5250 Old Orchard Road Skokie, Illinois 60077 Comanche County Hospital Authority Enterprise...

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Comanche County Hospital AuthorityEnterprise Strategic Plan 2009–2013

November 18, 2008

Angus Cameron Ricky Garcia

Benjamin KlineGreg Scrine

Contents Project Overview

Market and Organizational Assessment

Demand Forecast

Facilities Forecast

Strategic Priorities

Confidential and Proprietary © 2008 Sg2 3

Project Team

Sg2

Angus Cameron Regional Vice President, Client Engagement Lead

Greg Scrine Senior Vice President, Consulting Lead

Ricky Garcia Consultant, Project Manager

Benjamin Kline Senior Analyst, Project Analyst


Project Objectives and Phases Project Objectives:

Build a collaborative management and physician organizational five-year vision and consensus-driven set of strategies

Develop a strategic plan that identifies the requirements necessary to build successful clinical programs and informs the master facilities plan

Project Phases: Phase I – Develop current state assessment and demand forecast Phase II – Evaluate opportunities and formulate strategic plays Phase III – Develop and refine strategic plan



Demand Forecast

Facilities Forecast



CCHA Service Area and Institution Locations

Southwestern Medical Center

Reynolds Army Community Hospital

Lawton Indian Hospital

Duncan Regional Hospital

Jackson County Memorial Hospital

Comanche County Memorial Hospital

Note: Hospitals marked outside of PSA have more than 45 bedsSources: CCHA; Sg2 Analysis, 2008.

Sayre Memorial Hospital

INTEGRIS Clinton Regional Hospital

Pauls Valley General Hospital

Grady Memorial Hospital

Great Plains Regional Medical Center

Elkview General Hospital

Wilbarger General Hospital

33+ Hospitals in Greater

Oklahoma City

United Regional Health, North Texas – Wichita Falls Campus, Red River, HealthSouth Rehab and Wichita Valley

Primary Secondary


6%

5%

11%

30%

10%

-7%

-6%

7%

17%

0%

00-17

18-44

45-64

65-UP

Overall

23%25% 23% 24%

36%37%35% 38%

26%24%26%

25%

15%14% 16% 13%

2007CCHAMarket

(PSA/SSA)

18-44

45-64

65+

00-17

Population Distribution by Age CohortCCHA Market (PSA/SSA) 2007–2017

Sources: Claritas; National data from Third Wave Research; Sg2 Analysis, 2008.

% Change in PopulationCCHA Market (PSA/SSA) 2007–2017

CCHA Market (PSA/SSA)

National

2017

National

100% = 313K 313K 302,383K 331,658K

CCHA Market Population Will Remain Flat

2007

National

2017CCHAMarket

(PSA/SSA)


0

25,000

50,000

75,000

100,000

125,000

Comanche County Baseline BRAC - Direct Military BRAC - Non-Military

Comanche County Population Growth with BRAC Impact, 2007-2017

Population

* See Figure 4-1: Population/Employment Summary on next slideNote: Comanche County Baseline data from Claritas.Sources: Claritas; Lawton / Ft. Sill Growth Management Plan: Impacts Due to BRAC; Sg2 Analysis, 2008.

Comanche County Will See Population Growth Due to BRAC

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Baseline 111,348 111,111 110,875 110,640 110,405 110,170 110,021 109,872 109,723 109,574 109,426

Direct Mil. - 245 489 734 978 1,223 1,468 1,712 1,957 2,202 2,446

Non-Mil. - 517 1,034 1,551 2,068 2,585 3,102 3,620 4,137 4,654 5,171

Total 111,348 111,873 112,399 112,925 113,451 113,978 114,591 115,204 115,816 116,429 117,043

=(17,881-14,701)*13

=(73,753-67,031)*13

10 Year Growth: 5%


Greater than 51

26 to 50

11 to 25

Population Density, 2007 (pop. / sq. mile)

6 to 10

1 to 5

Sources: Claritas; Sg2 Analysis, 2008.
















Note: CCHA discharges are from CY 2007; market and market share data is from CY 2006; analysis excludes DRG 391.Sources: CCHA; Oklahoma State Department of Health; Sg2 Analysis, 2008.

CCHA Inpatient Market Share (PSA/SSA)

Several of the Service Area’s Largest Markets Remain Virtually Untapped

26%

46%

57%

7%

8%

2%7%

15%

2%

17%

23%Overall CCHA Market Share =

CountyCCHA

DischargesMarket

DischargesCCHA

Mkt. Share

Comanche 6,804 11,461 57%

Stephens 727 6,411 10%

Jackson 445 5,328 7%

Grady 94 5,102 2%

Caddo 730 4,352 17%

Kiowa 312 2,271 15%

Washita 25 2,033 2%

Tillman 414 1,482 26%

Harmon 65 1,379 7%

Jefferson 122 1,023 13%

Greer 50 943 8%

Cotton 447 690 46%

Overall 10,830 42,475 23%

10%

13%


Service Line Outmigrators % OutmigrationCY 2006 Market

DischargesWhere Are They Going?

