Read some of the best clinical care stories that HealthLeaders produced about the COVID-19 pandemic.
This year, HealthLeaders produced more than 100 clinical care stories related to the coronavirus pandemic.
The greatest U.S. public health crisis since the 1918 influenza pandemic, the COVID-19 pandemic dominated the clinical care landscape in 2020. At HealthLeaders, clinical care coverage of the pandemic spanned dozens of topics, including critical care, rural medicine, medical ethics, home-based medical care, and rising to the challenges of coronavirus patient surges.
The following is a list of the Top 10 HealthLeaders clinical care coronavirus stories of the year.
1. Medical ethics: "4 Ethical Dilemmas for Healthcare Organizations During the COVID-19 Pandemic"
In March, there had already been rationing of coronavirus testing, and healthcare providers were bracing for care rationing such as mechanical ventilation. Medical ethicist James Tabery, PhD, shared his perspectives on rationing of care and vaccines as well as ethical dilemmas for healthcare workers.
2. Home healthcare: "Home-Based Medical Care in High Demand During Coronavirus Pandemic"
The coronavirus pandemic has increased demand for home-based medical care, according to the chief medical officer of Landmark Health. In July, Landmark reported a spike in demand for its in-home medical services, with the organization's 2020 revenue projected to rise 230%.
3. Care rationing: "Coronavirus Care Rationing: 'It's Not Just About Ventilators'"
In addition to ventilators, there are four primary care rationing scenarios during the coronavirus pandemic, a bioethicist told HealthLeaders in May. Particularly in hotspots such as New York, the early phase of the pandemic prompted triage and rationing of care "at almost every level," said Christine Cassel, MD, a bioethicist and adjunct professor at UCSF Medical School in San Francisco, and a former president and CEO of the National Quality Forum.
4. Rural medicine: "6 Steps for Rural Hospitals to Rise to the Coronavirus Challenge"
In May, the president and CEO of Batesville, Indiana–based Margaret Mary Health shared how the organization's 25-bed critical access hospital coped with a surge of coronavirus patients. Successful strategies to address the patient surge included formation of a response team, increasing bed capacity, and securing essential equipment.
5. Lessons learned: "Prepared in Raleigh: 8 Lessons Wakemed Learned From the Coronavirus Pandemic"
In June, a pair of physician leaders at Wakemed Health & Hospitals in North Carolina discussed how the health system had prepared for the coronavirus pandemic. WakeMed was spared from an influx of coronavirus patients during the spring surge, which gave the health system an opportunity to effectively plan for future pandemic challenges.
6. Long haulers: "Coronavirus 'Long Hauler' Care Model"
A significant number of COVID-19 patients have experienced symptoms for weeks or months after the acute phase of their illness has passed. Valhalla, New York-based Westchester Medical Center has established a comprehensive clinical program to treat these long-hauler patients.
7. Specialty care: "Coronavirus: Speech Language Pathologists Playing Key Frontline Role"
Speech language pathologists are providing essential rehabilitation services to patients recovering from serious cases of COVID-19. For example, coronavirus patients who are placed on mechanical ventilation often require help from these specialists to restore the ability to communicate and swallow.
8. Critical care: "ECMO Life Support 'Last Ditch' Intervention for Coronavirus Patients"
Extracorporeal membrane oxygenation (ECMO) provides life support for severely ill coronavirus patients suffering respiratory failure. At Michigan Medicine, more than half of coronavirus patients who undergo ECMO are expected to survive.
9. Respiratory therapists: "Coronavirus: Providing Respiratory Therapy on Frontline of the Pandemic"
A respiratory therapist who traveled to New York City during The Big Apple's coronavirus patient surge in the spring shares her story. With respiratory distress common among seriously ill coronavirus patients, respiratory therapists are at the tip of the spear on the pandemic frontline.
Northwell Health, which features 23 hospitals and 800 ambulatory sites in and around New York City, treated about 20,000 hospitalized COVID-19 patients during the spring surge. Prime strategies and initiatives Northwell used during the spring surge included centralized decision-making, building surge capacity, and creating a clinical advisory board.
The Patient Safety Movement Foundation is seeking to reduce preventable patient deaths to zero by 2030.
The Patient Safety Movement Foundation has changed its commitment model for hospitals and other healthcare organizations to achieve zero preventable harm and deaths.
Despite making considerable progress over the past two decades since the publication of the landmark reportTo Err Is Human: Building a Safer Health System, patient safety remains a primary concern at U.S. healthcare organizations. Estimates of annual patient deaths due to medical errors range as high as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
The Irvine, California-based Patient Safety Movement Foundation has shifted its focus away from preventing specific kinds of patient harm, says Donna Prosser, DNP, RN, chief clinical officer of the nonprofit group.
"We have revised our commitment model because in the prior eight years what we were asking healthcare organizations to do was to make a commitment to improving safety and reducing incidents of medical harm through certain populations. When I say populations, I mean reducing falls, reducing healthcare-acquired infections, reducing sepsis, and so on. So, we had asked healthcare organizations to make a commitment to improve specific focus areas," she says.
Now, the Patient Safety Movement Foundation has adopted a three-part commitment model.
1. Person-centered culture of safety
Healthcare organizations should commit to ensuring the safety of every person who enters their doors, Prosser says. "For every person who comes into a healthcare organization, everybody needs to have in the front of their minds the safety of every person. It could be a patient, a family member, a physician, any staff member, or a vendor representative—it could be anybody."
The coronavirus pandemic has illustrated the need for a person-centered culture of safety at healthcare organizations, she says. "One of the things we have learned from the COVID-19 pandemic is that we did not have adequate healthcare worker safety. We did not have the personal protective equipment to keep our healthcare workers safe. If we have learned anything from the pandemic, it is that you cannot have patient safety without healthcare worker safety."
