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Interview With Wayne M. Lerner, DrPH,
FACHE, Past President and Chief Executive
Officer, Holy Cross Hospital
W
ayne M. Lerner, DrPH, FACHE, was president and CEO of Holy Cross Hospital
in Chicago, Illinois, from 2006 to 2013. He spent the first 17 years of his career
at Rush–Presbyterian–St. Luke’s Medical Center, where he rose to the position of vice
president for administrative affairs and chair of the Department of Health Systems
Management. During the early 1990s, Dr. Lerner served as president of Jewish Hospital of St. Louis, Missouri, and as a senior executive officer within the BJC Health System, where he was a key executive behind the merger of Jewish and Barnes hospitals
as well as the creation of the BJC Health System.
From 1997 to 2006, Dr. Lerner was president and CEO of the Rehabilitation
Institute of Chicago, an organization distinguished by its designation as the best
rehabilitation hospital in the United States since 1991 by U.S. News & World Report.
In 2006, Dr. Lerner became interim president and CEO of Holy Cross Hospital,
an inner-city, faith-based, disproportionate-share hospital in Chicago. In 2007, he
assumed the role on a full-time basis and stepped down from that position in 2013.
Dr. Lerner is a Fellow of the American College of Healthcare Executives and of
the Institute of Medicine of Chicago. He holds a bachelor’s degree from the University of Illinois and MHA and DrPH degrees from the University of Michigan. In
2013 he was the recipient of ACHE’s Gold Medal Award in the healthcare delivery
organization category. The Gold Medal Award is the highest honor bestowed by the
American College of Healthcare Executives on outstanding leaders who have made
significant contributions to the healthcare profession.
Dr. O’Connor: Congratulations on receiving the 2013 Gold Medal Award! The variety
of organizations (academic medical center; rehabilitation facility; large, integrated system;
inner-city, faith-based hospital) in which you have worked and the breadth of activities you
have managed are noteworthy. Similarly, you have filled many different types of leadership
roles. How have you been able to adapt to the different role demands and differences in
organizational context, culture, governance, resources, and so on, as you moved among these
various settings? What did you learn from working in these different types of organizations
and roles?
Dr. Lerner: First, we should establish a contextual baseline for this question. The
delivery system roles were important, but so were the many external roles in which
I also participated. I always tell people that I’ve had an atypical career, in that it has
not followed any type of linear trajectory. I have always been motivated by opportunities that are intellectually demanding and professionally exciting. If an opportunity
meets those criteria, then I tend to say yes. Those are the qualities that have driven
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me to follow a career path not considered to be the norm for someone with my
background.
I’m not sure I have a great secret here. I first became a hospital president when
I was about 40 years old. It was the biggest transition I had ever made. I tell students that the best job you will ever have is when you’re number two or three in an
organization, because you can be yourself, you don’t have ultimate responsibility
for the direction of the institution, and you can relate to people on a more humanto-human basis than you can in a higher position. When you become number one,
you assume a role for which you may have been prepared but you’re not really ready
for, as it can be very isolating in terms of personal interrelationships. People look
to you to provide the last word on whatever is going on in the institution. I finally
realized the true implications of being a CEO when I understood the need to change
my approach slightly. I had to modify my sense of humor, and in general I didn’t feel
free to relate to people in exactly the same way I had previously—I began playing the
role of president. That adjustment included acknowledging that now I’m responsible
for, say, 10,000 lives, 1,200 staff, 100,000 people in my community, and the strategic
direction of the organization.
The other major insight I gained from shifting roles or positions, whether staying within an institution or moving on outside of it, was that the lens through which
you see things changes. For example, when I became chair of the Illinois Hospital
Association board, all of a sudden, how I perceived and related to situations and
people, and how I managed my personality within the context of these organizations,
changed, because I now had a responsibility and an obligation to people outside
of my organization, or outside of my immediate circle. As my situation changed by
becoming a CEO, so did my orientation to the position and to those with whom I
interacted.
Ultimately, if you assume that you can apply a single template that will work in
all organizations and role responsibilities encountered in a career, you have made
a big mistake. Culturally and strategically, every organization is different. The one
constant is who you are.
Dr. O’Connor: Born and raised in Chicago, you spent most of your professional career
there (with the exception of six years in St. Louis). Could you have achieved the same level
of success and variety of activities if you had moved to a different city for each subsequent
professional position? In other words, are there unique career path prospects and opportunities embedded within a city such as Chicago that are not available in other places?
Dr. Lerner: I think it’s happenstance or serendipity that I ended up spending my
whole life in Chicago except for the time in St. Louis. It never was my plan to stay;
in fact, I was more than willing to move for an opportunity. I started at Rush–
Presbyterian–St. Luke’s Medical Center working with Gail Warden, LFACHE, which
was a great way to begin a career, and ended up having five different jobs there over
17 years. I decided to leave Rush because there was no place for me to grow at that
point and I didn’t know if I had the wherewithal to be a president. I was not the kind
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I nterv iew
of person who always wanted to be a president. There is no camp to attend to see if
you can or should become a president. You have got to do it, decide if you like it, and
see if the expectations of the position are those that you can meet or exceed.
For personal reasons, I drew an hour’s flight time around Chicago. I was lucky
enough to get an interview at The Jewish Hospital in St. Louis and even luckier to be
selected as its president. Six years later, after essentially merging myself out of a job,
I became a consultant back in Chicago, reinvigorated myself with my family, and
started to consider whether I wanted a lifelong career in consulting or other possible
opportunities. Again, serendipity or karma was at play when I learned of a unique
opportunity in Chicago: serving as president and CEO of a specialty hospital—the
Rehabilitation Institute of Chicago—whose specialty was the same area in which
my wife worked. I never really thought about location, perhaps because the societal
demands and cultural differences between the roles I had at Rush and Jewish were very
different than those at the Rehabilitation Institute, which was a very high-profile role.
I don’t believe location makes much difference when considering job opportunities for healthcare executives. The key factor is how well you adapt to the demands of
a particular job, how well you relate to the people for whom you work, and how well
you relate to your employees and the community. For example, despite their relative
proximity, St. Louis is very different than Chicago in terms of culture, local dynamics,
politics, and other factors. If you are attuned to such factors, you are likely to make
those transitions easier.
I have always maintained that it doesn’t matter where you go for your job. What
makes the difference is what the environment is like where you are going to work
and learn, and who your boss is. The job could be located in Alaska, Antarctica, or
Chicago; if you have a great environment, good support and people, and a supportive
boss or board, then theoretically you should be able to apply your talents anywhere.
Dr. O’Connor: The need for clinicians and administrators to work effectively together
has never been greater, yet the majority of today’s physicians, nurses, and administrators
are educated in isolation from each other—in silos, if you will, that don’t address the roles
or functions of other hospital occupations. What can our educational programs do to begin
overcoming this problem?
Dr. Lerner: This issue is near and dear to my heart. I had never taken an epidemiology course until I was working on my doctoral degree at the University of
Michigan. I had been working at Rush, whose organizational structure was based on
a tripartite relationship among doctors, nurses, and administrators. In other words,
each operating unit had a doctor, a nurse, and an administrator at the top, who were
expected to work together. I was always amazed to think how we were all educated
differently, how we talked differently, how we didn’t even relate to the variable of
time in the same way and were then thrown together around this entity called the
patient where we were expected to make everything better. And this occurred in an
organization that employed a matrix management model, which by its nature is the
most difficult model to operate within.
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Organizational behavior and organizational theory have always been my great
interests, and it is always fun for me to think about these topics. So when I went to
Michigan, I wrote a paper that my professor called turgid and irksome. I still have it;
she was right, my writing was not great. But the theory was good. The paper examined how we have no common language among doctors, nurses, and administrators
and how we are educated in silos and then thrown together and expected to work
together effectively. I thought it would be nice if we at least had a common language. I wrote that we all ought to be forced to take epidemiology, and we all should
conduct a joint epidemiologic project as a way to break down barriers and find at
least one core vehicle by which to communicate with one another. I believe our
educational programs should reach across the campus and find ways to get students
together and collaborate, not just from medicine, nursing, and administration but
from the other health professions as well.
With the Affordable Care Act in place, we have to deliver services across a continuum to a defined population in an effort to maximize both individuals’ health
and their functional status. If you don’t incorporate an understanding of primary
prevention with the acute and postacute models, how do you intervene to ensure
this population is healthy? Now add to the mix patient navigators, ombudsmen,
insurance professionals, lawyers, and others, all of whom are engaged in this effort
to maximize health. Some may see a complex morass that will never come together.
But wouldn’t it be fun to work collaboratively on a project that helps a community
achieve its potential?
Dr. O’Connor: What is the future for urban, safety net hospitals in the United States?
Dr. Lerner: Over the next 7 to 10 years, the entire healthcare landscape will
change. That transformation is one reason the Sisters of St. Casimir at Holy Cross
Hospital were encouraged to look at such options as selling the hospital to a forprofit firm, merging with one of the bigger Chicago-area systems, or becoming part of
a new initiative by creating a private safety net system. I worry that stand-alone safety
net hospitals will not survive once patients have more choices that come with their
new health insurance.
It is likely that we will begin to see unusual affiliations and relationships develop
for both public and private safety net hospitals, as I do not see the need for safety
nets ever going away. In the end, the safety nets remaining will need to find ways to
reduce expenses, control costs, and increase revenue while improving the health of
their populations, which will be a most challenging task, indeed.
I believe that over the next decade, the roles and points of focus of the private
practice of medicine, the stand-alone community hospital, and the urban and rural
safety net hospitals all will change. Those changes will come about not so much by
what the institutions choose to do as by what happens with the other entities they
work with. In fact, we may find these hospitals participating in multi-institutional
systems that include federally qualified health centers, private clinics, medical groups,
and perhaps even insurance companies.
