The Middleboro Casebook: Healthcare Strategy · The Middleboro Casebook: Healthcare Strategy and Operations can be used in many different ways. For example, the information presented

Copyright 2014 Health Administration Press

This is a sample of the instructor materials for The Middleboro Casebook: Healthcare Strategy

and Operations. The complete materials include

a 130-page instructor manual containing detailed information on how to use the book,

teaching notes, suggested assignments, and additional material on effective presentations

and business plans

32 Excel tables (also available to students at http://ache.org/books/Middleboro)

This sample contains the following pages from the manual and Excel tables:

complete Preface (pages 1–2)

complete Table of Contents (pages 3–4)

complete Section I “Using Middleboro” (pages 5–20)

two sample pages from Section II “Teaching Notes” (pages 21–22)

four sample pages from Section III “Suggested Assignments”

o two sample pages from “Assignment Questions by Case” (pages 37–38)

o sample page from “Assignment Questions by Subject” (page 63)

o sample page from “Assignment Questions for Companion Textbooks” (page 78)

sample page from Section IV “Other Materials”

o sample page on effective presentations (page 118)

two sample Excel tables

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as an instructor

You will receive an e-mail containing access information after we have verified your instructor

status. Thank you for your interest in this text and the accompanying instructor resources.

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Preface

Middleboro is a flexible and highly integrated case study focusing on strategy and operations of seven healthcare organizations (two hospitals, a long-term care facility, a home health agency, two physician group practices, and a local health department) located in and around the community of Middleboro in Hillsboro County. Students are introduced to the community, and its demographic, socioeconomic, political, epidemiological and environmental characteristics. It enables students to analyze the community in detail, focusing on those factors that drive the need for and use of healthcare services, as well as framing the strategic decisions made by healthcare organizations as service providers. Students are presented with information about a specific healthcare entity, including its history, governance, organizational structure, programs and services, finances, and particular issues and challenges. Challenges are presented to improve quality, lower cost, and enhance access.

Section I Using Middleboro

Presents many issues and suggestions related to problem based learning and case method teaching applied to this case. This section includes using assignment letters, case assignments to create the “problems” for student attention. Using the case across a curriculum is also discussed. This section also includes the authors’ perspectives on using the Middleboro Case in a recent baccalaureate membership review with the Association of University Programs in Health Administration (AUPHA) and in an accreditation review by the Commission on Accreditation of Healthcare Management Education (CAHME).

Section II Teaching Notes

Provides short essays that describe what the instructor needs to know to use these cases effectively. They are our attempt at providing instructional insight.

Section III Suggested Assignments

Provides recommended assignment in two categories: assignments for each individual case (e.g., Webster Hospital) and assignments by subject (e.g., marketing). Section III is a library of assignments that can help by providing the question(s) you need or providing support for you to author your own question(s). This section also includes specific assignments designed to integrate Middleboro as a supplement to select Health Administration Press textbooks.*


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Section IV Other Materials

Includes additional references on effective presentations and business plans.

Our hope that these sections will help you use The Middleboro Casebook: Healthcare Strategy and Operations to accomplish your instructional objectives. Just for the record, Middleboro, Jasper, and Hillsboro County are not located in either New Hampshire or Colorado. Lee F. Seidel, Ph.D. Professor of Health Management and Policy College of Health and Human Services University of New Hampshire Visiting Professor Executive MBA in Health Administration Program School of Business University of Colorado, Denver James B. Lewis, Sc.D. Associate Professor of Health Management and Policy College of Health and Human Services University of New Hampshire

*This book is available in e-book format at CourseSmart, CafeScribe, and Kno. Rental access is available at CourseSmart and Kno for 50% off the print list price. Perpetual access is available at CafeScribe and Kno at list price. For more information, please visit one of these preferred partners or contact us at [email protected].


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Instructor Manual Preface Table of Contents I. Using Middleboro II. Teaching Notes

A. The Community B. Hillsboro County Home Health Agency C. Physician Care Services D. Webster Hospital E. Middleboro Community Hospital F. Medical Associates G. Jasper Gardens H. Hillsboro County Health Department

III Suggested Assignments by Case and Subject

A. The Community B. Hillsboro County Home Health Agency (HCHHA) C. Physician Care Services (PCS) D. Webster Hospital (WH) E. Middleboro Community Hospital (MCH) F. Medical Associates (MA) G. Jasper Gardens (JG) H. Hillsboro County Health Department (HCHD)

I. Community Health and Epidemiology J. Economics K. Financial Management L. Human Resources M. Information Systems N. Law and Ethics O. Management and Organizational Behavior P. Marketing Q. Policy R. Quality Improvement S. Statistics and Quantitative Methods T. Strategy and Strategic Planning

U. Dunn, R. T. 2010. Dunn & Haimann’s Healthcare Management, 9th ed.

Chicago: Health Administration Press V. Gapenski, L. C. 2012. Healthcare Finance, 5th ed. Chicago: Health

Administration Press


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W. Gapenski, L. C. 2013. Fundamentals of Healthcare Finance. Chicago: Health Administration Press

X. Olden, P. C. 2011. Management of Healthcare Organizations: An Introduction. Chicago: Health Administration Press.

Y. Thomas, R. K. 2010. Marketing Health Services. Chicago: Health Administration Press.

Z. Walston, S. L. 2014. Strategic Healthcare Management: Planning and Execution. Chicago: Health Administration Press.

AA. White, K. R. and J. R. Griffith. 2010. The Well Managed Healthcare Organization, 7th ed. Chicago: Health Administration Press.

AB. Zuckerman, A. M. 2012. Healthcare Strategic Management, 3rd ed. Chicago: Health Administration Press.

