Explain the structure of the organization in the case study.
Analyze the communication patterns identified throughout the process in the case study.
Discuss the negotiation strategies applied as well as opportunities for relationship building across departments.
Describe how the organization’s performance changed as a result of the initiative.
Identify laws, regulations, accrediting bodies, and practice standards that should have been considered as part of the initiative in the case study.
Cite a minimum of 5 peer-reviewed resources.

A Systems Guide to Improve
Patient Care, Decrease Costs,
and Improve Population Health

232 Chapter ??: Three Case Studies: Mastering Change
The original CEO of a payer organization demonstrated foresight
when she proposed and submitted a grant to the United States
Federal government in 1999 to coordinate and provide electronic
medical records to their member clinics in order to reduce costs in
processing claims while creating a database which would be used to
improve patient care and community health. In 2000, she received a
small grant to plan and begin implementation of this idea.
The leadership team formed the Oregon Community Healthcare
Information Network (OCHIN) with their community clinic partners
to evaluate, choose, configure, and install electronic medical record
software. The partner collaborative selected EPIC as the software
solution that would best fit their needs for the present and the
future. It is interesting to note that EPIC was the first software to
be certified in 2010 by the U.S. federal government agency (Office
of the National Chairman [ONC]), charged to define and provide
Incentives for health care entities to install electronic medical
records under the Obama Affordable Care Act. In 2005, the current
executive group divested their information technology network and
OCHIN became an independent organization.
Strategic Intelligence
As OCHIN embarked as an independent entity, the leadership
group defined their purpose as ?providing technology information
and solutions to the medically undeserved.? Their core work was to
configure and install EPIC systems to nonprofit community clinics.
OCHIN eventually was given the license to configure and host EPIC
software for the unique billing and local reporting requirements
for community clinics throughout the United States allowing them
to expand their network of members outside of Oregon. Soon OCHIN
expanded to Oregon, Washington, and California and was receiving
inquiries from communities in Midwestern and Eastern states. As
their membership base expanded beyond Oregon, they redefined
OCHIN as ?Our? Community Healthcare Information Network.
Three Case Studies: Mastering Change 233
The original funding for OCHIN came from Health Resources and
Services Administration (HRSA) federal grants to research, install and
host EPIC. As OCHIN grew, they continued in a traditional manner to
expand the business in software support. For example, many clinics
have limited resources to hire billing expertise to resolve claim and
billing issues. As a result, OCHIN began contracting with members to
manage claims and accounts receivable.
OCHIN routinely partners with state and community entities.
These parties encouraged OCHIN to apply to the federal government
for a Regional Extension Center for Oregon. For CEO Abby
Sears (OCHIN?s first employee), this direction would move OCHIN
closer to the foresight of the original CEO who formed OCHIN not
just to install and support electronic medical records but to reduce
costs in processing claims while creating a database which would
be used to improve patient care and community health.
OCHIN was ready to move beyond being an EPIC hosting, confi
guration, installation, and support organization. As the EPIC host,
they had the database, and members who joined OCHIN shared
EPIC software solutions. The OCHIN membership permeated
Oregon with an existing learning network and trust relationship that
could be used to improve patient care and community health. Soon
all members in seven states were able to see medical records of any
patient in the system if they moved or were in an emergency situation.
OCHIN was already working with members to utilize the database
for better care of patients with a product called Solutions that
data-mined health care data in a usable format for health care professionals
to impanel and provide better patient care. The objective
of the Federal Regional Extension Centers was in total alignment
to the existing networking structure at OCHIN. It seemed logical
for OCHIN to submit a Regional Extension Center grant proposal,
which would serve not only OCHIN?s existing nonprofit community
clinics but also for-profit clinics, small hospitals with less than ten
beds, and small private practices with less than ten doctors.
In preparation for the future, OCHIN began a major effort to examine
its purpose and vision by reexamining its products, services, delivery
system, and personnel by focusing on creating a learning environment.