Cardiovascular 2,376 33% 7,1751. INTEGRIS Baptist MC (672)2. Oklahoma Heart Hospital (663)

Women's Health 1,715 28% 6,1771. Oklahoma University MC (628)2. Norman Regional Hospital (179)

Orthopedics 1,555 37% 4,2001. McBride Orthopedic Hospital (378)2. Oklahoma Spine Hospital (215)

Cancer 941 37% 2,5451. Oklahoma University MC (300)2. INTEGRIS Baptist MC (195)

Pulmonary 797 18% 4,4901. INTEGRIS Baptist MC (141)2. Oklahoma University MC (107)

General Medicine 772 16% 4,9071. INTEGRIS Southwest MC (168)2. Oklahoma University MC (73)

General Surgery 742 32% 2,3131. INTEGRIS Baptist MC (160)2. Oklahoma University MC (147)

Gastroenterology 659 19% 3,5421. INTEGRIS Baptist MC (181)2. Oklahoma University MC (73)

Neurosciences 650 27% 2,4331. Oklahoma University MC (73)2. Norman Regional Hospital (188)

Other 2,189 30% 7,2381. Oklahoma University MC (166)2. Great Plains Regional MC (69)

Total 11,455 27% 42,4751. Oklahoma University MC (2,113)2. INTEGRIS Baptist MC (1,799)

CCHA Market (PSA/SSA) Inpatient Outmigration by Service Line, CY 2006

Notes: Outmigrators defined as patients residing in CCHA’s service area and receiving care outside the service area; Other includes Nephrology, Endocrine, Psychiatry, Oncology, Urology, Hematology, Otolaryngology, Thoracic Surgery, Injury, Trauma; Cancer volumes are flagged at the ICD9 level and are therefore double counted in this analysis / Sources: Local market data provided by Oklahoma State Department of Health; Sg2 Analysis, 2008.

Over One-Fourth of the Overall Market is Seeking Care Outside of the Service Area


Greater than 500

101 to 500

11 to 100

6 to 10

CCHA Outpatient Origin, CY 2007

1

2

3

4

5

6

7

8

9

10

Note: Outpatient origin excludes visits.Sources: CCHA; Sg2 Analysis, 2008.

0 to 5

×

CountyCY 2007Volumes

Origin Distribution

Comanche 69,801 67%

Stephens 7,228 7%

Caddo 5,435 5%

Jackson 3,843 4%

Tillman 3,694 4%

Cotton 3,395 3%

Kiowa 2,182 2%

Jefferson 1,051 1%

Grady 975 1%

Harmon 485 0.5%

Greer 435 0.4%

Washita 198 0.2%

Outside 5,928 6%

Grand Total 104,650 100%


Sources: CCHA; Sg2 Analysis, 2008.

CountyCY 2007

DischargesOrigin

Distribution

Comanche 6,804 63%

Caddo 730 7%

Stephens 727 7%

Cotton 447 4%

Jackson 445 4%

Tillman 414 4%

Kiowa 312 3%

Jefferson 122 1%

Grady 94 1%

Harmon 65 1%

Greer 50 0.5%

Washita 25 0.2%

Outside 595 5%

Grand Total 10,830 100%

Greater than 100

51 to 100

11 to 50

1 to 10

CCHA Inpatient Origin, CY 2007

×

1

2

3

4

5

67

8

9

10


Geographic Attractiveness Drivers Absolute Population Growth Population Density Average Household Income Average Household Healthcare Expenditures

Geographic Attractiveness Drivers Absolute Population Growth Population Density Average Household Income Average Household Healthcare Expenditures

Source: Sg2 Analysis, 2008.

Decision Scale

Lev

el o

f A

ttra

ctiv

enes

s

0 to 8

33 to 40

25 to 32

17 to 24

9 to 16

×

10 Miles
















23%

57%

10%17% 15%

26%

11%

31%

5%

5%4%

10%

15% 5%

23%

5%

4%

7%

22%

4%

39%

16%

75%

45%

24%

15%7%

9%

3%

16%

10%

75%

12%

62%10%

5%

10%33%

9%

46%

6%

5%

9%

4%

6%

5%

6%

5%

7%

4%5%5%

51%

10%

Overall Comanche Stephens Jackson Grady Caddo Kiowa Washita Tillman Other

Other

OU Medical Center

Integris Baptist MC

St. Anthony Hospital

Harmon Memorial Hospital




Jackson County Memorial

Southwestern MC

CCHA

Inpatient Market Share (PSA/SSA) by County, CY 2006

Mkt. Discharges: 42,475 11,461 6,411 5,328 5,102 4,352 2,271 2,033 1,482 4,035

Notes: Analysis excludes DRG 391; Other includes Harmon, Jefferson, Greer and Cotton; Values less than 4% not labeled.Sources: Local market data provided by Oklahoma State Department of Health; Sg2 Analysis, 2008.