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I nterv iew
Dr. O’Connor: What topics and issues would you like to see addressed by authors in
the Journal of Healthcare Management?
Dr. Lerner: I would like to see authors address the changing face of healthcare
leadership in terms of education, experience, and background. What does it mean for
our field and those we serve if the traditional master’s degree–prepared individual no
longer is the gold standard for CEO positions? How will clinically educated executives change the way care is provided to populations—not just patients—and what
does this change in orientation mean for the graduate education system? What roles
will be assumed in the future by those coming from graduate programs? Who will
mentor them if the CEO does not have that orientation in her background? How will
the role, function, and expectations of the governing boards change as we migrate
our system to one that maximizes a population’s health and links payment to health
and functional status outcomes? Finally, how should our educational system change
in recognition of the contributions of clinical and nonclinical executives in the organization and delivery of health services? If we are to assume risk for a population’s
health, then we will need expertise across a wide continuum. Leading such a multidisciplinary team while engaging the community will present our field’s leadership
with new and daunting challenges.
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Developing a Pediatric Burn Treatment
Program in a Community Hospital
Pamela Jennings, Marc Cullen, Roseanne Mark, Mary Ellen Meloche,
Sandra Jaeger, and Tammy Lile
T
here are 120,000 pediatric
burn injuries annually in the
United States (Center for Research Injury and Policy
[CRIP], 2010). According to CRIP
(2010), pediatric burns result in 2,500
deaths and over 100,000 emergency
room visits every year. Burns are the
fourth leading cause of death in children under the age of 15 years and the
number one cause of accidental death
occurring in the home. Burn injuries
are also a major source of pediatric
disability and are associated with significant national health care resource
utilization (CRIP, 2010). Serious burns
are resource intensive, costing hundreds of thousands of dollars per
patient (Miller, Latenser, Jeng, &
Lentz, 2009). Many pediatric thermal
injuries are not severe; however, referral to a burn unit for any burn regardless of depth, size, location, or severity
is common. These patients are routinely transported long distances and
at great expense for treatment
(Vercruysse, Ingram, & Feliciano,
2011).
Pamela Jennings, DNP, PNP, RN, is a
Pediatric Clinical Nurse Specialist, St. John
Hospital, Detroit, MI.
Marc Cullen, MD, MPH, FACS, is Division
Chief–Pediatric Surgery, St. John Hospital,
Detroit, MI.
Roseanne Mark, MA, RN, is a Clinical Nurse
Manager, St. John Hospital, Detroit, MI.
Mary Ellen Meloche, BSN, RN, is a Pediatric
Surgery Nurse, St. John Hospital, Detroit, MI.
Sandra Jaeger, BSN, RN, is a Pediatric
Nurse, St. John Hospital, Detroit, MI.
Tammy Lile, ADN, RN, is a Nurse Preceptor,
St. John Hospital, Detroit, MI.
Acknowledgment: The authors would like to
thank Susanna M. Szpunar, PhD, Senior
Medical Researcher, for providing statistical
analysis.
There are 120,000 pediatric burn injuries annually in the United States (Center
for Research Injury and Policy [CRIP], 2010). Although many pediatric thermal
injuries are not severe, referral to a burn unit for any burn regardless of depth,
size, location, or severity is common. Many patients with smaller burns can be
effectively managed in a community hospital, which allows children and their
families to remain close to home, reducing costs and some stress associated
with hospital stays. This article describes the process of creating a community
pediatric burn care program at St. John Hospital in Detroit, Michigan, and initial
outcomes of the program.
Patients with large burns (greater
than 15% body surface area for young
children, and greater than 20% for
older children and adolescents) develop systemic responses to vasoactive
mediators released from damaged tissue after a burn injury (Joffe, 2010).
These patients are likely to require
aggressive, resource-demanding management available in a regional burn
center. However, most burns treated
in burn units within the United States
are superficial, partial thickness burns
that would heal without burn unit
referral (Vercruysse et al., 2011). Many
patients with smaller burns (less than
15% body surface area) can be effectively managed in a community hospital when a knowledgeable and
experienced staff establish and maintain a coordinated burn program.
When Vercruysse et al. (2011) considered the problem of overutilization of
regional burn centers for pediatric
patients, they noted that communitybased care eliminates the need for
children with less-severe burn injuries
to be transferred, and allows children
and their families to remain close to
home, reducing costs and some stress
associated with hospital stays.
St. John Hospital in Detroit,
Michigan, part of St. John Providence
Health System (SJPHS), is an 800-bed,
not-for-profit community hospital
with a 40-bed pediatric unit, an 8-bed
pediatric intensive care unit, and a
pediatric emergency room, and holds
a Level 2 Pediatric Trauma Certi-
PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5
fication. In keeping with attaining pediatric trauma certification, the pediatric surgery department, in collaboration with the inpatient units, began
a pediatric burn pilot program in
April 2009. The pilot program would
verify which patients can safely and
effectively be cared for in a community setting and establish the basis for a
permanent pediatric burn unit in the
hospital.
St. John Hospital pediatric services chartered the Pediatric Burn Care
Multidisciplinary Committee to examine standards of care for children
with burn injuries throughout SJPHS,
evaluate the need for and create burn
care guidelines for patients treated in
a community hospital, and educate
staff on the principles of pediatric
burn care. The committee established
its mission to provide uncompromising, compassionate care for children
who have sustained less-severe burn
injuries. A multidisciplinary team
committed to spiritually focused,
holistic healing was assembled to provide physical, emotional, social, and
spiritual support to injured children
and their families. The team was dedicated to giving the highest standard
of care, extending beyond the healing
of the skin to restoring a sense of
wholeness, acceptance, and reintegration into the community.
The committee conducted a literature search for information about pediatric burn care outside of regional burn
centers. PubMed and CINAHL search
219
Developing a Pediatric Burn Treatment Program in a Community Hospital
engines were utilized in January of
2009 and again in August 2011. There
was a plethora of articles describing the
medical and nursing care of children
with burn injuries (Death, 2005; Joffe,
2010); however, there was little information about pediatric burn programs
(Brignall & Death, 1999; Death 2005).
There were no publications addressing
burn care programs in community
hospitals. This paucity of information
demonstrated the need for the development of a model for a community
burn care program.
The committee used the American College of Surgeons (ACS) (2006)
Guidelines for the Operation of Burn
Centers as a framework to evaluate
their current standard of care for pediatric trauma patients. The committee
found most of the elements required
for a burn center were already in place
at St. John Hospital as components of
maintaining a level 2 Pediatric Trauma Center. The areas in which the
current program did not meet the
guidelines included admission and
census levels of a burn center hospital, one or more employees that are
Advanced Burn Life Support (ABLS)
instructors, and a specialized nursing
unit dedicated to acute burn care.
Organization of Pediatric
Burn Care Program
A burn team was identified and
was composed of the many services
required for the complex management of thermal injuries. Team members included surgeons, intensivists,
resident physicians, advanced practice and staff nurses, clinical pharmacists, nutritionists, social workers,
physical and occupational therapists,
chaplains, and a child life specialist
(see Table 1). The team reviewed and
revised existing policies and procedures, developed a burn care supply
cart, and established procedures for
burn wound management and guidelines for the use of procedural sedation for dressing changes. Standard
physician orders and prescriptions
established consistency. A comprehensive program of lectures and
hands-on workshops provided education to achieve health care professional competence consistent with national standards. The ACS (2006)
burn center referral criteria were used
as a guideline to establish admission
and transfer criteria for the burn program (see Table 2).
220
Program Development
The team reviewed and addressed
the many aspects needed to create
and implement the program, including policy development, supply organization, documentation, processes
for pain management and burn dressing changes, processes for follow-up
care, staff competency validation,
education tools, and program evaluation.
Policy
The existing pediatric burn care
policy was revised to reflect the current evidence-based practice guidelines established by the ACS (2006).
The policy now includes admission
criteria, mandatory consults, laboratory studies to be drawn, and medications to be given. It also includes a list
of equipment needed and a step-bystep procedure list. A portable burn
care cart was assembled to organize all
equipment and burn wound dressing
supplies.
Burn Care Communication
Tool
A burn care communication tool
was developed to convey which dressings and medications were applied to
each burn site to pass this critical information on to subsequent caregivers. The tool is used for family
home care instructions as well, and a
copy is included in the patient’s discharge folder. The staff also uses the
tool as a checklist to restock the burn
cart in readiness for the next dressing
change.
Procedural Analgesia
And Sedation
A procedural sedation protocol
was developed from evidence-based
guidelines (Mason, 2011). It specifies
medication set up, preparation, and
administration, and includes both
pharmacologic and non-pharmacologic pain management interventions. Non-pharmacologic interventions used include relaxation, guided
imagery, distraction, therapeutic
touch, music therapy, and aromatherapy. Most initial dressing changes
where debridement is needed are performed while the patient is under
moderate to deep sedation. Medications are generally given in combination, according to the age of the
patient: a) for children less than 2
years old, ketamine and midazolam
are given; b) children 2 to 5 years may
be given either ketamine and midazolam, or propofol and fentanyl; and c)
for children older than 5 years, propofol and fentanyl are used. When less
debridement is required and initial
healing has begun, intravenous analgesia (morphine) and sedation (midazolam [Versed®]) are given 10 to 15
minutes before the dressing change.
Dressing changes just prior to discharge are usually done with oral
analgesia (acetaminophen [Tylenol®]
with codeine) and sedation (diphenhydramine [Benadryl®]).
Burn Wound Dressing Change
Process
The process for changing burn
dressings was developed for inpatient
and outpatient care, and a written
guideline was created. Pictures are
taken before and after debridement
and/or dressing change with parental
consent. The pictures are shown during the monthly multi-disciplinary
pediatric burn care meeting while
case reviews are presented. A portable
surgery cart is used to assemble supplies.
