Google Glass is a hip new accessory gaining acceptance in clinical settings, but before widespread adoption can take place, organizations must ensure that the wearable device is HIPAA-compliant.
Imagine being able to find and view a patient's electronic health record with a simple nod of the head, or being able to maintain eye contact with patients while reviewing their records, or being able to check in on a patient from a remote location as if you were both in the same room.
This technology is already in use by healthcare providers and may be more widespread than you think. If it hasn't already made a debut in an emergency department near you, it will soon. Boston's Beth Israel Deaconess Medical Center and Brigham and Women's Hospital, Rhode Island Hospital, UC Irvine Medical Center, and Indiana State University Hospital are just a few of the organizations that are using Google Glass at least an experimental basis.
"From the patient perspective, there's nothing worse than watching a doctor sit down and type at a computer screen. Glass enables you to meet a patient at eye level," says Paul Porter, MD, a physician at Rhode Island Hospital's department of emergency medicine. "This is a starting point toward a complete telemedicine program," he continued.
Rhode Island Hospital is currently using Glass for dermatological emergencies, said Porter. "If it's after hours or the doctor is offsite, or they're otherwise unavailable, it puts [a dermatologist] right in room with the patient at the time of care."
The Science of Compliance While there are many clinicians like Porter who believe Google Glass and similar technologies will become standard tools in hospitals and doctors' offices, there are also those with concerns about privacy.
While the most common privacy concern is Google Glass's camera, that's the least of a hospital IT department's worries. The camera can be disabled. As a matter of policy, however, work remains. "We're currently investigating how to handle the camera, and investigating whether we need to disable that functionality," said Adam Landman, emergency physician and Chief Medical Information Officer for Health Information Innovation and Integration at the Brigham and Women's Hospital in Boston.
Karandeep Singh, M.D, is a nephrology fellow who is making alterations to Brigham and Women's version of Google Glass in order to make it HIPAA complaint. While he agrees that Glass will be a positive tool for clinicians, he also thinks about how it will change interactions between doctor and patient.
"The patient cannot see what the doctor is looking at. What is the appropriate etiquette for this situation?" he asks. Many patients like to see that a doctor is looking at their chart—they take that to mean that he is reviewing information and properly doing his job. "How will those patients feel when they don't know if the doctor has reviewed their information?"
And given that these devices are small and potentially easily misplaced, security—especially HIPAA compliance—is a major concern.
An Ounce of Prevention Most organizations using Glass have plans to integrate it with their electronic healthcare records systems. "We're working on a way to integrate with EHRs… It would be helpful to patients, and we're evaluating it as we get to know the technology and ensure there is no threat to security," says Porter.
Landman, at Brigham and Women's Hospital says, "We've built a prototype that can connect to [our EHR] infrastructure, but it's not in use yet." Security is a real concern, especially because the unaltered version of Google Glass sends all information it collects back to Google and allows the company to store that data—in a manner that is definitely not HIPAA-compliant.
"Any patient-identifying information cannot be sent to Google, or any other third party if you want to maintain HIPAA compliance," says Singh. "Our version is unique in that the voice input, which is usually reliant on Google, [is not served] to Google. We work with a HIPAA-compliant provider, Nuance, who provides us with that service. Also, we don't store any information on Glass—that info only lives on Glass as long as it needs to. Currently, we're vetting our version of Glass internally to ensure it'll be HIPAA-compliant," he says.
Other precautions taken have included altering Glass so that it only connect to the internet when inside of the hospital or adding an auto-erase feature for data. As Glass is built on the Android platform, it's fairly easy for anyone with knowledge of Android's API to modify it.
Many organizations also ask that their staff not use their hospital-issued Google Glass outside the organization. "[Google Glass is] a lot of fun. I use it to answer my phone, read and respond to some email, get directions. But not the hospital version, though—I keep that locked up," says Porter.
The consensus among early adopters is that once HIPAA compliance and other security concerns are resolved, Google Glass is poised to become a familiar tool in healthcare, simply due to its relatively low cost and convenience. "I think wearable technology has immense potential," says Landman. "We can look forward to it improving provider efficiency, patient safety, and clinical outcomes."
Big paydays for fundraising consultants have some HR professionals and senior executives weighing the merits of consultants versus building and maintaining an in-house development staff.
"A study of 280 nonprofits released by the Chronicle of Philanthropy shows nearly 30 top fundraisers have been earning more than $500,000, and at least two surpassed the $1 million mark. The data is from 2011, the most recent year available. The top compensation went to Anne McSweeney, campaign director at the Memorial Sloan Kettering Cancer Center in New York City, who was paid more than $1.2 million in 2011." – ABC News
Reading this news item the other day made me think about whether it's better for healthcare organizations to keep development officers and professional fundraisers in-house or to outsource this important work to professionals.
It also made me wonder if I've made a horrible career mistake.
In one of my first jobs after finishing college, I worked as an outsourced fundraiser or professional beggar, as the old-timers on the staff called themselves. After a week of fairly vague training, I was handed a headset and thrown on the phones.
