New research indicates incentives for clinician assessments of hospital-discharged skilled nursing facility patients should be strengthened.
At skilled nursing facilities, hospital-discharged patients who are not visited by a clinician are nearly twice as likely to be readmitted to a hospital as patients who receive visits, recent research shows.
About 20% of hospitalized Medicare patients are discharged to a skilled nursing facility (SNF). Readmissions have become a crucial metric for hospitals, with quality and financial dimensions. For example, Medicare has been penalizing hospitals financially for readmissions linked to several conditions such as pneumonia since 2012.
The recent study, published in Health Affairs and LDI Research Brief, found clinician visits to hospital-discharged patients at SNFs were strongly associated with readmission and mortality rates:
SNF patients who received at least one clinician visit had a 14.3% hospital readmission rate. SNF patients who received no clinician visits had a 27.9% readmission rate.
SNF patients who received at least one clinician visit had a 7.2% mortality rate. SNF patients who received no clinician visits had a 14.2% mortality rate.
The researchers examined data from more than 2 million Medicare fee-for-service SNF stays.
"Patients transitioning from hospitals to SNFs are often medically complex and at high risk of poor outcomes, with one in four of these patients deceased or re-hospitalized within thirty days. Results from this study suggest that missing and delayed care from physicians and advanced practitioners occurs during this vulnerable time," the study authors wrote.
Improving care at SNFs
Better incentives are needed to promote clinician assessments of hospital-discharged SNF patients, the researchers wrote. "Current regulatory and payment policies do not incentivize timely physician assessment of patients discharged from hospitals to SNFs. Medicare requires only that a physician complete an initial assessment within 30 days of SNF admission."
The lead author of the study, Kira Ryskina, MD, MS, told HealthLeaders that some new payment models are promoting enhanced SNF care. "Payment reform such as bundled payments that penalize hospitals for their patients' postacute care outcomes aim to encourage hospitals to invest more resources in SNFs."
Medical assessments of patients at SNFs generally feature three elements, she said.
"Typically, an effective assessment has an admission history including a review of medical records from the preceding hospitalization and medication reconciliation, physical examination, and delineation of plan of care," said Ryskina, an assistant professor of medicine at the University of Pennsylvania's Perelman School of Medicine.
The primacy of online reviews in the marketing of medical practices is the 'new normal,' according to a recent survey.
Online reviews are playing a pivotal role in how patients pick their healthcare providers, a recent survey shows.
For clinicians, online reviews should be a primary concern for several reasons: review websites such as HealthGrades and Vitals are collecting information and posting it across the country, online reviews can be robust marketing tool, and reviews can help hone clinician performance.
"This is the new normal for medical practices in 2019. Choosing a doctor based on online profiles and patient reviews is the old word-of-mouth at today's scale and speed. Number of reviews, average star rating, and convenient hours and locations are essential 'shopping' details that patients expect to find before stepping foot into a waiting room," the recent survey's report says.
The survey, which features responses from more than 800 people about online reputation and patient reviews, generated several key data points:
74.6% of respondents had researched doctors, dentists, or medical care online
69.9% said a positive online reputation is very or extremely important in selecting a healthcare provider
51.8% of patients who had submitted negative online reviews about a medical practice had not been contacted to address their concerns
Patient satisfaction doubles when a medical practice addresses a negative online review
"While satisfied patients are more prevalent online than unhappy ones, the fact remains more than 1 in 3 patients who've shared their experience online have submitted a negative review. Negative reviews are going to pop up—they're an unavoidable aspect of customer service for any business, in any industry," the survey's report says.
Responding to negative reviews
The survey—which was conducted by Santa Monica, California-based PatientPop—shows the key role online reviews are playing in patients' selection of healthcare providers.
"This illustrates just how influential reviews are in patients' decision-making process. If a doctor or practice isn't making a strong first impression with online reviews, that's the difference between a newly acquired patient and a lost one," says Joel Headley, director of Local SEO and Marketing at PatientPop.
