Question

Stakeholders and technological changes pertinent to hospitals

Answer 1

Stakeholder management is a critical component to the successful delivery of any project, programme or activity. Stakeholder management creates positive relationships with stakeholders through the appropriate management of their expectations and agreed objectives.

The major stakeholders in the healthcare system are patients, physicians, employers, insurance companies, pharmaceutical firms and government. Insurance companies sell health coverage plans directly to patients or indirectly through employer or governmental intermediaries. Stakeholders can affect or be affected by the organization's actions, objectives and policies. Some examples of key stakeholders are creditors, directors, employees, government (and its agencies), owners (shareholders), suppliers, unions, and the community from which the business draws its resources.

Hospital technology decisionmakers now confront a growing pipeline of information technology (IT) and major medical equipment that challenges traditional capital allocation processes. In a highly fragmented industry that is driven by coverage and reimbursement policies set by the Centers for Medicare and Medicaid Services (CMS) and private insurers, the cumulative impact of hospitals’ technology investment decisions shapes health care for decades.

Hospitals and hospital based health systems are struggling to keep pace with purchasing decisions about emerging technologies. New technologies have become more complex and challenging to evaluate, and in the case of disruptive technologies—those that change existing business models or work processes—estimating the impact on clinical programs, operating costs, and workforce and facility needs is particularly difficult. These problems are exacerbated by new demands for improvement in hospital safety and quality and for performance reporting, requiring further investments in information technology (IT) and in the clinical transformation of care processes.

Decisions to adopt a particular innovation may vary between stakeholders because individual stakeholders may disagree on the costs and benefits involved. This may translate to disagreement between stakeholders on priorities in the implementation process, possibly explaining the slow diffusion of innovations in health care.

A key stakeholder perspective, informed by illustrative quantitative and qualitative data, is developed for hospital administrators. These data provide answers to the questions, Who matters to hospitals? and Why do they matter? A tool kit for assessing stakeholders also is presented to help hospital executives identify their institutions' key stakeholders, determine the power of these stakeholders and their core values, and define who within their institutions should be responsible for the routine management of different stakeholders. These tools facilitate the management of each key stakeholder, ensuring that each strategic decision is examined in terms of the likely reaction of key stakeholders and is supplemented with plans for gaining stakeholder acceptance. Managers should recognize that the answers to Who matters? and Why? will vary by type of hospital and by the specific issue being addressed.

Many health systems are concerned with the issue of how best to configure their hospital-based services. In addition to their other roles, hospitals appear to have a particularly important symbolic role with the public in terms of representing a strong welfare state. Proposed changes to hospital services therefore often create high profile, contentious debates locally, and sometimes nationally. The term ‘reconfiguration’ has been used in the context of health policy in the UK to describe changes to hospital services. These terms may be seen by stakeholders, such as the media and the public, as euphemisms for ‘cutback management’, changes driven by financial concerns. “A deliberately induced change of some significance in the distribution of medical, surgical, diagnostic and ancillary specialties that are available in each hospital or other secondary or tertiary acute care unit in locality, region or health care administrative area”. Although it may be associated with mergers, or the formation of structured networks, reconfiguration is that measure of change which directly addresses operational rather than structural change: hospitals may merge, form networks, or change their divisional or governance structures, without reconfiguring services. The driving forces for these changes to hospital services are related to upward pressure on costs, as a consequence of new technologies and rising public expectations, in parallel with downward pressure from previous periods of economic recession and political unwillingness to increase taxes. Drivers have also included improved clinical safety and outcomes, using arguments relating to improvements in quality predicted through higher volumes of activity, better medical training, and easier recruitment and retention of staff. Evidence shows that higher volumes are associated with improved clinical outcomes for some conditions and procedures, but gains are exhausted at relatively low thresholds, and the mechanism for the relationship, if it is causal, is contested.

Healthcare, at its core, is a very intimate and personal industry. Individuals often develop long-term, trust-based relationships with their doctors, pharmacists, and other healthcare stakeholders. They strive for that level of personalization and intimacy in all aspects of their healthcare experience. Today we are truly at the intersection of humanity and technology in healthcare, where new ideas and innovations to improve people’s lives and health experiences are being enabled by technology and strategy.

