Thirteen equals two.

Athens Regional Medical Center, Inc. (ARMC, Inc.) continues to enjoy a strong overall reputation for quality of patient care, scope of services, and competent professionals on staff. As a result, the organization has been able to maintain a near-capacity occupancy level. However, two years ago Athens Regional noted, as have other hospitals, a complex change underway in the health care environment that presented tremendous challenges. Managed care forces were putting pressure on the hospital and the medical staff to sustain quality of care, and simultaneously tighten the budget, achieve continued improvements in efficiency, and retrain employees.[1] To ensure its leadership position in Northeast Georgia, ARMC, Inc. decided to restructure the organization to avoid a "slash and burn," crusade later.

To prepare for the 1994 Joint Commission Accreditation of Healthcare Organizations (JCAHO) survey, we diagrammed all of the medical staff programs. By the time this feat was accomplished, the programs filled three legal-sized papers and resembled the circuitry of a television set. Everyone agreed there had to be a simpler way, while maintaining the required functions. We decided to start the medical staff reengineering as soon as the JCAHO survey was completed.

The Medical Staff Executive Committee appointed an Ad Hoc Committee, chaired by the Past President, to undertake this process. The Ad Hoc Committee met several times over a time frame of about six months, and returned to the Executive Committee with a plan that eliminated five committees and reduced 13 Medical Staff departments to two. The plan was approved and implemented

Reengineering the medical staff was fairly easy because a strong peer review process was already in place. The Surgical Case Review Committee had been reviewing surgery morbidity and mortality cases for several years. Because of its success, a Medical Case Review Committee was similarly established and functioned just as well. During the evaluation process, the following committees were retained: Cardiac Committee, for peer review of invasive cardiology and open heart surgery; Perinatal Committee, which is required by the State of Georgia; and the Pharmacy and Therapeutics (P&T) Committee, because its activities are hospitalwide and could not easily be decentralized into specialty peer review committees, and the volume of work could not be readily delegated to any of the other committees.

But we determined that several committees could be eliminated and still carry on their required functions. Summaries of these activities are still presented at quarterly departmental meetings.

Medical Records/Resource Utilization Committee:

* Clinical Pertinence. On a quarterly basis, 100 medical records are pulled at random from the prior quarter's discharges. Using a group of volunteers, these records are reviewed, using the JCAHO Closed Medical Record Review Form criteria. In this manner, entries from all disciplines are evaluated simultaneously. The results are reported to each discipline accordingly. This approach assures compliance with JCAHO expectations, and should prove useful in our next survey by having a group experienced in reviewing charts using the JCAHO format.

* Medical Record Delinquencies. The Medical Record Department staff continues to monitor chart documentation. They report their findings directly to the Medical Case Review Committees or the Surgical Case Review Committee, whichever is appropriate, instead of to the Medical Records Committee. This function is carried out monthly, but is reported on a quarterly basis, unless adverse trends are identified; however, reporting will be done on a monthly basis until any problems are resolved.

* Resource Utilization. The concurrent chart review activities inherent in the monitoring of care rendered is the responsibility of the Medical Case Review Committee or Surgical Case Review Committee. Communication from the Peer Review Organization (PRO) are reported to the Case Review Committee or the Medical QA Committee, whichever is appropriate.

* Infection Control. The Infection Control staff continues to carry out all of its duties as before. Instead of bringing findings to the Infection Control Committee, a quarterly report is made to the Medical Quality Assessment Committee for dissemination to the medical staff. Any physician oversight needing correction is still provided.

* Transfusion Review. The Blood Bank staff still performs its responsibilities in following the American Red Cross requirements for the acquisition and dissemination of blood products, as well as the review and follow up of errors and reactions. The Quality Assessment Department still conducts the appropriateness of treatment reviews. Quarterly reports of these activities are provided to the Medical QA Committee to disseminate to the medical staff. Any individual physician problem that may arise are referred to the appropriate Case Review Committee for resolution.

* Endoscopy Committee. This Committee's review activities are now performed by the Medical Case Review Committee. As this is a multispecialty committee, it avoids the perception of being anti-competitive and thus encourages more process review, with resulting improvement in quality of service and care.

* Emergency Department/OutPatient Committee (ED/OP). The ED/OP Committee review activities are now done by the Medical Case Review or Surgical Case Review Committee, whichever is appropriate. This allows a system review from the Emergency Department into the inpatient area and subsequent discharge, resulting in improved quality of service and care.

Thirteen equals two

While the committee restructuring was relatively easy, the departmental structure was a challenge. We had 13 departments, each with its own autonomy, each with a Chief, and each required to carry out the mandates of the JCAHO and any other state and federal regulations. The Ad Hoc Committee decided to take a politically-sensitive approach to the reengineering to minimize concerns regarding the perceived loss of autonomy. It decided to leave the composition of the Executive Committee intact, and concentrate on the departmental structure.

It was able to consolidate the 13 departments into two: Medicine and Surgery. Within these two large departments, we retained all of the 13 specialties that had previously been departments. In the consolidation process, each of the 13 departments met for one last time, and elected their respective Division Chiefs. At the following Executive Committee meeting, all the Chiefs convened into two groups and elected their respective Departmental Chairpersons. Relevant summaries of all these activities are presented at the faculty department meetings.

To summarize, Athens Regional Medical Center, Inc. accomplished the following:

* Eliminated five standing committees: Infection Control, Transfusion, Endoscopy, Emergency Department/ Out-Patient (ED/OP), and Medical Records/Resource Utilization. Not the functions, just the committees. Peer review is conducted by the following committees: Medical Case Review Surgical Case Review, P&T, Perinatal, and Cardiac.

* Merged 13 medical staff departments into two divisions: Medicine and Surgery. Both divisional meetings are held on a quarterly basis. Any division (specialty) wanting to have additional meetings may do so as needed. Each previous department elects a Chief of Division; each Chief represents its specialty on the Medical Executive Committee and is still responsible for the credentialing activities of his or her respective specialty.

All functions appear to be flowing smoothly. The quality of care has been maintained, while service should improve as we move forward in the process. The direct impact on cost is uncertain, but the impact on reduced staff time at meetings is enormous - these are indirect costs to which it is difficult to assign the dollars saved. Much less time is spent in meetings; therefore, voluntary attendance is improved. The changes that we have implemented make the meetings more efficient, more meaningful, and just as effective.

References

[1.] Andersen, A., LLP and Greeley Associates, Ltd. Medical Staff Reengineering Institute, 1995. A Seminar Sponsored and Organized by the Accreditation Resource, Inc. Marblehead, Maine. September 14-15, 1995. [2.] Smaller and Smarter: Reengineering the Medical Staff. Medical Staff Briefing Newsletter. March 1995, 5(3). [3.] Thompson, R.E. Re-Forming the Traditional Organization Medical Staff. Physician Executive. April 1995, 21 (4):7-10. [4.] Hammer, M. and Champy, J. Reengineering The Corporation: A Manifesto For Business Revolution. New York, NY: Harper Collins Publishers, 1993. [5.] Lathrop, J.P. Restructuring Health Care: The Patient-Focused Paradigm. San Francisco, CA: Jossey-Bass, 1993.