Fitting the pieces into the puzzle as pediatric services return to Shands at UF

The COM and Shands work together to realign services

Verniece Roberts, 8, was one of the first pediatric medical patients admitted to Shands at UF after the realignment of services. Amanda Futch, Shands PCA, checks her vitals Tuesday, April 22.

A few years back officials from Shands and the University of Florida introduced the ampersand to the healthcare organization. The elegant symbol representing the word and was enlisted to help communicate a brand and define the relationship between the UF College of Medicine and Shands HealthCare. The strength of that one character was put to the test over the last few months, and the ampersand endured.

A massive realignment of services among four of UF & Shands venues took place primarily over a two-day period April 15 and 16, although some services had been transferred earlier in March. By all reports, the huge undertaking that required intense planning and unprecedented teamwork was a success and exceeded expectations.

The main move – or most publicized – was the reconsolidation of all pediatric inpatient services back to Shands at UF from Shands AGH. Mike Good, M.D., senior associate dean for clinical affairs, explained that moving pediatric services was part of a bigger project: the Quality Access and Care Realignment.

“This is an effort to better align our patients’ needs with the appropriate care venues,” he said. “We determined that our pediatric patients would get better care if they were in one venue.”

This meant reexamining how to best use the facilities at Shands at UF, Shands AGH, the Florida Surgical Center and Ayers Medical Plaza.

The most important task, according to UF and Shands officials was to get the kids to the right place. Both UF physicians and Shands administrators believe they’ve done that. Although not all the goals of the initial shift of a large portion of pediatric services to AGH 18 months ago were met, the pediatric move did highlight some of the unique aspects of our pediatric practice.

“Some very good things came out of the move of pediatrics to and then from Shands AGH,” said Dr. Richard Bucciarelli, pediatrics chairman. “We learned that we were not able to fit all the pediatric services at AGH. There was additional support that just wasn’t available, and we found it necessary to transport some kids to UF.

“We were not happy with the inconvenience and the stress this may have caused on the kids and their families,” Bucciarelli continued. “It wasn’t meeting our expectations of highest quality of care. We knew we had to move to a different setting.”

The realignment all began with an intensive investigation of the appropriate patient mix for each Shands venue. Out of this work several very dedicated planning committees were created. One group of surgical services leaders began meeting once week on Jan. 17 and continues to meet. Kayser Enneking, newly appointed chair of the department of anesthesiology who also has served as medical director for the Florida Surgical Center and assistant dean for clinical affairs, described the committee’s work as a “show of cooperation that has never been accomplished at this institution before.”

“We were charged with figuring out how to get the pediatric patients back to Shands at UF, and it required immense reorganization,” she said. “Both UF and Shands rolled up their sleeves and got things done.”

The job of moving services and people around to maximize capacity was much like working a jigsaw puzzle – finding the right fit for everybody.

“It was a struggle,” Enneking said. “But when it was suggested to use Ayers as a pediatric outpatient surgical center, it was a light bulb moment. If we split the services and operated only on kids at Ayers and the adults in our other centers, it would work great.”

With that big piece of the puzzle in place, they were left fitting quite a few smaller pieces.

“About 25 people worked diligently and strategically for months to make sure it was a smooth transition for staff, physicians and patients,” explained Good. “Twenty-one pediatric patients were moved from AGH in two days to the fourth floor of Shand at UF beginning Tuesday, and surgeons began operating in their new ORs with new schedules that same day.”

It wasn’t pain free, however. For example, Dr. Thomas Wright, an orthopaedic surgeon, not only switched his outpatient operating location from Shands UF to AGH, he was asked to move his main surgical day from Tuesday to Wednesday in order to smooth the flow of patients.

“So we had to bite the bullet and switch. It has created issues as far as the fact that the three attendings in our division share residents, fellows and PAs, and it required moderate reshuffling.” said Wright, who operates on hands and shoulders. “It is short-term pain, but it makes sense to have made the switch.

