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MedXellence Case StudyBackground/Set-upYou are a member of the local Commander’s Executive Board (CEB) at the Multi-Service MarketOffice (MSMO). This committee has been meeting for several years and has successfullycollaborated to resolve many issues that have impacted local health care delivery. It is comprised ofthe Chief Executive Officer and other executives of the Managed Care Support Contractor (MCSC)and the commanders and other executives of the three Military Treatment Facilities (MTFs) whocare for the communities large, and complex beneficiary population. About 40% are non-activeduty and active duty family member beneficiaries.These three MTFs consist of: • A tertiary care 300 bed medical center (Valhalla U.S. Air Force Medical Center), • A large ambulatory center (Olympus Navy Ambulatory Center), and • A small outpatient clinic (Army Cisifus Outpatient Clinic).More specifically, Valhalla Medical Center provides a complete spectrum of care except forneurosurgery, has a Level II emergency department, and acts as the referral center for the twooutpatient clinics which are ten and thirty-five miles away respectively, as well as for the entireRegion. The large Olympus Navy Ambulatory Center has a staff of 25 primary care and specialtyproviders and includes a large undersea medicine component. It provides a primary care clinic eachweekday from 0730-1630 and each weekday evening from 1800-2100. Some of the provider staffmembers at Olympus have been deployed on short notice, and backfill has not yet been complete oradequate. The small Army Cisifus outpatient clinic has a small staff consisting of approximately 4primary care providers, 2 pediatricians, and 2 Primary care nurse practitioners, and also maintains atroop medicine clinic supporting its line units. It provides a primary care clinic, which is open from0730-1630 on weekdays and from 0800-1400 on Saturdays.In addition to the MTFs, the community is served by an aggressive and quite profitable ManagedCare Support Contractor that is actively marketing to gain more of the market share. A recurringissue for the CEB is negative patient feedback reports. For the past two quarters, the metricsrelating to customer satisfaction have worsened and MTF commanders are aware that patients mayseek care elsewhere. The MTF commanders have all expressed concern about the potential financialimpact if more of their enrolled patients seek care from civilian emergency departments, or arereferred to the MCSC for care. They have therefore made a concerted effort to keep MTFproductivity and MHS Relative Value Units at appropriate levels. Despite this effort, however, thisissue continues to be problematic and a continuing CEB discussion item.
The ProblemWaiting time in the Valhalla Medical Center’s Emergency Department has been a center ofcontroversy for the past year, and has been a recurring agenda item at this Committee’s meetings. Ithas also been a heated agenda item at the Medical Center’s professional and executive staff meetings,and a vigorous topic of conversation in the local military newspaper and at local beneficiarymeetings.The general perception is that the waiting times for care in the Emergency Department are too long.Recent data, compiled by Red Cross volunteers who agreed to help the beleaguered EmergencyDepartment director, revealed that ED waiting times averaged over 4 hours and at peak timesextended up to 6 hours for some patients.To meet this workload, most Emergency Department provider and nursing staff have been working12-hour shifts for the past six months with a 60-hour workweek and frequent occurrences ofmandatory overtime to cover staff absences. Staff has expressed concern that this heavy workloadhas both staff welfare and patient safety implications.Two ED staff members have, indeed, openly complained that their working conditions arecompromising their ethical responsibility to their patients. One of these staff members took theircomplaint to the Medical Center Commander, and the other to the local Staff Judge Advocate. TheMedical Center awaits a possible JAG inquiry. A reportable sentinel event recently occurred in theEmergency Department in a patient with a cardiac diagnosis; a Root Cause analysis has beeninitiated to determine cause and to see if there is any linkage to the concerns voiced by staff overworking conditions. Additionally, Valhalla Medical Center has an impending Joint Commissionsurvey, and