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Strategy Management System in Perinatal Services: The Role of a Patient Resource Manager

Jones, Mary Lou Helfrich PhD, RN, CNAA; Filip, Stanley J. MD; Smith, Hope MSN, RN; Remsburg-Bell, Elizabeth MSN, RN

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The purpose of this article is to illustrate the role of a patient resource manager in an academic healthcare organization which has implemented a strategy management system. This management system is composed of communication tools organized in a balanced scorecard to support/promote ongoing growth and development using Kaplan and Norton’s Strategy Management System. The historical development of Duke University Health System (DUHS) is presented articulating the mission, vision, and strategic agenda of the DUHS with the Clinical Service Unit initiative and its relevance to Women’s Services. Kaplan and Norton’s 5 core principles of the strategy management system are applied to Women’s Services with implementation and evaluation of the patient resource manager role. Moreover, outcomes are discussed using the Balanced Scorecard. Lastly, implications and recommendations for replication of this system are summarized for ongoing development in this continuous learning organization.

Mary Lou Helfrich Jones, PhD, RN, CNAA, attended Washington Hospital Center, Washington, DC, for a diploma in Nursing, then earned a BSN at Southern College, TN, and an MSN and PhD in Nursing at the University of Florida. She has more than 30 years’ experience in Women’s and Children’s Health services in staff, management, and executive level positions. She is currently Assistant Operating Officer at Duke University Hospital and a Clinical Associate Faculty member of Duke University School of Nursing.

Stanley J. Filip, MD, attended Medical School at Mount Sinai School of Medicine in New York City and completed his OB/GYN training in Denver at the University of Colorado Health Sciences Center. He is currently Vice-Chairman for Clinical Affairs, Department of OB/GYN at Duke University School of Medicine and Medical Director of Women’s Services at Duke University Medical Center.

Hope Smith, MSN, RN, received a BSN at Indiana University of Pennsylvania, PA, and an MSN at University of North Carolina—Greensboro. Hope has nearly 20 years of experience in neonatal intensive care nursing and high-risk obstetrics. She is currently Patient Resource Manager, Duke Birthing Center at Duke University Hospital.

Elizabeth Remsburg-Bell, MSN, RN, has more than 20 years of experience as a nurse, practitioner, and administrator serving mothers and infants. She is currently Director of Clinical Operations, Duke Birthing Center at Duke University Medical Center.

Address correspondence and reprint requests to: Mary Lou Helfrich Jones, PhD, RN, CNAA, Assistant Operating Officer, Women’s Services, Duke University Medical Center, P.O. Box 3608, Durham, NC 27710 (e-mail: jones191@mc.duke.edu).

This article describes a systems approach that illustrates the structures and processes necessary to promote quality, effective patient-centered perinatal care with application of the patient resource manager role. The purpose of this article is to illustrate the role of a patient resource manager in an academic healthcare organization which has implemented a strategy management system that is composed of communication tools organized in a Balanced Scorecard to support/promote ongoing growth and development.

This article describes, discusses, and explains the following:

  1. The historical development of Duke University Health System (DUHS) will be presented.
  2. The mission, vision, and strategic agenda of the DUHS will be described.
  3. The Clinical Service Unit (CSU) initiative will be discussed and its relevance to Women’s Services.
  4. Kaplan and Norton’s Balanced Scorecard and the 5 core principles of the strategy management system will be explained and then applied to Women’s Services.
  5. The development of the patient resource manager role (PRM) and its implementation in the perinatal population will be described.
  6. Outcomes on the 4 perspectives of the Balanced Scorecard will be reported, noting the contributions of the PRM role.
  7. Implications with key findings and recommendations will be summarized for ongoing development in this continuous learning organization.
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Background and Historical Development of Duke University Health System

The DUHS was conceived and became a reality as an integrated academic health system. The vision of the health system was to provide healthcare for disease prevention and management throughout an individual’s life: infancy to adolescence, to adulthood, to senior care. The system was developed with 5 objectives:

  • support the academic mission,
  • grow the clinical enterprise at Duke University Hospital,
  • create new revenue streams,
  • further the development of the continuum of care, and
  • provide cost-effective, assessable population-based healthcare.

At a business level, the creation of DUHS was accomplished as a wholly owned subsidiary corporation of Duke University. This allowed the DUHS to enfranchise strategic partners and provide flexibility for integrating the clinical enterprise.

On a system level, the portfolio of services included physicians, hospitals, and alternative delivery systems. The physician services included the:

  • Duke University Hospital Physician Group (The Private Diagnostic Clinic), which includes 810 physicians in 90 specialties;
  • community private diagnostic clinic physicians, including 16 specialists at 17 practice sites in 11 surrounding counties;
  • Duke University Affiliated Physicians, including 59 primary care physicians in 17 practice sites in 7 surrounding counties; and
  • PrimaHealth Independent Practice Association (IPA), which included an additional 610 physicians in a wider range of counties from southern Virginia to south of Durham County.

