This is the first blog post in a new series of posts that we are calling the “Spine Case Study Challenge.” We have written several case studies that represent common situations our clients experience. Rather than addressing them ourselves, we are asking some of our alliances in the world of spine care to provide their input. This first case involves an administrator who has been directed to develop a spine center with both orthopaedic and neurosurgical physicians. Patrick Vega, with Vega Healthcare, responded to several questions about this case study.
Case Study #1 – Combining Ortho & Neuro
Until recently, Harold has been successfully growing the inpatient spine program at Community Hospital. Based on his recent success, hospital leadership has tasked him with the responsibility of organizing a virtual spine program with the intent of developing a brick and mortar facility in three years.
A previous attempt to coalesce their employed neurosurgical practice with the local private practice group, “Big Ortho Clinic (BOC),” failed in 2009. BOC has developed a large network of private ancillary services, which include x-ray and on-site physical therapy. They have shown an interest in participating with the hospital, but remain skeptical as to how an alliance will impact their bottom line.
Leadership strongly feels that creating a program without the orthopedic group would be a mistake because they are responsible for over 60% of the spine cases within the hospital. The employed neurosurgery group is hesitant to work with the non-employed practice. The hospital has nearly completed recruitment of a non-interventional physiatrist and she is expected to begin in four months. All indications point to the fact that the hospital is willing to make the necessary investments. Harold has a positive relationship with all physician parties, and his promotion was endorsed by everyone involved.
What are the actions that Harold should take in his first three months on the job?
When stepping into a new position in these circumstances, developing and sustaining credible relationships with the medical staff spine specialists is critical. With the history of a failed initiative and likely employed-private tensions, it is especially important to solicit and understand the perspectives of each individual. I have found that there is often a belief among private groups that hospital administration will treat employed staff preferentially. However, strong administrative leadership will demonstrate a balanced approach with both private and employed physicians to maintain trust and credibility.
A few specific suggestions:
- Meet with the spine specialists and ask them to describe their goals and barriers within their practice and in the hospital. Make sure to develop a relationship with the practice manager as well, as they are often a first line of access and the facilitator of communication with the medical staff.
- Ensure that departmental meetings and initiatives are focused and action oriented, with timelines attached. Prepare and adhere to a written agenda. If there are contentious issues to be discussed, manage them outside of group meetings by meeting in advance with each physician to understand his or her perspective and identify areas of consensus and divergence to draft acceptable solutions. If differences of opinion are not assertively managed, they may blossom into open conflict with the consequences of delays and further escalated tensions.
What are the two biggest concerns that Harold should have when dealing with the orthopaedic group?
1. Harold should be conscious of the group’s concerns that, in building a spine program, the hospital will take business from them. They will be worried about losing surgical cases and ancillary services. Moreover, the hospital’s hiring of a physiatrist could readily be perceived as a threat to the orthopaedic group. Harold needs to understand and very intentionally craft a program that supports the business aspirations and historical referral base of each group.
2. It is likely that the orthopaedic group is, among other things, concerned about the hospital’s ability to execute due to the previous failed initiative. Physicians often view hospital-led initiatives skeptically, as they require both an investment of time and, perhaps more importantly, an investment of reputation. When new projects stall or fail, it reflects on the doctors as well.
In light of these concerns, it would be wise to construct a timeline that fosters the resolution of these two issues. Programs that don’t seek direct physician input early and regularly throughout the project will fail for lack of physician support when it comes time to execute programming.
The physicians at BOC are concerned that any new referrals to the spine center will be steered to the employed neurosurgery group, rather than to their practice. What steps can Harold take to alleviate their concerns?
The hospital needs to build a comprehensive system for tracking patient referrals, triage disposition and treatment. Further, the system and data must be transparent. Monthly reports showing this data must be available for program physicians to review.
While a physician may occasionally dispute the data, it is still critical to provide it regularly in an organized and transparent fashion. When there is historic or current physician distrust of the hospital, a lack (or perceived lack) of transparency will only heighten tensions. This is only one of the reasons that I always encourage my clients to consider Priority Consult Spine when developing their programs. The introduction of a centralized and completely transparent system, with built-in reporting, will eliminate the need for “blind trust” from participating physicians. The data is there for everyone to see.
What organizational structure would you recommend to facilitate this virtual spine program?
Across the country, the prevailing model of spine center organization structure is the virtual model, rather than the “bricks & mortar” model of comprehensive and multi-specialty services in one physical location. Regardless of the model, patient navigation and care coordination are essential for success. For the virtual program, navigation that engages the patient from the initial contact over the complete episode of care creates consistent patient and provider satisfaction and also fosters greater patient readiness for care and ownership in their recovery.
What should Harold be measuring over the next three years to determine the viability of a bricks and mortar spine center?
Development of a bricks and mortar center is typically a significant organizational and financial commitment. Confirming that a
viable structure, supported by strong physician support (private and employed) and program revenues to fund development, are prerequisites for development. Operational data to measure impact should include: spine program revenues for both surgical and non-surgical treatments, clinical and functional outcomes data, and incremental growth in surgical and ancillary volumes resulting from program development and marketing.
The hospital leadership has asked Harold to put together a “Spine Center Committee” to meet quarterly. Who should Harold invite to be on the committee?
I advocate for developing a core working group, which may not include all committee members, but does have the flexibility to pull in specific members on an ad hoc basis for related discussions and decision making. The following list represents the typical stakeholders needed to effectively plan and execute spine program development:
* All physician spine specialists; surgery, physiatry, pain management, primary care, neurology
* Administration sponsor
* Nursing; executive and program level
* Perioperative Services
* Case Management
* Marketing & Community Relations
* Planning & Service Line Development
* Medical Records
* Information Technology
* Internal Medicine/Hospitalists
* Facilities/Plant Operations
What other advice do you have for Harold?
Harold needs to understand that building a comprehensive program requires a detailed plan and is usually completed over an extended period of time. Depending on existing assets and infrastructure, a program starting from scratch can take 5 -12 months to develop. A partially developed program may proceed faster.
He should also take into consideration industry and specialty-wide emerging phenomena, such as reimbursement, physician alignment and the necessity of meaningful outcome measures. Dynamic changes in healthcare are leading to unprecedented opportunities for physician/hospital collaboration; hospitals are actively seeking spine specialists who are eager to partner in the planning, development and delivery of care. Both employed and private practice physicians are pursuing hospital partners who provide medical leadership opportunities that cross all aspects of spine care: clinical, operational, financial and quality. By teaming in meaningful collaborations, hospitals and physicians can create and sustain services and quality in specialty programs that neither could achieve alone.