IV. Other Materials

A. Effective Presentations B. Business Plans C. Sample Course Syllabi


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Section I Using Middleboro

In the varied topography of professional practice, there is a high, hard ground overlooking a swamp. On the high ground, manageable problems lend themselves to solution through the use of research based theory and technique. In the swampy lowlands, problems are messy and confusing and incapable of technical solution. The irony of this situation is that the problems of the high ground tend to be relatively unimportant to individuals or society at large, however great their technical interest may be; while in the swamp lie the problems of greatest human concern. The practitioner is confronted with a choice. Shall he remain on the high ground where he can solve relatively unimportant problems according to his standards of rigor, or shall he descend to the swamp of important problems where he cannot be rigorous in any way he knows how to describe.1

The Middleboro case includes pages of information and data on a fictitious geographic area and its healthcare system(s). It is a realistic and plausible microworld designed for students—baccalaureate or graduate. It is comprehensive and provides students opportunities to make recommendations and decisions based on the systematic consideration of the realistic data. It does not have a specific theme or pre-determined solutions. We believe it meets Schon’s criteria as a “swampy lowland” just waiting for students interested in improving the effectiveness and efficiency of a health service delivery organization. There are no real outcomes that need to be considered. Middleboro is like Garrison Keillor’s Lake Wobegon. The case and the organizations were created to help integrate and apply theories and models learned is specific courses, such as medical care organizations, marketing, finance, epidemiology, financial management, health law, organizational behavior, health economics, law, medical sociology, and health policy. Although fictitious, however, the information in the entire case is realistic and plausible and is periodically reviewed by senior professionals to ensure it remains realistic and plausible. The Middleboro Casebook: Healthcare Strategy and Operations can be used in many different ways. For example, the information presented in the case may create a need for students to do additional research on a particular issue or practice. As just one example, Middleboro Community Hospital’s board of directors has 14 members, each of whom is elected for a four-year term with no limitations on the number of terms that can be served. In contrast, Webster Hospital has a much smaller board of trustees (eight members), each serving a four-year term, but with a limit of two consecutive terms. The expertise represented on the two boards also varies. The different approaches taken to governance structure by these two acute care

1 Schon, D. A. "Knowing-in-Action: The New Scholarship Requires a New Epistemology," 1995, Change, November/December, 27-34.


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hospitals can be employed by course instructors to require students to complete research related to different models and practices of hospital governance. Middleboro contains many opportunities to force students to complete external research related to truly understanding the complexity of the issues raised in the case. Students can be required to write a research paper related to the topic being explored, and in any case, this focused research will lead to a deeper understanding of the material. Even if no research paper is required, presumably, the fruits of a student’s research will be reflected in richer, more participatory class discussion. Case study analysis (either written or through oral presentation) relies less on a student’s ability to memorize and feedback details to an instructor, and more so on requiring students to ask questions, identify issues and problems, analyze and problem solve, all within a realistic community setting.

Middleboro as Problem-Based Learning

Middleboro is designed to support problem-based learning. We know that how we teach is as significant to student learning as what we teach. Some say that student learning is like dry ice, it evaporates very quickly and leaves little residue. Many regard problem-based learning as the pedagogy of choice to assist students develop competencies and more effectively bridge between the academic and professional setting. For example, there are many ways to teach about “meaningful use” as a federal parameter associated with medical information systems. You can assign readings, quiz and test the students or even have them present a paper on the topic. An alternative pedagogy is to assign the student a problem based on meaningful use. Research suggests that student retention and competencies are best established based on problem-based approaches.2 Student abilities are the acid test of any educational experience. Regardless of what is taught, unless the curriculum has imparted intended lasting competencies, the educational experience is a failure. Problem-based learning challenges the student with a problem.

Middleboro Cases Are Interdependent

The Middleboro Casebook includes a considerable amount of quantitative and qualitative information presenting a comprehensive (and realistic) framework for the scenarios. As a result, in assessing opportunities or challenges within Middleboro, it is essential that all types of information be considered. In many key cases, an individual introduced in a particular case may be married or otherwise related to other individuals in the community. The most talented and observant students will factor such relationships into their analysis. Assume that people sharing a last name are relatives.

2 For those interested in relevant research and the use of PBL in professional education we suggest Cooke, M., D. M. Irby, and B. C. O’Brien (2010) Educating Physicians: A Call for Reform of Medical School and Residency. San Francisco, CA: Jossey-Bass.


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The cases are designed to reflect the forces that influence strategic decision making. These forces are interrelated, evolving, and may come from external drivers. For example, while the town of Middleboro has been the central hub of activity of the county for decades, the environment is changing. Middleboro’s economy has experienced steady erosion in many areas, its population is aging, and much of the area’s growth and development has taken place south of the center of town and redirected the focus of the overall community to Jasper. This evolution presents a challenging set of circumstances for Middleboro Community Hospital that, for years, has focused almost entirely on Middleboro. Webster Hospital, on the other hand enjoys a somewhat more favorable position, due to its location, but also due to the more aggressive strategies the organization has employed. The situation is fluid, however. A new highway is coming into the area that has the potential to divert business activity (including healthcare) away from Middleboro and Jasper. In thinking strategically about the opportunities and challenges facing the area, management of all healthcare organizations need to take into account aspects such as demography, epidemiology, economic, competitive/market, financial, etc. The cases present opportunities for role-playing in discussion or presentations, requiring students to view a situation through a different lens, and to support a position with which they may not be familiar or that they do not personally support. The Middleboro Casebook also stresses the importance of the local community. In 1973 Ray Brown of Duke University, a founder of our field, wrote about the need for managers to develop consensus between the healthcare organizations they manage and the local communities served by their organizations. This case demands sensitivity to local events, circumstances, and issues and provides the opportunity to develop plans and strategies that articulate this local dimension with national issues and forces related to managing health services. In this case—just as in professional practice—it is impossible to exclude the local dimension from health services management. The case provides multiple opportunities to recommend what should be done specifically as well as part of a longer-term positioning strategy.