Burn Wound Care Competency
A process to validate burn wound
care competency for nurses and resident physicians was developed. The
process starts by attending a pediatric
burn care presentation, reading the
contents of the patient education
folder, and reviewing the contents of
the burn cart. The learners subsequently observe a burn dressing
change, assist with a dressing change,
and finally, perform a dressing
change, first under supervision and
then independently. The final step in
the competency validation process is
teaching burn wound care under
supervision, then independently, to
staff and parents. The clinical nurse
specialist, pediatric burn care nurse,
nurse preceptors, and lead burn care
nurses validate staff burn wound care
competency.
Orders and Prescriptions
The burn program medical director and the clinical nurse specialist
wrote standard physician orders and
prescriptions. Orders include consults, dressing changes, laboratory
and diagnostic studies, diet, activity,
and inpatient medications. Prescriptions include outpatient medications,
analgesics, and antipruritics, as well as
dressing change supplies.
PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5
Table 1.
Multidisciplinary Team Members
Medicine
• Burn program director is a pediatric surgeon with 30 years of pediatric burn care experience.
• Pediatric intensivists provide fluid management, monitoring, and procedural sedation.
• Pediatric emergency medicine physicians provide the initial assessment and urgent care to patients
who arrive in the emergency department with burn injuries.
• Pediatric child abuse program director is a board-certified pediatrician with specialty training in child
abuse prevention, recognition, and treatment; and is consulted for all patients with suspected abuse or
neglect.
Nursing
• Clinical nurse specialist (CNS) coordinates the program, develops the parent and staff education
programs, standard orders, and prescriptions; and assists with staff education. The CNS meets with
patients with burn injuries and their families and coordinates their inpatient care. The CNS also leads a
pediatric burn research project and mentors staff nurses in nursing research.
• Pediatric surgery/burn care (PS/BC) nurse works in direct collaboration with the Burn Surgeon, and
leads the nursing education program, providing lectures and workshops demonstrating burn wound
care. The PS/BC nurse provides direct patient care, both inpatient and outpatient, develops patient’s
plan of care, and coordinates the patient’s outpatient care with other team members.
• Pediatric trauma coordinator rounds on all pediatric patients with burn injuries and collects all data
needed for the National Burn Repository (NBR). The National Burn Repository is a database
summarizing some of the clinical characteristics and course of burn treatment for cases submitted to
the NBR from specialized burn care facilities (Miller et al., 2009).
• Pediatric and pediatric intensive care unit nurse preceptors mentor and support nursing staff while they
learn burn care.
• Lead burn care nurses from each unit (pediatric and pediatric intensive care unit) serve as a burn care
resource and mentor staff nurses as they develop burn care competence.
• Nurse case managers assist with issues involving insurance, home care, dressing supplies, and
equipment.
• Nurse managers provide administrative support for the development and maintenance of the burn care
program.
• Home care nurses provide education, assessment, and support once the patient returns home.
Social Work
• Social workers provide emotional support to families, assist with problem solving and decision making,
financial and transportation needs, and language barriers. They are liaisons with child protective
services in suspected child abuse cases.
Pharmacy
• A pediatric clinical pharmacist provides information on all medications used for treatment and symptom
management.
Nutrition
• Dietitians make nutritional recommendations and educate the child and family regarding a diet to
promote burn wound healing.
Spiritual Care
• Chaplains visit patients and families daily and are available to provide spiritual and emotional support.
Child Life
• Child life specialists are teachers as well as counselors that are specially trained in caring for ill
children. They provide communication with schools, assess educational needs, and assist children in
developing coping skills (relaxation, imagery, etc.) for use in managing the anxiety and/or pain
associated with burn care.
Occupation and
Physical Therapy
• An occupational or physical therapist is present at burn dressing changes to improve the range of
motion of involved joints, as this can be done with less discomfort while the child is sedated. They
demonstrate to the patient and parents the exercises that will need to be done at home.
Patient and Parent Education
A broad patient and parent education program was developed, including information regarding burn classification, pain, and pruritis management at home. The home dressing
change process is reviewed. Parents are
involved from the first inpatient dressing change and have ongoing participation in all subsequent dressing
changes. This helps assure that by the
time the child is ready for discharge,
parents are proficient at burn wound
care. The dietician reviews the patient’s
nutritional needs and a meal plan.
Occupational and physical therapists
explain strategies to prevent contractures and scarring. The child life specialist, social worker, and nurses
address psychological adjustment and
school issues. Parents often struggle
with the guilt associated with an accidental injury, and they receive support
from chaplains, nurses, the child life
specialist, and social workers during
PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5
the healing process. Finally, prevention of burn injuries is reviewed. A
burn injury education record developed for the program is used to document the education provided.
Costs of Instituting
The Program
The costs associated with instituting the burn program at SJPHS were
primarily construction and training
costs. The cost of reconstructing an
existing storage space into a burn
221
Developing a Pediatric Burn Treatment Program in a Community Hospital
Table 2.
Criteria for Admission and Transfer
Admission Criteria
Transfer Criteria
1. Partial thickness burns less than 15% total body surface
area (TBSA).
1. Partial thickness burns greater than 15% TBSA.
2. Burns that involve the face, hands, feet, genitalia,
perineum, or major joints.
2. Electrical burns.
3. Minor burn injuries that could be managed outpatient but
exist in patients who will require special social, emotional,
or rehabilitative intervention requiring inpatient care.
3. Complex thermal, chemical and inhalation burns.
4. Non-complex (not requiring intubation and mechanical
ventilation) inhalation burns.
4. Burn injury in patients with preexisting medical disorders
that could complicate management, prolong recovery, or
affect mortality.
5. Non-complex (partial thickness) chemical burns.
5. Any patients with burns and concomitant trauma in which
the burn injury poses the greatest risk of morbidity or
mortality.
treatment room was approximately
$120,000. This cost included architectural drawings, demolition, construction, and installation of the burn tub,
along with heating and lighting
options to create a more serene and
comfortable treatment space for
dressing changes. The construction
costs were covered entirely through
donations from the local community
and the SJPHS philanthropic and
fund-raising foundation. The approximate cost of staff training was
$2,000, using an average salary of
$30.70 per hour, multiplied by the 48
registered nurses who attended the
training. This cost was also covered
through donated community funds.
The training cost for other staff,
including physicians, nurse specialists, social workers, dietitians, and
therapists, was part of the operating
budget.
Program Evaluation
Three quality metrics and two
financial metrics were established to
evaluate the burn program. The three
quality metrics are length of stay,
infection rate, and readmission rate.
The two financial metrics are charges
per case and net revenue per case.
Quality measures were selected
because they are part of the core
measures SJPHS has established.
SJPHS selected the core measures
based on the Centers for Medicare
and Medicaid Services (CMS) and The
Joint Commission recommendations
to focus efforts on the use of data to
improve the health care delivery
process (The Joint Commission,
2013). The financial metric, charges
222
per case, was chosen based on the
American Burn Association (ABA)
(2012) report, which provides mean
total and daily charges for patients
with burn injuries. The second financial metric, net revenue per case, is a
standard financial indicator used at
SJPHS.
Staff and patient satisfaction data
are collected as part of the overall pediatric program evaluation at SJPHS.
Data specific to staff caring for patients
with burn injuries and data regarding
patient satisfaction with care were collected as part of this routine survey.
Although staff and patient satisfaction
were not established program evaluation indicators, data collected are
reported in this article.
Barriers to the Burn Care
Program and Solutions
Barriers to putting the burn care
program in place included lack of staff
participation and unfamiliarity with
burn care processes, lack of a reliable
and appropriate physical space for
procedures, the need to change established burn patient referral patterns,
lack of engagement and support from
the operating room and other multidisciplinary services, and availability
of a process for outpatient follow up
and management. These barriers to
implementation were analyzed, and
strategies to address each of these
were devised and implemented by the
team.
Staff Participation
The principal barrier to implementation of the burn program was
the reluctance of pediatric staff to care
for children with burn wounds. They
expressed discomfort with burn care
and fear of causing pain. Many experienced staff members recalled caring
for children with burns 15 to 20 years
ago. They remembered how the children suffered during “burn baths”
during that time.
A comprehensive program was
designed to address the nurses’ concerns. Education and grand rounds
addressing pediatric burn management was provided for staff in the
operating room, emergency department, pediatric unit, pediatric intensive care unit, and family practice
areas. Teaching guidelines were developed to ensure consistency and comprehensiveness of patient education.
Staff education regarding burn
patient-specific pharmacologic and
non-pharmacologic pain and anxiety
management was provided, to ease
staff concerns regarding patient comfort.
Burn Treatment Room
Another barrier to the burn program was the lack of appropriate facilities. The existing treatment room
was too small to accommodate the
staff and supplies required for burn
wound dressing changes. Initially, the
burn wound dressing changes were
done in the pediatric intensive care
unit (PICU) when moderate to deep
sedation was required. The child’s
hospital room was used when moderate to deep sedation was not needed.
Problems with providing care in the
PICU included an increased risk of
infection and a lack of privacy; diffi-
PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5
Figure 1.
Burn Treatment Room
15% burn injuries. The hospital website was updated to include information about pediatric burn injury prevention and treatment, as well as
adding an easy-access process for families and community physicians to
refer children for assessment, treatment and follow up.
Operating Room Support
The operating room staff lacked
experience with temperature control
or transfusion management in children with burn injuries. Operating
room and anesthesia personnel had
no experience doing skin grafts or
burn excisions, and were unprepared
for rapid blood loss and hypothermia
related to exposed burn patients.
Equipment like dermatomes and
hemostatic agents, as well as wound
care supplies, had to be stocked.
