Integrated Capstone

Integrated Capstone Course
Module 1: Scope of the Healthcare Administration Field
Case 1: Communication and Relationship Management
Memorial Hospital was moving rapidly to finalize its plans for new multiplespecialty outpatient center located 15 miles from the hospital campus. Strategically
this was exactly what the health system needed to do. First, it would provide a
presence in a community that traditionally was served by one of Memorial’s major
competitors. And second, increased the ambulatory care services of the health
system that lagged behind other health systems in this regard.
The plan called for seven specializations to provide services to the patient and
community population of this new area and to help channel patients that needed
more intense treatment and care to the hospital itself. Six departments had agreed
to this arrangement and were actively developing their budgets and management
resources to cover this new location. But the Department of Psychiatry, although an
initial service slated for the ambulatory facility, was now backing out of the
agreement suggesting that they could not adequately resource the operation and felt
it would significantly increase their overall patient volume.
The CEO of the hospital understood that Psychiatry needed to be part of the service
mix in order for this new facility to succeed. The market research conducted a year
earlier to provide information on community needs, clearly suggested this service
would be well received and perceived by people as a value addition to the other
medical specialties being offered. With this sense of urgency in mind, the CEO
arranged to meet with the Chair of Psychiatry and discuss the issue. The meeting
took place within the next week and it was not a comfortable exchange according to
the Chair. He felt pressured by the CEO to come on-board and develop the necessary
budgetary and operational plans to be part of the new ambulatory center. From the
perspective of the CEO, the meeting was equally non-productive. He reported that
the Chair seemed to miss the critical points of why Psychiatry was needed as part of
the service mix.
Two subsequent meetings took place by both individuals with significant ‘back and
forth’ between the two men until an agreement was met. The Chair of Psychiatry
agreed that his department would join the other services, but that it needed to be
phased-in process. The CEO, although disappointed that Psychiatry would require
six to eight months for full implementation into the facility, understood that this was
the most reasonable approach he could expect.
The final agreement allowed Memorial Hospital to eventually offer all six services to
its targeted community. It did require modifying some public relations materials
and gaining the support of the other five services that this special arrangement was
necessary to achieve the ultimate complement of services. The Department of
Psychiatry gained the time it felt it needed to align its resources to add this service
to its roster. The result was that Psychiatry actually achieved its adjusted
operational program for the new facility in four and a half months, a good two
months ahead of its original target date to begin operations. It is difficult to know
exactly why the CEO and the Chair of Psychiatry arrived at their agreement. Both
individuals did not appear too pleased with their initial exchange. Each seemed to
have his own agenda without much interest in understanding the expectations of
needs of the other party. It took two more projected meetings for a final agreement
to be outlined. It is not clear either, what if any, long term affect this had for either
the hospital administration or the leadership of the Department of Psychiatry. The
general opinion throughout the administration and medical officers of the health
system was the CEO paid a heavy political price for getting Psychiatry on board.
Integrated Capstone Course
Module 1: Scope of the Healthcare Administration Field
Case 2: Professionalism
The pressure was mounting with the nursing rank and file that nursing needed to
become part of a bargaining unit. There were signs and indications in all three
hospitals and one nursing facility that some level of organization was being
attempted by the professional nursing association. Pamphlets supporting this
association were seem in the cafeterias of these institutions. Directors of nursing
units were reporting that some of their staff members were openly discussing the
benefits of organizing in staff meetings and while performing their duties.
All of this was causing stress for the nursing supervisors and leadership. They
sensed a reduction in productivity and an increase in morale issues. After six
months of this type of activity, the Vice President of Nursing decided to take action.
She informed all of her directors and managers that no discussion of this matter
would be tolerated during working hours. She also stressed that any literature being
distributed to encourage membership in a bargaining unit would be grounds for
disciplinary action. It was as if the battle lines were being drawn and the very
culture of nursing was being threatened.
