Developing a High-performance Women's Health Program

by Susan Besanceney, R.N.

Nearly every healthcare organization thinks they address women's health. But until you define women's health, you really can't serve your constituency effectively.

Our business is not fractured hips, hysterectomies, or simply maternity services. Our business is women's health advocacy, and it's a big responsibility.

Essential Components for Success

I'm going to use The Elizabeth Blackwell Center, a hospital-based women's health center, as a case model for how we've met that objective. Elizabeth Blackwell was the first woman physician in the United States and a pioneer in women's health.

The Elizabeth Blackwell Center is positioned as the outpatient, community-focused service provider in the Women's Health service line of Grant/Riverside Methodist Hospitals, part of the OhioHealth system based in Columbus, Ohio. Over the past 13 years, The Elizabeth Blackwell Center has identified and implemented practices and programs that are successfully meeting the needs of women, health plans, and physicians.

The Elizabeth Blackwell Center was founded in 1985 as a result of many focus groups and other market research. We asked community leaders and local women, "What do you need in women's health?" We assumed they wanted something within the hospital. We were wrong.

We learned women want easy access to healthcare resources; they want childcare; they want a wellness and prevention focus. So we began teaching women preventive strategies and guidelines to stay well. This self-care concept was fairly innovative in 1985.

We started out as a resource center with a nursing staff, but quickly learned that we needed to be multidisciplinary. Women's health is complex, and the need for social workers, counselors and parenting educators was evident. Although the center is well known in the community, we know we're not the only resource in town. So we partner with community agencies who provide additional services to women. That way we can reach out to women wherever they need us. These community partnerships fill gaps in care for women and help improve access to essential services. A definite win-win.

Define Your Business

The first and perhaps most important component for success is to identify your customers and the services they want and need. We spent a lot of time defining women's health and decided that it encompasses those issues and conditions that are unique to women, are more frequent in women than in men, or are manifested or treated differently in women.

Women are important to all service lines. Our women's health program works with all of our service lines, but when you start to talk about making women's health a separate service line, everybody gets a little edgy. They start to wonder if you're going to cut into their revenue streams. A clear definition of women's health helps everyone stay focused and reduces turf issues.

Also, it's important to understand your core functions as a women's service line. In our organization, that means developing programs that meet gaps in care, coordination of care, providing essential women's health services and ensuring there is a smooth continuum of care between inpatient and outpatient programs.

At the grassroots level, start defining your values and the value of women as customers. Make it a priority to secure a strong organizational commitment to women's health. We started developing that commitment about two and a half years ago, one-on-one with our executive staff and board members. We set up a presentation with our senior level executives and basically said, "We'd like to tell you a little more about what we think women's health is and what a value it is to this organization."

Be Responsive to your Customers' Needs and Preferences

Identify your most valued customers and treat them accordingly. You can have the most beautiful facility, the best product inventory, and the finest programs, but if your service providers don't know how to treat women with dignity, how to listen, how to make sure that women are active partners in their health care, and how to support their decisions with reliable, credible health information, you will not be successful.

We use eight dimensions of wellness as a framework to achieve that goal. We respect the fact that if a health change impacts any one of these areas of a woman's life, holistically, it impacts other areas as well. Programs designed around these dimensions of wellness have been a key factor in our success.

Develop a Strategic Plan

The one thing that moved The Elizabeth Blackwell Center forward the most over the past few years was the ten months we spent developing our Women's Health service line strategic plan. We worked with a consultant to develop a plan that encompassed all of women's services at Grant/Riverside, including labor and delivery, neonatal intensive care, gynecology, The Elizabeth Blackwell Center and other services. It is now being used as a model for other strategic plans being developed throughout the organization.

Creating a strategic plan was critical in several ways. First, it helped us define our business. Even more importantly, it got all our stakeholders on the same page. Our physicians were at the table from the beginning, and provided valuable input on setting the direction for women's health within the organization.

We also supported the strategic plan with market research, including 800 phone surveys, multiple focus groups, mail-out surveys, demographics, psychographics, and other products. It was a huge project, but it gave us the framework in which to provide our services. When the plan was finished, we presented it to our executive staff and board of trustees for their approval. Now, when we need resources to implement one of the recommendations from the strategic plan, in many ways it's been "pre-approved."

As important as it is to define what you plan to do, it's also vital to identify those projects that you're not quite ready to tackle. When you look at women's health, there are so many good ideas and so many needs. A solid strategic plan helps everyone prioritize and stay focused. I've learned to never throw out a good idea. If you're convinced it's good for women but it's not the right time in your organization, file it. Sometimes timing is everything.