CCHA Has a Stronger Presence in Collar Counties

Anadarko and

Carnegie (22%)

Memorial Hospital (41%)

Majority to Greater OK City

Great Plains and INTEGRIS

Clinton (40%)


23%29% 28%

24% 20% 23% 19%

11%6% 10%

11%13%

19%

13%

12% 11%13%

9%8%

10%

13%

10% 7%

11%

10%9%

7%11%

7%

5%4%

4% 9%8%

4%5%

10%

5%

12% 7% 4%

22% 24%16%

30%19% 21% 21%

5% 4%

5%4%4%

Overall Cardiovascular Women's Health Orthopedics Cancer Neurosciences Other

Other

OU Medical Center

Integris Baptist MC







Southwestern MC

CCHA

Inpatient Market Share (PSA/SSA) by Service Line, CY 2006

Mkt. Discharges: 42,475 7,175 6,177 4,200 2,545 2,433 22,490

Notes: Analysis excludes DRG 391; Cancer volumes are flagged at the ICD9 level and are therefore double counted in this analysis; Values less than 4% not labeled.Sources: Local market data provided by Oklahoma State Department of Health; Sg2 Analysis, 2008.

CCHA Maintains a Leadership Position in Highly Fragmented Market


Inpatient Market Share (PSA/SSA) by Subgroup, “Other” Category, CY 2006

22% 24%16%

30%

19% 21% 21%

0%

10%

20%

30%

40%

Other Institutions Market Share

Rank OverallCardio-

VascularWomen’s

Health Orthopedics CancerNeuro-

sciencesOther

1. Oklahoma Heart Hospital, 2%

Oklahoma Heart Hospital, 9%

Norman Regional Hospital, 3%

McBride Clinic Ortho Hospital, 9%

Mercy Health Center, 5%

Great Plains Regional MC, 3%

Memorial Hospital and Phys. Group, 2%

2. Mercy Health Center, 2%

INTEGRIS Southwest MC, 2%


Oklahoma Spine Hospital, 5%



Physicians Hospital of Anadarko, 2%

3. Great Plains Regional MC, 2%

Carnegie Tri-County Hospital, 1%






4. Memorial Hospital and Phys. Group, 2%


Lakeside Women's Hospital, 1%

Community Hospital, 2%

Deaconess Hospital, 1%



5. INTEGRIS Southwest MC, 1%


Weatherford Reg. Hospital, 1%





6. Carnegie Tri-County Hospital, 1%


INTEGRIS Canadian Valley, 1%

Bone and Joint Hospital, 1%




Sources: Oklahoma State Department of Health; Sg2 Analysis, 2008.

Specialty Hospitals in Oklahoma City Are Drawing Significant Inpatient Volumes


57%62%

75%

51% 48% 50% 53%

31% 24%

19%

27% 34%41% 36%

5%

5%

9%4% 4%

5%14%

5% 4%11%

Overall Women's Health Cardiovascular Orthopedics Cancer Neurosciences Other

Other

OU Medical Center

Integris Baptist MC







Southwestern MC

CCHA

Inpatient PSA (Comanche County) Market Share byService Line, CY 2006

PSA Discharges: 11,461 1,960 1,679 1,213 719 714 5,895

Notes: Analysis excludes DRG 391; Cancer volumes are flagged at the ICD9 level and are therefore double counted in this analysis; Values less than 4% not labeled.Sources: Local market data provided by Oklahoma State Department of Health; Sg2 Analysis, 2008.

A Majority of Comanche County Cases Stay at Home

9% to orthopedic specialty hospitals


Sg2 Innovation Adoption Categories

Innovators 1

Develop and test new approaches Invest in research/development at an early stage Initiatives often cited at national meetings and in journals

Early Adopters

2

Seek to be the first in their market to adopt new technologies Adopt before broad-scale clinical trials are complete and/or reimbursement is secure Often report on the first widespread use of a particular technology

Consensus Adopters

3

Focus on technologies that are generally accepted and broadly available in their market

Adopt new approaches after several years of reports at national meetings

Cautious Adopters

4

Lag behind organizations of similar size in adoption of mature technologies Are slower to adopt new technologies due to a variety of factors, including capital

constraints, staff limitations, local consumer behavior and organizational priorities

Late Adopters

5

Characteristically have outdated technology and systems Often do not incorporate technology planning into strategy and future development

decisions Often are skeptical of new technologies

1 2 3 4 5Innovators Consensus LateEarly Cautious


1 2 3 4 5

Cancer

Cardiovascular

Imaging

Neurosciences

Orthopedics

Surgery

Clinical Services & Technology Adoption Profile: Summary

Innovators Late Adopters

Sources: Sg2 STEP™ On-line; Sg2 Analysis 2008.

= Current CCHA Position = Proposed CCHA Position


There is Medical Staff Succession Risk in Key Clinical Areas

31%25%

48%

57%

42%

41%

23%

69%

45%

38%

57%

29%

57%50% 50%

33%

50%

50%

31%

18%

58%29%

27%

63%

29%

14%

50%

18%25%

14%18%25%

12% 12%

50%29%

50%

62%

9% 15%

57%

9% 14%

67%

61+

51-60

35-50

00-34

Medical Staff 186 51 26 17 13 13 11 8 7 7 7 6 6 6 4 4

Note: Medical staff includes MDs, DOs, PAs and ARNPs; Not all subspecialties included.Sources: CCHA; Sg2 Analysis, 2008.

