When most people are asked to name to top traits of a leader, the same responses often come to mind — adaptability, vision, and communication skills, to name a few. But one that is often overlooked, especially in health IT, is the ability to “make sound decisions based on the needs of users and patients,” says Mike Mistretta.
In this interview, he talks about why listening and knowing your team is so critical for leaders. He also discusses his team’s strategy in rolling out Epic, why he didn’t hesitate to join an organization that was headed for a transformation, how Virginia Hospital Center has worked to develop (and retain) in-house expertise, and the surprising factor that’s become a recruiting tool for the organization.
- A community hospital surrounded by IDNs
- Replacing “a mishmash of systems”
- Big-bang strategy – “We didn’t want a disruption.”
- Limiting consultant use
- “This was a fantastic organizational initiative. It wasn’t an IT initiative.”
- Developing in-house super users – “We’re going to be stronger going forward.”
- Stabilization mode
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The board basically approached me to start an initiative to replace what I’ll call the “mishmash of systems” we had. For a variety of reasons, they weren’t speaking well together. They weren’t implemented very effectively, and it was becoming a bit of a patient safety issue, as well as productivity issue.
We wanted everything to be as seamless as it possibly could be from a patient perspective. Interestingly, it made it a little more challenging for us from a technical side supporting all the different points of care simultaneously and doing a deeper build to get everything done at the same time. But at the end of the day, we wanted to make sure it was right for the patients.
It’s not their typical model, but being a community hospital, it was just much more cost-effective for us to hire than it was to bring in a bunch of outside consultants at two to three times that rate.
We really just want to make sure we get it right out of the gate and everything is running as optimally as we can get it running. Then we’ll start worrying about or making changes to people’s preferences.
Gamble: I think the best way to start is with an overview about Virginia Hospital Center — what you have in terms of bed size and where you’re located.
Mistretta: We are just under 400 beds. I believe our licensed bed count is 397, but it’s kind of misleading because we typically run a census with observation patients that’s been as high as 480 at times. It’s a very busy facility, and we’re looking to expand for that very reason.
Virginia Hospital Center is locate in Arlington, Va., which is right across the river from Washington DC. We’re the last independent hospital in the DC market.
Gamble: And you’re surrounded by some pretty large systems.
Mistretta: Yes. Our primary competition on the Virginia side is Inova. Across the river, there is MedStar Health and Johns Hopkins. Those are some pretty big players in the market,
Gamble: And you said looking to expand. Are plans underway now for that?
Mistretta: Yes. Virginia requires a Certificate of Need (CON) so we have to go through the whole process for that. But we’re actually acquiring a five-acre piece of property from the county next door so that we can build an outpatient services pavilion there and move some services out of the current hospital and retrofit those into beds. We’ll probably hit a total of about 550 in the next 3 to 4 years.
Gamble: That’s a densely populated area, so I imagine there’s a real need to expand out.
Mistretta: Yes, and it’s still growing. It’s the only urban area that’s still expanding when you look at census data, which just drives the need. Like I said, we’ve actually hit censuses in the 480s, even without the population growth and migration that’s coming.
Gamble: Right. So, I’ve been following the Epic go-live through some of your LinkedIn updates. Obviously it was a big undertaking. But going backwards a bit, when did all of this start? When was Epic selected?
Mistretta: Shortly after I came, the board basically approached me to start an initiative to replace what I’ll call the “mishmash of systems” we had. For a variety of reasons, they weren’t speaking well together. They weren’t implemented very effectively, and it was becoming a bit of a patient safety issue, as well as productivity issue where the systems weren’t interoperating. And so we started the RFP process at the beginning of 2016. We took about six months to go through the process. We selected Epic, and then took the remaining six months to negotiate the contract and build the foundation for the project team in November and December of 2017. So we had the contract selected in the fourth quarter.
Gamble: As far as the implementation strategy, can you talk about how that was approached?
Mistretta: We really wanted to make sure we were cognizant from a patient perspective of the impact on our patient population. One of the things I was very impressed with about this health system is the focus on the patient and our patient engagement scores, and really wanting to optimize that experience for them, which is one of the reasons that we selected Epic. When we started talking about how we want to do the implementation strategy, our board and our executive team were fully engaged. We made the decision to do a big bang, because we didn’t want a disruption between our employed physician practices and the inpatient facility. We wanted everything to be as seamless as it possibly could be from a patient perspective. Interestingly, it made it a little more challenging for us from a technical side supporting all the different points of care simultaneously and doing a deeper build to get everything done at the same time. But at the end of the day, we wanted to make sure it was right for the patients.
Gamble: What about in terms of training and staffing up — did you use a third party or consultants?
