A new Declaration of Principles by 10 healthcare organizations calls for actions to safeguard the emotional, psychological, and physical safety of staff.
A group of healthcare organization CEOs recently adopted a Declaration of Principles to improve the safety of healthcare workers.
Healthcare settings pose several safety concerns for caregivers and other staff members. The dangers include emotional and psychological harm, hazards such as contaminated sharp objects, and workplace violence.
The CEO Coalition's Declaration of Principles focuses on three areas of healthcare worker safety. The CEO Coalition features the top executives at 10 healthcare organizations, including Cleveland Clinic, Henry Ford Health System, SSM Health, and UCLA Hospital System.
1. Safeguarding psychological and emotional safety:
Investing in processes and technologies that reduce emotional and cognitive burdens on team members and restore human connection to the healthcare experience.
Creating practices and policies that advance open communication between team members and leaders, so people feel safe to speak up and bring their full selves to work.
Providing resources to assess and support team members' emotional, social, and spiritual health, and alleviating the stigma and deterrents to seek support.
2. Promoting health justice:
Declaring equity and anti-racism core components of safety, and requiring explicit organizational and health equity-focused policies and practices to advance diversity, inclusion, and belonging.
3. Ensuring physical safety:
Implementing a zero-harm program for care team members to eliminate workplace violence, both physical and verbal, whether from colleagues, patients, families, or community members.
Ensuring that all healthcare organizations can procure and provide evidence-based personal protective equipment, technology, tools, and processes that healthcare team members need to do their jobs safely and care for patients.
Committed to healthcare worker safety
CEO Coalition member A. Marc Harrison, MD, president and CEO of Salt Lake City, Utah-based Intermountain Healthcare, says the Declaration of Principles elevates healthcare worker safety to the same plain as patient safety.
"We have talked about patient safety for a long time. But it seemed like we were not putting the safety of these amazing, heroic people who deliver healthcare on equal footing. One is not better than another; but healthcare workers are all human beings, and they deserve to be safe as well," he says.
The coronavirus pandemic spurred the CEO Coalition to action, Harrison says. "Intermountain has had five staff members die of COVID—not all of them got the virus at work. But I have never seen such a focus on caregiver safety out of necessity based on the challenges posed by the pandemic, particularly in the phase when we did not understand much about the virus. The Declaration of Principles is a natural offshoot of the concern that we felt about the pandemic."
Harrison, who is a pediatric ICU physician, cited a personal experience related to psychological and emotional safety.
"I am still haunted by a day in Syracuse, New York, when I was a young ICU attending physician and I attempted to resuscitate four little African American girls in an emergency department who all had died from smoke inhalation. We were unsuccessful at resuscitating every single one of them. I heard their mother's screams. If that does not affect your psychological wellbeing, I do not know what would. These kinds of experiences happen thousands of times a day across the United States. Historically, healthcare workers have been asked just to buck up. Now, we are smarter," he says.
Equity and racism are linked to healthcare worker safety, Harrison says. "We know there are huge inequities for the people we serve, and we know there are inequities for the people who are doing the serving."
He cited an example of how a racist incident at Intermountain impacted the physical and emotional safety of a nurse. "We had a Black nurse called the N-word by a gang member in one of our emergency departments. First, she felt physically unsafe. Second, she was emotionally traumatized by the experience. So, there are both physical and emotional parts to this puzzle," he says.
Workplace violence is a primary healthcare worker safety concern, Harrison says.
"We have seen workplace violence spike with the substance abuse crisis and the behavioral health tidal wave associated with the pandemic. Those are probably our greatest correlates to physical safety issues—whether people are getting punched, kicked, scratched, or spit upon. We report on this every day in our tiered huddles, and we have made huge progress with lots of tactics. But workplace violence against healthcare workers is a fact of life across the United States in emergency departments and behavioral health units in particular."
In a study conducted at Massachusetts General Hospital, pairing community health workers with hospital inpatients reduced readmissions nearly 50%.
Pairing community health workers with adult accountable care organization-insured hospital inpatients after discharge resulted in a significant reduction in hospital readmissions, a recent research article shows.
Readmissions are a key performance indicator for hospitals. Earlier research has shown that readmissions of adult inpatients within 30 days of hospital discharge are common and about 27% of the readmissions are preventable.
The recent research, which was published by JAMA Network Open, is based on data collected from 550 adult hospital inpatients drawn from six general medicine units at Massachusetts General Hospital in Boston. There were 277 patients placed in the community health worker intervention group and 273 patients placed in a control group receiving standard care, which included routine care from primary care clinics.
The study generated several key data points:
Compared to the control group, patients in the intervention group were less likely to experience a 30-day readmission (odds ratio 0.44).
Compared to the control group, patients in the intervention group were less likely to miss clinic appointments within 30 days of hospital discharge (odd ratio 0.56). For the intervention group, 22.0% of patients missed clinic appointments. For the control group, 33.7% of patients missed clinic appointments.