Anesthesia and operating room staff
were in-serviced on temperature and
transfusion management for burn
excision. Equipment was purchased
and inventory managed to support
skin grafting.
culties with in-patient room care were
lack of space and infection control. In
addition, performing wound treatment in the patient’s room violated a
space that should be reserved for the
safe, quiet, and comfortable convalescence from the injury.
Funding was obtained for a new
burn treatment room located within
the pediatric unit. This allows the
staff to provide appropriate care for
children with burn injuries in a secure
and appropriate environment. The
new burn treatment room has two patient therapy areas: a monitored treatment bay for dressing changes and
procedures, and an ARJO Rhapsody
Tub for cleaning and debriding burn
wounds (see Figure 1). The spacious
treatment room was specifically designed to accommodate parent participation in the burn dressing, if appropriate, to promote a holistic and family-centered approach. The space is
child-friendly, with soothing murals,
adjustable and color-changing LED
lighting, and distraction activities,
such as television and music. It is climate-controlled, and there are two
keypad locked entry doors, both with
electronic occupancy alerts exterior to
the room, to ensure privacy.
Referral Patterns
The established pattern of care
was to transfer children with burn
injuries from our health system sites
to a metropolitan children’s hospital.
Despite the high level of interest in
the program, it has been difficult to
change referral patterns. Changing
patterns requires informing all system
sites that a pediatric burn care program exists. It also requires support
from all system leaders. Burn program
success depends on a culture change
within the health system and constant attention to each triage opportunity for all burned children seen
within the organization.
The emergency room staffs of the
four referral hospitals within the
health system were targeted for outreach marketing. The pediatric medical education department held a conference at an area system hospital to
increase awareness of our pediatric
subspecialties, including surgery and
burn management. The medical
director presented the comprehensive
burn program to community and professional groups, emphasizing the
advantages of caring for these children within their own community
rather than at a regional hospital
some distance away. The pediatric/
PICU clinical nurse specialist visited
referral hospitals to educate emergency room and pediatric unit staff
on initial burn wound care, providing
information for the units to easily
and directly contact St. John Hospital
for transfer of children with less than
PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5
Outpatient Follow Up
Traditional physician office resources and availability are not conducive to patients with burn injury
needs. Having a burn program required that there be outpatient services
available within 24 hours to see
patients that were sent home from
the emergency room. Reviewing care
and ensuring the patients had the
proper supplies within 24 hours of
being discharged was challenging.
Office scheduling in the surgery
department was restructured to provide same-day or next-day appointments for children with burn injuries.
Children with thermal injuries are followed in the office burn clinic at regular intervals for wound evaluation,
dressing changes, physical/occupational therapy assessment and treatment, appraisal for potential complications, and ongoing education
regarding home care strategies. A staff
member from Care Transitions, a
patient satisfaction program, contacts
families by telephone after inpatient
and outpatient visits. Care Transitions
data show families report great satisfaction with the ease of access,
prompt attention, and individualized
care they receive from the office team.
Multidisciplinary Engagement
The occupational and physical
therapists were unfamiliar with posi223
Developing a Pediatric Burn Treatment Program in a Community Hospital
tioning, exercise, range of motion,
and scar management for children
with burn injuries. Social services and
nurse case managers were challenged
by length of stay and discharge
requirements.
Occupational and physical therapy staff received instruction on burn
management, emphasizing positioning, edema reduction, range of
motion, and scar management.
Monthly multi-disciplinary pediatric
burn care meetings are held, which
include the pediatric social worker
and nurse case managers. Staff nurses
who cared for the child with the burn
injury lead case reviews, which
include patient demographics, burn
type (pre- and post-treatment wound
pictures are shown), cause, length of
stay, wound care, use of sedation and
analgesia, symptom management,
complications, patient and family
education, consults, and discharge.
Care in the emergency room, pediatric or pediatric intensive care unit,
outpatient clinic, and patient home
are reviewed. Recommendations for
changes in the burn program based
on findings from case reviews are discussed and implemented.
Outcomes
Burn Care Provided
The pediatric burn program was
instituted in April 2009. From this
time until March 2011, 123 pediatric
patients with burn injuries were cared
for at St. John Hospital. Sixty-four
patients (52%) were seen in the emergency room only. Thirteen patients
(10.6%) were seen in the clinic only.
Forty-six (37.4%) were admitted to
the pediatric or pediatric intensive
care units. The mean age at the time
of the burn injury was 6.5 years. The
mean total body surface area burned
was 2.9%.
The ABA National Burn Repository (Miller et al., 2009) indicates that
for all pediatric patients with burn
injuries, 66% are male and 34% are
female. At St. John Hospital (51.2%)
were male and (48.8%) were female
(see Table 3). National statistics indicate scalds account for 60% to 80% of
burn injuries in young children, while
older children are more likely to be
injured from flames (ABA, 2009).
Consistent with national statistics,
the St. John patient population demonstrated the most common burn
type was scalds (50.8%) (see Table 4),
224
Table 3.
Gender
Frequency
Female
Percentage
60
48.8
Male
63
51.2
Total
123
100
Table 4.
Burn Type
Frequency
Chemical
Contact
Percentage
2
1.6
42
34.4
Electrical
1
0.8
Flame
11
9.0
Friction
4
3.3
62
50.8
Scald
Missing data
1
Table 5.
Age and Body Surface Area (BSA) by Burn Type
Total
(n)
Mean Age
Mean BSA
42
4.9
1.49
Flame
11
14.7
3.91
Scald
62
6.3
3.71
Other
7
5.9
1.86
Missing data
1
Contact
Table 6.
Mechanism of Injury
Frequency
Chemical
Percentage
4
3.3
20
16.5
Food
4
3.3
Liquid
56
46.3
Metal
30
24.8
Friction/Plastic/Unknown
7
5.8
Missing data
2
Electrical/Fire
and the mean age for children with
scald injuries was 6.3 years (see Table
5). The mean age for flame burn type
was 14.7 years. Flames also caused the
largest mean body surface area
burned (3.91%) (see Table 5). The
most frequent mechanism of burn
injury was liquid (46.3%), followed by
metal (24.8%) and electrical (16.5%)
(see Table 6).
Quality Metrics
The three quality metrics used
were length of stay, readmission rate,
and wound infection rates. None of
the 46 patients were readmitted, and
there were no infections. Although
not published, a widely used clinical
standard for expected length of stay
for a patient with a burn injury is one
day for each 1% percent of burn sur-
PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5
Table 7.
Patient Satisfaction Results (N = 28)
References
Do you feel that your emotional and
spiritual needs were met?
Yes – 100%
No –
0%
Are you doing well today?
Yes – 100%
No –
0%
Is there anything we could have done
differently during your stay?
Yes – 10%
No – 90%
On a scale of 0 to 10, how likely is it that
you would return to this facility for your
future health care needs?
Scale: 10 – extremely likely,
0 – not at all likely
(10) 80% (9) 10% (8) 10% (0-7) 0%
face involved. To meet this standard
and provide the most efficient care, a
one-day per 1% burn surface goal was
established and met for all 46 hospitalized patients. Meeting these three
quality metrics demonstrate that for
the 46 hospitalized patients, the program was safe and effective.
Financial Metrics
St. John Hospital Pediatric Burn
Program provides care for children
with less than 15% BSA burns.
Analysis of the St. John Hospital pediatric patients with burn injuries from
April 2009 to March 2011 shows
mean total charges per case is
$10,266, and mean daily charges per
case is $2,704. It is significant to note
that while charges are relatively low
on these lower-acuity burns, the net
revenue per case is $4,230.
Patient and Staff Satisfaction
Although patient and staff satisfaction were not established evaluation indicators, some preliminary
patient and staff satisfaction data
were collected. Positive inpatient satisfaction scores were obtained
through discharge surveys (see Table
7). Continued support and education
for the staff involved in caring for
children with burn injuries has
encouraged participation. Anecdotal
reporting and staff interest in burn
care suggests the fear of caring for
children with burn injuries and their
families has slowly dissipated. Work
environment survey results demonstrate that the successes in managing
patients in the pediatric burn program are building staff efficacy, confidence, and satisfaction.
munity setting is needed. Additionally, Vercruysse et al (2011) reported
community-based care reduces some
stress associated with hospital stays.
The pediatric burn pilot program did
not evaluate the level of stress for
patients or their families. This is an
important area that should be addressed in future research.
Conclusions
The pediatric burn treatment program at SJPHS demonstrates that
quality burn care can be provided in a
community setting. Based on the successes experienced, St. John Hospital
is considering expanding the pediatric burn program to become a burn
center in the future. There are census
criteria and physical space requirements that must be satisfied to meet
the guidelines for the operation of a
burn center. If those criteria can be
successfully met, the change to burn
center status will allow communitybased care not only for minor burns,
but more severe ones as well.
American Burn Association (ABA). (2012).
National Burn Repository. Retrieved
from http://www.ameriburn.org/2012
NBRAnnualReport.pdf
American College of Surgeons (ACS).
(2006). Resources for optimal care of
the injured patient. Guidelines for the
operation of burn centers. Chicago:
American College of Surgeons Committee on Trauma.
Brignall, J., & Death, A. (1999). Back to normal: Children’s care after burn injury.
Nursing Times, 95(39), 54-56.
Center for Injury Research and Policy
(CIRP). (2010). New national study
finds decrease in rate of pediatric burns.
Retrieved October 5, 2010, from
http://www.nationwidechildrens.org/
news-room-articles/new-national-studyfinds-decrease-in-rate-of-pediatricburns?contentid=49195
Death, A. (2005). Caring for children with
burn injuries. Nursing Times, 101(1),
76-77.
