Thursday, January 26, 2012

CoxHealth recognized as one of the nation’s top hospitals for neurosurgery, spinal surgery

CoxHealth has been named by Becker’s Hospital Review as one of the nation’s “101 Hospitals with Great Spine and Neurosurgery Programs.” The list recognizes some of the most outstanding hospitals for neurosurgery and spinal surgery care in the United States, including Johns Hopkins, Yale New Haven, Mayo Clinic, Cleveland Clinic, Stanford, Cedars Sinai and Barnes-Jewish.

Hospitals on this list are selected by the Becker’s Hospital Review editorial team based on nominations, quality care data, clinical accolades and contributions to the field of neurosurgery and spine care.

“It is gratifying to be recognized alongside of some of the best institutions in the world. We are deeply committed to providing world class care in southwest Missouri, and we intend to be second to none. This recognition is a reflection of years of hard work and devotion by our staff and the surgeons at Springfield Neurological and Spine Institute,” says Steve Edwards, CoxHealth President and CEO.

CoxHealth purchased SNSI in December 2010. SNSI is the largest group of neurosurgeons in the state of Missouri.

To learn more about the “101 Hospitals with Great Spine and Neurosurgery Programs,” list, visit

CoxHealth is Springfield’s only locally owned, not-for-profit health system. It is accredited by The Joint Commission and distinguished as one of the nation’s Top 100 Integrated Healthcare Systems (2006-2012).

Becker’s Hospital Review is a bimonthly publication offering up-to-date business and legal news and analysis relating to hospitals and health systems. Each issue reaches more than 18,000 people, primarily acute-care hospital CEOs and CFOs.

Families honor heroes in Missouri Hotel fire

Firefighters from Station 2 in Springfield visited Cox North Wednesday afternoon to reunite with the families they saved in last week’s fire at the Missouri Hotel. The firefighters were presented with a plaque from The Kitchen and a banner reading “Thank You God for Everyday Heroes.” 
Dozens of children staying at Cox North signed the banner before meeting the firefighters, who handed out coloring books, stickers and wristbands. Repairs continue at the Missouri Hotel and some residents are expected to begin moving back as early as next week.

Monday, January 23, 2012

Fighting our smallest enemies

Antibiotic-resistant MRSA, seen here in a culture held by medical laboratory scientist Danielle Lucore, is among the top challenges for infectious disease specialists.

For years, physicians and scientists around the world have documented an increase in the number of drug-resistant bacteria. Some new strains, such as the New Delhi strain of E. coli that recently emerged from India, show resistance to all existing antibiotics. With few new antibiotics in the development pipeline, many in the medical community have declared the situation dire.

“This is a public health emergency across the nation,” says Dr. Robin Trotman, CoxHealth infectious disease specialist and the physician who oversees the health system’s antibiotic stewardship program.

In 2008, CoxHealth launched the program, modeled on the successful programs found at larger health care institutions in major cities, to help bridge the gap between drug-resistant bugs and the lack of medicines to fight them.

By applying principles of antibiotic stewardship – matching the most appropriate antibiotic to each infection, carefully dosing the drugs to balance their effectiveness with cost and patient outcomes, and researching alternative therapies – the program aims to prevent the emergence of antibiotic-resistant infections at CoxHealth.

Pharmacist Melissa Steenhoek spends her days working on the program, acting as a steward of the system’s formulary. “I constantly review data and make recommendations for antibiotic selection and dosing to discourage antibiotic resistance and give our patients the best possible outcomes while decreasing costs,” she says.

Bacteria develop resistance over time.  During prolonged or inappropriate antibiotic exposure, they adapt to overcome the very drugs created to fight them.

“Each antibiotic has a different spectrum of infection it covers,” says Steenhoek. “If a broad-spectrum antibiotic is selected when a more narrow-spectrum antibiotic would be just as effective, the broad-spectrum drugs become overused, and resistance develops.”

But by carefully overseeing the use of antibiotics, reviewing individual cases and monitoring the resistance problems that most hospitals are dealing with, Steenhoek and Dr. Trotman are able to keep CoxHealth ahead of the curve – and in some cases, change our trajectory.

