Assessing aging physicians and other clinicians for professional competency can help them transition to more suitable roles and allows employers to preserve working relationships with valued workers.
William Norcross, MD, remembers a phone call from an anxious hospital chief of staff.
"A surgeon [there] had developed [full blown] Alzheimer's," recalls Norcross. "But his colleagues all felt such compassion for him, and he was so loved, nobody had the heart to tell him he no longer belonged in the operating room."
So the surgeon's coworkers found small jobs for him to do, such as holding retractors, which allowed him to still be a member of the surgical team.
But the chief of staff had a bad feeling. "I just want to know, can you conceive of any problems with this?" he asked Norcross.
As founder and Executive Director of the Physical Assessment and Clinical Education (PACE) program and professor of medicine at University of California, San Diego, Norcross helps evaluate troubled physicians referred by state medical boards and hospitals.
While there is no national standardized test for clinicians to ensure their ability to continue on in their jobs, some hospitals do ask their clinicians to regularly be tested for competence.
Norcross describes the tests PACE has created as "a physical, a hearing and vision test, a brief, computerized screening test of neurocognitive function and a paper and pencil screening for depression and substance abuse."
He says the test takes less than half a day to complete, is relatively inexpensive, and is evaluated confidentially by a board of non-competing peers. While Norcross knows that assessing aging physicians and other clinicians can be a controversial topic, he feels passionately that it's the best solution to ensure patient safety.
"If there are age-related deficits, we should learn about them and find accommodations so [clinicians] can keep practicing safely. In some cases, it may be discovered that it's time to retire, but I would want to know that. I think all good physicians would want to know that," he says.
Reasonable Accommodation In other fields, determining when to retire or shift work responsibilities is a deeply personal question, but in medicine, a practitioner's ability can mean the difference between life and death.
In Norcross' view, it should never get to the point where a clinician makes an error that can be blamed on age. "If it gets to that point, it's too late. As a patient, I don't want that," he says.
In the case of the chief of staff who called on Norcross' expertise regarding the surgeon with Alzheimer's, Norcross could not advise him to allow the surgeon to keep practicing in his current role.
"I admired the team's compassion and willingness to work with him—but, what if something went wrong? It's difficult to recover if you're a story on the front page of the newspaper."
"When [the clinician] can no longer do key, essential functions of working with a patient [it's time to retire]," says Vic Buzachero, corporate senior vice president for innovation, human resources and performance management at Scripps Health. "Or when their interest declines—if they burn out, or other interests develop."
But there are other options for aging practitioners who do not wish to retire completely.
The first option is to consider working fewer hours or different hours. Some older people are still able to work a normal workload, but shouldn't be on call at night. Others can handle working several days a week, but not a full-time schedule.
Buzachero suggests managers allow flexible hours to keep employees working longer. Scripps Health also offers a program that allows employees to retire in phases, so they don't have to stop working all at once.
Some employees might just need a more ergonomic setup, said Buzachero, who has equipped work stations with padded mats for older clinicians to stand on, special computer screens to reduce eye strain.
Another option is to help practitioners change roles A popular choice for older physicians is to become a family practitioner, a specialty where dexterity is not as important as in surgery. Some clinicians find a second professional act in teaching or coaching newer physicians and nurses, in administrative work, or as analysts.
As long as a clinician cares about patients and wants to use his or her talents, they should continue working in some capacity, says Buzachero. "When you can no longer be sensitive, read what a patient needs, or contribute, it's time to retire," he says.
Until then, it's a grave disservice to older clinicians who have wisdom and experience to contribute to be asked to exit before they are ready to go.
The potential adverse effects of unsafe injection practices are not typically seen immediately, but can have catastrophic consequences for patients and for providers, says The Joint Commission.
The Joint Commission, in its latest Sentinel Event Alert, is warning healthcare providers that serious blood-borne and bacterial infections are among the consequences of misusing single-dose/single-use and multiple-dose vials.
Thousands of patients have been adversely affected by misuse of contaminated vials, The Joint Commission reports. It cites information from the Centers for Disease Control, which has tracked at least 49 outbreaks since 2001 due to incorrectly administered injectable medical products. Of those, 21 involved the transmission of hepatitis B or C; the other 28 were outbreaks of bacterial infections.
Since 2007, nineteen outbreaks have been caused by the misuse of single-dose vials. Seven were blood-borne pathogen infections; 12 were bacterial infections. All outbreaks occurred in outpatient settings; eight were in pain remediation clinics.
Another recent study by the CDC and Centers for Medicare & Medicaid Services found that two-thirds of ambulatory surgical centers had lapses in basic infection control practices. Twenty eight percent of those surgical centers also reused single-dose vials on multiple patients.
