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© The Ireland Corporation, 1998-2003. All Rights Reserved.
Service Line Management:
Lessons from the Best
(Part Four in a Series)
by Richard C. Ireland
In this article for our Lessons from the Best series, we examine how service lines are developing at the Summa Health System in Akron, Ohio. Like the other three hospitals/systems in this series, Summa is an exemplary organization that ranks among the best hospitals and health systems regionally and nationally.
Summa is a three hospital, integrated health system: St. Thomas Hospital and Akron City Hospital and Cuyahoga Fall General Hospital, with 11 Centers of Excellence, four of which are operated as service lines, three community health centers, and a 126,000 plus member SummaCare health plan. The system is clearly a leader in the development of high quality, nationally recognized, clinical services and the service line model figures prominently in their strategy. Nine of its clinical services, including the four service lines, are listed in U.S. News and World Report’s 13th annual “America’s Best Hospitals” issue, 2002. Summa is also recognized by Healthgrades and is a special member of The Cleveland Clinic Health System.
All of the Summa hospitals are teaching organizations with a long history of clinical excellence that pervades the Summa system. A strong commitment to medical education is a key part of the organization’s philosophy. As a result, Summa has a very strong medical staff support culture with a high level of relational capital among physicians. And there is a high level of trust and support for senior management. Plus physician champions support the service line model . . . which is paramount to success.
Summa describes itself as a consensus organization that is in the developmental phase of service line management. It is part of an implicit organizational strategy, a hybrid model that is emergent, developmental, complex, and sometimes chaotic.
Summa’s four service lines include: women’s health, orthopaedics, cardiopulmonary, and senior services. Cancer is under development and likely to become a service line in the near future. Until very recently, each service line operated under a different model although each has a paid medical director who also serves as department chair of service area director as in the case of seniors and cardiac. Service lines can be characterized as in the process of finding their voice, i.e. their optimal organizational model and place within the Summa Health System. Each had multiple reporting relationships which are referred to as matrixed. However, the organizational structure in which they function is described as very traditional. This helps create a collaborative environment for service line management.
Overall, there is a positive feeling about the results of service line management although some people we interviewed felt that it is still too early to tell what the real effects will be. Much like Evanston Northwestern in Evanston, Illinois (SERVICE LINE LEADER, January/February 2002), Summa follows a corporate branding strategy. The service lines reinforce and strengthen the Summa Health System brand.
Thomas Strauss, CEO, strongly supports the service line model and had experience with service lines when he was president of the Meridia Institute at Meridia Health System in Cleveland, now part of the Cleveland Clinic Health System. The Institute was organized to create innovative services and to integrate service lines across the Meridia system. He explains that “the service line model is well understood at Summa, people understand and generally support the concept. Their expectations are realistic and they are giving each service line the opportunity to find its own voice. We are not really concerned about ownership, but about where the job can be most effectively performed.” He also feels strongly that you need a fully engaged, merged, medical staff that really want to create a value experience for their patients. Indeed, this is one of the distinctive strengths of Summa Health System.
Service line teams originally reported to Strauss and recently were assigned to Cliff Deveny, MD, Vice President for Clinical Services and Service Lines. Dr. Deveny was previously the medical director for the women’s health service line. Service line leaders meet with the senior management team on a monthly basis. They operate on a shared governance model. Service line operations, non-medical, meet every other week and use a matrix process as a way to collaborate with each other and with support departments. “You need to have quality, market share, and value including growth and profitability,” notes Strauss.
“The service line leaders here run their own businesses. They are, in effect, the CEO of their unit which gives them considerable latitude in managing their business. We want and need to have entrepreneurs running our service lines. It adds a whole new dynamic to the organization. They interface on a matrix to the Chief Nursing Officer and the Chief Medical officer. The physician leader/champion is one of the keys to success for our service lines. I believe in very strong staff support for service lines. Since service lines report to me – that helps eliminate the silos. There is also a natural tension in developing and implementing service lines. This is generally very good for our organization.”