Hospital services included the Duke University Hospital, a management contract for the Person County Memorial Hospital, a full-service community hospital (Durham Regional Hospital) and a community hospital (Raleigh Community Hospital). Alternative delivery sights included ambulatory surgery facilities, a lithotripsy facility, home care, rehabilitation, and aesthetics (See Table 1).

TABLE 1

TABLE 1

The largest obstacle in the integration of the hospital services for the DUHS was a prolonged negotiation for a relationship with the Durham Regional Hospital. In early 1998 these negations resulted in an agreement between the DUHS and the Durham County Hospital Corporation, the parent company of Durham Regional Hospital. This decision was supported in March of 1998 by a nonbinding vote of the Durham Regional medical staff, favoring a merger between the health systems in the community hospital. The final agreement between Duke and the Durham County Hospital Corporation was a 20-year lease effective July 1, 1998. The lease included the 446 licensed acute care beds, the Durham Ambulatory Surgery Center, Durham Regional Homecare, Oakley Alcohol and Substance Abuse Treatment Facility, the Watts School of Nursing, and the Wellness Institute.

In September of 1998, DUHS acquired Raleigh Community Hospital from Columbia/Hospital Corporation of America (HCA) in an outright purchase agreement for the 218-acute care beds in neighboring Raleigh, NC. Raleigh Community Hospital was built in 1978 by Tennessee-based HCA. When Columbia and HCA merged in 1993, the hospital was taken over by the merged entity. In September 1998, Columbia/HCA Healthcare Corporation announced it was selling 22 hospitals in its southeastern US network.

The strategic network development of the DUHS proceeded both horizontally and vertically. The horizontal integration as described above included the expansion of the Duke University Hospital and the Private Diagnostic Clinic expanding into the local community through allegiances with community hospitals and community physicians. The vertical integration began in the decade of the 1990s with the development of physician networks, infrastructure development (including insurance functions and care management), distribution systems, a primary care network, ambulatory services, alternative delivery development, and regional system development. As a mature health system the vision of total service throughout a patient’s lifetime has been achieved by acquiring assets that will be used for a patient’s lifespan including wellness and fitness, episodic medical care, inpatient hospital and ambulatory surgical care, extended care and home care, assisted and skilled nursing facilities, as well as end-of-life hospice care. 1

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Duke University Health System Strategic Agenda

As Duke University Hospital expanded its services in 1997 and broadened its scope to achieve the vision of becoming an integrated academic health system with multiple hospitals and healthcare facilities, an aggressive strategic agenda was developed, centering on its clinical, academic, research, and community mission.

In 1998 to 1999, DUHS reaffirmed this mission for excellence, innovation, and leadership in meeting the healthcare needs of patients it serves, improving community health, and fostering the best medical education and biomedical research. The Strategic agenda focused on three priorities:

  • promote quality, efficient patient care;
  • create a positive, supportive work environment; and
  • establish financial viability and stability within clinical services.

To achieve success on these priorities, a primary initiative was development of a concept called Clinical Service Units (CSUs). These CSUs were established for strategic and operational planning within the DUHS. This CSU model was a radical departure from the traditional academic health system with strong departmental chairpersons. Critical to its success was the commitment of these leaders to make this a successful management model. The CSUs were designed to span several related clinical services or, in some cases, be comprised of one distinct service line. The management model was intended to engage physician, administrative, and business support representatives. 2 Ten benefits were attributed to the CSU organization structure:

  1. Enhance the quality of patient care.
  2. Increase accountability to an easily identifiable management team.
  3. Improve communication among all the units involved in the continuum of care.
  4. Maintain the focus on patient and family needs.
  5. Minimize duplication of services within a service line.
  6. Promote service consistency along the continuum of care.
  7. Align incentives for all team members.
  8. Enhance the financial management and performance parameters.
  9. Optimize marketing efforts.
  10. Share learned knowledge among the CSUs.

Four prototype CSUs were developed:

  1. Women’s Services.
  2. Heart Services.
  3. Perioperative Services.
  4. Children’s Services.

The management team was appointed by the hospital’s Chief Operating Officer. The CSU Executive Team for each of the CSUs was comprised of a medical director, a hospital administrator, an administrator from the physician group, and a financial administrator. Success was demonstrated by the partnership developed between the medical director and hospital administrator. Interpersonal skills, political acumen, creativity, and “out of the box” thinking were crucial to support consensus building and change management during several challenging and complex situations. Each of the CSU Executive Teams participated in an institutionwide CSU Steering Committee that fostered collaboration on the strategic agenda through the use of the Balanced Scorecard Strategy Management System.

