Ambulatory Questions

How would you define your vision for ambulatory services at YNHHS?

Ambulatory should be a defined, integrated business segment with dedicated leadership and workforce. This would allow us to create an environment that fosters collaboration, integrated care, multidisciplinary teams, and quality performance. Giving these practices a platform to come together as one team and share best practices will allow us to bring about the organizational and cultural changes we need to thrive. We should be positioning our ambulatory enterprise to meet the growth opportunities in our region.

What strategies would you implement to improve access to ambulatory care services?

Our ambulatory services should be the front door to our system, showing patients the high-quality, patient-centered care we offer. This means really emphasizing convenience: extended hours, same day appointments, and user-friendly digital front doors. We also need to tailor our outpatient strategies to specific patient populations and age groups – what works for a 70-year-old grandmother is not what may work for a 20-year-old college student.

How do you ensure alignment between ambulatory care and the broader health system’s goals?

Ambulatory services align with the broader goals of YNHHS. We want to expand outpatient access and support enterprise financial goals by shifting care from inpatient to a more cost-efficient setting. We are focused on developing meaningful data driven insights and standardizing evidence-based protocols across the system to ensure consistent quality. There is a growing focus on prevention care initiatives to reduce costly acute care episodes – most of those screenings and early interventions happen in outpatient care.

This is a critical time for health care and our environment requires us to pursue a coordinated strategy to enhance quality, access, and service. Alignment will make us more agile, facilitating our ability to grow to meet the needs of our region and develop destination programs that will achieve regional and national recognition. All our decisions should support our ability to provide exceptional, patient centered care.

Can you describe a time when you led a major transformation in outpatient care?

I’ve spent the last 15 years in management at various academic medical centers. I have led a variety of initiatives to improve patient access, reduce operational inefficiencies, and enhance care delivery. Penn, like many health systems, was struggling with a capacity crisis and needed to better distribute volumes across the system. One of the major pillars of my role was access – the call center rolled up through me, I was the lead on designing and implementing our decision trees and care pathways, and I was really the key driver of a variety of pilots aimed at creating access for our patients. Within our ortho departments, I conducted a time-motion study to identify bottlenecks and oversaw the rollout of a real-time patient tracking system. I integrated radiology into our check out process, allowing patients to leave with both their follow up imaging and provider visit scheduled which reduced wait times in clinic, allowed for better staffing within radiology, and increased our capture rate from 60-80%. I oversaw the creation and roll out of an eConsult pilot throughout all of primary care, allowing providers to seek out specialty input for patients who otherwise didn’t need to establish a relationship with the specialist. Patients and physicians loved it, we had a NPS of above 90 and 34% of patients were able to avoid an in person visit. One of my divisions had a high volume of referrals and it was creating a patient backlog, so we implemented a triage process utilizing decision trees to more easily identify “target patients” and then had our APP team use 20-minute telehealth visits to assess the “low suspicion patients”. We increased our capture of target patients from 40% to 70%, netting an additional $2M in annual revenue.

How do you optimize operational efficiency while maintaining high-quality patient care?

Standardized workflows ensure that every patient receives the same high standard of care, reducing variability in treatment, minimizing delays, reducing redundancies and streamlining operations. We need to standardize anywhere we can and customize where we have to. A patient should expect the same high-quality care whether they walk into Westerly or Greenwich.

What metrics do you use to measure success in ambulatory services?

Patient access (wait time, percentage of same day/next day, referral turnaround time), capacity (throughput, patient cycle time, provider utilization, staffing ratios), retention (treatment conversion, downstream referrals, follow up compliance, portal adoption rate), patient satisfaction (Net promoter scores and Press Ganey, USNWR), financial performance (revenue per visit, cost per encounter, claims denial rate, payor mix), and clinical quality (patient outcomes, preventative care compliance, readmission rates)

How would you address physician alignment and engagement in an ambulatory setting?

We need to identify physician champions who can help promote organizational efforts to redesign care and improve patient access. Driving transformational performance improvement requires that we establish what our priorities are, set goals, and then provide metrics and data to every stakeholder. They need to understand how their role relates to the organizational goal and understand that they are accountable for our performance. Data needs to be shared transparently and the metrics that are most useful for increasing the value and effectiveness of our services should be tracked and reported regularly. 

How do you ensure compliance with regulatory and accreditation standards in ambulatory care?