In his new role Dr. Deveny is looking seriously at bringing management continuity to the service line structure with a triad model that includes clinical, operations, and business services. In his role as medical director of women’s health, this model worked extremely well. He explains that “I am also looking at creating a balanced scorecard that will be reproducible for each service line. I believe strongly in the service line model and that it is essential to the future success of health care. The new dynamics of health care with rapid change and thin margins requires that we continually evaluate our performance to stay on top of our businesses.”
Dale Murphy, MD, Vice President for Medical Affairs, explains that service lines at Summa are evolving, they are part of an ongoing conversation on effective ways to deliver high quality care. Initially, many people thought they would develop faster but sorting out the various relationships has taken longer than expected. He goes on to say that “We’re a very complex tertiary and teaching environment with a very traditional senior management structure. Each service line has developed a different model and that is not a bad thing. It allows each one to find the best or optimal approach for getting results. We have strong medical leadership in all our service lines which is crucial, and a core strength for us.”
Women’s health, he feels, is currently the strongest service line with a reporting connection to nursing. It really touches every service in the Summa system. Senior services is emergent and has strong support from the medical staff.
Dr. Murphy feels strongly that service lines are truly worth pursuing so that Summa has a chance to really do something significant in terms of quality, patient service, and growth and with the right caveats, e.g., strong administrative and physician leadership and support from senior management. “We’ve seen real success and want to keep it going. Service lines are a priority but, of course, not to the exclusion of other clinical services. We expect a higher level of accountability. If you want to ruin service lines, then do a lot of matrix reporting which can dilute accountability. They really need to be designed around a tight organizational structure with a commitment to results.”
“There is a real commitment for our service line experiment to continue. A lot of knowledge has been generated by the service line process. However, a key issue for us – and any service line organization – is how to pass on this experience and knowledge to the next group who will be managing the service lines. You really need a lot of corporate memory to survive. When they leave, there is a vacuum. I strongly recommend a mentoring or apprentice program be developed as part of the service line process. Some type of succession plan will be needed if service lines are to survive long term.”
Richard Rogen, Vice President, Managed Care & President of the
PHO, reports that Summa is developing as a truly integrated care delivery
system with a very strong physician support culture. He feels service
line management tends to support this effort, especially since physician
support is so strong and that Summa’s collaborative culture tends
to minimize the silo effect.
He stresses that “We have a strong medical staff leadership culture
that really wants to be more efficient. Our common objective is to
truly integrate clinical services. Carve-outs offer a real potential
for service line management. A lot of exclusive contracting is possible.
Akron is really a hospital dominated market. There is no employer coalition
and health plans are small and fragmented. The rubber companies no
longer exercise the control they once had.
“SummaCare, our HMO, is growing very fast and tends to lower our need to do a lot of marketing. We have an ongoing conversation across our clinical areas and our departments are very quality and education oriented. Service lines have facilitated this tradition. We continually strive to improve clinical and business outcomes. Women’s health is the first service line to be implemented across the system. Summa management believes strongly in cooperation and collaboration – not control. We tend to focus on people who can be real catalysts for change,” imparts Rogen.
“Service lines have created a new level of accountability,” says Patrice Lange, Vice President for Planning/Corporate Support, “they are the go-to people for a clinical service. We organized a group to develop service lines and created the criteria for selecting which ones to invest in and also looked closely at who had the real leadership potential for developing a service line. Since we did not want to begin from scratch, we looked at those clinical areas where we had the market recognition and the volume to support increased resources. On this basis, we selected women’s health, orthopedics, senior services, and cardiopulmonary services. These services had the physician support and leadership and service line management capability. In addition, we are also developing a cancer service line.”
Lange explains that several enabling events helped stimulate service line development at Summa: Two HCFA demonstration projects in orthopedics and cardiology and a shift in Medicaid managed care OB admissions from another area hospital to Summa Health System. In addition, we are very clinically and quality oriented with a long standing teaching culture, really a learning organization that strives to manage its knowledge. Our culture seems to naturally support the service line idea. With Dr. Deveny leading our service line efforts, they have a high degree of involvement with senior management process at Summa.”
