The management association presents survey data that highlights the best practices of the best medical groups.
Among physician practices, better performers excel in three primary areas: strategy, operations, and culture, according to a new report from the Medical Group Management Association (MGMA).
MGMA released its "Winning Strategies from Top Medical Groups" report this week during the organization's annual conference in Boston. The report is based on data collected from more than 2,900 medical groups.
In addition to the common themes of exceptional strategy, operations, and culture, top performing medical groups have an enlightened approach to investment, the report says.
"While better performers have lower costs in some areas, their total expenses are often higher. They invest in good people, good technology and good systems—and then they maximize the return on those investments, achieving lower operating costs as a percent of revenue," the report says.
This week, MGMA President and CEO Halee Fisher-Wright, MD, told HealthLeaders that top performing medical groups are methodical when investing in their organizations.
"We have found that better performers are systematic about improvement and continually invest time and effort in new resources while maximizing the tools and information already available to them. The decision on what to invest in is directly tied to what the practice identifies as organizational goals. They only invest in those items that allow them to make significant progress toward those goals," she said.
Strategy
Top performing medical groups can overcome "an overwhelmed, in-the-weeds mentality" by focusing continuously on strategic progress, the report says.
Fisher-Wright said planning and monitoring are essential for successful strategies.
"Identify what is important to the practice—more time, more revenue, better culture—then set goals. Those goals are your strategic outcomes. It is crucial to regularly monitor performance against your strategic plan or budget, and plan on making changes as necessary. We recommend checking in at least monthly. Better performing organizations understand that lasting progress first starts with clear, focused efforts and investing in tools to accompany the vision," she said.
The report identifies 11 successful approaches to strategy:
1. Establish metrics and goals to maintain performance and accountability
3. Review vendor contracts for cost, value and strategic alignment
4. Invest in appropriate technology
5. Assess costs and reduce them when possible
6. Revise systems and processes that support the organization, particularly revenue cycle, billing, and collections
7. Increase patient access and engagement with cross-departmental strategies
8. Develop and implement standard work
9. Tie incentives to goals
10. Adjust schedules, operating hours and staffing to achieve goals
11. Focus on efficiently reporting key metrics, then benchmark metrics to identify new strategic opportunities
Operations
Similarly to successful investment strategies, top performing medical groups take a methodical approach to operational improvements.
"Better performers are systematic about improvement—they invest time in the effort, they invest resources, and they maximize the tools and information available to them," the report says
Better performers reported three top areas for improvement efforts:
Better performers reported three top technology investments:
New or upgraded EHR systems to support better patient communication, better provider experience, and efficiency
Electronic communication systems such as secure text messaging platforms for use between providers and secure file transfer systems to reduce faxing
Upgraded billing and coding software as well as revenue cycle management systems
Culture
Top performing medical groups focus on patient and staff engagement as well as a patient-focused culture, the report says.
"One example is how they approach provider and staff satisfaction surveys. It probably won’t come as a surprise to learn that better performers are more likely to conduct them," the report says.
Better performers had a higher likelihood of conducting surveys to measure satisfaction metrics:
90.4% of top performing medical groups conducted employee satisfaction surveys compared to 79.8% of all medical groups
87.3% of top performing medical groups conducted provider satisfaction surveys compared to 74.9% of all medical groups
It is important for practice leaders model behavior and values to foster a patient-centered culture, Fisher-Wright said.
"Inclusiveness and transparency are keys to success in any organization. Including the main stakeholders on creating and sharing goals and results with everyone within the organization—even with the board of directors—allows the entire staff to collaborate and create positive progress and improvement," she said.
Medicare-eligible people living in housing with supportive services use less hospital services, new research shows.
Evidence is mounting that housing is a highly significant factor in population health.
A study released this week found that Medicare-eligible residents of housing with supportive services had lower hospital utilization than a comparable group of seniors living in housing without supportive services.
Michael Gusmano, PhD, the lead author of the research and an associate professor of health policy at Rutgers University in New Brunswick, New Jersey, says the utilization finding is the key takeaway of the study.
"Our research supports the hypothesis that stable housing with supportive services can reduce the use of expensive medical care. In particular, it can have a significant effect on hospitalizations for ambulatory care sensitive conditions because social work staff are able to identify people who require community-based services and facilitate their use," he told HealthLeaders last week.
The researchers studied 1,248 Medicare beneficiaries in a housing program operated by Selfhelp Community Services in New York City. In the same zip codes, 15,947 other Medicare beneficiaries who did not live in housing with supportive services functioned as the study's control group.
Supportive services included psychological assessments, counseling and advocacy, health education, wellness programs, socialization, referral to public benefits and entitlements, and educational programs to control chronic disease. The housing also had technology features such as telehealth systems for checking vital signs and a virtual senior center.