Some of us were good at getting people to part with their money, others weren't. But the company didn't seem to care about the integrity or quality of the people they hired; the object of their game was filling seats and turning over X-number of phone calls per hour.
That model of fundraising is not ideal for healthcare organizations, says Sarah Gnarre, vice president of development at Anna Jaques hospital in Newburyport, MA. "I think the bulk of fundraising should be by an in-house person who understands your organization from the inside out. Someone who knows the inner workings of the hospital, since that's what donors want to know," she says.
Can You Outsource Empathy? Fundraising is a necessity for healthcare organizations, especially in community and rural settings. It can make the difference between keeping the doors open, or spiraling into bankruptcy. It can finance a new hospital wing, technology purchase, or service line.
But given the current business trend of outsourcing, cutting costs and aiming for efficiency, does it makes more sense to outsource fundraising or to hire staff to do the work?
Bill Mountcastle, president of the Health Philanthropy Services Group, a firm that offers philanthropic services to non-profit healthcare organizations, says, "fundraising is about relationships. A good fundraiser is someone who has confidence in building relationships. You want that unique individual who knows how to sit with very educated surgeons and doctors, but also has the empathy to sit with an 80-year old widow who recently lost her husband," which is impossible to outsource.
And that relationship-building process and major gift fundraising must remain in-house. Other tasks related to fundraising, such as follow-up phone calls, mailings, training, consultants, even lawyers and estate attorneys who help advise gift planning are all roles that an organization can consider outsourcing, Mountcastle says.
A Few Considerations Outsourcing fundraising efforts comes with caveats, however, especially for smaller organizations.
While Bill McGinly, president and CEO of President of The Association for Healthcare Philanthropy, concedes that most healthcare organizations outsource some portion of their fundraising process, he warns against outsourcing too much of the work.
It's not unusual, he says, for fundraising organizations to say that they don't need any investment upfront; instead, they'll just take a portion of the funds they raise. Some will take 80 or 90 percent of the funds they bring in, which can ruin an organization's reputation for responsible fundraising.
"You never want to put your reputation at risk," he cautions.
Mountcastle raises privacy concerns as an issue, since many donors might not feel comfortable talking about the very personal experiences that led them to donate to anyone unaffiliated with the hospital. "You're dealing with private financial information and the sanctity of the patient-doctor relationship," he says.
And Gnarre offers yet another reason for fundraising to be kept in-house. Fundraisers are sometimes the first to become aware of hot topics, issues the community may have and the way the organization is perceived. "A fundraiser is often a liaison between the external community and internal world of the hospital. The fundraiser… is the person hearing everything," she says.
Fundraising isn't just a way to get additional funds for your organization; it's also a way to build relationships with patients, their families and the community. Outsourcing takes away an opportunity to gain feedback from the community and people who feel connected to your organization.
"It's been proven that investing in good people is a good ROI," reiterates Mountcastle. "If you get good people and give them the resources to be successful, the return on your investment will be good."
Is High Pay the Norm? So, this brings me back to the matter of super-highly compensated fundraisers.
"I don't think anyone is throwing away money when they bring in a fundraiser, says Gnarre. The income of a fundraiser varies is pegged to the donations that come in and "fifty million dollar-donors don't come along every year."
McGinly isn't seeing evidence of widespread big paychecks either. "I'm not aware of very many people making that kind of money." The top-earning fundraiser cited in the Chronicle of Philanthropy study did her work for New York City-based Sloan Kettering. New York City, has a notoriously high cost of living. Also, he said, anyone that highly compensated is likely working very hard for their money. "With these jobs, you're going 24/7, all the time."
Perhaps the most important consideration is this, says McGinly: A fundraiser is an asset an organization doesn't want to lose. "Higher compensation speaks to the tenure of a staff. The relationships you have to grow as a fundraiser are very long-term, so you definitely want your fundraisers to stick around."
Healthcare providers that adopt a leadership model of drug stewardship can reduce the inappropriate use of antibiotics in hospitals, says the CDC.
More than half of all hospital patients receive an antibiotic. These drugs are not only overprescribed in hospitals, but also poorly prescribed, which can put patients at risk.
A Centers for Disease Controlreport released in March shows that some clinicians prescribe antibiotics three times as much as clinicians in other hospitals, even when patients were receiving similar kinds of care.
"Today's antibiotics are miracle drugs," says Arjun Srinivasan, MD, medical epidemiologist and medical director of for the CDC's Get Smart program for Healthcare. But their misuse is liked to preventable allergic reactions, super-resistant infections, and C. Diff, which can be deadly.
Antibiotic overprescription is not a new problem. Clinicians have long felt pressured to prescribe antibiotics inappropriately. Sometimes, they feel they don't have time to view test results or even perform testing prior to prescribing. Other times they feel pressured by patients to "do something."
Checklists Can Help Checklists are an important tool toward ensuring that all clinicians know when antibiotic medications should be prescribed. The CDC's checklists highlight the core elements of the stewardship programs, Srinivasan says. While much of the information is basic, such as checking test results to ensure the patient actually has a bacterial infection—these are vital, commonsense steps that are frequently overlooked in the rush to treat many patients over the course of a day.
