Reaching Excellence in Health Management and Policy

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1 Program Proceedings Reaching Excellence in Health Management and Policy A Symposium Honoring Professor John R. Griffith, FACHE November 5, 2010 :::: Lydia Mendelssohn Theater :::: Ann Arbor, Michigan 1

2 Reaching Excellence Symposium Showcases Evidence-Based Management and Honors 50 Years of Contribution to the Field Dear Friends, Gail Warden ( 62) Griffith Leadership Center Advisory Board Chair Christy Harris Lemak ( 98), Griffith Leadership Center Steering Committee Chair Paula Lantz, SJ Axelrod Collegiate Professor and Chair of Health Management & Policy Linda Grosh ( 97), Griffith Leadership Center Managing Director In 2008, the Advisory Board of the Griffith Leadership Center (GLC) concluded it needed to have an event that had a major impact on health care leaders, alumni and students during a time of major health care reform. We committed ourselves to achieving 3 objectives: To hold a national symposium on health management and policy involving the top practitioners, researchers and policy makers today. To impact health care practice by bringing leaders from all aspects of health management and policy together to listen and share ideas. To convene alumni as a tribute to John R. Griffith and celebrate the University of Michigan Health Management and Policy Department as the #1 program in the nation. The events, speakers, and conversations detailed here provided a rich debate about how to improve health management and policy. We hope that if you were able to be a part of this amazing event you were challenged by the speakers and motivated by the exceptional colleagues you interacted with that day. If you were not, we hope that this summary will guide you and motivate you to learn more. The GLC is dedicated to linking research, practice and teaching, assisting those dedicated to the health field in achieving excellence in each of our communities. Please feel free to contact us at and visit the Griffith Leadership Center web site. We thank our sponsors and our Griffith Leadership Center Board for making our Center and this event so successful. We also thank those who participated with us in Ann Arbor on November 5. It was truly a spectacular event. The University of Michigan President Mary Sue Coleman addressed the 600 plus attendees: There may be no more important issues requiring careful and creative thought than reaching excellence in health management and policy. By starting our symposium with Dr. Donald Berwick, Administrator of the Centers for Medicare and Medicaid Services, we will hear from one of the greatest leaders in the field today. Further, President Coleman addressed the reason many made the trip across the United States and from other countries to attend the symposium. Mary Sue Coleman, President, The University of Michigan I can imagine some of you were drawn to campus today to pay tribute to a man who needs no introduction to this crowd, Professor John Griffith. He has been a leader in hospital administration education as long as he has been at Michigan and that is a very long time! He also is the namesake of the Griffith Leadership Center in the department of Health Management and Policy. This afternoon, you will hear him give his last lecture to cap off 50 years on the University of Michigan faculty. Professor Griffith, we salute you, and your dedication to this institution and more importantly, to your students. 2

3 Keynote Presentation: Improving Health Care in America: Partnership for Our Future Donald Berwick, MD, MPP, Administrator, Centers for Medicare and Medicaid Services (CMS), began the day by meeting with Institute for Healthcare Improvement (IHI) Open School students from Michigan. These students are working toward their advanced degrees in health management and policy, engineering, nursing, public policy, business administration, and medicine, all with a focus on health care quality improvement. The meeting was arranged by the Griffith Leadership Center and it facilitated student and faculty interaction with the founder of IHI, Dr. Berwick, on quality improvement in our health care settings. Dr. Berwick s final words to the students were to listen directly from patients on where to focus their improvement efforts. Donald Berwick, MD, MPP, Administrator, Centers for Medicare and Medicaid Services (CMS) Don Berwick is known more than anyone else in this country, or perhaps the world, for quality improvement. Gail Warden In his first public presentation outside Washington since assuming the leadership of CMS, Dr. Berwick discussed how CMS is basically the largest insurance company in the world with $850 billion payments, 100 million beneficiaries, and 4,000 employees. He discussed his dedication and that of the CMS staff to the task delegated to CMS in implementing the The Patient Protection and Affordable Care Act (PPACA). Dr. Berwick outlined his Triple Aim philosophy for improving health care in the U.S.: 1. Better Care 2. Better Health for the Population 3. Lower Cost through Improvement without harming a hair on any head Dr. Berwick explained that while we currently have stewards of each aim, we need stewards of all three aims together. He encouraged the audience to use innovative techniques to achieve these goals and shared his hope that the new CMS Innovation Center will help in our endeavors. Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Preconditions for this include the enrollment of an identified population, a commitment to universality for its members, and the existence of an organization (an integrator ) that accepts responsibility for all three aims for that population. The integrator s role includes at least five components: partnership with individuals and families, redesign of primary care, population health management, financial management, and macro system integration. Abstract from Health affairs Article, The Triple Aim: Care, Health, And Cost by Donald Berwick, Thomas W. Nolan and John Whittington. Dr. Berwick ended his session with a quote, If not the U.S., then who? If not now, then when? 3

4 Program Agenda and Table of Contents Friday, November 5, 2010 Lydia Mendelssohn Theater/Michigan League Registration/Networking Breakfast Page 2 Welcome Mary Sue Coleman, President, University of Michigan Paula Lantz PhD, MS, S.J. Axelrod Collegiate Professor of Health Management and Policy; Department Chair, University of Michigan School of Public Health, Department of Health Management and Policy Introduction of the current Griffith Leadership Center and the HMP Alumni boards Reaching Excellence in Health Management and Policy Introduction: Gail Warden, MHA, President and CEO Emeritus Henry Ford Health System, Professor; University of Michigan School of Public Health, Department of Health Management and Policy; Chair, Griffith Leadership Center Advisory Board Page 3 Pages 6 9 Keynote Presentation: Improving Health Care in America: Partnership for Our Future Donald Berwick, MD, MPP, Administrator, Centers for Medicare and Medicaid Services (CMS) Panel Discussion Moderator: Elizabeth McGlynn, PhD, Associate Director, RAND Health; RAND Distinguished Chair in Health Care Quality (now the Director of the Kaiser Permanente Center for Effectiveness and Safety Research) Peter W. Butler, MHSA, President and COO, Rush University Medical Center; Chairman, Department of Health Systems Management, Rush University Janet Corrigan, PhD, MBA, President and CEO, National Quality Forum Elizabeth McGlynn, PhD, Associate Director, RAND Health; RAND Distinguished Chair in Health Care Quality Question and Answer 4

