Healthcare organization leaders can pursue clinician-focused strategies to help achieve successful M&A transactions.

A significant proportion of clinicians have a skeptical view of healthcare organization merger and acquisition (M&A) deals, a survey report published recently by LocumTenens.com says.

Hospitals have been involved in a wave of M&A transactions over the past two decades, with studies documenting a spike in deals since 2010. Several other studies have shown that hospital service pricing increases after M&A transactions. A research article published earlier this month found hospital M&A deals do not improve care quality.

The LocumTenens.com survey report, which was published as part of the staffing agency's 2019 Physician and Advanced Practice Salary Report, is based on data collected from more than 3,500 physicians and advanced practice practitioners nationwide. The survey report includes several key data points.

• 48% of the clinicians surveyed said they did not feel valued by the new organization after an M&A transaction
   
• 39% of survey respondents said it took more than a year to integrate the organizations involved in an M&A deal
   
• 39% of respondents did not think leaders placed adequate value on shared culture
   
• Only 20% of respondents said their organization became more efficient after an M&A deal
   
• 43% of respondents did not think the cost of care for patients decreased
   
• 35% of respondents did not think quality of care improved

Clinician participation in M&A deals

Chris Franklin, president of LocumTenens.com, which is a subsidiary of Alpharetta, Georgia-based Jackson Healthcare, recently shared three clinician-focused strategies to achieve effective M&A deals.

1. Valuing medical staff after an M&A deal: The most meaningful action healthcare organization administrators can take to ensure medical staff feel valued after a merger or acquisition is to take a step back and listen, Franklin said.

"Encourage a culture where staff don't feel afraid to voice their opinions, concerns, and fears, and be open to their ideas. The employees are the ones who are most affected by policies and procedures day in and day out. They are knowledgeable and can provide healthcare organizations with a unique perspective and unique solutions to issues likely to arise during consolidation."

2. Promoting a shared culture: An organization's culture is defined by how it lives and models its values and beliefs, he said.

"A first step in a newly consolidated organization promoting a shared culture is reaching common ground on how values and beliefs contribute to achieving mission and vision. Be sure to actively involve medical staff in these conversations rather than disclosing details once they've concluded, and make sure that what emerges from those conversations is woven into every aspect of the organization's behaviors."

3. Amplify clinician voices throughout the M&A process: One of the best ways to amplify clinician voices during a consolidation is to regularly administer brief and anonymous surveys to medical staff, Franklin said.

"If the surveys are anonymous, clinicians are more likely to provide honest feedback. This is also another way to help them feel valued. It's not enough to simply conduct the surveys, though. Administration needs to acknowledge the collective feedback they receive and demonstrate how they are thoughtfully considering solutions and making progress toward resolving any issues that the surveys highlight."

Becoming more customer-friendly for patients was the primary reason IU Health launched its online ratings and reviews initiative, executive director of digital marketing and experience says.

This article appears in the March/April 2020 edition of HealthLeaders magazine. 

Indianapolis-based IU Health has launched and implemented an extensive effort to post physician and clinic-level star ratings and reviews online.

After University of Utah Health pioneered online physician reviews in 2012, a small but growing number of health systems have followed in its footsteps. For health systems that have implemented posting online ratings and reviews, the initiatives are viewed as an essential element of transparency and patient experience.

Becoming more customer-friendly for patients was the primary reason IU Health launched its online ratings and reviews initiative in 2018, says Jeremy Rogers, the health system's executive director of digital marketing and experience.

"We heard from our patients through studies and surveys that they wanted to have this type of information when they were making critical decisions about who their next physician or provider would be. We all know in our modern lives that we use ratings and reviews for almost every decision we make—whether it's our next vacation or purchasing a new car. One of the first things we do is go online and look for reviews from other customers," he says.

The IU Health initiative has achieved significant results since its launch a year-and- a-half ago:

• The health system is publishing ratings and reviews for more than 1,500 clinicians
   
• About 150,000 reviews have been posted online
   
• The volume of reviews is growing by about 7,500 reviews per month
   
• The average provider star rating is between 4.6 and 4.7 out of 5 stars
   
• More than 500 IU Health locations are getting star ratings. "These locations are at the clinic level, so a hospital could have dozens of locations with star ratings," Rogers says.

How online ratings and reviews are generated at IU Health

Star ratings and online reviews are drawn from a patient experience survey developed at IU Health three years ago.

For every patient inpatient and outpatient encounter, within 48 hours patients receive an email or a text message asking them to respond to the survey. The survey has a half-dozen questions such as likelihood to recommend a clinician to friends and family, whether the clinician spent enough time with the patient, and whether the clinician made the experience easy for the patient.

"We get a strong response rate to our surveys—about 20% to 25% of patients respond. On an annualized basis, we are processing about half a million survey responses," Rogers says.

In addition to generating star ratings for physicians and advanced practice practitioners, the data is used internally for score cards that go out to administrators and individual clinicians to show the experience they are providing to patients.

Online reviews are more difficult to administer.