“From our standpoint, things are going very well. We will know for sure by the end of the summer.”

Here’s a rundown of the moves:

  • With all pediatric inpatients moved to Shands at UF, less significantly ill adult patients will now go to Shands at AGH.
  • Outpatient pediatric surgery is now to take place at the Ayers Medical Plaza next to AGH – a move that has garnered the most enthusiasm from pediatric physicians and surgeons.
  • Orthopaedic outpatient surgery for hand and shoulder was moved to Shands AGH, and knees and hips will soon follow.
  • Ophthalmologic outpatient surgeries, which took place at Shands at UF, have been relocated to the Florida Surgical Center on Hull Road behind the UF Orthopaedics and Sports Medicine Institute. This move was made on March 17.
  • The emergency rooms from Shands at UF and Shands AGH are working in a coordinated fashion to direct the right ambulances to the right hospitals. The plan is to launch a central dispatch between the two hospitals whereby EMS personnel can call one number and they are directed to the appropriate hospital for the patient’s needs.

    The initial planning group that met weekly to strategize and develop a working transition. Those shown in the photo are identified below.

“The team came together,” said Gigi Lipori, a member of the main planning committee and assistant to Shands executive vice president and COO. “The equipment people’s attitude was ‘what do we need to support this?’ The transportation group had the same attitude and on down the line.”

Lipori, who created the mathematical modeling of acuity, is credited with helping the group determine which transitions would work.

“We racked our brains for months testing models and dodging pitchforks, and we never would have been able to do it without her (Lipori’s) work,” said COM dean Bruce Kone, M.D. “Tim Goldfarb, Jodi Mansfield, and Bill Robinson from Shands as well as our SVPHA Doug Barrett played major leadership and strategic roles. But this effort to improve care across our practice went beyond UF and Shands. VA director Tom Cappello and chief of staff Brad Bender accommodated changes that were necessary for the orthopedics component to work at AGH.”

“We began the process by identifying our philosophy – a premise for what we were trying to accomplish – and that was patient-driven,” Maggie Downey, the SUF Surgical Services business manager. “Then our strategy was data-driven. What fits and what doesn’t fit?”

William Driebe, M.D., chairman of ophthalmology, whose surgical services are now located at the Florida Surgical Center with pediatric surgeries remaining at Ayers, said the move to the FSC will provide better care for patients since the department will have increased operating room time.

Dr. David Kays, chief of pediatric surgery who will serve as medical director of the new outpatient surgery center for kids, said he is delighted with the decision to use the Ayers plaza solely for children.

“It was a great decision,” Kays said. “It will be the first little children’s hospital in Gainesville. If we are considering building a big pediatric hospital, we now have a small version to serve as a model.”

Not all the bugs have been worked out. It may take a few more weeks for surgeons to remember exactly where to direct their cars in the morning. But the planners, physicians and administrators are confident the reorganization will prove successful.

“There still is a huge amount of angst in the system and that’s to be understood,” Enneking said. “But there also is a lot of energy and optimism.

“In the long run, we will have a more cohesive and stronger unit for having done all of this.”

Members of the initial realignment planning group pictured above are from left: Gigi Lipori, assistant to Shands executive vice president and COO; Maggie Downey, Shands UF fiscal coordinator for perioperative services; Terry Wilson, clinical manager for Florida Surgical Center; Barb McClenathan, director of surgical services at SAGH; Suzy Bamberg, assistant business manager for Florida Surgical Center; Tammy Phillips, clinical manager for Ayers Surgical Center; Gail Avigne, director of surgical services for Shands at UF; and Kayser Enneking, M.D., COM. Members not present in the photo are David Burdette, MD, anesthesia, SAGH,;Georgiann Ellis, VP operations, Shands UF; Du Nguyen, senior management engineer; Shands HealthCare; Frank Pommett, administrator SAGH.