Three primary findings demonstrated healthcare utilization benefits of living in housing with supportive services:
Hospital utilization was measured by discharge rate. The researchers found the hospital discharge rate for the intervention group was 32% lower than the control group.
Hospital length-of-stay was one day shorter for the intervention group.
The rate of hospital discharges for ambulatory care sensitive conditions was 30% lower for the intervention group.
Earlier research has shown that tying affordable housing to supportive services allows the elderly to remain in their homes as they age with an improved ability to access healthcare and social services.
How healthcare providers can invest in housing
Government programs and community partnerships are being established to help health systems and hospitals invest in housing, Gusmano says.
"There are now 13 states with Delivery System Reform Incentive Payment waivers, which are designed to encourage hospitals to address social and economic determinants of health and healthcare services and reduce avoidable hospitalizations. Several other states have or are pursuing waivers to use Medicaid money to facilitate housing services for people who are homeless or at risk of homelessness," he says.
Partnerships between housing organizations and healthcare providers can address social determinants of health such as housing, Gusmano says. "Encouraging hospitals to work with community partners for the purpose of addressing the housing needs of their patients is consistent with that goal."
For health systems and hospitals, investing in housing is a component of the shift to value-based care, he says.
"Although hospital bottom lines may still be helped when patients use more hospital services, efforts to develop and implement 'value-based' payments are trying to change these incentives. If these efforts are successful, hospitals will need to understand and address the social factors that lead to avoiding the use of hospital services."
While conceding more research is needed, physician wellness advocates say there are compelling justifications to move ahead with burnout interventions.
Physician burnout contrarians are drawing a skeptical response from physician wellness advocates.
On Sept. 18, a JAMAeditorial claimed there is insufficient data about physician burnout to guide an effective response to the phenomenon.
"The term burnout has taken on meaning far beyond what is understood about it as an actual diagnosis or even a syndrome. The medical profession has taken a self-reported complaint of unhappiness and dissatisfaction and turned it into a call for action on what is claimed to be a national epidemic," the editorial says.
Jonathan Ripp, MD, MPH, senior associate dean for well-being and resilience at the Icahn School of Medicine at Mount Sinai, says the editorial has prompted reflection among physician wellness advocates.
"This editorial has had some reverberations in the community of individuals who are trying to take on and address the issue of well-being. … There are a number of things the editorial rightfully draws attention to. There is a lot of uncertainty about the best instrument to use to measure the well-being of physicians," Ripp says.
However, there is justified urgency to act, he says.
"There is a lot of suffering in our profession; and in some ways, to harp on the term that is used to describe the suffering or to focus on what measure you use lets the suffering continue without possible interventions that could help physicians."
Contrarian view
This week, a co-author of the editorial told HealthLeaders that terminology matters.
"We know that the general level of physician dissatisfaction and work misery seems to have increased, and physicians are certainly more vocal about their misery, with many suggestions for the source of that dissatisfaction. But labeling this as burnout implies a level of specificity and understanding of a defined clinical entity that I think is not justified," said Thomas Schwenk, MD, professor of family medicine and dean of the school of medicine at the University of Nevada in Reno.
Focusing on physician burnout, which is a relatively new diagnosis, could be dangerously misguided, Schwenk said.
"What is more important to note is the high level of depression as a criterion-based diagnosis, with a more clear understanding of pathophysiology and consequences including student, resident, and physician suicide. This would be a more worthy area of focus. It is possible that the use of the term 'burnout' has increased as a sort of more acceptable substitute for a diagnosis that still carries considerable stigma, namely depression," he said.
Schwenk singled out one intervention as problematic.
"I have particular concern about much of the attention on building resilience in students and physicians, as if we are simply not tough enough in a difficult world. Practicing medicine has always been exhausting, exhilarating, and demanding, but physicians never talked about burnout because they felt a greater reciprocity between the demands and the rewards of practice, and a stronger covenant with their patients and communities that energized them," he said.
Pressing ahead
Ripp says healthcare organizations have a duty to help suffering physicians even though there is incomplete information about burnout.
"We should not use the imperfection in how we measure well-being to say that we can't act. If you found an infection that affected 50% of the population, and you didn't have the best tools to diagnosis it, and you weren't exactly sure what to call it, but it was having real consequences, you would not wait to act until you had the perfect diagnostic tool," he says.
Ripp concedes more burnout research is needed but contends there is enough research to guide interventional approaches.
"We need more research, but we also have enough to act. The alternative would be to say, 'We don't have enough information, so we are not ready to look at interventions.' We have enough information to show that there is burnout and there are concerning consequences both to individual physicians and quality of care," he says.
