mha-fpx5014_GarciaMartina_Assessment5-1

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Process Improvement Proposal Martina Garcia Capella University MHA FlexPath 5014: Health Care Quality, Risk and Regulatory Compliance Assessment 5 August 12, 2023 1

2 Abstract Objective: In July 2023, the Joint Commission announced health equity as National Patient Safety Goal 16.01.01, with requirements for hospitals to begin data collection and reporting by January 2024.Margolis Medical Center (MMC) must begin collecting and reporting on language preference for limited English proficiency (LEP) patients as part of this requirement. The following process improvement proposal reviews recommendations positioned within the context of the organizational structure, directional strategies, and balanced scorecard to achieve optimal readiness for this requirement. Methods: After reviewing the proposed changes against the cost benefit analysis to understand the financial impact of implementation, the Quality and Patient Safety team conducted a literature review of best practices on improvement and implementation strategies. Results: The cost-benefit analysis conservatively estimated potential financial improvements of $12 million over the course of five years and position MMC well as the community’s LEP population continues to grow and mitigate risk of potential claims or litigation for non-compliance. Primary barriers to compliance include misalignment between provider understanding of the safety risks and perceptions of patient understanding; the comfort level and skills of admissions staff in capturing language, literacy, and national origin data; and staff concerns about efficiency and ease of use. Conclusions: MMC should focus on implementation and improvement strategies that re-align provider perceptions of risk and communication; increase ease of access to interpretive services; and build capacity of frontline workers to enable accurate data collection within the framework of the organization’s mission, vision, and values. Keywords: Balanced scorecard, directional strategies, service lines, organizational structure, limited English proficiency patients, readmission rates, average length of stay, interpreter services

3 Table of Contents Introduction ..................................................................................................................................... 4 Existing Organizational Structure, Mission, Vision Analysis ............................................................ 4 Organizational Structure ............................................................................................................. 4 Hierarchical Organizational Structure ..................................................................................... 5 Divisional Organizational Structure ........................................................................................ 5 Functional Organizational Structure ....................................................................................... 6 Mission ....................................................................................................................................... 6 Vision .......................................................................................................................................... 7 Finances, Internal Process, Learning & Growth, Customer Satisfaction ......................................... 7 Financial Perspective ................................................................................................................. 7 Internal Process .......................................................................................................................... 8 Learning and Growth Perspective .............................................................................................. 9 Customer Perspective ................................................................................................................ 9 Evidence-Based and Best-Practice for Monitoring & Improving .................................................... 10 Organization’s Values ................................................................................................................... 11 Conclusion .................................................................................................................................... 12 References .................................................................................................................................. 13

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4 Introduction Between 2010-2020, Margolis Medical Center (MMC) rapidly expanded through strategies of mergers and acquisitions. Originally called Dunwoody Medical Center, the facility relocated to Midvale and became part of the Margolis Healthcare umbrella in 2012 under the name Margolis Medical Center (MMC). This community is where Forsyth, Gwinnett and Fulton counties come together, and the hospital serves one of the most diverse communities in Georgia. With 36 percent of the population in the service area speaking a language other than English at home, MMC serves a multinational community with a multinational work force, with the percentage of East and South Asians nearly doubling since the 2010 census (U.S. Census Bureau, n.d.). In July 2023, the Joint Commission announced health equity as the newest National Patient Safety Goal, 16.01.01 (Joint Commission Standards, n.d.), indicating it would begin assessing accredited health care systems for their demonstrated efforts to prioritize health equity as a patient safety priority. In response, the MMC Quality and Patient Safety team conducted risk and balanced scorecard analyses to assess the current state of readiness in meeting the new reporting requirements of this patient safety goal. Through this process, MMC identified multiple areas of opportunity to increase readiness, specifically in the provision of qualified medical interpretation to patients with limited English proficiency. This process improvement proposal will review those recommendations within the context of the hospital’s directional strategies, organizational structure and the four balanced scorecard perspectives of financial, customer, learning and growth, and internal processes. Finally, the Quality and Patient Safety team will propose evidence-based strategies for measuring, monitoring and improving performance improvement efforts. Existing Organizational Structure, Mission, Vision Analysis Organizational Structure Due to its size, specialization and geographic spread, MMC has reflected a hybrid model to its organizational structure, with a combination of hierarchical, divisional and functional organizational structures. This hybrid approach enabled faster integration during the period between 2010-2020 when Emory Healthcare embarked on a rapid expansion through mergers and acquisitions, acquiring six new hospitals and more than 100 individual practices. In 2023, the new Executive Vice President for Woodruff