A major contributing factor to the misuse of vials is widespread lack of adherence to safe injection practices. For example, the misuse of vials frequently involves healthcare workers reusing single-dose vials. As single-dose vials usually lack preservatives, they can easily foster bacterial growth between uses.
A recent survey of 5,446 healthcare practitioners found that:
6% admitted to sometimes or always using single-use vials on multiple patients.
15% admitted to reusing syringes to re-enter a multiple-use vial numerous times for the same patient.
6.5% of those who admitted reusing syringes admitted to saving multiple-use vials for use on other patients.
Half of the 51 healthcare professionals who reported reusing syringes with multiple-use vials in multiple patients were in hospital settings.
Another cause of infections linked to improper administration of injectable medications is the nurse, physician, or technician who is opioid-addicted.
Sometimes the urge to re-use vials can be prompted by medication and supply shortages and high costs. But any savings achieved by reusing these products would be outweighed by other costs if even one patient develops an adverse clinical reaction to them, The Joint Commission maintains.
Of the known victims of these preventable outbreaks, many required prolonged, sometimes life-long, follow-up care. Some died. The costs of caring for these patients and containing an outbreak can be crippling to an organization. Furthermore, providers found to have caused harm can expect to face significant legal ramifications and disciplinary action.
Tips for Clinician Leaders
The CDC's One & Only Campaign, which aims to raise awareness of safe injection practices among healthcare workers, offers specific tips for managers. These include
Ensuring that there are enough supplies on hand to ensure safe injections
Providing a medication preparation area that is separate from the patient care area
Arranging for infection control training
The Joint Commission urges staff to always follow safe injection practices, including correct aseptic technique, hand hygiene, and one-time only use of needles and syringes. It also urges medical professionals to discard single-use vials after one use.
If a single-use vial must be entered multiple times, a new needle and syringe should be used for each entry, TJC recommends. Also, the unused contents of multiple opened single-use vials should never be combined, and opened single-use vials should never be stored for later use.
Multiple use vials should be confined to use by a single patient whenever possible to avoid contamination, and a fresh needle and syringe should be used for each entry.
The Joint Commission also urges the education of patients and caregivers who use injectable medical products as part of a home health regimen and the creation of a culture in all care settings where staff feel prepared to report errors, near misses and adverse events.
As healthcare continues to transform, the jobs within hospitals and health systems also continue to change. Recruiters who understand these changes are best equipped to compete to hire workers.
It's no secret that the way we do healthcare in this country is changing, and this means, of course, that the jobs needed to support hospitals and health systems are going to change right along with it.
"Things are evolving— the emphasis is moving more to outpatient and community health management," says Marcia Faller, chief clinical officer at San Diego-based AMN Healthcare, which operates several staffing and recruiting lines of business including Merritt Hawkins.
"Over the next five years, we will see many roles move from existing in hospitals go to outpatient or community settings," she said. The entire care delivery model is changing—and the jobs are changing with it." In fact, they're falling into three distinct categories.
1. Nurses and Coders
There are certain kinds of folks you just can't run a hospital without. Nurses are one of them.
By sheer volume alone, the largest demand for a single profession in healthcare is for nurses, which take up nearly half of a hospital's annual salary budget," says Faller.
The demand is even higher for APRNs, says Jill Schwieters, President of Cielo's healthcare division, an arm of the global talent acquisition and management solutions firm. Nurse practitioners, "can function as an extender to physicians," she says, performing many of the same functions of a physician when there isn't one available.
If restrictive scope-of-practice laws are relaxed or repealed at the state level, as many nursing groups are lobbying for, the doors will open for more of these jobs.
According to the Bureau of Labor Statistics we can expect the demand for advanced practice and specialized nurses such as nurse anesthetists, nurse midwives or clinical nurse specialist to grow 31% over the next ten years.
The demand for medical assistants is also steady, and for a good reason. Medical assistants are almost as versatile as nurses and can fill in as needed, handling tasks like performing immediate assessments of patients or triage.
Other jobs in high demand are medical coders and billing specialists. The need will rise "as we approach October, 2015—the deadline for ICD 10 implementation," says Faller. Billing and coding has become so complex that people who understand it well are going to be in demand, she says.
2. Allied Health Service Jobs
As the population ages, jobs related to rehabilitation services are expected to grow.
Among the fastest growing are occupational therapy assistants and aides, the demand for which is expected to grow 41% over the next decade and has a median salary of $48,940 annually. These jobs typically require only an associate of arts degree followed by certification.
The need for physical therapists and occupational therapists, which require further education, are also anticipated to grow much faster than average in the coming decade.
"We need more rehab specialists and occupational therapists, and as population ages, they will need even more of them. This area shows great return on investment," says Schwieters.
While not specifically rehabilitation-based, another hot job in this category is audiologist, with a projected growth of 34% over the next decade.