Align with the Organization's Objectives

You can come up with great ideas, but if they're not where the organization is focused you're probably in trouble before you start. Our organization's objectives include focusing on clinical quality, customer service, community health and outreach. Regarding financial objectives, we're focused on process improvement, cost management and integration of services across our network. The women's health strategic plan reflects those objectives.

Within The Elizabeth Blackwell Center, we measure quality using case conferences, clinical call and chart reviews, and assessment of clinical outcomes. We measure customer service using the system's standardized national tool. To measure community outreach, we use a standardized software program that assigns dollar value to community programs.

It's important that outpatient services such as a women's center are well-represented on the inpatient side. It promotes communication and a smooth transition for patients. We've found that since most physicians' practices are part of the outpatient continuum, they are also eager to eliminate fragmentation of care and appreciate one-stop referral resources for their patients.

Secure Physician Collaboration and Support

It's important to really work at an individual level with physicians and then allow them to promote ideas to their colleagues. It is beneficial to involve physicians from the very beginning. Their ownership and input in the work that is being done and the development of new programs and services is essential for future success.  

As noted previously, women's health is complex and not just obstetrics and gynecology. A multidisciplinary physician advisory committee is a must. We have OB/GYN, behavioral health, internal medicine, family practice, cancer physicians, all represented on our committee. We recently started publishing a newsletter and we're developing a physician advisory board for that, too. They will review articles for accuracy and act as a source for stories. Most are happy to help. It gives them exposure and promotes involvement in the women's health service line.

We also have a program for physician office staff. Nurses and office managers are key referral sources in physician practice so it's important to build relationships with them. We host an educational breakfast or dinner for physician office employees once or twice a year with CEU credits provided. The office staff are also an excellent informal focus group for new program ideas. Another win-win.

Demonstrate Fiscal Responsibility

Health care is in the midst of rapid change and as reimbursement diminishes, so do subsidies for negative margin programs. We need to be profitable in quick order. The hospital currently subsidizes about 45 percent of our costs. Forty percent is offset by revenue from programs and 15 percent is offset by community benefit. A year ago about 70 percent of our budget went to salaries and benefits. This year it's about 50 percent. That's because we've initiated several revenue-producing programs that will cover 50 to 55 percent of our costs. Our revenue sources include: educational programs, massage therapy, retail products, breast pump rentals and reimbursable clinical services.

We've also looked into some creative funding. We're developing corporate partnerships to underwrite some of our programs, which is a popular idea. A women's center or program has access to and relationships with women. Done with integrity, there are great opportunities to create win-win programs for women's health.

Of course, grants can be a rich source of funding but they are time consuming and can be a bit of a gamble. We have been successful supporting interns and graduate students in these efforts. We also have a very supportive Foundation who, through grants, provide scholarships for many services and allows us to provide fee-for-service programs to women who cannot afford them.

Identifying effective revenue sources will only get you so far. It's also important to identify opportunities to save. We're now looking at capitalizing on cross-training, space utilization, inventory management strategies, and ways to cross-sell other products within the centers and hospitals.

Operational efficiencies we have begun this year include implementing our hospital registration and billing system at each location. This allows daily volume and revenue tracking. We have also implemented an individual staff productivity matrix which helps staff be accountable for volume and revenue targets.

It's vital to not only look at your own operational economies, but to be involved in generating funds and/or cost-saving initiatives organization-wide. For example, we're now participating in a multi-department program to try to understand those patients who demonstrate unusually high utilization of health care, since probably 80 percent are women. These include patients with chronic pain, asthma, anxiety disorders and frequent emergency room users. We're looking for common behaviors with the goal to develop ways to reduce utilization while still responding to patient's needs. Are you seeing the win-win pattern?

A Word about Change and Organizational Structure

Whatever organizational structure you're in right now, the most important thing to realize is that it's probably temporary. Change is a natural result of leadership trying to determine the best way to be competitive and still provide excellent, cost-effective services. What it means, however, is that we have to be flexible.

And what about mergers? They're extremely challenging to live through, but in retrospect, they offer a lot of opportunities to combine the best of both organizations. They can serve as the sacrificial altar to streamline and improve.

Grant/Riverside is now developing an ambulatory services delivery network located in suburban Health Centers. The Elizabeth Blackwell Center's women's services is the only non-acute department in these new centers that is self-referred. Other departments represented include physical therapy, imaging, urgent care, pharmacy and lab. These centers are in the suburbs and very close to our patients. They're designed as health malls under one roof but with separate doorways covered by different colored awnings.

This new ambulatory network structure gives us the opportunity to position ourselves as a value to the organization. We bring several thousand people a year into these centers through our many programs and services. It gives customers an opportunity to see what else is available at the health center and it deepens our presence in these communities and helps us listen to women to determine ways we can continue to meet their needs.

