Dermatology Division Retreat 9/28/12

Minutes of UW Dermatology Division
Retreat9/28/2012

Dr. Olerud welcomed everyone and made introductions: New residents, fellows and faculty:

Laura Swanson, Alice Zhao, Soyeon Lippman, Angie Hertz, Renata Jenkin and Jennifer Gardner

State of the Division:

Dr. Olerud reviewed division financial summaries that were included in everyone’s packet.

Dr. Olerud reminded the division that there is a search committee being formed to seek out a new division head in the next 15 months.

Paul introduced research trainees and they spoke briefly about their work.

UPDATES FROM DIVISION SITES

Roy Colven: HarborviewMedicalCenter Update

Roy introduced Tracy Boyd, Clinic Manager, and Julie Sniadowski, Business Operations Specialist for 3 West Clinic Medical Specialties.

Phil Kirby is retiring November 7th (last day in office is Oct. 31). Meredith Sheedy will be hired at 0.35 FTE effective January 9. Roy will pick up the slack that remains.

Heike Deubner (Pathology) is leaving HMC in fall 2012. Dermpath will be sent to UWMC so they will not have an on site person.

Patient volumes remain high. They are barely covering patient needs. Wait times are 3.5 months for new and f/u patients and 6 – 8 weeks for procedural derm patients.

They cannot tap in to patients with richer payer mix.

29% of patients require interpreters (live interpreters are preferred).

HMC has contracted with WA State Dept of Corrections for teledermatologyservice provided by Dr. Colven (approx. $500 / patient)

Dr. Olerud reports that SOM is going all out to increase telemedicine so this will be coming our way.

Dr. Colven is unsure what impact healthcare reformwill have at HMC.

Linda Chang: VA MohsUnit Update

Derm Surgery used to work out of 1 room. Now there are 5 procedure rooms (shared by Plastic Surgery and others.

Linda reports an improved delivery of care resulting from now having 3 nurses and a dedicated patient care coordinator.

The VA still needs to hire histotechs and provide training. These classifications are hired within the Path Dept at the VA.

A slow ramp up planned with one day per week of Mohs surgeries initially.

Dr. Olerud reports Bill Campbell is fully supportive.

Catherine Cordner: UWMCRooseveltDermatologyCenter Update

Financial overview was presented. UWMC Derm bills $6 million and collects $3 million; generates $1.4 million contribution margin to UWMC.

Andrea and Andy spoke aboutAIDET (a piece of Patient First initiative):

  • Acknowledge the patient and others in the room
  • Introduction: Give your name and # years of experience or skill set or certification
  • Duration: describe how long the biopsy/procedure will take, etc.
  • Explanation: use language that is understandable to the patient
  • Thank the patient for coming and ask if their questions were answered.

The current payer mix at Roosevelt is 55% commercial, 8% self pay

Patients are Firstinitiative rates the following items:

  • Patient Rounding (managers poll patients)
  • Wait Times in Clinic (wait times are now posted outside exam door)
  • Late Charges
  • Patient Access to Specialty Care
  • Test Results Notification (patients will be notified of test results within 2 weeks)
  • Patient Satisfaction Scores

Patients do not mind waiting too long, so long as they are informed and

kept up to date (communicated with)

Internal referrals for FY12 were298. The projection for FY13 is an increase to 370. The largest referral source is UWNC.

Cosmetics update: The derm surgery clinic staff no longer does injectables. They perform laser hair removal, tattoo removal and V beam.

Site updates from Greg Raugi and Rob Sidbury are provided as handouts since they were absent.

MAJOR INITIATIVE UPDATES

Department vs. Division (Phil Fleckman and Kyle Garton):

It was pointed out that 8 of 16 faculty are “under 40.”We need resources for young faculty (to retain as well as hire).

Kyle shared Gary Woods story of Dermatology Division at Wisconsinbecoming a department in 2001.

  • Faculty growth from8 faculty to 24 faculty
  • An increase in endowments from $0 to $9 million
  • Addition of a MOHS unit
  • Addition of DermPath
  • Can take up to 10 years to complete a successful transition (worst case)

In comparison, at Duke it took 3 years for the first transition;the second transition took only 9 months!

New Practice Sites(Andrea Kalus):

Dr. Kalus agreesthat we need to get a handle on our economic situation.

UWMC did an analysis that showed patients on the Eastside are going elsewhere for care.

Neighborhood clinics are a non-hospital based site so there is no facility bill.

Eastside Specialty Clinic (ESC) is a non-hospital based site with no facility bill. There are plans for dermatology to share space at the new ESC site with Cardiology, Gastroenterology, Diabetes/Endocrine. They use EPIC and EMR at ESC. In this model the space is rented ($197 per exam room per half day). The site keeps 30% of collections and provides an MA. There are 30 exam rooms planned but no physician offices. There will be radiology (full MRI capability) and a lab. Financially we would be better off in the ESC than in a Neighborhood clinic.

NW Hospital reportedly has lots of space. Valley has 8 patient care clinics.