During the journey that will be described below, the need to
234 Chapter ??: Three Case Studies: Mastering Change
revise their organizational purpose became evident as they expanded
both their member base and their products and services. In 2011, the
board approved a revised mission to expand and align to the newly
designed system and members.
OCHIN Mission (purpose in our context)
2009?Providing technology information and solutions to the medically
2011?Partnering with communities to create the knowledge and information
solutions to promote access to high-quality and affordable
health care for all
The Journey
In December of 2009, the executive leadership team, senior leadership
team, and employee representatives used the Quality as a
Business Strategy (QBS) evaluation grid (basis for the evaluation
grid?strategic intelligence and Four Ps in Chapter 11) to identify
gaps and opportunities during a strategic retreat. As a result, OCHIN
began a transformation to a learning organization, by focusing on
the gap analysis and methods provided by the original Quality as a
Business Strategy evaluation grid. Their journey started in earnest
in 2010 by focusing on the alignment of their purpose and vision to
the system.
Aligning Purpose and Vision to the System
Because they were redesigning the mainstay or delivery system,
OCHIN initially utilized their existing mission (purpose in our context)
to begin redesigning their system using the system map.
However, work had been done to create a system map of how work
was currently done. Here is the original conceptual framework
of the OCHIN delivery system with two primary subsystems (see
Figure 10.13):
The natural inclination was to simplify and standardize the subsystem
that included most of OCHIN?s resources: configuration and
installation of EPIC software. But Sears recognized the system map
was incomplete. Refining the installation processes would not fulfill
the needs of the existing members. Sears needed a way to help
people see the new OCHIN and membership in a different light.
Delivery System (Mainstay)
Configure and Install Software
Provide Billing Support
Solicit, Receive, and
Respond to Requests
for Quotes
Define Product
Deliverable Plan
Configure Software
Design New
Interfaces or
Manage Billing Issues
Manage Accounts
Manage Centralize
Set Up Centralized
Solicit, Receive, and
Respond to Requests
for Quotes
Conduct Training
Install Software
on Host Platform
Resolve Issues
Figure 10.13 Original Conceptual Framework of the OCHIN Delivery System with Two Subsystems
236 Chapter ??: Three Case Studies: Mastering Change
Sears described her vision for OCHIN explicitly as a collaborative
learning organization which encompasses the whole system,
assisting health care providers with data analysis and tools for
effective and efficient patient and community care once any electronic
health care record system was installed. She acknowledged
that resources were being sucked up by the installation process and
focus on new members. The constraints of the past were to be put
aside to design new and redesign old processes that would leverage
strengths and knowledge within the ranks. Figure 10.14 shows
the mainstay framework that was initially created from the dialogue
that ensued, expanding from two subsystems to five to allow additional
products and services.
Redesigning the System
In January 2010, OCHIN was named the Regional Extension
Center for Oregon by the newly defined ONC which was charged
to defi ne and act as the officiating group for the new Affordable
Care Act?s Center for Medicare & Medicaid Services (CMS). The
objective was to install electronic medical records throughout the
nation by giving physicians financial incentives to not only install
but also use the data for improvement of care to patients. They
coined the term meaningful use of health care data with a complex
Knowledge and
Information to
New and Existing
Support for
Members Provide Billing Management Services
Develop and Test New Health Care
Technology Products and Services
Configure and Install Software
Delivery System (Mainstay)
Figure 10.14 2009 OCHIN Integrated Conceptual
System Map: First Draft
Three Case Studies: Mastering Change 237
tier. Funding would be dependent on the number of qualifying
members with signed agreements with each Regional Extension
Center. Although Regional Extension Center grants were awarded
in January, the document for defining and qualifying members,
incentives, and structural guidelines was not defined by the government
until late summer. At least 25 percent of members originally defined when the grants were written were disqualified by
late summer of 2010.
