At MaineGeneral Medical Center, clinical staff recruitment is boosted by an attractive organizational culture, an earnest approach to healthcare, and a state-of-the-art physical plant, the hospital's CMO says.
The CMO of MaineGeneral Medical Center says he has three primary challenges at the community hospital: clinician recruitment, financial sustainability, and mental health and addiction medicine resources.
Dana "Dan" Vick, MD, MBA, has been CMO of MaineGeneral Medical Center since 2022. MaineGeneral Medical Center, which is located in Augusta, Maine, is a 198-bed community hospital that is part of MaineGeneral Health. The hospital is considered a rural referral center, with Augusta a modestly sized city with only about 20,000 residents. His prior healthcare leadership experience includes serving as vice president of medical affairs for two Ascension health system hospitals: St. Vincent Evansville in Evansville, Indiana, and St. Vincent Warrick in Boonville, Indiana.
HealthLeaders recently talked with Vick about a range of issues, including how physicians are involved in administrative leadership at MaineGeneral Medical Center, patient safety at the hospital, and patient experience. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of MaineGeneral Medical Center?
Dana "Dan" Vick: There are three things that are challenging.
One is staff recruitment. We are constantly recruiting for various specialties. About 85% of our medical staff are employed, which puts the onus on us as an organization to recruit clinicians. Fortunately, one of the things that makes us attractive is we have a great organizational culture, which runs from the top down. We have a lot of longevity throughout our organization in many employment levels.
We are taking care of patients who are members of our community—sometimes they are family members and sometimes they are neighbors of people who work here. There is a sense of earnestness in how we approach healthcare, which helps with our recruitment. We also have an excellent physical plant—the hospital was built about 10 years ago with input from people who work throughout the organization. The hospital is a place that is convenient for patients and user-friendly for those who work here. When you step inside the hospital, it looks like it opened just last week. When we have recruits who come to the hospital, they are impressed by the facility.
The second challenge is financial. Like every healthcare organization, we are struggling with decreasing reimbursement while trying to figure out how to increase access for patients. We are trying to reduce length of stay to be a more financially adept organization, while providing the care that patients need in as timely a manner as possible.
The third challenge is mental health and addiction medicine resources. In Maine, we struggle to have enough resources to address the issues that occur in those realms. In many states, mental health and addiction medicine has become a crisis.
HL: How are you rising to the financial challenge?
Vick: We look at the ways we can improve upon the services that we offer to increase access and deliver those services in a cost-effective manner. We also try to limit length of stay for patients. Additionally, we try to make sure that we capture appropriately the services that we provide to boost reimbursement.
HL: How are you rising to the mental health and addiction medicine resources challenges?
Vick: We continue to recruit adult and pediatric behavioral health staff. We are also working with telehealth providers to help provide some of the care that we are not able to provide on-site.
HL: What is the physician compensation model at MaineGeneral Medical Center?
Vick: All physicians are on a base salary to guarantee them a base compensation. Most of the service lines can pay physicians additionally based on productivity. We used to have payment based on value, but we have folded that component into the base salaries because we found that we had to compete with other hospitals for recruitment, and that has made us more competitive.
Dana "Dan" Vick, MD, MBA, chief medical officer of MaineGeneral Medical Center. Photo courtesy of MaineGeneral Health.
HL: What is the approach to patient safety at MaineGeneral Medical Center?
Vick: We have a multipronged approach. We have a daily report prepared by risk management staff showing anything that may rise to the occasion of being a miss or a near miss. We have a peer review process with the medical staff that looks at cases that may rise to serious patient-safety criteria.
We also have a Speak Up Award—employees are encouraged to speak up if they see something that may have the potential to cause a problem. So, employees receive an award when they have found an issue and potentially avoided a patient safety event from happening. We also conduct rounds on staff and patients from the senior administrative director levels.
We try to promote a culture of safety. We have worked on flattening the hierarchy, so employees on the frontlines know they can bring their concerns forward quickly. We also have a process design department, and they do a lot of lean process work. We are doing everything we can to reduce errors and to improve patient safety.
HL: Is there a process in place when medical errors occur?
Vick: When a medical error occurs, we determine whether it represents a sentinel event or significant event. Then we implement our medical staff peer review process to look at the case.
HL: What are the keys to success in patient experience in the inpatient setting?
Vick: Two things that are important are teamwork and communication.
Healthcare is not an individual endeavor. It takes the work and input of everyone on the healthcare team. So, we have promoted teamwork and have built teamwork into our culture. We conduct interdisciplinary team rounding every day on our medical and surgical wards.
We also promote the value of communication. You can never communicate a message too frequently—that is very important. We want our patients to understand what is occurring with their healthcare. We want to hear from them if they have any concerns. So, we survey patients frequently.
HL: How are physicians involved in administrative leadership at MaineGeneral Medical Center?
Vick: They are involved in several manners. We have employed medical directors for our service lines. We have our medical executive committee, which consists of our department chairs. We have medical staff and hospital committees, where physicians serve in leadership roles. And we have medical staff members who are on the board of directors.
We have worked to build a leadership development program for our medical directors, assistant medical directors, and lead advanced practice providers. This consists of quarterly half-day retreats that we hold at an off-site facility. We cover several topics such as leading through a team-driven approach, how to overcome dysfunctions in a team, and understanding physician compensation. So far, this leadership development program has been well received, and it is helping us grow the next generation of leaders and helping current leaders grow in their roles.
HL: What are the benefits of having physicians involved in administrative leadership?
Vick: It helps because otherwise you can get engrained and focused on components of healthcare without understanding why we must do some of the things that we do in running a healthcare organization. When physicians have an opportunity to be involved in administrative leadership, it gives them a better sense of the other side of the equation beyond patient care, and it allows them to convey that message to their medical staff group or department.