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Communication Structure

The communication organizational chart for the Women’s Services CSU was typical of the structure established for the other CSUs (see Figure 1) to show the connectivity and information flow among the interdisciplinary groups. At the top of the chart was the Business Development Steering Committee, comprised of key leaders in the clinical and the administrative areas of Women’s Services. These key leaders monitored the progress of important projects and were also used for input regarding strategic planning and defining priorities for future work. Between the Business Development Steering Committee and the clinical units were 2 entities: the Women’s Health Advisory Board (whose function was primarily to raise funding for research initiatives) and the Community Advisory Council (which was comprised of persons in key leadership positions from the community, such as business leaders, superintendent of county schools, police chief, mayor’s office staff, county commissioners, human service organizations/ interest groups, and interfaith community). Four major clinical areas reported directly to the Business Development Steering Committee:

FIGURE 1

FIGURE 1

  1. the perinatal steering group, which is composed of the inpatient and outpatient obstetric service area;
  2. the benign gynecology and gynecologic oncology group;
  3. the ambulatory services group, which was comprised of the major administrators for ambulatory services; and
  4. the outreach and community education groups, which managed health promotion education and community outreach.

A fifth area, the Women’s Academic Advisory Committee, was integral to the academic mission of the DUHS. This multidisciplinary group advised the academic/research and development activities for Women’s Services.

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Strategy Management System

The Balanced Scorecard Model originated in 1990 from a 1-year multicompany study. 3 The study concluded that reliance on mere financial measures was insufficient for managing organizations in increasingly complex and continually changing environments, particularly in organizations with success factors based on intellectual capital and knowledge-based assets. Evolution of the Balanced Scorecard over the last decade transformed this model from an improved measurement system to a strategic management system. This evolution resulted in the expansion of senior executives to line management staff using the Balanced Scorecard as a central organizing framework to create, communicate, execute, monitor, and learn from strategic and tactical implementation. Using the Balanced Scorecard resulted in the attainment of a focus and alignment of all key stakeholders necessary to the successful achievement of the defined strategy.

The Balanced Scorecard strategic management system is composed of a framework, core principles, processes that translate an organization’s mission and strategic agenda into a comprehensive set of performance measures, and strategically aligned initiatives. The organization’s mission and strategy are the foundation on which the outcomes (i.e., customers, financial, internal business, and learning and growth) are developed. These 4 perspectives provide the framework for the Balanced Scorecard. 4,5

This framework provides a balance between the short-and long-term objectives, financial and nonfinancial indicators, internal and external measures, and specific outcomes the organization has targeted related to customer and financial perspectives and the underlying influences on these outcomes, particularly in the internal business (e.g., patient care flow) and learning and growth perspectives (e.g., clinical competencies, skills).

The Balanced Scorecard was successfully applied not only in industry but also in government, nonprofit, and healthcare organizations. 4–6 The main difference in applying the scorecard to the healthcare organizations was that the customer perspective was the primary outcome the organization was striving to achieve. In fact, Duke Hospital (within DUHS) placed the overarching objective (mission) to achieve excellence in clinical care at the top of the scorecard, with all the other objectives on the scorecard oriented toward improving this high-level objective, external, and customer satisfaction (see Figure 2).

FIGURE 2

FIGURE 2

Developing the scorecard was only the beginning. Leaders in organizations who successfully implemented a Balanced Scorecard adopted 5 principles of becoming a strategy-focused organization:4–6

  1. Translate the strategy to operational terms.
  2. Align the organization to the strategy.
  3. Make strategy everyone’s job.
  4. Make strategy a continuous process.
  5. Mobilize change through executive leadership.

Figure 3 illustrates the process of applying these core principles. To follow principle 1, the organization describes strategic initiatives in operational, understandable terms using cause-and-effect linkages among all 4 perspectives. The result of this work leads to creation of a “strategy map” which concisely illustrates the desired outcomes from the strategy and processes that facilitate achievement of outcomes. (Illustration of strategy maps for Women’s Services is shown later in the article.)

