🔒Transforming health care: Portland nonprofit trains doctors to be health care leaders

Jim Harnar, who's stepping down this month after serving 10 years as executive director of the Daniel Hanley Center for Health Leadership, has been thinking a lot recently about “impact.”

“How do you measure impact? How do you evaluate what you're doing?” he says. “Measuring leadership can be a really elusive thing. We started out looking at it in the traditional way: Pointing to individuals who've taken one of the Hanley Center's leadership programs and who then stepped up into a position of higher authority. We can point to dozens of care providers who've done that, and that's a significant measurement: When you're out trying to build support for your organization, that's a very helpful data point.”

But Harnar says that simple metric of leadership really didn't capture the essence of leadership exemplified by the organization's namesake, Dr. Daniel Hanley, who died in 2001 after a long career in sports medicine that included an eight-year stint as chief physician of the U.S. Olympic team and serving as executive director of the Maine Medical Association and editor of its journal. Soon after Hanley's death, Harnar joined family members and a small group of close colleagues at a dinner at Bowdoin College. They talked about the qualities that had made Daniel Hanley such an influential leader in health care — compassion, courage, collaboration, kindness and hard work being among them — and decided to create a nonprofit that would carry his legacy forward.

“We seized on one trait: collaboration,” Harnar says, regarding what became the center's guiding principle and a hallmark of its work since 2002.

Twelve years later, upwards of 600 health-care professionals in Maine have completed at least one of the Hanley Center's innovative leadership programs. Almost 300 of them have been physicians who've taken part in the center's Physician Executive Leadership Institute, which provides training in “whole system improvement,” strategic decision-making, financial business skills, team-building skills and health care trends. Others, including medical providers who aren't doctors, have taken its 16-day Health Leadership Development program or participated in Hanley Leadership Forums focusing on topics as diverse as behavioral health, health information technology, paying for quality health care and transforming Maine's primary care system.

Other states have taken note. Some have asked the center for help in creating similar programs. “We helped Texas start a statewide program last fall,” Harnar says. “We're under contract with South Dakota to build a program similar to ours and we're in discussions with New Jersey, which is looking at a collaborative institution aimed at improving end-of-life care.”

The Hanley Center also is one of several Maine health care nonprofits helping Maine meet its goals as one of six states receiving a State Innovation Models grant from the federal Center for Medicare and Medicaid Innovation to identify and implement health care reforms that might lower costs for Medicare, Medicaid and the Children's Health Insurance Program while also improving the health of Mainers enrolled in those federal programs. Maine's $33 million share of the overall $250 million first-round grant will pay for improvements to primary care, public health, behavioral health and long-term care, among other goals.

Even those metrics don't entirely satisfy Harnar's need to measure the Hanley Center's impact as he passes the baton of leadership to Judiann Ferretti Smith, who most recently has served as vice president of strategy and government relations at Spurwink, a statewide behavioral health organization with more than 800 employees. Having worked closely with Dr. Daniel Hanley, who was a stickler for data to support assertions about quality of care and patient outcomes, Harnar says he keeps coming around to “projects” as perhaps the best way of demonstrating how the center and its leadership graduates are slowly transforming health care in Maine.

Breaking down silos

“We've tried to make sure those projects are 'real time' and relevant, that they actually do require physician leadership and that they are aligned with the organization's strategic priorities,” Harnar says. “There's a discipline to the project-oriented approach, and it's based on process improvement, quality improvement and achieving the triple aim of improving health care and processes, improving patients' experience of care and reducing per capita costs of health care.”

One of the more sweeping examples is the Hanley Center's 6th annual leadership forum at the University of Southern Maine in June 2008 attended by nearly 75 health care leaders from across Maine. The forum tackled Maine's primary care system, focusing on the emerging “patient-centered medical home” model and payment reform issues arising from that model's emphasis on proactive medical care that fell outside traditional fee-for-service practices. The forum's participants identified six action steps and the guiding principles that could shape how those recommendations were implemented. Reflecting the Hanley Center's emphasis on collaboration, champions were identified to advance the six initiatives — among them, Maine Health Management Coalition, HealthInfoNet, Maine Quality Forum, Finance Authority of Maine and Maine Primary Care Association.

