Evaluation of the Lovell Federal Health Care Center Merger Findings, Conclusions, and Recommendations (2012) / Chapter Skim
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5 Lessons Learned from Other Federal and Private-Sector Collaborative Approaches to Health Care Services
5 Lessons Learned from Other Federal and Private-Sector Collaborative Approaches to Health Care Services
Pages 145-164
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The ensuing 171-page report, Legislation Needed to Encourage Better Use of Federal Medical Resources and Remove Obstacles to Interagency Sharing (HRD-78-54) , found a very 1 The private-sector discussion draws on a paper commissioned by the Committee on Evalu ation of the Lovell Federal Health Care Center Merger on the "Collaboration Among Health Care Organizations: A Review of Outcomes and Best Practices for Effective Performance," by Thomas D'Aunno, with the assistance of Yi-Ting Chiang and Mattia Gilmartin (see Appendix D)
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. 2 The sites for the budget and financial management demonstrations were the VA Pacific Islands Health Care System/Tripler Army Medical Center and the Alaska VA Health Care System/3rd Medical Group at Elmendorf Air Force Base (Navy Medicine, 2012)
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, the program was extended until September 30, 2015, by the NDAA 2010, the law that established the Captain James A Lovell Federal Health Care Center (FHCC)
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The JFURSWG developed standardized reporting templates for joint ventures and joint market areas in 2010, with performance metrics. Joint ventures and joint market areas are now expected to show a reduction of at least 5 percent in overall costs or cost avoidance through use of shared initiatives (Cox and Ruschmeier, 2011)
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In-depth interviews with and briefings by knowledgeable DoD/VA Program Coordination Office and VHA Intergovernmental Affairs Office staff were conducted to learn the history of and ascertain the lessons learned from the creation of sharing agreements through the development phase and into the current, ongoing operations. Discussions were held at the October 2011 annual VA/DoD joint venture conference in Charleston, South Carolina, with representatives of the joint ventures, who updated attendees on their progress and described the many lessons learned from their experiences.
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3rd Medical Group, Elmendorf Air Force Base/Alaska Veterans Affairs Health Care System Key West, Florida (established in 2000) Naval Branch Health Clinic Key West/Miami Veterans Affairs Health Care System Community Based Outpatient Clinic Key West Pensacola, Florida, and Biloxi, Mississippi (established in 2008)
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separate human resources policies and procedures along with high rates of turnover; and (4) the major, universally identified barrier cited by joint venture staffs, namely, the lack of a comprehensive electronic health record (EHR)
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After the initial implementation of planned collaborative services, a number of different strategies, including workaround processes, were used to improve operational effectiveness as the organizational model evolved. Strong leadership that was consistent and leaders who communicated long-term organizational commitment to joint strategic goals and objectives were also critical.
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No single facility or system included a full integration or merger of all patient care services available at one or the other DoD or VA facility involved in the collaboration. Likewise, within most of the joint venture collaboration models, some of the service operations were more effective than others.
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As with other large-scale medical centers, leaders and members of these DoD/VA joint ventures are interested in meeting the demands of patient care that are arising from new technologies, better therapeutic interventions, and the increased need for reducing the costs of health care. To that end, many organizations are planning initiatives to address these goals, including programs for better care coordination across the joint venture and among care providers; improved processes to triage, admit, and discharge patients from the system in a more timely manner; the development of previously unavailable services; outreach to the community for better continuity of care for patients and families; and more appropriate management of medical emergencies.
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Despite systems obstacles, leaders, managers, and caregivers sought a variety of ways to address problems because of strong commitment to high-quality patient care. At the time of this evaluation, most of the organizations had in-progress plans for enhanced services going forward, for example, expanded subspecialty care, restorative medical specialties, advanced rehabilitation services, vision services, and long-term pain management plans for patients.
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Similarly, some studies report little success at integrating the medical cultures of merged hospitals even after 3 years of effort. In short, substantial changes in core clinical services take a long time, and success is not guaranteed as conflicting interests emerge among stakeholders.
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Concluding Observations from the Literature Review Several concluding observations about the outcomes associated with collaboration among health care organizations and best practices for improving these outcomes arise from the literature review. First, there is considerable variation in the outcomes of collaborative ventures regardless of the criteria one uses to assess their performance.
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for a relatively thorough checklist of best practices for implementing collaborative ventures. Few studies have examined the use of many of these practices in combination.
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For example, the vast majority of studies of hospital mergers focus on their financial performance (Vogt and Town, 2006) , with little attention given to other key outcomes, such as access to care, and, similarly, with little attention to leadership using the concepts and principles discussed above.
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and systems change (especially information systems) are needed to promote change and to improve organizational performance People-Focused Leadership Tasks External pressure In most cases, external pressure/support for change increases both its speed and likelihood of success Buy-in from all levels; critical role Support from top managers and leaders is essential, of central authority and shared but buy-in is also needed from lower-level staff; a vision centralized group with authority for implementation of changes is critical, especially to develop a shared vision and goals for change Communication Communication is needed at all levels: What is the vision; why change is needed; what progress has been achieved Role of physician leaders Involvement of physician leaders, both formal and informal, in key decisions is critical to success Managing tensions, trade-offs Involving physicians versus respecting their time inherent in change for patient care; time needed to build trust versus frustration with slow progress; building stakeholder buy-in versus building technical capacity (especially when buy-in and trust are enhanced by demonstrated technical capacity and improved performance)
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These internal features then interact with pressures from and features of the external environment to determine the outcome of the collaboration. Lessons Learned Relevant to the Lovell Federal Health Care Center The Lovell FHCC was intended to address several lessons learned and barriers often cited by VA/DoD joint ventures seeking to improve services or reduce costs, or both.
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That process for reconciliation is scheduled to be completed and automated by FY 2014 and to form the basis for each department's funding of the FHCC. The Hawaii joint venture is developing an alternative joint system, called the bi-directional enhanced document referral, or eDR, system, which has four modules: billing, third-party collections, analytics, and patient referral management.
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The delays in delivering those capabilities have subjected the Lovell FHCC to the same limits on seamless patient care as the joint ventures have faced. Conclusion Collaborations are challenging, time-consuming, and expensive, even in the best of circumstances.
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Briefing by Karen T Malebranche, Acting Chief Officer for Intergovernmental Affairs, Veterans Health Ad ministration, Department of Veterans Affairs, for the IOM Committee on Evaluation of the Lovell Federal Health Center Merger, February 25.
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