3. HIT Jobs and the Care Continuum
This group includes some jobs that have been created by the PPACA, and some that have come about as a result of new technologies.
One class of jobs is related to healthcare IT. Hospitals and health systems will continue to have great demand for capable specialists who can handle EHRs including network specialists, database specialists, and data security professionals.
On the clinical side, there will be more need for workers along the care continuum such as health coaches, care coordinators and other preventative care roles—which may be appealing to people with backgrounds in either nursing or social work. "Health coaches didn't exist 10 years ago," points out Faller. "But, with accountable care, health systems are realizing that they need someone touching base with the patient."
One more hot job, genetic counselor didn't exist a decade ago, but BLS expects 41% growth over the next ten years. "New technologies and genomics are going to have an impact on hiring trends," says Faller.
Violence can erupt anywhere on a hospital campus. Human resources professionals play a vital role in preventing on-the-job violence by setting policies and training employees in techniques to keep everyone safer.
Emergency departments typically see the most violence. "We have people who come in under the influence of substances, or they're sick or scared," says Jason Berenstein, director of security at Oakland Regional Hospital in Southfield, MI.
But violence can erupt anywhere on a hospital campus. Patients will frequently lash out against doctors, nurses and other ED staff. Berenstein also remembers an incident where two clinicians got into a physical fight on the ED floor. "Given the stressful situations staff go through at times, they push each other's buttons," he says.
The Role of HR While human resources professionals are not on the front lines, they can be active partners in preventing on-the-job violence, says Marilyn Hollier, president of theInternational Association for Healthcare Safety and Security and director of hospital health center security at the University of Michigan.
Just the threat of workplace violence has been associated with reduced productivity, decreased retention, absenteeism and a decrease in quality of care for patients.
"A lot of times, employees report incidents to Human Resources, not security or the police," says Hollier. "They don't want to get their coworkers or patients in [legal] trouble, so they go to HR. It's real important HR establishes that they are a partner in hospital security," Hollier adds.
It is often up to HR to set policies and train employees in techniques that can keep everyone safer. "Train managers and supervisors to handle aggressive employees and patients," urges Hollier. She suggests training managers to watch employees for sudden personality changes and to confront them. If employees are feeling anxious due to a colleague or patient threatening them, or are having other problems that could lead to violence, there will likely be signs before the situation comes to a head.
Also, she cautions, "human resources should be taking additional steps to be sure we're not hiring the problem." Hospitals must be diligent to scrutinize the backgrounds of potential employees carefully, as healthcare employees work with a vulnerable population.
Often, hospital staff don't feel comfortable reporting abusive patients, but Hollier urges them to call it in.
"We'll determine whether [there's] a legitimate threat. In a hospital, people act out because they are stressed. People are not themselves. But we're looking for the needle in the haystack—the person who is actually going to follow through [on threats]."
Hollier also suggests training all front line employees to diffuse conflicts. "We train all of [them] in non-violent crisis intervention and how to use keywords to deescalate the behavior. Empathy skills are key."
If You See Something, Say Something The best hospital violence policy, according to Berenstein, is "zero tolerance."
His advice: "Know your surroundings, and train [your employees]. Educate them about workplace violence and how to handle difficult patients. Teach them to recognize warning signs," he says, echoing Hollier.
"Always be observant. Report to your supervisors and staff anything that's not right immediately. That's what keeps you safe. By not saying anything or taking action, it can be detrimental to your safety, and that of others."
Hollier agrees, but adds that HR staff must realize that no hospital is immune to violence. "Hospitals… with maintenance people doubling as security are the ones I worry about," she says, pointing out that many incidents with gun violence haven't been happening in big cities, but in rural areas where people wrongly assume they are immune to it.
"They gamble that it won't happen there, and that's when things do happen," she says.
"At a high level, we should be educating our politicians that hospitals should be gun-free zones," she continued, adding that keeping guns in a place where tempers are likely to flair and misunderstandings are likely to happen is a recipe for disaster.
"Everyone needs healthcare. Prisoners, people with drug problems, people with psychiatric problems all need healthcare. It's very a very diverse population, like a little city. A little city with a whole lot of stress," says Hollier.
Spending on electronic health records systems by hospitals and health systems continues to rise, as enthusiasm for them wanes among senior healthcare executives, survey results show.
Dissatisfaction with electronic records systems is ratcheting up among senior healthcare executives, says the group purchasing organization, Premier, Inc. Survey results released Monday show that that 41% of C-Suite respondents say they are either dissatisfied or indifferent toward their EHR systems.
"What we are hearing increasingly from healthcare leaders is dissatisfaction with their existing EHR systems, often citing cost and difficulty of use," said Michael J. Alkire, chief operating officer at Charlotte, NC-based Premier.
"Providers need a solution that integrates clinical, financial and operational data across their hospitals and health systems; the majority of EHR systems cannot do that."