One example: their work regarding MRSA infections with reduced Vancomycin susceptibility at CoxHealth. A poster the pair created on the topic was presented at a national conference hosted by the Infectious Diseases Society of America, and Dr. Trotman recently spoke at a conference hosted by the Carolinas Antimicrobial Stewardship Effort and Wake Forest Medical Center on the issue.

Vancomycin is one of the most commonly used antibiotics in the hospital setting, and the treatment of choice for MRSA, or methicillin-resistant Staphylococcus aureus infections. Dr. Trotman says research shows that MRSA is becoming resistant to Vancomycin – a dangerous development. Through the antibiotic stewardship program, he and Steenhoek looked at how to more appropriately use Vancomycin in the hospital, to reduce this level of resistance.

They developed a program that included using Vancomycin in higher doses to treat more difficult infections, stopping its use when it wasn’t needed and educating other pharmacists on how to more appropriately dose it. After a couple of years using this model, they compared the sensitivity of MRSA to Vancomycin before this project to its sensitivity afterward. They were able to show that, while most hospitals have seen an increase in MRSA infections with reduced susceptibility to Vancomycin, CoxHealth saw fewer of these cases.

“In essence, MRSA at our hospital and in our community is more sensitive to Vancomycin than it was before our program started,” says Dr. Trotman. “We’ve changed the ecosystem of the hospital.”

While the main goal of the program is improving patient outcomes, changing the way the system uses antibiotics also saves the system money. Developing best practices and order sets for the use of antibiotics in the hospital and working to keep CoxHealth in compliance with the many regulatory requirements that touch on this issue are an important part of this process. While a specific dollar amount tied to the CoxHealth Antibiotic Stewardship Program is not available, national research shows that these programs typically save hundreds of thousands of dollars in the long-term.

Currently, the antibiotic stewardship program is focused on inpatient antibiotic use, but Steenhoek is beginning to collect data through some CoxHealth walk-in clinics. The goal is to eventually expand the program – and the program’s successes – to the outpatient setting. 

Says Dr. Trotman: “This is a progressive program for a community hospital. We have outcomes and metrics that show we’re making a difference.”

How ‘lean’ helps us serve our patients

Patient Cynthia Ernst, who works in Physicians Billing, meets with orthopedic surgeon Dr. Erin Greer for a follow-up on her recent hand surgery. The team at Ferrell-Duncan Orthopedics is successfully handling a high volume of patients thanks to a lean project that focused on streamlining the patient experience.

If you want to know how powerful lean thinking can be, just talk to someone who’s been involved in a lean project at CoxHealth. They’ll tell you lean has improved the way their department works, but they’ll also point out how the skill of mapping the steps in a process and eliminating the waste gets internalized. Once you’ve seen it applied, it colors the way you view everything. It becomes clear that lean projects don’t just make satisfied workers, they make lean evangelists.

“The lean process is so valuable, the whole system should go through it,” says Karen Miller, medical secretary in Ferrell-Duncan Clinic’s Orthopedics department at the Bone & Joint Center. Lean thinking has her looking at everything her department does and asking “is this the best way?” or “does this add value for our patients?” “Lean really teaches you to be open minded to change. Keep your ears and eyes open and don’t get stuck in a rut.”

Miller’s first exposure to her new way of thinking came during a lean project the department conducted last spring. The project was designed to help staff members handle an increasing volume of patients while streamlining the patient experience. The lean team broke down the process from a patient’s initial phone call to having an appointment scheduled – any step that didn’t add value for the patient was a candidate for adjustment or elimination. At the same time, clinic staffers identified waste in their own work processes, which they eliminated and made their own workdays more efficient.

The orthopedics project is one of several lean projects under way at CoxHealth and leaders say the lean approach to constant improvement is key to getting the most out of the resources we have and thriving in the future.

