Outside Innovation

Gathering Best Practices from Other Organizations

Chronicling the next phase in our "Save St. Andrews" Hospital Project:

After gathering the "customer requirements" of the people on the Boothbay, ME peninsula, our Community Hospital Working Group embarked on a series of hospital site visits to learn more about how other small rural hospitals manage to serve their communities profitably.

Our group of local volunteers was organized by Maine State Representative Bruce MacDonald and includes:

• Dorothy Hurt, Emergency room RN and former Head of Quality at a Nebraska Community Hospital (who organized all the site visits)

• Sandra Rumery, Retired Mental Health Nurse Manager, Commonwealth of MA & Consultant to ER Clinical Team

• Margaret Perritt, Retired Exec. Dir. of 501(c)3 in Virginia and former Asst. Dean of Women, Virginia Commonwealth University

• Fran McBrearty, mediator with Maine Attorney General’s office and former Program Director for IT integration at Cisco Systems

• Dan Jameson, mediator with Maine Attorney General’s office and former HR Director at Raytheon

• Jane B. Good, small business owner, Southport and former organizer of multi-year peninsula-wide programs to prevent substance abuse and domestic violence

• Tom Hagan, CEO Actioneer, Inc. (software company), and former Chairman of the Board of a 501(c)3 in Massachusetts

• Dr. Judy Stone, Infectious Disease Specialist, Board-Certified in internal medicine, author of Conducting Clinical Research

• Peggy Pinkham, Consultant, Maine Quality Counts, and Critical Access Hospitals organization, and former CEO, St. Andrews CEO

• Yours truly...

As you can see, our research team is comprised of a group of pretty impressive people, each of whom brings years of experience and a unique perspective to these meetings.

Gathering Best Practices from Similar Hospitals

In the course of 2 months, we visited with the management teams of 8 different Critical Access Hospital, mostly face-to-face, but a couple via conference calls:

As of today, we have visited with the Exec Teams from 8 Critical Access Hospitals. Each team spent from 1 to 3 hrs. with us. The hospitals we visited with to-date are:

1. Blue Hill Memorial
2. CA Dean in Greenville
3. Down East Community Hospital in Machias
4. Houlton Regional Hospital
5. Mayo Regional in Dover-Foxcroft
6. Penobscot Valley in Lincoln (65% on govt. assistance)
7. Redington-Fairview in Skowhegan
8. Sebasticook in Pittsfield

(We still have a few more to go--there are 16 in all in the State of Maine, including ours, which is the only one whose future is in peril). Of the ones we have visited, CA Dean in Greenville is most like ours, in that it serves a very small community during the wintertime, which triples during the summer season. Blue Hill Memorial is also very similar. Like us, it's a small coastal community with a large seasonal population.

Warm, Candid Reception: All of the management teams we have met with have been very open, warm and helpful. They have been very generous with their time and expertise and have offered to help in any way they can.

Here are some of the highlights of our findings to-date:

Business Strategies are Driven By Reimbursement

Unfortunately MUCH of the discussion at each hospital centers around reimbursement. Not what services do patients and community members most need, but what services can you get reimbursed for! This is a sad commentary on the state of healthcare in this country!

The Typical Reimbursement Mix across the Hospitals we've met with:

• Medicare 47%
• MaineCare (Medicaid) 22%
• Commercial 18%
• Payment Plans: 6%
• Free Care: 7%

EMERGENCY ROOM:

• ER staffed at night in winter by RN/PA with MD on call [CA Dean];

• Use Telemedicine for Trauma and Psych –This is working well at a number of hospitals.

INPATIENT:

• Add 15 Long-Term Nursing Patients --  Offer “nursing home services” within 1 wing, providing long-term care to patients needing skilled nursing. Reimbursed by MaineCare @ $185/night (negotiated). Private Pay patients also accepted (same rate). (CA Dean)

• Aggressively recruit Patients from other facilities all over the state by proactively informing Case Managers (MaineCare) about open beds on a daily basis; Evaluate and accept/reject each case within 60 minutes. (CA Dean, Blue Hill)

• Have Nurses and CNAs work flexibly across nursing and acute care patients (CA Dean)

OUTPATIENT:

• Reinstate Operating Room and Outpatient Surgeries Schedule 1 day/week and increase to 2 or 3 days as needed. (1 day sterile; 1 day clean/scope)—Orthopedic surgeries and minor general surgery—Gall Bladder, Gynecological, Appendectomies, Hernias, and of course, colonoscopies – (CA Dean does 3 days/week most weeks)

• 24x7 Lab: Reinstate the Lab and aggressively recruit lab work from all over the state, including by visiting patients in nearby nursing homes with a physician and phlebotomist to collect fluids for testing.