The growing dissatisfaction continues despite almost half (49%) of respondents stating that their largest capital investment this year will be in health IT, an area that includes EHR as well as hospital telecommunications systems, telemedicine, and advanced data analytics.
This is the second year in a row that health IT has been the most commonly cited capital investment, but the percentage has risen from 46 percent in spring 2013 and from 45 percent in spring 2012. Additionally, 27% of respondents cited Health IT as the biggest driver of costs in their health system.
Spending on clinical healthcare information accounts for between 25% and 35% of an average hospital's capital budget.
While he thinks modern EHRs have come a long way from where they were even five years ago, Michael O'Rourke, senior vice president and chief information officer at Colorado-based Catholic Health Initiatives, a non-profit health system, can easily tally the major painpoints caused by EHRs.
Along with the transition to digital, problems with availability, interoperability and security begin to crop up. "If there's a glitch or planned downtime, it's very hard on our clinicians. But unplanned downtime— now, that's very, very tough on them," O'Rourke says, of staff in CHI's 89 hospitals in 18 states.
Many clinicians, he adds, have felt that their workflow has been disrupted by moving from the time-honored pencil and paper medical chart system to digital, causing widespread frustration with the new records systems.
O'Rourke also cites the expense of EHR implementations, the continual need for system upgrades, and concerns around data security as other frustrations attendant to EHRs.
Survey respondents cited as the second most commonly area for capital investment acquisition of clinical equipment, including surgical, imaging and lab equipment, which was cited by more than 20 percent of all respondents.
Other trends mentioned in the survey included widely reported primary care physician shortages (indicated by four out of five respondents) and a jump in provider consolidation, which is now reported by one in every four respondents.
Survey respondents comprised 127 hospital and health system e CEOs, CFOs and COOs. One hundred and twelve organizations of various sizes and types across 32 states were represented.
A hospital's CXO is often the one person who can coordinate cooperation among departments to ensure patient experience problems get resolved before they impact HCAHPS scores, which can affect reimbursement.
Sometimes, the only way forward is to break the rules.
After years yearning for a child, and less than three weeks after finally giving birth, Allana Guidry was diagnosed with acute lymphocytic leukemia. Guidry needed immediate treatment, but the Cleveland Clinic, where she was being treated, does not allow visitors under age 18 to stay overnight in the oncology ward.
That meant she would have to be separated from her newborn. And Guidry was reluctant to be treated for her cancer if she couldn't have her baby with her.
After some deliberation among departments, including nursing, housekeeping, and the office of patient experience, it was decided that being near her family was an integral part of Guidry's healing process. Guidry's husband and baby were got the OK to live with her in the hospital while she received a bone marrow transplant and chemotherapy.
IfJames Merlino, MD, chief experience officer (CXO) at the Cleveland Clinic, and others in his position have their way, the days of rigid adherence to outdated rules are numbered.
"The Cleveland Clinic began emphasizing patient experience about eight years ago," says Merlino. "Back then, our patient experience rating [determined by HCAHPS scores] was among the lowest in the United States. You can't be a top brand and have patients walking away with a bad experience."
"Now," he says, "it's important from a revenue standpoint, as the government has aligned Medicare reimbursement with patient experience." While the Cleveland Clinic is widely considered a pioneer in patient experience, other hospitals have begun realizing the importance of creating roles around patient experience, too.
Some initiatives developed under the guidance of CXOs have included expanded quiet hours, nurse hourly rounding to ensure patients feel they are being properly looked after and better communication systems so patients can feel confident in the ability to summon a doctor to their bedside at any time.
Innovations like these don't just make patients feel less frustrated during an already difficult time—they also foster better care.
Most importantly, though, the CXO can be the one person—maybe the only one—who can coordinate cooperation among departments to ensure problems get resolved before they begin impacting patient experience.
Sometimes the CXO is the only one who can find or create a solution in exceptional situations like Allana Guidry's.
What Makes a Good CXO? Given the newness of this role, HR departments are still figuring out the formula for the perfect CXO.
Donna Padilla, senior partner at executive search firm Witt/Kieffer, says she's seen many people with operations on their resume make their way to the CXO office, but hospitality management is also a much-sought after background.
But Merlino insists that someone with a strong medical background would be the best choice. "I think they have to have an understanding of hospital operations… You can't just take tactics from hospitality industry and relate them to hospitals. This needs to be a medical professional."
He also suggests that if CXO who are physicians be partnered with someone from the nursing side of the hospital and conversely, CXO who are nurses be partnered with a physician.
What Merlino and Padilla both agree on, however, is that CXO must have a strong, personable demeanor with excellent people skills. "They need the ability to form relationships and high emotional intelligence. They have to have successfully led change and managed change in complicated organizations," says Merlino.