'You basically cannot have patient safety without health equity,' says Yale New Haven Health executive.
Yale New Haven Health is striving to address the health equity elements of patient safety.
Health equity has become a top priority for healthcare providers nationwide. Last year, health equity was added as the Quintuple Aim for healthcare providers. In 2008, the Triple Aim for healthcare improvement was introduced, featuring improvement of population health, enhancement of the care experience, and reduction of costs. In 2014, the Quadruple Aim for healthcare improvement was created with the addition of workforce well-being as a fourth element to address healthcare worker burnout.
Linda Fan, MD, assistant professor of Obstetrics, Gynecology and Reproductive Sciences at Yale School of Medicine, and GME director of quality and safety at Yale School of Medicine and Yale New Haven Health, says health equity plays a significant role in patient safety.
"You basically cannot have patient safety without health equity. It is a glaring hole in how we have not been able to adequately address patient safety. In the past, we have believed that patient safety is an issue because the patient is not compliant—they did not listen to the directions or there is something intrinsically flawed with them. When you get to the root cause of a patient safety issue, it is possible that the patient did not understand directions, there could be language issues, or there could be issues with access," she says.
There are several elements of health equity that impact patient safety, Fan says. "There can be different domains of social factors, including language barriers. There are conventional ways that we look at patient safety—we look at the patient, we look at the caregivers, and we look at processes. In the past, there has not been the language to include health equity elements such as access to care, language barriers, transportation issues, and social supports. Those kinds of things do not fall into the normal ways we have looked at patient safety."
Pairing health equity with patient safety is a healthcare trend, she says. "We are not used to looking at patient safety through the equity lens. Health equity is a different way of looking at patient safety. Once you start looking at patient safety through an equity lens, you cannot unsee it. We are at the beginning of incorporating health equity in patient safety."
There are two primary approaches to addressing health equity issues in patient safety, Fan says. "When you are looking at quality and safety and health equity, one approach is to understand disparity indexes, where you might take something such as mortality related to myocardial infarction or how patients are treated for chest pain, and you compare how men and women are treated or how Blacks and Whites are treated. If there is a difference, then we should be trying to hone in on it and improve it. You need to be looking at information transparently and making sure that the data reflects disparities. Another approach is when you identify a safety event such as a medical error leading to a sentinel event, then you ask all the reasons why the error occurred, including health equity elements as part of the framework of looking at safety events."
Visualizing the data
Health systems, hospitals, and physician practices should follow four steps to develop a systemwide process for equity data visualization of quality and safety measures, says Lou Hart, MD, medical director of health equity at Yale New Haven Health.
With a multi-stakeholder, transdisciplinary team, launch a We Ask Because We Care education and training campaign directed to both patients and staff around the importance of sharing and collecting high fidelity patient self-reported demographic information to eliminate unwanted variation in care and patient outcomes. Start with REALD SOGI and social determinants of health data such as race, ethnicity, language, disability, sexual orientation, and gender identity. Co-create and update field values and selections after conducting focus groups with staff, patients, community advisors, neighboring health systems, state government agencies, and other stakeholders.
Agree upon and ratify standardized mapping and reporting guidelines to ensure the health information technology system uses one single source of truth for assigning demographic categorization to patients that persist across encounters in their legal electronic medical record.
Leverage existing or create formal quality and safety reports and dashboards, then calculate demographic subgroup-specific characteristics such as income, Zip code, language, disability, and race as process and outcome measures for the quality and safety metrics in question. For example, examine 30-day readmissions with subgroup readmissions and subgroup index admissions. Examine the Medicaid readmission rate by looking at patients with Medicaid experiencing 30-day readmissions and patients with Medicaid who had an index admission. Compare the Medicaid readmission rate to the commercial insurance rate by looking at patients with commercial insurance who experienced 30-day readmission and patients with commercial insurance who had an index admission. Start with metrics that are institutional priorities such as corporate objectives, risk-based contracted measures, and those that impact the most patients.
With the group-specific outcome rates stratified, create an equity index showing relative risk or risk ratios across the subgroups. This should be viewed in a bar chart for ease of understanding. The control group should be dynamic and the group with the best outcome rate.
Health equity and patient safety outcome
A recent example highlights collaborative change management led by Yale New Haven Health Pediatrics in partnership with Women's Health, Hart says.
There was a case of a child welfare report being filed for positive urine toxicology during pregnancy and a desire to test the baby. The former hospital procedure often involved testing the newborn at birth despite already having information from the parental test. This resulted in a child welfare investigation process that was traumatic, which led to a patient safety incident report being filed on behalf of the family.
During the investigation, it was found that Black and Hispanic parents were disproportionately tested for substance use during pregnancy compared to White patients. Black and Hispanic parents were also less likely to be positive when tested than were White parents. Given this clinical disparity and the potential for bias-driven healthcare inequity leading to disproportionate child welfare system involvement with racially minoritized families, a partnership was formed with the regional child welfare system—the Connecticut Department of Children and Families (DCF)—to address the concern locally and structurally.
Yale New Haven Health partnered with patient advocates and multiple clinical departments and quality improvement experts. The health system also created a partnership with DCF to educate on the lack of medical necessity for routine newborn toxicology testing because it was redundant to parental testing, often did not change clinical management, and could lead to bias in future care.
These efforts led to two key changes, Hart says, noting the changes not only decreased the racial disparity in newborn toxicology testing but also decreased unnecessary testing in all racial groups for newborn toxicology testing.
There was policy clarification and procedural change to limit use of newborn toxicology to cases where it was purely clinically necessary and not used for social risk stratification or confirmation of parental testing. The health system created an electronic medical record clinical design support tool to guide clinicians in real time to highlight the need for informed parental consent being required to perform newborn toxicology.