Joffee, M.D. (2010). Emergency care of moderate and severe thermal burns in children. Up to Date. Retrieved from
http://www.uptodate.com/contents/
emergency-care-of-moderate-andsevere-thermal-burns-in-children
Mason, K. (2011). Pediatric sedation outside
the operating room: A multispecialty
international collaboration. New York,
NY: Springer.
Miller, S., Latenser, B., Jeng, J., & Lentz, C.
(2009) National Burn Repository 2009
report. Retrieved from http://www.ameri
burn.org/2009NBRAnnualReport.pdf
The Joint Commission. (2013). Core measure sets. Retrieved from http://www.
jointcommission.org/core_measure_
sets.aspx
Vercruysse, G. Ingram, W., & Feliciano, D.
(2011). Overutilization of regional burn
centers for pediatric patients-a healthcare system problem that should be
corrected. The American Journal of
Surgery, 202(6), 802-809.
Future Research
Further study of patient and staff
satisfaction with burn care in a comPEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5
225
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individual use.
Healthcare Management Ethics
Moral Management as
a Leadership Priority
Frankie Perry, RN,
LFACHE
Treating employees well and managing
ethically is a business imperative.
In the June 6, 2013, cover story in
Bloomberg Businessweek, “The Cheapest,
Happiest Company in the World:
Costco, where toilet paper—and ecstatic
employees—can both be found in
bulk,” Costco CEO Craig Jelinek
attributes much of the company’s
financial and market success to treating its employees well. In a 2013 letter to Congress addressing raising the
federal minimum wage Jelinek wrote:
“We know it’s a lot more profitable in
the long term to minimize employee
turnover and maximize employee
productivity, commitment and loyalty.”
Putting employees first must be working because all indicators show Costco
outpacing its competitors. The Costco
experience about the value in treating
employees well and managing them
in an ethically responsible way draws
considerable parallels to healthcare.
In its Code of Ethics, ACHE provides
clear guidelines for healthcare executives’ ethical and professional obligations to employees. Most center on
creating and contributing to a work
environment and culture that promotes and supports ethical conduct
within the organization. Organizational
culture, ethical standards and a safe
and healthy work environment are
essential in fulfilling one’s ethical
responsibilities to employees.
58
Healthcare Executive
JAn/FEB 2014
But while the “right” policies and procedures and the “right” culture and work
environment may be in place to promote the ethical treatment of employees,
it is the day-to-day management actions
that determine whether managers are
fulfilling their ethical responsibilities to
the employees they supervise.
Maintaining an Ethical Culture
Creating an infrastructure that
includes such things as a code of ethics,
standards of conduct and an ethics
committee may be the easy management task; making ethical conduct
the norm throughout the organization from the boardroom to housekeeping is a much more difficult task.
More than anything, managers who
role model ethical conduct in the
treatment of their employees send a
clear message about what is acceptable behavior in the organization.
Employees who are treated with honesty, fairness and respect are more
likely in turn to treat patients, clients,
vendors and co-workers in this same
way, thus contributing to the success
of the organization in its many business and professional relationships
inherent in healthcare delivery.
Recruitment and Hiring Practices
Competent, ethical clinical and nonclinical employees want to work for an
ethical organization with leaders who
inspire and challenge them to achieve
high levels of ethical performance. A
culture where staff and employees are
treated ethically and are expected to
treat others in a like manner will
attract and retain a workforce that will
enhance the image of the institution.
When recruiting staff, it is sometimes
tempting to oversell your organization
and its position in the marketplace.
This is understandable in your desire
to attract highly qualified people. But
it is not fair to the recruit to paint an
unrealistic picture of the organization
and its viability or of the position, its
authority and responsibilities, especially if the recruit will be relocating
his or her family and committing
considerable investment in relocation.
When making a job offer to a new
hire, it is a questionable practice to
offer more compensation to a new
hire than what an existing employee
who has tenure and experience in
your organization and who is doing a
good job at the same level with the
same responsibilities is receiving.
Caution must be exercised to ensure
equitable compensation, benefits and
support for staff members.
In addition, hiring or promoting a
staff person into a position, giving
him or her clear expectations of the
job to be done and then failing to
provide the resources or the authority
needed for the employee to meet
those required expectations is unfair
to both the employee and the
organization.
Managing Diversity
Failure to understand the importance of having a cross-cultural
Healthcare Management Ethics
workforce will increasingly thwart
the achievement of organizational
goals and set the stage for discrimination of employees based on factors
such as race, ethnicity, national origin, gender, religion, age, marital
status, sexual orientation, gender
identity or disability. To avoid
derailment of organizational goals
and the threat of potential litigation,
healthcare leaders must create,
embrace and sustain a culture of
diversity that serves the needs of the
workforce and patients.
A recent legal action charging a
hospital with employee discrimination based on race made national
news. A parent demanded that
nursing staff of a different race
than himself not be assigned to care
for his child. The parent’s demand
was met in spite of a hospital policy
to the contrary. This case points
out the need for staff education,
especially of front-line workers,
related to anti-discrimination laws
and policies and their application to
the workforce.
Much has been written in academic
literature and in the media about
sexual harassment, and yet these
cases continue to make news. In an
ethical organization, management
will establish a zero tolerance policy
for sexual harassment, make certain
employees are well educated in the
law, and assign designated staff
members to investigate and handle
complaints and answer questions
other employees may have.
Performance Evaluations
In an ethical organization, performance evaluations will be fair, honest, objective, timely and focused on
the work. Consistent standards of
performance will be applied to all
staff. Employees will not be expected
to perform beyond their job descriptions or beyond what can reasonably
be expected of them given the
resources they have been provided.
Managers will not imply that poor
performance may be the result of
such factors as aging, health or family
issues that may be viewed as discriminatory and open the organization up
to litigation or disability claims.
Develop a Postgraduate
Fellowship
Creating future leaders benefits you, your
organization and the profession. It’s an
opportunity to teach others, groom talent and
invest in the next generation.
Building a program is easy!
ACHE’s Fellowship Development Guide will
assist you, and Natalie Lencioni, operations
coordinator in the Division of Member Services,
is available to answer your questions at
(312) 424-9374 or nlencioni@ache.org.
Learn more at ache.org/PostGrad
Healthcare Executive
60 Develop_PostGradDir_horz.indd
JAn/FEB 2014
1
5/20/13 9:05 AM
Managers often view performance
evaluations as a bureaucratic necessity—not a high priority on their
to-do list. They may even allow considerable time to lapse beyond the
due date for the review. This can be
especially unfair to the employee if a
pay raise is contingent upon the completion of a satisfactory performance
evaluation. Even if this is not the
case, employees deserve to know if
they are doing a good job, if there are
areas of their job performance that
require improvement and how
improvements might be facilitated
and measured.
Communication
Ethical managers practice two-way
communication with their workforce.
They seek employees’ opinions and
ideas, encourage civil debate and
avoid the practice of listening only to
those who agree with their position.
Ethical managers recognize that any
threat to the status quo or existing
stability of the organization such as
workforce reduction, mergers or
acquisitions will have a direct impact
on the job security of individual
employees. Employees need sufficient information to mobilize personal resources to plan or take
action if needed. It is unfair to withhold information from employees
that may allow them to make necessary adjustments for themselves or
their families.
Managers must not lose sight of the
fact that employees’ job satisfaction,
loyalty, commitment and productivity are in large part directly related to
how they are treated by their
“boss”—not primarily by the organization or human resources
department—but by their manager.
It is the day-to-day decisions imbedded in routine management functions
that reflect the moral treatment of
the workforce, which in turn reflects
the character of the leadership and, in
turn, the character and image of the
organization. s
Frankie Perry, RN, LFACHE, is an
ACHE faculty member and author of
several articles and books, including the
2013 book The Tracks We Leave:
Ethics and Management Dilemmas
in Healthcare, Second Edition (Health
Administration Press). She can be
reached at frankieperry@comcast.net.
Find New Vision at
With a strong commitment to raising the bar for healthcare in our community, Nassau University
Medical Center is a Level I Trauma Center and a 530-bed teaching hospital affiliated with the
North Shore/LIJ Health Care System and Stony Brook University. NuHealth is fully accredited by the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO) and has been the recent recipient of
many awards, such as the 2013 American Heart Association’s Gold Plus Quality Achievement Award for
Stroke and 2013 US News & World Report Best Nursing Homes in New York.
NuHealth System also includes a 589-bed Extended Care Facility and five Community Health Centers.We
are located in East Meadow, New York, a suburb of New York City.
President and
Chief exeCutive OffiCer
NuHealth is currently seeking a Chief Executive Officer. As a member of the Hospital’s senior management team,
the Chief Executive Officer (CEO) will participate in operational decision-making processes necessary for the
successful attainment of the hospital’s mission, in addition to maintaining an awareness of changes in healthcare
matters that could have an impact on the success of the hospital.
The ideal candidate will have the responsibility for working with the Board of Directors in leading our management
team and staff toward our goal of excellence and quality in patient care.
The ideal candidate will possess:
• Financial management knowledge.
• Proven leadership skills and strong decision making capability.
• Knowledge of current health care regulations and requirements.
• Must have proven ability to establish and maintain effective working
relationships with physicians, hospital staff and community.
• Ability to maintain confidential information concerning
personal, financial, or medical matters.
For more information on the
NuHealth System, please view
our website at www.NuHealth.net
Qualified candidates should
forward a CV or resume to:
jsoffel@numc.edu
Nassau University Medical Center
2201 Hempstead Turnpike, East Meadow, NY 11554
Equal OppOrtunity EmplOyEr
Client: NuHealth
Publicaton: Healthcare Exec
Date: January 2014
Size: 4.74 x 7”
Healthcare Executive
JAn/FEB 2014
61
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Executives and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.