Ken Jennings, operations administrator at Ferrell-Duncan  and a lean team facilitator, spells out the need for lean in a simple equation: Volumes are up, but reimbursements are down. Quality must go up. How do we make up this difference? By improving our own processes and cutting waste and inefficiency.

“Lean projects are exactly what we need to be doing at Cox,” Jennings says. “We need all the people we have, so where do we find the resources to make it work? We have to look at and streamline every single process.”

Applying lean

At Ferrell-Duncan Orthopedics, physician turnover had left the department with fewer doctors, but the demand for orthopedic services continued to rise.

“The issue became how do we sort, separate and filter this volume, this huge need in the community for orthopedic services, in a more appropriate way,” Jennings says.

Like many people hearing the term “lean” for the first time, some staff members were leery of what applying lean thinking would mean for their work. Scott Rogers, CoxHealth’s administrative director of organizational development, says that one of the first steps to introducing a lean project is making it clear what lean is and what it is not.

Lean began as a process-improvement discipline developed by Toyota as the company sought to perfect its manufacturing processes. They created the Toyota Production System, which studies how people work and looks for ways to eliminate waste – wasted time, wasted effort and anything that doesn’t add value for the customer.

Departments like orthopedics that take on a lean project examine their own work, beginning by mapping out all the steps in a particular process, such as how patient calls are routed. The lean team will take a step back from the map and look for barriers, bottlenecks or frustrations in the system, what Jennings calls “boulders” or “stones” in the stream of daily work.

Karla Riley, certified medical assistant for Dr. Erin Greer, says mapping the scheduling process from the patient’s perspective opened the eyes of the clinical staff.

“From a clinical perspective, you think about your area, but not about the broader context,” she says. Riley says having lean team members from administration, clerical and surgical scheduling helped everyone to think beyond their individual areas of responsibility. “This puts the patient at the center and helps you see how to be more effective.”

The lean team developed what’s called a “current state map” of all the workflows in the clinic. After identifying areas for improvement, they created a “future state map” to work toward. Ideally, that future map will become their new current state map and they will develop a new future state to work toward in a cycle of constant improvement.

Chad Kuhlmann, orthopedic department supervisor, says just looking at those maps and being able to ask questions and propose solutions brought staff on board with the lean process.

“When you map everything like this, light bulbs come on,” Kuhlmann says. “The staff support was incredible. Now the team is engaged and they throw out ideas to help everybody. You see your co-workers as a resource, not as a barrier.” 

Key measurements

With the department’s processes mapped out, the lean team could see where improvements were needed to help patients access care efficiently.

They began by focusing on two priorities: streamlining the way phone calls are handled and making sure patients are scheduled with the most appropriate physician for their case. 

After identifying the issues, the team began working on ways to collect relevant data. Kuhlmann says having concrete data is key to making the lean process work. It removes perceptions and allows the team to work with measurable facts everyone can agree on. The lean team looked at two key measurements: the volume of calls coming into the clinic and the physician/surgery ratio, a measurement of how often a meeting with a surgeon results in a surgery.

Phone volume: The sheer volume of phone calls coming into the department was an obvious first target – simply hearing the way the phones rang constantly illustrated the need for a new process. 

Staff members estimated that the main line for the department was receiving 3,200 calls each month. With the previous screening method, patients were being transferred among staff before getting to the right person. It was a process that could be frustrating for patients and staffers and calls were sometimes dropped.

Kuhlmann says that as staff members scrambled to handle the phones, they were less able to handle their regular duties in the department, a fact that was beginning to show up in Press-Ganey patient satisfaction scores.

Seeking a solution, the lean team took a “gemba walk” at Adult Medicine & Endocrinology Specialists. The gemba walk is a lean tool that involves looking closely at another group’s processes to see what can be applied to the problem at hand. They discovered Adult Medicine & Endocrinology Specialists uses an automated phone system to route their incoming calls. After seeing the system in action, the team recommended adding a phone system called Agent to the Orthopedics department.

The new system includes menus and a queuing process that allows patients to answer questions and actively assist in triaging their own calls. In its first few months of use, the system has greatly improved the way patients are connected with the appropriate areas.