Compared with control group patients, intervention group patients discharged to rehabilitation had a significant reduction in readmissions. However, intervention group patients discharged to home experienced no significant reduction in readmissions.
The three most common actions community health workers took were counseling to encourage adherence with clinical care plans (86.3% of patients), psychosocial support (82.7%), and making and confirming clinical appointments (46.2%).
The community health workers (CHWs) had a significant impact, the research article's co-authors wrote.
"In this randomized clinical trial at one academic medical center, a CHW intervention reduced 30-day hospital readmissions in adult general medicine inpatients by nearly 50%. However, subgroup analyses revealed that most of the effect occurred for participants initially discharged to short-term rehabilitation. Intervention participants also were less likely to miss clinic appointments, but no significant reductions in ED visits were noted. These results indicate that CHW interventions may help reduce hospital readmissions and improve preventive care among some clinically complex patients within an ACO," they wrote.
The co-authors speculated on why the CHW intervention achieved readmission reduction for hospital inpatients discharged to rehabilitation rather than hospital inpatients discharged to home. "Potential reasons for this effect may be that CHWs addressed unmet medical and social needs that occurred during the transition from rehabilitation to home and that CHWs improved communication among the patient, rehabilitation staff, and primary physician prior to return to home."
How the community health worker intervention worked
The CHW intervention with adult ACO-insured hospital inpatients after discharge had several primary elements:
CHWs met with hospital inpatients before discharge and worked with the patients for 30 days, including assistance with clinical access and social resources
CHWs interacted with patients through telephone calls, text messages, and field visits
CHWs provided psychosocial support and health coaching through behavioral strategies, including motivational interviewing and goal-setting to improve adherence to clinical care plans
CHWs addressed patient-identified social needs such as food, housing, and transportation
Interpreting the research
In comments to HealthLeaders, the lead author of the research article speculated on why the CHW intervention achieved fewer missed clinical appointments compared to the control group.
"For the study intervention, CHWs were trained to focus on reinforcing the patient care plan and addressing any unmet need related to social determinants of health including transportation. In these ways, CHW support may have contributed to better support and fewer missed appointments among intervention participants," said Jocelyn Carter, MD, MPH, internist, Department of Medicine, Massachusetts General Hospital.
Participants being insured by an ACO likely had an impact on the study's results, she said. "Pre-existing participant connections to primary care and the ACO network were essential for effective communication between CHWs and clinical teams and for assisting participants with access to post-discharge care. These ACO-associated factors were key to CHWs connecting participants with resources and programs when they needed them most."
New CMO says the healthcare stars of the coronavirus pandemic work in nursing, hospital medicine, critical care medicine, and emergency medicine.
Successful chief medical officers build trust with their medical staff, focus on quality care, and attend to the needs of the patient population, the new CMO of Memorial Healthcare System says.
The Hollywood, Florida–based health system recently named Marc Napp, MD, MS, as senior vice president and CMO. Previously, Napp served as deputy chief medical officer at Mount Sinai Health System in New York, where his responsibilities included leading the health system's emergency management program during the coronavirus pandemic.
HealthLeaders spoke with Napp about a range of issues, including physician engagement, quality improvement initiatives, and his vision for clinical care after the coronavirus pandemic has passed. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are the keys to success in serving as a CMO?
Marc Napp: There are various elements to what a chief medical officer is responsible for, and each one of those elements requires a specific set of characteristics, behaviors, or competencies to be successful.
For example, one of the requirements is dealing well with the medical staff. That requires the ability to engender trust among disparate colleagues. So, building trust is a very important factor.
In the quality arena, where you are responsible for the quality of care that is produced by a health system or individual providers, you must understand what quality is, how to improve quality, what metrics are important, and how to move an organization in a certain direction.
With regard to program development and meeting the needs of your community in terms of the services you provide, you must have an understanding of population health and public health. You need to have a keen awareness of what your community needs and the deficiencies in your set of services that need to be addressed.
HL: What are the primary elements of successful quality improvement initiatives?
Napp: First, there needs to be clarity. There needs to be a "why" for an initiative. Then, there is the issue of consensus building. You need to get the stakeholders to be aware that you want to move a particular performance indicator in a particular direction and what their role is.
The most important factor is getting the people who do the work to embrace change and participate in making change. When I have seen quality improvement initiatives fail it is because they are driven by a single individual who is on a mission—as opposed to bringing the people together who are involved in the process and working together as a team.
When I teach performance improvement, it is not so much about understanding the statistics and being able to figure out how many cycles you need to go through for plan-do-study-act. It is much more about getting the group together to figure out that they want to change and move something forward. It is much more about change management and less about the details of performance improvement.
Once you have the change management skills down, you have applied them, and you have a workforce that is ready for change, then you roll out the tools we use for performance improvement such as being technical about measurement and brainstorming.
HL: What are the main elements of physician engagement?
Napp: You must understand the mindset of physicians, recognizing that there is not a single mindset for a large group of physicians—every physician has his or her own concerns and challenges. It is very helpful to recognize those challenges—you can tap into their concerns and therefore be relevant.