FIGURE 3

FIGURE 3

Completion of the scorecard began by delineating a clear mission to meet the healthcare needs of the individuals served by DUHS. First, for the customer perspective, the cause-and-effect hypotheses generation process sought to ask who the organization was to serve to achieve this mission, and what was the value proposition to meet customers’ objectives. Second, for the internal business perspective, the cause-and-effect reasoning moved to determine the processes an organization must accomplish to serve its customers/patients well and achieve the vision (value proposition). Third, the cause-and-effect process for the learning and growth perspective sought to determine the infrastructure and competencies that would be present in the organization to support the delivery of optimal patient care as defined by this model. Fourth, for the financial perspective, the cause-and-effect analysis proceeded to define the clear financial objectives for organizational survival and growth. In summary, a thoroughly completed Balanced Scorecard made the mission explicit and described the organization’s strategy through cause-and-effect links between strategic objectives and outcomes in the multiple perspectives. Every outcome measure was part of this cause-and-effect association that described the organization’s strategy. A clear “line of sight” was created from the mission and strategic agenda to the local area where the employee could see the contribution the work has upon achieving this mission. During the implementation and ongoing work of the organization, the monitoring of these connected measures over time promoted organizational learning from its strategy. 4,6

For Principle 2, alignment of the organization around its strategy was achieved by engaging the entities within the organization to articulate the extension of the mission, vision, and strategic agenda to a specific clinical service, program, or department. This effort resulted in the development of a specific Balanced Scorecard for each program, reflecting the high-level themes of Duke University Hospital/DUHS and demonstrated how local program actions contributed to achieving the mission, vision, and strategy. 4,6

Once the Balanced Scorecards were formalized for each of the service areas, Principle 3 illustrated that the strategy must be everyone’s job and provided a clear line of sight from the local objectives and actions of individuals and programs/departments contributing to achieve the DUH/DUHS objectives. This principle focused on the development of ownership and accountability for specific activities. 4,6

The development of budgeting and learning processes through monitoring and decision support was an important activity within Principle 4. This process cultivated learning within the establishment of the cause-and-effect linkages from the strategy maps to illustrate financial impact on clinical outcomes.

Principle 5 illustrates the crucial leadership roles senior administration undertook throughout the process of shaping the scorecard and aligning all the programs/service units to the strategic agenda, effectively communicating the scorecard to all stakeholders on all levels, and managing performance against outcomes and targets in the scorecard.

Notably, Balanced Scorecard development was not an exercise in measurement but a major change initiative. The initial focus was on mobilizing and energizing the organizational leaders to launch the process for the strategy management system. Once this was launched, the focus centered on governance and building team-based approaches to transform to a new performance model. Over time, the management system transitioned to a strategic management system. This new system resulted in a cultural transformation and may take 2 to 3 years to become integrated into the organization’s operations. 2,4–7

Using such a strategic management system was crucial to success in today’s turbulent healthcare environment. To date, the Duke University Hospital has implemented the Balanced Scorecard with its core principles in the clinical service unit (CSU). Efforts are underway to extend these to departments and programs throughout the organization.

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Clinical Service Unit Development: Application of the Balanced Scorecard Strategy Management System

This section outlines the evolution of Women’s Services from its inception in 1998. The Women’s CSU Business Development Steering Committee began with a review and revision of the mission and vision of Women’s Services, originally created during a 1997 strategic planning process and most recently updated in 2000.

This mission: Duke Women’s Services will meet the healthcare needs of women in the community through accessible, compassionate, affordable, high-quality care; education and support of clinicians, teachers and researchers; research to conquer disease and to enhance women’s health; and, advocacy for improving women’s health through community collaboration and partnerships.

The shared vision: To be the premier academic center with multidisciplinary teams that partner with women; to provide high-quality care, information, and guidance; to be recognized as national innovators and valued in the local community; to reach out to women and their families in the community through health promotion, education, and information; and, to advocate for improvements in women’s health.

Extending the DUH strategic agenda, Women’s CSU set 6 major objectives, the first three of which were aligned with the institution’s objectives:

  1. promote quality, efficient patient care;
  2. create a nurturing work environment;
  3. establish financial viability and stability;
  4. enhance and build relationships with consumers and providers;
  5. explore new programs and services; and
  6. develop research/academic programs.

To achieve the overarching objectives, a strategy map for each objective was created. For each strategy map, a set of specific strategic objectives, skills, and outcomes were identified relating to the overarching strategy. Figures 4–9 illustrates the strategy maps developed. First, objectives were delineated that built on a focus on mission which included establishing targets, priorities, and expectations, with specific design teams (such as the care coordination team with the patient resource manager role) as a crucial component. Another essential objective was to respond to patient satisfaction data and meet/exceed expectations on targets set by Duke Hospital. Moreover, a key objective was to evaluate the skill mix for patient care delivery on the inpatient units, specifically the Duke Birthing Center. All of the identified objectives were centered on achieving value-added, high-touch care. 4,6