Some Final Words

Capitalize on new technology. We are now looking at some telemedicine opportunities with our high risk obstetrics ultrasound unit. In addition, we are fortunate to have teleconferencing available with several network locations. We're very serious about ensuring good communication throughout the organization, and are working on developing virtual meetings to keep all our staff throughout the city in the loop. 

We also track all visits and encounters at the Center. Everyone who visits The Elizabeth Blackwell Center goes into our Centaurus database and continues to get health information throughout the year. An accurate and extensive women's database is quite valuable and is essential in building lasting relationships with women.

To help keep us on top of the demographic information generated by our Women's Health Day, we've decided to outsource registration. This will allow participants to fax in their information. In addition, outsourcing will hopefully help us cope with group registrations, which can be difficult since employers often want to call in to say they're bringing 30 people without giving specific names.

Change is the name of the game and if you are risk adverse, you're in the wrong business. It's hard to reach second base if your foot is firmly planted on first, so be ready to move when the opportunity presents itself. Take the risks. Learn how to respond quickly and when to go to the line for what women want and need. But it's also important to know which issues are most important to women and stay focused on what your business is. That business is women's health. _____________

The Elizabeth Blackwell Center

The Elizabeth Blackwell Center along with the Family & Birth education program offered more than 1,400 educational programs serving almost 25,000 people last year. "It's a huge commitment of resources to do community and prenatal education," admits Susan Besanceney, R.N., director of Ambulatory Women's Health at The Elizabeth Blackwell Center. She adds that she and her staff continually strive to achieve more efficiencies.

Major programs at The Elizabeth Blackwell Center balance education and clinical services. All programs and services for the last fiscal year served more than 60,000 women and families. "We want to make sure we're not only meeting the needs of women, but also our physicians," says Besanceney. "The way we do that is to provide educational programs and clinical services that support physician practices and patients. They are very comfortable knowing that we will not make decisions for their patients, but will give patients the information they need to understand a specific condition or to stay well. It makes for better-informed patients. We focus on clinical services usually not available in physician practices."

The center focuses on four program areas:

Family and Birth Health which includes the Parenting and Lactation support programs, Breast Health, Midlife Health, and Behavioral Health for women.

Grant/Riverside averages about 9,100 deliveries per year, and Family and Birth Health services at The Elizabeth Blackwell Center encompass pre-pregnancy planning, prenatal education, infant care, adoption and infertility programs, breastfeeding support and pregnancy loss support. The center now offers a highly successful lactation consultation and services program based on a program developed by California Pacific Medical Center, San Francisco (see "Survival Strategies: How One Hospital Rental Station Overcame the Odds," The Ireland Report, November/December 1997). The program supports Grant/Riverside's post delivery mother's breastfeeding rate at close to 60 percent.

Parenting services include a variety of classes and educational programs for parents with children of all ages. The "Friends n' Fun" program, held five times per week at several Blackwell Center locations, resulted in more than 8,000 visits last year alone. The program features parenting consultants who answer non-clinical questions such as teething, sleeping and discipline issues and allows parents an effective support network opportunity. "Our parenting consultants also model appropriate communication and disciplinary interventions," says Besanceney.

The centers offer four mothers' support groups for different ages and a parent support line. "We do a lot of fragile family support through our special care nurseries," says Besanceney. "Unlike many parenting programs that are focused on child development, our program focuses more on parent development. . . Developing healthy parenting skills is a woman's health issue and we were one of the first hospital-based programs to recognize that and develop programs to meet this need."

The Blackwell Center's menopause and midlife clinic is designed to complement physician care by providing education and support on midlife issues and conditions such as osteoporosis and incontinence. The center has recently begun a "best practice" Biofeedback Incontinence program that many insurers now require prior to surgery. Besanceney says that the program is up to 85 percent effective in certain types of incontinence. "Our midlife program does not just address the physical aspects of midlife, but some of the transitions that women go through at this age, whether it is career, parenting, divorce or changes in relationships," she adds.

That concern extends to singles' issues, too. The Blackwell Center sponsors a monthly dance called "Second Saturday Singles." "There is no place in the city for singles to meet in a safe environment without alcohol or smoking, so we have our own dance," says Besanceney. An average of 200 to 300 people attend at a cost of $7 per person. "When you look at the eight dimensions of wellness that we use as our framework, the social and self-esteem aspects are a vital part of women's health," she explains. Besanceney adds that the dances also provide a significant revenue stream with relatively little labor. "And they are wonderful opportunities to cross-sell our other services," she says. Twice a year The Elizabeth Blackwell Center also partners with local singles ministries in the churches to provide a day-long workshop for singles covering finances, parenting, relationships, careers, stress management and other issues important to the singles community.

