COLLABORATIVE MANAGEMENT OF CHANGE

WILL LEAD CLINICAL CENTER INTO THE FUTURE

John Gallin

After almost 5 years as Clinical Center director, I am constantly reminded that many of the issues facing this organization are similar to those facing academic centers and other hospitals across the country.

Sometimes seemingly beset on all sides, we face common problems in recruiting patients, providing equitable access to services, and controlling costs while maintaining high-quality patient care and services and incorporating new technologies. The specific answers are not simple, nor are they the same for all health-care institutions; however, a general approach shared by all hospitals is the need to embrace change and manage it effectively—distinguishing threats from opportunities and balancing tradition and innovation.

At the Clinical Center, the key to managing change over the past few years has been collaboration in planning and governance.

Many positive changes are underway at the Clinical Center, the most visible being construction of the new Mark O. Hatfield Clinical Research Center (CRC). Others include evolution of a new governance structure, implementation of a new "school tax" funding approach, and planning for new technologies to facilitate protocol mapping, cost accounting, and imaging. At the same time, the Clinical Center has staved off some threatening changes, such as privatization and third-party payments.

Whether implementing positive changes or fighting off threats, we have learned that thoughtful planning, zealous communication, and increased collaboration among institutes, patients, and staff are essential.

In fact, success is driven by effective collaboration in patient care, science, management, and finance.

Our collective task must now be to foster a robust clinical research program, and three key assignments in meeting this challenge are 1) attracting and retaining clinical investigators, 2) recruiting patients, and 3) achieving operational efficiencies. Within the NIH intramural clinical research program, new collaborative teams, councils, and advisory groups representing a broad variety of interests have been established to tackle these jobs.

Attracting Clinical Investigators

In 1997 the Clinical Research Revitalization Committee, a trans-institute team chaired by Stephen Straus, NIAID, identified several improvements to help retain and recruit outstanding clinical investigators. Their recommendations included modifications in personnel and funding mechanisms, promotion and tenure processes, and research support and training. The committee also called for bench-to-bedside research proposals to promote collaboration between laboratories and called for the development of "Centers of Excellence" where leading-edge science is coupled with best practices in clinical medicine (See "Clinical Research Plans"). Many of these recommendations have been implemented or are now in the works.

Meanwhile, Michael Gottesman, deputy director for intramural research, has been contemplating NIH’s Final Frontier—space. He has been invited to the next Clinical Center Board of Governors meeting to discuss how space limitations affect recruitment of clinical investigators and, consequently, patient activity. There is hope: After completion of the new CRC, a suggested phased north- and south-side renovation of Building 10 E and F could allow for some expansion of space for new clinical investigators.

Recruiting Patients

The Medical Executive Committee (MEC) chaired by Scott Whitcup, clinical director of NEI, made several important decisions this year that should improve patient recruitment. For example, when the MEC learned that an increasing number of individuals now refer themselves to medical protocols via the web, the panel revised NIH’s physician referral policy to allow some flexibility in patient referrals that flow in via this route.

Additionally, a Clinical Center contract designed to improve patient recruitment and raise awareness of NIH intramural programs was awarded in 1998. Assessing how the Clinical Center is viewed by the world and how best to communicate its vision are key features of this initiative. The Institutes and Centers have been providing input for this project and, beginning in 1999, the Clinical Center will survey patients to identify ways to improve service and recruitment. These patient-oriented initiatives are facilitated by valued input from the Patient Advisory Group, a new standing committee of former and current patients.

Achieving Operational Efficiencies

The Clinical Center Board of Governors, first convened in October 1996, is our prime model of effective collaborative governance. The Board, comprised of institute leaders and outside experts in health-care management, has been particularly helpful on budgetary issues and operational improvements. At a time when

Clinical Center costs were becoming more unpredictable for the institutes amidst declining patient rolls, the Board suggested the new "school tax" funding model to stabilize the CC budget and boost patient numbers while providing fiscal predictability for the institutes. This new funding model will be implemented in fiscal year 2000.

Two other programs were instituted in 1998 to improve operational efficiency and generate cost savings: operational reviews for Clinical Center departments and a cost-savings incentives program. The reviews, conducted by outside experts, are designed to offer Clinical Center managers insight, advice, and assessment. Two departments reviewed in 1998 received constructive recommendations that will promote effective customer-responsive management, better service, improved quality, and cost reductions. The cost-savings incentives program, designed to reward cost-savings efforts by Clinical Center employees, was instituted by Clinical Center departments under the leadership of Adrienne Farrar, chief of social work.

The Clinical Center Advisory Council (CCAC), established in 1997, facilitates collaboration with the institutes and ensures that they have a strong voice in Clinical Center issues that affect their intramural clinical research rograms. Membership consists of representation from the five largest institutes using Clinical Center services and, on a rotating basis, three smaller user institutes.

The CCAC has provided input on many aspects of the budget process, including a definition for new institute initiatives and how they should be funded under the "school tax" model. This group has also managed the use of carryover funds and provided strong guidance on operational issues surrounding the institutes’ clinical research programs. But the CCAC’s best demonstration of its consensus-building prowess came in its planning for the utilization of the new CRC. The formation of Partners Groups last year by the Council created a structure of teams to provide direction throughout the Design Development phase of construction. As we continue to prepare for the new CRC, we will establish new collaborative governing structures for shared patient-care units.

1999 and Beyond

A major effort in 1999 will be planning for a Clinical Research Information System (CRIS), a new system to replace the current Medical Information System. Much more than just a static information system, CRIS will help the CC support operational efficiencies and other administrative initiatives by transferring data to support activity-based costing, protocol mapping, and performance measurement. CRIS will also contribute in many new ways to the support and advancement of clinical research, for example, through its inclusion of powerful medical informatics and imaging tools that allow viewing of digital images from any terminal in the hospital.

Collaboration is not new to NIH—but its increasing presence in managing the Clinical Center has helped to foster unity and valuable strategies essential to making needed changes. Such adaptation is central to success—–in science and management. As we begin a new year, I welcome input from everyone on how we can make the Clinical Center a better place to work, to practice medicine, to support clinical research, and to care for patients. Send your e-mail suggestions to: <jgallin@nih.gov>.

—John I. Gallin
Director, Clinical Center

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