The Authentic Capstone Experience

The text lends itself well to use as a capstone course and curricula experience intended to integrate learning. Each of the individual case studies includes aspects related to the wide variety of topics covered in a health management/policy curriculum. The extent to which students can recognize and use what they have learned in earlier courses within a curriculum can be evaluated by using the cases. For example, asking students to assess the feasibility/desirability of developing a new service line or to aggressively target a new market will require students to employ theories, approaches, and techniques presented in several courses taken earlier in the curriculum: strategic planning, accounting and finance, management, marketing, epidemiology, and so on. Assessing students’ capabilities in these distinct, functional areas, provides excellent feedback to a program and its instructors in evaluating program effectiveness, and identifying areas in need of further attention. To this end, if the course involves students making presentations on the material/questions on the materials, it can be particularly useful to include the instructors of the original course in the


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presentation. This direct observation of how well students are able to call on tools and skills presented in the earlier courses can be an extremely illuminating if humbling experience for instructors. In using the case studies, instructors can require students to go into a considerable analytical detail, or to simply address issues at a more superficial level. In effect, the course is like a series of analytical doors. As students complete their analysis on a particular topic and pass through the doorway, they are likely to encounter another doorway shortly down the hallway that requires additional analysis. Instructors can determine the level of analysis expected from students; i.e., they can determine the number of doorways through which students must successfully pass. Our experience continues to question whether traditional student internships are integrative.3 Do internships require students to rely on insights and skills included in the academic curriculum? While we have great respect for internships to help students learn and develop professional skills and insights, we have yet to encounter serious consideration of the consequences of the breadth of the internship experience. To be integrative, we argue that the student’s experience must challenge students with problems and issues drawn from across a curriculum, not just based primarily on one or two courses. As such we argue that a Middleboro-centered capstone experience is educationally superior to using internships and practica for capstone integrating experiences. The Middleboro-centered capstone experience allows faculty to specify and control the problem-based learning. Internships and practica can provide invaluable learning typically in specific areas. These types of educational experiences are especially challenged by macrolevel competencies.

The authors of the book typically require students to make an oral presentation of analytical findings, results, conclusions, and recommendations. This format enables instructors (or other members of the class) to ask contemporaneous questions of the presenter(s). This approach lets instructors assess how well students actually understand the material they are presenting, as well as evaluating their response to unexpected questions; that is, how well they can think on their feet. The authors of the book tape student presentations and meet with student presenters to debrief them on matters related to the substance of their presentation as well as their presentation style. This process has proven to be rather stressful, but, by their account, extremely valuable for students.

You Know Your Students Best You also know your specific learning objectives. As such, you will need to tailor this

case to your specific needs. This tailoring will not require that you change the case. Instead,

3 Seidel, L. F., R. D. Gorsky, J. B. Lewis, and D. A. Pearson. (1992) “Integrating a Curriculum: The Role and Function of a Capstone Course.” Journal of Health Administration Education, 10: 2.


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you tailor the case to your needs using specific assignments, assignment letters and curricular approaches.

Most agree that one cannot be an accomplished musician by merely studying music. One needs to practice and perform on the professional stage. We find this adage helpful. It reminds us that students approach their integrating experience with a focused repertoire created by study of specific methods, models, and issues. They face integration with both excitement and fear.

We remind our students that integrating—developing their managerial repertoire and applying it to realistic issues—is a challenging test for everyone. Few get it right the first time. Remember that truly integrating learning is the student’s responsibility; faculty can only provide the opportunity, support, and general direction. Most students—regardless of their background—love and hate this case. For some, it has too much information; for others, not enough. Over many years, however, most students agree that using it has validated, changed, and sharpened their professional skills, values, and insights as they strive to be a proficient manager of organized health services. Health services management requires preparation involving both education and experience. Our intent remains to provide some of each.

Assignment Letters There are no specific assignments included in the actual Middleboro case. Based on your decisions, you make the assignments in keeping with your learning objectives. One of your choices is to use an assignment letter. The assignment letter is a formal memo that transmits specific assignments to students. At the University of New Hampshire we use assignment letters in our senior level baccalaureate-level capstone course that serves our very traditional college age students. Subsequent sections of this manual provide examples and multiple assignments for your consideration. Assignment letters allow faculty to direct their students to specific problems and issues. We have found that less-experienced students need the structure provided by assignment letters. At the University of New Hampshire students working in three- or four-person teams answer two assignment letters with a formal oral presentation. A copy of the syllabus for this course is included in Section IV of this manual. An assignment letter (really a memo) is a formal assignment with a great deal more detail. The following is an example. It frequently includes data—for example, specific financial benchmarks for students to use to assess this specific medical group. Note the assignment letter is from a specific organization in the case—in the following example, the multispecialty group practice. It is addressed to a specific group of students and directs the students to complete specific types of activities.

Date To: Teams E & F


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From: Dr. R. Samuels President, Board of Directors Medical Associates The board of trustees has decided to retain outside consultants to assist with a strategic assessment and planning process currently being undertaken by the board and senior management. You will need to begin your formal oral presentation with a general assessment of our strengths, weaknesses, opportunities and threats. On completion of this assessment, provide a formal response to the following specific expectations: A. Utilization Analysis and Issues Analyze the utilization of our programs and services. Are there significant patterns associated with the group’s utilization data? Provide a three-year forecast of demand and utilization, beginning 2015. Indicate all assumptions and methods built into the forecasts. Your analysis should help us to answer these questions: What are the relevant characteristics of Medical Associates’ patients? Are there market implications associated with these characteristics? B. Internal Organization and Management Walter Graham has recently recommended that Medical Associates recruit and hire a deputy executive manager for human resources. His rationale is that “this portion of my position has grown and continued to take valuable time away from my other duties, including being the comptroller for the corporation.” Graham has stated that his job responsibilities, including attending all board and board committee meetings, “exceed his ability to function effectively.” On discussion with Graham it was agreed that an outside consultant would review the internal organization and management of Medical Associates. Note that at least two members of the board believe that “we spend too much on administration already…” Present an organizational chart of the current organization and (any) revisions you believe appropriate. Include this for all changes. Also, should Medical Associates be organized into two distinct operating entities by service area or remain as an integrated organization? Should the management team be expanded or changed to meet current and anticipated future requirements? Assess also the costs and benefits of all associated recommendations. C. Financial Analysis Review all facets of our finances including an analysis of the organization’s liquidity, capital structure, solvency and profitability. How does our payer mix affect the financial health of our medical group? What strategic opportunities and challenges are presented by the existing (and the likely future) payer mix? Benchmarks for our financial ratios can be found at www.unh.hmp.