There was broad internal messaging at the health system regarding the clinical disparity and to raise collective awareness among key stakeholders. There was internal and external training with hospital staff and DCF staff as well as re-evaluation of the statewide drug exposure reporting system to distinguish between mandated anonymous fetal substance exposure versus formal child welfare referrals for in utero substance exposure.
"I have a unique position, where I understand both the administrative and the clinical languages. The decisions then become more clinically integrated," says the CMO of Davis Health System.
The CMO role continually intersects between the worlds of the physicians and the executive leaders. And because of that, CMOs have the advantage of understanding the physician perspective and bringing that to the decision table in the C-suite, says Catherine "Mindy" Chua, DO, CMO of Elkins, West Virginia–based Davis Health System.
"I have a unique position, where I understand both the administrative and the clinical languages. I understand where doctors are coming from, so I can take that to the table. The decisions then become more clinically integrated and more patient-focused because we have the voice of the doctors," she says.
Chua has been CMO of Davis Health System since June 2016. In March 2020, she was appointed incident commander for the health system's coronavirus pandemic response. Prior to joining Davis Health System, Chua ran a private family medicine practice with her husband for 10 years.
HealthLeaders recently talked with Chua about a range of issues, including her role as liaison between the medical staff and the C-suite, recruiting and retaining physicians, and the keys to success in population health. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of Davis Health System?
Catherine "Mindy" Chua: One of the biggest challenges is recruiting and retention in small towns. That has been difficult for the main hospital but even more difficult for our critical access hospitals. Trying to find ways to bring people in and keeping them here has been difficult.
Another difficulty is I am trying to manage both CMO work and operations work. I also work in the clinic.
HL: How have you been rising to the recruiting and retention challenge, particularly when it comes to physicians?
Chua: We have worked hard here to establish a culture where physicians are valued. We work actively to achieve a good work-life balance. We also engaged a recruiter who is not only from this area, but entire generations of his family are from this area, so he is invested and knows how to point people in the direction of what would be interesting to them outside of the hospitals. We understand that selling a place of work is not only just about the brick-and-mortar walls that you are working in, but also the things that recruits are interested in and how we can get them and their families involved and engaged in the community. We want our staff to have a fulfilling work life and a fulfilling personal life.
HL: How are you balancing your role as CMO with operational responsibilities?
Chua: I must make sure that I have good and capable directors and managers working for me. I am a big believer in managing from the ground up; so, I listen to the people who are doing the work rather than micromanaging. I recognize my role is to remove barriers and to mentor rather than being in the weeds doing the work. That allows me the opportunity to get a bird's-eye view of what is going on in my departments, while still being able to maintain my patient care. I have had to attenuate my patient care. I went from a full-time outpatient family practice five days a week to two days a week in the family practice.
Catherine "Mindy" Chua, DO, chief medical officer of Elkins, West Virginia–based Davis Health System. Photo courtesy of Davis Health System.
HL: What are the keys to success in population health?
Chua: Education is a huge factor. It is a fairly new concept for some people, so educating about what population health is and what it means to the organization is important. Education is important for physician buy-in. You also need administration buy-in to get a good population health program going.
Collaboration is the other key component because population health is not just within the four walls of a hospital. It involves bringing in community resources and community experts, so you can get a broad picture of what your community needs. That is the macro view. Then there is the micro view within the hospitals that has to do more with quality metrics and cost metrics. That goes back to education and buy-in because you must have doctors understanding why they must do documentation and what that means to them and the organization.
I am a big proponent of leading with the "why." If you just tell doctors that they need to do this, and you do not give them a broader perspective of why, then they will lack motivation to participate.
HL: How are you serving as a liaison between the clinical staff and senior administrators?
Chua: That is the key role of a CMO. The administrative C-suite has a different set of vocabulary compared to what physicians are taught. Having been in both private practice and as an employed physician, I have a good understanding of the physicians' point of view when it comes to how a clinic should be run or what patients need. I am also having one-on-one communication with patients every day, which the administrators do not necessarily have. I can walk up to a floor and walk into a patient's room, then ask them what I can do to make their day better. I can talk to the physician and find out about the barriers the physician has that I can help remove.
I have a unique position, where I understand both the administrative and the clinical languages. I understand where doctors are coming from, so I can take that to the table. The decisions then become more clinically integrated and more patient-focused because we have the voice of the doctors.
HL: You have served as an American Association for Physician Leadership mentor. What are the qualities of a good healthcare mentor?
Chua: Patience, humility, affability, and the ability to be a good listener are important. When I mentor people, I do not give them a lot of advice—I listen to what they have to say and help them to work through their problems. Mentoring is not about saying, "This is how you need to do this." People cannot grow or learn if they are being shown exactly where to go. If you can be that person who can steer somebody without pushing them—that is a good mentor.
Health equity has become a top priority for healthcare providers nationwide. Last year, health equity was added as the Quintuple Aim for healthcare providers. In 2008, the Triple Aim for healthcare improvement was introduced, featuring improvement of population health, enhancement of the care experience, and reduction of costs. In 2014, the Quadruple Aim for healthcare improvement was created with the addition of workforce well-being as a fourth element to address healthcare worker burnout.