5 Health Sciences (the enterprise that oversees MMC, the Margolis School of Medicine, Margolis School of Nursing and Margolis School of Public Health) announced a new vision for MMC based on a service line structure, moving MMC to shift its distribution of organizational structures from a more divisional structure to a more functional model. The current distribution of organizational structures is described below. Hierarchical Organizational Structure MMC has a system-level executive leadership team that provides strategic direction across its hospitals and network of physician practices. This executive team includes the chief officers across core, shared services shared across all the individual operating units, such as finance and revenue cycle, marketing and communications, human resources, quality and patient safety, scheduling, information technology (IT), health information systems, supply chain and materials management, legal and compliance, research, etc. The system executive leadership also includes the chief executive officers for each of its operating units. This top-down approach allows for a clear chain of command throughout each individual entity and within the centralized, shared services departments. Divisional Organizational Structure MMC doubled in size since 2010, acquiring Saint Joseph’s Hospital, Dekalb Medical Center and its two other hospitals, and Dunwoody Medical Center (now MMC), and more than 100 practices and ambulatory care locations across the Atlanta metropolitan area. To support those integrations, the organizational structures from each acquisition were left relatively intact, with local-level senior leadership teams that included chief medical officers, chief nursing officers, and vs vice presidents of quality, operations, and human resources. These entities had their own cross-departmental reporting structures and operating units operate mostly independently, using centralized functions and processes through IT, medical records, and recruiting, but having local-level divisions for other operational and clinical functions, including rehabilitation services, laboratory services, imaging, respiratory therapy, etc. The benefit to a divisional structure is that it allows for more nimble decision-making at the local level and changes are easier to implement due to local control. It also provides a great deal of flexibility and opportunities for promotion for employees who want to stay within the system but may have limited growth potential at their own location or within their functional area. The drawback to this model is that

6 when issues arise that are system-level, the ability to navigate a solution can run into roadblocks with no clear determination of who has ultimate decision-making authority, especially if entity-level structures are not standard from operating unit to operating unit. From a patient perspective, patients may feel frustrated that the standard of care or service varies from location to location, which can diminish the reputation of the organization’s brand in the marketplace (Ginter et al, 2018). Functional Organizational Structure Traditionally at MMC, the functional organizational structures were focused on shared operational functions as described earlier. These functional units allowed the system to support economies of scale and standardization of processes and protocols. These functional units also have a smaller presence at each operating unit to provide critical roles specific to need, such as local employee relations managers, patient safety coordinators and field services for IT. With the shift away from an operating unit-based divisional structure to a more service line approach, the provision of medical services would become more system-based where collaboration, clinical pathways and performance metrics are established within practice areas regardless of geography. This organizing framework adopts a hierarchical leadership structure within its functional units with a clear chain of command. The benefit of this approach is a more consistent culture for employees and providers around shared work practices, responsibilities, and priorities. It also creates a more consistent patient experience, regardless of entry point to the system. The potential drawback to this model is that it tends to discourage inter-departmental collaboration, creates siloes and poses challenges in resolution of local-level issues (Louis et al, 2019). Mission The purpose of an organization’s mission statement is to outline the essential reason for existence for the organization and how this differentiates it from other organizations (Ginter et al, 2018). This serves as a “true north” for leaders and a calling to employees. S låtten et al (2020) researched this calling to employees, identifying that when employees feel mission-driven, their performance, creativity and loyalty to their employer is greater. At MMC, our mission statement is “improving the health individuals and communities at home and throughout the world” ( Welcome to Margolis Medical Center , n.d.). This language is broad enough to encompass the quadripartite mission of research, education, clinical excellence and population health more clearly defined in the vision statement below.

