group 4 consulting firm

GROUP 4 CONSULTING FIRM

CARDIAC CARE TRANSFORMATION

A Proposal To: GreenForest Health System

NURS 524 Autumn 2013

University of Washington

Si Feng

(GroupLeader)MarkMoon(LeadWriter)

KristineKim(Presenter)

TaoZheng(VisualArtist)

WenjiaSong(ChiefEvaluator)

Our Mission: Help you transform care and succeed in today’s healthcare Market

Running head: CARDIAC CARE TRANSFORMATION PROPOSAL 1

CARDIAC CARE TRANSFORMATION PROPOSAL 2

Abstract

This proposal is developed by Group 4 Consulting Firm to help GreenForest Health

System transform its Cardiac Care. It addresses four key elements of the cardiac care

transformation strategy to GreenForest CEO, Carol Boston Fleischhauer: developing a new

leadership culture for the GreenForest Health System, designing a cross-continuum care model

structure to support all facets of cardiac health, designing a clinical workforce strategy, and

designing a patient engagement and community strategy to ensure care partnership with patient

and community. Those strategies are consistent with GreenForest’s mission and vision of care.

The core of the recommendations is to maximize the value of care by achieving the optimal

outcomes at the lowest cost.

Keywords: GreenForest, Care Transformation, Cardiac Care, Values-based Care


A Cardiac Care Transformation Proposal to GreenForest Health System

Introduction

The GreenForest Health System (GFHS), based in Washington State, is a non-profit

healthcare organization that hosts three hospitals, one homecare agency, several primary and

multi-specialty clinics, and a physician group. The GFHS is losing its cardiac patient market to

other competitors in the area. Based on both internal and public reports, GreenForest’s current

cardiac health performance measures and patients satisfaction rate are at an average to low

quality level. In addition, the established partnership between GFHS and the communities it

serves, ensuring the integrated coordination of post-acute cardiac care, is inadequate and non-

continuous.

In current healthcare market, most of healthcare services, such as GFHS are still paid for

on a fee-per-service basis with little regard for its quality of service. The fee-per-service payment

system drives up healthcare costs by encouraging wasteful use of high-cost services and

potentially lowering the value of care. Cardiac care is especially a high-cost, high-margin service

under current system. If GFHS keeps current model of cardiac care and not participating in the

movement towards value-based care, it will suffer further the consequences of losing its cardiac

market share to other competitors and continuous declining in cardiac performance measures.

The 2010 Affordable Care Act (ACA) focuses on transforming our current volume-based

care into patient-centered, value-based care. The goal of value-based care is to achieve better

health outcome by increasing quality of care and efficiency and lowering costs (Kovner &

Knickman, 2011). The health reform tracks value measuring with readmission rates, hospital-

acquired infections and complications. For example, GFHS might face financial penalties if

cardiac readmission rate, particularly in the case of acute myocardial infarction, is high. Other


drivers that promote the model transformation are changes in medical practice that focus on

coordinated care across care continuum, standardizing care approaches to reduce care variation,

optimizing service distribution to ensure the right care at the right site, and providing financial

incentives to reward effective care coordination. The new value-based care model in GFHS

requires a strong leadership culture, well-coordinated care management, cohesive clinical

workforce, and engagement of the patient and the community.

This proposal focuses on the following four key elements of care transformation:

developing a new leadership culture for GreenForest Health System, designing a cross-

continuum care model structure to support all facets of cardiac health, designing a clinical

workforce strategy, and designing a patient engagement/community strategy to ensure

patient/community partnerships in the achievement of optimal cardiac health. This set of

recommendations will be implemented over a two-year time frame in order to show an improved

set of results in all domains.

Transformation Recommendations

New Leadership Culture

Edward Tylor defines a culture as a “complex whole, which includes knowledge, belief,

art, morals, law, custom and any other capabilities and habits acquired by man as a member of

society” (as cited in Cashmore, 1996, p. 91). In order to transform successfully from the old fee-

per-service system to a new value-based care system, the process should include all stakeholders,

especially leadership and management.

In this transition to value-centered care system, the role of senior management and board

levels are crucial because it requires a sweeping transformation from the past. The nature of

cardiac care transformation at GreenForest is a "radical" change, one of four categories of


organization change by Keen (Wager, 2013). This radical change in cardiac care leaves the

GreenForest health systems and their core mission intact but significantly alters the way the

health systems carries out its business. This major structural change means leaving decades-old

organizational structures and care patterns behind. It even means oftentimes sacrificing

everything for the value for patients, creating pains and struggles from the top management and

the very bottom employees. This kind of profound transition can be achieved when all

stakeholders embrace collective beliefs of value-centered care culture. To create and foster such

an important culture for value, particularly for a new leadership, the GFHS is advised to

contemplate and execute the five recommendations listed below.