Partnering with regulatory and legal teams, I would ensure all facilities meet local, state, and federal regulations, as well as accreditation standards. I have a strong track record of maintaining compliance by establishing rigorous internal audit processes and fostering a culture of accountability and I have led system-wide readiness programs for Joint Commission, CoC and NAPBC surveys, achieving full accreditation every time with no major findings.

How do you balance cost containment with growth and innovation in outpatient services?

Cost containment and growth aren’t mutually exclusive. I think both can be accomplished with a laser focus on efficient operations, including the elimination of duplicative infrastructure. We need to remove silos and reduce variation and duplication. Inconsistencies in staff roles can lead to overcompensation when staff work below their full capacity and increased risk when personnel exceed their scope of practice. Being part of a system offers the advantage of resource flexibility; by homogenizing roles, responsibilities and operations across the system, we can cultivate a flexible environment that maximizes staff and resource utilization.

What experience do you have in developing and managing budgets for ambulatory services?

While I was the director for Rheumatology at Penn, I oversaw the finances for the division with annual clinical and research expenditures of $13.0 million, hospital revenue of over $10.0 million and over 25,000 patient visits annually. I created, implemented, and monitored clinical and research budgets and I was able to balance Rheumatology’s budget, a division notoriously in deficit, to bring them to their first profit in a decade.

How would you approach payer negotiations and value-based reimbursement strategies?

Before entering any negotiation, I would analyze clinical and financial data to understand our costs, outcomes, and utilization patterns. We need to demonstrate how our ambulatory services reduce unnecessary ED visits and hospitalizations and position our system as a high value provider to strengthen our leverage. I also would ensure that our performance-based incentives tie to our key quality metrics so we can align system goals. While at Penn, we negotiated a shift of outpatient joint replacements to an ambulatory surgery center, and we agreed to bundle payments with rehab services. It reduced costs and improved patient satisfaction – a win for all parties.

Can you share an example of how you’ve expanded ambulatory services profitably?

I implemented a triage process utilizing decision trees to more easily identify “target patients” and then had our APP team use 20-minute telehealth visits to assess the “low suspicion patients”. We increased our capture of target patients from 40% to 70%, netting an additional $2M in annual revenue.

How do you enhance patient access and satisfaction in ambulatory services?

We need to create robust access channels and optimally distribute volumes across the system. We need to improve processes for coordinated patient care, resolve gaps in care, and enhance our patient tracking and reporting systems. Patient navigation programs are key for improving coordination throughout the patient’s healthcare journey and building patient trust and loyalty as a feeder for downstream care. And we need to improve our digital front door, our websites are confusing. Patients need to understand who they need to see and where they need to go and be able to easily access same day/next day care when needed.

What initiatives have you implemented to address health disparities in outpatient care?

A major focus of YCC has been on improving our outreach to underserved communities. Redesigning how we approach cancer screening and surveillance has allowed us to examine how we can reach patients before they are diagnosed, expanding their preventative and treatment options. I have helped integrate community health care workers within our clinic and standardize our SDOH screening. I am currently partnering with Genetics, Breast, Primary Care and Ob GYN on a high-risk breast program to proactively screen women at their annual visits to expand our reach from the typical mammogram patient. And I have worked with patient education and marking on the creation of virtual patient education resources in multiple languages to allow patients to confidently and comfortably prepare for their upcoming procedures.

How do you integrate social determinants of health into ambulatory care strategies?

I helped implement SDOH screening tools at intake and developed a co-located social work and CHW model to provide food assistance referrals, housing support, and job placement services. I also partnered with our Supportive Care team on a workflow that screens every patient to ensure that each patient has the support systems necessary to assist them in navigating their cancer treatment.

What role does technology (e.g., telehealth, remote monitoring) play in improving patient care?

Technology is a critical piece of patient-centered, high quality ambulatory care. Expanding virtual visits across primary care, behavioral health and specialty services creates access and allows us to meet the patient wherever they are. Utilizing eConsult’s for faster specialty input allows some patients to avoid an in person visit entirely and those that ultimately need face to face care, had a better work up in preparation for their visit resulting in a faster diagnosis and treatment. I also believe that remote monitoring will continue to play a large role moving forward, allowing a real time tracking of vitals and a reduction of hospital visits.

How do you foster a culture of innovation in ambulatory services?

We should be consistently working to evaluate and improve workflows, staffing structures, reporting systems, and financial practices to ensure delivery of high quality, effective, and efficient patient care. A commitment to performance improvement mindset and practice transformation needs to be part of the culture and every leader and manager must be made to understand why it is important and how he or she is critical to its success. Organizational culture is an enterprise asset. And like any major asset, it must be developed, maintained, and leveraged as a tool to achieve organizational goals.

