Health systems and hospitals can adopt effective strategies to address disruptions of patient sleep, mobility, nutrition, and mood.
Trauma of hospitalization such as disruptions in sleep, mobility, nutrition, and mood are associated with increased risk of readmission and ER visits after discharge, recent research shows.
Evidence is mounting that negative patient experiences during hospitalization can hinder rather than encourage recovery from illness. A 2013 study linked hospitalization to physiologic disturbances that make patients vulnerable to new or recurrent illnesses after discharge. In addition to patient suffering, readmissions and ER visits after discharge increase cost of care significantly.
This month in JAMA Internal Medicine, researchers found that a high degree of hospital disruption was associated with a 15.8% greater absolute risk of readmission or emergency department visits after discharge.
"The trauma of hospitalization, characterized by disturbances in sleep, mobility, nutrition, and mood, was common among medical inpatients and appeared to be associated with a markedly greater risk of 30-day readmission or ED visit," the researchers wrote.
The study featured 207 patients and focused on four metrics: sleep, mobility, nutrition, and mood. Patients who experienced disturbances in at least three of the metrics were categorized as high trauma. Nearly 30% of patients were listed in the high trauma category.
Trauma of hospitalization has multiple negative impacts on inpatients, the researchers wrote. For example, mobility disruption during hospitalization has been linked to loss of independence, persistent functional decline, and increased risk of readmission.
Easing trauma of hospitalization
The lead author of the research, Shail Rawal, MD, MPH, told HealthLeaders that there are effective strategies to address trauma of hospitalization, particularly if interventions target multiple sources of disruption.
"Our findings suggest that most people experience disturbances in more than one domain, and that the cumulative effect of disturbances has a greater impact on outcomes than disturbance in one domain alone. For this reason, we hypothesize that a multimodal approach to addressing disturbances in sleep, mobility, nutrition, and mood would be more effective than efforts targeting a single domain," said Rawal, a staff physician at Toronto Western Hospital in Canada.
Rawal, who is also an assistant professor in the Department of Medicine at University of Toronto, said there are interventions for all four of the hospital disruptions examined in her team's research.
Interventions to improve sleep in a hospital include reducing night-time alarms and other noise, dimming ambient light, and minimizing overnight disruptions such as unnecessary assessment of vital signs. There is also evidence to support the use of eye-masks, earplugs, white noise machines, and warm blankets.
Given that hospitalized patients often spend most of their time in bed or in their room, getting patients out of bed on a scheduled basis can reduce disturbances in mobility. Serving meals in a communal setting or organizing other ward-based activities for patients can also help improve mobility.
Disturbances in nutrition can be reduced by ensuring that patients are assessed by a dietician, minimizing interruptions to meals, and assisting patients who are unable to feed themselves. Patients can also be encouraged to bring in comforting food from home.
Interventions to improve mood in the hospital have not been well-studied but could center on efforts to reduce uncertainty. Interventions include providing patients with an orientation to the hospital, a daily schedule of activities, and a clear list of team members and their roles.
In NP, PA, and physician treatment of diabetes patients, no significant difference is found in three clinical measures.
Nurse practitioners and physician assistants are as well equipped to treat patients with chronic illnesses as physicians, recent research indicates.
The finding is a boost for advocates of deploying nurse practitioners (NPs) and physician assistants (PAs) to ease the country's physician shortage. The country is facing a projected shortfall as high as 104,000 physicians by 2030, according to a report by the Association of American Medical Colleges.
Research published last month in Annals of Internal Medicine found no significant clinical variation in care for treatment of diabetes by nurse practitioners, physician assistants, and physicians.
"In our study, we did not identify any clinically meaningful differences in commonly measured intermediate diabetes outcomes among patients with NP, PA, or physician primary care providers," the lead author of the research, George Jackson, PhD, MHA, of Durham VA Medical Center in Durham, North Carolina, told HealthLeaders this week.
The study featured 368,000 adult patients. The clinical measures examined were continuous and dichotomous control of hemoglobin A1c, systolic blood pressure, and low-density lipoprotein cholesterol.
"No clinically significant variation was found among the three primary care provider types with regard to diabetes outcomes, suggesting that similar chronic illness outcomes may be achieved by physicians, NPs, and PAs," Jackson and his colleagues wrote.