Additionally, the ideal candidate is someone who doesn't need a lot of time in the spotlight. They may never see credit for the improvements made—the applause will likely go to the nurses or the physicians or the IT team or even the janitorial staff.
The CXO needs to be someone who is comfortable being behind the scenes, always being a team player, finding ways to improve processes to benefit patients and bring together departments that need to communicate.
Recognition may be sparse, but the reward is in seeing warm relationships form between staff and patients, insists Merlino. "Every caregiver [at the Cleveland Clinic] communicates with heart. For physicians, this helps them build better relationships and improve communication with patients… They're there for the patients. It's all for the patients."
Even if hiring a C-level employee to manage patient experience isn't right for your organization, don't you think someone should be designated to make sure the patient is never forgotten? Let's not lose sight of what this industry is really all about—the well-being of the patient.
Padilla cites another force behind the rising stakes in patient experience. "It really is the rise of social media… Now, patients can post or tweet about their experience and reach lots of people." As a result, hospitals now have to work harder to protect their brands—or face the consequences after the patient with 10,000 Twitter followers leaves the hospital unhappy and digitally broadcasts it.
"Hospital leaders need to recognize that [patient experience] is not about making patients happy. [The highest priority is] delivering safe care, then high quality care, then patient satisfaction, but satisfaction is never more important than safety or quality," said Merlino.
The sort of rule bending that kept Allana Guidry and her baby together in the hospital can make the difference between a patient getting treatment or not getting treatment—and the CXO is the perfect person to be the advocate for the patient and ensure he or she gets what they need in their unique situation.
While Guidry is now on the road to recovery, she says in a video testimonial that she and her family will never forget the good experience they had at the Cleveland Clinic. She believe that the hospital going the extra mile positively impacted her cancer recovery.
Compensation is not a physician's only consideration when contemplating a new job, and it shouldn't be a hospital's only draw. Physician retention starts with healthcare executives making strong hiring decisions.
The physician shortage is driving up the value compensation packages and simultaneously making physician retention more challenging.
According to the Medical Group Management Association's Physician Placement Starting Salary Survey, released last month, first-year physicians are enjoying, signing bonuses, paid relocation fees and other perks such as student loan forgiveness as part of their compensation.
"It clearly is getting more and more competitive due to the shortage of physicians", says Kenneth Hertz, healthcare consultant with the MGMA. "The median [first year guaranteed starting salary] is $260,000, but there are salaries that we've seen that are considerably higher. I've personally seen them at $450,000 or $500,000."
Hertz also says he's seen starting bonuses in the $50,000 to $75,000 range, but that it wouldn't surprise him a bit to see a bonus topping $100,000. "Everybody is looking for a signing bonus when they come on," agrees Craig Talega, vice president of physicians' services at Divine Savior Hospital in Portage, WI.
Job hopping is hitting healthcare hard. "The average tenure for a new physician, just out of residency, is one and a half to two years," laments Talega, who has been with Divine Savior Hospital for 21 years. Experienced physician who want to find a new job, likely won't have to look far.
So, how do should HR execs select candidates who are going to stick around through this high compensation frenzy—and hold on to physicians already hired?
While it may feel like retaining physicians is a losing battle, that's not the case, maintain both Hertz and Talega. While money may sweeten any pot, cash incentives alone will backfire.
"I've done a lot of work with fellows coming out of medical school who say they see… an opportunity to make a lot of money. I try to have a conversation with these folks… and talk [them] out of that because I think that, in this chosen profession, [other] things matter," said Hertz.
"I think there are some people who chase the money, but… as time has gone on, the competition we have for physicians usually does not come down to money. The finances are important, but it's about location, what they like to do in their free time and families," says Talega.
Ultimately, while it might sound like a good idea to a young physician right out of residency to practice in a very remote area and get paid a hefty salary to do it, if he hates the climate, is far away from friends and extended family and his spouse and kids feel like they don't fit in, that placement won't last—which won't be good for the organization, the patients, or the physician and his family.
"The worst thing for a patient is to have to change doctors," Talega said. To avoid presenting patients with that situation, Divine Savior's HR department focuses on hiring medical professionals who have reasons to stay put.
Talega tries to focus on candidates who have a strong connection to the area—who are accustomed to harsh Wisconsin winters, have family and friends locally or perhaps went to school in the area. What he's looking for is an indication that they won't be pining for a warmer climate or bigger city.
Additionally, Talega looks for candidates who are likely to get involved in the close-knit local community in Portage, and who embrace the hospital's patient-centric and service-oriented goals.
"We're looking for people that embrace our mission, vision and values," he said. Given the social nature of Divine Savior's workplace, he looks for candidates who share common interests, both professionally and personally, with established physicians. He's also careful to screen out job hoppers—people who change jobs every two or three years.