5 Leading Health Care Performance Excellence in a Changing Policy Landscape Introduction: Christy Harris Lemak, PhD, Associate Professor, University of Michigan School of Public Health, Department of Health Management and Policy Moderator: Maulik Joshi, DrPH, President, Health Research & Educational Trust; Senior Vice President of Research, American Hospital Association Pages Panel Discussion Glenn A. Fosdick, MHSA, FACHE, President and CEO, Nebraska Medical Center Maulik Joshi, DrPH, President, Health Research & Educational Trust; Senior Vice President for Research, American Hospital Association Larry Levine, MHSA, President and CEO, Blythedale Children s Hospital Gwen M. MacKenzie, RN, MN, MHSA, President and CEO, Sarasota Memorial Hospital Question and Answer Reaching Excellence in 21st Century Health Care Paula Lantz PhD, MS, S.J. Axelrod Collegiate Professor of Health Management and Policy; Department Chair, University of Michigan School of Public Health, Department of Health Management and Policy Introduction: Kenneth E. Warner, PhD, Dean, University of Michigan School of Public Health; Avedis Donabedian Distinguished University Professor of Public Health Page 13 Page Page Page Page Page 26 John R. Griffith, MBA, FACHE, Andrew Pattullo Collegiate Professor of Hospital Administration; Professor, University of Michigan School of Public Health, Department of Health Management and Policy. Complete text of last lecture (pages 26 36) Response and Questions Stephen M. Shortell, PhD, MPH, MBA, Dean and Professor, University of California Berkeley School of Public Health; Blue Cross of California Distinguished Professor of Health Policy & Management Closing Remarks and thank-you s Gail Warden, MHA, President & CEO Emeritus Henry Ford Health System; Professor, University of Michigan School of Public Health, Department of Health Management and Policy; Chair, Griffith Leadership Center Advisory Board Speaker Biographies Sponsors and Donors to the GLC Griffith Leadership Advisory Board and Faculty 5

6 Panel I: Reaching Excellence in Health Management and Policy With the goals of the Triple Aim outlined for symposium attendees by Don Berwick, MD, MPP, administrator of the Centers for Medicare and Medicaid Services (CMS) three panelists plus Dr. Berwick explored their ideas of how the American health-care system can eliminate roadblocks and reach a level of excellence aspired by many. Elizabeth McGlynn, PhD, Associate Director, RAND Health; RAND Distinguished Chair in Health Care Quality (now the Director of the Kaiser Permanente Center for Effectiveness and Safety Research) Janet Corrigan, PhD, MBA, President and CEO, National Quality Forum Even with the challenges and uncertainties that currently exist, Elizabeth McGlynn, PhD, associate director of RAND Health, distinguished chair in health quality, and chair of AcademyHealth, emphasized that we have the resources and the talent and we cannot sit back and wait for someone else to step in, we need to take responsibility and begin working McGlynn proposed ideas to tackle the issues of cost, access and quality. First, she noted the opportunity the Affordable Care Act provides to experiment, especially with the new Center for Innovation within CMS, at multiple levels of the delivery system. She also explained the importance of evaluating the experimentation and being flexible to either abandon things that do not work or tweak them to make them work. In addition, she noted that some proposed ideas only constitute new names for old ideas and the importance of critically examining the original cause of failure for these ideas so that history is not repeated and progress is ensured. To improve access, McGlynn stated that RAND found the individual mandate to be the most powerful policy lever with the lowest cost to the government; however, to achieve progress in this area, the conversation must be reframed. The new watch words will be: how does this affect the deficit, productivity and efficiency? she said. Finally, gains in quality will require an improved information structure and the tools that allow providers to be more proactive, to continuously study the advancements in science and in an integrated manner, and to communicate and learn from each other s experiences. McGlynn concluded, Having information out there and making information widely available is critical and can make a difference. Although misaligned policies have hampered progress in the past, Janet Corrigan, PhD, MBA, president and chief executive officer of the National Quality Forum, believes, a huge amount of work was done over the last couple of decades to make the stars align in the health care galaxy to create a healthy policy environment that will drive us in the right direction. This is especially true of efforts focused on building the evidence base and policy analysis to encourage and reward high-performing healthcare systems. She noted, however, that challenges still exist and that one of the most helpful tools going forward will be having a mission statement and a performance dashboard that are the same for the policy environment and the high-performing healthcare system. This dashboard must include better information on patient perspectives and outcomes, cost data, and appropriate metrics for each level of the system: the individual physician, accountable care organization, and healthcare system as well as individual, community, and population health. Finally, Corrigan emphasized the importance of developing and communicating the joint message, and she said that to accomplish this, We have to stay very focused on our mission, and have performance metrics and information to tell us whether we are on course, to keep us on course and to remind us what to do next to eventually get better health for patients and populations. 6