For example, if there is a solo practitioner who is a primary care physician who practices in an office where the spouse happens to be the office manager, that is a very different set of circumstances than a large medical group. It is important for the chief medical officer to understand the stressors in every setting, be able to relate to them, and have an approach to engagement that seeks to be respectful of those stressors and those demands.
In our health system, we have many different constituencies. We have solo practitioners, we have small group practices, we have a large employed group, and we have contracted services. Listening to all of them is very important. In the short time that I have been here, I have been spending most of my time meeting people. I want to know people by their first name. I want them to know that they can call me—whether it be good news or bad news. Physicians need to know that they are listened to and that if they have a concern, they can bring it forward.
The next level is acting on concerns. When something turns up that is of importance to a member of the medical staff or large numbers of the medical staff, there needs to be an action plan to address it. That action plan must be executed and there need to be results.
HL: What is your vision for clinical care after the coronavirus pandemic has passed?
Napp: I was in New York for the peak of the pandemic in March, April, and May of last year, and I remember thinking about who the stars of the pandemic were during that surge. It was nurses, hospital medicine, critical care medicine, and emergency medicine physicians—those four disciplines. None of them tend to be the people who get the headlines for the miracles of healthcare. You hear about the cardiac surgeon who does a major heart transplant or some other specialist who does incredible work.
I have been hoping that hospitals would invest more in nursing, hospital medicine, critical care medicine, and emergency medicine, and less so in the areas that drive better funding for hospitals. I do not think that is going to happen. It is going to go back to where it was because the healthcare industry has faced immense costs and many hospitals are in horrendous shape due to the pandemic. There is going to be even more impetus to get back to pushing high-revenue specialties.
Ultimately, we must ensure that our infrastructure specialties—nursing, hospital medicine, critical care medicine, and emergency medicine—are supported and always maintained fully. We also must invest in infectious disease medicine and infection control—we have seen how important those specialties are in delivering healthcare safely.
HL: Gauge the long-term impact of the coronavirus pandemic on healthcare.
Napp: In the big picture, COVID is going to settle down. It will end up in the background in the way that other illnesses are that are recurring. It will ultimately be like a bad flu, and most people will either have immunity to it or they will have an immune system that can fight it. Some people will still get sick and die from COVID just like the flu.
From that perspective, we are going to pick up from where we left off in terms of the experiments in population health. How do you manage a population better and more cost effectively? And how do you craft the distribution of a workforce that meets the needs of the population best? We have not solved those issues, but those are the issues that are going to come back up to the surface when the pandemic settles down.
One of the impacts of COVID that will linger after the pandemic settles down is going to be the loss of members of the healthcare workforce. There already are lots of retirements. We are losing large numbers of healthcare providers. Those numbers will get replenished—there are a lot of people who want to be doctors, nurses, pharmacists, and technologists. But there will be a period of time when we have a labor shortage.
Physician burnout is widespread in the United States. In a survey The Physicians Foundation conducted in spring 2020, 58% of physicians reported feelings associated with burnout compared to 40% of physicians in a survey the organization conducted in 2018.
"We know from that survey last spring that only 13% of physicians sought medical attention for mental health problems, but 30% of them cited feelings of hopelessness or having no purpose and 50% reported having inappropriate emotions. In addition, 8% of physicians reported having thoughts of self-harm as a result of COVID-19's impact on their practices," says Gary Price, MD, president of The Physicians Foundation.
The Physicians Foundation's Personal Crisis Management Plan tool for physicians features five questions that physicians should answer before a mental health crisis arises:
1. What are my warning signs that a crisis is developing?
2. What are my healthy internal coping strategies—name a few things I can do to take my mind off my problems without contacting another person?
3. Who are a few people or what are the social settings that can provide me with a distraction?
4. Which people can I ask for help?
5. Who are the professionals or agencies I can contact during a crisis?
Personal Crisis Management Plan fundamentals
There are two primary reasons for physicians to use the Personal Crisis Management Plan tool, Price says.
"The first reason that it is important is that we had an epidemic of burnout among physicians even before COVID-19 struck. While we are still waiting for definitive data on the impact of COVID-19, it would be difficult to imagine that the burnout situation is any better. Another reason to have the Personal Crisis Management Plan in place is that when you come to the point of feeling overwhelmed and being in a crisis, that is not the time to figure out how to get help, especially when one of the symptoms is feeling powerless," he says.
The easiest way to remember the warning signs of a mental health crisis is to think of the HEART acronym, Price says.
"The 'H' in HEART is health, which includes a tendency to increase the use of medication or alcohol. The 'E' in HEART is emotions such as drastic mood swings and feelings of hopelessness. The 'A' in HEART is attitude such as negative feelings about professional life or personal life. The 'R' in HEART is relationships—withdrawal from relationships that are normally important in one's life. Temperament is the 'T' in HEART, which includes feelings of anxiety and agitation," he says.