Can you provide an example of how you’ve successfully led a major change initiative?

I successfully integrated two ambulatory networks when Penn Medicine merged with Princeton Health, aligning cultures, standardizing scheduling and call center processes, integrating physician call schedule, and maintaining employee retention rates above 90%. I also helped navigate the acquisition of HUP Cedar and the creation of a new teleconsult inpatient service, increasing access to an underserved patient population.

How do you manage resistance to change among staff and providers?

Because they are accountable for driving patient experience improvement, staff and providers need to understand how their role relates to the organizational goal. Transparently sharing data across our system also ensures that we have a standard to recognize, and by which we hold people accountable for their work. Your success depends on your ability to influence people outside your direct line control. I take a proactive approach to shape expectations and align interests; foster alignment and commitment by emphasizing clear communication, setting expectations and ensuring shared goals and accountability.

What is your approach to integrating digital health and telemedicine into ambulatory care?

Patients need to easily access on-demand, same day care when needed. We should be leveraging technology to deliver timely, convenient, and affordable service and care. Expanding our telehealth and hybrid care models and utilizing virtual care for routine visits, behavioral health, and chronic disease management allows us to increase our capacity and meet patients where they are. We’ll reach a point where virtual is removed from the “virtual care” and it will just be care – how teams interact and provide care.

How do you build and maintain strong relationships with physicians, staff, and external partners?

Building and maintaining strong relationships requires trust, transparency and shared goals. We need to develop and communicate an organizational vision for aligning around quality, the patient and staff experience, and patient flow. I take a collaborative leadership approach by engaging stakeholders early, fostering open communication, and ensuring alignment with strategic objectives. It’s important that they feel you are working together. While at Penn, I regularly heard the MD/APP relationship wasn’t working. So, I worked to define and expand the supervising relationship between the MD and NP and developed a financial model to better incentivize physicians to invest time and energy in training new NPs as well as incentivize NPs for their expanded MD support.

What experience do you have in partnering with community organizations to improve outpatient care?

It’s important to engage our community partners to address social determinants of health concerns for our patients. Here within Smilow we work with a variety of organizations to help support our patients throughout their cancer journey – covering things from transportation to scalp cooling services. We have an extremely successful medical legal partnership, offering our patients free legal services to help them deal with issues around immigration, housing, employment and family services. We lost funding for that program last year and I worked with our development team to identify funding to ensure we were able to continue this important work. At Penn, we partnered with the local cable provider to create patient education materials that patients could access from their homes. There are many ways to help support our patient centered mission outside our health system, sometimes you just need to be creative.

How do you align ambulatory services with inpatient and specialty care services?

Shifting care from high-cost hospitals to well prepared, lower cost, outpatient venues helps to create a system focused on patient centered care and financial stability. Reducing readmissions, a key priority for the health system, involves population health strategies with a focus on the impact of social determinants and outpatient access to the multidisciplinary, multilayered care team approaches of ambulatory care models.

How would you handle an operational crisis (e.g., staffing shortages, financial pressures)?

The keys to crisis management and problem solving are swift decision making, clear communication, and on-going evaluation to adapt as situations evolve. We are constantly working under staffing shortages, financial pressures, space constraints, etc. The important piece is to keep the patient’s experience at the center of your decision making. While you are focusing on the next best option available at the time, you need to be simultaneously working behind the scenes to ensure a better option is available for the future.

Can you describe a time you had to make a difficult decision under pressure?

During the peak of COVID-19, Penn was facing severe staffing shortages due to illness and burn out. I had to make a critical decision: either reduce clinic hours, which would limit access to patients in need, or quickly implement a cross-training and redeployment strategy to keep services running. I worked with clinical leadership and HR to identify staff who could be retrained and temporarily reallocated to high-demand sites. Within two weeks, we deployed a new staffing model heavily utilizing virtual care – increasing telehealth capacity by 50% and ensured that no clinics closed despite the crisis.

How did you lead ambulatory services through the COVID-19 pandemic or other major challenges?

During Covid-19, I led the rapid implementation of safety protocols across multiple outpatient sites including reorganizing clinic layouts, launching telehealth services, and developing communication plans to ensure continuity of care and minimized disruptions. It required crisis management and swift decision making when we shut down, and then problem solving, clear communication, and ongoing evaluation to adapt as the situation continued to evolve.