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Navigating Expansion, Growth,
and Change
Annual Community Health Institute
May 9-11, 2012
Resort & Conference Center of Hyannis
Hyannis, Ma
Terry Glasscock Senior Project Consultant, Capital Link
Cindy Barr, RN, EDAC Operations and Facilities Planner, Capital Link
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MLCHC May 2012
Presented by:
Terry Glasscock, Senior Project
Consultant, Capital Link
Navigating Expansion, Growth and Change Navigating
Expansion, Growth and Change
Part I: Financial Impacts
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There Is A Difference
• Growth (Internal/External)
– Creating Growth
– Managing Growth
– Sustaining Growth
• Expansion (Internal)
– Result of Growth • Un-served need
• New services
• Change (External)
– Another animal altogether
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Growth/Expansion
Growth creates Expansion
Expansion creates Growth
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Growth
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What Creates Growth?
• Population
• Public policy changes
• Age demographics
• Immigration
• Economy
• Service choices
• Marketing
• Location
• Facilities
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Growth is Necessary
• Expenses grow regardless of revenue growth
– Personnel (70% of expenses)
– Occupancy costs
– Utilities, supplies…etc.
– Practically all expenses increase regardless of revenue.
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Implications of Growth Before Expansion
• Indicators of need are mostly operational – Visits/provider
– Stagnating patient growth (counter intuitive)
– Wait times
– Requests for unoffered services
– Cindy Barr
• Financial indicators – Stagnating patient revenue
– Stagnating operating revenue
– Rising personnel costs v. total revenue
– Declining operating margin
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Implications of Growth After Expansion
• Patient Revenue increase: 20% to 35%
• Personnel expense increase
• Accounts receivable increase
• Accounts payable increase
• Manage your cash flow
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Expansion Considerations
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Out Growing Your Facilities?
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Expansion: Financial Implications
• Project Costs – Build v. lease
– Site
– Design
• Financing – Debt servicing cost – Fund raising
– Reserves
– Grants
– NMTC, HTC, USDA, Conventional loans, TE Bonds
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Expansion: Financial Implications
• Productivity improvement – Visits/provider
– Pharmacy
– Cross services
• Patient Revenue – More patients
– Payer mix?
• Operating expenses – Interest expense increase
– Depreciation increase
– Occupancy expense (increase?)
– Rent decrease?
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Change
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Change Ahead for CHCs
– Health centers will feel caught between the ongoing fiscal challenges from state and federal governments and the imperatives for growth by health care policy.
– How serious is it?
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International Monetary Fund
• The US must either increase taxes immediately and permanently by 60% or decrease Medicare and Medicaid benefits by 50% to avoid collapse of the programs.
• Why?
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Number of Workers Per Retiree
5
4.5
4
3
2
0
1
2
3
4
5
1990 2000 2010 2020 2030
OECD - Organization of Economic Cooperation and Development
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0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
% of GDP
3% 6%
15%
25%
1900
1964
1994
2020
Healthcare as % of GDP
18
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Medicaid
Medicare
02468
1012
141618202224
1990 2000 2010 2020 2030 2040 2050 2060 2070
Social Security
Social Security, Medicare , and Medicaid
Outlays as a Percentage of GDP 1990-2075
Source: C. Eugene Steurle and Adam Carasso, (Budget Crisis at the Door), The Urban Institute, 2003. Based on data
from the Congressional Budget Office, “A 125-Year Picture of the Federal Government’s Share of the Economy, 1950-
2075,” July 3, 2002, table 2.
19
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Federal Receipts vs. Entitlement Spending
0
2
4
6
8
10
12
14
16
18
20
22
1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040
Baseline SS, Medicare, and Medicaid
Baseline receipts (includes JGTRRA)
Return to 2002
Continue at same rate
Source: C. Eugene Steurle and Adam Carasso, (Budget Crisis at the Door), The Urban Institute, 2003 Based on data
from Budget of the U.S. Government, FY 2004 and CBO’s “Analysis of the President’s Budget, FY 2004.”