"We've already reached the point at which it's become critical to take preventative action," says Srnivasan. "We have infections that we've run out of antibiotics to treat. But we already have the knowledge [to prevent the worsening of the situation] at our fingertips. It's the perfect combination to take action to try and solve the problem."
Leadership is Vital
While there is no one solution to this problem, the CDC strongly suggests hospitals adopt drug stewardship programs to combat inappropriate use of antibiotics.
"This concept has been around for quite a long time. We used to call it drug management," says Srinivasan, "But stewardship is a much more accurate term. We're not trying to control or dictate—we're trying to manage a precious resource."
While there's no single model of stewardship, he suggests hospitals adopt programs that best fit their unique needs. One model that has worked in many settings is a physician leader running the program working closely with a pharmacist. A full stewardship checklist is here. At minimum, the CDC recommends these elements:
Leadership commitment: Dedicate necessary human, financial, and IT resources.
Accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
Drug expertise: Appoint a single pharmacist leader to support improved prescribing.
Action: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check drug choice, dose, and duration.
Tracking: Monitor prescribing and antibiotic resistance patterns.
Reporting: Regularly report to staff prescribing and resistance patterns, and steps to improve.
Education: Offer education about antibiotic resistance and improving prescribing practices.
Ideally, both the physician and the pharmacist would have some background in infectious diseases, although that's not always the case—some hospitals are very small and don't have infectious disease specialists on staff. "It doesn't have to be infectious disease physician," said Srinivasan. "Others have stepped forward—but this is what we recommend."
What's most important, said Srinivasan, is that leadership is established. "Leadership is vital. There must be a designated leader and pharmacist."
Another important and much overlooked step is improved communication with patients. Often, says Srinivasan, patients request information, but do so in a way that sounds like they're requesting an antibiotic.
"Many have said that even though they're asking for an antibiotic, what they really want is an explanation. They want to know what's going on, how long will it last, when will they feel better?" said Srinivasan.
Properly educating patients about their conditions and explaining that not every illness requires an antibiotic and why, as well as how to take any medications prescribed, are simple yet vitally important steps toward combatting antibiotic resistance.
The need for care coordinators is growing, but because they must be able to work with specific patient populations, careful and strategic recruiting practices are vital.
In an effort to drive down readmissions, many hospitals, clinics and healthcare systems have established the role of care coordinator to guide patients through the system and keep care programs on track.
But what a care coordinator is and what a care coordination team should look like may mean different things at different organizations.
Some are asking care coordinators to be interdisciplinary chimeras with the clinical knowledge of a registered nurse, the people skills of a social worker, the organization and planning ability of a personal assistant and a heart of gold to boot.
Unless you are very lucky, you probably won't find an entire team of people who all have those skills. So rather than focusing on a handful of exceptionally talented people, it makes more sense to hire a diverse team from varying backgrounds.
"A care coordination team is multidisciplinary. It's not just one person or one role," says Nancy Skinner, president of the Case Management Society of America and Riverside Healthcare Consulting. "Nurses and social workers have a professional background that brings the [clinical] knowledge that is necessary to begin a path to be a care coordinator… We have typically put people in this role because of the initials after their name. We can't do that anymore—we have to look at the capabilities of the person moving into that role," she says.
Attention to Detail In Skinner's opinion, the most important traits of a case manager or care coordinator are excellent communication skills, specifically with the patients they serve; extensive knowledge of the U.S. healthcare system; and the ability to navigate it for their patients. Finally, but perhaps most important, are sharp assessment skills and perception.
The ability to understand what the patient understands—and doesn't understand—and to look at their circumstances, including where they live, what kinds of assistance they have access to and [to be able to] accurately assess their situation—is a rare skill, but indispensable for a care coordinator, says Skinner.
"Does the coordinator truly understand what care coordination is? It's a process," she says. "Discharge is an event. We have to understand the process that leads to that patient being handed over to the next level of care, whatever that may be."
Ann Lindsay, MD, co-director at Stanford Coordinated Care, which serves the high-risk population among both Stanford University and Stanford Hospital's employees and their families, agrees that being thorough and detail-oriented and showing a strong interest in patients are vital skills for a care coordinator.
"When we interview people, we propose clinical situations to see how they would approach [them]. This gives us an idea of their creativity and their interest in people, and shows they see that people are people, not just numbers," Lindsay said.
Into the Patient's Hands Ultimately, the perfect care coordination team is a team crafted for a specific patient population.
Lindsay recalls the process Stanford Hospital's administration went through when it first began putting together its coordinated care program.
"We interviewed the first intended recipients of coordinated care. We looked at the data we had on those patients, and learned that our audience had many medical issues," she says. Quite a few of the patients saw multiple specialists and took multiple medications, and they also had high incidence of depression and chronic pain.
Lindsay recalls feeling that the patients didn't just need care coordinators—they needed advocates—which Stanford's coordinated care team brought on. They also hired clinical social workers, pharmacists, physical therapists who specialized in pain management, and a dietician to try to help combat the high incidence of diabetes and obesity.
For the population Stanford's team serves, that was the perfect combination of skill sets, and has led to a successful and popular program.