"Every month, we load the raw data from the third-party administrator of our experience surveys. We then have processes such as scrubbing out protected health information and scrubbing out profanity and incoherent language. These processes are all done using machine learning and artificial intelligence techniques. We have published about 150,000 patient reviews over the past year and a half. Once we've done the scrubbing, we then publish the reviews automatically," he says.

IU Health publishes both positive and negative reviews, and the health system rarely blocks publication of a review, Rogers says. "Our intent is to never edit a comment. We want to have the patient's review in their own words."

There is also a governance model to manage reviews when clinicians raise concerns about patient comments. A common example that requires governance is when a clinician questions whether a patient review should be directed to another provider because the patient has commented on the wrong clinician, he says.

"We have patients who have multiple IU Health physicians and they can have multiple appointments in a week. Occasionally, these patients may respond to the wrong survey for an encounter. In these cases, we have a governance process [in which] our team digs into the electronic medical record to verify the data based on the encounter ID of the survey."

Other clinician concerns are less clear cut, such as when a provider thinks that a review is unjust or does not reflect a patient encounter accurately. In those cases, the chief medical officer for the physician group in question conducts research to help determine whether a review should be removed.

"We're not trying to be punitive to our providers or trying to foster a culture where they feel disrespected, but we must be transparent. So, we are balancing both transparency for our patients and fairness for our physicians," Rogers says.

Impact of online reviews

IU Health has made several changes based on comments in online reviews, he says. "Part of our overall effort with online reviews is to empower our providers and other staff to drive change at the local level. For example, based on the real-time feedback from patients, our team members and providers have leveraged reviews from the patients to improve the performance of registration staff or add valet parking to their location."

Wait times are a common topic in negative reviews, which have prompted the health system to improve access at some clinics, Rogers says. "We use the data from the reviews to analyze how we are scheduling the providers, and, in some cases, how we are recruiting providers. If we see areas where we don't have sufficient access, we make changes to address that issue."

At IU Health, online ratings and reviews have become a key ingredient for patient engagement, he says.

"When you talk about consumers in healthcare, it is no longer optional for patients to have choice and options in their care. For us, we are moving beyond just physician ratings and reviews. We publish ratings for locations such as urgent care clinics. We are publishing ratings and reviews for advance practice providers. Patients expect this level of transparency and empowerment."

Within specialties, researchers found wide variation in the distribution of time spent by physicians using EHRs, indicating significant potential for improvement.

A new research article provides details about the time physicians spend working with electronic health records (EHRs) for outpatient encounters.

At most outpatient practices across the country, EHRs have replaced paper-based systems for documenting and retrieving patient data. Among physicians, primary complaints about EHRs include their impact on physician burnout and conversion of clinicians to data entry clerks. Earlier research has found that EHRs are strongly associated with physician job dissatisfaction.

The new research article, which was published today by Annals of Internal Medicine, is a large-scale study. The research features 2018 data collected from nearly 100 million patient encounters with 155,000 physicians.

The research includes several key data points:

• On average, physicians in outpatient settings spent 16 minutes 14 seconds per patient encounter using EHRs
   
• Three clinical functions dominated time spent on EHR use: chart review (33% of time using EHRs), documentation (24%), and order writing (17%)
   
• Physicians in the endocrinology, gerontology, internal medicine, and primary care specialties spent the highest mean times using EHRs per patient encounter—ranging from 18 to 22 minutes
   
• Sports medicine (8 minutes) and physical medicine and rehabilitation (10 minutes) spent the lowest mean times per patient encounter
   
• Within specialties, there was substantial variation in the distribution of time spent by physicians using EHRs

"The time spent using EHRs to support care delivery constitutes a large portion of the physicians' day, and wide variation suggests opportunities to optimize systems and processes," the co-authors of the research article wrote.

Interpreting the data

The top two clinical functions that physicians spend time using EHRs—chart review and documentation—have opposing impacts on clinicians, the article' co-authors wrote.

"Despite the effort sometimes required to find the relevant data in the EHR (33% of active EHR time devoted to chart review), physicians generally appreciate the improved availability of data. Documentation, on the other hand, accounts for the second-highest proportion of EHR time (24%) and is often a target of physician concern. Documentation may be easier to delegate than some other tasks," they wrote.

The third highest clinical function that physicians spend time using EHRs—17% of EHR use time writing orders—is a high priority activity that requires clinician attention, the co-authors wrote. "Ordering, particularly medication ordering in the ambulatory setting, is an important provider task because it is a basic tool for recording the specifics of the physician's intent and communicating these specifics to other team members."

Having EHR use times by specialty provides a valuable benchmarking tool for physicians and health system leaders, the co-authors wrote.

"Physicians can compare their own EHR time with the reported times for their subspecialty to understand their performance in the context of other providers. Health system leadership can use the data to gain realistic insight into the effort required by physicians to complete their work, including EHR use, and justify investment in optimizing the physician workflow in the EHR."

The EHR use time by specialty is also valuable for payers and policy makers, they wrote. "Payers can use the data to understand the level of effort required to complete this important part of a physician's work when using an EHR and consider adjusting their expectations for data capture considering the direct costs. Finally, policymakers may incorporate these data into EHR certification processes and data capture expectations."