In July 2021, the Health Information and Management Systems Society conducted a survey of hospital executives for the consultancy BDO regarding the executives' plans to understand, address, and measure health equity challenges. The survey found widespread adoption of health equity strategies or plans to implement health equity strategies:
37% of the hospitals had a health equity strategy in place
37% of the hospitals were planning to implement a health equity strategy in the next 12 months
13% of the hospitals were planning to implement a health equity strategy in the next 12 to 24 months
9% of the hospitals were planning to implement a health equity strategy after 24 months
Only 5% of the hospitals did not have plans to implement a health equity strategy
NCQA health equity accreditation is based on six core standards:
Organizational readiness such as building a diverse staff
The ability to gather race, ethnicity, language, gender identity, and sexual orientation data
Availability of language services
Practitioner network cultural responsiveness to diverse populations
Culturally and linguistically appropriate services that meet the needs of diverse populations
The ability to use data to assess the existence of healthcare disparities and the use of quality improvement initiatives to decrease healthcare disparities
WellSpan's health equity journey
WellSpan took an innovative approach by building a comprehensive health equity program, says Michael Seim, MD, senior vice president and chief quality officer of the health system. "With the work that we did to achieve NCQA accreditation, we had to make sure that we had the underlying infrastructure to be successful. We are working on looking at every aspect of our work at WellSpan through the lens of health equity. For example, we are working on a children's health initiative to make sure we set up children under the age of 6 to be healthy."
A primary focus of health equity work at WellSpan is decreasing life expectancy disparities, he says. "Throughout the country, there are disparities in life expectancy based on whether you live in an urban or rural area, whether you have access to education, whether you have access to housing, and whether you have access to healthy food. So, we are working on this issue as part of our community health needs assessment, our community health improvement plan, and our strategic plans. We are trying to look at all angles, including through a lens of equity."
WellSpan is taking an innovative approach to reducing life expectancy disparities, Seim says. "That focus is innovative in the fact that we have to tie together every aspect of not only our clinical practices within WellSpan but also within our community health work and our partnership programs."
WellSpan's health equity work has been based on a step-by-step process, he says. "We have to do things like support education and businesses in our communities. We must be committed to our diversity, equity, and inclusion program to build a reflective workforce within our service area. We must find key partners who share our vision because we cannot address many of the social drivers of health without key partners. We must make sure our philanthropic work, charity work, and community benefits are being honed to our mission of health for all. Then we must engage our medical groups to say, 'OK. What are the leading causes of death within our communities and are we putting the resources in to address these causes of death?' For example, we are making efforts in smoking cessation, hypertension control, and screening for colorectal and breast cancer."
WellSpan started doing health equity work before the market demanded it, Seim says. "Going back to 2017, we set up the infrastructure to screen patients for social drivers of health. We set up the process of prioritizing health equity by building a health equity steering committee. Four years ago, we set up strategic goals by our board of directors as part of our annual plan to achieve measurable outcome results in health equity. There are other health systems that are just working on process measures, but we are committed to outcome measures where we can show that we have improved the health of our communities."
Health equity work outcomes
WellSpan is monitoring several metrics to gauge the impact of the health system's equity work, Seim says. These metrics include Healthcare Effectiveness Data and Information Set measures, kidney health, colorectal and breast cancer screening, hypertension management, immunizations, and food security and housing security.
WellSpan has made significant progress in health equity efforts related to severe maternal morbidity and mortality, COVID-19 disparities, and food and housing insecurity, according to health system data.
An outcome-based goal was established to decrease severe morbidity and mortality associated with pre-eclampsia (hypertension). In calendar year 2018, the total number of severe maternal morbidity and mortality cases was 39 with an overall rate of 7.6%. Fiscal year 2020 hypertension outcome data demonstrated a 54% decline in severe morbidity and mortality among all races. Additionally, a 61% reduction in the rate of severe morbidity and mortality related to hypertension among Black individuals as compared to the baseline was also noted.
During the initial stages of the coronavirus pandemic, Black and Latino families were disproportionally impacted by COVID-19. Through data analysis and comparing infection rates among diverse populations, WellSpan was able to make strategic decisions, build key community partnerships, and allocate grants early in the pandemic, which resulted in a significant rate reduction of COVID-19 infections among ethnic and racial groups. The fiscal year 2022 annual plan also identified a disparity in vaccination rates between patients who identified as being non-white or identified a primary language other than English when compared to white and English-speaking patients. WellSpan expanded community, patient, and family partnerships to understand the needs of the community and explore barriers to vaccinations and routine screening. This significantly decreased the vaccination rate disparity between populations.
Since calendar year 2020, screening for food and housing insecurity has increased. During the first year of the program, WellSpan screened 55,792 unique patients and 5% of those screened were identified as having a need for housing or food. From October 1, 2021, to April 22, 2022, a six-month screening period, 19,051 patients were identified with a food insecurity, 16,044 patients were identified with housing instability, and 11,133 lacked transportation, and they were referred to a community partner program, case manager, or WellSpan program.
The CMO of Robert Wood Johnson University Hospital Rahway found the way to support physicians in moving to team-based care when they did not see the need to change.
CMOs must help physicians shift their mindset of autonomy to partner with administrators to manage and deliver strong outcomes, says Carol Ash, DO, MBA, CMO of Robert Wood Johnson University Hospital Rahway. "CMOs must be role models, addressing the challenge by helping their physician colleagues move from a culture of autonomy to working as part of a successful team, with the patient as the first priority."
Ash has been CMO of RWJ University Hospital Rahway since June 2018. The hospital is part of RWJBarnabas Health. Her previous leadership experience includes serving as director of the ICU at Robert Wood Johnson University Hospital Hamilton.
HealthLeaders recently talked with Ash about a range of issues, including the challenges of serving as a CMO, becoming the first CMO of RWJ University Hospital Rahway, and the keys to success in case management. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of RWJ University Hospital Rahway? How have you risen to these challenges?
Carol Ash: The way physicians do things has not changed much since 1919, when the American College of Surgeons (ACS) published the principles defining physician professionalism. These principles promoted physician self-governance and autonomy. More than two decades ago, the Institute of Medicine's two watershed reports, "To Err is Human" and "Crossing the Quality Chasm," showed us that the way we were doing things was not resulting in high-quality outcomes for patients. Change was needed. The Affordable Care Act and the advent of electronic healthcare records were meant to improve healthcare performance to reach new, high-quality goals. The CMO has played—and continues to play—a critical role in ensuring physicians can work with organizations to meet those goals and remain competitive.