There is value in having people who can serve as a distraction when a physician is at risk of a mental health crisis, Price says
"A lot of the warning signs involve feelings of powerlessness or being overwhelmed so that the physician is not engaging with others. The very act of engaging with other people—particularly other people who care about you—can offer short-term relief to help the physician feel more grounded and more in control. That kind of distraction is a quick and easy step to change direction and start to deal with things better instead of feeling out of control," he says.
It is important for physicians to have people from whom they can ask for help, Price says.
"When we surveyed physicians more than a year ago, we found that the first place physicians turn to is their families and the second place is to their professional colleagues. So, if a physician is in a crisis and feels alone and struggling, sharing that with people they trust and turn to for help in other situations can begin to break down the feeling of isolation. They are also recruiting allies in dealing with the things that have gotten out of hand," he says.
Physicians should note professionals or agencies that they can contact when they are at risk of a mental health crisis, Price says
"Just like other health problems, a mental health crisis deserves someone who is an expert at treating a crisis and managing it. So, like someone who has allergies, the time to make sure that you have access to medications or phone numbers for emergency contacts is when you are feeling fine, not when you are having an allergic crisis. Mental health is exactly like that. You want to have all of the treatment options and the protocol that you are going to follow if a crisis happens ready in advance," he says.
Routine preoperative testing before low-risk surgery is widely viewed as having low value.
A new research article indicates that routine preoperative testing before low-risk surgery is common despite having low value.
Over the past decade, healthcare reformers have called on the industry to reduce unnecessary tests. For example, the Choosing Wisely campaign was launched in 2012 to spur conversations between clinicians and patients about care that is truly necessary.
The new research article, which was published by JAMA Internal Medicine, is based on an analysis of administrative claims data in Michigan from January 2015 to June 2019. The researchers examined routine preoperative testing for three low-risk ambulatory surgeries: lumpectomy, gall bladder removal, and groin hernia repair. The surgeries were conducted on 40,000 patients.
51.6% of the patients underwent one or more preoperative tests, 29.4% of patients had two or more tests, and 13.5% of patients had three or more tests
The most common tests were complete blood cell count (33.1%), electrocardiograms (25.2%), and basic metabolic panel (11.3%)
Older patients and patients with comorbidities were more likely to undergo preoperative testing
"In this study of patients undergoing three common low-risk surgical procedures, preoperative testing was common, with approximately 52% of patients undergoing at least one test and 29% undergoing two or more tests," the research article's co-authors wrote.
Interpreting the research
This kind of testing clearly generates little value, Lesly Dossett, MD, division chief of surgical oncology at Michigan Medicine and the co-director of MPrOVE said in a prepared statement. "There aren't that many areas in medicine where the data is pretty definitive that something is low-value, but preoperative testing before low-risk surgeries is certainly one of them."
For most patients, preoperative testing before low-risk surgery should be a relic of the past, she said. "There was probably a time when some of the testing did reduce adverse events. But now there's been so many advances in surgery—complication rates are so low—that a lot of these tests are not necessarily helpful anymore."
Older patients and patients with comorbidities may require preoperative testing for low-risk surgery, but even those circumstances can result in unnecessary testing, said Nicholas Berlin, MD, MPH, a Michigan Medicine plastic surgery resident and lead author of the research article. "That's not to suggest there's an age threshold or a comorbidity that requires preoperative testing every single time. There's not."
Conducting preoperative tests generates revenue for hospitals, so there is an economic incentive for low-value preoperative tests to continue. But the country cannot afford the status quo, said Hari Nathan, MD, PhD, division chief of hepato-pancreato-biliary surgery at Michigan Medicine and director of the Michigan Value Cooperative.
"At the end of the day, we all recognize that as a society, we need to find ways to curb healthcare costs. That's in everybody's interest. Even if, on your balance sheet, you think it makes sense to do more tests just to make money, as healthcare providers and as a nation, it does not make sense. It is unsustainable."
Allina Health and Aetna still negotiate reimbursement for the health system's services but they bargain as amicable partners.
The Allina Health | Aetna health plan joint venture is capitalizing on its parent organizations' resources and a collaborative spirit, a pair of top executives say.
There are three primary types of "payvider" healthcare organizations. A healthcare provider can establish its own health plan. A healthcare payer can establish its own provider division. And a healthcare provider and payer can come together in a joint venture.
The Allina Health | Aetna joint venture was announced in January 2017, and it began offering fully insured and self-insured products in early 2018. Aetna is a division of Woonsocket, Rhode Island—based CVS Health. The joint venture has forged a collaborative relationship between Minneapolis-based Allina Health and Aetna, says Richard Magnuson, MBA, chief financial officer of Allina.
"We work in ways that align incentives that are more collective and in ways with more shared-risk models, so that you are jointly working together to ensure that what is best for the patient is best for both Allina and Aetna. It takes leadership from all sides to come at this with a different mindset," he says.
The joint venture has succeeded in stepping away from the traditionally contentious relationships between providers and payers, Magnuson says.