2. Holistic and continuous improvement framework
Although hospitals and other healthcare organizations have made progress in working collaboratively, siloes persist, Prosser says. "Since the publication of To Err Is Human, we have learned a lot about continuous improvement. But we have done continuous improvement the same way we have always delivered care, and that is in siloes. The Joint Commission has been telling us for 30 years to get out of our siloes in healthcare. And it has gotten better—it has gotten a lot more collaborative over the years."
A more holistic and coordinated approach to patient safety is needed, she says.
"In a hospital, there can be 10 or 100 committees that are all doing continuous improvement work. There are committees, departments, even students that are doing continuous improvement work. Everybody picks and chooses what they want to do, so we end up with a patchwork quilt of improvement where the right hand does not know what the left hand is improving. This makes it difficult for the frontline workers, who are the recipients of continuous improvement projects."
Coordination is crucial, Prosser says. "We need to look at continuous improvement holistically and figure out how we can have one department, one committee, or one person overseeing the continuous improvement work that is happening in a hospital. One entity needs to know what is going on and plot it on a calendar, so you do not have multiple committees or departments competing for the same resources, and you do not have the frontline being bombarded by change."
3. Effective model for sustainment
Sustaining patient safety initiatives is a daunting challenge, she says.
"For any healthcare leader, the most difficult aspect of performance improvement is sustainment. Healthcare is a profession made of human beings taking care of human beings. There is ambiguity in healthcare. So, if we do not give clear direction to the frontline, they are going to make up their own rules. And they are usually going to revert to rules that are comfortable that they know. It is not intentional—it is just human nature."
To achieve sustainment in continuous improvement of patient safety, healthcare organizations need to have an effective education plan, Prosser says. "You need to reinforce change. You need to build change into existing annual competency reviews, so that you make sure people stay on track and know what to do. Your education program needs to be aligned with your continuous improvement framework."
There are several primary elements of an education plan related to patient safety initiatives, she says. "To sustain continuous improvement with an education program, it is all about onboarding, orientation, annual competency validation, continuing education, and leadership development. That is the continuum of education for any healthcare organization. You need to learn how to keep people accountable."
For example, Prosser says if a hospital does an improvement project for appropriately restraining patients and rolls it out to the frontline staff, the hospital also must insert the change into orientation, insert it into competency evaluation on an annual basis, insert it into the continuing education curriculum, and insert it into leadership development, so that leaders can learn how to measure the change and hold staff accountable.
In addition to education, healthcare organizations must account for the human factor to sustain change, she says. "You must study human factors. You must understand the ways human beings react and behave. You must anticipate what is going to happen when you make a change."
Physician Orders for Life-Sustaining Treatment forms help ensure that resident and surrogate care preferences are honored.
Nursing facilities that use Physician Orders for Life-Sustaining Treatment (POLST) forms achieve a higher level of concordance between orders in the medical record and resident preferences than facilities that do not use the forms, a recent study shows.
POLST forms are available across the country. Compared to living wills and durable power of attorney documents, POLST forms have been associated with significantly higher decreased odds of resuscitation attempts in the field and increased odds of out-of-hospital death for patients with "comfort measures only" directives.
The recent study, which was published by the Journal of General Internal Medicine, is based on information collected from 40 nursing facilities in Indiana. POLST was used in 29 of the nursing facilities and was not used in 11 facilities.
The research article includes two key findings:
At nursing facilities using POLST, concordance between orders in the medical record and residents' preferences was 59.3%. At nursing facilities that did not use POLST, concordance was 34.9%.
When compared to nursing facility residents without POLST, residents with POLST were 3.05 times more likely to have orders for life-sustaining treatment match their current care preferences.
POLST basics
The lead author of the research article told HealthLeaders that POLST is a medical form that is used to document care preferences as orders, including orders about cardiopulmonary resuscitation, medical interventions, and artificial nutrition.
"The decisions that are most emergency-oriented are the orders for CPR and decisions around intubation, which is an intervention that is used when someone is having difficulty breathing and typically leads to the use of a ventilator. So, it is critical that preferences about those interventions be known in advance because there is rarely time in the moment to understand what a resident wants," said Susan Hickman, PhD, director of the Indiana University Center for Aging Research at Regenstrief Institute in Indianapolis.
POLST is a valuable care tool because it can be followed by medical personnel both within a nursing facility and outside of the facility, she said. For example, a copy of a resident's POLST form is usually included in the packet of materials that accompany a resident if he or she is taken to an acute care hospital.
"Emergency medical services play a crucial part in this process because they are a link between settings. So, if a resident starts to experience a medical emergency, EMS will be called to transport the resident to a hospital, and EMS is an important part of the process to make sure a resident's preferences are honored. When the resident arrives at a hospital, the POLST orders are relevant in terms of making decisions about what care will be given in that setting," Hickman said.
Nursing facilities use several strategies to ensure that POLST care preferences are honored, she said.
Nursing facilities that use electronic medical records typically have code status on the face page of the medical record
Code status is often communicated with a colored sticker on a resident's door or chart in their room
In addition to having a POLST form scanned into the medical record, some nursing facilities have a binder for every patient with a copy of the POLST form in it
In nursing facilities, POLST has taken on heightened importance during the coronavirus pandemic, Hickman said. "Nursing home residents and staff have been hard hit by COVID-19. For residents, this means that they are much more likely to imminently face decisions about hospitalization, ventilatory support, and cardiopulmonary resuscitation. Decisions that have been made previously may differ in the context of the pandemic."