Studies published in 2016 and 2017 demonstrate the causes of physician burnout and effective interventions, says Mickey Todd Trockel, MD, PhD, a clinical associate professor at the Stanford University School of Medicine in Stanford, California.
"Effective responses have already been crafted. Two good systematic reviews and meta-analyses demonstrate effectiveness of interventions. Nevertheless, we have much room to improve. Physicians and those they serve will benefit from continued research on the causes of burnout and associated development of more effective individual and organizational level interventions," Trockel says.
There is little doubt that physician burnout exists as a serious problem, he says.
"A growing body of research demonstrates compelling relationships between burnout and adverse consequences to affected physicians and the quality of care they provide for their patients. In this light, the risk of understating seems greater than the risk of overstating the problem of physician burnout," Trockel says.
Scribes have the potential to address several causes of physician burnout at primary care practices.
High-quality scribes generate high-level gains in primary care practices.
That's the conclusion of recent research published in JAMA Internal Medicine, which found scribes decreased physician EHR documentation burden, boosted work efficiency, and improved patient visit interactions.
Scribes can have a significant impact on a prominent factor for physician burnout, the researchers wrote.
"Emerging evidence indicates that EHRs, as currently implemented, increase clerical workload and physician stress and interfere with direct physician-patient interaction, thereby diminishing professional satisfaction and contributing to professional burnout," the researchers wrote.
The research featured 18 primary care physicians (PCPs) in a study conducted from July 2016 to June 2017. For the study, the researchers enlisted scribes from a private agency that was relatively more expensive compared to internally employed scribes.
There were several key results:
Scribes were associated with fewer after-hours EHR documentation by PCPs
Scribes increased the likelihood that PCPs would spend more than 75% of a visit interacting with the patient rather than interacting with a computer
Scribes were associated with PCPs completing encounter documentation by the end of the next business day
Among patients, 61.2% reported that scribes made a positive impact on visits, and only 2.4% reported scribes had a negative impact
The vast majority of PCPs (88%) reported satisfaction with the quality of scribe EHR documentation
"We found that scribe assistance resulted in significant reduction in PCP-reported EHR documentation burden outside visits and significant increase in time spent on face-to-face patient interaction during visits. These self-reported results were corroborated by objective improvement in measured time to completion of encounter documentation," the researchers wrote.
The scribes also demonstrated a likelihood of improving work-life balance, which has been linked to physician burnout.
"During periods of scribe assistance, the PCPs reported significant reductions in their EHR documentation burden during off hours, suggesting that scribes may also improve a physician's work-life balance," the researchers wrote.
Potential drawbacks
There are at least half dozen potential pitfalls associated with employing scribes in the primary care setting, according to Richard Grant, MD, MPH, a coauthor of the JAMA Internal Medicine article and member of the Division of Research at Kaiser Permanente Northern California in Oakland:
Cost of scribe services
Scribe quality, which was high with the private service used in the study but varies with internal scribes
Scribe turnover can be high such as scribes using the position as stepping stone for medical school or nursing school
Patients could be reluctant to share sensitive information with a scribe present during office visits
Many health systems view scribes as a way to add more patients to a physician's panel, which offsets burnout-condition gains
Scribes do not address EHRs that are poorly designed for patient care
Identification of syncope causes and predictors can help clinicians formulate care plans to avoid hospital readmissions.
There are four primary causes for syncope readmissions, new research shows.
Syncope accounts for about 3% of total emergency department visits. In 2000, the total cost of care for the treatment of syncope was estimated at $2.4 billion annually.
The new research, which was published this month in the Journal of the American Heart Association, found syncope readmissions were more costly than initial hospital admissions for syncope. The median cost of a syncope/collapse hospital admission was $19,439. The median cost of an all-cause 30-day readmission was $26,127.
The identification of syncope causes and predictors can help clinicians formulate care plans to avoid hospital readmissions.
The JAHA research, which examined more than 282,000 syncope admissions, identifies the causes and predictors. Four primary causes for readmissions were identified:
Syncope/collapse was the most common single diagnosis for 30-day readmissions at 7.9% of patients
Combined cardiac causes tallied 17.2% of readmitted patients, with arrhythmia accounting for the largest percentage of patients at 7.2%, followed by congestive heart failure at 3.7%
Combined infectious causes tallied 13.7% of readmitted patients, with septicemia accounting for the largest percentage of patients at 3.7%, followed by urinary tract infection at 2.9%
Combined neurological causes tallied 10.9% of readmitted patients, with acute cerebrovascular disease accounting for the largest percentage of patients at 3.2% followed by seizures at 2.2%
The research found that 9.3% of syncope patients were readmitted to a hospital within 30 days of a hospital admission. Eight factors were associated with a high risk for readmission:
There are several benefits to identifying syncope patients who are at high risk of readmission, says Amer Kadri, MD, lead author of the JAHA research and a clinical assistant professor of medicine at Cleveland Clinic's Medicine Institute.