The Agent phone system also provides real-time tracking of call volumes, which offers hard data that quantifies a truth staff members already knew: they are busy. In the first month, the total calls added up to more than 6,000, almost double their estimate.

“We all knew we were busy, but we didn’t see the real volume until we went through this project,” Miller says.

Now, with the Agent system in place and more calls going to the right staff member the first time, the phones have become quieter.

“Well, we don’t like to say that,” Miller says with a laugh. “As soon as we say it, they’ll start going ballistic. Let’s just say they’re peachy.”

The automated phone system frees up staff members to take care of the patients who are in the office in person rather than juggling duties answering phones. Similarly, nurses in the clinic are freed up to work with their patients with minimal interruptions.

Jennings points out that the phone changes are a good example of how eliminating waste produces a synergy of benefits for everyone involved. The more efficient system speeds things up for patients and it improves both the way employees work and the overall culture.

“Transferring calls is waste, and if staff members can’t take lunch because of trying to keep up with call volumes, that’s bad for morale.”

Physician/surgery ratio: When the team began looking at the overall workflow in the clinic, it became clear that patients and physicians would benefit from a better triage system as patients first made contact with the clinic. It wasn’t just a matter of handling the volume of calls, there needed to be a standardized way to route patients into the correct path of care. Before the lean project, there were times when patients with surgical needs were placed with non-surgical doctors and vice-versa.

“Our goal is to get the patient in the right exam room at the right time,” Jennings says.

Meeting that goal is a key to providing the best patient access for the clinic – getting patients to the care they need with the most efficient use of their time and the physician’s time. The lean team began looking at how often a visit with a surgeon was resulting in a surgery. The team wanted to improve scheduling accuracy for patients and move that ratio toward 1:1, ensuring that only patients needing surgery met with a surgeon. The team found the original number to be 2.76 patients seen for every surgery a physician scheduled.

To correct the issue, the lean team designed a clerical triage process in which schedulers ask patients a series of questions and then use a decision tree to confirm the correct course of action. The team worked with doctors to develop “scope of practice” documents for each physician. Those documents, updated quarterly, detail what surgeries and treatments a physician is currently doing and they make that information available at a glance for schedulers.

“This makes everything visual for everyone to see and it keeps the physician in the driver’s seat in terms of how they want to structure their practice,” Jennings says.

A team culture

In the first few months following the lean project, numbers tracked by the department were already showing that their efforts were paying off.

Press-Ganey scores on “ease of access to the clinic” had started around 85. By the end of October, the department had gained 5 percentage points on that question. On the question about the ease of reaching the clinic by phone, the numbers rose from the 81-82 range to the 88-89 range.

“The data reflects a positive change,” Kuhlmann says. “The patient is more in control than before and that’s a satisfier.”

Equally important is the change the project has made for the culture of the staff. The project has engaged staffers from throughout the department and given them a voice in ongoing efforts to improve their workplace.

Miller says the regular meetings offered a positive setting for staff members to discuss issues and find solutions together. She says there’s a real fellowship among co-workers and with their leaders.

“If you’re invited to join a lean project, say ‘yes’ and get involved,” Miller says. “It’s amazing. Instead of being told ‘here’s how you’re going to do it,’ the people who do a job every day have real input on how it should be done.”

Jennings says that’s what makes lean so valuable, and so empowering for the front-line staff who help drive the improvements. 

“The people who actually touch the work being done know where the barriers are and they know what the solutions can be,” he says. “We just bring the tools so they can remove those barriers to providing better patient care.”

The team is currently focusing those tools on the clinical side of their practice. Remember those maps of the current state of processes the team developed at the beginning of the first lean project? They included what’s called a “parking lot” – a space for additional issues that fall outside the scope of the current project. The items noted there are now forming the basis of a second lean project that is tracking the entire process of care a patient goes through. 

Team members are excited about the possibilities lean thinking brings as they look at the entire scope of care from the patient’s perspective. They know they’ll find ways to make things better for the people we serve every day.