First of all, GFHS will hold a 5-day-long conference for all executive members and board

members from the whole health systems including University of TreeHope Medical Center,

Moyen Sante Medical Center, GreenForest Community Hospital, United Woodland Physician

Group, and Bluelake Homecare Agency. Key staff members in cardiac care services should be

invited to the conference, for they can accurately portrait the current overall delivery of cardiac

care in a frontline perspective. The staffs are the key to implementation; change needs to happen

at the frontline of care. The agenda for the conference should be the value-centered care and all

stakeholders need to understand the necessity for this change. This call for the change should be

unmistakably differentiated with quality assurances that may be going on throughout GFHS.

This is a fundamentally new strategy. The conference may be held multiple times until all

stakeholders recognize the necessity and urgency for the inevitable change. The foremost output

of the conference(s) is an amendment of mission and vision statements that will incorporate the

value agenda for patients. The second output is a written and signed charter empowering an

organization-wide transformation initiative that aims to maximize the value for patients. Without


this consensus among all executive members, directors of the board, and key staff members at

the GFHS, no structural and fundamental transformation is possible.

The leaders at GreenForest should be able to envision what the change is about to bring

clearly. The cardiac care staff should understand the nature of the change and should know what

the world will look like when the change has been completed, how their roles and work life will

be different, and why making this change is important. The absence of this vision or a failure to

communicate the important of this new vision elevates the risk that the staff will resist the

change. They must understand the nature of the change and why they should go through what

they will experience as a difficult transition. To facilitate change, leaders and key staffs need to

make visits to learn from model healthcare organizations, which have been advancing to achieve

high value patient-centered care. Such organizations may include the integrated practice unit at

Virginia Mason Medical Center in Seattle, Geisinger Health System in Pennsylvania, and the

Cleveland Clinic in Cleveland, Ohio (Porter & Lee, 2013).

Second, it is critical to establish a special committee consisted of representatives from

each micro health system of the GFHS as a vehicle to plan and execute the change, as well as to

develop a culture of new leadership. All representatives should be adequately proportioned

according to its size and number of staff, thus effectively representing their respective entities.

Endorsed by all leadership and management in the GFHS, the committee is to suit the main

vehicle that governs and leads the Care Transformation for Cardiac Health. Ideally, this

committee and its chairperson should be formed and recognized at the conference(s). The

committee is an independent institution solely dedicated to the cardiac transformation, but

working together with various stakeholders during the care transformation. The scope of the

committee is system-wide that handles various strategic value agenda, including organizing


current various health entities into integrated practice units (IPUs) for optimal and value-centered

cardiac care units, measuring outcomes, moving to bundled payments for cardiac care cycles,

integrating care delivery systems, growing new cardiac care services across geography, and

building a competent information technology platform, consistently with the six-component

strategy previously proposed by Porter and Lee (2013). Empowering the committee with

independence and adequate authority is essential for a successful cardiac care transformation.

As the driving force for the change, the committee of leaders should be able to: 1) define

the nature of the change; 2) communicate the rationale for and approach to the change; 3)

identify, procure, and deploy necessary resources; 4) resolve issues and alter direction as needed;

and 5) monitor and control the progress of the change initiative (Wager, 2013). In the committee,

measuring outcomes is the first step by focusing everyone's attention on what matters the most

(Porter & Lee, 2013).

One of the main tasks that the committee should carry out is to create a comprehensive

plan for the cardiac transformation, which details how to accomplish changes (Boan, 2006).

Having all stakeholders supporting the plan is crucial to achieve the success in developing a new

leadership culture. In order to create a supportive environment for the change, identify

champions who will work with the staff to make the culture change a reality (Boan, 2006). The

champions should be persons with senior management support and staff confidence who can

solve problems and be relentless about keeping the process moving forward.

Third, in order to reinforce a collective belief value among all leadership and

management within the GFHS, the committee should clearly define goals for Care

Transformation for Cardiac Health. The goals must be "improving value for patients" that means

improving cardiac health outcomes by lowest possible costs (Porter & Lee, 2013). While


defining clear goals, the committee should clarify that the goals cannot be reached without a

profound transformation. Various vehicles such as workshops and summits can be utilized for an

effective dissemination of the information about the value and imminent call for change. While

nobody is against improving outcomes, the current decades-old system has been generating

varying quality and unsustainable costs. Thus all leadership across the GFHS should uphold the

collective beliefs that the old system must be replaced. Once the involving leaders mutually

agree and share the necessity for change and the defined goals, the collective beliefs for value

agenda can be disseminated to the all GFHS staff involving in the care transformation.