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7 Vision MMC’s vision is to “be the leading academic health science center in transforming health and healing through education, discovery, prevention and care” ( Welcome to Margolis Medical Center , n.d.). MMC added prevention to its vision in 2010 to reflect the growing emphasis on population health and preventative care that came out of the passage of the Patient Protection and Affordable Care Act (ACA) with its focus on improving the health of the overall population and improving health equity. MMC sits at the intersection of four counties with growing international populations with highly disparate socioeconomic differences. As such, addressing the challenges facing limited English proficiency patients as a safety and risk priority is in alignment with the Emory Healthcare directional strategies. Finances, Internal Process, Learning & Growth, Customer Satisfaction In developing strategies and initiatives for their organizations, it is imperative that leaders consider those changes within a larger context for the organization. By evaluating proposed changes against both the directional strategies of the organization and through a balanced scorecard lens, leaders can make more informed decisions that drive improvements in one area without sacrificing performance in other areas (Kaplan & Norton, 1992). It also forces organizations to define objectives, metrics, and targets to measure progress across four mission-critical domains: financial, customer, internal processes, and learning and growth (Kaplan & Norton, 1992). Financial Perspective Kaplan & Norton (1992) define the financial perspective as defining how the financial performance looks to shareholders. As a non-profit hospital, MMC does not have shareholders but is answerable to the Board of Directors and the MMC executive team which oversees the financial strength and sustainability of the system. As a non-profit, evaluating revenue and mitigating losses for the financial strength of the organization is critical, yet non-profit sector organizations also must consider financial stewardship of the organization in relation to donor expectations of the use of their contributions to advance the mission and vision ( Stejskal et al, 2020). Therefore, a recommendation in support of patient safety and quality must be evaluated against the financial implications of its implementation. Using a balanced scorecard analysis framework, MMC identified that by focusing on ensuring LEP patient access to qualified medical interpretation during the discharge process, the hospital could reduce the existing

8 disparity average length of stay (ALOS) for LEP (5.3 days) compared to 4.1 days for English proficient patients. This is in keeping with findings by Brandl et al (2020) which identified that LEP patients have a longer average length of stay 0.75-1.47 days. By achieving parity in ALOS, we could generate over $3.6 million in savings per year in unreimbursed costs. Internal Process The internal process perspective is the “how” behind the organization’s strategic initiatives and focus areas – defining the processes, protocols and standards that enable the delivery of its core business to consumers (Kaplan & Norton, 1992). Functions included within this perspective include productivity and efficiency, standard work, quality, and patient safety. At MMC, the internal process perspective is defined as Highest Quality and Safety (MMC Strategic Planning Office, n.d.). One of the primary key performance indicators measured by the organization is the rate of 30-day readmissions, as this KPI is often an indicator of a preventable error by the care team and results in denial of reimbursement from CMS if the readmission is considered an extension of the reason for the original admission. Studies show that LEP patients routinely have higher 30-day readmission rates than EP patients, with a correlation identified in whether a qualified medical interpreter was part of the discharge planning process (Karliner et al, 2017). Within this domain, the focus needs to be on overcoming any barriers that providers may cite in using qualified interpreters to ensure the safe discharge of LEP patients. Currently, MMC has a documentation rate of 22 percent in the use of qualified interpreters at discharge for LEP patients. Therefore, our target is to increase documentation of interpreter use to 85 percent, with a goal of reducing the 30-day readmission rate by 25 percent, which could save the hospital approximately $1.1 million per year. Learning and Growth Perspective Continuous learning and development is critical for thriving and sustainable organizations, as it drives productivity, innovation, employee engagement, recruitment and retention (Kaplan & Norton, 1996). In health care, this is critical as medical knowledge and practice are continually evolving and improving. Within a functional organizational structure organized around service lines, this allows for rapid improvements in the way care is delivered (Louis et al, 2019). As we look to improve the way we deliver care to LEP patients, there are two imperatives within the Learning and Growth domain, or what MMC