"The primary benefit is better patient care. That reflects higher survival, lower early readmission, and a better quality of life. From an administrative point of view, that would also decrease the burden on our resources and healthcare system," he told HealthLeaders via email.
Taking a thorough patient history and conducting a detailed physical examination are cornerstones of syncope diagnosis and treatment, Kadri says. "Once you know what the pathology is, it becomes easier to manage it appropriately."
Syncope patients at high risk for readmission require further measurement and monitoring before and after discharge, he says. For example, Kadri says patients discharged to an extended care facility (ECF) should trigger a "high-risk syncope pathway" of care:
The hospital-based care team should ensure that the ECF care team has information about what happened to the patient during hospitalization
There should be an effective management plan hand-off, including a printed discharge summary attached to the patient's chart
There should be a physician-to-physician phone call between the hospital-based clinician and the accepting physician at the ECF
Social workers or case managers should arrange specialty clinic follow-up appointments
A pharmacist should review pre-admission and discharge medication lists
Thorough assessment
All clinical variables should be considered when assessing a syncope patient's readmission risk, Kadri says.
Syncope can be a symptom rather than an underlying disease, which necessitates a thorough assessment, he says.
"Syncope is defined by transient loss of consciousness due to generalized cerebral hypoperfusion. That means syncope can be caused by any pathology that produces decreased brain blood perfusion followed by loss of consciousness with complete resolution shortly after," Kadri says.
For example, changes in medication can result in syncope, he says.
"If a patient reports recurrent syncope and presyncope—near fainting—in the morning there may have been a recent adjustment of their antihypertension medication, and they can suffer from low blood pressure, slow heart rate, or even more serious conditions like heart block. In this case, syncope would be a side effect of the medicine rather than a disease."
The JAHA research shows that considering all variables helps to identify true risk factors for readmission, he says.
"In our model, we found that older age—as an isolated variable—was a risk factor for readmission; however, when we implemented all other variables together, advancing age was not associated with higher risk of readmission."
In pediatric settings, care bundles for needle procedures such as lidocaine administration and comfort positioning can significantly reduce pain.
Needles don't have to hurt a child.
In 2014, Minneapolis-based Children's Hospitals and Clinics of Minnesota launched an initiative to close a painful care gap. Patients and families had reported in surveys that needle procedures were their single largest source of pain and anxiety. Staff members surveyed had said needle pain was a low priority.
Over a three-year implementation period, Children's Minnesota attained 95% compliance with best practice strategies for needle procedures and achieved several other measures of success, researchers wrote this month in the journal Pain Reports.
"Comparison of baseline audits with continuous post-implementation audits revealed that wait times for services decreased, patient satisfaction increased, and staff concerns about implementation were allayed," the researchers wrote.
In surveys, the percentage of families who said hospital staff "always did everything they could to help with pain” increased from 78.3% to 85.3%. For the metric "child's pain was always well controlled," family satisfaction increased from 59.6% to 72.1%.
At Children's Minnesota, which features two hospitals as well as 26 primary and specialty clinics, more than 200,000 patients undergo needle procedures such as vaccinations and blood draws annually.
Needle procedures are more than a pain.
Vaccinations are a common needle procedure in children and needles have been associated with vaccine hesitancy. An estimated 25% of adults fear needles, with most fears developing in childhood.
Children's Minnesota followed a four-step process to implement its needle-pain initiative, which is called Children's Comfort Promise.
1. Strategy selection
After conducting the surveys of patients, families, and staff members in 2013, Children's Minnesota performed a review of evidence-based pain management strategies.
The organization chose four bundles of care for needle procedures that would be offered to all patients and families:
For children 36 weeks or older, numbing of the skin with 4% lidocaine cream or needless-less lidocaine application with a disposable gas-propelled injector
For infants as old as 12 months, sucrose or breastfeeding
Comfort positioning such as swaddling and skin-to-skin contact for infants, and sitting on a parent's lap for children over 6 months
Age appropriate distraction, including toys, books, pinwheels, and videos
A key TPS concept that Children's Minnesota embraced was "value stream," which analyzes a current state and designs a future state, as well as examines a service from its beginning to end.
At Children's Minnesota, the TPS process featured identifying multidisciplinary core team members, leadership sponsors, scope, objectives, and metrics. A nurse served as the value stream manager, with support from a lean coach and physician sponsor. Executive sponsorship featured the chief medical officer and chief nursing officer.