In order to develop a new culture of leadership, establishing a strong connection between

leaders and all participating stakeholders is required. The committee and leaders should take

every available opportunity to present the vision for the high value cardiac care throughout

GFHS. Leaders may use department head meetings, medical staff forums, in-services, clinician

meetings, one-on-one conversations, internal publication, websites, blogs, and emails to

communicate the value-based vision. Communication should be continuous to ensure the vision

is clear and consistent to all members at any stage of cardiac care transformation.

Fourth, fostering a trustful and supportive environment in the GFHS. The members of

GreenForest cardiac care team must trust the integrity, intelligence, and skills of the leadership

for the change. On another hand, such a trust is earned or lost by the leadership behaviors of the

leaders. Therefore, the leaders must demonstrate to stakeholders and cardiac care team members

with their competencies in leadership skills by being knowledgeable and supportive. Leadership

should listen and respond to the concerns brought by stakeholders. Trust and mutual support, in

particular, are important components of transformation of cardiac care services.


Fifth, ongoing opportunities for learning and growth in leadership development need to

be offered. Organizational leaders in healthcare who believe in the value of learning and growth

are likely to invest heavily in leadership development activities and commit to sustaining the

program over time. In several healthcare organizations, the hiring of a Chief Learning Officer or

Leadership Development Program Director provides evidence and effectiveness in developing

new leadership culture (McAlearney, 2006). The more the organization’s senior leaders value

learning and growth, the more likely the leadership development is to be supported and sustained

within the GFHS. The GreenForest's commitment to leadership development can affect the

organization’s overall effectiveness by improving employee motivation, reducing turnover, and

building organizational flexibility to change.

Cross-continuum Care Model

In order to provide well-coordinated care for cardiac patients, GFHS is committed to an

interdisciplinary approach to manage patient care throughout the continuum. The mission of

cardiac care coordination is to coordinate the diverse aspects of patient care throughout the

continuum of patient's cardiac care to achieve the highest quality and most cost-effective

outcomes, reducing complications and patient readmissions.

To ensure value-centered cardiac services across continuum of care, the GreenForest

Health System should implement an integrated practice unit (IPU) for cardiac conditions. The

IPU, Cardiac Intervention Center, should be placed in the GreenForest Community Hospital, for

it has been demonstrating strong outreach programs within the GreenForest system in

rehabilitation and home health services, which will contribute to building a strong cross-

continuum care structure, particularly for chronic cardiac conditions. The IPU should mobilize

the currently renowned cardiac care at the University of TreeHope Medical Center to maximize


its competency and cutting-edge advancement in cardiac services. The other branch arms of the

GreenForest should be mobilized for carrying out the integrated and coordinated cardiac services

by the Cardiac Intervention Center. Patients with cardiac conditions call one central phone

number connected to Cardiac Intervention Center, and most of patients should be seen the same

day.

To facilitate integrated cross-continuum cardiac care, the IPU is committed to an

interdisciplinary approach to provide and manage the full care cycle for the cardiac patients---

from treatment of acute cardiac problems, engaging patients and their families in care, and to

supporting needed behavioral changes such as weight loss and diet. The core of cardiac care

coordination is to effectively organize diverse aspects of patient care throughout the continuum

of patient's cardiac care to achieve the highest quality and most cost-effective outcomes,

reducing complications and patient readmissions.

Under the Accountable Care Act, increased collaboration and coordination is encouraged

to facilitate high quality of patient care and promote patient outcome. With centralized cardiac

care in GreenForest Health System, physicians are able to consult and collaborate with others in

a timely manner, and they will come up with ideas on cardiac intervention and management of

patient’s condition, and what follow-ups that patient need over time. Centralized cardiac care

will also help keep track of the health status of the patient and further transition of patient care.

Multidisciplinary care teams, made up of both clinical and nonclinical personnel such as

physicians, nurses, nutritionists, educators, pharmacists, and social workers, will work together

to provide ongoing, proactive services in the inpatient setting. Cardiac care coordination staffs

are deployed along major service lines: cardiac services, which include cardiac intensive care

unit, cardiac step down unit, cardiology services (post cardiac events follow up), and cardiac


rehabilitation. The team of care coordination responds to the medical management and

psychosocial needs of all patients served by GFHS. Social workers provide patients and their

family emotional support and make referrals for patient and their family as needed. For example,

social workers may make support group referrals to support patients’ recovery.

