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TL 4 - Advocacy and Influence

The CNO is a strategic partner in the organization’s decision-making.

Provide one example, with supporting evidence, of the CNO’s involvement in the organization’s decision-making (not involving technology).
AND
Provide one example, with supporting evidence, of the CNO’s involvement in the organization’s technology decision-making.

Example A: CNO’s Advocacy and Influence in the Organization’s Decision to Recommend Submission for a Certificate of Need for Designation as a Pediatric Heart Transplantation Center

Background/Purpose

A strategic partner in organizational decision making, Jackie Gonzalez DNP, MBA, ARNP, NEA-BC, FAAN,  the Senior Vice President and Chief Nursing Officer (SVP/CNO) is an active member of the Senior Leadership Team (SLT).  The Senior Leadership Team is composed of the organization’s President/Chief Executive Officer, Chief Operating Officer, and Senior Vice Presidents. The CNO’s influence on decisions crosses interprofessional and multifunctional boundaries involves patient care quality, practice, process and strategy. One example of her impact in the organization’s strategic decision making was her analysis and advocacy for the establishment of a pediatric heart transplant program for Nicklaus Children’s Hospital. 

Because of Dr. Gonzalez’s leadership in the organization, she was asked to be a part of the organization’s strategic decision making team to determine submission for a certificate of need (CON) for heart transplantation within the state of Florida. In particular, Dr. Gonzalez was asked to provide expert testimony in response to the CON challenge from local competitors as part of the Agency for Healthcare Administration (AHCA) appeal process.

Advanced pediatric heart failure is the number one reason for pediatric heart transplantation.  There are approximately 400 pediatric heart transplants performed every year in the United States (Hsu. et al, 2009).  Pediatric advanced heart failure occurs in approximately 1 in 10,000 live births and 10% of these children are irreparable with a  mortality rate of 7% (Rossano. et al, 2012).  Most programs report survival rates of over 5 years with 59% survival rate for over 10 years. 

The Heart Program with Nicklaus Children’s Hospital has the largest heart surgery population within the state of Florida. In early 2015, Dr. Gonzalez began exploring the potential for performing pediatric heart transplantation.  Approximately 4 to 6 Nicklaus Children’s patients were being sent to other centers for heart transplantation evaluation annually.  Florida has 4 providers of pediatric heart transplant programs, two of which are located in Service Area 4 where Nicklaus resides.  However, sending patients out to centers for this critical life-saving procedure interrupts the relationship built between the child/family and their providers within an already nationally ranked heart program team. Also, in Service Area 4, one of the closest providers performed no pediatric heart transplants in a two year period, receiving warning from the Agency for Healthcare Administration in Florida.

Nicklaus’ Congenital Heart Institute continues to be recognized by U.S. News & World Report (USNWR) as a top program within the U.S. However, lack of a cardiac transplant program adversely impacts the program’s ranking. Specifically there are 2 areas within the USNWR survey that Nicklaus could not respond to: Survival after heart transplant & heart transplant program.  Most of the other ratings within the overall scoring are either in the high or excellent range, with a few in the average leading to an overall national ranking of #36 (without heart transplantation) in 2015-2016.  The cardiac surgical and cardiology team has demonstrated excellent outcomes and dedication to the best quality of care for children undergoing heart surgery. Establishing this program would eliminate the need for children to leave their providers and their homes when they need cardiac transplantation.

In order to serve these patients best, Dr. Gonzalez proposed the establishment of a pediatric heart transplant program.  She proposed utilizing  existing facility space within the new Advanced Care Pavilion’s Cardiac Intensive Care Unit to offer the new service.

Interventions


CNO Role in Influencing and Advocating for Pediatric Heart Transplantation

Recognizing the need for this service, Dr. Gonzalez, led the initial stages of exploring the pathway for potential pediatric heart transplantation services in March 2015.  She met  with fellow senior leaders April Andrews-Singh, JD, RN, Senior Vice President & General Counsel and Michael Davis, MBA, MPH, Senior Vice President Strategy, Business Development & Innovation to investigate the feasibility. 

In March 2015, Dr. Gonzalez & Andrews-Singh held an exploratory call was held with Sharon Girvin, a planner for the Girvin Group to analyze certificate of need requirements for solid organ transplantation for the state of Florida. Refer to Appendix TL4A-1 to view the conference call summary notes captured after the call.  