Rising to POLST challenges
The recent research article and earlier studies have found that two of the primary challenges of working with POLST in nursing facilities are staff difficulties with understanding and explaining the form as well as lack of time to have the POLST conversation.
These difficulties reflect both training gaps as well as advanced care planning often being an afterthought rather than being defined as part of staff members' roles, Hickman said.
"Nursing home facilities and companies can address these difficulties by creating policies and procedures that support advanced care planning as well as recognizing that advanced care planning is part of staff members' jobs. This may sound obvious, but it is often not. Advanced care planning is often added on without any clear responsibility or goals. There need to be policies for how often staff members talk about advanced care planning with residents and how staff members share what they learn," she said.
Staff education and training is crucial, Hickman said. "Education needs to be provided on a regular basis—not just for the staff members holding the POLST conversations but also for everyone in the facility. Advanced care planning is a team sport—everyone has a role in honoring resident preferences."
Additionally, nursing facilities routinely engage in quality improvement activities, and advanced care planning needs to become a focus of quality improvement initiatives on a regular basis, she said.
While acknowledging nursing facilities are "incredibly busy places," Hickman said time spent managing POLST forms is time well spent.
"One of the things we here from staff is that when a facility invests the time upfront to have advanced care planning conversations, it helps save time and energy in the long run. Advanced care planning needs to be viewed as an investment, with the payout coming over time. It needs to be a priority—not just for individual staff members but also for the company or standalone facilities. There needs to be leadership engagement and buy-in," she said.
Advanced care planning conversations
In healthcare settings, there are several skills that staff members should have to hold advanced care planning conversations, Hickman said.
"One important part of the skill set is knowledge about basic decisions that we are asking residents and surrogates to make. So, staff members need to understand the risks, benefits, and alternatives, and they need to be able to explain that information. Staff members need to know where there are resources to support the conversation. Additionally, it is critical for staff to have training to ask questions in value-neutral ways that help to understand the resident's preferences rather than what the staff member's preferences may be."
Other skills include being able to ask questions that are open-ended to explore preferences and to help residents and family members to connect values to treatment, she said.
Individuals can use the online calculator to estimate their risk of dying from COVID-19 if they become infected with the coronavirus.
Researchers at Johns Hopkins Bloomberg School of Public Health have developed online tools for estimating individual and community-level risk for COVID-19 mortality.
COVID-19 has become a leading cause of death in the United States. As of Dec. 18, more than 17,600,000 Americans had become infected with the coronavirus and more than 317,000 had died, according to worldometer.
The new online tools feature an online calculator that individuals can use to estimate their risk of dying from COVID-19 as well as interactive maps for viewing numbers and proportions of individuals at various levels of mortality risk across U.S. cities, counties, and states. The online tools are based on information drawn from several U.S. databases and the United Kingdom-based OpenSAFELY study.
The online risk calculator combines individual risk factors such as age, weight, and pre-existing medical conditions with community-level pandemic dynamics. As a result, if infections spike in a community, the mortality risk estimates for individuals will increase in that community. The data underlying the online tools is updated weekly.
A detailed description of how the online tools work was published recently in a Nature Medicinearticle.
"We developed a COVID-19 mortality risk model for the general U.S. population by combining information across multiple data sources. We believe that the model is unique in that it can be used to project absolute rate of mortality for individuals with different risk profiles by combining information on individual-level risk factors, as well as on changing dynamics in the epidemic at the community-level captured through available forecasting models. We applied the model to data available from U.S. national databases to identify high-risk cities and counties and estimate the size of populations at risk within these communities," the journal article's co-authors wrote.
High-risk cities include Baltimore City, Detroit, Miami, New Orleans, and Philadelphia, according to the journal article.
Applying the online tools
The senior author of the article told HealthLeaders that the online risk calculator is a powerful tool to assess COVID-19 mortality risk and help determine who should be prioritized for vaccination.
"The current guidance provided by the Centers for Disease Control and Prevention is to vaccinate healthcare workers and older individuals living in congregated conditions using the initial supplies of vaccine doses by the end of this year. After that, one of the major questions would be how individuals in the general population would be prioritized based on age and pre-existing conditions to receive vaccines. It is also known that individuals from certain minority populations as well as neighborhoods with high social deprivation have high risk. Further, the risk can widely vary for individuals based on the intensity of the pandemic in their communities at a given time," said Nilanjan Chatterjee, PhD, a professor of biostatistics and epidemiology at the Johns Hopkins Bloomberg School of Public Health.
The online risk calculator is unique and well-suited to prioritizing individuals and communities for vaccination because it generates quantitative information, he said.
"While the CDC and National Academy of Science, Engineering and Medicine have developed broad guidelines regarding how different factors may be prioritized, a risk calculator, such as ours, brings all of these factors together and weights them to define a single score according to their overall contribution to risk of mortality. Our risk calculator can help to bring in more quantitative risk information into vaccine prioritization than has been considered before."
Quantitative information is crucial in determining vaccination prioritization, Chatterjee said.
"Without quantitative analysis of risk, it is hard to figure out how all of this information should be weighed to come up with an optimal vaccine distribution strategy that will save the most lives. In our analysis, we were able to show if vaccination is performed based on underlying risk information, large proportions of deaths—about 50%—in the population could be quickly averted by vaccinating relatively small proportions of the population—less than 5%."
High-risk cities share a combination of risk factors, he said. "Many high-risk cities have a high proportion of African Americans, who are known to be at increased risk of COVID-19 infection and mortality. Further, these cities also rank high in social deprivation due to various socioeconomic conditions, which, independent of ethnicity, can contribute to risk of infection as well as complications after infection."