Diabetes has key characteristics that are similar to many other chronic illnesses, Jackson said.
"Diabetes represents an important indicator of care quality because it involves both complex medication management and helping patients learn to how to manage the illness themselves; for example, taking medicine as prescribed, changing diet, or getting more exercise," he said.
In the primary care setting, it appears ill-advised to place limits on the conditions that NPs and PAs treat, Jackson said.
"I would not say there are specific conditions that per se should or should not be cared for by specific types of primary care providers. Like all clinicians, primary care providers consider specific patient circumstances when deciding which other clinicians should be included as part of the care team or consulted when addressing patient needs," he said.
An editorial accompanying the Jackson team's research calls for giving NPs and PAs a higher degree of respect.
"It is time to stop calling NPs and PAs 'midlevel' providers, as is common in certain systems. Nurse practitioners and PAs are competent primary care providers in their own right and should be fully accepted as such," the editorial says.
Several steps are required to accelerate home care safety, including a commitment to self-determination and fostering a safety culture.
Initiatives to improve home care safety are far behind safety efforts in the hospital setting, according to a presentation at this week's IHI National Forum.
There are several sources of potential patient harm in the home, including adverse medication events, fall hazards, injuries related to medical equipment such as oxygen fires, infections, and medical conditions linked to poor nutrition. For health systems and hospitals, home hazards can lead to costly readmissions, and accountable care organizations face higher costs of care.
"Safety culture is a concept in hospitals," said Alice Bonner, PhD, RN, secretary of the Massachusetts Executive Office of Elder Affairs, and a presenter at the IHI National Forum session "Advancing Safe Care in the Home Setting."
"It's a culture where people can learn when errors happen in order to prevent serious harm and people can look at data to continuously learn from each other. We have learned this in hospitals pretty well; but in home care, this is a new concept," she said.
Bonner presented five principles and related recommendations to improve home care safety that are featured in a recent IHI report.
1. Self-determination and person-centered care
Many people such as the disabled do not view themselves as patients in their home. Honoring self-determination in the home balances autonomy with risk mitigation. A person-centered approach is broader than patient-centered care, accounting for family members, all caregivers, and the support that care recipients need to be active participants in their care.
For care workers, a benevolent communication style is crucial to advancing safety in the home, Bonner said. "It means asking questions and sitting down with someone and trying to breakdown an us versus them dichotomy. You need to say, 'I'm here to help you reach your goals. I need to get to know you. I need to understand you. I need to know what is most important to you.' "
Meaningful and relevant educational tools should be provided to home care recipients such as one-page information sheets about safety risks.
Tools and strategies to provide person-centered care should be employed, including a standardized assessment of the care recipient's needs that is based on the recipient's values and accessible to all caregivers.
2. Safety culture
Safety in the home requires an overarching commitment to safety from all organizations and individuals involved in the effort. "There are not just physical but also emotional and psychological aspects of safe care in the home for the care recipient, the home care workers, and family members. It's not just the caregiver burden," Bonner said.
Home care organizations and workers should create a safety culture vision such as discussing safety risks during every encounter with the care recipient and family members.
The emotional and physical safety of family caregivers and home care workers should be a top concern.
3. Learning and improvement
Developing a learning system is essential to improving home care safety. A learning system features leadership, transparency, reliability, measurement, improvement, and continuous learning. For example, widely sharing safety data and best practices across multiple healthcare organizations can significantly improve care recipient safety.
To support a learning system, build a measurement and reporting infrastructure such as population-based studies to determine the prevalence and types of harm. At least initially, measurement sets that gauge harm can be simple and easy to adopt.
Sharing data on home care safety requires creating a culture and expectation of transparency such as encouraging voluntary reporting of medical errors in the home.
Safety and improvement skills should be taught to all care workers and caregivers including simulation courses.
Intensive improvement collaboratives on risks such as adverse medication events should be created for early adopter organizations, with lessons learned widely distributed to partners.
4. Care coordination
Home care workers cannot function effectively in a vacuum, and they should have a coordinated team that includes supervision, management, and accountability. Team-based care is crucial to avoid medical errors, particularly during transitions of care.
The care recipient should have a care plan that is accessible to all healthcare providers, home care workers, and family caregivers.
Foster team-based care such as striving for consistent home care worker staffing that builds a strong relationship with the care recipient.