7 Peter Butler, MHSA, President and Chief Operating Officer of Rush University Medical Center and chairman of the department of health systems management at Rush University as well as a member of the Griffith Leadership Center Board, believes achievement of the Triple Aim will be through capitation, and he agrees that the new Center of Innovation within CMS should be used for experimentation in this area. We should get some robust, more aggressive models going and take a look at how to succeed at state levels, he said. However, challenges still exist in this area, as Butler explained, due to the powerful incentives of a fee-for service system and anxiety regarding having the appropriate skills and resources. These issues lead to the greatest resistance to changing the current reward system and conflict most with achieving the Triple Aim. Butler believes this is where leadership plays an important role in moving forward. Leadership needs to fill in the rest of the blanks. The true sign of leaders are ones who can take this whole package and implement change not only in their own organization but also while looking at the bigger picture. Peter W. Butler, MHSA, President and COO, Rush University Medical Center; Chairman, Department of Health Systems Management, Rush University As the U.S. health care community continues on the journey to reach excellence and achieve the Triple Aim, each of the speakers emphasized the importance of engaging communities. Corrigan highlighted current public-private partnerships the Robert Wood Johnson Foundation and the Beacon communities that are focused on bringing together stakeholders, and she emphasized, We need to create robust structures at the community level that will start to tackle many of these community-level, population-wide initiatives. To accomplish this, McGlynn noted that this may require a culture change, and it will be important to look at what works, what does not and how to gain traction with community engagement. Finally, the speakers once again noted the importance of improving communication within and between the health care policy and delivery systems as well as the public. We have a very important communication challenge, especially when using health policy language because it does not resonate, said Berwick. If we find better ways to discuss health care terminology and have mature conversations, we will find that the public is absolutely on the same page as the policy makers. 7

8 Panel Discussion Excerpts With an audience full of health leaders and academics there were many questions. Some are summarized below: Question: The organized delivery system, the role and function of the medical staff, and how we get the population to get engaged are three of my concerns. Any thoughts you have would be great. Donald Berwick, MD, MPP, Administrator, Centers for Medicare and Medicaid Services (CMS) McGlynn: Our tendency is to focus on the health system as the be all and end all, but the reality is that it affects a relatively small portion of outcomes. The Affordable Care Act includes some grants to communities to get engaged in this sort of wellness and health journey. It will take a cultural change to engage communities, but we have an opportunity to start thinking about what it takes to change culture. We will need to look at what works, what does not, and how do we get traction. Corrigan: We do have a lot of promising activities in many communities across the U.S. There are publicprivate partnerships that have been developed over the last few years the Robert Wood Johnson Foundation, the Aligning Forces communities, the Beacon communities all are focused on bringing together many stakeholders at the community level. Hopefully this will create a permanent and viable structure to work together. We need to create robust structures at the community level that will start to tackle many of these community-level, population wide initiatives. We also need to keep this in mind as we develop Accountable Care Organizations (ACO s) and new payment programs, because if we are not careful, one of the unintended consequences will be to create very strong, competing integrated health systems. Competition can be a good thing, but it can be a bad thing when you need widespread community collaboration. We need to be specific about where we want competition to thrive, such as to compete for better outcomes, but also to allow systems to come together on issues where community-wide collaboration is needed. Hopefully the CMS Innovation Center will consider some ideas around reward pools that reside at the community level. Butler: The physician alignment is going to take time. We need to make sure when organizations receive funding that they are acting on behalf of the community and not just their own organization. Panel discussion in progress 8

9 Question: What are your perspectives on the demand side? What about the behavioral economics of things (the old language of deductibles and co-pays), as it relates to demand management? How does that come to play in redesigning our health systems, or are those mechanisms played out? Butler: Medpac is still looking at behavioral economics because it is still a flaw in the design that needs to be addressed. Elizabeth McGlynn, PhD, Associate Director, RAND Health; RAND Distinguished Chair in Health Care Quality (now the Director of the Kaiser Permanente Center for Effectiveness and Safety Research) McGlynn: Some work has been done recently that translate this out of health care and into financial security and works with some of the mechanisms that are similar to retirement savings in order to get people align future financial security with investment decisions in health. That is a promising area because it changes the way we view the short-run versus the long run. Some of the challenges on the demand side can be thought of through the lens of our own contributions of waste in the system. A lot of tiny decisions that all of us make throughout the year related to our own health care utilization could be part of the solution. There are parallels to being green in an environmental way that could be used to frame the way we discuss management of scarce resources with respect to health care. If there is a positive framing such as this, we might get more traction. Corrigan: We cannot forget that we have created the perception that more is better. It will take time to overcome, but we need to think about a broader, stronger communication scheme to overturn that perception. We need to clearly explain the dangers of overuse. Question: The American College of Cardiologists estimates 12-15% of all their procedures are medically unnecessary, but legally medically necessary for fear of law suits. Various groups are citing this estimate. Will there be any push from CMS to couple reductions in medically unnecessary procedures with tort reform? Berwick: There are innovative ways to deal with this matter. Rick Boothman (at The University of Michigan Health System) has been a national leader thinking through much better ways to deal with compensation issues, but there is a lot to do. A lot of organizations have successfully dealt with matching patient needs and desires with appropriate care, even in this litigation environment. McGlynn: There is an opportunity to be more creative, since levers to limit litigation (such as caps on payout) do not have evidence of effectiveness. Malpractice is fundamentally about poor communication; the malpractice system does not do what it intended to do. Since malpractice is ineffective and annoying, it is time for a change, but that will not fix the health care spending problem. A lot of the focus needs to be on how we communicate with patients as a major way of preventing malpractice. But, unnecessary use is how physicians were trained to practice medicine; it stems more from the apprenticeship model than from a legal protection perspective. 9