The president of the health system decided that such a rigid position by Nursing
administration as counter-productive and would cause more issues than solve any
problems related to the issue of bargaining representation. In discussion with his
Chief Human Resource Officer and the lead legal counsel for the system, he
proceeded to develop an official response to the issue that would override what the
VP of Nursing had done. His position was grounded in the federal law regarding the
election of workers into bargaining units, and what the Labor Relations Board stated
were the fair and legal practices all employers needed to follow. He also based his
position on the advice of his HR officer who understood the mood and culture of the
nursing staff and was aware of why a percentage of nurses would advocate for such
representation.
Within two weeks of the President’s policy being implemented, noticeable changes
occurred. Nurses were free to discuss the merits and disadvantages of joining a
bargaining unit as along as it was did not interfere or in any reduce the level of
quality in patient care. All nursing units were to hold staff meetings that allowed
members of the HR team to speak to them about bargaining representation and
what it would mean in terms of working conditions, salary, and fringe benefits.
They were also encouraged to have a member of their staff who supported
representation present that side of the question if that was deemed something the
nurses on the unit wanted.
The President made it clear that this level of exchange should be done to educate
and inform, not to bully or coerce anyone into a position they felt was
uncomfortable or not desirable. When questioned by the VP of Nursing about this
position and policy, the President suggested that employees of the health system
needed to be treated as adults with certain rights that were protected under the law,
as well as being subject to ethical standards that support the overall vision of the
organization. No vote to accept a bargaining unit ever materialized. Those
individuals who were strong supporters of such representation became to realize
that there was far too little backing to take a vote for representation. Within the next
eight months there were little signs of any action being conducted for nursing to
organize. Nursing managers and directors reported that morale had returned to
normal levels, as well as productivity with no signs that any of what had happened
in the past number of months negatively affected patient care.
Integrated Capstone Course
Module 1: Scope of the Healthcare Administration Field
Case 3: Leadership
Mrs. Smith knew before any of her staff at General Valley Ob/Gyn that the practice
had been sold to the area’s leading health system. The physician-owners of the
practice were sure to keep her informed almost from the very beginning of the
negotiation for the purchase of the practice. It took three months for all of the
elements of the sell to be finalized, but in the end the physicians would become
employees of the health system along with Mrs. Smith and any of her staff she
deemed appropriate to maintain their positions. She had been in her role as senior
practice manger for 15 years and had witnessed this practice become one of the
most productive Ob/Gyn businesses in the region with nine practicing physicians
and close to 45,000 patients. The practice has relocated three times to accommodate
the space needs for this ever increasing volume of business. The original owners,
two physicians, had expanded their partnership to three more physicians during
this 15 year period. It was no wonder that area health systems were interested
pursuing the practice for ownership.
In the end one system offered the most comprehensive package and the most
lucrative arrangement for the physician partners over any other offers. But the
expectation was that the non-clinical staff under the supervision of Mrs. Smith
would remain in place to assure continuity of patient service and satisfaction. Faced
with this significant change from a small business that felt like a family operation to
a corporate unit within a large health company regarded major leadership on the
part of Mrs. Smith. She understood that several of her staff could easily respond to
the news that the practice was purchased in a “knee-jerk” fashion and quit on the
spot. Any form of walking out would be a serious challenge and certainly if it
represented more than one individual in the office personnel. To manage this
situation, Mrs. Smith decided to proactively orchestra a change process that would
minimize any negative perceptions on the part of staff about this buy-out. She
wanted to maintain the trust and loyalty the staff had with her and to orient the staff
to the new reality of being employees of a corporate health care company rather
than a small business.
Her first task was to develop a clear vision of what this change would mean for
people and to know how to answer key questions they would have almost from the
moment of being informed of this change. Second, she needed to influence key
members of her staff that this was a positive change and one they could embrace.