Promote the use of community-based services and underutilized resources such as behavioral health and firefighters.
Electronic medical records and other technology assets can boost care coordination.
5. Policies and payment models
Home care providers face a challenge from policies and payment models that fragment care in the home setting such as Medicaid waivers that only cover certain services.
Home care providers should encourage the Centers for Medicare & Medicaid Services and commercial payers to test new payment models such as financing through community-based organizations.
Lobbying for reforms should also focus on reduction of regulatory burden.
Partnership with Miami-based company features high-intensity primary care with capitated financing model.
OhioHealth is teaming up with a senior primary care company to open three new clinics next year that will serve low- to moderate-income seniors in Columbus.
Medical care is costliest for Americans over age 65, research shows. For example, medical expenses more than double between the ages of 70 and 90. In 2010, medical spending for people over 65 accounted for one-third of U.S. medical expenditures.
OhioHealth is opening senior primary care clinics as a high-impact starting point in a broader strategy to tailor care offerings to specific classes of patients, says Michael Krouse, senior vice president, and chief strategy and transformation officer, at OhioHealth.
"We have chosen to start in the senior arena because they are driving the majority of the dollar spend in healthcare. They are older, less healthy, often underserved, and driving about 80% of healthcare costs. To disrupt and have an impact, this is the best place to start," Krouse says.
The new clinics will be sited in neighborhoods that are underserved by primary care providers, he says. "The bottom line is serving as many people in our community as we possibly can, with an eye toward minimizing total cost and an eye toward maximizing access. This model fits very well with that mission."
Capitation and high-touch care
OhioHealth's new partner is Miami-based ChenMed, a senior primary care company that is teaming up with a health system for the first time. By next year, ChenMed will be operating more than 60 clinics in eight states.
ChenMed clinics, including the OhioHealth practices set to open in Columbus, are high-touch facilities that operate under a capitated financing model, says Gaurov Dayal, MD, president of new markets and chief growth officer for ChenMed.
"The capitated payment per member per month is much higher than what we would receive in a fee-for-service model. On the other hand, the expenses are much higher," Dayal says.
"Out of our own budget, we pay for hospitalizations. One admission for a patient might cost $10,000, which is higher than the annual premium we receive. However, if we can keep patients healthy by providing them with very good preventative care and great access so they don't go to the emergency room, those savings accrue to us. When you start spreading those savings over seven or eight states, you have an actuarial risk pool with significantly lower total costs," he says.
There are several elements of ChenMed's high-touch approach to senior care.
Patient panels cap out at 400 as opposed to patient panels at traditional primary care practices, which can be higher than 2,500 per physician
Onsite specialty visits such as cardiologists
Transportation services
Onsite pharmacy and radiology services
"We see our patients often and manage them very closely. On average, our doctors see their patients once a month, which is about 10 times more than the average primary care physician," Dayal says.
The frequency of the interactions elevates the clinical care, Krouse says.
"If you have a patient who has many complex conditions, the best way to provide clinical care is to talk with them and work with them on a regular basis. If they are not filling their prescriptions, or they are not showing up where you need them to be, you can intervene far more easily if you are seeing them regularly," he says.
The ChenMed model's frequency and intensity of care generates positive outcomes, recent research shows. Data published in American Journal of Managed Care include about a 50% reduction in hospitalization, 33% reduction in emergency room utilization, and 28% reduction in costs.
Serving the underserved
Krouse says neighborhoods that are "deserts of primary care" are an opportunity for OhioHealth to improve population health and lower total cost of care.
"They are clearly in underserved areas because the traditional healthcare model doesn't bode well for establishing a new practice in those communities and meeting the desire of physicians to make revenue. We are targeting these communities because when you take the long-term view of an unhealthy life and a desert of primary care, patients go to the emergency room, they go to the hospitals, they go to places that are available to them. Those are clearly the most expensive places to seek out care," he says.
The ChenMed model for senior primary care clinics in underserved neighborhoods has the potential for national scale, Dayal says.
"The need for this model exists in every city. There are underserved seniors in practically every part of the country. There's a lot we can do for these patients nationally, and we are looking forward to working with more health systems."
For patients with multiple morbidities, multidisciplinary care team meetings can develop valuable approaches to effective treatment.
Having complex care conferences in the primary care setting for high-risk patients can boost care coordination and collaboration, a clinical leader from Providence Health and Services said at this week's IHI National Forum.
