Corrective surgery Featured

8:00pm EDT March 26, 2008
The symptoms were typical of any billion-dollar company that had started as one primary business and branched out over the years. The founding concept — in this case, Mount Carmel Health System’s hospital division — was still revered as the pinnacle of the organization. All other subdivisions, such as outpatient care centers and the College of Nursing, were treated exactly as that: subordinate.

“There was a tendency years ago to have hospital-centric systems,” says Claus von Zychlin, who became president and CEO of Mount Carmel Health System, a member of Trinity Health, in July 2006, and quickly diagnosed this long-standing flaw in how the system was organized. “Our hospitals generate the largest volume, so a lot of these things became like a department of the hospital somewhere. They kind of got lost in the milieu.”

That stifled growth in certain areas and caused frustrating mismatches between leadership skills and organizational duties in some cases.

For example, the education division — which includes the Mount Carmel College of Nursing as well as the graduate medical education program that trains aspiring physicians during their residencies — has historically reported to one of the hospital administrators at Mount Carmel.

“At the time, they really had very little knowledge about graduate medical education, and it really got the attention only when something was broken, not the attention of, ‘Where do we go tomorrow?’” he says.

To fix these types of problems, von Zychlin tossed out the old organizational chart and created four new divisions — one each for education, ambulatory care, managed care and physicians — and put them all on equal footing with the hospital division. He also hired or promoted administrators with specific expertise in those areas to head up each of the five divisions within the $1.1 billion organization.

“By separating them out into divisions, with each of them having an executive sponsor, they each have the time and attention they need rather than being buried underneath some department of the hospital,” says von Zychlin. “That has added to their accountability, their ability, and, I think, in general, to the psyche of the people who work there. They realize they’re an actual division that has the same level of responsibility and visibility as the hospital traditionally had.”

The results have spoken for themselves. Expenses have dropped by $61 million between fiscal 2006 and 2007, thanks to a systemwide efficiency review. In that same time frame, supply costs have decreased $1.5 million and Mount Carmel College of Nursing’s operating performance has improved by 38 percent.

Here’s how von Zychlin’s eye for reorganizing and creating equality and collaboration within Mount Carmel is helping the system reach new heights.

Expect teamwork

Von Zychlin did not adopt a separate-but-equal philosophy for Mount Carmel’s five operating divisions. Quite the contrary; he believes the whole is still greater than its parts, and he expects teamwork, collaboration and partnerships across all divisions. After all, the common goal, as with any service-oriented business, is to increase customer satisfaction.

“We need continuity of care through all levels,” von Zychlin says.

“If you look historically, health care has been rather episodic. If you are seeking health care, you go to a doctor’s office. That’s one episode of care. If your doctor sends you to a hospital, that’s another episode. If he sends you to an outpatient center, that’s another episode of care. Those episodes or encounters were not very closely linked to each other in the past. We hope one day to create better and better links, better continuity between those episodes.”

That means better communication not just within Mount Carmel’s flagship division — the four hospitals, which traditionally had a lot of individual autonomy — but also between all the divisions that could share customers, or patients.

“If a patient registers at Mount Carmel West, then the next time registers at Mount Carmel St. Ann’s, not only will that information transfer with the patient, but key clinical processes and procedures that the patient may find comfort in will have commonality,” he says.

Commonality in systems and procedures across Mount Carmel’s divisions can also increase efficiency.

“If you look at how we go about overseeing quality of care, we track hundreds of indicators,” von Zychlin says. “It’s a whole lot easier for us to track those indicators if everybody is collecting data the same way, if it’s reported the same way and if the teams who work on improving quality of care work together so we’re not reinventing the wheel.”

Commonality can also save time. “If, for instance, a physician practices at more than one location, there is a lot of value in the procedural work and processes we engage in being the same so the physician doesn’t have to learn different processes at each hospital,” von Zychlin says.

The advantages are enormous — fewer opportunities for mis-communication, less time spent training on procedures and more time spent with patients — as well as vital to better serving Mount Carmel’s “customers.”

That said, there is still room for pioneering new ideas within various divisions.

