Ambulatory Operations Design Team

1. Ambulatory Operations Design Team Update & Review Meeting February 3, 1999

2. Agenda • Status report on current ACC/CC facilities plans • Review changes to clinical centers and stacking diagram • Review Ambulatory Operations Operating Model • Refine role and selection process for clinical center Medical Directors

3. Phase 1 Development

4. Ambulatory Care Center

5. Ambulatory Care Center

6. Ambulatory Care Center View looking south on Euclid

7. Ambulatory Care CenterView of Main Entry Drive from Euclid

8. Ambulatory Care CenterView of Main Entry Drive from Parkview

9. Ambulatory Care CenterView of Main Entry Drive from Parkview

10. View of Level One Lobby

11. View of Atrium

12. Clinical Center Entry

13. Clinical Center Stacking Diagram Private Physicians 13 Center Clin Stdy Ophthal- mology BRI 12 Urology ENT Derm 11 10 Endoscopy / Minor Procedures Mechanical 9 Cardio- vascular Lung GI Vas Lab CDL/PFT 8 Cancer Center Cancer Admin Infusion 7 Spine Musculoskeletal Neuro Sciences Plastics Rad/Rehab/ Neuro D&T 6 Women’s Prenatal Genetics General Med/Renal Breast Center 5 Current Stacking Diagram- January 1999

14. Requested Variations to Standards • Requested Variations to Modular Practice Area • Colon Rectal Surgery • Musculoskeletal Center • Neuroscience Center • Women’s Center • Urology Center • Ophthalmology (previously approved) • Requested Variations to Typical Exam Room • Women’s Center • ENT • Ophthalmology (previously approved)

15. Requested Modification to Typical Exam Room - (All centers except ENT) Approved Exam Room Desired Exam Room (Mirror Image) Right handed provider faces patient for interview Provider on right hand side of patient for exam

16. Exam Room Variations Typical Women’s ENT

17. Requested Modifications to Module-Colon Rectal Surgery Requesting toilet rooms opening directly up to 7 exam rooms

18. Clinical Centers and Volumes - 5th Floor • General Internal Medicine • Primary Care 13,036 • Infectious Disease 2,235 • Renal/Renal Transplant 4,904 • Women’s Center • GYN 9,180 • Maternal Fetal Medicine 2,249 • Center for Diabetes and Pregnancy 687 • Ancillaries • Breast Center • Prenatal Genetics

19. Clinical Centers and Volumes - 6th Floor • Neuroscience Center • Neurosurgery 2,340 • Neurology 14,826 • Spine Center • Orthopedic Surgery 3,360 • Neurosurgery 2,943 • Rehab Medicine 4,500 • Musculoskeletal Center • Bone Health 1,018 • Rheumatology 2,610 • Orthopedic Surgery 18,573

20. Clinical Centers and Volumes - 6th Floor • Plastic Surgery • Plastic Surgery 13,331 • Ancillaries • Neuro Diagnostics • Hand Center • Radiology

21. Clinical Centers and Volumes - 7th Floor • Cancer Center • Hematology 1,560 • Medical Oncology 14,634 • Bone Marrow Transplant 5,861 • GYN Oncology 8,914 • GYN Tumor 992 • Surgery Oncology 7,388 • Oto Head & Neck 3,200

22. Clinical Centers and Volumes - Ground Floor Radiation Oncology Wound Center (not part of Cancer Center)

23. Clinical Centers and Volumes - 8th Floor • Gastrointestinal Center • Gastroenterology 5,652 • Obesity 527 • Colon Rectal Surgery 5,200 • Hepatobiliary 2,437 • Transplant 497 • Lung Center • Pulmonary Medicine 4,293 • Thoracic Surgery 5,221 • Allergy and Immunology 2,598

24. Clinical Centers and Volumes - 8th Floor • Cardiovascular Center • Cardiology 17,047 • Cardiac Surgery 1,460 • Vascular Surgery 6,785 • Endocrine/Diabetes/Lipid 2,920 • Ancillaries • Cardiovascular Lab • Pulmonary Function Lab • Vascular Lab

25. Clinical Centers and Volumes - 11th Floor • Dermatology Center • Dermatology 20,700 • Urology Center • Urology Surgery 16,468 • Otolarynology Center • Otolarynology 19,450 • Audiology • Vestibular Oculomotor Lab

26. Clinical Centers and Volumes - 12th Floor • Ophthalmology Center • Ophthalmology 27,000

27. Ambulatory Operations Model - Levels of Resource Sharing Define optimal level of support staff sharing from a patient focused, clinical effectiveness, quality of care perspective that recognizes physician efficiency.

28. Staffing Model: Attributes: Support service excellence. Promote smooth patient flow. Maximize efficiency of ambulatory operations. Provide consistency across clinical centers. Goals: 1. Accountability to Physicians/Nurse Manager/FPP. 2. Define base level of staffing center. 3. Determine center-specific clinical staffing requirements above the base. 4. Determine degree of staff sharing across specialties within the center. 5. Functions will be assigned to the “right” level of staff. Considerations: Special procedures performed in center/equipment needed/specially trained staff.