Another theme that emerges loud and clear is the need for and use of reliable data notes Lange. “Our planning function currently is using data warehouses for its various database management and research studies. Part of my job is to support our service lines and other centers of excellence with reliable and timely information that ranges from utilization and market share to consumer studies. We are currently working on a new financial reporting system that will enable us to report costs at the service line level. ”
She also believes, like the service line organizations in this series, that there is no one best way to organize a service line. If you’ve seen one, you’ve only seen one. “I don’t believe that service lines within Summa have to be organized in one set way. It is really a matter of finding the form that works best for a clinical area.”
Support centers such as marketing and planning, and finance, provide a service representative to each service line. An informal matrix approach is used to supply services to the service lines and the other key clinical services. All the service line teams agree that this has been an effective approach to providing support services.
Summa recently broke ground on two state-of-the-art ambulatory services building on the Akron City Hospital campus– a Heart Center to include a cardiovascular and pulmonary center and a Specialty Health Center to include a women’s and men’s health center providing prevention, wellness, diagnostic care, rehabilitative care, chronic disease management services, and retail. These two four-story centers, each encompassing approximately 80,000-square-feet of space, will be joined by a common atrium. The building will be completed in early 2003.
WOMEN’S HEALTH
The women’s health service line, including inpatient services, is offered through the Judith A. Resnick Center for Women’s Health. Outpatient services will be offered in the new Specialty Health Center. The service line offers a comprehensive selection of women’s health services and functions as a specialized regional center. The goal is to meet the healthcare needs of all women at every stage of their life. Services include 14 LDR birthing suites, a level III regional perinatal center, a lactation center, gynecological and urogynecological services, breast health and osteoporosis services, pediatrics, and education and information services offer through the Joan A. Michelson Women’s Resource Center with three area community locations.
Pat Troyer, Business Director, reports that by 1998, “our obstetric program had declined in market share. So, to begin to correct this we did an extensive market and utilization analysis. We worked through an entire strategic planning process for women’s health, examined a lot of information, and developed physician relations and innovative services that would differentiate us in the greater Akron market. The service line administrative model was one of our recommendations and we are regaining our market share. There is a lot of change management going on across women’s health and the Summa organization. Quality is uppermost in the minds of our service line leadership team. For example, among several projects, we have implemented a core faculty of physicians to educate residents and provide staffing for an obstetrics triage area. We are very strong advocates for women and their families with a growing regional reputation for leadership in women’s health.”
Women’s health uses a triad model: medical director, nursing director, and business director. Women’s health is the only service line that includes nursing. “Women’s health functions as a group,” explains Dr. Deveny, “they are accountable for quality, volume, education, and financial performance and have been given the ability to really operate as a business unit. Troyer reports that “we reconcile charges to ensure a complete and accurate billing occurs, we interact with managed care contracting staff to help maximize rates to help them negotiate for reimburse of our services. We are responsible for managing our operating expense budget. Finance is working to improve the sophistication of cost accounting information. Communication is also key. We meet once a week but really it is the informal interactions, whether in person or by phone or email, that have created the chemistry for success.”
Troyer agrees and adds that “we also have a lot of product design flexibility and an opportunity to integrate lots of different facets of the Summa system. We are not a traditional department that just provides clinical services. We cross a lot of boundaries. This is key to our success. We have found new ways to work with people from all over the Summa system. We have a truly collaborative model that enables us to build a lot of trust. For example, we are leading an interdisciplinary process to enhance care provided to women with breast cancer.”
Susan Sorboro, Director of Nursing for the women’s health service line, reports to the Vice President for Patient Care Services and is a member of the service line triad team. This helps create the necessary consistency in nursing practice and policy throughout the organization. Sorboro oversees more than 300 staff in the inpatient units and outpatient departments that comprise women’s health.
Women’s health is responsible for developing a strategic plan consistent with Summa’s overall strategic initiatives. Troyer comments that “as part of this process, we do a thorough SWOTs (strengths-weaknesses-opportunities-threats) analysis. We feel that the key to a successful service line is collaboration, real flexibility, a strong information system to produce relevant data for analysis and tracking, and, above all, strong physician support. The Summa culture has a long history of physician support and involvement. We truly believe in the role of the physician champion for success.”
