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Joanne's Journal - Thursday, December 14, 2017

Joanne's Journal - Thursday, December 14, 2017

Dear Colleagues:

A critical aspect of creating a high-performing organization is always asking ourselves “Are we doing as well as we could?” This question was top of mind last week when our Board of Trustees convened for our quarterly meeting. Being a high-performing organization means constantly examining our leadership structure, our strategy, our core business health, our measurement systems, our workforce, our operations and our results. The priority areas of focus for this coming year are operational and financial stability, engagement, quality and safety, and developing and executing our strategy. Here are some reflections on a few of these priorities, based on our Board discussions:

Operational Stability

Our senior leadership team has spent the last three months discussing how to organize for more effective decision-making, resource allocation, revenue growth, operational effectiveness and overall management. We are continuing to develop a future-oriented basis for action where we set and test the objectives that define and guide critical actions and performance. We have restructured our leadership team (Click here for a previous Journal summary) across the health system as we grow our footprint and move into an operating model that supports risk-based payment systems. We do have many interdependent operations that are focused on consistency of plans, processes, measures and actions in order to operate in a fully interconnected, unified and mutually beneficial way to deliver results. These changes will help us focus on organization-wide metrics—including, but not limited, to financial performance, quality, productivity, utilization, and access—and the contribution each business unit makes toward those goals. We have to succeed at both a facility level and a system level.

Financial Stability

Senior leaders play a central role in setting values and directions, communicating, creating and balancing value, and creating an organizational focus on action. Success requires a strong orientation to the future and a commitment to improvement, innovation and intelligent risk taking to create organizational sustainability.

The good news is that Dartmouth-Hitchcock had a strong start to the new fiscal year, ending the first quarter with a 4.4 percent Operating Margin of $18.1 million, an amount that exceeded budget by $2.5 million and was $16.8 million above prior year first quarter results (a 0.4 percent Operating Margin). These results are promising as we head into the new calendar year.

Strategic Planning Process

Steve LeBlanc, chief strategy officer, is organizing a strategic planning event for the Board on May 21-22, 2018. The planning process will include information on all key influences, risks, challenges, and other requirements that might affect our future opportunities and direction. The goal is to provide a thorough and realistic context for developing a customer- and market-focused strategy to guide us. It also requires assessing service-line quality and profitability across facilities and sites of care, and an understanding of competitive threats and patient preferences. We are regionalizing services where it makes sense and driving integration of the individual business units as a cohesive health system.

In the meantime, we are continuing to solidify our base in Southern New Hampshire and Vermont. Steve spent the majority of the Board session on Friday reviewing our broader regional strategy with a focus on where we are in the execution of our Southern NH Region strategy and making recommendations for Board input and approval. 

Quality and Value

By delivering value to our patients and our communities, we build loyalty, support the local economy and contribute to society. A balanced composite of leading and lagging performance measures is an effective means to communicate short- and longer-term priorities, monitor actual performance and provide a clear basis for improving results. Dr. George Blike, chief quality and value officer, reviewed our scorecard results during the Board’s Value Committee meeting. Based on the 1-to-5 star rating scale set by the Centers for Medicare & Medicaid (CMS), we’ve improved our score from a 3 to 4 stars. There are only a few academic medical centers around the country that have achieved a 4-star rating! We will be posting this in the administrative hallway and outside of the Safety Huddle room on the 4th floor at DHMC.

yelling emoji

Preparations have been well underway for The Joint Commission’s (TJC) follow-up visit to evaluate our response to their finding from the November 10th survey. This visit can take place any time between now and the end of the year. And just when we thought we might be able to stop and take a deep breath, we became one of the 2 percent of hospitals that receive a validation survey (within two weeks of a TJC visit) by CMS (Centers for Medicare and Medicaid Services). We are currently hosting 10 surveyors from NH Health and Human Services who are performing this CMS survey. They will finish their work on Friday the 15th.

Next Steps for the New Year

We are not alone in experiencing significant cost pressures over the past few years. Most systems have already been through multiple rounds of cost cuts, and there is not much juice left to squeeze. Very little remains for health systems to capture in revenue by better managing individual facilities. We have to look to improve operations with a system-wide lens. We are focusing on bringing more accountability and a “line of sight” at the system level. The objective is to strike the right balance of centralized control over most transactional operations, such as reporting, while accommodating local nuances in areas where it truly matters. This requires us to engage business unit leaders and jointly develop our new operating model.

As a part of our strategic planning process, we are working on translating high-level, strategic objectives into very specific, tangible changes in day-to-day behavior, so we can all lead the change in a visible way. We will be communicating simply and directly, trying to explain what the changes will mean, with a minimum of jargon. We will be focusing on engaging all of you with the most direct knowledge of how work actually gets done each day, then use your invaluable insights and ideas regarding how to improve it. We’re in this together.