To promote coordinated care to improve patient outcome and reduce readmission rate

after patient’s discharged, forming a care coordination team can be implemented. The care

coordination should be started at the time of admission to start the process of planning. The care

coordination team will include: a medical staff who can be a mid-level provider (an advanced

nurse practitioner or a physician assistant), a pharmacist who understand patient’s current

medical management and potential management at home, staff nurses who are patient’s primary

nurses and who track patient’s progress on a daily basis. Staff nurses are also responsible for

monitoring patient’s lab results to ensure patient’s lab results meet the requirement at the time of

discharge. Staff nurses can also provide information regarding patient’s rehabilitation needs,

especially for surgical patients. Whether patients have social support to help them recover when

they are discharge is critical to know, as patients may need to go to a skilled nursing facility for

rehabilitation if patients do not have people to take care of them at home. Care coordinators play

an important role in the care coordination, as they will make arrangement for patients who need

rehabilitation after surgery. Care coordinators will contact appropriate skilled nursing facilities

that are capable to take care of patients who are in need of cardiac care, and bed availability from

the facility. In order to reduce readmission rate, care coordinator will keep track of facility

performance and keep a list of preferred facilities. Social workers are also within the care

coordination team, they will provide psychological support for patients and their family during


hospital stay, and they will also identify barriers for quality of care and rehabilitation in the home

environment.

Care coordination team members need to communicate with each other to promote

successful patient transition from the hospital to home or a skilled nursing facility. Daily patient

care coordination round with attendance of a medical staff, a pharmacist, staff nurses, cardiac

coordinator nurses, and social workers, will be initiated to share patient’s information and make

further plan of care for the patient. The care coordination meeting will start with the staff nurses

will give information of patient’s current condition, anticipation of when the patient will be

discharged, whether patient has a primary cardiologist for follow up, and concerns of patient

being discharged to prior living environment, which will raise the question whether patient will

need referral to a skilled nursing facility (SNF). Care coordinators will update staff nurses

regarding patient’s placement referral status, and when a skilled nursing facility bed will be

available for patient to transfer. If a patient’s being discharged on the day of meeting, staff nurses

will share with care coordinators that when patient will be ready to leave the hospital, so the care

coordinator can arrange patient’s transportation if no personal rides from patient’s family or

friends are not available. When a patient is being transferred from the hospital to a skilled

nursing facility, what type of transportation can be used depends on patient’s current condition.

For example, how many liters of oxygen patient requires on his/her current condition. Therefore,

staff nurses are responsible to pass on crucial information to the care coordinators before

transport arrangement is made.

In addition, switching from a paper-based data system to an electronic medical record

(EMR) system will enhance efforts in coordinated care. Medical records within the GreenForest

Health System were disjointed and difficult to update. Without having a unified EMR system,


patient care and safety is a large concern. Providers are not able to access notes, labs, or valuable

information regarding the patient’s history to build upon the care that the patient has already

received. Alternatively, if there was an error from a previous visit then if it was fixed at another

location the patient could come across issues regarding their care in the future. With a new,

connected EMR system, patient medical records will be kept in an efficient and uniform fashion

that providers will be able to continuously update. Confusion about visiting different providers

will be eliminated; medical records will be kept up-to-date and accurate, and notes from each

provider will elucidate any ambiguities.

Accountability is an important component in care coordination. To fulfill the standard of

accountability, GreenForest Health System should have the ability to track referrals and

transitions of cardiac care to assure their successful completion. An information system that

records important landmarks in the referral process, such as referral appointment made, patient

information received, appointment completed, consultation note returned, will make referral

tracking feasible. An electronic data base system can be created to record all referral made by

the facility and the landmarks of transition. E-referral system will generate electronic referrals

among providers and facilities; meanwhile it will also facilitate tracking of all referrals

("Reducing care fragmentation," n.d.).

The State Action on Avoidable Rehospitalizations initiative, known as STAAR, was

launched in four states including Washington in 2009, aims to reduce rates of avoidable hospital

readmission. STAAR mobilized state-level leadership to improve care patient transitions. As a

health system in Washington State, GreenForest Health System may adapt STAAR to promote

cross-continuum model. GreenForest Health System will be expected to form a cross-continuum

team. The team will consist of hospitals, providers, and skilled nursing facilities (both within the


system and in the community) that hospitals frequently share patients with. The hospitals will

partner with hospital providers who are the “senders”, the nursing skilled facilities or the

providers in the community who are considered as “receivers”, and patient and their family

representatives to collaborate to improve communication and coordination to the next level care

at the time of transition. Hospitals and the cross continuum team will be asked to analyses

through data collection to evaluate quality improvement efforts. They will collect the reasons

why readmission occurs within thirty days, and they will also perform chart review and

interviews of the recently readmitted patients and their family to identify opportunities to

improve transition. Under STAAR methodology recommendation, the hospitals and the cross-

continuum team will ensure comprehensive assessments of patients are performed, improvement

of patient education and clear and updated communication is provided to patients and their

caregivers upon discharge to ensure timely follow-up (Boutwell et al., 2013).