High-risk patients with multiple morbidities pose daunting challenges for health systems, hospitals, and physician practices, which often struggle to adequately manage patients with multiple health conditions, leading to high mortality rates, increased costs, and other negative outcomes.
At Providence, complex care conferences at primary care practices are fostering a team-based approach to treatment, Vanessa Casillas, PsyD, director of psychology at the Renton, Washington-based health system, told HealthLeaders after her forum presentation.
"One of the top reasons for complex care conferences is that the more intense the needs a patient has the more people who tend to be involved in the care. This is about coordinating and collaborating," she said.
The primary result of a complex care conference is a care plan that identifies two to four salient items such as medication adherence for care team members to focus upon.
"Care conferences help determine what we should be doing. We may decide to let some goals fall away in the short-term because they don't make sense. We want to get the patient engaged without overwhelming them," Casillas said.
During her forum presentation, she said there are four essential elements of effective complex care conferences.
1. Stratifying patient risk
To determine which patients could benefit from complex care conferences, Providence risk stratifies patients into four cohorts: very intense, intense, moderate, and low.
Providence developed its own computerized risk stratification algorithm that includes emergency room visits, hospital admissions, high-risk medications, and behavioral health diagnoses.
Care teams validate the computerized risk stratification. For example, some patients who are categorized as very intense risk could be shifted to a lower-risk tier if their comorbidities are managed well.
2. Preparing for complex care conferences
Casillas says "pre-work" for a conference helps identify which very intense risk patients are appropriate for a team meeting and ensures meaningful use of time.
Advance preparation should include a determination of why a conference would likely generate a valuable discussion.
Pre-work should include determining a patient's status and whether the patient has shared treatment goals with staff.
Barriers to care such as social determinants of health, physical barriers, and financial barriers should be identified.
The patient's support system should be evaluated to see whether there are people actively involved in their day-to-day life who could help the care team.
3. Conducting complex care conferences
Anyone who is actively involved in a patient's care can participate in a conference, including primary care physicians, embedded case managers, embedded behavioral health providers, embedded pharmacists, nurses, and clinic managers. Offsite healthcare staff such as ER physicians can attend in person or via a teleconference connection.
The conference should have a facilitator, who does not necessarily have to be a primary care physician. In most cases, the best facilitator is the person who knows the patient best.
The conference should be documented, including a list of attendees.
The electronic health record should be available to review if necessary.
Every discipline at the conference adds value, so each person in attendance should have an opportunity to contribute to the discussion.
Action items should be identified and assigned to care team members.
4. Following up after complex care conferences
After a conference is held, follow-up work is crucial to ensure time has been well spent and the patient's care plan is executed and widely distributed.
Document the care plan in the patient's chart.
Communicate the care plan to all care team members, particularly staff who were unable to attend the conference.
Distribute the care plan to all related care settings such as emergency departments.
Schedule a visit for the patient to review the care plan, with adequate time for the patient to ask questions.
Develop contingencies in case the care is unsuccessful or unanticipated barriers to care are encountered.
The physician executive's goals for the CMO role include fostering a high-reliability approach to care and using artificial intelligence to reduce medical errors.
Eric Eskioglu, MD, the newly appointed executive vice president and chief medical officer at Novant Health in Winston-Salem, North Carolina, says his main focus in his new role is reducing patient harm and using artificial intelligence to do it. His solution can be correlated to his background as an aerospace engineer.
Eskioglu worked on fluid dynamics models in the aerospace industry, focusing on jet engines and how they interface with airplanes before he became a vascular neurosurgeon.
“That was my transition to medicine—working with fluid dynamics models and turbulence from jet engines and now looking at the blood vessels in the brain. It's all dynamics—whether it be gas or liquid," he says.
Eskioglu's aviation engineering career included working at Boeing in Seattle. He began his neurosurgical career at Vanderbilt University Medical School, where he was an assistant professor of neurological surgery.
He joined Novant in 2015 and expanded the health system's neurosciences program from 35 to 82 providers.
HealthLeaders recently spoke with Eskioglu, who officially began his CMO role in October, to find out about his leadership goals. Following is a lightly edited transcript of that conversation.
HL: What are your primary goals in the CMO role?
