assignment 1IntroductionMidtown Neurology was started by a si.docx

assignment 1
Introduction:
Midtown Neurology was started by a single physician who had
been practicing in the community for nearly twenty years. As
the practice grew, it evolved from a “mom-n-pop” operation to a
more complex model. The founding physician recruited four
new neurologists to join and continue to help build the practice.
Subsequently, however, the new doctors took over and forced
him out of the practice.
Tasks:
Case Study Six: From Nothing to Something: Defining
Governance and Infrastructure in a Small Medical Practice
Read the above case study; your task would be to evaluate this
case study utilizing the format below. Make sure to include at
least two scholarly/peer-reviewed articles to help support your
evaluation.
Case Study Evaluation
· Prepare a written report of the case using the following
format:
· Background Statement: What is going on in this case as it
relates to the identified major problem?
· What are (only) the key points the reader needs to know in
order to understand how you will “solve” the case?
· Summarize the scenario in your own words—do not simply
regurgitate the case. Briefly describe the organization, setting,
situation, who is involved, who decides what, etc. Specifically
identify the major problems and secondary issues.
· What are the real issues? What are the differences? Can
secondary issues become major problems?
· Present an analysis of the causes and effects.
· Fully explain your reasoning. Declare your role in a sentence
or a short paragraph explaining from which role you will
address the major problem and whether you are the chief
administrator in the case or an outside consultant called in to

advise.
· Regardless of your choice, you must justify in writing as to
why you chose that role. What are the advantages and
disadvantages of your selected role? Be specific.
· Recognize the strengths and weaknesses of the organization.
· Identify the strengths and weaknesses that exist in relation to
the major problem. Again, your focus here should be in
describing what the organization is capable of doing (and not
capable of doing) with respect to addressing the major problem.
Thus, the identified strengths and weaknesses should include
those at the managerial level of the problem. For example, if
you have chosen to address the problem from the departmental
perspective and the department is understaffed, that is a
weakness worthy of mentioning. Be sure to remember to include
any strengths/weaknesses that may be related to diversity
issues.
· Find out alternatives and recommend a solution.
· Describe the two to three alternative solutions you came up
with. What feasible strategies would you recommend? What are
the pros and cons? State what should be done—why, how, and
by whom. Be specific. Evaluate how you would know when
you’ve gotten there. There must be measurable goals put in
place with the recommendations. Money is easiest to measure;
what else can be measured? What evaluation plan would you put
in place to assess whether you are reaching your goals?
· TIP: Write this section as if you are trying to “sell” your
proposed solution to the organization. Convince the reader that
your proposed solution is the best available and that it will
work as planned. Make sure that the goals you identify are
worth the effort required to achieve them!
As in all assignments, cite your sources in your work and
provide references for the citations in APA format.
· Your assignment should be addressed in a 4- to 6-page
document.
Midtown Neurology was started by a single physician who had

been practicing in the community for nearly 20 years. As the
practice grew, it evolved from a “mom-n-pop” operation to a
more complex model. The founding physician recruited four
new neurologists to join and continue to help build the practice.
Subsequently, however, the new doctors took over and forced
him out of the practice.
The large urban hospital with which Midtown was affiliated
achieved Level 1 trauma status, providing additional new
opportunities for the practice. The neurologists took on the
many responsibilities, including one of stroke team for the
hospital. Contractual rural outreach was practiced utilizing
telemedicine throughout the state and provided a robust revenue
stream.
While still a small physician group, it required a difficult call
schedule. Tracking call and distributing it equitably became a
challenge. The main reason for this was the founding physician
had written a proprietary program exclusively for this purpose.
Now the practice was beholden to the very person they had
forced out of the practice for a vital part of communication with
the other practices regarding the call schedule. This was very
unusual, as physicians don’t typically write proprietary software
for a practice. In addition, the entire platform including the
billing program, which he also developed, used MS-DOS.
The practice employed a practice manager who had started with
the founding physician. As the practice grew, the manager did
not keep up with the basics of managing a practice. Her
information relating to billing, reimbursement, and changes to
current CPT and ICD-9 issues was out of date. She was also
ignorant of the contracts the practice had, but more importantly
the impact of those contracts on the practice and how to carry
them out appropriately.
While the physicians were very productive, several significant
management problems became apparent as the practice grew. In
particular, the infrastructure suffered and there was no
governance. Infrastructure for a private practice is different
from that of a corporate model. For example, in a corporate