10 Panel II: Leading Health Care Performance Excellence in a Changing Policy Landscape Although the economic environment poses numerous challenges to the health care community, hospitals throughout the United States are achieving excellence. But how? Three speakers representing very different organizations a safety net hospital, a children s hospital and an academic medical center shared their thoughts on how to leverage both policy and management to excel in the rapidly changing environment. Larry Levine, MHSA, President and CEO, Blythedale Children s Hospital Forty-five minutes outside of New York City sits a children s hospital that provides rehabilitation care for children with complex medical conditions. It serves as a safety net hospital, treating children from the poorest neighborhoods of the five boroughs of the city, all of whom come from acute care hospitals with a majority transferred directly from intensive care units. These challenges, however, have not slowed Blythdale Children s Hospital (BCH) from striving to become a leader in the field. We have done a number of things to achieve high performance in quality and financial areas, including a goal of becoming an outcomes-driven hospital that utilizes evidence-based medicine, said Larry Levine, MHSA, president and chief executive officer of Blythdale Children s Hospital. These efforts include a clinical care team for each patient that meets regularly to discuss outcomes-based goals; a quality dashboard that uses appropriate pediatric peer benchmarks, which can be challenging to find; and the implementation of productivity standards within all departments. The leaders at BCH recognized, however, that excellence expands beyond management practices and that in order to be a high-performing organization, BCH needed more collaboration with policy-based organizations, such as New York Medicaid. Because BCH is unique, the State s Medicaid reimbursement system did not fit, said Levine. The hospital worked diligently over a 5-year period with the state legislature, the governor s office and the department of health to develop a reimbursement methodology that was then included in new legislation and regulations, which Levine credits with helping save the hospital. At a national level, BCH works with other organizations on policy initiatives, such as the Children s Health Insurance Plan, the creation of the refund for the children s graduate medical education program, and funding for a children s medial home demonstration project. Gwen M. MacKenzie, RN, MN, MHSA, President and CEO, Sarasota Memorial Hospital In Sarasota, Florida, there is only one public hospital Sarasota Memorial Hospital and it is the only hospital for 90 percent of the area s Medicaid population and 75 percent of the uninsured. Acknowledging the importance of meeting the community needs, Gwen M. MacKenzie, RN, MN, MHSA, president and chief executive officer of Sarasota Memorial Hospital, emphasized that the greatest strength of the hospital is that strategic planning is dynamic and community integrated to make sure care is accessible and cost-effective for the community served. To accomplish this, the hospital worked with the local health department to create a joint case management system for repeat emergency department patients, and the system, which is subsidized by the city of Sarasota, utilizes health coaches to follow-up with patients when an issue is not resolved and direct them to the most appropriate place to receive care. Panel discussion in progress 10

11 MacKenzie agreed that to be successful, collaboration and transparency are required across public and policy platforms, including community, government and public organizations. The board of her hospital is publically elected, and she stated that the relationships of the board, the community and the hospital will be critical to health care delivery in the future. The place to deliver the best care in the lowest cost setting is probably not in the hospital. If the hospital can serve as the navigator that is probably a more important role to serve. Even with these efforts, Mackenzie reminded the audience that excellence does not happen overnight. Maintaining organizational and community focus with all these competing factors and priorities is not easy for any organization, she said. Safety and quality have to capture the hearts and minds of people in the organizations. Glenn A. Fosdick, MHSA, FACHE, President and CEO, Nebraska Medical Center Maulik Joshi, DrPH, President, Health Research & Educational Trust; Senior Vice President for Research, American Hospital Association As health reform brings changes and new challenges to the health care community, Glenn A. Fosdick, MHSA, FACHE, president and chief executive officer, the Nebraska Medical Center (NMC), gave a lively presentation to the audience. He anticipates several initiatives that must be completed quality improvements, cost control, and improvements in marketing and physician alignment. Government, insurance companies, businesses and society are expecting more of us, as they should, said Fosdick, and we cannot afford to let poor quality maintain itself. NMC measures quality indictors and benchmarks its performance to comparable organizations other academic medical centers as a motivation for improvement efforts. From a cost perspective, NMC has set a goal of reducing the average cost per adjusted discharge by 15 percent over a three-year period, but Fosdick urged administrators to avoid mistakes during this cost-control process, such as cutting staffing ratios or preventing the ability to increase volume or more attractive payers. We need to work with the employees and all other stakeholders so that they are part of the solution and not the problem, said Fosdick. Maulik Joshi, DrPH, senior vice president of research, president, Health Research & Educational Trust (HRET), American Hospital Association, served as moderator of the panel, and he noted that an issue with health care reform is detecting signal from noise and asked how organizations stay focused on the current mission while planning for five to ten years in the future. In response, Fosdick noted that NMC already has taken steps to create an accountable care organization with a competing hospital in town. Although the ACO rules still have not been released, Fosdick said, the conversations have been terrific, and we already are talking about working out a structure for reducing readmission rates in a mutually collaborative way. As a second point, both MacKenzie and Levine agree it is key to start with the medical staff and bring them along in the health reform discussion. They are accomplishing this by facilitating conversations with outside experts that can explain how reform will affect patients, the medical staff and the hospital. Finally, Levine noted the challenges hospitals will face due to the financial constraints of many states and the federal government and the anticipated cuts in reimbursement. The panelists agreed that leaders must utilize their political, negotiation and consensus-building skills, not only to protect their hospitals, but also the populations they serve. As Levine summarized, We have a unique ability to help people impact people s lives. When thinking about a well-run health care organization, we must include efforts to influence state and federal legislation to protect and promote the public s health. That is our professional responsibility and moral obligation. 11