"Where the industry has been in the past—and it is not going to work in the future—is my job as the provider is to get as much from the payer as possible and get rewarded every time I do something with a member. In the past, the health plans have tried to reduce what they pay the provider and to put administrative hurdles in place for the provider to get paid. What that does is create a lot of administrative non-value-added work," he says.
In the joint venture, there is still negotiation over reimbursement for Allina's services, but the negotiation does not happen from a point of conflict, says Tom Lindquist, MBA, CEO of Allina Health | Aetna, which is based in St. Louis Park, Minnesota.
"The negotiation happens in the context of what is going on in the environment—what is happening with medical cost trends, what is happening with the overall health cost environment, and what we need to do to make the negotiation a win-win situation while holding costs as low as possible for the individuals we serve. That is the primary difference—no one side of the negotiation is trying to one-up the other. It is about finding the best landing spot so we can go about the business of the business, which is improving health outcomes, medical care, and patient experience," Lindquist says.
Sharing resources
The joint venture has been an effective vehicle for sharing resources between Allina and Aetna, Magnuson says.
"We have some collaborative clinical teams that work on opportunities to meet the care needs of our patient population. So, we bring together our clinical folks and their clinical folks on a periodic basis to help address those needs. From a data perspective, we can bring together data from the care side and the payer side in a way that helps us understand the patient as a person. If we were just a payer or provider, we could not do that. Lastly, we bring together a small group of our administrative teams to help work through issues from each of the owners' perspectives," he says.
The administrative teams meet regularly, Magnuson says. "About every six weeks, a couple of my Allina colleagues and I, some of the Aetna folks, and some of the joint venture folks come together on issues such as product design. We come together to create product design that meets the consumer's needs, Allina's needs, and Aetna's needs."
Allina and Aetna have shared resources in a recent Medicare initiative, Lindquist says. "In our Medicare program, we developed a complex-care-for-seniors initiative. We worked with both the Aetna infrastructure and the Allina clinical team to develop the program. It is going to utilize extra resources and clinical care from Allina along with the educational resources and outreach technology from Aetna to help improve results for the most vulnerable within the Medicare population. That initiative kicked off in January of this year."
Keys to joint venture success
Lindquist and Magnuson say there are several factors involved in achieving joint venture payvider success.
There must be willingness among the provider, payer, and joint venture organizations to have open, honest, and frank discussions about the business, where it is going, and what they want to accomplish. "Just like any joint venture, you need to keep the dialogue going," Magnuson says.
The payer, provider, and joint venture organizations must make sure that their goals are aligned.
There needs to be flexibility. "With the coronavirus pandemic, the changes have been incredible. So, the ability to be flexible is critical," Lindquist says.
You need to think about the joint venture in unique and different ways—not just coming at the joint venture from a payer lens or a provider lens.
You need to come together and collectively come up with more affordable and effective care in a way that you probably cannot do on your own.
You need to be open to seeing things from the other organization's perspective.
The payer and provider organizations need to listen and learn from each other.
The joint venture needs to be able to align around patients in a way where traditional incentives have not worked in the fee-for-service world. "You need to come together in a way that is best for the patient," Magnuson says.
Measuring joint venture performance
The Allina Health | Aetna joint venture has focused on several metrics to measure success, Magnuson says.
"Similar to most health plans, a key metric in the joint venture is about membership and how many members you are providing care for. From Allina's perspective, we watch how many members are attributed—how many members are getting their care from Allina. So, the joint venture wants to see growth overall and as much care as possible being provided by Allina. Patient satisfaction and engagement are also critical," he says.
The effort to build and open Wexford Hospital has included several obstacles, including keeping construction workers safe.
Allegheny Health Network has had to rise to several challenges in opening a new hospital during the coronavirus pandemic.
Constructing and opening a new hospital is a daunting task under the best of circumstances. The effort is more arduous during a global pandemic, with logistical and operational barriers to overcome.
AHN is set to open Wexford Hospital in Wexford, Pennsylvania, in September. The hospital is being built next to AHN's Wexford Health + Wellness Pavilion, a large outpatient services facility. Features of the 160-bed hospital include a women's labor and delivery unit, neonatal intensive care unit, a 24-bed emergency department, and a variable acuity ICU.
One challenge has been keeping construction workers safe, says Wexford Hospital President Allan Klapper, MD.
"Education was critical. We kept our construction colleagues informed of what they needed to do to stay safe—what symptoms to be concerned about, how to stay socially distanced, wearing masks, and adding personal protective equipment stations into the facility. They had daily safety meetings. We were fortunate that when COVID hit, most of the work was being done outside, and the building had not been completely enclosed," he says.
AHN has also made pandemic-related medical services available to construction workers, Klapper says. "We reached out to our construction colleagues when it came time for the coronavirus testing and vaccination programs that we were doing to make sure that those programs were available to them."
