Chapter 15: Disease-Site Reorganization;

Title

Chapter 15: Disease-Site Reorganization;

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Description

In this chapter, Dr. Balch focuses on the reorganization of patient care around disease sites and the creation of Rotary House, also an addition to patient care. He first sketches how Eva Singletary, MD and Gabriel Hortobagyi, MD [oral history interview] in Breast Medical Oncology asked patients to wear pedometers and discovered how far they were required to walk to circulate among the various specialists involved on their teams. He explains how this led to the decision to reorganize Breast Medical Oncology as the first multi-disciplinary breast center. He then talks about the building of Rotary House from funds from the Rotary Club and explains how it fit into Charles LeMaistre's vision of using hospital services for intensive and intermediate care. Next, he returns to the disease-site reorganization and explains how it led to specialization of the staff, cost-savings, and reduction in staff. Dr. Balch also notes that MD Anderson ran the largest pharmacy in the world, which could generate income that could be put back into clinical research for innovative therapy.

Identifier

BalchC_03_20181218_C15

Publication Date

12-18-2018

Publisher

The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; Leadership; Building/Transforming the Institution; Multi-disciplinary Approaches; Growth and/or Change; MD Anderson Culture; Professional Practice; The Business of MD Anderson; MD Anderson Impact

Transcript

T.A. Rosolowski, PhD:

What were the discussions like leading up to that reorganization?

Charles Balch, MD:

Well, actually, I know how it started. Eva Singletary and Gabe Hortobagyi [oral history interview] had worked together very closely, but they were in separate departments, and they worked in different locations. Eva Singletary actually put a pedometer on some of her patients. This is something where you can tell how many steps you walk, and what the distance is. And she brought the data to us, she and Gabe Hortobagyi, that my patients are walking almost a half a mile in one day, even though they're sick, or they may be suffering from their treatments, and checking into Surgery, Medicine, Radiation Oncology, Radiology, and Laboratory, five different places in one day. That's not very good for the patients. And it was actually their idea that the doctors should go to one place, and the patientsthe doctors should come to the patients instead of the patients coming to the doctors. That was a singular change in the mindset that we said, "All right, let's do that experiment, and we'll start out in breast cancer," formed the first multidisciplinary breast cancer that had been done, and it was such a success in that also at that time a lot of the specialty areas were working together collaboratively, but they weren't in the same geographic location.

T.A. Rosolowski, PhD:

So was this controversial, given the context?

Charles Balch, MD:

I wouldn't say so, because of the philosophy of care here that was multidisciplinary. And so even articulatingand also the service for the patients. So articulating that it's better for the patient if the doctors come to the patient, instead of the patients coming to the doctor; it's better for the patientit resonated with the medical staff. So I wouldn't say that there was a lot of resistance. There was a lot of logistics in reorganizing things, and, for example, in my personal practice I was taking care of breast cancer patients in melanoma. Those patients came to my surgery clinic, so the reverse for me, without a change in my time commitment, is I had to go to the Breast Center and the Melanoma Center, but I was fine about that if we worked out the scheduling for it. So the other thing that happened in the VP for Hospital and Clinics, and transitioning into the EVP, was buildings and fundraising. These were really big issues. I think during that time we raised 80 to 90 million dollars cash, and all of the funding that was necessary to build a new hospital, to build new radiation therapy, to build new clinical research facilities. And then another conceptagain, this was part of Mickey LeMaistre's visionwas to create a hotel for the patients. Most people don't remember that Mickey had money left over, and he built a bridge over Holcombe Boulevard that went nowhere. It was just over the street, because he had enough money. But he knew that at the other end of the bridge there was going to have to be a faculty building and a hotel, and it would need to be connected to a clinic that was not yet built. So we had the Lee Clark Building, that was being built when I came in 1985, but we had to raise the money and build what is now the LeMaistre Clinic, and then connect all of those with the overheads, including the bridge over Holcombe, which sat in isolation for at least five or six years, with everybody saying, "What is this bridge doing here that just goes over the street but doesn't go anywhere?"

T.A. Rosolowski, PhD:

I'm sure that people had some annoyed things to say about that.

Charles Balch, MD:

But he had a campus master plan in his mind, and he was a master at raising funds, so he got the Rotary Club in Houston to do the seed money for building this hotel for patients, and that's why it was called the Rotary House. He also had the wherewithal to say, "We're not in the hotel management business, so we'll contract with the Marriott Corporation to manage the hotel." So those were the partnerships that emerged to build the first version of the hotel, but he also had the vision that if this works we're going to run out of space, so we built in the original architectural plans a mirror image on the property that at the proper time you could double the size of the hotel, because the architectural plans and the groundwork was already done to do that. And, not surprisingly, the hotel had a 90-plus percent occupancy early on, and it wasn't too many years later that the money was put in place to double the size of the hotel. And this was --outside of the Mayo Clinic in Rochester-- was one of the first times that there'd been a hotel owned by a hospital that was connected to the hospital. When we opened the Rotary House, within the first week the length of stay in the hospital was reduced by a full day.

T.A. Rosolowski, PhD:

How did that happen?