FIGURE 4

FIGURE 4

FIGURE 5

FIGURE 5

FIGURE 6

FIGURE 6

FIGURE 7

FIGURE 7

FIGURE 8

FIGURE 8

FIGURE 9

FIGURE 9

Second, strategic skills needed to achieve the objectives were defined. These skills included team building with individual team member role definition and accountability defined by setting expectations and outcomes. An important aspect of team development was to create an infrastructure that would enhance effective communication and the work of the team with appropriate revisions for ongoing effectiveness. Other skills within the service included education and training to address the gaps that existed and would achieve necessary competencies. To facilitate achievement of these expectations, role modeling and coaching for desired behaviors was another important skill to master. Finally, the ability to translate data for decision support, establish, and monitor a communication process related to the monitoring of clinical and operational outcomes was crucial for successful attainment of the strategic objectives. Notably the strategic skills described were those expected in many of the strategy maps presented for overall successful performance in the organization. 4,6

The third component of a strategy map was to define specific performance measures that would report outcomes related to the strategic objective. For the strategic objective of achieving quality, efficient patient care, there were outcomes related to the 4 perspectives on the Balanced Scorecard. Patient and physician satisfaction, new referrals targeted for the population, market share, and preference rankings were described in the customer perspective. Patient flow was an important internal business measure. These measures were linked to the strategy maps of achieving financial survival and viability which focused on the financial perspective and that of creating a positive, supportive work environment that was measured in the growth and learning perspective with employee satisfaction, educational development, and retention statistics.

Translating the mission, vision, and strategic agenda to the reality of daily operations in the organization required use of a process of engaging department leaders and staff to organize their communication structures, employee development programs, and performance activities that would link effective managers and models for staff and team performance. A Perinatal Steering Group was formed, led by the Medical Director (also the Section Chief, Maternal Fetal Medicine), and the Director, Clinical Operations, Duke Birthing Center (DBC). This multidisciplinary group met quarterly and was composed of clinical leaders and support staff from Obstetrics, Newborn/Pediatrics, Perinatology, Nurse Midwifery, OB/GYN Clinic, Social Work, Patient Resource Management, Parent Education, Perinatal Outreach, Risk Management, Pastoral Care Services, Food/Environmental Services, Management Engineering/Finance, Information Services, and Innovation and Strategic Improvement. The Medical Director and Assistant Operating Officer, Women’s Clinical Services served as advisors. This forum provided an opportunity to communicate the progress on the strategic initiatives, dialogue on challenging issues across departments and disciplines to reach solutions, and make progress to achieve the specified targets for quality, cost-effective clinical care.

One role that was created to provide a clear linkage to patient care management on the continuum is the Patient Resource Manager. The next section of the article focuses on the historical development of the role, its implementation, and initial evaluation.

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Patient Resource Manager Role

The year 1995 brought the emergence of Managed Care at Duke University Hospital. It resulted in the creation of the Division of Managed Care Services. The program’s 4 objectives were to

  1. enhance service to patients and families,
  2. decrease length of stay,
  3. decrease cost per adjusted discharge, and
  4. improve services to payers.

At this time, care facilitation was overseen by multiple disciplines and departments, resulting in fragmentation of care. A multidisciplinary team was initiated in November 1998 to develop a solution to the fragmented care that frustrated patients, physicians, and hospital employees. Case Management, Social Work, and Advanced Practice Nurses all undertook roles in these processes, but no strong sense of accountability was evident. Physicians had limited involvement and understanding of the process, and had to seek multiple disciplines for follow-up to care coordination. The model was unit based for case management and social work, which resulted in these disciplines having to interact with multiple physicians. This limited their ability to round with the physician, creating a hindrance to a true understanding of the plan of care. It was obvious to many that changes needed to be made, and the hospital embarked on a redesign process.

In 1999, The Department of Patient Resource Management (PRM) emerged from this redesign process under the Division of Care Coordination. The vision for the program was the seamless coordination of the right resources at the right time for each patient to ensure the level of quality and cost effectiveness of care expected at a world-renowned academic medical center. The mission was to coordinate effective and efficient patient care along the continuum within the complex and dynamic healthcare environment by working collaboratively and innovatively with physicians and healthcare professionals. The PRM Program’s mission and vision statements were consistent and supported the organizational mission and vision, extending these values to the local department level. The successful creation of the PRM Program was the result of physician to hospital collaboration in an effort to maximize efficiency, monitor, maintain, and improve quality, while decreasing the cost of patient care. Key characteristics of this new program are outlined in Table 2.