Age Distribution of Medical Staff at CCHA, 2008



Demand Forecast

Facilities Forecast



Economy

Technology

Sociocultural Factors

Payment

Population

Consumerism

Care Delivery

Sg2’s Impact of Change® Forecasting Model

Facility Needs Beds Procedure rooms ORs Ancillaries Etc.

Strategic Forecast

OperationalForecast

OutpatientVolumes

InpatientDischargesand Days

BaselineUtilization Outpatient Shift Impact of Change®

2008–2018


Inpatient Discharges Will Remain Flat Over the Next Decade

Note: Analysis excludes DRG 391.Sources: Sg2 Impact of Change® v7.0; Sg2 Analysis, 2008.

10,500

10,700

10,900

11,100

11,300

11,500

2007 2009 2011 2013 2015 2017

CCHA Institution Inpatient Discharges, CY 2007 – CY 2017

Population-Based Forecast

Sg2 Forecast 0%

Discharges

CCHA CY 2007 CY 2017 % Change

Discharges 10,830 10,847 0%

Patient Days 54,599 50,875 (7%)

ALOS 5.04 4.69 (7%)

3%


91

78

77

117

120

293

1,206

1,033

424

1,406

619298

750

1,110

428728

236

1,127

0%

10%

20%

30%

40%

50%

60%

70%

-30% -20% -10% 0% 10% 20% 30% 40%

EPSSpine

CAD

PCI

CHF

Arrhythmia

DiagnosticCath

Vascular - Surgical

CABG

Joint

Gyn

Breast

Lung

Prostate

Neurological

DigestiveSystem

Kidney &Urinary Tract

Fracture - Surgical% Market Growth,

CY 2006-16

Market Share, CY 2006

Clinical Prioritization Matrix – Market Share & Forecasted Growth by Key Service LineInpatient Market Share and Forecasted Discharge Growth by Subspecialty, CCHA

Notes: Refer to Appendix for Subgroup definition.Sources: CCHA and Oklahoma State Department of Health; Sg2 Analysis, 2008.

Bubble size reflects 2007 Market discharges

Cancer

Cardiovascular

Orthopedics

Overall Forecasted Market Growth: 2%

OverallCCHA Market Share: 23%


9178

77

1,127

236

728

428

1,110

750

298

619

1,406

424

1,033

1,206

120

117

$0

$3,000

$6,000

$9,000

$12,000

-30% -20% -10% 0% 10% 20% 30% 40%

EPS

Spine

CADCHF

Arrhythmia

DiagnosticCath

Vascular - SurgicalCABG

Joint

Gyn

Breast

Lung

Prostate

Neurological

Digestive System

Kidney & Urinary Tract

Fracture - Surgical

% Market Growth, CY 2006-16

CM/Case, CY 2007

Clinical Prioritization Matrix – Contribution Margin & Forecasted Growth by Key Service LineInpatient CM/Case and Forecasted Discharge Growth by Subspecialty, CCHA

Notes: Refer to Appendix for Subgroup definition.Sources: CCHA and Oklahoma State Department of Health; Sg2 Analysis, 2008.

Bubble size reflects 2007 Market discharges

Cancer

Cardiovascular

Orthopedics

Overall CCHA CM/Case: $4,629

463

CM/Case: $15,875

PCI

Overall Forecasted Market Growth: 2%


Outpatient Institution Volume Growth Will Outpace a Population Based Estimate

CCHA Institution Outpatient Volumes, CY 2007 – CY2017

102,000

105,000

108,000

111,000

114,000

2007 2009 2011 2013 2015 2017

Volumes

CCHA CY 2007 CY 2017 % Change

Volumes 104,650 111,352 6%

Sources: Sg2 Impact of Change® v7.0; Sg2 Analysis, 2008.

Population-Based Forecast

Sg2 Forecast

6%

4%


A Number of Clinical Groups Will See Outpatient Procedural GrowthOutpatient Procedure Ten Year Growth Rates by Clinical Group, CCHA Institution (CY 2007– CY 2017)

7% 7%

3%

15% 16%

4%

17%

-6%

9%

-2%

6%

-10%

-5%

0%

5%

10%

15%

20%

25%CCHA

CCHA OverallInteg-ument

Cardio-vascular

Musculoskeletal

Cancer GIEndo-crine

GYN Urinary Nervous Other

CY 2007 Volumes 7,190 1,893 1,653 1,080 805 748 609 579 258 125 245

Absolute Change 478 123 55 164 129 33 103 (34) 23 (3) 14

*Excludes visits; Analysis includes major and intermediate procedures only.Note: Cancer does not sum to Overall.Sources: Impact of Change® v7.0; Sg2 Analysis, 2008.

% Growth


CT and MRI Will Show the Strongest Volume Growth Among All Modalities

Outpatient Imaging Ten Year Growth Rates by Modality,CCHA Institution (CY 2007– CY 2017)

8%

38%33%

-2%

10%

-20%

4%

-30%

-10%

10%

30%

50%

CCHA

CCHA Overall CT MRI X-ray US SPECTNuclear Medicine

CY 2007 Volumes 48,554 8,638 3,876 28,943 5,532 898 667

Absolute Change 3,999 3,260 1,267 (620) 241 (179) 29

Advanced Imaging Standard Imaging

*Excludes visits.Sources: Impact of Change® v7.0; Sg2 Analysis, 2008.


