InstructionsSupporting Lectures:Review the following lectures: Healthcare Leadership Healthcare ManagementProjectThe project assignment provides a forum for analyzing and evaluating relevant topics
CASE 2
Changing Physician Credentialing
Dale Buchbinder
You are the Chairperson of the Department of Surgery and you attend the quality committee meetings. You do not have a vote on the quality committee because you need to carry out the recommendations of that committee. The committee is reviewing several cases of Dr. Monitor, one of the busiest surgeons on staff. These cases have had bad outcomes and the committee is concerned about Dr. Monitor’s surgical judgment. When each case is reviewed individually, it appears the issues are minor. However, upon detailed review of many of Dr. Monitor’s cases, a devastating pattern of events has emerged and the committee feels his practice patterns are not safe for the patients at this hospital.
The committee has several choices; all choices are, however, only recommendations to you, the department Chairperson. The surgeon under scrutiny is not known to be arrogant or malicious and is, in fact, well liked. When you discuss these events with the partners in his practice, you find they are also concerned about Dr. Monitor’s practice patterns. You ask the committee to hold off on a recommendation giving you the opportunity to discuss the situation with the surgeon.
After a very open discussion with Dr. Monitor and one of his partners, the Division Chief, you ask Dr. Monitor to voluntarily give up his privileges to perform the procedures that are in question. After being informed that he can only assist one of his partners in the procedures of concern, Dr. Monitor cordially agrees to comply with this recommendation. At the next quality committee meeting, you announce Dr. Monitor has volunteered to reduce his privileges.
Discussion Questions
1. What are the facts in this situation?
2. Dr. Monitor volunteered to reduce his privileges. Does this event constitute a disciplinary action? Is this required to be reported to the physician licensing board?
3. What obligations, if any, does the Chairperson have to report this to other hospitals where Dr. Monitor has privileges?
4. If Dr. Monitor had been a difficult personality to deal with, do you think the Chairperson of surgery would have proceeded in the same manner? What type of communications do you think might have occurred in that scenario? Provide your reflections and personal opinions as well as your rationale for your responses.
5. Physician credentialing and privileging is a duty of the hospital Board of Trustees (BOT). The BOT delegates this responsibility to physician experts on the hospital staff. If the quality committee and the Chairperson of surgery had not done their jobs, what might the repercussions have been for patients and for the hospital? Provide your reflections and personal opinions as well as your rationale for your responses.
ADDITIONAL RESOURCES
Borkowski, N. (2011). Organizational behavior in health care (2nd ed.). Sudbury, MA: Jones and Bartlett.
Buchbinder, S. B., & Shanks, N. H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.
Greene, J. (2008). It’s a privilege: The board’s role in physician credentialing and privileging. Trustee: The Journal for Hospital Governing Boards, 61(3), 8.
Health Resources and Services Administration (HRSA). (n.d.). National practitioner data bank. Retrieved from http://www.npdb-hipdb.hrsa.gov/
Illinois court upholds imposition of summary suspension of physician’s open-heart surgical privileges. Lo v. Provena Covenant Medical Center. (2004). Hospital Law Newsletter, 21(7), 1–5.
Morrison, E. E. (2011). Ethics in health administration: A practical approach for decision makers (2nd ed.). Sudbury, MA: Jones and Bartlett.
Schneider, D., & Rapp, J. (2005). Credentialing for carotid artery stenting. Perspectives in Vascular Surgery and Endovascular Therapy, 17(2), 127–132.
Senft, D. (2002). Laws governing peer immunity, physician credentialing upheld. Managed Care, 11(2), 62–63.
Tammelleo, A. (2002). Patient sues hospital for failure to regulate surgical privileges. Hospital Laws Regan Report, 43(4), 2.
Unnecessary procedures: Court puts responsibility on nurses to report physician’s actions. (2010). Legal Eagle Eye Newsletter for the Nursing Profession, 18(9), 7.
CASE 3
The New Manager Needs a Coach
Sharon B. Buchbinder
Flora Fauna was promoted from a floor nurse to nurse manager of a surgical services floor at Happy Days Hospital (HDH), a 400-bed community hospital known for excellence in nursing care. The CEO of HDH believes the best managers come from the best clinicians because they are close to patient care issues. Flora was selected for promotion over three other nurse applicants because of her excellent scores on patient care, team work, and her course work toward her master’s in nursing administration. Delighted with her promotion, Flora decided to take charge immediately and called a meeting of the staff who reported to her.