12 Panel II: Leading Health Care Performance Excellence in a Changing Policy Landscape Questions and Answers Dr. Joshi asked his panel What are the implications for health management and policy education based on what you are doing today? MacKenzie: Leaders need the skills of negotiation, collaboration and consensus-building to communicate across disciplines, but these are also the most difficult skills to master. Fosdick: Students out of the program need to understand how to be change agents. Questions from the audience: What about the centers of excellence concept, where there is actually specialization within the health system so that the whole concept of continuing to do the same thing will actually reduce errors and make you more efficient within that specialty? MacKenzie: I think that works. That s probably not the be all and end all, but that certianly works to help identify what are the work processes that really move a clinical service towards great outcomes. But, typically you find centers of excellence are health system based, and they do not go beyond to population based. And, if you expand your centers of excellence to really be population based, then how can we monitor patients at home? How do we measure those outcomes and not just deliver them to the physicians and the home care nurse, but also to the out-of-town family that may be worried about their loved one? I think if you expand that concept in the broadest, deepest way possible, then it probably works better than our traditional centers of excellence approach. Levine: I would also say that childrens hospitals across the country have really exemplified this excellence. Over time, general hospitals have realized they may not have enough volume and expertise to handle sick kids. So what happens is many of these beds have closed and consolidated in children s hospitals so that more volume increases the level of quality. Fosdick: I think there is good and bad. The good is the fact that absolutely it gets into the specialization that is so important. But, if you are not big enough, what you have is duplication of services. And, we are going into a time when our reimbursement is going down in all of these areas, so you have to find out what is feasible and reasonable in that area. Question: I noticed when working with a local hospital system: they were involved in multiple collaborative efforts. One thing that would happen is that these collaboratives would start with a lot of energy, a lot of passion, but then they would peter out over time. What are some core principals for sustaining these collaboratives? MacKenzie: I think it is mutual dependence and trust. It really gets down to survival. For example, we used to have a primary care clinic in the hospital that would treat uninsured patients. Can you imagine, in a tertiary hospital, a primary care clinic? So having those clinics out in the community where patients could access them, our role in this collaboration relegated to having the ER for the emergency responses, and having the multi-discliplinary part of the clinic that the health department could not and should not do, and being able to develop the pharmacy approach to that. 12

13 John Griffith s Last Lecture Reaching Excellence in 21st Century Health Care John R. Griffith, MBA, FACHE, Andrew Pattullo Collegiate Professor of Hospital Administration and Professor, University of Michigan School of Public Health, Department of Health Management and Policy As one of Professor Griffith s longest serving colleagues, Kenneth E. Warner, PhD, Dean, University of Michigan School of Public Health; Avedis Donabedian Distinguished University Professor of Public Health, introduced Professor John Griffith to the friends, colleagues, family, former students, and fans who crowded into the UM s Lydia Mendelssohn Theater to hear him deliver his last lecture before retirement. Below is an excerpt from John Griffith s Last Lecture. Please see the complete text on page 26, or visit the Griffith Leadership website for a video of the lecture. John R. Griffith, MBA, FACHE, Andrew Pattullo Collegiate Professor of Hospital Administration; Professor, University of Michigan School of Public Health, Department of Health Management and Policy Reaching Excellence is a catchword for a revolution. It summarizes a profound, radical change in the management of American healthcare organizations (HCOs). Although it has only begun, I can say to you that the revolution is inevitable, profound, and positive in its impact. Reaching Excellence reflects a shift of the magnitude of the Flexner Report, a century ago, or the Hill-Burton Program after World War II. At its maturity, perhaps two decades from now, the revolution will create a new paradigm of HCOs that will come closer to the Institute of Medicine aims for safe, effective, patient-centered, timely, efficient, and equitable care. Beyond that, Reaching Excellence has the potential of shifting the cost curve of medical care, reducing the cost of both government and private insurance, and increasing Americans income as well as their health. That s a bold forecast, but not a casual one. I have staked my career on it, and I m willing to be judged by history on whether it comes true. The Green Book and Reaching Excellence by John R. Griffith Dean Warner addressed John s seminal contribution to the HMP department in both teaching and scholarly pursuits. As the #1 HealthCare Management Program in the country since the rankings began in 1983, Dean Warner said That (ranking) would have been inconceivable had it not been for John s involvement. John has published scores of academic papers said Dean Warner, of which 4 articles have been selected as articles of the year by the American College of Healthcare Executives. Warner assured those attendees who are not in academia there are very few individuals that have one or two articles of the year on their CV, yet alone 4. John is undoubtedly known for the green book, his textbook, The Well Managed HealthCare Organization, which is in its seventh edition. Dean Warner concluded by saying that one of John s greatest honors may be the establishment of the Griffith Leadership Center, made possible through the devotion and financial contributions of his fans from across the nation and world. John has thanked you, but on behalf of the school we thank you for sharing our vision of an institution that will carry John s quest for excellence decades into the future. 13