Dartmouth-Hitchcock’s focus will be to not just get bigger but to get better….. every day.  

New D-H Opioid Study Offers New Guidelines After Surgeries

Richard Barth, MD

Richard Barth, MD

A new study by Richard Barth, MD, section chief for General Surgery at Dartmouth-Hitchcock (D-H), offers surgeons specific guidelines for post-surgery prescriptions for pain-relieving opioids.

The study, published in the Journal of the American College of Surgeons, recommends that patients who have major abdominal surgery should be able to control their pain at home by taking the same number of opioids they took the day before they were discharged.

“This guideline was true for multiple different operations,” Dr. Barth said.  “It didn’t matter whether someone had a colon operation, liver procedure or hernia repair; no matter what type of general surgery operation they had, this association held throughout all procedures studied.  So the beauty of this finding is that one guideline would apply to multiple surgical procedures.”

According to the Journal, this is the first time specific guidelines have been proposed for prescribing opioids upon discharge after general surgery operations that require inpatient admission.

Although some states have adopted laws to curb opioid prescriptions, they are often ambiguous.  Barth noted that several New England states limit doctors to prescribing a seven-day supply of opioids, but they include no limits on dosing. “So a seven-day supply could be 84 pills or 21 pills,” he said.

Rising rates of opioid prescriptions have been linked to the opioid epidemic, and a significant number of opioid deaths have been traced to prescriptions written by surgeons.

This is the third post-surgery study by Barth and his research team. Two previous studies showed most outpatient surgeries for breast, gallbladder and hernia repair needed far fewer opioid pain medications than currently prescribed. Barth says, in the first studies, there was no published data to guide physicians for controlling post-surgical pain. 

The outpatient studies helped educate D-H providers and patients that a regimen of acetaminophen and ibuprofen could control 85 percent of post-surgical pain, resulting in a 53 percent reduction in opioid use by surgical outpatients. 

Barth’s latest study offers new guidelines for inpatient surgery prescriptions “that are easy to remember and easy to use” for providers and patients, he says. The recommendation does not mean patients will not get enough pills to manage their pain after they leave the hospital. “The guideline was based on satisfying at least 85 percent of patients’ home opioid requirement,” Dr. Barth says.  

The study included 333 hospital inpatients discharged to home after six different types of general surgery operations: bariatric procedures; operations on the stomach, liver and pancreas; ventral hernia repair; and colon operations. The researchers followed up with the patients after discharge by using questionnaires and phone surveys; 90 percent of the discharged patients completed the follow-up process. The study group did not include any chronic opioid users.

The guideline recommends the following schedule for a post-discharge prescription based on the number of opioid pills taken the day before discharge:

  • no pills for patients who took no opioids the day before they left the hospital;
  • 15 pills for those who took one to three pills the day before;
  • 30 pills for those who took four or more pills on their last day in the hospital. 

Barth says other D-H departments will study the recommendations in the coming year.  

Barth’s study co-authors are Maureen V. Hill, MD; Ryland S. Stucke, MD; Sarah E. Billmeier, MD, MPH; Julia L. Kelly, MS, and all of the Department of Surgery at Dartmouth-Hitchcock Medical Center. Early study results were presented at the New England Surgical Society Annual Meeting in September of 2017.  

Our Patients. Their Stories. Rick Lounsbury

Rick Lounsbury

Rick Lounsbury

Near midnight on December 28, 2016, a call came into the Lebanon Fire Department that heavy smoke was billowing from the First Baptist Church located downtown.

Rick Lounsbury was one of the firefighters who responded to the scene to battle the fire that ended up destroying the historic structure.

A firefighter for 27 years—22 of those with the Lebanon Fire Department—Lounsbury prides himself on his physical fitness at age 60. “It’s been a great motivator to be still able to do the job,” he says, “and a good challenge for me to keep up with the younger guys.”

If Lounsbury, an avid runner and regular at his fitness club, had any physical concerns on the night of the church fire, it might have about been his right shoulder, which he had previously dislocated four times.

“We were getting set up to start the firefighting operation,” he recalls, “and I was opening a fire hydrant to feed the water supply to one of the trucks.”

When he turned the valve on the hydrant, Lounsbury met some brief resistance with his outstretched right arm, and he says, “My shoulder popped out of joint.”

Thomas Trimarco, MD, emergency medical services director at Dartmouth-Hitchcock Medical Center (DHMC), was on standby at the scene and brought Lounsbury over to the ambulance, stabilized his shoulder and asked him if he wanted him to put his shoulder back in place. Says Lounsbury, “I told him, ‘I don’t think you have enough pain medication on the ambulance.’”

Lounsbury was transported to DHMC a few hours later to see a doctor in the Emergency Department who performed a shoulder reduction—the technique to move his shoulder back into place. About 4:30 am, Lounsbury rode in the ambulance back to the fire station to collect his gear and his truck and headed home.

