Session 1 - Case Study Content - Crawford
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The Commander's Executive Board will discuss several issues impacting the local military treatment facilities, including: long wait times at Valhalla Medical Center's emergency department, deployment of staff from Olympus Ambulatory Clinic, a recent sentinel event and lawsuit involving Valhalla, and water damage at Olympus Clinic. The Board will charge an Integrated Product Team to analyze the causes of long wait times at Valhalla ED and recommend solutions within 5 days.
Session 1 - Case Study Content - Crawford
- 1. MedXellence Case Study Background/Set-up You are a member of the local Commanders Executive Board (CEB) at the Multi-Service Market Office (MSMO). This committee has been meeting for several years and has successfully collaborated to resolve many issues that have impacted local health care delivery. It is comprised of the Chief Executive Officer and other executives of the Managed Care Support Contractor (MCSC) and the commanders and other executives of the three Military Treatment Facilities (MTFs) who care for the communities large, and complex beneficiary population. About 40% are non-active duty and active duty family member beneficiaries. These three MTFs consist of: A tertiary care 300 bed medical center (Valhalla U.S. Air Force Medical Center), A large ambulatory center (Olympus Navy Ambulatory Center), and A small outpatient clinic (Army Cisifus Outpatient Clinic). More specifically, Valhalla Medical Center provides a complete spectrum of care except for neurosurgery, has a Level II emergency department, and acts as the referral center for the two outpatient clinics which are ten and thirty-five miles away respectively, as well as for the entire Region. The large Olympus Navy Ambulatory Center has a staff of 25 primary care and specialty providers and includes a large undersea medicine component. It provides a primary care clinic each weekday from 0730-1630 and each weekday evening from 1800-2100. Some of the provider staff members at Olympus have been deployed on short notice, and backfill has not yet been complete or adequate. The small Army Cisifus outpatient clinic has a small staff consisting of approximately 4 primary care providers, 2 pediatricians, and 2 Primary care nurse practitioners, and also maintains a troop medicine clinic supporting its line units. It provides a primary care clinic, which is open from 0730-1630 on weekdays and from 0800-1400 on Saturdays. In addition to the MTFs, the community is served by an aggressive and quite profitable Managed Care Support Contractor that is actively marketing to gain more of the market share. A recurring issue for the CEB is negative patient feedback reports. For the past two quarters, the metrics relating to customer satisfaction have worsened and MTF commanders are aware that patients may seek care elsewhere. The MTF commanders have all expressed concern about the potential financial impact if more of their enrolled patients seek care from civilian emergency departments, or are referred to the MCSC for care. They have therefore made a concerted effort to keep MTF productivity and MHS Relative Value Units at appropriate levels. Despite this effort, however, this issue continues to be problematic and a continuing CEB discussion item.
- 2. The Problem Waiting time in the Valhalla Medical Centers Emergency Department has been a center of controversy for the past year, and has been a recurring agenda item at this Committees meetings. It has also been a heated agenda item at the Medical Centers professional and executive staff meetings, and a vigorous topic of conversation in the local military newspaper and at local beneficiary meetings. The general perception is that the waiting times for care in the Emergency Department are too long. Recent data, compiled by Red Cross volunteers who agreed to help the beleaguered Emergency Department director, revealed that ED waiting times averaged over 4 hours and at peak times extended up to 6 hours for some patients. To meet this workload, most Emergency Department provider and nursing staff have been working 12-hour shifts for the past six months with a 60-hour workweek and frequent occurrences of mandatory overtime to cover staff absences. Staff has expressed concern that this heavy workload has both staff welfare and patient safety implications. Two ED staff members have, indeed, openly complained that their working conditions are compromising their ethical responsibility to their patients. One of these staff members took their complaint to the Medical Center Commander, and the other to the local Staff Judge Advocate. The Medical Center awaits a possible JAG inquiry. A reportable