14 Response to John Griffith s Last Lecture Stephen M. Shortell, PhD, MPH, MBA, Dean and Professor, University of California Berkeley School of Public Health; Blue Cross of California Distinguished Professor of Health Policy & Management Reaching Excellence Through Evidence-Based Management The United States currently is an underperformer in health care when compared to other countries, and as Stephen M. Shortell, PhD, MPH, MBA, Dean and Professor, University of California Berkeley School of Public Health; Blue Cross of California Distinguished Professor of Health Policy & Management, puts it, instead of being faster, better and cheaper, we are slower and more expensive. Shortell noted that the challenges we face to become high-level performers are not due to a lack of people, information or technology but instead is a result of our inability to turn information and data into knowledge. This, he said, is due to a lack of organizing principles that link our resources of people, money, ideas and skills into a more costeffective health care system. For these guiding principles, Shortell suggests the management arena of health care begin generating and putting into practice evidence-based management the research on the organizational and behavioral social sciences that can be drawn on to make more effective decisions. To achieve this goal of evidence-based management, he suggests the creation of learning systems, that capitalize on what is being learned within the trenches in order to achieve the excellence and highperforming organizations envisioned and described by John Griffith. In the past, those organizations and people that have been working to accomplish this model have been punished, Shortell said, but this is changing. Even with proof of these changes, Shortell acknowledged that Griffith is correct that this transition period will be more of a marathon that requires continuous reform because of barriers that still exist. Like John said, I worry a lot about the lack of partnership and leadership between medical and management leadership. This is very difficult to bring about except at a few institutions, and I believe this is why [the changes] will go slowly, said Shortell. Other barriers include the lack of widespread information technology capability and the lack of standardized, but comprehensive, quality measurements. Shortell suggested to the audience that these problems must be thought of in terms of what must occur around strategy, culture, structure and technical areas. If any of these are missing, you won t get anything significant, but when they all align, you are able to achieve lasting organizational-wide impact and change, he concluded. In conclusion, Dr. Shortell laid out his recommendations for achieving excellence within the health care community: Create national evidence-based healthcare management centers. Expand practice-based research networks, such as expanding the AHRQ ACTION Network. Establish engineering and healthcare management research centers that link engineers, clinicians, health service researchers and executives, to tackle problems of improving healthcare delivery. Require external accreditation, certification and licensing bodies to look for evidence of evidence-based medicine and evidence-based management use by organizations under their review. Ask the CMS Quality Improvement Organizations (QIOs) to provide technical assistance in the implementation of evidence-based medicine and evidence-based management. Educate all healthcare professionals in the use of evidence-based medicine and evidence-based management. 14

15 Griffith and Shortell: A Discussion with the Audience After discussing the how to improve health care in the United States and the need to merge both management and policy, the symposium shifted gears as John R. Griffith, MBA, FACHE, and Stephen M. Shortell, PhD, MPH, MBA, outlined the specific processes to be undertaken and skills to be mastered by health care organizations in the rapidly changing environment of the 21 st century in order to achieve a level of excellence as demonstrated by some high-performing organizations. John R. Griffith, MBA, FACHE, Andrew Pattullo Collegiate Professor of Hospital Administration; Professor, University of Michigan School of Public Health, Department of Health Management and Policy Even though a roadmap to excellence exists, the speakers acknowledged that there are some rapidly changing areas that must be reexamined, for example the relationship between hospital executives and physicians. Although Shortell stated that he doesn t anticipate significant change in the relationships in the short run, organizations must set the groundwork for longer-term transitions. With the increase in the number of physicians and nurses that have management and leadership training, he noted that they have a greater understanding of the system of care as opposed to the more traditional individual orientation that you are trained with in medical school. This shift in thinking, Shortell believes, has trickled down into medical schools and younger physicians and nurses are becoming oriented to the system of care perspective earlier, allowing executives to more easily engage them. Griffith added that the new Accreditation Council for Graduate Medical Education (ACGME) criteria for team work, evidence-based medicine and continuous improvement in practice will bolster the relationship between physicians and health care executives. Another challenge the health-care community must tackle relates to the redistribution of revenue. Shortell anticipates this will occur in a shift from the specialty side to the primary care side, and since this may not be well-received in all communities, savvy, change managers are going to come into play. Griffith acknowledged the need for strong change models within organizations and he outlined how to lead successful change by starting with a team even if it is a single doctor-patient unit and demonstrating how a specific changes make that team look good. They are excited and talking about how this is a better job and when they start to say that, you get a change in the whole environment. To sustain the necessary changes and new initiatives in health care, Shortell stated that the governing body must play a more active role. There are so many examples of the rotating CEO turnovers, in which the physicians say, Let s just wait him or her out. In four or five years, someone else will come in with a fresh agenda, and we ll still be here. To combat this, he believes the governing board must increasingly back up the changes to ensure initiatives continue into the future. Stephen M. Shortell, PhD, MPH, MBA, Dean and Professor, University of California Berkeley School of Public Health; Blue Cross of California Distinguished Professor of Health Policy & Management The development of accountable care organizations poses additional challenges and may require a shift of the traditional views of revenue distribution, power and influence. This is apparent with the potential governance structures of ACO. It is not clear if the governing body will be hospital dominated or primaryor specialty-care dominated, or how this group will then balance the competing interests of each group, in particular the revenue distribution. Shortell stated that he believes, The rewards have to follow those caregivers that are producing the results that keep you and I out of the hospital and emergency room when we do not need to be there and that get you out of the hospital without a hospital-acquired infection. Finally, as organizations strive to reach excellence in the 21st century, questions and challenges remain regarding how to cope with expanded coverage and the anticipated increase in demand for health care services as well as the role of health care systems in the future. Both Shortell and Griffith noted that to absorb the continuing demand growth, strategic planning across all stakeholders hospital systems, safety-net hospitals, accountable care organizations (ACOs), federally qualified health centers (FQHCs) will be necessary to ensure access to patients that have not had access in the past. In addition, as the community moves into the future, the phenomenon of system building will continue. To be successful in this area, however, Griffith stated it will require more information sharing on how to build systems and incentives to expand. Shortell added that it will require the capabilities for either new systems to develop or current ones to reconfigure themselves. All of this needs to spread as quickly as it can, he said, and, we need a learning system in place to learn from mistakes as quickly as possible. 15