CCHA Should Expect Growth in Chemotherapy and Radiotherapy

12%

20%CCHA

CCHA Radiotherapy Chemotherapy Interventional Oncology

CY 2007 Volumes 7,698 677Procedures include thermal ablations, catheter-delivered

therapies, endoscopic approaches and energy-based

therapies.Absolute Growth 942 138

Outpatient Cancer Radiation and Chemotherapy Ten Year Growth Rates, CCHA Institution (CY 2007 – CY 2017)

Sources: CCHA; Sg2 Impact of Change® v7.0; Sg2 Analysis, 2008.

28%

Sg2 National Forecast



Demand Forecast

Facilities Forecast



The Transformation of the Hospital

Capital and Labor Information and Logistics

Health System Market Maker

• Physicians organize around capital

• Physicians bring patients

• Local monopolies

• Hospital stay is the center of care

• Long stay, large nursing input

• Municipal finance model

• Physicians organize around patient

• Physicians own patients

• Competition Hosp-Hosp & Hosp-Doc

• Hospital stay is one element of care

• High service intensity, knowledge worker

• Corporate finance model


Vision Elements

Capacity constrained

Comanche county focused

Community hospital

Fragmented physician community

Financially constrained (8% EBITDA margin)

Available capacity to support growth

Multi-county focused

Regional referral center (selected services)

Cohesive and sustainable physician community

Financially sustainable (12% EBITDA margin)



Evolve the Medical Group Platform


Enhance Capabilitiesin Core Clinical Programs

Enhance Capabilitiesin Core Clinical Programs

VisionCreate Capacity in Key Facility Areas

Create Capacity in Key Facility Areas

Create a Culture of Ownership & Accountability

Create a Culture of Ownership & Accountability

1

23

4


Strategic Priority #1:

Evolve the Medical Group PlatformStrategic Objective

Evolve the essential physician platform to foster the ongoing renewal (succession planning) and growth (incremental new physicians) of the CCHA medical staff

Rationale

The current economic model is unsustainable and threatens the long term viability of the CCHA organization

A robust and sustainable physician group model is an essential strategic asset to CCHA and a requirement for continued growth of local programs and services

The creation of an organizational core competency in the recruitment and development of CCHA-aligned medical staff is essential to retention and growth of market position


Strategic Plays Targets Timeline Accountability

1. Evolve the CCHA Medical Group model: Include as a department of CCHA Develop physician leadership and governance Migration to productivity based compensation Design agenda to include:

Growth orientation Patient experience Clinical quality Succession planning and recruiting Economic sustainability

Model Developed(Y/N)

Model Substantially Implemented

(Y/N)

End of Q3CY 2009

End of Q4CY 2010

TBD

2. Invest in physician leadership development: Identify potential physician leaders for development Invest in physician leadership education Dedicate time, resources and funds for program

Program / Services

Developed (Y/N)

End of Q4CY 2009

TBD

3. Enhance CCHA’s in-house recruiting capability: Develop lifestyle proposition package Design call-burden management program and

communication materials Develop alternative physician sourcing channels (e.g.,

physicians with local ties) Employ dedicated physician recruiter

Program / Services

Developed (Y/N)

Physician Recruiter

Employed (Y/N)

End of Q4CY 2009

End of Q4CY 2009

TBD





Overcoming Barriers to Group Evolution

There is no alternative…the current economic model is unsustainable and threatens the organization’s viability

Compensation by specialty unit avoids cross subsidies (e.g., ortho w/ ortho)

Keep clinician admin time light, just enough to act as one strategic unit

Give physicians a real stake in practice operations and capital decisions

Can’t move to productivity based comp without losing physicians

Internal group cross specialty subsidies don’t work…

Bureaucratic admin structure wastes productive clinical time…

Physician collaboration ends up just being social…

Barriers Paths Forward



Comanche Medical Group Strawman

Comanche County Hospital Authority

Board of Directors


CAO and EVP CCHA

Comanche Medical Group

Exec Dir and EVP CCHA

Management Council Physicians and Admin Represent Practice Units Specific Admin Compensation

Practice Units

UnitOrtho

UnitNeuro

Unit Others

Etc

President & CEO



Federation Group Model

Shared Services Physician leadership, administrative and staff Billing Purchasing

Shared Responsibilities Proactive operations and efficiency Overhead expense management Capital spending

Specialty 1

Economic Unit

Comp

Specialty 2

Economic Unit

Comp

Specialty 3

Economic Unit

Comp

Specialty n

Economic Unit

Comp

Practice Performance Comp Pool

Confidential and Proprietary © 2008 Sg2


Create Capacity in Key Facility AreasStrategic Objective

Create capacity to enable program growth in selected areas

Rationale

Profitable volumes currently leave the CCHA market to go to other providers and the ability to accommodate certain attractive case types is critical to achieving financial sustainability

40



1. Develop highly efficient case management program, key elements include:

Model design Role definition Resource management and staffing Data management tools and reporting

Capabilities Developed

(Y/N)

