Healthcare

Arroyo Fresco Community Health Center 

 

 

Abstract

Arroyo Fresco Community Health Center serves the people of western Arizona with the vision of being the healthiest in the entire state, and the mission of providing safe, affordable, quality care to all those in need of health services.  However, the organization faces the difficult challenge of delivering high quality healthcare that is cost effective.  Thus, a new strategy for this organization should focus on cost-effective high-quality healthcare.  A proposed initiative and part of the new strategy involves the re-alignment among the stakeholders or clarifying the roles of physicians, staff, community partners, and others.  Along with the new strategy, a new organizational structure for the organization should focus on the long-term success of their strategy, focusing on ongoing performance improvement that allow evaluation of current processes and ability to modify them in order to increase profitability, streamline workflow, and reduce inefficiencies.  In order to achieve these goals, the use of benchmarking is recommended to develop and implement best practices.  Overall, a change in strategy involves all aspects of an organization, from creating a plan, executing a plan, monitoring and evaluating performance as well as taking risks.  Although a new strategy might be difficult, it is necessary for growth and improvement.

Introduction

Joe Garcia and Martin Rosales founded Arroyo Fresco, AF, in 1968, Arroyo Fresco serves 3 counties in western Arizona. Those counties include LaPaz, Yuma, and Mohave. AF consists of four mobile service vehicles, and eleven clinics. This community Health Center like the others provides high quality for everyone including those less fortunate. AF service area consists of 83.7% white, 4.7% African-American, 5% Native American, 3.3% Asian slash Pacific Islander, and 30.5% Hispanic heritage In the state of Arizona within all three counties combined. Several factors that present as barriers to care include high accident mortality rates, high suicide rates, high rates of sexually transmitted diseases and tuberculosis. There is also a high rate of diabetes in the community and other chronic illnesses such as substance abuse, health disease, asthma, depression, and obesity. AF’s vision is for western Arizona to be the healthiest and the entire state by providing training and education to the residents through effective leadership and community engagement. Their mission is to provide affordable, quality care to the residents of western Arizona and in a timely manner their values include respect, trust, relationship, performance, and accountability. While  AF has been able to provide care to a diverse population of about 6% of the population in Arizona, we will discuss a new strategy for the Arroyo Fresco Community Health Center. We will also discuss an analysis of the new organizational structure, goals and recommendations, and funding.

New Strategy (Nicki)

Arroyo Fresco Community Health Center, despite their leadership in health services, is facing challenges in delivering high-quality and cost-effective care to patients due to misalignment of key requirements of key customers and stakeholders (Case study P.1-7, iii). Effective high-quality care is not a key requirement for the community, physicians, staff, and volunteers, and efficient (cost-effective) care is not a priority for physicians, staff, and volunteers within the organization based on the table provided below.

Retrieved online from https://www.nist.gov/system/files/documents/2017/07/19/2017-arroyo-fresco-community-health-center-case-study-part1.pdf

Patient safety is also not a key requirement for partners, whereas information and training on the current medical technology is not a key requirement to all stakeholders except the physicians which has a direct impact on quality of care. These misalignments in key customer requirements and stakeholders suggests the significant gaps in understanding among the stakeholders of their roles and responsibilities to patients.

The new strategies for AF is to deliver high-quality and cost effective care by addressing the alignment among the stakeholders and redefining the strategic plan with emphasis on the importance of cost-effective high-quality care. By clarifying the roles of the physicians, staff, volunteers, and community partners, informing customers, patients, caregivers and other stakeholders of changes and cultivating shared understanding and focus, AF can provide better care for their patients. This new strategy is achievable with the use of modern technology as an upgrade of the existing Electronic Health Records (EHRs) system for meaningful use to the 2015 Certified Electronic Health Records tool (CEHRT) to meet the Center for Medicare and Medicaid Services reporting requirements. The effective way to address patient safety and alignment in policy and procedures across all stakeholders is with the support of the team and consist of the use of medical technology and training with functionality beyond electronic prescribing for outcomes reporting and population health monitoring for disease prevention. The upgrade to the 2015 Certified Electronic Health Records tool (CEHRT) satisfies the interoperability components under the Quality Payment Program (QPP) Merit-based Incentive Payment System (MIPS) which can help improve quality of care. The use of EHR cannot only improve quality of care, but it can help provide cost-effective care by increasing efficiency or productivity of the organization. 