9 calls Best Place to Learn, Work and Grow (Emory Healthcare Strategic Planning Office, n.d.): 1) Staff, providers, patients and their families all prefer the use of in-person interpretation over telephonic or virtual, and qualified interpretation must be the standard to direct those interactions over the use of ad hoc translation provided by non-clinical staff or patient family members (Gerchow et al, 2021), and 2) increase the comfort and confidence of registration staff in capturing language needs of patients upon admission, as this data capture sets in motion the quality of interactions for the remainder of the patient’s stay (Rajaram et al, 2020).By focusing on these two areas, we can significantly improve the way in which we achieve compliance with Joint Commission requirements, while fostering our commitment to creating a culture of inquiry. Customer Perspective The customer perspective ensures that while shareholder needs are met, it cannot be at the expense of the consumer or customer (Kaplan & Norton, 1992). MMC defines the customer perspective as “Best Patient Access and Experience” with an emphasis on increasing accessibility across the system, mostly by improvements in our centralized scheduling and appointment availability ( MMC Strategic Planning Office, n.d.). Key performance indicators in this area include percentage of first-time appointments, weeks to first available appointment and customer expressed satisfaction for ease of scheduling via the Press-Ganey patient satisfaction surveys. However, with the transition to Epic in October 2022, our phone tree to our main switchboard no longer prompts patients to select a language. Instead, it asks patients to perform a series of commands in English before they can speak to a human being or indicate a language preference. Once connected, call center representatives often eschew the use of qualified interpretation as they feel pressure to meet performance targets on total call time and number of calls completed per hour. Thus, customer satisfaction during scheduling suffers, as does employee satisfaction, contributing to ongoing turnover challenges within the call center. In developing strategies to address these challenges, leaders must develop improvement processes that facilitate ease of scheduling for both customer and employees in the call center (Chicu et al, 2019). One best practice to consider is the change implemented by CMS in their Medicare Part C and D call center to provide LEP callers immediate access to interpreter services before accessing a call center representative. They also

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10 adjusted their performance metrics to focus on caller and employee satisfaction, first-call resolution and decreases in call abandonment (Chavez-Valdez, 2021). Evidence-Based and Best-Practice for Monitoring & Improving In 2019, MMC began its EmPower journey, its adoption of Lean management processes to improve efficiency and increase value for consumers. Lean employs multiple tools and strategies consistent with process improvement strategies and is an exceptional resource for several of the strategies recommended in this process improvement proposal; however, a variety of methods will be required to ensure the success of the proposed changes, which we will outline below. For the financial perspective of decreasing average length of stay, studies show that LEP patients are more likely to experience adverse events in the health care setting and these events are more likely to increase ALOS. In addition, LEP patients are also more likely to have additional, medically unnecessary tests ordered for them due to language issues, which, given the current volumes and daily backlogs of patients waiting on diagnostic imaging and endoscopic procedures, may be inflating the overall length of stay. For this recommendation, using the Lean tools of a value stream analysis would enable a clear view into the areas of opportunity, such as gemba to observe how the work happens in a real-time environment, identification of areas of waste in terms of waiting, movement or efficiency, and engagement of front-line staff and providers to develop solutions and increase buy-in to proposed changes. This strategy is consistent with numerous studies that have looked at the efficacy of Lean Six Sigma principles to decrease ALOS, as referenced by the meta-analysis of 23 projects conducted by Zepeda-Lugo et al (2020). To address the internal process recommendation to increase utilization of qualified interpreters by addressing provider resistance to the need, implementation science would be a better strategy to support this process improvement method. While Lean focuses on efficiency and throughput, implementation science focuses on addressing barriers to adoption of best practices in clinical practice. Research published by Lion et al (2023) used this approach to specifically increase adoption rates of qualified interpretation in primary care settings. The study compared the efficacy of two different evidence-based strategies to see which was more effective at increasing adoption rates and increasing provider compliance with regulations. They assessed provider belief in their own ability to assess patient