Eskioglu: Most CMO roles are traditional. They keep up with the regulatory environment, and they make sure the medical staff works well. Obviously, I have to maintain those parts of the CMO role, but I want to reinvent the role at Novant Health.
We want to get into strategy—how we build strategy for the clinical team and enable people to think about artificial intelligence. Because of my engineering background, I am extremely interested in AI. Medical knowledge doubles rapidly and the doubling is accelerating—our doctors are going to have a huge issue coping with this avalanche of knowledge, but we don't have the gift of time. Everybody talks about physician burnout—that's one of the reasons. We are getting so much data where we just can't cope with it.
My goal with AI is to work with the technology leaders—it could be Microsoft, it could be Google, it could be Apple—and team up to automate some of our processes with not only machine learning but also artificial neural networks. I want to be able to give back the gift of time to physicians, so we can lessen physician burnout, which will help us improve quality and efficiency as well as cut costs.
HL: How can AI have an impact in clinical care?
Eskioglu: One of my biggest goals in the CMO role is predicting which hospitalized patients are going to get sick before they get sick. Once they get sick, you can't turn back the hands of time.
We get so much data from our EMRs, but we don't use that data efficiently. We don't know what to do with that data. That's where artificial intelligence with machine learning can help. Using algorithms, we can see a chest x-ray does not look good or fevers are going up. Then, looking at past medical history we can see when patients got infected before and know that they are at risk. Doctors can then be alerted to look closely at these patients.
That kind of approach will sharpen our clinical expertise and reduce clinical errors. Nationwide, about a third of our medical care involves clinical errors. That's a huge amount of money we lose every year and a huge amount of patient suffering. We want to end that suffering. Patients come here to get well, but about a third of them get sicker because of what we do. That's not just at Novant—that's everywhere.
HL: What constitutes a good physician leader?
Eskioglu: The physician leader is a constantly evolving role. There are many challenges—governmental, clinical, and personality.
The biggest thing I have learned over the years as a physician executive is you have to listen more than you talk. That's tough for physicians—when you go to a doctor's office, who does most of the talking? It's the doctor, not the patient.
Another part of physician leadership is being collaborative. At medical school, we are taught to be the captain of the ship; but when you are a physician executive, you can't go it alone. You need to collaborate with different parts of the organization—whether it be your HR counterparts, your IT counterparts, or your chief nursing officer.
HL: What are the biggest opportunities for quality of care improvement at Novant?
Eskioglu: Our focus as a team is going to be zero tolerance for hospital-acquired infections, for serious safety events, and for any kind of harm we can do to patients while they are in the hospital. It's going to take some discipline and a methodical approach. I do not have a magic wand that I can wave and achieve change overnight.
This is our biggest focus now, and we will be teaming up with our digital chief executive. We are excited about bringing artificial intelligence to this effort and being able to use billions and billions of data to reduce errors.
I get told that it can't be done. I hate that phrase. It can be done. It's been done in the aerospace industry and we definitely can reduce errors in the healthcare industry.
We also are going to look at the quality of all physicians. Today, you can look for a car and see which car is best, but you can't do that for physicians. Patients don't have a good way to look at physicians.
We want to get a better handle on how we can improve the quality of our physicians and how we can lower costs. When my surgeons operate, they have no idea about what their surgery cost. When they get out of the operating room, our goal is to give them a receipt that quotes their charges, how much the total operation cost, the amount of time they spent, how they compare with their peers within Novant, and how they compare with their peers outside Novant.
We want to be transparent with our physicians. That should improve what we do tremendously.
Effective management of quality improvement initiatives includes leadership, teamwork, planning, and pace setting.
The Institute for Healthcare Improvement has developed a QI Project Management Tool to help health systems and other healthcare organizations implement quality improvement initiatives.
As healthcare organizations seek out greater efficiency and shift their business models from volume to value, quality improvement project management has become an essential capability in operational areas ranging from clinical care to finance to innovation.
The IHI officials who led the effort to create the QI Project Management Tool—Executive Director Karen Baldoza, MSW, and Head of Operation Excellence Christina Gunther-Murphy, MBA—say there are several qualities of successful project team leaders.
Successful team leaders can manage a project such as identifying needed processes and developing workplans, and they can facilitate meetings and conversations, Baldoza and Gunther-Murphy told HealthLeaders this week via email.
