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Physician Leader Advances the Quality Agenda
Through Service Line Development
by Mary M. Nisbet
Located in Raleigh, North Carolina, Rex Hospital is a 394-bed facility with 850 physicians on staff and 26,862 admissions. Dr. Leland Garrett serves as Physician Chair for Rex’s Pulmonary/Nephrology/Renal Service Line. His insights from his interview with Service Line Leader are shared here. In a future issue of Service Line Leader, Rex Hospital will be the featured organization.
His discipline and focus stems in part from his time in the U.S. Air Force. Dr. Garrett’s path has been interesting and has cultivated his talent for leadership. He served as the director for a nephrology fellowship program and subsequently took on new challenges as chief consultant for internal medicine for the Air Force Surgeon General’s Office. As chief consultant, he had administrative responsibility for all internists, medical sub- specialists, pathologists and dermatologists in the Air Force.
After 20 years in the service, private practice beckoned and Dr. Garrett joined a nephrology practice in Raleigh in 1991.
His Air Force experiences as well as training from Continuous Quality Improvement (CQI) guru Jonathan Deming sharpened his skills for healthcare administration. “CQI was an integral part of my government sector work, so I already had three or four years of experience working with quality and process improvement. I also knew that involvement at the leadership level was key to making and managing change.”
In 1996, Rex Hospital’s CEO (who has since left the organization) determined that the organization’s performance required a change in direction. Medical leadership was disenfranchised and also believed that change was necessary. Although he was somewhat distanced from the medical staff, the CEO realized that involvement and support from the physicians was of paramount importance.
“He sat all factions at the table,” says Dr. Garrett, “and they discussed Rex Hospital’s performance, goals and objectives. The focus was on finance, but it soon shifted to a focus on quality. We all believed then ¼ as we believe now ¼ that improved care results in improved costs. ”
These conversations were the beginning of the cultural revolution at Rex. What evolved was a focus on quality, with patient populations as the foundation for reorganization. The leadership team reshaped the structure around DRGs and began its journey to retool Rex into business units. The story of that evolution will be covered in a future issue of Service Line Leader.
Dr. Garrett’s service line is called PRIME ¼ Pulmonary/Renal/ICU/Medicine. How this service line came to be had a great deal to do with geography and the complicated nature of patient care for these patients.
- One nursing unit housed both pulmonary and renal patients.
- Both the pulmonologists and nephrologists wanted to develop physician protocols.
- Nursing leadership wanted to enhance clinical competencies for care of these complex patients.
Thus, the PRIME service line was born. “Many organizations wouldn’t think to group pulmonary and renal in one service line; Rex may be the only organization to do so. That’s the beauty of service lines; what works for us at Rex may not work elsewhere, but that’s okay. Our focus has brought the right physicians and the right operational leaders together to focus on quality, patient satisfaction, and cost ¼ in that order.”
An organizational strength Dr. Garrett observes is leadership’s ability to rethink a strategy and take action. “With the advent of our new CEO, the leadership team felt that a review of our service lines was in order. A streamlined approach emerged, as the organization’s core businesses were re-confirmed for focus. The Medicine Service Line team believed that their work could be better accomplished by dispersing rather than maintaining a less than functional service line. And the ICU needed a voice in the QI environment.”
Previously the Medicine Service Line was floundering because its patients were spread throughout the system. With the inception of Rex’s hospitalist program, the internists began developing protocols in partnership with the PRIME physicians.
The changes that were made in the structure were bold and decisive, sending a message throughout the ranks that strategies are meant to reshape over time.
Rex’s service line reporting structure also sends a message to the system at large. For operations, PRIME reports to a vice president. For Quality, the service line reports directly to the health system’s Quality Improvement Committee, which is chaired by the president of the Medical Staff. The QI Committee chair appoints service line physician leaders.
“With service lines reporting directly to the Quality Improvement Committee, all dots are connected. We have everyone we need at the table to review quality improvement activities and issues. If one area is impacting another, the players are there to determine next steps.” The PRIME service line discusses its strategic business and quality plans with the QI committee chair once a year, during the budget process.
