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The assignment is to design a plan that aligns patient satisfaction scores with quality care metrics. The instructor’s manual (IM) introduces models for designing and implementing a strategic plan to approach the quality improvement process.

This is a field research case. The author(s) had access to the Chief Operating Officer (COO) and other members of the management team, meeting with them on numerous occasions. Cleveland Clinic Florida (CCF) provided the data included in the appendices. Additionally, relevant hospital data, also included in the appendices, is required to be made public on Centers for Medicare and Medicaid Services (CMS) databases. Accordingly, all data and information are provided by original sources.

Osmel “Ozzie” Delgado, MBA and COO of CCF was faced with a dilemma. Under the new CMS reimbursement formula, patient satisfaction survey scores directly impacted hospital reimbursement. However, the CCF patient satisfaction surveys revealed some very unhappy patients. Delgado pondered these results that really made no sense to him because CCF received the highest national and state rankings for its clinical quality at the same time. Clearly, patients were receiving the best medical care, but they were still unhappy. Leaning back in his chair, Delgado shook his head and wondered incredulously how one of the most famous hospitals in the world could deliver such great care but receive negative patient feedback on CMS surveys. What was going wrong and how was the hospital going to fix it?

This case is designed for graduate Master’s in Business Administration (MBA), Master’s in Health Sciences Administration (MHSA) and/or Public Health (PA) audiences. While a healthcare concentration is useful, the case raises the generic business problems of satisfying the customer to increase brand recognition in the marketplace and displacing competition to increase annual revenues. Indeed, the same analysis can be applied in other heavily regulated industries also suffering from a change in liquidity and growth occasioned by regulatory change.

The first three years of operation of the West Kendall Baptist Hospital (WKBH) in Miami, Florida provided a “poster child” for efficient and cost effective healthcare delivery to the West Kendall community that it served. The hospital leadership and management team exemplified a quality-oriented staff that moved as a cohesive and dedicated organization. WKBH exceeded every budget prediction and showed a profit in year 3, well before expected. Then came the winds of regulatory change. With the passage of the Affordable Care Act (ACA) and the attendant imposition of new reimbursement metrics, the picture at WKBH changed almost overnight. By the first quarter of 2016, WKBH started to lose money in excess of budget predictions despite its increased patient admissions, careful financial planning, expense reductions, quality service, and excellence in patient care delivery. A serious financial crisis was looming with little relief in sight. The hospital management team began to search for solutions.

The research methodology includes collecting quantitative data: original financial statements and financial data from WKBH, as well as qualitative data: interviews of hospital administrators and historical information.

Graduate capstone course in a finance course; masters in health administration; and/or the MBA program.

While it is clear that the ACA was designed with all good intentions, it has created substantial and perhaps, unanticipated financial burdens for caregivers. These issues are not only faced by WKBH. Most hospitals could relate to one or more of the four questions examined as part of this learning process. Graduate MBA students worked with the hospital to identify, define, focus, and resolve difficult quantitative and qualitative issues faced by the hospital as a result of major changes in the regulatory environment with the passage of the ACA. This case focuses upon the current reimbursement environment that has only recently emerged as a result of the implementation of the ACA.

Learning outcomes are as follows: students will discover the importance of process orientation in management; students will determine the root cause of the problem by applying root cause analysis technique; students will identify the failure modes, analyze their effect, score them on a scale and prioritize the corrective action to prevent the failures; students will analyze the processes and propose error-proof system/s; and students will analyze organizational culture and ethical issues.

Purpose: This case study is intended as a class-exercise, for students to discover the importance of process-orientation in management, analyze the ethical dilemma in health care and to apply quality management techniques, such as five-why, root cause analysis, failure mode and effect analysis (FMEA) and error-proofing, in the management of the health-care and service industry. Design/methodology/approach: A voluntary reporting of a case of “radiation overdose” in a hospital’s radio therapy treatment unit, which led to an ethical dilemma. Consequently, a study was conducted to establish the causes of the incident and to develop a fail-proof system, to avoid recurrence. Findings: After careful analysis of the process-flow and the root causes, 25 potential failure modes were detected and the team had assigned a risk priority number (RPN) for each potential incident, selected the top ten RPNs and developed an error-proofing system to prevent recurrence. Subsequently, the improvement process was carried out for all the 25 potential incidents and a new control mechanism was implemented. The question of ethical dilemma remained unresolved. Research limitations/implications: Ishikawa diagram, FMEA and Poka-Yoke techniques require a multi-disciplinary team with process knowledge in identifying the possible root causes for errors, potential risks and also the possible error-proofing method/s. Besides, these techniques need frank discussions and agreement among team members on the efforts for the development of action plan, implementation and control of the new processes. Practical implications: Students can take the case data to identify root cause analysis and the RPN (RPN = possibility of detection × probability of occurrence × severity), to redesign the protocols, through systematic identification of the deficiencies of the existing protocols. Further, they can recommend quality improvement projects. Faculty can navigate the case session orientation, emphasizing quality management or ethical practices, depending on the course for which the case is selected.