Based on the STAAR initiative, GreenForest Health System will develop a Cardiac

Performance Review Committee to specifically monitor cardiac care health outcomes and

compare them to the national standards. The committee will include case management experts

and representatives from multidisciplinary teams to cover all aspects of cardiac care

measurements. The committee will be responsible for monitoring GreenForest cardiac

readmission rate, patients’ satisfaction with hospital stay and follow up care, and evaluating

performance of the cardiac care team. They will review patients’ medication records and care

plans to analysis care coordination and reduce potential cardiac complication and readmissions.

Clinical Workforce Strategy

The United States is estimated to spend about $444 billion on total costs related to

cardiovascular diseases (Fye, 2004). Treatment of these diseases accounts for $1 of every $6


spent in this country (National Association of Community Health Centers, 2007). Although there

has previously been a decline in the acute cardiac events, the increasing population older patients

have developed higher incidences of chronic cardiovascular diseases. As the population in the

United States ages in next few decades, the economic impact of cardiovascular diseases in our

nation’s healthcare system will become even greater. In response to the growing cost in cardiac

health care, few health systems are able to estimate their future workforce needs accurately or

develop a strategy for keeping the clinical workforce at a balanced level. As GFHS starts

reforming the cardiac health services division, major organizational changes are needed to ensure

GFHS providing cost-effective cardiac care services while maintaining a financial stability.

A centralized location for cardiac health major interventions will be lead through the

GreenForest Community Hospital. Moyen Sante Medical Center will have an operating branch

of cardiac services through a specialized cardiac clinic, but the main hub of intervention

specialists will be based at the GreenForest Community Hospital. GreenForest Community

Hospital will be obtaining the new Cardiac Intervention Center. The other health care facilities of

the GFHS will obtain specialized cardiac clinic services within existing locations or nearby

outpatient clinics will be established in order to create a unified cardiac health care experience

for the patient. At all locations within GFHS, cardiology patients will have an option to schedule

appointments with physicians or mid-level providers to address their concerns. Instead of

staffing specialty cardiologists at every clinic location, cost of maintaining an efficient and

knowledgeable cardiac service team will decrease by having a centralized center specializing in

cardiac interventions.

Mid-level practitioners are very versatile and will be able to complement the patient care

that is provided by cardiologists. Therefore, coordinated patient care will continue to be the main


focus by giving other locations within the GFHS an option to hire more mid-level providers.

Mid-level providers are able to intake patients, order necessary labs, and even prescribe

indicating medications. Maintaining a stabilized staffing with mid-level providers is cost-

effective and valuable patient care experiences are still a priority because mid-level providers

have extensive education requirements, which make them very educated. In a situation that

further investigation is beyond the resources and services that the clinics can provide, the patient

will be referred to the GreenForest Community Hospital Cardiac Intervention Center.

Communication between the community clinics and the Cardiac Intervention Center will

be continuous with accessibility to electronic systems to alleviate any stresses with a paper

record system. With the addition of the electronic medical health record system, communication

among all healthcare providers will be vastly improved thereby making the transition from the

generalist to specialist care easier for the patients. Having the patients’ medical records available

throughout the entire electronic health care system can effectively deliver patient-centered

coordinated care. The restructure of the existing system will be better to provide an integrated,

coordinated care for GFHS patients.

In addition to the new Chief Nursing Officer (CNO), GFHS will need to hire a Director

of Cardiology (DC) in order to manage the department of cardiology. With the leadership of the

CNO and DC will ensure that newly developed system will be instituted and well maintained.

Educational requirements for the position include a Bachelor’s Degree in Business or Health

Administration; it would also be recommended to have at least five years of leadership

experience in healthcare training and finance within a health system organization. The DC will

be responsible for the patient care that is delivered to all cardiac patients within the GFHS. The

DC will participate as a member of the hospital’s management team in planning, policy


formation, and cardiac services. The DC will also be responsible for the patient care

management, resource management, and fiscal management within the department. The DC will

need to establish a set of cardiac care protocols practices that will guide the practices, ensure the

quality and safety of the service, and become the references for future quality improvement

surveillance. The protocols will be systematically researched utilizing current clinical research in

order to create an effective framework for interventions that maximize fidelity and patient

treatment effectiveness. All approved protocols will be implemented as a set standard of practice

throughout all patient care locations in the GFHS.