(As percent of GDP)
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Successful centers will be the ones who are willing to take risk in an uncertain environment and who have a well-founded plan to manage the downside risk
The need for rapid growth will likely advantage health centers that have already achieved a certain level of scale.
Active smaller centers that are less sophisticated will also be trying to get in the game
Managing Growth is Essential
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Part Two:
Tips for Making a Successful Transition
Presented by: Cindy Barr
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From Concept to Reality
Strategic Facility Planning
Site Selection and Control
Design Development Secure Financing
Construction
Operational Readiness Financial Readiness Staff Development
Tools Development
Process Development
Patient Preparedness
Community Preparedness
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From Concept to Reality
Operational Readiness Financial Readiness
Construction Complete
Activation of New Site Deactivation of Old Site
Equipment/Furnishings/Support Systems
Moving Process
Opening Day
Celebrations
Honeymoon Phase
Cucumber Phase
Full Activation
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The Five “W”s
What is Operational Transition Planning?
Taking your health center from how it functions today in the environment in which you live -
To how it will function, on a daily basis, in the environment which you are creating.
"We shape our buildings; thereafter, our buildings shape us." – Winston Churchill
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The Five “W”s
When do you start preparing for Transition?
As soon as you have:
• Secured a Site
• Signed your Construction Documents
• Secured your Financing
Or, now!
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The Five “W”s
Who leads the Operational Transition?
The Facility Planning Team who went through the Design Development Process.
• They have credibility with the staff
• They know the rationale for decisions
• They know the differences between “now” & “then”
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The Five “W”s
Where does Transition Planning Take Place?
At the Team Level:
• To own their success – or failures
• To define their day-to-day reality
• To participate in developing staff
At the Management Level:
• To define the Staffing Plan
• To allocate appropriate resources
• To coordinate team efforts
• To lead community preparedness
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The Five “W”s
Why commit resources to transition planning?
Your facility is only a tool.
$ - Capital financing only pays for the tool.
Ongoing operational cost must be covered by full, effective utilization of that tool.
- The curiosity factor is short-lived.
Sustained growth is built on good first impressions.
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The Faces of Operational Transition
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The Project is Real!
Quickly Engage Staff -
– Celebrate - at the new site!
– Confirm inclusion (How do I fit in?) –
Describe how the new site will be organized.
– Role out pilot projects
– Schedule demonstration equipment/furnishings
– Initiate a photographic timeline
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The Transition Work Begins
The Work of the Planning Team
– Provide accurate and timely communication
– Manage pilot projects; define new processes
– Confirm fixtures, furnishings and equipment
– Prepare Staff – Train-to-Retain Plan
Recruitment Plan
– Monitor the Internal Timeline
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Validate Staff Readiness …
Train-to-Retain Plan
– Are job descriptions altered as needed?
– Have all competencies been confirmed?
– Have new team compositions been defined and team building exercises completed?
Recruitment Plan – Have new hires been identified, trained and integrated?
Scenario Building – Have you defined and practiced team-based and
facility-wide “what-if” scenarios?
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Validate Staff Readiness …
Cheerleaders and Nay-Sayers
– Have you identified informal leaders and inserted them appropriately into the moving process?
– Have you met with Team Leaders to explore their fears and concerns? Have you familiarized them with the new building?
Consensus Building – Have you confirmed the operational objectives and the
timeline for meeting them?
– Have you reviewed the patient-focused design decisions and how to actively support their success?
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Moving Day!
Tips for Making It Go Smoother
Communicate Clearly and Consistently:
– Define team areas (zones) by color
– Define spaces using construction document #s
– Label all equipment & furnishings to be moved to the new space with space # on a zone colored label
– Label purchase orders with zone color & space #
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Moving Day!