Stakeholder support, beginning with program design and continuing through the evaluation, is critical to a successful Medicaid care management program. Stakeholders should be involved during each stage of the program to build support for it, provide suggestions for its design, and participate in evaluation and continuous quality improvement activities. Stakeholders include senior Medicaid and agency leadership, the Governor's office, the provider community, the patient and advocacy community, the State legislature, and the Centers for Medicare & Medicaid Services (CMS). Stakeholders in a Care Management Program, provides information to State Medicaid staff and policymakers about the:

• Importance of engaging key stakeholders.
• Strategies for developing relationships with key stakeholder groups.
• Communication strategies for demonstrating program value.

Involving stakeholders during all stages of a care management program can lead to early buy-in, successful program design, and establishment of long-term support for the program. Strategies to engage stakeholders-identifying "champions," establishing relationships and communicating regularly with stakeholders, and managing expectations of the care management program.

Identify Champions

One strategy for stakeholder engagement is to identify program "champions" to assist with program rollout or expansion and to build program sustainability. Program champions are stakeholders actively involved in the care management program and influential among their peers. Influential program champions can include State legislators and their staff, staff members from the Governor's office, senior Medicaid leadership, and providers. Program champions can help program staff plan and design a program, provide expertise based on their experiences, promote program continuation and sustainability, and help manage other stakeholders' expectations. Moreover, program champions can provide feedback on the program by identifying areas for program refinement and offering comments on new initiatives. Program staff can share preliminary evaluation results with champions to better understand how stakeholders might interpret these results.

Communicate Regularly

Ongoing communication represents another strategy to secure and maintain stakeholder support. By maintaining regular communication with stakeholders, program staff can establish themselves as the key contact or source for information about the program. Serving as the key contact ensures that stakeholders receive recent and correct program information and provides a resource for stakeholders' questions or concerns. Once the program is implemented, communicating routinely with stakeholders regarding program successes, failures, and new initiatives will help manage expectations and build support for the program.

Manage Expectations

States also have maintained stakeholder support effectively by sharing program outcomes early and often. In sharing program successes and outcomes, program staff should consider what types of outcomes stakeholders will find most meaningful. For example, providers and consumer groups might be interested in standardized measures that allow for comparison across providers; meanwhile, the legislature might be interested in cost savings. Program staff should identify early outcomes that key stakeholders would consider a "success" to demonstrate and communicate results.

Strategies for Developing Relationships with Key Stakeholder Groups

Developing relationships with senior Medicaid and agency leadership, other State agencies, the Governor's office, the provider community, the patient and advocacy community, the State legislature and staff, and CMS is critical for a care management program's success. For each stakeholder group, the following subsections outline strategies for stakeholder engagement during the planning, designing, implementation, and evaluation stages of a care management program.

Senior Leadership
Medicaid and senior agency leadership are unique in their capacity to influence program design, staffing, resources, and budget allocation. Program staff should engage senior agency leadership during all stages of a care management program to understand their goals for the program and ensure support.

Planning and designing stages. Program staff should involve senior leadership during the initial planning stage to take advantage of their expertise, as well as to understand their program goals. Senior leadership, including the Medicaid Director, the Secretary of Health, and the Governor's office might have specific program goals or might have areas and directions that they are uninterested in pursuing. For example, senior leadership might be interested in testing electronic medical records through the care management program. In addition, other senior leadership within the State might want to focus the program on a particular population or chronic condition.

Implementation and evaluation stages. Program staff should communicate regularly about program successes and areas for improvement with senior leadership. Keeping senior leaders apprised of issues or situations as they develop will help manage expectations of the care management program and build leaders' support. One strategy for facilitating regular communication is to E-mail regular program updates to senior leaders detailing program successes, issues, and plans. These updates could also serve as talking points if staff are asked to discuss the care management program.

Other State Agencies
Coordination and communication with other State and community programs represents a crucial part of Medicaid care management programs. Medicaid beneficiaries are more likely to have issues related to poverty (e.g., transportation or housing needs) and behavioral health that can be met through established programs.

Planning and designing stages. States should communicate with other State agencies, solicit feedback on program design, and identify any potential synergies between the new care management program and established State programs. For example, synergies might exist between an established Department of Public Health diabetes program and the new care management program targeting diabetes. The two programs can potentially share lessons learned. Opportunities might exist to coordinate more directly with established programs.

Implementation and evaluation stages. During the implementation and evaluation stages, program staff should work with other State agencies to coordinate interventions and outreach materials.