They said successful team leaders are also good communicators; adept at bringing out the best in people; committed to subordinates, customers, and results; and willing to take risks.
The core team members of a successful quality improvement project possess a similar set of qualities, Baldoza and Gunther-Murphy said.
"A successful core team represents the key perspectives of the area targeted for improvement and has both process and subject matter expertise; has created a culture of trust and psychological safety where team members can bring their whole-self and contribute thoughts, ideas, experience, and constructive skepticism; is made up of ambassadors for the work; and is action-oriented and willing to try."
The QI Project Management Tool has five elements—each with ideas for project leaders to try.
1. Frontload the work
Planning at the beginning of a project such as gathering baseline data and organizing the project team increases the likelihood of success.
Hold a project kickoff event with planning activities
Establish a checklist of tasks to show the team progress
Set a pause date in case early project milestones are not met
2. Build the project team
Successful quality improvement project teams have the right people doing the right work in the right roles with the right team culture.
Ensure the right people are on the team, or consider changing the project's scope to have better alignment with goals and staffing
Engage the project's sponsor to help push the team beyond the status quo
Get experienced staff members to share past quality improvement efforts that can help the team predict whether initiatives will be successful
3. Set the pace
Maintaining momentum for quality improvement projects requires a time-limited work plan with milestones.
Ensure the project has start dates and end dates
Seize opportunities to quicken the pace such as holding huddles instead of full-fledged meetings
Make sure time is used purposefully to meet project goals
4. Make the project easy
Quality improvement work should be easy, efficient, meaningful, and fun for the team. The beginning of a project should feature learning to propel progress.
Use a standard agenda to keep meetings short
Make team meetings fun and meaningful such as sharing stories about the project's impact
Remain curious and willing to change course
5. Start with the end in mind
Projects should be designed with built-in capabilities for scale growth and sustainability.
Staff who will be involved with an initiative over the long-term should be involved in a project from the onset
Venues should be found where compelling stories about a project can be told
Staff who will be involved in the scaling up of a project should shadow the initiative
Firearm Safety Check features screening for the presence of guns in the home, counseling about safe firearms storage, and distribution of free gun locks.
Firearm safety programs in pediatric primary care such as screening for the presence of guns in the home can serve as an effective youth suicide prevention strategy, recent research indicates.
Suicide is the second leading cause of death for people 10 to 24 years old, and guns are the most common means of these deaths, according to the Centers for Disease Control and Prevention. There is an opportunity to curb youth suicide in the primary care setting—more than three-quarters of youths who commit suicide visit pediatric primary care in the year before their deaths.
Firearm Safety Check—a program that features screening for the presence of guns in the home, counseling about safe firearm storage, and distribution of free firearm locks—can be deployed in pediatric primary care and save lives, researchers wrote recently in Journal of the American Medical Association.
The proposal does not run counter to the National Rifle Association's recent call for physicians to abstain from participating in debates about gun policy, a co-author of the JAMA research told HealthLeaders this week.
"We can all agree to a shared agenda on saving kids' lives. To move the needle on this public health crisis, we need to partner and take multiple approaches toward promoting firearm safety. That includes firearm owners and experts, healthcare clinicians, parents, and other community members. I see Firearm Safety Check as one approach to moving the needle," said Rinad Beidas, PhD, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
Stakeholder views
The research team interviewed 58 stakeholders, including parents, physicians, nurses and nurse practitioners, leaders of pediatric primary care practices, behavioral health staff, health system leaders, and payers. The stakeholders, who included gun owners, said firearm safety should be a health system priority.
The stakeholders said most patients and families would have a positive view of Firearm Safety Check
The patients served by the two health systems that participated in the research featured both inner city youth who had firearms in the home for protection as well as suburban and rural youth who had firearms in the home for hunting and recreation
Stakeholders said inner city families could be more receptive to Firearm Safety Check because of the free provision of safety locks
Many stakeholders said U.S. gun culture could impact implementation of Firearm Safety Check, with some families feeling gun ownership screening violates their Second Amendment rights
Implementation strategies
In general, stakeholders suggested implementing Firearm Safety Check in pediatric primary care with medical assistants and nurses screening patients for gun ownership and distributing locks, and physicians counseling gun safety during wellness visits.