At the gathering she asked people for input on what they would like to see changed. When one of her former coworkers spoke up and suggested that they hire another full-time RN, Flora crossed her arms, frowned, and shook her head. “No, no, no. Too expensive. That just isn’t possible.” She looked around the room. “Do any of you have ideas that won’t break the bank?” Silence fell over the room like a heavy blanket. “I don’t understand. All you guys ever do is complain about being overworked. If you’re not part of the solution, then you’re part of the problem. I can’t be expected to fix everything by myself. If you don’t have any reasonable ideas, then we might as well finish this meeting.”
Unbeknownst to Flora, her boss, Ida Caresalot, happened to be near the open door and heard everything. Ida waited for the staff to disperse and invited Flora to come to her office.
“Flora, I think you have a lot of potential. Right now, you would benefit from a leadership coach. We only offer this type of mentoring to people we believe will become good leaders in our organization.”
Flora was floored. She just got the job and already she was being told she had to be retrained. On the other hand, Ida said this was an investment in Flora’s future with the hospital. She took a deep breath and asked, “What’s involved in this coaching?”
“You would have a 360-degree evaluation by family, colleagues, and stake-holders using a survey that assesses Emotional Intelligence (EI). We know managers who have strong emotional intelligence skills outperform those who don’t. We don’t do this just to be nice. It’s good business. EI encompasses self awareness, self regulation, self motivation, social awareness, and social skills, and within each of these areas, specific skill sets.”
Flora agreed to participate in the EI360 and EI coaching. When she read the results of the EI360, the following scores upset her:
• Adaptable/Flexible (60%; normal range 64–80%)
• Communication (62%; normal range 66–83%)
• Emotional Self Awareness (70%; normal range 61–81%)
• Empathy (65%; normal range 61–80%)
The feedback on empathy was most distressing to her, despite being within normal limits, because she was a nurse and in the “helping professions.” She assumed she excelled in that competency. Didn’t she always ask her people for input? Wasn’t she always available? Or so she thought. Clearly, others did not see her the way she saw herself.
At Flora’s first one-on-one session, her coach asked what she wanted to get out of the experience. Flora said, “I want to be a better listener.”
The first month, the coach had her focus on her listening skills. Flora had one-on-one meetings with every member of her staff and asked what she could do to make their jobs better. She kept a notebook of observations of when listening experiences went well and when they went poorly. After a two-week time period, Flora found her best listening and best outcomes occurred when
• she was prepared with script, notes, data, lists, and plans;
• she trusted the other person; and,
• she was calm and relaxed.
Flora also found her worst listening and worst outcomes occurred when
• she felt under attack or sandbagged;
• she was told her facts/perceptions were not real; and,
• old history was dredged up, and was not relevant to the current situation at hand.
Flora scheduled a second meeting with the entire staff for the following week and hoped she’d do better this time.
Discussion Questions
1. What is going on in this case?
2. What is the nature of the organizational behavior problem?
3. What are three things contributing to this problem?
4. Why do you think Flora behaved the way she did at her first staff meeting?
5. Based on the information provided in this case, what do you think Flora should do in preparation for her next meeting? What other resources might she want to bring into the meeting?
6. Have you ever had a manager who could have used EI coaching? Is this something you think you would like to take advantage of for your own leadership development? Provide your reflections and personal opinions as well as a rationale for your responses.
ADDITIONAL RESOURCES
Borkowski, N. (2011). Organizational behavior in health care (2nd ed.). Sudbury, MA: Jones and Bartlett.
Buchbinder, S. B. (2009, July 29). Emotional intelligence and leadership. Retrieved from http://blogs.jblearning.com/health/2009/07/29/emotional-intelligence-and-leadership/
Buchbinder, S. B., & Shanks, N. H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.
The Consortium on Research for Emotional Intelligence in Organizations. (2009). The emotional competence framework. Retrieved from http://www.eiconsortium.org/reports/emotional_competence_framework.html
Fallon, L. F., & McConnell, C. R. (2007). Human resource management in healthcare: Principles and practices. Sudbury, MA: Jones and Bartlett.