Universal Health Services Inc. has picked Mark Friedlander, MD, MBA, to lead the sprawling health system's behavioral health services.
Behavioral health is a challenging field in medicine, but it is moving in the right direction, a new behavioral health leader at Universal Health Services Inc. says.
Based in King of Prussia, Pennsylvania, UHS operates about 400 acute care hospitals, behavioral health facilities, and ambulatory clinics in the United States and the United Kingdom. Mark Friedlander, MD, MBA, was recently named as the chief medical officer of UHS' Behavioral Health Division.
Friedlander is a practicing psychiatrist. Prior to joining UHS, he was CMO for a decade at Aetna's behavioral health unit, where his responsibilities included utilization management, quality, and clinical compliance. Before working at Aetna, he was corporate medical director for Penn-Friends Behavioral Health Systems in Plymouth Meeting, Pennsylvania, where he developed enterprise behavioral health strategies and implemented an emergency assessment capability to triage and manage high-risk patients.
Friedlander recently spoke with HealthLeaders on a range of behavioral health issues, including leadership, promoting evidence-based care, and achieving parity between health plan coverage of behavioral health conditions versus coverage of medical-surgical care. The following is a lightly edited transcript of that conversation.
HealthLeaders: What do you think will be the key to success in your new leadership role at UHS?
Mark Friedlander: I want to have a clear vision so that the people who work at the UHS Behavioral Health Division understand what we are dealing with. They need to understand that our commitment to patients is not just for someone who came into a hospital, got fixed up, and went about their way. For behavioral health patients, hospitalization is just one step in a journey.
The vision needs to recognize that behavioral health patients have a chronic condition that is going to keep coming back. These conditions not only affect individuals but also their families, their friends, and their jobs. These conditions do not occur in isolation. They are impacted by social determinants of health, health literacy, and access to care—those factors are aspects of the mission that UHS has for behavioral health.
When it comes to figuring out how to become a successful leader of a health system's behavioral health division, the important thing is having a clear strategic vision of where the organization is heading. At UHS, we are building a system for tomorrow that includes more than just hospitals. It includes peer counseling, it includes health coaches, and it includes secure transitions from one setting to the next one.
HL: Give examples of the biggest challenges of providing behavioral healthcare.
Friedlander: Even before the coronavirus pandemic, there was very high demand for behavioral health services, with limited resources. Stigma remains an issue. The delivery system is very fragmented, so navigation of the fragmented and confusing system of care remains a huge challenge for individuals.
Behavioral health is not like orthopedics; where if you break an arm and get an x-ray, everybody can see it is a broken arm. In behavioral health, the diagnoses are more subjective and somewhat expandable—there are blurred boundaries between what is normal behavior and what is abnormal.
HL: Standardization and evidence-based care are buzz words in medicine. How can behavioral health providers get away from subjectivity in the diagnosis and treatment of patients?
Friedlander: It is going to be an ongoing process, and there is no silver bullet. Subjectivity is present in many of the other medical specialties. There was a recent study in the Journal of the American Medical Association on the interpretations of electrocardiograms, which are used to detect heart arrhythmias and heart abnormalities. Depending on the level of training, the concordance of physicians on electrocardiograms can vary widely.
Our aspiration for standardization in behavioral healthcare does not need to be perfect. There does not need to be perfect adherence to a protocol or perfect agreement on a diagnosis, but the aspiration needs to be that standardization is the direction in which we are heading.
We know certain treatments work, and certain treatments have little evidence to support them. At UHS, we are emphasizing interventions that work. So, the quest for standardization and evidence-based care in behavioral health is a journey. It is not going to happen in one step. But psychiatry as a field has advanced tremendously. There are still some grey areas, but what works and what does not work is increasingly clear.
As I think about what UHS can accomplish, we are moving in the right direction. We are moving toward evidence-based practice. I would argue that in most of our facilities most of the time, the care that is provided is evidence-based.
HL: It has been more than a decade since the passage of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act. Is there still work to be done to achieve parity between health plan coverage of mental health care versus medical-surgical care?
Friedlander: The report card has mixed grades.
In terms of the spirit of the law rather than the letter of the law, we have a long way to go. We still see a system of care where behavioral health is in its own silo, and medical-surgical care is in its own silo.
There was a very good study released earlier this year by Milliman about the presence of a behavioral health condition driving medical costs. When we look at the overall spend of medical-surgical care versus behavioral healthcare, mental healthcare accounts for about 4% of the spend but it drives about 44% of the total cost of care. So, parity still has a long way to go.
Health plans still look at behavioral health separately from medical-surgical care. What we need to achieve real parity is to integrate behavioral healthcare into medical-surgical care. Behavioral health is undervalued. The coverage from health plans needs to manage behavioral health in terms of the total cost of care, not just the cost of behavioral healthcare.
If you look at the letter of the law, health plans can say that they are managing behavioral health benefits in a manner that is not more restrictive than medical-surgical benefits. That is probably true, but that represents the letter of the law rather than the spirit of the law.
The Providence health system is conducting about 10,000 telehealth clinic visits daily.
There are several keys to building and sustaining successful telehealth programs at health systems, hospitals and physician practices, a top executive at Providence health system says.
Largely due to concern over the spread of the coronavirus in healthcare settings, many patients have avoided in-person visits and healthcare providers have expanded telemedicine programs. A recent research article published by JAMA Internal Medicine shows explosive growth of telehealth in the first half of the year. From the weeks of Jan. 1 to June 10, the rate of telemedicine visits increased 2,013%, rising from 0.8 to 17.8 visits per 1,000 health plan enrollees, the study found.