This new strategy also encourages safety and disease prevention among the internal and external stakeholders and promotes training sessions on medical technology and procedures. By leveraging partnerships with the State Association of Community Health Center’s partners, AF can focus on grant writing skills to increase funding and to obtain additional financial resources to cover the CEHRT upfront fees as well as educational programs for clinicians, administrators, and board members to improve quality of care. The new strategy also promotes Continuous Medical Education (CME) activities to support licensing state requirements. It also consists of developing health and safety risks prevention programs for the clinical staff and volunteers for exposure prevention of communicable diseases, radiation and chemicals, needle sticks, ergonomic injuries, and accidents in an ambulatory patient care setting. Continuous Education (CE) credits ensure that the staff are meeting licensing requirements and the organization is in compliance with providing care to meet the needs of the patients. Risks prevention educational programs should be provided for the patients and caregivers on topics of focus such as exposure to communicable diseases, ergonomic injuries, fall prevention, and accidents. AF should leverage information technology (IT) partners to promote injury prevention education through online interactive programs for patients, families, and community members. These tools should be made available trought the patient portals. 

Analysis of New Organizational Structure

The organizational structure of Arroyo Fresco Community Health Center focuses on their mission, vision, and values to build an organization that provides culturally competent, safe, high-quality healthcare now and in the future for the people of western Arizona.  To achieve this, their organizational structure adopted the Baldrige Criteria as a business model.  Since its adoption in 1997, Arroyo Fresco Community Health Center has focused on continuous efficiency improvement and on providing higher quality of care for patients.  This performance improvement framework integrates all aspects of performance management across the organization as a comprehensive and systematic approach.  More recently, under current chief executive officer (CEO) Ramon Gonzalez and other senior leaders, together have created a more sustainable organization by utilizing key elements of measurement, analysis, and improvement of organizational performance.  This involves not only utilizing the FOCUS framework (financial performance, organizational learning, clinical excellence, utilization, and satisfaction) but also the plan-do-check-adjust (PDCA) and the define-measure-analyze-improve-control (DMAIC).  All allowing the organization to track daily operations and overall organizational performance (“Arroyo Fresco Community Health Center Case Study”, 2017).

A new organizational structure for the Arroyo Fresco Community Health Center would involve the long-term success of performance improvement since it already relies on a sustainable and strong infrastructure.  To achieve this, the Arroyo Fresco Community Health Center could develop and perform initiatives within an ongoing performance improvement program. Currently, aside from the mythologies already mentioned, they also utilize the opportunity identification, assess or analyze, set targets and timelines, improve, share and sustain (OASIS) improvement model (“Arroyo Fresco Community Health Center Case Study”, 2017).  

A clear advantage of using performance improvement methodologies is the evaluation of current processes and ability to modify them in order to increase profitability, streamline workflow, and reduce inefficiencies.  The use of improvement methodologies depends on the areas that an organization might want to improve.  For instance, the Six Sigma methodology, often used in the manufacturing industry and in the service sector, helps minimize defects and inconsistencies as well as improving quality, reducing health costs, and increasing revenues (Ganti, 2004).  Two main processes form part of the Six Sigma methodology: DMAIC for existing processes (which the Arroyo Fresco Community Health Center is currently using), and the define-measure-analyze-design-verify (DMADV) for new processes.  There are clear differences among the two with the most obvious being their primary focus.  While DMADV focuses on the development of new services or new adjustments, DMAIC focuses on improving existing ones.  DMADV is specifically useful when implementing new strategies since it is based on current data and provides a structured process for improvement (“DMAIC Vs DMADV”, 2021).

Often, a disadvantage of most performance improvement methodologies is that they are based on labor productivity, supply, and other non-labor related costs and do not include or are not in sync with emerging marketplace requirements.  An ongoing improvement program should increasingly focus on long-term initiatives on different levels of performance improvement such as process, structural, and portfolio.  The process level represents routine operational modifications made on a daily basis such as work schedules, role design, and workflow to improve staff utilization to optimize healthcare delivery to patients.  The structural level involves the redesign of leadership roles to leverage management resources across departments.  The portfolio level goes beyond process and structural changes.  This occurs when health organizations redesign programs and services in response to changes in market demand to maximize revenues (Auton, 2018).