The center's comprehensive breast health program includes five specially trained Breast Health Specialists, two inpatient and three at The Elizabeth Blackwell Center locations to ensure a smooth continuum of care for women. The Breast Health Specialists work with physician practices or women who self-refer to provide coordination of care and serve as a resource for women who have been diagnosed with breast pathology or who are seeking breast health education, including breast self-examination, breast cancer support services, and post-surgery classes and services for issues such as breast prosthetics. The center recently began a lymphedema management program that helps radical breast or pelvic surgery patients reduce chronic swelling through physical and massage therapy.

Behavioral health programs at Elizabeth Blackwell are defined by counseling and education on a variety of issues, from anxiety, depression, and stress to divorce and aging. The center is well known in the community for its Violence Prevention and Recovery services. "On the wellness side, we focus on self-defense, assertive communication and understanding abusive relationships," says Besanceney. "We also provide rape counseling and a rape support group."

Prevention and wellness programs focus on essential principles of self-care for women, along with cardiovascular and reproductive health, nutrition and body movement through a variety of traditional and alternative strategies such as aerobics, yoga, Ta'i Chi and therapeutic massage services.

To round out the program, The Elizabeth Blackwell Center offers a variety of consultation services through nurse consultants, social workers, parenting consultants and counselors.

Each of the centers features a small gift shop that sells tapes, CDs, yoga mats and books. Besanceney says the center also sells health, wellness and parenting books of topical interest through a consignment agreement with a national chain. To avoid competing with the hospital's pharmacy, the Blackwell center on the main campus doesn't sell lactation supplies, but its two centers in the community carry a full line of breast pumps, nursing bras, and accessories.

The center's staff is comprised of six nurses including three Clinical Nurse Specialists, a nurse practitioner and two licensed nurse counselors. In addition, The Elizabeth Blackwell Center has an administrative manager, two licensed social workers, two parenting consultants, a health education coordinator and a business coordinator. An operations coordinator at each site is responsible for staff clerical support, phone line triage, supplies, client registration and facility management.

Sidebar 2 

Women's Health Day

Grant/Riverside's annual signature event is its two-day Women's Health Day, held at the Ohio Exposition Center. Since women's health touches all service lines, it makes perfect sense to focus on women as a way to highlight services of the entire organization.

The free event is educational in nature and more than 100 physicians and health professionals now participate, says Susan Besanceney, R.N., director of Ambulatory Women's Health and clinical co-chair of the event for five years. Women's Health Day attracts an average of nearly 5,000 women, which is the center's target number, she explains. "If we have much more than 5,000-6,000, we really don't have time to talk with people as they visit the more than 130 educational and screening areas."

Besanceney says Women's Health Day is not an exposition. "We have some corporate underwriting but even our corporate sponsors must provide educational displays and information," she explains.

The event features three stages offering a variety of programs from wellness, aerobics and movement therapies to career, financial planning and yoga. Women's Health Day participants can also take advantage of 17 different kinds of health screenings offered at the event.

Besanceney explains that Women's Health Day provides an ideal forum to market the Elizabeth Blackwell Center's programs and products. "From a marketing perspective, Women's Health Day is primarily an acquisition strategy. It attracts a lot of new people, but it also gives us an opportunity for those women who are very familiar with our system and our Health Plan to come in and speak with more than 100 physicians and health professionals and to participate in all the screenings. It enhances our market share on two levels, acquiring new customers and retaining our existing clientele."

Sidebar 3

Dimensions of Wellness

The Elizabeth Blackwell Center's focus is defined by the center's "Eight Dimensions of Wellness." Susan Besanceney, R.N., director of Ambulatory Women's Health, explains that each of the eight aspects of a woman's life can have profound effects on her personal health.

Physical Wellness, including not only physical fitness and good nutrition, but healthy self-care practices such as monthly breast self-examination and other health screenings according to guidelines.

Emotional Wellness, developing a healthy enthusiasm and sense of purpose in life. Learning healthy coping strategies and developing a positive attitude.

Social Wellness, involving healthy relationships with others through effective communication, safe sex practices and avoidance of substance abuse.

Spiritual Wellness, encompassing personal spiritual beliefs, values and individual creative endeavors.

Intellectual Wellness, encouraging learning experiences and mental stimulus at any age.

Occupational Wellness, bringing a sense of meaning and purpose to a woman's career and ensuring a healthy and productive work environment.

Environmental Wellness, engaging each individual's personal responsibility for the environment and ensuring a healthy home and workplace.

Financial Wellness, involving effective management of personal resources resulting in financial stability and security.

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