The powerful impact of addressing negative reviews was an unexpected finding of the survey, he said.
"It was surprising to see just how much patient satisfaction can increase—99%—following a negative review based on just one action: practices reaching out to address the patient's concerns. We assumed that good common courtesy and customer service would bump up respondents' satisfaction rates, but I don't think we expected they would double."
There are a handful of best practices when responding to negative reviews, Headley says.
"First, being prompt is critical—practices should respond to any negative review by the next business day. Second, whomever is responding for the practice should keep it short and professional, being clear that the patient's concerns are important and stating they want to help remedy the issue. They should also offer to reach out directly to the patient and take the conversation offline. Finally, practices must keep HIPAA compliance in mind, never including any personal health information or care details within the response even if the patient does."
Prompt identification of patients who are at high risk of sepsis could be the difference between life or death.
Emergency department crowding leads to a significant increase in door-to-antibiotic time for septic patients, recent research shows.
On an annual basis, sepsis affects about 1.7 million American adults and the infection is linked to more than 250,000 deaths. Prompt administration of antibiotics is the standard of care for patients who have been identified with sepsis.
The recent research found only 46% of emergency department sepsis patients received antibiotics within 3 hours of ED arrival when the emergency room was crowded compared to 63% receiving timely antibiotics when the ER was not crowded.
The researchers examined data collected from more than 3,500 sepsis patients.
"We observed a consistent association between increased ED crowding and decreased antibiotic timeliness. When ED occupancy rate was in the highest quartile, the adjusted probability of starting antibiotics within 3 hours was more than 50% lower than when ED occupancy rate was at or below the 25th percentile," the researchers wrote.
Achieving standard of care under crowded ER conditions
Even in a crowded ED and with the diagnostic challenges of sepsis, meeting the 3-hour standard of care for administration of antibiotics to sepsis patients is a reasonable expectation, the lead author of the research told HealthLeaders.
"Myocardial infarction treatment and stroke treatment also require a team evaluation and multiple aspects of clinical evaluation—there is intensive resource mobilization. However, for MI or for stroke, we don't say, 'The ED was overcrowded, so it's OK that we didn't achieve our one-hour time to treatment goals,'" said Ithan Peltan, MD, MSc, an attending physician in the Department of Medicine at Intermountain Medical Center, Murray, Utah.
EDs should have a similar approach to sepsis treatment as MI and stroke treatment, with the acknowledgement that sepsis diagnosis is definitely not as clear cut, he said. "We should determine how we can achieve our treatment goals for sepsis without increasing harm to patients—without increasing overtreatment or giving antibiotics unnecessarily to patients."
Accelerating sepsis assessment
Peltan's research team found that delayed administration of antibiotics results mainly from challenges in the early stage of patient care.
"Crowding-associated antibiotic delays resulted from delays in initial patient assessment (patient triage, evaluation by a clinician, and diagnostic data collection) rather than delay occurring between initial assessment completion and antibiotic initiation," the researchers wrote.
There are methods to improve early-stage care of sepsis patients in crowded EDs, Peltan told HealthLeaders.
"One factor is that the earliest stages of sepsis treatment are critical. You need to recognize the patients who might have sepsis. That is not to say we are going to diagnose sepsis right away, immediately start treatment, and give antibiotics indiscriminately. That is clearly not the right thing to do," he said.
In the early stage of patient care, identifying patients who are at high risk of sepsis is pivotal, Peltan said. "Identifying patients who are at increased risk for sepsis can be based on clinician suspicion with increasing education of our frontline providers and more advanced sepsis prediction models."
Once an ED patient has been identified as high risk for sepsis, the assessment process should be accelerated, Peltan said.
"The next step is to do what we have done for stroke and MI, which is to take measures that expedite the assessment that is necessary before the treatment decision can be made for patients. We should bring all of the resources into the room, we should get the blood tests done quickly, we should conduct point-of-care tests, we should have the nurses getting IV access, we should get a basic chest X-ray done, and we should collect a urinalysis sample."