executive management is worried that these waiting times and patient safety concernsmight be potential accreditation problems.About four months ago, without notice, the Cisifus Outpatient Clinic shut down its SaturdayPrimary Clinic activity and advised all patients that they could receive needed care at the ValhallaMedical Center Emergency Department. This action brought immediate, loud complaints from theEmergency Department chairperson and Administrative director, who argued that they were alreadyseeing too many of the other MTFs’ patients in the emergency room. They contended that thesepatients were the major contributor to their long waiting times. They complained that this was thelast straw and that something had to be done to resolve their workload and waiting time problems.The Medical Center Commander has brought this problem to this Committee, which has taskedyour MTF group to analyze it and propose recommendations to resolve it by Thursday.TaskYour MTF task force is to analyze this problem and bring a consensus opinion as to resolution tothe Committee at its next meeting. Pertinent data is available on request.Narrative: Updated June 2009
Agenda Region 71 Commander’s Executive Board July 2009 Review and approval of the minutes of June 2009 Key issues: • Patients complaining of long waiting times at Valhalla ED • Routine screen shows increasing times to next routine appointment at Cisifus Outpatient Clinic • Water damage to Record Room at Olympus Ambulatory Clinic from overhead pipes Old Business • Delayed opening of Endoscopy Suite at Valhalla New Business • Plans for Civic Pride Day at Valhalla involving Mayor and Congressman Palermo’s office • Develop a Region-wide schedule for performing and reporting routine QA screening results • Valhalla announces hiring of new MEPRS Coordinator (after long and extensive search) • Water purity issue at Olympus following repairs Action items • MTF Commanders to provide Council with information about appointment availability, and waiting times in the ED.Agenda T-6 Months.doc
Agenda Region 71 Commander’s Executive Board October 2009 Review and approval of the minutes of July 2009 Key issues: • Plans for Civic Pride Day at Valhalla • Develop schedule for reporting routine QA screening results • Patients complaints: • Waiting times at Valhalla ED • Times to next routine appointment • Water damage to Record Room at Olympus Ambulatory Clinic • Delayed opening of Endoscopy Suite at Valhalla • Water contamination at Olympus after major leak Old Business • Status of endoscopy suite construction • Plans for Civic Pride Day at Valhalla (next week); Mayor coming but Congressman Palermo indefinite • Schedule for routine QA results developed by Exec Board; needs approval • Commanders’ report on patient issues New Business • Change of Command preparations at Olympus • Pending deployments at Olympus • Council participation at Tricare ConferenceAgenda T-3 Months.doc ii
Agenda Region 71 Commander’s Executive Board –December 2009Review and approval of the minutes of October 2009Key issues:• Endoscopy suite ready for opening in 30 days• Valhalla Civic Pride Day plans; still uncertain about VIP guests• Waiting times not improved at ValhallaOld Business• Pending results of water treatment tests from Olympus Clinic• Report from IPT re parking problems and patient feedback issues at Cisifus• Olympus Change of Command delayed• Olympus Deployments• Region poster for Tricare Conference; assignment of presentersNew Business • Deployment of personnel from the Olympus Ambulatory Clinic • Unknown length of deployment • Affects GMOs most • Nursing also depleted • Recent Sentinel Event at Valhalla • Cardiac case in ED • Newspapers covering the incident • Family has filed lawsuit • Personnel complaints in Valhalla ED • Report from Commander • Report from JAG office • Report from Cisifus re closure of their Saturday clinic hours • Report on Water damage to Supply Room at Olympus Clinic • Report from Olympus on disappointing backfill status • Anticipated JCAHO visit for ValhallaAction items • Charge IPT to address the waiting times in Valhalla ED • Determine information needs • Review supplied information to determine probable cause • Report to Council in five working days on recommended next steps.Enclosures:(1) Valhalla ED Source of Patients from BPT and CHCS(2) DX of Patients Seen on a Typical Day at Valhalla ED(3) Valhalla ED Waiting Times (in hours)(4)Valhalla ED Workload by ShiftAgenda Yesterday.doc