The challenge is that despite recognizing the need to transform and put the needs of the patient and community first, our nation's medical community remains entrenched in the mindset of the ACS model of professionalism.
When I arrived at RWJ University Hospital Rahway, I knew what had to be done. I had to clearly communicate our new direction to my colleagues, explain their roles, and help them understand what the change would mean for them. To rise to this challenge, I first had to understand my own mindset, motivations, strengths, and weaknesses. It was hard work.
Before I pursued the role of CMO, I spent 10 years gaining the knowledge and administrative skills necessary. This included attaining an MBA and pursuing fellowship status in the American College of Healthcare Executives. It was Dartmouth College's Master of Healthcare Delivery Science program that gave me the big-picture understanding of system science for healthcare redesign and the skills to successfully align and support the implementation of local innovation that could be taken to scale. Gaining this knowledge, plus my years of clinical experience, gave me the confidence to proceed.
Healthcare transformation is finally happening now, and I am excited to be part of it.
Carol Ash, DO, MBA, CMO of Robert Wood Johnson University Hospital Rahway. Photo courtesy of RWJBarnabas Health.
HL: You are the first CMO at RWJ University Hospital Rahway. How have you defined the role?
Ash: I was not only the hospital's first CMO, I was the first female CMO at an acute care hospital across our health system. Adding to that hurdle, a year and a half after I started, we had to respond to the COVID-19 pandemic. With no prior CMO to set the example, I challenged myself to use the power of the position to remove obstacles and create opportunities for my colleagues, our patients, and the community we serve.
Along with superb clinical and administrative knowledge, a CMO needs to be humble. I do not have all the answers, and I openly admit my mistakes. I try to let others do most of the talking, so that I can see things from their perspective. My goal is to be a resource for the people who are doing the work. I aim to build respect and trust as well as unite and unlock the potential of our team every day.
HL: What are the keys to success in case management?
At RWJ University Hospital Rahway, we successfully shifted most patients to case management by hospitalists. This allowed us to focus limited case management resources into a multidisciplinary team-based approach with a focus on accurately recognizing, diagnosing, and removing obstacles to management and discharge. The focus was delivering high-quality care in minutes, not hours or days.
Supporting cultural change is hard to do. It was especially hard at RWJ University Hospital Rahway because most staff physicians were in private practice, and they were resistant to change. My primary challenge was to support my physician colleagues in that endeavor when they did not see the need to change.
Ultimately, while dealing with the pandemic in a community hospital entrenched in a culture that still valued fee-for-service, we were able to achieve a significant shift in the number of employed physicians practicing in our hospital from zero hospitalists to 60%–70%. More patients are now under the care of a doctor employed by the hospital versus those in private practice.
What did this mean for our patients? These doctors now have the support of an entire team, which helps them raise the overall well-being of their patients. They have access to nurses, social workers, navigators, and professionals that can connect them with necessary services. We were able to shift care from a model focused on financial outcomes to a model focused on patient-centered outcomes. The best result has been a decrease in hospital length of stay.
Find out how top healthcare executives have developed solutions for their workforce shortages.
Workforce shortages are impacting healthcare organizations nationwide, and HealthLeaders has been talking with healthcare leaders to see how they are rising to the challenge.
Health systems, hospitals, and physician practices are experiencing a range of workforce shortages, including nurses, physicians, and medical assistants. The four stories below feature 10 different ways that healthcare organizations have addressed their workforce shortages.
Read about workforce shortage solutions from chief medical officers and chief nursing officers who participated in a HealthLeaders virtual roundtable. They discuss the role strong leadership plays in retaining healthcare workers, adjusting care models, and telehealth solutions.
See how a pipeline can propel students to healthcare careers, find out how artificial intelligence can more accurately schedule nurses, and read about succession planning as a tool to increase retention and lower costs.
Establishing effective communication is crucial in leading a large health system, the chief medical officer of AdventHealth says.
At large health systems, it is essential to bridge the gap between the corporate leadership and the frontline, says Brent Box, MD, senior vice president and CMO at AdventHealth.
Box has been SVP and CMO of the Altamonte Springs, Florida–based health system since February 2018. His prior leadership experience includes serving as the health system's senior medical director and chief of hospital medicine.
HealthLeaders recently talked with Box about a range of issues, including the challenges of serving as CMO of a large health system, care transformation initiatives, and the keys to success in hospital medicine. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: AdventHealth is a large health system with more than 1,200 care sites, including 51 hospitals in nine states. What are the primary challenges of serving as CMO of such a large health system?
Brent Box: The biggest challenge is we are large and have significant diversity in the size and scope of the services we provide to the different communities we serve. For example, in Orlando, Florida, we have more than 1,000 beds in a group of facilities, but we also have rural hospitals with less than 70 beds. So, there is a difference in the work that we do in different communities.
What we have done at AdventHealth is we are highly focused on safety and quality. So, despite the diversity, you must have common goals. We have common goals for our acute care facilities. Particularly with the Centers for Medicare & Medicaid Services (CMS) star ratings, we want every hospital to be four or five stars. We want all of our facilities to earn an "A" from Leapfrog, and we want all of our facilities to be in the top quartile for mortality. We want to meet external measures and pay continuous attention to the data and information you must have for our leadership teams to make decisions and achieve improvements.
There are other challenges.
First, communication is a challenge. We are a large organization geographically. There is a lot of space between leadership and the frontline, particularly leadership at the corporate level and the frontline. So, we need to make sure that communication avenues are open bi-directionally and effectively. Leadership needs to listen. We need to make sure we know who the operators are in terms of the folks who are taking care of patients in the markets, and we need to listen to their expertise as we make decisions.
