Diagnosis & Treatment of The Failing Wound Care Center: 2 Underappreciated Considerations

When wound care clinicians and their administrators open a discussion on how to improve the prospects for outpatient wound care clinics, the dialogue is typically drawn to clinical concerns, referral generation, and/or revenue cycle management initiatives. Properly assessing and addressing these topics is truly an integral part of any wound center’s turnaround efforts, and there are multiple valuable discussions to be had on such topics, including articles that readers will find in this edition of Today’s Wound Clinic. 

However, all too often the solutions offered to struggling wound care programs are not properly and impartially assessed and addressed in the proper context. Through this author’s experiences in opening, directing, mentoring, and advising wound care centers, a critical question consistently emerges: Why do the same wound care delivery “solutions” sometimes result in positive improvements, yet other times lead to continued decline of the program? The answer, more often than not, lies in yet another question: Does the wound care program have the correct organizational and management structure to set it up for success? This article will focus on how to make that determination and what considerations can be taken to align these important factors for the turnaround of a failing United States-based wound care center.

IS ORGANIZATIONAL REPORTING STRUCTURE A GOOD FIT? 

Before turning to any specific processes and solutions, we must take a step back and look at the organizational structure and management apparatus as a whole. Some of the related organizational questions to ask include:

• To whom does the wound center report? (Or is it a freestanding, self-incorporated clinic?)
• What are the other responsibilities and goals for these stakeholders, and how does the wound center fit in (if at all)?
• Do these individuals have enough time, resources, and influence within the hospital/health system to properly advocate for the program’s success?

Wound centers often report to senior-leadership members, such as the hospital’s chief executive officer, chief operational officer, chief financial officer (CFO), chief medical officer (CMO), chief nursing officer, or another member of the C-suite. On the one hand, these individuals are often focused and evaluated on the major hospital metrics and incentives: volumes, hospital-acquired conditions, patient satisfaction, and the streamlining of staffing and supply costs, to name a few. Insofar as the wound center positively impacts these high-level drivers, senior leadership can likely advocate for budget, staffing, and other resources needed to support these goals. On the other hand, despite the influence and resources at their disposal, the breadth of the C-suite’s responsibilities can potentially cause problems for the wound center as well. Does the CFO fully appreciate the impact of being understaffed on wound care-specific clinical outcomes? Does the CMO recognize the urgency of ensuring that backend coding rules are set up for a new local coverage determination or electronic health record integration? In many cases, the answer is “yes,” in which case the hospital has dynamic leadership and the next point can be addressed. If the answer is, “no,” an open discussion about where the wound center should be on the organization’s reporting structure is recommended.

Another common reporting structure for the wound center is to report to a director of outpatient services, ancillary services, surgical services, or the like. These types of reporting relationships can benefit from a more granular level in understanding specific business problems — and communication may be more frequent. Yet, wound centers operating under these arrangements can also suffer from micromanagement by overzealous individuals and may require an additional level of approvals for processes, such as posting of staffing requisitions or receiving approval of new products. A third common organizational structure is the independently/owner-managed (often by a physician) freestanding wound care center. The relative strengths of this structure include fast decision-making and appreciation of the day-to-day clinical (and related) challenges. Such structures, however, often suffer from a lack of administrative, operational, and financial expertise. Due to a combination of a lack of formal management training and the need to oversee both patient care and business operations, many (but not all) such centers may be unaware of critical issues until the consequences are overwhelming. Sometimes, a provider-managed wound center operates within one of the other frameworks previously discussed. Table 1 discusses common wound center organizational approaches taken in the U.S.

Additionally, determining whether wound care is led by the equivalent of a coordinator, manager, director, vice president, or other level role is extremely important to consider. With few exceptions, the program should have a separate “profit and loss.” In other words, it should have its own budget, though this can get a bit trickier when there are multiple areas of responsibility beyond the clinic (eg, inpatient and outpatient together). There is no “correct,” one-size-fits-all organizational structure for wound care centers. But before attempting to tweak or shake up specific elements of one’s program, it is valuable to step back to see if the reporting structure is aligned with where the program is expected to be performance-wise. One’s reporting structure may be holding back a facility’s success by design, or perhaps may even be the root of problems itself. Having an open discussion about modifying the wound care center’s organizational structure should be among the first moves made when a center is struggling.

IS THE MANAGEMENT APPROACH ALIGNED?

The story of the rise of U.S. wound care centers and management firms is a fascinating one.¹ Historically, most outsourced management approaches have been focused on getting wound care programs up and running. Yet, as the programs mature, new center openings plateau, and healthcare incentives shift, various “flavors” of wound care program management services have emerged. This trend is likely to continue into the foreseeable future. Table 2 on page 11 describes some of the broad approaches to wound care management. When wound care stakeholders are experiencing a struggling (or mediocre) wound care program, the second question to ask is: Under which of these management approaches is the program currently (or planned)? The next step is to determine a list of key considerations relevant to the program. This typically includes areas such as clinical quality management, supply chain/purchasing streamlining, clinical-operational flow, patient volumes, medical leadership, revenue cycle management, information technology/electronic health record capabilities, intersystem/interdepartmental collaboration, patient satisfaction, and a host of others.

Using the considerations in Table 2, one should map the clinic’s current needs with potential solutions, including the following:

1. What are the most pressing current and anticipated wound care challenges?
2. If the clinic is currently independently managed, for which considerations would improvements have the greatest impact?
3. What are the organization’s core strengths that could be accomplished independently?
4. In which areas might the clinic stand to benefit from third-party management and/or other resources?
5. How does the management approach impact the organization and program (financial and otherwise)?
6. In what way(s) might incorporating, or eliminating, third-party involvement impact key considerations?
7. How will the anticipated future landscape be affected by the choices made today?
8. Might other approaches or models exist that could help solve these challenges?

The decision to either bring on, increase/decrease involvement of, or terminate a wound care management firm is not one to be taken lightly — and there is no blanket recommendation. Rather, each wound care program, when considering its unique situation and long-term goals, should be considered and matched to the management models and other tools available. If the decision is made to contract (or renegotiate) with a management firm, it can also be extremely valuable to enlist the support of an expert who’s familiar with both the organization’s needs and the wound care management business to sit on the facility’s side of the table during discussions and negotiations. Likewise, if and when the decision is made to disengage from a management firm, it is important to have a real understanding of the aftermath and to line up tools and other contingencies to minimize the repercussions.

CONCLUSION

Many considerations and approaches to fixing failing wound care centers exist. As with clinical wound management, the most important approach can often be to address underlying issues before reaching for topical therapies. Likewise, wound center administrators should address organizational and management strategies before tweaking specific aspects of center administration and operations. 

Rafael Mazuz is managing director of Diligence Wound Care Global LLC, a leading advisory firm providing wound care executives, investors, and specialists confidence in their business decisions. He previously opened and led award-winning wound care centers for the world’s largest provider of wound care management services and actively advises wound care product and services stakeholders in both the developed and emerging markets. He can be reached at rafael@diligencewcg.com 

References

1. Mazuz R. What the recent healogics developments can teach us about the future of wound care. LinkedIn. 2017. Accessed online: www.linkedin.com/pulse/what-we-can-learn-future-wound-care-from-recent-healogics-mazuz

2. Global Budgets. The Maryland Health Services Cost Review Commission. Accessed online: www.hscrc.state.md.us/pages/budgets.aspx