OCHIN was renamed the Oregon Regional Extension Center
O-HITEC. There was no government model to .
follow; only expected
results to deliver. OCHIN was ready for the transformation since
the new conceptual delivery system defined how work would fl ow
and the interdependencies. All of these subsystems would be necessary
for O-HITEC. While other Regional Extension Centers were
focused primarily on the installation of electronic medical record
programs and trying to sell them, O-HITEC was looking at developing
an integrated system. Five subsystems were integrated into
the delivery system, with three new subsystems to focus their
1. Providing knowledge and information to new and existing membership
(which expanded beyond EPIC requests for quotes)
2. Coordinating member support
3. Developing and testing new health care products and services
Manpower was immediately added to the first subsystem to
develop and execute processes to provide knowledge and information
to new and existing members. This group designed educational
sessions, a new website, and solicited information from
potential new members into the O-HITEC incentive system to help
identify their needs. An installed certified EMS was the base requirement
of the incentive system. EPIC was predicted to be one of the
certifi ed systems. Therefore, physicians in the OCHIN membership
would automatically qualify for the first year?s incentive, but that
was not sufficient to meet the first year?s quota for O-HITEC. Small
private practices and small hospitals that had a defined percentage
of Medicare/Medicaid patient populations were the qualifying
group. The cost of EPIC was prohibitive for most small practices
238 Chapter ??: Three Case Studies: Mastering Change
and OCHIN was not authorized to install EPIC in small hospitals.
O-HITEC would leverage OCHIN?s strength, configuring and installing
electronic health record (EHR). But they needed to assess other
products and get feedback from potential members. Currently
installation capabilities have expanded to include All scripts EHR,
eClinicalWorks EHR, addition authorization for EPIC applications
in hospitals with fewer than ten beds, and recently Greenway?s
PrimeSuite EHR. All products include secure health information
exchange capabilities and web-based patient portals that let
patients and doctors communicate easily, safely, and securely over
the Internet.
All products offered by OCHIN are geared to enable members
and clients to implement and achieve meaningful use of their EHR
as required to secure federal incentive payments and support provider
and practice efforts to advance clinical, financial, and operational
goals?the preconditions for clinical transformation.
The intent of installing electronic health records goes beyond
input of a patient?s data by the health care provider. Expanding
from an internal system?s view to responding to the needs of clinics,
health care professionals, and all users and potential patients
has enabled OCHIN to expand services to include
1. Business Services provides multitier support designed to create
operational efficiencies and drive savings directly into OCHIN-supported
2. Data Services provides the capability to aggregate data from any
number of vendor sources enabling users to interface with, and
build on, existing clinical, financial, and operational tools already
in place for reporting and improving health outcomes. OCHIN?s
data warehouse is tailored to a health care environment and uses
an innovative proprietary data aggregation architecture that makes
the accurate measurement of clinical and operational variables
straightforward, thus making it possible to compare metrics
easily across different organizations without the need for complicated
audits. All data exchange is governed by agreements that are
compliant with applicable laws and regulations governing protected
health information.
Three Case Studies: Mastering Change 239
3. Health Information Exchange (HIE) connects all OCHIN network
members via Epic Care Everywhere network that connects hospitals
nationally and through the emerging Nationwide Health Information
Network (NwHIN) exchange. OCHIN is also building a national HIE
capability that utilizes the rules and guidelines for how computer
systems should exchange information defined by Health Level
Seven International (HL7) with the international Integrating the
Healthcare Enterprise (IHE) initiative for health care?specifi c data.
These solutions enable OCHIN to seamlessly integrate multiple
systems including hospital registration systems, laboratory systems,
immunization registries, and, via the NwHI, to support information
exchange with federal agencies. Using OCHIN, administrative and
clinical staff can coordinate patient care across multiple states and
unrelated health care entities, giving care providers the knowledge
to improve patient outcomes regardless of where patient treatment
took place.