The hospital project's construction contractor, Providence, Rhode Island-based Gilbane, had to closely monitor the ordering of materials, he says. "When COVID first hit and work stopped across the world, Gilbane and the trades had to go through and determine which materials had yet to arrive and where they were coming from. If the materials were coming from overseas or there was the potential for delays, they ordered those materials as quickly as possible so we could get the materials on time and not have construction delays."
Staff recruitment
The pandemic has affected how AHN has recruited staff for Wexford Hospital, Klapper says.
"The biggest challenge has been that we had a schedule of events that were supposed to take place over the course of the past year to attract workers and inform the community about job opportunities that are available in the hospital. We could not do those in-person events during the pandemic, so we had to adapt a completely virtual recruitment program," he says.
The virtual recruitment effort has gone well, says Amy Cashdollar, DBA, RN, chief operating officer of Wexford Hospital. "I have been working with the talent team to do several virtual career fairs with the colleges in the area. One of the virtual career fairs attracted more than 120 people to hear about the job opportunities at Wexford Hospital. It was great to see that level of interest."
Staff training and orientation
AHN has adopted new approaches to staff training and orientation to open Wexford Hospital, Cashdollar says.
"From a training perspective, we are looking at a lot of different ways to deploy training. We are being mindful of group size and how large of a group we will be allowed to congregate. We are looking at hybrid education models, time in the building, time in the classroom, and training by Zoom. We plan to use a variety of different training methodologies to get employees set up from an orientation perspective," she says.
Community events
The pandemic has had a major impact on the ability of AHN to hold community events associated with the new hospital, Klapper says.
"At this point, we are at a standstill. We are planning two parallel pathways as we get closer to opening the hospital. First, under the assumption that enough of the population will be vaccinated and we do not have additional COVID surges, we will be able to have a ribbon-cutting and VIP ceremony. Although this kind of event may not be as large as what we would typically hold, it should be large enough with members of the community and our employees to celebrate the opening of the hospital. Second, we are being realistic that there could be another surge, and we could pivot to have a virtual event or an event on a much smaller scale," he says.
Researchers compared the estimation of the presence of disease by primary care clinicians and an expert panel.
Primary care clinicians overestimate the probability of disease before and after diagnostic testing, which likely leads to overutilization of treatment that could harm patients, a recent research article says.
With 14 billion laboratory tests performed annually in the United States, effective ordering and interpretation of tests is essential to avoid waste and overutilization of treatment such as medications and procedures. Diagnostic errors account for a significant proportion of serious harm to patients.
The recent research article, which was published by JAMA Internal Medicine, is based on data collected from more than 550 primary care clinicians. The clinicians were asked to estimate the probability of the presence of disease in clinical scenarios before and after diagnostic tests for four conditions. The probability estimates were compared to the estimates of an expert panel that determined the probability of disease based on a literature review that included diagnosis text books.
The researchers found that the primary care clinicians overestimated the probability of disease for all clinical scenarios before testing:
For pneumonia, the median estimate of pretest probability of disease by the primary care clinicians was 80%, compared to a range from 25% to 42% for the expert panel
For breast cancer, the estimate of pretest probability by the primary care clinicians was 5%, compared to a range from 0.2% to 0.3% for the expert panel
For cardiac ischemia, the estimate of pretest probability by the primary care clinicians was 10%, compared to a range from 1.0% to 4.4% for the expert panel
For urinary tract infection, the estimate of pretest probability by the primary care clinicians was 20%, compared to a range from 0% to 1% for the expert panel
The researchers found that the primary care clinicians also overestimated the probability of disease after positive test results:
For pneumonia, the estimated probability of the presence of disease by the primary care clinicians after positive radiology results was 95%, compared to a range from 46% to 65% for the expert panel
For breast cancer, the estimated probability of the presence of disease by the primary care clinicians after positive mammography results was 50%, compared to a range from 3% to 9% for the expert panel
For cardiac ischemia, the estimated probability of the presence of disease by the primary care clinicians after positive stress test results was 70%, compared to a range from 2% to 11% for the expert panel
For urinary tract infection, the estimated probability of the presence of disease by the primary care clinicians after positive urine culture results was 80%, compared to a range from 0% to 8.3% for the expert panel
"This survey study suggests that for common diseases and tests, practitioners overestimate the probability of disease before and after testing. Pretest probability was overestimated in all scenarios, whereas adjustment in probability after a positive or negative result varied by test. Widespread overestimates of the probability of disease likely contribute to overdiagnosis and overuse," the researchers wrote.
Interpreting disease overestimation
Overestimation of the probability of disease can have negative consequences, the lead author of the research article told HealthLeaders.
"If doctors overestimate chance of disease, they will often diagnose patients with diseases they do not have. There is no final test that is 100% accurate. Probability is central to making a diagnosis, and we need to consider probability both before and after testing, knowing that there are often overestimates that can lead to harms for patients. Overdiagnosis of disease leads to unnecessary and sometimes harmful treatments and procedures," said Daniel Morgan, MD, MS, professor of epidemiology, public health, and medicine at University of Maryland School of Medicine.