Second, we need to be intentional about not working in siloes. It is easy to have siloes in a large organization. We work hard at building partnerships—such as partnerships between the markets, partnerships between the clinical staff and supply chain, and partnerships between the clinical staff and marketing. We are always working hard to be on the same page.
HL: Since coming to AdventHealth, are there initiatives or programs that you are particularly proud of?
Box: When I first came to AdventHealth, my job was in hospital medicine. We have a large number of hospitals across the footprint of AdventHealth, and organizing hospitalists and working toward common clinical improvement goals is something I am very proud of.
We started a clinical excellence program, which is our effort to achieve improvement in CMS stars ratings and mortality.
I am very proud of the work we did in COVID-19 care. This is a large organization, and we came together in ways that we had never come together before. We achieved some great clinical results treating a disease that we knew nothing about initially.
Finally, we have been rolling out a high reliability program for about four years. We call it HRO-Unit Culture. The program gives voice to our teams at the frontline to improve care and achieve reliability in the care that we provide. It is about the culture you need to have at the unit level to achieve high reliability.
HL: Give examples of care transformation initiatives that you have worked on.
Box: We have a sepsis initiative. Sepsis is one of the highest volume diagnoses, particularly when it comes to mortality and cost of care. We are working on a systemwide effort to reduce morbidity and mortality by improving early recognition of sepsis and early intervention. As a health system, we are already top quartile in sepsis mortality, but we believe this is an area we can focus on to save lives. All of our facilities are working on a sepsis plan, order set usage, and achieving compliance with the SEP-1 bundle.
We are also working on length of stay for two reasons. First, it is about the clinical care that you provide as well as the effectiveness and efficiency of the care. Second, it is also a marker of value. The length of stay initiative involves boosting teamwork; working with our care managers, nursing teams, and physicians; and providing interdisciplinary care that is more effective and efficient.
Brent Box, MD, senior vice president and CMO at AdventHealth. Photo courtesy of AdventHealth.
HL: What are the keys to success in hospital medicine?
Box: Hospital medicine is a particular interest for me because I spent several years as a hospitalist as part of my clinical career. We have more than 800 hospitalists across our system, and they take care of 80% of our hospital patients. There are four keys to hospital medicine:
1. We must have a common "why" across our system. When I started working at the corporate level in 2016, the "why" became that we wanted every patient attended to by our hospitalists to receive the best clinical care, we wanted patients to have great communication and coordination of healthcare services, and we wanted it all done with uncommon compassion.
2. We also focused on the fact that every patient deserves a "captain of the ship." We lifted up our hospitalists as the captain of the ship for their patients.
3. We have spent a lot of time over the past five or six years developing hospital medicine leaders. We have a yearlong hospital medicine leadership program to develop leaders to align with our system goals.
4. We have common measurements for success. Across AdventHealth, all of our hospitalists and hospital medicine leaders know what the measurements are, they know what they are after, and they synchronize with our clinical agenda.
HL: What are the primary elements of achieving high clinical quality at AdventHealth?
Box: We have had a consistent strategy for achieving high clinical quality. We have a recognition that good healthcare is the continuum of care. It is not just what happens in the four walls of the hospital—it also involves the primary care clinics, the ambulatory care arena, the emergency departments, and post-acute facilities.
To achieve excellence, we feel we need four other things—three of them are pillars and the fourth is an undergirding process:
A good infrastructure. For example, we need to have a systemwide electronic medical record. (Editor’s note: Box explained AdventHealth is about 85% of the way through rolling out Epic as an organization.)
Good data. We have been focused on data and analytics as well as understanding that we need to communicate data and help leaders across the health system use data to achieve improvement.
Clear systemwide goals for mortality and trying to be the safest healthcare organization in America. So, we want to reduce measurable harm and reduce unnecessary variation.
Undergirding those three structural elements in our strategy, we want to recognize that clinical culture is extremely important in achieving high reliability. That's our HRO-Unit Culture program.
One more thing is you must have committed leadership at every level to achieve high clinical quality, and we have that here.
HL: You have a clinical background in internal medicine. How has this clinical background helped you serve in physician leadership roles such as CMO?
Box: I spent more than 20 years in direct patient care before I came to AdventHealth—some of that was in private practice and hospital medicine. That experience grounded me in what it takes to provide good care to patients. When you spend time taking care of patients, you learn that often the work is long, the work is hard, and the work is exceptionally rewarding. That experience is key to leading clinical care teams because it is hard to lead unless you have been there and done it.
HL: You have served in medical education roles. What are the qualities of a good medical educator?
Box: You must know your subject; and more than that, you must be willing to spend time preparing to teach. You must [also] have a passion for teaching. Not everybody has a passion for teaching, and the best teachers are passionate. They are passionate about cultivating curiosity.
Finally, a good medical educator must be patient and must start with the belief that you are building the caregivers of the future … so you must constantly both educate and build up students to be great clinicians.
Many health systems and hospitals consider it crucial to be clinician-led organizations.
As part of HealthLeaders' chief medical officer Q&A series called "The Exec," many CMOs have said that physicians play active roles in their organizations' administrative leadership.
According to the CMOs, physicians serve in a range of administrative roles at their health systems and hospitals, including hospital president, medical directors, and department chiefs. In playing administrative roles, physicians can help ensure that clinical care is a paramount concern at their organizations.
The following is a list of The Exec HealthLeaders stories that include descriptions of how physicians serve in administrative leadership roles.
The Exec: Respect Primary Element of Physician Experience: Banner Health has an eight-week long leadership program for physicians called Advanced Leadership for Physicians. Physician leadership roles at the health system's hospitals include medical executive committees and we medical directors for nearly every clinical department.
The Exec: How to Succeed in Value-Based Care Payment Arrangements: At Yuma Regional Medical Center, the hospital has physicians serving as executive medical directors overseeing surgery, medical specialty, and primary care. Under them, there are physicians serving as medical directors in areas such as trauma, stroke, and intensive care.