Although speeding up the assessment process is challenging in a crowded ED, it is an essential step to reach an initial decision on whether sepsis is present or more assessment is necessary, he said. "This approach is helpful when there is ED crowding. One of the big challenges that ED crowding poses is for the physician at the bedside to have all of the data needed to make decisions."
New research indicates comprehensiveness in primary care could be just as significant as care access and coordination.
Patients who receive comprehensive primary care have lower Medicare expenditures, fewer hospitalizations, and less emergency department visits, recent research shows.
More comprehensive care has been linked to improved care coordination; reduced diagnostic tests, medications, and interventions; health gains; lower costs; and improved equity.
"Our findings, when taken in the context of prior literature, suggest that promoting comprehensiveness of primary care could avert preventable ED visits and hospitalizations and lower overall costs," the authors of the recent study published in Health Services Research wrote.
The researchers examined three measures of comprehensiveness:
Involvement in patient conditions: This new metric gauges the comprehensive of clinicians based on their involvement in the care of a broad range of patient health conditions.
New problem management: This new metric measures how much a clinician manages a patient's new symptom or problem rather than making a referral to a specialist.
Range of services: This previously established metric shows the range of services that a clinician provides to all patients.
The research is a leap forward in the ability to examine the comprehensiveness of primary care, the lead author of the study, Ann O'Malley, MD, MPH, told HealthLeaders.
"This work helps us assess comprehensiveness more deeply than prior work by adding two new measures—new problem management and involvement in patient conditions—and we demonstrate that both are important dimensions of primary care clinician comprehensiveness," she said.
O'Malley's research team found a high degree of new problem management was associated with reduced total Medicare expenditures, hospitalizations, and ED visits.
The research shines a light on comprehensiveness of primary care—an issue that has received insufficient attention in the past, O'Malley said.
"To date, comprehensiveness has received less attention than other key elements of primary care, such as access or continuity, which are more easily measured, and coordination, which is now the focus of a variety of new payment models. Without explicit measurement and support for its improvement, comprehensiveness may wither as other aspects of primary care such as access and coordination receive more resources and attention."
Expanding knowledge about comprehensiveness of primary care
The new study builds on earlier research about comprehensiveness of primary care and outcomes, she said.
"This work shows that particular aspects of primary care physician comprehensiveness—in particular the primary care physician's management of patients' new problems and the primary care physician's involvement in the care of a broad range of a patient's conditions—are associated with lower rates of emergency department visits, lower hospitalization rates, and lower total Medicare expenditures."
The new study also advances the understanding of how comprehensiveness impacts care, O'Malley said.
"This work adds to prior efforts, which have chiefly focused on comprehensiveness in terms of the types of services a primary care practice offers. Our analyses suggest that, for Medicare beneficiaries, high physician comprehensiveness on our two new measures is as important as assessing the range of services they provide."
She cautioned that the study's findings are useful to primary care researchers but have limited utility for applications such as payment models. "These claims-based measures are not suitable for high-stakes performance metrics for individual primary care clinicians or practices."
CEO Pat Basu speaks on a range of opportunities to defeat cancer.
Pat Basu, MD, MBA, has been on a quest to cure cancer since he decided to go to medical school.
"I went into medicine in the first place to become a radiologist, in large part, due to cancer being one of the great battles that humanity is fighting today, and has been fighting for many centuries," Basu, the new president and CEO of Cancer Treatment Centers of America (CTCA), told HealthLeaders recently.
Cancer claims the lives of more than 600,000 Americans annually, according to statistics from the National Cancer Institute.
The University of Chicago Pritzker School of Medicine graduate brings an extensive professional background to his new role.
He has worked as a physician at Stanford University Medical Center; a partner at Chicago Pacific Founders Private Equity and at Pritzker Group Venture Capital; senior vice president at Optum; a White House fellow; and president, chief operating officer, and chief medical officer at vRad, a provider of radiology services.
Basu is also one of the founders of Doctor On Demand, a telehealth video visit company.