4. Practice-Based Research Network (PBRN) operates as an independent
business unit within OCHIN for the purpose of encouraging practice based
research that advances understanding of the health of
underserved populations, increases health equity, improves quality
of care, and informs health policy. The OCHIN PBRN is unique among
other practice-based research networks because it has no formal
affiliation with a particular academic health center and is comprised
almost exclusively of federally qualified health centers (FQHCs) and
rural health centers (RHCs).
The evolution of the OCHIN system map has expanded to
show these important subsystems and their integration to achieve
the organization?s purpose. Systems thinking continues to drive the
organization to solicit and assess member and patient needs. PDSA
symbols have been added to the OCHIN system map to reflect
where internal prioritized Accelerated Model for Improvement projects
(Ami? charters) are targeted. In addition, OCHIN is using their
system map as part of their analysis, prioritization, resource allocation,
and communication of joint improvement projects initiated by
members? requests to address growing member and patient documentation
and analysis needs (see Figure 10.15).
Figure 10.15 2012 OCHIN Conceptual System Map with
Internal and Member Ami? Improvement Projects
Three Case Studies: Mastering Change 241
Using Personality Intelligence in a Changing Environment
Early in 2009, OCHIN began using the Strength Deployment Inventory
(SDI) from Personal Strengths Publishing as a means to educate and
develop personality intelligence throughout OCHIN. Assessment of
the 2009 delivery processes using the new system maps revealed
some interesting issues. First, the billing subsystem had only one
manager, Phil Skiba. He was an experienced manager who had executive
experience at larger companies with a strong personality to
get things done and a willingness to make changes, while routinely
treating risk as a challenge. Skiba was also aware that his strong personality
had to be held back when working with more analytic and
nurturing personalities, which was the predominant cultural norm.
He used his SDI learning to modify his communication methods
to improve relationships and communications. In a relatively short
time, he had taken the small subsystem over and grown it with more
clients, delivering excellent results for these billing customers.
In contrast, the install subsystem was composed of six managers.
Five of them had been promoted from within, with no management
experience nor any management or leadership training. They were
in a high-stress environment and were constantly adapting and
making changes to make things work. But some changes were not
aligned with strategic plans, which forced them to make additional
changes. This only created more stress and confusion. Their flexible adaptive
personality profiles explained this behavior. In a rapidly
growing and changing organization, management needs alignment
and experienced leadership.
By the end of 2009, the decision was made to begin the transition
to test the revised delivery system. Within weeks, OCHIN
was officially informed that they had been selected as the
Oregon Regional Extension Center, renamed O-HITEC. Realigning
resources to move toward the new integrated delivery system was
critical for success. Five managers were moved back into the organization
for added delivery resources. Experienced leaders within
the organization were reassigned. The previous COO, Clayton
Gillett, now became the designated leader of the O-HITEC group
and was assigned to develop and integrate the processes to provide
knowledge and information to new and existing members.
The existing quality assurance director was moved to coordinating
support for members. Skiba (a certified project manager) retained
billing but was allowed to hire a billing manager so that he could
242 Chapter ??: Three Case Studies: Mastering Change
also manage the project managers for the installation processes.
The new COO, Jane Norman, managed personnel for EPIC confi
guration and development of new products and services.
OCHIN began a series of communication sessions with their
associates, many of whom had been with the organization from
the beginning. Initially, the leadership team delegated communication
to the COO, who conducted weekly meetings. Later the executive
leadership team took ownership. Leadership predicted weekly
meetings and openness in these meetings would help the associates
make the transition.
With the announcement of O-HITEC, the new delivery system
was unveiled. The first stage reallocated leadership responsibilities.
These were shared using the revised delivery system map with
leaders? names noted in the next stage. Demand in the subsystems
was assessed to begin a transition of people for dedicated
resources. Roles had not been determined, but would be shortly. In
order to do this without disrupting the installation process, OCHIN?s
primary financial resource, some programmers would work in two
Subsystems for the first few months. In an effort to dispel anxiety
that changes were permanent, leadership stated that the delivery
system was like Jell-O?as we mold it, we will review it. Changes
that were not working would be abandoned and a new mold would
be created from what was learned.