Management
Managing the Accountability
of Your Staff
By Ronald B. Pickett
In this article…
Explore ways to improve accountability among your
staff members by first assessing individual levels of
maturity.
You have a wonderful staff. You have given all the
assignments, and now it’s time to sit back and wait for the
results to roll in. Sadly, that’s not my world.
There is a lot more to getting things done than assigning tasks. Personal accountability is a vital, necessary
ingredient. But it’s not your job to follow your staff around,
checking to see that tasks are accomplished. So what can
you do to enhance the level of accountability of your staff?
Managing accountability of individuals
One fact you will have observed is that each member
of your staff demonstrates a different level of maturity or
responsibility. A good definition of an adult is someone who
takes full responsibility for his or her actions. As a manager
you need to assess the maturity level of each member of
your staff and provide the appropriate degree of direction,
coaching and guidance.
This does not imply a detailed, formal assessment, but
more of an observation of what works and what each person
wants and needs to be effective on the job.
For new staff members it may be necessary to provide
very specific direction on what has to be done, how to do it,
and to monitor the results with frequent coaching. This is
the entry level of maturity. With time and experience, the
employee will be able to take on additional responsibility
and will require less specific direction.
Your role shifts during this development process from
providing specific guidance and close monitoring to ultimately describing the desired outcomes and providing an
environment in which the employee can select the best way
to achieve those outcomes. There are intermediate steps as
20
PEJ JULY•AUGUST/2014
the person assumes greater responsibility.
The manager’s role is to be less directive and more participative, seeking more input from the person as he or she
assumes increased responsibility. This process may sound
complicated, but it quickly becomes second nature and is
the essence of what managing people is all about.
An employee’s maturity level is a combination of ability
or skill and willingness or motivation. He or she can have a
high level of ability, but lack a willingness to actually do the
work. Additional training would be useless in this situation.
Maturity levels are also task specific. A person could be
generally skillful, confident and motivated in most aspects
of their job but would have a low level of maturity when
asked to perform a task requiring skills they don’t possess.
Understanding this concept is especially important in
the transition process when one of your staff is given additional responsibilities. It does little good to provide training
when the person already has the skills but lacks the motivation to do the job — able, but not willing. High levels of
maturity guarantee personal accountability.
Developing people and self-motivation
A good leader develops the competence and commitment
of their people so they’re self-motivated rather than dependent on others for direction and guidance. A leader’s high but
realistic expectations lead to high performance of followers.
A leader’s low expectations lead to low performance.
Think about how often those statements have been borne
out in your personal experience.
In order to develop an effective staff, a manager needs
to motivate followers, and to do that the management style
and the rewards must be individualized and appropriate.
Not understanding and using the concept of variable levels
of maturity is one of the major contributors to poor personal accountability and low morale.
Effective leaders need to be flexible and must adapt
themselves to the individual situation and personality of
each staff member.
High
S
k
i
l
l
s
Motivate!
Clone!
Fire!
Train!
Low
Low
Motivation
High
This model is used for coaching, but it is
also useful in building accountability.
The role of performance appraisals
The best and first tool for developing and enhancing accountability
is the performance appraisal. Set and
agree on high standards that can and
will be monitored jointly. This may
seem like a primitive method, but all
the necessary elements are there —
expectations jointly arrived at, monitoring measures and consequences.
Simple steps to take:
• Schedule periodic update
meetings.
• Provide the appropriate level of
detail for each individual.
• Ask “What do you need from me
to be successful?”
• Become less involved in specifics, or the “how to,” and more
involved in the “what if.”
• Set objective, “self-measuring”
standards or metrics. Assist staff
with incorporating measurements
that will help them get on track and
stay on track to achieve their goals.
Effective leaders need to be flexible and must adapt themselves to the individual
situation and personality of each staff member.
Things you can do
Here are some more mature,
longer-range steps you can take to
achieve a climate of accountability:
• Move intentionally toward a more
participative climate.
• Get input from your staff —
frequently and openly.
• Nurture involvement in decisionmaking, goal setting and
performance monitoring.
• Lead through collaboration.
• Spot and reward individual
initiative.
An important issue to resolve is
whether to focus on the accountability
of teams or individuals. The answer to
this question will change depending on
the projects you are working on. When
that is established, set accountability
standards that recognize and reward
the appropriate achievements.
So if your practice has large
projects and success is dependent on
the aggregate outcome of the work
of several contributors, ensure that
your monitoring and reward systems
shape team contributions, not
individual ones.
In one of my jobs there were
three peers. While each of us wanted
to stand out from the others, we
wanted to be highly effective as a
team. It was the only time I recall
that if you didn’t do something, it
would be done for you. This was a
great environment: competitive, and
yet mutually supportive — not a cutthroat setting, simply everyone dedicated to getting the job done quickly
and efficiently. How did that climate
evolve? Each of us had a strong personal commitment to an important
and challenging goal.
ACPE.ORG
21
Consider this checklist for assessing
personal accountability:
1. Does your staff feel like they have
a positive role in the management
of the organization?
2. Are things that need to be done
identified and resolved on the
spot?
3. Is your staff given the appropriate,
individualized level of responsibility
and support?
4. Does a climate of mutual support
and teamwork exist?
5. Is there clarity and focus on the
organization’s goals?
6. Do people focus on team outcomes
rather than individual contribution (assuming you need a team
focus)?
22
PEJ JULY•AUGUST/2014
If your answers to this short
checklist are negative, or if you don’t
know the answers, you may want to
begin a purposeful effort at raising
the level of accountability. Significant
improvements can be achieved by a
shift in attitude (yours) and minor
changes in communication patterns.
What will you gain as a result
of an environment with enhanced
accountability?
• High morale.
Ronald B. Pickett is an organizational effectiveness consultant based in Escondido, CA.
ronp70000@aol.com
Resources:
1.
Cook I. “How to Build Accountability
in Your People,“ http://www.
evancarmichael.com/Leadership/4354/
How-to-Build-Accountability-in-YourPeople.html
2.
Eden D. Leadership And Expectations:
Pygmalion Effects And Other SelfFulfilling Prophecies In Organizations,
Leadership Quarterly, 3(4), 1992, 271-305.
3.
MacAdam M. “Ten Steps to Promoting
Staff Accountability,“ http://www.
bizymoms.com/business/Article/
Ten-Steps-to-Promoting-StaffAccountability/400
4.
Pickett RB. “Performance Appraisals,“
Lab Manager Magazine, October 2010.
http://www.labmanager. com/?articles.
view/articleNo/3840/
• Greater productivity.
• Staff maturity.
• Excellent retention.
• Improved recruiting of new staff.
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F R A M IN G HEALTH M ATTERS
A Framework for Describing Health Care Delivery Organizations
and Systems
| lleana L. Pina, MD, MPH, Perry D. Cohen, PhD, David B. Larson, MD, MBA, Lucy N. Marion, RN, PhD, MN, Marion R. Sills, MD, MPH, Leif I. Solberg, MD,
and Judy Zerzan, MD, MPH
D escribing, e v a lu a tin g , and conducting research on th e questio n s raised by
c o m p a ra tiv e effectiveness research and characterizing care d e liv e ry o rg a n iza
tion s o f all kinds, fro m in d e p e n d e n t in d iv id u a l p ro v id e r units to large in teg rated
health system s, has b ecom e im p e ra tiv e . R ecognizing this c h alleng e, th e D elivery
S ystem s C o m m itte e , a s u bg ro u p o f th e A g e n c y fo r H ealth care Research and
Q u a lity 's E ffective H ealth Care S takeh old ers G ro u p , w h ich represents a w id e
d iversity of perspectives on health care, created a d raft fra m e w o rk w ith d o m a in s
and ele m e n ts th a t m a y be useful in characterizing variou s sizes and typ es o f care
d e liv e ry o rg anization s and m a y co n trib u te to key o utcom es of interest. T he
fra m e w o rk m a y serve as th e d o o r to fu rth e r studies in areas in w h ich clear
d e fin itio n s and descriptions are lacking. [Am J Public Health. 2 0 1 5 ;1 0 5 :6 7 0 -6 7 9 .
d oi:1 0 .2 1 0 5 /A J P H .2 0 1 4 .3 0 1 9 2 6 )
Recent and ongoing innovation in systems
for the delivery and reimbursement of health
care in the United States have broadened
stakeholders’ need for standardized methods
to describe, measure, compare, and evaluate
delivery system changes. A common taxonomy
of delivery system characteristics would allow
for improved communication and transparency
regarding these changes, potentially enhancing
the quality of decisions and care for patients,
providers, researchers, policymakers, payers,
and other stakeholders.1-5 The comparative
effectiveness of delivery system characteristics
is ranked as a top priority by the Institute of
Medicine, which has defined comparative ef
fectiveness research (CER) as “the generation
and synthesis of evidence that compares the
benefits and harms of alternative methods to
prevent, diagnose, treat, and monitor a clini
cal condition or to improve the delivery of
care.”6^ 203) Yet, there is no standard way to
describe care delivery units or systems that
encompasses their breadth, ranging from in
dependent individual provider units to large
integrated health systems.7 Thus, the absence
of a common parlance for describing delivery
systems hinders stakeholders from determining
the generalizability of a study or an innovation
introduced in 1 setting. The effectiveness of an
intervention may be quite different depending
on whether the setting is a large integrated care
system or a small independent practice and
whether providers are paid on production or
salaried. W e propose a preliminary framework
for description of health care delivery systems
that will allow health care stakeholders to better
understand, evaluate, disseminate, and imple
ment delivery system innovation in a more
informed, transparent, and stakeholder-centered
fashion and permit comparisons among them.
Our objective is to present the domains and
elements of the framework, the methods that
were used to derive i t and examples of its
potential application in diverse settings.