At Providence, the Renton, Washington-based health system has made nearly a decade worth of progress in expanding telehealth services in a matter of months, says Todd Czartoski, MD, chief medical technology officer.
"We are doing about 10,000 telehealth clinic visits per day across the health system. We are doing direct-to-consumer telehealth visits in the 500-to-1,000 visits per day range across multiple states. We have monitored more than 12,000 patients in their home with COVID-19 or symptoms of COVID-19 to help keep them safe and out of our facilities. We are way down the road compared to where we were a year ago in fulfilling the vision of telehealth being used across the care continuum to improve access, improve quality, and lower overall cost of care," he says.
Building telehealth programs
Whether a telemedicine initiative is based in a hospital, clinic, physician practice, skilled nursing facility, or patient homes, Providence asks four essential questions before building a program, Czartoski says.
1. Is the telehealth program safe for patients?
2. Is the telehealth program as good or better than an in-person visit?
3. Is the telehealth program reimbursable by government or commercial payers?
4. Is the telehealth program supported by a clinician champion?
Having a clinician champion for a telehealth program is often overlooked at other health systems, he says. "Whether it is an obstetrics program, primary care program, or any other telehealth program, you need to have a clinician champion to pull their partners and colleagues along."
With 15,000 clinicians who are now telehealth-enabled, Providence has many clinician champions for telemedicine programs, Czartoski says. "We still have some naysayers. Not surprisingly, there are still people who do not believe in telehealth and do not like it. But the wholesale change we have seen with most of our providers has been toward accepting telehealth. We are seeing most of them excited about how they can use telehealth to effectively and efficiently care for their patient panels."
Sustaining telehealth programs
There are three primary factors necessary to sustain a telehealth program, he says.
1. Financial return on investment
"We need to make sure that if we are going to operate a program there is a model to get paid, whether it is Medicare fee-for-service, commercial payers, or at-risk payment models," Czartoski says.
At-risk contracts such as accountable care organizations and Medicare Advantage have significant potential to sustain a telehealth program, he says. "Where you see risk being taken by the care delivery system, you will see providers pushing the envelope of what they can do safely and effectively with virtual care."
2. Patient and provider experience
"You need to consider both the patient and the provider journey. We need to make the telehealth experience more seamless, frictionless, and efficient for our providers and the patients who are using this technology," Czartoski says.
The biggest driver for patients in terms of telehealth experience is the ease of connecting to the service such as adequate bandwidth and having the device that they need, he says. "It should not require a bunch of apps or log ins—patients should be able to touch a button and the provider pops up."
Providence has tried to use existing tools to ease the way patients connect to telehealth services such as MyChart. "We have also used some secure texting to engage with patients and folks who are not as tech savvy—they do not want to download an app and they do not want to log in. They just want something that comes to their phone when they need it in a way that is easy to manage and use. How you engage patients is critically important," Czartoski says.
Clinicians also need to put patients at ease to generate a positive telehealth patient experience, he says. "We give basic training to our providers such as eye contact with the camera and putting people at ease. If it is a new visit, providers are trained to show their ID to assure patients that you are who you say you are. Simple things may not sound that important, but they are."
The ease of use and efficiency of telehealth platforms are crucial for provider experience, he says. "Clinicians want to be able to care for their patients efficiently. If they are running late, they want to be able to let a patient know through secure text that they will be five minutes late. Providers also want to have their telehealth visits embedded in their electronic health record. They do not want to open up another app. Almost all of our telehealth visits are conducted through Epic. Providers want telehealth visits to be seamless as part of their workflow."
3. Retooling the provider setting
The third primary factor for sustaining telehealth programs can be the most challenging, Czartoski says.
"You must re-envision what a practice is going to look like. Many practice groups have been reluctant to do that, mainly because there is no certainty that the shift to telehealth to see Medicare patients is going to be permanent. Without that reassurance or confidence, completely overhauling your practice such as changing the number of nurses and front office staff as well as changing the physical footprint that you need, the technology, and the scheduling of patients is daunting."
For example, several Providence physician practices and medical groups have launched an initiative to use a centralized team of medical assistants to conduct blood pressure monitoring and to call high-risk patients to check on them. The medical assistants have taken those responsibilities off the plate of primary care doctors, he says.
"This is an example of monitoring patients at the enterprise level through calls, texts, and Bluetooth-enabled home monitoring. It improves access and adds touchpoints to the patients who we are serving."
In the initiative, a team of about 50 medical assistants is supporting nearly 1,800 clinicians, Czartoski says.
With the initial vaccine supply expected to be limited, Dartmouth-Hitchcock Health has prioritized which healthcare workers will get vaccinated first.
Under state and federal guidance, Dartmouth-Hitchcock Health is poised to distribute the first supplies of coronavirus vaccine.
Last week, the U.S. Food and Drug Administration granted emergency use authorization for the Pfizer-BioNTech coronavirus vaccine. Distribution of the vaccine is beginning this week.
In a conversation with HealthLeaders last week, Michael Calderwood, MD, MPH, associate chief quality officer at Dartmouth-Hitchcock Medical Center, and an associate professor of medicine at the Geisel School of Medicine at Dartmouth College, shared the health system's plans to distribute the vaccine. The following is a lightly edited transcript of that discussion.
HealthLeaders: What are the primary elements of Dartmouth-Hitchcock Health’s coronavirus vaccine distribution plans?
Michael Calderwood: As we look at how we are going to be distributing vaccine, we are looking at guidance from the state of New Hampshire as well as federally at the Centers for Disease Control and Prevention.