3. Rolling implementation
In early 2014, Children's Minnesota launched Children's Comfort Promise at the organization's two outpatient laboratories. The labs were chosen as pilot sites because they had relatively small staffs and high needle-procedure volumes, with more than 30,000 needle procedures annually.
The initiative was rolled out methodically through 2016:
After the lab pilots, five inpatient medical-surgical units began the initiative later in 2014
In 2015, several sites got involved, including both emergency departments, four neonatal units, three critical care units, two short-stay units, radiology, and the outpatient surgery program
In 2016, all 26 ambulatory clinics implemented Children's Comfort Promise
After the pilot phase at the laboratory settings, expansion of the initiative was supported with baseline audit reviews, observations, and findings from the pilot to guide the TPS process.
The audits featured three metrics: the type of needle procedure, whether the four pain avoidance strategies were offered, and whether the staff found the strategies helpful when used.
4. Cultural shift
Measuring and communicating the positive performance of the needle care bundles was crucial to overcoming initial resistance to Children's Comfort Promise from staff members, the researchers wrote.
Three positive results were particularly convincing:
Wait times went down instead of up, contrary to many staff members' expectation
Lidocaine administration did not result in a single case of venous constriction impeding insertion of a needle into a vein
The four care bundle strategies provided immediate benefit to patients
To cement Children's Comfort Promise organization-wide, leadership performance bonuses were tied to attaining target goals. "The new care standard was integrated into all organizational policies, the electronic medical record, and new staff orientation, making nonadherence a performance issue," the researchers wrote.
Best practices for giving bad news over the phone include communicating directly from physician to patient, being supportive, and arranging a follow-up visit.
Conveying breast cancer diagnoses over the phone has been on the rise over the past decade, new research shows.
"Reports of communication problems by cancer patients have been associated with poor compliance with medical treatment and increased distress. Consequently, disparities between physician practices and patient expectations about the mode of bad news delivery may negatively impact breast cancer patient outcomes," the Supportive Care in Cancer researchers wrote.
The researchers examined data from nearly 2,900 patients who had received a breast cancer diagnosis from 1967 to 2017. There were several key findings:
From 1967 to 2006, breast cancer diagnoses were conveyed more often in person than via telephone calls
From 2006 to 2017, more than half of breast cancer diagnoses were conveyed through telephone calls
From 2015 to 2017, 60% of breast cancer diagnoses were conveyed via telephone calls
The researchers say there are two primary reasons why breast cancer patients are receiving more diagnoses via telephone calls.
First, modes of communication have changed over the past decade.
"The digital age has increased the use of telemedicine for cancer care, especially for patients living far from cancer centers. … Consequently, our study suggests that some physicians have decided to talk to their patients about test results sooner over the telephone and before the posting of the test results versus later at a clinic visit," the researchers wrote.
Second, more patients are requesting test results over the phone.
"Some patients are actively involved in their care and request delivery of bad news over the telephone. This mutual decision between the healthcare provider and patient about when, where, and how to communicate medical results is a natural sequel to the cultural shift toward patient autonomy and shared decision-making," the researchers wrote.
Best practices
There are several best practices for delivering bad news such as a breast cancer diagnosis, according to Natalie Long, MD, a family physician at University of Missouri Health Care in Columbia, Missouri. Four out of seven of the co-authors for the Supportive Care in Cancer research are affiliated with the University of Missouri. Long was not a co-author.
First, try to anticipate how the patient would like to be informed—a telephone call, in-person visit, or portal message. Try to determine whether the patient's preference will change based on the results.
Bad news should be conveyed in a caring and informative manner.
Any time bad news is delivered it should be given directly by the physician to the patient. Bad news should not be conveyed by staff, via voice mail, or through a family member.
In-person discussions should be held in a private and quiet location.
For telephone conversations, the physician should ask whether now is a good time to talk before delivering the news. If the time is not good, an alternative time should be arranged.
Set the context and prepare the patient by leading with an introductory statement to allow the patient to prepare for the possibility of bad news such as, "Unfortunately, the biopsy results are not what we were hoping for."
Bad news should be delivered clearly and unequivocally, followed by a pause to allow the patient to process the news.
The physician should be supportive because the patient is likely to have an emotional response. Empathy can include supportive phrases and physical contact, if appropriate.
Securing close follow up is crucial, especially if bad news is given over the phone. This allows the patient to prepare questions and bring supportive friends or family members.
Medical education
Medical schools should develop curriculum for delivering bad news over the phone, Long says.
"University of Missouri School of Medicine's curriculum now includes additional training for first-year medical students to talk about situations and techniques for breaking bad news over the phone. We teach students to use the same principals we use for in-person notification and apply those techniques over the phone," Long says.
Timing and empathy are crucial factors.