Behind the underlying goals of providing care to cardiac patients, the leadership

committee will develop a leadership culture that integrates management and continual

improvement of services and demonstrates professional values and skills through the GFHS

healthcare providers. The Cardiac Leadership Committee will include anyone who has a

leadership role in respect of health and care professional such as Medical and Nursing Directors,

the consultant body, clinical managers, and team leaders within the entire GFHS system. All

members will work together in order to ensure that GFHS has excellent leadership at all levels of

the clinical workforce.

Fye (2004) reported there would be a shortage of cardiologists and cardiac services in the

2010’s and 2020’s when the baby boomer population reaches the prime heart disease range.

Implementation of productivity and utilization strategies will reduce the demand, but will not

fully close the gap of patient demand for cardiac services. In response to the growing shortage of

cardiologists, it is advantageous to hire mid-level healthcare providers such as nurse specialists,

advanced nurse practitioners, and/or physician’s assistants to complement the care provided by

cardiovascular specialists. Recently the numbers and types of mid-level practitioners employed


by GHFS have increased dramatically (National Association of Community Health Centers,

2007). Community-based cardiac care such as cardiac disease screenings and preventions,

primary management of chronic cardiac disease, and cardiac disease educations depends heavily

on these mid-level professionals, thus the cardiologists will be able to focus more on cardiac

intervention specialization, such as in-patient cardiac catheterizations or cardiac surgeries.

Having an extensive group of mid-level providers will become a cost-effective management of

patient care without sacrificing the quality of care that GFHS will provide to cardiology patients.

In addition, pharmacists will be collaborating with cardiologists and mid-level providers

to make recommends in cardiac medications, dosages, schedule/frequency, and directions. With

the collaborative agreement of the cardiologist, pharmacists will also be able to assist with

follow-up appointments regarding medication management questions, inquiries about potential

medication side effects, drug-drug interactions, medication allergies, poly-medication

management, and medication therapy change requests. Such cooperation allows cardiologists’

spending more time with the patients on the treatment of cardiac disease instead of other side

issues related to the course of therapy.

GFHS will strive for excellence in training and educating its staff. In order to ensure the

best outcomes, GFHS will study innovations in education and training with partners in order to

implement those that will support the delivery, learning, and value of patient care. In-service

training will be used to strengthen the knowledge base of the practitioners that are employed

within the GFHS system. Opportunities for training and development of the entire workforce will

expand. GFHS will create a plan for teaching and training material requirement for continuing

professional development and lifelong learning for all staff to develop appropriate knowledge

base for future workforce needs. This will involve external courses as well as internal


development of courses tailored to the newest available research and treatment within the realm

of cardiology.

Subscriptions to popular cardiology journals will be accessible through the GFHS

intranet system; subscriptions to popular, notable databases will also be included for quick and

efficient access to results of recent clinical trials. Health providers will be required to attend

weekly "journal club" meetings where current events, new technologies, recent clinical trial

results, and other relevant information will be discussed. By providing training to healthcare

providers at the GFHS, providers will be up-to-date with current policies, procedures, and

technologies relating to cardiology to better provide patient care. Future plans for the GFHS will

incorporate an "Education Health Center" model with residency training and service delivery as a

dual component under the same organization. By striving to become an educational institution,

eventually this program will provide future healthcare providers who will be equipped with the

education, training, and excellent standard of care at GFHS who will become retained employees

within the cardiology department.

To maintain a steady flow of quality health care providers within GFHS, a recruitment

team should be formed. This recruitment team would be focused on bringing candidates for

interview for potential employment opportunities. The recruitment team will be lead by a

coordinator, and the team will be responsible for communication with the interview, recruiting

the significant other/spouse of the interviewer, checking credentials and references of the

interviewer, and developing promotional material to market employment opportunities within

GFHS. Also, by reaching out the educational medical institutions within the vicinity of GFHS,

recruitment for specific types of healthcare providers can be marketed accordingly through the

educational organization. Creating ties with educational institutions to form programs for


internships, externships, and residencies will ensure a likelihood of consistent interviewers for

potential employment opportunities. Along with a successful recruitment program, an effective

retention program needs to be developed. Providers need to be supported with a work

environment that promotes the quality of care and high patient satisfaction. Appropriate

incentive plans and deferred compensation plans which are compatible with GFHS’s fiscal

resources are a necessity; competitive compensations and benefits packages that are kept current

with the market need to be offered as incentives to support long-term retention and productivity

of healthcare providers within GFHS.

The providers’ health and safety is a major concern for the retention of employees. The

health and safety of employees will be included through measures to ensure consistent use of

universal precaution as well as infection prevention and control; health workers will be provided

with comprehensive health care to ensure physical safety and meet their psychosocial needs.