16 Concluding Remarks Gail Warden, MHA, President and CEO Emeritus Henry Ford Health System; Professor, University of Michigan School of Public Health, Department of Health Management and Policy; Chair, Griffith Leadership Center Advisory Board Gail noted that this symposium had been a great success thanks to an excellent faculty, great organization on the part of Linda Grosh, Christy Lemak, Paula Lantz, Ken Warner, and others. He also thanked the underwriting sponsors: Beaumont Hospitals, Blue Cross Blue Shielf of Illinois, Hall Render Killian Heath & Lyman, St. John Providence Health System, United Health Group, and St. Joseph Mercy Health System. Finally, he thanked the steering committee and the advisory board for the Griffith Leadership Center, and most particularly all of those who attended. Giving Back: Guiding Future Health Care Leaders Speakers, board members and others took time and arrived early to the symposium to meet with students and guide their career goals and research. We thank and acknowledge the following mentors that hosted students at these amazing networking breakfasts. IHI Open School Student Breakfast Don Berwick Paula Lantz PhD, MS, S.J. Axelrod Collegiate Professor of Health Management and Policy; Department Chair, University of Michigan School of Public Health, Department of Health Management and Policy HSOP Student Breakfast Janet Corrigan Maulik Joshi Elizabeth McGlynn Steve Shortell HMP Residential Masters Student Breakfast Vernice Anthony Leon L. Haley Christine Boesz Mark Herzog Paul Boulis Lindy Hinman Peter W. Butler Nancy Keyes Deborah Chang Sally Kraft Mason Dixon Richard Kraft Janet Dombrowski Robert M. Lane Ebbin Dotson Larry Levine Stacey Easterling Alonzo Lewis Ernie Raymond Ford Kimberly Lynch Glenn Fosdick Claire McAndrew Elizabeth Goldman Kevin McDermott Tim Gronniger James Meidlinger Gerry Meklaus Steve Merz Amir Rubin Nicole Rubin Pamela Shaheen Dana Sherwin David Spivey Bo Synder Barney Tresnowski Deborah Vandenbroek Gail Warden Patricia Warner 16

17 Reaching Excellence in Health Management and Policy Symposium Advisory Committee Tremendous thanks to our symposium advisory committee Paul Boulis Glenn Fosdick Richard Jelinek Larry Levine Steve Loebs Terri Mellow Lori Rehban Nicole Rubin Bo Snyder Deborah VandenBroek Symposium Organizers Gail Warden, MHA, President & CEO Emeritus Henry Ford Health System; Professor, University of Michigan School of Public Health, Department of Health Management and Policy; Chair, Griffith Leadership Center Advisory Board Christy Harris Lemak, PhD Associate Professor, Health Management and Policy GLC Steering Committee Chair Linda Grosh, Managing Director, Griffith Leadership Center A special acknowledgement to students Clare Wrobel, Ashley Smith, and Saurabh Vyas who helped prepare these proceedings and to Savitski Design. 17

18 Symposium Speaker Bios: Donald Berwick Donald M. Berwick, MD, MPP, is the Administrator for the Centers for Medicare and Medicaid Services (CMS). As Administrator, Dr. Berwick oversees the Medicare, Medicaid, and Children s Health Insurance Program. Together, these programs provide care to nearly one in three Americans. Before assuming leadership of CMS, Dr. Berwick was President and Chief Executive Officer of the Institute for Healthcare Improvement, Clinical Professor of Pediatrics and Health Care Policy at the Harvard Medical School, and Professor of Health Policy and Management at the Harvard School of Public Health. He also is a pediatrician, adjunct staff in the Department of Medicine at Boston s Children s Hospital and a consultant in pediatrics at Massachusetts General Hospital. Dr. Berwick has served as Chair of the National Advisory Council of the Agency for Healthcare Research and Quality, and as an elected member of the Institute of Medicine (IOM). He also served on the IOM s governing Council from 2002 to In 1997 and 1998, he was appointed by President Clinton to serve on the Advisory Commission on Consumer Protection and Quality in the Healthcare Industry. Dr. Berwick is the recipient of numerous awards and honors for his work, including the 1999 Ernest A. Codman Award, the 2001 Alfred I. DuPont Award for excellence in children s health care from Nemours, the 2002 American Hospital Association s Award of Honor, the 2006 John M. Eisenberg Patient Safety and Quality Award for Individual Achievement from the National Quality Forum and the Joint Commission on Accreditation of Healthcare Organizations, the 2007 William B. Graham Prize for Health Services Research, and the 2007 Heinz Award for Public Policy from the Heinz Family Foundation. A summa cum laude graduate of Harvard College, Dr. Berwick holds a Master in Public Policy degree from the John F. Kennedy School of Government. He received his medical degree from Harvard Medical School, where he graduated cum laude. John R. Griffith John R. Griffith is the Andrew Pattullo Collegiate Professor in the Department of Health Management and Policy. He was Director of the program and bureau of Hospital Administration at the University of Michigan from 1970 to 1982, and Chair of his department from 1987 to Professor Griffith has been at Michigan since He is an educator of graduate students and practicing health care executives. He has served as Chair of the Association of University Programs in Health Administration and as a Commissioner for the Accrediting Commission on Education in Health Services Administration. Professor Griffith is active as a consultant to numerous private and public organizations. He has served as an examiner for the Malcolm Baldrige National Quality Award, He is the author of numerous publications. His text, The Well-Managed Health Care Organization, is currently in its seventh edition. The first edition won the ACHE Hamilton Prize for book of the year in 1987, and the fourth was named Book of the Year by Healthcare Information and Managment Systems Society. Four of his articles have been recognized for excellence by the American College of Healthcare Executives. Professor Griffith is honored by the Griffith Leadership Center. The Center works to enhance understanding of excellent leadership in healthcare finance and delivery by increasing communication between department faculty, students, and outstanding practitioners. 18