Hertz and Talega both agree that, to be happy, candidates must find a practice that has similar values to their own, whether that is patient-centered care, teamwork or a shared faith. And if the candidate's primary value is making money?
"You may find a practice where everyone wants to make as much money as possible. Then, I guess you've found a practice that shares your vision." But, in Hertz's experience, a practice more concerned with making money than caring for patients is bad news.
"And if your family is unhappy, or you are unhappy in that care setting, well… I just don't think it's sustainable."
Bottom line: It makes sense to worry about physicians leaving for better compensation, but a hospital's best weapon for retention of its physicians is to continue to offer competitive benefits and compensation—and to hire purposefully. It may be a seller's market, but ultimately, making good hires is the best first step toward retaining physicians.
A widespread shortage of saline solution is forcing hospital pharmacists and healthcare clinicians to stretch existing supplies, find workarounds, and formulate substitutes.
As director of pharmacy and materials management at Union Hospital of Cecil County in Elkton, MD, David Jaspan, RPh, MBA, is used to dealing with shortages of pharmaceutical products. He's not, however, used to supply problems affecting one of the most basic hospital staples—intravenous saline solution.
"It's not just saline solution, it's all IV solutions in general," says Jaspan. Since saline is a key ingredient to administering drugs to hospital patients, this is an especially tough shortage to face. "Most inpatients get IVs… I'd say 85% of inpatients are affected by this," says Jaspan.
The Federal Drug Administration has issued three updates so far this year on the nationwide shortage of saline. The dearth of the product is forcing healthcare clinicians and hospital pharmacists to stretch existing supplies and find alternatives.
Drug shortages are not uncommon. But hospitals have more experience dealing with not enough cancer drugs than not enough bags of saline.
"We've been dealing with national drug back orders for years. We're used to this in pharmacy, but it's unusual to see [a shortage] at one of the most basic levels with solutions… This is just another one in a long line of unavailable products," Jaspan says.
'Very Serious' Shortage
Erin Fox, PharmD, director, Drug Information Service, University of Utah Hospitals and Clinics, characterizes the saline supply problem as "very serious. It's serious when clinicians have to make a decision to use an alternate product. A big part of the treatment plan now has to be asking, 'is that product available?'"
Until recently, saline solution was routinely taken for granted. Jaspan recalls that it used to be standard practice to use a 1000 milliliter bag of saline solution in any situation calling for an IV in order to avoid refilling it.
"You used what you needed and tossed what was left at the end of day. A lot of people are used to doing that," he says. Now staff at his hospital are conserving saline by using smaller bags and changing them frequently.
"If you just need to keep a vein open, you can use a 250-milliliter bag rather than a larger one," he says.
Another way Jaspan's team has been coping with the shortage has been by formulating substitutions. "We can use Dextrose 5% and half-normal solution in saline's place," he says.
Jaspan has other tricks to make sure patients get the right solution, too. "If there's no half-normal solution available for the patients who need it, pharmacists can compound that [in house]. You just take sterile solution with sodium chloride added. Need Dextrose? We'll find a way to compound that as well."
"For the most part, we're able to use an alternative. You can [stretch supplies] for a long period of time, but if you run out of product, you can find an alternative that works for the patient," he said.
Still, the widespread saline shortage can be more than inconvenience. It can drive up costs. Some providers, particularly small and rural community hospitals, may not have a pharmacy resources to formulate alternatives and have fewer options for sourcing alternatives.
Root Cause Analysis "The question I'd like answered is, why is this happening?" says Jaspan. "I can't get a straight answer from anyone as to why this is occurring. We had adequate supplies until five months ago.
"I read through one [pharmaceutical] company's letter—they blamed the shortage on flu season. But the flu wasn't that big [of a problem] here," he said.
Bona E. Benjamin, director of medication-use quality improvement with the American Society of Health-System Pharmacists (ASHP), has another theory. She believes the saline shortage is rooted in product recalls.
"Most saline solution used in the US comes from one of three big pharmaceutical firms. There is one other supplier that is significant as well. Of the three firms, two [had] recalls of saline solution in late 2013. [The other] announced that they had a routine maintenance shut down. With the recalls and [manufacturing] shutdown, that strained the supply. Additionally, one more supplier from Europe that supplies saline solution for dialysis had an import delay from their plant in Mexico, which shifted demand to US suppliers," explained Benjamin.
Wayne Russell, senior director of pharmacy at Premier, Inc., a group purchasing organization, has a similar take. "My view is not the same as the FDA's. The FDA has said the shortage was caused by an increased number of flu cases and extra hospitalizations… and use of fluids, but I can tell you that every manufacturer of IV fluids in the US has had recent [manufacturing related] quality issues."
Russell says those quality issues necessitated a manufacturing slowdown and "they still haven't caught up with demand."