Each patient group is different, and will require different skill sets, but what's most important, both Skinner and Lindsay agree, is that care coordinators can reach the patient and motivate them to be a part of their own care.
"You have to make the patient part of it," said Skinner, suggesting that care coordinators be passionate about educating their patients, giving them goals, following up with them and empowering them to take their health into their own hands.
"An emphasis on self -management is important," says Lindsay. "If you give a man a fish, he'll eat for a day. If you teach a man to fish, well, he'll know how to fish."
While HR handles most personnel issues in hospitals, the use of professionalism committees is on the rise. Staffed by physicians, they confront peers who are exhibiting disruptive behavior and they provide counseling.
As a human resources professional, have you ever felt like there's a cultural gap between your team and the clinicians employed by your organization? Perhaps you've felt you're not the right person to speak directly with a physician known for being nasty or with the too-casual resident who fails to respond to pages?
If so, you're not alone. The sentiment that the cultural chasm between HR and physicians might be a bit too hard to cross is becoming increasingly recognized and understood by both parties.
"There are some things human resources are good at, but, regarding professionalism, I think a peer-to-peer, physician-to-physician conversation is what's needed. It's complicated to talk to a physician about unprofessional behavior," says Daniel Wolfson, Executive Vice President and Chief Operating Officer of the American Board of Internal Medicine Foundation, an organization with a dedicated mission to spread professionalism among medical staff.
While HR handles most personnel issues in hospitals, a small-yet-growing number of organizations have been developing professionalism committees. These are groups outside of human resources that confront physicians who are exhibiting disruptive behavior, provide counseling, and follow up on the issue to ensure things have been remedied. Members of these committees are often physicians.
For Physicians, By Physicians "I absolutely one hundred percent agree [that feedback from fellow physicians is more impactful]," says Pamela Galowitz, program manager at the Center for Professionalism & Peer Support at Brigham and Women's hospital in Boston. "Other physicians understand the pressures, the dynamic on the team, the responsibility that falls on their shoulders."
"HR is about rules," Lee Fleisher, chair of both the department of Anesthesiology and the department of professional liability and University of Pennsylvania told me. "The professionalism committee is about changing behaviors and determining if those behaviors can be changed."
Another advantage of having a professionalism committee that is run by physicians is that it is an opportunity for medical professionals to regulate themselves. "If you can't self-regulate, you're in peril of being regulated, whether by state licensing boards, the government, or another entity," says Wolfson.
Fleisher agrees, and adds that it is very powerful as a profession to decide together that certain behaviors are not acceptable. "Behaviors that were acceptable 20 years ago are no longer acceptable," he says.
The medical community has come to accept that disruptive behavior—including yelling, demeaning others, lack of boundaries or other unprofessional actions within the hospital setting, whether toward patients, nurses, support staff or other doctors is unacceptable," says Fleisher. He points out that making coworkers uncomfortable creates an uncommunicative atmosphere where people are afraid to work together.
Peer-to-Peer Feedback Galowitz describes her committee's procedures for providing feedback to a disruptive physician as follows:
"We work with the doctor, trying to understand their frame of mind. One common response we hear from physicians is that they feel they have to behave in an assertive way because they're protecting their patient, and they mistakenly believe that the best way to do it is to be aggressive or yell."
In this situation, her team explains to the physician that this behavior undermines patient safety. "This is not helping your patients, not reaching the goals you think it's reaching," Galowitz would tell them.
The next stage is to monitor the employee to ensure that they got the message. "Sometimes, more senior physicians are brought into the conversation," Galowitz added. Other times, they organize meetings with behavior coaches who can help them understand the root of their behaviors and how to change them.
Occasionally, they also introduce the offending physician to an employment lawyer. "They'll let the physician know they can keep doing this if they want, but there can be real legal consequences for these behaviors," said Galowitz.
Galowitz says her team receives a wide range of responses when physicians are confronted about their behavior. Sometimes, the physician doesn't realize they're behaving inappropriately, or they're frustrated and feel like things being done correctly, and that being insensitive and yelling is the only way to make the urgency of the situation known.
University of Pennsylvania's Fleisher agrees. "I think one of the most important questions is, 'are these bad people? Or is this a system or a culture that allows bad behaviors to occur that, with proper training and education, would disappear?
"We assume that these are not bad people," he says.
Not the Place for Human Resources "I think in terms of coaching or mentoring, it's far more beneficial to have physicians work with physicians. Regarding professional issues, I'm quite certain that physicians will respond in virtually every case better to other physicians than they will to 'civilians,'" says Ken Hertz, principal at MGMA Healthcare Consulting Group, a healthcare management consultancy.
"Effectively, HR does not have a major role in this," Fleisher said. Professionalism committees, teams and groups are for physicians, by physicians. "This is really medicine policing itself… It's much more powerful to have colleagues talk to you about your behavior and create a plan to help modify your behavior than have a non-colleague create rules."
It's time for human resources professionals to realize that there are certain personnel processes HR should not have complete control over. HR's proper role is to step in if the professionalism committee can't handle its physicians. HR should ultimately be working to promote a strong culture to promote the values of its organization, but let the committee take the first crack at managing its people.