The leadership team was committed to learning from experience
and making necessary changes. Skepticism that the delivery
system would never be more than an installation effort fl owed
from side conversations spreading skepticism to others who had
been optimistic. Communication and transparency was essential.
As Mark Twain once noted, ?A lie can travel halfway around the
world while the truth is still putting on its shoes.? In addition, the
COO learned at the second communication session that the Jell-O
analogy was causing anxiety. She was a flexible-adaptive personality
who was comfortable with uncertainty and learning from
changes. But for the analytic and nurturing programmers, Jell-O
communicated uncertainty. They needed specific direction. They
wanted to be told what to do and that the plan was solid.
The Jell-O analogy was abandoned. The COO replaced it with
another analogy of ?building the bridge as we walk on it? and
stated that the framework of most of the bridge was already in
place. O-HITEC would take the response to quotes, defi ne additional
Three Case Studies: Mastering Change 243
processes, and integrate into subsystem 1. Subsystem 2 was putting
new processes in place for the informal help desk. Subsystem 3 was
dedicating more resources to new products like Solutions, which
was already in place. More resources for O-HITEC and the delivery
system would be added. Developing processes and roles were the
next hurdles. Throughout the transition everyone was responsible
for learning and sharing knowledge. The new analogy and explanation
of the new delivery system, ?building the bridge,? soon became
a common theme. And leadership learned more about personality
intelligence and the communication needs of the organization.
Using Role Descriptions to Integrate People into the
Learning Organization
Starting in 2007, OCHIN doubled its members and the number of
visits hosted yearly. When OCHIN had under twenty people, it was
easy to learn from one another. But in 2009, with sixty-two people,
it became harder to facilitate learning. Once the revised delivery system
was in place, the organization was flattened with existing and
new resources allocated to the five major interdependent subsystems
of the delivery system. The initial restructuring of existing resources
in the fi ve subsystems exposed other weaknesses in the system, specifi
cally personnel with underdeveloped skills and those who were
doing more than their share of work to make up for the inadequacies
of others. What skills did individuals need to be successful? How could
OCHIN leverage and utilize individuals? strengths and knowledge?
In 2009, approximately one-third of the staff were application
specialists whose skills were critical for the success of support,
installation, and new products, or 60 percent of the delivery subsystems.
These skills were developed in three main categories:
basic structure, clinical, and billing. There was no master skill list
for training or assessing application specialist?s knowledge or skills.
Leadership worked with subject matter experts to defi ne 100 skills
for each of the three skill categories. Skills were self-assessed by
each of the application specialists using a similar format to the portion
of the form below. This helped defi ne what an application specialist
knew. The list has since been refined to 122 skills in seventeen
areas. In addition, 53 skills for training members in EPIC functions
have been defined in five areas to assess and develop application
trainers? skill levels. Figure 10.16 describes the Skills Assessment
Tools Format.
Figure 10.16 Skills Assessment Tools Format
Three Case Studies: Mastering Change 245
Based on the results, each application specialist was classified
by skills in one of four categories: basic structure, clinical, billing, or
training. For each category a technical lead (who had demonstrated
the highest knowledge) was identified. The leads were charged with
conducting learning sessions and utilizing the skills inventory to
build the skills of their technical group. Fridays were declared learning
days to support the time needed to develop the skills. As application
specialists mastered and demonstrated new skills, salaries
were adjusted.
The skills inventories also became a tool for hiring experienced
individuals. Candidates self-assessed their skills, and if they passed
the previous screening interviews, a technical lead interviewed them
to verify their skill levels.