model individual departments exist with defined responsibilities
to support the needs of the corporation and other areas of the
entity, such as an IT department. Conversely, in a private
practice when IT systems need repair, the responsibility falls to
the administrator or manager, and this individual must know
how to address and fix the problem. In this instance, the IT
department and the owner of the practice were one and the
same. Because of the proprietary nature of the software,
outsourcing was not an option. The practice essentially was
backed into a corner because of the lack of necessary
infrastructure upgrades, such as in the case of IT. This dynamic
created tension and frustration for the manager of the practice
and the employees. The situation did not allow management to
function normally in some instances.
The governance structure of the group required change after the
solo physician hired the new neurologists. The new physicians
had a more contemporary view of what a practice should look
like and how it should function. This concern was the basis of
many governance and trust problems. The IT and billing
systems were grossly outdated, but the founding physician had
taken great pride in his proprietary abilities and had not allowed
changes. This attitude was prevalent in nearly every decision
made, from what referring physicians the group would associate
with to choices of staff. When decisions needed to be made,
there was not a single voice for the practice, and this created
confusion for the hospital and other referring colleagues. The
group was resistant to appointing anyone as president and this
habit had continued after the founding physician was forced out.
The physicians did not particularly like or trust each other. No
one wanted anyone to become the practice leader or be the voice
of the practice when building relationships with referring
physicians. Each physician wanted to have his or her own
individual PC and to run different revenue streams through the
practice. All were secretive about their side deals. Employment
contracts were never created and thus potential partner
arrangements or what constituted partnership did not exist.

Policies, procedures, and basic business documents, such as an
employment manual for the staff, were never written or
implemented.
Having access to neurological consultations on a 24/7 basis is a
huge benefit for a Level 1 trauma hospital. The group was able
to fulfill the need for the hospital; however, the outpatient piece
of the practice suffered. Therefore, the hospital recruited three
other physicians for the group to take over the out-patient
portion of the practice. Due to the unstable relationship of the
current physicians in the group, all three of these physicians
subsequently left the practice, leaving the responsibility of
finding replacements with the remaining physicians.
A requirement for smooth governance is the ability of the
physicians, staff, and managers to trust each other. As the
relatively new administrator of the practice you have come to
realize that one of your first challenges is to bring the
importance of governance to the attention of these physicians.
You will also need to educate the physicians on the
consequences of “going off on their own” and making
arrangements on the side.
ASSIGNMENT 2
You are the chief information officer (CIO) of a large
healthcare system. Medicare has mandated that all medical
practices seeking Medicare compensation must begin using
electronic medical records (EMR). Medicare has incentivized
medical practices to place EMR in their offices by giving
financial bonuses to medical practices that achieve certain
goals.
Tasks:
Case Study Thirty-Six: The Electronic Medical Record:
Efficient Medical Care or Disaster in the Making?
evaluation.

format:
advise.
issues.

document.
You are the Chief Information Officer (CIO) of a large health
care system. Medicare has mandated that all medical practices
seeking Medicare compensation must begin using electronic
medical records (EMR). Medicare has incentivized medical
practices to place electronic medical records in their offices by
giving financial bonuses to medical practices that achieve
certain goals. These EMR systems are supposed to allow
communication between practitioners and hospitals, so medical
information can be rapidly transferred to provide more efficient
medical care. The EMR will enable physicians to allow access
to the records of their patients by other providers. Eventually
these records are supposed to be easily accessed so any
physician or hospital will have complete medical information on
a patient.
The physician practices in your health care system have been
mandated to use the Unified Medical Record System (UMRS).
The UMRS was designed by a central committee; all hospital-
owned physician practices have been mandated to use the
system. As part of the incentives, Medicare will add dollars
back to each practice when they meet goals for reaching
meaningful use (MU). MU has been defined by the U.S.
Department of Health and Human Services (n.d.) as “using
certified electronic health record (EHR) technology to:

• Improve quality, safety, efficiency, and reduce health
disparities
• Engage patients and family
• Improve care coordination, and population and public health
• Maintain privacy and security of patient health
information.”
It is a step-by-step system requiring “electronic functions to
support the care of a certain percentage of patients” (Jha,
Burke, DesRoches, Joshi, Kralovec, Campbell, & Buntin, 2011,
p. SP118).
One of the hospitals in your system has many primary care and
specialty practices; however, the UMRS system was designed
primarily for the primary care practices. The committee that
developed UMRS did not take into account the needs of the
specialty practices, which are significantly different from the
primary care practices. This issue has been brought to the
forefront by several medical specialists who have stated UMRS
is not only cumbersome, but also extremely difficult to use.
UMRS also does not give the specialist the information he
needs. Specialists noted that after UMRS was implemented, it
took them approximately 10 to 15 minutes longer to see each
patient. Since an average day for a specialist consists of seeing
between 20 and 25 patients, adding 10 to 15 minutes per patient
adds 200 to 250 additional minutes, or 3 to 4 hours more each
day. And, the physician cannot see the same number of patients
each day. In reality, this represents a 30% decrease in
productivity because of the amount of time it takes to use
UMRS. Now the specialist office schedules constantly run
significantly later than they should, and patients become
unhappy and impatient. Several of the specialists reported that a
number of patients have gotten up and left without being seen.
In short, the mandate to use UMRS has impacted the efficiency
and productivity of the subspecialists and specialists, further
decreasing revenues for the system.
In addition, all of the physicians have complained the UMRS
does not communicate well with other electronic medical record

systems, or even the hospital’s own patient information
systems. There is no real integration of the medical databases as
intended, levels of meaningful use are unclear, and in some
areas, difficult to achieve, again because the UMRS was
tailored to primary care practices’ prescribing patterns.
Specialists, particularly surgeons, do not write a large number
of prescriptions. Surgeons have been mandated to write
electronic prescriptions to reach meaningful use; however, in
many cases this is not appropriate for surgical patients.
All of these issues and concerns were reported to the central
committee that created UMRS in response to federal mandates
and financial incentives. The committee responded it cannot
modify the system to make it more friendly to specialists and
subspecialists, despite the fact that procedures performed by the
subspecialists account for substantial revenues. Revenues are
down and the morale of the specialists and subspecialists has
plummeted to the point that many are talking about taking early
retirement or leaving the system. Still, the committee refuses to
fix the problems. Since you are the CIO of the entire health care
system, the situation is now in your hands. What will you do?
ASSIGNMENT 3
Introduction:
The Nursing Home Administrator has set up a meeting with his
team of administrators and asked for their input on a test of
their All Hazards Continuity of Operations Plan. Bob believes
there is no substitute for experiential learning and wants to have
a real-time scenario, acting out an All Hazards Disaster.
Tasks:
Case Study Fifty-Three: Is Whispering Willows Nursing Home
Prepared for a Disaster?
evaluation.

format:
· What are (only) the key points a reader needs to know in order
to understand how you will “solve” the case?
or a short paragraph explaining from what role you will address
the major problem and whether you are the chief administrator
in the case or an outside consultant called in to advise.
issues.

document.
Bob Freundlich is a Nursing Home Administrator at Whispering
Willows Nursing Home (WWNH). He runs a 200-bed facility in
a rust belt town on the banks of a river that flooded 10 years
ago during a hurricane. The WWNH residents are primarily on
Medicaid and their lower income families have been hard hit by
the latest downturn in the economy. WWNH is located one
small town away from a 72,500-acre military garrison that
stockpiles and tests biological, chemical, and other hazardous
materials. In addition, terrorist experts now are concerned about
attacks on “soft targets” such as schools, shopping malls, and
health care facilities (Blair, 2005). With the history of the town,
this report, and the nearby base, Bob has good reason to be
concerned about a disaster (FEMA, 2012).
Bob has set up a meeting with his team of administrators and
asked for their input on a test of their All Hazards Continuity of
Operations Plan. Bob believes there is no substitute for
experiential learning and wants to have a real-time scenario,
acting out an All Hazards Disaster. Bob begins his meeting by
sharing the recent Office of Inspector General (OIG) report that
identified “gaps in nursing home emergency preparedness and
response during disasters” (OIG, 2012). The authors found that
although every facility had a written plan on hand, when it came
down to operationalizing the plan, over 70% of the institutions
fell down on the following items on the CMS Emergency