Most doctors likely overestimate the probability of disease, not just primary care providers, he said. "Humans are not naturally good at probability and medicine is extra difficult as we often do not get feedback. We often do not follow patients for long and many diagnoses are uncertain. Doctors like other people have biases such as neglecting how rare a disease is in a population—they remember recent or rare cases, and we are generally rewarded for making diagnoses even if they are incorrect."
Probability is often not applied effectively by clinicians, Morgan said. "Probability is the scientific basis for how we teach evidence-based diagnosis and how we conduct and interpret trials for the benefits of treatments. So, probability is central to diagnosis and treatment. However, medical practice often ignores this. A shaky understanding of probability likely leads to significant medical overuse."
Karmanos Cancer Institute CMO George Yoo is bullish on the future of telehealth in oncology care.
Telehealth is well-suited to providing a range of services for oncology patients, the chief medical officer of the Karmanos Cancer Institute says.
Telehealth has expanded exponentially during the coronavirus pandemic. However, in the long term, there is uncertainty about the future of telehealth, including whether government and commercial payers will continue to reimburse telehealth visits at rates comparable to in-person visits and which specialties will remain committed to utilizing telehealth.
Karmanos, which is part of Grand Blanc, Michigan–based McLaren Health Care, has 15 locations across Michigan. Karmanos CMO George Yoo, MD, is bullish on the future of telehealth in oncology care.
"Telehealth has become a great tool for many patients. Not everybody likes telehealth; but there are quite a few patients who like to use telehealth, especially patients who are frail and cannot travel or just live very far away from our main facility. Telehealth is a great tool, and it is going to stay in the future—it is not just going to be useful during the pandemic. Telehealth is a great way to give initial consults, for example," he says.
Convenience is a powerful driver for adoption of telehealth in oncology, Yoo says. "Telehealth is going to be a way for more and more patients to get oncology care from our institute. There are patients who do not want to travel three or four hours to our main facility in Detroit to see whether they really need a certain type of surgery, radiation, bone marrow transplant, or clinical trial. With telehealth, it is going to be much easier for patients to explore these services."
Telehealth is an excellent way to engage families when an oncology patient is facing advanced stages of cancer or end-of-life situations, he says. "When we have end-of-life discussions that are very sensitive, family input is tremendously important. With telehealth, the whole family can be present. It can be difficult to involve the family if the patient is coming into an office, clinic, or exam room, and they have to call their family members. With telehealth, family members can be present for the whole discussion."
As long as the possibility of coronavirus infection remains a concern, telehealth will remain an attractive care option for oncology patients, Yoo says.
"These patients are going through therapies that make them more immune-compromised than many other patients. The cancer itself can make patients immune-compromised. So, these patients are at risk if they get COVID—they get much sicker than other patients. Some patients are being very cautious and do not want to go out into a public environment where they could expose themselves to the coronavirus. So, they are finding it much more comfortable to stay in their home setting with telehealth."
About 90% of Karmanos' telehealth visits are conducted using video, says Scott McCarter, vice president of information technology. "There are some technology challenges that patients have—they may not have a cellphone that works like a smartphone. We have a very challenged population here in Detroit, where patients often do not have as much technology as other patients. It would be impossible to go to 100% video."
Oncology services fit for telehealth
There are several kinds of oncology patients and oncology services that are appropriate for telehealth, Yoo says.
1. Newly diagnosed patients: "For the new patient, telehealth is an excellent tool for a second opinion. It is an excellent tool for specialized care. Karmanos and McLaren Health Care have a network of cancer centers across the state. There is a lot of general treatment that can be done in these network sites. Telehealth visits can determine whether a patient has to come down to the main hospital in Detroit or not," he says.
2. Return patients: "For return patients, telehealth is a good tool when the care is mainly looking at results of tests; for example, a prostate cancer patient with a prostate-specific antigen test. If a patient is coming in for a yearly radiological test and they need to review the results, telehealth is an excellent tool," Yoo says.
3. Surgery consults: "Just about every type of surgical consult is appropriate for a telehealth visit. Some patients just want to get confirmation on whether a surgery can be performed. For example, I had a patient in Northern Michigan who wanted the surgery in Detroit, but she did not want to come down to the city twice. She did not want to come down just for a surgery consultation, then have to come down for the surgery," he says.
4. Radiation consults: "Telehealth is a good tool if the patient wants specialized radiation treatment. For example, we have a gamma knife, which is specialized delivery of radiation to the brain. Telehealth consultations are good for determining whether gamma knife or standard radiation is more appropriate. Any time when there are specialized services, it can be appropriate to have a telehealth visit for consultation. The patient does not want to travel just to be told that they are or are not a candidate for a specialized service," Yoo says.
5. Genetic consultations: "Right now, about 80% of our genetic consultations are being conducted via telehealth. A lot of information can be exchanged between the patient and the genetic counselor through questions. An exam is not necessarily important; and if any testing is ordered, the results can be followed up with the patient. There are certain specialties such as genetic counseling and palliative care that lend very well to telehealth," he says.
