Chapter 14: A Physician in Chief's View on Strategic Planning: Successes and

Chapter 14: A Physician in Chief's View on Strategic Planning: Successes and ""Stumbles""

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Description

In this chapter, Dr. Buchholz offers his views on the institution's strategic planning process he participated in once he assumed the role of Physician in Chief [in 2014] and joined the Executive Committee. One priority, he explains, was to shift MD Anderson into a more patient-centered perspective in recognition that several dimensions of patient experience directly affect treatment outcomes. In response to a question posed from a ""cynical perspective,"" that treating patients like customers is really about making money, Dr. Buchholz talks about how gratified he feels helping patients. He notes that the institution has made headway in addressing the aspects of patient experience the Executive Committee identified as priorities.For contrast, Dr. Buchholz discusses the lessons learned from a transition that did not go as smoothly as planned: centralizing the process of securing healthcare authorization for treatments.

Identifier

BuchholzT_02_20180131_C14

Publication Date

1-31-2018

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; MD Anderson Culture; Institutional Mission and Values; The Business of MD Anderson; Survivors, Survivorship; Patients, Treatment, Survivors; Human Stories; Offering Care, Compassion, Help; Patients; This is MD Anderson; Understanding the Institution; The Institution and Finances; Professional Practice; Critical Perspectives on MD Anderson

Transcript

Tacey Ann Rosolowski, PhD:

And we are recording, and it’s about three minutes after 10:00, and I’m at the home of Dr. Thomas Buchholz for our third session together. Today is March 8th, 2018, and, for the record, I’m Tacey Ann Rosolowski. And thank you so much.

Thomas Buchholz, MD:

You’re welcome.

Tacey Ann Rosolowski, PhD:

You retired on the 28th of February.

Thomas Buchholz, MD:

I did, yeah, after a twenty-and-a-half-year career.

Tacey Ann Rosolowski, PhD:

Yes, though it’s not going to be true golfing and eating bonbons, right? (laughs)

Thomas Buchholz, MD:

Well, that’s true. Yeah, on April 16th I start my new job.

Tacey Ann Rosolowski, PhD:

Oh, it is, okay. April 16th, yeah. So that’s a little bit—like, five weeks?

Thomas Buchholz, MD:

I know.

Tacey Ann Rosolowski, PhD:

Six weeks? That’s exciting.

Thomas Buchholz, MD:

I know. Thank you. I’m excited.  

Tacey Ann Rosolowski, PhD:

Yeah. Well, we were going to talk a little bit today. We’re going to talk a little bit more about your role as Physician-in-Chief, and I guess a question that—I mean, you may have a list of things in your mind that you’d like to address, and I guess a thing that occurs to me is that you were serving as Physician-in-Chief during a time of turbulence. And how did that manifest itself? Or did it? Maybe it didn’t. Maybe the operating issues you had to deal with would have come up at any time. But at any rate, that just sort of occurred to me.

Thomas Buchholz, MD:

There was—yeah, it was a period of significant turbulence, and significant institutional change, all at the same time. I may have mentioned when Dr. DePinho asked me to be Physician-in-Chief I had to think about it a long period of time—a couple months, in fact—because I had experienced some of that turbulence. And I didn’t feel completely empowered to make the turbulence go away. Somehow, as a division head and department chair I felt as if I was ultimately responsible for the culture of our group, and it was a defined group of people that is academically defined and structurally defined. And I felt kind of as the leader of the group that you really are empowered to do that. With the Physician-in-Chief role, I became part of an executive team, and ultimately didn’t have that same level of empowerment to shape the entire culture of the organization, because it was the team responsibility, one that was ultimately the responsibility of the president. So clearly that was a change, and I think that was one of the struggles. Now, the Physician-in-Chief scope of MD Anderson is, at that time, very vast.

Tacey Ann Rosolowski, PhD:

Yeah, you were mentioning that—I mean, I thought it was interesting; you said you had underestimated the job grossly. (laughter)

Thomas Buchholz, MD:

Yeah. And part of the excitement for me was the ability to take on some very important issues for the institution’s health, for the institution’s wellbeing, for our patients, ultimately.

Tacey Ann Rosolowski, PhD:

What were some of those issues?

Thomas Buchholz, MD:

Well, again, I may have mentioned I came in at the time where we were undergoing a strategic plan, which was a fantastic opportunity for me to work with the collective institution, and define what are the most important issues surrounding patient care. I’d always been proud to be a member of the most outstanding multidisciplinary-focused team of oncologists and supporting care providers, and yet there were still some aspects that were particularly around the patient experience that can actually translate into worse outcomes, too.

Tacey Ann Rosolowski, PhD:

What are some of those issues?