Charles Balch, MD:

Well, because patients that you wouldn't send out of town, because they were too sick, were in the bed, but not needing nursing care, but it was okay for them to be across the street in our hotel. And so we actually reduced the use of the hospital beds and the care by nurses where patients' family could do the same thing, in feeding patients, in doing things, giving them their oral medications, and having them across the street, so that they could come to the outpatient area on a daily basis for their follow-up. And this really was the forerunner of day hospital, day care, outpatient basis. In many countries, even today, in the year 2018, the delivery of care is all in the hospital. When the care is given, the intravenous lines are out, but the patients are too sick yet to travel, they're too weak, they stay in your hospital bed, cared for by expensive nurses, sometimes for a week or more. So people were having hospitals with a thousand, two thousand, even more beds, but without a parallel outpatient area. Part of Mickey LeMaistre's strategy was to use the hospital for intermediate and intensive care patients, but to build an ambulatory network around that so that patients would not need to be cared for by nurses when they didn't need to, to train caregivers, and this was a formal program to train the spouses and family members to understand what to look for, and to participate in the care of the patients.

T.A. Rosolowski, PhD:

Who offered that training program?

Charles Balch, MD:

This was part of our volunteer network and our training by the nurses to give patients and their family members written instructions, such as measuring the amount of drainage, taking the temperature every eight hours, and writing it down so they could bring itand also if the drainage or the temperature exceeds this amount, call this number. So this was a very important part of taking care of the same volume of patients with a small number of hospital beds that other places in America and around the world were doing in a more expensive way with inpatient facilities. And even in Mickey's strategy, grand strategy to not only have it on the campus of the Texas Medical Center, but to allow patients in a more convenient way to be seen on an outpatient basis somewhere around Houston, such as in Clear Lake, where we started MD Anderson at Clear Lake, or even in other cities, like Austin, Corpus Christi, Fort Worth, Waco, and so forth, and even nationally or internationally, which we started in Orlando and Madrid.

T.A. Rosolowski, PhD:

The sister institutions, yeah.

Charles Balch, MD:

So this was all part of this grand vision for giving good care and exporting the quality of care and the standards of care outside of the Texas Medical Center, and reducing cost and improving the quality of care for patients by reducing the length of stay in the hospital.

T.A. Rosolowski, PhD:

I wanted to briefly go back to the period of doing the disease site centers, because you talked about some of the direct outcomes of some of these other changesputting in the hotel, reducing stays, all of that. What were some of the outcomes that you began to see with the multidisciplinary care sites?

Charles Balch, MD:

The outcome was so amazing, there were so many benefits that everybody saw immediately, that I think this concept was embraced pretty quickly. The biggest outcome that I think was a surprise was the specialization by the staff. The doctors were used to working together, but we had surgery nurses, medical nurses, we had research nurses, but they were off in separate parts of the organization, in physical therapy. Physical therapists specialized in surgical rehabilitation, but not lymphedema of the arm in patients with breast cancer. So what we found is when you have the multidisciplinary center, it's not just the doctors working together but the nurses, the staff, the physical therapists, the social workers, the volunteer patients, all specialized in one disease. Instead of being a surgical nurse that they might have to deal with routines of breast cancer, melanoma, GI cancers, and so forth, they really didn't have a chance to be super-specialized the way the doctors were. So that became very valuable and very efficient. We also found that the patients loved it, because in my surgery clinic if a patient relapsed and developed distant disease, the change in nurses, the change in location was more emotionally traumatic, or at least the same level as the fact that they had developed distant disease. They had to have a whole new set of nurses, a new location, they had to physically move somewhere else, whereas with the disease site center the doctors were caring for the same patient. The patient never moved out of that examining room. The nurses didn't change. There was a continuity of care that we didn't have with the specialty organized clinics that we received, and the patient saw the value of by having disease site specialization. That also allowed the patients in the waiting room, [who were?] the same patients in network together. And finally, the thing we found: we saved a lot of money. In fact, it was surprising, the reduction in costs. But think about it: before, a patient had to go to the surgery clinic. They checked in with a clerk. They go to the medicine clinics; they check in with a clerk. They go to all of those places, they have to check in again, whereas in the disease site center they check in with one clerk and they see one nurse, instead of seeing pieces of people based upon their specialty. And we found that we could reduce the staffing very significantly when we reorganized into the clinics, because of the efficiency of patients seeing one group of staff. So we reinvested that money back into infrastructure for more comprehensive care, such as physical therapy, social workers, clinical research nurses, and so forth.

T.A. Rosolowski, PhD:

Were there any downsides to either the specialization of individuals taking care of patients or to the reorganization itself? Anything that came up?

Charles Balch, MD:

No, only the resistance you always get in making changes, and not everybody benefits to the same degree as the champions who want to make the changes, but you can't do it halfway. You either have to make it all disease-oriented, or all specialty-oriented. So there was a little bit of resistance in some circles, but I wouldn't say it was very much, because the culture of the institution was about service to the patient, and if you're making these changes because it benefits the patients, people will rally around that, and make the adjustments to do it. One other thing that I might mention when I was the Director of Hospital and Clinics is we ran the largest pharmacy in the world. In the world. Roger Anderson[oral history interview, phase 1] was the most amazing director of the pharmacy. And, of course, because we could buy wholesale and we could charge at retail price for the insurance companies, our pharmacy became a very big source of profit. Roger ran this amazingly well. We started the first automated pharmacy with robots, to make sure that we had the dose correct and everything the same. But this was the first robotic pharmacy that had ever been done that he instilled. But also, because we knew that profit source, we put the profit of that back into the clinical research enterprise, because the innovative therapy was the reason that patients came. Most of that innovative therapy was more around new drugs, or different types of systemic agents, so it was logical if that's the reason patients come to use the profits from the pharmacy to reinvest it back into that part of the enterprise. And so if you're going to invest in clinical research, and there's a cost of research personnel and doing this, you have to have sources of money to do that, and the pharmacy profits were a very important source of doing that.

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Chapter 15: Disease-Site Reorganization;

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