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D. Realty Trust Medical Systems, Inc. We have been contacted by this organization to determine our interest in selling our physical facilities to them and then leasing them back for our continued use. They have asked to make a presentation to our board. If we agree, please provide us questions we should have them address as part of their presentation and preliminary estimates of the financial costs, benefits, and other implications associated with this type of action. Please present your findings and recommendation using a formal oral presentation to our board. Copies of all Power Point slides should be made available to all attendees at the time of your presentation. You will have one-hour on ____________.

As you can see, this type of assignment letter is very specific and can include additional data (e.g., www.unh.hmp) and/or additional plausible scenarios (e.g., D) not included in the master case. Examples of assignments for assignment letters are included in Section III of this manual. The Case Assignment In contrast, a case assignment is a macro assignment. The following is the case assignment used in capstone course in the executive MBA in health administration at the University of Colorado (CU), Denver.

The board needs recommendations concerning the operation, structure, strategic direction and position, and—if appropriate—the governance of this organization. Overall, what is your assessment of this organization? What should this organization do and why? For this question, we desire specific plans, strategies and recommended actions—a formal and comprehensive business plan—that will position the organization to fulfill its existing or revised mission, enhance its profitability, and/or better position it in its competitive markets. We also need your recommendations concerning pace.

Each student uses this question as the framework for a written management assessment and strategic plan for one of three organizations in the case: Hillsboro County Home Health Agency, Physician Care Services (Urgent Care), or Jasper Gardens Nursing Home. Subsequently their study group of four to seven students uses the same case assignment for one of three other organizations: Webster Hospital, Middleboro Community Hospital, or Medical Associates. This latter assessment and strategic plan are formally presented and videotaped. A copy of the syllabus for this course is included in Section IV of this manual. Middleboro Across the Curriculum Developed in collaboration with the Graduate Program in Health Systems Administration at Georgetown University, with leadership provided by Professor Gary Filerman, students use the


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Middleboro case sequentially as they matriculate through their two-year graduate curriculum. As stated in a recent poster presentation:

It is generally agreed that an effective graduate program in health administration is more than simply an array of courses that address key competencies. In addition to teaching specific domains, (academic) programs must provide students with the opportunity to integrate content across courses. Approaches to meet this goal include residencies, capstone courses, comprehensive papers, and an array of other pedagogical approaches. 4

Georgetown University describes its approach as embedding and infusing the Middleboro Case approach throughout its entire two-year curriculum.

On entry into the program, our graduate students are immediately engaged with the case; during the first semester they complete a thorough community assessment of Middleboro, identifying key health challenges, resources and gaps; during the second semester they work in teams to complete organizational assessments of the five delivery organizations. During the summer semester, in the context of their strategic planning course, each team develops a strategic plan for their organization, aligning strategy with data from the community and organizational assessments they have completed. The capstone experience with the case occurs during the third semester when the teams develop complete business plans for a new service (or the elimination of a service). As a class, they consider the impact of one organization’s strategy on the other organization in the community, providing them with a deep understanding of “systems thinking” and interdependencies.5

Multiple courses use the Middleboro Case. Their finance course prepares them to assess the financial condition of their target organization and prepare the financial section of their business plans. The course in community health and epidemiology provides the tools and context for their community assessment of health needs and issues. Their courses in quality have students develop performance indicators and use current quality data systems. Their course in strategic planning assists students develop strategic business opportunity maps and plans. Their marketing course provides the context and support for marketing plans for specific populations. “Middleboro Across the Curriculum” is an innovative approach to problem-based learning. While not restricted to graduate studies, the experience at Georgetown University indicates interesting benefits associated with this model.

The case provides a very meaningful opportunity for the students to “think like administrators,” accomplish complete work as part of a team, and build a repertoire of problem-solving skills. The use of the case has helped students move beyond simple

4 Cloonan, P., B. Horvak, M. J. Mastorovich, and L. Seidel. (2011) The Middleboro Case: An Innovative Approach to Curriculum Integration. Poster presentation at the annual meeting of the Association of University Programs in Health Administration, Charlestown, S.C. 5 ibid.


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knowledge of the discipline and to construct connections across content areas, as well as between theory and application. The case assignments get students into the “swamp” of managerial practice, help them mature intellectually and prepare them to maximize the experiential component of the curriculum, the residency. In addition, faculty benefit by developing a deeper understanding of content being taught across the curriculum, offering opportunities for them to draw connections within their own courses. 6

Using Middleboro: CAHME and AUPHA In 2013 we used Middleboro: A Case for Health Services Managers in the University of Colorado, Denver’s program application for accreditation by the Commission on Accreditation of Healthcare Management Education (CAHME). We also used it in the University of New Hampshire’s recertification review conducted by the Association of University Programs in Health Administration (AUHPA). The experience we report is our own and is provided solely for information. No guarantee or warranty is stated or implied.

AUPHA Undergraduate Membership AUPHA welcomes undergraduate program members who adhere to its membership

criteria. One of these criteria states, “The program must demonstrate how it provides integrative experiences that allow students to apply the skills and knowledge obtained in the liberal arts foundation, conceptual and technical competencies in healthcare management/ administration.” 7 The undergraduate program in health management and policy includes a required senior-level capstone course.

HMP 742: Strategic Management for Healthcare Organizations The application of managerial methods involving financial, marketing and operational analysis to health management. Case studies. Prerequisite: Senior standing in HMP, completion of all junior year major courses, the practicum, and the post-practicum.

As stated on the course syllabus, objectives include:

6ibid.7See:www.aupha.org/files/public/Revised%20Criteria%20for%20Undergraduate%20Certification.pdf.


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A. Knowledge—On completion of this course students should be able to:

1. Describe, analyze and interpret major environmental (internal and external) forces acting on healthcare organizations; and

2. Understand the various essential components of defining effective organizational management strategy.

B. Skills—On completion of this course students should be able to:

1. Analyze complex management situations and apply (appropriate) health management

concepts, theories and models to develop recommendations, working within a team environment;

2. Integrate material covered in previous HMP courses involving healthcare systems, epidemiology, ethics, hospital and health services management, health planning, financial accounting, reimbursement, microeconomics, quantitative methods, organizational behavior, and statistics;

3. Identify sources of data and develop a useful database;

4. Enhance willingness to make rational assumptions in developing management

strategies;

5. Deliver a professionally competent oral report based on the complex dynamics of a multi-person project team; and

6. Present sensitive and potentially provocative information to extremely interested

audiences.