TABLE 2

TABLE 2

In November 1999 the first group of 10 PRMs was launched representing the Heart Center, Orthopedics, and Rehabilitation. The DBC hired 2 of the 4 designated PRM positions in October 2000. The third was hired December 2000 and the fourth started orientation in February 2001. Of these 4 positions, 1 PRM coordinates care along the continuum for complex high-risk pregnancies and women with known fetal anomalies. This PRM was previously the Perinatal Clinical Nurse Specialist. The additional 3 PRMs coordinate care for designated Obstetrical Practices, primarily in the inpatient setting. Two of the 3 PRMs transitioned from Case Management and 1 transitioned from a Nurse Discharge Coordinator position. The members worked well together prior to the transition, and each brought their own strengths to the team. This allowed them to move forward quickly and the evolution of the DBC PRM Program began. As you will see from the program objectives, the opportunities for a positive impact on care were numerous. The prime question was where to start.

Patient care coordination was an obvious focus for the DBC PRMs. They facilitated patients through the system, worked with physicians to implement the plan of care, worked with colleagues to maximize efficiency, strategized alternative sites of care and care processes, and built relationships with community providers.

Discharge planning was another priority focus. This required a proactive approach, first with a review of the nursing admission assessment for high-risk discharge planning needs, and followed by a face-to-face screening. With the coordination of discharging a mother and her infant(s), strategies needed to be developed to decrease discharge delays. This included establishing a targeted focus on length of stay as an internal business outcome.

Resource management was another focused objective for this role. PRMs served as a resource for physicians and staff. They were also the communication resource for managed care companies and the singular communicator for third-party payers. One of the goals was to improve communication to third-party payers in order to optimize reimbursement and decrease insurance denials.

There were many opportunities for process, quality, and outcomes improvement. PRMs shared CSU accountability for setting and achieving Balanced Scorecard targets and outcomes. An opportunity for current development centered on clinical cost reduction while maintaining quality care. PRMs participated in data collection, and facilitated outcome measurement with a quarterly report including Balanced Scorecard indicators. They met regularly with the CSU Leadership and Physicians, identifying areas for system/process improvements to develop strategies, implement change, and evaluate effectiveness. PRMs reported quality issues and participated in focus groups as requested.

Another objective was relationship and team building. PRMs were a role model for collaborative practice for patient care teams. They also acted as a liaison between physician practice and the hospital. This included relationship building with our referring physicians and external customers.

Physician partnership was essential to the success of this program. There was a shared accountability structure that was hospital based. PRMs were hired for specialty services, with physicians, hospital, and clinical administrators interviewing prospective PRMs and providing valuable feedback considered in the hiring process. PRMs participated in daily rounds, and partnered with physicians, to identify and analyze practice patterns. They were a conduit for operation issues that impact patient care. Physicians and staff relied on the PRMs for resource utilization questions, discharge planning issues, reimbursement, regulatory requirement and compliance, and other issues related to improving progression on the continuum of inpatient to outpatient care.

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Balanced Scorecard Application to the Duke Birthing Center

In this section, use of the Balanced Scorecard to monitor progress on targeted performance measures in the 4 perspectives is illustrated as applied to the DBC. A key learning objective was to assess the balance of the outcomes for these perspectives, then visualize the linkages and connections that each one contributed to the successful achievement of the mission for quality, cost-effective, patient-centered care to meet the healthcare needs of the people served by Duke Hospital.

Within the Women’s CSU, an OB Executive Team was organized as a local team to establish priorities for the DBC to align them with the overall DUH mission/vision and strategy. This multidisciplinary team, also led by the Medical Director, (also the Section chief, Maternal Fetal Medicine), and the Director, Clinical Operations, DBC, was composed of the Medical Director, Newborn Nursery, Patient Resource Managers, Management Engineering, and the Women’s Services Medical Director and Assistant Operating Officer. This team met monthly to determine priorities for patient care management and operational processes, set Balanced Scorecard indicators extended from the organization and defined on the local level, monitored outcomes and communicated with various stakeholders, and planned for ongoing development. A discussion follows related to the identified Balanced Scorecard indicators with progress and plans on the customer service, business, growth and learning, and financial perspectives.

In the DBC, there is a reception area for triage, an operating suite, and 2 patient care units. The OB Reception area has 8 patient care beds used for triage, antenatal/postpartal procedures, and postanesthesia recovery. The operating suite has 3 operative delivery rooms. The “5700 unit” has 20 labor-delivery-recovery-postpartum (single room maternity stay) rooms. The “5800 unit” has 16 rooms with the scope of service directed at primarily postcesarean section care. Both units have closed-circuit hospital education programs. The difference between the 2 units is related to the physical facilities as most of the staff are cross-trained to provide care in both units. The “5700 unit” has larger rooms with whirlpool tubs in the bathrooms. The “5800 unit” has a traditional-sized private hospital room with a shower. There is one “dissatisfier” that patients may experience: When the unit is busy, the patient in the “5700 unit” may be moved to the “5800 unit” postbirth to accommodate a mother in active labor.