Goleman, D. (1998, December). What makes a leader? Harvard Business Review, 76(6), 93–102.
Goleman, D. (2006). Social intelligence. New York, NY: Bantam Books.
Hatfield, E., Cacioppo, J. L., & Rapson, R. L. (1993). Emotional contagion. Current Directions in Psychological Sciences, 2(3): 96–99.
Morrison, E. E. (2011). Ethics in health administration: A practical approach for decision makers (2nd ed.). Sudbury, MA: Jones and Bartlett.
CASE 4
Why Won’t She Just Retire?
Sharon B. Buchbinder
Denise Gogetter, RN, MSN, has been at City Medical Center (CMC) for two years as the Assistant Vice President of Nursing (AVP). She is a hard working, bright, articulate nurse who has contributed many creative ideas for providing excellent quality of care at CMC. Recently, however, she has gone from a pleasant, easy-to-work-with coworker to a cranky one. She used to bubble with enthusiasm about her job and the opportunities it afforded her. Denise made no secret of the fact that she wanted to advance within the organization.
Today she comes up to you in the cafeteria and says, “If I have to work for Rose Durham one more week, I’ll scream.”
You’re more than a coworker, you’re Denise’s friend, and you are the AVP to the CFO. You are alarmed by her tone of voice and suggest you go out after work to discuss the matter. Over coffee and dessert, Denise confides that when she was hired, she was promised a promotion at the end of 2 years. As soon as Rose retired, she was supposed to be the VP of Nursing. However, today HR informed Denise the promotion was not a promise, merely a possibility mentioned to her during recruitment. Rose, like many others, had been hard-hit by the recession and was not in a financial position to retire. She decided to put off her retirement to age 70, instead of 65. And Rose wasn’t interested in taking a cut in pay and stepping down from her role. Denise has no interest in remaining as an AVP. She’s ready to be promoted NOW.
While you understand Denise’s frustration, you wonder to yourself how such a major misunderstanding could have occurred. Denise took copious notes at every meeting. The recruiter, who was an independent headhunter, put nothing in writing except for e-mails setting up interview days and times. Denise shows you the letter from HR. It is a standard letter with salary, start date, and benefits package. The letter includes nothing about opportunities for advancement, nothing about promotions, and nothing about older nurses retiring to make way for younger nurses.
Did the headhunter really promise her a promotion after two years? Or did Denise read more into the statements than was there?
Discussion Questions
1. What are the facts of this case?
2. What is the nature of the organizational behavior problem?
3. What are three factors contributing to this dilemma?
4. What are the top three management issues in this case?
5. Who should be responsible for addressing these organizational issues?
6. Headhunters earn commissions on finding candidates for jobs. If the employee stays for a year or more, the headhunter often gets to keep a large amount of money. Do you think the headhunter made promises she couldn’t keep? Or, do you think Denise heard what she wanted to hear?
7. Do you think Denise should have wondered if the headhunter’s promises were too good to be true? Should she have insisted on getting those statements in writing?
8. At this point in time, what, if anything, can Denise do? What choices does she have? Provide your reflections and personal opinions as well as your recommendations and rationale for addressing this problem.
ADDITIONAL RESOURCES
Baker, J., & Baker, R. M. (2011). Health care finance: Basic tools for nonfinancial managers (3rd ed.). Sudbury, MA: Jones and Bartlett.
Borkowski, N. (2011). Organizational behavior in health care (2nd ed.). Sudbury, MA: Jones and Bartlett.
Buchbinder, S. B., & Shanks, N. H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.
De Milt, D., Fitzpatrick, J., & McNulty, S. (2011). Nurse practitioners’ job satisfaction and intent to leave current positions, the nursing profession, and the nurse practitioner role as a direct care provider. Journal of the American Academy of Nurse Practitioners, 23(1), 42–50.
Feldman, L. (2010). Report: New workforce models needed to adapt to changing environment. H&HN: Hospitals & Health Networks, 84(3), 12.
Morrison, E. E. (2011). Ethics in health administration: A practical approach for decision makers (2nd ed.). Sudbury, MA: Jones and Bartlett.