C. Values—On completion of this course students should be able to:

1. Appreciate the critical and ever evolving role of strategic management in healthcare organizations;

2. Appreciate the importance and difficulty of working within an environment of incomplete and imperfect information;

3. Appreciate the importance and difficulty of presenting sensitive information

To accomplish these objectives the class begins with students conducting a community health needs assessment of Hillsboro County. Students are then organized into four- or five-person student teams. Each team is assigned (using an assignment letter) specific questions involving one of the organizations in the Middleboro Case. This initial assignment always begins with an analysis of the organization’s strengths, weaknesses, opportunities, and threats (SWOT). Two weeks after their assignment the team provides a 40- to 50-minute Power Point presentation that is videotaped.


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After a team’s first presentation, the team meets with the instructor to critique both the content and style of the first presentation. In the second half of the course, the same student team is again tasked with another assignment (using the same organization from the case) and delivers a 45-minute presentation. This assignment always includes an assessment of the organization’s mission, vision and vales given it environment. Assignment letters for both presentations typically emphasize organizational analysis, financial management, marketing, program planning, and quantitative analysis. The role of the instructors in this course is different. They are not just content experts. Instead they also serve as tutors and mentors. They assist students to search through their repertoire for skills and insights that may apply to specific problems and issues. As stated on the syllabus, “This course enhances your ability to analyze complex management situations and issues and to offer specific management strategies using the competencies learned in previous courses. You will be required to formally present your work. We expect excellence in your work. The following criteria will be used in evaluating all work: The degree to which your work:

a. Is based on recognized, analytical conventions used in the field of health services management, and uses them flawlessly;

b. Improves on the ability of a health services organization to thrive and contribute to the health status of clients and potential clients;

c. Is sensitive to national and local events and forces as they affect the delivery of health and medical care services;

d. Is practical – the ability to be implemented given the multiple stakeholders and available resources;

e. Is logical, in terms of being internally consistent and based on an identifiable vision for the organization;

f. Is presented in accordance with recognized professional standards.” Due to the nature of the course, although rarely used, we have found it important to have an explicit rule concerning our expectation that all students actively contribute to the team’s projects.

Exclusion Rule: With the permission of the instructors, a team may vote to exclude a team member from being involved in a project based on non-performance of assigned tasks (i.e., a “free rider”). If an individual is excluded, he/she will be required to complete the assigned team’s project independently under the direction of the course instructor.

Being assigned to one specific organization in the Middleboro case facilitates our objectives and the talents and capabilities of our traditional baccalaureate students. With their teams they are able to understand the organization, its role and function in the community and its issues


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and use their individual and collective repertoire to improve the organization and its ability to contribute to population health.

CAHME Accreditation

The Commission on Accreditation of Healthcare Management Education (CAHME) requires applicants to indicate the specific competencies students develop as a result of matriculation and the methods used by the program to assess them. The Fall 2013 CAHME Criteria for Accreditation stated that “The Program will adopt a set of competencies that align with the mission and types of jobs graduates enter. The Program will use these competencies as the basis of the curriculum, course content, learning objectives and teaching and assessment methods.” 8 To fulfill this requirement the MBA in Health Administration at the School of Business, University of Colorado, Denver (CU) selected to use competencies identified by the National Center for Healthcare Leadership (NCHL) as part of its health Leadership Competency Model.9 In total all 25 of the “L” competencies included in NCHL Leadership Competency Model, Version 2.1 were used. Students use the Middleboro case as their primary assignment in this program’s capstone course (i.e. XHAD 6463 Management of Healthcare Organizations).

MANAGEMENT REVIEW QUESTION

The Board needs recommendations concerning the operation, structure, strategic direction and position, and—if appropriate—the governance of this organization. Overall, what is your assessment of this organization? What should this organization do and why? For this question, we desire specific plans, strategies and recommended actions —a formal and comprehensive business plan—that will position the organization to fulfill its existing or revised mission, enhance its profitability, and/or better position it in its competitive markets. We also need your recommendations concerning pace.

Using the Management Review Question, author an individual paper (Capstone B) on one of the assigned cases and develop and deliver a formal Power point presentation with their four- to seven-member study group on another case (Capstone C). Individually, the students also report their Community Health Needs Assessment (Capstone A). 8See:main.cahme.org/Application.html.9See:www.nchl.org/Documents/NavLink/Competency_Model‐summary_uid31020101024281.pdf.


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As stated in the application for accreditation and in the XHAD 6463 Management of Healthcare Institutions syllabus: This course addresses the following primary competencies. See following detailed matrix

L.6 Communications Skills: Students present formal written and oral reports (Capstone Projects A-C.) Any written report that does not adhere to professional conventions is slash graded (e.g., C-/B) and returned for resubmission. Videos of Capstone C are available for review.

L14 Innovative Thinking: Capstone B and C requires that the student assess the Middleboro case so as to develop a coherent and realistic assessment and intervention. These assignments require the students to answer the Management Review Question.

L18 Process Management and Organizational Design: The Management Review Question requires the evaluation of the assigned organization’s structure with the implicit expectation that changes may be needed in order to realize specific strategic goals and objectives. Examples of this can be found in student presentations (written and oral). The first unit of the course is an examination of the governance function and related issues. This is then used within the Management Review Question for Capstone projects B and C.

L19 Professionalism: Organizational integrity is achieved when a health services organization fulfills its mission and the health needs it faces and maintains its ability to financially prosper. One without the other jeopardizes organizational integrity as a healthcare organization. To accomplish this balance requires an assessment of health needs and disparities faced by healthcare organizations (i.e. Capstone A). Intervention plans (i.e., Capstone B and C) are based on multiple criteria including how the proposed intervention plan improves the ability of a health services organization to survive and contribute to the health status of clients and potential clients.