"What's most important is a consistent culture and consistent values within an organization, whether you're a receptionist, or a physician, or a CEO," Hertz says.
As tensions between employed physicians and their hospital bosses ratchet up, HR professionals need to draft a strategy for either blocking or accepting the likely event that doctors will organize into labor unions.
If the phrase "labor union" brings to mind construction workers in hard hats, longshoremen on the docks and nurses in their scrubs demanding more favorable nurse/patient ratios, get ready—growing numbers of employed physicians may give rise to a new group of laborers seeking solidarity.
"I think the time is fast approaching when a combination of trends will drive physicians to organize," says David Leffell, Section Chief of Dermatologic Surgery and Cutaneous Oncology at Yale School of Medicine.
"Tensions between large hospital and health systems and doctors are increasing. Large health systems and hospitals are striving to de-professionalize doctors and create structures in which doctors have even less voice than they have now," he told me.
Frustrated by the lack of control he felt doctors have in modern healthcare settings, Leffell wrote an op-ed for the Wall Street Journal in January of 2013. He was surprised to see the response it got. "I believe it was the number one emailed article in the WSJ that day," said Leffell. "Clearly, it touched a nerve."
Why Unions, and Why Now?
At the root of the incipient labor movement is the growing number of physicians working as employees. According to a 2012 study sponsored by staffing group Accenture, while 57 percent of physicians were in private practice in 2000, the number had dropped to 39 percent in 2012, and shows no sign of rebounding.
"In my region, a hospital-owned physician 'foundation' gives doctors demerits for 'being late,'" Leffell says. "I call it the industrialization of medicine driving the infantilization of doctors."
As physicians and other healthcare professionals leave private practice and become employees, new issues that did not previously exist begin to creep up, including issues around compensation, working conditions, hours worked and other problems one would traditionally see with in a service industry.
While there are still few physicians' unions, some do exist, including two affiliated with the Service Employees' International Union (SEIU). The Union of American Physicians and Dentists, which is primarily active in California. And there are smaller unions affiliated with particular institutions. Additionally, many physicians are involved in state or city workers' unions—although those are not specifically unions for healthcare workers.
Flavio Casoy, public psychiatry fellow at Columbia University Medical Center is vice president of the Committee of Interns and Residents (CIR), a union affiliated with SEIU. Casoy says his involvement in CIR and the SEIU stems from his dedication to patient care.
"All these forces in healthcare make it so the places where patients are going to get care are bigger and bigger institutions. Care is becoming less and less humane, and increasingly less patient centered," he says.
"I think physicians need to have a voice to ensure [that] good, clinical care is the main objective, rather than the profits of some corporate entity," he continued. Casoy points out that non-unionized psychiatrists are asked to see as many as five patients per hour, and asks what quality of care could be expected with a patient load that high.
With a union looking out for him, ensuring that he has a voice in the care of the patient, he says he "can actually do what needs to be done to take care of this person."
Industry consolidation and shrinking reimbursements are two more motivating factors that are pushing physicians out of private practice and onto the payroll of hospitals and health systems in growing numbers. When they get there, some are finding they could use the protections offered by organized labor organizations.
Unions and HR
"I don't want to say that unions are a bad thing," says Tedd Trabert, chief human resource officer for the Health Choice Network in Doral, FL, and an ASSHRA board member. His own grandfather, he told me, was involved in a coal miners' union for years, "but I would have to say that right now is not the right time and place for [physician] unions.
Tedd Trabert
Chief Human Resource Officer for the Health Choice Network in Doral, FL
Trabert acknowledges the right of the employee to organize—on their own time, outside of working hours, of course. If he were confronted by physicians seeking to organize, he would ask, "What's the driving factor behind this? What causes the need for this?"
"Human resources should be the representation and voice of the people in an organization," Trabert says. He maintains that what's best for employees is a robust HR team that's working hard to protect their interests. "Get out of your office. Listen to your employees."
Labor unions in the United States first began growing in response to the industrial revolution, as artisans lost their means of production and had to begin working for others. This pattern repeats itself as physicians move from being self-reliant professionals to being duty-bound employees.
Physicians are highly educated, tend to be politically engaged and have invested significantly both financially and in terms of time, into training for their profession. While it makes little sense for doctors in private practice to unionize, it is not farfetched to think that as employed persons they would seek to organize.
The desire is exacerbated by the pace of industry consolidation and the size of mega-organizations that form as a result of all those mergers and acquisitions. "As organizations grow beyond themselves, as they become that big box, it's difficult to manage expectations," said Trabert. But "if an organization has a strong culture, it could squash the rumblings of a union."
Two Options
Would trying to squash the unions be the right way to handle the situation?
Human resources professionals have two options. They can fight the growth of unions by attempting to block them legally—a move that will cause even greater employee dissatisfaction and resentment, or they can accept what was once unthinkable—an organized labor force made up of physicians.
In the meantime, Trabert suggests a good labor relations strategy is attempting to keep lines of communications open with employees. The key to ensuring that human resources is part of the conversation—and has a real chance of staving off union growth—is stepping outside of offices and listening to what employees have to say.