Riley says: “Everything you do is for the patient and increasing value for the customer.

“Satisfied customers improve the bottom line and we want to provide the best care we can provide. That’s why I went into health care, I want to take care of people.”

About lean

Lean thought has its roots in a process improvement discipline developed by Toyota. While it began in the world of manufacturing, the lean approach can be used to examine and improve a variety of work processes. Here are a few of the terms you’re likely to hear as lean projects are deployed at CoxHealth:

Muda: A Japanese term for an activity that is wasteful and doesn’t add value.

Gemba walk: When leaders examine first-hand how work is done on the front lines. They’re visiting “gemba,” or “the real place” in Japanese.

Value stream: All the steps in a process of producing or delivering a product or service. Value streams are mapped to show the flow of information and work in the process. How work is carried out at the beginning of a lean project is defined on a current state map while a goal for how processes could be improved is spelled out in a future state map.

Friday, January 20, 2012

CoxHealth responds to fire at Missouri Hotel

Updated 5 p.m., Jan. 23:

Our efforts to temporarily house Missouri Hotel residents at Cox North continue to go smoothly. 

Staff from multiple departments including EVS, Security, Engineering and Volunteers continue working hard to ensure we have no significant challenges.Busses from Springfield Public Schools picked up the children staying at Cox North this morning and transported them to school. 

Eighty-one displaced residents from the Missouri Hotel are now settled into 23 rooms on L200, L300 and L400 at Cox North. CoxHealth staff have been working hard since Incident Command was activated at 11 a.m. Friday morning to help ensure a smooth transition to temporary housing for these families.
Staff from the Missouri Hotel and local Red Cross chapter are also at Cox North tonight and will be on-site for the duration of this event. The CERT team and Greene County OEM are at Cox North as well, helping to manage the situation. 
The latest reports state that the Missouri Hotel is expected to reopen at the end of next week. In the meantime, we have established a phone line, 269-2690, that members of the community can call if they need to reach a Missouri Hotel resident staying at Cox North. A staff member will take a message that will be posted on a message board for the residents. A public phone to make local calls is available for the residents' use. 
Missouri Hotel residents will take their meals, provided by the Red Cross, in the old Emerald Garden Café area. In the near future, food support will transition from the Red cross to Franciscan Villa. 
Rehabilitation of the Missouri Hotel is under way and going well. The staff anticipate some rooms will be available by mid-week and are anticipating return of the Cox residents within the week. 
The situation continues to evolve and we will share more details as they become available.
How to help
The Kitchen, which operates the Missouri Hotel, is asking for cash donations or gift cards to help residents with immediate needs and with repairs. Formula and diapers top the list of immediate needs.
Those wishing to donate can call The Kitchen at 837-1500 or donate online at

Friday, January 13, 2012

Cardinals players visit kids on Pediatrics

Cardinals Jason Motte and Mitchell Boggs along with Cardinals' alumnus Jason Simontacchi stopped by Pediatrics at Cox South this afternoon. The trio, who were in town for the Cardinals Caravan, met with young patients and signed hats and souvenir bats for patients and staff.

Friday, January 6, 2012

Free program for runners, taught by local experts

Running is great exercise. But you can get even more out of your running program year-round if you properly train for the sport – and train for the weather.

To help, CoxHealth will present the free program “Cross Training and Cold Weather Training for Runners,” Saturday, Jan. 28, from 9 a.m. – 11 a.m.

This program includes both a lecture and lab component. During the lecture, Dr. Shannon Woods, board-certified and fellowship-trained sports medicine physician, will discuss cross training, muscle confusion and injury reduction. Mark Millsap, MEd, RRCA-USATF certified coach, will give tips on cold-weather running including proper gear. Then, CoxHealth experts in physical therapy, athletic training and fitness will be on-hand during the lab session, where you can learn more about plyometrics, strength training and cross training – and participate in a Q & A with Dr. Woods.

This program will be held in The Meyer Center Conference Room, 3545 S. National. Please call 269-INFO or visit for more information and to register.