Preparedness for Every Emergency checklist (CMS, 2009):
• “Pre-disaster planning had little input from outside
agencies, such as emergency planning officials, fire departments
and public health;
• When drills took place, they were primarily fire drills, table
top exercises, or county level exercises;
• Family members are expected to take residents in time of
disasters; less family involvement was found in facilities with
lower income families;
• Transportation contracts with bus and ambulance companies
were in place, however, there were issues related to these
vehicles being commandeered by the county during a disaster”
(Howard & Blake, 2012, slides 16–18).
Bob has invited the head of the county emergency planning
agency, John Spotte, to today’s meeting. He goes around the
room, introduces everyone, and asks his key administrators for a
status report on their part of the plan, noting gaps, to address
gaps, and their perspectives.
• The facility manager, Red Foxx reports, “I’ve looked at the
CMS checklist and I have everything ready to shelter in place
for seven days. However, I’m worried that our five-year-old
back-up generator, which has tested fine for short power
outages, may not be able to take the strain of a week’s worth of
work, especially if we’re to continue running the laundry
facilities. There are some newer generators on the market that
run on propane. I took the liberty of obtaining three bids to
purchase, install, and maintain five generators that would power
our entire facility for a week. They are a large investment and
would need to go into our capital budget.”
• The dietary manager, Kathy Gold, reports, “Like Red, I used
the checklist and have enough food and water on hand for seven
days. My only concern is keeping a fresh inventory. Most of the
goods are canned, but even they have an expiration date. My
dietary aides are already overworked, so I’m checking the
inventory on a regular basis.I found a software program that we
could use to scan the barcodes and dates. It will alert us to when

the inventory needs to be refreshed. It’s cheaper than Red’s
generators, but it still requires an investment of money and the
labor to do the initial data input. If we could get a health care
management intern from a local university, that would be the
first thing I’d assign to the student.”
• The transportation manager shakes his head. “You guys are
in much better shape than I am. If we have to evacuate our
residents anytime soon, we’re in trouble. I’ve been working on
contract negotiation with a bus company and an ambulance
company for transporting patients out of harm’s way in case of
a disaster. Neither company has responded to my concerns about
the ability of the company to handle disabled or ill residents.
And, they won’t promise to provide services if the county
commandeers their vehicles. We would also need to transport
food, water, medications, and specialized equipment. If we
could afford to buy a large container truck, two buses, and two
ambulances, I think we could work the rest out with the WWNH
vans and staff vehicles.”
Bob’s head is spinning. His disaster planning meeting is turning
into a disaster. His administrators are identifying more issues
and more potential expenses than he thought possible. Hoping to
hear some good news, he turns to the Ombudsman.
• Peter Peacemaker reports, “The good news is, I identified
and have a list of shelters that would take us in, if we need to
evacuate. Per CMS, they are at least 50 miles away from our
facilities, and the potential disaster. They are a little spread out,
but the director of each shelter has assured me in writing that
they will have grief counselors and mental health counselors
there at the time of the incident. The bad news is I met with as
many family members as I could find to set up an emergency
evacuation plan. Out of the 200 families, I could only track
down 100 who still lived in the state. Many have moved out of
state to find jobs because the industries they once worked in no
longer exist here. The other half is in state, but has challenges.
In the event of an evacuation, I could get about 50 families to
commit to come here in a disaster and pick up their loved ones.

So, that leaves us with 150 residents to move in a safe and
compassionate manner.”
The migraine that was lurking has now blossomed in Bob’s right
eye. He turns to the Director of Nursing (DON) and with a
pleading tone of voice says, “Sally Feelgood, do you have any
optimistic news for us?”
• The DON crosses her arms over her chest and says, “If there
is a smallpox outbreak, we are out of luck. We have 50
employees who have never been immunized against smallpox.
We do require them to have the flu vaccine every year. We
made that mandatory for continued employment last year. And
we fired two people who refused to get the shots, despite ample
warnings. However, I’m not sure what the legality of requiring
a smallpox vaccination is vis-à-vis a health care provider. I
looked at the CDC website, and the side effects can vary from
redness, swelling, and blisters at the injection site to
inflammation of the heart or a heart attack. If I didn’t already
have this smallpox vaccination scar on my arm, I don’t know if
I’d do it. In addition, when I asked the staff if they’d be willing
to remain during an All Hazards lockdown, half of them said
absolutely not, they would go home. We have to provide care
for our residents 24/7. I think we need to get some legal counsel
and coordinate with HR on this issue. I don’t want to overstep
any laws if I order people to stay during a disaster.”
Bob thanks everyone for their time and effort, asks them to e-
mail their reports and recommendations to him. After he pops
two aspirin, Bob asks John Spotte if he can stay for a while so
he can ask him some questions.
Assignment 4
You are the executive in charge of finances for the operating
room at Sleepy Hollow General Hospital. It has come to your
attention that you have five major orthopedic surgeons, all
using different vendors for their knee and hip implants. You
have held several meetings with the implant companies and
determined that if you went with one standard set of implants,
you could reduce your implant costs by 40%, a potential net

savings of $2.8 million to your institution in the next year. This
seems to be a reasonable objective, and you set up meetings
with the different orthopedic surgeons.
Tasks:
Case Study Seventy-Three: Conflict of Interest
Read the above case study, your task would be to evaluate this
evaluation.
format:
advise.