A High Price to Pay Whatever the cause of the shortage, its effect is hitting hospital budgets. Jaspan's longtime supplier, proposed a price hike of "300%—that would have been my increase had I stayed with Hospira," says Jaspan. He found an alternate vendor.
When substitution or careful rationing of saline isn't enough, organizations can expect to feel the pinch when paying for saline. "The product being imported to the US is about ten times higher than [what hospitals are accustomed to paying], said Russell.
So far, the FDA has given a major European manufacturer of saline, Fresenius Kabi, permission to export saline manufactured in Norway to the US, and is allowing Baxter to supplement its normal supplies with saline manufactured in its plant in Spain.
It must be distributed through the normal channels and "it's being very tightly managed," says Russell.
The manufacturers have handled allocation and distribution of saline throughout the shortage. "They try to fairly distribute it. If they didn't do that, you would have some hospitals buying more than they need and hoarding it," he said.
But the allocations have been meager. "You get maybe 60% of what you usually get," said Jaspan. "Sixty percent will not cover everything you need when you're used to 100%."
No Impact on Quality Detected And "sometimes, what you thought you were going to get doesn't come through. Every day is disaster mode planning, figuring out how to minimize the impact for patients," Fox says.
Despite all the work Jaspan's team has done in substituting and stretching their resources, there's been no impact on the quality of care to his organization's patients. "I haven't read or heard about it impacting [quality in] any other hospitals, either," he said.
"We're working so hard to make the problem invisible [to patients]," says Fox. Until the shortage has completely cleared up, she urges healthcare leadership to be supportive of the clinicians who need additional time to build a plan, and that they understand the cost implications.
According to Russell, it may be a long wait. He takes the FDA's recent decision to grant Fresenius Kabi permission to export saline to the US through the end of 2014 as a sign that the shortage will last until at least the end of the year.
It's tempting to dismiss healthcare fundraising and development professionals as little more than specialized salespersons. But it would be a mistake to underestimate the full array of skills they must have to meet your organization's financial goals.
The announcement last week that Johns Hopkins' Kimmel Cancer Center has received a gift of $65 million earmarked for a new patient care building, isn't just good news for future cancer patients—it also highlights the importance of fundraising efforts and healthcare philanthropy.
The benefits of having a dedicated, in-house fundraising teamdepend largely on recruiting and hiring the right professionals. Knowing a candidate is in possession of the full complement of skills can be tricky. Some experts share their insights:
1. More Than Just Sales Experience
It's tempting to dismiss a fundraiser as a glorified salesperson, but don't stop there—look further. While a similar skillset is needed, the best fundraising professionals and development specialists are motivated not only by earning bigger commissions and crushing their sales goals and competitors, but by something else.
Fundraisers absolutely must feel passionately about the cause they're raising funds for, says Sarah Gnarre, vice president of Development at Anna Jaques Hospital in Newburyport, MA.
If someone were to attempt to raise funds for a cause they didn't believe in, "It wouldn't work out," she says. A fundraiser must have a deep connection to healthcare philanthropy, either due to a personal experience, a sense of altruism, or other personal reasons.
2. Human Touch
While fundraisers often earn decent and at top levels handsome compensation packages, they rarely earn as much as sales professionals, so those who seek work in the field of healthcare philanthropy are often pursuing more than a paycheck.
"It's a rare combination [of traits] Bill Mountcastle, president of Health Philanthropy Services Group, told me. He believes the most important attributes of a professional fundraiser in healthcare are personal integrity and confidentiality. "You're dealing private financial information and the sanctity of the patient-doctor relationship."
Another trait Mountcastle lists as desirable is a high level of empathy. "We're looking for that unique individual who knows how to sit and talk with very educated surgeons and doctors, but also has the empathy to sit and talk with an 80-year old widow who recently lost her husband."
Bill McGinly, president and CEO of the Association for Healthcare Philanthropy, agrees. "You want enthusiasm, a can-do attitude, and the ability to be a closer. [You want] someone who doesn't just ask, but follows through to make sure they're paying attention to the donor's needs and matching them to the needs of the community," he says.
Candidates must also have a firm understanding of what's going on in healthcare and the inner workings of hospital and health systems as well, he adds.
3. The Right Stuff
The most important skill of all is probably the ability to ask for—and get—money from donors.
"Someone can't just be committed to a cause with no follow through [and be a successful fundraiser]. They must be able to ask for a gift," says Gnarre. She suggests looking at job candidates' results in their last jobs. "How many visits, proposals, and gifts did they generate each year?"
Another factor to look at is how long a candidate has stayed with former employers and their reasons for leaving previous jobs—a 2013 study by CompassPoint found that 50% of development directors plan to leave their current organizations within the next two years and 25% of executive directors fired their last development director.
While that high turnover rate is unfortunate in any office, it's especially bad in fundraising, where it is essential to cultivate strong relationships with donors. "The relationships you have to grow are very longterm. You want your fundraisers to stick around," said McGinly.