Dr. Gonzalez began working with these senior leaders. Given the organizational programmatic and strategic importance of this initiative, she prioritized her 2015 goals (seen in Appendix TL4A-2) to include analysis of transplant opportunities, including heart and kidney transplant.


CNO Analysis and Development of a Strategic Business Case

Dr. Gonzalez’ initial efforts in the development of the heart transplant business plan began by working with Finance to understand the full scope of services and to perform the market analysis. Pediatric heart transplant is aligned with MCHS’s strategic priority of Growth as well as its mission of “for health, for life”.  The cardiac service line is one of the organization’s premier programs and the addition of transplant services would  enhance the program’s national brand. 

Dr. Gonzalez developed the underlying analysis that would be required for the CON application for State of Florida’s Area 4.  On June 30, 2015, a business plan (seen in Appendix TL4A-3) was submitted by Dr. Gonzalez to Martha McGill, RN, MBA, MHA, Executive Vice President & Chief Operating Officer, for strategic consideration, including the recruitment of key personnel, such as a pediatric heart transplant surgeon and transplant program director. The executive decision, heavily influenced by Gonzalez’ evaluation, was to move forward with the CON application in collaboration with Patti Greenberg National Healthcare Associates, Inc.


Certificate of Need Application Submission and CNO Expert Testimony

After months of work by Dr. Gonzalez and her team, gathering 118 required data elements from across the organization and within the community, the CON application was submitted to the Agency for Healthcare Administration for the October 2015 batching cycle.  A challenge was issued by local competitor, Jackson Health System, on April 4, 2016, that prompted a request for production of documents.  An administrative hearing was then scheduled in November of 2016.  On November 16, 2016, Dr. Gonzalez was asked to provide expert testimony as to the organization’s commitment to quality and outstanding clinical outcomes in Tallahassee, FL for the hearing advocating for Nicklaus Children’s Hospital’s pediatric heart transplant designation and certificate of need.  Refer to Appendix TL4A-4 to view Dr. Gonzalez’s involvement in the final trial to provide expert testimony.
 

Participant List

Name Credentials Role / Title Discipline
Jackie Gonzalez DNP, ARNP, MBA, NEA-BC, FAAN Senior Vice President/Chief Nursing Officer & Patient Safety Officer NURSING
April Andrews-Singh Esq, RN General Counsel & Senior Vice President of Legal & Governmental Affairs Administration
Michael Davis MBA, MPH Senior Vice President Strategy, Business Development & Innovation Administration
Martha McGill RN, MBA, MHA Executive Vice President & Chief Operating Officer Administration

Outcomes

On July 31, 2017, General Counsel April Andrews-Singh was notified by the state of Florida’s Agency for Health Care Administration that Certificate of Need Number 10421 had been issued to Nicklaus Children’s Hospital to establish a pediatric heart transplantation program in District 11 of Miami-Dade County, Transplantation Service Area 4 as shown in Appendix TL4A-5. The issuance of this CON was in spite of heavy contest from local competitor Jackson Memorial Hospital which constituted the prior judicial hearing in Tallahassee, FL in November 2016. Estimated project cost was $1,890,034 including the September 22, 2016 recruitment of Dr. Kris Guleserian, heart transplant surgeon.  The benefits for the children and families who are in need of these precious services outweighed the cost, including the ability for families to remain closer to home and their care providers.

The heart transplant program is in the planning stages for implementation over the next 18 month period with the goal of the first transplant recipient in 2018.  The heart surgeon is in place, the heart failure cardiologist is being recruited and the clinical team including nurses, pharmacists, social work and others have been attending national educational offerings and visiting large transplant centers to prepare, including visits to Texas Children’s Hospital and Dallas Children’s Hospital in May of 2017.

Example B: CNO’s Advocacy and Influence in the Organization’s Technology Decision-Making to Purchase Surgical Profitability Compass Information Technology

Background/Purpose

Jackie Gonzalez DNP, ARNP, MBA, NEA-BC, FAAN. Senior Vice President and Chief Nursing Officer (SVP/CNO), is an active member of the Senior Leadership Team (SLT) and a strategic partner in organizational decision making. The SLT is composed of the organization’s President/Chief Executive Officer, Chief Operating Officer, and Senior Vice Presidents. The CNO’s influence on decisions crosses interprofessional and multifunctional bounderies involving practice, process, policy and technology. One example of her impact in the organization’s technology decision making was her analysis and decision to sign an agreement with the Healthcare Advisory Board for the “Surgical Profitablity  Compass”, a web based national benchmaking technology tool. This multi-functional technology tool gives the organization the ablity to benchmark internally and externally Operating Room (OR) procedural costs, productivity, efficiency and quality, including medical, nursing, contracts, purchasing and supply cost information with over 240 hospitals across the United States.