Goals and Recommendations (Janaye)

The goals for the new organizational strategy are to deliver high quality care that is cost effective, and efficient, promote safety and disease prevention, and increased safety awareness. In order to meet these goals, the following steps are recommended for the future to change current practices. The first step to implementing change within the organization is to develop a business plan. The business plan should provide a list of the goals and tactics to address those goals. There should also be a deadline for the tactics to be completed. Once goals and strategies have been established the next step is to share the business plan and make sure everyone on the team is aware of the changes and they have been provided with the correct resources to meet and address those goals. After the tactics have been communicated and implemented, the next step is to complete an audit and provide feedback. A summary of the performance of the clinic to improve the organization is known as audit and feedback (Alagoz et al., 2018). This can be done through a process known as benchmarking. Continuous quality improvement can be accomplished through benchmarking (Ettorchi-Tardy et al., 2012). Benchmarking and Healthcare is a fairly new concept. The purpose of benchmarking in healthcare is to develop and implement best practices within the organization at the best cost. The benchmark is the comparison point where other products or services can be compared. Completing a monthly benchmark can help identify where the organization stands presently and comparison to past performance. Throughout this process of implementing the tactics and strategies, effective and consistent communication about expectations and processes should be provided to the team to keep everyone engaged. Following 60 to 90 days and may be determined if the new strategy is effective and leadership should conduct a meeting to review the results and discuss next steps. If during this discovery process it is determined that there has not been a significant amount of change, adjustments should be made immediately. Whatever the outcome of the meeting, it should be communicated back to the team. During frequent meetings to discuss the business plan, a discussion or meeting regarding funding should be incorporated. Below we will discuss the process for funding.

Funding  

Implementing a new strategy requires formulating rational thought and discussing the plan. In this situation, implementing a new strategy requires information from the stakeholders, sponsors, management, employees, and information to patients. To avoid confusion or inconvenience while implementing the new strategy, the hospital must be ready to involve all mentioned personnel in the implementation process. In an organization like the arroyo fresco community health center, the implementation must be legally and ethically binding to the existing organization's strategy. This requires extra attention to detail and the implementation process to ensure it does not distract the order of services and employee engagement. 

The CEHRT system upgrade is likely to be cost prohibitive for the institution; therefore, the Medicare and Medicaid Incentive Programs provide financial support to the health professionals to offset the cost. From the Medicare Incentive Program, the eligible professionals (EPs) receive a maximum of $44,000 who use e-prescribing, and Medicaid EHR Incentive Program pays a maximum of $73,750 per EP over five years (Health IT, 2019). Note the difference between the incentive programs that the Medicare Incentive program falls under the federal government purview and uses the traditional definition of meaningful use (Health IT, 2019). The Medicaid Incentive program is state managed by the state government and is not mandatory, with the flexibility to add additional criteria for meaningful use (Health IT, 2019). Considering that AF has 419 employees, and if 50 of them are HCPs, then by upgrading to CEHRT, the organization can potentially receive $2,200,000 from Medicare Incentive Program, and $3,687,500 in funding from Medicaid EHR Incentive Program per eligible HCP, which is over $5,887,500 in incentives from both programs over five years and is approximately $1,177,500 per year (Award OMB Control No. 0693-0006 Expiration Date: 06/30/2019 Page E-9 of 12). The current funding from Medicare is 6% and Medicaid 33% for the system upgrade. AF is likely to receive additional reimbursements based on Quality Payment Program (QPP) Merit-based Incentive Payment System (MIPS) (Figure P.2-4 v: Revenue Sources (2016). The financial incentives can help AF accelerate the adoption of CEHRTs, reduce administrative waste, prevent medical errors, and optimize the outcomes reporting for higher reimbursement incentives. The new system enables AF to asses organizational performance and quality measures for reimbursement incentives under the CMS programs and patient surveys for performance satisfaction assessment and further redefine the objectives. The initial upfront expenditures still need to be considered; however, leveraging the partners for grant writing assistance can support those costs.  For example, in New Mexico, twelve rural hospitals received $3,100,512 for COVID-19 testing and mitigation in federal funding (Small Rural Hospital, 2022). The grant funding is available but requires application submission. 

The strategy is designed to provide guidelines for organizations to develop and implement change strategies to address the deficit in health situations (Correa et al.,.2020). The strategies are designed to establish a clinically appropriate framework for improving health equity in the local settings, which will also lead to improved care and outcomes for patients with chronic conditions by supporting evidence-based interventions.