For the customer service perspective in the DBC, patient satisfaction was measured using the Press Ganey Survey tool. 8 This survey was introduced into DUHS in July 1999. Table 3 provides a comparison of scores on patient satisfaction variables related to overall satisfaction and discharge coordination indicators. Over the first 8 quarters, the overall trend analysis for the DBC “5700 Unit” related to patient satisfaction reveals an increase by 7.2% from 73.9% in the third quarter 1999, to 81.1% for the second quarter 2001. The DBC “5800 unit” demonstrated an increase by 4.6% from 74.9% to 79.0%. Specific indicators related to discharge coordination and preparation for home services were also positive. These indicators are instructions regarding care at home and the extent the patient felt ready for discharge. Instructions regarding care at home improved on 5700 by 4.6% and declined on 5800 by 6.2%. Notably, patients on the “5700 unit” reported a higher level of satisfaction with the extent they felt ready for discharge, increasing by 7.8% from 80.6 to 88.4%. On the “5800 unit” a higher level of satisfaction was reported with the extent patients felt ready for discharge, increasing by 2.0%, from 84.3 to 86.3%. The “5800 unit” was recognized as most improved on patient satisfaction scores in FY 2001, ending June 2001.

TABLE 3

TABLE 3

From a business perspective, patient flow measures revealed positive progression to reduce length of stay as illustrated in Table 3. For vaginal deliveries without complications, the length of stay declined by 0.11 days, from 2.25 days in FY 2000 to 2.14 days in FY 2001. For cesarean births without complications, the length of stay declined by 0.26 days, from 3.72 in FY 2000 to 3.46 days in FY 2001. Readmission rates were another indicator. The readmission rate for vaginal deliveries without complications within 7 days was 4 (0.2%), and within 30 days was 13 (0.6%) in FY 2000 (of 2,350 vaginal deliveries) compared to 16 (0.7%) in 7 days, and 24 (1.0%) in 30 days in FY 2001 (of 2,351 vaginal deliveries). For cesarean sections without complications the readmission rate within 7 days was 23 (2.6%), and within 30 days was 28 (3.2%) in FY 2000 (of 882 cesarean sections) compared to 18 (2.0%) in 7 days, and 27 (3.0%) in 30 days in FY 2001 (of 902 cesarean sections).

From a growth and learning perspective, indicators identified were orientation data indicating RN cross-training levels, position vacancy for retention, and work culture activities to provide a positive, supportive work environment (see Table 4). The educational measures related to providing cross training for competency in multiple areas within the DBC. In July 1999, 31 RNs of 65 RNs (47.7%) were cross trained for labor and delivery and maternal newborn care. In July 2001, 60 RNs of 78 RNs (76.9%, an increase of 29.2%) were cross trained with a targeted goal to complete cross training of all current staff by Spring 2002. In the orientation program, RNs received cross training during their 12-week orientation period. Data Retention statistics (positions filled/vacancies) were also monitored. In July 1999 there were 12 RN vacancies of 65 RNs. In July 2001 there were no RN vacancies, with 8 to 10 RNS in orientation (which would fill all vacancies). Among the other clinical team in July 1999, there were 5 Nursing Care Assistant I and Nursing Care Assistant II vacancies, 4 OB Techs vacancies, and 4 Health Unit Coordinator (HUC) vacancies. In July 2001, the vacancy rates were 1 NCA, 0 OB Techs, and 0 Health Unit Coordinators.

TABLE 4

TABLE 4

Specific strategies to enhance the work environment included a management team structure to support staff, changing orientation schedules to be 8-hour days, providing assigned preceptors with orientee’s working their preceptor’s schedule, consistent charge nurses, and formalized opportunities to evaluate their orientation. Engaging DBC staff in governance structures such as a clinical practice council, education committee, and cost containment team have been successful. Additionally, a scheduling committee developed processes to enhance meeting employee’s scheduling needs.

For the financial perspective, the cost per discharge for vaginal deliveries and cesarean sections without complications were targeted for an expense reduction of 10% over 3 years. These indirect and direct costs were reported. Results shown in Table 5 reveal the direct cost per case for vaginal deliveries declined by $26 (2%) from $1,408 to $1,382 with a targeted cost of $1,270, which exceeded target by $112 (9%). The direct cost per case for cesarean sections declined by $108 (6%) from $1,934 to $1,826, which exceeded targeted cost of $1,741 by $85 (5%). Activities to reduce expenses and generate revenue are underway with a revision in the charge structure to more completely charge for appropriate expenses and to renegotiate contracts for a realistic reimbursement for care provided. Expected changes are planned for October 2001 and results anticipated within the first quarter.