M ETHODS
Our proposal builds on previous taxonomic
descriptions of the US health care system. In
response to the increasing complexity and het
erogeneity of health care deliveiy systems, the
Agency for Healthcare Research and Qualify
(AHRQ) funded development of a taxonomy of
organizations, categorized by shared structural
and strategic elements.8 The resulting taxon
omy8 categorized 70% of health networks and
90% of health systems into clusters using 3
dimensions—differentiation, integration, and
centralization—and applied the same dimensions
to hospital services, physician arrangements,
6 7 0 I Framing Health M atters | Peer Reviewed | Pina et al.
and provider-based insurance activities. In
2004, the taxonomy was updated to include
a redefinition of centralization and updated
descriptors of health care systems because of
the continued evolution of organizations.91,1
In 2006, Luke11 noted that taxonomies de
rived from local systems were not appropriate
for large multihospital systems and recom
mended that further taxonomic studies were
needed. Subsequent taxonomic approaches
broadened the role of a systems approach, giving
primacy to the interrelationships, not to the
elements of the system alone.12,13
The pieces (elements) of the framework we
describe will certainly become further complex
as organizations other than medical care groups
(e.g., public health agencies) enter the arena
of health care delivery. Rather than describe
the lack of an element in a specific organization,
one must consider the integration of other
organizations bringing the missing elements
with them. In parallel to the work of Bazzoli
et al.10 and Luke,11 Mays et al.14 concurrently
described methodology to classify and com
pare public health systems on the basis of elements
of organization and defined 7 configurations
with 3 tiers on the basis of their level of dif
ferentiation. Also paralleling Bazzoli et al.,10
Mays et al.14 found that public health systems
were in a state of fluidity from 1998 to 2006.
F rag m e n ta tio n
The escalating complexity and heterogeneity
of health care delivery systems has led to in
creased fragmentation of how and where health
care is delivered and has created new and often
ill-defined relationships between fragments.
The Commonwealth Fund Commission on a
High Performance Health System has described
traditional health care in the United States as
a cottage industry wherein fragmentation oc
curs at the federal, state, and local levels.15
Fragmentation can contribute to unnecessary,
American Journal of Public Health | April 2 0 1 5 , Vol 10 5, No. 4
FRAMING HEALTH MAHERS
redundant utilization and poorer quality of
care.
representatives, policymakers, researchers, and
research institutions.
Recognizing the challenges of a complex,
dynamic, and often fragmented health care
delivery system, the AHRQ’s Effective Health
Care Stakeholders Group (SG) decided to draft
an updated framework for describing health
care delivery systems, with domains and elements
that might be useful for characterizing various
sizes and types of care delivery organizations.
The SG was a part of AHRQ’s Community
Forum initiative, funded by the American Re
covery and Reinvestment Act, to formally and
broadly engage stakeholders and to enhance
and expand public involvement in its entire
The Delivery Systems Committee (DSC),
a subgroup of the SG, consisted of 7 members
including clinicians, policymakers, patient ad
vocates, and researchers who were involved
with a variety of care delivery organizations
and represented diverse perspectives. The DSC
convened to address a specific objective of
interest to AHRQ: to develop guidance for
AHRQ on how to approach CER on health
Effective Health Care Program. Nomination of
individuals for the SG occurred via a public
process (a Federal Register notice) and was
broadly inclusive. A committee composed
of representatives from AHRQ reviewed all
nominations and selected stakeholders to rep
resent a diversity of perspectives, expertise,
geographical locations, gender, and race/ethnidty.
The group represented broad constituencies
of stakeholders including patients, caregivers,
and advocacy groups; clinicians and profes
sional associations; hospital systems and med
ical clinic providers; government agencies;
purchasers and payers; and health care industry
delivery organizations and systems by devel
oping a framework that could be used to char
acterize potentially important differences in
structure and function. DSC discussions were
facilitated by 2 members of the AHRQ Com
munity Forum. All meetings were attended by
at least 1 AHRQ staff member who provided
feedback. The charges of both the SG and the
DSC are detailed in the box below.
The DSC’s initial work focused on defining
the basic unit of consideration: the health care
organization or system. Common definitions
for health care delivery systems generally refer
to all the components providing health care in
a country or locality. For example, the World
Health Organization16 has defined a health
system as all organizations, people and actions
whose primary intent is to promote, restore
or maintain health. The framework presented
here is meant to be broadly descriptive. To
ward that end, the DSC developed an elements
framework with 28 key elements grouped by
6 domains that characterize organizations
and delivery systems and may contribute to
key outcomes of interest. The DSC tested the
framework for face validity among SG stake
holders representing a broad variety of systems
of care.
For the purposes of this article, we defined
a health care delivery system as the organiza
tion of people, institutions, and resources to
deliver health care services to meet the health
needs of a target population, whether a single
provider practice or a large health care system.
A pproach
For each step in the development of the
framework, the DSC used 2 approaches: review
of the literature and the Delphi method, in
cluding facilitated group discussions and itera
tive rounds of individual written feedback on
successive drafts of the framework. Descrip
tions of conflict and resolution were recorded
in detailed meeting notes and in framework
drafts, preserving an audit trail.
Although the DSC (at face-to-face meetings)
did prioritization exercises, substantial discussion
Charges of the Stakeholder Group and the Delivery Systems Committee in Developing a Framework
to Describe Health Care Delivery Organizations and Systems
S ta ke ho ld e r Group
Provide g u idance on program im p le m e nta tio n , including
Delivery System s C om m ittee
How to c om pare diffe re nt ways o f delivering care , including to subpopulations
1. Q uality im provem ent,
2 . O p p o rtun itie s to m axim ize im p a ct and expand program reach,
3 . Ensuring s ta ke h olde r interests are considered and included, and
4 . Evaluating success
Provide inp u t on im p le m e ntin g Effective H ealth Care Program reports and findings in p ractice
W h a t a re the ingredients o r e lem en ts needed for com parison o f ways to deliver care?
and policy settings.
Identify o ptions and recom m end solutions to issues identified by Effective H ealth Care
Program staff.
Provide input on c ritical research inform ation gaps for p ractice a nd policy, as well as research
Can those e lem en ts be exam ined across delivery organizations and system s to
get a sense o f w h a t works b est fo r patients?
W h at com ponents o f delivery organizations and systems do researchers need to
m ethods to address th e m . Specifically,
1. Inform ation needs and types o f products m ost useful to consum ers, clinicians,
1. Identify and e lab o ra te , and
and policym akers;
2 . Feedback on Effective H ealth Care Program reports, reviews, and sum m ary guides:
2 . R elate to th e p atie n t-ce n te re d outcom es th a t are m ost im p o rtan t?
3 . S cientific m ethods and applications; and
4 . C ham pion objectivity, accountability, a n d transparency in the Effective H ea lth Care program .
April 2015, Vol 105, No. 4 | American Journal of Public Health
Pina et a/. | Peer Reviewed | Framing Health Matters | 671
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examples of possible measures are presented
in Table 1, and summarized here.
FIGURE 1-D eliv e ry systems methods flowchart of the creation of a draft framework to
describe health care delivery organizations and systems.
occurred by e-mail and in conference calls,
which resulted in additional edits and revisions
to the framework. The richness of those dis
cussions contributed significantly to the final
product. Each step of the process involved all
3 methods: literature review, facilitated group
discussions, and synthesis of individual written
feedback.
P rocess
The DSC initially constructed a framework
consisting of elements of health care organiza
tions, focusing on outcomes of interest broadly
defined as quality, cost, equity, and patient
centeredness. Next, it identified several com
mon medical conditions, for example, diabetes,
as basic examples for developing the list of
elements relevant to outcomes for the selected
conditions. These elements were grouped into
domains on the basis of commonalities, with
the resulting framework initially consisting of
30 elements categorized according to 4 domains:
structure, resources, culture, and function-process.
A reiterative process initially resulted in 35
elements housed in 7 domains: physical assets,
human assets, the customer, financial aspects,
culture, process-function-system structure,
and integration, with each element assigned
to 1 domain only.
Each member applied the framework to the
delivery system with which they were most
familiar to test its goodness of fit. Comments
from this validation exercise were used to further
reorganize the framework into 26 elements in
6 domains: capacity, organizational structure,
finances, patients, care processes and infra
structure, and culture. The model of these
processes is shown in Figure 1.
The full SG was subsequently asked to pro
vide feedback regarding the domains, elements,
and definitions and to prioritize the elements.
Feedback from the SG included 2 primary re
commendations. First, it was valuable to have
the full set of elements available rather than
to eliminate elements or designate a core set
of measures. On the basis of this feedback,
the DSC decided to allow future users of the
framework to select elements relevant to their
individual application of the framework. Sec
ond, the SG recommended including both ex
amples of the application of each element and
information about measurability of each ele
ment. The DSC responded to these suggestions
by adding more information about measur
ability, including (1) whether the element is
feasible to measure and, if so, providing ex
amples of instruments or formats for this mea
surement and (2) whether the measure of the
element involves description or increasing value
(i.e., is more better?). The DSC decided to use
both generic and specific instruments, when
possible, for measurement of the elements, with
the understanding that additional instruments
may currently exist or be developed.
R ESU LTS
The elements of the framework were divided
into 6 domains and their respective elements.
Descriptions of the elements and potential
6 7 2 I Framing Health M atters | Peer Reviewed | Pina et at.
1. Capacity: the physical assets and their own
ership, personnel, and organizational char
acteristics of a delivery system that determine
the number of individuals and breadth of
conditions for which the system can pro
vide care. Elements include size, capital
assets, and comprehensiveness of services.
2. Organizational structure: the components
of an organization, both formal and in
formal, that describe functional operations
in terms of hierarchy of authority and
the flow of information, patients, and re
sources. Elements include organizational
configuration; leadership, structure, and
governance; research and innovation; and
professional education.