One in five healthcare organizations will not hire smokers. Some are screening for nicotine use, saying they wish to promote a healthier workforce. Not everyone is buying it.
Twenty-one states do not accept smokers as a protected group of people or recognize a right to smoke, which allows employers to legally refuse to hire smokers. The most common industry banning smoking is healthcare, particularly hospitals, where 21% of organizations will not hire smokers—or, in many cases, anyone with nicotine in their system, including those currently using nicotine replacement products to break the habit.
A common argument for healthcare organizations banning smoking among their ranks is that, as healthcare staff, they should be setting a positive example for their patients and community. Many healthcare organizations also say that they wish to promote a healthier workforce and lifestyle for their employees. But not everyone is buying it.
"We have to ask ourselves what this is really about," said Philip Gordon, managing partner at the Gordon Law Group in Boston, Mass, which specializes in employment law. "It's about money. Employers think smokers are going to increase health costs," he said.
DeAnn McEwen, RN, a nursing practice specialist at National Nurses United, remembers the smoke-filled nurses' lounges of the seventies and is glad they're gone. But she also firmly believes that what healthcare employees do outside the hospital while on their own time is none of their employers' business.
"This crosses the line. If a smoking habit doesn't affect your work, employers might be going a bit too far. You have to ask what's next," McEwen said. "They say smokers take longer and more frequent breaks—but that's a management issue, and [it's] on management to fix it." "If employees are getting up every 20 minutes to have a cigarette, you can tell them you don't like it, that this isn't the kind of work environment you offer. But you can't tell people what they can't do at home," agreed Gordon.
McEwen is concerned that policing employees' lifestyles can contribute to an uncomfortable work environment. "Who is really benefiting?" she asked. "Programs like that [which] allow employers to target their employees' off-duty activities encourage workers to blame each other for the high cost of healthcare," she said, adding that these factors can contribute to infighting and bullying among employees.
Who really benefits from stringent anti-smoking bans depends upon who you ask. Gordon asserts that employers aren't really looking for nicotine or cotinine (an alkaloid found in tobacco and metabolite of nicotine) when conducting screens—they're looking for higher odds of developing other health problems related to nicotine addiction.
Under the Americans with Disabilities Act, employers cannot ask if an applicant has ever had cancer or emphysema, Gordon said—but they can legally test for the presence of nicotine, which can indicate a greater likelihood of developing these and other illnesses.
Butting Out It's not impossible to have a firm anti-smoking policy that doesn't ask employees to take an invasive urine screen.
While Penn Medicine does have a policy against hiring smokers, its employees are on the honor system. "Penn Medicine does not test for cotinine in any applicants," said Michele Fletcher, Vice President of Human Resources-Decision Support at the University of Pennsylvania Health System. However, she added, "Applicants must attest that they are non-tobacco users when applying for a job."
Fletcher says she knows of at least two human resources employees who quit smoking as a result of Penn's smoking ban and the free smoking cessation program they offer. She believes Penn's position on smoking has made employees more aware of the importance of their personal well-being and caused it to become a more healthful organization.
But McEwen has a different perspective. "It's easy for the employer to blame the employee rather than look at problems in the system." She contends that if hospitals and healthcare systems really want to improve employee quality of life, they should look into alleviating understaffing, unsafe work environments, productivity demands, and employee exposure to workplace intimidation.
Gordon agrees that this will not be the last time working people will hear of the unhealthy being scapegoated. "Why wouldn't you want to hire an obese person? Because obesity is possibly a marker for other health conditions," he says, highlighting the similar health risk factors between smoking and being obese.
Gordon compares the situation to the unfair practice of asking young, female employees or potential employees if they were recently married, with the hidden agenda of deciding whether or not they're likely to get pregnant in the near future. "It's unlawful discrimination. You can't legally discriminate, so you find a pseudo-legal marker you can use," he said.
Medical records are a high-value commodity, fetching up to $50 each. Medical data breaches are being reported ever more frequently. Risk assessments and basic IT and social media policies can help protect your organization.
Eight computers were stolen from medical billing contractor Sutherland Healthcare Solutions in Torrance, CA, on February 5, 2014. A month later, the week of March 6, many patients received letters on Sutherland letterhead alerting them that their personal data, including first and last names, social security numbers, and billing information—and possibly their dates of birth, addresses and even their personal medical information and diagnoses—had potentially been compromised. As many as 173,900 patients may be affected.
Medical records are a high-value commodity. While social security numbers go for about one dollar each on black market websites, medical records can fetch as much as $50 each, according to the Medical Identity Fraud Alliance.
The information in a medical record is an identity theft goldmine, including social security numbers, a home address, and date of birth, which is useful for committing generic identity theft. A more specific kind of identity theft, in which a patient's medical records are resold to uninsured patients who are desperate to access medical care, has been particularly lucrative.
Medical data breaches like the one in California are being reported more frequently. Since 2009, there has been a 138% increase in HIPAA data breaches, according to healthcare IT security firm Redspin.
But is this increase due to more breaches actually happening, or simply better reporting? Since last year, the penalties for not reporting a data breach have increased along with the number of reported breaches.