Tips for Making It Go Smoother
Define a Process Timeline and Stick To It:
– Define deliveries, set-ups in order of occurrence
– Adjust schedule by the process not the clock
– Have Team Leads on-site in new spaces
– Have Planning Team on-site in old spaces
– Have Planning Team Lead on-site in new spaces
Don’t forget the Food!
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Celebrations!
Tips for Making them Effective
Build Momentum with Variety - Celebration Week
Schedule a variety of events
Align them with the community culture
Post all events – with defined target audience
Stay focused on two objectives:
Staff confirmation and encouragement
Community exposure and attachment
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The Honeymoon
Fully enjoy it!
It only happens once!
It is all about the expectations!
It is over too quickly!
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When the Honeymoon is Over …
Moving to the Sidelines –
“Nobody asked us!”
You remember you did – but it is all a blur!
– Enlist the Process Historian
to gently but assertively take staff on a
“Remember when Journey”
Key Peer Process Recommendation
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When the Honeymoon is Over …
Loss of Control –
“This will never work!”
– Acknowledge changes that have happened that will require alteration in the original plan.
– Incorporate the Two Week Rule from college.
– Encourage productive problem solving.
– Encourage patients to share their experiences.
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When the Honeymoon is Over …
Digging in the heels –
“I can’t ... We won’t!”
– Acknowledge fear of future demands.
– Acknowledge the post-adrenaline effect.
– Be alert to the comfort of old habits.
– Don’t inform – dialogue.
– Celebrate small steps toward long-term goals.
Be alert: Serious staff division is possible…
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Effectively Moving Forward
Reassemble the Planning Team
Acknowledge and discard disappointment
Incorporate new staff leaders
• Do a “clean slate” assessment of your space -
Capture the power of the Pilot Project
• Refocus the Staff -
Create a new Common Goal
• Reengage the Community -
Launch an Exposure Campaign
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Effectively Moving Forward
Assemble the Leadership Team
Act Decisively,
Quickly,
Confidently – and Collaboratively
– Communicate daily
– Monitor financials closely
– Continue recruitment
– Foster accessibility
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Travel Alerts from Your Peers
When the Facility is not “All Done”
When IT Utilization is not “Up to Speed”
When Recruitment is not “Successful”
When Staffing & Design are not “Aligned”
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When It is Not “All Done”
Carefully and Consistently Communicate:
Funded Phasing
vs.
Unfunded Phasing
vs.
Potential Expansion
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Challenges of Unfunded Phasing
The Operational Reality:
Flow patterns through the building will not work as smoothly encouraging “jury-rigging”.
“Interim” work zones will not function as smoothly because function now follows form.
Operational Goals may not have been adjusted!
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Done
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When Technology Lags Behind
The Dance between IT and Facility
is best led by IT.
Define the use of technology – by patients and staff - during Design Development.
Transition to Electronic Records at least three months prior to activation of the new site.
Train staff – software, hardware, equipment –
prior to activation of the new site .
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When Recruitment Lags Behind
Between concept and reality, things change!
The inability to recruit key positions (competition, environment, credibility)
The inability to absorb the initial cost of new staff positions (cash flow)
The inability to guarantee projected growth (risk vs. opportunity)
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When Recruitment Lags Behind
Take a fresh look …
The inability to recruit key positions (capture the curiosity factor)
The inability to absorb the initial cost (define target activities for each team)
The inability to guarantee projected growth (report growth weekly)
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When Staffing & Design Conflict
Design Development is often a catalyst for defining a new practice model –
What happens if it is not implemented?
Position Silos Interdisciplinary Teams
Adult/Child Family Units
Centralized Support De-Centralized Support
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When Staffing & Design Conflict
The Old Site Design The New Site Design
Virginia CHC - 2011
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Remember the Goal
Culturally Appropriate,
Clinically Effective and
Operationally Efficient
Sustainable Growth
delivered within a Supportive Environment –
and as quickly as possible.
Yes, it is Attainable!