The allocation criteria consider a few things. We are looking at the risk of an individual acquiring infection and the risk to that individual if they were to become infected having severe illness or death. We are also looking at the societal impact and looking at who is most likely to transmit coronavirus to others. That is going to be an important point as we think about moving from the early phases—where we are focused on healthcare workers, first-line responders, and those people living in nursing homes—to later phases and figuring out who add first to the list and who come second, third, and so forth.
HL: If you must prioritize which members of the medical center's staff will receive the vaccine first, how will you do that?
Calderwood: There has been a lot of work in advisory groups at the state level and nationally, so we are using some of that guidance in terms of risk stratification. Regarding high-risk healthcare workers, there has been a big focus on physicians and nursing staff as well as individuals working at testing facilities, emergency departments, and urgent care centers. In addition to all of that, we need to be aware that healthcare is a broad group of individuals, so we need to consider vaccinating dentists and dental hygienists, and home caregivers and people going out into the community.
So, we have a set list in terms of the risk stratification for healthcare workers that we will be following. Even within those groups, it may be possible that we will receive insufficient vaccine in the first delivery to get to everyone in the high-risk categories. If we look at those individuals who have been prioritized as being at highest risk, we are looking at people who have high-risk medical conditions, those who are over the age of 65, and healthcare workers who are providing direct patient care—particularly working in COVID-19 units.
HL: The Pfizer-BioNTech and Moderna vaccines require extreme low-temperature storage. How are you going to be storing vaccine at the medical center?
Calderwood: This will also change over time. With the initial delivery, the National Guard will be delivering vaccine to state authorities. So, the deep freezing of the vaccines will be at state facilities. They are then going to deliver the vaccine out to sites like ours based on the vaccinations they are planning on a given day. There is variation between the vaccines in terms of how long you can have them out of deep freeze before you vaccinate people after doing some prep at your site. All of those logistics have been worked out.
Longer term as we get more and more vaccines, we will be storing vaccine at healthcare sites—hospitals, clinics, and pharmacies have all begun to develop that infrastructure. We do have minus-80-degree freezers distributed strategically across our region to support the broader vaccination effort.
HL: The Pfizer-BioNTech and Moderna vaccines must be thawed and prepared before vaccination can proceed. How is the medical center managing those processes?
Calderwood: We have a very large, multidisciplinary team. Most hospitals have had strong involvement of pharmacists. We have our chief pharmacy officer involved in the day-to-day logistics.
For the vaccination, we have a dedicated vaccination staff that has a lot of experience doing flu clinics. So, once our pharmacists prepare the vaccine, it will be administered by our vaccination staff, which has a long history of doing these types of clinics.
HL: In addition to your medical center, Dartmouth-Hitchcock Health is affiliated with several smaller hospitals. How has the health system integrated these smaller facilities into its vaccine distribution plans?
Calderwood: We are making this effort as a health system. So, each hospital has to submit their own list of who they are planning to vaccinate and a time schedule for that vaccination. That is all being coordinated centrally. And as we think about vaccination for the general public and the continued need for cold storage of vaccines, we will be storing vaccines in a couple of central locations and distributing vaccine out to the system based on need.
This year's Institute for Healthcare Improvement Forum covered a range of topics, including quality improvement, health equity, population heath, patient safety, joy in work, and telemedicine.
More than 5,000 healthcare professionals convened virtually this week for the Institute for Healthcare Improvement's IHI Forum 2020.
The Boston-based organization's annual forum is the largest healthcare improvement event held in the country and draws educational session presenters and keynote speakers from around the world. This year's event covered a range of topics, including quality improvement, health equity, population heath, patient safety, joy in work, and telemedicine.
HealthLeaders attended several educational sessions, which included the following three big ideas.
1. Ensuring successful adoption of quality improvement initiatives
Chris Hayes, MD, MSc, MEd, a former IHI fellow and chief medical information officer at Trillium Health Partners in Mississauga, Ontario, Canada, presented an educational session on strategies to ensure that quality improvement improves joy in work.
Hayes' presentation included six primary factors for highly adoptable quality improvement initiatives.
1. End-user participation: End-user staff such as physicians should be involved in the initiative.
2. Alignment and planning: The initiative should be aligned with the organization's or healthcare team's goals, and the launch of the initiative should be planned effectively.
3. Resource availability: The required resources for the initiative such as equipment and personnel should be known and made available.
4. Workload: The cognitive, physical, and time workload should be defined and manageable.
5. Complexity: The initiative should not be overly complex.
6. Efficacy: There should be evidence and belief that the initiative will achieve the intended outcomes.
"In the assessment of projects, we get people to say where they are in these six factors for their project or the planning of the project. Then we give them tools to measure workload and to reduce workload and complexity," Hayes said.
He said one of his favorite assessment tools for quality improvement initiative adoptability is the NASA Task Load Index.
"This is a subjective workload assessment tool. For example, you ask people: How mentally demanding was the task? How rushed or hurried were you? How successful were you in completing the task? How hard did you have to work to accomplish the level of performance? And how insecure, discouraged, irritated, distressed, or annoyed were you? If people rank very high on the last question, the initiative is not going to work, or at least it is not going to work for very long because it is too demanding on people," Hayes said.
2. Launching quality improvement initiatives
Christine Southey, MSc, an IHI improvement adviser and faculty member as well as principal at SoutheyC Consulting in Toronto, Ontario, Canada, was part of a three-member panel that conducted an educational session on quality improvement concepts, methods, and tools. She said a crucial first step for any healthcare quality improvement initiative is engaging members of the organization as well as patients and their families.
"When we have done some of our quality improvement work with long-term care facilities around COVID-19, one of the common themes is to talk with the staff. You need to find out what is important to them, to find out what troubles they are experiencing, and to find out what they are concerned about. That effort not only helps you get a sense of the key focus of your quality improvement but also helps lay the groundwork for engaging people in whatever quality improvement initiative you pursue in the weeks and months to follow," she said.