Fast forward seven years: In their first-year report on its State Innovations Model initiatives, delivered last November, Maine's SIM partners note that upwards of 74 primary care practices, with roughly 567 providers, are participating in the patient-centered medical home pilot program. Another 100 practices, with roughly 508 providers, are participating in a similar initiative for MaineCare, a federal/state program that provides assistance to people with limited resources.

Although the SIM initiative won't end until 2017, the first-year report cites a consensus among stakeholders that the transformation of Maine's primary care system is heading in the right direction — setting the stage for improved coordination of health care as well as payment reforms that are tied to keeping people healthy.

In Harnar's view, that's an affirmation of the Hanley Center's collaborative leadership focus and the impact that hundreds of its graduates are now having in the real world of Maine's health care system.

“This has been building now for a number of years — virtually every piece of Maine's health sector is undergoing massive and most would say 'long overdue' change that should lead to less duplication, better coordination of care, greater efficiencies, all resulting in better quality and bending the cost curve. We have been right in the center of this work, building the case for greater collaboration and providing leaders with the skills, knowledge, trusted networks and confidence to lead change.”

New generation of leaders

Harnar's successor, Judiann Ferretti Smith, is a 2009 graduate of the Hanley Center's Health Leadership Development program. She credits it with giving her the skills and confidence to take on a broader leadership role as Spurwink's vice president of strategy and government relations, a job that had her spending a fair amount of time working with lawmakers in Augusta.

“Relationships are key,” she says. “Maine is a small state. You can't get anything done without trust and relationships. I took it upon myself to share Spurwink's story, sharing my knowledge, whenever I could.”

In her leadership program at the Hanley Center, Smith says her project focused on health care disparities in Maine, which can be based on geography, age, race or income levels. Too often in health care, she adds, knowledge is in silos, with each specialty working in isolation of all the other specialties. In recent years, she says, health care providers have become increasingly aware that behavioral health issues —often thought of as “mental health” but in fact including substance abuse, autism and other barriers to optimum health — often contribute to poor general health.

Although integrating behavioral and primary care medical records would give family doctors a deeper understanding of their patients' total health picture, that goal can hit the roadblock of confidentiality surrounding mental health diagnoses. Removing that barrier, obviously, will require trust and collaboration among medical providers, patients and insurers.

“That was part of my goal in the behavioral health field,” to break through those barriers, Smith says, noting that the Hanley Center is continuing to work with health care partners on finding ways to incorporate mental health information, with patients' consent, into electronic medical records so that providers can better manage their overall care.

“It was an opportunity to be exposed to a broader health care community,” she says of her Health Leadership Development program. “I came to have a real comfort level in making system-level changes happen.”

A lawyer with a license to practice in Massachusetts, Smith says her legal training has served her well in health care. “Lawyers are trained to be critical thinkers,” she says, adding that she expects those skills will be put to good use in her new role as the Hanley Center's executive director.

Harnar, whose 30-year career in health care includes stints as vice president of public affairs at the Maine Hospital Association and president of the Maine Health Information Center (now Onpoint Health Data), expects the Hanley Center's impact will continue to grow as literally hundreds of physicians trained as leaders work with other stakeholders to improve health care in Maine. Within another year or two, the center will achieve its goal of training roughly 10%, or 400, of Maine's practicing physicians to take on greater leadership roles in improving care and moderating the growth of health care costs.

“I feel like the organization is poised for substantial growth,” he says. “It has a solid base of support. In order to move to the next level, we need the input of new energy, passion and drive. I'm 62. When we launched the physician leadership program there was one full-time person: me. It was our biggest initiative, a huge effort, a huge risk. It took 10 years to get a clear fix on what the organization's mission would be. Then it took a couple of years to get strong enough to get staffing in place. Then it was off to the races.”