issues.
worth the effort required to achieve them! assignment should be
addressed in a 4- to 6-page document.
You are the executive in charge of finances for the operating
room at Sleepy Hollow General Hospital. It has come to your
attention that you have five major orthopedic surgeons, all
using different vendors for their knee and hip implants. You
have held several meetings with the implant companies and
determined that if you went with one standard set of implants,
you could reduce your implant costs by 40%, a potential net
savings of $2.8 million to your institution in the next year. This
seems to be a reasonable objective, and you set up meetings
with the different orthopedic surgeons.
First you meet with Dr. Goodcut and tell him you would like to
standardize the implants in the hospital. Dr. Goodcut tells you
he believes that this is a good idea. However, he will only use
the products from Alpha Company. He has used them for many

years, he knows how to use the equipment, and feels they are by
far the best product.
You next meet with Dr. Safari, one of your busiest orthopedic
surgeons. You again explain this process. He in turn agrees this
is a good idea. However, he will only use the products from
Beta Company. He has essentially the same logic and reasons as
Dr. Goodcut. This is beginning to seem like a theme.
You meet with the three remaining busy orthopedic surgeons to
see if they might be interested in switching to another implant
company. However, two of the surgeons would like to know
what is in it for them if they make the switch. The third surgeon
in this group will only use products from Gamma Company. He
has the same reasons that you have previously heard from the
first two surgeons. At best, you may be able to go with three
vendors instead of five;however, this will yield only a $200,000
savings.
You are a bit concerned at the surgeons’ reluctance to select a
standard implant company. Their reasoning seems insincere to
you. You begin to examine the websites of each of these
companies. Each company lists physicians who have either been
involved in the development of the product, or have played
consulting roles with their companies. Additional investigation
leads you to the discovery that Dr. Goodcut has been involved
with the development of the products at Alpha Company. In
addition, he is listed on the patent for several other devices.
You find similar relationships between the companies and the
other two orthopedic surgeons who are unwilling to switch their
implants. You begin to be concerned these surgeons have more
reasons than stated to resist switching. Each of them may, in
fact, have a conflict of interest.*
Assignment 5
Robert and Roy, emergency medical technician paramedics
(EMT-P), were back on the streets after a slow afternoon of
handling administrative tasks in the office. Neither paramedic
had checked the divert status board before heading out, so they

were unaware that numerous hospitals in the city were on
emergency department (ED) divert.
Tasks:
Case Study Eighty-Three: Emergency Divert Status
evaluation.
format:
advise.

issues.
document.
Robert and Roy, emergency medical technician paramedics
(EMT-P) were back on the streets after a slow afternoon of
handling administrative tasks in the office. Neither paramedic
had checked the divert status board before heading out, so they
were unaware that numerous hospitals in the city were on
Emergency Department (ED) divert.* After having worked 18
hours with only 3 hours off, they were hoping to settle into a
quiet shift that would allow them an opportunity to get some
rest.
Within 30 minutes of getting to their first assigned post, the
radio call came through that an adult and child were injured in
an automobile accident. Robert and Roy headed to the scene to
find that a father and daughter had been riding a bicycle when
they were struck at high speed by an automobile. The injuries

were serious and both needed emergency treatment. The
paramedics decided to take both patients to the nearby city
hospital for treatment.
Robert rode in the back and was in charge of caring for the
patients, while Roy drove. On the way to the facility the young
girl quit breathing and required intubation to sustain her airway.
Because of the time required to intubate and stabilize the
patient, Robert never notified the receiving facility that they
were coming with two critical emergent patients. In addition,
Roy, as the driver, never contacted the facility and also never
contacted dispatch to see if the facility was on divert.
Upon their arrival at the city hospital, Robert and Roy found out
that the hospital was on ED divert as well as pediatric trauma
divert. In other words, they were not accepting any patients to
the ED and they were not accepting any children. Because
Robert and Roy felt that they could not support the pediatric
patient any longer in the back of an ambulance, they wheeled
both patients into an unprepared Emergency Department. A
verbal battle ensued between the emergency room physician and
the paramedics, which led to a further delay in care for the
injured trauma patients. Ultimately, the hospital agreed to care
for the patients, but soon realized that the young girl had gone
into cardiac arrest and died. She could not be resuscitated.

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