Scripps Health has physicians in the C-Suite and leading the medical staff.
Physicians are playing key administrative leadership roles at Scripps Health.
Physicians are well-suited to succeed in administrative leadership roles. With health systems, hospitals, and physician practices nationwide facing tight finances, physicians can be pivotal in helping organizations maintain high standards of patient care with limited resources.
Ghazala Sharieff, MD, MBA, corporate senior vice president as well as chief medical and operations officer for acute care at Scripps Health, says the San Diego-based health system has a strong physician leadership infrastructure that has been strengthened over the past three years.
"Scripps President and CEO Chris Van Gorder divided the CMO role into two sides—I am the acute care CMO and Dr. Anil Keswani is the CMO on the ambulatory side. As of this year, Van Gorder has assigned me and Dr. Keswani operations responsibilities as well. We are driving to both clinical and operational excellence. What that means on my side of the house is the hospitals report up to me, including pharmacy, supply chain, and support services. So, starting with patient experience and quality, we are driving change all the way through the organization by aligning administration and physician leadership," she says.
Ghazala Sharieff, MD, MBA, corporate senior vice president as well as chief medical and operations officer for acute care at Scripps Health. Photo courtesy of Scripps Health.
Physicians play crucial leadership roles at the health system's five hospitals, Sharieff says. "We have a physician operating executive at each hospital—they are a dyad partner to our chief operating executives, so they help run the hospitals on a day-to-day basis. They report up to me. We have about 80 medical directors who report up to the physician operating executives. We truly have alignment up and down the organization. The medical directors help us with our patient experience, quality metrics, and cost control. We also have strong chiefs of staff. I meet with them at least twice a month. They are now becoming more involved in operational leadership decisions. The chiefs of staff are in charge of our medical staff. They align bylaws across all five hospitals. So, they are in charge of the physicians on the medical staff. The chiefs of staff also govern peer review if cases do not go as expected."
Physicians also have a voice in capital expenditures, she says. "One of the things we started this year is a brand new medical equipment and imaging capital process. We have our service lines, which have a dyad partner with physicians, and they prioritize the list of things we are going to need for next year because we can't have everything. They prioritize, then we have our chief operating executives, regional directors, and physician operating executives look at the list and prioritize what they think we really need for the next fiscal year. In the end, we will have one list by site that is transparent to the entire organization. We can't do this process without physician leadership."
Selecting physician leaders
The most important qualities of physician leaders are being open to change and being situational leaders, Sharieff says. "As we saw through COVID, there were times when we all had to be directive but there were also times to be collaborative. So, being fluid in your leadership style is critical as well as being able to pivot quickly. You must avoid always standing firm—just because one decision is made, that may not be the way it always has to be."
For physician leaders, having years of experience in clinical care is more important than a particular background, she says. "Physicians are not going to follow somebody who is one year out of residency. What I advise my junior physicians who want to be in leadership is to get clinical credibility first, then they can advance their leadership journey. People are not going to respect you as much if you have not been working on the frontline."
Physician leadership is often not about compensation, Sharieff says. "There are so many committees and so many ways to get involved. At Scripps, we started what we call Sprint Teams, which address issues that arise. We ask for volunteers to be on those committees, which is a great way to get known as a leader. We will pull you up if we see leadership skills. The way we grow leaders is to give them an opportunity to be involved. It's awesome when we launch a Sprint Team and there are many physician volunteers who want to be involved in the committee. Physicians want to be involved because they realize funds are tight, but they want to make sure that we make the best decisions for patient care."
Physician leaders and the healthcare system
Physician leaders at health systems can have a positive impact on the broader healthcare system, she says.
"Physicians in leadership at health systems can be incredibly instrumental—if the state and federal agencies are willing to listen to those of us truly on the frontlines. The practical experiences that physicians bring to the table are invaluable in guiding smart policy and planning decisions. In San Diego, we formed a regional chief medical officer group, which worked closely with county health officials during COVID to help coordinate COVID practices and have regional alignment. That being said, often decisions are made at levels by people who really have no insight as to what happens at the frontlines of patient care, so I hope for more collaboration, especially in the face of unfunded mandates."
The chief medical officer of Providence Newberg Medical Center says physicians are natural team leaders.
The chief medical officer (CMO) of Providence Newberg Medical Center says her clinical background in internal medicine prepared her for physician leadership by providing insight to giving care at the bedside.
Amy Schmitt, MD, has been CMO of the Newberg, Oregon-based hospital since March 2013. She took on the role of interim CEO in June. The hospital has 40 inpatient beds and 15 emergency department beds.
HealthLeaders spoke with Schmitt recently about a range of issues, including the challenges of serving as CMO of the hospital, balancing the roles of CMO and interim CEO, and lessons learned during the coronavirus pandemic. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of Providence Newberg Medical Center?
Amy Schmitt: Providence Newberg is a relatively small community hospital. We function at a much higher level than most hospitals our size. We have a relatively small medical staff, but we hold ourselves to the same quality standards and other aspirations of larger hospitals.
With a small medical staff, leadership is always a challenge because we have only a few capable and dedicated individuals who are willing to be leaders and to be tasked with multiple hats. You find someone who is really good, and you ask them to participate in many ways.
Another challenge is also related to our size. We are held to the same quality standards as other hospitals. We want to meet the infection ratios that the Centers for Disease Control and Prevention recommend, but because we don't see the volume of patients that larger hospitals see, many times our threshold for an acceptable infection rate is zero. For example, we may only be allowed 0.4 catheter-associated urinary tract infections, which essentially equates to zero infections. Zero is a difficult standard for us to hold ourselves to, but we do it. There is no margin for error for us in meeting quality standards.