• Provide Diagnostic Imaging Services on site
  

• Infusion Center – Establish an Infusion Center and aggressively recruit patients who need convenient infusion/transfusion services (CA Dean)

• Chemotherapy – Provide chemotherapy with part-time oncologist and telemedicine support (Houlton, Redington-Fairview; Blue Hill)

• Become a Rural Health Clinic: Turn our Family Care facility into a RHC for Family Care, Pediatrics, OB/Gynecology, Gerontology, Internal medicine (need to have an avg. of 4,200 office visits per year per physician; 2,400/yr for mid-level PA’s to qualify as a Rural Health Clinic); Receive total cost-based reimbursement from Medicare/Medicaid. [CA Dean, Houlton, Mayo]

• Proactively Recruit and Welcome Seasonal Patients for monitoring of chronic conditions and routine labs and imaging and visits by Local Physicians (CA Dean, Blue Hill)

• Specialist Clinics and Visiting Docs for ENT, Urology, Cardiology, Oncology, Neurology, Endocrinology, Psychiatry – needs separate office space/PA support for reimbursement purposes (not part of RHC or CAH)

• Provide Telemedicine consults for patients/PA’s with specialists, including psychiatry, oncology, etc.

• Provide Walk-In Clinics at the existing Rural Health Center/Family Care Center--If these are done as 7 to 9 am office visits by NP’s, PA’s and physicians, they will count towards productivity goals per Family Care practice (CA Dean)

• Provide Diabetes Outreach/Cardiac Rehab/Pulmonary Rehab:  Services provided by nurses and therapists. Cost-reimbursed for Medicare patients. (Redington-Fairview)

STRATEGIC IDEAS:

• Wellness Program for Residents of the Peninsula: Includes 1 or 2x/year health screening visits with a nurse; case management; incentives for exercising, good dietary and wellness practices, and proactive tests—prevent and reduce chronic conditions. (Houlton)

• Mental Health Program Phase 1: Proactive outreach through the Y for youth with a young counselor; Use Telemedicine for Psychiatric Consults (Mayo, others)

• Mental Health Program Phase 2: Later: Add a special wing/with mental health beds for both local use and to provide stabilization/care for mental health patients in other parts of Maine.  (Mayo suggestion)

• Substance Abuse/Rehab Program

• Veterans’ Clinic (Houlton)

For the complete report, see:

Best Practices from Site Visits to 8 Community Hospitals in Rural Maine

See also, the write-up in our local paper, The Boothbay Register, (which criticized our approach, claiming that we hadn't met with any of the execs from the hospitals that belong to the group that wants to shut our hospital down.)

Using Voice of the Customer (VOC) to Change Minds

Whenever you’re making any customer-impacting changes to your product or service mix and/or to the experience you offer to customers, it’s really important to get customers’ input and ideas beforehand. There are some companies that seem to be able to make major product launches and updates and/or customer experience changes without checking in with actual customers or with the target audience – Apple comes tomind – but most of us aren’t Apple.

I’ve been actively involved in a local community uproar that ensued when the parent organization of our local hospital decided to shut down our emergency room and change the service mix. While the changes may be necessary and logical, they were introduced so badly (with no attempt at community input or outreach or even employee involvement), that they unleashed a huge and prolonged activist resistance effort among the people in the four affected communities. “Hell no, we won’t go!” is a good way to summarize the locals’ feelings—particularly since they view the affected hospital as “theirs.” The hospital’s land and buildings were donated to the town by a local doctor, and the hospital has been upgraded and supported by locals’ philanthropy over the years. But, along the way, its Board decided to affiliate with a larger “healthcare system.” Apparently, when they did so, they ceded complete control and essentially sold out (although no money changed hands) to Maine Health, which is based in Portland, Maine. Maine Health has a different vision of the future of healthcare in Maine. They want a few large multi-disciplinary hospital hubs in the state and doctors’ offices in local communities. There are other health care systems in our state that actively support emergency healthcare in rural communities, believing that essential services should be close to home and distributed.