"The first goal is to make sure the patient is in a good place to talk, not in a car, at the store, or in the middle of a work setting. The students are taught skills related to listening, empathy, offering a good follow-up plan, and ensuring the patient has a support system to process the news," Long says.
Arranging follow-up visits in-person are also essential.
"We also talk to our students about the importance of offering a follow-up visit to go over the results in more detail. It gives the patient time to process the news before we talk about next steps in the treatment. Often, the patient is only able to process a small amount of information when delivering bad news, so an in-person follow up will allow time to provide a more detailed explanation," she says.
Medical students should be prepared to hold these conversations, Long says. "By teaching our medical students a patient-centered approach to notification, we are leading the next generation of physicians to inject humanity into healthcare."
Rural healthcare providers can pursue multifaceted strategies to improve care availability, accessibility, and affordability.
Care access is a pressing problem in rural areas of the country because it impacts the quality of care that patients receive, according to a recent National Quality Forum report.
"Access and quality are intertwined and difficult to de-link," the NQF report says.
The report's recommendations on care access in rural areas are based on several assumptions:
Long distances to care sites and lack of transportation are major barriers to care access
Telehealth is a potential solution but has drawbacks such as needing to travel to a medical practice to use a secure telehealth service
Staffing shortages such as limited numbers of specialists are a driver of care access problems in rural areas
Quality measures for healthcare providers could be improved by risk adjustment for factors in the rural environment, including social determinants of health and transportation needs
Risk-adjusting quality measures for social factors would benefit rural healthcare providers and their patients, says Elisa Munthali, senior vice president for quality measurement at NQF, which is based in Washington, DC.
"Risk adjusting would make measures a fairer assessment of the quality of care that providers give to rural residents. It would account for the challenges they are facing that can prevent them from providing more comprehensive care," Munthali told HealthLeaders this week.
"To the extent that we want to recognize those challenges in measurements, it would be good for providers because we could start talking about the actual quality they are delivering for their residents," she says.
To improve rural care access, the NQF report focuses on three sets of recommendations: availability, accessibility and affordability.
1. Availability
The report says the most important elements of healthcare availability in rural areas are access to after-hours and same-day appointments, access to specialty care, and timeliness of care.
Team-based care is crucial to boost availability, the report says.
"This could mean bringing additional nonphysician providers into the practice, as well as supporting nonphysicians in maximizing their scope of practice. By supporting clinicians such as nurse practitioners and physician assistants to practice to the 'top of their license,' practices may be able increase the number of available appointments."
Team-based care should be paired with patient education, the report says.
"Many individuals prefer to see a medical doctor instead of another type of practitioner, in some cases because they may believe that no other practitioner will have needed knowledge or skill to meet their care needs. Thus, practices, health plans, states, and national campaigns should educate consumers about the various types of qualified practitioners who are available."
Telehealth could help ease the shortage of specialists in rural areas, but there are challenges linked to telehealth in rural areas such as regulatory and licensing restrictions, the report says. For example, telehealth providers are often required to be in the same state as the patient.
To promote timeliness of appointments, the report says effective referral relationships and strong care coordination with referral sites are crucial.
2. Accessibility
To obtain healthcare service in rural areas, the report focuses on language interpretation, health information, health literacy, transportation, and physical accommodation.
For language interpretation, the report recommends interpreter services via phone or web-based platforms when interpreters are not available on-site.
Regarding health information, the report calls for better access to information from payers, particularly about providers who are in-network or out of network.
The report makes a pair of recommendations about improving health literacy: educating both patients and clinicians about the importance of patient engagement, and improving clinician-patient communication in general.
Transportation is one of the most daunting care access hurdles in rural areas. The report offers several recommendations to rise to the challenge:
Establishing partnerships with transportation services such as taxis
Contracting with bus services
Hiring drivers
Working with community partners such as nursing homes when conducting community needs assessments
Leveraging paramedics and other community health workers
3. Affordability
Total out-of-pocket costs and delayed care because of the inability to pay are the essential aspects of affordability for rural residents, the report says.
"The shift to higher deductible plans or other forms of underinsurance, lack of medical insurance, and network inadequacy are key factors that cause rural patients to delay care," the report says.
Healthcare providers can assist rural patients to afford care by helping them understand their insurance coverage, the report says. Providers can monitor the balances patients owe after insurance payments and increase literacy about insurance such as the financial consequences of picking a high-deductible health plan.
Training care teams to deal with disrespectful behavior includes role modeling and rehearsing.
Clinicians do not have to endure disrespectful patients and family members.
That's the message from a Utah-based physician who is training her care team to address inappropriate behavior at the bedside that creates an unhealthy workplace.