End of Q2CY 2009

TBD

2. Establish comprehensive CHF program (See Cardiovascular Section)

Clinic Operational

(Y/N)

End of Q2CY 2009

TBD

3. Evaluate the current surgical and interventional platform:

Cath lab scheduling, prep and recovery care model

Surgical capacity and case mix

Evaluation Complete (Y/N)

End of Q4CY 2009

TBD

4. Evaluate campus master plan and facility optimization: Use of McMahon-Tomlinson Nursing Center Current bed configuration


End of Q4CY 2011

TBD

5. Evaluate off campus or freestanding business model potential:

Imaging services Ambulatory surgery and endoscopy services


End of Q4CY 2011

TBD


Create Capacity in Key Facility Areas

41


CCHA Bed Need Forecast WithBRAC Impact and ALOS Reduction

Bed Type

Days

2007 – 2017% Change

Actual Beds2008*

Projected Beds2017

∆ Beds2007 – 2017

(Deficit)/Surplus

CurrentOccupancy

2007 2012 2017

Med/Surg 32,620 29,276 29,038 (11%) 139 124 15 64%

ICU 4,146 3,698 3,650 (12%) 12 11 1 95%

CCU 1,624 1,460 1,451 (11%) 8 7 1 56%

CVCU 4,897 4,185 3,967 (19%) 16 13 3 84%

Bed Need Forecast, CY 2007 – CY 2017, Current Occupancy

Bed Type

Days

2007 – 2017% Change

Actual Beds2008*

Projected Beds2017

∆ Beds2007 – 2017

(Deficit)/Surplus

TargetOccupancy

2007 2012 2017

Med/Surg 32,620 29,276 29,038 (11%) 139 99 40 80%

ICU 4,146 3,698 3,650 (12%) 12 12 0 80%

CCU 1,624 1,460 1,451 (11%) 8 5 3 80%

CVCU 4,897 4,185 3,967 (19%) 16 14 2 80%

Bed Need Forecast, CY 2007 – CY 2017, Target Occupancy

* Staffed bed count as of 2008.Note: ALOS reduction targets 0.5 day decrease in ALOS by 2012. This 0.5 day decrease is maintained from 2012-2017.Sources: CCHA; Sg2 Analysis, 2008. 42


CCHA Ancillary Need Forecast WithBRAC Impact

Modality

Current Utilization Target Utilization

FY 2008 Units

FY 2008Encounters

%Growth ’08-’18

IPNeed

OP Need

FY 2018 Total Need

IPNeed

OP Need

FY 2018 Total Need

(Deficit)/Surplus

CT 3 9,608 34% 1.0 3.0 4.0 0.4 0.9 1.3 1.7

MRI 2 4,216 35% 0.3 2.4 2.7 0.1 1.3 1.4 0.6

U/S 5 10,044 10% 1.6 3.9 5.5 1.3 3.2 4.5 0.5

X-Ray (Fixed) 6 31,419 5% 1.5 4.8 6.3 1.3 4.1 5.4 0.6

Mammography 2 5,143 12% 0.0 2.2 2.2 0.0 1.7 1.7 0.3

SPECT/NucMed 3 3,038 10% 0.8 2.5 3.3 0.6 2.0 2.6 0.4

Imaging Forecast, FY 2008 – FY 2018

Procedure Rooms

Current Utilization Target Utilization

FY 2008 Units

FY 2008Encounters

%Growth ’08-’18

IPNeed

OP Need

FY 2018 Total Need

IPNeed

OP Need

FY 2018 Total Need

(Deficit)/Surplus

ORs 10 6,858 7% 3.1 7.6 10.7 2.4 6.0 8.4 1.6

Cath Lab 2 2,755 9% 0.5 1.7 2.2 0.4 1.3 1.7 0.3

GI Lab 3 3,858 11% 0.3 3.0 3.3 0.2 2.0 2.2 0.8

Procedure Room Forecast, FY 2008 – FY 2018

Sources: CCHA; Sg2 Analysis, 2008.43


Strategic Priority #2: Case Management Program Development Case Management Model Design

Standardize processes, establish protocols for accountability, and develop productivity standards Develop and facilitate implementation teams focused on communication, operations, clinical

practice and desired program outcomes Role Definition

Complete detailed role analysis to determine the correct skill mix of RN case managers and medical social workers

Define roles and responsibilities of the medical staff, CM medical director, case managers, medical social workers and nursing staff during the admission, concurrent review and discharge phases of care

Resource Management and Staffing Realign existing FTE resources and hire additional support as appropriate to achieve outcomes Provide clinical mentoring of case management staff in their new roles (e.g., discharge planning,

clinical care coordination, physician collaboration, insurance contracts and payment operations) Implement a case manager education plan to define best practice improvement opportunities

and strategies for physician involvement Data Management Tools and Reporting

Implement reporting tools to assist case managers and departmental staff in efficiently managing patients with the redesigned model

Implement a daily supervisory tool for coordination and accountability of case management resources

44


Example: Analysis of LOS Opportunity by Physician


Case Management

Cases include all attending physicians; GMLOS = geometric mean length of stay; ALOS index = physician ALOS divided by GMLOS.Sources: General Hospital ; Sg2 Analysis, 2008