11 comprehension and satisfaction with the encounter, beliefs about consequences, intention to change behavior and elimination of operational barriers. Using this approach effectively can overcome human resistance to change, when awareness and education on the need is already high but not followed (Lion et al, 2023). For the Learning and Growth perspective, the American Hospital Association TeamSTEPPS LEP module is an evidence-based training strategy that increases staff capacity and confidence to implementing change. The training includes skills development through problem-solving, teamwork, communication, collaboration on performance measures and simulation training in real-world scenarios ( Chapter 3: Improving Team Communication to Foster Safety for LEP Patients: TeamSTEPPS LEP Module , n.d.). Finally, for the customer perspective, we recommend the implementation of strategies outlined by CMS in its guidance published in 2021, outlining best practices for call center structure and performance metrics to address leader and staff resistance to changes and increase buy-in through performance metrics focused more on outcomes and satisfaction than efficiency and timeliness (Chavez-Valdez et al, 2021). This gives teams time to adapt to changes and address logistical issues that arise with the change in workflow before they begin focusing on throughput. Organization’s Values An organization’s values should both reflect and define the norms and behaviors of its people, and should be clear, easily understood and interwoven into the daily activities and strategies of the organization (Ginter et al, 2018). The MMC values are: We exemplify excellence, innovation, and collaboration; We treat everyone with respect, caring and compassion; We embrace diversity, equity and inclusion; We steward our resources responsibly to optimize value; and We serve with integrity ( Welcome to MMC, n.d.). Within that framework, it is fundamental to who we are and our ethical responsibility that we protect the rights of our patients and deliver high quality, safe and equitable care to everyone, regardless of race, ethnicity, national origin, or language – in addition to being a legal and regulatory requirement. Moreover, this process improvement proposal aligns with the American College of Healthcare Executive’s Code of Ethics which mandates that we work to create a culture of respect, equity

12 and dignity, and work to ensure processes to provide and evaluate safety, quality, and equity ( ACHE Code of Ethics , n.d.). Conclusion One of the greatest benefits of the conversion to Epic as MMC’s electronic health record that MMC has yet to fully realize is the robust data collection and reporting capabilities in identifying social determinants of health. With anticipated regulatory changes in the collection of language preference for limited English proficiency patients, it is imperative that MMC immediately begin the implementation of a four-pronged approach to improving compliance with initiatives across all four perspectives of the balanced scorecard. Not only will this increase the overall delivery of care and patient satisfaction, but it will also enhance employee engagement, provider satisfaction, better quality of care and positive influence the financial strength and sustainability of the hospital. If the above recommendations are implemented, we can serve as a model for other operating units within the MMC system and for other organizations who struggle with the challenge of providing equitable care to LEP patients.