MBA or PG Diploma in Management – health-care management, hospital administration, operations management, services operations, total quality management (TQM) and ethics.

Teaching Notes are available for educators only.

CSS 9: Operations and Logistics.

Bottom of the Pyramid (BOP); social innovation and business modeling.

Undergraduate and graduate level management/business school students. It can be taught in marketing management and entrepreneurship/innovation courses.

LifeSpring Hospitals Pvt. Ltd is an expanding chain of hospitals that provide high quality health care to lower-income women and children across Andhra Pradesh. It is a 50-50 equity partnership between Hindustan Latex Ltd and the Acumen Fund. LifeSpring has demonstrated exceptional management principles, some of them being the most innovative and attractive ones. The entire focus of LifeSpring is on one particular niche: maternal care. Some argue about its strategy of not adopting diversification, but LifeSpring has proved its point by actually turning out to be a profitable business. The strategy of focusing on one niche has led to reduction in cost in terms of specialized doctors and the range of equipment needed to serve. Adding to the strategic strength of LifeSpring, its operations (management) is perfectly aligned with the organization's vision and quality is achieved via highly standardized procedures for maternal care service.

This case will cover two important aspects of BOP and social innovation. MBA students will investigate an innovative business model and apply their analytical skills to analyse the sustainability of the model.

Teaching notes and exercise for class-based discussion.

The teaching objectives of the case study will enable the students as follows: to recognise the challenges of information technology (IT) implementation in the health-care sector associated with employee resistance, to apply the technology acceptance model for analysing the degree of employee resistance, to relate the utilisation of Kotter’s 8-step change management approach in successful IT implementation in the health-care sector and maintenance of employee productivity and to classify the leadership traits reflected by the leaders in training the 600 diverse employee population of Al-Ain hospital.

The case highlighted the predicament the government-owned Al-Ain City Hospital, United Arab Emirates, faced following the surge in the incidences of COVID-19 in the country in March 2020. The hospital management decided to initiate the work-from-home arrangement as a non-pharmaceutical intervention of handling the spread of the disease amongst its employees. Fatima Almur, the Information Technology Director in Al-Ain Hospital, asked the Application Support Manager, Aysha Shahwan, to deploy some IT tools significant for remote support to patient care within two weeks. Shahwan faced significant challenges in deploying the IT tools in two weeks given the diverse workforce, with the majority of them having limited knowledge in operating the tools, and hence, their apprehension in the usefulness of the tools. Besides, Shahwan had to deploy some advanced tools for easy and secured access to the electronic health record, telemedicine and telecommuting using mobile phones, tablets or PCs. The deployment of these advanced tools would be jeopardised by employee acceptance and consequent dwindling productivity. Considering the issue of employee acceptance of the change and their limited knowledge, Shahwan had, therefore, to develop training frameworks to boost the former’s perceived usefulness and ease-of-use of the IT tools. Will Shahwan successfully deploy the advanced IT tools to enable the hospital staff, including medical staff and departments, to ensure efficient patient care from a remote location? Will she be able to train the 600 employees across genders, ages and knowledge, use the IT tools and safeguard them from common software threats like email phishing and ransomware? Will the hospital be able to sustain its vision of quality patient care using advanced technologies through this new arrangement of remote support amidst the pandemic when patients are more?

Undergraduate business management.

Teaching Notes are available for educators only.

CSS 10: Public sector management.

