The cost of the health care industry has always been rising since the early 1980s. It has been a growing concern in both the industry and society. Massachusetts General Hospital (MGH) is no exception. Even though the average length of stay (LOS) for the patients in MGH has been declining (Exhibit 10), it is still the highest compared to their competitors (Exhibit 6).
Besides the cost, there is no uniformity of process and standardization across different facilities and departments of the hospital. MGH lacks communication and coordination between the facilities.
Key Issues: Dr. David Torchiana (Cardiac Surgeon) and Dr. Richard Bohmer (Quality Improvement Administrator) want to improve the process in the hospital by implementing a newly created care path across all the departments in the MGH without affecting the patients. Some of the key issues that MGH is facing are: Operating expenses are very high. The overall bottom-line profit compared to their operating revenues are very low. Exhibit 1 indicates that it is lower than 2%. This is mainly due to their high operating expense. Average length of stay in MGH for DRG is highest (Exhibit 7) compared to the other hospitals in the area. One of the reason is due to the operational inefficiencies. Lack of data to improve outcomes.
No standard procedures or uniformity to improve coordination and communication between various medical disciplines and to improve overall quality. Standardizing the process is expected to reduce the length of stay for the patients by 20 to 30%. Expected resistance to accept change in process by personal in different areas or departments such as cardiologists, surgeons, physicians, nurses, anthologists, physical therapists, residents, non-medical staff etc., Capacity planning does not meet expectations especially such as floor needed for patient overflow, bed availability in Ellison 8 rooms, lack of staff in SICU, handling medical complications that requires longer stay in the hospital causing bottlenecks in Ellison room etc., (Exhibit 9)
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To address most of the above issues, the care path committee was formed and it first picked the CABG surgery to implement the care path as the cardiac area is the highest utilizers of the resources in terms of cost and also number of days the beds are utilized (Exhibit 5).
Moreover, implementing the care path in CABG surgery by Dr. Torchiana can act as a model for the rest of the groups and departments to follow.
Alternatives: Process Focus: This is one of the process strategies that will improve the process and address the operational issues by reducing the cost and length of stay. Implementing the care path is focused on the process improvement. However, this would take intermediate to long term to implement and does not address the planning of capacity when there are overflow of patients, lack of beds in Ellison rooms or short of staff in SICU. Process Redesign: MGH can rethink the business processes to bring dramatic changes in the process and improve performance by focusing on cost, time, and customer value.
The process can be hospital layout, payment methods, patient tracking system, outsourcing radiology (X-ray, CT-Scan, MRI) etc. These changes could help address individual areas of improvement. However, there is a heavy cost involved in radically changing the process and could make many staff unhappy. Changing the layout for example could also affect patients. Improve technology: This will increase the productivity especially in the surgery room where the cost is highest overall for the patient’s. There are several areas of technology where MGH could research on buying. Some of them are process control through information technology, robots to perform surgery, automated guided vehicles (AGVs) to transport clean linens in hospital.
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Technology can be used to educate patients, surgeons, nurses and all personnel involved in the hospital. It can also monitor patients and nurses using RFID. However, purchasing the machines would cost more and would not address the communication and coordination issues between the groups. Moreover, MGH cannot pass that cost to patients as 80% of the CABG patients are on DRG which means they cannot increase the price for these 80% of patients. Managing demand and capacity: MGH could forecast the demand and research the bottlenecks in each area of process flow diagram (Exhibit 8) such as surgery room, Ellison 8 rooms, SICU floor bed, and other hospital beds. Based on the research, they can increase or decrease the resources such as staff or beds or even expand the facility. They need the data to forecast and manage the capacity. Without the data, it is impossible to manage the capacity. So MGH need to start collecting data to better manage the demand and available capacity.
However, this would not help solve the current immediate problem in hand to improve the process and reduce costs. No change: The cost is increasing every year in the health care industry. There is no way to transfer these costs to patients as the services are already costly. Change is the only constant. Change is inevitable for MGH to survive in this industry. There are no pros with this option and several cons such as having no standards, poor communication and coordination between groups and poor maintenance of patient’s track records.
Recommendation: The best alternative from the above is to adopt the strategy of focusing on the process (1st alternative).
This can be achieved by the proposed care path. Most of the operational issues under Key issues section will be resolved by the care path. The operational costs are high as there are no standards leading to inefficient or poor coordination and communication between various medical disciplines degrading the overall quality. As mentioned in the case study, standardizing the process is expected to reduce the length of stay for the patients by 20 to 30%. This will also help to collect extensive information on each patient in computer database to assist in further research. Care path needs to be successfully implemented first with CABG surgery and then extended to all other practices slowly. This way, it will influence other groups and increase their acceptance of care path.
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Action plan: MGH should keep the care path flexible while implementing it. Dr. Torchiana must lead the efforts of rolling out the CABG care path plan with the help of Dr. Bohmer. It requires either charismatic or servant leadership style to implement. Servant leaders often lead by example. They have high integrity and lead with generosity. Dr. Torchiana is best suited given his involvement with several process improvements committees at MGH and his knowledge of the hospital. He can set an example by leading the care path for CABG using servant leadership style. Dr. Torchiana and Dr. Bohmer must Plan, Lead, Influence, Negotiate, and Communicate (PLINC) in all these efforts to successfully complete this challenge.
Short Term (30 to 90 days): Team members of the CAGB care path must educate all the staff involved in CABG surgery (Exhibit 2 & 3).
Educate the patients and reduce the length of stay following surgery to 5 days. It is the duty of the staff to educate the patients as per Education Pathway (Exhibit 4) to gain their trust. Document the implementation plan of care path and patient education pathway. Add visual representation of the process in each area.
Start the implementation first with Pre-Operative and operation day for the short term. Communicate the implementation plan to all the staff involved during Pre-Operative and Operation day of the CABG surgery. Survey the patients to measure their satisfaction rate.
Dr. Torchiana and Dr. Bohmer must meet to analyze the feedback collected by care path team members, analyze the data captured about the patients on weekly basis and fine-tune the process.
Mid Term (90 days to 1 year): Dr. Torchiana and Dr. Bohmer must roll out the CABG care path implementation plan to rest of the phases including SICU, Post operation days in Ellison 8 rooms, discharge and post discharge. Dr. Bohmer must ensure the cooperation of all departments to successfully follow the care path. Perform a reality check of the implementation every month.
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Evaluate whether the physical therapy is needed prior to surgery and remove the process if it does not add value. Continue to provide the physical therapy after the surgery. Compare the operating costs and the profits (after operating expenses) for each quarter to verify if the operating costs have reduced. Dr. Torchiana and Dr. Bohmer must create the implementation plan for each of the DRG groups (Exhibit 5) and form the team members in each DRG group.
Long Term (2 to 5 years): Dr. Torchiana and Dr. Bohmer must repeat the rollout plan that has been successfully implemented for CABG surgery to the rest of the DRG groups (other than CABG surgery) based on the implementation plan created during mid-term. As the resources are streamlined using the CABG care path, it will be time to forecast the demand and plan for capacity addition using the realized profits obtained from reduced operating costs.