Lee Kim, director of privacy and security at HIMSS, says that while it's still unclear whether the number of breaches is growing, healthcare leaders should assume the numbers are accurate until we learn otherwise. "The number of breaches and quantification surrounding them depends upon who is responding, what the culture is about reporting such breaches within the organization, and the rate of detection of looking for these incidents," Kim says.
The number of breaches depends heavily on sources, how adept they are at catching the infiltration to begin with and how dutifully they report the breach to begin with, she says. "There's something to be said for how on our toes we are regarding reporting breaches quickly. Are we being proactive enough?"
Five ounces of prevention
Kim has the following tips for avoiding theft of your patients' medical identities:
"You should be doing regular risk assessments," she says. "Remediate and mitigate risks. Consider all risk factors inside and outside of your organization, including all factors relevant to a mobile workforce." Kim adds that mobile computing, VPNs, and cloud computing can all be added risk factors employees might not immediately consider.
Perform simple measures like ensuring routers are set up correctly, install firewalls properly, and change your passwords frequently. These steps alone can prevent many breaches. Since most healthcare organizations don't operate at a huge profit, other expenses tend to take priority over recruiting IT staff and installing strong security systems—but spending a little extra on hiring the right people for this job and ensuring an adequate technology budget can pay off.
The distributed nature of healthcare makes it vulnerable to breaches—not only does a doctor's office have access to records, but also hospitals, insurers and billing contractors like Sutherland Healthcare Solutions. While some of this is simply the nature of the industry, Kim adds that it's a good idea to regularly inventory all "containers" of information, then remediate and mitigate the risks as needed.
"Strengthen your social media and file sharing policies," implores Kim, adding that all organizations need official acceptable use policies.
Being familiar enough with your system to know you've been breached isn't as easy as it might sound, but it can mean the difference between proactively notifying clients early and notifying clients only because it's required by law or regulation—which is not good for consumer relations. "Is your team looking for breaches or security incidents proactively? What are your organization's technological capabilities? Even if they have the ability to determine they've been breached, what's their process if there's a possible incident or breach?" Kim asks. Have an action plan in place in case a breach does occur, too.
Of course, preventing breaches from happening is the ideal, in which case the IT team may not see or hear anything. "If it's a well-oiled machine, you won't hear the engine cranking," Kim says, adding that many potential breaches are prevented by the expert security professionals. "There's a hidden battle going on.… Sometimes, the security pro is the unsung hero."
While most human resource professionals are good listeners and genuinely want to help employees struggling with the stresses of balancing work and life, they cannot take on the role of a mental health provider.
Americans seem to be more stressed out than ever before. Lack of job security, decreased compensation, and increased workloads are pervasive across most industries. But is it the responsibility of human resources professionals to step in and help employees de-stress, and if so, how far should they go?
Healthcare workers are especially vulnerable, in part due to industry consolidation, pressure from eroding reimbursements, and seismic changes 'introduced by the PPACA, including the push for implementation of EHR systems and the transition to ICD-10. All of these stressors come in addition to the already highly emotional nature of helping the sick and injured.
A February 2014 study by MiracleWorkers.com and Career Builder found that healthcare workers are the most stressed workers in America. Seven out of 10 (69%) of employees said they're "stressed" and 17 percent said they're "highly stressed." By contrast, in manufacturing, an industry that has seen many losses in recent decades, only 55 percent of respondents said they were "stressed" and 10 percent "highly stressed."
Maureen O'Keeffe
President of the Board of Directors of ASHHRA
"I've been in healthcare for 18 years, and… over the last couple years, it feels like the pace of work is faster and things are more intense. There's definitely more stress on the employees than there has been in the past," Maureen O'Keeffe, SPHR, CHHR, vice president and chief human resource officer at St. Luke's Health System in Boise, ID told me during a recent interview. O'Keeffe, who is also president of the board of directors of The American Society for Healthcare Human Resources Administration (ASHHRA) agrees that the implementation of the healthcare reform law has created a sense of uncertainty and insecurity for healthcare workers.
Let Them Know Help is Available But is it HR's job to help guide stressed out employees in the first place?
"Partly, I think so," O'Keeffe said. "It's our responsibility to set up the systems that help them find the right resources, then make the resources known so they don't have to come to HR to find them."
'Many employers, hospitals and universities have already implemented less-traditional ways to help their employees relax and take stressors off their minds, from the functional (free childcare on-site) to the invigorating (yoga and Zumba classes) to the quirky (a roomful of puppies).
It's essential that employees know of the existence of EAPs and other resources that will help them to get a handle on stress, O'Keefe says. What good is a yoga class if no one knows of its existence or if employees are too busy to take advantage of it?
"We have developed a very robust wellness program which extends to physical wellness," she said, 'regarding her healthcare system's wellness program. "We encourage wellness in our employees by having incentives around stopping smoking, maintaining a healthy body weight, monitoring blood pressure, [and] just dealing with stress in productive ways."
A new benefit St. Luke's is offering is health coaches, who actively work with employees to find fitness solutions they can work into their schedules, such as on-campus yoga classes and lunchtime walking groups.