ORTHOPAEDICS
The orthopaedic service line offers a full complement of clinical and support services that include total joint replacement, diagnosis and treatment of bone problems, sports medicine that includes a program for women, trauma management, spine, oncology, and a first of its kind for the Akron area – a musculoskeletal lab. Orthopaedics ranked in the top 35 for the past five years in the U.S. News and World Report’s 13th annual “America’s Best Hospitals” issue and is winner of the Top 100 Hospitals Orthopedic Benchmarks for Success.
Patrick Flanagan, MD, Chair, Department of Orthopaedics, explains
that “Summa’s St. Thomas Hospital was originally slated
to be a women’s hospital. However, it had an under-utilized OR
while the OR at Akron City Hospital was over capacity and it was very
hard to schedule a case.
So, St. Thomas was the only logical place to grow our orthopaedics
service line. It is really becoming a freestanding orthopaedic hospital.”
He notes, “Initially, we looked at having a VP/CEO for the Orthopaedics service line and it may ultimately evolve that way. Our current model of having a service line director and a medical director responsible is working very well.”
Cheryl Paterson, RN, Director, Orthopaedic Service Line, explains, “My service line role includes accountability for patient satisfaction, nurse and physician satisfaction, financial performance, marketing, strategic and tactical planning, and care delivery. Physician involvement and the information system are key to service line success. There is a lot of collaborative work across the orthopaedic service line and with other departments. We are very alert to what our data are telling us telling us about change and variance.”
She stresses that “Summa is a large healthcare system that emphasizes
medical, patient, and community education. It is a lot like a community
hospital – a family atmosphere with a high
level of collaboration and trust. And, at the same time there is excellent
resident education and continuing education for all disciplines. We
tend to look out for each other. There is lots of collaboration with
other service lines and clinical services: women’s health/the
female athlete, corporate health, senior services, and so on. Orthopaedics
has developed a very strong collaborative network among physicians
and clinicians across the Summa system.”
CARDIOPULMONARY SERVICES
Although Summa offers a comprehensive line of services and programs that includes cardiovascular surgery, a surgical cardiovascular intensive care unit, three cath labs, cardiac rehabilitation, and a vascular research lab, the cardiopulmonary service line is in transition and currently functions as an outpatient unit. Cardiovascular and pulmonary outpatient services with be consolidated in the new Heart Center adding a much needed capacity for the service line. Summa ranks 18 in heart in the U.S. News and World Report’s 13th annual “America’s Best Hospitals” issue, 2002, and winner of the 100 Top Hospitals Cardiovascular Benchmark for Success.
Cardiopulmonary services represent a hybrid service line strategy for Summa.
Vincent Johnson, MD, chief of the service since 1995, has long dreamed of having a comprehensive outpatient cardiac center. While he serves as medical director for the service line, he is also involved in Summa’s PHO and SummaCare where he is Chairman of the Board, and medical director for an LLC formed by cardiologists and pulmonologists. The LLC gives the physicians oversight for the Heart Center.
“We did a pilot,” explains Dr. Johnson, “creating a business plan for outpatients services, and now operate as a service line within the Summa system. We view cardiopulmonary services as a business and as a clinical quality unit. We really don’t know our full potential yet, what we can really accomplish. Cardiology is a growth business for us and we are getting our house in order, trying to expand capacity. For example, the waiting times have been far too long for non-invasive tests, creating a real problem for us and our patients. Our new Heart Center will consolidate outpatient services and help correct these problems.”
Inpatient units such as critical care and the cardiac care unit are
not, at present, included in the Heart Center. Relationships in the
Heart Center are very different from the other service lines. Bryan
Fredericks, the previous Executive Director of the Cardiopulmonary
Service Line reported to the board of an LLC organization and is paid
from a management contract with Summa Health. “This is a service
line with lots of caveats. The key is to delegate operational and business
responsibility to the service line. We have most of this. We are responsible
for making this service line successful. We are held accountable for
its performance, including patient and physician satisfaction. I have
matrix reporting relationships with a lot of people including key functions
such as patient care. Like the other service lines, we are evolving
into a clinical and business enterprise,” explains Fredericks.