In short, the strongest candidates for fundraising positions have industry knowledge, sharp sales skills coupled with an ability to display empathy and develop relationships with donors and potential donors.
The $65 million announced by Johns Hopkins last week, while among its largest gifts, is only the organization's latest. Earlier this year it received $90 million from a benefactor who had previously given $20 million. While it can be said that Johns Hopkins has been fortunate, it's unlikely these gifts would have happened without the active hard work, persuasive skills, and empathy of fundraising professionals.
The NBA acted swiftly to fine and ban for life a team owner accused of making racist comments. What can you do about bad behavior among employees in your hospital or health system?
Krishna Payne, director of equal employment opportunity and HR regulations Menninger Clinic, a psychiatric hospital in Houston, TX, remembers confronting a loudly sexist physician at one of her previous jobs.
"I think women should be at home raising kids, not working. You shouldn't be working, Krishna!" he chided her when she confronted him. Once she made it clear his comments would no longer be tolerated, he tried to poo-poo her concerns.
"Oh, I'm just an old dinosaur," he groaned in response.
His response might sound familiar to anyone following the saga of Donald Sterling, principal owner of the NBA's LA Clippers. He was recorded last monthmaking racist commentsin what may have been the capstone on along history of bad behavior. The NBA reacted quickly and decisively, banning Sterling from the organization for life, and fining him $2.5 million, and in the process sending a strong message that racism will not be tolerated.
The Clippers scandal is an unpleasant reminder that racism, sexism and other forms of bigotry can still find their way into unexpected places—even workplaces populated by highly paid professionals.
While the powers of most HR leaders don't quite match up to the muscle of NBA Commissioner Adam Silver, HR leaders must use what powers they have to send a strong a message to their employees who cross the line. Here are a few tactics:
1. Address Discrimination in Place Veronica Zaman, corporate vice president of HR and Learning at Scripps Health in San Diego, says her organization has a clear expectation that employees respect one another, regardless of race, gender, sexuality, age or any other personal quality. Zaman says Scripps has become one of the most diverse organizations in the country in part because it has processes in place to deal with discrimination.
"If someone feels discriminated against, they should go to our employee assistance program. We have dedicated psychologists from within our team to assist them. They are internal, not a third party, as many EAPs are. We did that intentionally, as we wanted our EAP to be seen as co-leaders and colleagues.
"We get all the parties around the table and discuss the situation. 'What was the intent? What was real, what was perceived? Why?'" says Zaman.
2. Maintain Cultural Competence Scripps requires its employees to undergo affirmative action training. "We have a very strong training program here. Everyone in supervisor or above role must complete [affirmative action] training online," Zaman told me.
Payne agrees that those in management need to lead by example when it comes to cultural competency. "Management is a reflection on you… and managers should be evaluated on diversity and cultural awareness." Like Scripps, her organization works to keep its managers up to date regarding diversity and inclusion.
Because healthcare is a field employing workers from diverse racial and cultural backgrounds, it is necessary to have a heightened sense of cultural awareness and an understanding that certain actions or comments that might make others uncomfortable. In such a diverse environment, cultural competency is indispensable. HR should ensure that leaders are culturally aware and that they foster an environment of inclusion and tolerance.
"If you're really trying to promote diversity and non-discrimination, recognize and encourage those who promote it and actively demonstrate fairness and equality," Payne told me.
3. Practice Zero-Tolerance Scripps has had very few problems with cultural insensitivity, says Zaman, because it's something its employees simply will not stand for. "Respect is one of our core values. Human resources usually doesn't even have to consider intervening, because our employees hold each other accountable. It's what we're about."
Payne agrees. "While some people act out of ignorance, some know full well what they're doing, and believe they have every right to be that way. You have to remind them that this is the professional world, not their world, and at this company, we treat people with respect."
After the doctor she'd confronted about his comments regarding women in the workplace said he was 'just an old dinosaur,' she took him to task.
"We didn't hire you to be an old dinosaur; we hired you to be the head of a department. It's not legal for you to inflict your view on your coworkers… it's not what we pay you to do," she remembers saying to the doctor.
"We have to have those crucial conversations," says Payne, adding that, even in zero-tolerance environments, it's vital to be sensitive to the offender, too—they may just have to be educated or may not realize they have a bias. They may take the feedback personally, but the conversation has to take place. "Take your time. Don't jump to conclusions or be judgmental," she advises.
"You approach it respectfully and factually," she says. "Ask them, 'What do you think the impact was on that person? How do you think it made them feel?' Then, tell them how it made them feel."
These conversations are confrontational and may be uncomfortable, but they are necessary. It's the responsibility of HR leadership to initiate them to ensure that bad behavior is eradicated from the workplace.