Thomas Buchholz, MD:

Like the inability to get into the institution. Important one, right? Our degree of success cannot just be measured from the time that the patient gets in. It has to be measured from the time that access starts. So someone reaches out to us to receive care at MD Anderson, is a great candidate for care at MD Anderson, but never comes to MD Anderson, it’s kind of a failure on MD Anderson’s part. And I think that shifts the focus, and the doctors don’t think of that because they never meet the patient, and that’s really an organizational, administrative hurdle that had confronted MD Anderson for some time, and that’s called patient access. And patient access was a real trying thing. Patient financial health: we don’t want patients to become bankrupt because of performing procedures that weren’t preauthorized. We don’t want our institution to not have the resources to put back into our wonderful education and academic missions, because we don’t get paid for the work that we do. So there’s some nonmedical, social, economic issues that really affect outcomes that we could provide as a community. So patient access, and then patient experience, too. How can we enhance what it’s like to be a patient? Patients love their providers. We have a tremendously caring environment. But it’s not uncommon for patients to be sitting in waiting rooms for extended periods of time. It’s not uncommon to see people with 12-hour days at MD Anderson, where if it was run more efficiently they could be in and out. It’s not uncommon to have sometimes have seen the patient not be the first consideration, but other parameters, whether they’re institution or physician-related, sometimes took hold. And so shifting our culture to become more patient-centric was a major goal of not just mine, but a recognition within our institution as a way that we need to move forward.

Tacey Ann Rosolowski, PhD:

Now, let me ask you, because there are a lot of cynical people who see health organizations going in this direction, and they’re saying, well, we’re treating the patients more like customers and consumers, and it’s really money-driven. I mean, what do you say to people like that, who have that mindset?

Thomas Buchholz, MD:

I’d say listen in to the numerous calls that I have with people reaching out to MD Anderson for help. One of the greatest roles that I was able to play as Physician-in-Chief was to be an individual ambassador for our clinical care. And obviously, with the number of 140,000 patient visits, I should not be putting my efforts as Physician-in-Chief into helping each one of those visits go smoothly. But yet, countless times I called people trying to get into the institution that are kind of referred from a Board of Visitors, or referred... And the gratitude and the assurance that people have is one of the most rewarding things you could do. These are real human moments. There’s such a power of being told you have cancer, or the feeling of helplessness, and even if the appointment’s not for a week, to have an assurance that, okay, we got this, and we have a plan, someone cares, someone tells me we’re going in the right direction, someone has given me an opportunity to come, instead of being approached to say, “Oh, we might be able to get you appointment. We have to review your pathology first. Can you go find your pathology slides?” The patients don’t even know what the term “pathology” means, and feel all of a sudden a lack of empowerment. They’re trying. They go to their referring physician, who oftentimes doesn’t want to lose the case to MD Anderson, and is going to put up barriers, and people feel trapped, and they feel helpless. And you only have to talk to one person to recognize the power—there’s no cynicism in this. This is really helping people at a time of sometimes the most critical psychologically important need for them. And it’s very much in keeping with our core value of caring. And it’s tremendously rewarding. You really are forever remembered in these people’s lives as a really important person who helped them at their hour of greatest need. So I think we have to be focused in this. Now, I kind of get customer service, right? We’re not going to be a back of the yellow pages cosmetic dentist or cosmetic plastic surgeon who has most beautiful waiting room, and serves tea while you’re waiting, because we’re going to have it all focused on economic rewards for the institution. I think that where we want to be is to help people in their journey for cancer, and to do it in the way that provides the best outcome for them, outcome meaning medical outcome—that’s the most important; outcome meaning survivorship; outcome meaning the patient experience; outcome meaning financial outcome. The whole package. And we have to look at that in totality, and prioritize it. If you don’t prioritize it, there’s going to be competing priorities. I’m on the MCI Breast Cancer Steering Committee. We have conference calls. Sometimes those conference calls are right in the middle of my clinic. I’m not going to choose an equally important thing to just say, “Oh, don’t worry about it. The patient can wait.” Or am I going to choose to figure out a system that really affords us to do both? Am I going to say, “I want all my patients to come and be scheduled at 8:00 in the morning,” because one time a patient didn’t show and I was there doing nothing from 8:15 to 8:30, and it was a real downtime, so that can never happen again? So all my patients come at 8:00, and there’s never an interruption in my schedule, but unfortunately that means someone else is being seen at 11:00, because there’s a whole bunch of patients waiting until their time comes up, and they’ve had to wait three hours. So it’s choices like that that our providers probably don’t recognize, because you’re just working your tail off, going room to room. And we have to have that administrative expertise, that system operational expertise, to really facilitate that care for the patients, but we also have to have an agreement that this is an important tenet that we’re trying to achieve. And I think we are able to make headways in that. We are able to come up with—strategic plan really helped that. We had a plan about access. We had a plan about patient flow. We had a plan about enhancing the efficiency by which we work, through prefilling out a lot of data, through not being duplicative, and that leads to the Epic implementation of getting an electronic system that works for both the patient and the provider to deliver more efficient care. So we did a lot of transformative things. Sometimes in the long run they’re good; in the short term there’s a lot of pain, and there’s a lot of stumbles, and there are things that—mistakes are made. And it’s quick to say, “Let’s go back to the old way.”