Doing this for a few, well respected employees would allow them to influence the
others and help get these folks on board. Finally, Mrs. Smith needed to have all staff
members understand this new reality and be able to describe it in their own terms.
It had to become personal in a positive way for every office member. Fortunately,
Mrs. Smith understood such a process could not happen overnight. She would need
to work on this this for a number of weeks if not months to create the buy-in for
change that was required. She would also need to spend this much time to assure
that people would truly embrace the change and feel that it was to their advantage
to support it.
On the day the health system and the physician owners signed the sales agreement,
it was almost impossible to see any difference in how the staff was working or
handling the patients. They knew that at that moment they were employees of the
health system, but they also knew that they understood what that change would
mean for them and what the benefits would be. It was a welcome change.
Module 1: Scope of the Healthcare Administration Field
Case 4: Knowledge of the Healthcare Environment
A new administrator in a large suburban healthcare system was hired to work in the
corporate offices as a patient service coordinator for the five hospitals, one
rehabilitation hospital and one skilled nursing facility for the system. Her major role
and responsibilities included the overall coordination of patient services for these
facilities so that each organization was offering similar services and doing so with
similar levels of quality and effectiveness.
The initial charge for this person was to inventory current patient service practices
throughout the system and determine what was the existing baseline for such
services that would provide a platform for future development and change. For the
first two months on the job, the systems coordinator visited facilities, talked to key
people in these organizations and tried to determine what precisely was being done
for patient services and what the level of quality and effectiveness this work was.
Things appeared to be going well for several weeks. The information seemed fairly
straight forward despite the fact that it was obvious there were major differences in
what each of these organizations was doing in the name of patient care
coordination. By week 6, the systems coordinator was ready to visit the long term
care nursing facility and the acute care rehabilitation hospital. The appropriate
meetings with key folks in these organizations were scheduled and the site visits
began. But it quickly became clear from her perspective that what these two
organizations were offering as patient care coordination services were significantly
different and not at all what she expected they should be in comparison with what
was being done at the five acute care hospitals in the system.
Her vice president of systems operations for the healthcare system expected her
report on baseline services within four weeks and the fact that she was experiencing
such discrepancies in these service agendas was disturbing. But her data collection
through interviews, meetings, and related sources had been completed and there
was no other options but to report on what she had found. Over the next two weeks
she compiled her report on system-wide patient care service coordination. In brief,
it suggested that all five acute care hospitals were relatively similar in their
activities related to such services. There were noticeable differences in the overall
quality of services among the five institutions and that range of performance was a
concern but at least, all five places were on the same page. But her interpretation of
what was happening in the skilled nursing facilities and in the acute care
rehabilitation facility was far different. For both of these organizations, she reported
missing services or services that hardly reflected what was so obvious with the
acute care hospitals. By the time the report was completed and ready for submission
to the vice president, the systems coordinator was sure that the situation she was
reporting represented job security for several years into the future.
She submitted the report and was told that the VP would set up a meeting to discuss
it in the next several days. On Thursday after submitting the report, she and the vice
president met. What she anticipated would be a positive reaction from the VP and
an indication that she was doing a good job as a new member of the administrative
team turned out to be an embracing response suggesting that she had seriously
misinterpreted the information collected from the nursing and rehabilitation
facilities. The VP asked how she could have so badly gaged this material and
misjudged what was happening in terms of patient care services. The meeting was a
major blow to her and she was asked to revisit the patient care services for these
two facilities and resubmit her report in three weeks.
Despite feelings of complete failure, she quickly started reassessing what she had
learned from the nursing facility and from the rehab hospital. It’s hard to know
exactly why she began to understand her errors in judgment, but she came to realize
that the fundamental issue was in how she misunderstood the mission, role, and
work of these two organizations. She had applied the same criteria for patient care
coordination services to these two places that she had done for the five acute care
hospitals. It was true there was some overlap, but in many ways the work of the
skilled nursing facility and that of the rehabilitation hospital were quite different
from that of the acute care hospitals. The patient and family member expectations
were different. How patient care coordination of services was assessed was also
much different, and how those performing this work assigned their measures of
quality was significantly different. Overall, she had severely misunderstood what it
meant to offer patient care coordination across a healthcare system with the
diversity of organizations it represented.