Palumbo, M., McIntosh, B., Rambur, B., & Naud, S. (2009). Retaining an aging nurse workforce: Perceptions of human resource practices. Nursing Economics, 27(4), 221.
Patterson, K., Grenny, J., McMillan, R. & Switzler, A. (2004). Crucial confrontations. New York, NY: McGraw-Hill.
Patterson, K., Grenny, J., McMillan, R. & Switzler, A. (2011). Crucial conversations: Tools for talking when stakes are high. New York, NY: McGraw-Hill.
Two-thirds of managers report economy has affected staffing. (2011). OR Manager, 27(9), 1–10.
CASE 5
No Plan in Sight? Succession Planning in a Small Rural Hospital
Amy Dore
Stratlin Memorial Hospital is located in Keen, Kansas, a small rural town in the Midwest. The county seat of Markley County, Keen has a population of 6,128, not including cows. Markley County is an area of 1,856 square miles that consists of farming and agriculture, which are also the main sources of jobs for the county residents, specifically corn, wheat, soybeans, and alfalfa. There are also numerous livestock farms. The town of Keen is unique in its geographic positioning and unique attractions. Keen lies along Interstate 35, 49 miles south and 37 miles east of the next largest urban cities. A major attraction for visitors to Keen is the Toy & Action Figure Museum and a well known chocolate factory.
If you ask residents why they live in Keen, they reply by telling you that the community is family oriented, peaceful, traffic-free, and has plentiful parks and recreation activities and abundant grocery stores, including local farmers’ markets. Of course, Keen comes with its challenges that are standard in small rural towns, including residents that are older and have lower education levels, lower income status, and less healthy lifestyles. The area is also characterized by occasional droughts, lack of seat belt use, farming accidents, large numbers of residents who are uninsured and underinsured, limited business growth, and high incidences of kidney disease and chronic obstructive pulmonary disease (COPD).
Stratlin Memorial Hospital opened its doors in 1970, but has a long-standing history dating back to 1905 when Drs. Calhoun and Lewis partnered to form the first 5-bed hospital, known as the Keen Sanitarium. The current hospital has 45 set-up and staffed beds, and offers services in acute care, emergency care, home health services, diagnostic testing, surgical services, laboratory services, hospice care, and therapy services. There are 130 full-time equivalent (FTE) staff and 145 employees working at the hospital, including 8 active staff physicians, 1 certified registered nurse anesthetist (CRNA), 1 full-time surgeon, and 1 full-time physician assistant (PA). Stratlin Memorial Hospital is one of the three base sites for the county-wide emergency medical service (EMS). The hospital averages 180 admissions and 147 emergency room visits per month, and approximately 7,300 outpatient visits per year. There are on average 45 babies born at Stratlin Memorial Hospital each year. Additionally, in 2007, an independent and assisted living center, The Willows, was built directly east of the hospital’s parking lot. There are four senior administrators including an interim CEO, a CFO, a part-time interim CNO, and an Ancillary Service Director. There are 16 managers within the hospital for the varying departments and service areas. The average tenure for the hospital managers is 14.25 years.
Up until two years ago, the hospital had a very stable senior administrative staff. The CEO had 21-year tenure, the CFO 19-year tenure, and the CNO 33-year tenure. Due to unexpected health conditions, the CEO was forced into immediate retirement. Since his retirement, Stratlin Memorial Hospital has had two CEOs, neither lasting more than nine months. This situation mimicked a domino effect where the first quit because his wife did not like the rural lifestyle, and the second was fired due to shady dealings within the hospital. The two other members of the senior management team voluntarily quit and retired. Plans are currently underway to promote the interim CNO to full-time status.
Stratlin did not have a succession or mentoring plan in place. It had never seemed necessary, as it was assumed that longevity within a job (clinical and administrative) had worked in the past and would continue. In fact, hospital cofounder Dr. Calhoun’s great-great-grandson recently retired as a general surgeon, ending a 100 year family legacy of physicians at Stratlin Memorial Hospital. The Stratlin Board of Trustees, which has always been comprised of five community leaders and volunteers, never thought succession issues of the administrative and clinical staff would become a problem. Currently, the Board is comprised of four males and one female. The men range in age from 55 to 74, and the female board member is 31 years old. Occupationally, the board members come with a range of career experiences. However, only one board member has any clinical background. The others are community members, including a high school teacher, an attorney, the city art director, and the local grocery store owner. Obviously, many things had changed for everyone involved.