TABLE 5

TABLE 5

In summary, the Balanced Scorecard data provides information for evaluating performance and influencing appropriate changes to achieve the organizational goal of quality, efficient care, a nurturing work environment, and financial viability and stability. The 8-month old fully staffed DBC PRM program has resulted in several key positive influences. They have contributed to the increased patient, staff, and internal and external physician satisfaction. Patients now have a singular resource for questions or concerns, both inpatient and outpatient. Improved communication between referring physicians and the PRMs has resulted in increased referrals to the Duke Birthing Center. Participation in the daily rounds of Obstetrics and Pediatrics has improved communication among the multidisciplinary team, contributing to a more efficient discharge process and increased member satisfaction. There have been no “delay in notification” insurance denials, a significant decrease since implementation of the program. It is anticipated that future positive influences will be seen as a result of this ongoing program.

TABLE

TABLE 6

TABLE 6

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Key Learnings

As the Women’s CSU was organized in a multidisciplinary structure, efforts have been made to be inclusive and engage the contributions of all the key stakeholders for program improvements to enhance clinical patient care and financial outcomes in a nurturing environment.

Using Kaplan and Norton’s Strategy Management System implemented by the Senior Administrative level of the DUHS—extended to DUH and to Women’s Services—has created a structure built on the core principles of the alignment strategy. Corporate and business units recognize the value of making it everyone’s job, essentially creating a “line of sight” for individual employees to know that the work each individual performs makes a difference in the delivery of patient care. The alignment strategy allows the organization to achieve the mission that “we meet the healthcare needs of the people we serve and are the preferred providers of care in our local community as well as on a regional, national, and international basis.”

The structures created promote communication on multiple levels, from the local departments to the CSU teams and to the DUH Executive Team. This communication supports the underlying goal of creating a learning organization by establishing processes that enhance the learning of the day-to-day operational work with outcomes. By receiving data that are used for information to assess success on an objective, the clinical and operational teams can affirm that progress is being made toward the desired direction, or provide the opportunity to alter interventions to steer the department or service in a direction that will achieve the desired result.

The PRM role has begun to significantly affect the care delivery system. This role supports the healthcare providers and administrative personnel with effective communication tools on which to progress and recognize the factors that contributed to the success of meeting the Balanced Scorecard indicators. This program is new and the role is continually evolving.

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Summary

Now that this work has begun in DUH on the CSU level, it is being extended to departments and support services areas to encompass the entire organization. As one reflects on the application of this Strategy Management System in Women’s Clinical Services within the Duke University Hospital, it is important to recognize that this organization is in continual evolution, ever changing and growing to be the preferred provider of Women’s Services for the patients, employees, and payers in this market. Initially a nonhealthcare industry model, the Strategy Management System has proven valuable in a healthcare setting to the extent that clinical services are enriched, informed, and influenced in a positive direction. Using this system, clinical and administrative leaders are equipped to manage the uncertain environment of emerging healthcare systems and intervene with innovative strategies that balance short-term activities with long-term objectives. This approach allows the organization to survive and thrive while serving the healthcare needs of women in this community. 7,9,10

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References

1. Zimmer J. Duke to buy North Raleigh Hospital. The Durham Herald, C-1. May 20, 1998.
2. Jones MLH, Filip SJ. Implementation and outcomes of a balanced scorecard model in women’s services in an academic health care institution. Quality Management in Health Care. 2000; 8 (4):40–51.
3. Kaplan RS, Norton DP. The balanced scorecard: Measures that drive performance. Harvard Business Review. 1992;Jan–Feb:71–79.
4. Kaplan RS, Norton DP. Using the balanced scorecard as a strategic management system. Harvard Business Review. 1996;Jan–Feb:75–85.
5. Kaplan RS, Norton DP. The Balanced Scorecard: Translating Strategy into Action. Boston: Harvard Business School Press; 1996.
6. Inamdar N, Kaplan RS, Jones ML, Menitoff R. The application of the balanced scorecard to the National Women’s Health quality initiative. Quality Management in Healthcare. 2000; Summer, 21–39.
7. Chow CW, Ganulin D, Teknika O, Haddad K, Williamson J. The balanced scorecard: A potent tool for energizing and focusing healthcare organization management. Journal of Healthcare Management. 1998; 43 (3):263–280.
8. Press, Ganey, and Associates. Client Reference With a Guide to Interpreting Your Report. South Bend, IN: Press, Ganey, and Associates; 2001.
9. Castaneda Mendez K, Mangan K, Lavery AM. The role and application of the balanced scorecard in healthcare quality management. Journal Of Healthcare Quality. 1998;Jan–Feb:1–7.
10. Anderson RA, McDaniel RR. Managing health care organizations: Where professionalism meets complexity science. Health Care Management Review. 2000; 25 (1):83–92.
© 2002 Lippincott Williams & Wilkins, Inc.