19 Peter Butler Peter W. Butler is a nationally recognized health care executive with more than 25 years of experience in teaching hospitals and health care systems. In addition to being President and Chief Operating Officer of Rush University Medical Center in Chicago, Illinois, Mr. Butler is an Associate Professor and Chairman of the Department of Health Systems Management at Rush University. Before joining Rush in 2002, he served in senior positions at The Methodist Hospital System in Houston and the Henry Ford Health System in Detroit. Mr. Butler currently serves on the Governing Board of University HealthSystem Consortium. Previously, he served on and the Board of the Health Research and Educational Trust, the Board of the Michigan Hospital Association, and the Texas Hospital Association. He has also been on numerous American Hospital Association councils, including chairing the Section for Healthcare Systems Council. In 2008, he was appointed to a three year term as Commissioner of the Medicare Payment Advisory Commission (MedPAC). Mr. Butler is a 1973 graduate of Amherst College where he received a bachelor of arts degree in psychology. He received his master of health services administration from the University of Michigan in Janet Corrigan Dr. Corrigan is President and CEO of The National Quality Forum, a private, not-for-profit standard-setting organization established in The NQF mission includes: setting national priorities and goals for performance improvement; endorsing national consensus standards for measuring and publicly reporting on performance; and promoting the attainment of national goals through education and outreach activities. From 1998 to 2005, Dr. Corrigan was Senior Board Director at the Institute of Medicine (IOM). She provided leadership for IOM s Quality Chasm Series which produced ten reports during her tenure including: To Err is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century. Prior to joining IOM in 1998, Dr. Corrigan was Executive Director of the President s Advisory Commission on Consumer Protection and Quality in the Health Care Industry. She is the recipient of numerous awards including: IOM Cecil Award for Distinguished Service (2002), American College of Medical Informatics Fellow (2006), American College of Medical Quality Founders Award (2007), Health Research and Educational TRUST Award (2007), and American Society of Health System Pharmacists Award of Honor (2008). Dr. Corrigan received her doctorate in health services research and master of industrial engineering degrees from the University of Michigan, and masters degrees in business administration and community health from the University of Rochester. Glenn A. Fosdick Mr. Fosdick has had a distinguished career in hospital/health system administration spanning more than 30 years. In August 2001, he was named President and Chief Executive Officer of The Nebraska Medical Center in Omaha, NE. The Nebraska Medical Center is a 687-licensed bed acute care teaching hospital, comprised of the former Bishop Clarkson Memorial Hospital and the former University of Nebraska Medical Center Hospital. In addition, the medical center also owns hospitals in Iowa, Missouri, a freestanding orthopedic facility in Omaha, and a new 100-bed community hospital in Bellevue, NE. which opened in May Prior to his appointment at The Nebraska Medical Center, Fosdick served as President and Chief Executive Officer of Hurley Medical Center in Flint, MI. He originally joined Hurley Medical Center in 1992, a 495-bed teaching hospital and regional referral center, as Executive Vice President and Chief Operating Officer. Between 1976 and 1992, Fosdick also held administrative positions at The Buffalo General Hospital, Buffalo, NY, and the Genesee Memorial Hospital, Batavia, NY. Mr. Fosdick is a 1973 graduate of the State University of Buffalo, New York, where he earned a bachelor s degree in business administration. He received his masters in health services administration from the University of Michigan. 19

20 Maulik Joshi Maulik S. Joshi, DrPH is President of the Health Research & Educational Trust (HRET) and Senior Vice President for Research at the American Hospital Association (AHA). HRET conducts applied research in critical areas of the healthcare system. Dr. Joshi also leads Hospitals in Pursuit of Excellence, AHA s strategy to accelerate performance improvement and support health reform implementation. Previously, Dr. Joshi served as Senior Advisor at the Agency for Healthcare Research and Quality, President and CEO of the Delmarva Foundation, recipient of the 2005 U.S. Senate Productivity Award the highest level award in Maryland based on the Malcolm Baldrige Award, Vice President at the Institute for Healthcare Improvement, and Senior Director of Quality for the University of Pennsylvania Health System. Dr. Joshi has a doctorate in public health and a master s in health services administration from the University of Michigan and a bachelor of science in mathematics from Lafayette College. Dr. Joshi is Editor-in-Chief for the Journal for Healthcare Quality. He also co-edited The Healthcare Quality Book: Vision, Strategy and Tools, and authored Healthcare Transformation: A Guide for the Hospital Board Member. Larry Levine Larry Levine is the President and CEO of Blythedale Children s Hospital in Valhalla, New York. A graduate of the University of Michigan School of Public Health (Department of Medical Care Organization), Mr. Levine has 35 years of experience in healthcare management, particularly in the field of children s hospitals. He is a frequent speaker on topics related to the organization and management of children s hospital services and children s health policy issues, as well as a tireless advocate for the interests of children with special healthcare needs. Mr. Levine has served as a trustee of the National Association of Children s Hospitals and Related Institutions (NACHRI). He is currently the Chair of the Alumni Board, Department of Health Management and Policy at the University of Michigan. Gwen MacKenzie Gwen MacKenzie, BSN, MN, MHSA is President and CEO of Sarasota Memorial Health Care System, a regional medical center consisting of an 806-bed hospital, physician practices, nursing and rehabilitation center, psychiatric hospital and network of outpatient campuses and clinics. Sarasota Memorial has been listed for six consecutive years in U.S. News America s Best Hospitals. Trained as an oncology nurse, MacKenzie worked for 25 years at the nine-hospital Detroit Medical Center, serving as Vice President and COO. She received a bachelor s degree in Nursing and master s degree in Health Services Administration from the University of Michigan and a master s degree in Nursing from UCLA. 20

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