The aim of succession planning is to ensure there is an appropriate training and development program for junior employees as a method to prepare them to assume increasingly higher level positions of leadership throughout their tenure. Stratlin Memorial Hospital has learned its lesson. Although not initially prepared to address resignations and retirements, the Board has hired you as its consultant to create a succession plan with the focus on their troubled senior administrative staff. In order to make consultative recommendations, what are the next steps you must complete to prepare for this role?
Discussion Questions
1. What is the current situation at the hospital?
2. What are three organizational issues going on in this case? Which organizational theories do you think best apply to this situation?
3. What are Stratlin’s areas of strengths? What are its weaknesses?
4. What should a short-term plan to immediately handle the management situation include? Should they consider promoting from within to help alleviate the immediate situation, such as appointing an interim administrator; utilizing a temporary “on-loan” executive; or developing alternative strategies?
5. What role might hospital politics have played in the rapid turnover of CEOs?
6. How will you educate the Board of Trustees about succession planning? What role should they play in this process?
7. How would you introduce the concept of succession planning to the staff of Stratlin Memorial Hospital? Should workshops be used to familiarize the management staff with the succession issues? Should you include all managers in the process?
8. What recommendations and steps are needed in order to establish a long-term plan for continued succession planning? Who should be involved and lead this process?
9. Should the institution adopt a succession plan for clinical staff members?
ADDITIONAL RESOURCES
Alexander, J. A., & Shoou-Yih, D. L. (1996). The effects of CEO succession and tenure on failure of rural community hospitals. Journal of Applied Behavioral Science, 32(1), 70–88.
Buchbinder, S. B., & Shanks, N. H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.
Ledlow, G. R., & Coppola, M. N. (2011). Leadership for health professionals. Sudbury, MA: Jones and Bartlett.
Rubino, L. (2012). Leadership. In S. B. Buchbinder & N. H. Shanks (Eds.), Introduction to health care management (2nd ed., pp. 17–38). Burlington, MA: Jones & Bartlett.
Sniff, D. D. (2008). Succession planning for rural hospitals [PowerPoint slides]. Retrieved from http://www.slideshare.net/ebayworld/succession-planning-for-rural-hospitals
CASE 7
Practicing Organizational Culture Without a Leader
Dea Robinson
Small Feet OB/GYN was at one time a robust practice with five physicians, a midwife, and two PAs. The practice had a strong following in the community, was trusted by the many women it had served, and recently began delivering “legacy” babies of patients. Dr. Smith was the founder of the practice and had been the lead physician for many years.
Two competing systems with hospitals only one mile apart had vied for the affiliation with the Small Feet practice. Dr. Smith decided to change her affiliation to the other hospital. As a result, the practice experienced a move that seemed to only strengthen the patient base, and the new space (which was twice as large as the previous office) seemed to suit the new practice well.
The medical staff and CEO of the new hospital supported Dr. Smith’s move for several reasons. First, Dr. Smith, as mentioned, was delivering legacy babies and in the OB/GYN field this speaks to the trust the provider has been able to create and sustain throughout the years. This resulted in lots of community goodwill; that intangible quality is highly sought after in the medical community, yet is so difficult to quantify. Second, the new affiliation of Dr. Smith and her patients would bring positive revenues to the hospital through the move. Finally, the new hospital had a Level 1 trauma center, known for neurological cases, but not for delivering babies. The expansion of labor and delivery with the addition of a seasoned, legacy-delivering physician was a real coup for the hospital to attain.
Dr. Smith became ill and had to go on medical leave for almost a year. During that time the cohesiveness among the other providers suffered. When Dr. Smith came back things were very different. Dr. Smith became suspicious of everyone and had feelings that the staff and other providers were conspiring against her. Her suspicious attitude toward the physicians and staff in her practice led to dysfunctional problems throughout the practice. When Dr. Smith was confronted by the manager, Amy, she became distrustful and suspicious that Amy was conspiring with the other providers in the group against her.