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13 References ACHE Code of Ethics . (n.d.). American College of Healthcare Executives. https://www.ache.org/about- ache/our-story/our-commitments/ethics/ache-code-of-ethics . Brandl, E. J., Schreiter, S., & Schouler-Ocak Meryam. (2020). Are Trained Medical Interpreters Worth the Cost? A Review of the Current Literature on Cost and Cost-Effectiveness. Journal of Immigrant and Minority Health, 22 (1), 175-181. https://doi.org/10.1007/s10903-019-00915-4 . Chavez-Valdez, A. L. (2021). 2022 Part C and Part D Call Center Monitoring - Timeliness and Accuracy & Accessibility Studies. In cms.gov . Retrieved August 5, 2023, from https://www.cms.gov/files/document/2022partcandpartdcallcentermonitoring.pdf Chicu, D., del Mar Pàmies, M., Ryan, G., & Cross, C. (2019). Exploring the Influence of the Human Factor on Customer Satisfaction in Call Centres. BRQ Business Research Quarterly, 22 (2), 83–95. https://doi.org/10.1016/j.brq.2018.08.004 MMC Strategic Planning Office (2023). MMC Balanced Scorecard [Dataset]. http://www.ourehc.org/departments/performance/files/bsc/bsc-fy23/fy23-bsc-souce-document.pdf Ginter, P.M., Duncan, W.J., & Swayne, L.E. (2018). Strategic Management of Health Care Organizations, 8 th Edition . Hoboken, NJ: Wiley. Improving Team Communication to Foster Safety for LEP Patients: TeamSTEPPS LEP Module . (n.d.). Agency for Healthcare Research and Quality. https://www.ahrq.gov/health-literacy/professional- training/lepguide/chapter3.html . Kaplan, R. S., & Norton, D. P. (1992). The Balanced Scorecard-Measures That Drive Performance. Harvard Business Review, 70 (1), 71–79. Kaplan, R. S., & Norton, D. P. (1996). Linking the Balanced Scorecard to Strategy. California Management Review, 39 (1), 53–79. Karliner, L. S., Pérez-Stable, E. J., & Gregorich, S. E. (2017). Convenient Access to Professional Interpreters in the Hospital Decreases Readmission Rates and Estimated Hospital Expenditures for Patients With Limited English Proficiency. Medical Care , 55 (3), 199–206. https://doi.org/10.1097/MLR.0000000000000643 . Lion, K. C., Zhou, C., Fishman, P., Senturia, K., Cole, A., Sherr, K., Opel, D. J., Stout, J., Hazim, C., Warren, L., Rains, B. H., & Lewis, C. C. (2023). A sequential, multiple assignment randomized trial comparing

14 web-based education to mobile video interpreter access for improving provider interpreter use in primary care clinics: the mVOCAL hybrid type 3 study protocol. Implementation Science , 18 (1). https://doi.org/10.1186/s13012-023-01263-6 . Louis, C. J., Clark, J., Gray, B., Brannon, D., & Parker, V. (2019). Service line structure and decision-maker attention in three health systems: Implications for patient-centered care. Health Care Management Review , 44 (1), 41–56. https://doi.org/10.1097/hmr.0000000000000172 Molina, R.L. & Kasper, J. (2019). The power of language-concordant care: A call to action for medical schools. BMC Med Educ , 19 (378). https://doi.org/10.1186/s12909-019-1807-4 . Rajaram, A., Thomas, D., Sallam, F., Verma, A. A., & Rawal, S. (2020). Accuracy of the Preferred Language Field in the Electronic Health Records of Two Canadian Hospitals. Applied Clinical Informatics , 11 (4), 644–649. https://doi.org/10.1055/s-0040-1715896 Slåtten, T., Mutonyi, B. R., & Lien, G. (2021). Does organizational vision really matter? An empirical examination of factors related to organizational vision integration among hospital employees. BMC Health Services Research , 21 (1), 483. https://doi.org/10.1186/s12913-021- 06503-3 Stejskal , K., Sayed , N., & Lento, C. (2020). Mapping Stakeholder Expectations of a Publicly Funded Post- Secondary Institution: A Balanced Scorecard Perspective. Accounting and the Public Interest , 20 (1):104–137. https://doi.org/10.2308/api-19-002 . Welcome to Emory Healthcare (n.d.). https://www.emoryhealthcare.org/about/index.html Zepeda-Lugo, C., Tlapa, D., Baez-Lopez, Y., Limon-Romero, J., Ontiveros, S., Perez-Sanchez, A., & Tortorella, G. (2020). Assessing the Impact of Lean Healthcare on Inpatient Care: A Systematic Review. International Journal of Environmental Research and Public Health, 17 (15):5609. https://doi.org/10.3390/ijerph17155609 .

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