A comment was made that we should move faculty based practice to one of these 3 sites and leave the complex practice at UWMC.

Dr. William Bremner Presentation

Dr. Bremner sent out an announcement today to Division Heads about Dr. Olerud’s plan to step down as Division Head in approx. 16 months (Feb 2014). He also sent out a letter inviting faculty to sit on search committee for the next Dermatology division head.

Dr. Bremner reviewed Department of Medicine finances and provided slides with data on research, endowments, gifts, state funds, practice plan, etc.

Endowments in the department grew from approx. $25 mil in 1998 when he began as Chairman up to $80 mil. After the decline in the stock market it is now about $70 mil. (Dermatology makes up about 12% of this endowment total.)

Indirect costs from research results in about 6% coming to School of Medicine and 3-4% to the Dept of Medicine. It is then proportionately distributed to the Divisions based on their research dollars. A portion is retained by the Dept for faculty recruitment/retention and departmental administration.

The number of faculty in the department is now at about 900. There are a number of open searches ongoing in the department.

Data was shared about faculty salary averages by ranks. There is potential for retention increases for faculty but requires special act of the state legislature on a case by case basis.

Kyle asked Dr. Bremner for advice on how we might be able to generate revenue like the Dermatology program at Wisconsin. They have considerable endowments and are able to help fund resident education. Dr. Bremner speculates the Wisconsin program probably includes major revenue stream from dermpath. He suggested we should first determine what our main mission is and whether we want to grow to be a major competitor in the NW. If that is our mission then he suggests we increase the number of clinicians and do more MOHS.

Hospital funded positions have grown from $3-4 mil at UW to approx. $55 mil per year for HMC/UWMC. Many programs are falling back on hospital funded agreements.

Donna suggested that if Derm wants to grow our division that we may be able to explore opportunities at NW, Valley and the Eastside.

Andrea commented that we may want to consider taking incremental steps to grow our division by “X” number of FTE per year to get to our ultimate goal whatever that may be.

Dr. Bremner said he will be happy to discuss with us what our future goals are and if it turns out that we want to grow our division how to go about achieving these goals.

Accountable care organization (ACO) vision statement – strong push to reduce total costs of care while improving service and quality.

Dr. Bremner mentioned UWMC is currently in discussion with Boeing to contract directly with Boeing to provide health care.

Studer’s “Patients are First” is aprogram being implemented at UW Medicine that faculty have been hearing about. Dr. Bremner is cautiously optimistic that it will be beneficial to our institution.

Dr. Bremner gave an update on the MedicalCenter(MontlakeTower) and Eastside Specialty Clinic construction projects. There are numerous things being addressed as part of the increase in space such as:

•Interdisciplinary Care Teams

•Rooms that adapt to variable acuity

•Consolidation of spaces based on care delivery

•Point of Care Supplies

•Maintenance of line of site for patient safety

•Cleanable (Infection Avoiding) environment

•Quiet Ambient Sounds

•Decentralized nursing stations

•Clear access from key support areas to inpatient areas

•Integration of data and video into all procedure rooms

MontlakeTower (new completed construction)

Phase I

•NICU (47 beds, 14 are incremental, with an OR)

•Oncology Inpatient Unit (30 beds)

•Radiology (Angiography, MRI, CT, Ultrasound)

•Support Space (mechanical, education, loading dock)

•Shell Space (3 future inpatient units, future ORs)

Phase II (accelerated completion of space)

•Intensive Care Unit

•Medical Surgical Inpatient Units

•Operating Rooms

Phase II – Additional Projects / Renovations of Existing Space

•Connections to MontlakeTower

•ORs and related support space (Prep & Recovery, Waiting)

•Oncology (Infusion, Satellite Pharmacy Support, Clinic)

•Neurology (EEG, EMG, Clinic)

Eastside Specialty Clinic (ESC)

The current ESC lacks sufficient space (8,300 sq ft) to meet increasing needs of UW Medicine Eastside patients being referred for secondary specialty care. As a result, UW Medicine patients often go outside of our system to other systems on the Eastside. Priority has been given to relocate the ESC and renovations will begin soon in a building located one mile from the current ESC. The address is 3100 Northup Way and includes 33,492 sq ft over two floors with 126 parking spaces. The specialties identified for this space are Cardiology, Gastroenterology, Dermatology and Endocrine/Diabetes.

There was discussion about how Dermatology faculty should be compensated for providing inpatient consult service. Donna mentioned it is a problem across all specialties. Dr. Olerud will continue to have discussions with Dr. Bremner to brainstorm about this topic.

Kyle asked Dr. Bremner what he thought about bringing dermpath into the derm division. He would be all for it but he understands it would likely involve a major battle to do so.

There was discussion about the cost of dermpath in our facility based practice and whether or not we would have the option for ESC to send dermpath to an outside lab or if it must be sent to UWMC Path. It is strongly encouraged to send the dermpath cases to UW.

Kyle commented that if we are going to staff the ESC we need to explore our options about dermpath. Could we build dermpath into the ESC equation? Could we send dermpath to outside practice?