Greatest Potential for

Targeted High-Volume,

High-ALOS Physicians

Average

GMLOS

Discharges

AL

OS

In

dex

Area of Best Practice0.0

0.5

1.0

1.5

2.0

2.5

3.0

0 100 200 300 400 500 600 700

45


Strategic Priority #3: Enhance Capabilities in Core Clinical ProgramsStrategic Objective

Enhance the scope and capabilities of selected clinical services to retain more cases locally, garner new cases from the broader market, fully leverage branding and differentiation opportunities, and facilitate long-term durable patient relationships Cardiovascular Orthopedics Spine Cancer

Rationale

Clinical capability strategic initiatives are focused on cardiovascular, orthopedics, spine and cancer; these are key areas of disease burden, market demand and financial viability, as well as service expectations from the Lawton community

Building clinical programming will require significant time and effort; limiting the number of priority areas in the short-term, and slowly expanding over time, improves the likelihood of success

Capital and organizational focus limitations preclude broad-based investment in and focus on all clinical programs



1. Obtain National Society of Chest Pain Centers accreditation

Accreditation Acquired (Y/N)

End of Q2CY 2009

TBD

2. Form Chest Pain Network and expedited referral channels with nearby hospitals:

Establish concierge service (one call transfers) Focus on Duncan, Altus and Hobart area hospitals

Network Established (Y/N)

End of Q4CY 2009

TBD

3. Develop a comprehensive CHF clinic Clinic Operational

(Y/N)

End of Q2CY 2009

TBD

4. Develop formalized stroke program: Obtain JCAHO stroke center certification Establish protocols with outlying hospitals Become preferred EMS destination for stroke

Program Established (Y/N)

End of Q4CY 2009

TBD

5. Develop the EMS channel: Identify opportunities to develop and strengthen

relationships with market area squads Develop comprehensive regional plan for STEMIs

with regional hospitals Develop protocols for staff

EMS Program Established (Y/N)

End of Q2CY 2010

TBD


Cardiovascular



6. Establish cardiology clinic(s) in key market(s): Stephens County – 73533 (Total of 734 CV

Discharges and 15% Market Share) Medical Cardiology - 431 Cardiac Surgery - 55 Interventional & EP - 150 Vascular - 98

Stephens County – 73055 (Total of 246 CV Discharges and 23% Market Share)

Medical Cardiology - 138 Cardiac Surgery - 13 Interventional & EP - 51 Vascular – 44

Clinic(s) Operational (Y/N)

End of Q2CY 2010

TBD

7. Develop electrophysiology capabilities: Recruit fellowship-trained EP Implement EP lab

Capabilities Developed (Y/N)

End of Q4CY 2010

TBD

8. Invest in direct-to-consumer and direct-to-physician media campaign

Marketing Plan Implemented

(Y/N)

End of Q4CY 2010

TBD


Cardiovascular



1. Recruit three orthopedic surgeons – one surgeon to serve as service line champion

Three Orthopods Recruited (Y/N)

End of Q4CY 2009

TBD

2. Pursue aggressive cost management on implants via a request for proposal process

RFP Process Complete (Y/N)

End of Q4CY 2009

TBD

3. Enhance and promote the total joint replacement program: Expedite work up to procedure process Adopt aggressive quality initiative (eliminate “never” events) Optimize referring physician communications Create a patient follow up program Develop leading communication and education materials

Program Developed (Y/N)

Marketing Plan Implemented (Y/N)

Total TJR Discharges:

600

End of Q2CY 2010

End of Q3CY 2010

End of Q4CY 2010

TBD

4. Enhance and promote the sports medicine program: Accelerate diagnosis process (e.g., MRI to scope to

treatment) Evaluate additional opportunities to partner with area sports

teams (e.g., “after work” leagues, high school and college teams)

Provide directed promotion and education for all athletic organizations

Market sports medicine offering directly to patients via internet and print communication channels



End of Q2CY 2011

End of Q3CY 2011

TBD

5. Explore an affiliation with McBride Orthopedic Hospital: Recruitment Others to be identified


End of Q4CY 2011

TBD


Orthopedics



1. Develop a comprehensive spine/back pain program, components include:

Imaging and diagnostics Surgery Physical and occupational therapy Pain management and rehabilitation


End of Q2CY 2011

TBD

2. Invest in direct-to-consumer and direct-to-physician media campaign

Marketing Plan Implemented

(Y/N)

End of Q3CY 2011

TBD

3. Pursue aggressive cost management on implants via a request for proposal process

RFP Process Complete (Y/N)

End of Q4CY 2009

TBD


Spine

50


Revenue/Patient

Strategic Priority #3: Comprehensive Spine Care Provides Multiple Revenue Opportunities

Back Pain: 80% of the Population

450K780K

13.7Mvisits

39M hours

3.2M

10.3M

PT/OT = physical therapy and occupational therapy; CAM = complementary and alternative medicine.Sources: MedPac, 2005; Sg2 Analysis, 2008.