Drawing Boundaries It's important to remember that healthcare is a business and that, while most human resource pros are very good listeners with inviting personalities, they are not the office shrink or guidance counselor. Employees to find the information they need without HR's help.
''It's our job to set up the resources, and then make sure we're communicating it very well," O'Keeffe said.
Sometimes, she says, it's helpful for HR to know what's going on in an employee's life. For example, if a spouse has cancer or an employee's child has a substance abuse problem, it will likely affect their performance, and it can be helpful for HR to know this information.
But what's the procedure if an employee is opening up to you and it's getting a bit too personal?
"If it was not in some way work-related, like harassment or hostile work environment—I would listen carefully, then redirect it," said O'Keeffe, adding that she would recommend the EAP in that situation.
"We go to healthcare because we care about people," she said. "We care about patients, about our colleagues and their families. But you have to have healthy boundaries—overstepping that isn't good for you or the employee."
"We're trying to walk the walk and talk the talk. We've got to be thoughtful and proactive with our employees. Make sure people are taking care of their health amidst the stress. Stress can kill you," O'Keeffe said.
It may be counterintuitive, but proactively developing a system for identifying future healthcare leaders doesn't incent them to jump ship. Instead, this strategy keeps employees engaged and productive, one Pennsylvania health system finds.
Think your healthcare organization doesn't need succession planning? Consider this non-healthcare example and think again.
Jerry Junkins, the CEO of Texas Instruments, saw no need for a succession plan. "I'm as lean and healthy as a horse," he said in 1996 at the age of 58. A few months later, he had a heart attack while on a business trip to Germany and died. With no clear successor in place, Texas Instruments, once a technology juggernaut, scrambled for over a decade to recover from the leadership crisis.
In the tumultuous culture surrounding business and politics, leadership positions commonly have to be replaced at a moment's notice because of illness, death, or unexpected resignation, for which there seem to be an endless variety of explanations, including allegations of bribery, mysterious disappearances, and other "personal reasons."
But many healthcare leaders are reluctant to discuss succession planning—these are people for whom work is a very important part of life, and they frequently avoid planning for the inevitable. Often, it's HR who will have to bring it up, likely persistently. But that persistence will pay off if it helps avoid a leadership crisis.
An Ounce of Prevention Some organizations within healthcare have wisely begun trying to prevent the succession crisis before it starts.
Lancaster General Health, a regional, not-for-profit healthcare system in Lancaster, PA decided in 2009 that healthcare leadership is too important to leave to chance. The leadership team proactively began developing its own talent pipeline internally.
LG Health has developed a system of identifying potential leaders, evaluating their skills, taking their own interests and aspirations into account and then developing the candidates to move into leadership positions, rating them as "ready in 3–5 years," "ready in "1–2 years" or "ready now," according to how developed their leadership skills are.
"This is not just a talent review process," said Kay Brady, vice president human resources, talent management and organizational development at LG Health. "All our leaders are assessed," she told me, adding that employees at the director level and above participate in professional development programs which are developed in collaboration with Harvard Business Publishing's ManageMentor division. During yearly reviews with their managers, employees decide which modules of the program make the most sense for them to complete.
Not-So-Secret Formula LG Health relies on the 70/20/10 formula for professional development supported by Harvard Business Publishing. According to the formula, 70 percent of talent building is based on experience. Examples of how to develop this include employees taking on expanded roles within their current departments or being assigned interim positions in different departments to develop the skills necessary to become effective leaders.
Twenty percent of development involves feedback, such as coaching or mentoring; and 10 percent of the development process should ideally come from personal learning, including online courses, lectures and reading.
Other development techniques LG Health employs include learning groups called leadership development cohorts, an MBA program developed for physicians and hospital administration at St. Joseph's University, and a Harvard executive education program for VP level employees and above.
Brady said that while they do follow the 70/20/10 guidelines, every employee's plan is "highly individualized" and tailored to each person's specific developmental needs. "We take a close look at the leaders we want to develop, and compare them to what will likely become available. Often, we develop projects with high-potential leaders in mind," said Brady.
Brady has real-life examples of how LG Health has used this strategy to keep employees engaged and productive while also protecting its talent pool. She says it's not uncommon to take employees out of clinical roles and move them to administration. "We had a director of nursing who we thought could benefit and be benefitted by being in IT," she said. That nurse oversaw the implementation of the HER system, then went into LG Health's Health Access department, and is now in a population health role.
Square Pegs? One criticism of leadership succession planning is that it can lead to people being pushed into roles they don't really want based on the needs of the company above the aspirations of the employees themselves. Brady resolutely maintains that this is not the case.
"No, we definitely don't do that," said Brady. "On our succession plan, we may have one VP appear in 3 different potential slots regarding where he could go. Every step of the way, we ask, 'What are your career aspirations? Where would you like to go?'"
Brady said that there are no downsides to succession planning that her organization has found, but that there have been many benefits. Their organization is performing above talent retention metrics published by PricewaterhouseCoopers, and LG Health a better developed, more nimble workforce.
"This policy has given us more insight into strengths of leaders and their competencies. It really allows us to be proactive in preparing for the future," Brady said.