Her revised report was submitted by the three week deadline and she had a followup meeting with the VP. But this error in judgment so early on in her career with
this healthcare system proved to be a difficult issue to overcome. Within two years,
she decided to seek employment with another healthcare company since her
chances for upward advancement with the current health system appeared to be
slim.
Integrated Capstone Course
Module 1: Scope of the Healthcare Administration Field
Case 5: Business Skills and Knowledge
The director of food and nutrition services for a rural hospital had been in the
position for five years and had repeatedly received strong and highly favorable
performance reviews. She knew that the senior administration were pleased with
her work and that her overall reputation throughout the hospital was quite positive.
She was frequently asked to be on major committees and at times to serve on
project management teams. From all accounts, she was in a ‘good place’ and there
was no signs this would not change going forward.
In January her boss announced that she was resigning her position to relocate with
her husband to Utah and seek a health administration position with one of the
healthcare systems in and around Salt Lake City. The news was not particularly
disturbing to the director of food and nutrition. She felt she had a fine relationship
with this vice president but she also believed she was well positioned to work for
any new appointment to that VP slot.
By April, the new vice president was on board and quickly announced that his
immediate concern was to develop a new budgetary approach for the six
departments that reported to him to strengthen their collective bottom line and to
create a more rigorous budgetary process going forward. At the core of this new
approach would be zero-based budget process to begin with the new budgetary
cycle for the next fiscal year period. Preliminary budget submissions for each of the
six departments would be due by May 1 with the expectation that finalized versions
of the budget would be on his desk by June 1 ready to be folded into the entire
hospital budget for Board approval in June 15th of that year.
It quickly become apparent to the director of food and nutrition that she knew little
about zero-based budgeting. She had heard of the term, but never in the five years of
her work with the hospital had she ever been asked to do anything like this in terms
of budget preparation and submission. Most of her previous experience with her
department’s budget would be relatively useless given what the new VP was
expecting. It was a major dilemma. Should she try and work her way through the
process and hope that she could master enough of the essentials that she could pull
it off? Or should she seek professional assistance and get the knowledge and skills
needed to produce a zero-based budget that was accurate and would be successful
for her department? If she went for the first strategy, she might avoid any
embarrassment with the new VP although that was, by no means, a sure thing. If she
opted for the second approach, she would acknowledge this blind spot in her
financial management competencies but she would produce a quality budget
document and know that her department would not suffer.
In the end she did a little of both. She sought some measure of assistance from
another department head who she believed understood the zero-based budget
process, but avoided going to anyone in the finance department or her new boss for
help. With determination and a desire to work through the issue, she produced a
zero-based budget ready for submission by May 1. It contained the right language
for such a budget and its computations for the individual line items were accurate.
On the surface it would pass for a legitimate zero-based budget. The crisis was met
and passed. By mid August of that new fiscal year, she realized that although she had
effectively satisfied her new boss and avoided any potential embarrassment, she
would be paying the price of her lack of knowledge and skill around zero based
budgeting.
The resources her department was so use to having began to drop. More financial
reports were now being requested from Finance on a monthly basis to justify
spending requests and revenue projections. By October, she realized the cost of
trying to fool her fool and perhaps, herself. The department would not be able to
operate for the remaining seven months of the fiscal year without major
adjustments and allowances that were not planned at the beginning of the fiscal
year. That March when the annual performance reviews were being done, the
director of food and nutrition services received the lowest performance rating of
any of the six departments reporting to her VP. Her development plan for the next
year had one critical goal to achieve – to gain command of the new budgetary
process and demonstrate that her department would not suffer from this process in
the future.

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