Session 1 - Case Study Content - Crawford

Initial Case study

1. MedXellence Case Study


Background/Set-up


You are a member of the local Commander’s 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. Narrative: Updated June 2009
The Problem

Waiting time in the Valhalla Medical Center’s Emergency Department has been a center of
controversy for the past year, and has been a recurring agenda item at this Committee’s meetings. It
has also been a heated agenda item at the Medical Center’s 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.

3. Agenda
Region 71 Commander’s Executive Board
July 2009
Agenda T-6 Months.doc

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
Palermo’s 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.

4. Agenda
Region 71 Commander’s Executive Board
October 2009
Agenda T-3 Months.doc
ii

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

5. Agenda
Region 71 Commander’s Executive Board –December 2009
Agenda Yesterday.doc

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