Interventions


CNO Influence in the Purchase of Surgical Profitability Compass Information Technology

In early November 2013, Dr. Gonzalez, SVP/CNO, and Carolyn Domina, MSN, ARNP, CNOR, NEA-C, Administrative Nursing Director of Surgical Services, meet with Whitney Hopkins, Business Analyst from The Advisory Board Company to discuss potential licensure of the “Surgical Profitability Compass “ technology tool at Nicklaus Childrens Hospital (NCH).  Dr. Gonzalez led an interprofessional group from Finance (Michael Durr, Admin Director of Finance), Nestor Ventura, MBA (Business & Financial Analyst), Carolyn Domina, (Administrative Nursing Director of Surgical Services) and Jeffrey Friedman (Director of Supply Chain) in review of the potential uses/benefits to the organization.    

Dr. Gonzalez talked with Senior Vice President/Chief Information Officer, Ed Martinez, about the potential benefits to achieving strategic, financial and operational results through utilization of Surgical Profitability Compass.  Some of these benefits included readily available reporting to individual surgeons as to their use of block time by day of the week, time of day and actual time used in the operating room.  Real time availability to information including first case starts, room turnaround time, cost of supplies and comparative costs were a few of the items identified that would be beneficial and that were not available through Surginet.  Benchmarking ability with like co-horts of other children’s hospitals was also of great value. 


Collaborating with Executive Peers

Martinez was skeptical as to the value and Dr. Gonzalez spent time walking him through the organizational benefits of this technology implementation. There was also no automated solution available that could provide the level of information in a timely manner that Surgical Profitability Compass provided. Dr. Gonzalez also brought the item to Executive Vice President/Chief Operating Officer, Martha McGill, MBA/MHA, BSN, RN, who approved the purchase. Finally, Dr. Gonzalez reviewed with the Operations Leadership Team (OLT) of vice presidents who endorsed moving forward.


Negotiating  Costs

In December of 2013, Nestor Ventura summarized further the value of the program, seen in Appendix TL4B-1, which included:
  1. Merging Surginet clinical data and billing with Lawson supply chain data, drilled down to the encounter level
  2. Ability to address variation, such as differences in procedure costs by surgeon, supply costs, turnover time and first case start benchmarking
  3. Comparison with a 240 member cohort including 26 children’s hospitals.  Demographic and ICD code comparison is available.
  4. Supply cost reduction estimate of at least 2% ($200K) in year one.
Costs were negotiated by the Jeffrey Friedman, Supply Chain director and were reduced from the original request of $150,000/year and the organizational contract was signed off and approved by Legal.


CNO Endorsement of Surgical Profitability Compass Information Technology

As a trusted and highly respective executive who sought the endorsement of the purchase of a tool that would improve organizational operations and finances, the contract was endorsed by the CNO and signed by the Supply Chain Director with a start date of December 31, 2013.  Terms included a 3 year contract of $128,000 in year 1 with 2nd year of $98,000 per year to finance the “Surgical Profitability Compass” technology tool at Nicklaus Childrens Hospital as seen in Appendix TL4B-2. With full buy-in across the organization including Executive Vice President & Chief Operating Officer, Martha McGill, in purchasing this technology, next steps included full engagement of Information Technology (IT) and implementation.