L22 Self-Confidence: Students use skills and insights originally learned in other courses (e.g. financial and market analysis) to define problems and craft their recommendations. They must independently draw the required skills and insights from their repertoire. Capstone B and C both require the student to develop and define an assessment and plan. Furthermore, Capstone C requires students to demonstrate this competency in a team situation.

L.23 Self Development individually and a team member submits complex work (papers/presentation) and receives feedback based on both academic and professional norms.


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Course Learning Objectives NCHL Competency

COGNITIVE DOMAIN

AFFECTIVE DOMAIN

1

Identify actual or potential problems in a healthcare setting where decisions must be made

L14.4 Clarifies Complex Ideas or Situations

Analysis, Evaluate Characterization

2

Collect and organize data presented in an unstructured environment into a usable information format for decision-making

L14.4 Clarifies Complex Ideas or Situations Evaluate Organization

3

Apply and integrate concepts and techniques from the functional areas of management in a problem solving process

L14.4 Clarifies Complex Ideas or Situations

Knowledge, Comprehension, Synthesis Characterization

4

Defend opinions and recommendations with appropriate theory, practice insights and logical assumptions

L18.3 Evaluates Organizational Structure and Design; L18.4 Understands the Basics of Organizational Governance

Application, Evaluate Characterization

5

Communicate their decision process to their classmates in an effective manner

L6.1Uses Generally Accepted English Grammar; L6.2 Prepares Effective Written Business cases or presentations; L6.3 Makes Persuasive oral presentations. Communication Skills

Valuing; Characterization Characterization


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6

Develop insights into their own management style and value system as a leader in the healthcare environment

L19.2 Promotes Organizational Integrity; L22.2 Acts Confidently as the Limits or Slightly Beyond the Limits of job or Role; L: 23.1 Seeks Feedback; L23.2 Improves own Performance Characterization Characterization

This course also contributes to the development of student competencies related to:

L3.4 Develops Complex Plans or Analyses

L4.1 Identifies Areas for Change

L4.2 Expresses Vision for Change

L8.4 Evaluates Financial Analyses and Investments

L9.3 Aligns Human Resources Functions with strategy

L10.4 Calculates Impact of Actions or Words

L16.4 Considers Priorities and Values of Multiple Constituencies

L17.1 Monitors Indicators of Performance

L17.2 Monitors a “Scorecard” of Quantitative and Qualitative Measures

L24.3 Aligns Organization to Address Long-with Environment

Overall, the case provides the opportunity to support individual capstone courses, as demonstrated at the University of New Hampshire and University of Colorado, Denver. It also provides the ability to use a formal problem-based learning (PBL) approach to one or many health administration courses (e.g., “Middleboro Across the Curriculum”).

Benchmarking and Data Characteristics The data included in the case need not be adjusted per se. Consider all data as “normalized.” Epidemiological problems and issues, for example, are sufficiently pronounced to appear when the local (unadjusted) rates are compared with national adjusted or unadjusted rates. The operational data for the organizations are also normalized in the sense that median values were first determined—e.g., national occupancy rates for hospitals 50 to 100 beds—and then


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modified to fit this case. As such, when students ask, tell them to use national (not state-specific) rates for comparison or benchmarking purposes. Case data are comparable with the latest available data. If the latest national data available on a specific point—such as ambulatory care utilization—are 2007 data, these 2007 data can be compared with the data in the case. Problems and issues will not be lost using this approach. As long as benchmarking data are within seven years of the case data, they can serve as a legitimate benchmark To use this case, remember it is a frozen snapshot in time—it is exactly midnight on December 31, 2014; 2014 has just ended and the case reports all data through 2014. And 2015 is about to begin.


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Section II Teaching Notes This section contains Teaching Notes for each of the following sections of the Middleboro Case:

A The Community B Hillsboro County Home Health Agency, Inc. C Physician Care Services, Inc. D Webster Hospital E Middleboro Community Hospital F Medical Associates G Jasper Gardens Nursing Home H Hillsboro County Health Department

The formula used to report an organization’s financial ratios is included as the last page in this section. A. The Community

Hillsboro County is experiencing slow but significant changes. More is ahead. The economic, demographic, and political center of the county is slowly shifting from Middleboro to Jasper. The new interstate road between Jasper and Capital City will significantly contribute to rapid change, especially regarding health and medical care services. Middleboro has an industrial base that includes heavy manufacturing and is surrounded by an agricultural area. It has been the banking and political center of the country. In contrast, Jasper is developing. Its industrial park has attracted a broad range of industries. Increasingly, Jasper is also becoming a commuter town to Capital City. The future of both cities depends on their industries. This suggests that Middleboro is very much a high-risk community today and in the future, and Jasper has a very positive future. For example, if Carlstead Rayon were to leave Middleboro, the impact would be a game changer. Jasper will benefit from its proximity to Capital City. A primary question is whether—now and in the future—Middleboro can support two hospitals: Middleboro Community and Webster Hospitals. Related isses include the continuing and developing need for additional health services in Jasper and the impact of any certificate of need (CON) changes. Hillsboro County may actually be two distinct areas. The area south of the existing interstate (Statesville and Jasper) is different from the area north of interstate (Middleboro, Harris City, Mifflenville, Carterville, Boalsburg, and Minortown). This difference includes demographics and economics and (most important) present and future access to health and medical care services. The northern area is older, economically stagnant, and growing very slowly. The southern area is just the opposite.