"I have been privileged to work at organizations that are at the forefront of some of the major transformations in healthcare—technology and data, value-based care, and healthcare reform working in the White House," he says.
HealthLeaders spoke with Basu, who is succeeding Rajesh Garg, MD, JD, to find out about his vision for CTCA. Following is a lightly edited transcript of that conversation.
HealthLeaders: What are the biggest challenges facing cancer treatment providers such as CTCA?
Basu: Clinically, we have amazing potential clinical tools that are on the verge of breakthrough such as precision medicine and immunotherapy. But cancer is still an unbelievable plague on our society, with one-out-of-three Americans who will be diagnosed with cancer during their lifetime.
From a care delivery standpoint, cancer care providers face similar—and in some instances extenuated—versions of what other healthcare providers in America are experiencing. On the one hand, cancer care providers are delivering very complex care despite an accelerating decline in reimbursement. At the same time, cancer care providers are dealing with increasing input expenses such as pharmaceutical costs.
There are also challenges throughout the American healthcare system that are highly relevant to cancer care providers. There are changes in care models—there are shifts from treatments that used to be inpatient therapy that are now outpatient therapy and may soon be shifted to telehealth. That sounds nice; but as an organization, those shifts are challenging operationally.
There are shifts in the marketplace in terms of value-based care and increasing patient deductibles. There is the impact of technology, which is a good thing, but technology in and of itself is not a solution. You need to have solutions that deploy technology, not technologies that deploy solutions.
HL: What is an example of a new business venture at CTCA that is designed to expand access to higher-quality cancer care?
Basu: We have incredibly big opportunities in the data space, where we are working with pharmaceutical companies and biotechnology companies. At CTCA, we have been treating patients end-to-end, with holistic, integrated care for more than 35 years. So, we have lots of data from the time that patients came to us, to the time they were treated and went home, and everything in between.
So, we have clinical trials with pharmaceutical companies to use that data to unlock better cures.
HL: Why is data such a valuable commodity in medicine?
Basu: How many times in our profession have we said that something works, then we came back later and said it doesn't work? You just don't use the latest and greatest because it is the latest and greatest. You have to think about whether you are adding value to the patient, and you need data that says one therapy is better than another.
History is littered with medical treatments that we thought were great, but they ended up not great and actually harmful.
HL: What would you pick as the most promising technologies in cancer care?
Basu: In the purely clinical axis, I hold a lot of faith in precision medicine and immunotherapy.
Precision medicine is based on the idea that each of us have unique factors that—to date—have not been taken into account. American medicine has been monolithic—if you take a certain dose, I take a certain dose. Immunotherapy is also powerful because it is unlocking the body's own powerful defenses.
On the technology axis, I am most excited about what data can unlock. In cancer care, which is a highly complex disease and a highly prevalent disease, we have lots of data. We should be able to unlock treatments, wisdom, and nuances.
On the care delivery axis, I am excited about the notion of getting care out to the patient in terms of telehealth and remote monitoring and other things that allow us to come to the patient instead of the patient always having to come to us. That has relevance in primary care, and it has relevance in oncologic care.
Despite feeling lack of preparedness, most clinicians report willingness to provide substance abuse or mental health services for patients.
Clinicians are poorly prepared to screen and treat patients with substance abuse and behavioral health disorders, a recent survey found.
About 65 million Americans will experience a mental health or substance use disorder in their lifetime, which raises risk of disease and mortality as well as increases healthcare costs. Integrating behavioral health services into routine care creates opportunities for clinicians to assess mental health and substance abuse, then intervene if appropriate.
"Healthcare professionals responding to this survey report not feeling adequately prepared to address the needs of patients with potential substance use and mental health problems. Such lack of preparedness means that patients will go undetected for common behavioral health problems for which screening measures and intervention models exist and can be feasibly administered in most healthcare settings," the survey authors wrote.