Fredericks feels strongly that the best interdisciplinary communication
occurs within the service line and across all of Summa’s service
lines and brings a needed level of stability because of the alignment
with the system’s strategic plan, a stronger focus on collaboration
within and across service lines and other centers of excellence,
and physician support and investment in the success of cardiopulmonary
services. It also enables Summa to compete more effectively, especially
with niche services.
Dr. Johnson stresses that “service lines will demonstrate real financial value to Summa. I feel that you really must use a service line approach; it’s one of the few ways you can leverage your advantages. For a long time, there was really no physical capacity for growth at Summa and this placed a constraint on the promotion of this and other service lines. With our new outpatient center, we’ve solved part of that problem. There is a lot of untapped demand in Summit County and beyond, and we aim to serve the needs of these future patients through the service line model.”
Senior Services at Summa is the most recently formed service line. Like women’s health, Senior Services offer a wide range of clinical services to seniors in the Akron area and also serves as a gateway, referral center, and as an internal clinical and program consultant on geriatrics care issues for the other service lines and clinical programs across the Summa system. For the past three years, the reputation of Summa’s geriatric medicine program has been gaining national recognition as reflected by the rankings in U.S. News and World Report’s annual “America’s Best Hospitals” issue 2000-2002. Older adults represent more than 13 percent of the greater Akron metropolitan area, with frail elderly a rapidly growing segment. It is becoming a core, and growing, market segment for the hospital. And this, of course, creates a real problem. As we know too well, Medicare reimbursement barely covers the costs of care, placing a major constraint on the ability to serve this age group.
Kyle Allen, DO, Chief, Division of Geriatrics, explains that “We use a comprehensive consult-support model for geriatric care. We are basically a staff support service for the hospital, medical staff community, and a teaching laboratory for our many local students in health professions such as nursing, social work, medical students, medical residents, and geriatric medicine fellows through a joint program with the Cleveland Clinic. We have gained a great deal of experience in creating and implementing a new interdisciplinary team care delivery model, one that is getting national attention as an effective method for improving the outcomes and quality of care for hospitalized older adults.
“Often, I feel that I am working as an “intrapreneur” -- creating new and innovative approaches and methods to enhance quality and cost-effectiveness so that the health system can more effectively manage risk and complex cases that have fixed payment reimbursement. These innovations can form the basis and substrate for developing a business model around senior health. Senior services are offered in a high touch-low tech, high quality, care management type environment. We have created a lot of excellent innovative programs that the system owns as its intellectual property that can help to improve the system’s bottom line for the narrow margins of the traditionally prospective and capitated payment system for Medicare. We assist other parts of the health system, clinical areas, and other service lines in how to implement care management and interdisciplinary team models.
In this context, Dr. Allen and his associates have created a new care delivery model for hospitalized older adults, one that is designed and shown to improve the clinical outcomes and prevent functional decline for hospitalized older adults. The Acute Care for Elders (ACE) Unit is a 34-bed unit located at Summa’s Akron City Hospital. It is designed to help older patients maintain self-care abilities, social skills, and independence while recuperating from illness or injury. “ACE is multi-component intervention that is aimed at improving the care and preserving the functional status of hospitalized older adults. The ACE intervention includes an advanced practice nurse care manager and a geriatrician to create an interdisciplinary team and care delivery model that works in collaboration with the attending and primary care physicians assisting them in the care of their patients. The advanced practice nurse is supported by an interdisciplinary team consisting of a PT, OT, speech therapist, dietician, pharmacist, and a social worker. As a result, people at Summa really do think differently about older patients. Nationally, we have had more than 55 site visits from other hospitals who are interested in this program. In addition, we have “transferred” this ACE technology internally and created a Stroke Unit on another med-surg floor using the same ACE care model as the basic framework and specifically modifying some of the protocols for stroke care. Again -- in less than a year -- our health system has seen a significant improvement in clinical and process of care outcomes such as decreased average length of stay, mortality, and improved provider and patient satisfaction for stroke patients. Thus we feel that the basic model is transferable within the system.”