"Ignoring disrespectful behavior shuts everybody down. You get off track—it's disruptive. It's like ignoring an elephant in the room," says Amy Cowan, MD, MS, a physician at George E. Wahlen Veterans Affairs Medical Center in Salt Lake City, and a faculty member of the Department of Internal Medicine at the University of Utah in Salt Lake City.
"What I have found is disrespectful behavior erodes the team," she says.
Inappropriate behavior can temporarily paralyze care team members, she wrote.
"When I walk into an examination room, I expect the general interaction to proceed in a predictable manner, and usually it does. Sometimes, however, a patient or family behaves or reacts in an unexpected or outrageous way, which is surprising, shocking, or even confusing. I often find myself stunned, feet weighted, mouth paralyzed. My mind whirls to make sense of the unexpected departure from the customary script."
Tactics and training
This week, Cowan told HealthLeaders how she handles these situations and how she is training care team members to react.
"I try to keep it simple. If I can normalize for my team that freezing happens, then people can notice it in themselves that it is happening. Then they can call upon one simple phrase. I call on phrases like 'cut it out' or 'let's keep it professional.' It has to be something you can think of quickly before things get ramped up," she says.
Cowan has made training to address disrespectful behavior part of the rounding process.
"Before we round, I will pose a question to the group: 'When was a time when you were a target?' Or, 'When was a time when you noticed someone's bad behavior targeted toward someone else?'" she says.
"We talk about what was noticed, what went well, what they could have done different. That segues into how I deal with inappropriate behavior. For me, it's finding that line I can think of quickly on the fly. When you freeze, you have to have something you can call upon quickly to say, so you can move on."
In preparing care team leaders to address disrespectful behavior, role modeling is key, Cowan says.
"Part of this is role modeling that it is OK to create an environment of compassion where people are kind to each other. Part of that role modeling is making it clear that you don't have to tolerate super disrespectful behavior."
Rehearsing is also crucial, she says. "If I keep practicing, even though I will freeze, maybe I will feel more comfortable leaning into that discomfort of confronting someone."
Re-engaging patients
After addressing inappropriate behavior, Cowan circles back to most patients to find out why interactions went awry.
"I have to really mean it. I have to be authentic that I am curious about where the behavior is coming from. I don't do it for everybody. For some patients, I am not going to explore the hate," she says.
Cowan holds these conversations later in the shift or the next day.
"I come back and say, 'Is this a good time?' Then I just say it, 'Yesterday during rounds, this is what I observed. What did you mean by that?' Oftentimes, I find there was some sort of incident that happened when I wasn't there. Maybe a nurse or other doctor was rude to the patient, or the patient and the family didn't feel a doctor was on their side. There was some sort of unmet need or something was going on behind the scenes. You drill down and figure out how we can do better with our communication."
Most of these follow-up conversations generate a positive result, but some don't, she says. "Sometimes, I end up reinforcing that we have to be respectful to each other."
An ASC leader and orthopedic surgeons share their success strategies for conducting safe invasive procedures at ASCs.
Ambulatory surgery centers (ASCs) are on the frontline of efforts to shift healthcare outside the hospital walls in several specialties, including endoscopy, ophthalmology, and pain management. And within those efforts, physician leaders are reinforcing the safety advantages of ASCs for invasive procedures, according to an ASC leader, surgeons, and scientific data.
Amid questions and concernsthat ASCs could be less safe than hospitals, several physician leaders share successful strategies they use to make their ASCs safer.
"The advantage we have in the ASC environment is that we are smaller. That helps us be closer with our employees, and we communicate with them daily," says Rebecca Craig, RN, CEO of Harmony Surgery Center and Peak Surgical Management in Fort Collins, Colorado.
Asheesh Gupta, MD, MPH, an orthopedic surgeon at Bethesda, Maryland-based Centers for Advanced Orthopaedics, agrees that ASCs have an advantage: "I think it's safer for the patient."
"I can do hip arthroscopy surgery in an hour to an hour and 15 minutes. At the hospital, the exact same procedure takes two to two-and-a-half hours because nobody knows the setup, and they don't have the same staff every day. It's like I'm doing the procedure for the first time every time, and that leads to more complications for the patient because they are under anesthesia longer and have longer traction time," Gupta says.
Research published earlier this year in the Journal of Health Economics found ASCs on average provide higher-quality care than hospital outpatient departments (HOPDs):
After a procedure, ASC patients are less likely to visit an emergency room or have a hospital inpatient admission than HOPD patients.
ASC patients have fewer ER visits because of adverse events compared to HOPD patients. On the day of surgery, 0.1% of ASC patients visited an ER. From one to seven days after surgery, 0.52% of ASC patients visited an ER. From eight to 30 days after surgery, 1.41% of ASC patients visited an ER.