In late 2012 Adeline Herzog Memorial Hospital in Castle Rock, Colorado, was facing a problem with patient satisfaction. The Press-Ganey scores for the third-floor nursing unit–the primary destination (70 percent) for patients admitted through the emergency department–were at the 15th percentile, and the key HCAHPS score for inpatients was well below the Colorado average. Over the past six months Jeri Tinsley, director of medical, surgical, and intensive care services, had made various changes to try to improve the patient satisfaction scores for her 32-bed unit, but the scores seemed stuck at an unacceptably low level.

Tinsley worried that if improvements were not made soon, patients would start “voting with their feet” and take their business to competing hospitals. As a registered nurse, Tinsley's expertise was helping people heal; it was not analyzing data. In particular, she was overwhelmed by the patient comments included in the surveys; she had no idea how to analyze them and could not decide which issues to address first.

After analyzing the case, students should be able to:

• Organize and analyze qualitative data using affinity diagrams

• Identify priorities using Pareto diagrams

• Identify which aspects of a problem are (1) within their control to solve, (2) within their influence to solve, or (3) outside their control to solve

Organize and analyze qualitative data using affinity diagrams

Identify priorities using Pareto diagrams

Identify which aspects of a problem are (1) within their control to solve, (2) within their influence to solve, or (3) outside their control to solve

Key State Blue Cross and Blue Shield Plan (a disguised case of an actual BCBS Plan) is the merged product of three state plans. Initially burdened with a reputation of poor customer service, Key State's executives decided to invest heavily in service improvement, eventually achieving superior levels. Key State's high-quality customer service emerged as a true competitive advantage for its customers, who were primarily businesses and health benefits consultants who influenced corporate purchasers of health insurance. The Key State brand came to be synonymous with personal service, security, choice, and dependability. But the health care insurance market was changing under Key State's feet. Spiraling costs meant that high-quality service became less of a competitive advantage as employers were lured by low-cost, low-service providers. Many employers cut or dropped health care benefits entirely, swelling the ranks of the under- and uninsured, who in turn were extremely price-sensitive when shopping for health insurance on their own. Finally, the health care insurance market was being revolutionized by financial institutions willing to hold health benefit accounts and pay providers directly, thereby eliminating the need for Key State as a mediator. Key State executives were aware of these changes but were challenged by the mindset, culture, and organizational design custom-fit to their business accounts. The case asks the reader to consider whether Key State has the right number of target markets, whether it should have one brand or several for its different target markets, what it should do for the uninsured, and how it should improve its brand experience in light of the industry's changing landscape. All of these decisions will have significant implications for the organizational design of Key State.

To better understand the challenges involved in a successful health insurance company to cope with a rapidly changing and unpredictable environment; to formulate a new strategy and a new organizational design to accomplish this adaptation.

First National Healthcare (FNH) runs a large network of hospitals and has worked to systematically reduce waiting times in its emergency departments. One of FNH's regional networks has run a successful marketing campaign promoting its low ED waiting times that other regions want to emulate. The corporate quality manager must now determine whether to allow these campaigns to be rolled out and, if so, which waiting time estimates to use. Are the numbers currently being reported accurate? Is there a more accurate way of estimating patient waiting time that can be easily understood by consumers?

The central lesson to be learned from studying the case is to understand the challenges and constraints posed by contextual conditions in designing contracts in public–private partnerships (PPP) for financing and delivering health care in emerging economies such as India.

Perverse incentives, along with contextual conditions, led to extensive opportunistic behaviors among involved agencies, limiting the effectiveness of otherwise highly regarded innovative design of the program.

India’s “Rashtriya Swasthya Bima Yojana” or National Health Insurance Program, launched in 2007 provided free health insurance coverage to protect millions of low-income families from getting pushed into poverty due to catastrophic health-care expenditure. The program was implemented through a PPP using standardized contracts between multiple stakeholders from the public and private sector – insurance companies, hospitals, intermediaries, the provincial and federal government.

Teaching Notes are available for educators only.

CSS: 10 Public Sector Management.

This case, “One Mission, Multiple Roads: Aravind Eyecare System in 2009” is a sequel to the earlier case, “Aravind Eyecare System: Giving Them the Most Precious Gift” (BP 0299). It describes the new challenges facing AECS in 2009. It presents the strategic choices facing a mission driven organization like AECS. For its future growth it had the option of several paths. Following any of these paths would not dilute its mission and yet it could not pursue all of them at the same time. It would have to prioritize them. The case encourages participants to develop criteria for this prioritization.