Donna said the charge structures vary within HMC and UWMC. We should get our information straight,think broadly and not limit our thinking about how we should build dermatology.

Division Head Search

Dr. Bremner explained that another division head is tasked with heading the search committee for the new dermatology division head. Dr. John Edinome, Gastroenterology Division Head, will Chair the committee. Several dermatology faculty have been invited to participate in the search committee. Suggestions can be forwarded to Dr. Bremner for additional committee members. Ads will be placed in journals in the coming weeks. Faculty is encouraged to submit names of potential candidates. Typically the top 3 candidates will be invited to Seattle. The process typically takes 18-24 months.

Dr. Colven asked whether or not this transition to potentially become a department should be part of the package or leverage for the potential transition. Dr. Bremner is neutral on this topic and believes it is working very well as a division but has no objections if it is the will of the faculty and there is a sensible plan for becoming a department. There are lots of ups and downs to consider, one being that we would be one of the smallest departments in the School of Medicine. Currently there are 30 departments in the school. Another consideration is the additional substantial amount of administration involved for a department and the significant increase in administrative staff it would take to run a department. Whether there is a benefit to become a department is open for discussion.

Dr. Colvenmentioned the general trend seems to be for divisions to become departments and in looking at this trend wonders if we are missing out on something if we do not become a department.

Dr. Bergsummarized the concept that we are coming to a fork in the road as Dr. Olerud steps down as division head. There are two directions to consider whether we go forward as a department or as a division: incremental growth as we have been doing or taking a more robust growth. He asked if the department would support the robust growth approach if we were to stay as a division. Dr. Bremner confirmed he would support this approach.

Donna Devine recommends the search committee to work hard to get the best athlete for the new division chief. The candidate can work with the division toward becoming a department if that is determined to be the wishes of division faculty.

GROUP REPORTS

Group I- Strengthen Dermatology Faculty (John Olerud, Greg Raugi)
2012 group members: Sandy Barnes, Lauren Biesbroeck, Melinda Hughes, Sue Montgomery, Brenda Newman, Jonathan Olson, John Zhang, Rob Sidbury, Stephanie Timm

The 1st discussion topic was efficiencies.

Roosevelt is utilizing nurses and MA’s to expand physician tasks. Culture has changed.

Kyle spoke about how he is working with residents to think about efficiencies – i.e., how can we leave by 5:30pm with our work done? He is building doc phrases – things that are efficient. He would like a way on his iphone to call and leave a voice mail forhis MA to call patient with results and document that it was done.

Nic spoke about what efficiencies they are working on at the VA. The physicians have been doing all follow-up since they have staff on leave or who have left. Melinda is their only administrative staff. The improvements made at the VA entail creating a safety net/safety line to be sure patients that have something done do not fall through the net. They created a new electronic follow-up system (green book went away). The database will now pull data from the CPRS system so they won’t have to enter so much information. Nic created a system to follow-up on patients seen by family practice residents and internal medicine residents. CJ was following up on those biopsies and labs. He created a document based on pathology diagnosis, exactly what should be said to the patient. CJ or another staff can provide follow-up.

Brenda Newman raised concern about efficiency. It’s a requirement to provide follow-up information to patients but she thinks the best solution is to put staff in charge of providing patient follow-up and the documentation that they have done so. For example, Dan Berg’s nurses manage his follow-up book which is a very effective and efficient practice.

The next topic of discussion for this group was the issue of changing faculty titles. Currently there is no differentiation between volunteer faculty who have limited involvement and those who are full-time paid or part-time paid clinical faculty or those who make significant contributions to our program. The group proposed two titles: Volunteer Faculty and Clinical Faculty. (Consideration of a “stewardship” title was explored and determined not to be a viable title.) Those with a clinical faculty title will be promoted through the ranks as usual. Those with the volunteer title will not be promoted.

The proposal from the group is as follows:

Clinical: those who work between 10% and 49% and are paid (such as Michi and Kyle)will be retained in the clinical faculty title and those who work 50% or more will retain the clinical faculty title. Faculty who make significant contributions such as Dan Lantz and Mark Valentine who are regular contributors but are not paid will retain the clinical faculty title (this will be determined on a case by case basis with a required or definedlevel of participation).

The volunteer title would include everyone else. They are giving of their time but not in a significant way. The criteria are outlined for each title– see below.

Clinical Faculty Criteria:

>10% - 100% Paid

Significant Contributions / High Impact

Grandfathered in / case by case basis

Faculty Consensus

Evaluated Regularly

Volunteer Faculty Criteria:

Less Significant Contributions

Available for Med Students/Residents

WWAMI

In Derm clinic or other training sites

HuBio only

Few clinics/year

Must re-apply if inactive >2 years

Eligible for Baker award

Application Process (letters, etc.)

Evaluated Regularly

Discussion:

Philip Fleckman reminded us of the need to obtain evaluations for all faculty whether volunteer or clinical. It is a requirement for the promotion process. Even though the volunteer faculty will not be promoted we should obtain feedback on their performance/professionalism, etc.