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2014 Percent of Percent Percent Percent Community County Population Population Population Statistics Population >65 Female White

Hillsboro County 100.00% 14.12% 51.12% 88.34%

Jasper 34.82 7.91 49.84 95.19

Middleboro 33.65 19.17 52.59 73.32

Statesville 10.15 6.15 50.23 98.10

Harris City 9.12 14.72 51.07 94.98

Mifflenville 7.95 16.62 49.93 96.57

Carterville 1.46 31.51 57.02 94.77

Minortown 1.49 33.33 53.30 99.81

Boalsburg 1.37 48.94 52.92 99.43

This case also includes a significant amount of data for hospital utilization and vital, morbidity, and mortality statistics. It also includes select data for Capital City, the state capital, which is not located in Hillsboro County. The following data highlights the similarities and differences by town. Jasper’s uniqueness is clearly evident. 2014 Hospital Discharges Average Hospital Patient Days Hospital Length of Utilization Per 1,000 % from HC Stay-days Per 1,000 % from HC

Population Hospitals (ALOS) Population Hospitals Hillsboro County 121.89 91.80% 5.12 623.88 94.35%

Jasper 108.68 77.26 4.50 489.05 83.51

Middleboro 130.30 98.66 5.70 742.72 98.76

Statesville 106.62 98.37 4.70 501.11 98.40

Harris City 134.07 97.69 5.20 697.15 97.41

Mifflenville 129.54 97.94 5.00 500.00 97.90

Carterville 159.73 96.06 5.20 830.59 97.49

Minortown 199.71 99.52 5.73 1,145.03 99.54

Boalsburg 113.70 98.18 5.53 628.94 98.11

(Note HC = all Hillsboro County)

As mentioned, it is important to provide students direction regarding benchmarks as they analyze the health status data. We recommend that you national data as benchmarks. If not available, students should use state statistics as benchmarks. Benchmark data should be no


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Section III Suggested Assignments This section is organized into three parts. Part1 (A-H) provides assignment questions by case. Part 2 (I-T) provides assignment questions by subject. There is some duplication between Parts 1 and 2. Part 3 provides suggested assignments to link the Middleboro cases with leading textbooks in healthcare management. Part 1 Assignment Questions by Case

A. The Community B. Hillsboro County Home Health Agency, Inc. C. Physician Care Services, Inc. D. Webster Hospital E. Middleboro Community Hospital F. Medical Associates G. Jasper Gardens Nursing Home H. Hillsboro County Health Department

Part 2 Assignment Questions by Subject

I. Community health and epidemiology J. Economics K. Financial management L human resources M. Information systems N. Law and ethics O. Management and organizational behavior P. Marketing Q. Policy R. Quality improvement S. Statistics and quantitative methods T. Strategy and strategic planning

Part 3 Assignment Questions for Companion Textbooks published by Health

Administration Press: Chicago, IL. U. Dunn, R. T. 2010. Dunn & Haimann’s Healthcare Management, 9th ed. Chicago:

Health Administration Press. V. Gapenski, L. C. 2012. Healthcare Finance, 5th ed. Chicago: Health Administration

Press. W. Gapenski, L. C. 2013. Fundamentals of Healthcare Finance. Chicago: Health

Administration Press


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X. Olden, P. C. 2011. Management of Healthcare Organizations: An Introduction.

Chicago: Health Administration Press. Y. Thomas, R. K. 2010. Marketing Health Services. Chicago: Health Administration

Press. Z. Walston, S. L. 2014). Strategic Healthcare Management: Planning and Execution.

Chicago: Health Administration Press. AA. White, K. R., and J. R. Griffith. 2010. The Well Managed Healthcare Organization, 7th

ed. Chicago: Health Administration Press. AB. Zuckerman, A. M. 2012. Healthcare Strategic Management, 3rd ed. Chicago: Health

Administration Press. A. The Community

A01 Demographic and Population Analysis We need an analysis of the population changes and characteristics in Hillsboro County.

Please address each of the following questions and provide appropriate quantitative justification to support your conclusions and recommendations

1. Over the past five and ten years, which of the communities located in Hillsboro

County have grown faster than the overall rate of population increase in Hillsboro County? Over the last five and ten years, which of the communities in Hillsboro County have grown slower than the overall rate of population growth in Hillsboro County?

2. What should we expect the population to be as of CY+5 for all towns located in

Hillsboro County? 3. To what degree does the age profile of Hillsboro County resemble the overall

age profile demographic of the United States? Which towns in the county are the “oldest” and the “youngest?”

4. Assess the implications of your findings related to the delivery of health

services in the county.

A02 Nursing Home Need Study National statistics indicate that approximately 3.9 percent of the population 65 or older is in

nursing homes. Historically, nursing homes in Hillsboro County have an average


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ASSIGNMENT QUESTIONS BY SUBJECT I. Community Health and Epidemiology

I01 Hillsboro County Health Analysis

Using the available data, indicate the top ten health challenges facing residents in this county. Use the state of ______________ for purposes of reference. Note that Capital City is not in Hillsboro County. For Hillsboro County list your findings in priority order with explanations and rationales. What are the implications of your findings on the organized health services in the county?

I02 Hillsboro County vs. Capital City

Compare and contrast the health status of residents in these two areas. Your analysis should include vital statistics and disease specific death rates. Are these two adjacent areas similar or different? Why? What are the implications?

I03 Public and Community Health Challenges

Assess Hillsboro County’s readiness for any large-scale epidemic or disaster. We need a memo that indicates the challenges and issues related to this county’s ability to surge to meet a large-scale disaster. What would you recommend and why?

J. Economics

J01 Pricing Analysis

Big Box Stores, Inc., with locations in Jasper and Middleboro, is considering opening a walk-in, no-appointment medical clinic (staffed by a nurse practitioner) in each of its stores in Hillsboro County. At other locations around the state, the basic visit fee is $30.00 (cash, credit card, or check). If this occurs, PCS is concerned that these new services will have a negative impact on its market. Should PCS alter its pricing policies for private pay patients? If yes, what do you recommend and why?

J02 Workers’ Compensation—Anticipated Changes

As you are aware, as of January 1, 2016, new regulations change workers’ compensation—health insurance for injured workers. Under the new regulations, employers select the medical care providers. Recently, another proposal has been introduced in the legislature to change this system. This proposal would allow an employer to either contribute to the state insurance pool for workers’ compensation or self-insure with a mandatory reinsurance policy for cases above $50,000. Note that


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Part 3 Suggested Assignments for Companion Textbooks The following questions are based on specific chapters/sections in this book. Each question links a specific book to one or more specific organizations described in the Middleboro case. Questions are examples of many possible areas of inquiry. The examples provided here are not meant to be exhaustive. Our questions are merely our questions if we were to use the specific book as a companion text with the Middleboro case. Each question is a linkage between a specific book and the case that we believe worthy of consideration and the basis for important learning. We readily admit that the best questions for students are written by their instructor and hope that these questions provide a reasoned starting point. We are totally responsible for the questions. The authors of the specific books have not been consulted. U. Dunn, R. T. 2010. Dunn & Haimann’s Healthcare Management, 9th ed.