Additional technical leads were identified throughout the organization
and Friday learning days were used for sharing learning
during the week. Helping the technical leads learn the difference
between telling or managing people and leading and developing
people was a challenge. A three-day leadership workshop at
Gettysburg was conducted by Austin API, Inc., with follow-up sessions
for learning. Primarily the executive leadership team attended.
Attendees used the experience to learn, reflect with one another, and
become better leaders. A key lesson from experience is courage,
which was discussed in Chapter 8. On the battlefield a leader must
display physical courage. In business, the effective leader must display
moral courage and be prepared to move beyond the second
level of ethics and morality discussed in Chapter 4 to a third level,
where the leader and team might have to sacrifice for the overall
system. The following year, a second group of technical leads and
additional managers attended the three-day Gettysburg leadership
experience. These learning sessions were building leaders at all levels
within OCHIN and creating a learning environment with a shared
understanding of the three levels of ethics and morality necessary
to support the practical values of OCHIN.
The skills inventory (including training) for different levels of
application specialists requires understanding the processes a role
performs and the knowledge needed to be effective. Traditional job
descriptions focus on reporting structure, pay scales, qualifications
and generalized skills. Formal role descriptions are a critical tool to
align individuals and develop them within a learning organization.
246 Chapter ??: Three Case Studies: Mastering Change
Role descriptions have been developed for all associates and have
replaced job descriptions. They are currently used for yearly individual
development plans. Processes and the skills required were
used to defi ne the role descriptions, so that organizational pay
grades were matched with market levels, but also demonstrated
expertise. In addition to traditional job description information the
role description explicitly states the following additions (see Role
Description Template in Exhibit 10.2):
1. How the role contributes to the purpose of the organization
2. The processes in which the individual is expected to execute
3. Measures of the process to detect when an individual needs help or
when the process needs to be redesigned
4. Rules of conduct that are aligned with the organization?s practical values
5. Expectations for improvement
6. Organizational relationships (external and internal)
Role Description Template
Role Statement
Position Title:
Department Title: Function: Supervisor:
Pay range: Type of position: Hours/week:
(Depending upon
experience and level
of responsibility and
Exempt Nonexempt
Three Case Studies: Mastering Change 247
OCHIN recognizes that people do their best work and are most
satisfied when working in a healthy work environment. OCHIN
seeks to nurture a healthy and productive work atmosphere that
supports current members of the team and one that is eager to welcome
and adapt to new members as they are added. The following
values have been identify
ed as essential characteristics and behaviors
of OCHIN?s work environment. They establish a framework for
Employee and organizational expectations about what it means to
Work at OCHIN.
Organization Mission
OCHIN partners with communities to create the knowledge and
information solutions to promote access to high-quality and affordable
health care for all.
Role Statement?How This Position Supports the Mission
The (role name) supports the mission of OCHIN by
Process and Measurement Responsibilities
All work is a process. Each role has process responsibilities which
are interdependent and impact the OCHIN system and network.
Processes currently defined for this role have been defined below.
We must be alert to defining new processes and eliminating obsolete
processes as needs of our role dictate. Performance measurement
measures the system and the individual together. Below are
the key processes for this role and measures that have been currently
defined for this position which will be presented on control
charts with a weekly frequency:
Process Name (#) Process Measurement
Secondary Process Responsibilities (Back Up for Others)
The (role name) will model behaviors consistent
with the published values of OCHIN.
248 Chapter ??: Three Case Studies: Mastering Change
Responsibilities for Improving the System
All OCHIN employees are responsible for working together to
improve the OCHIN network (internally and externally.) Friday afternoons
are allocated for this purpose. When changes are considered,
we will use the following questions from the Model for Improvement
What changes do we want to test?
What are we trying to accomplish or learn from these changes?
How will we know a change is an improvement?
(Use of measures will help us understand if our changes are
The (role name) is responsible for
? Documenting, communicating, sharing information and
developing solutions.
? PDSA cycles are the approach to all improvement work that we
? Routinely monitoring all personal measures. Special causes
will be noted, rese


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