Mistretta: It’s a great question because I think we’re a little bit different from an Epic perspective. We did one engagement with a third party from a revenue cycle preparation perspective to make sure we had all the parts, because we wanted to move to a consolidated billing office instead of having ambulatory separate and broken out. But that was really the only significant engagement we did with consultants. And so I moved my existing application team over to Epic, for the most part. We did outsource the legacy support to a third party. But that was really the only place that we used any significant third parties. We did use them, as you imagine, when we lost a resource for a variety of reasons, like a relocation or an instance where we needed resource augmentation, but those were small numbers. It wasn’t significant on the build side.
We did use a couple of companies for the go-live itself, which is a one-time event where we needed at-the-elbow support for the physicians or to augment our helpdesk. But outside of that, we pretty much did everything ourselves so we could retain that knowledge. Moving forward, I think we’ll be better because of that.
Gamble: That’s interesting, and not what we typically hear from Epic customers, but it seems like it was the right call.
Mistretta: It was. That was my call, and it was actually a little bit of a risk as you might imagine, with the knowledge base not being here. But we were able to work with Epic to supplement in some areas where we needed them. It’s not their typical model, but being a community hospital, it was just much more cost-effective for us to hire than it was to bring in a bunch of outside consultants at two to three times that rate.
Gamble: And like you said, you wanted to keep that experience in-house afterward.
Mistretta: Fortunately, throughout the project, we only lost two or three people. We hired over a hundred on the project team, so the retention rate was very good as well.
Gamble: From start to go-live, this is a really kind of a quick timeline in terms of the implementation.
Mistretta: Yes. We did it in about 16 or 17 months, from start to finish. There were a few months where we did some very high-level planning with Epic, but we really did it in that timeframe. There are two reasons we were able to do that. One, we stayed primarily with the foundational system — we really didn’t deviate from that. My CEO basically stood up in front of leadership and said any deviations from foundational workflows required his approval, and so we didn’t get a whole lot of them, as you might imagine. That kept the scope pretty solid, because one of the challenges when you go through these things is everyone wants their piece of a pie, and we didn’t have to deal with a lot of that through the implementation. And then with the limited turnover we had, that helped substantially as well. But we also had very active end user support from our clinicians and billing office, etc. This truly was a fantastic organizational initiative. It wasn’t an IT initiative at all.
Gamble: You mentioned the super users — how were you able to recruit them? What was that process like?
Mistretta: We went to each area and we basically said, here’s the level of support we’re looking to train. And so there was additional training these folks all went through. First we took volunteers. Those folks were all vetted through their managers, so we made sure we got the right people to do it. We chose to take people out of staffing and dedicate them to these processes, and then backfill if we needed to take in outside resources for their regular rotations. We went that route instead of hiring again so that we could retain the knowledge once we were done with this. That way, all of the training we invested in stays here now that we’re live and people are starting to go back to staffing.
Gamble: I’m sure that make a tremendous difference at the go-live having those super users on hand.
Mistretta: It does — not only for the go-live but I think we’re going to be a stronger organization forward as well.
Gamble: Did you implement most of the Epic modules?
Mistretta: Yes. There are only three modules I’m aware of that we did not implement to date: outpatient pharmacy, Tapestry, which is their insurance product, and Healthy Planet. Those are the only three modules in their suite that we did not implement.
Gamble: You had mentioned earlier that the goal of the entire initiative was to have a better level of interoperability between the hospital and the clinicians within your own organization?
Mistretta: Correct, and one of the other reasons is there’s that very high density of Epic facilities here in Northern Virginia, and so Care Everywhere is becoming a big deal also. We have a very strong relationship with Kaiser; we actually have a whole floor of the hospital dedicated to Kaiser, and so the ability institutionally to receive referrals and transfers from their outpatient facilities is pretty strong as well.
Gamble: Now, are you officially in the optimization mode? What’s really the focus right now?
Mistretta: We’re still stabilizing. It’s actually a big discussion we just had. We’re still in stabilization mode. Looking at ticket counts right now, we’re about even with what we’re resolving versus what is still coming in. Remember, we’re only a few weeks post-go-live. We told the organization that at this point in time, we’re not going to be getting to optimization tickets unless they’re critical in nature — which some of them are — for 90 days, at the earliest.
Gamble: Right, that makes sense. I forgot just how new this was.
Mistretta: We really just want to make sure we get it right out of the gate and everything is running as optimally as we can get it running. Then we’ll start worrying about or making changes to people’s preferences and those types of things.
Gamble: Right. You mentioned patient experience. Can you talk about some of the priorities there?
Mistretta: We have a pretty big effort with MyChart. We’ve already got a pretty substantial blast out to our practice patient panels that went out two weeks before go-live to start getting sign ups. I haven’t seen any metrics on exactly what the enrollments are, but as a part of that, we also have a lot of patient forms on there that they fill out prior to coming to the office. We’re actually getting self-scheduled patients through that now where they’re scheduling their own appointments in the practices based on blocks that we’ve opened up. So far, the communication back and forth from the secure messaging portions have been very successful. A lot of the letters that we used to fax or mail are now going on electronically through the MyChart. So again, it’s only been a few weeks, but we’re pretty happy with the success rate we’ve had.