Tacey Ann Rosolowski, PhD:

What were some of the learning moments? I mean, I think it’s always interesting to look at those moments, that, ooh, there was a stumble here, but look what we learned, and hanging in there was worth it.

Thomas Buchholz, MD:

I think one of the biggest feelings of stumbling—we wanted to move to centralization and sharing of services, and one of the first ones we did was with financial authorization, which used to be controlled at a local level.

Tacey Ann Rosolowski, PhD:

What does that—meaning?

Thomas Buchholz, MD:

Meaning that we have 37 disease site centers, and they were run by 37 center administrative directors. And oftentimes, some of these were run even within departments, if they weren’t multidisciplinary. So some of the hematology ones, where there’s just medical oncology, a lot of the medical oncology department administrators would be involved. And they would have to get authorization. There were kind of governing sets of rules. But the reporting structure was fragmented within the context of authorization. Each reported to their own CAT or department administrators. They weren’t brought together in one way of doing things. And healthcare authorization’s get—it’s just dynamic. It changes monthly. It’s complex. Across the institution, we might be calling Blue Cross Blue Shield of Texas for 15 authorizations. If you have 15 people calling across the institution at the same time to get these 15 authorizations, it’s much less efficient than if one person calls and gets—Blue Cross Blue Shield gets 15 authorizations. So just that structure was recognized that it needed to change, but we moved this from the clinical arena into the finance arena, and we were partnering with the people who really knew healthcare authorization. These are the people who interact, who negotiate our contracts with the healthcare authorization, whose job and responsibility is to know this space, and as the space becomes increasingly complex it’s hard for any individual distributed person to have the same expertise. So I think there was an agreement that that was kind of broken, and it’s not just a self-recognition at MD Anderson. The people from Epic were saying this. The people from Ernst & Young, who were consulting about best healthcare practices, everybody’s reaching the same conclusion, for us to be more efficient, to eliminate revenue loss through bad debt, or procedures done that weren’t authorized and not paid for, or financial hardship for patients that were getting stuck with bills for unauthorized procedures. There had to be a different system. And I think it’s done remarkably well now in the long term, but as it got started we were pulling people who had this expertise from the distributed system into a centralized person. And when you had someone with content expertise now supervising someone, they found a whole variety of skillsets, some of whom were fantastic, some of whom they were saying, “Whoa, I can’t believe this has been happening for five years.” So there was a variety of education that needed to get started. It soon became clear that we didn’t build up the center with the—over-resource the center so that everything would go smoothly. There was still a feeling as if how come my person’s not right here next to me. This isn’t working. It’s much less efficient. They would used to say, “This isn’t authorized.” I’d say, “Well, it’s medically necessary, (snaps) and we’ll take care of it down the road sometime.” Now we’re getting a sense that the physicians sometimes were feeling, well, who runs this? I’m the doctor, and we can’t have administrative roadblocks to giving care. And that’s, I think, the importance of change management, and having physician leaders, like a physician-in-chief, who really gets the medical aspect, to have department chairs and physician leaders and executive medical directors distributed to be peers with this, and can understand and say, “Well, I get what you’re saying, but I’m sorry, we work in the United States healthcare system. We do. It’s crazy sometimes, but these are the steps that we have to take. And if we just shortcut them every time, we’re going to be worse off. The patient’s going to be worse off. And we’re just going to have to deal with the frustrations of our modern healthcare system.” So there were a lot of—I think the lesson learned from that was we really stumbled a little bit, and I think we didn’t fully anticipate what we would find when we brought everybody together, and in doing so didn’t have—we didn’t adequately resource it. They suddenly kind of uncovered, like, wow, look at the backlog of things that we have to do, and look at the people we have to be doing it. And it took, not surprisingly, some time to really make headway in there. And it got to be, unfortunately—it stumbled enough that there was kind of this archival memory that wouldn’t go away. There was always the antidote from, well, three months ago we had this case where we had to cancel the surgery because it wasn’t authorized. Those stories, once they’re out there, are hard to change, and we should’ve been more anticipatory to help, and probably resourced it in a different fashion, and really be... I think what happened wasn’t really shocking, right? It could’ve been anticipated, and it could’ve been better prepared for. And we could’ve been through mock scenarios, like disaster planning, to help say what are we going to do when this happens. Let’s do an exercise, a mock planning. We go live with this financial clearance center, and here’s the responses we’re getting. How are we going to react to that? Are we sure? Because this could be a real setback. In Epic, we did that.

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Chapter 14: A Physician in Chief's View on Strategic Planning: Successes and

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