The survey has several key findings:
57% of clinicians reported not feeling adequately prepared to screen patients for substance abuse or mental health disorders
64% of clinicians reported not feeling adequately prepared to use motivational interviewing to boost patients' desire to change behavior or seek help
62% of clinicians reported not feeling adequately prepared to work with patients to craft an action plan
84% of clinicians reported willingness to provide substance abuse or mental health screening, brief interventions, and treatment referrals to patients
The survey collected data from nearly 700 healthcare professionals from more than 50 organizations.
Preparing clinicians to provide care
Addressing prejudice and improving behavioral health education are the keys to better preparing clinicians to care for patients with substance abuse problems and mental health disorders, Deborah Finnell, DNS, CARN-AP, FAAN, a faculty consultant at Johns Hopkins University's School of Nursing in Baltimore and co-author of the survey, recently told HealthLeaders.
"It is essential that clinicians recognize their biases toward this population that is vulnerable and among the most stigmatized globally. My 2018 publication in Substance Abuse reviews the neural pathways of disgust, bias, prejudice, and discrimination that fuel stigma. A non-judgmental approach to this population is key to developing a trusting relationship," Finnell said.
Education about established measures for screening is crucial, she said.
"These measures need to be those that have been established through research, for the intended purpose and population, and administered in the way they are intended. For example, the CAGE questionnaire is useful for detecting persons with an alcohol use disorder, yet the Alcohol Use Disorder Identification Test (AUDIT) is a screening tool that can be used to identify the level of risk related to alcohol—from low risk to moderate risk to severe. Thus, the AUDIT is a sound measure for universal screening in populations."
Once a risk is identified, then clinicians need to know how to intervene effectively, Finnell said.
"Motivational interviewing skills are invaluable for promoting behavior change—whether that is encouraging patients to take medications consistently or encouraging patients to consider reducing the amount of alcohol consumed. Clinicians also need to know when and how to refer an individual who could benefit from specialty treatment."
Seizing primary care opportunity
Some clinicians may fear upsetting patients or otherwise abdicate their role in addressing substance abuse as part of primary care to specialists. The barrier may be their own attitudes and perceptions toward the population and fears about their own lack of knowledge about screening, brief intervention, and referral to treatment (SBIRT), Finnell told HealthLeaders.
"As this clinical set of strategies is implemented in primary care, then patients with low and moderate risk can be managed in that setting while those who could benefit from specialty treatment can—and should—be referred to specialists."
The SBIRT technique can help provide patients with timely treatment, she said. "SBIRT is about preventing the progression of risks that can be detected early with evidence-based screening measures, interventions, and treatments provided in primary care at the same time as the patient visit."
New research shows that in-hospital delirium patients are vulnerable during the early posthospitalization period.
In-hospital delirium is a predictor of readmission, emergency department visits, and discharge to a location other than home, recent research shows.
The development of delirium in the hospital setting impacts about 12.5% of general medical admissions and as many as 81% of intensive care unit patients. Earlier research has shown delirium among hospitalized patients is predictive of prolonged hospital length stay, lengthened mechanical ventilation, and mortality.
The recent research in the Journal of Hospital Medicine featured data collected from more than 700 delirious patients and nearly 8,000 non-delirious patients. The researchers found delirious patients had increased odds for 30-day readmissions, ED visits, and discharge to postacute care facilities.
"These results suggest that patients with delirium are particularly vulnerable in the posthospitalization period and are a key group to focusing on reducing readmission rates and post-discharge healthcare utilization," the researchers wrote.
Link between in-hospital delirium and readmissions
The Journal of Hospital Medicine research builds on earlier studies about in-hospital delirium, the lead author of the research told HealthLeaders.
"Prior studies have shown that delirium is associated with functional decline at discharge, so these patients may be particularly vulnerable in the days and weeks following hospital discharge. Our work helps to confirm this as we show that patients who become delirious in the hospital are far more likely to be readmitted within 30 days of discharge, compared with patients who do not develop delirium," said Sara LaHue, MD, a resident physician at the Department of Neurology, School of Medicine, University of California San Francisco.
The new research indicates that hospital-based interventions should be targeted at delirious patients to reduce readmissions, she said. "Hospital-based interventions that reduce the development of delirium may then reduce the complications of delirium, such as readmission."