This first step familiarizes quality improvement leaders with the day-to-day operations of an organization as well as the patients that the organization serves, Southey said. "You not only connect with staff members on a one-on-one level but also get very valuable information about what it is really like to work within the organization. You also want to talk with patients and family members, which gives you a good sense of what it is like to receive care or to support someone who is receiving care."
This foundational work generates gains in the long run, she said. "As you start moving to improvement initiatives, you can go back and show people how their concerns informed the work that is moving forward. You invite people to be a part of the work; and as you start spreading ideas, you have laid the groundwork to be able to engage with people so that they know how they might be able to be involved."
3. Caring for caregivers in a crisis
Jesse McCall, MBA, a director and improvement adviser at IHI and Arpan Waghray, MD, CMO of the Well Being Trust in Oakland, California, led an educational session on joy in the workforce. Their session featured "psychological personal protective equipment" during a crisis for individual healthcare professionals and team leaders.
Individual psychological PPE:
1. Take a day off to create space between work and home life
2. Avoid unnecessary publicity and media coverage of the crisis
3. Get mental health support during and after the crisis
4. Seize on opportunities to show gratitude
5. Recast negative experiences in a positive light
Team leader role in psychological PPE:
1. Limit the length of shifts or time in the workplace
2. Design clear roles and leadership responsibilities
3. Train managers to be aware of risk factors and to monitor for signs of stress
4. Make peer support services available to frontline staff
5. Pair workers together in a buddy system
Leaders can limit the length of shifts or time in the workplace by establishing "float teams" through cross training so that staff members with appropriate licensure, skills, and experience can help in stressed medical units during a crisis, McCall said.
"Moving staff around creates organizational capacity and increases caregiver resources when they are needed most. … To support float teams, leaders should have a set of questions to gauge how the float teams are doing in mixed roles. The people who are doing the work are the ones who are really going to know how the float teams are functioning. Leaders also should ask patients about the staff that is rotating into a unit."
Waghray said healthcare leaders need to use several skills and methods in times of crisis.
Tolerance for uncertainty is one of the more important skills.
During a crisis, leaders should recognize that their role evolves over time. In the early days of the coronavirus pandemic, it was important for leaders to be visible, to offer transparent communication, and to project calm and empathy. As the pandemic advanced, other roles became significant such as addressing anger and frustration among healthcare workers while continuing to provide hope.
For leaders, communication during a crisis is essential such as establishing formalized listening sessions and intentional leadership rounds.
Being vulnerable as a leader is an important skill. It helps to exhibit humility, curiosity, inclusion, and genuine empathy.
A practical action leaders can take is to ask about what is going well—leaders can try to overcome the negativity bias that can run rampant during a crisis.
In healthcare, seeking help is often seen as a sign of weakness, so leaders should try to normalize help-seeking behavior.
A patient throughput plan at USA Health University Hospital includes addressing patient safety, efficiency, transitions of care, and discharge processes.
An Alabama-based hospital is benefiting from developing a surge plan to manage inpatient bed capacity before the onset of the coronavirus pandemic.
The efficiency of patient throughput—the inpatient processes and transitions of care from admission to discharge—is a concern at all hospitals. For example, inefficient patient throughput can delay hospital admissions from emergency departments, which leads to emergency room crowding and decreased patient satisfaction.
USA Health University Hospital in Mobile, Alabama, started designing its surge plan in late 2018 and implemented the initiative in March 2019.
"The surge plan provides structure and guidance for how to manage bed capacity. We lacked that structure and guidance when we conducted an assessment prior to designing the surge plan. The surge plan tells us what to do when we are at a certain level of bed capacity," says Sheri Salas, MSN, RN, director of nursing at USA Health University Hospital.
The hospital's analysis of pre-surge plan data from March 2018 to February 2019 and post-surge plan data from March 2019 to March 2020 shows several benefits from the bed capacity management initiative:
Partial diversion of patients to other hospitals was reduced from 331 hours in the pre-surge plan period to 202 hours in the post-surge plan period (39% decrease)
Emergency department admissions increased from 553 per month in the pre-surge plan period to 713 per month in the post-surge plan period (29% increase)
Hospital admissions increased from 798 per month in the pre-surge plan period to 916 per month in the post-surge plan period (15% increase)
Hospital referral acceptance rate increased from 61% in the pre-surge plan period to 92% in the post-surge plan period (51% increase)
Hospital discharge orders by 11 a.m. increased from 25% in the pre-surge plan period to 30% in the post-surge plan period (20% increase)
The surge plan initiative has been beneficial during the coronavirus pandemic, Salas says. "Just having a surge plan has helped during the pandemic. If we did not have a plan to begin with, we would have been all over the place. Having a plan with daily guidelines to follow has kept us from having to come up with a plan at the last minute."
Surge plan levels
The surge plan created color-coded levels of inpatient bed capacity, ranging from green, yellow, orange, red, and black.
"Green means we are wide open. Within the green level, we have daily practices that keep us in a mode of constantly monitoring and assessing our bed capacity levels. The policy for the green level includes a check list that we monitor several times a day to monitor bed capacity," Salas says.
The intensity of attention to patient throughput escalates along the color-coded scale, she says. "As we move up the levels of bed capacity, there are reminders and guidelines for what to do such as speeding up the cleaning of rooms so patients can be admitted from the emergency department. There are things that you do not want to assume are being done to keep everyone moving and make patient flow efficient."
Black is the direst bed capacity level in the surge plan.