Clinician stakeholders had mixed views on Firearm Safety Check implementation, the researchers wrote. "Some clinicians stated they lacked expertise around firearm locks and wanted additional training. While many clinicians said that it was important and within their scope of practice to facilitate conversations about firearms, some reported feeling uncomfortable."
The stakeholders identified six primary implementation strategies.
Stakeholders said Firearm Safety Check should be launched across entire health systems with the support of system leadership to ensure key implementation elements such as funding for gun locks
Screening for gun ownership was called feasible, and stakeholders suggested screening should be brief, done during wellness visits, and incorporated with other screening questions such as bike helmet usage
Clinicians said counseling about safe gun storage would be feasible if the interaction lasted less than 1 minute
Stakeholders said distribution of gun locks was the most problematic element of Firearm Safety Check, with concerns such as financing of free gun locks and clinician apprehension about teaching proper use of the devices
Stakeholders called for integrating Firearm Safety Check into health system EMRs to trigger reminders about screening and for ongoing monitoring
Staff training was recommended to ensure effective management of Firearm Safety Check, with education sessions set for standard sessions such as monthly clinical meetings
Health systems should explore partnerships and other creative approaches to launching and sustaining Firearm Safety Check, the researchers wrote.
"Additional implementation strategies identified included a policy mandate and exploring creative financing. These included partnering with local police, gun shops, and/or firearm safety programs, applying for grants, and working with private payers and insurers to cover the cost of locks."
In the effort to improve quality and save money, IU Health is creating service line-based clinical councils to tap into the problem-solving power of its medical staff.
The Indianapolis-based health system is seeing promising results, in both identifying workable solutions and engaging physicians along the way. The tactic could catch on, especially as systems across the country respond to the industry's business model shifting from volume to value.
Since last year, IU Health has formed 18 clinical councils to identify and pursue value opportunities in areas such as information services, pharmacy, and supplies. Service lines picked for clinical councils include cardiovascular surgery, cardiology, orthopedics, neurosurgery, neurology, medical oncology, emergency medicine, palliative care, and general surgery.
The clinical councils are physician-led, with members selected by IU Health regional presidents and chief medical officers.
"We tell the presidents and CMOs that we are interested in people who are actively practicing in the specialty and who are considered thought leaders in their region. Often, it is somebody who is a medical director or leader by title, but it doesn't have to be that way," says Chris Weaver, MD, MBA, senior vice president of clinical effectiveness at IU Health. "We really want someone who is a thought leader—someone others will follow."
The primary duties of the clinical councils are improving quality through eliminating variation in care and seeking opportunities to lower costs.
"When it comes to variation from region to region and provider to provider, we are able to dig into the data and the processes and see whether there are opportunities to bring everybody up to the best performer," he says.
The clinical councils are well-positioned to root out cost savings at the provider level, Weaver said. "Differences in costs are often something the provider is unaware of. They may be using a supply that costs $500 more than everybody else."
He says the clinical councils, which meet quarterly or every other month, have generated several "wins" over the past year:
Pharmacy: Clinical council initiatives have saved more than $7 million in inpatient pharmacy costs year-over-year. The percentage of patients discharged from emergency departments across the system with a narcotic decreased from 14.5% to 8.3%.
Supply chain: Preferred-vendor contracting saved $3.5 million annually. Contracting changes lowered the cost for total hip and knee replacement procedures.
Information services: Order sets guidelines have been reduced by 651 from a total of about 3,500 to decrease care variation. The percentage of EMR transactions that take more than 5 seconds has been reduced by more than 50%, easing user burden on clinicians.
IU Health has taken five primary steps to form its clinical councils and put them to work.
1. Borrow from other health systems
Before launching its clinical councils, IU Health found two other health systems that were pursuing similar concepts: Phoenix-based Banner Health and Vanderbilt University Medical Center in Tennessee.
"Banner Health has care collaboratives, where they bring providers in their regions together. They really focus on information services like care pathways and order sets. We took their idea and broadened the scope to areas like pharmacy and quality work," Weaver says. "Vanderbilt has a similar idea that we have tweaked and made it a much broader approach."
2. Roll out strategically
IU Health started its clinical council initiative with the health system's top service lines.
"We wanted to start with those councils to make sure that they had support and direction at the system level. So we started with cardiovascular surgery, cardiology, orthopedics, neurosurgery, neurology, and oncology. Then, when we had big initiatives that we knew we wanted to drive across the system, we would organize a council," Weaver says.