Reducing delirium-associated postacute care service utilization
To avoid hospital readmissions linked to delirium, clinicians should focus on preventing patients from becoming delirious in the hospital, LaHue said.
"This may include systems for identifying patients at high risk of becoming delirious, screening for active delirium, and enacting interventions that target the underlying cause in order to reduce the severity or duration of delirium. While such a program can take a bit of work to get off the ground, the benefits for patients, their families, and the hospital system can be significant."
One team member who is often overlooked is the caregiver at home, she said.
"Educating caregivers about delirium risk factors can be very helpful—he or she can bring glasses or hearing aids from home, engage the patient in meaningful conversation to help with orientation, and encourage regulation of sleep-wake cycles. If a patient does become delirious, the caregiver can continue to help with these interventions."
Caregivers at home are an essential component of postacute care, LaHue said.
"We know that delirium is associated with functional decline at discharge, so coordinating safe discharge plans with the caregiver, especially to identify need for resources—physical therapy, occupational therapy, home health, and nursing—can potentially help reduce post-discharge complications."
Follow-up care is another crucial factor, she said. "Ensuring expedited follow-up with a primary care provider, who can assess for any additional needs, is also important."
The postoperative care initiative at a California-based children's hospital has 11 elements.
A new approach to cardiac surgery postoperative care at Lucile Packard Children's Hospital Stanford slashed the surgical site infection rate.
SSIs have been linked to significant negative outcomes such as increased duration of mechanical ventilation, longer ICU and hospital lengths of stay, and higher mortality rates.
For pediatric cardiac surgery patients, a new postoperative care bundle at Lucile Packard Children's in Palo Alto, California, reduced SSIs from 3.4 incidences per 100 procedures to 0.9 per 100 procedures, recent research shows.
The lead author of the research, Thomas Caruso, MD, MEd, told HealthLeaders that other hospitals seeking to reduce SSIs should also assess postoperative care.
"The national guidelines focus on the preoperative, intraoperative, and immediate postoperative period, but SSIs can occur up to 30 days postoperatively," said Caruso, a clinical associate professor in the Division of Pediatric Anesthesiology at the Stanford University School of Medicine, Stanford, California.
The first step is examining instances of SSIs, he said.
"For an institution with high rates of SSIs, I would recommend starting with an analysis of when the majority of SSIs occur and whether they occur more commonly during a specific surgery. If the majority of SSIs are occurring in postoperative days 10 to 30, consider examining the extended recovery care, in addition to the typical perioperative guidelines."
Care bundle components
The new cardiac surgery postoperative care bundle at Lucile Packard Children's has 11 elements.
1. Antiseptic wipe: Once a day, patient skin is wiped with 2% chlorhexidine gluconate
2. Linen and gowns: Maintaining clean gowns and linens reduces patients' potential antibiotic burden
3. Dressing removal: With an aseptic technique, dressings are removed within 48 hours because they can provide a conducive environment for infection development
4. Covering incision site: In some circumstances such as placing ECG cables, the incision site is covered to avoid contamination
5. Sterile echocardiograms: Using a sterile sheath and gel on the probe lowers risk of infection
6. Sterile environment standards: When procedures are performed in the cardiovascular intensive care unit, appropriate attire is donned and the surgical bed is demarcated with physical barriers and draping
7. Home blankets: While home blankets are considered a comfort measure for children, they are a potential source of contamination, and a clean gown or linen is placed between the blanket and the surgical site
8. Wound documentation: EMR modification reduces variability in documentation of wound status
9. Wound monitoring: Swabbing of wounds for infection is only conducted if there are signs of erythema or purulence
10. Postoperative antibiotics: Rather than make nurses responsible for appropriate time and dose of first postoperative antibiotics, a pharmacist determines appropriate administration
11. Continuation of antibiotics: Administration of postoperative antibiotics is maintained for 24 hours or extended beyond a day if the chest remains open
At health systems, hospitals, and physician practices, one-dimensional approaches to burnout are unlikely to succeed.