29. Levels of Resource Sharing:Criteria for Sharing Criteria No Sharing Assigned to Individual Physicians • Narrow clinical focus • Highly sub-specialized knowledge required • Relates to physician or small group • May not be limited to out-patient setting Level 4 • Narrow clinical focus • Specialized knowledge required • Relates to a subspecialty or small group of • Physicians • Out patient setting only Resources Shared within Subspecialty Level3 • Clinical focused and clinical knowledge • required at the center level • Regular assignment with a Clinical Center • Dedicated to ambulatory setting • Potential for cross training between similar • Centers Resources Shared Within a Clinical Center Level 2 • Relationships with physicians at • Clinical Center not essential • Same level of service needed • by all Centers • No clinical knowledge needed Resources Shared Across Entire Site Level 1

30. Levels of Resource Sharing:Functional Differences Between Levels • Function • Nurse Coordinator • Nurse Practitioner • Specialized RN • Specialized Technician • Specialized RN • Specialized Scheduler • Specialized Technician • Clinical Manager • Referral Expert • Standard RN • LPN • Medical Technician • Billing Clerk • Medical Records Technician • Check-in/Check-out Clerk • Standard Scheduler • Cashier • Facility Manager • Registrar • Patient Account Rep. • Cashier • Standard Scheduler • Transcriptions • Patient Escort • Concierge • Housekeeper Criteria No Sharing Assigned to Individual Physicians • Narrow clinical focus • Highly sub-specialized knowledge required • Relates to physician or small group • May not be limited to out-patient setting Level 4 • Narrow clinical focus • Specialized knowledge required • Relates to a subspecialty or small group of • Physicians • Out patient setting only Resources Shared by Physicians within a Specialty Level3 • Clinical focused and clinical knowledge • required at the center level • Regular assignment with a Clinical Center • Dedicated to ambulatory setting • Potential for cross training between similar • Centers Resources Shared Within a Clinical Center Level 2 • Relationships with physicians at • Clinical Center not essential • Same level of service needed • by all Centers • No clinical knowledge needed Resources Shared Across Entire Site Level 1

31. ClinicalSupportManagement Structure:Reporting Relationships Examples of Functions Reporting Relationships No Sharing Assigned to Individual Physicians • Nurse Coordinator • Specialized Technician • Clinic Manager • Specialized RN • Specialized Scheduler • Specialized Technician • Standard RN • Medical Technician • Medical Records Technician • Check-in/Check-out Clerk • Standard Scheduler • Registrar • Cashier • Patient Escort • Concierge Level 4 • Hospital and physician • Department/Division and physician Resources Shared within Subspecialty Level3 • Clinical Manager/Practice Plan • Designated physician/Practice Plan Resources Shared Within a Clinical Center Level 2 • Clinical Manager/Practice Plan • Designated physician/Practice Plan Resources Shared Across Entire Site Level 1 • Facility manager • Practice Plan/Hospital

32. Ensure Accountability to Physicians Examples of Functions Accountability No Sharing Assigned to Individual Physicians • Nurse Coordinator • Specialized Technician • Clinic Manager • Specialized RN • Specialized Scheduler • Specialized Technician • Standard RN • Medical Technician • Medical Records Technician • Check-in/Check-out Clerk • Standard Scheduler • Registrar • Cashier • Patient Escort • Concierge Level 4 • Direct accountability to physician as determined • by hiring entity (hospital/department/division) Resources Shared within Subspecialty Level3 • Part of hire/fire process • Significant input on performance evaluation • For manager & senior clinical positions: • part of hire/fire process and significant • influence on performance evaluation • For basic level positions: influence • through clinic manager Resources Shared Within a Clinical Center Level 2 Resources Shared Across Entire Site • Physician needs to know • who is the administrator • responsible Level 1

33. Clinical Center Manager - Position Description Position Summary: Position functions as the manager of clinical operations with (a) defined clinical center(s) • Manages the clinical operations of the Clinical Center • Responsible and accountable for all aspects of day-to-day operations • Assures positive patient experience • Assures smooth patient flow • Responsible for the clinical support staff • Manages clinical support staff • Conducts performance reviews • Ensures competency of nursing staff • Interfaces with Medical Director to ensure operational efficiency • Plans and implements appropriate facility utilization (room use and assignments) • Coordinates the quality improvement activities within the Clinical Center(s) • Manages performance of the Clinical Center • Prepares budget in consultation with the Medical Director(s) • Monitors compliance with practice standards (e.g., report cards) • Participates as member of the Clinical Center management team • Participates in the Ambulatory management Forum POSITION REPORTS TO: Medical Director and Director of Ambulatory Operations

34. Clinical Center Medical Director • Physician representative of the clinical center group to ensure operational issues have physician input • Partners with the FPP Ambulatory Operation Director in hiring/firing process for clinical manager and with the manager for the senior clinical support staff • Share in the performance review process (directly or indirectly) of all clinical support staff, with joint sign off required for the center manager and all senior clinical support staff • Designated physician liaison between the Clinical Center and the Practice Plan • Physician liaison across clinical centers

35. Medical Directors - Working Relationshipsand Communication with... • Clinical Center Physicians • Daily operations • Liaison with Clinic Manager • Scheduling issues • Space issue resolution • Personnel issues • Performance evaluations • Service/staffing levels

36. Medical Directors - Working Relationships and Communication with ... • Faculty Practice Plan • Site Medical Directors Committee • FPP Board/Medical Management Committee • FPP Physician Executive/CEO • FPP Service Commitments • Department/Division Heads

37. Medical Directors - Selection “A Medical Director will be appointed by the faculty within each clinical center”AODT, Final Report, 4/21/97 • Selection Process Alternatives • One vote per clinical center physician? • Weighting of votes by clinical schedules? • Block votes by subspecialty? • Rotation amongst subspecialties? • Same for each clinical center?

38. Medical Directors - Selection • Approval Process Issues • Review/Approval by FPP Board • Review/Approval by Department/Division Heads • Length of Term • Balance broad representation with administrative/operational stability