Read the full story online here.

Dr. Joanne Conroy Joins Other Hospital CEO’s to Support Organ and Tissue Donations

Dr. Joanne Conroy with New England Donor Services’ Kerrie Casey (left), director of hospital relations, and Karen Lord (right), RN, MSN, FNP-C, advanced practice donation specialist

Dartmouth-Hitchcock CEO and President Dr. Joanne Conroy, center, recently met with New England Donor Services’ Kerrie Casey, director of hospital relations, left, and Karen Lord, RN, MSN, FNP-C, right, advanced practice donation specialist, at Dartmouth-Hitchcock Medical Center.

Dartmouth-Hitchcock (D-H) CEO and President Dr. Joanne Conroy recently met with New England Donor Services’ Kerrie Casey (left), director of hospital relations, and Karen Lord (right), RN, MSN, FNP-C, advanced practice donation specialist, at Dartmouth-Hitchcock Medical Center. D-H is partnering with the organization to honor and remember those who gave the gift of life through organ and tissue donation. The annual focal point of this remembrance is the Donate Life Rose Parade float, which has been part of the famed Rose Parade in Pasadena, California, since 2004, and is the world’s most visible campaign to inspire people to become organ and tissue donors. When the Rose Parade is held on January 1, the Donate Life float will include a dedication garden made up of roses with handwritten dedications from hospital CEO’s across the country, including Conroy. 

Dr. Conroy signing her dedication

Dr. Conroy signing her dedication.

Conroy is shown right signing her dedication, which she then presented to Casey and Lord. This year’s parade theme is “Making a Difference,” to highlight the importance of becoming an organ and tissue donor. A single organ donor can save the lives of up to eight people and improve the lives of as many as 75 more through the donation of corneas and tissue.

CME Receives Accreditation with Commendation

In renewing Dartmouth-Hitchcock’s (D-H) accreditation for providing continuing medical education for physicians on December 6, the Accreditation Council for Continuing Medical Education (ACCME) awarded D-H “accreditation with commendation,” the organization’s highest level. D-H is now accredited through November 30, 2023.

In a letter to Dwayna M. Covey, D-H’s director of operations for the Center for Learning and Professional Development, the ACCME noted that “accreditation with commendation” is awarded to providers that “demonstrate compliance in all criteria and the accreditation policies. We commend your organization for meeting the ACCME’s accreditation requirements and for demonstrating that yours is a learning organization and a change agent for the physicians and patients you serve. You have demonstrated an engagement with your environment in support of physician learning and change that is part of a system for quality improvement.” 

Covey partnered on the accreditation process with Brian D. Sites, MD, MS, director of D-H’s Regional Anesthesiology Fellowship Program and Orthopedic Anesthesiology, and the associate dean of Continuing Medical Education (CME) at the Geisel School of Medicine at Dartmouth. The pair were delighted by the news that D-H had been given the ACCME’s highest distinction.

“Accreditation with commendation means that we met the required 13 criteria for CME policies and the nine additional criteria that show our high level of engagement with the broader D-H environment,” says Covey. “Our surveyors were impressed most specifically with our major new initiatives since our last accreditation.”

Sites notes that these initiatives include:

  • The D-H Learning Technology team that was assembled, funded and deployed in fiscal year 2016.
  • A new alliance with Quality and Safety, and the impact we have made on our hospital-acquired conditions (HAC) reduction measures.
  • Accreditation for the online Yellowbelt and Greenbelt programs.
  • Materials designed to educate physicians about the opioid epidemic.
  • The reorganization of CME into the Center for Learning and Professional Development with truly shared resources, and the close working relationship between Marc Bertrand, MD, interim medical director for D-H's Simulation-Based Education and Research Department (SIM), and associate dean for General Medical Education (GME), and medical director Sites for CME.
  • The connection of learning to clinical outcome improvements, such as reductions in CLABSI (Central Line Associated Bloodstream Infections), CAUTI (Catheter-Associated Urinary Tract Infections) and sepsis.

“I want to recognize the efforts of our full reaccreditation team, led by CME Manager Terri Farnham,” says Sites, citing Covey, Wendy Murphy, Theresa Gilbane, Katelyn Daly, Cara DeLura, Mary Turco, Debra Hastings and Marcus Jenkyn. “They all worked together to tell our story in a succinct and powerful way.”

Covey adds, “We appreciate the support that CME has received by the Board of Trustees and our D-H leadership team. This has allowed us to be innovative and to do further work in connecting quality learner outcomes to patient safety and quality outcomes.”

Share Your Holiday Traditions for Joanne's Journal on December 21

As Dr. Joanne Conroy mentioned in Joanne’s Journal on November 30, we all have some “interesting” holiday traditions. We’ll be collecting some of these traditions and publishing them in next week’s journal. Please share yours by emailing them to