3. Finances: mechanisms by which a health
care delivery system is paid for its services
and the financial arrangements and prac
tices of the system and organizations
within the system to allocate those funds,
as well as the system’s financial status.
Elements include payment received for
services, provider payment systems, own
ership, and financial solvency.
4. Patients: demographic characteristics, as
well as wants, needs, and preferences of
individuals and families of individuals
who receive health care services from
a health care delivery system. Elements
include patient characteristics and geo
graphic characteristics.
5. Care processes and infrastructure: the meth
ods by which a health care delivery system
provides health care services to its cus
tomers and patients as well as the degree of
coordination of those methods. Elements
include integration, standardization, per
formance measurement, public reporting,
quality improvement, health information
systems, patient care teams, clinical de
cision support, and care coordination.
6. Culture: The long-standing, largely implicit
shared values, beliefs, and assumptions
that influence behavior, attitudes, and
meaning in an organization.21 Elements
include patient centeredness, cultural
competence, competition-collaboration
continuum, community benefit, and inno
vation diffusion and working climate.
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The selected domains were chosen in an
effort to cluster those elements that describe
similar aspects of the delivery system. By its
nature, an element may not fit perfectly within
a domain or, conversely, may be related to
aspects of multiple domains. Rather than repeat
elements in multiple domains, committee
members placed each element in the single
domain that the majority felt best represented
that element. Many of the elements are simply
descriptive rather than normative, such as
organizational size, configuration, or type of
payments received. In other words, no or little
inherent value is generally ascribed to having
a large versus small staff, employment versus
partnership model, or receiving payment on
a fee-for-service versus capitation basis, for
example. The descriptive nature of these elements
is expected to result in relative ease of mea
surement and protection from manipulation.
However, some elements are inherently
normative or value based, such as care co
ordination, patient centeredness, and cultural
competence. In other words, it is inherently
desirable for a health care delivery system to
effectively coordinate care, be patient centered,
and be sensitive to patients’ cultural back
ground. These elements also tend to describe
less tangible characteristics of the organization
and are thus less easily measured and poten
tially more subjective and vulnerable to bias.
Furthermore, they tend to describe charac
teristics that are more structural, cultural, or
longitudinal. Nevertheless, the DSC decided
to include these elements despite their ac
knowledged limitations because they represent
important aspects of care delivery, with the
expectation that objective measures may al
ready be accessible or will evolve over time.
One such example is organizational culture—a
domain that is easier to describe than to measure.
Yet, various instruments are already available,
albeit with some limitations, as reviewed by
Scott et al.22 and Zazzali et al.,23 who surveyed
physician culture and found great variability
within groups. Another less tangible element,
but equally as essential, is care coordination.
The Care Coordination Measures Atlas 24 pub
lished by AHRQ introduces a framework for
structure and processes that influence care
coordination and can be used today.
Although many of the value-based measures
are directional (i.e., “more is better”), improving
April 2015, Vol 105, No. 4 | American Journal of Public Health
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1 desirable attribute may come at the expense
of another desirable attribute, such as financial
solvency versus comprehensiveness of services
and community benefit or standardization
versus patient centeredness and research and
innovation. The framework as a whole is meant
to be used in such a way as to balance such
competing values. Elements were chosen as
aspects of health care delivery systems that,
in the stakeholders’ opinion, were likely to
contribute to a delivery organization’s ability
to fulfill its mission. The DSC acknowledged
that the elements do not necessarily capture
every important aspect of a care delivery system
but include enough to serve as a basis for a
framework describing health care organiza
tions. Conversely, not all elements are neces
sarily needed to describe a given organization.
In addition, the DSC intentionally focused on
elements and domains rather than specific
measures or measurement systems; measures
staff-model health maintenance organizations.
From the aspect of specialties, 79% were in
single-specialty practices, and only 21% were
in multispecialty groups.27 Therefore, creating
this framework only for large health care orga
nizations would be myopic. The DSC’s inten
tion has been to provide domains and elements
that could also be applied to organizations of
all sizes, from very large to very small, from
single providers to groups of providers. Fur
thermore, this work was intended to bring an
organized set of domains and elements that
have been created by all stakeholders (i.e.,
providers, administrators, policymakers, and
health care consumers) under the auspices of
AHRQ. The inclusion of this diverse group
of stakeholders is in accordance with the In
stitute of Medicine report, which emphasizes
their inclusion in CER to ensure its relevance
to health care delivery.6 Health care delivery
systems also include those responsible for the
among these apparently similar organizations.
Solberg et al.18 created a set of measures of
functional, structural, and financial aspects of
integration from the organizational point of
view, whereas Singer et al.34 instead built
measures from the patient’s perspective. In
spite of these measures, no consensus has been
reached on how best to measure integration.
Less controversial than integration is the
importance of team care as an essential com
ponent of better quality, although whether it
also decreases costs is less clear. For example,
the collaborative care model for major depres
sion has clearly been demonstrated to produce
higher quality, although it takes 3 to 4 years
to have any impact on costs.35 38 This model
is based not only on having a care manager
in the primary care practice but also on regular
consultation visits by a psychiatrist. The de
velopment of effective team care for quality
improvement in chronic illness has been ex
included in Table 1 serve only as examples.
public health.
The Commonwealth Fund Commission re
port15 has described the characteristics of high-
plored by Shortell et al.39 and suggests the
importance of patient satisfaction. Similarly, the
chronic care model by W agner et al.40 presents
the importance of patient engagement as part
of the team for chronic care, such as in diabetes.
Team care is also a key feature of many of the
elements of the medical home. Hence, it seems
an important component of this framework (see
DISCUSSION
In this article, we present a draft framework
created for describing important differences
in health care delivery organizations of all sizes
and types, one that might facilitate under
standing as we study and move from traditional
models of care to a system-oriented approach
while maintaining a patient-centered focus. In
the process, the DSC considered the current
status of the health care sector, medical prac
tices in the United States, and current innova
tive models of care and the overall importance
of patient centeredness, which traverses all of
the domains.
C u r re n t H e a lth C a r e S e c to r
The number of single-physician practices
dropped from 69% in 20 0 3 and 11% with
2 physicians to 33% in solo or 2-physician
practices in 20 08.25 In 2008, 92% were single
specialty and 8% multispecialty; 15% were
in practices of 3 to 5 physicians, and 19%
were in groups of 6 to 50 physicians. Thirteen
percent practiced in hospital settings, with 44%
of hospital-based physicians working in office
practices or clinics and the remainder split
evenly between emergency rooms and hospital
staff.26 Of the physicians, 3% worked in com
munity health centers and 4% in group- or
performing systems, which include access to
information, active management, interdepen
dent accountability, patient access to care, and
continuous innovation. The reader may find
several of these attributes among the domains
and elements we present that can serve re
searchers as a roadmap to add definitions and
borders to their work. Consequently, the cur
rent fragmentation of care further highlights
the need for the draft framework presented
here. One of the key and controversial features
of care delivery organizations, primarily large
ones, is the extent to which the care they provide is
integrated.28-30 This observation is especially
true because many studies of care delivery
redesign and qualify have been conducted in
large integrated organizations such as the Veteran’s
Health Administration, Group Health, Kaiser
Permanente, and Health Partners, among others.
T here are many definitions of integration,
b u t we have chosen the one developed by
Shortell et al.31 and Gillies et al.32 (see Table 1,
Domain V). Using this definition, Solberg
et al.18,33 demonstrated that, among 100 large
medical groups nationally, there was a positive
correlation between functional integration
and the presence of practice systems that have
been associated with higher quality of care
and, yet, a lot of diversity existed in integration
6 7 6 I Framing Health Matters | Peer Reviewed | P/na et a t
Table 1, Domain V).41"43
In n o v a tiv e C a r e M o d e ls
In fight of the creation of innovative care
systems, the DSC believed that it was important
to make this framework capable of describing
the key features of organizations of all sizes
so that organizational structure and function
can more consistently be incorporated into re
search design, publication, and policy decisions.
In addition, the DSC’s intent has been to help
compare health care organizations across dif
ferent settings and provide a framework that
will facilitate CER of care delivery functions
and outcomes. There is no better example of
distinct and different settings than the current
care delivery reform emphasis on the medical
home and accountable care organizations,
encompassing both large and small care orga
nizations.42 Much of the research on these and
other care redesign topics is being conducted
among dimes of varying size and ownership,
often members of practice-based research net
works.44 The Kaiser Permanente system, as
American Journal o f Public Health | April 2 0 1 5 , Vol 10 5, No. 4
FRAMING HEALTH MATTERS
compared with independent traditional prac
tices, offers a model of a physician organization
that has adopted value- and quality-oriented,
system-level care tools to deliver more effective
care.45 To understand whether the results
apply to any particular practice, it is essential to
understand whether the clinics involved are
similar or, if they are not, to decide whether the
differences affect generalizability.
R o le o f P u b lic H e a lth in C o m p a r a tiv e
E ffe c tiv e n e s s R e s e a r c h
Health issues that have the greatest impact at
the population health level and how to com
pare them should also be part of CER. Teutsch
and Fielding46 argued that comparative effec
tive assessments of public health interventions can
positively influence health at all levels—that is,
the individual and the population as a whole—and
that studies should also focus on the develop
ment of research methodology applied to public
health. However, most of the current published
CER work has centered on the comparison of
2 or more interventions focused on or targeted
to disease management or therapies. Other
studies, however, must explore the relevance
of this work to public health efforts so that in
terventions can and should be studied not only
within systems of care but at the population
level. Certainly, the application of CER meth
odology to public health will present challenges
because, for example, randomization as in con
trolled clinical trials may not always be possi
ble. However, these challenges may lead to
more innovative statistical techniques, such as
propens...
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