Physician burnout is a multifactorial phenomenon that requires a multifaceted response, a recently published white paper says.
Recent research indicates that nearly half of physicians are experiencing burnout symptoms, and a study published last October found that burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.
The Chicago-based Chartis Group's recent white paper calls for healthcare organizations to take a broad approach to solving their physician burnout problems, an author of the report told HealthLeaders.
"When single-threaded solutions are executed in isolation or without an understanding of the full set of factors that are contributing to this epidemic, the impact can be limited and short-lived," said Tonya Edwards, MD, a principal in the I&T Practice at Chartis.
Several factors are often at play when a healthcare organization is experiencing alarming levels of physician burnout, she said.
"What we have tried to do is put together an approach that looks at many of the factors that contribute to provider burnout, including workplace overload, lack of control, breakdown of community, inefficiency, and poor leadership practices such as lack of respect and setting unrealistic performance expectations."
Two-pronged strategy
The white paper has a two-part framework for addressing physician burnout:
1. Operational dimension: At the grassroots, burnout mitigation efforts include process redesign such as streamlining of workflows, assessment and reform of care-team models such as staff fully practicing at the top of their licenses, and optimal use of technology such as realizing the full potential of the electronic health record.
2. Transformational dimension: At an organizational level, Chartis' approach focuses on leadership such as whether senior leaders involve physicians in decision making, culture such as fostering an environment that values collaboration and mutual trust, and engagement such as whether performance expectations well-articulated and understood.
"The first thing that needs to happen is a listening tour. Particularly after joining large organizations, providers feel like administrators are making all of the decisions, and there is a significant loss of autonomy. Physicians no longer feel respected," Edwards said.
Implementing burnout solutions
Every healthcare organization should design physician burnout mitigation efforts that are carefully crafted, Sue Fletcher, engagement manager in the Performance Practice at Chartis, told HealthLeaders.
"We believe we have to assess all of the factors, then tailor the solution based on the unique needs of physicians and the specific setting. The needs of primary care physicians are going to be unique and different compared to those of hospitalists or surgeons," she said.
Imposing physician burnout solutions on a healthcare organization rarely works, Fletcher said. "We have partnered with organizations to assess the specific needs of physicians—working with the care teams and working with the physicians to understand the factors that are causing burnout. Then we work directly with the physicians to figure out observable improvements in their experience."
Establishing and tracking metrics is crucial for a successful physician burnout initiative, Edwards said. "A key factor is making sure we are making measurable improvements. We have to identify key performance indicators. We have to show improvement over time."
Cleveland Clinic is achieving multiple benefits at the health system by creating a high-reliability culture.
High reliability is a high priority at health systems and hospitals across the country.
For example, recent research identified achieving high reliability as the top priority at children's hospitals. And Novant Health in Winston-Salem, North Carolina, has adopted a culture of zero tolerance for hospital-acquired infections, serious safety events, and any harm to patients while they are hospitalized, says Eric Eskioglu, MD, the executive vice president and chief medical officer.
Another example of a healthcare organization prioritizing high reliability is Cleveland Clinic, which began initiatives in 2013.
"There has been a revolution at Cleveland Clinic over the past several years to emphasize a culture of high reliability and safety, as well as to emphasize a team approach to everything we do," says Edmund Sabanegh, MD, main campus and regional hospitals president at the Cleveland-based health system.
Cleveland Clinic's quest to become a high-reliability organization has achieved a trifecta: improved patient outcomes, boosted physician satisfaction, and reduced physician burnout.
"There is a big problem in healthcare with burnout, which is complex and involves lack of job enjoyment, feeling stressed, and work-life balance challenges. All of those things improve when you have a team working together smoothly to get the best outcomes for patients," Sabanegh says.
The correlation between team-based care and physician satisfaction is direct, he says. "Things that help us successfully treat patients—team approaches, checklists, and spreading of responsibility—improve our engagement and satisfaction with our career field."