Implementing Surgical Profitability Compass Information Technology

Dr. Gonzalez initiated the roll-out negotiations with the IT Department, specifically Anita Wilson, MSN, RN, FHIMSS, CHCIO, CPHIMS, Admininstrative Director of Clinical Operations. Wilson explained there were competing priorities for implementation including planned work with the Revenue Cycle and Finance teams. Roll-out timelines were negotiated with the first on-site meeting scheduled in January of 2014 and a Technical On-site Meeting was held on February 11, 2014 (see Appendix TL4B-3 meeting agenda) with attendees CNO Dr. Gonzalez, Jeff Friedman, Maureen Martin, Vice President of Finance, Anita Wilson, Director of Information Technology, Nestor Ventura, Pascale Prepetit, Director of Health Information Management, Mario Del Mazo, Supply Chain Data Specialist, Ruben Reinis, BSN, MBA, RN, Nurse Manager Surgical Services, William Riley, Nurse Manager, Surgical Services, Dwight Witter, Clinical System Analyst III and Ingrid Gonzalez, Nurse Manager Clinical Informatics, to plan the elements of implementation. From that period of time a timeline was developed for implementation and testing.  The system was rolled out in Janauary and went live in April 2014.
 

Utilizing Surgical Profitability Compass Information Technology

Nestor Ventura  compiles the data and provides this information to the Surgical Services leadership team, the Operating Room Committee and the Department of Surgery meeting.  Data is also shared with each surgeon on a quarterly basis as to their profile of OR use.  This web based data mining technology tool is then used by Carolyn Domina and the Surgical Services Team to analyze surgeon block time utilization, operating room utilization, first case on time start rates, operating room turnover times, and supply cost per case for internal efficiency comparisons as well as external benchmark comparisons. The data is monitored monthly, and shared with physicians and staff for continuos quality improvement and identification of cost reduction opportunities. On July 10, 2014, Whitney Hopkins from the Surgical Profitability Compass hosted the first outcome review meeting including Ventura, Carolyn Domina, Jackie Gonzalez and Jeff Friedman to review potential program reports, outcomes and scenarios.  The automation of block scheduling was a tremendous enhancement to what was a very manual process.

Participant List

Name Credentials Role / Title Discipline
Jackie Gonzalez DNP, ARNP, MBA, NEA-BC, FAAN Senior Vice President and Chief Nursing Officer NURSING
Carolyn Domina MSN, ARNP, CNOR, NEA-C Administrative Director Surgical Services NURSING
Edward Martinez MHA, CIO Senior Vice President & Chief Information Officer Administration
Martha McGill RN, MBA, MHA Executive Vice President & Chief Operating Officer Administration
Maureen Martin MBA Director of Financial Operations Finance
Anita Wilson MSN, RN, FHIMSS, CHCIO, CPHIMS Administrative Director, IT Clinincal Operations Information Technology
Jeff Friedman MBA Director Supply Chain and Contracting Materials Management
Nestor Ventura MHSA, MBA Surgical Services Business Manager Finance
Whitney Hopkins MBA Manager Technology The Healthcare Advisory Board Information Technology
Ruben Reinis BSN, MBA, RN Former Nurse Manager Surgical Services
William Riley BSN, RN Former Nurse Manager Surgical Services

Outcomes

Surgical Profitability Compass technology implementation was selected and advocated by Dr. Gonzalez yielding improved information for operational and strategic results within Surgical Services.  Dr. Gonzalez was able to influence members of SLT to make the investment that would enable Surgical Services to achieve operational results such as automating block time usage by surgeon, including turnover time, reviewing supply costs with comparative benchmarks. Refer to Appendix TL4B-4 to view a sample of a Surgical Compass OR utilization report. By utilizing these results since implementation in 2014, adjustments have been made to OR block based on actual time used versus on anecdotal information.  On a quarterly basis, surgeons receive a profile report including their use of block time, first case starts as well as turnover time.  By engaging surgeons with relevant information, Surgical Profitability Compass has allowed the OR nursing team to create movement with in the OR block schedule as well as improving overall efficiency within the OR over the last 3 years.  By 2015, the OR had achieved cost-savings of $338,468 with renegotiated contracting and reallocation and rightsizing of block time as shown in Appendix TL4B-5, a 2015 return on investment summary. The contract was renewed on October 21, 2016, due to its sustained success over the prior 3 year period.
 

References

Hsu, D.T & Pearson, G.D. (2009).  Heart failure in children: part 1: history, etiology, and pathophysiology. 
Circulation, 2(1), 63-70. 

Rossano, J.W., Kim, J.J., Decker, J.A., Price, J.F., Zafar, F., Graves, D.E.,...Jefferies, J.L.  (2012). Prevalence, morbidity, and mortality of heart failure-related hospitalizations in children in the United States:  a population-based study. Journal of Cardiac Failure, 18(6), 459-470.