Integrated Delivery Systems: Mercy Health Services, Part II

Nursing Economics, May, 2000 by SueEllen Pinkerton

This is the second part of a two-part interview with Bruce Van Cleave, MD, executive vice president for professional services, and Barbara Moore, BSN, RN, vice president for professional services. The interview focuses on the development and functioning of Mercy Health Services (MSH), an integrated delivery system. Part I appeared in the January/February 2000 issue of Nursing Economic$ (Vol. 18, No. 1, pp. 32-35, 41).

Pinkerton: Do you still have a structure similar to the one you mentioned earlier, with regular meetings with the patient care executives?

Moore: Absolutely. We've just "ramped" it all up. For instance, with the CEOs, Bruce is regularly talking about strategy and getting their input to see how we can do things differently. How can it make a difference? We have it on the agendas of the COO, patient care executives, vice president of medical administration (VPMA), and the clinical leadership councils (CLC). We've realized that we've got to value the relationships that we have and build the message based on those relationships. The system has committed to this but that doesn't mean that everyone understands it in the same way. So how do we translate the message so everyone understands the same thing based on their frame of reference?

Pinkerton: A question then about your relationship with the CEOs, for instance, and the patient care executives; do you have line authority or are you in a staff position?

Moore: I'm in a staff position, and I think one of the greatest things I've learned is that our ability to influence people is based upon on their perception of me as an individual with integrity, with expertise, and with knowledge and understanding of what their needs are so that I respond to them based on their frame of reference and their needs. All of this work has arisen, in a way, out of the work the CLC has done. That's how it's become foundational to what we're doing. That group wants to be accountable for it. They want to ensure they're sending the right people to the groups both at the system level and at the local level. There is a real advantage to this type of a role in that you can move from place to place but you have to be able to influence people and to have them respect you as an individual. This can bring value to the work that they're doing.

Van Cleave: In my work on care management I'm also in a staff role in supporting the work of the local operations, and our thinking is still that the responsibility and accountability for care delivery must reside at the local operational site. We don't have that operational accountability at the corporate office. What we can do is build on the relations we have and understand the needs and meet the needs. And what we've talked about is an economy of intellect or leveraging the intellect of the system and being able to provide the best information. We've talked about an intelligent network of sharing what we all know, best practice sharing, and those sorts of things to get everybody up to speed as quickly as we can. Hopefully, we don't have to have things repeated many times over at each of our sites.

Pinkerton: Is the message from the corporate leadership all the same as far as the commitment to the outcomes that you're pursuing?

Van Cleave: Yes.

Moore: All the way up to the board.

Van Cleave: The things that we've accomplished in the past here are to have the clinical outcomes looked at by governance at all levels, the same clinical outcomes that are looked at by the senior management team, and the same clinical outcomes that are looked at by the clinical leaders across the system. The alignment of what we're trying to achieve and the language that we use is the same. The specific actions that each of the groups may be engaged in may be a little different. But they're all working to achieve the same overall outcome.

The Value Chain

Pinkerton: Shortell has published some models that relate to the value chain of health care delivery, some key findings and overarching lessons (Shortell et al. (1996). I wonder if any of those helped or guided you in your pursuits.

Van Cleave: Shortell's Value Chain of Health Care Delivery (see Figure 1) was a key document for us, and we used that in many educational sessions to get people to understand why we were working on functional, physician, and clinical integration. We wanted to achieve competencies to build the kind of end states and respond to stakeholder need. I've used that slide many times. I almost have it memorized.

[Figure 1 ILLUSTRATION OMITTED]

Moore: The Value Chain of Health Care Delivery (see Figure 1) was used a lot with the CLC when we went out into the community health care systems. We found it very helpful. Also the House of Integration (see Figure 2) in the early Shortell work was used to build the community health care management system.

[Figure 2 ILLUSTRATION OMITTED]

Vision, culture, strategy, and leadership were at the bottom of the model and then we built up. We used some of that in the preliminary discussions and then moved it over to the Value Chain. Of importance for me was having come to MHS after much of the development work had been done and having the opportunity to be here during the implementation of the later phases. Now we are evolving to care management, and what we are doing today is based on experience with those Shortell models. Having used these models, we have become much more pragmatic in our language. Many of us think in concepts and think in vision but when we take it down to the local community level where health care is delivered, we must answer several questions: What is this going to do for me? What can I expect when I've accomplished this? It's been a really wonderful experience, and we're very excited about the next phase taking us to our overarching care management initiative. We have a concept document and Hoshin plan that's just been completed. We're getting ready to implement it in one of our states and have incredible commitment by that state's leadership group of CEOs as well as the clinical leadership. They're geared up to go because they recognize it as the differentiating strategy. It's about serving the communities we are partners with in a very effective fashion.