Chapter 09: 
Learning Administrative Approaches by Leading the Myeloma Clinic

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Chapter 09: Learning Administrative Approaches by Leading the Myeloma Clinic

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Dr. Rodriguez begins this segment by explaining that the Myeloma Clinic was originally jointly managed with Transplant Leukemia services. She served as Clinic Chief of the Lymphoma/Myeloma Section from 1994−1996. Dr. Rodriguez explains what she learned from working in this environment of shared resources and how she acquired basic knowledge of how to assess patient volume and flow and determine hours of clinic operation. Next Dr. Rodriguez explains how the administrative issues shifted once the Myeloma Clinic became autonomous in 2003 and was stressed with challenged of internal utilization of resources. At this point she began her habit of writing reports to ensure transparency. (She notes that she used to have access to downstream revenue reports, but these have since disappeared.) She talks about the biggest lesson she learned at the time: how an individual’s work has an effect on the whole. As an example, Dr. Rodriguez explains that she became aware that the Myeloma Clinic was one of the biggest customers of the CT Scan Unit. She details how this effected operations of the CT Unit and had an effect on other services. She explains that this refined her thinking about how to strategize care delivery in an arena of low resources. Dr. Rodriguez also notes that most physicians tend not to see the big picture in which the deliver care and use resources; she gives examples of stresses to the system that can result. Dr. Rodriguez observes that she began to attend administrator education courses around this time. As an example of slow administrative development at MD Anderson, Dr. Rodriguez notes that she never filled out a for-service charge form until the 1990s. She talks about issues that arose once billing forms were introduced.

Identifier

RodriguezA_02_20150306_C09

Publication Date

3-6-2015

Publisher

The Historical Resources Center, Research Medical Library, The University of Texas Cancer Center

City

Houston, Texas

Topics Covered

The Administrator; The Administrator; Professional Path; MD Anderson History; Building/Transforming the Institution; Devices, Drugs, Procedures

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

Disciplines

History of Science, Technology, and Medicine | Oncology | Oral History

Transcript

Tacey A. Rosolowski, PhD:

OK, we are officially recording. And today is the 6th of March, 2016. The time is about twenty minutes after ten.

Alma Rodriguez, MD:

Two thousand and fifteen.

Tacey A. Rosolowski, PhD:

Two thousand and fifteen. What did I say?

Alma Rodriguez, MD:

Sixteen.

Tacey A. Rosolowski, PhD:

Oh, my gosh! That—I usually don’t do that one.

Alma Rodriguez, MD:

You’re time traveling.

Tacey A. Rosolowski, PhD:

(laughs) I know! I am time traveling. Thank you for catching that. And I’m on the eighteenth floor of Pickens Academic Tower today in the office of the Executive Vice President, talking my second session with Dr. Alma Rodriguez. So thank you very much for making time for me again today.

Alma Rodriguez, MD:

Not at all. Thank you.

Tacey A. Rosolowski, PhD:

And we strategized a little bit beforehand, and decided it would make a lot of sense to start now talking about your administrative experience. And I know that last time you mentioned your first experience with administration, which kind of let you know that you had a gift in that area. So if you could tell me about your next significant experience, which I believe was in 2005, you were Director of Clinical Investigation for Lymphoma/Myeloma?

Alma Rodriguez, MD:

Right. So, before getting to that—

Tacey A. Rosolowski, PhD:

OK.

Alma Rodriguez, MD:

There were several stages, if you will, in the evolution of the Lymphoma/Myeloma clinic.

Tacey A. Rosolowski, PhD:

Oh, OK.

Alma Rodriguez, MD:

Because initially, we were included in or jointly managed with leukemia and stem cell transplantation. We were a single, if you will, operational unit, and we shared resources. We shared space, nursing assignments, funding, etc. And it was very interesting, quite frankly, to be in an environment of shared resources where each one of the participants felt they were entitled to more than the other.

Tacey A. Rosolowski, PhD:

Huh. What did you, what did—

Alma Rodriguez, MD:

So, and this was a very—pardon me?

Tacey A. Rosolowski, PhD:

What did you learn from that experience? \

Alma Rodriguez, MD:

Well, what I learned from that experience was that one had to be very well-prepared, first of all, in understanding the fundamentals of how resources are allocated and distributed, according to need. So you had to—so I learned how to assess patient volumes, patient flow, how to assess nurses to Physician ratios, hours of operation, etc. And being well-informed certainly lends credibility to one’s claims on, or requests for, resources. And that’s a very fundamental principal in operations. You have to justify cost for the operation.

Tacey A. Rosolowski, PhD:

And just to refresh the memory of the listener, this would have been when you were Medical Director of the lymphoma section?

Alma Rodriguez, MD:

Correct.

Tacey A. Rosolowski, PhD:

From 2000 to 2003.

Alma Rodriguez, MD:

Well, it was even earlier than that—

Tacey A. Rosolowski, PhD:

Oh, really? OK.

Alma Rodriguez, MD:

—when we were still joined. Now, we were eventually, if you will, divorced, or separated. Each of the clinics was then separated, which then comes to the period of 2000 to 2003 when we are our own freestanding clinic.

Tacey A. Rosolowski, PhD:

Oh, OK. So the joining that you were talking about had always—I mean, that was pretty much how it was conceptualized.

Alma Rodriguez, MD:

Mm-hmm. Mm-hmm.