6. Psychological and palliative counseling: "Those services are provided through telehealth visits. It is up to the preference of the patient. A lot of patients still want to have face-to-face contact for palliative care and psychological care. But telehealth tends to work very well for those specialties because clinicians do not have to make physical contact in the evaluation of a patient. A lot of the care can be done verbally and by video," Yoo says.
Burnout mitigation includes streamlining communication and vocalizing appreciation, chief medical officer says.
It is imperative for healthcare organizations to address physician burnout, the chief medical officer of a Dallas-based clinically integrated network says.
Burnout is one of the top challenges facing physician and other healthcare workers nationwide. A report published in September by The Physicians Foundation found that the coronavirus pandemic has worsened physician burnout. Research published in September 2018 indicated that nearly half of physicians across the country were experiencing burnout symptoms.
"Burnout is real. If we do not address the causes of burnout, we are going to lose good providers, and we cannot afford that as a country," says Jason Fish, MD, senior vice president and CMO of Southwestern Health Resources in Dallas. The clinically integrated network features nearly 5,000 physicians and advanced practice providers.
Fish says four actions can ease physician burnout.
1. Streamlining communications
Reducing unnecessary emails and noncritical data can help reduce physician burnout, he says.
"For email and communication in general, as providers we are being completely overwhelmed from so many different angles. Everybody wants a piece of the physician. So, what we have tried to do is to streamline our communication. If we are not asking what is valuable to the providers, then we are missing the mark," Fish says.
Physicians should not be overloaded with email, he says. "For us, when we communicate, we do not want 20 different people communicating with our providers. We want to streamline our email. We try to step back and see how we can combine those communications or find communications that we can let go of if there is no value in them. Or we try to direct communications to somebody else because those communications may not be of value to the provider—they may be of value to the office manager."
Similarly, physicians should be presented with critical data, he says.
For example, Southwestern Health Resources has used predictive analytics to harness data related to their efforts for coronavirus vaccination. "Here in Texas, when coronavirus vaccines became available, the first people who were eligible for vaccine were everyone who was 65 years old or older. But there were groups within that age cohort who were at higher risk than others. So, we were able to run our patients through a predictive algorithm based on where they lived, social determinants, medical conditions, and past utilization patterns to prioritize who should get the vaccine," Fish says.
Focusing on high-risk patients has allowed Southwestern Health Resources physicians to manage vaccination data, he says. "If primary care provider had a panel of 2,500 adult patients, with 1,800 patients over age 65, it is not helpful to send the provider a list of all 1,800 patients. Instead, we sent a tiered list of patients. So, if there were 200 patients at highest risk, we told the provider to get them in for vaccination. The provider could get on the phone and answer questions about the vaccine and tell patients where they could get vaccinated. All 1,800 of the older patients are important, but we wanted to guide providers with a hierarchy."
2. Vocalizing appreciation
Acknowledging good performance can be a powerful tool to reduce burnout, Fish says. Southwestern Health Resources recognizes top performers during regular "pod meetings," which are organized by large physician practices or combinations of smaller practices, he says. "For example, we had a practice during the early phase of the pandemic that was the first out of the gate doing testing in the parking lot. It was new. We showcased that—we highlighted that. We celebrated that in our network through our pod meetings, through our newsletters, and through our website."
Vocalizing appreciation promotes the sharing of best practices and effective initiatives, Fish says. "When you have teams that are doing great work, rather than just giving out accolades, you want them to share their stories. You want to share how they did great work with other practices. That is another way you can celebrate the good work. You want to permeate that good work across the organization."
3. Implementing team-based models of care
Promoting teamwork is another way to combat physician burnout, he says. "One thing we have done is to help engineer team-based models of care in the clinics. We have a performance improvement team that goes into the clinics and helps them build team-based models of care. The PI team can help clinics design daily huddles and move clinics to team-based models of care within their staff."
Team-based models of care help physicians manage medically complex patients, Fish says. "You bring in all of the adjunct staff—the care management team, the utilization team, the disease management team, and the quality team for the coders for clinical documentation. You wrap these individuals around the providers to form a team, which brings value to the providers, then the providers do not feel like they are on a journey with complex patients alone."
Including care managers and social workers in a physician practice team can also reduce burnout, he says. "When you add a care manager and a social worker to the team, you can find out what is going on in the home or what is going on in the neighborhood. You can find out barriers that patients have to living their optimal health and to have their best quality of life. You can connect patients to community resources. That kind of team is incredibly important to driving success and taking burdens off providers."
4. Working at top of medical license
To limit burnout, healthcare organizations should ensure that physicians are working at the top of their medical license, Fish says.
"If you want providers to Google community resources for their patients or sift through a list of 2,000 patients to figure out which ones are at risk, you are going to have physician burnout. You need to use the analytics platform, and you need to use the team that you have such as social workers and care managers. The physician's job should be working with the patient around counseling for optimal health, diagnosing critical disease, and managing critical disease. The minute you pull a physician into other things, they are not working at the top of their license."