7.2M4.1M

$43–$724$349–$506

$405–$1,238

$333–$632

Avg. $5,041

$405–$1,238

Patient Diagnostics X-Ray MR

Noninvasive Treatments PT/OT CAM

Percutaneous Procedures Spinal

InjectionsSurgery IP OP

Rehab

Volume

51



1. Expand market penetration in core tumor type areas (breast, colorectal, lung and prostate) by:

Increasing community screening efforts in colonoscopies, mammographies and DRE/prostate-specific antigen tests

Creating focused marketing and awareness campaign around tumor specific services

Outreach Initiated (Y/N)


End of Q2CY 2009

End of Q2CY 2009

TBD

2. Establish a patient-focused service model that accomplishes positive breast screening to diagnosis in less than 5 days:

Communicate positive screening within 24 hours Complete ultrasound and additional views within 24 hours Perform biopsy within 24 hours Obtain pathology report within 24 hours

Process Executed in Less Than 5

Days

End of Q2CY 2009

TBD

3. Develop breast reconstruction capabilities: Consider training general surgeon in oncoplastic surgery Explore relationship with OK City based plastic surgeon

Training Evaluated (Y/N)

Relationship Explored (Y/N)

End of Q2CY 2009

End of Q2CY 2009

TBD

4. Aggressively promote thoracic surgery capabilities across the region through outreach activities and continuing education


End of Q2CY 2009

TBD

5. Recruit pulmonologist and dedicated female breast surgeon Physicians Recruited (Y/N)

End of Q4CY 2010

TBD

6. Migrate endoscopy procedures to the ambulatory setting Migration Complete (Y/N)

End of Q4CY 2010

TBD


Cancer



7. Prepare to consolidate urology services from: Ft. Sill Duncan Altus

Ft. Sill Succession Plan Completed

(Y/N)

Duncan and Altus Succession Plan Completed (Y/N)

End of Q2CY 2009

End of Q4CY 2010

TBD

8. Employ leading technologies to differentiate the center’s diagnostic capabilities:

Breast MRI PET/CT

Technologies Implemented (Y/N)

End of Q4CY 2010

TBD


Cancer



Oncoplastics TrainingObjective Consider training a general surgeon in oncoplastic techniques to augment their

technical capabilities and increase patient satisfaction

Definition Oncoplastic surgery combines cancer surgery (e.g., lumpectomy) with cosmetic techniques; it is aimed mainly at women with early-stage breast cancer

Oncoplastic surgeons are trained in plastic surgery techniques that preserve or restore a breast’s shape or appearance

Advantages/Benefits

Allows breast cancer patients to reduce the number of times they are operated upon and expedites psychological recovery

Can benefit patients who need a mastectomy by helping their bodies prepare for subsequent reconstruction

Training in oncoplastic techniques can assist cancer surgeons in managing a shortage of reconstructive surgeons

Physician Training

There is currently no professional certification for oncoplastic techniques Introductory oncoplastic training is offered by the following organizations:

American Society of Breast Surgeons – sponsors introductory course at annual meeting; provides sessions on surgical assessment and techniques

The American Society of Breast Disease – holds 3-day “School for Oncoplastic Surgery” in Texas, including a session at the cadaver laboratory at Baylor Medical Center

Intensive training is needed for more complicated procedures, such as reconstruction using artificial implants



Oncoplastics Training

Price - $1,475


Strategic Priority #4: Create a Culture of Ownership & AccountabilityStrategic Objective

Create a cohesive team with the motivation, skills and collaborative spirit enables CCHA to execute operationally and strategically while making the organization the preferred employer and physician partner

Rationale

Establishing a sense of pride and commitment among all CCHA associates is foundational to the ability to execute as an organization

A positive and cohesive culture where employees and physicians have pride in “wearing the CCHA jersey” is essential to attracting and retaining the best people



1. Develop and roll out performance objectives and metrics tied to the organization’s Strategic Priorities:

Capacity creation Physician Platform evolution Clinical program development Culture development

Established (Y/N)

End of Q1CY 2009

TBD

2. Determine whether to pursue Nursing Magnet Designation Evaluation Completed

(Y/N)

End of Q2CY 2009

TBD

3. Establish CCHA Leadership Development Academy: Craft tenets and “CCHA Leadership” guiding principles Identify candidate selection criteria for all staff levels Allocate funds and resource to manage program Identify external resources to support program

Program Implemented

(Y/N)

End of Q4CY 2010

TBD

4. Instill an organizational focus on cost and resource efficiency: Focus on improving cost/reimbursement ratio Develop improved reporting system of

inpatient/outpatient (IP/OP) Medicare cases using ratios of costs to charges

Set organizational contribution margin goals for high volume Medicare case types

Establish a reporting system to provide regular enhanced reports to physicians

Program and Processes Developed

(Y/N)

End of Q2CY 2009

TBD

Strategic Priority #4: Create a Culture of Ownership & Accountability



5. Revise and refine associate selection process: Develop a standard and CCHA ideal Training for managers in employee selection Develop standard interviewing process

Processes Operational (Y/N)

End of Q1CY 2009

TBD

6. Develop standardized communication materials for all new associates and physicians: Welcome video Revise orientation package

Materials Developed (Y/N)

End of Q2CY 2009

TBD

Strategic Priority #4: Create a Culture of Ownership & Accountability

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