Provider Community
Providers are critical to any care management program; interested providers will endorse the concepts of the interventions with patients, identify interventions needed for patients, and provide valuable program input. By involving providers, States build long-term support for the care management program in addition to improving program outcomes and physician practice. Providers can offer suggestions for program refinements based on their clinical expertise and experience with the care management program. Finally, provider champions can help secure buy-in for the program from other providers and additional stakeholder groups. States can solicit and garner support from physician and provider organizations and societies (e.g., Pediatric Society, Public Health, Academy of Family Physicians, and Hospital Association). These organizations can endorse the program to their memberships and affiliations as well as advocate for the care management program to senior leadership, patients, and legislators.

Planning and designing stages. During the planning and designing stages, program staff should involve the provider community to garner input on clinical aspects of the care management program and to develop champions and others to serve as ambassadors to patients for the program.

Implementation and evaluation stages. Providers should be involved during the implementation stage to achieve early buy-in to the program. To activate providers during the implementation stage, States have formed provider advisory boards or groups to provide feedback on program interventions, measures, guidelines, and strategies.

Patient and Advocacy Community
A significant component of a care management program focuses directly on understanding the patient and his or her needs and subsequently providing appropriate interventions. By securing the patient and patient advocacy community's support, States have received useful input on program design and significant support for program sustainability.

Planning and designing stages. By involving consumers during the planning and designing stages, program staff will be better able to gauge the possible impact of certain interventions and will be able to design a better, more effective program overall. Attaining support from the patient and advocacy community provides insight into the patients' needs and fosters support for program sustainability. By establishing infrastructure such as standing committees or focus groups, program staff can plan the care management program and identify areas for program improvement.

Implementation and evaluation stages. Engaging patients during the implementation and evaluation stages of a care management program can also help program staff understand the program's effects on patient behavior and identify areas for program improvement. In addition, engaged patients are more likely to follow providers or care managers' recommendations. Finally, patients can advocate for the care management program to State legislators and senior agency leadership. Involving the patient community through committees and focus groups can represent an effective strategy to build support, increase awareness of the program, and improve program outcomes.

State Legislature
Similar to senior leadership, the State legislature retains the ability to influence the care management program significantly. Legislators are unique in their capacity to influence program design and budget allocation through the legislative cycle. Program staff should work with State legislators and their staff during all stages of a care management program to understand their goals for the program and ensure support.

Planning and designing stages. Since legislators might lack the necessary information to realize the impact of certain design features, program staff should coordinate and communicate regularly regarding the care management program. Specifically, program staff should understand the State legislature's expectations of the program, program design requirements, and whether a mandatory savings requirement exists. In addition, since State legislators and their staff will not necessarily approach program staff for input, program staff should remain proactive and set up meetings to exchange ideas. Program staff should become the key contact for questions surrounding the care management program for legislators.

Implementation and evaluation stages. Once the program is implemented, program staff should involve the legislators on an ongoing basis; periodic briefings can help build support and manage expectations in case the program progresses more slowly or has different outcomes than anticipated.

State legislatures often require savings guarantees from care management programs. However, because cost savings might be an unrealistic expectation for the program's first few years, communication with the legislators and senior leadership can help establish realistic expectations for care management programs.

Centers for Medicare & Medicaid Services
Program staff also should work with CMS to obtain Federal approval for the program.

Planning and designing stages. In addition to State approval, the design of the care management program might require CMS formal approval in the form of a State plan amendment or a waiver. Although many States have implemented care management programs, considerable variability exists in program design and Federal authority. Therefore, approval procedures are individualized, usually depending on the program model. As a result, during the planning stage, program staff should work with CMS staff, both at the regional and national levels, even when they are simply soliciting feedback to understand the type of authority that must be used to implement certain care management program components versus others.

Implementation and evaluation stages. Program staff also should maintain contact with CMS after the program is implemented, because CMS can help guide waiver evaluation reports and programmatic changes.

Conclusion
Engaging key stakeholders is critical to the success of a Medicaid care management program. Involving stakeholders during the planning and designing stages can lead to early buy-in, successful program design, and establishment of long-term support for the program. In many States, stakeholders' long-term support has led to assistance with program expansion and sustainability. Care management program staff and policymakers should not underestimate the value of program champions in designing, implementing, and sustaining a successful program.