GFHS will make efforts to promote a healthy lifestyle within our patients, but also within the

team of healthcare providers. A focus will be placed on managing work-related stress through

confidential groups meeting with counselors trained to deal with stress management, work-

related anxiety, and meditation techniques. There will also be programs instituted to promote a

healthy lifestyle among the health care providers within the GFHS system; this will include

programs such as smoking cessation and obesity campaigns. Having healthy providers employed

within the GFHS will be a positive example for patients to attain their goals of a healthy lifestyle

as well.

Patient Engagement and Community Strategy

Over the past decade, healthcare values a community-based health promotion as a main

approach for achieving population-level change in risk behaviors. Such an approach represents a


shift from emphasizing the individually focused explanations of health behavior to ones that also

encompass social and environmental influences. Community-based health promotion requires a

formation of partnership between communities and healthcare agencies. Such a partnership

motivates patients and communities to participate in making shared decisions and assists

healthcare agencies delivering an integral health promotion services. Therefore, our firm

proposes a strategic program, “Healthy Community Plan”, to establish and maintain a

partnership between GreenForest and communities that it serves in order to promote community

cardiac health. The goals of this program are: 1) to increase the involvement of individuals in

determining their own health and well-being; 2) to increase the involvement of the community in

the planning, design, delivery and evaluation of services that affect health and well being; and 3)

to increase the involvement of the community in improving the service system that supports

health and well-being (Upper Hume Primary Care Partnership, 2002).

Our proposed program will locate three types of platforms in the communities for

program implementations: public health department, community churches, and public schools.

GreenForest will nominate two leaders for each type of platforms. The roles of leaders are to

bring together the key stakeholders whose core business is found within the particular platform

in order to enable planning and service delivery activities being coordinated (Upper Hume

Primary Care Partnership, 2002). It is through these platforms that needs are identified, priorities

determined, views are sought and the Healthy Communities Plan is developed, implemented and

evaluated (Upper Hume Primary Care Partnership, 2002).

The following strategic plans, adapted from National Heart, Lung, and Blood Institute

(2013)’s community partnership program, provide explanations regarding program designs for

each type of platforms:


1. Public Health Department: partnering with Public Health Department that has strong

community networks with churches, schools, specialty clinics and other community

organizations, GreenForest will be able to utilize a comprehensive community-wide

approach in risk factors identification and treatment for cardiac problems. The

cooperative services provided by both Public Health and GreenForest may involve

community cardiovascular risk factor screenings and referrals, collaboration with

community-based hypertension and lipid specialty clinics, and assistances with education

activities with schools, churches, and other community organizations such as YMCA.

Public Health Department is also a place where underserved, multi-ethnic, less-educated

patients visit for health services. GreenForest may team with Public Health to use the

available cardiac health data to better assess the cardiac health promotion needs of these

populations and plan for realistic, and cost-effective health promotion strategies (e.g.:

affordable healthy food plans).

2. Public schools: in collaboration with public school system and American Heart

Association chapter, GreenForest will be able to develop a school-based intervention for

school-aged children, their families, and school staff. Educational interventions, such as

Helping Educators Attack Cardiovascular Disease Risk Factors Together (HEART)

(National Heart, Lung, and Blood Institute, 2013), will enhance the local public school

curriculum to provide information about healthy lifestyles and expand physical education

programs to promote personal fitness and aerobic conditioning. Educational interventions

also will improve school meals and provide in-service training programs for teachers to

increase their effectiveness in teaching health-related school subjects. In addition, school

administrators and GreenForest may collaboratively conduct outreach program targeting


at promoting cardiac awareness regarding healthy lifestyles and advancing the knowledge

about cardiac disease preventions as well as risk factors among parents. Meanwhile,

children and families with CVD risk factors will be screened and identified, and referrals

will be made for treatment.

3. Churches: trained GreenForest health professionals will cooperate with church personnel

to conduct cardiac health programs at church facilities. The cooperative work between

GreenForest and churches will kick off with a health fair in each church at which

participants will undergo a cardiac health assessment and be screened for blood pressure

and cholesterol levels. Those found to have CVD risk factors would be referred either to

their personal physicians or community clinics. All participating churches will be offered

the opportunity to provide educational activities for congregation members in a wide

range of health areas, including smoking cessation, nutritional counseling, and exercise

classes. Cooking demonstrations and youth group presentations aimed at discouraging

tobacco use and encouraging heart healthy eating and physical activity will also be

available. In addition, survivors of stroke or heart disease will be recruited from each

congregation to work with a health educator to present information to the congregation

about CVD risk factors and their own personal experiences with CVD.

Sustaining the partnership between GreenForest and communities is essential.