What should you do if you goofed and didn’t engage customers at the outset of a change that produces a lot of bad will? My answer is: go back and start over. Honestly solicit input and ideas. Get your customers engaged in solving the problem you’re trying to address. People love to complain. But they also love to roll up their sleeves and try to create something new that meets difficult constraints, budgets, and timelines. In the case of St. Andrews Hospital in Boothbay, Maine, the community members are collecting their own VOC and doing their own business planning and co-design.

Our Task Force also hired a lawyer who prepared a great position paper making a case to the Attorney General in Maine, that Maine Health and Lincoln County Healthcare have violated the trust of our community and ignored the needs of the people the charitable organization was established to serve.

The parent organization has responded by stepping back and saying, “OK, we’ll give you more time to convince us.” It’s not ideal; it’s not true co-design; but it’s a step in the right direction.

Read my case study. Read the VOC Report, The Community Speaks Out. Read the Legal Position Paper.

Related articles

Progress Report on "Save St. Andrews" Community Hospital Effort

Shifting Costs or Saving Lives??

David & Goliath: Top Down vs. Bottoms Up

Progress Report on "Save St. Andrews" Community Hospital Effort

Whoo-Hoo! A small victory has been achieved! Proof that grass roots community support DOES matter!

MaineHealth and Lincoln County Healthcare have DEFERRED closing our Critical Access Hospital from April 1st, 2013 to October 1st, 2013.

So that gives us time to do several things:

• Get a viable business plan completed -- we're working on that now!

• Appoint a shadow board and a shadow management team -- just like an opposition government (don't you LOVE the debates in the UK parliament!) so we'll be ready to roll.

• Pursue negotiations with Maine Health and Lincoln County Healthcare to gain control back over the future of our hospital and appoint our own Board while remaining part of MaineHealth (NOT what we want, unless there are significant changes to the culture!)

• Pursue strong legal action that will allow us to Roll Back the original "merger" -- (it was actually an Affiliation -- with Maine Health. In which they never PAID our 501(c)3 for our hospital or our assets, they just absorbed them and got rid of our management team and board, folded everything up into one board of trustees and then began to ignore the needs of the people for whom the not for profit charitable organization had been chartered to serve) -- so that we can reclaim our hospital and our assets.

• Keep our Emergency Room open 24x7 with local, skilled medical talent AND the use of telemedicine for trauma consultations.

• Go back to admitting patients for in-patient care while they are getting stabilized or recovering from procedures and/or taking advantage of our world-class physical therapy

• Continue to offer exquisite, friendly, personal end-of-life care

• Recruit existing and new doctors and surgeons to join us! We want to establish a VIBRANT Rural Health Clinic along with our Critical Access Hospital with strong family care, womens center (ob/gyn + internal + breast cancer screening) pediatrics, internal medicine and gerontology right here, locally. We want local orthopedic surgery and basic surgery for common procedures. A lot of that can be outpatient surgery. That's the trend. We'd like holistic practitioners: acupuncture)

• Recruit part-time specialists to come once a week or twice a month: urologist, cardiology, oncology, opthamologists, hearing, Ear, Nose & Throat, dermatology, etc.

• Ideally, we'd like to establish a mental health center and substance abuse center that is proactively integrated into our community and provides much needed mental health care for people from all over Maine who are being left untreated and uncared for due to insufficient psychiatric care and no place for anyone to stay until they're stabilized.

• Partner proactively with the Primary Care Physicians for our 20,000 seasonal residents, particularly those whose families have people with chronic conditions that need proactive monitoring and care, regular lab work, scans, and check ups.

There is no reason that people on the Boothbay peninsula should have to drive 45 minutes to an hour or more each way for good healthcare! AND, we've found that in many other far less gorgeous communities in rural Maine, doctors are moving to these communities to enjoy a better quality of life for their families. We are 3 hours from Boston! Not exactly the Boonies! And, we already have many physicians who DO spend as many as 5 months/year in our community.

All of this looks daunting, but do-able, for the group of 50+ local people and many seasonal people who have been working essentially full-time on this project since the end of July. The formal Task Force and committees are joined by thousands of others both on our peninsula and off who are contributing $$, time, and talent, and ideas! We feel we have a shot at reshaping the future of wellness and health in one of the most beautiful and welcoming places to live in the world! If not here? Where???

Your suggestions are welcome--and please tell any docs you know that we're hiring!! (Well, almost...)