The implementation design will be executed in steps. The steps are a hierarchy from the most important and most effective to the existing strategy (Correa et al.,.2020). However, we must consider the financing and incurred expenses of the proposed solution. Financially, the organization operates on a budget to minimize expenses and maximize revenue through legal and authorized. by the community health association. In an agreement with the sponsors-the federal government, well-wishers, management, and health stakeholders, the financing will be executed on the initial budget generated at the planning stage (Smol, Marcinek, Duda,  & Szołdrowska,2020). The implementation process includes;

·      Setting clear goals and defining key variables and effects of the new proposed implementation. At this stage, the committee is expected to visualize the new strategy and evaluate the possible outcome in terms of advantages, disadvantages, and challenges in the implementation process and possible solutions.

·      Determining roles, assigning responsibilities, and determining the proposed solution for particular departments and individuals (Smol, Marcinek, Duda,  & Szołdrowska,2020). At this stage, the management and committee of experts will discuss the responsibilities, cordially assign the new strategy implementation roles to employees and stakeholders, and communicate changes to their patients in the most effective mode.

·      Budgeting. At this stage, the implementation panel will consider the project financing mode, expenses, and the estimated revenue after implementing the new strategy. The changes are expected to be financed mainly by the management through the previous financial year's revenue and semi annually collected revenue. The raised finances will cover the expenses of stakeholders and the federal government (Smol, Marcinek, Duda,  & Szołdrowska,2020). The daily revenue for the first half month will also fund minor expenses during new strategy implementation.

·      Delegating the work to respective departments and encouraging teamwork for easier and affordable implementation.

·      Execute the plan, monitor the progress, and evaluate performance. The performance will be evaluated on the previous performance analysis in the old strategy.

·      Take corrective action, including adjusting, revising, and reviewing the process.

Conclusion  ( Maureen)

Change can be very difficult but it is also necessary for growth and improvement. In order for the Arroyo fresco community health center to improve on delivering high-quality and cost-effective care to patients, a new strategy has to be implemented. Implementing a new strategy in the arroyo fresco community health center involves taking risks and interrupting the current operation. However, the new strategy can revolutionize the whole process; the community health center should focus on the positivity of the new strategy, including increased revenue and reduced operational cost.

References

Alagoz, E., Chih, M., Hitchcock, M., Brown, R., & Quanbeck, A. (2018). The use of external change agents to promote quality improvement and organizational change in healthcare organizations: a systematic review. BMC Health Services Research, 18(1). https://doi.org/10.1186/s12913-018-2856-9

https://journals.sagepub.com/doi/10.1177/1062860617702741

Auton, G. (2018, August 14). A new framework for healthcare performance improvement. HFMA. Retrieved from https://www.hfma.org/topics/article/61619.html

Correani, A., De Massis, A., Frattini, F., Petruzzelli, A. M., & Natalicchio, A. (2020). Implementing a digital strategy: Learning from the experience of three digital transformation projects. California Management Review, 62(4), 37-56. 

DMAIC vs. DMADV. (2021, May 28). Purdue University. Retrieved from https://www.purdue.edu/leansixsigmaonline/blog/dmaic-vs-dmadv/

Ettorchi-Tardy, A., Levif, M., & Michel, P. (2012). Benchmarking: A Method for Continuous Quality Improvement in Health. Healthcare Policy | Politiques De Santé, 7(4), E101-E119. https://doi.org/10.12927/hcpol.2012.22872

Ganti, A. (2004, February 20). Six sigma and healthcare. Retrieved from https://www.iise.org/uploadedfiles/SHS/Resource_Library/Details/02_ganti.pdf

Health IT. (2019, March 29). What are the differences between Medicare and Medicaid EHR Incentive Programs? Retrieved from https://www.healthit.gov/faq/what-are-differences-between-medicare-and-medicaid-ehr-incentive-programs

 Small Rural Hospital Improvement Program (SHIP) COVID-19 Testing and Mitigation Program Funding Distribution | HRSA. (2022, March 21). Hrsa.Gov. https://www.hrsa.gov/rural-health/grants/rural-health-research-policy/rrpd-awards

 Smol, M., Marcinek, P., Duda, J., & Szołdrowska, D. (2020). Importance of sustainable mineral resource management in implementing the circular economy (CE) model and the European green deal strategy. Resources, 9(5), 55.