HL: Do you characterize the communities you serve as rural?
Schmitt: We are not technically a rural hospital. We are about 25 miles outside of Portland. However, we have a rural population in that they like being outside of Portland, and they prefer not to go to Portland unless they absolutely have to go. So, we try to do what we can to meet the needs of our community at our hospital. We offer services that other hospitals our size would not typically offer.
HL: In addition to serving as CMO of the hospital, you have been serving as interim CEO. How are you balancing these roles?
Schmitt: It has been interesting. Since becoming interim CEO, I have been dedicating more of my time to the CEO role, which is new to me in many ways. Thankfully, I have been the CMO here for 10 years, so I have that piece down well and we do not have any medical staff upheavals at the moment. I have been able to pull some of my time from the CMO responsibility to take on new tasks.
There is some overlap between the roles. Previously, the CEO and I partnered on many of the contracts and medical staff engagements. Now, instead of the two of us working in those areas, it is just me.
The other piece is having a great team that has been able to fill in the gaps and to help bring me up to speed. We have a great executive team and administrative team as well as great managers in all our departments. They are largely self-sufficient, but they come together when they need support; and when I need support, they are right there to help me.
Amy Schmitt, MD, chief medical officer of Providence Newberg Medical Center. Photo courtesy of Providence health system.
HL: You served as CMO of the medical center during the coronavirus pandemic. What were your primary learnings from this experience?
Schmitt: It took healthcare to a new level of having to become more interdependent on our community. Healthcare used to be more siloed than it is now. We have learned to partner with other health systems and with our county health departments. To promote public health, it caused us to create lines of communication and collaboration that were weak before. We were able to learn best practices from each other, and we figured out how to navigate the pandemic together rather than each of us trying to go through it individually. It was good to see the connections with Oregon Health & Science University and Legacy Health as well as some of the other major healthcare providers in our area.
Another piece was the critical nature of being consistent both in our approach between hospitals and clinics as well as having constant communication about changes. What created more problems than anything was when one hospital may have done something differently and a patient was going back and forth between different health systems and getting mixed messages about the best ways things could be done. Coming together and deciding best practices was crucial.
Things changed rapidly with COVID, so what we said one week could change two or three weeks later based on expert advice or new data. We were constantly going back to our staff and trying to be transparent about what we knew and did not know. We would have to say that as new data comes forward and new studies are completed, we may have to revisit things and change the communication over time. Things that we were doing early in the pandemic changed over time, and it was a very fluid process.
HL: What is the approach to patient safety at the hospital?
Schmitt: We started a journey of high reliability in 2013. That journey started with trying to figure out how we could create an environment where patient safety was at the center of everything we did. When we started, the journey was reactive, and we tried to create psychological safety so that everyone within our walls felt comfortable raising safety concerns—whether you were an environmental services worker, a nurse, a provider, a technician, or other staff member. We wanted everyone to be able to say, "I'm concerned about this process because it may not be safe for our patients." Then, we wanted to be able to react to concerns and put corrective processes and systems solutions in place.
As we have developed our high-reliability efforts over time, we have tried to become more proactive to prevent situations that impact patient safety. Part of that is every decision, every change, and every new workflow is viewed through the patient safety lens.
We still want to have psychological safety, and we want to treat everybody with respect and dignity, so they feel comfortable raising concerns; but at the same time, we want to be proactive in looking at our processes and preventing people from getting into a situation where they have to report and speak up.
One of the ways we track our progress is by how many Datix reports we get. Datix is the system we use for anyone in the hospital to be able to speak up regarding an unusual event or something they feel is out of the ordinary. They can file an electronic report such as near misses or an error that reached a patient. We track those Datix events and categorize them as reaching the patient, causing any injury, or near misses. We want to see a high volume of Datix reports because that means people are comfortable reporting; and when we started our high reliability journey, we saw an increase in Datix reports. The goal over time is to decrease our safety events. Over time, we have seen a dramatic decrease in our serious safety events.
HL: What is the role of physicians in administrative leadership at the hospital?
Schmitt: This is my passion. We have physicians at all levels of leadership. Sometimes, physicians get shuffled around, and as one leaves a role, we pull them into another position because when you have a capable leader, you do not want to lose that expertise.
We have several layers of leadership. We have our department chairs, who work side-by-side with nurse managers in each department to make sure that their department is high functioning, has good quality standards, and they can meet patient care needs. For our medicine department, we have a medicine department chair paired with our med-surg nurse manager for surgical services. We have a surgery department chair. We have an OB/GYN chair. These chairs provide local expertise that is needed to develop processes and to make sure everything they are doing is up to date.
Each of the department chairs serves on our medical executive committee, which governs our medical staff. We nominate a president of the medical staff, who chairs the medical executive committee. Together, that group, with administration in attendance, makes decisions such as whether we have the right composition of our medical staff or whether we need to recruit new physicians or whether there are quality standards we need to rally around as a medical staff. If there are disciplinary actions that need to be taken, the medical executive committee is in charge of that process.
HL: You have a clinical background in internal medicine. How has this clinical background helped prepare you to serve in physician leadership roles such as CMO?
Schmitt: I strongly believe that all physicians are leaders whether they choose to embrace leadership or not. Just by the nature of their training and experience, physicians are natural team leaders whether it is in an office with medical assistants, an operating room with a surgical team, or another setting.
As I have gone through my training and career, I have been willing to embrace leadership. All physicians have opportunities to embrace leadership—it is a matter of who is willing to develop it.
The internal medicine training I received was an opportunity to be at the bedside. I have been a clinical hospitalist since 2005. Even as a CMO, I have maintained that hospitalist work. It gives me the perspective of what it is like at the bedside as well as what our physicians, nurses, and advanced practice providers are facing day in and day out, and how I can ease their way as a leader.