An editorial accompanying the research article says the scale of the study is impressive. "Others have tackled this same research, but they have studied only a single or small number of sites or specialties. As a result, this study provides perhaps the final word on the question, how much time do outpatient physicians spend using the EHR?"

Ongoing trends are likely to loom large in the realm of patient safety this year.

A patient safety expert at The Joint Commission says four ongoing trends will dominate the patient safety landscape in 2020.

Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark report To Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.

Anne Marie Benedicto, MPP, MPH, vice president of the Center for Transforming Healthcare at The Joint Commission, recently shared her trend outlook for 2020 with HealthLeaders.

1. Patient advocacy

In 2020, there will be two primary forces at play in patient advocacy, Benedicto says.

"Healthcare providers have become more commercial in how they track patients as 'customers,' and patients are becoming more like consumers and using those skills to help navigate the healthcare system. This means more and more patients feel they have a say in what diagnoses mean for them, how they are treated, and how they engage with their care teams," she says.

With research resources such as WebMD literally at their fingertips, many patients have become savvy healthcare consumers, Benedicto says. "I see it in my personal life, where family members are doing research before they see a physician, or they make sure that they don't go to a doctor visit alone. When you are a patient and a visit is not a routine physical, you want someone else with you to ask clarifying questions because patients can be afraid or preoccupied."

Health systems and hospitals are increasingly embracing patient advocacy, she says.

For example, the Center for Transforming Healthcare is working with a Texas-based health system to boost quality improvement skills in neonatal intensive care units (NICU). The effort initially focused on clinicians, but the health system wanted to achieve quality and safety gains through empowering patients' families, Benedicto says.

"Our biggest surprise has been that the organization not only wanted clinicians trained in improvement skills but also the patient advisory council. We also provided training to parents of babies who were in the NICU for long periods of time. We found that the training gave parents permission to talk about quality issues with clinicians in a way that we had not seen before," she says.

The training for parents has focused on bridging language and skills gaps.

2. Improving the work environment

Ensuring adequate staffing at healthcare organizations is a key element of patient safety, and health systems, hospitals, and physician practices need to step up efforts to care for caregivers, Benedicto says. "This is an ongoing trend because we are already seeing clinician shortages. We are not recruiting and retaining enough medical staff members to meet the demand."

Healthcare organization leaders must shape work environments in ways that ease stress on staff members, she says.

For example, clinicians often struggle to find equipment or supplies such as medication pumps, she says. "They can spend 20 minutes looking for this equipment. It may sound like a simple inconvenience, but it can happen several times daily for a care team. When you put that all together, it can be tremendously wasteful. It also adds frustration and danger to an already stressful day."

She says "the solution to this challenge is to put the proper systems in place such as supply chain management that makes it easier for staff members to do their work."

Another way to improve the work environment at healthcare organizations is to tap into the knowledge and experience of staff members, Benedicto says. "They can not only make their workday better—they can make their patients' day better. If there is no mechanism in an organization to take those ideas and turn them into improvements, then those ideas dry up and stop coming. One of the ways we can retain people in healthcare is to make sure their voices are heard."

3. High reliability

Promoting high reliability at healthcare organizations improves patient safety and reduces wasteful spending, she says. "Going back to the example of a clinician looking for equipment or supplies for 20 minutes—that's 20 minutes of waste. That is time they could spend more cost-effectively on other issues and projects."

Falls with injury are a prime example of persistent patient safety problems that are missed high-reliability opportunities, Benedicto says. "Often, an organization will target falls every couple of years, saying that their fall rates are unacceptable. They come up with a solution, put it in place, it lasts for a few months, then the old practices creep back."

There needs to be an understanding that persistent problems in healthcare persist because they are complex, and they require structured and sustained solutions, she says. "The use of highly reliable process tools is necessary to get to zero harm. It's not just a matter of picking the easiest solution and putting it in place. It's a matter of stepping back and figuring out why the problem is happening, finding out why it is persisting, looking at the contributing factors, then developing solutions."

4. Surgery center safety

With the continuing trend of increasing numbers of procedures shifting from the hospital setting to ambulatory surgery centers, improving safety at surgery centers will be a top concern in 2020, Benedicto says.

"Technology is enabling this trend. In addition, if patients can get care in less complicated settings, then those options should be pursued. However, this opportunity comes with a risk. Many surgical centers do not have the same levels of protection that hospitals have. For example, more and more spine surgeries are happening in surgical centers, and those centers may not know what to do when there is a serious complication."

Surgery centers need to adopt patient safety protocols that have become common at hospitals, she says.

"Over the past decade, hospitals have been investing in process improvement and improvement methodologies, so they could make their care as safe as possible. That same type of trend needs to happen in other settings of care such as surgery centers. Achieving zero harm not only requires embracing high reliability as a goal, it means making sure that resources are in place to get to that goal—stronger improvement skills, stronger safety culture, and leadership commitment to zero harm."