Throughout the implementation process of community engagement program, GreenForest may

use the following strategies to sustain its partnering relationship with the communities:

• Supportive leadership: GreenForest will need a supportive leadership to establish and

sustain a community partnership. Support from leadership level is particularly needed

when issues arise from resource utilization (e.g.: staffing), making mutual agreement with


community agencies, and quality assurance/improvement (e.g.: continuous program

evaluation).

• Community assessment prior to implementing community engagement program: a

community assessment identifying the cardiac health care needs of community residents

is the first, and the most important step that leads to an appropriate design of cardiac

health promotion programs.

• Being inclusive: partnership between GreenForest and communities should seek to

increase the role of all service users and the community in general, but critically those

people who are often excluded from decision-making processes. Those with multiple

social disadvantage have the most need for participation but are likely to be the most

difficult to recruit. Considerable barriers can exist for many individuals and groups.

GreenForest needs to use ways of engaging people that are tailored to their particular

needs.

• Continuous evaluation: ongoing evaluation of community engagement process allows

GreenForest to identify any problem disrupting the sustained partnership between

GreenForest and communities. Evaluation may also provide essential data for future

community-based cardiac health service planning and community-based participatory

research (National Institutes of Health, 2013).

Single Biggest Concern

The single-biggest concern for our firm’s collective recommendations is facing potential

employee resistance regarding human resources relocation and leadership changes. Based on our

proposal, GFHS will implement the consolidated set of recommendations that require major

workforce renovation, includes both management level and frontline workforce. All employees


will be affected by this systematic change. As a new chief nursing officer will be appointed to

co-manage the entire system with chief medical officer, we can expect adjustment would be

needed for different leadership methods and the new leadership culture. In addition,

consolidating existing GreenForest facilities will demand personnel changes in the system.

Further, the way care has been provided will be significantly altered, most likely causing a

serious resistance from stakeholders.

At the management level, resistance will happen if managers are not aware of their involvement

in the change. They should be notified in details at the beginning of why the change is needed

and what is going to happen. They need to know their inputs are valuable and they are part of the

change agents. The process of innovation is heavily depended on organizational culture and

leadership. Managing resistance in GFHS takes action by leadership to commit to recommended

changes and new development of cardiac care. Communication is the key element to reduce

resistance among staffs (Li Bassi, Ranzani, & Torres, 2013).

At the frontline employee level, resistance can come from fear of job insecurity and

environmental changes. Focusing on the root of resistance and engaging with employees to

discuss resolutions will facilitate change to the positive direction. A supportive, trusting,

employee-oriented workforce culture will mostly minimize resistance. Help employee recognize

the benefits the restructure will bring to GFHS, cardiac department, and at the individual level.

Nothing is more important to an individual employee than to know the positive impact on his/her

own career. One motivation is providing financial incentives for employees to reward their

compliance with the transformation.

To succeed in today’s dynamic healthcare market, GFHS must acknowledge that change

is inevitable and continuous. As change agents, each individual healthcare provider at GFHS


should participate in defining and achieving goals, realizing that change is the catalyst for

organizational improvement as well as personal development.

Conclusion

In a reaction to market demands and ever-increasing pressure on cost containment, the

GreenForest is transforming to maximize the value of care for the patient by achieving the best

possible outcomes at the lowest cost. The healthcare organizations that are successful in

achieving such goals often use a strategy of expansion (Boan, 2006). They start small, with one

team, unit, or microsystem. Once established, the pilot group can be the model for others and the

source for spreading throughout the organization. In macro level, the entire GreenForest Health

System is embarking on a comprehensive radical change aiming to achieve a high-value care for

its patients. To that end, the Care Transformation for Cardiac Health serves as a pilot initiative

for the entire GreenForest Health System. In that sense, this change is truly important for the

GFHS, and it cannot afford failing in this cardiac transformation. This change that is thoughtfully

planned and executed will be a stepping-stone to a new health system that achieves a high value

care for patients. The leadership and the Board of the GFHS should fully contemplate the four

strategic recommendations described above, consistent with the transformation guidelines by

Porter and Lee (Porter & Lee, 2013), in key elements of developing a new leadership culture,

designing a cross-continuum care model structure, cardiac workforce strategy, and designing

patient and community engagement.

This call for change is urgent, but it requires substantial time as if a necessary gestation

period is required for a full-term infant to be born. The cardiac care team cannot get there

overnight. Stakeholders and leaders need time and commitment to accommodate change and

develop new leadership skills and clinical practices tailored for delivering improved value for


patients, without compromising the vision and pursuit of quality for change. Once achieved, all

stakeholders and the entire GFHS will enjoy benefits brought by the value-centered care.


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