"The black level is what most hospitals would have if they have a diversion plan. The black level is what we call full diversion. It means that we are at full capacity and are unable to take most new patients. If we are at full diversion, most of the area's hospitals are usually at full diversion as well. There has never been a time when we were absolutely unable to take new patients," Salas says.
Key surge plan elements
The implementation and operation of the hospital's surge plan includes six primary components.
1. Training: The first step in implementing the surge plan was training staff, Salas says. "We educated nursing, clinicians, environmental services, transporters, and patient care assistants. We did 'round robin' sessions, where we talked with staff members in person. We provided cards that were tailored to particular roles that told those staff members what to do to support the surge plan on the various color-coded levels."
2. Leadership: The Patient Throughput Committee has led the hospital's surge plan initiative. The panel, which is chaired by the hospital's CMO and is currently meeting monthly, is interdisciplinary. Members of the committee include hospital administrators, hospitalists, nurses, emergency department leadership, operating room staff, post-anesthesia care unit staff, the environmental services director, and the transport director.
"This team meets to discuss our bed capacity status, gaps, and what we need to do to address patient throughput. The committee looks at data and tackles challenges. One of the roles of the committee is to look at the surge plan and to revise it as needed. Especially since the pandemic began, there is always a new challenge to address," she says.
Focal points for the committee include patient safety, efficiency, transitions of care, and discharge processes.
3. Management team for patient throughput: "The Transfer Center is at the core of patient movement and throughput. It is a referral center. It is where patient bed movement happens. What some hospitals call 'house supervisors' work out of that department. We have staff in the Transfer Center who are nurses and paramedics who handle the referral portion of the Transfer Center," Salas says.
The Transfer Center was launched with a few staff members but has grown to about 19 staff members, she says.
4. Daily huddles: "We have a core group that we call our Surge Team that gets together every morning. They go over key points such as patients who need a bed, patients who are potential discharges, and operating room cases. It is a daily huddle regarding bed capacity status. The Surge Team includes our Transfer Center manager, our emergency department director, our operating room and post-anesthesia care unit teams, clinical nurse leaders, and our environmental services director," Salas says.
5. Transitional Care Unit: To reduce emergency department crowding and facilitate inpatient admissions, the hospital has a six-bed Transitional Care Unit. "It is a unit where patients can move from the emergency department until we have discharges throughout the day, then they can move to an inpatient bed. It helps with the patients being more satisfied from moving out of the emergency department," she says.
6. Clinician engagement: The surge plan initiative has boosted clinician engagement, Salas says. "They have been involved in assisting us, giving their input, and working with us on the surge plan and issues related to patient throughput. They are continuing to come to us with new ideas and areas we need to work on."
Before launching interventions to improve interprofessional collaboration in hospitals, leaders should conduct baseline assessments, an expert says.
Hospitalists and nurses working on general medical services have varying perceptions of the quality of interprofessional collaboration, a recent research article indicates.
Earlier research has shown that teamwork and interprofessional collaboration are key elements of providing safe care and boosting patient satisfaction. However, there are several challenges to effective teamwork in the hospital setting such as the large size of medical care teams and physicians working across multiple care units with little opportunity to establish lasting work relationships with nurses and other staff members who are assigned to designated units.
The recent research article, which was published by The Joint Commission Journal on Quality and Patient Safety, is based on data collected from four U.S. hospitals that were participating in the Redesigning Systems to Improve Teamwork and Quality for Hospitalized Patients project. The project is crafted to establish and spread care models that increase interprofessional teamwork and improve outcomes for hospitalized patients.
Nearly 400 medical staff members participated in the study: 193 nurses, 94 nurse assistants, 80 hospitalists, and 13 resident physicians. The research generated two primary results:
63.3% of hospitalists rated the quality of collaboration with nurses as high or very high, but only 48.7% of nurses rated the quality of collaboration with hospitalists as high or very high
Teamwork climate scores varied significantly across the four hospitals in the study
"This study found significant differences in perceptions of teamwork climate across sites and in collaboration across professional categories on general medical services. Given the importance in providing high-quality care, leaders should consider conducting similar assessments to characterize teamwork and collaboration on general medical services within their own hospitals," the research article's co-authors wrote.
Interpreting the data
The lead author of the research article told HealthLeaders that there are likely multiple causes for the perception gap on collaboration between hospitalists and nurses.
"It seems that physicians feel that they have the information they need, while nurses realize that they do not have the information they need. The team members lack a shared mental model of the plan of care. Nurses may be more aware of this lack of a shared mental model because they spend more time with patients and are responsible for administering the treatments such as medications, activity, and diet ordered by physicians," said Kevin O'Leary, MD, MS, professor of medicine at Northwestern University Feinberg School of Medicine and medical director for quality at Northwestern Memorial Hospital in Chicago.
Other underlying causes of the perception gap on collaboration likely include differences in training, experience, and hospital culture, he said. "Teamwork challenges are probably more common in hospitals that continue to have a culture with steep hierarchies."
The research article's finding that there was significant variation in teamwork climate scores at the four hospitals in the study shows the importance of conducting baseline assessments of teamwork and collaboration at hospitals, O'Leary said.
"Baseline assessment of teamwork climate is important for two main reasons. First, it allows hospital leaders to identify whether an opportunity for improvement exists, or assessment may reveal that teamwork is going well. Second, if an opportunity for improvement exists, baseline assessment will serve as an important comparator to post-intervention assessment to determine whether teamwork has improved."
Three complementary interventions can increase teamwork and collaboration between physicians and nurses, he said.
Assigning physicians to work in a minimal number of medical units
Establishing a co-leadership structure in medical units featuring physicians and nurses
Utilizing well-designed interprofessional rounds in medical units