Tacey A. Rosolowski, PhD:

In that joint operation.

Alma Rodriguez, MD:

But as we were the separated, and each of us were allocated our own resources, it was interesting because there’s always—at every level, there are different challenges. So now it was not so much paying attention to how we competed, if you will, for resources with the other two groups, but in fact it was the competition within the group. I want to work with this nurse, I want my clinic on these days.

Tacey A. Rosolowski, PhD:

Right.

Alma Rodriguez, MD:

You know, I do not want to be here on Fridays—so the process then became more one of analyzing internal utilization; how is work distributed internally within our own work group? By this time we were a much larger operation, as well within lymphoma.

Tacey A. Rosolowski, PhD:

How had it grown in terms of faculty numbers and provider numbers?

Alma Rodriguez, MD:

I can’t tell you the exact numbers. But we certainly—I can tell you by this time, we had probably nearly doubled the number from when—way back when, we had been joined with leukemia and stem cell transplant, which is one of the reasons why the three clinics were separated, because the operation had gotten so large. It was not possible to efficiently manage all three together. And so in internal resource management, people are much closer to you, if you will. So it becomes necessary to be far more transparent. So I began to create reports that would display how many patients were seen by each of the providers, what their clinic days were. Back in those days, we would also be provided with sheets of downstream revenue that the whole clinic had generated, and at some point, those disappeared, and I’m not sure why. But it used to be that we would know how many—you know, what the revenue to lab, what the revenue to diagnostic imaging and the chemotherapy areas had been from our referrals to those areas, or generating, if you will, business for those areas, for lack of a better word. How many x-rays we ordered, how many chemotherapy cases we had treated, and so on. So it was a learning period for me as well, obviously, in that I began to understand then the effect that the work of individual has on the whole. I mean, we, in essence, like all other clinics, we were driving downstream benefits and work and workload. So, for example, we became aware that we were one of the biggest customers, again for lack of a better word, of the CT scan unit, I mean patients with lymphoma for staging purposes require that you image the entire lymphatic system. So we had to do CT scans from head or neck, thorax, body. And so we were a big customer of theirs. So we then began to ask that they participate more actively in helping us to plan and strategize for the growth of the clinic. If we’re going to generate so many—if we’re going to be asked to increase the number of new patients that we’re seeing by so many percents, what is that going to mean for CT scans? And if you can’t manage that volume, what are we going to do? So, for example, sometime in this period of time, somewhere in this period of time, there were not enough CT scan machines in the organization to handle the volume that not just us, but the entire clinical operation was generating for diagnostic imaging. So we had to think of alternatives, such as negotiating with St. Luke’s at the time. They had started to build some of their external or ambulatory CT scan units. If we send our patients there, will you send us the reports in a timely fashion? How will we communicate with you? So thinking strategy for care delivery under stress of low resources, I mean, that’s very challenging. And that was another learning point for me.

Tacey A. Rosolowski, PhD:

Yeah, after we turned off the recorder last time, you were saying that every time you reached another administrative level, you realized that you were operating in an entirely different institution. And I—

Alma Rodriguez, MD:

Correct.

Tacey A. Rosolowski, PhD:

—can kind of see how this is an example of that.

Alma Rodriguez, MD:

Correct.

Tacey A. Rosolowski, PhD:

And you’d just seen an entirely new—it’s like putting a different lens up to the Institution.

Alma Rodriguez, MD:

Correct. Correct.

Tacey A. Rosolowski, PhD:

Yeah.

Alma Rodriguez, MD:

And, you know, being in that particular scenario, for example, of the CT scanners, understanding who else needs the CT scanners, the sarcoma, thoracic, GI service—you know, understanding how the other services whose clinical work demands that they also have access to the same imaging resources makes one aware of how we’re not the only fish in the pond, if you will.

Tacey A. Rosolowski, PhD:

Right.

Alma Rodriguez, MD:

And I can tell you that the individual Physician providers do tend to be very ingrown, if you will, and view the world only as within the boundaries of their own life. Like I said, you know, it can get fairly—it can get into a sibling rivalry situation, almost, where people are competing for the same day, or I want to work with Nurse So-and-So, well, so do I. So-and-so is my mid-level provider, well, I want to work with them, too. You know. And so, the management and distribution of work internally, but then also proceeding how the internal work affects the external operation of the organization. That was an important learning curve for me. Also, sometime around this time, and I have to look at all my different diplomas, some of which are hidden by now, were put away. I attended so many administrative educational courses this time to learn more about operations, to learn more about how budgets are done, how forecasting of business is done, how or why third party payers view services rendered, why documentation is so important, why the appropriate billing structure was so important. I know that it astonishes many people when I tell them that when I first arrived at MD Anderson, we didn’t even drop bills. We never filled out a charge form, ever. As a Physician, I never saw a charge form, probably until the ‘90s, the late ‘90s, the mid to late ‘90s. We became aware that, oh my gosh, we get paid for what we do! (laughs) And we introduced the billing forms, and oh my God, you would have thought that this was a revolution. People were not used to seeing those forms, so they conceived of that as just more added paperwork. And then even within the forms, the rules about how we were reimbursed changed, and you had to explain the complexity of the visit. And there were rules about how you calculated the complexity, etc. So there have been many evolutionary changes that have occurred.

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Chapter 09: 
Learning Administrative Approaches by Leading the Myeloma Clinic

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