There are three strategies to form a clinical council and guide a new council, he says.
First, when clinical councils are organized, members are asked to identify opportunities where they see practice varying or where they see variation in quality or cost from place to place or provider to provider.
Second, the health system uses Vizient data to benchmark externally and identify opportunities in either quality or cost for supplies and drugs. If significant opportunities are found, it prompts formation of a new council.
Third, physician leaders have sometimes prompted IU Health to form a clinical council. When providers push initiatives to improve quality or reduce costs, a clinical council can start with "buy-in that we need," Weaver says.
3. Select council members purposefully
The clinical councils exemplify how IU Health has embraced and elevated physician leadership, Weaver says.
"Our leadership at the highest level is saying, 'Instead of us sitting in offices making decisions for physician practices or the whole system, we believe in the experts providing care to patients making these decisions,' " Weaver says. "The one caveat is they have to make decisions; otherwise, someone will come along and make decisions for them."
4. Prepare to tackle tough issues
Clinical councils must be ready to confront resistance to change, Weaver says.
Making changes in supply chain such as reducing 10 vendors to two for implants can be controversial. "Some providers can be adamant about practicing under those guidelines, but the clinical council can get involved along with the regional leadership to have a conversation about why there are quality benefits," he says.
5. Capitalize on physician engagement
IU Health's clinical councils have successfully heightened physician engagement despite challenging circumstances, Weaver says.
"It's not an easy environment for providers these days, with all of the changes in healthcare. So, engagement and satisfaction are more and more of a struggle," he says.
The clinical councils are a genuine attempt to enlist physicians in significant decision-making, and they appreciate the effort, Weaver says.
"As decisions are being made, we are putting them in providers' hands, so they don't feel like changes are happening to them," he says.
A recent survey of healthcare providers on the clinical councils found a 90% attendance rate and 85% of members indicating the highest level of satisfaction, Weaver adds.
"They felt the health system was listening to them."
Selection of a surrogate for end-of-life decisions is just the starting point for effective advance care planning.
Patients' end-of-life surrogates are overly confident in their readiness to make crucial decisions for their loved ones, recent research shows.
Ill-prepared surrogates at the end of life are a vexing challenge for health systems and hospitals, with care teams often facing a heart-wrenching struggle to determine appropriate care plans in the absence of clear direction. Several studies have shown that surrogates are not well-acquainted with patient preferences, but patients believe that their loved ones already know their wishes.
The lack of surrogate knowledge takes a heavy toll on loved ones when life-or-death decisions arise, researchers wrote recently in JAMA Internal Medicine. "Substantial proportions of surrogate decision makers who have made end-of-life decisions experience burden, expressing stress, guilt, and doubts about having made the right decision."
The researchers focused on decisions related to three health states that could result from treatment of serious conditions: physical disability, cognitive disability, and severe pain. The health states were rated as acceptable or unacceptable by 349 patients and their surrogates.
Although 75% of surrogates said they were extremely confident of their loved ones' wishes, only 21% of surrogates knew the patients' ratings for all three health states.
"Surrogates' confidence in their ability to make treatment decisions based on knowledge of patients' ratings of the acceptability of health states resulting from treatment of serious illness far exceeded and was not associated with their actual knowledge of these ratings," the researchers wrote.
The determination is consistent with the results of an earlier study, which found 79% of surrogates rated themselves as confident or very confident, but only 35% knew their loved ones' wishes.
Preparing surrogates
The lead author of the research told HealthLeaders that health systems and hospitals can help prepare surrogates for end-of-life decisions.
"The first essential step is for these organizations to recognize the need to include surrogates in the process of advance care planning. Without this recognition, if any planning happens at all, it is done only with the patient. Unfortunately, healthcare organizations can think their work is done when the patient formally names a surrogate," said Terri Fried, MD, of the VA Connecticut Healthcare System in West Haven, Connecticut.
Once surrogates have been included in advance care planning, programs and tools can facilitate conversations about end-of-life care, she said.
"Respecting Choices is an intensive program utilizing a specially trained facilitator to conduct conversations with patients and their surrogates. Because it requires the commitment of resources, it is probably best suited for patients with advanced illness and a high likelihood of needing a surrogate decision maker in the near future," Fried said.