Data indicates that reduced medical complications is a possible reason why ASC-based procedures result in fewer ER visits than HOPD-based procedures. On the day of surgery, 0.02% of ASC patients visited an ER for a medical complication. From one day to seven days after surgery, 0.07% of ASC patients visited an ER for a medical complication. From eight days to 30 days after surgery, 0.17% of ASC patients visited an ER for a medical complication.
The relatively low number of hospital visits after ASC-based procedures applies to both low-risk and high-risk patients, indicating even high-risk patients can be treated safely in the ASC setting.
5 elements of ASC facility safety
Craig, who is the immediate past president of the Ambulatory Surgery Center Association, says there are five primary elements that underpin ASC safety:
1. There are fewer patients with dangerous infections such as MRSA in ASCs, she says.
"If you are having a knee replacement, a gall bladder removal, or a hernia repair, you don't want to be anywhere near the superbugs that a hospital has to deal with. So, that is probably the most significant infection control difference," she says.
2. Small staff size and procedure specialization fuels care coordination in the ASC setting, Craig says.
"We work very closely with all team members, passing along pertinent patient information at every point of care and hand-off transition. Whether the ASC is a large multispecialty facility center with 100 employees or a two-procedure room endoscopy ASC with 25 employees, it is a finely orchestrated flow centered on the patient," she says.
3. Well-run ASCs adhere to a wide range of safe surgery checklists, industry guidelines, and regulations, Craig says.
4. ASCs have the potential to retain a high percentage of their perioperative staff, Craig says. "One of the advantages in the surgery center environment is we don't have weekend or holiday shifts. We don't work on call or come back to work for emergency cases in the middle of the night. So, that is a staffing advantage."
5. Procedure specialization drives efficiency in the ASC setting, she says.
"In the ASC environment, we are nimble, which allows us to quickly address any roadblock in our process that could cause us to be inefficient or could be a potential patient safety issue. We utilize patient satisfaction, physician satisfaction, employee satisfaction, turn-over time, on-time starts, and many other benchmarks to drive our quality assurance and performance improvement," Craig says.
ASC surgical safety practices
Gupta, and Barry Waldman, MD, an orthopedic surgeon at Centers for Advanced Orthopaedics, say safety practices are key in patient selection, and preoperative, perioperative, and postoperative care.
1. Patient selection
Some patients are not appropriate for surgery in an ASC, with medical, surgical, and motivational considerations.
"First and foremost, the patient has to get medical clearance, which can include clearance from other specialists such as cardiologists or pulmonologists, depending on what other disease processes they have. Based on those processes, other specialists may recommend an inpatient setting for closer monitoring and follow up," Gupta says.
High-risk medical conditions often disqualify a patient for surgery at an ASC, he says. "If someone has coronary artery disease and high-risk factors related to the heart, instead of sending a patient home the same day of surgery they may want to monitor them overnight or two nights."
Several medical factors can disqualify a patient for ASC care, Waldman says. "You don't want anyone who has a high-end seizure risk, someone who is obese, someone who is going to have trouble with physical therapy, or someone with a lot of comorbidities."
2. Preoperative care
"Traditionally, outpatient total joint replacement—hip and knee—was performed in the inpatient setting. Patients would stay in the hospital for two to five days. Now, we have to change those expectations. You can go home the same day, and the outcomes are the same if not better. You don't have the germs that are in hospitals, which potentially seed the wound," Gupta says.
Planning is an important part of the preoperative phase of care at ASCs to ensure the patient's well-being, he says.
"We share what time to show up, what time the surgery is, how long the surgery will be, how long you will be in recovery, and when you are going to go home. We also discuss whether the patient will need an assistive device and whether someone will be at the center to take the patient home," he says.
3. Perioperative care
On the day of surgery, mobility and medications are top concerns to ensure safety for the patient, Waldman says.
"With anesthesia, you need to make sure that patients can get up and walk. You need to make sure patients can urinate after surgery, and make sure they are on their antibiotics; sometimes we have to do IV doses in the center before the regular doses at home. We also have a physical therapist at the center to make sure patients are walking correctly."
4. Postoperative care
Postoperative care is more intense for ASC patients compared to hospital patients, Waldman says.
"We do physical therapy more often with our outpatient cases. Patients will work with a therapist five days a week for five days straight. We also see them back in the office sooner; for a lot of patients, I will see them three to five days after surgery. I will check the wound and make sure there are no complications. We want to be much more on top of them than the hospital patients because they are not being watched in a hospital."
Gupta makes sure patients set up their postoperative appointments.
"I also give patients a physical therapy referral, so they can schedule that along with their postoperative visit. I try to take care of as many questions and issues that I can preoperatively; so that postoperatively, patients can hit the ground running."