sentinel event recently occurred in the Emergency Department in a patient with a cardiac diagnosis; a Root Cause analysis has been initiated to determine cause and to see if there is any linkage to the concerns voiced by staff over working conditions. Additionally, Valhalla Medical Center has an impending Joint Commission survey, and executive management is worried that these waiting times and patient safety concerns might be potential accreditation problems. About four months ago, without notice, the Cisifus Outpatient Clinic shut down its Saturday Primary Clinic activity and advised all patients that they could receive needed care at the Valhalla Medical Center Emergency Department. This action brought immediate, loud complaints from the Emergency Department chairperson and Administrative director, who argued that they were already seeing too many of the other MTFs patients in the emergency room. They contended that these patients were the major contributor to their long waiting times. They complained that this was the last straw and that something had to be done to resolve their workload and waiting time problems. The Medical Center Commander has brought this problem to this Committee, which has tasked your MTF group to analyze it and propose recommendations to resolve it by Thursday. Task Your MTF task force is to analyze this problem and bring a consensus opinion as to resolution to the Committee at its next meeting. Pertinent data is available on request. Narrative: Updated June 2009
- 3. Agenda Region 71 Commanders Executive Board July 2009 Review and approval of the minutes of June 2009 Key issues: Patients complaining of long waiting times at Valhalla ED Routine screen shows increasing times to next routine appointment at Cisifus Outpatient Clinic Water damage to Record Room at Olympus Ambulatory Clinic from overhead pipes Old Business Delayed opening of Endoscopy Suite at Valhalla New Business Plans for Civic Pride Day at Valhalla involving Mayor and Congressman Palermos office Develop a Region-wide schedule for performing and reporting routine QA screening results Valhalla announces hiring of new MEPRS Coordinator (after long and extensive search) Water purity issue at Olympus following repairs Action items MTF Commanders to provide Council with information about appointment availability, and waiting times in the ED. Agenda T-6 Months.doc
- 4. Agenda Region 71 Commanders Executive Board October 2009 Review and approval of the minutes of July 2009 Key issues: Plans for Civic Pride Day at Valhalla Develop schedule for reporting routine QA screening results Patients complaints: Waiting times at Valhalla ED Times to next routine appointment Water damage to Record Room at Olympus Ambulatory Clinic Delayed opening of Endoscopy Suite at Valhalla Water contamination at Olympus after major leak Old Business Status of endoscopy suite construction Plans for Civic Pride Day at Valhalla (next week); Mayor coming but Congressman Palermo indefinite Schedule for routine QA results developed by Exec Board; needs approval Commanders report on patient issues New Business Change of Command preparations at Olympus Pending deployments at Olympus Council participation at Tricare Conference Agenda T-3 Months.doc ii
- 5. Agenda Region 71 Commanders Executive Board December 2009 Review and approval of the minutes of October 2009 Key issues: Endoscopy suite ready for opening in 30 days Valhalla Civic Pride Day plans; still uncertain about VIP guests Waiting times not improved at Valhalla Old Business Pending results of water treatment tests from Olympus Clinic Report from IPT re parking problems and patient feedback issues at Cisifus Olympus Change of Command delayed Olympus Deployments Region poster for Tricare Conference; assignment of presenters New Business Deployment of personnel from the Olympus Ambulatory Clinic Unknown length of deployment Affects GMOs most Nursing also depleted Recent Sentinel Event at Valhalla Cardiac case in ED Newspapers covering the incident Family has filed lawsuit Personnel complaints in Valhalla ED Report from Commander Report from JAG office Report from Cisifus re closure of their Saturday clinic hours Report on Water damage to Supply Room at Olympus Clinic Report from Olympus on disappointing backfill status Anticipated JCAHO visit for Valhalla Action items Charge IPT to address the waiting times in Valhalla ED Determine information needs Review supplied information to determine probable cause Report to Council in five working days on recommended next steps. Enclosures: (1) Valhalla ED Source of Patients from BPT and CHCS (2) DX of Patients Seen on a Typical Day at Valhalla ED (3) Valhalla ED Waiting Times (in hours) (4)Valhalla ED Workload by Shift Agenda Yesterday.doc