Inclusiveness is key to Dr. Garrett’s approach to problem solving and team dynamics. PRIME has three service line medical directors; in this case, three is not a crowd.
Dr. Gerald Maccioli, anesthesiologist, heads ICU and is board certified in critical care. Dr. Stuart Levin is a board certified pulmonologist. Dr. Garrett is a board certified nephrologist. All three work closely with Gail Sturtevant, service line sponsor (administrator), Kathy Quarttocci, and Joan Cederna-Moss (service line coordinators).
“Our Critical Care physician leader has a national reputation and has shaped the ICU into one of the best community hospital ICUs in the country. Dr. Maccioli needed direct access to the quality improvement process; our service line had a strong patient presence in the ICU, so physician linkages were crucial. It made sense to bring him as co-chair of the service line.”
Each chair has a working group that focuses on a quality improvement initiative. For example, Dr. Levin has an asthma working group that is working on an adult asthma protocol. The ICU working group is focusing on outcomes research. Dr. Maccioli, who is an anesthesiologist, also reports to the chair of the Department of Surgery ¼ thereby shoring up the linkage between surgery and ICU.
The PRIME team also includes a nutritionist, a PharmD, respiratory therapist, pathologist, and service line sponsor (administrator). “The model is totally evolutional,” says Dr. Garrett. “As the issues focused, we found we had to add members to the team in order to cross departmental lines and improve care.”
A case in point was the team’s focus on time to antibiotic therapy for pneumonia. “The Emergency Department had to be at the table but wasn’t excited about following the process across the continuum. Since then, the ED has become heavily involved and one of the senior ED nurses sits on the team. We collaborated to improve care along a continuum and broke through departmental silos. Now the ED has better time to antibiotic administration than the direct admissions to the floor.”
For the PRIME team, care of the renal patient was a source of frustration. Patients sometimes waited hours for bedside dialysis. To improve quality and access, the team recently shifted care from the bedside to a four-station dialysis unit. Within six months, the unit was running on two shifts and paid for itself.
The PRIME team’s agenda is always jam packed and includes:
- ICU outcomes data report
- PRIME outcomes data
- Patient Satisfaction Survey data
- Market Analysis
- Policy Changes
- Drug Utilization and ADEs
- Nursing Home Bed Availability/ventilator and dialysis patients
“The service line concept is very similar to the approach used by the nephrology team. Our specialty has used team care for years, bringing together social work, nursing, dietician, and physicians to address patient care issues. Service line management aligns everyone with a vested interest in care of the patient. Problem solving moves to a higher plane.”
In PRIME’s early days, for example, the service line encountered in working with Purchasing to stock multiple forms of dialysis solutions in different concentrations. With the assistance of Dr. Garrett, a nurse manager designed a service level agreement between the service line and purchasing to assure that par levels would be maintained. Now agreements and signatures are not required. Relationships have cemented and interests are aligned, a sign of maturity in the evolution of the structure. “We have come a long way since those early days. Today, a phone call is all that would be needed to effect such a change.”
PRIME’s service line structure is sometimes “invisible” to the medical staff because care is exceptional, staff is working well together, and physicians are involved. According to Dr. Garrett, the service line environment is much less confrontational ¼ the cross pollination of ideas puts everyone on the same team.
Dr. Garrett believes that he and his fellow service line physician chairs can take PRIME to new heights of performance because they focus on what he calls “macro” quality. Their quality perspective is on the overall picture, rather than on comparative data by physician. “When a group is covering a patient on a rotating basis, the stats of the attending physician don’t really reflect that person’s care. One physician may admit the patient, while a partner may pick up care for several days, and then someone else covers on the weekend. Standardizing protocols is the answer.”
There is no doubt that Dr. Lee Garrett will use his depth of experience,
disciplined approach to meetings and management, and his passion for
team work to advance the agenda of PRIME, an uncommon service line.
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