The practice had also gone through some growing pains from a one-physician practice to five. Though originally the physicians worked well together, they now seemed to be less willing to collaborate. The practice also suffered as a result of a manager who had not kept up with the managerial requirements needed to run a midsize practice. For example, staff and provider performance reviews had never been done, the physicians had not established policies and procedures for the practice, there was no employee handbook, and tardiness was an acceptable behavior among the ranks.
When Dr. Smith wanted to complete a performance review on Amy, who had been with Small Feet for 13 years, she handed in her resignation the next day. Subsequently, three providers resigned and set up practices on the same hospital campus. Since the provider contracts (the ones who had one) were devoid of noncompete clauses, the providers exercised the right to set up a practice and some of them went into practice together.
Dr. Smith hired a consultant, Mary, to assist with management, as well as to handle the financial side of the practice. The consultant hired a new administrator, Susan, who had an MBA but little day-to-day experience. She subsequently resigned for another position with a large medical system. Mary provided an exit interview with Susan, even though Mary had mentored and been closely involved with Susan the entire time. Ironically, through the exit interview, Susan stated the reason for leaving was not because of the pay, but because of Dr. Smith’s harsh treatment of her, as well as her lack of appreciation and teamwork.
Now the practice can barely make payroll or cover other practice payables. The remaining staff is afraid of being laid off or fired due to the arbitrary and erratic lead physician behavior. You have just been hired as the administrator and learn about the many problems only after you’ve come on board. Other problems soon emerge. Embezzlement is discovered, and the lead physician was the only signer on the accounts. There was no system in place for ordering supplies or managing payroll; these duties had been performed by the prior manager verbally with no paper trail. Credit balances owed to patients had been written off at the end of the month by the manager. It was later discovered the practice owed new mothers and postsurgical patients almost $80,000 in credits that had been written off.
Dr. Smith contends that the culture of the practice comes from management, although it has been shown that culture comes from the “top.” Dr. Smith refuses to accept this, and continues to blame her staff for all of the problems that are at the forefront of the practice. You need to break this news to Dr. Smith and make suggestions on how to tackle the debt and how to manage the practice. One option is to encourage her to become a hospital system employee where she would have no control over management decisions. You know Dr. Smith does not want to become an employed physician due to her control issues; however, you see few options with the insurmountable debt as well as the clinical responsibility of the large patient base (most of whom are pregnant). The simple act of treating patients in the clinic has become difficult because supplies and devices (IUDs, etc.) cannot be ordered due to the lack of working capital.
Discussion Questions
1. What are three organizational issues going on in this case? Which organizational theories do you think apply best to this situation?
2. Make a list of things you need to do as the new administrator and prioritize them. What would you do on day one if you were the administrator in this practice? What data would you collect on the first day in order to go forward? What would you do next? Provide a rationale for your list and priorities.
3. What type of management style does Dr. Smith practice here?
4. What steps would you take to address and disclose the embezzlement issue to her?
5. How would you actively manage the staff in this environment of “unknowns” among a pregnant patient base?
6. Dr. Smith wants YOU to change the culture in the practice—how would you do this?
7. Why do you think the providers left the practice? What could you have done to keep them in the practice, knowing they could leave with their practice and associated revenue?
ADDITIONAL RESOURCES
Borkowski, N. (2011). Organizational behavior in health care (2nd ed.). Sudbury, MA: Jones and Bartlett.
Buchbinder, S. B., & Shanks, N. H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.
Duden, A. (2011). Trust and leadership—Learning culture in organizations. International Journal of Management Cases, 13(4), 218–223.
Edmondson, A. C. (2011). Strategies for learning from failure. Harvard Business Review, 89(4), 49–55.
Keyton, J. (2011). Communication & organizational culture: A key to understanding work experiences. Los Angeles, CA: Sage.
Lowes, R. (1996). How a group’s personality affects its members. Medical Economics, 73(24), 35+.
Schein, E. H. (2010). Organizational culture and leadership. San Francisco, CA: Jossey-Bass.
Spreitzer, G. & Porath, C. (2012). Creating sustainable performance. Harvard Business Review, 90(1/2), 92–98.