“On occasion, we will pilot something at one of the sites, and if that pilot seems to be effective, then it can be rolled out to all the sites,” he says. “So there is also the benefit of the individual initiative and effort.”

Balance your goals

Despite the push for increased uniformity across the Mount Carmel Health System, the market still plays a role in how things are done at times.

“You have to be able to recognize the value of interdependence and recognize the value of market independence,” von Zychlin says. “When I look at our College of Nursing, I’m looking not only at how can it benefit Mount Carmel Health System, but how does it benefit nursing education and the growth of nursing education in the region that we serve. I can’t just look at how it will help me fill my nursing vacancies; I also have to concentrate on how it can be responsive to its students and the community that needs more nurses. How do we take it to the next level?”

That’s where having the head of Mount Carmel’s College of Nursing reporting directly to von Zychlin — rather than two levels removed from him — comes in handy. Ann Schiele, president and dean of the college, now has the resources and attention she needs to constantly look ahead to what’s next, stay competitive and, by doing so, help the system as a whole.

“Can we build into the curriculum and the practical, clinical experiences a way to show how doctors work with nurses in partnership and nurses work with doctors in partnership rather than just training nurses to be nurses and doctors to be doctors?” von Zychlin says. “We can take it beyond just the corridor of training in their respective professions.

“We have lots of ambulatory sites. Does it make sense to open nursing education into those sites and create a broader experience? Same thing with physicians.”

The winners in all of this, again, are the customers. With better, multifaceted training upfront, nurses are apt to adapt more quickly to any medical environment in which they are called to serve. Therefore, patients should receive better care.

“Those are some of the things we are looking forward to in creating the synergy between the hospitals and the College of Nursing and graduate medical education,” von Zychlin says.

Still, it’s a continual balancing act. “You have to be able to weigh internal benefit with external benefit,” he says. “If you concentrate too much on the outpatient or external side, then you have to question what’s the value of having that division as part of your health system. Does it add value? Because it takes management time, it takes capital, it takes lots of things; so if it can’t add to the value of the system and all it’s doing is external, then you have to really question whether that division makes sense for you to have or not.

“Vice versa, if you only concentrate on how it supports your organization, you may lose the value and quality of the best students and its success in the community. If students perceive us as being 100 percent internal-focused around how do we fill our own vacancies, then they’re going to say that doesn’t give me the broad experience I’m looking for as an individual nurse for my future growth and career path. So we have to look at it and say, ‘How can we do both?’”

Evaluate your progress

Although the organizational chart has been modified and the mission of cooperation between divisions has been clearly set, there’s still plenty of monitoring and evaluating taking place. There always will be.

“This is a journey,” von Zychlin says, adding that the role of technology in the ever-changing medical field is likely to have significant bearing on how to best create operational efficiencies under the new, five-division internal structure at Mount Carmel.

“I have it as a priority that we are looking at things in a systematic way,” von Zychlin says. “What’s the best way to provide this particular service? Does it make sense for it to remain specific to the individual sites with some oversight? Or does it make sense to consolidate it into a single department that operates at four different locations or more? What makes the most sense from a quality of practice standpoint? Is it more cost-effective one way or the other? I suspect sometimes we’ll consolidate and find out that the market or technology has changed, and it might make more sense to decentralize again.”

Take, for example, the medical laboratory. “Rather than duplicating expensive lab equipment, it’s probably better to consolidate certain components of the lab and get critical mass at one site,” von Zychlin says. “If you look at today’s world, with digital equipment, once you get the sample to the lab, reporting back out is instantaneous because it’s done by a computer. But technology changes. As it does, we will determine whether it still makes sense to centralize or whether it needs to be reconsidered for decentralization.”

Even if decentralization ends up as the best choice in the long run for certain services at Mount Carmel, that doesn’t equate to complete independence.

“For me, it’s more around coordinated and decentralized or centralized,” he says. “I can’t think of anything that is so decentralized that there’s no coordination going on.”

Whichever way the pendulum swings at any given time in the future, the ultimate goal will remain clear.

“If you look at the core or genesis of it, it is patient care,” von Zychlin says. “We are a people business.”

HOW TO REACH: Mount Carmel Health System, (614) 234-5000 or