Chicago: Health Administration Press. Part I: Stepping into Management 1-1 You have recently received a request for proposal from Middleboro Community

Hospital to establish an in-house supervisory training program. Your proposal, limited to three pages, should indicate the need for this type of training and the primary topics to be addressed. The program focuses on managers, supervisors, and select administrative employees (see Exhibit 1.2) with either clinical or administrative responsibilities.

1-2 Pages 16–18 indicate five managerial functions: planning, organizing, staffing,

influencing, and controlling. Read the case narrative on the Jasper Gardens Nursing Home with special attention to the duties and responsibilities of the administrator. For each managerial function give two examples of how she executes and performs this function.

1-3 Organizations and their management are eclectic. None are managed in keeping with

just one school of thought. Each uses management strategies drawn from multiple conceptual paradigms. For example, most organizations adhere to some degree to the Bureaucratic Management Theory (pg. 29–30). Read the case narrative for Physician Care Services and cite five examples for three of the paradigms. One paradigm should be from the Classical School, Human Resources School, and Contemporary Management Theories.

1-4 Consider the question: Are successful managers made (via training or experience) or

born with specific traits? Indicate your perspective on this question and in the process define management and cite examples using the CEOs in the case.

Part II: Connective Processes


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IV. Other Materials A. Effective Presentations

Most colleges and universities have a service to assist students and faculty in best practices related to oral presentations. Our advice is to first consult your own college or university. The following three URLs each provide valuable insights related to using Power Point and designing and delivering formal presentation. They are examples of the many resources that can be found on the Internet.

http://www.utexas.edu/lbj/21cp/syllabus/powerpoint_tips2.htm

http://www.utexas.edu/lbj/21cp/syllabus/powerpoint_tips.htm

http://www.hamilton.edu/oralcommunication/using-powerpoint-effectively-in-an-oral-presentation

Every oral presentation has a specific purpose. Too often students overdesign their oral presentations with content and charts and underdesign them based on the purpose of the presentation. For example, is the purpose to help decision-makers make a decision? Is it to recommend a specific decision? If so, these types of presentation should be different than a presentation designed to inform and educate. What is the purpose of your presentation? Other questions we ask our students:

1. Where do you indicate the primary points, conclusion or recommendation? Beginning or end? Why? Implications?

2. What criteria do you use to justify a table of data, graph or charts? Do you need both

the data and graphs? Different types of charts (e.g., pie, bar, trend) have strengths and weaknesses. Are you using the best type of chart based on why the chart is included in your presentation? Can your chart, graph, or data table be understood in five seconds or less?

3. Do all of your tables and charts indicate their source?

4. How much is too much important information on one power point slide?

5. Which are the extraneous 10 percent of your slides? Justify each one or remove it.

6. How many times have you rehearsed this presentation in front of peers? What did you

learn from each rehearsal?


The Community

Table 1.1Hillsboro County Population: 1989–2004

Town 1989 1994 1999 2004 2009 2014

Middleboro 44,590 45,460 45,861 46,995 47,364 47,590Jasper 28,452 31,560 39,871 42,657 46,902 49,247

Harris City 11,950 12,009 12,203 12,953 12,951 12,904Statesville 10,840 11,788 11,750 11,790 12,750 14,350

Mifflenville 10,310 10,325 10,623 10,945 10,952 11,240Carterville 2,310 2,356 2,367 2,145 2,378 2,066Minortown 2,077 2,160 2,163 2,190 2,056 2,103Boalsburg 1,759 1,790 1,885 1,893 1,891 1,935

Total 112,288 117,448 126,723 131,568 137,244 141,435

Capital City 110,450 120,450 155,340 160,230 163,440 177,560University Town 78,990 81,044 81,370 83,560 84,500 85,840

Other Towns Outside Hillsboro County


The Community

Table 1.3Age Profile for Hillsboro County by Sex for 2014

Town TOTAL Under 5 5–14 15–24 25–44 45–64 65–74 75+

Middleboro 47,590 3,165 5,850 5,378 15,067 9,007 4,703 4,420Male 22,562 1,690 3,097 2,278 7,289 4,438 2,260 1,510

Female 25,028 1,475 2,753 3,100 7,778 4,569 2,443 2,910

Jasper 49,247 4,128 6,567 6,228 21,420 7,011 3,203 690Male 24,702 1,904 3,256 3,086 11,349 3,531 1,456 120

Female 24,545 2,224 3,311 3,142 10,071 3,480 1,747 570

Harris City 12,904 812 1,519 1,567 2,883 4,224 976 923Male 6,314 412 795 796 1,679 2,090 420 122

Female 6,590 400 724 771 1,204 2,134 556 801

Statesville 14,350 1,176 2,168 2,881 3,876 3,367 314 568Male 7,142 590 1,077 1,445 1,973 1,707 155 195

Female 7,208 586 1,091 1,436 1,903 1,660 159 373

Mifflenville 11,240 1,050 1,030 1,780 2,175 3,337 961 907Male 5,628 512 577 886 1,156 1,890 426 181

Female 5,612 538 453 894 1,019 1,447 535 726

Carterville 2,066 118 120 442 297 438 406 245Male 888 56 57 208 147 188 155 77

Female 1,178 62 63 234 150 250 251 168

Minortown 2,103 101 139 268 407 487 390 311Male 982 50 69 139 213 268 192 51

Female 1,121 51 70 129 194 219 198 260

Boalsburg 1,935 31 75 175 207 500 525 422Male 911 13 36 77 110 249 260 166

Female 1,024 18 39 98 97 251 265 256

Total 141,435 10,581 17,468 18,719 46,332 28,371 11,478 8,486Male 69,129 5,227 8,964 8,915 23,916 14,361 5,324 2,422

Female 72,306 5,354 8,504 9,804 22,416 14,010 6,154 6,064

Age Profiles