High-Reliability Components
Cleveland Clinic's high-reliability initiative has revolved around basic team building, policy standardization, real-time operational management, creating a culture of safety, and sustaining redundancy in the clinical setting.
But inconsistency in administrative and operational policies is a major challenge for health systems seeking to attain high reliability, Sabanegh says.
"One of the challenges for any large healthcare system is there are many sites for delivery of care. A pitfall that you can have is failing to recognize the nooks and crannies of the system, then having different policies and standard operating procedures for different areas," he says.
Cleveland Clinic, which features 19 acute-care hospitals, has made policy standardization a priority, Sabanegh says. "We have worked hard to standardize our policies to make sure that a nurse who works in one ward, then works in another location in our system has a similar expectation and similar understanding of processes."
One of Cleveland Clinic's high-reliability cultural initiatives has upended decades of tradition in the health system's operating rooms. As opposed to the top surgeon dominating discussions and decision-making in the OR, the health system has adopted a team-oriented approach, including operating room pauses, he says.
"If we have a surgery and anyone in the room is unsure of equipment status or a missing supply like a sponge, there can be a pause. Any member of the team can say, 'I want to look at where we are before we proceed any further with this procedure.' It could be the most junior member of the surgical team or it could be the most senior member."
To achieve real-time operational management, Cleveland Clinic adopted a reporting system based on tiered huddles this year.
"Every morning, on every nursing unit, there is a huddle of the team. They discuss what has gone right, opportunities, and concerns for the day ahead," Sabanegh says.
The discussions at the ward level are reported to hospital leadership, including the president, chief nursing officer, chief medical officer, and chief quality officer.
The hospital leadership's huddle is reported to health system leaders. Information gathered through the tiered reporting allows senior leadership to act quickly at any location in the organization, he says.
"As the hospitals' president, I am hearing every day from every hospital in our system about their challenges and opportunities for the day ahead. What is our workload and how can we balance it? What kind of infrastructure support do we need? What kinds of repairs are needed?"
Gathering timely information from throughout the health system is invaluable from both management and labor perspectives, he says.
"Real-time operational management gives us both an early warning system for problems and challenges for the entire enterprise, and a great venue to communicate up and down the organization. Everybody is hearing about challenges at other places and how those challenges are being solved."
Cultural considerations
Culture is essential to creating a high-reliability organization, Sabanegh says. "We are working very hard to create a culture of safety and high reliability. Every time the leaders of the organization speak, they talk about this theme."
Staff members are encouraged to identify quality concerns with public recognitions such as awards. "We don't want to be in a reactive mode. Our system fails when we have a serious safety event. What we want to identify is the near miss or something that could turn into a serious safety event down the road," Sabanegh says.
Although redundancy is often equated with waste, Cleveland Clinic sees value in redundancy in the clinical setting, he says.
"We still believe some redundancy is necessary. We are leveraging technology to assist in catching things; but, in this generation, technology will not replace the need to have multiple sets of eyes looking at a challenge."
Education and communication have been key elements of engaging physicians in high-reliability efforts at Cleveland Clinic, Sabanegh says.
Educational programs that support the health system's high-reliability efforts include Solutions for Value Enhancement (SolVE). "Physician leaders learn about high reliability, performance improvement, and tackling processes with risk and opportunity while avoiding risk. We have trained thousands of people in our organization in these areas," he says.
High-reliability benefits
Cleveland Clinic also communicates with clinicians about the benefits associated with high-reliability organizations, he says.
Engaged clinicians have helped Cleveland Clinic achieve significant high-reliability gains. The average 30-day readmission rate has fallen from 14% to 12.65%, which represents 2,100 patients per year who did not require a readmission.
Outpatient hypertension control has increased from 66% to 76%, with 15,000 more patients at prescribed goals. Cleveland Clinic estimates improved hypertension care has saved about 100 lives.
"We have seen a steady improvement in our quality outcomes, a reduction in serious safety events, and improvements in our readmissions—all things that are important to our patients and improve when our care team makes sure we are highly reliable," Sabanegh says.