Dr. Allen is enmeshed in the organizational matrix of reporting relationships. “I have a reporting relationship with our Vice President for Patient Care for nursing issues, our Vice President for Medical Affairs for medical and physician issues, the Chair of the Department of Medicine, and our Vice President of Medical Education for educational program development. It is not a problem really, as it gives me an opportunity to develop strong relationships which is obviously important for collaboration and service line development.” This sounds overwhelming, after all, the more people you report to, the more you report. But, in Dr. Allen’s case, this offers a unique opportunity to build critical relationships and trust across the Summa system. And because of the pervasive needs of Summa’s growing geriatric patient population, a necessity.
Dr. Allen rightly feels that because of demographic trends and heightened awareness of the needs of frail elderly, the timing is right for a senior service line. Because of the pervasive nature of geriatric services, i.e. they touch nearly every service in the Summa system, he favors the triad model for service line management as used in women’s services. He notes that “The core values of Summa are very powerful and really facilitate the development of this service line. Though we struggle with how to measure the business effectiveness in the traditional profit and loss sense, we are very engaged in finding an agreeable method to measure the value of these programs in cost savings. A notion that is intuitively accepted but being accountable as a service line demands that we find an acceptable and demonstrative way to measure and report this value.”
Judy Akins, Executive Director for Post Acute and Senior Services agrees. “Summa,” she says, “is indeed very committed to the care of seniors, particularly those who are at risk. Prior to becoming a service line senior services tended to be siloed. Now that we are focused with resources under our control, we are empowered to help strengthen clinical service development for our at risk seniors across the Summa system. We are now looking at creating one umbrella concept that delivers a consistent message for senior services. We are really geared to help our physicians and staff understand the needs of seniors and the services and programs we offer. While it is difficult, because our patients are located in just about every part of the Summa system, we are working to develop measures for volume and profitability, improve outcomes, and to help control costs.”
Like hospitals everywhere, Summa is facing serious capacity problems and needs to move older patients across the continuum of care more efficiently. Problems occur when patients are transferred from one point of care to another so coordination and communication are essential. The service line, Akins feels, has the potential to reduce these problems and improve quality of care and cost effectiveness.
She comments further that, “I really love my job. I am a believer in the service line concept. It has really positively impacted the quality of care of our patients. I would hate to go back to what we had before. We are in our infancy but the potential for delivering better care is tremendous.”
Summa currently offers a senior membership program called Premier Years. With more than 30,000 members, Premier Years offers discounts at participating pharmacies and selected Summa services, free private room upgrade, quarterly Opportunities newsletter, and fitness and lifestyle activities. Akins feels that this is an important point of entry into the Summa system and provides much needed education and information to help seniors make better decisions about their health.
There is a general agreement among those interviewed for this case story that there is a high level of effective communication within and across the service lines and other clinical services and that service lines have produced substantial financial, operational, and most importantly, patient satisfaction results. Service lines clearly function as a business model for clinical services. A strong patient focus, sense of mission and vision, a culture that fosters quality care and collaboration, cross-marketing of services, and knowledge sharing form the underlying conceptual framework for service lines.
It is also clear, that one of the enabling factors for Summa’s overall success – and its success with service lines – hinges in no small part on the tremendous relational or social capital that has become part of their culture. It manifests itself at all levels of the organization and particularly with physicians. Without a high level of relational capital, one that is built on a high level of trust, mutual interest and respect, and a common ideal for patient care, service lines would have a difficult time developing. Relational capital is the currency of a highly successful organization and enables the service line approach. There are silos at Summa, of course, but they are closer together and more porous than at many of the organizations we have visited.
Summa Health System is clearly a leader in the development of high quality, nationally recognized, clinical services and the service line model figures prominently in their organizational strategy.
Detailed information about Summa Health System and its services is
available at www.summhealth.org.
Do not publish or copy without prior written consent.
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